Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Help Wanted: Mental Health and Social Stressors Among Latino Day Laborers

Latino day laborers may be especially vulnerable to poor mental health due to stressful life experiences, yet few studies have described patterns of mental health outcomes and their correlates in this population. Patterns of depression (PHQ-9) and anxiety (GAD-7), and associations with demographic characteristics, social stressors, and substance use in a recruited sample of male Latino day laborers ( n = 101) are described. High rates of depression and anxiety were identified. Specifically, 39% screened positive for moderate or severe depression and 25% for moderate or severe anxiety. Higher levels of depression and anxiety symptoms were associated with being single, being homeless or in temporary housing, experiencing discrimination, acculturation stress, and marijuana use. While tobacco and unhealthy alcohol use were common in this sample (39% and 66%, respectively), they were not associated with depression and anxiety. These findings suggest that depression and anxiety are common among Latino day laborers and associated with stressful life experiences. Future research should further assess ways to ameliorate social stressors and reduce risk for poor mental health.

Impact of a Social Worker in a Glaucoma Eye Care Service: A Prospective Study

The purpose of this study was to evaluate the effects of a six-month social worker intervention for participants with a glaucoma-related diagnosis in an urban ophthalmic setting (N = 40). The social worker assessed common barriers to eye care, helping participants with transportation, access to low-vision resources, and supportive counseling. The Distress Thermometer, Patient Health Questionnaire-9, and a satisfaction survey were administered to determine the effect of the social worker intervention and participants' overall impressions of the social worker. The most common barrier to eye care was emotional distress (77.5 percent). There was a significant decrease in the number of participants with symptoms of major and moderate depression. Fourteen participants experienced a clinically relevant decrease in depression, 37 participants felt that the social worker's support addressed their issues, and 29 participants thought it helped them in managing their glaucoma. This study provides evidence that a social work intervention may improve care coordination and management of individuals afflicted with vision impairment due to glaucoma and other ocular diseases.

Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Case Study of a Veteran With Violent Intrusive Thoughts

Exposure and Response Prevention (ERP) is the gold standard treatment for obsessive-compulsive disorder (OCD); however, few studies have evaluated the use of ERP with veterans. This case study describes ERP and medication treatment of a veteran who experienced violent sexual thoughts, countered by compulsions of focusing on the distressing thought to ensure a negative emotion or reversing the thought to a nonviolent thought or image. The veteran had previously received supportive psychotherapy and medication for depression, anxiety, and sleep difficulties, with poor treatment adherence. Upon reengagement in treatment, the therapist provided ERP in 34 sessions over 14 months, with 15 sessions via video telehealth to home. The patient used the OCD Workbook as a resource throughout treatment. The patient developed a hierarchy of target obsessions and rituals with associated subjective units of distress; completed exposures, beginning with lower-level items; and wrote imaginal scripts. He also received zolpidem for insomnia and venlafaxine for anxiety and depression. His scores on the nine-item Patient Health Questionnaire and Yale Brown Obsessive-Compulsive Scale decreased significantly.

A short intervention targeting psychosomatic care in older adults with complex health care needs-results of a randomized controlled trial

OBJECTIVE

The aim of this randomized controlled trial (RCT) was to assess the efficacy of a short intervention targeting psychosomatic care in older adults with complex health care needs.

METHODS

Participants were recruited in the frame of the 11-year follow-up of a large population-based study by means of the INTERMED interview. The INTERMED interview is an integrative assessment method to identify bio-psycho-social health care needs. Persons with high health care needs (interview score ≥ 17) were invited to take part. Participants were randomized with a 1:1 ratio to a control and an intervention group. The intervention group received a home visit conducted by a doctor trained in psychosomatic medicine. The primary hypothesis stated that the intervention group would have a better outcome with respect to health related quality of life (HRQOL) measured by the 12-item short-form health survey (mental component score, MCS) 6 months after randomization (T1). Secondary outcomes were physical HRQOL, health care needs, depression, anxiety, and somatic symptom severity.

RESULTS

In total, 175 participants were included. At the three-year follow-up (T2), 97 participants (55.4%) were included. At T1, we did not find a difference regarding MCS between the intervention and control groups. At T2, the intervention group showed significantly lower health care needs compared with the control group. Regarding HRQOL, depression, and somatic symptom severity the two groups did not differ at T2.

CONCLUSIONS

The primary hypothesis was not confirmed. However, results indicate that a short intervention with complex patients could lead to reduced bio-psycho-social health care needs.

Understanding the mental health and recovery needs of Canadian youth with mental health disorders: a Strategy for Patient-Oriented Research (SPOR) collaboration protocol

BACKGROUND

While considerable progress is being made to understand the health and self-management needs of youth with mental health disorders, little attention has focused on the mental health and recovery needs that the youth themselves identify-this despite a national priority to incorporate patient-oriented research into the development and assessment of mental health services. To address this gap, estimates of the extent to which existing patient-reported outcome measures (PROMs)-originally developed for use amongst adult populations-are clinically meaningful and psychometrically fit for use among youth are needed. In tandem, a recovery profile for youth can be constructed incorporating the youth perspective of the services provided within a community mental health setting.

METHODS/DESIGN

This study will utilize a mixed methods design incorporating qualitative focus group interviews and cross-sectional survey. Our process will begin with the hiring of a youth peer research partner who will provide lived experience expertise through all phases of the study. We will advertise, recruit, and conduct four focus groups with youth who receive services from the Foundry Vancouver Granville located in British Columbia, Canada. In the first two focus groups, we will recruit youth aged 15-18 years (n = 10). In the second two focus groups, we will recruit young adults aged 19-24 years (n = 10). In parallel, we will conduct a cross-sectional survey of the recovery and mental health needs of youth, informed by ten widely used and validated PROM. Thematic analysis techniques will guide the identification of predominant thematic trends in the qualitative focus group data. We will use Classical and Rasch measurement methods to test and analyze the reliability and validity of selected PROM measures for youth populations.

DISCUSSION

The proposed study has the potential to produce a preliminary conceptual and measurement model for understanding the mental health and recovery needs of youth with mental health disorders. This evidence will inform how youth mental health services can grow, support, and sustain the capacity for a collaborative, interdisciplinary and innovative patient-oriented research environment. Findings will also contribute much needed evidence to improve the standard of care for youth who experience mental health disorders in Canada and beyond.

Extending access to a web-based mental health intervention: who wants more, what happens to use over time, and is it helpful? Results of a concealed, randomized controlled extension study

Background

Web-based mental health applications may be beneficial, but adoption is often low leaving optimal implementation and payment models unclear. This study examined which users were interested in extended access to a web-based application beyond an initial 3-month trial period and evaluated if an additional 3 months of access was beneficial.

Methods

This study was a concealed extension of a multi-center, pragmatic randomized controlled trial that assessed the benefit of 3 months of access to the Big White Wall (BWW), an anonymous web-based moderated, multi-component mental health application offering self-directed activities and peer support. Trial participants were 16 years of age or older, recruited from hospital-affiliated mental health programs. Participants who received access to the intervention in the main trial and completed 3-month outcome assessments were offered participation. We compared those who were and were not interested in an extension of the intervention, and re-randomized consenting participants 1:1 to receive extended access or not over the subsequent 3 months. Use of the intervention was monitored in the extension group and outcomes were measured at 3 months after re-randomization in both groups. The primary outcome was mental health recovery as assessed by total score on the Recovery Assessment Scale (RAS-r), as in the main trial. Linear mixed models were used to examine the time by group interaction to assess for differences in responses over the 3-month extension study.

Results

Of 233 main trial participants who responded, 119 (51.1%) indicated an interest in receiving extended BWW access. Those who were interested had significantly higher baseline anxiety symptoms compared to those who were not interested. Of the 119, 112 were re-randomized (55 to extended access, 57 to discontinuation). Only 21 of the 55 extended access participants (38.2%) used the intervention during the extension period. Change in RAS-r scores over time was not significantly different between groups (time by group, F(1,77) = 1.02; P = .31).

Conclusions

Only half of eligible participants were interested in extended access to the intervention with decreasing use over time, and no evidence of added benefit. These findings have implications for implementation and payment models for this type of web-based mental health intervention.

Trial registration

Clinicaltrials.govNCT02896894. Registered retrospectively on September 12, 2016.

Effectiveness of a Multimodal Digital Psychotherapy Platform for Adult Depression: A Naturalistic Feasibility Study

Background

Although psychotherapy is one of the most efficacious and effective treatments for depression, limited accessibility to trained providers markedly limits access to care. In an attempt to overcome this obstacle, several platforms seeking to provide these services using digital modalities (eg, video, text, and chat) have been developed. However, the use of these modalities individually poses barriers to intervention access and acceptability. Multimodal platforms, comprising those that allow users to select from a number of available modalities, may be able to provide a solution to these concerns.

Objective

We aimed to investigate the preliminary effectiveness of providing psychotherapy through a multimodal digital psychotherapy platform. In addition, we aimed to examine differential responses to intervention by gender, self-reported physical health status, and self-reported financial status, as well as how prior exposure to traditional face-to-face psychotherapy affected the effectiveness of a multimodal digital psychotherapy intervention. Finally, we aimed to examine the dose-response effect.

Methods

Data were collected from a total of 318 active users of BetterHelp, a multimodal digital psychotherapy platform. Data on physical health status, financial status, and prior exposure to psychotherapy were obtained using self-report measures. Effectiveness was determined by the extent of symptom severity change, which was measured using the Patient Health Questionnaire at Time 1 (time of enrollment) and Time 2 (3 months after enrollment). Intervention dosage was measured as the sum of individual therapist-user interactions across modalities.

