Category: Depression

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Journal Reference:

1. W. T. L. Cox, L. Y. Abramson, P. G. Devine, S. D. Hollon. Stereotypes, Prejudice, and Depression: The Integrated Perspective. Perspectives on Psychological Science, 2012; 7 (5): 427 DOI: 10.1177/1745691612455204

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Journal Reference:

1. Marco A Arruda and Marcelo E Bigal. Behavioral and emotional symptoms and primary headaches in children: A population-based study. Cephalalgia, 2012; DOI: 10.1177/0333102412454226

Previous analysis of the efficacy of TMS has been provided through more than 30 published trials, yielding generally consistent results supporting the use of TMS to treat depression when medications aren't sufficient. "Those previous studies were key in laying the groundwork for the FDA to approve the first device for delivery of TMS as a treatment for depression in 2008," said Linda Carpenter, MD, lead author of the report and chief of the Mood Disorders Program and the Neuromodulation Clinic at Butler Hospital. "Naturalistic studies like ours, which provide scrutiny of real-life patient outcomes when TMS therapy is given in actual clinical practice settings, are the next step in further understanding the effectiveness of TMS. They are also important for informing healthcare policy, particularly in an era when difficult decisions must be made about allocation of scarce resources."

Carpenter explains that naturalistic studies differ from controlled clinical trials because they permit the inclusion of subjects with a wider range of symptomatology and comorbidity, whereas controlled clinical trials typically have more rigid criteria for inclusion. "As a multisite study collecting naturalistic outcomes from patients in clinics in various regions in the U.S., we were also able to capture effects that might arise from introducing a novel psychiatric treatment modality like TMS in non-research settings," said Carpenter. In all, the study confirms how well TMS works in diverse settings where TMS is administered to a real-life population of patients with depression that have not found relief through many other available treatments.

The published report summarized data collected from 42 clinical TMS practice sites in the US, and included outcomes from 307 patients with Major Depressive Disorder (MDD) who had persistent symptoms despite the use of antidepressant medication. Change during TMS was assessed using both clinicians' ratings of overall depression severity and scores on patient self-report depression scales, which require the patient to rate the severity of each symptom on the same standardized scale at the end of each 2-week period. Rates for "response" and "remission" to TMS were calculated based on the same cut-off scores and conventions used for other clinical trials of antidepressant treatments. Fifty-eight percent positive response rate to TMS and 37 percent remission rate were observed.

"The patient outcomes we found in this study demonstrated a response rate similar to controlled clinical trial populations," said Dr. Carpenter, explaining that this new data validates TMS efficacy in treating depression for those who have failed to benefit from antidepressant medications. "Continued research and confirmation of the effectiveness of TMS is important for understanding its place in everyday psychiatric care and to support advocacy for insurance coverage of the treatment." Thanks in part to the advocacy efforts of Dr. Carpenter, TMS was recently approved for coverage by Medicare in New England, and it is also now covered by BCBSRI. "Next steps for TMS research involve enhancing our understanding of how to maintain positive response to TMS over time after the course of therapy ends and learning how to customize the treatment for patients using newer technologies, so TMS can help even more patients."

ART is being studied as an alternative to traditional PTSD treatments that use drugs or lengthy psychotherapy sessions. The talk therapy uses back-and-forth eye movements as the patient fluctuates between talking about a traumatic scene, and using the eye movements to help process that information to integrate the memories from traumatic events. The two major components of ART include minimizing or eliminating physiological response associated traumatic memories, and re-envisioning painful or disturbing experiences with a novel technique known as Voluntary Image Replacement.

For the initial study, USF researchers recruited 80 adult veterans and civilians, ages 21 to 60, in the Tampa Bay area. Before receiving ART, patients were tested for symptoms of PTSD and depression, with the vast majority testing positive, 80 percent for PTSD and 90 percent for depression. After the patients received ART-based psychotherapy, the research team reported a dramatic reversal in symptoms. In as few as one to four sessions, those showing symptoms had decreased to only 17 percent for PTSD and 28 percent for depression. Improvements were also seen in trauma-related growth and self-compassion in just one to four treatments.

