A retrospective follow-up study of body dysmorphic disorder

BACKGROUND: Although research on body dysmorphic disorder (BDD) is increasing, no follow-up studies of this disorder's course of illness have been published. METHODS: The status of 95 outpatients with BDD treated in a clinical practice was assessed by chart review. Standard scales were used to rate subjects at baseline and the most recent clinic visit (mean duration of follow-up, 1.7 +/- 1.1; range, 0.5-6.4 years). Ratings were also done at 6-month intervals over the first 4 years of follow-up. RESULTS: Allowing for censoring, life table analysis estimated that the proportion of subjects who achieved full remission from BDD at the 6-month and/or 12-month assessment was 24.7%; the proportion who attained partial or full remission at 6 months and/or 12 months was 57.8%. After 4 years of follow-up, 58.2% had experienced full remission, and 83.8% had experienced partial or full remission, at one or more 6-month assessment points. Of those subjects who attained partial or full remission at one or more assessment points, 28.6% subsequently relapsed. Between baseline and the most recent assessment, BDD severity and functioning significantly improved: at the most recent assessment, 16.7% of subjects were in full remission, 37.8% were in partial remission, and 45.6% met full criteria for BDD. Greater severity of BDD symptoms and the presence of major depression or social phobia at baseline were associated with more severe BDD symptoms at study end point. All subjects received at least one medication trial, and 34.3% received some type of therapy during the follow-up period. CONCLUSIONS: A majority of treated patients with BDD improved, although improvement was usually partial. Prospective longitudinal studies are needed to further elucidate the course of BDD.     

Personality disorder assessments in acute depressive episodes: stability at follow-up

Assessment of personality disorders during the acute phase of major depression may be invalidated by the potential distortion of personality traits in depressed mood states. However, few studies have tested this assumption. We examined the stability of personality disorder diagnoses during and then after a major depressive episode (MDE). Subjects with major depression (N = 82) completed the 17-item Hamilton Depression Scale (HAM-17) and the Structured Clinical Interview for Axis II both at baseline during an MDE and at 3-month follow-up. We compared subjects who continued to meet DSM-IV criteria for the same Axis II diagnoses with patients whose diagnosis changed and patients with no DSM-IV personality disorder to determine the relationship to major depression and its severity. Sixty-six percent of subjects met DSM-IV criteria for at least one Axis II diagnosis at baseline and 80% had the same personality disorder diagnoses at follow-up. Thirty-four percent had a full remission of MDE at 3-month follow-up. Instability of Axis II diagnosis was associated with number of Axis II diagnoses at baseline (p = .036) and Hispanic ethnicity (p = .013). HAM-17 score change was unrelated to differences in the number of symptoms of personality disorders from baseline to follow-up, nor was remission from MDE on follow-up. Axis II diagnoses in acutely depressed patients reassessed after 3 months are often stable and not associated with remission of or improvement in major depression.     

Reciprocal relationship between pain and depression in elderly Chinese primary care patients

BACKGROUND: Pain and depression are common in old age but the reciprocal relationship between pain and depression has not been established in a single study. Moreover, few studies have addressed this issue in a primary care setting. The purposes of this study were to examine the reciprocal relationship between pain and depression and to identify whether social support, functional disability or social functioning mediated the link between pain and depression among Hong Kong Chinese elderly primary care patients. METHOD: Subjects were 318 patients assessed by a trained assessor with MDS-HC at baseline and these subjects were randomly selected from attendants of three randomly selected elderly health centers in Hong Kong. These patients were re-assessed one year after baseline evaluation. RESULTS: Multiple regression analyses revealed that pain at baseline significantly predicted depression at 12-month follow-up assessment when age, gender, martial status, education, and depression at baseline were adjusted for, but depression at baseline was not associated with pain at 12-months after baseline measure while controlling for age, gender, martial status, education, and pain at baseline. However, depression did predict the onset of pain. Moreover, social support, physical disability or social functioning did not mediate the impact of pain on depression. CONCLUSIONS: These data suggest that pain is an important predictor of depression in elderly primary care patients. Therefore, aged care service practitioners must take this risk factor into consideration in their preventive intervention and treatment for psychological well-being.     

Importance of subsyndromal symptoms of depression in elderly patients.

