Facilitators and barriers to modifying dietary and hygiene behaviours as adjuvant treatment in patients with depression in primary care: a qualitative study.

BACKGROUND: Major depression is a highly prevalent condition. Its pathogenesis is related to a wide variety of biological and psychosocial factors and among these is factors related to lifestyle. Lifestyle-based interventions seem to be appropriate strategies as coadjutant treatment. The objective of this study is to explore and identify expectations and experiences of both patients and healthcare professionals that can point to the main barriers and facilitators with regard to the promotion of healthy dietary and hygiene behaviours in patients suffering from major depression. METHODS: A qualitative design was used to collect information from a wide range of purposefully and theoretically guided samples of depressed patients and health professionals from Primary Care (PC). Both in-depth interviews and discussion groups were used. A standardized protocol was designed to guide the interviews and groups, including the preparation of a topic list to be addressed, with previously tested, open suggestions that could be of interest. A thematic analysis was performed from grounded theory in order to explore, develop and define until saturation the emergent categories of analysis derived from the individual interview and group data. RESULTS: Both patients as well as PC professionals noted a series of central aspects with respect to the implementation of a programme for the acquisition of healthy dietary and hygiene habits for depressive patients, which may be organized around 'personal', 'programmatic', and 'transversal' aspects. As for the personal aspects, categories regarding 'patient history', and 'disposition' were found; the programmatic aspects included categories such as 'presentation and monitoring', and modification of 'cognitive' and 'behavioural' habits; whereas the transversal aspects comprised the possibilities of 'social support' and defining categories of 'objectives'. CONCLUSION: The implementation of intervention programmes that combine dietary and hygiene-related factors in patients with depression is complex, given the nature of the disorder itself, and its symptoms such as apathy and feelings of guilt or incompetence. Key issues exist for the success of the intervention, such as the simplicity of guidelines, tailoring through motivational interviewing, prolonged and intense monitoring throughout the different stages of the disorder, and the provision of adequate feedback and social support. PC could be an appropriate level in which to implement these interventions.

Obesity, metabolic syndrome and Mediterranean diet: Impact on depression outcome.

OBJECTIVE: Obesity, metabolic syndrome (MetS) and low adherence to Mediterranean diet are frequent in major depression patients and have been separately related with prognosis. The aim of this study is to analyse their predictive power on major depression outcome, at 6 and 12 months. METHODS: 273 Major depressive patients completed the Beck Depression Inventory for depressive symptoms and the 14-item Mediterranean diet adherence score. MetS was diagnosed according to the International Diabetes Federation (IDF). RESULTS: At the baseline Mediterranean diet adherence was inversely associated with depressive symptoms (p=0.007). Depression response was more likely in those patients with normal weight (p=0.006) and not MetS (p=0.013) but it was not associated with Mediterranean diet adherence (p=0.625). Those patients with MetS and obesity were less likely to improve symptoms of depression than patients with obesity but not MetS. CONCLUSIONS: Obesity and MetS, but not low adherence to the Mediterranean diet at baseline, predicted a poor outcome of depression at 12 months. Our study suggests that MetS is the key factor that impacts negatively in depression prognosis, rather than obesity or diet. If this finding is confirmed, clinicians should be aware about MetS diagnosis and treatment in overweight depressed patients, especially if outcome is not being satisfactory enough.

Lifestyle change recommendations in major depression: Do they work?

BACKGROUND: Modifying some lifestyle factors can be useful in depression, at least as an adjuvant treatment. Combining different lifestyle interventions seems to be an adequate strategy to increase their antidepressant efficacy according with preliminary studies, but this issue has not been enough investigated. METHODS: The present study is a randomized, double-blinded, multicentre, two arm-parallel clinical trials, with a 12 month follow-up. The sample consisted of 273 Primary Care patients. Four combined hygienic-dietary written recommendations were given to the patients about diet, exercise, light exposure and sleep hygiene. RESULTS: Both active and control interventions were associated with improvement on BDI (Beck Depression Inventory) scores. However, there were not statistically significant differences (7.0 vs. 7.6; p=0.594). LIMITATIONS: We were unable to monitor whether patients carry out recommendations. Intervention could be too difficult to accomplish for depressed patients without enough support and supervision. CONCLUSIONS: Just giving written lifestyle recommendations are not enough for depressive patients to benefit from them, so perhaps lifestyle change recommendations work or do not work on Depression depending on how they are presented to patients and on monitoring systems of their implementation.

