Diretrizes clínicas para tratamento da depressão: análise de fatores associados à qualidade e comparação de recomendações para pacientes não respondedores e com depressão resistente / Clinical guidelines for the treatment of depression: analysis of factors associated with quality and comparison of recommendations for nonresponding patients and for patients with resistant depression

Diretrizes clínicas (DCs) de alta qualidade são importantes para a assistência efetiva de pacientes com doenças crônicas, incluindo a depressão. A depressão é um dos principais problemas de saúde mundial, sendo um dos transtornos psiquiátricos mais comumente encontrados na prática médica, afetando cerca de 300 milhões de pessoas. Além de sua natureza debilitante e onerosa, muitas vezes pode levar a desfechos graves, tal como o suicídio, principalmente em pacientes que não respondem aos tratamentos. Assim, o objetivo geral desta tese foi identificar fatores das DCs associados à qualidade metodológica desses documentos e de suas recomendações, e comparar as recomendações para duas situações de falhas da farmacoterapia: pacientes não respondedores e pacientes com depressão resistente ao tratamento (DRT). Operacionalmente, foram feitas revisões sistemáticas da literatura em bases científicas e específicas de DCs, e incluídas DCs publicadas nos últimos onze anos que contivessem recomendações para o tratamento farmacológico de adultos com depressão. Para avaliação geral das DCs, foi aplicado o instrumento AGREE II, e para avaliação específica das recomendações, o instrumento AGREE-REX. As DCs foram consideradas de alta qualidade quando pontuaram com escores maiores ou iguais a 60% (no estudo descrito no capítulo 2) e maiores ou iguais a 80% (no estudo descrito no capítulo 3) no domínio 3 (Rigor de desenvolvimento) do AGREE II. As DCs com recomendações de alta qualidade foram as que pontuaram com mais de 60% no domínio 1 (Aplicabilidade Clínica) do AGREE-REX. Das 63 DCs selecionadas, 17 (27%) apresentaram alta qualidade, e 7 (11%) apresentaram recomendações de alta qualidade. Os fatores associados à maior qualidade foram gerenciamento de conflitos de interesses, equipe multiprofissional e tipo de instituição. A inclusão de representante do paciente na equipe também foi associada a recomendações de maior qualidade. Verificou-se que a maioria das DCs concorda com a necessidade de: reavaliar o diagnóstico, a presença de comorbidades, a adesão ao tratamento, ajustar a dosagem do antidepressivo e adicionar psicoterapia como os primeiros passos para aqueles que não respondem ao tratamento antidepressivo de primeira linha. Em relação às recomendações, há falhas importantes, incluindo a não apresentação de definição padronizada de resposta adequada/inadequada/parcial, e o não estabelecimento de tempo de tratamento necessário para declarar DRT. Todas as DCs incluíram a possibilidade de substituição do antidepressivo, potencialização com outros medicamentos e combinação de antidepressivos. Todavia, três DCs não recomendaram uma sequência entre eles. Por fim, verificou-se que das 17 DCs de alta qualidade e das 7 DCs com recomendações de alta qualidade, apenas duas incluíram definição e recomendações para DRT. Não existe consenso entre as DCs de alta qualidade quanto à definição e uso do termo DRT. Não foi possível extrair uma estratégia terapêutica convergente para DRT em adultos. Os resultados obtidos reforçam a necessidade de maior foco no aprimoramento da qualidade das DCs e de suas recomendações, especialmente nos subgrupos relativos à resposta inadequada ao tratamento e a DRT, nas quais as definições não são claras

High-quality clinical practice guidelines (CPGs) are important for treating patients with chronic diseases such as depression. Depression is a major health concern worldwide, affecting approximately 300 million people. It is one of the most prevalent psychiatric disorders in medical practice. It is not only debilitating and costly but can also lead to tragic consequences such as suicide, particularly in patients who do not respond to treatment. The objective of this thesis was to identify CPGs factors associated with the methodological quality of these documents and their recommendations. Furthermore, this thesis aimed to compare the recommendations in two pharmacotherapy failure situations: inadequate response to treatment and treatment-resistant depression (TRD). Systematic literature reviews were conducted on scientific and CPG-specific databases. Reviews were also conducted on CPGs published in the last eleven years that included recommendations for pharmacological treatment of adults with depression. The AGREE II instrument was used for the CPGs general assessment, while the AGREE-REX instrument was used specifically to assess their recommendations. CPGs were considered high quality if they achieved a score of at least 60% in the study mentioned in Chapter 2 and a score of at least 80% in the study mentioned in Chapter 3 in the AGREE II, rigour of development domain. The CPGs with high-quality recommendations were those that scored greater than 60% in Domain 1 (Clinical Applicability) of the AGREE-REX. Of the 63 selected CPGs, 17 (27%) were high quality, and 7 (11.1%) had recommendations of high quality. Factors associated with higher quality were conflict of interest management, multi-professional team, and type of institution. Inclusion of a patients representative on the team was associated with higher quality recommendations. Most CPGs agreed with the need to reassess diagnoses, comorbidities, and treatment adherence. They also agreed on adjusting antidepressant dosage and providing psychotherapy as a first step for patients who do not respond to first-line antidepressant treatment. There are significant shortcomings in the recommendations. In particular, the lack of a standardized definition of adequate, inadequate, or partial response to treatment and the lack of clarity surrounding the duration of treatment required to establish TRD. All CPGs included the possibility of antidepressant substitution, potentiation with other drugs, and a combination of antidepressants. However, three CPGs did not recommend a preferred sequence for these interventions. Finally, of the 17 high-quality CPGs and the 7 CPGs with high-quality recommendations, only two included definition and recommendations for TRD. There is no consensus among the high-quality CPGs regarding the definition and use of the term TRD. Ultimately, finding a convergent therapeutic strategy for TRD in adults was not possible. These results highlighted the need to focus more on improving the quality of CPGs and their recommendations, especially in the subgroups related to inadequate response to treatment and TRD, where definitions are unclear