OBJECTIVE: There is a debate about the importance of subsyndromal symptoms of depression (SSD). The current study examined the cross-sectional and longitudinal significance of SSD in geriatric subjects both with and without a past history of major depression. METHODS: Elderly primary-care subjects with SSD, both with (SSD+; N=54) and without (SSD-; N=204) a history of major depression, were compared with subjects with major depression (MDD; N=111), minor depression (MinD; N=74), and symptom-free comparison subjects (N=59). Assessment domains included physical and psychological disability, health-care utilization, hopelessness, death and suicidal ideation, and a diagnostic evaluation at a 3-month follow-up. RESULTS: Both subjects with SSD+ and SSD- differed from the symptom-free comparison subjects on measures of psychological disability, hopelessness, and death ideation, with SSD+ subjects being more severely psychologically disabled than SSD- subjects. There were few differences between SSD+ and MinD subjects or those with MDD, except on measures of psychological disability. Finally, more than 24% of SSD+ subjects progressed to meet criteria of MDD, MinD, or dysthymia over a 3-month period. Utilization of outpatient services did not differ among any of the depression groups or comparison subjects. CONCLUSIONS: SSD (with or without a past history of MDD) is associated with significant disability. Moreover, the risk of developing a diagnosis of MDD, MinD, or dysthymia is substantially elevated in subjects with a past history of MDD.     

Relationships between major depressive disorder and comorbid anxiety and personality disorders

OBJECTIVE: The aim of the study was to examine whether comorbid anxiety disorders influence depressed patients' likelihood of meeting criteria for a personality disorder (PD) and whether comorbid anxiety disorders influence the stability of the PDs in patients with remitted depression. METHODS: The initial sample consisted of 373 outpatients who met criteria for major depressive disorder (MDD) (by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition-Patient Edition) and who were enrolled in the 8-week acute treatment phase of a study of fluoxetine for MDD. Sixty-four subjects who responded to fluoxetine treatment in the acute phase met criteria for remission throughout a 26-week continuation phase during which they remained on fluoxetine with or without cognitive behavioral therapy. Stability of PDs was defined as meeting criteria for a PD at both beginning and end point of the continuation treatment phase. RESULTS: Before fluoxetine treatment, anxious depressed patients (defined as meeting criteria for MDD as well as at least one comorbid anxiety disorder) were significantly more likely to meet criteria for any comorbid PD diagnosis compared with depressed patients without comorbid anxiety disorders. In particular, there was a significant relationship between the presence of Cluster A and C PDs and the presence of anxious depression at baseline before antidepressant treatment. After successful treatment of MDD, we found a significant relationship between anxious depression diagnosed at baseline and the stability of a Cluster C PD diagnosis. CONCLUSION: Anxious depression may place patients at greater risk of having a PD diagnosis, especially one from Cluster A or C. Once the depression remits, patients who initially met criteria for anxious depression may be more likely to maintain a Cluster C PD diagnosis compared with patients initially diagnosed with MDD alone.     

Severity and comorbidity predict episode duration and recurrence of DSM-IV major depressive disorder

BACKGROUND: Information on the naturalistic outcome of major depressive disorder (MDD) is important in developing rational clinical practices. The aim of this study was to determine the outcome of MDD in a modern secondary-level psychiatric setting and the influence of comorbidity plus psychosocial factors on the outcome of MDD. METHOD: The Vantaa Depression Study is a prospective, naturalistic cohort study of 269 secondary-level care psychiatric outpatients and inpatients diagnosed with a new episode of DSM-IV MDD. Patients were initially interviewed to determine the presence of MDD using the World Health Organization Schedule for Clinical Assessment in Neuropsychiatry and to assess Axis II diagnoses using the Structured Clinical Interview for DSM-III-R personality disorders between February 1, 1997, and May 31, 1998, and were interviewed again at 6 months and 18 months. The exact duration of the index episode and the timing of relapses/recurrences were examined using a life chart. RESULTS: The median length of time that patients met full criteria for a major depressive episode was 1.5 (95% CL = 1.3 to 1.7) months, and the median time to full remission was 8.1 (95% CL = 5.2 to 11.0) months after entry. During the follow-up, 38% of patients had a recurrence. Although numerous factors predict outcome of MDD to some extent, severity of depression and current comorbidity were the 2 most important predictors of longer episode duration and recurrence. CONCLUSION: The course of MDD in modern psychiatric settings remains unfavorable. Any estimates of duration of depressive episodes and rates of recurrence are likely to be dependent on the severity of depression and level of comorbidity. At least among a population of mostly outpatients with MDD in medium-term follow-up, severity of depression and comorbidity appear to be more useful predictors of recurrence than does the number of prior episodes. These factors should influence clinical decision-making regarding the need for maintenance therapy.     

