Treatment response for acute depression is not associated with number of previous episodes: lack of evidence for a clinical staging model for major depressive disorder

Mental illness has been observed to follow a neuroprogressive course, commencing with prodrome, then onset, recurrence and finally chronic illness. In bipolar disorder and schizophrenia responsiveness to treatment mirrors these stages of illness progression, with greater response to treatment in the earlier stages of illness and greater treatment resistance in chronic late stage illness. <br /><br />Using data from 5627 participants in 15 controlled trials of duloxetine, comparator arm (paroxetine, venlafaxine, escitalopram) or placebo for the treatment of an acute depressive episode, the relationship between treatment response and number of previous depressive episodes was determined. Data was dichotomised for comparisons between participants who had &gt;3 previous episodes (<em>n</em>=1697) or &le;3 previous episodes (<em>n</em>=3930), and additionally for no previous episodes (<em>n</em>=1381) or at least one previous episode (<em>n</em>=4246). Analyses were conducted by study arm for each clinical trial, and results were then pooled. <br /><br />There was no significant difference between treatment response and number of previous depressive episodes. This unexpected finding suggests that treatments to reduce symptoms of depression during acute illness do not lose efficacy for patients with a longer history of illness.

Safety and acceptability of practice-nurse-managed care of depression in patients with diabetes or heart disease in the Australian TrueBlue study

<b><span style="font-size: 12px;">Objectives</span></b><span style="font-size: 12px;">: <br />To determine the safety and acceptability&nbsp;</span><span style="font-size: 12px;">of the TrueBlue model of nurse-managed care in the&nbsp;</span><span style="font-size: 12px;">primary healthcare setting.<br /></span><div><b style="font-size: 12px;">Design</b><span style="font-size: 12px;">:&nbsp;</span><br />A mixed methods study involving clinical&nbsp;record audit, focus groups and nurse interviews as a&nbsp;companion study investigating the processes used in&nbsp;the TrueBlue randomised trial.</div><div><b>Setting</b>: <br />Australian general practices involved in the&nbsp;TrueBlue trial.</div><div><b>Participants</b>: <br />Five practice nurses and five general&nbsp;practitioners (GPs) who had experienced&nbsp;nurse- managed care planning following the TrueBlue&nbsp;model of collaborative care.</div><div><b>Intervention</b>: <br />The practice nurse acted as case&nbsp;manager, providing screening and protocol management&nbsp;of depression and diabetes, coronary&nbsp;heart disease or both.</div><div><b>Primary outcome measures</b>: <br />Proportion of patients&nbsp;provided with stepped care when needed, identification&nbsp;and response to suicide risk and acceptability of the&nbsp;model to practice nurses and GPs.</div><div><b>Results</b>: <br />Almost half the patients received stepped&nbsp;care when indicated. All patients who indicated suicidal&nbsp;ideations were identified and action taken. Practice&nbsp;nurses and GPs acknowledged the advantages of the&nbsp;TrueBlue care-plan template and protocol-driven care,&nbsp;and the importance of peer support for the nurse in&nbsp;their enhanced role.</div><div><b>Conclusions</b>: <br />Practice nurses were able to identify,&nbsp;assess and manage mental-health risk in patients with&nbsp;diabetes or heart disease.</div>

