One-year costs of second-line therapies for depression

BACKGROUND: We compared patterns of medical resource utilization and costs among patients receiving a serotonin-norepinephrine reuptake inhibitor (venlafaxine), one of the selective serotonin reuptake inhibitors (SSRIs), one of the tricyclic agents (TCAs), or 1 of 3 other second-line therapies for depression. METHOD: Using claims data from a national managed care organization, we identified patients diagnosed with depression (ICD-9-CM criteria) who received second-line antidepressant therapy between 1993 and 1997. Second-line therapy was defined as a switch from the first class of antidepressant therapy observed in the data set within 1 year of a diagnosis of depression to a different class of antidepressant therapy. Patients with psychiatric comorbidities were excluded. RESULTS: Of 981 patients included in the study, 21% (N = 208) received venlafaxine, 34% (N = 332) received an SSRI, 19% (N = 191) received a TCA, and 25% (N = 250) received other second-line antidepressant therapy. Mean age was 43 years, and 72% of patients were women. Age, prescriber of second-line therapy, and prior 6-month expenditures all differed significantly among the 4 therapy groups. Total, depression-coded, and non-depression-coded 1-year expenditures were, respectively, $6945, $2064, and $4881 for venlafaxine; $7237, $1682, and $5555 for SSRIs; $7925, $1335, and $6590 for TCAs; and $7371, $2222, and $5149 for other antidepressants. In bivariate analyses, compared with TCA-treated patients, venlafaxine- and SSRI-treated patients had significantly higher depression-coded but significantly lower non-depression-coded expenditures. Venlafaxine was associated with significantly higher depression-coded expenditures than SSRIs. However, after adjustment for potential confounding covariables in multivariate analyses, only the difference in depression-coded expenditures between SSRI and TCA therapy remained significant. CONCLUSION: After adjustment for confounding patient characteristics, 1-year medical expenditures were generally similar among patients receiving venlafaxine, SSRIs, TCAs, and other second-line therapies for depression. Observed differences in patient characteristics and unadjusted expenditures raise questions as to how different types of patients are selected to receive alternative second-line therapies for depression.     

Cognitive therapies of depression

Among brief psychotherapies of depression, cognitive therapy, a theoretical model which was proposed by A.T. Beck as early as the sixties, holds that depression comes from a distorted view of the environment: depressed patients view themselves, the world and the future negatively (cognitive triad). This conception is based upon cognitions, preconscious schemes and faulty information processing, that cognitive therapy corrects, using in a pragmatic way cognitive and behavioral techniques requiring an active collaboration of the patient. Cognitive therapy is indicated, alone or combined with anti-depressants, in neurotic depressions (DSM-II) and in most of major depressions (DSM-III) treated on an outpatient basis. Comparative outcome studies prove the effectiveness of cognitive therapy.     

Translating depression biomarkers for improved targeted therapies

Mood disorders are among the most common medical conditions and cause amongst the greatest disease burden. Currently approved antidepressants target monoamine pathways; these medicines take many weeks to relieve symptoms, and most patients do not have sustained responses. This review will highlight recent advances in translational science identifying dysfunctional biochemical processes and neuronal circuits associated with mood disorders. We will also summarize strategies for targeting these pathways and for enhancing synaptic plasticity to develop most effective and rapidly acting antidepressant therapies.     

Potential mechanisms of the sleep therapies for depression

Sleep deprivation for one night has been investigated as a treatment for depression since the first publications describing its antidepressant properties almost 30 years ago [Pflug and Tolle, 1971: Int Pharmacopsychiatry 6:187-196]. It remains a field of active research. It is the only intervention consistently demonstrated to produce next-day antidepressant results. This makes sleep deprivation an exciting and unique tool to study the pathophysiology of depressive disorders and to formulate targets for novel antidepressant agents. Importantly, it is also an effective, but underused, clinical treatment for unipolar and bipolar depression.     

The sleep therapies of depression

This paper reviews five different types of deliberate sleep-wake manipulations which are reported to have antidepressant effects: total sleep deprivation, partial sleep deprivation, a phase advance of the sleep periods, and REM deprivation. The effects of total sleep deprivation are best documented. Of 852 depressed patients studied, 493 or 57.9% improved following sleep deprivation. The REM deprivation procedure acts more slowly, but is of more lasting clinical value than the other forms. Partial sleep deprivation during the second half of the night may be as good as total sleep deprivation and better tolerated. The findings are reviewed in terms of psychological, neurophysiological, biochemical, and chronobiological perspectives.     

卒中后抑郁的非药物治疗研究进展

本文目的是对卒中后抑郁(PSD)的非药物治疗方法及其效果进行综述,以期为PSD患者的综合治疗提供参考。PSD是脑卒中的常见并发症,严重影响患者康复及日常生活,给患者及家庭带来沉重的负担。非药物治疗是改善PSD患者的重要干预手段,故本文对非药物治疗中的心理治疗和物理治疗进行综述。     

Three-year outcomes for maintenance therapies in recurrent depression

We conducted a randomized 3-year maintenance trial in 128 patients with recurrent depression who had responded to combined short-term and continuation treatment with imipramine hydrochloride and interpersonal psychotherapy. A five-cell design was used to determine whether a maintenance form of interpersonal psychotherapy alone or in combination with medication could play a significant role in the prevention of recurrence. A second question was whether maintaining antidepressant medication at the dosage used to treat the acute episode rather than decreasing to a "maintenance" dosage would provide prophylaxis superior to that observed in earlier trials in which a maintenance dosage strategy was employed. Survival analysis demonstrated a highly significant prophylactic effect for active imipramine hydrochloride maintained at an average dose of 200 mg and a modest prophylactic effect for monthly interpersonal psychotherapy. We conclude that active imipramine hydrochloride maintained at an average dose of 200 mg is an effective means of preventing recurrence and that monthly interpersonal psychotherapy serves to lengthen the time between episodes in patients not receiving active medication.     