Predicting 6-week treatment response to escitalopram pharmacotherapy in late-life major depressive disorder

OBJECTIVE: Approximately half of older patients treated for major depressive disorder (MDD) do not achieve symptomatic remission and functional recovery with first-line pharmacotherapy. This study aims to characterize sociodemographic, clinical, and neuropsychologic correlates of full, partial, and non-response to escitalopram monotherapy of unipolar MDD in later life. METHODS: One hundred and seventy-five patients aged 60 and older were assessed at baseline on demographic variables, depression severity, hopelessness, anxiety, cognitive functioning, co-existing medical illness burden, social support, and quality of life (disability). Subjects received 10 mg/d of open-label escitalopram and were divided into full (n = 55; 31%), partial (n = 75; 42.9%), and non-responder (n = 45; 25.7%) groups based on Hamilton depression scores at week 6. Univariate followed by multivariate analyses tested for differences between the three groups. RESULTS: Non-responders to treatment were found to be more severely depressed and anxious at baseline than both full and partial responders, more disabled, and with lower self-esteem than full responders. In general partial responders resembled full responders more than they resembled non-responders. In multivariate models, more severe anxiety symptoms (both psychological and somatic) and lower self-esteem predicted worse response status at 6 weeks. CONCLUSION: Among treatment-seeking elderly persons with MDD, higher anxiety symptoms and lower self-esteem predict poorer response after six weeks of escitalopram treatment.     

Major depression in elderly home health care patients

OBJECTIVE: Despite the growth of geriatric home health services, little is known about the mental health needs of geriatric patients seen in their homes. The authors report the distribution, correlates, and treatment status of DSM-IV major depression in a random sample of elderly patients receiving home health care for medical or surgical problems. METHOD: Geriatric patients newly admitted to a large, traditional visiting nurse agency were sampled on a weekly basis over a period of 2 years. The 539 patients ranged in age from 65 to 102 years; 351 (65%) were women, and 81 (15%) were nonwhite. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to interview patients and informants. The authors reviewed the results of these interviews plus the patients' medical charts to generate a best-estimate DSM-IV psychiatric diagnosis. RESULTS: The patients had substantial medical burden and disability. According to DSM-IV criteria, 73 (13.5%) of the 539 patients were diagnosed with major depression. Most of these patients (N=52, 71%) were experiencing their first episode of depression, and the episode had lasted for more than 2 months in most patients (N=57, 78%). Major depression was significantly associated with medical morbidity, instrumental activities of daily living disability, reported pain, and a past history of depression but not with cognitive function or sociodemographic factors. Only 16 (22%) of the depressed patients were receiving antidepressant treatment, and none was receiving psychotherapy. Five (31%) of the 16 patients receiving antidepressants were prescribed subtherapeutic doses, and two (18%) of the 11 who were prescribed appropriate doses reported not complying with their antidepressant treatment. CONCLUSIONS: Geriatric major depression is twice as common in patients receiving home care as in those receiving primary care. Most depressions in patients receiving home care are untreated. The poor medical and functional status of these patients and the complex organizational structure of home health care pose a challenge for determining safe and effective strategies for treating depressed elderly home care patients.     

