Sensitivity to changes during antidepressant treatment: a comparison of unidimensional subscales of the Inventory of Depressive Symptomatology (IDS-C) and the Hamilton Depression Rating Scale (HAMD) in patients with mild major, minor or subsyndromal depression.

In the efficacy evaluation of antidepressant treatments, the total score of the Hamilton Depression Rating Scale (HAMD) is still regarded as the 'gold standard'. We previously had shown that the Inventory of Depressive Symptomatology (IDS) was more sensitive to detect depressive symptom changes than the HAMD17 (Helmreich et al. 2011). Furthermore, studies suggest that the unidimensional subscales of the HAMD, which capture the core depressive symptoms, outperform the full HAMD regarding the detection of antidepressant treatment effects. The aim of the present study was to compare several unidimensional subscales of the HAMD and the IDS regarding their sensitivity to changes in depression symptoms in a sample of patients with mild major, minor or subsyndromal depression (MIND). Biweekly IDS-C28 and HAMD17 data from 287 patients of a 10-week randomised, placebo-controlled trial comparing the effectiveness of sertraline and cognitive-behavioural group therapy in patients with MIND were converted to subscale scores and analysed during the antidepressant treatment course. We investigated sensitivity to depressive change for all scales from assessment-to-assessment, in relation to depression severity level and placebo-verum differences. The subscales performed similarly during the treatment course, with slight advantages for some subscales in detecting treatment effects depending on the treatment modality and on the items included. Most changes in depressive symptomatology were detected by the IDS short scale, but regarding the effect sizes, it performed worse than most subscales. Unidimensional subscales are a time- and cost-saving option in judging drug therapy outcomes, especially in antidepressant treatment efficacy studies. However, subscales do not cover all facets of depression (e.g. atypical symptoms, sleep disturbances), which might be important for comprehensively understanding the nature of the disease depression. Therefore, the cost-to-benefit ratio must be carefully assessed in the decision for using unidimensional subscales.

Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients' choice arm.

BACKGROUND: Little is known about the influence of depressed patients' preferences and expectations about treatments upon treatment outcome. We investigated whether better clinical outcome in depressed primary care patients is associated with receiving their preferred treatment. METHODS: Within a randomized placebo-controlled single-centre 10-week trial with 5 arms (sertraline; placebo; cognitive-behavioral group therapy, CBT-G; moderated self-help group control; treatment with sertraline or CBT-G according to patients' choice), outcomes for 145 primary care patients with mild-to-moderate depressive disorders according to DSM-IV criteria were investigated. Preference for medication versus psychotherapy was assessed at screening using a single item. Post-baseline difference scores for the Hamilton Depression Rating Scale (HAMD-17) were used to assess treatment outcome (mixed-model repeated-measures regression analysis). RESULTS: Depressed patients receiving their preferred treatment (n = 63), whether sertraline or CBT-G, responded significantly better than those who did not receive their preferred therapy (n = 54; p = 0.001). The difference in outcome between both groups was 8.0 points on the HAMD-17 for psychotherapy and 2.9 points on the HAMD-17 for treatment with antidepressants. Results were not explained by differences in depression severity or dropout rates. CONCLUSIONS: Patients' relative preference for medication versus psychotherapy should be considered when offering a treatment because receiving the preferred treatment conveys an additional and clinically relevant benefit (HAMD-17: +2.9 points for drugs; +8.0 points for CBT-G) in outcome.

The Inventory Of Depressive Symptomatology (IDS-C(28)) is more sensitive to changes in depressive symptomatology than the Hamilton Depression Rating Scale (HAMD(17)) in patients with mild major, minor or subsyndromal depression.