"From this initial assessment, ART appears to be a brief, safe, and effective treatment for symptoms of PTSD," the report concludes.

"Early results are very promising," said principal investigator Kevin E. Kip, PhD, professor and executive director of the USF College of Nursing Research Center. "Most people who came in to be treated had very high scores for PTSD, and after treatment, the majority had very large reductions. The treatment also reduced other symptoms, like depression, as well as improved sleep."

According to the National Institutes of Health (NIH), PTSD has become an epidemic in the United States. Recent NIH statistics show more than 7.7 million American adults and as many as 31 percent of war veterans suffer from PTSD. They experience mild to extreme symptoms, often with greatly impaired quality of life and physical and psychological functioning.

ART is a particularly promising alternative to traditional PTSD treatments, because it uses no drugs, has no serious adverse effects, and can improve symptoms in -few therapy sessions. The compelling results achieved principally with civilians in the first study prompted the USF College of Nursing to seek and facilitate expansion of a second ongoing ART study funded by the U.S. Army. This expanded study encompasses active duty service members, veterans, and reservists across all branches of service at sites around the country.

"As part of RESTORE LIVES at USF, the innovative nursing research being conducted by Dr. Kip and his team demonstrates our commitment to the health and welfare of our nation's military, veterans and their families," said Dianne Morrison-Beedy, PhD, senior associate vice president of USF Health and dean of the College of Nursing. "We are energized that the Department of Defense has agreed to extend the scope of the current study funded by the U.S. Army. The results that the ART studies have shown so far are truly amazing, and offers new hope to those suffering from PTSD."

Earlier this month, the USF research team traveled to Las Vegas to conduct the first mobile ART study with military reservists.

"We are happy about our collaboration with USF College of Nursing," said Navy Lt. Cmdr. Raul Rojas, commanding officer for the Naval Operations Support Center (NOSC). "We're honored to be the first West Coast study site for the USF College of Nursing's ART study. "We hope our relationship will help get the word out to those who can benefit from the study."

ART is one of the five sub-studies of the USF College of Nursing's Research to Rehabilitate/Restore the Lives of Veterans, Service Members and their Families (RESTORE LIVES) grant funded and administered by the U.S. Army Medical Research and Materiel Command and the Telemedicine & Advanced Technology Research Center (TATRC) at Fort Detrick, MD.

"All the pieces are coming together, with published results on ART, effectiveness leading to Department of Defense approval to extend the scope of the study, and our first national study site in Las Vegas. It looks like we are closer to getting a more efficient evidence-based treatment into place that will actually eliminate the traumatic response to memories and bring relief to the troops and their families," said co-principal investigator Carrie Elk, PhD, assistant professor and military liaison at the USF College of Nursing.

Researchers led by corresponding author, Renée Boynton-Jarrett, MD, assistant professor of pediatrics at BUSM, found a 49 percent increase in risk for early onset menarche (menstrual periods prior to age 11 years) among women who reported childhood sexual abuse compared to those who were not abused. In addition, there was a 50 percent increase in risk for late onset menarche (menstrual periods after age 15 years) among women who reported severe physical abuse in childhood. The participants in the study included 68,505 women enrolled in the Nurses' Health Study II, a prospective cohort study.

"In our study child abuse was associated with both accelerated and delayed age at menarche and importantly, these associations vary by type of abuse, which suggest that child abuse does not have a homogenous effect on health outcomes," said Boynton-Jarrett. "There is a need for future research to explore characteristics of child abuse that may influence health outcomes including type, timing and severity of abuse, as well as the social context in which the abuse occurs."

Child abuse is associated with a significant health burden over the life course. Early menarche has been associated with risks such as cardiovascular disease, metabolic dysfunction, cancer and depression, while late menarche has been associated with lower bone mineral density and depression.

