Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Developing a research diagnostic criteria for burning mouth syndrome: Results from an international Delphi process

OBJECTIVE

To develop a beta version of a preliminary set of empirically derived research diagnostic criteria (RDC) for burning mouth syndrome (BMS) through expert consensus, which can then be taken into a test period before publication of a final RDC/BMS.

DESIGN

A 6 round Delphi process with twelve experts in the field of BMS was used. The first round formed a focus group during which the purpose of the RDC and the definition of BMS was agreed upon, as well as the structure and contents. The remaining rounds were carried out virtually via email to achieve a consensus of the beta version of the RDC/BMS.

RESULTS

The definition of BMS was agreed to be 'an intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day over more than 3 months, without evident causative lesions on clinical examination and investigation'. The RDC was based upon the already developed and validated RDC/TMD and formed three main parts: patient self-report; examination; and psychosocial self-report. A fourth additional part was also developed listing aspirational biomarkers which could be used as part of the BMS diagnosis where available, or to inform future research.

CONCLUSION

This Delphi process has created a beta version of an RDC for use with BMS. This will allow future clinical research within BMS to be carried out to a higher standard, ensuring only patients with true BMS are included. Further validation studies will be required alongside refinement of the RDC as trialling progresses.

Is the health literacy of informal caregivers associated with the psychological outcomes of breast cancer survivors?

PURPOSE

To investigate whether health literacy (HL) among informal caregivers of breast cancer (BC) survivors is associated with patient psychological outcomes.

METHODS

We used data (n = 340 pairs) from baseline questionnaires administered in the MyHealth trial investigating nurse-led BC follow-up. All BC survivors and their invited caregivers were included immediately after completion of primary treatment. We performed multivariate regression analyses to examine the association between caregiver HL (nine dimensions as measured by the Health Literacy Questionnaire) as exposure and patient depression, anxiety, and health-related quality of life (HQoL) as outcomes. We further examined whether any association differed according to type of caregiver, patient HL, and patient activation (skill in managing one's health).

RESULTS

Three dimensions, "ability to engage with providers" (β = - 0.2), "navigating the system" (β = - 0.2), and "understand health information" (β = - 0.2), were significantly associated with lower patient depression (p < 0.05), while four dimensions, "having sufficient information" (β = 0.3), "navigating the system" (β = 0.2), "find health information" (β = 0.2), and "understand health information" (β = 0.2), were significantly associated with better patient HQoL (p < 0.05). No significant associations were found for anxiety. Patient HL and activation did not significantly modify the associations, while certain associations for depression were stronger in patients with non-partner caregivers.

CONCLUSIONS

The HL of informal caregivers may play an important role in optimizing psychological outcomes in cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Involving informal caregivers, who can provide support related to health information and services, may be beneficial for the psychological well-being of cancer survivors.

Telemonitoring in patients with chronic heart failure and moderate depressed symptoms: results of the Telemedical Interventional Monitoring in Heart Failure (TIM-HF) study

AIMS

Depression is a frequent comorbidity in patients with chronic heart failure (CHF). Telemonitoring has emerged as a novel option in CHF care. However, patients with depression have been excluded in most telemedicine studies. This pre-specified subgroup analysis of the Telemedical Interventional Monitoring in Heart Failure (TIM-HF) trial investigates the effect of telemonitoring on depressive symptoms over a period of 12 months.

METHODS AND RESULTS

The TIM-HF study randomly assigned 710 patients with CHF to either usual care (UC) or a telemedical intervention (TM) using non-invasive devices for daily monitoring electrocardiogram, blood pressure and body weight. Depression was evaluated by the 9-item Patient Health Questionnaire (PHQ-9) with scores ≥10 defining clinically relevant depressive symptoms. Mixed model repeated measures were performed to calculate changes in PHQ-9 score. Quality of life was measured by the Short Form-36. At baseline, 156 patients had a PHQ-9 score ≥10 points (TM: 79, UC: 77) with a mean of 13.2 points indicating moderate depressiveness. Patients randomized to telemedicine showed an improvement of their PHQ-9 scores, whereas UC patients remained constant (P = 0.004). Quality of life parameters were improved in the TM group compared to UC. Adjustment was performed for follow-up, New York Heart Association class, medication, age, current living status, number of hospitalizations within the last 12 months and serum creatinine. In the study population without depression, the PHQ-9 score was similar at baseline and follow-up.

CONCLUSION

Telemedical care improved depressive symptoms and had a positive influence on quality of life in patients with CHF and moderate depression.

