RESUMO
Studies of patients with major depressive disorder (MDD) have consistently reported reduced hippocampal volumes; however, the exact pattern of these volume changes in specific anatomical subfields and their functional significance is unclear. We sought to clarify the relationship between hippocampal tail volumes and (i) a diagnosis of MDD, and (ii) clinical remission to anti-depressant medications (ADMs). Outpatients with nonpsychotic MDD (n=202) based on DSM-IV criteria and a 17-item Hamilton Rating Scale for Depression (HRSD17) score ⩾16 underwent pretreatment magnetic resonance imaging as part of the international Study to Predict Optimized Treatment for Depression (iSPOT-D). Gender-matched healthy controls (n=68) also underwent MRI scanning. An automated pipeline was used to objectively measure hippocampal subfield and whole brain volumes. Remission was defined as an HRSD17 of ⩽7 following 8 weeks of randomized open-label treatment ADMs: escitalopram, sertraline or venlafaxine-extended release. After controlling for age and total brain volume, hippocampal tail volume was larger in the MDD cohort compared to control subjects. Larger hippocampal tail volume was positively related to clinical remission, independent of total hippocampal volume, total brain volume and age. These data provide convergent evidence of the importance of the hippocampus in the development or treatment of MDD. Hippocampal tail volume is proposed as a potentially useful biomarker of sensitivity to ADM treatment.
Assuntos
Antidepressivos/uso terapêutico , Transtorno Depressivo Maior/diagnóstico por imagem , Transtorno Depressivo Maior/tratamento farmacológico , Hipocampo/diagnóstico por imagem , Adulto , Fatores Etários , Citalopram/uso terapêutico , Estudos de Coortes , Preparações de Ação Retardada , Transtorno Depressivo Maior/patologia , Transtorno Depressivo Resistente a Tratamento/diagnóstico por imagem , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Transtorno Depressivo Resistente a Tratamento/patologia , Feminino , Hipocampo/efeitos dos fármacos , Hipocampo/patologia , Humanos , Interpretação de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Tamanho do Órgão , Reconhecimento Automatizado de Padrão , Prognóstico , Escalas de Graduação Psiquiátrica , Indução de Remissão , Sertralina/uso terapêutico , Cloridrato de Venlafaxina/uso terapêuticoRESUMO
BACKGROUND: Prior studies have suggested that major depressive disorder (MDD) with pre-adult onset represents a distinct subtype with greater symptom severity and higher rates of suicidal ideation. Whether these patients have poorer response to various types of antidepressant treatment than those with adult-onset MDD is unclear. Method A total of 665 psychiatric and primary care out-patients (aged 18-75 years) with non-psychotic chronic or recurrent MDD participated in a single-blind, randomized trial that compared the efficacy of escitalopram plus placebo, bupropion sustained-release plus escitalopram, or venlafaxine extended-release plus mirtazapine. We compared participants who self-reported MDD onset (before age 18) to those with a later onset (adult onset) with respect to baseline characteristics and treatment/outcome variables at 12 and 28 weeks. RESULTS: Early-onset chronic/recurrent MDD was associated with a distinct set of sociodemographic (female, younger age) and clinical correlates (longer duration of illness, greater number of prior episodes, greater likelihood of atypical features, higher rates of suicidality and psychiatric co-morbidity, fewer medical problems, poorer quality of life, greater history of child abuse/neglect). However, results from unadjusted and adjusted analyses showed no significant differences in response, remission, tolerability of medications, quality of life, or retention at 12 or 28 weeks. CONCLUSIONS: Although early-onset chronic/recurrent MDD is associated with a more severe clinical picture, it does not seem to be useful for predicting differential treatment response to antidepressant medication. Clinicians should remain alert to an increased risk of suicidality in this population.