A Comparative study of insight in patients of depressive spectrum disorders attending outpatient department of tertiary care centre.

Introduction: Poor insight is a common feature of bipolar depression and unipolar depression with and without psychotic symptoms (PS) which may lead to poor clinical outcome. Studies on insight in these populations are relatively limited and the majority of studies were published over the previous decade. Methods: This was a cross-sectional, observation study conducted in Psychiatry O.P.D. of tertiary care hospital. The sample consisted cohort of 20 outpatients each with unipolar depression, unipolar depression with psychotic symptoms and bipolar disorder current episode depression with psychotic symptoms. The depression was assessed by HAM-D and insight by Item G12 of the General Psychopathology section of PANSS. Results: Significant difference in insight is seen in all three groups. Bipolar patients with PS had the poorest insight, patients with unipolar depression had best. Statistically significant correlation is present with older age and lack of insight among patients of unipolar depression with PS (rho =.599, P =.005) and bipolar depression with PS (rho =.686 P=.001). Conclusion: Insight in depressive illness is affected by multiple factors; this study shows that age, bipolarity and presence of psychotic symptoms are associated with poor insight. Management of the patients of depressive spectrum should incorporate strategies to improve insight

Combinación de antidepresivos vs. aumentación con antipsicóticos atípicos tras no lograr la remisión en la depresión unipolar / Combination of antidepressants vs. augmentation with atypical antipsychotics upon failure to achieve remission in unipolar depression

RESUMEN: Introducción: Lograr la recuperación funcional lo más rápido posible en el tratamiento de la depresión unipolar es un reto que la práctica clínica debe tratar de afrontar en la actualidad, ya que cualquier retraso en lograr la remisión de los síntomas es predictivo de un mayor número de recurrencias y mayores tasas de morbimortalidad. En esta revisión comprensiva, nuestro objetivo es guiar a los clínicos en su elección de aumentar con antipsicóticos atípicos o combinar el fármaco de referencia con un segundo antidepresivo, después de que se haya optimizado la dosis del antidepresivo seleccionado inicialmente y/o se haya cambiado el antidepresivo, sin lograr remisión, o bien cuando solo han obtenido una respuesta parcial después de un tiempo suficiente a una dosis apropiada. Estas decisiones surgen con frecuencia en la práctica clínica diaria. Metodología: Se realizó una búsqueda sistemática en PubMed bajo varias combinaciones clave de palabras, resultando en 230 informes. Después de aplicar los criterios de inclusión y según el título y el resumen, el número final de informes seleccionados para la revisión completa fue de 113. Se respondieron dos preguntas principales con base en estos estudios: 1) ¿Existe evidencia para recomendar claramente la combinación de antidepresivos versus potenciación con antipsicóticos (y el momento correcto para hacerlo) en la depresión unipolar no respondedora, una vez que las estrategias de optimización o de cambio han fallado en obtener la remisión? y 2) ¿Es posible identificar algunas características clínicas para guiar la decisión de combinación de antidepresivos versus potenciación con agentes antipsicóticos? Resultados: Según nuestro análisis, no hay datos disponibles para seleccionar una estrategia de otra de manera clara. Sin embargo, sugerimos favorecer una combinación o estrategia de aumento, basada en un enfoque de "tratamiento contra objetivos dianas" para perfilar al paciente, considerando una o dos características clínicas predominantes que permanecen activas como parte de una depresión mayor con respuesta parcial. Un adecuado análisis de los dominios sintomáticos presentes, una visión crítica de las guías clínicas actuales y de las opciones preferidas, considerar la bipolaridad oculta como uno de los principales diagnósticos diferenciales y adoptar una actitud enérgica pero lúcida en esta etapa del tratamiento son, a nuestro juicio, fundamentales para lograr recuperación ad integrum del paciente.