Stressful life events severity in patients with first and recurrent depressive episodes.

BACKGROUND: Stressful life events are associated with depression and their role in first onset and recurrences is a promising but controversial perspective of research. The objective is to analyze the role of number of previous episodes and life events exposure in a large sample of primary care depressive patients taking into account life events severity. METHOD: 10,257 patients with DSM-IV criteria for a current single or recurrent major depressive episode were recruited by 2,056 general practitioners in a cross-sectional epidemiological study. Patients answered the Montgomery-Asberg Depression Rating Scale, the Patient Health Questionnaire and the Social Readjustment Rating Scale (SRRS). Stressful life events were categorized into three levels of severity (severe, moderate and mild). All relevant confounding variables were analyzed: age, gender, depression severity, somatic symptoms severity and length of episode. RESULTS: We found a significant positive correlation with number of episodes and depression severity. There was no significant correlation of SRRS scores with age, gender and length of episode. ANOVA exploring life events severity with regard to number of episodes showed statistically differences in SRRS total score, moderate life events and mild life events (F = 15.14, p < 0.001) but not for severe life events. CONCLUSIONS: Prevention and treatment strategies for recurrent depression need to manage life stressful events during mild and long-term periods and not just in the initial recurrences of the disease.

Medical comorbidity in recurrent versus first-episode depressive patients.

OBJECTIVE: This study compares the comorbidity of affective disorders and medical diseases in primary care patients with either a first or recurrent depressive episode. METHOD: A cross-sectional epidemiological study in primary care centres in Spain was designed. A total of 10,257 primary care patients suffering a DSM-IV major depressive episode (MDD) were analysed. Depression was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS), and World Health Organization (WHO) medical diagnoses were provided by the patient's general practitioner according to medical records revised on the basis of radiology or laboratory test data. RESULTS: A total of 88.6% of recurrent patients and 71.1% of first-episode depressive patients reported a medical condition (aOR = 2.61, CI = 2.31-2.93). All medical conditions were more prevalent in the recurrent group than in first-episode group, and with the exception of myocardial infarction, psoriasis and migraine, all other crude ORs showed statistically significant differences between first- and recurrent episodes patients after adjusting for gender, age, education, socioeconomic status and body mass index (BMI). CONCLUSION: Recurrent depression is associated with a decrement in health that is significantly greater than in first-episode depression. Special attention needs to be paid to the physical health in the middle- and long-term management of patients with affective disorders.

[Use of antidepressant treatment. Patients' perception]. / Uso de los tratamientos antidepresivos. La percepción del paciente.

INTRODUCTION: A major determinant of response to antidepressant drugs is how the patients use them. Our objective is to take a look over the antidepressants use in a real sample. METHODS: In determining which factors may be relevant for treatment good use, social, demographic, disease and treatment-related data were gathered from 550 patients, who were currently taking antidepressants for any motive. The questionnaire included two items, the patients' perceived difficulty of following treatment and the level of acknowledged non-compliance by the patient, which may be considered as both an indirect and guiltless way of approximating the patients' real use of treatment. RESULTS: Compliance was poor among the less educated, as well as those living in rural areas and in patients receiving concomitant treatment for organic diseases. Use was good in 61.5% and was particularly good among those with an affective disorder (69.8%). Among patients who did not respond to treatment, the incidence of non-compliance (49.1%) was higher than for those achieving improvement (31.2%). CONCLUSIONS: It's important to explore and reinforce a good use of antidepressants in clinical settings and to be sure this type of treatment is necessary if the indication is not clear.

