The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder

BACKGROUND: This article describes the development of consensus medication algorithms for the treatment of patients with major depressive disorder in the Texas public mental health system. To the best of our knowledge, the Texas Medication Algorithm Project (TMAP) is the first attempt to develop and prospectively evaluate consensus-based medication algorithms for the treatment of individuals with severe and persistent mental illnesses. The goals of the algorithm project are to increase the consistency of appropriate treatment of major depressive disorder and to improve clinical outcomes of patients with the disorder. METHOD: A consensus conference composed of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families was convened to develop evidence-based consensus algorithms for the pharmacotherapy of major depressive disorder in the Texas mental health system. After a series of presentations and panel discussions, the consensus panel met and drafted the algorithms. RESULTS: The panel consensually agreed on algorithms developed for both nonpsychotic and psychotic depression. The algorithms consist of systematic strategies to define appropriate treatment interventions and tactics to assure optimal implementation of the strategies. Subsequent to the consensus process, the algorithms were further modified and expanded iteratively to facilitate implementation on a local basis. CONCLUSION: These algorithms serve as the initial foundation for the development and implementation of medication treatment algorithms for patients treated in public mental health systems. Specific issues related to adaptation, implementation, feasibility testing, and evaluation of outcomes with the pharmacotherapeutic algorithms will be described in future articles.     

Olanzapine in the treatment of depression with psychotic features: A prospective open-label study

Objective. Depression with psychotic features is a severe subtype of major depression associated with the presence of delusions, hallucinations and specific neurobiological features. Despite clinical consensus and guideline recommendations, data comparing the efficacy of combining antipsychotics with antidepressants compared to antidepressants alone remain inconclusive. The aim of the study was to investigate effectiveness and tolerability of the atypical antipsychotic olanzapine in acute depression with psychotic features. Methods. Seventeen inpatients with major depressive disorder with psychosis (MDDp) were treated with a combination of an antidepressant and olanzapine for 6 weeks in a prospective open-label study. Depressive and psychotic symptoms, extrapyramidal and general side effects were assessed every 2 weeks. Sixteen patients were eligible for final analysis. Results. The Brief Psychiatric Rating Scale (BPRS) showed a 30% symptom reduction after week 2, a 45% symptom reduction after week 4 and no considerable improvement thereafter. Depressive symptoms (Bech–Rafaelsen Melancholia Scale, BRMS) receded by 37% after week 2 and 50% after week 4. No extrapyramidal side effects occurred. Conclusion. Olanzapine is effective and tolerable in combination with an antidepressant in an MDDp inpatient sample. The results concur with data supporting good efficacy in negative and depressive symptoms of patients with schizophrenic and schizoaffective diseases.     

Depressive symptoms in schizophrenia.

OBJECTIVE: The authors assessed the presence and severity of depressive symptoms, as well as their associations with other clinical measures, in a group of mid- to late-life patients with schizophrenia who were not in a major depressive episode or diagnosed with schizoaffective disorder. METHOD: Sixty outpatients with schizophrenia between the ages of 45 and 79 years and 60 normal comparison subjects without major neuropsychiatric disorders, proportionally matched for age and gender, were studied. Depressive symptoms were rated primarily with the Hamilton Depression Rating Scale. Standardized instruments were also used to measure global psychopathology, positive and negative symptoms, abnormalities of movement, and global cognitive status. RESULTS: Depressive symptoms were more frequent and more severe in schizophrenic patients than in normal comparison subjects; 20% of the women with schizophrenia had a Hamilton depression scale score of 17 or more. Severity of depressive symptoms correlated with that of positive symptoms but not with age, gender, negative symptoms, extrapyramidal symptoms, or neuroleptic dose. CONCLUSIONS: Depressive symptoms are common in older patients with schizophrenia. They may be an independent, core component of the disorder or, alternatively, may be a by-product of severe psychotic symptoms.     

Depressive symptom profiles and severity patterns in outpatients with psychotic vs nonpsychotic major depression

Background

Previous research suggests that patients with psychotic major depression (PMD) may differ from those with nonpsychotic major depression (NMD) not only in psychotic features but also in their depressive symptom presentation. The present study contrasted the rates and severity of depressive symptoms in outpatients diagnosed with PMD vs NMD.