The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial

<b><span style="font-size: 12px;">Objectives</span></b><span style="font-size: 12px;">: <br />To determine the effectiveness of&nbsp;</span><span style="font-size: 12px;">collaborative care in reducing depression in primary&nbsp;</span><span style="font-size: 12px;">care patients with diabetes or heart disease using&nbsp;</span><span style="font-size: 12px;">practice nurses as case managers.<br /></span><div><b>Design</b>: <br />A two-arm open randomised cluster trial with&nbsp;wait-list control for 6 months. The intervention was&nbsp;followed over 12 months.<br /><b>Setting</b>: <br />Eleven Australian general practices, five&nbsp;randomly allocated to the intervention and six to the&nbsp;control.<br /><b>Participants</b>: <br />400 primary care patients (206&nbsp;intervention, 194 control) with depression and type 2&nbsp;diabetes, coronary heart disease or both.<br /><b>Intervention</b>: <br />The practice nurse acted as a case&nbsp;manager identifying depression, reviewing pathology&nbsp;results, lifestyle risk factors and patient goals and&nbsp;priorities. Usual care continued in the controls.<br /><b>Main outcome measure</b>: <br />A five-point reduction in&nbsp;depression scores for patients with moderate-to-severe&nbsp;depression. Secondary outcome was improvements in&nbsp;physiological measures.<br /><b>Results</b>: <br />Mean depression scores after 6 months of&nbsp;intervention for patients with moderate-to-severe&nbsp;depression decreased by 5.7&plusmn;1.3 compared with&nbsp;4.3&plusmn;1.2 in control, a significant (p=0.012) difference.&nbsp;(The plus&ndash;minus is the 95% confidence range)&nbsp;Intervention practices demonstrated adherence to&nbsp;treatment guidelines and intensification of treatment for&nbsp;depression, where exercise increased by 19%, referrals&nbsp;to exercise programmes by 16%, referrals to mental&nbsp;health workers (MHWs) by 7% and visits to MHWs by&nbsp;17%. Control-practice exercise did not change,&nbsp;whereas referrals to exercise programmes dropped by&nbsp;5% and visits to MHWs by 3%. Only referrals to MHW&nbsp;increased by 12%. Intervention improvements were&nbsp;sustained over 12 months, with a significant (p=0.015)&nbsp;decrease in 10-year cardiovascular disease risk from&nbsp;27.4&plusmn;3.4% to 24.8&plusmn;3.8%. A review of patients&nbsp;indicated that the study&rsquo;s safety protocols were&nbsp;followed.<br /><b>Conclusions</b>: <br />TrueBlue participants showed&nbsp;significantly improved depression and treatment&nbsp;intensification, sustained over 12 months of&nbsp;intervention and reduced 10-year cardiovascular&nbsp;disease risk. Collaborative care using practice nurses&nbsp;appears to be an effective primary care intervention.</div>

Screening, referral and treatment for depression in patients with coronary heart disease: a consensus statement from the National Heart Foundation of Australia

In 2003, the National Heart Foundation of Australia position statement on &ldquo;stress&rdquo; and heart disease found that depression was an important risk factor for coronary heart disease (CHD). This 2013&nbsp;statement updates the evidence on depression (mild, moderate and severe) in patients with CHD, and provides guidance for health professionals on screening and treatment for depression in patients with CHD.<br /><br />The prevalence of depression is high in patients with CHD and it has a significant impact on the patient&rsquo;s quality of life and adherence to therapy, and an independent effect on prognosis. Rates of major depressive disorder of around 15% have been reported in patients after myocardial infarction or coronary artery bypass grafting.<br /><br />To provide the best possible care, it is important to recognise depression in patients with CHD. Routine screening for depression in all patients with CHD is indicated at first presentation, and again at the next follow-up appointment. A follow-up screen should occur 2&ndash;3&nbsp;months after a CHD event. Screening should then be considered on a yearly basis, as for any other major risk factor for CHD.<br /><br />A simple tool for initial screening, such as the Patient Health Questionnaire-2&nbsp;(PHQ-2) or the short-form Cardiac Depression Scale (CDS), can be incorporated into usual clinical practice with minimum interference, and may increase uptake of screening.<br /><br />Patients with positive screening results may need further evaluation. Appropriate treatment should be commenced, and the patient monitored. If screening is followed by comprehensive care, depression outcomes are likely to be improved.<br /><br />Patients with CHD and depression respond to cognitive behaviour therapy, collaborative care, exercise and some drug therapies in a similar way to the general population. However, tricyclic antidepressant drugs may worsen CHD outcomes and should be avoided.<br /><br />Coordination of care between health care providers is essential for optimal outcomes for patients. The benefits of treating depression include improved quality of life, improved adherence to other therapies and, potentially, improved CHD outcomes.

Subjective well-being, homeostatically protected mood and depression: a synthesis

This chapter concerns the idea that Subjective Wellbeing (SWB) is&nbsp;managed by a system of psychological devices which have evolved for this purpose.&nbsp;It is proposed that this management is actually directed at the protection of&nbsp;Homeostatically Protected Mood, as the major component of SWB. We normally&nbsp;experience HPMood as a combination of contentment, happiness and arousal.&nbsp;A theoretical description of this construct is offered that can account for many of&nbsp;the commonly observed empirical characteristics of SWB data. It is further proposed&nbsp;that when homeostasis fails, due to the overwhelming nature of a negative&nbsp;challenge, people lose contact with HPMood and experience the domination of&nbsp;negative rather than positive affect. If this condition is chronic, people experience&nbsp;the clinical condition we call depression.

