Nonpharmacologic versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder

Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians

Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline

Amicus Brief Regarding California v. Texas

ACP Statement for the Record: House Resources Committee Hearing on the Impacts of Climate Change

ACP Statement to the Senate HELP Committee in Support of Funding for the National Health Service Corps (NHSC)

ACP Statement to Energy and Commerce Committee on the Dr. Lorna Breen Health Care Provider Protection Act

ACP Statement for the Record to the Energy and Commerce Health Subcommittee on Texas v US and its Impact on Those with Pre-Existing Conditions

ACP Statement for the Record for Hearing 'Addressing the Public Health Emergency of Gun Violence'

ACP Statement for the Record to the United States Senate Committee on Health, Education, Labor and Pensions On “Mental Health and Substance Use Disorders: Responding to the Growing Crisis”

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit.

Adult Major Depressive Disorder: Coordination of Care of Patients with Specific Comorbid Conditions

INACTIVE REVIEW: This measure review is older than five years. Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.

Dementia: Screening for Depressive Symptoms

INACTIVE REVIEW: This measure review is older than five years. Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period

Universal Access to Cognitive Behavioral Therapy and Antidepressants Is Necessary for All Patients With Major Depressive Disorder

ASCENDing to New Heights in Our Understanding of the Treatment of Depression Among Individuals Receiving Hemodialysis

Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 170, No 6

Background: Although depression is common among patients receiving maintenance hemodialysis, data on their acceptance of treatment and on the comparative efficacy of various therapies are limited. Objective: To determine the effect of an engagement interview on treatment acceptance (phase 1) and to compare the efficacy of cognitive behavioral therapy (CBT) versus sertraline (phase 2) for treating depression in patients receiving hemodialysis. Design: Multicenter, parallel-group, open-label, randomized controlled trial. (ClinicalTrials.gov: NCT02358343) Setting: 41 dialysis facilities in 3 U.S. metropolitan areas. Participants: Patients who had been receiving hemodialysis for at least 3 months and had a Beck Depression Inventory-II score of 15 or greater; 184 patients participated in phase 1, and 120 subsequently participated in phase 2. Intervention: Engagement interview versus control visit (phase 1) and 12 weeks of CBT delivered in the dialysis facility versus sertraline treatment (phase 2). Measurements: The primary outcome for phase 1 was the proportion of participants who started depression treatment within 28 days. For phase 2, the primary outcome was depressive symptoms measured by the Quick Inventory of Depressive Symptoms–Clinician-Rated (QIDS-C) at 12 weeks. Results: The proportion of participants who initiated treatment after the engagement or control visit did not differ (66% vs. 64%, respectively; P = 0.77; estimated risk difference, 2.1 [95% CI, −12.1 to 16.4]). Compared with CBT, sertraline treatment resulted in lower QIDS-C depression scores at 12 weeks (effect estimate, −1.84 [CI, −3.54 to −0.13]; P = 0.035). Adverse events were more frequent in the sertraline than the CBT group. Limitation: No randomized comparison was made with no treatment, and persistence of treatment effect was not assessed. Conclusion: An engagement interview with patients receiving maintenance hemodialysis had no effect on their acceptance of treatment for depression. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment than with CBT. Primary Funding Source: Patient-Centered Outcomes Research Institute, Dialysis Clinic, Kidney Research Institute, and National Institute of Diabetes and Digestive and Kidney Diseases.

The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model: Annals of Internal Medicine: Vol 171, No 11

Background: Most guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain. Objective: To quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression. Design: Decision analytic model. Data Sources: Relative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications. Target Population: Adults with newly diagnosed major depressive disorder in the United States. Time Horizon: 1 to 5 years. Perspectives: Health care sector and societal. Intervention: Initial treatment with either an SGA or group and individual CBT. Outcome Measures: Costs in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: In model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, −$1800; societal, −$2500). Results of Sensitivity Analysis: In probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment. Limitation: Long-term trials comparing CBT and SGA are lacking. Conclusion: Neither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted. Primary Funding Source: Department of Veterans Affairs, National Institute of Mental Health

Should You Screen for and Manage Depression in Patients With a Recent Acute Coronary Syndrome?