Method

The sample consisted of 1112 patients diagnosed with major depression, of which 60 (5.3%) exhibited psychotic features. Depressive symptoms were assessed by trained diagnosticians at intake using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and supplemented by severity items from the Schedule for Affective Disorders and Schizophrenia.

Results

Patients with PMD were more likely to endorse the presence of weight loss, insomnia, psychomotor agitation, indecisiveness, and suicidality compared with NMD patients. Furthermore, PMD patients showed higher levels of severity on several depressive symptoms, including depressed mood, appetite loss, insomnia, psychomotor disturbances (agitation and retardation), fatigue, worthlessness, guilt, cognitive disturbances (concentration and indecisiveness), hopelessness, and suicidal ideation. The presence of psychomotor disturbance, insomnia, indecisiveness, and suicidal ideation was predictive of diagnostic status even after controlling for the effects of demographic characteristics and other symptoms.

Conclusions

These findings are consistent with past research suggesting that PMD is characterized by a unique depressive symptom profile in addition to psychotic features and higher levels of overall depression severity. The identification of specific depressive symptoms in addition to delusions/hallucinations that can differentiate PMD vs NMD patients can aid in the early detection of the disorder. These investigations also provide insights into potential treatment targets for this high-risk population.     

Depressive episodes in stable schizophrenia: critical evaluation of the DSM-IV and ICD-10 diagnostic criteria

Depressive episodes are a common and potentially severe occurrence in schizophrenia but are poorly recognised by psychiatrists. Coherent diagnostic criteria are necessary to improve diagnosis and treatment of these conditions. To evaluate the usefulness of the ICD-10 category of post-schizophrenic depression (PSD) and the DSM-IV category of postpsychotic depressive disorder of schizophrenia (PDDS), 80 clinically stable schizophrenic outpatients were evaluated with two independent measures of depression, a dimensional measure and a categorical measure. One rater applied the DSM-IV criteria for major depressive episodes (MDE), and the other applied the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, and the Extrapyramidal Symptoms Rating Scale. Thirteen patients (16.3%) met criteria for MDE. All of them met the DSM-IV PDDS research criteria, but only two patients matched the ICD-10 PSD criteria, which require that the episode occurred in the 12 months after the last psychotic episode. There was no significant difference in the incidence of depressive episodes within 12 months after an acute psychotic episode and outside this time period. The data suggest that depressive episodes in schizophrenia are not restricted to the first year following the psychotic episode. Useful criteria for depressive episodes in schizophrenia should avoid a temporal relation with the psychotic episode.     

伴非典型特征抑郁症的临床评估与诊治指导建议

非典型特征是抑郁症常见的临床伴随特征之一,这类患者具有起病早、病程长、共病率高、预后差、转相风险大、自杀风险高等特点。然而,目前临床实践中对伴非典型特征的抑郁症缺乏认识,针对其临床评估、诊断及治疗等方面尚未形成基于循证证据的指南或共识。鉴于此,中华医学会精神医学分会抑郁障碍研究协作组专家们立足临床实践需求,遵循循证医学证据,参考国内外指南,提出针对伴非典型特征的抑郁症的临床评估与诊治建议,以期为精神卫生工作者提供参考。     

Depressive related symptoms among preschool-age children

A parental survey of 241 preschoolers failed to document any major depressive disorder in this age group. The findings indicate that the prevalence of Major Depressive Disorder in preschoolers may be less than that of prepubertal and adolescent children; alternatively; modifications of the DSM III Criteria for Major Depression in Children under six years of age may be warranted. While cognizant of the shortcomings inherent in a study design based on a solitary source of information, the authors are unaware of any previous investigation addressing this issue.     

Depressive symptoms and schizophrenic relapses: the effect of four neuroleptic drugs.