Staff-focused interventions to increase referrals for depression in aged care facilities: a cluster randomized controlled trial

<b>Objective</b>:&nbsp;<div><span style="font-size: 12px;">While there is evidence that depression training can improve the knowledge of staff in residential care facilities, there is an absence of research determining whether such training translates into practice change. This study aimed to evaluate the impact of staff training and the introduction of a protocol for routine screening and referral for depression on the numbers of residents detected and referred by care staff for further assessment.</span><br /><b>Method</b>: <br />A cluster randomized controlled design was used to compare the referral rates for residents in seven facilities randomly allocated into one of three conditions: staff training, staff training plus a screening and referral protocol and wait-list control. Participants were 216 aged care residents (M age&thinsp;=&thinsp;87 years), who agreed to a 12-month audit of their facility file.<br /><b>Results</b>: <br />Staff training on its own did not increase the rate of referrals for depression; however, staff training plus the screening protocol and referral guidelines did lead to a significant increase in the number of residents who were referred to a medical practitioner for further assessment. However, this increase in care staff referrals did not result in substantial changes in the treatment prescribed for residents.<br /><b>Conclusion</b>: <br />Staff training in depression, supplemented with a protocol for routine screening and guidelines on referring residents, can improve pathways to care. However, strategies to overcome barriers to appropriate subsequent treatment of depression are required for staff-focused initiatives to translate into better outcomes for depressed older adults. Methodological limitations of this study are discussed.</div>

Integrated depression management: a proposed trial of a new model of care in a low vision rehabilitation setting

<b>Purpose</b>: <br />Depression is a common problem among people with visual impairment and contributes to functional decline. This article presents a study protocol to evaluate a new model of care for those patients with depressive symptoms in which psychological treatment is integrated into low vision rehabilitation services. Low vision staff will be trained to deliver &quot;problem solving therapy for primary care&quot; (PST-PC), an effective psychological treatment developed specifically for delivery by non-mental health care staff. PST-PC is delivered in 8 weekly telephone sessions of 30-45 minutes duration and 4 monthly maintenance sessions. We predict this new integrated model of care will significantly reduce depressive symptoms and improve the quality of life for people with visual impairment. <br /><br /><b>Methods and Design</b>: <br />A randomized controlled trial of PST-PC will be implemented nationally across low vision rehabilitation services provided by Vision Australia. Clients who screen positive for depressive symptoms and meet study criteria will be randomized to receive PST-PC or usual care, consisting of a referral to their general practitioner for more detailed assessment and treatment. Outcome measures include depressive symptoms and behaviors, quality of life, coping and psychological adjustment to visual impairment. Masked assessments will take place pre- and post-intervention as well as at 6- and 12-month follow-up. <br /><br /><b>Conclusion</b>: <br />We anticipate that this innovative service delivery model will lead to sustained improvements in clients' quality of life in a cost effective manner and provide an innovative service delivery model suitable for other health care areas in which depression is co-morbid.

A study protocol to investigate the management of depression and challenging behaviors associated with dementia in aged care settings

<b>Background</b>:&nbsp;<div><span style="font-size: 12px;">The high occurrence and under-treatment of clinical depression and behavioral and psychological symptoms of dementia (BPSD) within aged care settings is concerning, yet training programs aimed at improving the detection and management of these problems have generally been ineffective. This article presents a study protocol to evaluate a training intervention for facility managers/registered nurses working in aged care facilities that focuses on organisational processes and culture as well as knowledge, skills and self-efficacy. <br /><br /><b>Methods</b>. <br />A Randomised Control Trial (RCT) will be implemented across 18 aged care facilities (divided into three conditions). Participants will be senior registered nurses and personal care attendants employed in the aged care facility. The first condition will receive the training program (Staff as Change Agents - Enhancing and Sustaining Mental Health in Aged Care), the second condition will receive the training program and clinical support, and the third condition will receive no intervention. <br /><br /><b>Results</b>: <br />Pre-, post-, 6-month and 12-month follow-up measures of staff and residents will be used to demonstrate how upskilling clinical leaders using our transformational training approach, as well as the use of a structured screening, referral and monitoring protocol, can address the mental health needs of older people in residential care. <br /><br /><b>Conclusions</b>: <br />The expected outcome of this study is the validation of an evidence-based training program to improve the management of depression and BPSD among older people in residential care settings by establishing routine practices related to mental health. This relatively brief but highly focussed training package will be readily rolled out to a larger number of residential care facilities at a relatively low cost.</span></div>