Longitudinal comparison of depressive personality disorder and dysthymic disorder

BACKGROUND: Few studies have compared the related diagnostic constructs of depressive personality disorder (DPD) and dysthymic disorder (DD). The authors attempted to replicate findings of Klein and Shih in longitudinally followed patients with personality disorder or major depressive disorder (MDD) in the Collaborative Longitudinal Personality Disorders Study. METHODS: Subjects (N = 665) were evaluated at baseline and over 2 years (n = 546) by reliably trained clinical interviewers using semistructured interviews and self-report personality questionnaires. RESULTS: Only 44 subjects (24.6% of 179 DPD and 49.4% of 89 early-onset dysthymic subjects) met criteria for both disorders at baseline. Depressive personality disorder was associated with increased comorbidity of some axis I anxiety disorders and other axis II diagnoses, particularly avoidant (71.5%) and borderline (55.9%) personality disorders. Depressive personality disorder was associated with low positive and high negative affectivity on dimensional measures of temperament. Depressive personality disorder subjects had lower likelihood of remission of baseline MDD at 2-year follow-up, whereas DD subjects did not. The DPD diagnosis appeared unstable over 2 years of follow-up, as only 31% (n = 47) of 154 subjects who had DPD at baseline and also had follow-up assessment met criteria on blind retesting. LIMITATIONS: Results from this sample may not generalize to other populations. CONCLUSIONS: Depressive personality disorder and dysthymic disorder appear to be related but differ in diagnostic constructs. Its moderating effect on MDD and predicted relationship to measures of temperament support the validity of DPD, but its diagnostic instability raises questions about its course, utility, and measurement.     

Problem-solving ability and comorbid personality disorders in depressed outpatients

Major depressive disorder (MDD) is associated with poor problem-solving abilities. In addition, certain personality disorders (PDs) that are common among patients with MDD are also associated with limited problem-solving skills. Attempts to understand the relationship between PDs and problem solving can be complicated by the presence of acute MDD. Our objective in this study was to investigate the relationships between PDs, problem-solving skills, and response to treatment among outpatients with MDD. We enrolled 312 outpatients with MDD in an open, fixed-dose, 8-week fluoxetine trial. PD diagnoses were ascertained via structured clinical interview before and after fluoxetine treatment. Subjects completed the Problem-Solving Inventory (PSI) at both time points. We used analyses of covariance (ANCOVAs) to assess relationships between PD diagnoses and PSI scores prior to treatment. Subjects were divided into three groups: those with PD diagnoses that remained stable after fluoxetine treatment (N=91), those who no longer met PD criteria after fluoxetine treatment (N=119), and those who did not meet criteria for a PD at any time point in the study (N=95). We used multiple chi(2) analyses to compare rates of MDD response and remission between the three PD groups. ANCOVA was also used to compare posttreatment PSI scores between PD groups. Prior to fluoxetine treatment, patients with avoidant, dependent, narcissistic, and borderline PDs reported significantly worse problem-solving ability than did patients without any PDs. Only subjects with dependent PD remained associated with poorer baseline problem-solving reports after the effects of baseline depression severity were controlled. Patients with stable PD diagnoses had significantly lower rates of MDD remission. Across PD groups, problem solving improved as MDD improved. No significant differences in posttreatment problem-solving were found between PD groups after controlling for baseline depression severity, baseline PSI score, and response to treatment. Treatment with fluoxetine is less likely to lead to remission of MDD in patients with stable PDs. More study is needed to investigate causal links between PDs, problem solving, and MDD treatment response.     

Quality of life in major depressive disorder: the role of pain and pain catastrophizing cognition

ObjectivePain symptoms are frequent complaints in patients with major depressive disorder (MDD). Although it is known that pain intensity and pain-related cognition predict quality of life (QOL) in patients with chronic pain, limited studies have examined their roles in MDD. The study aimed to determine whether pain and pain catastrophizing were independent predictors of QOL in MDD after accounting for the impact of anxiety and depression.MethodsThis is a prospective, naturalistic follow-up study. Ninety-one Chinese patients were enrolled during an acute episode of MDD, 82 of them were reassessed 3 months later using the same assessment on pain, anxiety, depression, and QOL. Pain intensity was evaluated using a verbal rating scale and a visual analog scale. Quality of life was assessed using the 36-item Short Form Health Survey. Pain-related cognition was assessed at baseline with the Pain Catastrophizing Scale.ResultsThere was significant improvement in pain, anxiety, depression, and QOL from baseline to 3-month follow-up. Hierarchical regression analyses showed that pain intensity was significantly associated with QOL at baseline and 3 months. Pain complaint was more important than anxiety and depressive symptoms in predicting changes in both physical and psychosocial domains of QOL. After controlling for the severity of pain, anxiety, and depression, Pain Catastrophizing Scale score was independently associated with QOL in MDD.ConclusionThe study supports the specific role of pain and pain-related cognition in predicting QOL in depressed patients. Further studies targeting pain-related cognition for improving the outcome of MDD are necessary.     

