Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults

Jack, R.H. et al. | Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults: an open cohort study using English primary care data | BMJ Mental Health 2023; 26: e300855 | http://dx.doi.org/10.1136/bmjment-2023-300855

The objective of this cohort study was to determine whether there are seasonal patterns in primary care antidepressant prescribing and mental health issues in adolescents and young adults.

The findings show an increase in SSRI prescribing, depression and anxiety incidence in male and female adolescents in the autumn months (September–November) that was not seen in older age groups. These higher rates of antidepressant prescribing and consultations for depression and anxiety at the start of the school year among adolescents suggest that support around mental health issues from general practitioners and others should be focused during autumn. Future research should examine whether these patterns are also seen in younger children and those who do not present to GPs.

Full paper: Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults: an open cohort study using English primary care data

NICE recommends staged withdrawal of antidepressants

Adults with depression who want to stop taking antidepressants should have the dose of their medication reduced in stages to reduce the likelihood and severity of withdrawal symptoms | via National Institute for Health and Care Excellence (NICE).

A new draft quality standard, which sets out priority areas for quality improvement for the care of adults with depression, includes a statement to help adults who want to come off the medication permanently. The independent advisory committee, which includes experts in treating adults with depression, has recommended the staged withdrawal of antidepressants.

The committee said primary care and mental health professionals should follow the NICE guideline recommendations on stopping antidepressant medication, including agreeing with their patient whether it is right for them to stop taking the medication and if so, the speed and duration of withdrawal from it. Reducing the dose of an antidepressant in stages over time, known as ‘tapering’, helps to reduce withdrawal effects and long-term dependence on the medication.

Any withdrawal symptoms need to have been resolved, or to be tolerable, before making the next dose reduction the committee has said.

Full detail: Adults with depression who want to quit antidepressants should be given support on how to do it safely over time, says NICE

See also: Draft quality standard for depression in adults | NICE

Depression in adults: treatment and management

National Institute for Health and Care Excellence | Depression in adults: treatment and management | NICE guideline [NG222]

This guideline covers identifying, treating and managing depression in people aged 18 and over. It recommends treatments for first episodes of depression and further-line treatments, and provides advice on preventing relapse, and managing chronic depression, psychotic depression and depression with a coexisting diagnosis of personality disorder.

This guideline updates and replaces NICE guideline CG90 (October 2009). This guideline was previously called depression in adults: recognition and management.

Full detail: Depression in adults: treatment and management

NICE have also created a series of visual summaries to explain the treatment and management of depression in adults:

• Discussing first-line treatments for less severe depression
• Discussing first-line treatments for more severe depression
• Preventing relapse
• Further-line treatment
• Treatment options for chronic depression, depression with personality disorder or psychotic depression
• The matched care model

Association Between Depressive Symptoms and Incident Cardiovascular Diseases

Question  Are depressive symptoms associated with incident cardiovascular diseases?

Findings  In a pooled analysis of individual-participant data from 563 255 participants in 22 prospective cohorts, depressive symptoms (assessed by the Center for Epidemiologic Studies Depression [CES-D] scale and other validated scales) were significantly associated with incident cardiovascular disease, including scores lower than the threshold typically indicative of depressive disorders (CES-D ≥16; hazard ratio per 1-SD higher log CES-D, 1.06).

Meaning  Depressive symptoms, even at levels lower than what is typically indicative of potential clinical depression, were associated with risk of incident cardiovascular disease although the magnitude of the association was modest.

Reference: JAMA. 2020;324(23):2396-2405.

Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India

Question  Among patients with diabetes and depression in India, does a 12-month collaborative care intervention that includes nonphysician care coordinators, decision support functions in electronic health records, and specialist case reviews improve depressive symptoms and measures of cardiometabolic health more than usual care at 24 months?

Findings  In this randomized clinical trial that included 404 patients at urban clinics in India with poorly controlled diabetes and depression, patients in the collaborative care intervention group, compared with the usual care group, were significantly more likely to achieve the composite outcome of at least a 50% reduction in the 20-item Symptom Checklist Depression Scale score and at least 1 of the following: reduction of at least 0.5 percentage points in hemoglobin A_1c, reduction of at least 5 mm Hg in systolic blood pressure, or reduction of at least 10 mg/dL in low-density lipoprotein cholesterol at 24 months (71.6% vs 54.7%).

Meaning  Among patients with diabetes and depressive symptoms in urban India, a multicomponent collaborative care intervention resulted in statistically significantly greater improvements in a composite measure of depressive symptoms and cardiometabolic indices compared with usual care.

Reference: JAMA. 2020;324(7):651-662.

Effect of Long-term Vitamin D3 Supplementation vs Placebo on Risk of Depression or Clinically Relevant Depressive Symptoms and on Change in Mood Scores. A Randomized Clinical Trial

Question  Can long-term supplementation with vitamin D₃ prevent depression in the general adult population?

Findings  In this randomized clinical trial that included 18 353 adults aged 50 years or older without depression or clinically relevant depressive symptoms at baseline, vitamin D₃ supplementation compared with placebo did not result in statistically significant differences in the incidence and recurrence of depression or clinically relevant depressive symptoms (hazard ratio, 0.97) or for change in mood scores over a 5-year treatment period.

Meaning  These findings do not support the use of vitamin D₃ in adults to prevent depression.

Reference: JAMA. 2020;324(5):471-480. doi:10.1001/jama.2020.10224

Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression

Question  What is the accuracy of the Patient Health Questionnaire (PHQ)–2 alone and in combination with the PHQ-9 for screening for depression?

