Resistant depression is a long-term, disabling illness. The aim of this study was to compare the efficacy of antidepressant monotherapy (ADM) and combinations of antidepressants (CAD) in the treatment of resistant patient (≥1 unsuccessful antidepressant treatment) in current clinical practice.

We reviewed chart documents of resistant patients hospitalized at Prague Psychiatric Center for major depressive disorder (DSM IV) and had finished at least 4 - weeks of treatment with ADM or CAD. Clinical status was assessed using MADRS, CGI and BDI-S at baseline, after 2 weeks and in the end of treatment in the framework of regular evaluation during the hospitalization. Response to treatment was defined as a reduction of MADRS score ≥ 50%.

Results: We analyzed 78 inpatients (CAD=27, ADM=51). Both groups were equal in baseline characteristics (number of previous treatments, severity of depression etc.) and in the length of index treatment. The CAD group was superior to ADM group in the MADRS score reduction (14.6 vs 10.2 pts, p=0.02) and the proportion of responders (67% vs. 39%, p=0.03) in the end of treatment. The post-hoc effect size of CAD compared to ADM was moderate (Cohen's d=0.54).

Conclusion: The results of this study suggest that combinations of antidepressants may be more effective than a monotherapy in patients with resistant depression.

This study was supported by a grants from Internal Grant Agency of Ministry of Health of Czech Republic No. NS 10368-3 and a grant from Ministry of Health of Czech Republic MZ0PCP2005.

Absence of social support has its role in the etiology and maintaining of depression, showing inability of the depressive subjects to built and to sustain interpersonal relationships, and to mobilize social support at the time of crisis. The objective of our investigation was to establish the level of social support in the patients suffering from dysthymic disorder, in the course of the disorder.

The sample participants included 40 patients who fulfilled DSM-IV criteria for the dysthymic disorder (mean age 40.65, SD 3.70), and 40 corresponding healthy controls (M 37.50, SD 8.05). The following instruments for assessment of social support were used: Social Support Index, Family Hardiness Index, Family Coping Coherence Index, Relative and Friend Support (McCubbin, et al., 1982,1986).

The dysthymic disorder patients compared to the healthy controls, had statistically significant lower values (p< 0.001) of Social Support Index, Family Hardiness Index, Family Coping Coherence Index and of Relative and Friend Support.

In the course of the disorder, those suffering from dysthymic disorder compared to the healthy controls, had a significantly lower level of social support, indicating absence of a reparative role of social support in maintaining the psychological well-being.

This SERENITY study was designed to investigate the effectiveness of atypical antipsychotics (AAPs) as defined by the three areas of patient functioning, efficacy and tolerability in general practice.

Between January 2007 and June 2008, 252 patients were enrolled, as planned, in this non-interventional study in Belgium. Inclusion criteria were patients 18-65 years old, willing and able to participate, diagnosed with Schizophrenia or Bipolar Disorder and currently in a manic episode and for whom the general practitioner (GP) decided to prescribe an AAP.

Patient demographics, selection criteria, psychiatric and medical history and condition were assessed at Visit 1. Additional psychotropic drugs, name and dose of AAP, the QoL questionnaire Q-LES-Q-16, the Sheehan Disability Scale (SDS) for patient wellbeing, the Clinical Global Impression (CGI) and Patient Global Impression of Change (PGIC) scores for clinical efficacy and tolerability were assessed at Visit 1 (day 0), Visit 2 (week 4) and at Visit 3 (week 8).

A mean change of 24.62 was observed in the Q-LES-Q results. The SDS total score decreased substantially with a mean change of -9.26. Number of days lost, and the number of unproductive days, at work or school decreased with a mean change of -1.88 and -2.31, respectively. CGI-S scores decreased by a mean -1.92 and the CGI-I and PGIC scores also decreased. A weak but positive correlation was seen between the medication satisfaction and the efficacy, tolerability and patients’ well-being.

This study indicates that GP-based management of antipsychotic treatment is effective in the community.