"We need to work toward better understanding how child abuse influences health and translate these research findings into clinical practice and public health strategies to improve the well-being of survivors of child abuse," added Boynton-Jarrett.

To develop a more effective treatment for co-occurring youth anxiety and depression, University of Miami psychologist Jill Ehrenreich-May and her collaborator Emily L. Bilek analyzed the efficacy and feasibility of a novel intervention created by the researchers, called Emotion Detectives Treatment Protocol (EDTP). Preliminary findings show a significant reduction in the severity of anxiety and depression after treatment, as reported by the children and their parents.

"We are very excited about the potential of EDTP," says Ehrenreich-May, assistant professor of psychology in the College of Arts and Sciences at UM and principal investigator of the study. "Not only could the protocol better address the needs of youth with commonly co-occurring disorders and symptoms, it may also provide additional benefits to mental health professionals," she says. "EDTP offers a more unified approach to treatment that, we hope, will allow for an efficient and cost-effective treatment option for clinicians and clients alike."

Emotion Detectives Treatment Program is an adaptation of two treatment protocols developed for adults and adolescents, the Unified Protocols. The program implements age-appropriate techniques that deliver education about emotions and how to manage them, strategies for evaluating situations, problem-solving skills, behavior activation (a technique to reduce depression), and parent training.

In the study, 22 children ages 7 to 12 with a principal diagnosis of anxiety disorder and secondary issues of depression participated in a 15-session weekly group therapy of EDTP. Among participants who completed the protocol (18 out of 22), 14 no longer met criteria for anxiety disorder at post-treatment. Additionally, among participants who were assigned a depressive disorder before treatment (5 out of 22), only one participant continued to meet such criteria at post-treatment.

Unlike results from previous studies, the presence of depressive symptoms did not predict poorer treatment response. The results also show a high percentage of attendance. The findings imply that EDTP may offer a better treatment option for children experiencing anxiety and depression.

"Previous research has shown that depressive symptoms tend to weaken treatment response for anxiety disorders. We were hopeful that a broader, more generalized approach would better address this common co-occurrence," says Bilek, doctoral candidate in clinical psychology at UM and co-author of the study. "We were not surprised to find that the EDTP had equivalent outcomes for individuals with and without elevated depressive symptoms, but we were certainly pleased to find that this protocol may address this important issue."

The study, titled "The Development of a Transdiagnostic, Cognitive Behavioral Group Intervention for Childhood Anxiety Disorders and Co-Occurring Depression Symptoms," is published online ahead of print in the journal Cognitive and Behavioral Practice. The next step is for the team to conduct a randomized controlled trial comparing the EDTP to another group treatment protocol for anxiety disorder.

Common mental disorders such as anxiety and depression will affect 1 of 3 of us at some point in our lives. The core symptoms of mental disorders affect a person's emotional, cognitive and social functioning, which can impact on working ability. Previous studies have found a link between mental disorders and sick leave, though they have been uncertain as to whether mental disorder increases the risk of sick leave, or the other way around. Prolonged absence from the workplace can contribute to avoidance behaviour, especially in those with anxiety, which can make it even harder for these individuals to get fully back to work. It is therefore important to examine the long-term associations between common mental disorders and sick leave in order to help plan more effective interventions aimed to prevent and reduce sick leave among individuals with common mental disorders.

This study examined anxiety and depression levels among 13 436 participants in the Hordaland Health Study. Common mental disorders were assessed at the start of the study with the Hospital Anxiety and Depression Scale. Participants were then followed for up to 6 years, retrieving information on sick leave of 16 days or more from the official Norwegian registry over state paid sick leave benefits. Information on other possible causal factors such as socioeconomic status and physical health was also obtained from the health study.