Depression rating scales play a decisive role in the assessment of the severity of depression and the evaluation of the efficacy of antidepressant treatments. The Hamilton Depression Rating Scale (HAMD) is regarded as the 'gold standard'; nevertheless, studies suggest that the Inventory of Depressive Symptomatology (IDS) is more sensitive to detect symptom changes. The aim of the present study was to investigate whether the IDS is more sensitive in detecting changes in depression symptoms in patients with mild major, minor or subsyndromal depression (MIND). Biweekly IDS-C(28) and HAMD(17) data from 340 patients of a 10-week randomized, placebo-controlled trial comparing the effectiveness of sertraline and cognitive-behavioural therapy in patients with MIND were analysed. We investigated sensitivity to change for both scales (1) from assessment-to-assessment, (2) in relation to depression severity level, and (3) in relation to DSM-IV depression criterion symptoms. The IDS-C(28) was more sensitive in detecting changes in depression symptomatology over the treatment course as well as for different severity levels, especially in patients with a low depression severity. It assesses the DSM-IV criteria more thoroughly, is better able to track the change of cognitive symptoms and to identify residual symptoms. Both scales are well able to assess depressive symptomatology. However, the IDS-C(28) surpasses the HAMD(17) in detecting small changes especially in the core symptoms of depression. This is important for an optimal treatment by capturing early improvements, enabling prompt reactions and detecting residual symptoms.

Effects of pharmacotherapy and psychotherapy in depressed primary-care patients: a randomized, controlled trial including a patients' choice arm.

Mild depressive syndromes are highly prevalent among primary-care patients. Evidence-based treatment recommendations need to be derived directly from this diagnostically heterogeneous group. The primary aim was to assess the efficacy of sertraline and cognitive-behavioural group therapy for treatment of depressed primary-care patients, the secondary aim was to evaluate if receiving treatment according to free choice is associated with a better outcome than randomization to a particular treatment. We conducted a randomized, placebo-controlled, single-centre, 10-wk trial with five arms: sertraline (flexible dosages up to 200 mg/d) (n = 83); placebo (n = 83); manual-guided cognitive-behavioural group therapy (one individual session and nine group sessions per 90 min) (n = 61); guided self-help group (control condition, n = 59); and treatment with sertraline or cognitive-behavioural group therapy according to patients' choice (n = 82). From 1099 consecutively screened adult patients, 368 formed the intent-to-treat population with milder forms of depression. Primary outcome was a global efficacy measure combining z-converted Hamilton Depression Rating Scale and clinician-rated Inventory for Depressive Symptomatology scores. Sertraline was superior to placebo (p = 0.03). Outcome for guided self-help groups was worse compared to cognitive-behavioural group therapy (p = 0.002) and compared to all other treatment arms including pill placebo (secondary analyses). Outcome in the patients' choice arm was similar to that in the sertraline and cognitive-behavioural group therapy. Overall, sertraline is efficacious in primary-care patients with milder forms of depression. The superiority of cognitive-behavioural group therapy over guided self-help groups might partly be explained by 'nocebo' effects of the latter.

A 12-month-old boy with a localized verrucous tumor.

A 12-month-old boy was admitted suffering from a localized pad-like thickening of tissue affecting the area of his right hand joint. First affection of skin was detected at age of 6 months, when a red macula was noted. The parents were now afraid of a viral or malignant disorder. The lesion completely resolved by the second birthday without medical intervention.

The controversial link between antidepressants and suicidality risks in adults: data from a naturalistic study on a large sample of in-patients with a major depressive episode.

Some meta-analyses of randomized placebo-controlled trials on antidepressants conclude that there might be an increased risk for suicidal behaviour, especially in children and adolescents but also in adults. Placebo-controlled trials exclude patients with serious suicidality and might therefore underestimate the risk of respective adverse events. The change of suicidal ideation and the prevalence of suicides and non-fatal suicide attempts were therefore analysed in a large naturalistic prospective multicentre study of depressed in-patients. Additionally, specific risk factors for new emergence of suicidal ideation were investigated. The naturalistic prospective study was performed in 12 psychiatric hospitals of the German research network on depression and suicidality (seven psychiatric university hospitals and five district hospitals) in Germany. All patients (n=1014) were hospitalized and had to meet DSM-IV criteria for major depressive disorder. Six events were defined for the purposes of statistical analysis: 'emergence', 'extended emergence', 'improvement' and 'worsening of suicidal ideation', 'suicide attempts' and 'suicides'. Logistic regression analysis and classification and regression trees (CART) analyses were conducted to determine specific risk factors for new emergence of suicidal ideation. The mean HAMD total score decreased from 24.8 at baseline to 10 after 10 wk. An effect on suicidality was evident by week 2 in the sense of a decrease of the mean HAMD item-3 score. Emergence, worsening and improvement of suicidal ideation occurred in 3.2%, 14.74% and 90.79% of patients, respectively. A total of 10 suicide attempts and two suicides were reported. The rate of suicides (13.44/1000 patient-years) was rather low and comparable to the rate observed in randomized controlled antidepressant trials. Five risk factors for emergence of suicidal ideation were determined with two independent statistical methods: age (with higher risk at age <45 yr), treatment resistance, number of hospitalizations, presence of akathisia and comorbid personality disorder. Age <45 yr as one of five risk factors for the emergence of suicidal ideation is in line with the meta-analysis performed for the recent US Food & Drug Administration (FDA) memorandum; although the naturalistic study design does not permit definite conclusions to be made about certain compounds. The rate of suicides was comparable to that seen in randomized controlled trials, as were the rates of emergence and worsening of suicidal ideation, but more improvement was found. Thus, in-patient treatment in a psychiatric care setting, including daily assessments of suicidality by trained psychiatrists adhering to the rules of good clinical practice (e.g. use of specific co-medications, supportive psychotherapy and continuous medical attendance by nursing staff) might be beneficial.

