The Canadian Journal of Psychiatry

This research aims to investigate the relapse rates of major depressive disorder (MDD) within primary care and evaluate the efficacy of relapse prevention therapies. Despite primary care being the common point of contact for MDD patients, there are limited studies around this.

We included randomized controlled trials and observational studies examining MDD relapse incidence and the effect of pharmacological and non-pharmacological interventions in preventing relapse in primary care. Databases; Medline via Ovid, EMBASE, The Cochrane Library, PsycInfo (ebsco), and Clinical Trials.gov were searched from their inception until September 7, 2022. Joanna Briggs Institute (JBI) appraisal instrument for methodological quality assessment was used. A proportional data analysis estimated the MDD relapse incidence. Therapy effectiveness results were shown as odds ratios with 95% confidence intervals, with heterogeneity explored via subgroup analysis.

Out of the reviewed studies, 35 met the eligibility criteria. Quality appraisal scores varied between 73% and 96%. MDD relapse incidence was divided into subgroups, revealing that both pharmacotherapy and non-pharmacotherapy led to a similar decrease in relapse rates with combination therapies showing further reduction in relapse. Subgroup analyses by study design, follow-up length, date of study and quality of study also yielded noteworthy findings.

Our findings showed that MDD relapse rates in primary care settings can be effectively reduced by pharmacotherapy, non-pharmacotherapy, or combination therapy. Some psychological interventions might also reduce relapse likelihood. More studies are needed on individual and combined treatments over longer periods to understand their long-term impacts on MDD relapse in primary care.

How Often Depression Returns and How Well Treatments Work in Primary Care: A Review of Studies

The genetic architecture of antidepressant response is poorly understood. This study investigated whether polygenic risk scores (PRSs) for major psychiatric disorders and a personality trait (neuroticism) are associated with antidepressant treatment outcomes.

We analysed 148 participants with major depressive disorder (MDD) from the Canadian Biomarker Integration Network for Depression-1 (CAN-BIND-1) cohort. Participants initially received escitalopram (ESC) monotherapy for 8 weeks. Nonresponders at week 8 received augmentation with aripiprazole (ARI), while responders continued ESC until week 16. Primary outcomes were remission status and symptom improvement measured at weeks 8 and 16. At week 16, post-hoc stratified analyses were performed by treatment arm (ESC-only vs. ESC + ARI). Eleven PRSs derived from genome-wide association studies of psychiatric disorders (e.g., MDD and post-traumatic stress syndrome (PTSD)) and neuroticism, were analysed for associations with these outcomes using logistic and linear regression models.

At week 8, a higher PRS for PTSD was nominally associated with a lower probability of remission (odds ratio (OR) = 0.08 [0.014–0.42], empirical p-value = 0.017) and reduced symptom improvement (beta (standard error) = −29.15 (9.76), empirical p-value = 0.019). Similarly, a higher PRS for MDD was nominally associated with decreased remission probability (OR = 0.38 [0.18–0.78], empirical p-value = 0.044). However, none of the results survived multiple testing corrections. At week 16, the stratified analysis for the ESC-only group revealed that a higher PRS for MDD was associated with increased remission probability (empirical p-value = 0.034) and greater symptom improvement (empirical p-value = 0.02). In contrast, higher PRSs for schizophrenia (empirical p-value = 0.013) and attention-deficit hyperactivity disorder (empirical p-value = 0.032) were associated with lower symptom improvement. No significant associations were observed in the ESC + ARI group.

These findings suggest that PRSs may influence treatment outcomes, particularly in ESC monotherapy. Replication in larger studies is needed to validate these observations.

Relapse rates in major depressive disorder (MDD) remain high even after treatment to remission. Identifying predictors of relapse is, therefore, crucial for improving maintenance strategies and preventing future episodes. Remote data collection and sensing technologies may allow for more comprehensive and longitudinal assessment of potential predictors.