ABSTRACT Introduction: achieving functional recovery as quickly as possible in the treatment of unipolar depression is a challenge that clinical practice must try to meet nowadays, since any delay in accomplishing remission of the symptoms is predictive of a larger number of recurrences and higher morbidity and mortality rates. In this topical review we aim to guide clinicians in their choice to augment with atypical antipsychotics or to combine the baseline drug with a second antidepressant, after the dose of the antidepressant initially selected has been optimized and/or the antidepressant has been changed, not achieving remission, or resulting only in a partial response after sufficient time at an appropriate dose. These decisions arise frequently in everyday clinical practice. Methodology: a systematic search in PubMed was performed under several key combinations of words, resulting in 230 reports. After applying inclusion criteria and based in title and abstract, the final number of reports selected for full revision were 113. Two main questions were answered based on these studies: 1) Is there evidence to clearly recommend combination of antidepressants vs. augmentation with antipsychotics (and the correct moment to do it) in non-responsive unipolar depression, once optimization or switching strategies have failed to obtain remission? and 2) Is it possible to identify some clinical features to guide the decision of combination of antidepressants vs. augmentation with antipsychotic agents? Results: According to our analysis, there is no data available to select one strategy from another in a clear-cut manner. Nevertheless, we suggest favoring a combination or augmentation strategy, based in a "treating to target" approach to profile the patient, considering one or two predominant clinical features that remain active as part of a major depression with partial response. Proper analysis of the symptomatic domains present, a critical view of current clinical guidelines and preferred options, considering hidden bipolarity as one of the main differential diagnoses and adopting an energetic but lucid attitude at this stage of treatment are, in our view, fundamental for achieving ad integrum patient recovery.

The impact of cognitive emotion regulation strategies on adolescents with unipolar depression and bipolar depression / 中华行为医学与脑科学杂志

Objective:To explore the impact of different dimensions of cognitive emotion regulation strategies on adolescents with unipolar depression and bipolar depression.Methods:From June 2019 to July 2021, a total of 216 adolescents with depressive disorder were selected, including 134 patients in unipolar depression group, 82 patients in bipolar depression group, and 111 normal controls were selected at the same time.Hamilton depression scale (HAMD), Hamilton anxiety scale (HAMA) and cognitive emotion regulation questionnaire (CERQ) were used to evaluate the emotional symptoms and cognitive emotion regulation strategies of all enrolled subjects. SPSS 23.0 was used for statistical analysis of the data. Kruskal-Wallis rank sum test and multiple Logistic regression analysis were used for statistical analysis.Results:There were significant differences in the dimensions of cognitive emotion regulation strategies and emotional symptoms among the three groups (all P<0.01). The scores of self-blame (14.00(12.00, 17.00), 13.50(12.00, 16.00), 12.00(11.00, 12.00)), rumination (15.00(12.00, 19.00), 14.00(12.00, 17.00), 12.00(10.00, 13.00)) and catastrophizing (13.00(11.00, 17.00), 12.00(9.00, 16.00), 8.00(6.00, 12.00)) in bipolar depression group and unipolar depression group were significantly higher than those in normal control group (all P<0.01). The score of blaming others (11.00(8.75, 13.25), 9.00(8.00, 12.00)) in bipolar depression group was significantly higher than that in normal control group ( P<0.01). The score of positive reappraisal (12.00(12.00, 15.00), 11.00(8.75, 13.00)) in normal control group was significantly higher than that in unipolar depression group ( P<0.01). The putting into perspective score(10.00(8.00, 12.00), 12.00(10.00, 13.25), 12.00(10.00, 13.00)) of normal control group was significantly lower than those of unipolar depression and bipolar depression group (both P<0.01). The scores of HAMD (25.00(22.00, 26.25), 23.00(18.00, 28.00), 3.00(0, 6.00)) and HAMA (17.00(14.00, 21.00), 20.00(16.00, 27.00), 1.00(0, 3.00)) both in unipolar depression group and bipolar depression group were significantly higher than that in normal control group (both P<0.01). Multivariate Logistic regression analysis showed that self-blame, rumination, and catastrophizing were risk factors for unipolar depression ( OR=1.19, 95% CI=1.05-1.35; OR=1.17, 95% CI= 1.06-1.30; OR=1.14, 95% CI=1.02-1.27) and bipolar depression( OR=1.30, 95% CI=1.14-1.50; OR=1.21, 95% CI=1.07-1.36; OR=1.13, 95% CI=1.01-1.28) compared to normal controls, while positive reappraisal were protective factors for unipolar depression ( OR=0.83, 95% CI=0.73-0.95) and bipolar depression ( OR=0.84, 95% CI=0.73-0.98). However, after controlling for HAMD, HAMA and gender, the effects of each dimension of cognitive emotion regulation strategies on unipolar depression and bipolar depression were no longer significant(both P>0.05). Conclusion:The negative cognitive emotion regulation strategies are correlated with the risk of disease in adolescents with unipolar and bipolar depression, and this effect is affected by the patients' own depression, anxiety and other factors.

Comparison of Metacognitive Beliefs Between Patients with Unipolar Depression and Bipolar Depression

ABSTRACT Objective: The aim of this article is to compare differences in metacognitive beliefs between bipolar disorder type I depressed (BPD1) patients with Unipolar Depression (UPD) patients, and a control group; and to discuss the relationship between metacognitive beliefs and depression parameters. Methods: Sixty six consecutive outpatients with a diagnosis of depressed BPD1, 70 patients with UPD and 70 healthy controls were enrolled in the study. Following assessment with the Sociodemographic Data Form, Structured Clinical Interview for DSM-IV (SCID-I), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scales (HAM-A), Young Mania Evaluation Scale, and the Metacognition Questionnaire-30 (MCQ-30). Results: UPD and BPD1 patients included in the study had higher scores in metacognitive beliefs other than positive beliefs compared with healthy controls (p<0.05), but no significant difference was found between the BPD1 and UPD groups (p>0.05). A statistically significant positive correlation was observed between the HAM-A, HAM-D scores and MCQ-30 scores in UPD group (p<0.05) but not in BPD1 group (p>0.05). Discussion: The metacogitive structures of UPD and BPD1, may be helpful in identifying and choosing the right treatment modality. We think that our results may have implications for the metacognitive approaches in the treatment of BPD1.

