Identifying Patients at Risk of Complete Nonresponse in the Outpatient Treatment of Depression

Background: The temperament harm avoidance (HA) has consistently demonstrated an association with major depressive disorder (MDD), serotonin functioning and reduction in depression symptoms in response to antidepressant medications targeting the serotonin system. In the current investigation, we examine HA as a potential mediator of treatment response to a serotonergic tricyclic antidepressant. Methods: Outpatients (n = 150) with MDD were randomized to receive clomipramine or a control treatment. Patients completed the Hamilton Rating Scale for Depression (Ham-D) and the Tridimensional Personality Questionnaire (TPQ) prior to treatment initiation, and then again after at least 8 weeks of treatment. Using structural equation modeling, we evaluated a ‘mediation model’ in which change in HA is a mechanism of depression change in response to clomipramine, and a ‘complication model’ in which reduction in HA is a by-product of depression change. Results: The mediation model provided a good fit to the data by all indices, whereas the complication model did not. Patients treated with clomipramine exhibited a greater decrease in HA as compared to those in the control group; moreover, HA reduction was associated with depression reduction. Conclusions: HA mediated the response to antidepressant treatment, such that any treatment effect of clomipramine occurred through HA reduction. Although replication with multiple assessment periods is required to determine if HA reduction actually precedes depression reduction, the results contribute to a growing body of literature implicating personality constructs subsumed within negative emotionality as mediators of treatment response to medications targeting serotonergic functioning.

Section: Discussionmentioning

confidence: 99%

Harm Avoidance as a Mediator of Treatment Response to Antidepressant Treatment of Patients with Major Depression

Quilty¹,

Godfrey²,

Kennedy³

et al. 2010

“…This cut-off was based on clinical consensus. On the one hand, it reflects slightly more improvement then the usual operationalization of <25% decrease for complete nonresponse [39,40,41,42]. On the other hand, it reflects a realistic approach to the expected change in the first phase of psychotherapy.…”

Section: Methodsmentioning

confidence: 99%

What Is the Best Sequential Treatment Strategy in the Treatment of Depression? Adding Pharmacotherapy to Psychotherapy or Vice Versa?

Dekker

Van

Hendriksen

et al. 2012

Self Cite

Background: Insufficient response to monotreatment for depression is a common phenomenon in clinical practice. Even so, evidence indicating how to proceed in such cases is sparse. Methods: This study looks at the second phase of a sequential treatment algorithm, in which 103 outpatients with moderately severe depression were initially randomized to either short-term supportive psychodynamic therapy (PDT) or antidepressants. Patients who reported less than 30% symptom improvement after 8 weeks were offered combined treatment. Outcome measures were the Hamilton Depression Rating Scale (HAM-D), the Clinical Global Impression of Severity and Improvement, the SCL-90 depression subscale and the EuroQOL questionnaire. Results: Despite being nonresponsive, about 40% of patients preferred to continue with monotherapy. At treatment termination, patients initially randomized to PDT had improved more than those initially receiving antidepressants, as indicated by the HAM-D and the EuroQOL, independently of whether the addition was accepted or not. Conclusions: Starting with psychotherapy may be preferable in mildly and moderately depressed outpatients. For patients who receive either PDT or antidepressants, combined therapy after early nonresponse seems to be helpful. Nevertheless, this sequential strategy is not always preferred by patients.

“…Further, the purpose of the science of clinimetrics is to provide a home for a number of clinical phenomena which do not find room in customary clinical taxonomy, such as type, severity and sequence of symptoms, rate of progression of illness (staging), well-being and distress [36]. In recent years, there have been several exemplifications of this approach in research on mood and anxiety disorders [38,39,40,41,42,43,44]. …”

Section: Emergence Of New Modelsmentioning

confidence: 99%

Psychosomatic Assessment

Fava

Sonino²

2009

The primary goal of psychosomatic medicine is the incorporation of its operational strategies into clinical practice. The traditional attitude toward disease and the functional/organic dichotomy were criticized by George Engel in the early sixties. Only recently, however, there has been increasing awareness of the limitations of disease as the primary focus of medical care. It is not that certain disorders lack an organic explanation; it is our assessment that is inadequate in most clinical encounters. The research evidence which has accumulated in psychosomatic medicine offers unprecedented opportunities for the identification and treatment of medical problems. Taking full advantage of clinimetric methods (such as the use of Emmelkamp’s two levels of functional analysis and the Diagnostic Criteria for Psychosomatic Research) may greatly improve the clinical process, including shared decision making and self-management. Endorsement of the psychosomatic perspective may better clarify the pathophysiological links and mechanisms underlying symptom presentation. Pointing to individually targeted methods may improve final outcomes and quality of life.