Assuntos
Antidepressivos de Segunda Geração/uso terapêutico , Citalopram/uso terapêutico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/epidemiologia , Tentativa de Suicídio/estatística & dados numéricos , Adolescente , Adulto , Idade de Início , Idoso , Antidepressivos de Segunda Geração/administração & dosagem , Bupropiona/administração & dosagem , Bupropiona/uso terapêutico , Maus-Tratos Infantis/psicologia , Maus-Tratos Infantis/estatística & dados numéricos , Citalopram/administração & dosagem , Comorbidade , Cicloexanóis/administração & dosagem , Cicloexanóis/uso terapêutico , Preparações de Ação Retardada/administração & dosagem , Preparações de Ação Retardada/uso terapêutico , Quimioterapia Combinada , Feminino , Humanos , Modelos Logísticos , Masculino , Mianserina/administração & dosagem , Mianserina/análogos & derivados , Mianserina/uso terapêutico , Pessoa de Meia-Idade , Mirtazapina , Placebos , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Qualidade de Vida , Recidiva , Autorrelato , Índice de Gravidade de Doença , Método Simples-Cego , Ideação Suicida , Tentativa de Suicídio/psicologia , Resultado do Tratamento , Cloridrato de Venlafaxina , Adulto JovemRESUMO
BACKGROUND: The aim of the present study was to determine whether a combination of baseline features and early post-baseline depressive symptom changes have clinical value in predicting out-patient non-response in depressed out-patients after 8 weeks of medication treatment. METHOD: We analysed data from the Combining Medications to Enhance Depression Outcomes study for 447 participants with complete 16-item Quick Inventory of Depressive Symptomatology - Self-Report (QIDS-SR16) ratings at baseline and at treatment weeks 2, 4 and 8. We used a multi-time point, recursive subsetting approach that included baseline features and changes in QIDS-SR16 scores from baseline to weeks 2 and 4, to identify non-responders (<50% reduction in QIDS-SR16) at week 8 with a pre-specified accuracy level. RESULTS: Pretreatment clinical features alone were not clinically useful predictors of non-response after 8 weeks of treatment. Baseline to week 2 symptom change identified 48 non-responders (of which 36 were true non-responders). This approach gave a clinically meaningful negative predictive value of 0.75. Symptom change from baseline to week 4 identified 79 non-responders (of which 60 were true non-responders), achieving the same accuracy. Symptom change at both weeks 2 and 4 identified 87 participants (almost 20% of the sample) as non-responders with the same accuracy. More participants with chronic than non-chronic index episodes could be accurately identified by week 4. CONCLUSIONS: Specific baseline clinical features combined with symptom changes by weeks 2-4 can provide clinically actionable results, enhancing the efficiency of care by personalizing the treatment of depression.
Assuntos
Antidepressivos/farmacologia , Transtorno Depressivo Maior/tratamento farmacológico , Resultado do Tratamento , Adulto , Algoritmos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de TempoRESUMO
BACKGROUND: Major depressive disorder (MDD) is commonly chronic and/or recurrent. We aimed to determine whether a chronic and/or recurrent course of MDD is associated with acute and longer-term MDD treatment outcomes. METHOD: This cohort study recruited out-patients aged 18-75 years with non-psychotic MDD from 18 primary and 23 psychiatric care clinics across the USA. Participants were grouped as: chronic (index episode >2 years) and recurrent (n = 398); chronic non-recurrent (n=257); non-chronic recurrent (n=1614); and non-chronic non-recurrent (n = 387). Acute treatment was up to 14 weeks of citalopram (≤ 60 mg/day) with up to 12 months of follow-up treatment. The primary outcomes for this report were remission [16-item Quick Inventory of Depressive Symptomatology - Self-Rated (QIDS-SR(16)) ≤ 5] or response (≥ 50% reduction from baseline in QIDS-SR(16)) and time to first relapse [first QIDS-SR16 by Interactive Voice Response (IVR) ≥ 11]. RESULTS: Most participants (85%) had a chronic and/or recurrent course; 15% had both. Chronic index episode was associated with greater sociodemographic disadvantage. Recurrent course was associated with earlier age of onset and greater family histories of depression and substance abuse. Remission rates were lowest and slowest for those with chronic index episodes. For participants in remission entering follow-up, relapse was most likely for the chronic and recurrent group, and least likely for the non-chronic, non-recurrent group. For participants not in remission when entering follow-up, prior course was unrelated to relapse. CONCLUSIONS: Recurrent MDD is the norm for out-patients, of whom 15% also have a chronic index episode. Chronic and recurrent course of MDD may be useful in predicting acute and long-term MDD treatment outcomes.