Effect of antidepressant therapy on blood glucose and blood lipid in patients with unipolar depression / 西安交通大学学报(医学版)

Objective: This study investigated the occurrence and possible causes of metabolic abnormalities in patients with unipolar depression. Methods: We recruited 103 hospitalized patients with unipolar depression and 100 healthy controls. The patient group was treated with antidepressants for 3 weeks. Metabolic indicators (fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein) were measured before and after treatment. Results: Fasting blood glucose, total cholesterol and high-density lipoprotein were significantly higher in patients with unipolar depression than in healthy controls (P0.05). After treatment with antidepressants, serum fasting blood glucose level was significantly lower than the baseline value (P<0.05). Fasting blood glucose and total cholesterol were significantly higher in patients with recurrent unipolar depression than in the healthy controls (P=0.049, P=0.031). The patients aged above 30 years had significantly higher fasting blood glucose and total cholesterol levels than those aged 30 or younger (P=0.001, P=0.016). Fasting blood glucose level was positively correlated with the number of episodes, and a regression equation could be established as Yfasting blood glucose=0.26xincidence times +4.01. Conclusion: Repeated episodes of depression increase the risk of metabolic problems. Antidepressant treatment helps improve fasting blood glucose. The risk of unilateral depression metabolism may be related to the recurrent disease and has little to do with drug treatment.

Comparisons of exploratory eye movement, adrenocorticotropic hormone and cortisol levels in bipolar and unipolar depression aged patients / 中国神经精神疾病杂志

To explore the characteristics of exploratory eye movement (EEM) and hypothalamic-pituitary-adrenal axis (HPA) in elderly patients with acute bipolar and unipolar depression. Methods Thirty-eight elderly patients with bipolar depression (bipolar group) and thirty-nine patients with unipolar depression (unipolar group) were enrolled. The 24-item Hamilton depression rating scale (HAMD-24) was used to evaluate depressive symptoms. The levels of peripheral serum adrenocorticotropic hormone (ACTH) and cortisol (COR) were detected. EEM was recorded to obtain the number of eye fixation (NEF), responsive search score (RSS) and discriminant analysis (D). Results Compared with the unipolar group, the bipolar group had earlier onset, longer duration, and more admissions (P＜0.05). In comparison with the bipolar group, the unipolar group had higher levels of ACTH and COR (P＜0.05), and higher abnormal proportion of COR and ACTH levels. D-values were higher and RSS-values were lower in unipolar group than in bipolar group. There were no significant differences in NEF and HAMD total scores and its subfactors between the two groups (P＞0.05). Correlation analysis showed that the D value of unipolar group was positively correlated with COR level (r=0.482, P=0.002) but not with other indexes (P＞0.05). There were no significant correlations between EEM parameters and serum levels of HPA hormones in bipolar group (P＞0.05). Conclusion There are different clinical features, EEM indicators, the serum levels of ACTH and COR between acute unipolar and bipolar depression, which suggests the heterogeneity between the two diseases.

Combined Measures of Psychomotor and Cognitive Alterations as a Potential Hallmark for Bipolar Depression

OBJECTIVE: The current study aimed to examine whether specific features of psychomotor retardation (PMR) and cognitive functioning established different profiles in unipolar (UD) and bipolar depression (BD).METHODS: Two groups of age-matched patients with UD (n=54) and BD (n=20) completed the Montgomery-Asberg Depression Rating Scale (MADRS/60), the Montreal Cognitive Assessment (MoCA/30), and the Salpêtrière Retardation Rating Scale (SRRS/60). We analyzed the group effect and then performed intra-group analyses.RESULTS: The BD patients have higher SRRS score, and lower MoCA score than UD despite no difference on the level of depression between UD and BD. Our results show that PMR can be predicted by the level of depression in UD and by the cognitive alteration and onset of disease in BD.CONCLUSION: PMR is a relevant marker of depression. Our results highlight the importance of concomitant evaluation of psychomotor and cognitive functions in the distinction of UD and BD symptoms.

Comparison of Psychological Characteristics of Lesch Types 2 (Anxiety Model) and 3 (Depressive Model) Alcoholism / 우울ㆍ조울병

