Atypical antipsychotic augmentation for treatment-resistant depression: A systematic review and network meta-analysis

Background: Previous meta-analyses of atypical antipsychotics for depression were limited by few trials with direct comparisons between two treatments. We performed a network meta-analysis, which integrates direct and indirect evidence from randomized controlled trials (RCTs), to investigate the comparative efficacy and tolerability of adjunctive atypical antipsychotics for treatment-resistant depression (TRD). Methods: Systematic searches resulted in 18 RCTs (total n = 4422) of seven different types and different dosages of atypical antipsychotics and a placebo that were included in the review. Results: All standard-dose atypical antipsychotics were significantly more efficacious than placebo in the efficacy (standardized mean differences [SMDs] ranged from-0.27 to-0.43). There were no significant differences between these drugs. Low-dose atypical antipsychotics were not significantly more efficacious than the placebo. In terms of tolerability, all standard-dose atypical antipsychotics, apart from risperidone, had significantly more side-effect discontinuations than placebo (odds ratios [ORs] ranged from 2.72 to 6.40). In terms of acceptability, only quetiapine (mean 250-350 mg daily) had significantly more all-cause discontinuation than placebo (OR = 1.89). In terms of quality of life/functioning, standard-dose risperidone and standard-dose aripiprazole were more beneficial than placebo (SMD =-0.38; SMD =-0.26, respectively), and standard-dose risperidone was superior to quetiapine (mean 250-350 mg daily). Conclusions: All standard-dose atypical antipsychotics for the adjunctive treatment of TRD are efficacious in reducing depressive symptoms. Risperidone and aripiprazole also showed benefits in improving the quality of life of patients. Atypical antipsychotics should be prescribed with caution due to abundant evidence of side effects

Methodological Issues in Conducting Treatment Trials for Psychological Nonepileptic Seizures

View of window in upper story; In 1581-1586 Domenico worked as the contractor and supervising architect for the façade of Giacomo della Porta's S Luigi dei Francesi, the first recorded undertaking of his workshop or architectural 'firm'. It is the official church of France in Rome and actually entitled to the Virgin Mary, to St. Dionigis Areopagitas and St. Louis IX, King of France. Source: Grove Art Online; http://www.groveart.com/ (accessed 1/20/2008

Treatment matching in the posthospital care of depressed patients

Objective: This study assessed the efficacy of 1) matching patients to treatments and 2) adding additional family therapy or cognitive therapy in a group of recently discharged patients with major depression. Method: Patients with major depression were recruited during a psychiatric hospitalization. After discharge, they were randomly assigned to one of four treatment conditions that were either matched or mismatched to their pattern of cognitive distortion and family impairment. The four treatment conditions were 1) pharmacotherapy alone; 2) combined pharmacotherapy and cognitive therapy; 3) combined pharmacotherapy and family therapy; and 4) combined pharmacotherapy, cognitive therapy, and family therapy. Randomly assigned treatment continued for 24 weeks on an outpatient basis. Results: Among patients with at least moderate depressive symptoms at hospital discharge, low rates of remission (16%) and improvement (29%) were obtained. Matched treatment led to a significantly greater proportion of patients who improved and greater reductions over time in interviewer-rated depressive symptoms than mismatched treatment. However, matched treatment did not produce greater change in self-reported depression or interviewer-rated suicidal ideation. Treatment that included a family therapy component also led to a greater proportion of patients who improved and to significant reductions in interviewer-rated depression and suicidal ideation than treatment without family therapy. Conclusions: These results suggest that 1) current treatments are not very efficacious in the aftercare of hospitalized depressed patients, 2) treatment matching moderately improves outcome for patients who are symptomatic at hospital discharge, and 3) inclusion of family therapy improves the outcome of posthospital care for depressed patients