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3.
Medicine (Baltimore) ; 99(47): e23199, 2020 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-33217832

RESUMO

BACKGROUND: Major depression disorder (MDD) is a severe health threat characterized by persistent depression, loss of interests, lack of initiative, and even suicidal tendencies. Traditional Chinese medicine (TCM) is well tolerated and effective in treating adult MDD. However, research on the evaluation of efficacy and acceptability of different TCM strategies for adult MDD is insufficient. Consequently, it is high time to evaluate the efficacy of TCM strategies for adult MDD. Meanwhile, the acceptability of different TCM strategies is worth exploring. METHODS: Comprehensively and systematically retrieve the literature in PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure Database (CNKI), Wanfang Database, China Science and Technology Journal Database (VIP), and Chinese BioMedical Literature Database (CBM). The literature search will focus on randomized controlled trials (RCTs) with TCM in adult MDD. Two reviewers will search the literature and extract relevant data back-to-back. Once mismatched outcomes appear, arbitration will be conducted by a third reviewer. Based on the Bayesian framework, data analysis is carried out with STATA and WinBUGS software. Heterogeneity, transitivity, consistency test, bias risk assessment, subgroup and sensitivity analysis, evidence quality evaluation will be performed accordingly. RESULTS: The efficacy and acceptability of different TCM strategies for adults with MDD will be compared and sorted. CONCLUSION: The study will facilitate the treatment options of adults MDD according to the supporting evidence. INPLASY REGISTRATION NUMBER: INPLASY2020100028.


Assuntos
Transtorno Depressivo Maior/terapia , Medicina Tradicional Chinesa/métodos , Aceitação pelo Paciente de Cuidados de Saúde , Adulto , Pesquisa Comparativa da Efetividade , Humanos , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Revisões Sistemáticas como Assunto
4.
Lancet Psychiatry ; 7(12): 1075-1080, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33129374

RESUMO

Major depressive disorder is a common and debilitating disorder. Although most patients with this disorder benefit from established treatments, a subset of patients have symptoms that remain treatment resistant. Novel treatment approaches, such as deep brain stimulation, are urgently needed for patients with treatment-resistant major depressive disorder. These novel treatments are currently being tested in clinical trials in which success hinges on how accurately and comprehensively the primary outcome measure captures the treatment effect. In this Personal View, we argue that current measures used to assess outcomes in neurosurgical trials of major depressive disorder might be missing clinically important treatment effects. A crucial problem of continuing to use suboptimal outcome measures is that true signals of efficacy might be missed, thereby disqualifying potentially effective treatments. We argue that a re-evaluation of how outcomes are measured in these trials is much overdue and describe several novel approaches that attempt to better capture meaningful change.


Assuntos
Transtorno Depressivo Maior/terapia , Terapia por Estimulação Elétrica/métodos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
5.
Artigo em Inglês | MEDLINE | ID: mdl-33153062

RESUMO

Background: A large number of low-intensity Internet-based interventions (IBIs) for the treatment of depression have emerged in Primary Care; most of them focused on decreasing negative emotions. However, recent studies have highlighted the importance of addressing positive affect (PA) as well. This study is a secondary analysis of a randomized control trial. We examine the role of an IBI focused on promoting PA in patients with depression in Primary Care (PC). The specific objectives were to explore the profile of the patients who benefit the most and to analyze the change mechanisms that predict a significantly greater improvement in positive functioning measures. Methods: 56 patients were included. Measures of depression, affect, well-being, health-related quality of life, and health status were administered. Results: Participants who benefited the most were those who had lower incomes and education levels and worse mental health scores and well-being at baseline (7.9%-39.5% of explained variance). Improvements in depression severity and PA were significant predictors of long-term change in well-being, F (3,55) = 17.78, p < 0.001, R2 = 47.8%. Conclusions: This study highlights the importance of implementing IBIs in PC and the relevance of PA as a key target in Major Depressive Disorder treatment.