BACKGROUND: Lesch types 2 (L2, anxiety model) and 3 (L3, depressive model) of alcoholism exhibit different responses to anti-craving agents, and most treatment guidelines provide differential treatment strategies for bipolar depression (DEP) and unipolar DEP. We compare the psychological characteristics of L2 and L3 alcoholism and between the unipolar and bipolar subgroups.METHODS: We reviewed medical records of patients who were diagnosed with alcohol use disorder using the DSM-5 diagnostic criteria and classified as L2 and L3 using Lesch Alcohol typology software. All patients completed self-report scales (Alcohol Use Disorders Identification Test [AUDIT], Beck Anxiety Inventory [BAI], Beck Depression Inventory-II [BDI-II], and Korean Symptom Checklist-95 [KSCL95]). The data were analyzed using descriptive statistics, the Wilcoxon Rank-Sum test, and ANOVA.RESULTS: Of the 43 patients, 23 were assigned L2, and 20 were assigned L3. The scores for the KSCL95 subscales fell generally in the increasing order of the L2-unipolar (L2U, n=10), L2-bipolar (L2B, n=13), L3-unipolar (L3U, n=11), and L3-bipolar (L3B, n=9) types. The L3B scores were greater than the L3U scores for most KSCL95 subscales, by contrast with the DEP and BAI scores.CONCLUSION: We found psychological differences between L2 and L3 and identified the unique psychological characteristics for each subgroup by polarity. The psychological characteristics of these subgroups of alcohol use disorder may help improve the treatment success rates through individualized treatment strategies.

Detection and clinical study of serum thyroid hormone levels in patients with depression / 国际检验医学杂志

Objective To investigate the changes and clinical significance of thyroid function in patients with depression by detecting serum thyroid hormone levels.Methods Totally 127cases of depression in the Department of Psychiatric of our hospital from January 2016to January 2018were collected as research objects.According to the characteristics of depression, patients with unipolar depression were selected as unipolar group (n=45), while patients with bipolar depression were selected as bipolar group (n=82).Meanwhile, 53cases of healthy volunteers underwent physical examination in the same period in our hospital were collected as control group.The serum samples of three groups were collected and the serum levels of thyroid hormones (T3, T4, FT3, FT4, TSH) were detected by chemiluminescence immunoassay.The changes of thyroid function between the three groups were compared and analyzed.Results The proportion of patients with T3and T4decreased in unipolar group were significantly higher than those in bipolar group, and the proportion of patients with T3increased in unipolar group was significantly lower than that in bipolar group, and the proportion of patients with FT4decreased in unipolar group was significantly higher than that in bipolar group;and the proportion of patients with TSH increased and TSH decreased in unipolar group were significantly higher than those in bipolar group, the differences were statistically significant (P＜0.05).The level of FT3in unipolar group was significantly lower than that in bipolar group (P＜0.05), while the level of FT4in unipolar group was significantly lower than that in control group and bipolar group, and the differences were statistically significant (P＜0.05).Conclusion The level of thyroid hormone in patients with different types of depression was different, so the treatment should be distinguished.Psychological treatment should be focused on the unipolar depression patients with hypothyroidism, while attention should be paid to drug treatment for bipolar depression patients with high levels of free thyroid hormone.

Clinical outcomes of psychotherapy dropouts: does dropping out of psychotherapy necessarily mean failure?

Objective: A large proportion of psychotherapy patients remain untreated, mostly because they drop out. This study compares the short- and long-term outcomes of patients who dropped out of psychotherapy to those of therapy completers. Methods: The sample included 63 patients (23 dropouts and 40 completers) from a controlled clinical trial, which compared narrative therapy vs. cognitive-behavioral therapy for major depressive disorder. Patients were assessed at the eighth session, post-treatment, and at 31-month follow-up. Results: Dropouts improved less than completers by the last session attended, but continued to improve significantly more than completers during the follow-up period. Some dropout patients improved with a small dose of therapy (17% achieved a clinically significant change before abandoning treatment), while others only achieved clinically significant change after a longer period (62% at 31-month follow-up). Conclusion: These results emphasize the importance of dealing effectively with patients at risk of dropping out of therapy.Patients who dropped out also reported improvement of depressive symptoms without therapy, but took much longer to improve than did patients who completed therapy. This might be attributable to natural remission of depression. Further research should use a larger patient database, ideally gathered by meta-analysis.

Síntese de recomendações: um recurso para subsidiar o processo de adaptação de guia de prática clínica para o tratamento farmacológico da depressão / Summary of recommendations: a resource to support the process of adaptation of the clinical practice guidelines for the pharmacological treatment of depression

A depressão é um dos maiores problemas de saúde pública do século XXI. Guias de prática clínica (GPCs) estão disponíveis para o tratamento da depressão e têm como objetivo fornecer a melhor e mais recente evidência disponível para os cuidados dos pacientes. Visando reduzir a duplicação de esforços e realizar a adequação de GPC ao contexto local o objetivo desta pesquisa é sintetizar as recomendações de GPCs de alta qualidade sobre o tratamento farmacológico da depressão em adultos na atenção primária. Foram realizadas as etapas busca sistemática dos GPCs, avaliação e seleção dos GPCs de melhor qualidade, e elaboração da síntese de recomendações de acordo com o preconizado no método ADAPTE. Foram considerados os GPCs com recomendações para o tratamento farmacológico da depressão em adultos em atenção primária, em língua inglesa, portuguesa ou espanhola, publicados a partir de 2011. Para a avaliação da qualidade dos GPCs, foi utilizado o Appraisal of Guidelines for Research & Evaluation II (AGREE II) sendo considerados de alta qualidade os GPCs com 80% ou mais no domínio "rigor metodológico". As características associadas à alta qualidade dos GPCs foram analisadas por meio do teste estatístico de Fisher. A extração das recomendações foi realizada de modo independente por dois avaliadores e estas foram organizadas em tópicos. Dos 28 GPC avaliados apenas cinco (18%) foram considerados de alta qualidade. A realização de revisão sistemática e da revisão externa e a aplicação de consenso formal foram características associadas à alta qualidade. Na síntese, além dos GPCs de alta qualidade, foram incluídos 2 GPCs muito empregados na prática clínica. Constatou-se que a maioria dos GPCs traz recomendações concordantes e complementares. Quase todos os GPCs recomendam o uso de inibidores seletivos de recaptação de serotonina como primeira escolha de tratamento. Uma das principais divergências é a recomendação de agomelatina, milnaciprano e mianserina por um dos GPCs como opção de primeira linha de tratamento. A pesquisa demonstra que a qualidade dos GPCs está aquém do desejável, tal qual evidenciado em outros estudos. A elaboração da síntese de recomendações permitiu evidenciar que há um GPC que se destacou por recomendar o uso de medicamentos considerados pouco eficazes na depressão. Considerando que a maioria das recomendações eram concordantes e os GPCs complementavam-se, essa síntese pode contribuir para que sejam realizadas discussões e adaptações locais, favorecendo a elaboração de novos GPCs que possam atender às necessidades de distintos grupos de usuários e demandas regionais