Reliability and validity of the brief dimensional apathy scale

OBJECTIVE

Apathy is composed of different demotivational subtypes measurable by the dimensional apathy scale (DAS) and can be quickly assessed using the brief DAS (b-DAS). The aim was to determine the reliability and validity of the b-DAS.

METHODS

53 amyotrophic lateral sclerosis (ALS) patients and 53 of their informants were recruited. Informants completed the b-DAS, the original informant/carer-rated DAS and behavioral interview about the patients (i.e., presence of behaviors such as apathy/inertia, loss of sympathy/empathy). Patients completed measures of depression, anxiety, emotional lability, cognitive functioning, and functional disability measures.

RESULTS

The b-DAS showed good internal consistency, excellent test-retest reliability, significant positive correlation with the original DAS, and no significant correlations with depression, anxiety, emotional lability, cognitive functioning or functional disability measures. Semi-structured behavior interview showed patients with apathy/inertia had significantly higher b-DAS subscale scores and patients with loss of sympathy/empathy had significantly higher emotional apathy scores only.

CONCLUSIONS

The b-DAS is a fast, reliable, and valid instrument for screening apathy subtypes independent of physical disability.

A collaborative care psychosocial intervention to improve late life depression in socioeconomically deprived areas of Guarulhos, Brazil: the PROACTIVE cluster randomised controlled trial protocol

BACKGROUND

The elderly population has been growing in most low- and middle-income countries (LMIC), and depression is a common condition among these populations. The lack of integration between mental health and primary healthcare services and the shortage of mental health specialists in the public health system contribute to underdiagnosis and undertreatment of depression. One of the strategies to reduce this gap is task shifting and collaborative care treatments. This study therefore aims to evaluate the effectiveness and cost-effectiveness of a collaborative care psychosocial intervention to improve the clinical management of depression among elderly people in poor neighbourhoods in Guarulhos, Brazil.

METHODS

Two-arm, cluster randomised controlled trial with Basic Health Units as the clusters and a 1:1 allocation ratio. Twenty Basic Health Units have been randomly selected and randomised to control or intervention arms. We aim to recruit 1440 adults (72 per cluster) aged 60 years or over identified with depression (9-item Patient Health Questionnaire (PHQ-9) score ≥ 10). The control arm participants will receive an enhanced usual care, while the intervention arm participants will receive an enhanced usual care and a 17-week psychosocial intervention programme delivered at home by community health workers with the help of an application installed on tablet computers. The primary outcome is the proportion with depression recovery (PHQ-9 < 10) at 8 months' follow-up. We will also assess the maintenance of any earlier clinical gains and the cost-effectiveness of the intervention at 12 months.

DISCUSSION

This is the first randomised trial to investigate a collaborative care intervention to treat depression among poor elderly in LMIC/Latin America. This is a major public health problem worldwide, but in these countries, there are no locally tested, evidence-based interventions available to date.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN57805470 . Registered on 25 April 2019.

Detection and prevalence of depression among adult type 2 diabetes mellitus patients attending non-communicable diseases clinics in Lilongwe, Malawi

Background

Depression is associated with chronic physical illnesses and negatively affects health outcomes. However, it often goes undiagnosed and untreated. We investigated the prevalence of depression among adult type 2 diabetes mellitus (T2DM) patients attending non-communicable diseases (NCD) clinics in Lilongwe, Malawi, and estimated the level of routine detection by NCD clinicians. This study set out to determine the prevalence of major depression and its detection among adult type 2 diabetes mellitus (T2DM) patients attending NCD clinics in Lilongwe, Malawi.

Methods

In a cross-sectional study design, 323 T2DM patients aged ≥ 18 years were screened for depression with the Patient Health Questionnare-9 (PHQ-9) followed by diagnostic assessment with the Structured Clinical Interview for DSM-IV (SCID). We analysed the association between presence of major depression and sociodemographic factors using logistic regression.

Results

Three quarters of the participants (76%) were females. The participants’ ages ranged from 21–79 years. Of the 323 participants, 58 (18%) met criteria for DSM-IV major depression. None of the cases of major depression had been identified by the NCD clinicians. Major depression was found not to be significantly associated with any of the sociodemographic factors.

Conclusions

We found that depression is common among NCD clinic attendees with T2DM in Malawi, and poorly detected by NCD clinicians. Given the high prevalence and challenges in clinical identification, integration of depression screening with a standardized validated tool should be a high priority so as to link patients to appropriate services.