Assuntos
Depressão , Transtorno Depressivo Maior , Intervenção Baseada em Internet , Adulto , Afeto , Depressão/terapia , Transtorno Depressivo Maior/terapia , Expressão Facial , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Qualidade de Vida , Resultado do Tratamento
6.
Adv Mind Body Med ; 34(4): 24-32, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33186128

RESUMO

Background: This case illustrates the relationship between gut, hormonal, and brain function in that dietary changes, mindfulness interventions, and detoxification led to resolution of disabling psychiatric symptoms and protracted psychotropic medication withdrawal symptoms. Summary: A 50-year-old partnered, unemployed, Caucasian female with a history of major depressive disorder, multiple suicide attempts, extensive trauma and abuse, and substance abuse presented for outpatient management. The patient reported limited benefit from over two decades of conventional treatment with psychotropic medications. She presented with depression and symptoms of protracted withdrawal after self-discontinuation of multiple psychiatric medications and was prescribed a dietary, detoxification, and supplementation regimen by the primary author. Additional lifestyle interventions implemented included daily meditation, dry-skin brushing, and coffee enemas. Conclusion: This case exemplifies dramatic clinical remission after cessation of medication treatment and engagement of lifestyle interventions, which include dietary change, meditation, and detoxification. As such, when limited results are achieved by psychotropic medication, tapering combined with dietary interventions as the first-line therapy should be considered. This case is also evidence of the role of lifestyle interventions in treating protracted withdrawal symptoms associated with discontinuing psychotropic medications.


Assuntos
Depressão/psicologia , Transtorno Depressivo Maior/terapia , Estilo de Vida , Transtornos Relacionados ao Uso de Substâncias/terapia , Antidepressivos/uso terapêutico , Feminino , Humanos , Pessoa de Meia-Idade , Tentativa de Suicídio , Resultado do Tratamento
7.
Sci Rep ; 10(1): 17057, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33051528

RESUMO

Electroconvulsive therapy (ECT) is a highly effective neuromodulatory intervention for treatment-resistant major depressive disorder (MDD). Presently, however, understanding of its neurophysiological effects remains incomplete. In the present study, we utilised resting-state electroencephalography (RS-EEG) to explore changes in functional connectivity, network topology, and spectral power elicited by an acute open-label course of ECT in a cohort of 23 patients with treatment-resistant MDD. RS-EEG was recorded prior to commencement of ECT and again within 48 h following each patient's final treatment session. Our results show that ECT was able to enhance connectivity within lower (delta and theta) frequency bands across subnetworks largely confined to fronto-central channels, while, conversely, more widespread subnetworks of reduced connectivity emerged within faster (alpha and beta) bands following treatment. Graph-based topological analyses revealed changes in measures of functional segregation (clustering coefficient), integration (characteristic path length), and small-world architecture following ECT. Finally, post-treatment enhancement of delta and theta spectral power was observed, which showed a positive association with the number of ECT sessions received. Overall, our findings indicate that RS-EEG can provide a sensitive measure of dynamic neural activity following ECT and highlight network-based analyses as a promising avenue for furthering mechanistic understanding of the effects of convulsive therapies.


Assuntos
Transtorno Depressivo Maior/fisiopatologia , Eletroconvulsoterapia/métodos , Rede Nervosa/fisiologia , Adulto , Encéfalo/fisiopatologia , Estudos de Coortes , Conectoma/métodos , Transtorno Depressivo Maior/metabolismo , Transtorno Depressivo Maior/terapia , Eletroencefalografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Descanso/fisiologia , Resultado do Tratamento
8.
JAMA Netw Open ; 3(10): e2019854, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33030552

RESUMO

Importance: Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. Objective: To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. Design, Setting, and Participants: This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Exposures: Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Main Outcomes and Measures: Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. Results: The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). Conclusions and Relevance: This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.