The UNIQUE study assessed the effect of Quetiapine fumarate augmentation on the overall depression status of patients with major depressive disorder and who did not respond to any acute treatment with selective serotonin reuptake inhibitors (SSRIs) or selective noradrenalin reuptake inhibitors (SNRIs) and naïve to any atypical antipsychotics.

Between March 2006 and November 2007, 39 male and female patients, aged 18-65, were enrolled into this four-week, open label, non-comparative, multicentric, phase II prospective study. Treatment with Quetiapine fumarate began at enrolment, with a titration to a target dose of 300mg. The following scales were completed during all five visits: Montgomery-Asberg Depression Rating Scale (MADRS); Clinical Global Impression (CGI); Brief Psychiatric Rating Scale (BPRS); Sheehan Disability Scale (SDS).

All questionnaire mean scales were significantly reduced (Friedman P< 0.0001) at the end of the study from baseline: MADRS 16.9 (12.8-21.0); CGI 1.94 (1.52-2.37); BPRS 10.3 (6.7-13.6); SDS 8.5 (5.6-11.5). Response, defined as a reduction in MADRS total score >50% was observed in 45.9% of the 37 patients completing at least 2 weeks of the study and 37.8% were considered in remission e.g. MADRS total score ≤ 12 at visit 5.

Quetiapine fumarate augmentation improved the overall depression status of patients resistant to SSRI or SNRI treatment.

Progressive hepatolenticular degeneration or Wilson's disease is a rare autosomal recessive genetic disorder of copper metabolism, which is characterised of hepatic and neurological disorders due to the accumulation of copper in organs such as the liver or the basal ganglia. The manifestations of Wilson's disease are multiple and sometimes insidious, which makes the diagnosis very complicated.

A clinical case was followed and reviewed to illustrate the psychiatric symptoms in Wilson's disease.

A 23-year-old male came to the emergency room presenting insomnia, logorrhea, euphoria, irritability and a slight tremor in the upper limbs. Symptoms started two weeks before. The previous year, he was diagnosed of bipolar disorder after a manic episode which required inpatient treatment with risperidone and lithium. During the actual hospitalization, the tremor increased progressively and affected all four limbs and his head. He was then examined by neurology and an ophthalmology service, who ordered some specific complementary exams. Low levels of ceruloplasmin and serum copper and high levels of urinary copper confirmed the diagnosis of Wilson's disease. Treatment with copper chelants was introduced and the psychiatric symptoms and the analyses got better in several weeks.

Even a typical presentation of a psychiatric syndrome can be part of the spectrum of an organic illness. So an organic etiology should always be considered in the differential diagnosis, as sometimes it is possible to be treated.

In recent years increased indices of bipolarity in treatment-resistant depression were found. The objective of the study was to assess and compare Mood Disorder Questionnaire (MDQ) positive screen between patients with treatment-resistant (TR) depression and non-treatment-resistant (NTR) depression and identify significant predictors of MDQ positive screen.

The population studied included patients aged 18-65 who had a diagnosis of first or recurrent major depressive disorder. Each psychiatrist included 5 consecutive patients, from all the patients he is treating, where the depressive episode was assessed as treatment-resistant (study group) and 5 consecutive patients with a non-treatment-resistant episode (control group). The symptoms of bipolarity were assessed by the MDQ. A positive screen of MDQ showing the features of bipolarity requires seven or more items be endorsed, at least several of the items co-occurred, and the symptoms caused at least moderate psychological impairment. One thousand and fifty-one patients entered the study: 570 in treatment-resistant group and 481 in non-treatment-resistant group.

The percentage of patients having MDQ positive screen was significantly higher in the treatment-resistant than in the non-treatment-resistant group (13.7% vs. 5.6%, respectively, p< 0.001). Significant predictors of MDQ positive screen identified in logistic regression were: family history of bipolar disorder (OR=4.04, p< 0.001), early onset of first major depression (< 20 years) (OR=3.27, p=0.001), and incomplete last remission (OR=3.11, p< 0.001).

Our results may suggests bipolar diathesis in treatment- resistant depression.

To estimate the association between obesity, central obesity and depression in a population sample of Greek type 2 diabetic patients.

