Rajini Ramana

Residual symptoms after partial remission : an important outcome in depression

This paper draws attention to an important adverse outcome in depression, the occurrence of residual symptoms after partial remission. Among patients with definite major depression followed every 3 months to remission and thereafter, residual symptoms reaching 8 or more on the Hamilton Depression Scale 17-item total were present in 32% (19) of the 60 who remitted below major depression by 15 months. The pattern was of mild but typical depressive symptoms. Residual symptoms were more common in subjects with more severe initial illness, but were not related to any other predictors, including longer prior illness, dysthymia, or lower dose of drug treatment during the illness episode. There were weak associations with personality that might have been consequences of symptom presence. Residual symptoms were very strong predictors of subsequent early relapse, which occurred in 76% (13/17) of those with residual symptoms and 25% (10/40) of those without.

Remission and relapse in major depression: a two-year prospective follow-up study.

This paper reports the course with respect to remission and relapse of a cohort of predominantly in-patient RDC major depressive subjects, who were followed at 3-monthly intervals to remission and for up to 15 months thereafter. Remission was comparatively rapid with 70% of subjects remitting within 6 months. Only 6% failed to do so by 15 months. However, 40% relapsed over the subsequent 15 months, with all the relapses occurring in the first 10 months. Greater severity of the depression and longer duration of the illness predicted a longer time to remission. Greater initial severity of depression also predicted relapse. Subjects with a worse outcome had not received less adequate treatment than the remainder. Our results confirm the comparatively poor outcome subsequent to remission that has been reported in recent literature, in spite of the availability of modern methods of treatment. The clustering of relapses in the first 10 months gives some support to the distinction between relapse and later recurrence.

THE EPIDEMIOLOGY OF BIPOLAR AFFECTIVE-DISORDER

This paper reviews the current position of studies on the epidemiology of bipolar affective disorder. A disorder that cannot be recognized until sometime after its onset poses special difficulties for epidemiological study. These are discussed and attempts made to solve them. Community psychiatric surveys suggest a morbid risk of bipolar disorder of around 2–2.5%, but probably include many false-positives. Studies of treated cases indicate a morbid risk of 0.5%, but will miss untreated cases. It is probably reasonable to suggest a compromise value of 1–1.5%; bipolar disorder is thus still a rare condition. It is possible to quantify the unipolar-bipolar conversion rate, which is of the order of 5%, and it is of particular interest that female sufferers have proportionately fewer manic episodes. Age at onset, possible cohort phenomena, comorbidity, and sociodemographic correlates are discussed.

Life events, social support and marital relationships in the outcome of severe depression.

The effects of life events, social support and marital relationships on outcome were examined in a predominantly recurrent in-patient sample of depressives studied longitudinally every 3 months to remission and up to 15 months thereafter. Outcomes examined were length of time to remission, presence of residual symptoms at remission, and subsequent relapse. There were few associations between these outcomes and the social variables. These findings add to other recent evidence that psychosocial factors are relatively unimportant in the subsequent course of severe and recurrent depressions, in contrast to their contribution to onset of such depressions and subsequent outcome of milder depressions.

Aftercare of depressed inpatients--service delivery and unmet needs.

Abstract.Background: In contrast to acute treatment, delivery of aftercare to depressed patients has not been well studied. Poor care may contribute to poor outcomes for treated depression. Methods: One hundred and two patients discharged from hospital with unipolar depression were followed up 18 months later and were interviewed in detail regarding aftercare and treatment received. Unmet needs were assessed on the community version of the MRC Needs for Care Assessment. Results: In the first month after discharge approximately 70 % of subjects received contacts with mental health services and in the first 3 months over 80 % received at least one contact. About 40 % were in contact with mental health services at 18 months. Needs assessment found comparatively low unmet needs, reaching highest levels (around 25 % in any 6-month period) for medication. Two-thirds of unmet needs for medication and psychotherapy were due to patient refusal or non-compliance. Aftercare levels were higher in those with more previous admissions and were unrelated to presence of personality disorder. Conclusions: There were some deficiencies in service aftercare for depressed patients in a British NHS setting, although unmet need was not high. Some aftercare failures reflect patient reluctance to receive further treatment, representing a challenge to overcome in patients entitled to autonomous choices.

Protocol for the insight study: a randomised controlled trial of single-dose tocilizumab in patients with depression and low-grade inflammation.