Depression and Suicidal Ideation Among HIV-Infected Adults Receiving Efavirenz Versus Nevirapine in Uganda: A Prospective Cohort Study: Annals of Internal Medicine: Vol 169, No 3

Background: Evidence regarding potential adverse neuropsychiatric effects of efavirenz is conflicting, and data from sub-Saharan Africa, where 70% of persons living with HIV (PLHIV) reside and efavirenz is used as first-line therapy, are limited. Objective: To estimate associations between efavirenz use and depression and suicidal ideation among PLHIV in Uganda. Design: Prospective observational cohort study. (ClinicalTrials.gov: NCT01596322) Setting: Mbarara, Uganda. Participants: Adult PLHIV enrolled at the start of antiretroviral therapy (ART) and observed every 3 to 4 months from 2005 to 2015. Measurements: The exposure of interest was time-varying efavirenz use, defined as use during the 7 days and in 60 or more of the 90 days before a study visit, compared with nevirapine use. Self-reported outcomes were depression, defined as a mean score greater than 1.75 on the Hopkins Symptom Checklist depression subscale, and suicidal ideation. Multivariable-adjusted generalized estimating equations (GEE) logistic regression, Cox proportional hazards regression, and marginal structural models were fit to estimate the association between efavirenz use and the risk for depression and suicidal ideation. Results: 694 participants (median age, 33 years; median pretreatment CD4+ count, 1.8 × 109 cells/L) contributed 1200 person-years of observation (460 person-years receiving efavirenz). No baseline differences in depression or suicidal ideation were found between patients ever exposed to efavirenz and those never exposed to efavirenz and receiving nevirapine (P > 0.80 for both). Of 305 participants ever-exposed to efavirenz, 61 (20.0%) and 19 (6.2%) had depression and suicidal ideation, respectively, on at least 1 follow-up visit, compared with 125 (32.1%) and 47 (12.1%) of the 389 who received nevirapine. In adjusted GEE models, efavirenz use was associated with decreased odds of depression compared with nevirapine use (adjusted odds ratio, 0.62 [95% CI, 0.40 to 0.96]) and was not significantly associated with suicidal ideation (adjusted odds ratio, 0.61 [CI, 0.30 to 1.25]). Time-to-event and marginal structural models yielded similar estimates. Limitation: Nonrandom assignment to treatment and substantial differences between the efavirenz and nevirapine groups. Conclusion: No evidence was found that use of efavirenz in first-line ART increased the risk for depression or suicidal ideation compared with nevirapine use among PLHIV in Uganda. Primary Funding Source: National Institutes of Health.

Benefits and Harms of Cranial Electrical Stimulation for Chronic Painful Conditions, Depression, Anxiety, and Insomnia: A Systematic Review: Annals of Internal Medicine: Vol 168, No 6

Background: Cranial electrical stimulation (CES) is increasingly popular as a treatment, yet its clinical benefit is unclear. Purpose: To review evidence about the benefits and harms of CES for adult patients with chronic painful conditions, depression, anxiety, and insomnia. Data Sources: Several databases from inception to 10 October 2017 without language restrictions and references from experts, prior reviews, and manufacturers. Study Selection: Randomized controlled trials of CES versus usual care or sham CES that reported pain, depression, anxiety, or sleep outcomes in any language. Data Extraction: Single-reviewer extraction checked by another; dual independent quality assessment; strength-of-evidence grading by the first author with subsequent group discussion. Data Synthesis: Twenty-eight articles from 26 randomized trials met eligibility criteria. The 2 trials that compared CES with usual care were small, and neither reported a statistically significant benefit in pain or anxiety outcomes for patients with fibromyalgia or anxiety, respectively. Fourteen trials with sham or placebo controls involving patients with painful conditions, such as headache, neuromuscular pain, or musculoskeletal pain, had conflicting results. Four trials done more than 40 years ago and 1 from 2014 provided low-strength evidence of a possible modest benefit compared with sham treatments in patients with anxiety and depression. Trials in patients with insomnia (n = 2), insomnia and anxiety (n = 1), or depression (n = 3) had inconclusive or conflicting results. Low-strength evidence suggested that CES does not cause serious side effects. Limitation: Most trials had small sample sizes and short durations; all had high risk of bias due to inadequate blinding. Conclusion: Evidence is insufficient that CES has clinically important effects on fibromyalgia, headache, neuromusculoskeletal pain, degenerative joint pain, depression, or insomnia; low-strength evidence suggests modest benefit in patients with anxiety and depression. Primary Funding Source: Veterans Affairs Quality Enhancement Research Initiative. (PROSPERO: CRD42016023951)