Results

Depression symptom severity was significantly reduced after the use of the multimodal digital psychotherapy intervention (P<.001). Individuals without prior traditional psychotherapy experience revealed increased improvement after intervention (P=.006). We found no significant dose-response effect of therapy, nor significant differences in outcomes across gender, self-reported financial status, and self-reported physical health status.

Conclusions

Users of BetterHelp experienced significantly reduced depression symptom severity after engaging with the platform. Study findings suggest that this intervention is equally effective across gender, self-reported financial status, and self-reported physical health status and particularly effective for individuals without a history of psychotherapy. Overall, study results suggest that multimodal digital psychotherapy is a potentially effective treatment for adult depression; nevertheless, experimental trials are needed. We discuss directions for future research.

Patient-reported allergies predict postoperative outcomes and psychosomatic markers after spine surgery

BACKGROUND CONTEXT

Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.

PURPOSE

The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery.

STUDY DESIGN/SETTING

This is a retrospective cohort study at a single tertiary care institution.

PATIENT SAMPLE

The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014.

OUTCOME MEASURES

The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission.

METHODS

Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes.

RESULTS

A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1-58.2 for cervical patients and 79.4-58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05-4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03-1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10).

CONCLUSIONS

Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year.

Telephone-delivered cognitive behavioral therapy for veterans with chronic pain following traumatic brain injury: Rationale and study protocol for a randomized controlled trial study

BACKGROUND AND OBJECTIVES

Chronic pain is a highly prevalent and potentially disabling condition in Veterans who have had a traumatic brain injury (TBI) and access to non-pharmacological pain treatments such as cognitive behavioral therapy is limited and variable. The purpose of this randomized controlled trial (RCT) is to evaluate the efficacy of a telephone-delivered cognitive behavioral therapy (T-CBT) for pain in Veterans with a history of TBI.

METHODS

Veterans with a history of TBI and chronic pain of at least six months duration (N = 160) will be randomized to either T-CBT or a telephone-delivered pain psychoeducational active control condition (T-Ed). The eight-week T-CBT intervention builds on other efficacious CBT interventions for chronic pain in the general population but is novel in that it is conducted via telephone and adapted for Veterans with a history of TBI. Outcome variables will be collected pre, mid-, and post-treatment, and 6 months following randomization (follow-up).

PROJECTED OUTCOMES

In addition to evaluating the effects of the interventions on pain intensity (primary outcome), this study will determine their effects on pain interference, sleep, depression, and life satisfaction. We will also examine potential moderators of treatment outcomes such as cognition, PTSD, and alcohol and drug use. This non-pharmacologic one-on-one therapeutic intervention has the potential to reduce pain and pain-related dysfunction, improve access to care, and reduce barriers associated with geography, finances, and stigma, without the negative effects on physical and cognitive performance and potential for addiction as seen with some pharmacologic treatments for pain. This trial is registered at ClinicalTrials.gov, protocol NCT01768650.

Mental health outcomes and alcohol consumption among UK military spouses/partners: a comparison with women in the general population

Background: Military families can experience unique stressors that may contribute towards poorer well-being among the spouses/partners of Service personnel. However, there is little UK research regarding mental health or alcohol consumption among this population. Objective: This study examined mental health outcomes (probable depression and post-traumatic stress disorder (PTSD)) and alcohol consumption among UK military spouses/partners compared to women in the general population. Associations with military and socio-demographic characteristics were examined. Method: Survey data from 405 female spouses/partners of current and former UK Service personnel participating in a study of military-connected children (2010-2012) was analysed. Comparisons to women in the general population were made using the 2007 Adult Psychiatric Morbidity Survey (n = 1594). Results: Compared to women from the general population, military spouses/partners were significantly more likely to meet criteria for probable depression (adj. OR 2.50 (95% CI 1.52-4.11)). There was no significant difference regarding probable PTSD. Spouses/partners were significantly more likely to meet criteria for hazardous alcohol consumption (adj. OR 2.55 (95% CI 1.87-3.47)) and more likely to report episodes of weekly, daily or almost daily binge-drinking (adj. OR 2.15 (95% CI 1.28-3.61)) than women in the general population. Binge-drinking was significantly higher among spouses/partners of Service personnel reporting family separations of more than 2 months in the last 2 years compared to those reporting no, or shorter, separations (adj. OR 1.88 (95% CI 1.08-3.27)). Conclusion: This is the first study to examine mental health and alcohol consumption among UK military spouses/partners. The significantly higher prevalence of probable depression, hazardous alcohol consumption, and binge-drinking compared to women in the general population suggests further research is needed into the drivers of poor mental health and alcohol consumption among this population and in identifying or developing prevention campaigns to reduce alcohol use and support their well-being.

The impact of disease-specific fears on outcome measures of pulmonary rehabilitation in patients with COPD

Anxiety is a highly prevalent psychological comorbidity in patients with chronic obstructive pulmonary disease (COPD) and has detrimental effects on pulmonary rehabilitation (PR) outcomes. It has been suggested that disease-specific fears could play an even more important role in COPD patients' disease progression. However, little is known about how different disease-specific fears impact COPD. This study examined how different disease-specific fears relate to different PR outcome measures in COPD patients and how these relationships evolve over the course of PR. Before and after a 3-week inpatient PR program, COPD patients (N = 104) underwent a 6-min walking test to measure functional exercise capacity. Disease-specific fears (fear of physical activity, fear of dyspnea, fear of disease progression, fear of social exclusion) were assessed with the COPD-Anxiety-Questionnaire-Revised. Health-related quality of life (HQoL), COPD health status, dyspnea in daily life, depression, and anxiety were measured using validated questionnaires. Multiple regression showed that greater disease-specific fears at the start of PR were associated with worse functional exercise capacity, HQoL, health status, and depression at the start and end of PR (controlling for age, sex, lung function, smoking status, and general anxiety). Patients who showed a stronger decrease in disease-specific fears improved more in PR outcome measures over the course of PR. Furthermore, different disease-specific fears were related to different PR outcome measures. The results show that disease-specific fears are associated with treatment outcome measures, both cross-sectionally and prospectively. Therefore, disease-specific fears should be addressed in COPD patients as they might play a significant role in disease progression.

Exploring the efficacy of an electronic symptom assessment and self-care intervention to preserve physical function in individuals receiving neurotoxic chemotherapy

Background

Impaired physical function due to chemotherapy-induced peripheral neuropathy (CIPN) symptoms may lead to diminished quality of life. However, even with the knowledge of the effects of CIPN on physical function, clinicians infrequently assess and manage CIPN. Interventions that prioritize the early identification of CIPN to provide prompt treatment may reduce the impact of CIPN on physical function. The purpose of this paper is to compare self-reported physical function in individuals receiving neurotoxic chemotherapy between Electronic Symptom Assessment-Cancer (ESRA-C) intervention group (e.g., opportunity for symptom screening, self-care recommendations, communication coaching, and symptom tracking) and control group participants (i.e., electronic assessment alone). Secondary outcomes include pain intensity, sensory/motor CIPN, depression, fatigue, and insomnia.

Methods

The data used in this paper are a subset of a randomized controlled trial that examined the impact of the ESRA-C intervention on symptom distress in individuals receiving cancer treatment. Since the interest in this analysis is on the effects of neurotoxic chemotherapy on physical function, subjects were included if they received platinum and/or taxane-based chemotherapy and completed the baseline and end-of-treatment measures. Participants completed standardized questionnaires of physical function, CIPN, fatigue, depression, pain intensity, and insomnia prior to treatment, 3–6 weeks after treatment initiation, and after the completion of treatment. Changes in mean scores are compared between groups using linear mixed models adjusting for age.

Results

Intervention group participants reported significantly less reduction in physical functioning (baseline: 87.4/100; end-of-treatment: 84.5/100) relative to the control (baseline: 90.2/100; end-of-treatment: 81.8/100) (p = 0.011). For secondary measures, significantly less depression (p = 0.005) was observed in the intervention group as compared to the control, but otherwise, there were no between-group differences. Among participants who received high cumulative doses of neurotoxic chemotherapy, the intervention group reported significantly less severe sensory (p = 0.007) and motor CIPN (p = 0.039) relative to the control.

Conclusion

Use of the ESRA-C intervention led to less reduction in physical function in comparison to the control in individuals receiving neurotoxic chemotherapy. Further research is needed to confirm our findings and to identify how electronic symptom assessment technology may mediate physical function preservation.

Trial registration

ClinicalTrials.Gov NCT00852852. Registered 27 February 2009.

Peer counseling in depression care: A pilot study in a psychiatric inpatient setting

To evaluate in a pilot study whether peer counseling is feasible and accepted for inpatients with depression. A one-to-one peer counseling intervention was implemented in an inpatient psychiatric department. Patients were invited to ask questions concerning their illness. Three trained counselors with a history of depressive episodes supervised peers. The patients evaluated the counseling and their mood. The peer counselors evaluated the counseling; in addition their depression stigma was assessed. Twenty-nine patients (F32 or F33 according to ICD-10, mean age 43 years, 58% female, hospitalized for three weeks minimum) participated. Main topics addressed were 'the patient himself' and 'treatment options, offers and services in the local area'. 94% would recommend peer counseling, 72% would like to take part again. Self-rated mood was significantly higher after than before the counseling. The findings suggest that peer counseling is a useful, additional offer for inpatients with depression as it appears to meet needs yet not addressed. Patients especially valued the counselor's personal experiences. Routine care of depression can be enhanced with peer counseling, e.g. by smoothing the transition from inpatient to outpatient treatment. Further, RCTs on peer counseling in depression should be conducted prospectively.

Exergames vs. traditional exercise: investigating the influencing mechanism of platform effect on subthreshold depression among older adults

OBJECTIVE

This study aimed to examine the influencing mechanism of exercise platform effect on subthreshold depression among older adults by comparing exergames and traditional exercise.

METHOD

One hundred and two Singaporean older adults were assigned to either playing Wii exergames or performing traditional exercise programs once a week, for six weeks.