1. A prevalence of depressive symptomatology, ranging from 25% to 80% has been reported during the course of schizophrenia. 2. Depressive symptoms were assessed in 144 schizophrenic patients (DSM IV) during an acute exacerbation phase. 3. Depressive symptoms showed a prevalence ranging from 5.5% (severe clinical pictures) to 54.8 (mild clinical pictures). 4. The authors did not find a correlation between depressive symptoms per se and the presence of negative psychotic symptoms. Depression may be linked not so much to negative symptoms but to the psychotic state itself. 5. Depressive symptomatology concurrently occurred with schizophrenic relapses and improved together with the psychotic clinical picture, independently of the neuroleptic drug employed. Haloperidol, haloperidol decanoate and fluphenazine decanoate all showed a similar improvement of depressive symptoms. 6. L-sulpiride showed a trend to be most effective on depressive symptomatology in comparison to the other neuroleptics.     

Analysis of depressive symptomatology in mood disorders

Depressive disorder is a polymorphic syndrome with a wide range of clinical manifestations. Most analyses of depressive symptomatology have been performed by ignoring psychotic symptoms, despite a substantial proportion of depressives presenting psychotic features. The purpose of this study was to include psychotic features in an analysis of depressive symptomatology. Six hundred sixty-nine inpatients affected by major depressive (n = 259) and bipolar (n = 410) disorder were rated for lifetime depressive symptoms using the Operational Criteria checklist for psychotic illness (OPCRIT) and included in a factorial analysis. Three factors were obtained: the first consisted of core depressive symptoms, the second comprised psychotic features, and the third comprised atypical symptoms. Separate analyses performed on major depressive and bipolar samples showed a similar factor structure, though there was some evidence of greater heterogeneity in the major depressive sample. Thus, when scored by the OPCRIT checklist, depressive symptomatology results were composed of core depressive symptoms, psychotic features, and atypical symptoms. Depression and Anxiety 8:80–85, 1998. © 1998 Wiley-Liss, Inc.     

A comparison of alternative assessments of depressive symptom severity: a pilot study

This study compared the performance of an itemized symptom self-report (Inventory of Depressive Symptomatology - Self-Report; IDS-SR), patient global ratings, and clinician global ratings with an itemized clinician-rated symptom severity measure (Inventory of Depressive Symptomatology - Clinician-Rated; IDS-C) in detecting treatment effects in patients with major depressive disorder (MDD). A total of 28 inpatients (30.8% psychotic) and 34 outpatients (17.9% psychotic) with MDD began treatment that followed the Texas medication algorithm. The clinicians completed the IDS-C and a Physician Global Rating Scale (PhGRS) at each assessment visit, while the patients completed the IDS-SR and a Patient Global Rating Scale (PtGRS). Change scores from the baseline to subsequent weeks were computed for all subjects, utilizing all four measures. The IDS-SR was a significant independent predictor of the response to treatment as compared to the two global ratings. The IDS-SR was as sensitive to change as the IDS-C. While the clinician-rated itemized symptom severity rating scale remains the standard to assess the symptomatic outcome of the treatment of MDD, a self-report of identical symptomatology may be a reasonable alternative for many patients.     

A comparison of alternative assessments of depressive symptom severity: a pilot study

This study compared the performance of an itemized symptom self-report (Inventory of Depressive Symptomatology - Self-Report; IDS-SR), patient global ratings, and clinician global ratings with an itemized clinician-rated symptom severity measure (Inventory of Depressive Symptomatology - Clinician-Rated; IDS-C) in detecting treatment effects in patients with major depressive disorder (MDD). A total of 28 inpatients (30.8% psychotic) and 34 outpatients (17.9% psychotic) with MDD began treatment that followed the Texas medication algorithm. The clinicians completed the IDS-C and a Physician Global Rating Scale (PhGRS) at each assessment visit, while the patients completed the IDS-SR and a Patient Global Rating Scale (PtGRS). Change scores from the baseline to subsequent weeks were computed for all subjects, utilizing all four measures. The IDS-SR was a significant independent predictor of the response to treatment as compared to the two global ratings. The IDS-SR was as sensitive to change as the IDS-C. While the clinician-rated itemized symptom severity rating scale remains the standard to assess the symptomatic outcome of the treatment of MDD, a self-report of identical symptomatology may be a reasonable alternative for many patients.     

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE: To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking. METHOD: A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents. RESULTS: Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment. CONCLUSIONS: Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.     