Anxiety is most important

The study has several findings that have not been previously shown in similar studies. Firstly, it shows that common mental disorders increase the risk of very prolonged absence (over 90 days) and repeated episodes of sick leave. Secondly, it shows that the risk of these outcomes is highest among those with both anxiety and depression simultaneously. Thirdly, the results indicate that anxiety may be more important than depression:

"Surprisingly, we found that anxiety alone is a stronger risk factor for prolonged and frequent sick leave than depression alone. Further, anxiety seems to be a relatively stable risk factor for sick leave, as we found an increased risk of sickness absence up to six years after the anxiety level was assessed," says Ann Kristin Knudsen, who is lead author of the study and PhD student at the University of Bergen and the Division of Mental Health at the Norwegian Institute of Public Health.

The effects of pain

A number of risk factors can simultaneously influence long-term sick leave. In particular, pain was found to have a considerable impact on the association between common mental disorders and sick leave: adjusting for pain ("removing" its effect in the statistical model) reduced the association.

"Adjusting for pain may have given us artificially low effect sizes, since pain, anxiety and depression are closely related and may reflect the same underlying health condition," explains Knudsen.

In other words, the association between common mental disorders and sick leave may actually be stronger.

Benefits of prospective studies

This is the first study with a long enough follow-up period (6 years) to show that the effect of mental disorder on sick leave remains over time.

"Previous research has largely been based on patient data, organizational data or diagnoses of sick leave certificates, or in studies where the prevalence of mental disorder was measured during sick leave. The latter is problematic because we do not know what comes first, sick leave or mental health problems," explains Knudsen.

Since this was a prospective study, following individuals both with and without common mental disorders over time, it provides evidence that common mental disorders increases risk of sick leave and not the other way around. On the other hand, people with common mental disorders also suffered several episodes of sick leave during the follow-up time, which may indicate that both sick leave and the mental health problems affect each other and thus result in a "vicious circle" with repeated sick leaves.

Implications for clinicians

This study is one of the few to show the importance of anxiety, which has largely been ignored in previous studies in this area. Previous studies not accounting for the impact of anxiety may thus have overestimated the effect of depression on sick leave. Without awareness of anxiety, physicians and clinicians may not detect anxiety sufficiently, which can hamper rehabilitation efforts. Future research should focus on how health professionals dealing with sick leave can best identify anxiety and other mental disorders to help prevent the prolongation of sick leave or further sick leave episodes.

The study was a collaboration between the Norwegian Institute of Public Health, the University of Bergen, the University of New South Wales and the Black Dog Institute in Australia, and King's College London UK.

About the Hordaland Health Study

The Hordaland Health Study was conducted between 1997 and 1999 with people aged 40 to 46 living in Hordaland county in Norway. Both physical and mental health, and social and economic factors that affect health, were surveyed, and this information has been linked with public health records, such as sick leave and disability pension registries. The link between individual data from the survey and information in the official health records is relatively unique in an international context, and enables complete studies with long follow-up.

In a new proof-of-concept study, researchers from three South Korean universities and the University of Utah report that women with major depressive disorder (MDD) who augmented their daily antidepressant with 5 grams of creatine responded twice as fast and experienced remission of the illness at twice the rate of women who took the antidepressant alone. The study, published Aug. 3, 2012, in the American Journal of Psychiatry online, means that taking creatine under a doctor's supervision could provide a relatively inexpensive way for women who haven't responded well to SSRI (selective serotonin reuptake inhibitor) antidepressants to improve their treatment outcomes.

"If we can get people to feel better more quickly, they're more likely to stay with treatment and, ultimately, have better outcomes," says Perry F. Renshaw, M.D., Ph.D., M.B.A, USTAR professor of psychiatry at the U of U medical school and senior author on the study.

If these initial study results are borne out by further, larger trials, the benefits of taking creatine could directly affect many Utahns. The depression incidence in Utah is estimated to be 25 percent higher than the rest of the nation, meaning the state has an even larger proportion of people with the disease. This also brings a huge economic cost to both the state and individuals.

According to numbers recently compiled at the U of U, the state of Utah paid an estimated $214 million in depression-related Medicaid and disability insurance in 2008. Add the costs of inpatient and outpatient treatment, medication, and lost productivity in the workplace, and the total price of depression in Utah reached $1.3 billion in 2008, according to the U estimate. With those large numbers, any treatment that improves outcomes not only could ease the life of thousands of Utah women but also would save millions of dollars.