The Canadian Biomarker Integration Network in Depression Wellness Monitoring for MDD (CBN-WELL) study was a prospective, multicentre observational study with an aim to identify biomarkers associated with relapse in patients on maintenance treatment for MDD. Participants had a DSM-5-TR diagnosis of MDD in remission and a Montgomery–Åsberg Depression Rating Scale (MADRS) score ≤14. Participants remained on their baseline medication regimens and were followed bimonthly for up to 2 years. Relapse criteria included MADRS > 22 for 2 consecutive weeks, suicidality or hospitalization, and initiation or change in medication for worsening symptoms. Data collection included clinical assessments, self-report questionnaires, and remote monitoring using wrist-worn actigraphs and smartphones.

A total of 96 participants had follow-up data. Of these, 28.9% experienced a depressive relapse during the study period, with an average time to relapse of 211 days. Baseline depressive severity, as measured by MADRS, was higher in participants who relapsed compared to those who did not, but few other baseline clinical measures differentiated these groups.

Individuals with MDD in remission continued to have high relapse rates despite maintenance treatment. The paucity of clinical factors that predict relapse underscores the need for biomarkers. The CBN-WELL database can be used for future research to integrate multiple predictive factors and to identify objective measures to predict relapse in individuals.

Non-suicidal self-injury (NSSI) is a common behaviour in youth with mental disorder and in the general population. While NSSI is an important predictor of suicide attempts, not all youth with NSSI experience this outcome. The objective of this study is to report on the overlap between NSSI and suicidal ideation or attempt among Canadian youth self-reporting these behaviours in the general population to define a group of youth who engage in NSSI alone. This group of youth may represent a unique clinical phenotype.

We used data from 14–17 year olds (N = 2,576) from the 2014 Ontario Child Health Study, a province-wide, cross-sectional, epidemiologic study of child health and mental disorder. Based on their responses to questions about past year experiences of suicidal thoughts and behaviours including NSSI, 6 mutually exclusive groups were created reflecting their differing profiles of suicidal thoughts and behaviours. These groups were compared to each other on socio-demographic and symptom characteristics.

A total of 9.2% of youth reported NSSI, and half of these youth endorsed NSSI alone (without suicidal ideation or attempts). Both groups had significantly more females. Compared to other groups of youth endorsing suicidal thoughts and behaviours, the NSSI alone group had lower symptoms of mental disorder in all domains except for social anxiety symptoms. They also had the lowest perceived need for help of all groups.

About half of youth who self-harm do so without suicidal intent, and some for as long as 1 year during adolescence. Further prospective study of youth with NSSI alone is needed, to determine symptom stability as well as incident more risky suicidal behaviour before recommendations regarding the appropriateness of minimal medical or psychological intervention for youth who engage in this behaviour can be considered. There also are important sex differences in NSSI that deserve additional prospective study.

Traumatic experiences constitute a risk factor for developing different psychopathologies, such as post-traumatic stress disorder (PTSD), complex PTSD (CPTSD), and positive symptoms of psychosis. However, on the symptom level, it is still unclear how CPTSD and positive symptoms of psychosis associate with each other. The present study aimed to shed light on these dynamics by investigating the symptoms network of CPTSD and positive symptoms of psychosis.

A network analysis was performed on CPTSD and psychosis symptoms among a Canadian community sample with a history of traumatic life events (n = 747). Measures included the international trauma questionnaire and the mPRIME screen.

In total, 4.8% of the sample reached the criteria of probable PTSD and 7% fulfilled the criteria of probable CPTSD. PTSD and CPTSD groups had a significantly higher severity of positive symptoms of psychosis compared to the no-disorder group. Network analysis revealed 3 distinct communities of symptoms of PTSD, disturbances in self-organization, and psychosis. Affective dysregulation served as the bridging symptom between the communities. Hearing one's own thoughts aloud was the most central symptom in the network.

Findings show that positive symptoms of psychosis can be considered trauma-related responses. Furthermore, interventions targeting affective dysregulation as well as the experience and distress associated with hearing one's own thoughts aloud may contribute to symptom reduction and improved functioning.