Predictors of 1-year outcome in depression

OBJECTIVE: We compared several different methods for assessing depression 'recovery' over a 1-year review interval, to determine the utility of the contrasting approaches. Second, we assessed baseline predictors of 1-year outcome and recovery status. Third, we examined the extent to which predictors showed consistency across the variable definitions of outcome and recovery. METHODS: Twelve-month outcome was assessed in a sample of 182 subjects who at baseline assessment met DSM criteria for a major depressive episode. The contrasting methods involved a defined percentage reduction in Beck Depression Inventory self-rating scores, formalised change point definitions, no longer meeting DSM-IV major depression criteria, and clinical global improvement (CGI) ratings. RESULTS: Sixty-one per cent reached formalised change point criteria for full remission or recovery when trajectories across the 12-month interval were examined. Other measures quantified recovery rates ranging from 43% to 70%. Those with a psychotic or melancholic depression were more likely to have achieved recovery status in some analyses. Non-recovery at 12 months was predicted most consistently by higher baseline levels of anxiety and depression; high trait anxiety and a lifetime anxiety disorder; disordered personality function; and having reported exposure to acute and enduring stressors at baseline assessment. CONCLUSIONS: While the CGI was the superior system in terms of number of significant discriminating predictors of outcome, the change point definitional approach provides much greater information across the follow-up interval, arguing for their complementary utility. As several currently identified baseline predictors of outcome (i.e. anxiety, disordered personality function) also predicted onset of depression, their relevance as both depression-inducing and depression-propagating variables is suggested.     

The role of depression chronicity and recurrence on neurocognitive dysfunctions in HIV-infected adults

Research assessing whether major depressive disorders (MDD) impacts neurocognitive functions in HIV+ persons has yielded inconsistent results. However, none have considered the role of MDD remission, chronicity, and stability on treatment. Ninety-five HIV+ adults clinically stable on combined antiretroviral treatment completed a psychiatric interview, a depression scale, a neuropsychological, daily living, and cognitive complaints assessments at baseline and 18 months. Participants were screened for current (within 12 months of study entry) alcohol and/or substance use disorder. History of alcohol and/or substance abuse disorder prior to the 12 months entry screen and MDD treatments were recorded. Participants were grouped into two psychiatric nomenclatures: (1) lifetime: no MD episode (MDE), single MDE life-event treated and fully remitted, chronic MDD treated and stable, chronic MDD treated and unstable, and baseline untreated MDE; (2) recent: last 2 years MDE (yes or no). We found that lifetime and recent psychiatric history were more strongly associated with decreased in independence in daily living and cognitive complaints than with baseline neuropsychological performance. However, lack of full remission, instability on treatment in chronic MDD, and severity of symptoms in current MDE were factors in whether MDD impacted baseline neuropsychological performance. Depressive symptoms improved at follow-up in those with baseline moderate-severe symptoms, and MDD was not associated with neurocognitive change at 18 months. A history of alcohol and/or substance abuse disorder was significantly more frequent in those with treated and unstable chronic MDD but it was not associated with neuropsychological performance. MDD recurrence, chronicity profiles, and associated comorbidities are keys factors to understand any potential impact on neurocognitive abilities in HIV infection. More comprehensive consideration of these complex effects could serve at constructively updating the HAND diagnostic criteria.     