The US FDA 'black box' warning for topical calcineurin inhibitors: an ongoing controversy.

Atopic dermatitis is a chronic inflammatory skin disease characterized by recurrent intense pruritus and a distinctive distribution of skin lesions. The topical calcineurin inhibitors tacrolimus and pimecrolimus were approved in the USA, as an ointment and a cream, respectively, for the treatment of atopic dermatitis in 2000 and 2001, respectively. In 2005, the Pediatric Advisory Committee of the US FDA implemented a 'black box' warning for tacrolimus ointment and pimecrolimus cream due to the lack of long-term safety data and the potential risk of the development of malignancies. This article focuses on the safety aspects of these agents by discussing the findings from preclinical and clinical studies and postmarketing reports with regard to malignancies occurring after the use of tacrolimus ointment and pimecrolimus cream.

Atypical symptoms in hospitalised patients with major depressive episode: frequency, clinical characteristics, and internal validity.

OBJECTIVE: The objective was (1) to assess the frequency of atypical depression (AD) in depressed inpatients; (2) to compare clinical features of patients with atypical and nonatypical depression (Non-AD) (3) to evaluate the meaning of single psychopathological symptoms with special respect to mood reactivity. METHOD: Diagnoses of 1073 inpatients were assessed according to DSM-IV using SCID (Structured Clinical Interview for the DSM-IV) and AMDP (Association for Methodology and Documentation). Diagnosis of atypical depression was defined according to criteria of the DSM-IV specifier for AD. All patients were rated using HAMD-21 (Hamilton Depression Scale). RESULTS: A high percentage of patients met criteria for AD (15.3%, 95% CI 13.0-17.9%). Women were more likely to suffer from AD (OR=1.54, p=0.037). There were no significant differences between AD and Non-AD patients regarding age, HAMD total baseline score, and diagnosis of any bipolar illness. In terms of psychopathology patients with AD were significantly more likely to suffer from somatic anxiety, somatic symptoms, guilt, genital symptoms, depersonalisation and suspiciousness as defined by HAMD-21 items. Interestingly, mood reactivity was not found to be significantly associated with the presence of two or more additional symptoms of AD. LIMITATIONS: Results were assessed by a post-hoc analysis, based on prospectively collected data. Compared to other inpatient samples with MDE, prevalence of bipolar disorder was rather low. CONCLUSION: (1) Frequency of AD may be underestimated, especially in inpatient samples. Further studies of inpatient samples are recommended. (2) Quality of distinct anxiety symptoms may be different in both groups, with AD patients being more likely to suffer from somatic symptoms and somatic anxiety. The presence of suspiciousness and even paranoid phenomena may not exclude a diagnosis of AD, but may be related to rejection sensitivity. (3) The mandatory presence of mood reactivity for the diagnosis of AD needs further consideration, regarding its validity for the concept.

Lost needle: a simple search device for the operating room's floor.

BACKGROUND/AIMS: Needle-stick injuries provide a substantial threat in regard to health of victims and may cause extra costs to health systems. MATERIALS AND METHODS: We report on simple strategies to prevent a needle-stick injury by analysing search devices which can detect a lost needle. RESULTS: A magnetic device enables the surgeon as well as other staff members working in the operating room to locate a lost needle on the floor rapidly. For search in body cavities, X-ray examination is recommended. CONCLUSION: With simple methods, a lost needle can be found easily to prevent any harm for others in the future.