Uso de los tratamientos antidepresivos. La percepción del paciente / Use of antidepressant treatment. Patients’ perception

Introducción. Un determinante fundamental de la respuesta al tratamiento antidepresivo es cómo el paciente lo toma. Nuestro objetivo es observar el uso de los antidepresivos en una muestra real de pacientes. Métodos. Para determinar que factores pueden ser relevantes para un buen uso del tratamiento se recogieron datos sociales, demográficos, relativos a la enfermedad y al tratamiento de 550 pacientes que estaban siendo tratados con antidepresivos por cualquier motivo. El cuestionario elaborado incluía dos ítems, la dificultad percibida por el paciente para seguir las indicaciones del tratamiento y el nivel de reconocimiento de falta de cumplimiento, lo que puede ser considerado como una forma indirecta y poco culpabilizadora de aproximarse al uso real del medicamento por parte del paciente. Resultados. El cumplimiento fue peor en el grupo con un nivel inferior de educación, así como en aquellos que vivían en zonas rurales y en los que recibían otro tratamiento concomitante para enfermedades orgánicas. El uso era bueno en el 61,5 % y, particularmente bueno, entre aquellos diagnosticados de un trastorno afectivo (69,8%). Entre los pacientes que no respondían al tratamiento, la incidencia del no-cumplimiento (49,1%) era superior a aquellos que sí referían haber mejorado (31,2%).Conclusiones. Es importante explorar y reforzar un buen uso del tratamiento antidepresivo en todos los dispositivos asistenciales y estar seguro de que este tipo de tratamiento es necesario si la indicación no está clara (AU)

Introduction. A major determinant of response to antidepressant drugs is how the patients use them. Our objective is to take a look over the antidepressants use in a real sample. Methods. In determining which factors may be relevant for treatment good use, social, demographic, disease and treatment-related data were gathered from 550 patients, who were currently taking antidepressants for any motive. The questionnaire included two items, the patients’ perceived difficulty of following treatment and the level of acknowledged non-compliance by the patient, which may be considered as both an indirect and guiltless way of approximating the patients’ real use of treatment. Results. Compliance was poor among the less educated, as well as those living in rural areas and in patients receiving concomitant treatment for organic diseases. Use was good in 61.5% and was particularly good among those with an affective disorder (69.8%). Among patients who did not respond to treatment, the incidence of non-compliance (49.1%) was higher than for those achieving improvement (31.2%).Conclusions. It’s important to explore and reinforce a good use of antidepressants in clinical settings and to be sure this type of treatment is necessary if the indication is not clear (AU)

[Transcranial magnetic stimulation, tinnitus and auditory hallucinations]. / Estimulación magnética transcraneal, tinnitus y alucinaciones auditivas.

Transcranial magnetic stimulation (TMS) has been shown to be effective in modulating cerebral cortex activity. Most of the published controlled studies have reported that left temporoparietal area stimulation with 1 Hz frequencies has managed to improve auditory hallucinations at least partially and transiently in patients suffering from schizophrenia. These stimulation parameters have been demonstrated to be useful in otologic patients with tinnitus sensation. The clinical relevance of these findings has already been discussed. However, in spite of the clinical benefit of TMS for these or other patients, it is revealing new data and new questions about the neurobiological basis of mental disorders. For example: which is the common substrate in tinnitus and auditory hallucinations that could explain such a therapeutic coincidence? In this work we present two representative clinic cases and we discuss this question.

Estimulación magnética transcraneal, tinnitus y alucinaciones auditivas / Transcranial magnetic stimulation, tinnitus and auditory hallucinations

La estimulación magnética transcraneal (EMT) se ha demostrado capaz de modular la actividad de la corteza cerebral. La estimulación del área temporoparietal izquierda con frecuencias de 1 Hz ha conseguido mejorar, al menos de forma parcial y transitoria, las alucinaciones auditivas de pacientes con esquizofrenia en la mayoría de los estudios controlados publicados. Lo mismo podemos decir de dichos parámetros de estimulación aplicados a pacientes otológicos con sensación de tinnitus. Se discute todavía la relevancia clínica de estos hallazgos. Sin embargo, aparte del beneficio clínico que pueda aportar en un futuro la EMT a estos u otros pacientes, nos está aportando nuevos datos y nuevas preguntas sobre las bases neurobiológicas de los trastornos mentales. Por ejemplo: ¿qué tienen en común el tinnitus y las alucinaciones auditivas para semejante coincidencia terapéutica? En este trabajo se presentan dos casos clínicos ilustrativos y se discute acerca de la pregunta formulada (AU)