Depression is one of the most significant public health problems of the 21st century. Clinical practice guidelines (CPGs) are available for treating depression and are used for providing the best and latest evidence available for patient care. To avoid the duplication of effort and allow the adequacy of CPGs to regional healthcare networks, the objective of this study is to summarise the recommendations of high-quality CPGs on the pharmacological treatment of depression in adults in the primary healthcare network. The stages of this study were the systematic search of CPGs, analysis and selection of high-quality CPGs, and summarisation of the recommendations according to the ADAPTE guidelines. The CPGs published in English, Portuguese, and Spanish since 2011 with recommendations for the pharmacological treatment of depression in adults in the primary healthcare network were considered. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) was used to evaluate the quality of CPGs. CPGs with a score of >=80% in the domain 'methodological rigour' were considered high-quality. The factors associated with high quality were analysed using Fisher's exact test. The recommendations were extracted independently by two evaluators and organised into topics. Of the 28 evaluated CPGs, five (18%) were considered high-quality. The inclusion of systematic reviews and external reviews and the application of formal consensus were associated with high quality. In addition to high-quality CPGs, two CPGs commonly used in clinical practice were included in the summary. The recommendations provided by most CPGs were consistent and complementary. Almost all CPGs recommended using selective serotonin reuptake inhibitors as the first choice of treatment. One of the main divergences was the recommendation of agomelatine, milnacipran, and mianserin by one CPG as a first-line treatment option. The quality of CPGs was below desirable, and this result was corroborated by other studies. The analysis of the recommendations indicated that one CPG advised using medications with low efficacy in treating depression. Provided that most suggestions were concordant and the CPGs were complementary, this summary may contribute to local discussions and adaptations and promote the development of new CPGs that meet the needs of different user groups and regional demands

More Resilience in Males with Probable Bipolar Depression than Probable Unipolar Depression among Korean Conscripts

OBJECTIVE: This study investigated whether the resilience of males with probable bipolar depression (PBD) can be strengthened and compared it to that of males with probable unipolar depression (PUD). METHODS: Prospective data for 198 participants (PBD: 66, PUD: 66, normal control: 66) were analyzed. The participants' resilience, bipolarity and severity of depressive symptoms were evaluated at baseline and after 5 weeks. Analysis of variance (ANOVA) and repeated measure ANOVA was performed for comparing resilience between three groups through a basic military training. RESULTS: The PBD group demonstrated more resilience than the PUD group at baseline. Participants with PBD became significantly more resilient than participants with PUD after 5 weeks (p<0.01, F=6.967, η²(p)=0.052). CONCLUSION: The study indicates that interventions that strengthen resilience need to be developed for males with PBD and that such interventions are more effective for males with PBD than PUD.

Diferencias en la experiencia subjetiva entre depresión unipolar y bipolar / Differences in Subjective Experience Between Unipolar and Bipolar Depression

Introducción: Es importante distinguir la depresión unipolar de la bipolar, pues hay diferencias en el tratamiento y el pronóstico. Dado que el diagnóstico de las dos condiciones es netamente clínico, encontrar diferencias sintomáticas puede ser de gran utilidad. Objetivos: Buscar diferencias en la experiencia subjetiva (de primera persona) entre depresión unipolar y bipolar. Métodos: Estudio exploratorio de tipo cualitativo, de orientación fenomenológica, con 12 pacientes (7 con depresión bipolar y 5 con depresión unipolar; 3 varones y 9 mujeres). Se utilizó una entrevista semiestructurada basada en el Examen de la Experiencia Anómala del Self (EASE). Resultados: Estado de ánimo predominante: en la depresión bipolar es el apagamiento emocional; en la unipolar, la tristeza. Experiencia del cuerpo: en la bipolar, el cuerpo se siente pesado, francamente cansado y como un obstáculo para el movimiento. En la unipolar, la experiencia del cuerpo se parece a la pereza cotidiana. Cognición y flujo de conciencia: en la depresión bipolar, en comparación con la unipolar, el pensamiento se vive lentificado, como si tuviera que vencer obstáculos en su curso; hay mayor dificultad para comprender lo que se escucha o se lee. Perspectiva del futuro: en la depresión bipolar, la desesperanza es más intensa y de mayor alcance que en la unipolar, como si se perdiera la posibilidad misma de la esperanza. Conclusiones: Se encontraron diferencias cualitativas en el estado de ánimo predominante, la experiencia corporal, la cognición y la perspectiva del futuro entre la depresión unipolar y la bipolar.