Assuntos
Transtorno Bipolar/economia , Dedutíveis e Cosseguros/estatística & dados numéricos , Transtorno Depressivo Maior/economia , Financiamento Pessoal/estatística & dados numéricos , Medicare/economia , Esquizofrenia/economia , Adulto , Idoso , Transtorno Bipolar/terapia , Estudos de Coortes , Custo Compartilhado de Seguro/estatística & dados numéricos , Transtorno Depressivo Maior/terapia , Feminino , Humanos , Renda/estatística & dados numéricos , Benefícios do Seguro/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Esquizofrenia/terapia , Estados Unidos
9.
Cochrane Database Syst Rev ; 10: CD006237, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33052607

RESUMO

BACKGROUND: Work disability such as sickness absence is common in people with depression. OBJECTIVES: To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders. SEARCH METHODS: We searched CENTRAL (The Cochrane Library), MEDLINE, Embase, CINAHL, and PsycINFO until April 4th 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-RCTs of work-directed and clinical interventions for depressed people that included days of sickness absence or being off work as an outcome. We also analysed the effects on depression and work functioning. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data and rated the certainty of the evidence using GRADE. We used standardised mean differences (SMDs) or risk ratios (RR) with 95% confidence intervals (CI) to pool study results in studies we judged to be sufficiently similar.  MAIN RESULTS: In this update, we added 23 new studies. In total, we included 45 studies with 88 study arms, involving 12,109 participants with either a major depressive disorder or a high level of depressive symptoms. Risk of bias The most common types of bias risk were detection bias (27 studies) and attrition bias (22 studies), both for the outcome of sickness absence. Work-directed interventions Work-directed interventions combined with clinical interventions A combination of a work-directed intervention and a clinical intervention probably reduces days of sickness absence within the first year of follow-up (SMD -0.25, 95% CI -0.38 to -0.12; 9 studies; moderate-certainty evidence). This translates back to 0.5 fewer (95% CI -0.7 to -0.2) sick leave days in the past two weeks or 25 fewer days during one year (95% CI -37.5 to -11.8). The intervention does not lead to fewer persons being off work beyond one year follow-up (RR 0.96, 95% CI 0.85 to 1.09; 2 studies, high-certainty evidence). The intervention may reduce depressive symptoms (SMD -0.25, 95% CI -0.49 to -0.01; 8 studies, low-certainty evidence) and probably has a small effect on work functioning (SMD -0.19, 95% CI -0.42 to 0.06; 5 studies, moderate-certainty evidence) within the first year of follow-up.  Stand alone work-directed interventions A specific work-directed intervention alone may increase the number of sickness absence days compared with work-directed care as usual (SMD 0.39, 95% CI 0.04 to 0.74; 2 studies, low-certainty evidence) but probably does not lead to more people being off work within the first year of follow-up (RR 0.93, 95% CI 0.77 to 1.11; 1 study, moderate-certainty evidence) or beyond (RR 1.00, 95% CI 0.82 to 1.22; 2 studies, moderate-certainty evidence). There is probably no effect on depressive symptoms (SMD -0.10, 95% -0.30 CI to 0.10; 4 studies, moderate-certainty evidence) within the first year of follow-up and there may be no effect on depressive symptoms beyond that time (SMD 0.18, 95% CI -0.13 to 0.49; 1 study, low-certainty evidence). The intervention may also not lead to better work functioning (SMD -0.32, 95% CI -0.90 to 0.26; 1 study, low-certainty evidence) within the first year of follow-up.   Psychological interventions A psychological intervention, either face-to-face, or an E-mental health intervention, with or without professional guidance, may reduce the number of sickness absence days, compared with care as usual (SMD -0.15, 95% CI -0.28 to -0.03; 9 studies, low-certainty evidence). It may also reduce depressive symptoms (SMD -0.30, 95% CI -0.45 to -0.15, 8 studies, low-certainty evidence). We are uncertain whether these psychological interventions improve work ability (SMD -0.15 95% CI -0.46 to 0.57; 1 study; very low-certainty evidence). Psychological intervention combined with antidepressant medication Two studies compared the effect of a psychological intervention combined with antidepressants to antidepressants alone. One study combined psychodynamic therapy with tricyclic antidepressant (TCA) medication and another combined telephone-administered cognitive behavioural therapy (CBT) with a selective serotonin reuptake inhibitor (SSRI). We are uncertain if this intervention reduces the number of sickness absence days (SMD -0.38, 95% CI -0.99 to 0.24; 2 studies, very low-certainty evidence) but found that there may be no effect on depressive symptoms (SMD -0.19, 95% CI -0.50 to 0.12; 2 studies, low-certainty evidence). Antidepressant medication only Three studies compared the effectiveness of SSRI to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Improved care Overall, interventions to improve care did not lead to fewer days of sickness absence, compared to care as usual (SMD -0.05, 95% CI -0.16 to 0.06; 7 studies, moderate-certainty evidence). However, in studies with a low risk of bias, the intervention probably leads to fewer days of sickness absence in the first year of follow-up (SMD -0.20, 95% CI -0.35 to -0.05; 2 studies; moderate-certainty evidence). Improved care probably leads to fewer depressive symptoms (SMD -0.21, 95% CI -0.35 to -0.07; 7 studies, moderate-certainty evidence) but may possibly lead to a decrease in work-functioning (SMD 0.5, 95% CI 0.34 to 0.66; 1 study; moderate-certainty evidence). Exercise Supervised strength exercise may reduce sickness absence, compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54; one study, low-certainty evidence). However, aerobic exercise probably is not more effective than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24; 2 studies, moderate-certainty evidence). Both studies found no differences between the two conditions in depressive symptoms. AUTHORS' CONCLUSIONS: A combination of a work-directed intervention and a clinical intervention probably reduces the number of sickness absence days, but at the end of one year or longer follow-up, this does not lead to more people in the intervention group being at work. The intervention may also reduce depressive symptoms and probably increases work functioning more than care as usual. Specific work-directed interventions may not be more effective than usual work-directed care alone. Psychological interventions may reduce the number of sickness absence days, compared with care as usual. Interventions to improve clinical care probably lead to lower sickness absence and lower levels of depression, compared with care as usual. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. Further research is needed to assess which combination of work-directed and clinical interventions works best.