RESULTS

Results confirmed a direct negative platform effect on subthreshold depression and further supported the mediation role of positive emotions in the platform effect. It implied that exergames led to higher positive emotions than traditional exercise, which further reduced the subthreshold depression among older adults. Self-efficacy was not supported to be a significant mediator in the relations between exercise platform and subthreshold depression.

CONCLUSION

A better understanding of the mechanisms behind the antidepressant effects of exercise platform would not only provide additional insight into a possible causal association, but also inspire the future use of exergames in the treatment of subthreshold depression.

Assessment of perceived mental health-related stigma: The Stigma-9 Questionnaire (STIG-9)

Mental health-related stigma is common and inhibits help-seeking. It triggers fears of devaluation and can add to the burden of a mental disorder. To counter the consequences of mental health-related stigma, its sound assessment is crucial. Therefore, we developed a new measure, the Stigma-9 Questionnaire (STIG-9), and evaluated its psychometric properties and applicability in patients with mental disorders. Item development was based on the modified labelling theory, psychometric reasoning, and discussion with focus groups including patients and clinicians. Data from 919 consecutive patients from an outpatient clinic for mental disorders (69% female, mean age 41 (SD = 14) years) was used to psychometrically evaluate the measure. The STIG-9 consists of nine items assessing cognitive, behavioural and affective aspects of perceived mental health-related stigma. Higher scores indicate stronger expectations of negative societal beliefs, feelings, and behaviours towards 'mentally ill' people. Confirmatory factor analysis revealed a single factor structure. The scale showed high internal consistency. Male gender, social impairment and higher levels of psychopathology corresponded with higher STIG-9 scores. The STIG-9 is a new, theory-grounded, patient-oriented and psychometrically promising self-report measure of perceived mental health-related stigma. It is brief, comprehensive, and appears to be well accepted by patients with mental disorders.

Guided Internet-Based Cognitive Behavioral Therapy for Adult Depression and Anxiety in Routine Secondary Care: Observational Study

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) is a promising new treatment method for depression and anxiety. However, it is important to determine whether its results can be replicated in routine care before its implementation on a large scale. Although many studies have demonstrated the efficacy of iCBT under controlled conditions, only a few studies have investigated its effectiveness in routine care. Furthermore, several effects of iCBT such as treatment effects in routine care are unclear.

OBJECTIVE

This study aimed to evaluate the clinical effectiveness of iCBT for depression and anxiety in routine secondary care.

METHODS

n a retrospective cohort study, we analysed patients treated for depression or anxiety in a dedicated iCBT clinic in secondary care in Denmark. Patients were examined before treatment and weekly thereafter by using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 scales for the diagnoses of depression and anxiety, respectively. Primary analyses were conducted using a linear mixed-effects model with random slope and intercept. Secondary analyses were conducted using baseline characteristics as predictors (gender, age, highest level of education, occupational status, marital status, psychotropic medication use, consumption of alcohol, and leisure drugs). Additionally, logistic regression analyses were used to predict noncompletion of treatment.

RESULTS

A total of 203 (depression, N=60; anxiety, N=143) patients were included. Participants were mainly female (78.3% with depression and 65.7% with anxiety), with a mean age of 36.03 (SD 10.97) years (range, 19-67 years) for patients with depression and 36.80 (SD 13.55) years (range, 19-69 years) for patients with anxiety. The completion rates were 62% (37) and 40% (57) for depression and anxiety treatments, respectively. The primary analyses revealed large and significant reductions in the symptom levels of depression (beta=-6.27, SE 0.83, P<.001, d=1.0) and anxiety (beta=-3.78, SE 0.43, P<.001, d=1.1). High baseline severity of the primary disorder was associated with high treatment gains (r=-0.31 for depression; r=-0.41 for anxiety). In patients with anxiety, high baseline severity also predicted a high risk of noncompletion (odds ratio=1.08, CI=1.01-1.16, P=.03). An increase in the baseline severity of the comorbid disorder slightly increased the risk of noncompletion for both disorders (depression: odds ratio=1.03, CI=1.01-1.06, P=.02; anxiety: odds ratio=1.08, CI=1.01-1.16, P=.03).

CONCLUSIONS

iCBT can be clinically effective in routine care. Since depression and anxiety are costly and debilitating disorders that are vastly undertreated, this finding is important. Additionally, iCBT may help bridge the gap between the need for treatment and its provision. Our results are comparable to the within-group results of efficacy and effectiveness studies. Our noncompletion rates are similar to those observed in psychotherapy but are higher than those reported in similar clinics. Multiple factors predicted outcome and noncompletion. However, all predictor effects were statistically weak.

Reducing wait time from referral to first visit for community outpatient services may contribute to better health outcomes: a systematic review

BACKGROUND

Many people wait long periods for community outpatient services. However little is known about the impact of waiting from referral to first visit on patient outcomes. The aim of this systematic review is to investigate whether waiting for community outpatient services is associated with adverse effects on patient outcomes.

METHODS

Medline, Embase, Psych Info and CINAHL databases were searched, combining the key concepts of waiting for healthcare and patient outcomes. Studies were included if they reported data comparing health outcomes for patients with different waiting times for the same period. Three reviewers applied inclusion and exclusion criteria to identified studies and assessed quality using the McMaster Critical Review Forms. Levels of evidence were assessed using National Health and Medical Research Council guidelines. Included studies were analysed using a descriptive synthesis, and summarised according to levels of evidence and clinical significance for key outcomes.

RESULTS

Fourteen studies that included 69,606 adult patients were selected. Selected studies included patients referred for treatment for musculoskeletal disorders (n = 28,722) or to cardiac rehabilitation (n = 40,884). There was low-level evidence that reduced wait time is associated with moderate improvement in workplace participation for patients seeking care for musculoskeletal conditions; and moderate improvement in exercise tolerance for patients referred to cardiac rehabilitation. There was inconsistent evidence that improvements in quality of life, patient satisfaction and psychological symptoms may be associated with shorter wait times. Pain, function and physical activity outcomes were not associated with wait time.

CONCLUSIONS

This review found low-level evidence suggesting an association between early access to community outpatient services and improvement of some patient outcomes. Specifically, shorter wait times from referral to first visit for musculoskeletal pain services may improve patient work participation. Shorter wait times for cardiac rehabilitation may improve patient exercise capacity. The effects of a short wait time for other patient conditions and patient outcomes, including quality of life, psychological symptoms and patient experience, are inconclusive. The modest benefits in health outcomes observed in reducing wait time for community outpatient services suggest that other possible benefits such as increasing patient flow should be explored.

TRIAL REGISTRATION

PROSPERO registration no: CRD42016047003.

Cigarette Smoking Modulation of Saliva Microbial Composition and Cytokine Levels

Tobacco use has been implicated as an immunomodulator in the oral cavity and contributes to the development of oral cancer. In the present study, we investigated the effects of cigarette smoking on bacterial diversity and host responses compared to healthy nonsmoking controls. Saliva samples were collected from eighteen smokers and sixteen nonsmoking individuals by passive drool. The 16S rRNA gene was used to characterize the salivary microbiome by using the Illumina MiSeq platform. Cytokine and chemokine expression analyses were performed to evaluate the host response. Significant differences in cytokine and chemokine expression levels of MDC, IL-10, IL-5, IL-2, IL-4, IL-7, adrenocorticotropic hormone (ACTH), insulin, and leptin were observed between smokers and nonsmokers. Taxonomic analyses revealed differences between the two groups, and some bacterial genera associated with the smokers group had correlations with hormones and cytokines identified as statistically different between smokers and nonsmokers. These factors have been associated with inflammation and carcinogenesis in the oral cavity. The data obtained may aid in the identification of the interactions between the salivary microbiome, host inflammatory responses, and metabolism in smokers.

Validity and sensitivity to change of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in a clinical population

OBJECTIVE

The SSD-12 is a brief self-report questionnaire to measure the psychological criteria of DSM-5 Somatic Symptom Disorder. This study examines its psychometric properties in a German inpatient sample from a psychosomatic rehabilitation setting, and provides evidence to its sensitivity to change.

METHOD

Patients completed the SSD-12 and the Health49-subscale on somatoform complaints before and after receiving inpatient treatment. Therapists evaluated the psychological improvement of their patients at the end of treatment. Effect sizes (ES) and standardized response means (SRM) of pre- and post-SSD-12 mean changes were calculated for subgroups of patients who did or did not improve.

RESULTS

SSD-12 scores at discharge were significantly lower compared to scores at admission for subgroups of patients who improved according to clinicians (t=2976, df=103, p=.004), and for patients who improved according to self-report (t=5.059, df=159, p<.001). Effect sizes of change in SSD-12 scores in the improved subgroups were ES=-0.19 and ES=-0.30, and standardized response means were SRM=-0.29 and SRM=-0.40, respectively.

CONCLUSION

The SSD-12 shows sound psychometric properties and is useful and time-efficient for monitoring psychological burden associated with bothersome somatic symptoms. Its sensitivity to change over time could be documented.

Study protocol for evaluating the effectiveness of depression management on gylcaemic control in non-communicable diseases clinics in Malawi

INTRODUCTION

Depression is associated with negative patient outcomes for chronic diseases and likely affects consistent physical non-communicable diseases (NCDs) care management in relation to clinic attendance and medication adherence. We found no published studies on the integration of depression management in physical NCD clinics in Malawi and assessing its effects on patient and service outcomes. Therefore, the aim of this study is to evaluate the effectiveness of integrating depression screening and management in physical NCD routine care on patient and service outcomes in Malawi. We will also determine the sensitivity and specificity of the Patient Health Questionnaire-9 (PHQ-9) in the detection of depression in NCD clinics.

