Course and prognosis

Questions and Answers

Moclobemide is a non-reversible type-A MAOI.

False

MAOIs are generally recommended as first-line antidepressant drugs.

False

Tri-cyclic antidepressants are less effective than MAOIs in treating moderate to severe depressive disorders.

False

Moclobemide is as effective as conventional MAOIs for patients with resistant depression at standard doses.

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MAOIs are ineffective in treating depressed patients who have not responded to tricyclic antidepressants and SSRIs.

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Moclobemide does not produce hazardous interactions with other drugs.

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Interpersonal therapy is less effective when combined with antidepressants than when given alone.

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Couple therapy is significantly less effective than a waiting list control.

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Dynamic psychotherapy aims to modify the interactions with a partner that contribute to causing or maintaining the depressive disorder.

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Sleep deprivation has a long-term antidepressant effect.

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Bright light treatment is only effective for seasonal depression.

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Antidepressant drugs have been shown to be effective in the acute treatment of major depression.

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The onset of the antidepressant effect of bright light is usually within 2-10 days.

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Short-term response rates in controlled trials for antidepressant treatment are around 70% for patients on active treatment.

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Patients with 'typical' depressive features respond best to bright light treatment.

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Dynamic psychotherapy is less effective than cognitive behaviour therapy or antidepressant medication.

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Selective serotonin reuptake inhibitors (SSRIs) are considered less effective than tricyclic antidepressants for hospitalized patients.

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Interpersonal therapy is less effective than antidepressant medication.

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There is substantial evidence suggesting that tricyclic antidepressants are overall more effective than SSRIs.

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Mood disorders rarely recur if left untreated.

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The net number needed to treat (NNT) for antidepressants is typically higher than 5 for patients with major depression.

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All patients with unipolar depression will eventually have a manic illness.

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The age of onset of major depression always occurs before the age of 21.

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Patients with late-onset major depression are more likely to have a family history of mania.

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Aetiological factors contributing to major depression are the same for early- and late-onset cases.

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All patients who present with a depressive disorder will eventually be diagnosed with bipolar disorder.

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The average length of a depressive episode is typically around 12 months.

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Approximately 80% of patients with major depression will experience further episodes.

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Only 50% of patients with recurrent major depression achieve at least 5 years of clinical stability.

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Dysthymia is characterized as a temporary disorder that typically lasts less than a year.

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Patients with minor depressive disorders may later be diagnosed with major depression.

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Individuals with depression have a mortality risk that is about equal to that of the general population.

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Suicide rates in individuals with depression are lower in unipolar disorder compared to bipolar disorder.

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The risk of suicide is highest during the early stages of depression.

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Early age of onset is a protective factor against future episodes of depression.

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Chronic depressive disorders such as dysthymia can sometimes develop into major depression.

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The odds ratio for the TCA category compared to placebo is less than 1.

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In the meta-analysis, 19% of patients allocated to NARI experienced depressive relapse.

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The placebo adjusted relapse rate for SSRIs is higher than that for MAOIs.

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The total number of depressive relapse events in those allocated to antidepressants is lower than those allocated to placebo.

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NARI has the highest rate of depressive relapse among the antidepressant categories listed.

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Anticonvulsants like carbamazepine and valproate are effective in treating unipolar depression.

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Antipsychotic drugs are ineffective in patients with depressive psychosis.

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Electroconvulsive therapy (ECT) is considered less effective than simulated treatment for patients with severe depression.

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Psychological treatment such as reassurance and education is essential for all depressed patients.

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Moclobemide is an example of a tri-cyclic antidepressant.

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Supportive psychotherapy does not focus on the identification and resolution of current life difficulties.

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Cognitive behaviour therapy is superior to other structured psychological treatments, such as behavioural activation and interpersonal therapy.

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Behavioural activation uses the principles of operant conditioning by tracking the links between thoughts and emotional outcomes.

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Structured psychotherapies are less effective than drug treatment in moderately depressed patients.

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Problem-solving treatment is less effective than treatment as usual in moderately depressed patients in primary care.

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Cognitive behaviour therapy is not effective as a sole treatment for patients with severe depression.

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Therapist expertise is not a critical factor in the delivery of effective cognitive behaviour therapy.

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Bright light treatment is effective for non-seasonal depression.

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Couple therapy is as effective as a waiting list control.

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Dynamic psychotherapy aims to modify the interactions with a partner that do not contribute to causing or maintaining the depressive disorder.

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The treatment to prevent relapse should be called continuation treatment.

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The relapse rate for patients continuing antidepressant treatment for longer than 6 months is significantly reduced.

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Cognitive therapy can lessen the risk of subsequent relapse in patients with depression.

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Interpersonal therapy combined with medication is less effective than medication alone.

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Mindfulness-based cognitive therapy (MBCT) is found to be ineffective in reducing relapse rates.

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Study Notes

Depressive Disorders

The average length of a depressive episode is 6 months, with 25% of patients experiencing episodes that last over 1 year and 10-20% developing a chronic unremitting course.

Recurrence of Major Depression

80% of patients with major depression will experience further episodes, with an average of four further episodes over 25 years.
The interval between episodes becomes progressively shorter.

Complete Symptom Remission

50% of depressed patients do not achieve complete symptom remission between episodes and experience continuing subsyndromal depressive symptomatology of fluctuating severity.

Long-Term Prognosis of Recurrent Major Depression

The long-term prognosis is modest, with only 25% of patients achieving a period of 5 years of clinical stability with good social and occupational performance.

Dysthymia

Dysthymia is a chronic disorder that lasts for many years.
50% of outpatients may be expected to show a clinical recovery over a 5-year follow-up.
Some patients with dysthymia develop major depression (double depression).
Some patients who originally present with major depression subside into dysthymia.
Development of mania is rare.