Diagnosis of co-morbid axis-I psychiatric disorders among women with newly diagnosed,untreated endocrine disorders

Abstract

Objectives. To determine the prevalence of major depressive disorder (MDD) and other selected axis-I disorders among women with newly diagnosed, untreated endocrine disorders. Methods. Two hundred and eighteen consecutive women, aged 18–65, with newly diagnosed, untreated endocrine disorders were referred for potential diagnosis of co-morbid axis-I disorders with the use of the Structured Clinical Interview for Axis I-Patient Edition (SCID-P). The SCID-P was re-administered after 12 weeks. Results. At baseline, 64 (29.3%) women met criteria for at least one axis-I disorder. Women who were diagnosed with hyperthyroidism were more likely to meet criteria for generalized anxiety disorder and panic disorder than women without hyperthyroidism. Nine of 154 (5.8 %) women who did not meet criteria for an axis-I disorder at baseline met criteria for at least one axis-I disorder during follow-up. Among them, the presence of diabetes mellitus was statistically correlated with a higher probability of developing major depressive disorder at follow-up. Conclusions. Although preliminary, our findings are consistent with previous studies and suggest an increased prevalence of MDD and other axis-I disorders among women with newly diagnosed endocrine disorders, providing further evidence suggesting that women with endocrine abnormalities may be at increased risk of depression and/or anxiety disorders.     

Response speed and rate of remission in primary and specialty care of elderly patients with depression.

OBJECTIVE: Depression treatment in primary care elderly patients has been inadequate, resulting in low rates of response and remission. The authors compared treatment remission rates and time-to-remission of elderly subjects enrolled in two ongoing depression treatment studies, one in primary care practices ("PROSPECT") and the other in an academic tertiary mental health care center ("MTLD-2"), in order to assess the value of standardizing and intensifying depression treatment in primary care elderly patients. METHODS: Authors compared remission rates and time to criterion endpoints via survival analysis. The 126 PROSPECT subjects (mean age 71) included primary care patients with either current episodes of major depression or minor depression. The 129 MTLD-2 subjects (mean age 77) had single or recurrent unipolar major depression. PROSPECT subjects received a variety of open treatments, including the drug citalopram and/or interpersonal psychotherapy (IPT). Both patient and provider preferences influenced treatment selected. MTLD-2 subjects received more structured, open paroxetine treatment and IPT. RESULTS: The remission rates of PROSPECT and MTLD-2 were 86.5% and 88.4%, respectively. Median time-to-remission in PROSPECT was significantly longer than in MTLD-2 (12 weeks versus 8.7 weeks). Limiting the survival analysis to subjects with major depression produced faster attainment of remission criteria. CONCLUSION: Notwithstanding these differences in speed and rate of symptom resolution, good treatment can work well in geriatric depression in the primary care sector.     

Cost-utility of 2 maintenance treatments for older adults with depression who responded to a course of electroconvulsive therapy: results from a decision analytic model.

OBJECTIVE: The prevalence of major depressive disorder (MDD) in community-dwelling elderly populations is 1% to 3%. After initial treatment of the acute phase of depression, only about 25% to 30% of elderly patients remain well after 1 to 3 years of follow-up. Previous studies suggested that patients who received maintenance electroconvulsive therapy (MECT) demonstrated lower relapse rates, a better subjective sense of well-being, and lower health care costs at 12-month follow-up. This study provides a cost-utility analysis of 2 maintenance treatments for recurrent depression in elderly patients. METHOD: We used a Markov decision model to compare maintenance pharmacotherapy (MPT) with MECT in a theoretical cohort of elderly individuals with MDD who responded to an initial course of ECT. We estimated total costs and total quality-adjusted life years (QALYs) for each strategy as well as the cost per QALY. RESULTS: The model produced a cost per patient of dollar 436,102 for MPT and dollar 281,356 for MECT. The MPT strategy yielded 7.55 QALYs and the MECT strategy yielded 11.43 QALYs. Therefore, MPT cost dollar 57,762 per QALY and MECT cost dollar 24,616 per QALY. CONCLUSION: Our model suggests that MECT may be more cost-effective than MPT in the maintenance treatment of older adults with depression who have responded to a course of acute ETC.     