METHODS AND ANALYSIS

The study will have two phases. Phase I will involve the validation of the PHQ-9 screening tool for depression, using a cross-sectional study design involving 323 participants, in two specialised physical NCD clinics in one of the 28 districts of Malawi. Using a quasi-experimental study design in four districts of Malawi not involved in the phase I study, the phase II study will evaluate the effectiveness of integrating depression screening (using PHQ-9) and management (based on a specially designed toolkit). Outcomes will be measured at 3 months and 6 months among patients with comorbid diabetes (poorly controlled) and depression attending physical NCD clinics in Malawi.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee (COMREC) on 31 August 2017 (reference P.07/17/2218). The findings will be disseminated through presentations at journal clubs, senior management of the Ministry of Health, national and international conferences as well as submission to peer-reviewed publications. Policy briefs will also be created.

TRIAL REGISTRATION NUMBER

PACTR201807135104799.

Hatha yoga for acute, chronic and/or treatment-resistant mood and anxiety disorders: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically investigate the effectiveness of hatha yoga in treating acute, chronic and/or treatment-resistant mood and anxiety disorders.

METHODS

Medline, Cochrane Library, Current Controlled Trials, Clinical Trials.gov, NHR Centre for Reviews and Dissemination, PsycINFO and CINAHL were searched through June 2018. Randomized controlled trials with patients with mood and anxiety disorders were included. Main outcomes were continuous measures of severity of mood and anxiety symptoms. Cohen's d was calculated as a measure of effect size. Meta-analyses using a random effects model was applied to estimate direct comparisons between yoga and control conditions for depression and anxiety outcomes. Publication bias was visually inspected using funnel plots.

RESULTS

Eighteen studies were found, fourteen in acute patients and four in chronic patients. Most studies were of low quality. For depression outcomes, hatha yoga did not show a significant effect when compared to treatment as usual, an overall effect size of Cohen's d -0.64 (95% CI = -1.41, 0.13) or to all active control groups, Cohen's d -0.13 (95% CI = -0.49, 0.22). A sub-analysis showed that yoga had a significant effect on the reduction of depression compared to psychoeducation control groups, Cohen's d -0.52 (95% CI = -0.96, -0.08) but not to other active control groups, Cohen's d 0.28 (95% CI = -0.07, 0.63) For studies using a follow-up of six months or more, hatha yoga had no effect on the reduction of depression compared to active control groups, Cohen's d -0.14 (95% CI = -0.60, 0.33). Regarding anxiety, hatha yoga had no significant effect when compared to active control groups, Cohen's d -0.09 (95% CI = -0.47, 0.30). The I2 and Q-statistic revealed heterogeneity amongst comparisons. Qualitative analyses suggest some promise of hatha yoga for chronic populations.

CONCLUSIONS

The ability to draw firm conclusions is limited by the notable heterogeneity and low quality of most of the included studies. With this caveat in mind, the results of the current meta-analysis suggest that hatha yoga does not have effects on acute, chronic and/or treatment-resistant mood and anxiety disorders compared to treatment as usual or active control groups. However, when compared to psychoeducation, hatha yoga showed more reductions in depression. It is clear that more high-quality studies are needed to advance the field.

An Internet-based Acceptance and Commitment Therapy intervention for older adults with anxiety complaints: study protocol for a cluster randomized controlled trial

Background

Anxiety is among the most prevalent and disabling mental health problems in older adults. Few older adults with mild to moderately severe anxiety symptoms receive adequate interventions, putting them at risk for developing anxiety disorders, depression, and various somatic problems. Effective, low-threshold interventions should be developed. Blended care, in which a web-based intervention is combined with a limited amount of face-to-face contacts with a mental healthcare counselor at the general practice, is a promising option. The online self-help intervention “Living to the Full”—an Acceptance and Commitment Therapy (ACT) intervention—has been proven to reduce depression and anxiety in several patient groups, but has not yet been investigated in older adults. The aim of this study is to evaluate the (cost-)effectiveness of a blended form of “Living to the Full” in reducing anxiety symptoms in adults aged 55 to 75 years. Furthermore, moderators and mediators of the treatment effect are investigated.

Methods/design

The (cost-)effectiveness of the ACT intervention will be investigated in a cluster single-blind randomized controlled trial (RCT). The blended intervention will be compared to treatment-as-usual. Thirty-six mental health counselors working at general practices in the Netherlands will be randomized to deliver blended care or treatment as usual. A total of 240 participants (aged 55–75 years) with mild to moderately severe anxiety complaints (defined as a total score of 5–15 on the GAD-7) will be recruited. There are four measurements consisting of online questionnaires (primary outcome: GAD-7) and a telephone interview: before the start of the intervention; directly following the intervention (14 weeks after baseline); and six and twelve months after baseline. Possible mediator variables will be assessed multiple times basis during the intervention.

Discussion

This RCT will evaluate the effectiveness of a blended ACT intervention for older adults with anxiety symptoms. If the intervention is shown to be effective, it will be implemented, thereby improving the accessibility and quality of preventive interventions for older adults with anxiety problems.

Trial registration

Netherlands Trial Register, NTR6270. Registered on 21 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2731-3) contains supplementary material, which is available to authorized users.

Whole Person Care in Under-resourced Communities: Stakeholder Priorities at Long-Term Follow-Up in Community Partners in Care

Objective

Depressed individuals may require help from different agencies to address health and social needs, but how such coordination occurs in under-resourced communities is poorly understood. This study sought to identify priorities of Latino and African American depressed clients, explore whether service providers understand client priorities, and describe how providers address them.

Methods

Between October 2014 and February 2015, we interviewed 104 clients stratified by depression history and 50 representatives of different programs in health and social community agencies who participated in Community Partners in Care, a cluster-randomized trial of coalition-building approaches to delivering depression quality improvement programs. Clients were queried about their most pressing needs; program representatives identified their clients' needs and explained how they addressed them.

Results

Physical and mental health were clients' top priorities, followed by housing, caring for and building relationships with others, and employment. While persistently depressed clients prioritized mental health, those with improved depression prioritized relationships with others. Program representatives identified housing, employment, mental health, and improving relationships with others as clients' top priorities. Needs assessment, client-centered services, and linkages to other agencies were main strategies used to address client needs.

Conclusion

Depressed clients have multiple health and social needs, and program representatives in under-resourced communities understand the complexity of clients' needs. Agencies rely on needs assessment and referrals to meet their clients' needs, which enhances the importance of agency partnership in "whole person" initiatives. Our results illustrate agency capacity to adopt integrated care models that will address clients' multiple needs through multi-sector collaboration and describe potential strategies to help reach the goal of whole person care.

The relationship between depression and cognitive function in adults with cardiovascular risk: Evidence from a randomised attention-controlled trial

Background and aim

This study assessed the association between depressive symptom severity and cognition in middle-to-older aged adults with mild-to-moderate depression and cardiovascular risk factors using an online test battery (CogState) and whether changes in depressive symptoms over 3 months were associated with changes in cognition.

Methods

Participants (mean age = 57.8) with cardiovascular risk and mild–to-moderate depressive symptoms completed measures of psychomotor speed, learning, and executive function prior to (n = 445)_and after (n = 334) online depression or attention control interventions. The symptom severity-cognition relationship was examined both cross-sectionally and prospectively.

Results

Participants exhibited significantly reduced psychomotor speed and variable impairments on measures of learning and executive functioning relative to normative data. However, there was no association of depression severity with cognition at baseline or of change in depressive symptoms with change in cognitive performance.

Limitations

Participants were well-educated, which may have protected against cognitive decline. Attrition may limit generalisability, though is unlikely to explain the lack of association between depression symptoms and cognition.

Conclusions

Adults with comorbid mild-to-moderate depressive symptoms and cardiovascular risks performed less well than age-matched normative data on three online cognitive tests; however, we were unable to show any symptom-cognition association cross-sectionally or longitudinally, despite significant improvements in depressive symptoms. This challenges the generalisability of such associations found in more severely unwell clinical samples to those with a broader depressive symptom profile, or suggests that underlying cardiovascular disease may account for the association seen in some clinical studies. This has implications for scaling up selective prevention of cognitive decline.

Mental Health Disparities Among College Students of Color

PURPOSE

Understanding the mental health needs of students of color is a growing priority on college and university campuses nationwide. This study aims to capture the state of mental health among students of color, including the prevalence of mental health problems and treatment utilization.

METHODS

The sample is comprised of 43,375 undergraduate and graduate students at 60 institutions that participated in the survey-based Healthy Minds Study from 2012 to 2015. These data include over 13,000 students of color; we look separately at African-American, Latinx, Asian/Asian American, and Arab/Arab American students. Data are analyzed at the individual level using bivariate and multivariate modeling to elucidate variations across race/ethnicity. We examine symptom prevalence (measured by validated screens such as the Patient Health Questionnaire-9 for depression), help-seeking behaviors, and related factors (including knowledge and stigma).

RESULTS

Across race/ethnicity, we find modest variation in symptom prevalence and larger variation in service utilization. Overall, treatment use is lower among students of color relative to white students, even when controlling for other variables in regression models. Asian/Asian American students have the lowest prevalence of treatment, at only 20% among those with apparent mental health conditions. Attitudes related to mental health treatment also vary significantly and help to explain the primary findings.

CONCLUSIONS

College students of color represent a disparities population based on greater levels of unmet mental health needs relative to white students. This paper takes an important step toward understanding these needs and points to implications for future research and practice.

Comparative Effectiveness of Usual Care With or Without Chiropractic Care in Patients with Recurrent Musculoskeletal Back and Neck Pain

BACKGROUND

Chiropractic care is a popular alternative for back and neck pain, with efficacy comparable to usual care in randomized trials. However, the effectiveness of chiropractic care as delivered through conventional care settings remains largely unexplored.

