Real-World Treatment Patterns, Outcomes, Resource Utilization and Costs in Treatment-Resistant Major Depressive Disorder: PATTERN, a Retrospective Cohort Study in Belgium.

OBJECTIVE: Treatment-resistant depression (TRD), a subgroup of major depressive disorder (MDD) that does not adequately respond to treatment, has a substantial impact on the quality of life of patients and is associated with higher medical and mental health care costs. This study aimed to report real-world treatment patterns, outcomes, resource utilization, and costs in the management of TRD by psychiatrists in Belgium. METHODS: We conducted a retrospective, non-interventional cohort study of patients ≥ 18 years, with diagnosed MDD who are treatment-resistant, defined as not responding to two different antidepressant treatments in the current moderate to severe major depressive episode (MDE). Data obtained from medical records of patients included patient health state (MDE, response, remission, and recovery) and resource use (number of consultations and emergency room visits, non-drug and drug interventions, and hospitalizations). RESULTS: One hundred and twenty-five patients were enrolled in nine sites, with an average observation period of 34 months. During the MDE, 89.7% of patients were treated with selective serotonin reuptake inhibitors, 63.2% with serotonin-norepinephrine reuptake inhibitors, and 60.8% with anti-psychotics. Twenty-four percent of patients did not respond to any treatment; 76% responded, of whom 61% experienced a relapse; 28% of patients reached recovery, of whom 31.4% experienced recurrence. The average yearly direct cost of a TRD patient is €9012, mainly driven by hospitalization in the MDE. The observed absenteeism relates to a high indirect cost, representing 70% of the total MDE cost. CONCLUSION: TRD is associated with a high unmet need and economic burden for patients and society, with highest costs in the MDE health state driven by absenteeism.

[Between response and resistance: pseudo-resistance during treatment of major depressive disorder]. / Tussen respons en resistentie: pseudo­resistentie bij de behandeling van een depressieve stoornis.

BACKGROUND: Although the efficacy of antidepressants has been clearly established, 30-60% of patients with major depressive disorder (MDD) appear to have a poor response. However, many patients labeled with treatment-resistant depression actually have pseudo-resistance due to suboptimal approach. AIM: To provide an overview of the causes of pseudo-resistance, as well as the interventions to counteract it in patients with MDD. METHOD: A literature search was conducted using the PubMed, Embase, and Web of Science databases. RESULTS: The causes of pseudo-resistance can be multiple and can be attributed to both the clinician (inappropriate prescribing behavior, misdiagnosis or incomplete diagnosis) and the patient (ultra-fast metabolism, poor medication adherence, comorbidity). Advice and interventions to prevent pseudo-resistance must therefore be targeted to the clinician (knowledge of clinical guidelines, simplified dosage schedules, correct diagnosis, interventions to improve poor medication adherence), as well as the patient (personalized psychoeducation, social support, care management). CONCLUSION: Pseudo-resistance is a multifactorial phenomenon that requires complex intervention strategies. In addition to adequate treatment provided by the clinician, personalized psychoeducation, good patient support and intensive follow-up of, as well as open communication with the patient are also required.

[Effectiveness of anti-stigma interventions regarding severe mental illness: a systematic literature review]. / Effectiviteit van interventies tegen stigma van ernstige psychiatrische aandoeningen; systematisch literatuuroverzicht.

BACKGROUND: Stigma is one of the greatest challenges facing people with severe mental illness (smi) and can have profound psychological, social and professional consequences.
AIM: To systematically review the evidence of effectiveness of anti-stigma interventions (anti-stigma campaigns and specific interventions to reduce public stigma and self-stigma) for people with smi and to make recommendations for clinical practice.
METHOD: A systematic literature search for individual studies and reviews concerning the efficacy of interventions that reduce stigma for people with smi.
RESULTS: Anti-stigma interventions have small-to-medium effects. Although head-to-head comparisons do not show a clear advantage for educational or contact interventions, results suggest that the elements of contact, recovery and continuity (for public stigma) and psycho-education (for self-stigma) may yield the greatest effects. Due to the short follow-up period of most studies, there is limited evidence on the long-term effectiveness of these interventions. More specifically, it remains unknown whether these interventions lead to changes in actual behavior.
CONCLUSION: Anti-stigma interventions have limited effects on knowledge, attitudes and behavior. Several methodological shortcomings, as well as short follow-up periods in most studies, preclude making firm conclusions.