Problem solving therapies for depression: a meta-analysis.

PURPOSE: In the past decades, the effects of problem-solving therapy (PST) for depression have been examined in several randomized controlled studies. However, until now no meta-analysis has tried to integrate the results of these studies. METHODS: We conducted a systematic literature search and identified 13 randomized studies examining the effects of PST, with a total of 1133 subjects. The quality of studies varied. RESULTS: The mean standardized effect size was 0.34 in the fixed effects model and 0.83 in the random effects model, with very high heterogeneity. Subgroup analyses indicated significantly lower effects for individual interventions in studies with subjects who met criteria for major depression, studies in which intention-to-treat analyses were conducted instead of completers-only analyses, and studies with pill placebo and care-as-usual control groups. Heterogeneity was high, and the subgroup analyses did not result in clear indications of what caused this high heterogeneity. This indicates that PST has varying effects on depression, and that it is not known to date what determines whether PST has larger of smaller effects. CONCLUSION: Although there is no doubt that PST can be an effective treatment for depression, more research is needed to ascertain the conditions and subjects in which these positive effects are realized.     

Five-year outcome for maintenance therapies in recurrent depression.

After conducting a randomized, 3-year maintenance trial in 128 patients with recurrent depression who had responded to combined short-term and continuation treatment with imipramine hydrochloride and interpersonal psychotherapy, we asked those individuals who survived the 3-year trial receiving active medication (with or without psychotherapy) to continue in a 2-year additional randomized trial of active medication vs placebo. The question was whether maintaining antidepressant medication at the dosage used to treat the acute episode beyond 3 years would continue to provide a significant prophylactic effect compared with medication discontinuation after the 3 years of effective maintenance treatment. Survival analysis demonstrated a highly significant continued prophylactic effect for active imipramine hydrochloride treatment maintained at an average dose of 200 mg. We conclude that active imipramine treatment is an effective means of preventing recurrence beyond 3 years and that patients with previous episodes less than 2 1/2 years apart, therefore, merit continued prophylaxis for at least 5 years.     

Somatic therapies for treatment-resistant depression: new neurotherapeutic interventions.

This brief review provides an overview of neurotherapeutic interventions for major depression that are available currently or are being studied in clinical trials. The growing utility of surgical and device-related treatments for psychiatric conditions may represent a sea change in the field of psychiatry comparable to that seen in other clinical disciplines. For example, for many years the overwhelming majority of cardiac conditions were treated with medications and behavioral interventions. With the advent of cardiac surgical procedures such as ablation and cardiac bypass surgery and the use of devices such as cardiac stents and pacemakers, the ability to treat cardiac disease has improved dramatically. The hope is that the use of neurotherapeutic interventions will lead to a similar improvement in the treatment of psychiatric illness. The future of neurotherpeutic interventions in psychiatry may include the use of neuroimaging technology to predict with patients may respond to which procedures or to guide the placement of DBS electrodes on an individual basis. DBS electrodes also could be placed in multiple brain regions. Clinical trials of cortical stimulation using surgically implanted electrodes on the brain surface are underway. These cortical-surface electrodes could provide cortical stimulation comparable to that induced by rTMS at the same location, obviating the need for visits to a physician for rTMS treatments and providing cortical stimulation of a greater magnitude and for an extended duration. Also, one can foresee surgical interventions in which neurotransmitter release is potentiated either by stimulating appropriate nuclei in the brain or by releasing neurotransmitters or neurotransmitter precursors into target brain regions using cannulae or an implanted device. Neurotrophic factors also could be introduced into target brain regions using analogous techniques. Although the future of neurotherapeutic interventions in psychiatry is hard to predict, it is clear that these treatments will have a growing role in the field.     

Treatment of bipolar depression: focus on pharmacologic therapies

Recent studies have highlighted significant limitations in our capacity to effectively treat bipolar depression. This article reviews the present status of treatments for this condition, highlighting emerging new pharmacotherapies such as lamotrigine, olanzapine and quetiapine, while also addressing modern psychologic interventions such as cognitive behavioral therapy and psychoeducation. The role of older treatments such as lithium and the antidepressants is also discussed, particularly as a recent meta-analysis has thrown into question current heightened concern over antidepressant-induced mania. The advent of new pharmacologic and psychologic treatments provides optimism for improved outcomes for this highly disabling condition.     

Post-schizophrenic depression]

The post-psychotic depression is a very controversial subject in psychiatry. Among the authors who have dealt with post-psychotic depression there is no general agreement on the topic ; their point of views can be summarized as follows: -- It is a phenomenon which can be regularly observed and which is a phase of psychotic evolution. -- It can be considered only as a phase which is secondary neuroleptic administration. -- The depressive mood as one which had always been present but hidden by the acute psychotic phenomena and thus not observable. -- It is a consequence of an intensive psychotherapeutic approach. This paper summarizes the literature concerning the above-mentioned point of views.     

Active music therapy for senile depression]

68 cases with senile depression were divided randomly into two groups--test group and control group. Patients of both groups received same antidepressive drugs while for the patients in the test group active music therapy was provided everyday in addition and the course of music therapy was 8 weeks. Patients in the test group showed improvement of their symptoms at the end of first week while most patients in the control group were getting somewhat better at the 3rd-4th week. The effectiveness of combined treatment in the test group is better than that in the control group. Patients in the test group became calm and active and the atmosphere on the ward appeared to be somewhat harmonized so that it was beneficial to the nursing care.