OBJECTIVE

To evaluate the comparative effectiveness of usual care with or without chiropractic care for patients with chronic recurrent musculoskeletal back and neck pain.

STUDY DESIGN

Prospective cohort study using propensity score-matched controls.

PARTICIPANTS

Using retrospective electronic health record data, we developed a propensity score model predicting likelihood of chiropractic referral. Eligible patients with back or neck pain were then contacted upon referral for chiropractic care and enrolled in a prospective study. For each referred patient, two propensity score-matched non-referred patients were contacted and enrolled. We followed the participants prospectively for 6 months.

MAIN MEASURES

Main outcomes included pain severity, interference, and symptom bothersomeness. Secondary outcomes included expenditures for pain-related health care.

KEY RESULTS

Both groups' (N = 70 referred, 139 non-referred) pain scores improved significantly over the first 3 months, with less change between months 3 and 6. No significant between-group difference was observed. (severity - 0.10 (95% CI - 0.30, 0.10), interference - 0.07 (- 0.31, 0.16), bothersomeness - 0.1 (- 0.39, 0.19)). After controlling for variances in baseline costs, total costs during the 6-month post-enrollment follow-up were significantly higher on average in the non-referred versus referred group ($1996 [SD = 3874] vs $1086 [SD = 1212], p = .034). Adjusting for differences in age, gender, and Charlson comorbidity index attenuated this finding, which was no longer statistically significant (p = .072).

CONCLUSIONS

We found no statistically significant difference between the two groups in either patient-reported or economic outcomes. As clinical outcomes were similar, and the provision of chiropractic care did not increase costs, making chiropractic services available provided an additional viable option for patients who prefer this type of care, at no additional expense.

High altitude with monotonous environment has significant impact on mood and cognitive performance of acclimatized lowlanders: Possible role of altered serum BDNF and plasma homocysteine level

BACKGROUND

Monotony resulting due to the wilderness, sparse population and isolation from society could adversely affect human physiology and cause mood alterations. Thus, observations need to be conducted in order to elucidate the possible role of circulating biomarkers in inducing altered mood and cognitive performance following prolonged exposure to high altitude (HA) with persistent monotonous environment.

OBJECTIVE

The present study aimed towards investigating the impact of monotonous environment in remote HA on mood and cognitive performance of human volunteers and its correlation with serum brain derived neurotrophic factor (BDNF) and plasma homocysteine level.

METHODS

The present study was conducted on male lowlander participants who had normal social life prior to induction in HA environment. Baseline data was acquired at altitude ≤240 m mean sea level (MSL). Thereafter, the participants were inducted to an altitude of 4500-4800 m MSL. After acclimatization to HA, the participants were assigned as acclimatized low landers (ALL). Longitudinal follow up was conducted after 8 months of high altitude induction on acclimatized low landers (8ALL). Further, to study the effect of monotony, the participants were randomly assigned into different group sizes during their further stay of 4 months in HA viz. ≤5 (12ALL ≤ 5) and ≥10 (12ALL ≥ 10). Mood and cognitive performance of the participants were assessed by standard self-administered questionnaires. Serum BDNF and plasma homocysteine were estimated and their correlation with mood and cognition were determined.

RESULTS

The findings showed significantly low serum BDNF in 12ALL ≤ 5 group when compared to baseline, 8ALL and 12AL ≥ 10 groups. Alleviated serum BDNF was associated with increased prevalence of mood alterations in HA with persistent monotonous environment. Participants of 12ALL ≥ 10 group showed significantly higher cognitive performance as compared to 12ALL ≤ 5 group which was associated with reduced plasma homocysteine level.

LIMITATIONS

Total registered volunteers during baseline study were not available during the entire period of this study. The second limitation was exclusion of participants with medical history of severe head injuries, chronic diseases in family and extreme baseline serum profile. Third limitation of the study was to exclude the participants detected with MCI after 8 months of HA induction for negating the role of hypobaric hypoxia on mood and cognition.

CONCLUSION

The study advocated that ALLs of 12ALL ≤ 5 group have increased prevalence of depressive trait and cognitive impairment which was correlated with reduced serum BDNF and augmented plasma homocysteine level as compared to participants of 12ALL ≥ 10 group having better social interaction with improved cognition and mood. The basic findings of the present study revealed that prolonged HA stay after physiological acclimatization should be regulated by proper social interaction involving normal group size to avoid detrimental effect of monotony and its significant impact on circulatory biomarkers.

Morita Therapy for depression (Morita Trial): a pilot randomised controlled trial

OBJECTIVE

To address uncertainties prior to conducting a fully powered randomised controlled trial of Morita Therapy plus treatment as usual (TAU) versus TAU alone, or to determine that such a trial is not appropriate and/or feasible.

DESIGN

Pilot parallel group randomised controlled feasibility trial.

SETTING AND PARTICIPANTS

Participants aged ≥18 years with Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV major depressive disorder, with or without DSM-IV anxiety disorder(s), recruited from general practice record searches in Devon, UK.

INTERVENTIONS

We randomised participants on a 1:1 basis stratified by symptom severity, concealing allocation using a secure independent web-based system, to receive TAU (control) or 8-12 sessions of Morita Therapy, a Japanese psychological therapy, plus TAU (intervention).

OUTCOMES

Rates of recruitment, retention and treatment adherence; variance and estimated between-group differences in follow-up scores (on the Patient Health Questionnaire 9 (PHQ-9) (depressive symptoms); Generalised Anxiety Disorder Questionnaire 7 (anxiety symptoms); Short Form 36 Health Survey Questionnaire/Work and Social Adjustment Scale (quality of life); Morita Attitudinal Scale for Arugamama (attitudes)) and their correlation with baseline scores.

RESULTS

We recruited 68 participants, 5.1% (95% CI 3.4% to 6.6%) of those invited (34 control; 34 intervention); 64/68 (94%; 95% CI 88.3% to 99.7%) provided 4-month follow-up data. Participants had a mean age of 49 years and mean PHQ-9 score of 16.8; 61% were female. Twenty-four of 34 (70.6%) adhered to the minimum treatment dose. The follow-up PHQ-9 (future primary outcome measure) pooled SD was 6.4 (95% CI 5.5 to 7.8); the magnitude of correlation between baseline and follow-up PHQ-9 scores was 0.42 (95% CI 0.19 to 0.61). Of the participants, 66.7% and 30.0% recovered in the intervention and control groups, respectively; 66.7% and 13.3% responded to treatment in the intervention and control groups, respectively.

CONCLUSIONS

A large-scale trial of Morita Therapy would require 133 participants per group and is feasible with minor modifications to the pilot trial protocol. Morita Therapy shows promise in treating depression and may provide patients with a distinct alternative to current treatments.

TRIAL REGISTRATION NUMBER

ISRCTN17544090; Pre-results.

Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial

BACKGROUND

Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches.

OBJECTIVE

This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control).

METHODS

We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys.

RESULTS

We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=-2.66, P=.006) over the treatment course, outcomes did not vary by treatment app.

CONCLUSIONS

Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of "low-touch" research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01808976; https://clinicaltrials.gov/ct2/show/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz).

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

BACKGROUND

Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions.

AIMS

The current study examined the assumption of iatrogenic effects among BPD adults.

METHODS

Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization.

RESULTS

Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity.

CONCLUSIONS

Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial

Importance

Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication.

Objective

To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care.

Design, Setting, and Participants

Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016.

Interventions

Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care.

Main Outcomes and Measures

The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders.

Results

We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.

Conclusions and Relevance

This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study.

Trial Registration

ClinicalTrials.gov identifier: NCT01933789.

Body dissatisfaction and suicidal ideation among psychiatric inpatients with eating disorders

The current study the relationship between eating disorders (EDs) and suicidal ideation and suicide attempt in adult inpatients. In particular, the present study investigated one potential mechanism, body dissatisfaction (BD), which may contribute to increased risk for suicide in adult ED patients. A sample of 432 psychiatric inpatients ranging from 18 to 65 years of age participated in the current study. Findings indicated that patients who have higher levels of BD also had higher levels of passive and active suicidal ideation and previous suicide attempts. Higher levels of BD were also related to increased suicidal ideation after controlling for depression and emotion dysregulation. Although additional risk factors for suicide should be investigated in adults with EDs, this study provides evidence regarding the relationship between BD and risk for suicide ideation and attempt.

Dextromethorphan/Quinidine for Pseudobulbar Affect Following Stroke: Safety and Effectiveness in the PRISM II Trial

BACKGROUND

Dextromethorphan (DM) / quinidine (Q) was approved for pseudobulbar affect (PBA) treatment based on efficacy and safety trials in patients with PBA caused by amyotrophic lateral sclerosis or multiple sclerosis. The PRISM II trial evaluated DM/Q as PBA treatment in patients with stroke, dementia, or traumatic brain injury.

OBJECTIVE

To report results from the stroke cohort of PRISM II, including the Stroke Impact Scale (SIS).

DESIGN

Open-label trial evaluating twice-daily DM/Q over 90 days.

STUDY PARTICIPANTS

Adults (n = 113) with a clinical diagnosis of PBA secondary to stroke; stable psychiatric medications were allowed.

METHODS

PRISM II was an open-label, 12-week trial enrolling adults with PBA caused by dementia, stroke (reported here), or TBI. All study participants received DM/Q 20/10 mg twice daily. Study visits occurred at baseline and at days 30 and 90.

SETTING

150 U.S. centers.

MAIN OUTCOME MEASUREMENTS

Primary efficacy measure was changed from baseline to day 90 in Center for Neurologic Study-Lability Scale (CNS-LS) scores. Secondary outcomes included PBA episodes (estimated over 7 days), Clinical and Patient/Caregiver Global Impression of Change (CGI-C and PGI-C), Quality of Life-Visual Analog Scale (QOL-VAS), SIS, Patient Health Questionnaire (PHQ-9), and Mini-Mental State Examination (MMSE).

