Antidepressants

Although many people with cancer experience depressive moods, not all will have a major depressive episode. It is therefore important to distinguish and address subsyndromal depression from a depressive syndrome that could benefit from psychopharmacologic intervention. This chapter discusses risk factors for depression in cancer patients and provides suggestions for improving identification of depression in complicated cancer situations. The goal is to help non-prescribing clinicians more easily decide when referrals for medication are warranted and how to maintain connections and enhance communication with prescribers after medications are started. Pearls and potholes of why different medications are used for specific circumstances, and how prescribers seek to obtain more than one use out of a single medication, are described.

Chronic subsyndromal depression and risk of dementia in older adults

Objectives: Subsyndromal depression is prevalent and associated with poor outcomes in late life, but its effect on the risk of dementia has barely been investigated. This study is aimed to investigate the effect of subsyndromal depression on dementia risk in cognitively normal older adults and patients with mild cognitive impairment. Methods: Data were collected from a nationwide, population-based, prospective cohort study on a randomly sampled Korean elderly population aged 60 years or older, which has been followed every 2 years. Using 6-year follow-up data of 4456 non-demented elderly, the authors examined the risk of dementia associated with late-onset subsyndromal depression using multivariate Cox proportional hazard models. After standardized diagnostic interviews, subsyndromal depression and dementia were diagnosed by the operational diagnostic criteria and Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria, respectively. Results: Subsyndromal depression tripled the risk of dementia in non-demented elderly individuals (hazard ratio = 3.02, 95% confidence interval = [1.56, 5.85], p < 0.001). In subgroup analyses, subsyndromal depression was associated with the risk of dementia in cognitively normal participants only (hazard ratio = 4.59, 95% confidence interval = [1.20, 17.54], p = 0.026); chronic/recurrent subsyndromal depression with increasing severity during the follow-up period was associated with the risk of dementia (hazard ratio = 15.34, 95% confidence interval = [4.19, 56.18], p < 0.001). Conclusion: Late-onset subsyndromal depression is a potential predictor of incident dementia when it is chronic or recurrent with increasing severity in cognitively normal older adults.

Cost-effectiveness of an indicated preventive intervention for depression in adolescents

Background Adolescent depression has negative health and economic outcomes in the short- and long-term. Indicated preventive interventions, in particular group based cognitive behavioural therapy (GB-CBT), are effective in preventing depression in adolescents with subsyndromal depression. However, little is known about the cost-effectiveness of these interventions. Methods A Markov cohort model was used to conduct cost-effectiveness analyses comparing a GB-CBT indicated preventive intervention for depression, to a no-intervention option. Taking a time horizon of 5- and 10 years, incremental differences in societal costs and health benefits expressed as cases of depression prevented, and as quality adjusted life years (QALYs) gained were estimated. Through univariate and probabilistic sensitivity analyses, the robustness of the results was explored. Costs, presented in 2018 USD, and effects were discounted at a yearly rate of 3%. Results The base-case analysis showed that GB-CBT indicated preventive intervention incurred lower costs, prevented more cases of depression and generated higher QALYs compared to the no-intervention option for both time horizons. Offering the intervention was even a cost saving strategy and demonstrated a probability of being cost-effective of over 95%. In the sensitivity analyses, these results were robust to the modelling assumptions. Limitations: The study considered a homogeneous cohort and assumed a constant annual decay rate of the relative treatment effect. Conclusions GB-CBT indicated preventive interventions for depression in adolescence can generate good value for money compared to leaving adolescents with subsyndromal depression untreated. Key messages Indicated preventive interventions for depression are cost-saving and can generate substantial health benefits. Indicated preventive interventions can be adopted as cost-effective preventive strategies for depression.