Assuntos
Antidepressivos de Segunda Geração/uso terapêutico , Citalopram/uso terapêutico , Transtorno Depressivo Maior/psicologia , Adolescente , Adulto , Idoso , Análise de Variância , Antidepressivos de Segunda Geração/administração & dosagem , Doença Crônica , Citalopram/administração & dosagem , Estudos de Coortes , Transtorno Depressivo Maior/tratamento farmacológico , Progressão da Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Escalas de Graduação Psiquiátrica , Recidiva , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To compare within the framework of a novel pharmacopsychometric triangle, augmentation treatment with bupropion vs. buspirone in the acute therapy of major depression in the STAR*D study. The triangle provides a composite view in three domains of antidepressive activity, side effects, and quality of life. METHOD: Within the pharmacopsychometric triangle, the short six-item subscales of the Hamilton Depression Scale (HAM-D(17)) and of the Inventory of Depressive Symptomatology (IDS-C(30)), referred to as HAM-D(6) and IDS-C(6), were focussed on pure antidepressive effect. Side-effects (tolerable vs. intolerable) and quality of life were measured using patient-administered questionnaires. A modified intention to treat sample was used. RESULTS: Within the pharmacopsychometric triangle, bupropion-SR (sustained release) was superior to buspirone when augmented to the current citalopram treatment. Thus, in the domain of pure antidepressive effect, bupropion-SR was superior (P = 0.05) on the HAM-D(6), IDS-C(6), and IDS-C(30), but not on the HAM-D(17). In the domain of side effects, the total scores on the Patient Rated Inventory of Side Effects (PRISE) were reduced significantly more by bupropion-SR than by buspirone (P = 0.03). In the domain of quality of life, the total scores on the Quality of Life Enjoyment and Satisfaction Questionnaire (QLES-Q) showed a trend (P = 0.10) from baseline to endpoint of a superiority for bupropion-SR compared with buspirone. CONCLUSION: In all domains of the pharmacopsychometric triangle, bupropion-SR was superior to buspirone as augmentation therapy in depressed outpatients not responding to citalopram.
Assuntos
Ansiolíticos/uso terapêutico , Antidepressivos de Segunda Geração/uso terapêutico , Bupropiona/uso terapêutico , Buspirona/uso terapêutico , Citalopram/uso terapêutico , Transtorno Depressivo Maior/tratamento farmacológico , Adulto , Ansiolíticos/efeitos adversos , Antidepressivos de Segunda Geração/efeitos adversos , Bupropiona/efeitos adversos , Buspirona/efeitos adversos , Citalopram/efeitos adversos , Preparações de Ação Retardada/uso terapêutico , Transtorno Depressivo Maior/fisiopatologia , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Resultado do TratamentoRESUMO
Irritability is a diagnostic symptom of major depressive disorder (MDD) in children and adolescents but not in adults in both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and International Classification of Diseases (ICD-10) systems. We explore the importance of irritability for subtyping adult DSM-IV MDD in the National Comorbidity Survey Replication (NCS-R), a national US adult household survey. The WHO Composite International Diagnostic Interview (CIDI) was used to assess prevalence of many DSM-IV disorders in the lifetime and in the year before interview (12-month prevalence). MDD was assessed conventionally (that is, requiring either persistent sadness or loss of interest), but with irritability included as one of the Criterion A symptoms. We also considered the possibility that irritability might be a diagnostic symptom of adult MDD (that is, detect cases who had neither sad mood nor loss of interest). Twelve-month MDD symptom severity was assessed with the Quick Inventory of Depressive Symptomatology and role impairment with the Sheehan Disability Scale. After excluding bipolar spectrum disorders, irritability during depressive episodes was reported by roughly half of respondents with lifetime DSM-IV MDD. Irritability in the absence of either sad mood or loss of interest, in comparison, was rare. Irritability in MDD was associated with early age of onset, lifetime persistence, comorbidity with anxiety and impulse-control disorders, fatigue and self-reproach during episodes, and disability. Irritability was especially common in MDD among respondents in the age range 18-44 and students. Further investigation is warranted of distinct family aggregation, risk factors and treatment response. Consideration should also be given to including irritability as a nondiagnostic symptom of adult MDD in DSM-V and ICD-11.