A primer of current molecular genetic strategies for clinicians.

For the clinician to take full advantage of the rapid advances in molecular medicine, a working knowledge of the recombinant DNA methodologies employed will be required. This primer introduces current cloning strategies by examination of the cloning of the cystic fibrosis gene, an opioid receptor, and olfactory receptors that used the methodologies of DNA linkage analysis, functional cloning, and polymerase chain reaction with degenerate oligonucleotide primers, respectively. Molecular information obtained after cloning has had immediate effects on diagnosis and genetic counseling and holds the promise of novel treatment strategies, including somatic gene therapy.

A pairing-sensitive element that mediates trans-inactivation is associated with the Drosophila brown gene.

Position-effect variegation in Drosophila is the mosaic expression of a gene juxtaposed to heterochromatin by chromosome rearrangement. The brown (bw+) gene is unusual in that variegating mutations are dominant, causing "trans-inactivation" of the homologous allele. We show that copies of bw+ transposed to ectopic sites are not trans-inactivated by rearrangements affecting the endogenous gene. However, when position-effect variegation is induced on an ectopic copy by chromosome rearrangement, the allele on its paired homolog is trans-inactivated, whereas other copies of bw+ are not. This confirms that trans-inactivation is "chromosome local" and maps the responsive element to the immediate vicinity of brown. Subsequent P-transposase-induced deletions within the ectopic copy in cis to the rearrangement breakpoint caused partial suppression of trans-inactivation. Surprisingly, the amount of suppression was correlated with deletion size, with some degree of trans-inactivation persisting even when the P[bw+] transposon was completely excised. The chromosome-local nature of the phenomenon and its extreme sensitivity to small disruptions of somatic pairing leads to a model in which a regulator of the brown gene is inactivated by direct contact with heterochromatic proteins.

Trans-inactivation of the Drosophila brown gene: evidence for transcriptional repression and somatic pairing dependence.

Position-effect variegation in Drosophila is the variable inactivation of a gene that occurs when it is juxtaposed to heterochromatic regions of chromosomes. The brown gene, required for pteridine pigment in the eye, is unusual in that expression of the unrearranged homolog also is affected. This dominant effect can be very strong, as inactivation is detectable when as many as three trans copies of the gene are present. We show that pteridine reductions coincide with similar reductions in the accumulation of brown mRNA. The dominant effect is suppressed by certain altered structural configurations of the brown region, suggesting that somatic pairing is involved in the phenomenon. We propose that direct transmission of the altered chromatin structure characteristic of position-effect variegation (heterochromatinization) occurs between paired homologs in the region of the brown locus.

The brown protein of Drosophila melanogaster is similar to the white protein and to components of active transport complexes.

The brown gene of Drosophila melanogaster is required for deposition of pteridine pigments in the compound eye and other tissues. We isolated a ca. 150-kilobase region including brown by microdissection and chromosome walking using cosmids. Among the cDNAs identified by hybridization to the cosmids, one class hybridized to a genomic region that is interrupted in two brown mutants, bw and In(2LR)CK, and to 2.8- and 3.0-kilobase poly(A)+ RNAs which are altered in the mutants. Nucleotide sequencing of these cDNAs revealed that the two transcripts differ as a consequence of alternative poly(A) addition and that both encode the same predicted protein of 675 amino acids. Searches of available databases for amino acid sequence similarities detected a striking overall similarity of this predicted protein to that of the D. melanogaster white gene. The N-terminal portion aligned with the HisP family of membrane-associated ATP-binding proteins, most of which are subunits of active transport complexes in bacteria, and to two regions of the multidrug resistance P-glycoprotein. The C-terminal portion showed a structural similarity to integral membrane components of the same complexes. Taken together with earlier biochemical evidence that brown and white gene products are necessary for uptake of a pteridine precursor and genetic evidence that brown and white proteins interact, our results are consistent with suggestions that these proteins are subunits of a pteridine precursor permease.

Effects of anti-C23 (nucleolin) antibody on transcription of ribosomal DNA in Chironomus salivary gland cells.