WHITE MATTER INTEGRITY UNDERLYING SUBSYNDROMAL DEPRESSION SYMPTOMS IN DEMENTIA CAREGIVERS

Past research shows that major depression is associated with lower white matter integrity in fronto-limbic and other areas. But it is not known whether the integrity of these white matter connections is associated with subsyndromal depression symptoms, a marker of risk for major depression, in family dementia caregivers (dCGs) who reported stress. If specific aspects of white matter integrity are related to depression symptoms in this high-risk group, this could provide a biomarker of vulnerability or target for treatment. Participants included 41 dCGs (average age=69, standard deviation=6.4), who underwent a 7 Tesla 64-direction (12-minute) diffusion-weighted imaging sequence. Analyses compared dCGs with (n=20) and without (n=21) subsyndromal depression symptoms (nine-item Patient Health Questionnaire scores ≥5). Using fractional anisotropy (FA), we assessed differences in the integrity of 11 white matter aspects implicated in prior studies of major depression. We found that caregivers with subsyndromal depression had lower FA in tracts connecting to the posterior cingulate cortex (Cohen’s D=-0.9, p-value=0.006, FDR=0.03) and in white matter connecting the dorsolateral prefrontal cortex with the rostral cingulate (Cohen’s D=-1.2, p-value=0.0005, FDR=0.006). Thus, differences in the integrity of white matter (and related functions) reaching the posterior cingulate (autobiographical memory/planning) and connecting dorsolateral prefrontal and rostral cingulate regions (emotion re-appraisal) may contribute to depression vulnerability in dCGs. These observations require contextualizing further (e.g., assessing roles of depression history and other risk factors) for their meaning to be fully elucidated. Potentially, relationships between known risk factors (e.g., subjective stress) and depression emerge from or drive changes in white matter.

Morbidity and mortality in very old individuals with subsyndromal depression: an 8-year prospective study

ABSTRACTObjectives:Both morbidity and mortality are elevated for individuals with subsyndromal depression (SSD) compared to non-depression (ND) in those of younger ages, but scientific studies are scarce for very old individuals. The aim of this study was therefore to compare the morbidity and mortality in very old individuals with SSD and ND.Design and setting:An 8-year prospective population-based study was undertaken on 85-year-old individuals in Sweden.Measurements:Data were collected from postal questionnaires and clinical assessments at baseline, after 1, 5, and 8 years. Depressive symptoms were measured with Geriatric Depression Scale and the results were classified into ND, SSD, and syndromal depression. Mortality was investigated using multivariable cox regressions, and variables of morbidity were investigated using linear mixed models.Results:Compared to ND, in people with SSD, mortality was elevated in the univariate regression, but this association vanished when controlling for relevant covariates. Morbidity was elevated with regard to basic activities of daily living (ADLs), instrumental ADLs, loneliness, self-perceived health, and depressive symptoms for individuals with SSD compared to ND, whereas cognitive speed, executive functions, and global cognitive function were not significantly impaired when adjusting for covariates.Conclusions:SSD among very old individuals is longitudinally associated with elevated morbidity but not mortality, when controlling for relevant covariates. Considering the high prevalence of SSD and the demographic development of increasing numbers of very old people, the findings highlight the need to develop clinical and societal strategies to prevent SSD and associated negative outcomes.

Epidemiological characteristics of subsyndromal depression in late life

Objectives: Subsyndromal depression is prevalent and associated with poor outcomes in late life, but its epidemiological characteristics have barely been investigated. The aim of this prospective cohort study is to compare the prevalence, incidence and risk factors of subsyndromal depression with those of syndromal depression including major and minor depressive disorders in community-dwelling elderly individuals. Methods: In a nationwide community-based study of randomly sampled Korean elderly population aged 60 years or older ( N = 6640), depression was assessed with standardized diagnostic interviews. At baseline and at 2-year and 4-year follow-ups, the authors diagnosed subsyndromal depression by the operational criteria and syndromal depression by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic criteria. Multivariate logistic regression analyses were conducted to identify the risk factors for incident depression. Results: The age- and gender-adjusted prevalence rate of subsyndromal depression was 9.24% (95% confidence interval = [8.54, 9.93]), which was 2.4-fold higher than that of syndromal depression. The incidence rate of subsyndromal depression was 21.70 per 1000 person-years (95% confidence interval = [19.29, 24.12]), which was fivefold higher than that of syndromal depression. The prevalence to incidence ratio of subsyndromal depression was about half that of syndromal depression. The risk for subsyndromal depression was associated with female gender, low socioeconomic status, poor social support and poor sleep quality, while that of syndromal depression was associated with old age and less exercise. Conclusion: Subsyndromal depression should be validated as a clinical diagnostic entity, at least in late life, since it has epidemiological characteristics different from those of syndromal depression.