Introduction: It is important to make distinction between bipolar and unipolar depression because treatment and prognosis are different. Since the diagnosis of the two conditions is purely clinical, find symptomatic differences is useful. Objectives: Find differences in subjective experience (first person) between unipolar and bipolar depression. Methods: Phenomenological-oriented qualitative exploratory study of 12 patients (7 with bipolar depression and 5 with unipolar depression, 3 men and 9 women). We used a semi-structured interview based on Examination of Anomalous Self-Experience (EASE). Results: The predominant mood in bipolar depression is emotional dampening, in unipolar is sadness. The bodily experience in bipolar is of a heavy, tired body; an element that inserts between the desires of acting and performing actions and becomes an obstacle to the movement. In unipolar is of a body that feels more comfortable with the stillness than activity, like laziness of everyday life. Cognition and the stream of consciousness: in bipolar depression, compared with unipolar, thinking is slower, as if to overcome obstacles in their course. There are more difficult to understand what is heard or read. Future perspective: in bipolar depression, hopelessness is stronger and broader than in unipolar, as if the very possibility of hope was lost. Conclusions: Qualitative differences in predominant mood, bodily experience, cognition and future perspective were found between bipolar and unipolar depression.

Distinguishing role of brain imaging between unipolar depression and bipolar depression / 中华行为医学与脑科学杂志

Differentiating bipolar disorder (BD) from unipolar depression (UD) is an important clinical challenge.Review the development of Magnetic Resonance Imaging ( MRI) in distinguishing the BD and UD, identifying objective markers of BD, to optimize clinical decision making.Database including PubMed,Wan Fang,CNKI and so on.The key words were usedunipolar depressionormajor depressive depression,bipolar depression,MRI,modeland so on.A little neuroimaging studies to date have directly compared UD and BD depressions.Most results from these studies suggest more heavy neural circuit abnormalities in BD than UD depression,involved in different brain regions.Predictive models based on neu-roimaging characteristics of BD and UD obtain a higher accuracy and can help differentiate BD from UD.This review serves as a call to highlight the need for more neuroimaging studies to compare individuals with BD depression with individuals with UD depression directly.Using neuroimaging results as objective biological i-dentification markers is a feasible research field.

Study on cognitive function of the patients with bipolar depression and unipolar depression and their first-degree relatives / 中华行为医学与脑科学杂志

Objective To explore the cognitive function of the patients with bipolar depression (BP), unipolar depression (UP) and their first-degree relatives.Methods 52 patients with BP and 49 their first-degree relatives ,67 patients with UP and 59 their fi~t-degree relatives, 97 normal controls were tested by information, arithmetic, digital symbol, digital span test, block design,logical memory (included immediately and delayed) , visual memory(included immediately and delayed), Stroop Test (included Stroop C and Stroop CW), trail making test (included Part A and Part B) ,verbal fluency and modified Wisconsin card sorting test(M-WCST).Results The scores of digital symbol, block design, immediately logical memory, delayed logical memory, immediately visual memory,delayed visual memory,trail making test B and WCST in the patients with BP and UP were worse than those in normal control(P＜0.01).The score of WCST in the patients with BP was lower than that in the patients with UP ((3.02± 1.96), (4.40± 1.13), P＜0.01).The score of WCST in the relatives of the patients with bipolar depression was worse than that in the normal control((4.32±1.66), (5.15±1.27), P＜ 0.05).Conclusion The patterns of impaired cognitive function on sustained attention,concept of visual space,visual memory,verbal memory and executive function are similar in the patients with BP and UP.The executive function of the patients with BP is worse than the patients with UP.

Study on fractional amplitude of low-frequency fluctuation in male patients with unipolar and bipolar depression / 中华行为医学与脑科学杂志

Objective To explore the characteristic differences of the fractional amplitude of low-frequency fluctuation (fALFF) feature of the spoutaneous neural activity between young male unipolar depression and bipolar depression patients,and determine the biological markers to distinguish the two disorders.Methods Twelve male unipolar depression,12 bipolar depression patients and 11 age and educated-matched healthy males underwent resting-state functional magnetic resonance imaging scanning at 3.0 Tesla.The whole brain' s fALFF were calculated and analyzed.Results The differences of the fALFF of the three groups had significant differences (P＜0.01,Alphasim) in the right orbital medial frontal gyrus (6,33,-9;K =29),the left medial frontal gyrus (-6,60,3;K =44) and the left paracentral lobule (-3,-27,5 1;K =20).The unipolar depression subjects had significantly higher fALFF compared with heahhy controls in the left anterior cingulate gyrus.The bipolar depression subjects had significantly higher fALFF compared with healthy controls in the bilateral medial frontal gyrus and the left middle cingulate gyrus.And the unipolar depression subjects had significantly lower fALFF compared with bipolar depression ones in the right orbital medial frontal gyrus,the right anterior cingulate gyrus and the bilateral medial frontal ~rus(all P＜0.05).Conclusions Abnormalities exist in the brain regions in male with unipolar or bipolar depression patients in the resting state,and the abnormal regions are different.