Minor Depressive Disorders

Minor depressive disorders do not meet threshold criteria for major depression, even of mild severity.
The prognosis is similar to that of major depression.
Patients who meet the criteria for minor depression may then subsequently be diagnosed as suffering from major depression, and vice versa.
Minor depression is likely to be a risk factor for major depression and may also be a residual state following remission of major depression.
Longitudinal data suggest that major and minor depression and dysthymia are not distinct conditions, but represent part of a spectrum of depressive disorders.

Mortality of Depressive Disorders

Mortality is significantly increased in patients with depression, largely due to suicide.
The standardized mortality ratio in mood disorders is about twice that found in the general population.
Excess deaths are due to accidents, cardiovascular disease, and comorbid substance misuse.
Depressive disorders increase the risk of general medical conditions such as diabetes and cardiovascular disease.
Possible common pathophysiological mechanisms include inflammation and increased cortisol secretion.

Rates of Suicide

Rates of suicide in patients with depression are at least 15 times higher than those in the general population.
Longer-term follow-up of patients with depression has yielded differing rates of lifetime risk of suicide.
In those with severe illnesses who have been treated as inpatients, the risk may be as high as 15%.
In community samples, the risk is lower.
The proportion of patients with mood disorders who die by suicide decreases as the period of follow-up increases, presumably because mortality from natural causes becomes more significant.
The risk of suicide is highest during the early stages of the illness.

Prognostic Factors

The best predictor of the future course is the history of previous episodes.
The risk of recurrence is much higher in individuals with a history of several previous episodes.
Other factors that predict a higher risk of future episodes include:
- Incomplete symptomatic remission
- Early age of onset
- Poor social support
- Poor physical health
- Comorbid substance misuse

Monoamine Oxidase Inhibitors

The efficacy of MAOIs in the treatment of major depression has been a matter of controversy.
Placebo-controlled trials have shown that MAOIs are effective antidepressants and of equal therapeutic activity to tricyclic antidepressants for moderate to severe depressive disorders.
MAOIs are liable to cause dangerous reactions with other drugs and some foods, and for this reason, they are not recommended as first-line antidepressant drugs.
Controlled trials have shown that MAOIs can be effective in depressed patients who have not responded to tricyclic antidepressants and SSRIs.

Clinical Excellence (2009a)

Interpersonal therapy is more effective than placebo with clinical management and GP treatment as usual.
Interpersonal therapy is as effective as antidepressant medication.
Interpersonal therapy is more effective when combined with antidepressants than when given alone.
It is not clear whether the combination of interpersonal therapy and antidepressants is better than antidepressants alone for the treatment of acute depression.

Couple Therapy

Couple therapy can be offered to depressed patients for whom interactions with a partner appear to have contributed to causing or maintaining the depressive disorder.
The aim of the intervention is to understand the nature of these interactions and modify them so that the relationship becomes more mutually supportive.
There are few randomized trials available, but the limited evidence suggests that couple therapy is significantly more effective than a waiting list control and as effective as cognitive behavior therapy.
There are insufficient data to indicate how couple therapy compares with antidepressants.
In practice, antidepressant treatment and couple therapy are often used together, but the combination has not been well evaluated.

Dynamic Psychotherapy

Dynamic psychotherapy has a different aim from the treatments described so far, in that it aims to resolve underlying developmental conflicts and attendant life difficulties that are believed to be causing or maintaining the depressive disorder.
While it has been suggested that dynamic psychotherapy may be less effective than cognitive behavior therapy or antidepressant medication, more recent meta-analyses have shown equivalent benefit in depressed patients for short-term psychodynamic therapy compared to other psychotherapies.
Therapist training and patient selection are likely to play an important role in the efficacy of psychodynamic therapy in depression.

Other Treatments

Sleep Deprivation

Several studies suggest that, in some depressive disorders, rapid short-term changes in mood can be brought about by keeping patients awake overnight.
The alleviation of depressed mood after total sleep deprivation is nearly always temporary; it disappears after the next night's sleep or even during a daytime nap after the night of sleep deprivation.
Although the antidepressant effect of sleep deprivation is of great theoretical interest, its brevity makes it impractical.
However, there are reports that sleep deprivation can be used to hasten the onset of effect of antidepressant drugs, and also that some pharmacological manipulations can prolong the effect of sleep deprivation.

Bright Light Treatment

Over 50% of patients with recurrent winter depression respond to bright light treatment.
Treatment is usually given for an hour or two in the morning, but the timing of light treatment is not always critical, and evening light or even midday exposure can be effective.
The duration of exposure usually needs to be 1-2 hours.
Designing placebo-controlled trials of bright light for winter depression presents problems, because most patients are aware before treatment that bright light is believed to be the important therapeutic ingredient.
Within this limitation, most studies have found that dim light is less effective than bright light.
The usual onset of the antidepressant effect of bright light is within 2-5 days, but longer periods of treatment appear to be needed in some patients.
Patients with 'atypical' depressive features such as overeating and oversleeping appear to respond best.
To avoid relapse, light treatment usually needs to be maintained until the usual time of natural remission, in the early spring.
Some studies have shown that bright light treatment may also be effective in non-seasonal depression - for example, in elderly people with depression, where circadian rhythm disturbances may be involved in pathophysiology.
However, the durability of such an effect has not been established.

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Description

This quiz assesses understanding of Moclobemide, a non-reversible type-A MAOI, and its effectiveness in treating depression. It covers the comparison of MAOIs with tricyclic antidepressants and SSRIs, and their interactions.