Protein C23 (also called nucleolin or 100-kDa nucleolar protein) is a major nucleolar phosphoprotein involved in ribosome biogenesis. To determine the effects of protein C23 on preribosomal RNA (pre-rRNA) synthesis anti-C23 antiserum was microinjected into nuclei of Chironomus tentans salivary glands. Transcription was measured by incubation of the glands with 32P-labeled RNA precorsors followed by microdissection of nucleoli, RNA extraction, and electrophoretic analyses. Injection of the anti-C23 antibody caused a 2- to 3.5-fold stimulation of 32P incorporation into 38S pre-rRNA. No stimulation was observed in salivary glands injected with preimmune serum or antiserum preabsorbed with protein C23. The stimulatory effect was selective for pre-rRNA as indicated by the lack of stimulation of 32P incorporation into extranucleolar RNA. Injection of the antiserum produced little or no effect on pre-RNA processing as measured by the relative amounts of 32P-labeled intermediate cleavage products of pre-rRNA in stimulated versus control glands. When protein extracts of Chironomus tentans salivary gland nuclei were probed on Western blots with anti-C23 antibody the predominant cross-reacting species was a 110-kDa polypeptide which had an electrophoretic mobility similar to that of protein C23. These results suggest that protein C23 not only is involved in ribosome assembly but also plays a role in regulating the transcription of the preribosomal RNA.

Developmentally regulated expression of a Balbiani ring 1 gene for a 180-kD secretory polypeptide in Chironomus tentans salivary glands before larval/pupal ecdysis.

The expression of a Balbiani ring 1 gene that codes for a salivary gland-specific 180-kD secretory polypeptide (sp180) is regulated developmentally. Immunoblots of salivary gland protein incubated with an affinity-purified nonapeptide-reactive antibody demonstrated that the salivary gland content of sp180 increases as much as 10-fold between stages 8 and 10 of the fourth larval instar. Hybridization of RNA dot-blots with an oligonucleotide probe indicated that the observed increase in sp180 was preceded by a parallel 20-fold increase in the steady state level of its mRNA beginning between stages 7 and 8. In vitro nuclear transcription experiments demonstrated that there was a 10-fold acceleration in the rate of sp180 gene transcription between stages 6 and 10. The limited period of expression of the sp180 gene contrasted dramatically with the expression of Balbiani ring genes BR1, BR2 alpha, BR2 beta, and BR6, which code for the sp-I family of fibrous secretory polypeptides. The appearance of sp180 in secretion coincided with microscopically visible changes in the bundling of these fibrous polypeptides. At the same time, we noticed changes in the appearance and consistency of feeding tubes that larvae construct with this secretion. These results lead us to propose that sp180 may modify the structure or utilization of fibrous secretory polypeptides specifically for the assembly of pupation tubes necessary for larval/pupal ecdysis.

A peptide-reactive antibody to a Balbiani ring gene product: immunological evidence that a 6.5-kb RNA in Chironomus tentans salivary glands is mRNA for a 180-kDa nonfibrous component of larval secretion.

An immunological approach was utilized to demonstrate that a tissue-specific Balbiani ring (BR) transcript in Chironomus tentans is the mRNA for a secreted 180-kDa polypeptide. Balbiani ring 1 (BR1) on the polytene chromosome IV of larval salivary glands contains a gene comprised of tandemly duplicated nucleotide sequences that are transcribed into a salivary gland-specific, 6.5-kb poly(A)+RNA for which a partial cDNA sequence exists [Dreesen et al., J. Biol. Chem. 260 (1985) 11824-11830]. A nonapeptide was synthesized so that its amino acid sequence corresponded to an open reading frame in the cDNA. This peptide was used to raise rabbit polyclonal antisera and to purify the peptide-reactive antibody by affinity chromatography. The affinity-purified antibody bound specifically to a 180-kDa polypeptide on Western blots containing extracts of total salivary gland protein. Western blot analysis of microdissected cellular vs. lumenal fractions of salivary glands indicated that this 180-kDa polypeptide was primarily localized in the lumen. Consequently, this polypeptide was designated a secretory polypeptide (sp180). Finally, the peptide-reactive antibody was used to localize sp180 in a nonfibrous component of salivary gland secretion by indirect immunofluorescence microscopy.