"There has been a misunderstanding of how crippling and common this disease is in Utah," says Renshaw, who's also medical director of the Mental Illness Research, Education and Clinical Center at the Salt Lake City Veterans Affairs Health Care System. "It begs that we understand it better than we do."

Creatine is an amino acid made in the human liver, kidneys, and pancreas. It also is found in meat and fish. Inside the body it is converted into phosphocreatine and stored in muscle. During high-intensity exercise, phosphocreatine is converted into ATP, an important energy source for cells. For this reason, creatine has become a popular supplement among bodybuilders and athletes who are trying to add muscle mass or improve athletic ability.

How creatine works against depression is not precisely known, but Renshaw and his colleagues suggest that the pro-energetic effect of creatine supplementation, including the making of more phosphocreatine, may contribute to the earlier and greater response to antidepressants.

The eight-week study included 52 South Korean women, ages 19-65, with major depressive disorder. All the women took the antidepressant Lexapro (escitalopram) during the trial. Twenty-five of the women received creatine with the Lexapro and 27 were given a placebo. Neither the study participants nor the researchers knew who received creatine or placebo. Eight women in the creatine group and five in the placebo group did not finish the trial, leaving a total of 39 participants.

Participants were interviewed at the start of the trial to establish baselines for their depression, and then were checked at two, four, and eight weeks to see how they'd responded to Lexapro plus creatine or Lexapro and a placebo. The researchers used three measures to check the severity of depression, with the primary outcomes being measured by the Hamilton Depression Rating Scale (HDRS), a widely accepted test.

The group that received creatine showed significantly higher improvement rates on the HDRS at two and four weeks (32 percent and 68 percent) compared to the placebo group (3.7 percent and 29 percent). At the end of eight weeks, half of those in the creatine group showed no signs of depression compared with one-quarter in the placebo group. There were no significant adverse side effects associated with creatine.

Antidepressants typically don't start to work until four to six weeks. But research shows that the sooner an antidepressant begins to work, the better the treatment outcome, and that's why Renshaw and his colleagues are excited about the results of this first study. "Getting people to feel better faster is the Holy Grail of treating depression," he says.

Study co-author Tae-Suk Kim, M.D., Ph.D., associate professor of psychiatry at the Catholic University of Korea College of Medicine and visiting associate professor of psychiatry at the U of U, already is recommending creatine for some of his female depression patients.

In prior studies, creatine had been shown to be effective only in female rats. But that shouldn't rule out testing the supplement in men as well, according to Renshaw. U of U researchers expect soon to begin another trial to test creatine in adolescent and college-age females who have not responded to SSRI medications. Principal investigator Douglas G. Kondo, M.D., assistant professor of psychiatry, says he is looking for 40 females between the ages of 13-21. Recruitment of participants will begin as soon as the U of U Institutional Review Board approves the study, which is expected in early July.

After the initial eight weeks of treatment, study participants will be offered a six-month extension of close supervision and monitoring by the research team and board-certified child, adolescent, and adult psychiatrist at no charge. Those interested in joining the study can visit the study Web site www.UtahBrain.org.

The first authors on the study are In Kyoon Loo, M.D., Ph.D., professor of the Seoul National University College of Medicine and College of Natural Sciences, Seoul, South Korea, and USTAR research associate professor of psychiatry at the U of U, and Sujung Yoon, M.D., Ph.D., associate professor of psychiatry at the Catholic University of Korea College of Medicine, Seoul, and visiting associate professor of psychiatry at the U of U.

Other authors include Jaeuk Hwang M.D., Ph.D., of the Soonchunhyang University College of Medicine, Seoul; Wangyoun Won, M.D., Catholic University of Korea College of Medicine, Seoul; Jieun E. Kim, M.D., Ph.D., Ewha Womans University Graduate School, Seoul; Sujin Bae, Ph.D., Seoul National University College of Natural Sciences.