Chronic pain and major depressive disorder in the general population

This study aims (1) to assess the prevalence of Chronic Painful Physical Condition (CPPC) and major depressive disorder (MDD) in the general population; (2) to evaluate their interaction and co-morbidity with sleep and organic disorders; and (3) to investigate their daily functioning and socio-professional consequences. A random sample of 3243 subjects (?18 years), representative of California inhabitants, was interviewed by telephone. CPPC duration was at least 6 months. Frequency, severity, duration and consequences on daily functioning, consultations, sick leave and treatment were investigated. MDD were assessed using DSM-IV criteria. The point prevalence of CPPC was 49% (95% confidence interval: 47.0-51.0%). Back area pain was the most frequent; 1-month prevalence of MDD was at 6.3% (95% CI: 5.5-7.2%); 66.3% of MDD subjects reported at least one CPPC. In 57.1% of cases, pain appeared before MDD. Pain severity was increased by poor sleep, stress and tiredness in MDD subjects. Being confined to bed, taking sick leave and interference of pain with daily functioning were twice as frequent among MDD subjects with CPPC than in non-MDD subjects with CPPC; obese individuals with CP were 2.6 times as likely to have MDD. Pain is highly linked with depressive disorder. It deteriorates physical, occupational and socio-professional activities. Pain and sleep disturbances are a prime motive of consultation rather than depressed mood, underlining the risk of missing a depression diagnosis.     

Medication use patterns and two-year outcome in first-admission patients with major depressive disorder with psychotic features

OBJECTIVE: This study examined the patterns and predictors of medication use and 24-month course/outcome in first-admission patients with major depressive disorder with psychotic features (MDD/P). METHOD: An epidemiological sample of 87 first-admission patients with research diagnoses of MDD/P received intensive clinical assessments at baseline and at 6- and 24-month follow-ups and telephone assessments at 3-month intervals. Use of medications (antidepressant [AD], antipsychotic [AP], and antimanic agents) was determined from self-reports corroborated by external sources where possible. Outcome was assessed with the Global Assessment of Functioning and consensus evaluations of illness course and time in remission. RESULTS: More patients received APs (77.0%) than ADs (57.5%) at discharge, with almost half (49.4%) receiving these in combination. At 24-month follow-up, 40.2% reported using no medications; 39.1% used ADs, and 32.2% used APs. Only early AD use predicted regular AD use during the 6- to 24-month follow-up. A minority (29%) achieved functional recovery (Global Assessment of Functioning score > or = 71) by 24 months. Although about 60% of the sample achieved a period of complete remission by 24 months, only about 40% had a sustained remission for at least 19 months. Medication use was not predictive of these outcome measures. There was little evidence that changes in medication, augmentation strategies, or electroconvulsive therapy was used to reduce symptoms during the 24-month follow-up. Fewer than half of our subjects received a MDD/P clinical diagnosis at discharge, which appeared to influence medication use patterns over the 24-month follow-up. CONCLUSIONS: These findings suggest that for most of these patients with MDD/P, outcome was suboptimal for both functional and syndromal recovery. The lack of an association between medication use and outcome suggests that medication changing and augmentation strategies, electroconvulsive therapy use, and/or strategies to improve medication adherence might be considered in the treatment of patients with MDD/P who remain low functioning and symptomatic even while receiving pharmacotherapy. Finally, our findings highlight the need for routine systematic diagnostic procedures to ensure appropriate diagnosis and treatment of MDD/P at first admission as well as the need for replication of our findings in a more contemporary sample.     

Predictors of fluoxetine remission for hospitalized patients with major depressive disorder

Aim: The goal of treating major depressive disorder is to achieve remission. This prospective study aimed to identify predictors of remission in a cohort of depressive inpatients who received fluoxetine. Methods: A total of 131 newly hospitalized patients with major depressive disorder received a fixed dose of 20 mg/day (the recommended dose from the literature) of fluoxetine for 6 weeks. Symptom severity was assessed using the 17‐item Hamilton Depression Rating Scale at weeks 0, 1, 2, 3, 4 and 6. Remission was defined as a score of ≤7 on the 17‐item Hamilton Depression Rating Scale after 6 weeks of treatment. We compared the remitters and non‐remitters in terms of baseline variables. The Short‐Form‐36 pain interference item was used to assess pain. It was classified as high (score ≥ 3) or low (score < 3). Results: A total of 31 (27.7%) of 112 completers remitted after 6 weeks of treatment. The remitters and non‐remitters did not differ in baseline variables, except pain interference, baseline depression severity, and depression improvement at week 1. Conclusion: These findings obtained from newly hospitalized major depression patients support the previous notion that pain interference, depression severity, and early improvement can be the predictors for remission. Patients with high pain interference, a greater depression severity or a less early improvement are likely to require aggressive treatment early. These data require confirmation and extension to outpatients and other antidepressants.