Assuntos
Absenteísmo , Depressão/terapia , Transtorno Depressivo Maior/terapia , Saúde do Trabalhador , Retorno ao Trabalho/psicologia , Adulto , Antidepressivos/uso terapêutico , Viés , Terapia Cognitivo-Comportamental , Humanos , Exercícios de Alongamento Muscular , Ensaios Clínicos Controlados Aleatórios como Assunto , Licença Médica , Desempenho Profissional
10.
BMC Psychiatry ; 20(1): 441, 2020 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912154

RESUMO

BACKGROUND: The role of explicit learning of treatment content in internet-based cognitive-behavioural treatment (ICBT) is an emerging field of research. The objective of this study was to explore clients experiences of their ICBT treatment for depression with a focus on knowledge gain and usage of knowledge learned during treatment. METHODS: A strategic sample of ten adolescents, aged between 15 and 19 years, who had received ICBT for major depression within a clinical controlled trial were recruited for the study. Semi-structured interviews were conducted 6 months following trial completion. Data were transcribed and analysed using thematic analysis. The participants had a general adherence rate of 6-8 opened modules out of 8 possible. RESULTS: Two main themes were identified; "Active agents of CBT" and "Passive agents of CBT", with each theme consisting of three and two sub-themes. Active agents of CBT reflect a tendency to specifically remember and actively apply specific CBT principles in present life situations. Passive agents of CBT reflect a tendency to remember CBT treatment principles vaguely and express a passive or reactive usage of learned therapy content. CONCLUSION: The findings suggest that young clients can remember and apply CBT principles 6 months after their treatment. However, while experiencing benefits of treatment, clients recall and application of treatment strategies vary. The study emphasizes the importance of exploring client recall of CBT components and how valuable it is to explicitly remember contents of a treatment in order to improve and maintain improvement. Further studies on the role of knowledge and memory of ICBT for adolescent populations are warranted.