A total of 200 patients with type 2 diabetes were enrolled in the study. They were stratified according to sex, obesity and central obesity (BMI≥30 Kgr/m2, waist>102cm in men and >88cm in women). Beck Depression Inventory II scale was used to establish the presence of a depressive disorder (DD).

The frequency of DD among the whole population was 31.5% (34.6% for the female vs. 26% for the male patients, p=0.207). BMI was statistically significant increased in depressive diabetic patients compared to non depressive diabetics, in the total (p=0.003), in women (p=0.013), but not in men (p=0.200). In addition, DD rates were statistically significant increased in diabetic patients with central obesity compared to those without central obesity, in the total (p=0.011) and in men (p=0.014). In female diabetic patients, DD was not related to central obesity (p=0.489).

Our data support a strong association between type 2 diabetes and depression in Greek patients. A significant association between obesity and depression is also observed in type 2 diabetic patients. Increased BMI is strongly related to depressive type 2 diabetic women, while central obesity is more related to depressive type 2 diabetic men.

To study reasons for not receiving treatment, and examine characteristics and one-year outcome of untreated anxiety and depression.

Data were used of 743 primary care patients with a six-month anxiety or depressive disorder in the Netherlands Study of Anxiety and Depression (NESDA). Diagnoses were confirmed by the Composite Interview Diagnostic Instrument (CIDI). Patients’ perceived need for care, service utilisation, and reasons for no treatment were assessed by the Perceived Need for Care Questionnaire (PNCQ).

43% of the respondents received no treatment. Of these untreated patients, 25% did not perceive a mental problem; 26% perceived no need for care; and 49% expressed a need for care which was not met. Untreated patients with a treatment need showed the same symptom severity and disability as treated patients, and reported even more loneliness. Compared to other untreated patients, they were more handicapped regarding clinical and psychosocial functioning.

After one year, treated and untreated patients with a treatment need showed a poorer outcome than untreated patients without a self-perceived mental problem or need for care.

Many patients with anxiety or depression do not seek treatment. Half of them are probably right: they do not perceive a mental problem or treatment need, suffer from relatively mild symptoms, and show a favourable one-year course. Untreated patients with a perceived treatment need, however, suffer from severer symptoms, and show a poorer outcome than other untreated patients. Therefore, care providers should pay considerable attention to this worrisome group.

The new standard computerized reading span test (RST), which is a complex verbal working memory test, was used for the first time in the assessment of verbal working memory capacity (Van den Noort et al., 2008) in two clinical populations.

Sixty participants, divided over three different groups; 20 patients with chronic schizophrenia, 20 patients with chronic depression, and 20 healthy participants, entered the study. The selection of the participants was based on strict inclusion and exclusion criteria. There was no comorbid depression in the patients with schizophrenia, as measured by the BDI-II. A comparison was made between the 3 different groups with respect to their verbal working memory capacity. The new standard computerized RST (Van den Noort et al., 2008) was used.

In this study, in line with previous studies, a significant decrease in verbal working memory capacity and a general slowing down was found in chronic patients with schizophrenia and chronic patients with depression in comparison with healthy participants. In addition, patients with schizophrenia showed a nearly significant higher reading span score but were significantly slower than the chronic patients with depression.

The new standard computerized RST (Van den Noort et al., 2008) is a suitable complex verbal working memory test that could be used for clinical applications, for instance, for the assessment of verbal working memory capacity in patients with chronic schizophrenia and chronic depression.

Untreated disrupted sleep is an important precursor for the development of depression. Several studies have confirmed the negative impact of pre-sleep cognitive and emotional activity such as worry and negative affect on subsequent sleep. Emotional stress may affect latencies to sleep onset, to REM-sleep and other markers of sleep disruption such as arousals. The way we cope with emotional stressors and events may have important effects on subsequent sleep.

In this study we investigated the effects of a failure-experience on polysomnographically recorded sleep in volunteers. Furthermore we explored whether dispositional coping factors such as emotion regulation moderate this effect.

In contrast to the control condition the effect of the failure induction was clearly observed in emotional experience as well as within the physiological sleep architecture. Furthermore, we notice a tendency in which not only emotional experience, but also sleep physiology was affected by low and high emotional approach as emotion regulation style (cf. Stanton, 2000).