Diagnostic Accuracy of Screening Tests and Treatment for Post–Acute Coronary Syndrome Depression: A Systematic Review: Annals of Internal Medicine: Vol 167, No 10

Background: Patients who have had an acute coronary syndrome (ACS) event have an increased risk for depression. Purpose: To evaluate the diagnostic accuracy of depression screening instruments and to compare safety and effectiveness of depression treatments in adults within 3 months of an ACS event. Data Sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews from January 2003 to August 2017, and a manual search of citations from key primary and review articles. Study Selection: English-language studies of post-ACS patients that evaluated the diagnostic accuracy of depression screening tools or compared the safety and effectiveness of a broad range of pharmacologic and nonpharmacologic depression treatments. Data Extraction: 2 investigators independently screened each article for inclusion; abstracted the data; and rated the quality, applicability, and strength of evidence. Data Synthesis: Evidence from 6 of the 10 included studies showed that a range of depression screening instruments produces acceptable levels of diagnostic sensitivity, specificity, and negative predictive values (70% to 100%) but low positive predictive values (below 50%). The Beck Depression Inventory-II was the most studied tool. A large study found that a combination of cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health–related function, and overall life satisfaction more than usual care. Limitation: Few studies, no evaluation of the influence of screening on clinical outcomes, and no studies addressing several clinical interventions of interest. Conclusion: Depression screening instruments produce diagnostic accuracy metrics that are similar in post-ACS patients and other clinical populations. Depression interventions have an uncertain effect on cardiovascular outcomes, but CBT combined with antidepressant medication produces modest improvement in psychosocial outcomes. Primary Funding Source: Agency for Healthcare Research and Quality (PROSPERO: CRD42016047032).

Seize the Day to Implement Depression Guidelines

Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Description: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for major depressive disorder (MDD) in children and adolescents. Methods: The USPSTF reviewed the evidence on the benefits and harms of screening; the accuracy of primary care–feasible screening tests; and the benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years. Population: This recommendation applies to children and adolescents aged 18 years or younger who do not have a diagnosis of MDD. Recommendation: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger. (I statement)

Fatal Severe Systemic Thromboembolism in Nonbacterial Thrombotic Endocarditis as the Initial Manifestation of Ovarian Cancer: A Case Report | Annals of Internal Medicine: Clinical Cases

Nonbacterial thrombotic endocarditis (NBTE) is a rare underdiagnosed cause of systemic embolism, typically associated with advanced malignancy. We report a previously healthy 64-year-old woman who developed fulminant systemic thromboembolic phenomena with multiorgan infarcts and thrombotic coronary occlusion. Echocardiography revealed rapidly progressive mitral valve vegetations. NBTE was diagnosed in the absence of bacteremia and a presumed metastatic ovarian cancer. Despite anticoagulation and percutaneous coronary intervention, cerebral and systemic embolization persisted, ultimately leading to multiorgan failure and death. This case underscores the devastating prognosis of NBTE, which is deadly in rapidly progressive presentations, with the need for early suspicion and prompt multidisciplinary management.

Unusual Presentation of Vaginal Squamous Cell Carcinoma in Older Woman With Hyperarousal and Unwanted Orgasms | Annals of Internal Medicine: Clinical Cases

Vaginal squamous cell carcinoma is a rare gynecologic malignancy that typically presents with nonspecific symptoms, such as abnormal vaginal bleeding, discharge, and pelvic pain. It most often arises in postmenopausal women and is strongly associated with persistent high-risk human papillomavirus infections. Here, we discuss a unique case of an 87-year-old woman who presented with spontaneous orgasmic sensations. Pelvic magnetic resonance imaging revealed a vaginal mass and necrotic inguinal lymph node; biopsy confirmed squamous cell carcinoma. This case highlights considering vaginal cancer in postmenopausal women with atypical sexual symptoms.