Assuntos
Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/fisiopatologia , Humor Irritável/fisiologia , Adolescente , Adulto , Idoso , Distribuição de Qui-Quadrado , Comorbidade , Transtorno Depressivo Maior/diagnóstico , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Seguimentos , Inquéritos Epidemiológicos , Humanos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Prevalência , Índice de Gravidade de Doença , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Many patients with major depressive disorder (MDD) who experience full symptomatic remission after antidepressant treatment still have residual depressive symptoms. We describe the types and frequency of residual depressive symptoms and their relationship to subsequent depressive relapse after treatment with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. METHOD: Participants in primary (n=18) and psychiatric (n=23) practice settings were openly treated with citalopram using measurement-based care for up to 14 weeks and follow-up for up to 1 year. We assessed 943 (32.8% of 2876) participants who met criteria for remission to determine the proportions with individual residual symptoms and any of the nine DSM-IV criterion symptom domains to define a major depressive episode. At each visit, the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) and the self-report Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale were used to assessed depressive symptoms and side-effects respectively. RESULTS: More than 90% of remitters had at least one residual depressive symptom (median=3). The most common were weight increase (71.3%) and mid-nocturnal insomnia (54.9%). The most common residual symptom domains were sleep disturbance (71.7%) and appetite/weight disturbance (35.9%). Those who remitted before 6 weeks had fewer residual symptoms at study exit than did later remitters. Residual sleep disturbance did not predict relapse during follow-up. Having a greater number of residual symptom domains was associated with a higher probability of relapse. CONCLUSIONS: Patients with remission of MDD after treatment with citalopram continue to experience selected residual depressive symptoms, which increase the risk of relapse.
Assuntos
Antidepressivos de Segunda Geração/uso terapêutico , Citalopram/uso terapêutico , Transtorno Depressivo Maior/tratamento farmacológico , Adulto , Antidepressivos de Segunda Geração/efeitos adversos , Citalopram/efeitos adversos , Terapia Cognitivo-Comportamental , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/psicologia , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Inventário de Personalidade/estatística & dados numéricos , Psicometria , Recidiva , Fatores de Risco , Distúrbios do Início e da Manutenção do Sono/psicologia , Aumento de Peso , Adulto JovemRESUMO
BACKGROUND: Painful physical symptoms (PPS) are both common and reduce the likelihood of remission in major depressive disorder (MDD), based upon results of clinical trials in selected populations. Whether PPS significantly contribute to poorer treatment outcome overall in primary or specialty psychiatric care settings remains unclear. METHOD: Out-patients (n=2876) with MDD were treated in the first step of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial with citalopram up to 60 mg/day for up to 14 weeks. Presence of painful symptoms, as well as severity of depression, physical illness, and demographic and treatment factors were examined. Time to and overall rates of remission were analysed in relation to the presence of PPS. RESULTS: Of the participants, 80% complained of PPS. These patients, both in primary and specialty psychiatric settings, had significantly lower remission rates and took longer to remit. Increasing severity of PPS was associated with greater physical illness burden, lower socio-economic status, absence of private insurance and being female, African-American or Hispanic. After adjustment for these factors, patients with PPS no longer had significantly poorer treatment outcomes. CONCLUSIONS: Presence and severity of PPS is an indicator of MDD that may have poorer treatment outcome with an initial selective serotonin reuptake inhibitor. These poorer treatment outcomes are multifactorial, however, and are not explained by the presence and severity of pain per se.