The present study has shown that emotional stress as a failure experience before sleep-goes together with a worsening of mood, an increase of level of rumination and enhanced sleep fragmentation with a moderating effect of emotion regulation as dispositional factor.

To evaluate the impact of conflicting patient and psychiatrist conceptualizations of the depression over the treatment response and general prognosis.

A group of 25 patients, mean age 36.8, diagnosed with major depressive disorder, first depressive episode, according to DSM IV TR criteria, have completed a closed-ended questionnaire that included their perspective over the depression (on a 7 points Likert scale, from the pure medical/pharmacological, to the pure psychological/reactive paradigm). Psychiatrists who managed their treatment responded to a similar questionnaire regarding their preferred method of treatment. Patients were evaluated initially and after 3 and 6 months using Hamilton Depression Rating Scale-17 items (HAMD), Beck Depression Inventory (BDI), Global Assessment of Functioning. Patients satisfaction over the treatment (on a 10 points visual analogic scale) was evaluated at endpoint.

Patients who received a treatment corresponding to their preferred paradigm (n=17) responded better (−5.6 on HAMD, −4.5 on BDI, +7.6 on GAF, p< 0.01) to the treatment, compared to the group where the paradigms weren’t the same. The satisfaction over the treatment was also significant higher in the first group (+2.5, p< 0.01). Patients who have discussed their beliefs about the disorder and were informed by their psychiatrists about the advantages of the treatment had a greater rate of response to treatment (p< 0.05).

Psychiatrists should routinely explore the patient conceptualization of the depression and to discuss together the best treatment approach. Prognosis, patient satisfaction and treatment response are significantly influenced by exploring the patient beliefs about its disorder.

140 patients have been observed: basic group - 70 patients with depressive disorder with anxiety disorder; control group - 70 patients with depressive disorder alone. All patients were treated with SSRIs. We used in study 17-item HRS-D and CGI.

Baseline average score according to CGI has constituted 4,8±0,6 and 4,5±0,7. Comparative assessment of clinical picture of depression in groups has shown that in basic group more frequently (p< 0,05) dysphoric (31,4% and 12,9%) and conversion (21,4% and 11,4%) syndromes were noticed, while in the control group - adynamic (30% and 12,9%,). Statistical analysis of data of age at the onset of depressive disorder has revealed intergroup differences (p< 0,05), testifying to emerging depressive disorders in patients of basic group at younger age (39,6±12,1 years), as compared with patients of control group (43,9±12,9 years).

Index of cyclicity of disease in patients with RDD was calculated as ratio of disease duration in years to cycles of disease. Average value of the corresponding index in basic and control groups differed reliably (p< 0,05) and has constituted 3,2±1,1 and 7,6±1,6. I.e., in the basic group exacerbation of depressive symptoms in recurrent depressive disorder was noticed more frequently as compared with control group.

Thus, comorbidity of depressive and anxiety disorders results in complicating symptoms, change of its syndromal validation, more adverse course (acceleration of depressive phases in recurrent depressive disorder).

To assess the efficacy and tolerability profile of treatment with escitalopram under naturalistic conditions, in elderly outpatients (≥65 years and above) with depression.

2050 patients completed 8 weeks of treatment with escitalopram in a multi-centre naturalistic study. Rating scales included a short version of the Montgomery-Åsberg Depression Rating Scale (svMADRS) for the assessment of response.

Most patients improved in their general state of health and showed a decrease in the severity of their depression. The majority (83.8%) of patients received 10mg/day escitalopram. The mean svMADRS total score decreased from 31.9 (SD=7.9) at baseline to 14.2 (SD=8.5) at Week 8. On completion, 63.9% of the patients were responders (≥50% decrease of svMADRS from baseline) and 48.6% were remitters (svMADRS≤12). Statistically significant more patients aged ≤75 years responded to treatment and achieved remission than those aged >75 years. Logistic regression was used to model response to treatment. Statistically significant positive factors were having a current episode of less than 1 month and duration of illness of less than 1 year. The diagnosis showed increasing responder rates from affective disorder (F31 or F34; odds ratio=1.00) over involutional depression (F03; odds ratio=1.68) and depressive episode (F32; odds ratio=2.21) to recurrent depressive episode (F33; odds ratio=2.32). The differences between affective disorders and involutional depression were significant, while F32 and F33 showed no relevant differences in the responder rates.