Revised Korean medication algorithm for bipolar disorder

The rapid progress in treatments for bipolar disorder makes it necessary to revise the Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) published in 2002. This study was performed to timely revise KMAP-BP 2002. A questionnaire comprising 37 questions and 645 treatment options was developed for surveying the opinions of Korean experts. We classified the opinions into three categories: first-, second-, and third-line treatments. Fifty-three (75.7%) of the 70 selected experts answered the questionnaire. For an acute manic episode, the combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP) was the preferred first-line treatment. Most experts recommended divalproex and lithium as MSs, and olanzapine, quetiapine, and risperidone as AAPs. For moderately to severely depressed bipolar patients, MS monotherapy and a combination of an MS and an antidepressant (AD) were considered to be preferred treatments respectively. A combination of an MS and an AD was the preferred strategy in severe nonpsychotic depression. Most ADs were rated as second-line drugs. Overall, the preference for lamotrigine and AAPs was higher than in KMAP-BP 2002. The algorithm was developed mainly using consensus among experts supplemented with findings of recent clinical trials to ensure that our algorithm was both up to date and balanced. These results suggest that the medication strategies of KMAP-BP are changing rapidly, reflecting recent studies and clinical experiences.     

Depressive symptoms amongst adolescent primary care attenders

Abstract. Background: Background High rates of depressive disorder have been documented amongst adolescents attending general practitioners (GPs) in urban areas. However, little is known about the associations of adolescent depression in primary care. Method: We completed a cross-sectional questionnaire survey of adolescents, their parents and general practitioners, following adolescent attendance at the surgery. Results: We found high levels of depressive symptoms to be present in adolescent attenders of a broad range of social backgrounds. Depressive symptoms were associated with the following demographic and contextual factors: older age, female gender and parental psychiatric symptoms. They were also associated with the presence of physical symptoms causing psychosocial impairment, with health risks (use of cannabis and exposure to drugs) and with use of services (both primary care and mental health services). Levels of depressive symptoms were similar in urban and suburban groups. However, associations of depressive symptoms with smoking, exposure to drugs, cannabis use and primary care attendance were demonstrated in the suburban group and not the urban group. Conclusion: Adolescent GP attenders have high levels of depressive symptomatology. GP recognition and intervention should have the potential to impact on adolescent depression and on associated risks.     

The Reliability and Validity of the Korean Version of the Mood and Feelings Questionnaire for Depression in Youth: A Cross-Cultural Perspective

We aimed to assess cross-cultural differences in depressive symptoms and the validity of the Korean version of the Mood and Feelings Questionnaire (MFQ). Four hundred and sixty-four children and adolescents (aged 7–19, 278 girls) with any psychiatric diagnosis, 290 of whom had major depressive disorder, were included. The levels of depressive symptoms in children and adolescents were evaluated by children/adolescents and their parents. We conducted Pearson’s r and Cronbach’s α, confirmative factor analysis and item response theory tests. The Korean version of the MFQ demonstrated excellent criterion validity and discriminant validity. There were no cultural differences in the clinical manifestations of depression in youth from Western countries and Korea. Korean youths with depression were more likely to complain of cognitive and emotional symptoms than somatic symptoms. The Korean version of the MFQ demonstrated promising psychometric properties in a clinical sample of children and adolescents.

     

The development of ICF Core Sets for multiple sclerosis: results of the International Consensus Conference

To systematically and comprehensively describe functioning and disability in Multiple sclerosis (MS), practical tools based on the International Classification of Functioning, Disability and Health (ICF), such as ICF Core Sets, are needed. Objective: to report on the results of an evidence-based International Consensus Conference to develop the Comprehensive and Brief ICF Core Set for MS. A formal and iterative decision-making and consensus process was undertaken, involving the integration of evidence from preparatory studies (expert survey, systematic literature review, qualitative study, empirical cross-sectional study) and expert opinion. The decision-making and consensus process included discussions and voting in working groups and plenary sessions involving selected international experts from different health professions. Twenty-one experts from 16 countries selected 138 ICF categories for the Comprehensive ICF Core for MS (40 Body functions, 7 Body structures, 53 Activities and Participation categories and 38 Environmental factors) and 19 categories for the Brief ICF Core Set for MS (8 Body functions, 2 Body structures, 5 Activities and Participation categories, 4 Environmental factors). An evidence-based and formal decision-making consensus process led to the approval of ICF Core Sets for MS which should be further validated.     