Moving singing for lung health online in response to COVID-19: experience from a randomised controlled trial

INTRODUCTION

Singing for lung health (SLH) is a popular arts-in-health activity for people with long-term respiratory conditions. Participants report biopsychosocial benefits, however, research on impact is limited. The 'SLH: Improving Experiences of Lung Disease trial', a randomised controlled, single (assessor) blind, trial of 12 weeks SLH versus usual care for people with chronic obstructive pulmonary disease (COPD) (n=120) was setup to help to address this. The first group (n=18, nine singing and nine controls) started face-to-face (five sessions) before changing to online delivery (seven sessions) due to COVID-19-related physical distancing measures. As such, the experience of this group is here reported as a pilot study to inform further research in this area.

METHODS

We conducted semistructured interviews and thematic analysis regarding barriers, facilitators and key considerations for transitioning from face-to-face to online delivery. Pilot quantitative outcomes include attendance, premeasures and postmeasures of quality of life and disease impact (Short Form 36 Health Survey, COPD Assessment Test score), breathlessness (Medical Research Council breathlessness scale, Dyspnoea-12), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalised Anxiety Disorder-7), balance confidence (Activity specific Balance Confidence, ABC scale) and physical activity (clinical visit PROactive physical activity in COPD tool, combining subjective rating and actigraphy).

RESULTS

Attendance was 69% overall, (90% of the face-to-face sessions, 53% online sessions). Analysis of semistructured interviews identified three themes regarding participation in SLH delivered face to face and online, these where (1) perceived benefits; (2) digital barriers (online) and (3) digital facilitators (online). Findings were summarised into key considerations for optimising transitioning singing groups from face-to-face to online delivery. Pilot quantitative data suggested possible improvements in depression (treatment effect -4.78 PHQ-9 points, p<0.05, MCID 5) and balance confidence (treatment effect +17.21 ABC scale points, p=0.04, MCID 14.2).

DISCUSSION

This study identifies key considerations regarding the adaptation of SLH from face-to-face to online delivery. Pilot data suggest online group singing for people with COPD may deliver benefits related to reducing depression and improved balance confidence.

Prevalence and risk factors of depression in patients with drug-resistant tuberculosis in Nepal: A cross-sectional study

•

Patients with drug-resistant tuberculosis (DR TB) are at high risk for depression.

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DR TB patients in Nepal were screened with Health Questionnaire 9 for depression.

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81 out of 129 patients (62.7%) were found to have possible depressive disorder.

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Duration of illness was a significant risk factor for depression (p < 0.001).

Background

Patients with drug-resistant tuberculosis (DR TB) have a protracted course of illness and the available treatment has a low success rate. These factors combined with the associated stigma and financial implications put the patients with DR TB at an increased risk of depression. The psychiatric side effects of anti-tuberculosis drugs further aggravate the problem. This study aimed to estimate the prevalence of depression among patients with DR TB in Nepal and identify risk factors.

Methods

We conducted this cross-sectional study in April 2018 at all the functioning 11 programmatic DR TB treatment centers across Nepal. We selected 129 patients aged ≥ 16 years receiving treatment for DR TB by non-probability quota sampling. Six trained data collectors conducted face-to-face interviews and administered the Nepali language version of Patient Health Questionnaire 9 (PHQ-9) to screen for depression. We summarized sociodemographic and treatment characteristics with median (Interquartile Range [IQR]) and proportions as appropriate. We performed univariate analysis for the variables hypothesized as risk factors for depression. We fitted a multivariable binary logistic regression model with depression as the outcome variable and the variables with a significance level of < 0.25 as explanatory variables. We regarded a p-value of < 0.05 as significant for individual variables in the logistic regression model.

Results

Of the 129 patients studied, 92 (71.3%) were male and the median age was 36 years (IQR 25–48). The majority (109, 84.4%) had multi-drug resistant tuberculosis (MDR TB). We identified 81 patients (62.7%, 95% Confidence Interval [CI] 53.7–71) with the PHQ-9 score of 10 or more signifying probable depressive disorder. In univariate analyses, age, treatment center location, DR TB treatment duration, and duration of current illness had a p-value lower than the pre-specified cut-off of 0.25. In the multivariable logistic regression model, we found a statistically significant association of depression with the duration of illness (adjusted Odds Ratio 1.15, 95% CI 1.07–1.26, p < 0.001).

Conclusion

This study has found that a large proportion of the patients with DR TB screened have depression suggesting the need for screening and management of comorbid depression within the National TB Control Program.

Play Mode Effect of Exergames on Subthreshold Depression Older Adults: A Randomized Pilot Trial

BACKGROUND

Subthreshold depression is a common mental disorder in late life. Increasing studies have supported the positive effects of exergames to subthreshold depression. The current study aims to investigate how play mode potentially affects exergames' effects on subthreshold depression among older adults.