Transcranial magnetic stimulation (TMS) has been shown to be effective in modulating cerebral cortex activity. Most of the published controlled studies have reported that left temporoparietal area stimulation with 1 Hz frequencies has managed to improve auditory hallucinations at least partially and transiently in patients suffering from schizophrenia. These stimulation parameters have been demonstrated to be useful in otologic patients with tinnitus sensation. The clinical relevance of these findings has already been discussed. However, in spite of the clinical benefit of TMS for these or other patients, it is revealing new data and new questions about the neurobiological basis of mental disorders. For example: which is the common substrate in tinnitus and auditory hallucinations that could explain such a therapeutic coincidence? In this work we present two representative clinic cases and we discuss this question (AU)

Perfil cognitivo de la depresión mayor y la distimia: los errores en tareas acústico-vocales / Cognitive profile of major depresión and dysthimia: errors in vocal-acoustic performance

Dentro de los desórdenes afectivos, la distimia se considera modernamente una patología con entidad propia, aunque parte de la sintomatología típica de este trastorno coincide con varias de las manifestaciones características de la depresión mayor, razón por la cual el diagnóstico diferencial entre ambas patologías se hace complicado. El presente artículo se ha centrado en el análisis del rendimiento cognitivo mediante tareas acústico-vocales. En él participaron un total de sesenta voluntarios repartidos en tres grupos; personas sanas, pacientes con depresión mayor y pacientes con distimia. Se aplicó a todos ellos un protocolo acústico-vocal compuesto por tres tipos de tareas diferenciadas entre sí por su nivel de procesamiento cognitivo. Los resultados nos indican unas diferencias significativas en las distribuciones de errores que comenten los grupos de pacientes lo que sugiere un procesamiento cognitivo en la distimia cualitativamente diferenciado del de la depresión mayor

Among affective disorders, dysthymia is considered as a separated pathology, although one pan of its characteristic symptomatology coincides with some typical manifestations of mayor depression, complicating differential diagnosis between both entities. The study is focused on the cognitive performance analysis by using vocal-acoustic tasks. Sixty volunteers were divided in three groups: healthy subjects, major depression patients and persons with dysthymia. A vocal-acoustic protocol composed of three different cognitive processed level tasks was administered to all participants. Results showed significant different errors distributions between groups of patients suggesting that the cognitive processing in dysthymia and in mayor depression is qualitative different

Respuesta a olanzapina en episodios de inicio y recurrencias precoces de la esquizofrenia: un estudio observacional / Response to olanzapine in first episodes and early recurrences of schizophrenia: an observational study

FUNDAMENTO: El tratamiento antipsicótico en un primer episodio de esquizofrenia debe proporcionar con rapidez el mayor grado de remisión, aunando tolerancia para evitar el incumplimiento. Con ello se favorece el proceso rehabilitador que mejorará el funcionamiento psicosocial. El objetivo de este estudio fue evaluar la seguridad, la tolerancia y la eficacia de la olanzapina en el tratamiento de los primeros episodios de la esquizofrenia, el trastorno esquizofreniforme o las recurrencias de la esquizofrenia sin sintomatología residual. PACIENTES Y MÉTODOS: Un total de 35 pacientes fueron tratados con olanzapina segun la práctica clínica diaria, durante un período de 6 meses. El estado clínico fue evaluado mediante la Brief Psychiatric Rating Scale (BPRS), la Escala de Impresión Clínica Global de gravedad y mejoría (ICG) y la Escala de Evaluación de la Actividad Global (EEAG). RESULTADOS: Catorce pacientes (40 por ciento) no presentaron ningun acontecimiento adverso (n = 14), y fuero los más frecuentes el aumento de peso (22,9 por ciento) y la sedación (14,3 por ciento). El 74,36 por ciento de los pacientes no manifestó síntomas extrapiramidales y ningún caso precisó medicación antiparkinsoniana. Se observó una respuesta a la olanzapina (reducción en la BPRS superior al 40 por ciento o una puntuación < 18 junto con CGI de mejoría de 1 o 2) en 25 pacientes (71,4 por ciento). No se detectaron diferencias en la respuesta clínica entre los tres grupos diagnósticos del estudio. CONCLUSIONES: En este estudio naturalístico, la olanzapina resultó ser segura y efectiva en el tratamiento de los primeros episodios de la esquizofrenia, el trastorno esquizofreniforme o las reagudizaciones de la esquizofrenia, con muy baja incidencia de síntomas extrapiramidales, lo que puede favorecer el cumplimiento y, en consecuencia, el curso de la enfermedad (AU)