Assuntos
Terapia Cognitivo-Comportamental , Transtorno Depressivo Maior , Adolescente , Adulto , Depressão , Transtorno Depressivo Maior/terapia , Humanos , Internet , Aprendizagem , Resultado do Tratamento , Adulto Jovem
11.
BMC Psychiatry ; 20(1): 453, 2020 09 16.
Artigo em Inglês | MEDLINE | ID: mdl-32938410

RESUMO

BACKGROUND: Major depressive episode (MDE) is worldwide one of the most prevalent and disabling mental health conditions. In cases of persistent non-response to treatment, electroconvulsive therapy (ECT) is a safe and effective treatment strategy with high response rates. Unfortunately, longitudinal data show low sustained response rates with 6-month relapse rates as high as 50% using existing relapse prevention strategies. Cognitive side effects of ECT, even though transient, might trigger mechanisms that increase relapse in patients who initially responded to ECT. Among these side effects, reduced cognitive control is an important neurobiological driven vulnerability factor for depression. As such, cognitive control training (CCT) holds promise as a non-pharmacological strategy to improve long-term effects of ECT (i.e., increase remission, and reduce depression relapse). METHOD/DESIGN: Eighty-eight patients aged between 18 and 70 years with MDE who start CCT will be included in this randomized controlled trial (RCT). Following (partial) response to ECT treatment (at least a 25% reduction of clinical symptoms), patients will be randomly assigned to a computer based CCT or active placebo control. A first aim of this RCT is to assess the effects of CCT compared to an active placebo condition on depression symptomatology, cognitive complaints, and quality of life. Secondly, we will monitor patients every 2 weeks for a period of 6 months following CCT/active placebo, allowing the detection of potential relapse of depression. Thirdly, we will assess patient evaluation of the addition of cognitive remediation to ECT using qualitative interview methods (satisfaction, acceptability and appropriateness). Finally, in order to further advance our understanding of the mechanisms underlying effects of CCT, exploratory analyses will be conducted using video footage collected during the CCT/active control phase of the study. DISCUSSION: Cognitive remediation will be performed following response to ECT, and an extensive follow-up period will be employed. Positive findings would not only benefit patients by decreasing relapse, but also by increasing acceptability of ECT, reducing the burden of cognitive side-effects. TRIAL REGISTRATION: The study is registered with ClinicalTrials.gov . Study ID: NCT04383509 Trial registration date: 12.05.2020.


Assuntos
Remediação Cognitiva , Transtorno Depressivo Maior , Transtorno Depressivo Resistente a Tratamento , Eletroconvulsoterapia , Adolescente , Adulto , Idoso , Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Humanos , Pessoa de Meia-Idade , Prevenção Secundária , Resultado do Tratamento , Adulto Jovem
12.
BMC Psychiatry ; 20(1): 471, 2020 09 29.
Artigo em Inglês | MEDLINE | ID: mdl-32993573

RESUMO

BACKGROUND: Depressive illness is associated with significant adverse consequences for patients and their families, and for society. Clinical challenges are encountered in the management of patients suffering from depression whether they are designated difficult-to-treat or treatment-resistant. Prospective serial depression treatment trials have shown that less than 40% of patients with major depressive disorder remit with an initial pharmacotherapy trial, and a progressively smaller proportion of patients remit with each subsequent trial. For patients who suffer from difficult-to-treat depression (DTD), treatments should focus on patient-centred symptom control, patient functioning, and improving patient quality of life. Among the treatment options for patients with DTD is Vagus Nerve Stimulation (VNS) Therapy. VNS Therapy involves intermittent electrical stimulation of the left cervical vagus nerve and has been shown to be efficacious for long-term management of patients with DTD. METHODS: RESTORE-LIFE is a prospective, observational, multi-site, global post-market study intended to assess short-, mid-, and long-term effectiveness and efficiency outcomes in a 'real-world' setting among patients with DTD treated with adjunctive VNS Therapy. A minimum of 500 patients will be implanted with a VNS Therapy System at up to 80 global sites. Eligible patients will participate in a baseline visit between 1 and 6 weeks before device implant and will be followed for a minimum of 36 months and a maximum of 60 months. The diagnosis of depression and comorbid disorders will be determined using the Mini-International Neuropsychiatric Interview (MINI). The primary endpoint is response rate, defined as a decrease of ≥50% in Montgomery Åsberg Depression Rating Scale (MADRS) total score from baseline to 12 months post-implant. DISCUSSION: A standardized approach in the management of DTD may not be appropriate for the treatment of such a complex heterogenous patient population. This study has been designed to evaluate whether VNS Therapy meaningfully improves and sustains clinical and depressive symptom outcomes in patients with DTD. This study will investigate the durability of VNS response in DTD and utility of VNS for long-term disease management of DTD. In addition, the study results will potentially clarify clinical, functional, and health economic questions in a real-world patient population with DTD. TRIAL REGISTRATION: ClinicalTrials.gov NCT03320304. Registered 25 October 2017.