METHOD

A between-group experiment was carried out to compare the effect of exergames with different play modes. Fifty-two Singaporean older adults with subthreshold depression were randomly assigned into two conditions, and performed either single-player or multiple-player Nintendo Wii Tennis exergames for 6 weeks, while the key variables of depression, social support and loneliness were measured at both pre- and post-study period.

RESULTS

Findings from path analysis suggested that older adults in multiple-player exergames experienced lower levels of loneliness, and further more reduction on subthreshold depression, when compared to those in single-player exergames. Although social support was not affected by play mode, the significant relationship among social support, loneliness, and depression was found in the context of exergaming.

CONCLUSION

This study not only provides additional insight into a possible causal association lining play mode and health outcomes of exergames, but also opens the discussion of how to optimize antidepressive effect of exergames for older adults.

Effects of a mind-body program on symptoms of depression and perceived stress among adults with neurofibromatosis type 2 who are deaf: A live-video randomized controlled trial

INTRODUCTION

Neurofibromatosis type 2 (NF2) is a rare, progressive and incurable genetic disorder associated with progressive hearing loss and eventual deafness. As a group, patients with NF report high levels of stress and depressive symptoms. However, no studies have explored improvement in these symptoms after psychosocial interventions. We have previously shown that a mind-body program tailored to adults with NF2 who are deaf (the Relaxation Response and Resiliency Program for Deaf NF2, d3RP-NF2) improves quality of life and resiliency over and above a Health Enhancement program when both are delivered via live-video and assisted by Communication Access Realtime Translation (CART). Here we tested the effects of the programs on depression and perceived stress.

METHODS

Forty-five patients with NF2 and significant hearing loss were randomized to the d3RP-NF2 or Health-Enhancement program and completed measures of depression (PHQ-9) and perceived stress (PSS-10) at baseline, post-intervention, and six-month follow-up.

RESULTS

Patients randomized to the d3RP-NF2 program, but not to the control condition, experienced significant decreases on both measures from baseline to post-test, which were maintained at follow-up (within group tests). However, improvements following the d3RP-NF2 program was not significantly higher than those observed in the control group (between group tests).

CONCLUSION

Results provide the first evidence of improvement in symptoms of depression and perceived stress among deaf patients living with NF2 who participate in a virtual mind-body program.

Behavioural activation therapy for post-stroke depression: the BEADS feasibility RCT

BACKGROUND

There is currently insufficient evidence for the clinical effectiveness and cost-effectiveness of psychological therapies for post-stroke depression.

OBJECTIVE

To evaluate the feasibility of undertaking a definitive trial to evaluate the clinical effectiveness and cost-effectiveness of behavioural activation (BA) compared with usual stroke care for treating post-stroke depression.

DESIGN

Parallel-group, feasibility, multicentre, randomised controlled trial with nested qualitative research and a health economic evaluation.

SETTING

Acute and community stroke services in three sites in England.

PARTICIPANTS

Community-dwelling adults 3 months to 5 years post stroke who are depressed, as determined by the Patient Health Questionnaire-9 (PHQ-9) or the Visual Analogue Mood Scales 'Sad' item. Exclusions: patients who are blind and/or deaf, have dementia, are unable to communicate in English, do not have mental capacity to consent, are receiving treatment for depression at the time of stroke onset or are currently receiving psychological intervention.

RANDOMISATION AND BLINDING

Participants were randomised (1 : 1 ratio) to BA or usual stroke care. Randomisation was conducted using a computer-generated list with random permuted blocks of varying sizes, stratified by site. Participants and therapists were aware of the allocation, but outcome assessors were blind.

INTERVENTIONS

The intervention arm received up to 15 sessions of BA over 4 months. BA aims to improve mood by increasing people's level of enjoyable or valued activities. The control arm received usual care only.

MAIN OUTCOME MEASURES

Primary feasibility outcomes concerned feasibility of recruitment to the main trial, acceptability of research procedures and measures, appropriateness of baseline and outcome measures, retention of participants and potential value of conducting the definitive trial. Secondary feasibility outcomes concerned the delivery of the intervention. The primary clinical outcome 6 months post randomisation was the PHQ-9. Secondary clinical outcomes were Stroke Aphasic Depression Questionnaire - Hospital version, Nottingham Leisure Questionnaire, Nottingham Extended Activities of Daily Living, Carer Strain Index, EuroQol-5 Dimensions, five-level version and health-care resource use questionnaire.