RESULTS

Compared with baseline, CNS-LS scores (SD) improved by -6.2 (6.1, P < .001) at day 30 and -7.6 (6.7, P < .001) at day 90. PBA episodes were reduced by 65% and 75% at day 30 and 90, respectively. Seventy-five percent of clinicians and 67% of patients/caregivers rated PBA as "much" or "very much improved." All SIS items significantly improved from baseline (P < .05, all). Adverse events included diarrhea (4.4%), headache (3.5%), constipation (2.7%), and dizziness (2.7%); 5.3% had adverse events leading to study discontinuation.

CONCLUSIONS

DM/Q effectively treated PBA and was associated with global and functional improvement; adverse events were consistent with the known safety profile of DM/Q.

Managing Cancer and Living Meaningfully (CALM): A Randomized Controlled Trial of a Psychological Intervention for Patients With Advanced Cancer

Purpose Individuals with advanced cancer experience substantial distress in response to disease burden and impending mortality. Managing Cancer And Living Meaningfully (CALM) is a novel, brief, manualized psychotherapeutic intervention intended to treat and prevent depression and end-of-life distress in patients with advanced cancer. We conducted a randomized controlled trial to compare CALM with usual care (UC) in this population. Methods Patients with advanced cancer were recruited from outpatient oncology clinics at a comprehensive cancer center into an unblinded randomized controlled trial. Permuted block randomization stratified by Patient Health Questionnaire-9 depression score allocated participants to CALM plus UC or to UC alone. Assessments of depressive symptoms (primary outcome), death-related distress, and other secondary outcomes were conducted at baseline, 3 months (primary end point), and 6 months (trial end point). Analyses were by intention to treat. Analysis of covariance was used to test for outcome differences between groups at follow-up, controlling for baseline. Mixed-model results are reported. Results Participants (n = 305) were recruited between February 3, 2012, and March 4, 2016, and randomly assigned to CALM (n = 151) or UC (n = 154). CALM participants reported less-severe depressive symptoms than UC participants at 3 months (Δ = 1.09; P = .04; Cohen's d = 0.23; 95% CI, 0.04 to 2.13) and at 6 months (Δ = 1.29; P = .02; d = 0.29; 95% CI, 0.24 to 2.35). Significant findings for greater end-of-life preparation at 6 months also favored CALM versus UC. No adverse effects were identified. Conclusion Findings suggest that CALM is an effective intervention that provides a systematic approach to alleviating depressive symptoms in patients with advanced cancer and addresses the predictable challenges these patients face.

Effectiveness of a Stepped, Collaborative, and Coordinated Health Care Network for Somatoform Disorders (Sofu-Net): A Controlled Cluster Cohort Study

OBJECTIVE

Stepped, collaborative, and coordinated approaches have been proposed as the optimal treatment strategy for somatic symptom and related disorders, but evidence supporting this strategy is lacking. The aim of this study was to assess the effectiveness of a guideline-based health care network for patients who are at high risk of somatoform disorder (Sofu-Net).

METHODS

In a controlled, prospective, observer-blinded cluster cohort study, patients who were at high risk of somatoform disorder were recruited at 18 primary care practices in the Sofu-Net and at 15 primary care practices that provided care as usual (CAU). The primary outcome at 6-month follow-up was the rate at which the patients received mental health treatment since the establishment of Sofu-Net. The secondary outcomes included the patients' clinical symptom severity.

RESULTS

A total of 119 patients in the Sofu-Net intervention group and 100 patients in the CAU control group who were at high risk of somatoform disorder were followed for 6 months. A significantly greater proportion of Sofu-Net patients than CAU patients received mental health treatment (47.9% versus 31.0%; odds ratio = 1.96; 95% confidence interval, 1.07-3.58). However, the Sofu-Net group did not show greater reductions in clinical symptom burden compared with the CAU group.

CONCLUSIONS

The treatment of somatoform disorders within a guideline-based health care network resulted in increased rates of mental health treatment but failed to improve patient clinical outcomes. Future investigations are needed to investigate the combined value of health care networks with specialized psychotherapy interventions in patients at high risk of somatic symptom and related disorders.

TRIAL REGISTRATION

ISRCTN55870770.

Guideline-based stepped and collaborative care for patients with depression in a cluster-randomised trial

Guidelines recommend stepped and collaborative care models (SCM) for depression. We aimed to evaluate the effectiveness of a complex guideline-based SCM for depressed patients. German primary care units were cluster-randomised into intervention (IG) or control group (CG) (3:1 ratio). Adult routine care patients with PHQ-9 ≥ 5 points could participate and received SCM in IG and treatment as usual (TAU) in CG. Primary outcome was change in PHQ-9 from baseline to 12 months (hypothesis: greater reduction in IG). A linear mixed model was calculated with group as fixed effect and practice as random effect, controlling for baseline PHQ-9 (intention-to-treat). 36 primary care units were randomised to IG and 13 to CG. 36 psychotherapists, 6 psychiatrists and 7 clinics participated in SCM. 737 patients were included (IG: n = 569 vs. CG: n = 168); data were available for 60% (IG) and 64% (CG) after 12 months. IG showed 2.4 points greater reduction [95% confidence interval (CI): -3.4 to -1.5, p < 0.001; Cohen's d = 0.45] (adjusted PHQ-9 mean change). Odds of response [odds ratio: 2.8; 95% CI: 1.6 to 4.7] and remission [odds ratio: 3.2; 95% CI: 1.58 to 6.26] were higher in IG. Guideline-based SCM can improve depression care.

Effects of a depression-focused internet intervention in slot machine gamblers: A randomized controlled trial

BACKGROUND

Problematic and pathological gambling have been linked to depression. Despite a high demand for treatment and negative financial consequences, only a small fraction of problematic and pathological gamblers seek professional help. The existing treatment gap could be narrowed by providing low-threshold, anonymous internet-based interventions. The aim of the present study was to examine the acceptance and efficacy of an online-intervention for depression ("Deprexis") in a sample of problematic and pathological slot-machine gamblers. We hypothesized that the intervention group would show a greater reduction in both depressive and gambling-related symptoms compared to a wait-list control group.

METHOD

A total of 140 individuals with self-reported gambling and mood problems were randomly allocated either to the intervention group or to a wait-list control group. After 8 weeks, all participants were invited for re-assessment. The Patient Health Questionnaire - 9 (PHQ-9) served as the primary outcome assessment. Problematic gambling was measured with the Pathological Gambling Adaptation of Yale-Brown Obsessive Compulsive Scale (PG-YBOCS) and the South Oaks Gambling Screen (SOGS). The trial is registered with the German Registry for Clinical Studies (DRKS00013888).

RESULTS

ITT analyses showed that the intervention led to a significant reduction in depressive symptoms as well as gambling-related symptoms compared to the control group, with moderate to strong effect sizes. PP analyses failed to yield significant results due to high rates of non-completion and limited statistical power. Moderator analyses indicated that Deprexis was particularly beneficial in reducing problematic gambling for those scoring high on baseline gambling-related symptoms and for those who gamble due to loneliness.

DISCUSSION

Results of the present study suggest that Deprexis might be a useful adjunct to traditional interventions for the treatment of problematic gambling. The potential of internet-based interventions that are more targeted at issues specific to gambling should be evaluated in future studies.

TRIAL REGISTRATION

German Registry for Clinical Studies DRKS00013888.

Cross-cultural validation of the German and Turkish versions of the PHQ-9: an IRT approach

BACKGROUND

The Patient Health Questionnaire's depression module (PHQ-9) is a widely used screening tool to assess depressive disorders. However, cross-linguistic and cross-cultural validation of the PHQ-9 is mostly lacking. This study investigates whether scores on the German and Turkish versions of the PHQ-9 are comparable.

METHODS

Data from Germans without a migration background (German version, n = 1670) and Turkish immigrants in Germany (either German or Turkish version, n = 307) were used. Differential Item Functioning (DIF) was assessed using Item Response Theory (IRT) models.

RESULTS

Several items of the PHQ-9 were found to exhibit DIF related to language or ethnicity, e.g. 'sleep problems', 'appetite changes' and 'anhedonia'. However, PHQ-9 sum scores were found to be unbiased, i.e., DIF had no notable impact on scale levels.

CONCLUSIONS

PHQ-9 sum scores can be compared between Turkish immigrants and Germans without a migration background without any adjustments, regardless of whether they complete the German or the Turkish version.

Cost and Outcome of BehaviouRal Activation (COBRA): a randomised controlled trial of behavioural activation versus cognitive-behavioural therapy for depression

BACKGROUND

Depression is a common, debilitating and costly disorder. The best-evidenced psychological therapy - cognitive-behavioural therapy (CBT) - is complex and costly. A simpler therapy, behavioural activation (BA), may be an effective alternative.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of BA compared with CBT for depressed adults at 12 and 18 months' follow-up, and to investigate the processes of treatments.

DESIGN

Randomised controlled, non-inferiority trial stratified by depression severity, antidepressant use and recruitment site, with embedded process evaluation; and randomisation by remote computer-generated allocation.

SETTING

Three community mental health services in England.

PARTICIPANTS

Adults aged ≥ 18 years with major depressive disorder (MDD) recruited from primary care and psychological therapy services.

INTERVENTIONS

BA delivered by NHS junior mental health workers (MHWs); CBT by NHS psychological therapists.

OUTCOMES

Primary: depression severity (as measured via the Patient Health Questionnaire-9; PHQ-9) at 12 months. Secondary: MDD status; number of depression-free days; anxiety (as measured via the Generalised Anxiety Disorder-7); health-related quality of life (as measured via the Short Form questionnaire-36 items) at 6, 12 and 18 months; and PHQ-9 at 6 and 18 months, all collected by assessors blinded to treatment allocation. Non-inferiority margin was 1.9 PHQ-9 points. We undertook intention-to-treat (ITT) and per protocol (PP) analyses. We explored cost-effectiveness by collecting direct treatment and other health- and social-care costs and calculating quality-adjusted life-years (QALYs) using the EuroQol-5 Dimensions, three-level version, at 18 months.