Introduction Observational studies indicate a potentially causal role for interleukin 6 (IL-6), a proinflammatory cytokine, in pathogenesis of depression, but interventional studies based on patients with depression have not been conducted. Tocilizumab, anti-inflammatory drug, is a humanised monoclonal antibody that inhibits IL-6 signalling and is licensed in the UK for treatment of rheumatoid arthritis. The main objectives of this study are to test whether IL-6 contributes to the pathogenesis of depression and to examine potential mechanisms by which IL-6 affects mood and cognition. A secondary objective is to compare depressed participants with and without evidence of low-grade systemic inflammation. Methods and analysis This is a proof-of-concept, randomised, parallel-group, double-blind, placebo-controlled clinical trial. Approximately 50 participants with International Classification of Diseases 10th revision (ICD-10) diagnosis of depression who have evidence of low-grade inflammation, defined as serum high-sensitivity C reactive protein (hs-CRP) level ≥3 mg/L, will receive either a single intravenous infusion of tocilizumab or normal saline. Blood samples, behavioural and cognitive measures will be collected at baseline and after infusion around day 7, 14 and 28. The primary outcome is somatic symptoms score around day 14 postinfusion. In addition, approximately, 50 depressed participants without low-grade inflammation (serum hs-CRP level <3 mg/L) will complete the same baseline assessments as the randomised cohort. Ethics and dissemination The study has been approved by the South Central—Oxford B Research Ethics Committee (REC) (Reference: 18/SC/0118). Study findings will be published in peer-review journals. Findings will be also disseminated by conference/departmental presentations and by social and traditional media. Trial registration number ISRCTN16942542; Pre-results.

Community Mental Health Teams: A Guide to Current Practices . By T. Burns. (Pp. 189; Price £29.95, ISBN 0-19-852999-6.) Oxford University Press: Oxford, UK. 2004.

At a time when the very existence of Community Mental Health Teams (CMHTs) seems to be under threat, it is a great pleasure to see a book on them, especially one written by an author who is an authority on the topic. I was, therefore, more than a bit disappointed when I glanced through the contents. Only one chapter was devoted to the endangered generic adult CMHT. The rest covered all the other specialist teams that policy makers in the government insist on implementing countrywide, regardless of local priorities. Can we really call an early intervention team a Community Mental Health Team? One constantly hears of generic CMHTs losing staff to the new specialist teams around the country. Losing their identity as well would certainly be the last straw! Having overcome my initial disappointment about the contents I set about reading the book. Despite the dry nature of the topic, I found it to be surprisingly readable, partly because of the consistent style and the clear writing. The book starts with an introductory chapter on the origins of community psychiatry. The second chapter on modern multidisciplinary working addresses the structure and functioning of any multidisciplinary team. All aspects of team functioning from referrals to pathological team dynamics are covered surprisingly well in 27 pages. It is obvious that the author has drawn heavily on his own extensive experience of actually working in teams. The next chapter is on generic CMHTs. CMHTs have evolved to meet human rather than technical needs and that this has made them variable and ‘untidy’, which is why they seem to have fallen out of favour with central planners, who would prefer uniformity and standardization. Despite this perceived variability in how CMHTs seem to feel and function, there is a surprising similarity in their core activities. The next few chapters are on new specialist teams that work in the community. It was reassuring to read a chapter on assertive outreach teams (AOTs), in which the evidence and the pros and cons of these teams was presented objectively, without any ‘hard sell ’. Many practical issues, however minor, were addressed thoughtfully. I took away many simple and practical solutions to the usual problems of working in busy teams with challenging patients from this chapter. The dangers of an extremely prescriptive and research-based approach to a group of extremely ill and vulnerable patients was also highlighted. The chapter on early intervention teams is similar, but is packed with more practical and clinical information. Difficult issues such as restrictive inclusion criteria and prodromal teams are discussed in a balanced and objective way. In the chapter on crisis resolution teams, the author rightly takes issue with the prescriptive guidelines and exclusion criteria in the Policy Implementation Guidance from the Department of Health, which are clearly unworkable, if a CRT is to be effective. He is critical of the widespread assumption that these services will reduce bed usage but feels that their rapid availability and wide access can enhance any mental health service. There is a further chapter on highly specialized teams and a concluding chapter on the wider context and the future. Change and development within any service is inevitable, and highly desirable. However, this change is best brought about by adaptive evolutionary changes based on evidence, rather than by prescriptive imperatives with a political basis. The current move to regulate the way services are delivered, regardless of local needs and scarce evidence about their efficacy, is clearly based on a political will to ensure uniformity in service delivery and on the need to bring about a change, just for the sake of it. It constrains local innovativeness, particularly since the implementation of these changes is tied in with Psychological Medicine, 2005, 35, 453–458. f 2005 Cambridge University Press Printed in the United Kingdom

Biological Effects of Very Long Term Antidepressant Treatment

In a preliminary study the mydriatic effect of tyramine was reduced in patients who had been taking tricyclic antidepressants for periods of up to 15 years. These findings, together with the withdrawal effects seen in these patients, show that the drugs were still pharmacologically active, even after many years of use. However, the lack of drug effect upon melatonin suggests that net noradrenergic neurotransmission may have been unaltered.