成人癫痫患者抑郁状况及其生态学执行功能特点

目的探讨成人癫痫患者抑郁状况及其生态学执行功能特点。方法应用汉密尔顿抑郁量表(HAMD)和执行功能行为评定量表成人自评问卷(BRIEF-A)对96例成人癫痫患者和54例性别、年龄、受教育程度等与之匹配的正常成人进行抑郁和生态学执行功能评定。结果癫痫患者抑郁障碍发生率明显高于正常对照组,差异有统计学意义(P0.01)。回归分析显示,经济收入、癫痫控制情况与癫痫伴发抑郁障碍显著相关(P0.01)。癫痫抑郁组和非抑郁组BRIEF-A总分及各因子得分均明显高于对照组,差异有统计学意义(P0.01);抑郁组除抑制、感情控制和组织3个因子外其它各因子得分均明显高于非抑郁组,差异有统计学意义(P0.05)。结论成人癫痫患者抑郁发生率高,伴发抑郁的癫痫患者生态学执行功能障碍更明显,临床上应重视癫痫合并抑郁的诊断和治疗。     

Phenomenology associated with age at onset in patients with bipolar disorder at their first psychiatric hospitalization

OBJECTIVE: To compare the clinical presentation of patients with early-onset (age <18 years) and typical-onset (age 20-30 years) bipolar disorder at the time of first hospitalization. METHODS: Patients, aged 12-45 years at their first psychiatric hospitalization, with a DSM-IV diagnosis of bipolar disorder, manic or mixed, were evaluated on measures of manic, depressive, and positive psychotic symptoms. Differences in symptom profiles between early- and typical-onset groups were examined. RESULTS: One hundred three early-onset and 58 typical-onset patients were compared. Mixed episodes were more common in the early-onset group, while psychotic features and current substance use were more common in the typical-onset group. There was no significant difference in manic symptom severity ratings between early- and typical-onset groups (F = 1.8, df = 11, 144, p = 0.06). However, these groups differed in depressive (F = 4.2, df = 16, 139, p < 0.001) and positive psychotic (F = 2.8, df = 16, 139, p = 0.001) symptom profiles. Typical-onset bipolar patients reported more severe weight loss and formal thought disorder compared with early-onset patients. CONCLUSIONS: Depressive and positive psychotic symptoms may differ in association with age at onset among patients with bipolar disorder. Additional studies are necessary to determine whether homogeneous phenotypes of bipolar disorder can be delineated based upon age at onset.     

Om final kausalitet

Background: The purpose was to present the prevalence of all psychotic and bipolar (BP) disorders in a total general population (n=3563), which has been followed from 1947 to 1997. Materials and Methods: Best-estimate consensus DSM-IV diagnoses, supported by data from interviews, case notes, registers and key-informants, were assessed. The period prevalence from 1947 to 1997 and the lifetime prevalence (LTP) in 1997, respectively, was calculated. Results: The period prevalence per 100 was: 4.24 for any psychotic or BP disorder, 2.25 for non-affective psychotic (NAP) disorder, 0.76 for psychotic disorder related to a general medical condition (GMC), 0.62 for affective psychotic (AP) disorder and 0.59 for substance-induced psychotic (SIP) disorder. The LTP per 100 was: 2.82 for any psychotic or BP disorder, 1.38 for NAP disorder, 0.54 for psychotic disorder related to a GMC, 0.48 for SIP disorder and 0.42 for AP disorder. The specific diagnosis with the highest period prevalence 1.43 per 100 and LTP 0.84 per 100, respectively, was schizophrenia. The LTP of psychotic disorder related to a GMC, SIP disorder, schizophrenia and delusional disorder, respectively, was higher than in most recent community studies while the LTP of brief psychotic disorder, schizophreniform disorder and AP disorder, respectively, was lower. However, the findings were in approximate accord with the estimates in the Psychoses in Finland (PIF) Study . Conclusions: The findings suggest that psychotic disorders are common in the community, and should be considered a major public health concern.