Assuntos
Transtorno Depressivo Maior , Estimulação do Nervo Vago , Depressão , Transtorno Depressivo Maior/terapia , Humanos , Estudos Prospectivos , Qualidade de Vida , Resultado do Tratamento
13.
Compr Psychiatry ; 102: 152204, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32905995

RESUMO

BACKGROUND: The recovery of psychosocial functioning is an important treatment goal for patients with depression. The aim of the present study is to investigate psychosocial functioning restoration 1 year after major depressive disorder (MDD) remission. METHODS: Depression symptoms and psychosocial functioning were assessed in 167 remitted MDD patients at baseline, as well as 1, 2, 6, 9, and 12 months following remission, according to the Hamilton Depression Scale (HAMD-17) and Generic Quality of Life Inventory (GQOLI-74). RESULTS: Of the 167 MDD patients, 85 completed the final evaluation at 1 year, 32 relapsed, and 50 dropped out. The total relapse rate over 1 year was 27%. A rapid increase in psychosocial functioning was found in the first 2 months after remission in the non-relapse group. In the non-relapse group, psychosocial functioning was higher at 2 months than at baseline. At baseline and 2 months, psychosocial functioning was lower in the relapse group patients compared to those in the non-relapse group. CONCLUSIONS: Patients with MDD showed continuous improvement in psychosocial functioning during the first year after remission, though psychosocial functioning in the relapse group remained the same during the first two months, suggesting possible further relapse.


Assuntos
Transtorno Depressivo Maior , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/terapia , Humanos , Estudos Longitudinais , Qualidade de Vida , Recidiva
15.
Obstet Gynecol ; 136(3): 613-621, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32769639

RESUMO

OBJECTIVE: To estimate the effect of an interpersonal therapy-based intervention on reducing the risk of postpartum depression in adolescents. METHODS: A randomized controlled trial enrolled 250 pregnant adolescents who were aged 18 years or younger at conception. The initial sample size calculation estimated 276 participants (324 with attrition) were needed to detect a 50% reduction in risk of the primary outcome, postpartum major depressive episode, with an alpha of 0.05% and 80% power. An interim analysis by the Data Safety and Monitoring Committee informed a revision in the sample size target to 250. Participants were randomized to the intervention (n=129) or a time-matched control group (n=121) who attended sessions about pregnancy topics. Each group received five prenatal sessions and a postpartum booster session. A structured diagnostic interview was administered at baseline and specific time points through 12-months postpartum to assess for major depressive episode onset. RESULTS: Participants were recruited from December 2011 to May 2016 through urban prenatal care sites in the state of Rhode Island. Of the 250 participants, 58% identified as Hispanic and 20% as black or African American. The rate of major depressive episode by 12 months postpartum was 7.0% (95% CI 2.3-11.7%) in the control group and 7.6% (95% CI 2.5-12.7%) in the intervention group, with no significant difference between groups at any time point (P=.88 by log-rank test). CONCLUSION: No benefit was shown between the intervention and control groups in the rates of major depressive episode, which is likely related to a lower than predicted rate of this outcome in the control group (7.6% actual vs 25% predicted). Enhanced local community resources available to pregnant and parenting adolescents during the study period may be an explanation for this result. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01482832.