[Panic disorder and transcranial magnetic stimulation]. / Trastorno de angustia y estimulación magnética transcraneal.

Transcranial magnetic stimulation (TMS) has been tried in some Anxiety Disorders (Obsessive-compulsive disorder and Posttraumatic Stress Disorder) with different results. We present a pilot study including three Panic Disorder patients. The subjects who were enrolled had a history of the disease for at least 1 year and they had unsuccessfully followed psychotherapy and pharmacological treatment. The patients received 10 sessions during two weeks; each session lasted 30 trains of 60 seconds at a frequency of 1 Hz, on the right dorsolateral prefrontal cortex, at 110% of the motor threshold. All three patients experienced a modest and partial symptom improvement that did not seemed to be clinically relevant. Two patients accepted to participate in a TMS second phase, where the previous stimulation parameters were alternated with an application of 30 trains of 20 Hz during 2 seconds on the left prefrontal cortex. This alternate application of high and low frequency TMS in each session was also well tolerated, but failed to produce additional improvement. In addition to presenting these three cases, we emphasize some features concerning the neurobiological basis of the anxiety disorders and we connect them to the previously described TMS neurophysiological actions in order to justify further investigation.

Trastorno de angustia y estimulación magnética transcraneal / Panic disorder and transcranial magnetic stimulation

La estimulación magnética transcraneal (EMT) ha sido probada en el algunos trastornos de ansiedad (trastornos obsesivo compulsivo y trastorno por estrés postraumático) con resultados dispares. En este trabajo presentamos un estudio piloto en el que participaron tres pacientes con diagnóstico DSM-IV de trastorno de angustia. Todos llevaban más de un año de evolución, y no habían respondido satisfactoriamente al abordaje psicofarmacológico y psicoterapéutico. Recibieron a lo largo de dos semanas 10 sesiones de 30 trenes de 60 segundos de duración a 1Hz en el córtex prefrontal dorsolateral derecho, al 110 por ciento del umbral motor. Los tres refirieron una muy discreta y parcial mejoría sintomática, que no parecía clínicamente relevante. Dos pacientes aceptaron continuar con una segunda fase de EMT en la que se alternó la misma pauta de estimulación previa con 30 trenes de 2 seg a 20 Hz en córtex prefrontal izquierdo. Esta forma de administración alternativa en cada sesión de EMT de alta y baja frecuencia fue igualmente bien tolerada, pero no supuso mejoría clínica adicional. Además de exponer estos tres casos clínicos y su pobre respuesta global, destacamos la relación entre algunos hallazgos neurobiológicos descritos en los trastornos de ansiedad con las acciones neurofisiológicas inducidos por la EMT que creemos merece seguir siendo estudiada (AU)

Inefficacy of burst-suppression anesthesia in medication-resistant major depression: a controlled trial.

Burst-suppression anesthesia (BSA) has been previously compared with electroconvulsive therapy (ECT) in drug-resistant depression, with promising results. We have carried out a double-blind randomized clinical trial comparing BSA with sham-BSA in 20 patients meeting DSM-IV criteria for major depression with inadequate response to antidepressant drugs and who chose BSA as an alternative to ECT. After withdrawing antidepressant drugs, patients were randomized to receive four sessions of either BSA (induction with propofol followed by the anesthetic agent sevoflurane, achieving BSA for 1 hour) or sham-BSA (induction with propofol until loss of consciousness, followed by spontaneous awakening in 5-10 minutes). Decrease in the Hamilton Rating Depression Scale was larger with BSA (-6.0 +/- 7.3) than with sham-BSA (-2.5 +/- 4.5), but differences did not reach statistical significance ( t = -1.08, p = 0.3). In our sample, we have not found BSA to be superior to sham-BSA and therefore cannot consider BSA as an alternative to ECT.