Assuntos
Antidepressivos/uso terapêutico , Citalopram/uso terapêutico , Depressão/tratamento farmacológico , Depressão/epidemiologia , Dor/epidemiologia , Dor/fisiopatologia , Transtornos Somatoformes/epidemiologia , Transtornos Somatoformes/fisiopatologia , Adolescente , Adulto , Idoso , Efeitos Psicossociais da Doença , Depressão/diagnóstico , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/diagnóstico , Medição da Dor , Indução de Remissão , Índice de Gravidade de Doença , Fatores Socioeconômicos , Transtornos Somatoformes/diagnóstico , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Dyadic discord, while common in depression, has not been specifically evaluated as an outcome predictor in chronic major depressive disorder. This study investigated pretreatment dyadic discord as a predictor of non-remission and its relationship to depressive symptom change during acute treatment for chronic depression. METHOD: Out-patients with chronic depression were randomized to 12 weeks of treatment with nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy or their combination. Measures included the Marital Adjustment Scale (MAS) and the Inventory of Depressive Symptomatology - Self Report (IDS-SR30). Of 681 original patients, 316 were partnered and 171 of these completed a baseline and exit MAS, and at least one post-baseline IDS-SR30. MAS scores were analysed as continuous and categorical variables ('dyadic discord' v. 'no dyadic discord' defined as an MAS score >2.36. Remission was defined as an IDS-SR30 of 14 at exit (equivalent to a 17-item Hamilton Rating Scale for Depression of 7). RESULTS: Patients with dyadic discord at baseline had lower remission rates (34.1%) than those without dyadic discord (61.2%) (all three treatment groups) (chi2=12.6, df=1, p=0.0004). MAS scores improved significantly with each of the treatments, although the change was reduced by controlling for improvement in depression. Depression remission at exit was associated with less dyadic discord at exit than non-remission for all three groups [for total sample, 1.8 v. 2.4, t(169)=7.3, p<0.0001]. CONCLUSIONS: Dyadic discord in chronically depressed patients is predictive of a lower likelihood of remission of depression. Couple therapy for those with dyadic discord may increase remission rates.
Assuntos
Antidepressivos de Segunda Geração/uso terapêutico , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo Maior/terapia , Triazóis/uso terapêutico , Adolescente , Adulto , Idoso , Doença Crônica , Terapia Combinada/métodos , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/psicologia , Feminino , Humanos , Masculino , Casamento/psicologia , Casamento/estatística & dados numéricos , Pessoa de Meia-Idade , Piperazinas , Valor Preditivo dos Testes , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Indução de Remissão , Autorrevelação , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Attitudes and expectations about treatment have been associated with symptomatic outcomes, adherence and utilization in patients with psychiatric disorders. No measure of patients' anticipated benefits of treatment on domains of everyday functioning has previously been available. METHOD: The Anticipated Benefits of Care (ABC) is a new, 10-item questionnaire used to measure patient expectations about the impact of treatment on domains of everyday functioning. The ABC was collected at baseline in adult out-patients with major depressive disorder (MDD) (n=528), bipolar disorder (n=395) and schizophrenia (n=447) in the Texas Medication Algorithm Project (TMAP). Psychometric properties of the ABC were assessed, and the association of ABC scores with treatment response at 3 months was evaluated. RESULTS: Evaluation of the ABC's internal consistency yielded Cronbach's alpha of 0.90-0.92 for patients across disorders. Factor analysis showed that the ABC was unidimensional for all patients and for patients with each disorder. For patients with MDD, lower anticipated benefits of treatment was associated with less symptom improvement and lower odds of treatment response [odds ratio (OR) 0.72, 95% confidence interval (CI) 0.57-0.87, p=0.0011]. There was no association between ABC and symptom improvement or treatment response for patients with bipolar disorder or schizophrenia, possibly because these patients had modest benefits with treatment. CONCLUSIONS: The ABC is the first self-report that measures patient expectations about the benefits of treatment on everyday functioning, filling an important gap in available assessments of attitudes and expectations about treatment. The ABC is simple, easy to use, and has acceptable psychometric properties for use in research or clinical settings.