Isolated Cutaneous Perianal Crohn Disease With Rare Perineal Involvement | Annals of Internal Medicine: Clinical Cases

We present a rare case of isolated perianal Crohn disease (iPCD) with perineal involvement in a 28-year-old woman who remained free of luminal gastrointestinal symptoms for more than 10 years. The diagnosis was significantly delayed due to clinical overlap with hidradenitis suppurativa and pilonidal disease. The patient had multiple unsuccessful treatments, including antibiotics, immunosuppressants, and biological agents. Complete remission was ultimately achieved with combination therapy using infliximab and azathioprine. This case underscores the importance of early recognition, accurate differentiation from mimicking conditions, and a multidisciplinary approach to managing iPCD.

Stress Cardiomyopathy in Chronic Obstructive Pulmonary Disease and Asthma Exacerbations: A Narrative Literature Review | Annals of Internal Medicine: Clinical Cases

In patients with asthma or chronic obstructive pulmonary disease exacerbations, the association between use of β-adrenergic agonists and stress cardiomyopathy is becoming increasingly recognized. Considering the emergence of this association, we sought to consolidate information from the existing body of literature to derive observational trends. One case series and 8 case reports were reviewed. Sex, age, ethnicity, comorbid conditions, presenting symptoms, electrocardiogram findings, troponin values, amount and type of β-agonist used, and time to resolution of cardiomyopathy were examined.

Sideroblastic Anemia in a Young Woman Being Treated for Wilson Disease | Annals of Internal Medicine: Clinical Cases

D-penicillamine and zinc are both useful in the treatment of Wilson disease. Both drugs can cause pancytopenia by the direct toxic effect on the marrow or sideroblastic anemia caused by hyperzincemia-induced hypocupremia. Although serum copper levels are not useful in the diagnosis of pancytopenia in patients with Wilson disease, a bone marrow aspirate correlating with clinical context and biochemical variables can make the differentiation. We present a 20-year-old patient with Wilson disease and an acquired cause of sideroblastic anemia.

Recurrent Strokes in a Hypertensive Smoker: An Atypical Case and Review of Thrombotic Thrombocytopenic Purpura | Annals of Internal Medicine: Clinical Cases

Thrombotic thrombocytopenic purpura (TTP) can present with neurologic symptoms before the development of typical hematologic abnormalities. We describe a patient presenting with decreased grip strength in his right hand who was found to have an ischemic stroke from acute TTP. In the setting of subtle hematologic abnormalities, detection of severely decreased ADAMTS13 activity aided in early diagnosis and prompt initiation of plasmapheresis. Hence, we emphasize the need for high clinical suspicion for TTP in patients with recurrent and cryptogenic strokes, especially in the setting of subtle hematologic findings, as early treatment decreases mortality rate by almost 90%.

Right Coronary Artery Ectasia Manifesting With Acute Coronary Syndrome and Atrial Fibrillation: A Case Report | Annals of Internal Medicine: Clinical Cases

The patient is a 59-year-old man who presented with substernal chest pain. Electrocardiogram showed evidence of inferior ST-segment elevation, and his troponin I level peaked at 40 µg/L. Coronary angiogram showed a severely ectatic right coronary artery with near-total acute thrombotic occlusion of the distal right coronary artery and total acute thrombotic occlusion of the distal posterior descending artery. He had a successful intravascular ultrasound-guided aspiration thrombectomy with a penumbra and intracoronary tissue plasminogen activator infusion. This case highlights an alternative way of treating acute thrombotic occlusion of ectatic arteries asides from the conventional but challenging practice of coronary revascularization with stent placement.

Recurrent Myopericarditis and Fulminant Cardiogenic Shock Due to Autoimmune Polyglandular Syndrome 2 | Annals of Internal Medicine: Clinical Cases

A 34-year-old man presented with acute pericarditis and a small pericardial effusion but rapidly decompensated into cardiac tamponade and fulminant cardiogenic shock, requiring venoarterial extracorporeal membrane oxygenation cannulation. He was diagnosed with autoimmune polyglandular syndrome 2 and was treated with stress dose steroids and an interleukin-1 inhibitor, with improvement in his cardiac function.