[Speed of onset of depressive episodes: a clinical criterion helpful for separating uni- from bipolar affective disorders]. / Geschwindigkeit des Depressionsbeginns: Ein Unterscheidungsmerkmal hinsichtlich uni- versus bipolarer affektiver Störungen.

OBJECTIVE: Depressive episodes can begin abruptly or start very slowly (over weeks). This relevant clinical feature of affective disorders has not been systematically investigated so far. The aim of this study was to analyze speed of onset of depressive episodes in patients with unipolar depression (UD) and bipolar affective disorders (BD). METHODS: 158 adult patients with UD (N = 108) and BD (N = 50) were examined using the structured "Onset-of-Depression Inventory". Only patients without acute critical life events preceding the onset were included in the study. RESULTS: There was a significant positive correlation between speed of onset of the present and that of the preceding depressive episode (rho = 0.66; p < 0.001). The association between speed of onset and speed of decay of depressive episodes failed to be significant (rho = 0.20; p = 0.09). Patients with bipolar disorder were found to develop depressive episodes significantly faster than patients with major depression (p < 0.001): Whereas depressive episodes started in 58% of patients with bipolar disorder within one week, this was only the case in 7.4% of patients with major depression. CONCLUSIONS: Within subjects, the speed of onset of depression is similar across different episodes. In the absence of acute critical life events, rapid onset of depressive episodes (within one week) is typical for bipolar depression, but not for unipolar depression. A rapid onset of depressive episodes might point to BD in patients with solely depressive episodes in the past and to subgroups with different neurobiological pathogenetic mechanisms.

One-year follow-up of a randomized controlled trial of sertraline and cognitive behavior group therapy in depressed primary care patients (MIND study).

BACKGROUND: The long-term course of symptoms in patients with mild-to-moderate depression is not well understood. A 12-month-follow-up analysis was performed on those participants from a randomized controlled 10-week trial (RCT, MIND-study), who had received either treatment with an antidepressant (sertraline) or a psychotherapeutic intervention (group cognitive-behavioral therapy (CBT)). METHODS: The longitudinal interval follow-up evaluation (LIFE) was applied to 77 patients with mild-to moderate depression. The primary outcome was the number of weeks in the one-year follow-up period spent completely recovered from all depressive symptoms. Functional outcome was measured with the Global Assessment of Functioning (GAF) scale. Further outcomes were relapse and remission rates based on weekly psychiatric rating scales (PSR) and the number of weeks in the follow-up period during which patients had a depressive disorder or subthreshold symptoms of depression. RESULTS: Patients with acute treatment (10 weeks) with SSRI and those with acute treatment with CBT (also 10 weeks) did not differ significantly concerning the number of weeks in the follow-up period in which they were completely recovered (primary outcome) (SSRI: 31.6 weeks (standard deviation (SD): 23.7), CBT: 27.8 weeks (SD: 24.3)). Sertraline was superior to CBT regarding GAF scores by trend (p = 0.06). LIMITATIONS: The generalizability of the findings is limited by the moderate sample size and missing values (LIFE). CONCLUSIONS: Sertraline and group CBT have similar anti-depressive effects in the long-term course of mild-to-moderate depression. Regarding long-term global functioning, sertraline seems to be slightly superior to CBT.

Fabry disease: case report with emphasis on enzyme replacement therapy and possible future therapeutic options.

A 38-year-old male Caucasian with Fabry disease presented with angiokeratomas and tortuous conjunctival and retinal vessels. Additionally, the patient showed characteristic skin lesions of psoriasis and seborrheic dermatitis. His past medical history revealed anhidrosis, acral paresthesias, myocardial infarction, phlebothrombosis, hypertension, antithrombin III deficiency, factor V Leiden disease, chronic obstructive lung disease, tinnitus, diarrhea, recurrent abdominal pain, headache, and depressive mood. He was treated with intravenous substitution of the deficient enzyme alpha-galactosidase A. Possible future options in treatment of Fabry disease are discussed.

Treatment of depression with atypical features: a meta-analytic approach.