Assuntos
Depressão Pós-Parto/epidemiologia , Depressão Pós-Parto/terapia , Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/terapia , Psicoterapia Interpessoal , Adolescente , Criança , Feminino , Humanos , Medição de Risco , Método Simples-Cego
16.
JAMA Netw Open ; 3(8): e207434, 2020 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-32809030

RESUMO

Importance: There is an unmet need for effective treatments for suicidality in mental disorders. Magnetic seizure therapy (MST) has been investigated as an alternative to electroconvulsive therapy, a known effective treatment for suicidality, in the management of treatment-resistant major depressive disorder, with promising findings. Yet, there are very limited data on the association of MST with suicidality directly. It is important to explore the potential of MST as a viable treatment alternative to electroconvulsive therapy for suicidality. Objective: To determine the association of MST with suicidality in patients with treatment-resistant major depressive disorder. Design, Setting, and Participants: This nonrandomized controlled trial took place at a single tertiary care psychiatric facility in Canada. It followed an open-label study design with consecutive treatment cohorts. Consecutive groupings of 67 patients with treatment-resistant major depressive disorder and with baseline suicidality present were treated for up to 24 treatments. The study was run from February 2012 through June 2019. Patients were followed up for 6 months at the end of the treatment period. This post hoc secondary analysis of the trial was performed from January to November 2019. Interventions: MST was delivered at 100% stimulator output over the prefrontal cortex with low (25 Hz), moderate (50 or 60 Hz), or high (100 Hz) frequency, for a maximum of 24 sessions. Main Outcomes and Measures: Remission from suicidality was measured as an end point score of 0 on the Beck Scale for Suicidal Ideation. A linear mixed model was used to assess the trajectory of Beck Scale for Suicidal Ideation scores. Results: A total of 67 patients (mean [SD] age, 46.3 [13.6] years; 40 women [60.0%]) received a mean (SD) of 19.5 (5.1) MST treatments. The overall number of patients achieving remission was 32 (47.8%). Sixteen patients (55.2%) receiving low-frequency MST achieved remission, as well as 12 patients (54.5%) in the moderate-frequency group, and 4 patients (25.0%) in the high-frequency group. The linear mixed model revealed an association of time with Beck Scale for Suicidal Ideation scores (F8,293.95 = 5.73; P < .001). Conclusions and Relevance: These findings suggest that MST may be an effective treatment for suicidality, and sensitivity analysis shows this may be particularly so at low and moderate frequencies. Future studies should directly compare MST with electroconvulsive therapy for treating suicidality and should evaluate MST as a treatment for suicidality across mental disorders. Trial Registration: ClinicalTrials.gov Identifier: NCT01596608.


Assuntos
Transtorno Depressivo Maior , Terapia de Campo Magnético , Ideação Suicida , Adulto , Transtorno Depressivo Maior/fisiopatologia , Transtorno Depressivo Maior/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
17.
JAMA Netw Open ; 3(8): e2012389, 2020 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-32749468

RESUMO

Importance: Although electroconvulsive therapy (ECT) is often effective, approximately half of patients with depression undergoing ECT do not benefit sufficiently, and relapse rates are high. ECT sessions have been shown to weaken reactivated memories. The effect of emotional memory retrieval on cognitive schemas remains unknown. Objective: To assess whether emotional memory retrieval just before patients receive ECT sessions weakens underlying cognitive schemas, improves ECT effectiveness, increases ECT response, and reduces relapse rates. Design, Setting, and Participants: In this multicenter randomized clinical trial conducted from 2014 to 2018 in the departments of psychiatry in 3 hospitals in the Netherlands, 72 participants were randomized 1:1 to 2 parallel groups to receive either emotional memory reactivation (EMR-ECT) or control memory reactivation (CMR-ECT) interventions before ECT sessions. The Hamilton Depression Rating Scale (HDRS [total score range: 0-52, with 0-7 indicating no depression and ≥24 indicating severe depression]) was used to measure symptoms of depression during and after ECT, with a 6-month follow-up period. Participants were between ages 18 and 70 years with a primary diagnosis of unipolar major depressive disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) and in whom ECT was indicated. Data analysis was performed from July to November 2019. Interventions: EMR-ECT or CMR-ECT interventions prior to ECT sessions. Main Outcomes and Measures: Depression scores and relapse rates within 6 months were assessed with the HDRS and analyzed using logistic and linear multiple regression analyses. Results: A total of 66 patients (mean [SD] age, 49.3 [12.3] years; 39 [59.1%] women) were randomized to the EMR-ECT group (n = 32) or the CMR-ECT group (n = 34). Regardless of the memory intervention, 42.4% (28 of 66) of patients responded (≥50% decrease of symptom severity on the HDRS). Of patients who responded, 39.3% (11 of 28) relapsed within 6 months. Remission rates (CMR-ECT group, 29.4% [10 of 34] vs EMR-ECT group, 25.0% [8 of 32]; P = .58), mean (SD) HDRS scores after the ECT course (CMR-ECT group, 14.6 [8.6] vs EMR-ECT group, 14.9 [8.8]; P = .88), total mean (SD) number of required ECT sessions for response (CMR-ECT group, 14.9 [7.9] vs EMR-ECT group, 15.6 [7.3]; P = .39), and relapse rates (CMR-ECT group, 46.7% [7 of 15] vs EMR-ECT group, 30.8% [4 of 13]; P = .33) were not significantly altered by the intervention. Conclusions and Relevance: Study findings suggest that the EMR-ECT intervention just before patient receipt of ECT for depression did not improve effectiveness, increase speed of response, or reduce relapse rates after the ECT course compared with patients receiving CMR-ECT. Trial Registration: Trialregister.nl Identifier: NL4289.