Assuntos
Transtorno Bipolar/tratamento farmacológico , Transtorno Depressivo Maior/tratamento farmacológico , Objetivos , Psicotrópicos/uso terapêutico , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Inquéritos e Questionários , Adaptação Psicológica , Adulto , Algoritmos , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/economia , Transtorno Bipolar/psicologia , Escalas de Graduação Psiquiátrica Breve/estatística & dados numéricos , Terapia Combinada , Análise Custo-Benefício , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/economia , Transtorno Depressivo Maior/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inventário de Personalidade/estatística & dados numéricos , Psicometria , Psicotrópicos/economia , Esquizofrenia/diagnóstico , Esquizofrenia/economia , Ajustamento Social , Resultado do TratamentoRESUMO
OBJECTIVE: In order to evaluate the presence of treatment emergent suicidal ideation (SI), it becomes necessary to identify those patients with SI at the onset of treatment. The purpose of this report is to identify sociodemographic and clinical features that are associated with SI in major depressive disorder (MDD) patients prior to treatment with a selective serotonin reuptake inhibitor. METHOD: This multisite study enrolled 265 out-patients with non-psychotic MDD. Sociodemographic and clinical features of participants with and without SI were compared post hoc. RESULTS: Social phobia, bulimia nervosa, number of past depressive episodes, and race were independently associated with SI by one or more SI measure. CONCLUSION: Concurrent social phobia and bulimia nervosa may be potential risk factors for SI in patients with non-psychotic MDD. Additionally, patients with more than one past depressive episode may also be at increased risk of SI.
Assuntos
Bulimia Nervosa/complicações , Transtorno Depressivo Maior , Transtornos Fóbicos/complicações , Inibidores Seletivos de Recaptação de Serotonina , Tentativa de Suicídio , Adulto , Idoso , Instituições de Assistência Ambulatorial , Antidepressivos/administração & dosagem , Antidepressivos/efeitos adversos , Bulimia Nervosa/diagnóstico , Pesquisa Comparativa da Efetividade , Demografia , Transtorno Depressivo Maior/complicações , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/psicologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Fóbicos/diagnóstico , Escalas de Graduação Psiquiátrica , Fatores de Risco , Prevenção Secundária , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Inibidores Seletivos de Recaptação de Serotonina/efeitos adversos , Ideação Suicida , Tentativa de Suicídio/prevenção & controle , Tentativa de Suicídio/psicologia , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To evaluate psychometric properties and comparability ability of the Montgomery-Asberg Depression Rating Scale (MADRS) vs. the Quick Inventory of Depressive Symptomatology-Clinician-rated (QIDS-C(16)) and Self-report (QIDS-SR(16)) scales to detect a current major depressive episode in the elderly. METHOD: Community and clinic subjects (age >or=60 years) were administered the Mini-International Neuropsychiatric Interview (MINI) for DSM-IV and three depression scales randomly. Statistics included classical test and Samejima item response theories, factor analyzes, and receiver operating characteristic methods. RESULTS: In 229 elderly patients (mean age = 73 years, 39% male, 54% current depression), all three scales were unidimensional and with nearly equal Cronbach alpha reliability (0.85-0.89). Each scale discriminated persons with major depression from the non-depressed, but the QIDS-C(16) was slightly more accurate. CONCLUSION: All three tests are valid for detecting geriatric major depression with the QIDS-C(16) being slightly better. Self-rated QIDS-SR(16) is recommended as a screening tool as it is least expensive and least time consuming.
Assuntos
Transtorno Depressivo Maior/diagnóstico , Determinação da Personalidade/estatística & dados numéricos , Inventário de Personalidade/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Transtorno Depressivo Maior/psicologia , Feminino , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Psicometria/estatística & dados numéricos , Curva ROC , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered. METHODS: A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic. RESULTS: The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive. LIMITATIONS: The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials. CONCLUSIONS: DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.