A second gene in a Balbiani ring. Chironomus salivary glands contain a 6.5-kb poly(A)+ RNA that is transcribed from a hierarchy of tandem repeated sequences in Balbiani ring 1.

A second gene has been discovered at a previously studied Balbiani ring in Chironomus. Northern hybridizations demonstrated that cDNA clone pCt35 originated from a salivary gland specific 6.5-kilobase (kb) RNA that was abundant, nonribosomal, and apparently poly(A)+. pCt35 had a 120-base pair (bp) insert with 1.6 copies of a 75-bp sequence that contained two open reading frames. Southern hybridizations indicated that pCt35 was homologous to at least a 4-kb block of genomic DNA organized as a hierarchy of 150- and 300-bp tandem repeats. In situ hybridization localized these sequences to Balbiani ring 1. From these results we postulated that a 6.5-kb RNA gene may have evolved by stepwise duplication and amplification of a 75-bp ancestral sequence.

Odorous chemical perturbations of (Na+ + K+)-dependent ATPase activities. Effects on native and lipid-substituted preparations from individual turbinals from dog olfactory tissue.

Individual turbinals from the right and left sides of dog olfactory tissue were removed and nerve-ending-particle preparations were prepared. (Na+ + K+)-dependent ATPase activities of the individual preparations, and the effect of several odorous compounds [including (+)- and (-)-carvone] on the (Na+ + K+)-dependent ATPase activities, were determined. The maximally stimulatory odorant concentration in the reaction mixture for the majority of odorants was found to be 1.0 mM. Matched pairs of left/right turbinals showed a lack of bilateral symmetry of response. (Na+ + K+)-dependent ATPase activities of various dog brain nerve-ending particle preparations responded only slightly to 1.0 mM odorants. The role of phospholipids in the (Na+ + K+)-dependent ATPase activity was found to be critical. Partial replacement of endogenous lipid with either synthetic phospholipids or extracted lipids resulted in changes in stimulation obtained with endogenous lipids alone.

Partial purification and characterization of a Ca(2+)-stimulated lipoxygenase from soybean seeds.

A highly purified Ca(2+)-stimulated lipoxygenase was isolated from the Hill variety of soybean seeds. Separation of Ca(2+)-stimulated lipoxygenase from lipoxygenase active in the absence of Ca(2+) (lipoxygenase-1) was readily obtained using a DEAE-cellulose column. Sample size applied to the ion exchange column was found to be critical. Both enzymes were bound to the column, although some highly active Ca(2+)-stimulated lipoxygenase eluted with buffer in the presence of bound lipoxygenase-1. Ca(2+)-stimulated lipoxygenase bound to DAAE-cellulose required the use of a NaCl gradient for elution. Ca(2+)-stimulated lipoxygenase showed an apparent isoelectric point at pH 5.90 and optimum activity at pH 7.5 and at 1.1 mM calcium. Lipoxygenase-1 was inhibited over 95% in the presence of 60 µM methyl mercuric chloride, while Ca(2+)-stimulated lipoxygenase showed a maximum of only 20% inhibition under the same conditions.

Rapid cell surface appearance of endocytic membrane proteins in Chinese hamster ovary cells.

Lactoperoxidase was used to selectively radiolabel endocytic membrane. CHO cells were incubated with enzyme at 37 degrees C for 10 min to permit lactoperoxidase internalization. Radioiodination was done at 4 degrees C. About 90% of the radioiodinated products pelleted at 100,000 X g. From 12 to 15 different electrophoretic species were detected by one-dimensional gel electrophoresis. When cells labeled by internalized lactoperoxidase were warmed to 37 degrees C, the incorporated radioactivity was lost in a biphasic manner with an overall t1/2 of approximately 20 h. Upon warming cells to 37 degrees C, the labeled species became sensitive to pronase or trypsin digestion. The increase in protease sensitivity was progressive over a 10- to 20-min period. Maximally 45% of the initially intracellular radiolabel could be released. A digest of exterior-radioiodinated cells released 50% of the incorporated radioiodine. These observations strongly suggest a rapid shuttling of approximately 90% of the radioiodinated membrane species initially present within the cell to the cell surface.