Evidence based guidelines to improve engagement and participation for people experiencing depression

<b>Background:</b><br />Depression can have a strongly negative impact on a person&rsquo;s ability to engage with and participate in activities of daily living. Clinicians currently seeking guidance on best practice in this area currently need to access and critique a wide range of evidence from a number of disciplines. While some clinical practice guidelines are available, this form of evidence presentation presents several barriers to implementation.<br /><br /><b>Procedures:</b><br />This article proposes a new procedure for developing guidance for clinicians, known as evidence based guidelines. The purpose of the guidelines presented here is to provide guidance on appropriate assessment and intervention strategies with people experiencing depression, who wish to improve their engagement and participation in daily activities. They were constructed using a multiple methods procedure, with five phases.<br /><br /><b>Results:</b><br />Evidence based guidelines for the general population, older adults and people with co-morbid physical conditions are presented at the conclusion of this article.<br /><br /><b>Conclusion:</b><br />The procedure described here produces evidence based guidelines with built in measures to promote implementation into practice. The resulting guidelines for depression will enable clinicians from all disciplines to engage in best practice, and assist people with depression participate more fully in their lives.

An algorithm for determination of rank and degree of contribution of sMRI volumetric features in depression detection

Brain volume changes at structural level appear to have utmost importance in depression biomarkers studies. However, these brain volumetric findings have very minimal utilization in depression detection studies at individual level. Thus, this paper presents an evaluation of volumetric features to identify the relevant/optimal features for the detection of depression. An algorithm is presented for determination of rank and degree of contribution (DoC) of structural magnetic resonance imaging (sMRI) volumetric features. The algorithm is based on the frequencies of each feature contribution toward the desired accuracy limit. Forty-four volumetric features from various brain regions were adopted for evaluation. From DoC analysis, the DoC of each volumetric feature for depression detection is calculated and the features that dominate the contribution are determined.

Evaluation of feature selection algorithms for detection of depression from brain sMRI scans

Detection of depression from structural MRI (sMRI) scans is relatively new in the mental health diagnosis. Such detection requires processes including image acquisition and pre-processing, feature extraction and selection, and classification. Identification of a suitable feature selection (FS) algorithm will facilitate the enhancement of the detection accuracy by selection of important features. In the field of depression study, there are very limited works that evaluate feature selection algorithms for sMRI data. This paper investigates the performance of four algorithms for FS of volumetric attributes in sMRI scans. The algorithms are One Rule (OneR), Support Vector Machine (SVM), Information Gain (IG) and ReliefF. The performances of the algorithms are determined through a set of experiments on sMRI brain scans. An experimental procedure is developed to measure the performance of the tested algorithms. The result of the evaluation of the FS algorithms is discussed by using a number of analyses.

Physical activity, leisure-time screen use and depression among children and young adolescents

<b>Objectives:<br /></b>Adolescent mental disorders remain a relatively neglected area of research, despite evidence that these conditions affect youth disproportionately. We examined associations between physical activity, leisure-time screen use and depressive symptoms among Australian children and adolescents.<br /><br /><b>Design:<br /></b>Large cross-sectional observational study.<br /><br /><b><span style="font-size: 12px;">Methods:</span><br /></b>Self-reported physical activity and leisure-time screen behaviours, and depressive symptoms using the Short Mood and Feeling Questionnaire were assessed in 8256 students aged 10&ndash;16 years (mean age = 11.5 years, SD = 0.8).<br /><br /><b>Results:<br /></b>Thirty three percent of the sample reported moderate to high depressive symptoms, with rates higher among females (OR = 1.18; 95% CI: 1.02, 1.36; p = 0.001). Increased opportunities to be active at school outside class (OR = 0.70; 0.58, 0.85; p &lt; 0.001), being active in physical education classes (OR = 0.77; 0.69, 0.86; p &lt; 0.001), greater involvement in sports teams at school (OR = 0.77; 0.67, 0.88; p &lt; 0.001) and outside of school (OR = 0.84; 0.73, 0.96; p = 0.01) were all independently associated with lower odds for depressive symptoms. Meeting recommended guidelines for physical activity (OR = 0.62; 0.44, 0.88; p = 0.007) and, for 12&ndash;14 year olds, leisure-time screen use (OR = 0.77; 0.59, 0.99; p = 0.04) were also independently associated with lower odds for depressive symptoms.<br /><br /><b>Conclusions:<br /></b><span style="font-size: 12px;">Higher levels of physical activity among children and young adolescents, and lower levels of leisure-time screen use among young adolescents, are associated with lower depressive symptoms. Longitudinal studies are needed to understand the causal relationships between these variables.</span>

