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Recent research: six studies on depression – pregnancy, young children, antidepressant side effects, SAD & CBT, and suicide risk

Here are half a dozen recent research papers on depression (all details & abstracts to these studies are given further down this blog posting).  Yonkers et al's publication is a very welcome one - "The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists."  At last here's a major review giving good advice on this extremely important subject.  To learn more it's worth getting hold of a copy of the complete text.  You may have access to this through your academic department.  If not, authors are usually happy to send a PDF via email when asked to - emails can be dug out via a little Google detective work.  Following the [Abstract/Full Text] link will also provide various access routes including a low-cost patient information option.  In further work looking at depression having effects early in life, Luby describes treatment of depression in children as young as age 3 using a " ... novel dyadic psychotherapeutic model, Parent Child Interaction Therapy-Emotion Development".

I've also included a couple of papers on antidepressant side-effects.  Price et al in their paper "Emotional side-effects of selective serotonin reuptake inhibitors: qualitative study" comment "Emotional side-effects of SSRIs are a robust phenomenon, prominent in some people's thoughts about their medication, having a demonstrable impact on their functioning and playing a role in their decision-making about antidepressant adherence."  Uher and colleagues carefully assessed more general "side-effects" in a group of over 800 depressed adults.  They found that "Most complaints listed as adverse reactions in people with depression were more common when they were medication-free rather than during their treatment with antidepressants" but also emphasised that "Attention to specific adverse reactions may improve adherence to antidepressant treatment."

Switching to the topical subject (in the Northern hemisphere) of winter depression, Rohan et al reported on "Winter depression recurrence one year after cognitive-behavioral therapy, light therapy, or combination treatment."  Fascinatingly they found that subjects who had been treated with a specific SAD-tailored group cognitive-behavioral therapy had a lower recurrence rate the following year than those treated with light therapy - "CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%).  See reports of these researchers' earlier research for more on this approach.  Finally Nock et al report on "Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior" concluding that "These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts."      

Yonkers, K., A. , K. Wisner, L. , et al. (2009). "The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists." General Hospital Psychiatry 31(5): 403-413.  [Abstract/Full Text] 
To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management. Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved. Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment. Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy.

Luby, J. L. (2009). "Early Childhood Depression." Am J Psychiatry 166(9): 974-979.  [Abstract/Full Text] 
Although empirical evidence has recently validated clinical depression in children as young as age 3, few data are available to guide treatment of early childhood depression. Considering this gap in the literature, a novel dyadic psychotherapeutic model, Parent Child Interaction Therapy-Emotion Development, based on a well-known and effective manualized treatment for disruptive preschoolers, is currently being tested for use in depression. To balance safety and efficacy, dyadic developmental approaches are currently recommended as the first line of treatment for preschool depression. In the absence of data on the safety and efficacy of antidepressants in preschool depression, these agents are not recommended as a first- or second-line treatment at this time. This article provides an illustrative case example of preschool depression, outlines key considerations in differential diagnosis, and describes this novel form of treatment. It also clarifies parameters for the rare situations in which antidepressants may be tried when psychotherapeutic options fail and depression is severe and impairing.

Price, J., V. Cole, et al. (2009). "Emotional side-effects of selective serotonin reuptake inhibitors: qualitative study." The British Journal of Psychiatry 195(3): 211-217.  [Abstract/Full Text] 
Background Some people who take selective serotonin reuptake inhibitor (SSRI) antidepressants report that their experience of emotions is blunted'. This phenomenon is poorly understood. Aims To understand patients' experiences of this phenomenon. Method Qualitative study, gathering data through individual interviews, a group interview and validation interviews; and searching patient websites for relevant posts. Results There was strong evidence that some people taking SSRIs experience significant emotional symptoms that they strongly attribute to their antidepressant. These emotional symptoms can be described within six key themes. A seventh theme represents the impact of these side-effects on everyday life, and an eighth represents participants' reasons for attributing these symptoms to their antidepressant. Most participants felt able to distinguish between emotional side-effects of antidepressants and emotional symptoms of their depression or other illness. Conclusions Emotional side-effects of SSRIs are a robust phenomenon, prominent in some people's thoughts about their medication, having a demonstrable impact on their functioning and playing a role in their decision-making about antidepressant adherence.

Uher, R., A. Farmer, et al. (2009). "Adverse reactions to antidepressants." The British Journal of Psychiatry 195(3): 202-210.  [Abstract/Full Text] 
Background Adverse drug reactions are important determinants of non-adherence to antidepressant treatment, but their assessment is complicated by overlap with depressive symptoms and lack of reliable self-report measures. Aims To evaluate a simple self-report measure and describe adverse reactions to antidepressants in a large sample. Method The newly developed self-report Antidepressant Side-Effect Checklist and the psychiatrist-rated UKU Side Effect Rating Scale were repeatedly administered to 811 adult participants with depression in a part-randomised multicentre open-label study comparing escitalopram and nortriptyline. Results There was good agreement between self-report and psychiatrists' ratings. Most complaints listed as adverse reactions in people with depression were more common when they were medication-free rather than during their treatment with antidepressants. Dry mouth (74%), constipation (33%) and weight gain (15%) were associated with nortriptyline treatment. Diarrhoea (9%), insomnia (36%) and yawning (16%) were more common during treatment with escitalopram. Problems with urination and drowsiness predicted discontinuation of nortriptyline. Diarrhoea and decreased appetite predicted discontinuation of escitalopram. Conclusions Adverse reactions to antidepressants can be reliably assessed by self-report. Attention to specific adverse reactions may improve adherence to antidepressant treatment.

Rohan, K. J., K. A. Roecklein, et al. (2009). "Winter depression recurrence one year after cognitive-behavioral therapy, light therapy, or combination treatment." Behav Ther 40(3): 225-38.  [PubMed]
The central public health challenge in the management of seasonal affective disorder (SAD) is prevention of depression recurrence each fall/winter season. The need for time-limited treatments with enduring effects is underscored by questionable long-term compliance with clinical practice guidelines recommending daily light therapy during the symptomatic months each year. We previously developed a SAD-tailored group cognitive-behavioral therapy (CBT) and tested its acute efficacy in 2 pilot studies. Here, we report an intent-to-treat (ITT) analysis of outcomes during the subsequent winter season (i.e., approximately 1 year after acute treatment) using participants randomized to CBT, light therapy, and combination treatment across our pilot studies (N=69). We used multiple imputation to estimate next winter outcomes for the 17 individuals who dropped out during treatment, were withdrawn from protocol, or were lost to follow-up. The CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%). CBT alone, but not combination treatment, was also associated with significantly lower interviewer- and patient-rated depression severity at 1 year as compared to light therapy alone. Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy. If these findings are replicated, CBT could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy.

Nock, M. K., I. Hwang, et al. (2009). "Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys." PLoS Med 6(8): e1000123.  [Free Full Text] 
Background: Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.  Methods and Findings: Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9-8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5-5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.  Conclusions:  This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.

 

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