The present meta-analysis addressed the empirical evidence regarding the treatment of major depression with atypical features. The superiority of monoamine oxidase inhibitors (MAOIs) compared with other antidepressants in the treatment of major depression with atypical features has been frequently reported. According to the CONSORT Statement, studies included in our meta-analysis had to meet several criteria, especially a double-blind, controlled condition and an operational diagnosis according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-III or DSM-IV criteria, respectively. Four databases for research-based evidence were used in a systematic review: Medline, Embase, Psyndex and PsycInfo. Only eight publications met inclusion/exclusion criteria, resulting in 11 comparisons. Our results contrast an effect size of 0.45 (95% confidence interval) for a comparison of MAOIs vs. placebo with an effect size of 0.02 (95% confidence interval: - 0.10-0.14) for a comparison of MAOIs vs. selective serotonin reuptake inhibitors. The effect size for MAOIs vs. tricyclic antidepressants was 0.27 (95% confidence interval: 0.16-0.42). MAOIs may be more effective for atypical major depressive disorder than tricyclic antidepressants. Most clinical research has been conducted on irreversible MAOIs. Additional studies testing more recently developed antidepressants (including reversible MAOIs) with an improved safety profile would be warranted. The available data are insufficient for a direct comparison between MAOIs and selective serotonin reuptake inhibitors.

Differential effects of reboxetine and citalopram on hand-motor function in patients suffering from major depression.

RATIONALE: Motor dysfunctions might be a more common side effect of serotonergic than noradrenergic antidepressants. However, the effects of antidepressants on motor function in depression have rarely been analyzed systematically. Computerized methods allow the objective registration of drug-induced motor dysfunction and were applied in this study. OBJECTIVES: To examine the effects of a selective noradrenaline re-uptake inhibitor (NARI) (reboxetine) and a selective serotonin re-uptake inhibitor (SSRI) (citalopram) on hand-motor function in patients with major depression. METHODS: Different types of hand movements (drawing of circles and handwriting probes) were recorded and analyzed in 16 acutely depressed inpatients receiving citalopram (30-60 mg/day) and 12 acutely depressed inpatients treated with reboxetine (4-8 mg/day), using a digitizing tablet for the analysis of movement dynamics. Both groups were comparable regarding mean age (42-43 years), gender, handedness (preponderance of right-handers) and the mean baseline HAMD score (about 27). Five kinematical parameters reflecting velocity, regularity and degree of automation of hand movements have been computed. RESULTS: Reboxetine had significantly more favorable effects on fine motor function (increased velocity of rapid hand movements) in depressed patients than citalopram. These differences became obvious when patients conducted more complex tasks and are not explained by differential antidepressant effects. CONCLUSIONS: Our findings are in line with the hypothesis that SSRI tend to have small, but more pronounced negative effects on motor function than NARI.

Depression with atypical features in a sample of primary care outpatients: prevalence, specific characteristics and consequences.

BACKGROUND: In the context of the current debate on the clinical relevance of atypical depression, the present study investigated the prevalence and specific characteristics of the disorder in depressed primary care outpatients and compared patients with atypical and with the prototypical form of depression ("non-atypical" depression). METHODS: 403 patients were examined using the Composite International Diagnostic Interview, Inventory of Depressive Symptomatology, Hamilton Depression Scale and DSM-IV criteria. Configurational frequency analyses (CFA) were conducted to identify non-random configurations of symptoms. Moreover, tests for independent sample comparisons were applied. RESULTS: The prevalence of atypical depression in our sample of depressed patients was 26.3%. CFA revealed one significant symptom pattern: mood reactivity without additional atypical features (p<0.000001). A significant difference emerged between patients suffering from atypical versus non-atypical depression in terms of severity (p< or =0.001). LIMITATIONS: The sample size was modest. CONCLUSIONS: A considerable proportion of depressed primary care outpatients may suffer from atypical depression which may contribute to under-recognition of depression in primary care. Results of CFA indicated the significance of mood reactivity which may also occur in depressed patients without additional atypical symptoms. Patients with atypical depression may suffer from less severe depression as compared to patients with non-atypical depression.

Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups.