Detection of prodromal symptoms of relapse in mania & unipolar depression by relatives & patients.

Background & objectives: Detection of prodromal symptoms among patients with mania by their immediate relatives has been seldom examined. We carried out this study to examine the ability to detect and report prodromol symptoms of manic relapses by patients themselves and their relatives. Methods: The ability of patients and their relatives to detect prodromal symptoms was examined among 60 remitted patients, 30 each with DSM-IV diagnoses of bipolar disorder and recurrent depressive disorder, with recent manic/depressive relapses, and their 60 immediate relatives, using an instrument composed of items from common symptom-scales, as well as by unstructured interview. Results: Seventy per cent of patients with mania reported prodromes prior to relapse. This was significantly (P<0.01) less than the proportion of their relatives (97%), as well as the proportion of patients with unipolar depression (93%), reporting prodromal symptoms (P<0.05) among patients. Mean duration of the prodromal period reported by patients with mania was about 20 days (median-10 days); relatives reported durations which were longer by about 5 days. Prodromes of unipolar depression (mean 42.7 days; median- 21 days), were significantly longer than of mania, when reported by patients, but not by their relatives. Differences in reporting of prodromes, between relatives and patients seen in mania, were not observed in unipolar depression. The number and type of prodromal symptoms of mania reported was similar among patients and relatives. Interpretation & conclusions: Our findings showed that relatives of patients with mania were better at detecting prodromes of relapse; thus, input from relatives can improve the early detection of prodromal symptoms to prevent relapses of bipolar disorder.

Comparison of the Rorschach Test Characteristics between Bipolar Disorder and Unipolar Depression / 대한정신분열병학회지

OBJECTIVES: Differential diagnosis based on descriptive psychopathology between bipolar and unipolar depression in the clinical setting is a still huge challenge. Projective psychological tests might provide additional clues. This study aimed to find distinct Rorschach test characteristics of bipolar depression in comparison with unipolar depression. METHODS: Medical records and raw data of the Rorschach Inkblot test applied using standardized procedure for the Exner Comprehensive System were retrospectively reviewed for patients with bipolar disorder or unipolar depression. Individual variables of the Rorchach test were compared among three groups, i.e., (hypo) mania (n=59), bipolar depression (n=56) and unipolar depression (n=25). RESULTS: Bipolar depression group, in accordance with (hypo) manic group, showed more color reponses (WSumC), more extroverted and intuitive decision-making (EBright), and higher emotional expression (CF+C) and instability (ebright), compared to unipolar deperssion group. On the contrary, the (hypo) mania group displayed more cognitive errors (Sum6, WSum6) compared to both depression groups. CONCLUSION: This study suggests that Rorchach test might provide valuable markers for differential diagnosis between bipolar and unipolar depression, and that some of those markers could be regarded as trait markers of bipolar disorder.

Comparative study for effects of repetitive transcranial magnetic stimulation on cognitive function in unipolar depression / 中华行为医学与脑科学杂志

Objective To investigate the effects of left dorsolateral prefrontal cortex with 10HZ , 80%motor threshold repetitive transcranial magnetic stimulation ( rTMS ) on the cognitive function in unipolar depression. Method Sixty-nine patients with unipolar depression were randomly assigned to either the real rTMS group or the sham rTMS treatment( the control group) ,all patients were given extended releasing venlafaxine. the cognitive function was evaluated using P300 and Repeatable battery for the assessment of neuropsychological status ( RBANS-immediate memory, visuospatial, language, attention, delayed memory, total score), Wisconsin card sorting test ( WCST-Right responses, Completed categories, Total errors , Preservative errors, Nonpreservative errors ). The depression severity was assessed with the 24-item Hamilton Rating Scale for Depression(HAMD-24). All of tests were examined before and after six weeks with thirty times rTMS. Results At the end of six weeks treatments, regarding the WCST,real rTMS group showed better improvement in the right responses than control group(33.23±10.29 vs 27.09 ± 9.82, F= 16. 116 , P= 0. 000), besides right responses, real rTMS group had better performance in the rest items than control group(F=4.862 ～ 17.758, P= 0.031 ～ 0.000) ;concerning the RBANS, real rTMS group was significantly superior to control group in total score( (88.83 ± 16.48 ) vs (78.85 ± 13.51 ), F= 8. 425,P = 0. 005 ), besides total score , the real rTMS group had better performance in some rest factors than control group (F= 10.088 ～20. 801, P=0. 002 ～0.000);real rTMS group showed better improvement in the amplitude of P3than control group( (8.27 ± 2.97 ) μV vs ( 7.37 ± 2.66) μV, F= 5. 838 , P=0.018 ) ;real rTMS group demonstrated better improvement in HAMD-24 than control group( (4.7 ±2.4)vs ( 11.2 ±5.1 ), F= 29.537, P=0. 000).Conclusion rTMS can significantly improve cognitive function and depressive symptoms with unipolar depression.