The results from this observational study corroborate the effectiveness and tolerability of escitalopram treatment of elderly patients in a naturalistic treatment setting.

To probe the factors that contributes to the relapse of the major depression after being hospitalized for a period of three consecutive months in a psychiatric clinic.

22 patients (8 men) who were in the clinic were examined (average age 49.2, SD=7.2) suffering from major depression and who fully recovered between episodes. The criteria for their participation in the sample were according to DSM-IV®, and the >2 relapses/year.

By the stepwise multiple regression analysis it was found that by hierarchy the factors that cause the relapse are, the fact that the patient does not respond to the first antidepressant treatment (parameter estimate p< 0.002), child or teenage depression background (p< 0.002), the presence of stressful facts (diseases, financial problems, loss of 1st degree relatives, p< 0.004) and the co morbidity with character disorders in the II (p< 0.01) axis.

The importance of a negative outcome of the major depression should be co estimated with the danger of self-destruction as a result of the illness, the difficulties of the interpersonal relationships, the professional activities, the impact on the family, alcoholism, drug abuse etc. and mainly the empirical impact on the patient.

Affective temperaments (AT) are suggested as antecedents of mood disorders (MD) currently. MD especially depression is very common in epilepsy. In this study we investigated AT in epilepsy as probable predictors of MD.

83 epileptic patients and 83 healthy controls were included and evaluated using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version (TEMPS-A) and SCID-I.

In epilepsy group 16 depressive, 3 cyclotimic, 12 irritable, 9 anxious temperaments; in healthy group 4 depressive, 3 irritable, 4 anxious temperaments were diagnosed. The difference was significant in depressive (x2: 8.36, p< 0.05) and irritable temperament (x2: 6.06, p< 0.05). Depressive, cyclotimic, irritable, anxious temperaments mean scores were significantly higher in epilepstics (depressive 8.35±4,37; cyclotimic 9,86± 4,67; irritable 7,00±4,58; anxious 9,18±5,94) than healthy controls (depressive 5,89±3,68; cyclotimic 6,87±4,55; irritable 3,39±3,57; anxious 5,11±4,78) (all p< 0,001). 16 patients in epilepsy group and 6 patients in control group were diagnosed as Major Depressive Disorder (MDD) and the difference was significant (x2: 5,38, p< 0,05). Anxious temperament predicted MDD in epileptics and none of the temperaments were significant predictor of MDD in controls in logistic regression analysis.

Epileptic patients had higher scores at all AT except hypertimic. Anxious and irritable temperaments were diagnosed more in epileptics and anxious temperament was related with MDD. The tendency of epileptics to MD are known but this is the first study shows tendency of epileptics to AT. Further investigations are needed to explain the etiology and treatment relationship between MD and AT in epilepsy.

Chinese trials were rarely included in western meta-analyses. This systematic review investigates the efficacy of venlafaxine in the treatment of major depression (MDD) in Chinese populations.

Chinese databases (VIP and CNKI) were searched for blinded randomised clinical trials (RCTs) comparing venlafaxine with any other pharmacotherapy and/or placebo. Quality of included studies was assessed with the Jadad scale. Furthermore, fulfilment of the CONSORT items was recorded. Final mean HAM-D scores and response rates were extracted and combined using a fixed-effects model. Subgroup analyses by drug class were performed to assess further differences.

23 blinded RCTs were included in the analyses. Six compared venlafaxine with selective serotonin reuptake inhibitors (SSRIs), 15 with tricyclic antidepressants (TCAs) and two with tetracyclic antidepressants. The average Jadad score was 2.7 and on average 55% of all CONSORT items were reported. On average, 36 patients were randomised per group. Only three trials included more than 80 patients per group.