RESULTS

We recruited 440 participants (BA, n = 221; CBT, n = 219); 175 (79%) BA and 189 (86%) CBT participants provided ITT data and 135 (61%) BA and 151 (69%) CBT participants provided PP data. At 12 months we found that BA was non-inferior to CBT {ITT: CBT 8.4 PHQ-9 points [standard deviation (SD) 7.5 PHQ-9 points], BA 8.4 PHQ-9 points (SD 7.0 PHQ-9 points), mean difference 0.1 PHQ-9 points, 95% confidence interval (CI) -1.3 to 1.5 PHQ-9 points, p = 0.89; PP: CBT 7.9 PHQ-9 points (SD 7.3 PHQ-9 points), BA 7.8 PHQ-9 points (SD 6.5 PHQ-9 points), mean difference 0.0 PHQ-9 points, 95% CI -1.5 to 1.6 PHQ-9 points, p = 0.99}. We found no differences in secondary outcomes. We found a significant difference in mean intervention costs (BA, £975; CBT, £1235; p < 0.001), but no differences in non-intervention (hospital, community health, social care and medication costs) or total (non-intervention plus intervention) costs. Costs were lower and QALY outcomes better in the BA group, generating an incremental cost-effectiveness ratio of -£6865. The probability of BA being cost-effective compared with CBT was almost 80% at the National Institute for Health and Care Excellence's preferred willingness-to-pay threshold of £20,000-30,000 per QALY. There were no trial-related adverse events.

LIMITATIONS

In this pragmatic trial many depressed participants in both groups were also taking antidepressant medication, although most had been doing so for a considerable time before entering the trial. Around one-third of participants chose not to complete a PP dose of treatment, a finding common in both psychotherapy trials and routine practice.

CONCLUSIONS

We found that BA is as effective as CBT, more cost-effective and can be delivered by MHWs with no professional training in psychological therapies.

FUTURE WORK

Settings and countries with a paucity of professionally qualified psychological therapists, might choose to investigate the delivery of effective psychological therapy for depression without the need to develop an extensive and costly professional infrastructure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN27473954.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 46. See the NIHR Journals Library website for further project information.

Social Participation Determines Quality of Life Among Urban-Dwelling Older Adults With Stroke in a Developing Country

BACKGROUND AND PURPOSE

Poor quality of life (QoL) is a well-recognized consequence after stroke. Quality of life is influenced by a complex interaction between personal and environmental factors. Most previous investigations of the QoL after stroke have focused on personal factors, for example, physical deficits directly resulting from stroke. The influence of environmental factors, including social participation, is relatively understudied partly due to its high variation across different sociocultural contexts. The purpose of this study was to investigate the determinants of QoL among older adults with stroke living in an urban area of a developing country.

METHODS

This cross-sectional observational study included 75 older adults who were at least 3 months poststroke and 50 age-matched healthy controls. Depressive symptoms were quantified using the World Health Organization Quality of Life Brief version (WHOQoL-BREF). Physical function was examined using Functional Ambulation Category, grip strength, 5 times Sit-to-Stand test, and Box and Block tests. The Montreal Cognitive Assessment and visual-manual reaction time were used to index cognitive function. Depressive symptom was quantified using the Patient Health Questionnaire-9. The Barthel Index and Fatigue Severity Scale were used to quantify activity limitation. Social participation and environmental participation were assessed using the Assessment of Life Habit and Craig Hospital Inventory of Environment Factors, respectively. Linear stepwise regression models were used to determine explanators for WHOQoL-BREF domain scores.

RESULTS

Individuals with stroke demonstrated significantly worse QoL on all WHOQoL-BREF domains compared with healthy controls. Stroke was a strong determinant for QoL and explained 16% to 43% of variances. Adding other outcome measures significantly improved the robustness of the models (R change = 12%-32%). The physical, psychological, social, and environmental domains of WHOQoL-BREF were all explained by the LIFE-H scores (β = -10.58, -3.37, 4.24, -5.35, respectively), while psychological, social, and environmental domains were explained by Montreal Cognitive Assessment scores (β = .47, 0.78, 0.54, respectively).

CONCLUSION

Social participation and cognition were strong determinants of QoL among urban-dwelling older adults with stroke. Social and recreational activities and cognitive rehabilitation should therefore be evaluated as potential strategies to improve the well-being of older adults affected by stroke.

Association Between History of Multiple Concussions and Health Outcomes Among Former College Football Players: 15-Year Follow-up From the NCAA Concussion Study (1999-2001)

BACKGROUND

Previous research has examined associations between concussion history and adverse health outcomes among former professional football players. Less is known about the potential effects of concussion among former college football players without additional exposure at the professional level.

PURPOSE

To examine the association between concussion and adverse health outcomes in a cohort of former college football players without exposure to professional football, 15 years after their playing careers ended.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A sample of 204 former collegiate football players (23.4% of eligible athletes with available contact information)-all of whom played at least 1 season of football from 1999 to 2001 in the National Collegiate Athletic Association (NCAA) and had no professional football exposure-completed a general health survey that assessed lifetime concussion history and included the following: the Veterans RAND 36 Item Health Survey, containing a physical composite score (PCS) and mental composite score (MCS); the depression module of the Patient Health Questionnaire; and the 4-item CAGE alcohol dependence questionnaire (for "cutting down, annoyance by criticism, guilty feeling, and eye-openers"). Multivariable binomial regression models estimated adjusted prevalence ratios (PRs) with 95% CIs while controlling for demographics and playing history covariates through forward selection model building.

RESULTS

Most participants reported a concussion history (84.3%). Overall, 22.1% and 39.2% of participants reported a PCS and an MCS <50, respectively (indicating worse health than the US national average); 19.1% reported Patient Health Questionnaire scores ≥10 (indicating moderate/severe depression); and 24.8% reported CAGE scores ≥2 (indicating alcohol dependence). The prevalence of having an MCS <50 was higher among those reporting ≥3 versus 0 concussions (PR, 2.5; 95% CI, 1.3-4.9). Controlling for body mass index (BMI), the prevalence of moderate/severe depression was higher among those reporting ≥3 versus 0 concussions (PR, 4.2; 95% CI, 1.0-16.3). Controlling for BMI, the prevalence of having a PCS <50 was higher among those reporting ≥3 versus 1 or 2 concussions (PR, 2.6; 95% CI, 1.3-5.0) but not 0 concussions (PR, 1.5; 95% CI, 0.6-3.6). No associations were found for alcohol dependence.

CONCLUSION

Associations between a history of multiple concussions and adverse health outcomes were found among former collegiate football players without professional football exposure but were limited to those reporting ≥3 prior concussions. Because only 23.4% of eligible athletes responded to the survey, the possibility of ascertainment bias exists, and our findings should thus be interpreted with some caution. Continued examination within nonprofessional football populations is needed, but findings highlight the need for prevention efforts to reduce concussion incidence.

Coping Skills Practice and Symptom Change: A Secondary Analysis of a Pilot Telephone Symptom Management Intervention for Lung Cancer Patients and Their Family Caregivers

CONTEXT

Little research has explored coping skills practice in relation to symptom outcomes in psychosocial interventions for cancer patients and their family caregivers.

OBJECTIVES

To examine associations of coping skills practice to symptom change in a telephone symptom management (TSM) intervention delivered concurrently to lung cancer patients and their caregivers.

METHODS

This study was a secondary analysis of a randomized pilot trial. Data were examined from patient-caregiver dyads (n = 51 dyads) that were randomized to the TSM intervention. Guided by social cognitive theory, TSM involved four weekly sessions where dyads were taught coping skills including a mindfulness exercise, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication. Symptoms were assessed, including patients' and caregivers' psychological distress and patients' pain interference, fatigue interference, and distress related to breathlessness. Multiple regression analyses examined associations of coping skills practice during the intervention to symptoms at six weeks after the intervention.

RESULTS

For patients, greater practice of assertive communication was associated with less pain interference (β = -0.45, P = 0.02) and psychological distress (β = -0.36, P = 0.047); for caregivers, greater practice of guided imagery was associated with less psychological distress (β = -0.30, P = 0.01). Unexpectedly, for patients, greater practice of a mindfulness exercise was associated with higher pain (β = 0.47, P = 0.07) and fatigue interference (β = 0.49, P = 0.04); greater practice of problem solving was associated with higher distress related to breathlessness (β = 0.56, P = 0.01) and psychological distress (β = 0.36, P = 0.08).

CONCLUSION

Findings suggest that the effectiveness of TSM may have been reduced by competing effects of certain coping skills. Future interventions should consider focusing on assertive communication training for patients and guided imagery for caregivers.

The VITamin D and OmegA-3 TriaL-Depression Endpoint Prevention (VITAL-DEP): Rationale and design of a large-scale ancillary study evaluating vitamin D and marine omega-3 fatty acid supplements for prevention of late-life depression

RATIONALE

Depression is a leading cause of disease burden and disability for older adults; thus, prevention is a priority. Biologic and observational data support potential mental health benefits of vitamin D and omega-3 fatty acids; however, it is unclear whether these supplements can prevent late-life depression.