Heterogeneity of performance of screening tools in different patient groups has rarely been considered in the literature on depression screening in primary care. The objectives of the present study were to assess and to compare diagnostic accuracy of three screening questionnaires (Brief Patient Health Questionnaire, General Health Questionnaire-12, WHO-5) in identifying depression across various patient subpopulations and to assess the accuracy of the unaided clinical assessment of primary care physicians in the same subgroups. We conducted a cross-sectional validation study in 448 primary care patients. Two-by-two tables as well as receiver operating characteristics were applied. Results indicated that diagnostic accuracy (sensitivity, specificity) of the three screening instruments as well as of the clinical diagnoses differed in the various patient groups. Superiority of one screening tool over the other depends on the subgroup considered. Gender, age, form (subtype), and severity of depression influence the test characteristics of a screening tool. This should be considered if routine depression screening should be widely introduced. Of course, the benefit of routine screening also depends on efforts made for treatment and monitoring of patients in whom depression was diagnosed.

Can effects of antidepressants in patients with mild depression be considered as clinically significant?

BACKGROUND: How to define clinical significance of antidepressants has become a matter of far-reaching clinical and regulatory consequences. A mean difference of at least 3 points on the Hamilton Depression Rating Scale (HAMD-17) between active treatment and placebo has been proposed as cut-off score for clinical significance in antidepressant trials. OBJECTIVE: We aimed to present arguments that this, and other commonly used related approaches to establish clinical significance are likely to be misleading and risky depriving patients with mild depression of efficient treatments. METHODS: These problems are exemplified with the data from a randomized placebo-controlled five-arm clinical trial with primary care patients with milder depressive syndromes (MIND-study). RESULTS AND CONCLUSIONS: Designs for studying clinical significance have to be distinguished from those assessing efficacy. Moreover, evaluation of the clinical significance of psychotherapy as a possible alternative to antidepressants faces the problem of how to define a valid control group where blinding of neither therapists nor patients is possible.

Study design features affecting outcome in antidepressant trials.

BACKGROUND: A key issue in the approval process of antidepressants is the inconsistency of results between antidepressant clinical phase III trials. Identifying factors influencing efficacy data is needed to facilitate interpretation of the results. METHODS: We reviewed data packages submitted as new drug applications to Swissmedic focusing on pivotal, short-term antidepressant trials. Included studies used HAMD-17 or HAMD-21 as primary measures and enrolled patients aged 18-65 years with a diagnosis of major depression. Due to the hierarchical structure of the data a mixed-effect regression model has been applied with responder rates as primary outcome criterion. Random intercepts were estimated for the different trials, while study design factors were assigned as explanatory fixed effects. RESULTS: The final dataset was based upon 35 study reports with a total of N=10,835 patients. Significant results were found for study arm (placebo vs. active compound, p<0.001), sample size (p=0.002), duration of treatment (p=0.024), two or more active treatment arms (p=0.022) and the individual drug (p=0.029). Furthermore, a tendency to an association with the outcome was observed for baseline disease severity (p=0.077) and possibility of dosing adaptation (p=0.076). LIMITATIONS: Due to strict confidentiality agreements, individual drugs are not reported here. Further research should consider additional variables that might have an impact on the results of antidepressant trials. CONCLUSIONS: Efficacy data in antidepressant trials is significantly affected by various factors. These factors and their potentially confounding role have to be considered in the interpretation of the results.

Clinical predictors of response and remission in inpatients with depressive syndromes.

BACKGROUND: Most predictor analyses search for single predictors or rely on data from randomized controlled trials. We aimed at detecting a set of clinical baseline variables for prediction of response and remission in 1014 naturalistically treated inpatients with major depressive episode treated for 53.62 ± 47.5 days. METHODS: A three-staged procedure was implemented. First, univariate tests were used for finding associations with baseline variables. Second, logistic regression and third-CART analyses were used to determine predictors of response to inpatient treatment. RESULTS: Presence of suicidality, a higher initial HAMD-21 total score, an episode length <24 months, fewer previous hospitalizations, and absence of any ICD-10F4 comorbidity predicted response in 2 different statistical models. Remission was predicted by lower HAMD-21 baseline score, episode length <24 months and fewer previous hospitalizations in both models. LIMITATION: Results were assessed by a post-hoc analysis, based on prospectively collected data. No controlled study design. CONCLUSION: Contrary to current beliefs, baseline suicidality might be associated with higher chances for response. In addition, baseline severity might impact outcome depending on which criterion (remission or response) used.