Assuntos
Transtorno Depressivo Maior/terapia , Eletroconvulsoterapia/métodos , Memória/fisiologia , Adulto , Emoções/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
18.
Psychiatry Res Neuroimaging ; 304: 111157, 2020 10 30.
Artigo em Inglês | MEDLINE | ID: mdl-32799057

RESUMO

Electrode placement in electroconvulsive therapy (ECT) has a major impact on treatment efficacy and cognitive side effects. Left Anterior Right Temporal (LART) is a lesser utilised bilateral montage which may produce more optimal clinical outcomes relative to standard bitemporal ECT. In this study we used computational modelling to explore how stimulation effects from LART and two novel variants (LART - F3 and LART - Frontal) compared to the more common bilateral placements of bitemporal and bifrontal ECT. High resolution finite element human head models were generated from MRI scans of three subjects with Major Depressive Disorder. Differences in regional stimulation were examined through parametric tests for regions of interest and subtraction maps. Compared to bitemporal ECT, LART - Original resulted in significantly greater stimulation of the left cingulate gyrus (hypothesised to be associated with treatment efficacy), and relatively reduced stimulation of the bilateral hippocampi (potentially associated with cognitive side effects). No additional clinical benefit was suggested with the novel LART placements compared to the original LART. The original LART placement is a promising montage for further clinical investigation.


Assuntos
Encéfalo/diagnóstico por imagem , Transtorno Depressivo Maior/terapia , Eletroconvulsoterapia/métodos , Eletrodos , Hipocampo , Humanos , Imagem por Ressonância Magnética , Resultado do Tratamento
19.
Psychiatry Res ; 291: 113275, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32763538

RESUMO

Repetitive transcranial magnetic stimulation (rTMS) is an effective and evidence-based treatment for major depression, which is now as a mainstream treatment in clinical practice. However, there is limited data concerning its use in Australian private psychiatric hospital settings. This retrospective study examined routinely collected data of 153 inpatients, who received 20 rTMS treatments over four weeks. Primary outcomes measures were the 17-item Hamilton Depression Rating Scale (HAMD-17) and the 21-item Depression, Anxiety and Stress Scale (DASS-21). At post-treatment, response and remission rates were 54% and 28%, respectively, for the HAMD-17; and 53% response and 16% remission rates, for the DASS-21 Depression subscale, respectively. Although no gender differences were observed, younger patients demonstrated more improvements during acute rTMS but the effect was not significant after accounting for pre-treatment symptom severity. The findings of this naturalistic study suggest that an acute course of rTMS provided in private clinical settings resulted in similar response and remission rates to longer rTMS courses. Shorter rTMS courses appear to have satisfactory efficacy in treating major depression, in clinically diverse and real-world practice.


Assuntos
Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/terapia , Hospitais Privados/tendências , Estimulação Magnética Transcraniana/métodos , Estimulação Magnética Transcraniana/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Transtorno Depressivo Maior/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
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