Mean final HAMD scores were significantly lower in the venlafaxine groups compared to TCA (Hedges’ g 0.14, 95%-CI, 0.01-0.26), but not in comparison to SSRI treated groups (Hedges’ g 0.05, 95%-CI, -0.12-0.21). These findings were confirmed by analyses of response rates. (MH RR Ven vs. TCA: 1.11, 95%-CI, 1.04-1.18, Ven vs. SSRI: 1.01, 95%-CI, 0.93-1.11).

These results suggest that venlafaxine is significantly more effective than TCAs, but not than SSRIs in depressive Chinese populations. However, large high quality trials are needed to verify these findings.

There is a need for more research on women with coronary disease and potential gender differences. This paper report a study of gender differences in psychological distress, health behavior, and coronary health in patients having coronary artery bypass graft surgery (CABG).

229 patients (41 women) having CABG treatment at a hospital in Northern Norway completed a questionnaire 3-15 months after discharge (mean = 8.8, SD = 3.2), and medical data were gathered from their hospital records. Age ranged from 35 to 65 years (Mean = 60.5, SD= 7.4).

No gender differences were found on age, education, work status, or living alone, on coronary health measured by LVEF, NYHA, blood pressure, diabetes, on health related life style measured by smoking, BMI, and physical activity, or the number of days treated at the hospital, or time since hospital discharge.

In univariate analysis, women (compared with men) reported higher levels of mental distress (SCL10; mean = 1.85 versus 1.57, t = 2.73, p< .006). Furthermore, women experienced the time at home following hospital discharge as more difficult than what men did. In a logistic regression analysis of gender, SCL10 together with LVEF were significant predictors, controlling for time since hospital discharge and days treated at the hospital

The higher rate of depression among female CABG patients in this study from Northern Norway is comparable to studies elsewhere. Results are discussed in light of theories of coping and self-regulation, other studies on gender differences in CAD, and implications for treatment.

To overcome these limitations, we combined CBT with mindfulness meditation.

In our mood clinic, two different programs have been proposed to this day:

• - A short mindfulness-based, stress-reduction program (8 weekly sessions), well-adapted to bipolar patients :

• - A program of 20 weekly relapse prevention sessions, including 5 consecutive constructive therapy stages (T. Bonvalot et al.: Constructive Psychotherapy of Bipolar Disorder: A New Approach (abstract) - Bipolar Disorders, special issue, June 2009).

Bipolar patients with more extensive clinical conditions are successively invited to participate to both programs.

Every session has been facilitated by a mindful attitude progressively developed by the patients all along the programs.

We observed that mindfulness meditation, along with CBT, presents most often a high acceptation level on the part of most bipolar patients, and a capacity to restore self-image, self-confidence and hopefulness.

The patients’ involvement in the treatment programs have developed on a regular basis, and consequently a low dropout rate has been observed.

These observations are to be now formally evaluated.

Current treatment approaches for depression center on various forms of psychosocial therapy and the use of antidepressant drugs. The response rates for both of these approaches are similar, with mostly reduction, but not complete remission, of symptoms. Poor adherence to recommended treatment is an issue complicating the management of depression and prevention of recurrent episodes. This study evaluated the efficacy of a novel form of receptive music therapy which can be easily adminstered to out patients.

Enrolled subjects (n=203, average age 49.6 ± 13.1 years, 28.1% male) were randomized into four arms: Music Therapy 1 (MT1), Music Therapy 2 (MT2), Placebo (nature sounds) and waiting-list Control. Subjects listened for 30 minutes, twice daily. Multivariate linear regression models assessed depressive symptom changes over five weeks, based on a composite scale (COMP) and the Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS-D) alone.

On average, a significant, positive change in COMP was observed for MT1 (β=1.44, p=0.030), but not for MT2 (β=1.14, p=0.059) or Placebo (β=0.57, p=0.397). After 15 weeks, study participation was associated with a mean HAM-D score reduction of 60% for 89,1% of the compliant probands.

Newly composed receptive music therapy, as explored in this study, is associated with reduced depressive symptoms and high treatment compliance, and may therefore potentially represent an effective depression treatment alternative or adjunctive therapy to pharmacological and psychosocial approaches.