Assuntos
Depressão , Transtorno Depressivo Resistente a Tratamento , Consenso , Humanos , Psicoterapia , Qualidade de VidaRESUMO
The influence of genetic variations in SLC6A4 (serotonin transporter gene) on citalopram treatment of depression using the Sequenced Treatment to Relieve Depression (STAR*D) sample was assessed. Of primary interest were three previously studied polymorphisms: 1) the VNTR variation of the second intron, 2) the indel promoter polymorphism (5HTTLPR or SERT), and 3) a single nucleotide polymorphism (SNP) rs25531. Additionally, SLC6A4 was resequenced to identify new SNPs for exploratory analyses. DNA from 1914 subjects in the STAR*D study were genotyped for the intron 2 VNTR region, the indel promoter polymorphism, and rs25531. Associations of these variants with remission of depressive symptoms were evaluated following citalopram treatment. In white non-Hispanic subjects, variations in the intron 2 VNTR (point-wise P = 0.041) and the indel promoter polymorphism (point-wise P = 0.039) were associated with remission following treatment with citalopram. The haplotype composed of the three candidate loci was also associated with remission, with a global p-value of 0.040 and a maximum statistic simulation p-value of 0.0031 for the S-a-12 haplotype, under a dominant model. One SNP identified through re-sequencing the SLC6A4 gene, Intron7-83-TC, showed point-wise evidence of association, which did not remain significant after correction for the number of SNPs evaluated in this exploratory analysis. No associations between these SLC6A4 variations and remission were found in the white Hispanic or black subjects. These findings suggest that multiple variations in the SLC6A4 gene are associated with remission in white non-Hispanic depressed adults treated with citalopram. The mechanism of action of these variants remains to be determined.
Assuntos
Antidepressivos de Segunda Geração/uso terapêutico , Citalopram/uso terapêutico , Transtorno Depressivo Maior/genética , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Proteínas da Membrana Plasmática de Transporte de Serotonina/genética , Adulto , Negro ou Afro-Americano/genética , Alelos , Ensaios Clínicos como Assunto , Transtorno Depressivo Maior/tratamento farmacológico , Feminino , Frequência do Gene , Variação Genética , Haplótipos , Hispânico ou Latino/genética , Humanos , Íntrons , Desequilíbrio de Ligação , Masculino , Pessoa de Meia-Idade , Repetições Minissatélites , Polimorfismo de Nucleotídeo Único , Regiões Promotoras Genéticas , Indução de Remissão , Análise de Sequência de DNA , Resultado do Tratamento , População Branca/genéticaRESUMO
Antidepressants are important in the treatment of depression, and selective serotonin reuptake inhibitors are first-line pharmacologic options. However, only 50% to 70% of patients respond to first treatment and <40% remit. Since depression is associated with substantial morbidity, mortality, and family burden, it is unfortunate and demanding on health resources that patients must remain on their prescribed medications for at least 4 weeks without knowing whether the particular antidepressant will be effective. Studies have suggested a number of predictors of treatment response, including clinical, psychophysiological, neuroimaging, and genetics, each with varying degrees of success and nearly all with poor prognostic sensitivity and specificity. Studies are yet to be conducted that use multiple measures from these different domains to determine whether sensitivity and specificity can be improved to predict individual treatment response. It is proposed that a focus on standardized testing methodologies across multiple testing modalities and their integration will be crucial for translation of research findings into clinical practice.
Assuntos
Antidepressivos/uso terapêutico , Cognição/efeitos dos fármacos , Transtorno Depressivo/tratamento farmacológico , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Transtorno Depressivo/genética , Transtorno Depressivo/patologia , Predisposição Genética para Doença , Humanos , Imageamento por Ressonância Magnética/métodos , Prognóstico , Proteínas da Membrana Plasmática de Transporte de Serotonina/genética , Resultado do TratamentoRESUMO
A systematic review of the cases documented in the literature regarding Pleomorphic hyalinizing angiectatic tumor of soft parts (PHAT) was performed in order to identify (1) location on presentation (2) surgical treatment modality (3) recurrence rate (4) any associations between location, age, histology, surgery type on recurrence. A systematic review of medical literature listed on PubMed was conducted identifying any prior case report and/or case series of diagnosed PHAT, with no exclusion based on language or time. Twenty-nine articles were identified removing any articles with duplicated cases yielding a total of 93 cases. Cases were broken down by gender, presenting location (UE/LE/axial), surgery type [wide local resection, non-wide local, wide local with radiation therapy (RT), non-wide local with RT], recurrence, and time to recurrence. The mean age at presentation was 54.5 ± 17.1 (range 10-89) with the 76% of cases appearing in the lower extremity (15% UE, 9% Axial). Of the 93 patients, 74 had a known surgical procedure, 31% WL, 40% NWL, 8% WL + RT, 1% NWL + RT. Of those treated surgically, 63 pts had documented follow-up and 18 (29%) had recurrence. A strong association was observed between surgery type and recurrence. Local recurrence was more common within the group undergoing NWLE in 52% (16/41) of cases (p = 0.002). Kaplan-Meier analysis showed an estimate mean time for recurrence of 43.87 months [95% confidence interval (CI) 24.52-63.22; and standard error (SE) 7.59] for the entire population. A trend was also seen toward males having a shorter disease-free survival than females (29.4 mos. vs. 69.5 mos.). No significant association seen between size, location, histology type and recurrence. PHAT has a characteristic presentation in the LE with a relatively high rate of local recurrence and slow-growing potential. Wide local excision appears to be superior in decreasing recurrence rates and a long-term follow-up period is needed.