Findings  In an individual participant data meta-analysis that included 10 627 participants from 44 studies with semistructured diagnostic interviews, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had a sensitivity of 0.82, specificity of 0.87, and area under the receiver operating characteristic curve of 0.90.

Meaning  PHQ-2 followed by PHQ-9 may provide acceptable accuracy for screening for depression.

Reference: JAMA. 2020;323(22):2290-2300. 

Trial of SAGE-217 in Patients with Major Depressive Disorder

BACKGROUND

Altered neurotransmission of γ-aminobutyric acid (GABA) has been implicated in the pathogenesis of depression. Whether SAGE-217, an oral, positive allosteric modulator of GABA type A receptors, is effective and safe for the treatment of major depressive disorder is unknown.

METHODS

In this double-blind, phase 2 trial, we enrolled patients with major depression and randomly assigned them in a 1:1 ratio to receive 30 mg of SAGE-217 or placebo once daily. The primary end point was the change from baseline to day 15 in the score on the 17-item Hamilton Depression Rating Scale (HAM-D; scores range from 0 to 52, with higher scores indicating more severe depression). Secondary efficacy end points, which were assessed on days 2 through 8 and on days 15, 21, 28, 35, and 42, included changes from baseline in scores on additional depression and anxiety scales, a reduction from baseline of more than 50% in the HAM-D score, a HAM-D score of 7 or lower, and a Clinical Global Impression of Improvement score of 1 (very much improved) or 2 (much improved) (on a scale of 1 to 7, with a score of 7 indicating that symptoms are very much worse).

RESULTS

A total of 89 patients underwent randomization: 45 patients were assigned to the SAGE-217 group, and 44 to the placebo group. The mean baseline HAM-D score was 25.2 in the SAGE-217 group and 25.7 in the placebo group. The least-squares mean (±SE) change in the HAM-D score from baseline to day 15 was −17.4±1.3 points in the SAGE-217 group and −10.3±1.3 points in the placebo group (least-squares mean difference in change, −7.0 points; 95% confidence interval, −10.2 to −3.9; P<0.001). The differences in secondary end points were generally in the same direction as those of the primary end point. There were no serious adverse events. The most common adverse events in the SAGE-217 group were headache, dizziness, nausea, and somnolence.

CONCLUSIONS

Administration of SAGE-217 daily for 14 days resulted in a reduction in depressive symptoms at day 15. Adverse events were more common in the SAGE-217 group than in the placebo group. Further trials are needed to determine the durability and safety of SAGE-217 in major depressive disorder and to compare SAGE-217 with available treatments. (Funded by Sage Therapeutics; ClinicalTrials.gov number, NCT03000530. opens in new tab.)

Reference N Engl J Med 2019; 381:903-911

Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis

Objective To determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression.

Design Individual participant data meta-analysis.

Data sources Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-February 2015).

Inclusion criteria Eligible studies compared PHQ-9 scores with major depression diagnoses from validated diagnostic interviews. Primary study data and study level data extracted from primary reports were synthesized. For PHQ-9 cut-off scores 5-15, bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, among studies that used semistructured diagnostic interviews, which are designed for administration by clinicians; fully structured interviews, which are designed for lay administration; and the Mini International Neuropsychiatric (MINI) diagnostic interviews, a brief fully structured interview. Sensitivity and specificity were examined among participant subgroups and, separately, using meta-regression, considering all subgroup variables in a single model.

Results Data were obtained for 58 of 72 eligible studies (total n=17 357; major depression cases n=2312). Combined sensitivity and specificity was maximized at a cut-off score of 10 or above among studies using a semistructured interview (29 studies, 6725 participants; sensitivity 0.88, 95% confidence interval 0.83 to 0.92; specificity 0.85, 0.82 to 0.88). Across cut-off scores 5-15, sensitivity with semistructured interviews was 5-22% higher than for fully structured interviews (MINI excluded; 14 studies, 7680 participants) and 2-15% higher than for the MINI (15 studies, 2952 participants). Specificity was similar across diagnostic interviews. The PHQ-9 seems to be similarly sensitive but may be less specific for younger patients than for older patients; a cut-off score of 10 or above can be used regardless of age..

Conclusions PHQ-9 sensitivity compared with semistructured diagnostic interviews was greater than in previous conventional meta-analyses that combined reference standards. A cut-off score of 10 or above maximized combined sensitivity and specificity overall and for subgroups.

Registration PROSPERO CRD42014010673.

Reference BMJ 2019;365:l1476

Effect of Integrated Behavioral Weight Loss Treatment and Problem-Solving Therapy on Body Mass Index and Depressive Symptoms Among Patients With Obesity and Depression

Question  Does an integrated collaborative care intervention improve weight loss and depressive symptoms among patients with obesity and depression?

Findings  In this randomized clinical trial that included 409 patients with obesity and depression, an intervention that integrated behavioral weight loss treatment and problem-solving therapy with as-needed antidepressant medications resulted in statistically significant reductions in body mass index compared with usual care (−0.7 vs −0.1, respectively) and depressive symptoms (−0.3 vs −0.1 on the 20-item Depression Symptom Checklist; score range, 0-4) at 12 months.

Meaning  A collaborative care intervention integrating behavioral weight loss treatment and problem-solving therapy with as-needed antidepressant medication led to statistically significant reductions in body mass index and depressive symptoms compared with usual care; however, the effect sizes were modest and of uncertain clinical importance.

Reference:
JAMA. 2019;321(9):869-879.