DESIGN

We describe the novel methodology of a large-scale study: VITAL-DEP (VITamin D and OmegA-3 TriaL-Depression Endpoint Prevention), an ancillary to the VITAL trial. Primary Aims of VITAL-DEP are to determine effects on prevention of depression and on trajectory of mood symptoms of long-term (mean=5years) supplementation with vitamin D (vitamin D3 [cholecalciferol], 2000IU/day) and marine omega-3 fatty-acids (eicosapentaenoic acid + docosahexaenoic acid, 1g/day), in a 2×2 factorial design, among 25,874 older adults. Secondary Aims will evaluate: vitamin D's effects among African-Americans (an at-risk group for vitamin D deficiency); both agents' effects among those with high-risk factors or sub-syndromal depression in a sub-set of ~1000 participants with detailed examinations at baseline and 2-year follow-up; whether baseline nutrient levels influence depression risk and/or modify agents' effects. Additional planned analyses will use pre-randomization blood samples available in ~17,000 participants to address whether key biomarkers and factors influence long-term mood and depression risk and/or the agents' effects.

CONCLUSION

VITAL-DEP applies all modalities of state-of-the-art prevention research - universal, selective and indicated. VITAL-DEP will clarify effects of supplemental vitamin D and/or omega-3 on mood, and inform clinical care and public health guidelines on the use of these agents for prevention of depression in mid-life and older adults.

Assessing the effectiveness of Enhanced Psychological Care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): a pilot cluster randomised controlled trial

BACKGROUND

Around 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation.

METHODS

An external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed.

RESULTS

Eight out of twenty teams were recruited and randomised. Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI - 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI - 1.4 to 10.2; N = 17) at 8 months.

DISCUSSION

While valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions.

TRIAL REGISTRATION

ISRCTN34701576 . Registered on 29 May 2014. Funding details: UK NIHR HTA Programme (project 12/189/09).

Effect of a Collaborative Care Intervention vs Usual Care on Health Status of Patients With Chronic Heart Failure: The CASA Randomized Clinical Trial

IMPORTANCE

Many patients with chronic heart failure experience reduced health status despite receiving conventional therapy.

OBJECTIVE

To determine whether a symptom and psychosocial collaborative care intervention improves heart failure-specific health status, depression, and symptom burden in patients with heart failure.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, 2-arm, multisite randomized clinical trial was conducted at Veterans Affairs, academic, and safety-net health systems in Colorado among outpatients with symptomatic heart failure and reduced health status recruited between August 2012 and April 2015. Data from all participants were included regardless of level of participation, using an intent-to-treat approach.

INTERVENTIONS

Patients were randomized 1:1 to receive the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) intervention or usual care. The CASA intervention included collaborative symptom care provided by a nurse and psychosocial care provided by a social worker, both of whom worked with the patients' primary care clinicians and were supervised by a study primary care clinician, cardiologist, and palliative care physician.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient-reported heart failure-specific health status, measured by difference in change scores on the Kansas City Cardiomyopathy Questionnaire (range, 0-100) at 6 months. Secondary outcomes included depression (measured by the 9-item Patient Health Questionnaire), anxiety (measured by the 7-item Generalized Anxiety Disorder Questionnaire), overall symptom distress (measured by the General Symptom Distress Scale), specific symptoms (pain, fatigue, and shortness of breath), number of hospitalizations, and mortality.

RESULTS

Of 314 patients randomized (157 to intervention arm and 157 to control arm), there were 67 women and 247 men, mean (SD) age was 65.5 (11.4) years, and 178 (56.7%) had reduced ejection fraction. At 6 months, the mean Kansas City Cardiomyopathy Questionnaire score improved 5.5 points in the intervention arm and 2.9 points in the control arm (difference, 2.6; 95% CI, -1.3 to 6.6; P = .19). Among secondary outcomes, depressive symptoms and fatigue improved at 6 months with CASA (effect size of -0.29 [95% CI, -0.53 to -0.04] for depressive symptoms and -0.30 [95% CI, -0.55 to -0.06] for fatigue; P = .02 for both). There were no significant changes in overall symptom distress, pain, shortness of breath, or number of hospitalizations. Mortality at 12 months was similar in both arms (10 patients died receiving CASA, and 13 patients died receiving usual care; P = .52).

CONCLUSIONS AND RELEVANCE

This multisite randomized clinical trial of the CASA intervention did not demonstrate improved heart failure-specific health status. Secondary outcomes of depression and fatigue, both difficult symptoms to treat in heart failure, improved.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01739686.

Reliability and validity of the Farsi version of the Patient Health Questionnaire-9 (PHQ-9) with Iranian psychiatric outpatients

Abstract Introduction: The Patient Health Questionnaire-9 (PHQ-9) is a brief screening and diagnostic tool for depression. It has been used in research and clinical practice in primary care and other clinical and non-clinical settings. The PHQ-9 has not had its validity examined in psychiatric and psychological settings in Iran. Methods: A cross-sectional study was conducted to investigate the validation of the Farsi version of the PHQ-9. A convenience sample of 130 Iranian volunteer psychiatric outpatients was selected from psychiatric and psychological clinics. They completed the PHQ-9, the Patient Health Questionnaire-15 (PHQ-15), the World Health Organization-five Well-Being Index (WHO-5), and the short form of the Beck Depression Inventory-13 (BDI-13). Data were analyzed by descriptive statistics, Cronbach's α, Pearson correlation coefficient, principal component analysis, exploratory factor analysis, and confirmatory factor analysis. Results: Mean score of the PHQ-9 was 12.83 (standard deviation = 6.25), indicating moderately severe depression in the sample. Cronbach's α coefficient for PHQ-9 was 0.88, and one-week test-retest reliability 0.79. The PHQ-9 correlated 0.64 with PHQ-15, −0.35 with WHO-5, and 0.70 with BDI-13, indicating good construct and criterion-related validity. The results of the factor analysis of PHQ-9 items identified and confirmatory factor analysis confirmed a single factor labeled general depression. Conclusions: The PHQ-9 appears to have a unidimensional structure, adequate validity and reliability, and can be useful in epidemiological/research settings. Based on previous literature and on the present findings, the PHQ-9 may have applicability to other contexts in the studied population, but this needs to be confirmed by other studies.

Improving Recovery and Outcomes Every Day after the ICU (IMPROVE): study protocol for a randomized controlled trial

Background

Delirium affects nearly 70% of older adults hospitalized in the intensive care unit (ICU), and many of those will be left with persistent cognitive impairment or dementia. There are no effective and scalable recovery models to remediate ICU-acquired cognitive impairment and its attendant elevated risk for dementia or Alzheimer disease (AD). The Improving Recovery and Outcomes Every Day after the ICU (IMPROVE) trial is an ongoing clinical trial which evaluates the efficacy of a combined physical exercise and cognitive training on cognitive function among ICU survivors 50 years and older who experienced delirium during an ICU stay. This article describes the study protocol for IMPROVE.

Methods

IMPROVE is a four-arm, randomized controlled trial. Subjects will be randomized to one of four arms: cognitive training and physical exercise; cognitive control and physical exercise; cognitive training and physical exercise control; and cognitive control and physical exercise control. Facilitators administer the physical exercise and exercise control interventions in individual and small group formats by using Internet-enabled videoconference. Cognitive training and control interventions are also facilitator led using Posit Science, Inc. online modules delivered in individual and small group format directly into the participants’ homes. Subjects complete cognitive assessment, mood questionnaires, physical performance batteries, and quality of life scales at baseline, 3, and 6 months. Blood samples will also be taken at baseline and 3 months to measure pro-inflammatory cytokines and acute-phase reactants; neurotrophic factors; and markers of glial dysfunction and astrocyte activation.

Discussion

This study is the first clinical trial to examine the efficacy of combined physical and cognitive exercise on cognitive function in older ICU survivors with delirium. The results will provide information about potential synergistic effects of a combined intervention on a range of outcomes and mechanisms of action.

Trial registration

ClinicalTrials.gov, NCT03095417. Registered on 23 March 2017. Last updated on 15 May 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2569-8) contains supplementary material, which is available to authorized users.

Electroacupuncture plus standard of care for managing refractory functional dyspepsia: protocol of a pragmatic trial with economic evaluation

INTRODUCTION

This trial proposes to compare the effectiveness and cost-effectiveness of electroacupuncture (EA) plus on-demand gastrocaine with waiting list for EA plus on-demand gastrocaine in providing symptom relief and quality-of-life improvement among patients with functional dyspepsia (FD).

METHODS AND ANALYSIS

This is a single-centre, pragmatic, randomised parallel-group, superiority trial comparing the outcomes of (1) EA plus on-demand gastrocaine group and (2) waiting list to EA plus on-demand gastrocaine group. 132 (66/arm) endoscopically confirmed, Helicobacter pylori-negative patients with FD will be recruited. Enrolled patients will respectively be receiving (1) 20 sessions of EA over 10 weeks plus on-demand gastrocaine; or (2) on-demand gastrocaine and being nominated on to a waiting list for EA, which entitles them 20 sessions of EA over 10 weeks after 12 weeks of waiting. The primary outcome will be the between-group difference in proportion of patients achieving adequate relief of symptoms over 12 weeks. The secondary outcomes will include patient-reported change in global symptoms and individual symptoms, Nepean Dyspepsia Index, Nutrient Drink Test, 9-item Patient Health Questionnaire (PHQ9), and 7-item Generalised Anxiety Disorder Scale (GAD7). Adverse events will be assessed formally. Results on direct medical costs and on the EuroQol (EQ-5D) questionnaire will also be used to assess cost-effectiveness. Analysis will follow the intention-to-treat principle using appropriate univariate and multivariate methods. A mixed model analysis taking into account missing data of these outcomes will be performed. Cost-effectiveness analysis will be performed using established approach.

ETHICS AND DISSEMINATION

The study is supported by the Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region of China. It has been approved by the Joint Chinese University of Hong Kong - New Territories East Cluster Clinical Research Ethics Committee. Results will be published in peer-reviewed journals and be disseminated in international conference.

TRIAL REGISTRATION NUMBER

ChiCTR-IPC-15007109; Pre-result.