Altered cardiac autonomic nervous function in depression

<b>Background:</b><b><br /></b>Depression is an independent risk factor for coronary artery disease. Autonomic instability may play a mediating or moderating role in this relationship; however this is not well understood. The objective of this study was to explore cardiac autonomic function and cardiac arrhythmia in depression, the correlation between depression severity and Heart Rate Variability (HRV) related indices, and the prevalence of arrhythmia.<br /><br /><b>Methods:</b><br />Individuals (n&thinsp;=&thinsp;53) with major depression as assessed by the Diagnostic and Statistical Manual of Mental Disorders, who had a Hamilton Rating Scale for Depression (HAMD) score &ge;20 and a Zung Self-Rating Depression Scale score&thinsp;&gt;&thinsp;53 were compared to 53 healthy individuals, matched for age and gender. Multichannel Electrocardiograph ECG-92C data were collected over 24 hours. Long-term changes in HRV were used to assess the following vagally mediated changes in autonomic tone, expressed as time domain indices: Standard deviation of the NN intervals (SDNN), standard deviation of 5 min averaged NN intervals (SDANN), Root Mean Square of the Successive Differences (RMSSD) and percentage of NN intervals&thinsp;&gt;&thinsp;50 ms different from preceding interval (pNN50). Pearson&rsquo;s correlations were conducted to explore the strength of the association between depression severity (using the SDS and HRV related indices, specifically SDNN and low frequency domain / high frequency domain (LF/HF)).<br /><br /><b>Results:<br /></b>The values of SDNN, SDANN, RMSSD, PNN50 and HF were lower in the depression group compared to the control group (P&lt;.05). The mean value of the LF in the depression group was higher than the in control group (P&lt;.05). Furthermore the ratio of LF/HF was higher among the depression group than the control group (P&lt;.05). A linear relationship was shown to exist between the severity of the depression and HRV indices. In the depression group, the prevalence of arrhythmia was significantly higher than in the control group (P&lt;.05), particularly supraventricular arrhythmias.<br /><br /><b>Conclusions:<br /></b>Our findings suggest that depression is accompanied by dysfunction of the cardiac autonomic nervous system, and further, that depression severity is linked to severity of this dysfunction. Individuals with depression appear to be susceptible to premature atrial and/or ventricular disease.

Biological phenotypes underpin the physio-somatic symptoms of somatization, depression, and chronic fatigue syndrome

<b>Objective</b><br />Somatization is a symptom cluster characterized by &lsquo;psychosomatic&rsquo; symptoms, that is, medically unexplained symptoms, and is a common component of other conditions, including depression and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This article reviews the data regarding the pathophysiological foundations of &lsquo;psychosomatic&rsquo; symptoms and the implications that this has for conceptualization of what may more appropriately be termed physio-somatic symptoms.<br /><br /><b>Method</b><br />This narrative review used papers published in PubMed, Scopus, and Google Scholar electronic databases using the keywords: depression and chronic fatigue, depression and somatization, somatization and chronic fatigue syndrome, each combined with inflammation, inflammatory, tryptophan, and cell-mediated immune (CMI).<br /><b><br />Results</b><br />The physio-somatic symptoms of depression, ME/CFS, and somatization are associated with specific biomarkers of inflammation and CMI activation, which are correlated with, and causally linked to, changes in the tryptophan catabolite (TRYCAT) pathway. Oxidative and nitrosative stress induces damage that increases neoepitopes and autoimmunity that contribute to the immuno-inflammatory processes. These pathways are all known to cause physio-somatic symptoms, including fatigue, malaise, autonomic symptoms, hyperalgesia, intestinal hypermotility, peripheral neuropathy, etc.<br /><b><br />Conclusion</b><br />Biological underpinnings, such as immune-inflammatory pathways, may explain, at least in part, the occurrence of physio-somatic symptoms in depression, somatization, or myalgic encephalomyelitis/chronic fatigue syndrome and thus the clinical overlap among these disorders.<br />