Functional cerebral asymmetry in affective disorders: new facts contributed by transcranial magnetic stimulation.

A growing body of experimental data usually finds a slightly lower activation in the left hemisphere than in the right in depressive syndromes, whereas the opposite occurs in mania. Transcranial magnetic stimulation (TMS) seems to have a distinctive lateralized effect with manic or depressed patients. These clinical findings provide new elements for discussion of the significance of unbalanced hemispherical activation as a biological substrate in affective disorders. Based on these data and on the theories of chaos and complexity, a hypothesis for the physiopathology of affective disorders and the functional mechanism of TMS is proposed. This hypothesis is in agreement with valence theory.

Prefrontal repetitive transcranial magnetic stimulation as add on treatment in depression.

A growing number of studies report antidepressant effects of repetitive transcranial magnetic stimulation (rTMS) in patients with major depression. The hypothesis that high frequency (20 Hz) rTMS (HF-rTMS) may speed up and strengthen the therapeutic response to sertraline in MD was tested. Twenty eight patients who had not yet received medication for the present depressive episode (n=12) or had failed a single trial of an antidepressant medication (n=16) were started on sertraline and randomised to receive either real of sham HF-rTMS. HF-rTMS was applied to the left dorsolateral prefrontal area in daily sessions (30 trains of 2 s, 20-40 s intertrain interval, at 90% motor threshold) on 10 consecutive working days. The results suggest that in this patient population, HF-rTMS does not add efficacy over the use of standard antidepressant medication.

Modest adjunctive benefit with transcranial magnetic stimulation in medication-resistant depression.

BACKGROUND: Controverted results have been obtained using high frequency transcranial magnetic stimulation (HF-rTMS) as an antidepressant treatment. METHODS: Forty patients suffering from drug-resistant major depression received ten sessions of HF-rTMS at 90% of the motor threshold on the left prefrontal cortex or sham stimulation, added to their pharmacological treatment, in a randomized double-blind design. In a second open phase, patients still fulfilling criteria of inclusion received ten additional sessions of HF-rTMS at 90 or 110%. RESULTS: Real, but not sham HF-rTMS, was associated with a significant decrease in the Hamilton Depression Rating Scale, but only twelve patients decreased more than 50%. CONCLUSIONS: Left prefrontal HF-rTMS was effectively associated with antidepressant treatment, although the size effect was small. LIMITATIONS: Shortage of the sample and control difficulties of the placebo effect. CLINICAL RELEVANCE: Questionable in more than half of the patients studied.

Psychopathology and the binding problem.

Normal cerebral activity is based on the rapid and flexible alternation of an enormous quantity of spatial-temporal patterns of neuronal firing. There is still much to learn about the mechanism that keeps neurons on functionally closed assemblies firing in synchronization. The explanation of this mechanism is the so called 'binding problem', one of the cornerstones of the generation of perceptions, cognitions, emotions and behaviours by the brain, and therefore of great interest to psychiatry. We explore the possibility that a 'binding dysfunction' could be a relevant aspect of the pathophysiology of mental disorders, and apply it to schizophrenia, in an attempt to integrate some neurobiological findings in this disorder, including a few preliminary data obtained with transcranial magnetic stimulation (TMS).

Prosody impairment in depression measured through acoustic analysis.

This work attempts to explore the association between depression and prosody impairment through acoustic techniques of voice analysis. For this purpose, we selected 10 quantitative vocal parameters, obtained instrumentally, and related to the variability and psychomotor control of phonation, which we have considered as prosody indicators. The sample consisted of 23 patients with diagnosis DSM-III-R of major depression and a control group of 20 healthy volunteers. We obtained results in 7 of the 10 acoustic parameters that suggest reduced prosody in depressed subjects. In a second voice test, carried out 2 months after baseline situation, and while patients were under antidepressant treatment, it was not possible to demonstrate that all these prosody indicators change to normality in those 13 subjects who clinically improved.