SYNERGISTIC RELATIONSHIPS AMONG STRESS,DEPRESSION, AND TROUBLED RELATIONSHIPS: INSIGHTS FROM PSYCHONEUROIMMUNOLOGY

Stress and depression consistently elevate inflammation and are often experienced simultaneously, which is exemplified by people in troubled relationships. Troubled relationships also elevate inflammation, which may be partially explained by their ability to engender high levels of stress and depression. People who are stressed, depressed, or in troubled relationships are also at greater risk for health problems than their less distressed counterparts. Inflammation, a risk factor for a variety of age‐related diseases including cardiovascular disease, Type II diabetes, metabolic syndrome, and frailty, may be one key mechanistic pathway linking distress to poor health. Obesity may further broaden the health implications of stress and depression; people who are stressed or depressed are often overweight, and adipose tissue is a major source of proinflammatory cytokines. Stress, depression, and troubled relationships may have synergistic inflammatory effects: loneliness, subclinical depression, and major depression enhance inflammatory responses to an acute stressful event. The relationship between distress and inflammation is bidirectional; depression enhances inflammation and inflammation promotes depression. Interesting questions emerge from this literature. For instance, some stressors may be more potent than others and thus may be more strongly linked to inflammation. In addition, it is possible that psychological and interpersonal resources may buffer the negative inflammatory effects of stress. Understanding the links among stress, depression, troubled relationships, and inflammation is an exciting area of research that may provide mechanistic insight into the links between distress and poor health.     

Achieving a sustained reduction in benzodiazepine use through implementation of an area-wide multi-strategic approach

OBJECTIVE: This study aimed to evaluate the impact, in a regional setting, of a multi-strategic partnership approach for reducing benzodiazepine use in the management of insomnia, as recommended in Australia's National Policy on Quality Use of Medicines. METHOD: The setting was a rural region of South Australia, covering approximately 2000 km2, with a population of over 20 000. The study involved participatory action research, with qualitative and quantitative evaluations. The intervention involved a multi-strategic approach, including provision of treatment guidelines, provision of consumer information, a local media campaign and education and training of health professionals. The quantitative evaluation involved a single region before/after study with 2 years of follow-up using pharmacy-based dispensing data for benzodiazepines and antidepressants, gathered for the months of November to April in 1998/99 ('before' period) through to 2000/01 ('after' period). The data were analysed using non-parametric statistics. RESULTS: There was a 19% reduction in benzodiazepine dispensing 2 years after the intervention compared with a 6% reduction nationally. Dispensing of antidepressants increased by 33%, compared with a 28% increase nationally. CONCLUSION: It was concluded that the multi-strategic approach to the management of sleep disorders proved successful in promoting the use of non-drug alternatives, achieving sustained reduction in benzodiazepine consumption in a rural community, without therapeutic substitution of antidepressants. IMPLICATIONS: The study demonstrated that a sustainable reduction in prescribing of benzodiazepines can be achieved through the implementation of a multi-strategic approach involving local consumers, health professionals, a Division of General Practice, a government department, aged-care facilities and the local media.     

Antidepressant-related adverse effects impacting treatment compliance: Results of a patient survey

Background:

Despite the high prevalence of depression in the United States, 10 few studies have identified which adverse effects (AEs) patients are willing or unwilling to tolerate when receiving antidepressants.

Objective:

The aim of this study was to identify reasons for discontinuation10 and noncompliance with antidepressant medications, the impact of AEs on compliance and quality of life (assessed using impact of AEs on activities of daily living), and patients' suggestions for improving their medication, using a patient survey.

Methods:

Patients aged 18 to 65 years with mild to severe depression were 10 randomly selected by their physicians to be sent an invitation to complete the 42-question survey. Three hundred physicians nationwide assessed the severity of depression and symptoms of anxiety in each respondent, using their judgment. Patients were asked specific questions to assess reasons for discontinuation/noncompliance. Patients were also asked to rate AEs based on how difficult they were to “live with,” and what 2 aspects of their antidepressant medication they would change if they could.

Results:

In a separate, concurrent study, physicians classified 175 (50%) abdResults:0 mildly to moderately depressed and 84 (24%) as severely depressed. Ninety-one respondents (26%) were classified as having symptoms of anxiety. Two hundred seven patients (60%) indicated they had discontinued treatment with an antidepressant agent at some point in their lives, the most common reason for which was lack of efficacy (92 patients [44%]). Of the 344 patients currently being treated with an antidepressant, 75 (22%) reported noncompliance. The most common reasons for noncompliance were “have trouble remembering to take it” (19/44 patients [43%]), “gained a lot of weight” (11/41 [27%]), “unable to have an orgasm” (8/40 [20%]), and “lost interest in sex” (8/41 [20%]). The 4 AEs patients expressed as “extremely difficult to live with” were “weight gain” (104 patients [31%]), “unable to have erection” (83 [25%]), “difficulty reaching orgasm” (80 [24%]), and “tired during the day/no energy” (69 patients [21%]). The 3 most frequently cited improvements patients (n = 327) would make to their medications were better efficacy (176 patients [54%]) and eliminating AEs related to sexual desire and weight gain (112 [34%] and 105 [32%] patients, respectively).

Conclusions:

The findings of this survey of patients with mild to severe10 depression suggest that compliance, and hence efficacy, can be promoted by (1) understanding what patients expect and desire from the antidepressants they are prescribed and (2) prescribing antidepressants associated with low rates of weight gain, sexual dysfunction, or tiredness.     

Prenatal Cocaine Disrupts Serotonin Signaling-Dependent Behaviors: Implications for Sex Differences,Early Stress and Prenatal SSRI Exposure

Prenatal cocaine (PC) exposure negatively impacts the developing nervous system, including numerous changes in serotonergic signaling. Cocaine, a competitive antagonist of the serotonin transporter, similar to selective serotonin reuptake inhibitors (SSRIs), also blocks dopamine and norepinephrine transporters, leaving the direct mechanism through which cocaine disrupts the developing serotonin system unclear. In order to understand the role of the serotonin transporter in cocaine’s effect on the serotonergic system, we compare reports concerning PC and prenatal antidepressant exposure and conclude that PC exposure affects many facets of serotonergic signaling (serotonin levels, receptors, transporters) and that these effects differ significantly from what is observed following prenatal SSRI exposure. Alterations in serotonergic signaling are dependent on timing of exposure, test regimens, and sex. Following PC exposure, behavioral disturbances are observed in attention, emotional behavior and stress response, aggression, social behavior, communication, and like changes in serotonergic signaling, these effects depend on sex, age and developmental exposure. Vulnerability to the effects of PC exposure can be mediated by several factors, including allelic variance in serotonergic signaling genes, being male (although fewer studies have investigated female offspring), and experiencing the adverse early environments that are commonly coincident with maternal drug use. Early environmental stress results in disruptions in serotonergic signaling analogous to those observed with PC exposure and these may interact to produce greater behavioral effects observed in children of drug-abusing mothers. We conclude that based on past evidence, future studies should put a greater emphasis on including females and monitoring environmental factors when studying the impact of PC exposure.     

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders,Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders

Abstract

Objectives. This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. Methods. The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. Results. This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. Conclusions. To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.