A Case of Relugolix-Associated Rhabdomyolysis | Annals of Internal Medicine: Clinical Cases

Androgen deprivation therapy is an integral component of systemic therapy for advanced prostate cancer. However, androgen deprivation therapy causes an array of adverse events secondary to castrate levels of testosterone. A relatively uncommon adverse event of androgen deprivation agents is rhabdomyolysis. The novel oral gonadotrophin-releasing hormone receptor antagonist relugolix received Food and Drug Administration approval recently for treatment of advanced prostate cancer. However, there are no case reports in the literature of rhabdomyolysis associated with relugolix use. Here, we report a case of a 76-year-old man who developed this uncommon toxicity associated with relugolix taken concomitantly with rosuvastatin, with a fatal outcome.

A Presentation of Rare Heidenhain-Variant Creutzfeldt-Jakob Disease | Annals of Internal Medicine: Clinical Cases

Heidenhain-variant Creutzfeldt-Jakob disease (HV-CJD) is a rare pathologic prion disease characterized by visual symptoms preceding progressive neurodegeneration and death. In HV-CJD, pathologic prions display demyelinating neurotropism for the occipital lobe, yielding characteristic visual changes and hallucinations. Herein, we describe the case of a patient who presented with antecedent visual hallucinations followed by declining neuropsychiatric status, startle myoclonus, gait ataxia, and personality change. Clinical symptoms, electroencephalography, magnetic resonance imaging, and lumbar puncture supported a diagnosis of HV-CJD. This case emphasizes the importance of multidisciplinary management for ruling out alternative medical diagnoses, performing appropriate diagnostic studies, and implementing patient-centered management.

ACP advises on physician suicide prevention; study examines depression in med students

Nondrug therapies outperformed drugs for depression symptoms in dementia, review finds

Meta-analysis finds no association between beta-blocker therapy, depression

SSRIs associated with remission of depression following intracerebral hemorrhage

Long-term vitamin D supplementation does not appear to protect against depression

Depression, time pressure negatively affect physicians' ability and well-being, studies find

Anti-inflammatory agents may effectively, safely curb major depressive symptoms, study finds

CBT may offer equivalent value to antidepressants as initial therapy for major depression

Antidepressants associated with decreased mortality rates in patients with diabetes and depression

Recommendations issued for diagnosing, managing depression during menopause

Guidance highlights risk of psychological distress post-MI | ACP Hospitalist

Nitrous oxide misuse no laughing matter | ACP Hospitalist

CNS-active medications increase readmission risk in older patients | ACP Hospitalist

ACC issues guidance on diagnosis, management of pericarditis | ACP Hospitalist

Sync with psych | ACP Hospitalist

Medetomidine complicates fentanyl withdrawal | ACP Hospitalist

No difference in time to extubation with propofol, dexmedetomidine, or clonidine | ACP Hospitalist

Save lives by treating substance use | ACP Hospitalist

Have scope—will travel | ACP Hospitalist

Dealing with devices | ACP Hospitalist

Spotlight on perceptions of glycemic control

Basal insulin does not contribute to emotional distress in type 2 diabetes, study finds

MKSAP quiz: Screening recommendations

‘Night owls' more likely to have unhealthy lifestyles, higher diabetes risk

Young adults' lack of regular diabetes care may be linked to beliefs about medication

Nocturnal hypoglycemia underdiagnosed in older patients on insulin for type 2 diabetes

Treatment pathways compared for diabetic peripheral neuropathy

Comprehensive telehealth approach improved HbA1c in type 2 diabetes

Adults with diabetes more likely to report mental stress during the COVID-19 pandemic

Antidepressant adherence linked to lower risk of advanced complications of diabetes

MKSAP Quiz: Confusion and a history of cirrhosis

Severe COVID-19 associated with more IBS, less constipation

Spotlight on functional GI disorders

Use of drugs, nondrug treatments for functional bowel disorders analyzed

Two-year results show continued benefit of phone or web CBT for refractory IBS

Hints for preventive care in inflammatory bowel disease

Spotlight on mental health and gastrointestinal symptoms

Spotlight on colorectal cancer survival

Antidepressants and psychological therapies reduce IBS symptoms, meta-analysis finds

ACG updates guideline on diagnosis, management of Crohn's disease