Assuntos
Neoplasias de Tecidos Moles/terapia , Distribuição por Idade , Terapia Combinada , Gerenciamento Clínico , Intervalo Livre de Doença , Seguimentos , Humanos , Recidiva Local de Neoplasia , Distribuição por Sexo , Neoplasias de Tecidos Moles/epidemiologia , Neoplasias de Tecidos Moles/radioterapia , Neoplasias de Tecidos Moles/cirurgia , Resultado do TratamentoRESUMO
Clinical practice guidelines for primary care providers that address the detection, diagnosis, and treatment of depression may have an impact on psychiatric practice as well as on general medical education and the research agenda. This commentary highlights the conceptual and scientific issues that surrounded the development of these guidelines and speculates on their potential practical impact, particularly on psychiatry.
Assuntos
Transtorno Depressivo , Guias de Prática Clínica como Assunto/normas , Psiquiatria/normas , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/terapia , Honorários e Preços , Humanos , Imperícia , Padrões de Prática Médica , Psiquiatria/educação , Pesquisa , Estados Unidos , United States Dept. of Health and Human ServicesRESUMO
Recognizing depression in brain-damaged patients poses considerable problems. The standard diagnostic criteria often are not applicable since the neurological lesion may distort or even obliterate salient features of depression. Patients actually may deny being depressed or dysphoric, not have a depressive affect, or be totally unaware of abnormal vegetative behaviors. Furthermore, brain lesions themselves may produce striking behavioral alterations that can be mistakenly attributed to depression, or striking behavioral changes due to depression may be mistakenly attributed to the brain lesion. Based on five case studies, several clinical guidelines for recognizing and diagnosing depression in brain-damaged patients are offered. These cases also provide a data base to generate initial hypotheses about the neuroanatomical basis of the depressive syndrome. By observing how focal brain lesions modify the signs and symptoms of depression, inferences are made about brain areas crucial for modulating the various features of the depressive syndrome.
Assuntos
Encefalopatias/complicações , Encéfalo/patologia , Transtorno Depressivo/etiologia , Afeto , Idoso , Afasia de Wernicke/complicações , Comportamento/fisiologia , Encéfalo/diagnóstico por imagem , Transtornos Cerebrovasculares/complicações , Cognição/fisiologia , Traumatismos Craniocerebrais/complicações , Transtorno Depressivo/diagnóstico , Dexametasona , Feminino , Humanos , Lobo Temporal/patologia , Tomografia Computadorizada por Raios X , Comportamento Verbal/fisiologiaRESUMO
Using a controlled, clinical-trial format, 44 nonpsychotic, nonbipolar, depressed outpatients were treated with cognitive therapy or imipramine hydrochloride over a 12-week period. Although both interventions were associated with significant reductions in levels of depression, the cognitive-therapy patients showed greater symptomatic improvement and a higher treatment-completion rate. A one-year naturalistic follow-up of the 35 subjects who completed the protocol revealed that although many of the patients had a variable clinical course, both original treatment groups remained generally well. Self-rated depressive symptomatology was significantly lower for those who, one year earlier, had completed cognitive therapy than for those who had been in the clinical trial's pharmacotherapy cell. While there were several other interesting trends in favor of the cognitive-therapy patients, none of the between-group differences were significant. The pragmatic and clinical implications of the followup results are discussed.