RESULTS

Forty-eight participants were recruited in 27 centre-months of recruitment, at a recruitment rate of 1.8 participants per centre per month. The 25 participants randomised to receive BA attended a mean of 8.5 therapy sessions [standard deviation (SD) 4.4 therapy sessions]; 23 participants were allocated to usual care. Outcome assessments were completed by 39 (81%) participants (BA, n = 18; usual care, n = 21). Mean PHQ-9 scores at 6-month follow-up were 10.1 points (SD 6.9 points) and 14.4 points (SD 5.1 points) in the BA and control groups, respectively, a difference of -3.8 (95% confidence interval -6.9 to -0.6) after adjusting for baseline PHQ-9 score and centre, representing a reduction in depression in the BA arm. Therapy was delivered as intended. BA was acceptable to participants, carers and therapists. Value-of-information analysis indicates that the benefits of conducting a definitive trial would be likely to outweigh the costs. It is estimated that a sample size of between 580 and 623 participants would be needed for a definitive trial.

LIMITATIONS

Target recruitment was not achieved, although we identified methods to improve recruitment.

CONCLUSIONS

The Behavioural Activation Therapy for Depression after Stroke trial was feasible with regard to the majority of outcomes. The outstanding issue is whether or not a sufficient number of participants could be recruited within a reasonable time frame for a definitive trial. Future work is required to identify whether or not there are sufficient sites that are able to deliver the services required for a definitive trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12715175.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 47. See the NIHR Journals Library website for further project information.

Comparative Effectiveness Between Primary and Revision Foraminotomy for the Treatment of Lumbar Foraminal Stenosis

BACKGROUND

Foraminotomy has demonstrated clinical benefit in patients with lumbar foraminal stenosis (LFS), as evidenced by several small retrospective investigations. However, there is a subset of patients who have recurrent symptoms following the operation and therefore require revision surgery. Yet, despite this phenomenon, the relative efficacy of revision foraminotomy (RF) is not well elucidated due to limited literature on the quality of life (QOL) outcomes and cost associated with primary foraminotomy (PF) and RF.

PURPOSE

To compare the effectiveness of PF and RF in terms of QOL outcomes and relative costs.

STUDY DESIGN/SETTING

This is a retrospective cohort study conducted at a single tertiary-care institution. The patient sample consisted of patients undergoing foraminotomy for the treatment of LFS between 2008 and 2016. The primary outcome measure was improvement in postoperative QOL, as measured by EuroQol 5-Dimensions (EQ-5D), and secondary outcome measures included Pain Disability Questionnaire (PDQ) and Patient Health Questionnaire-9 (PHQ-9) perioperative cost as well as minimum clinically important difference (MCID).

METHODS

A retrospective chart review was conducted to identify individuals who underwent PF or RF for LFS and to collect clinical, operative, and demographic data. QOL scores (EQ-5D, PDQ, and PHQ-9) were collected between 2008 and 2016, and perioperative financial data were extracted via the institution's cost utilization engine. Paired t tests were used to assess changes within treatment groups, and Fisher exact tests were used for intercohort comparisons.

RESULTS

Five hundred seventy-nine procedures were eligible: 476 (82%) PF and 103 (18%) RF. A significantly higher proportion of males underwent RF than PF (71% versus 59%, P = .03), and PF was done on a significantly higher number of vertebral levels (2.2 versus 2.0, P = .04). There were no other significant differences in demographics. Preoperatively, mean PDQ-Functional scores (50 versus 54, P = .04) demonstrated significantly poorer QOL in the RF cohort. Postoperatively, EQ-5D index showed significant improvement in both the PF (0.547→0.648, P < .0001) and the RF (0.507→0.648, P < .0001) cohorts. Similarly, total PHQ-9 improved significantly in the PF cohort (7.84→5.91, P < .001) and in the RF cohort (8.55→5.53, P = .02), as did total PDQ (PF: 77→63, P < .0001; RF: 85→70, P = .04). QOL scores were also compared between groups preoperatively and postoperatively, and the only significant difference between PF and RF was observed in the preoperative PDQ-Functional score (49.7 versus 54.3, P = .04). The proportion of patients achieving MCID was not significantly associated with cohort. Finally, perioperative cost did not differ significantly between cohorts (PF: $13,383 versus RF: $13,595, P = .82).

CONCLUSIONS

Both PF and RF produced significant improvement in nearly all measures in patients with LFS. There was no significant difference in cost between PF and RF, but both PF and RF showed postoperative QOL improvements as compared with preoperative scores, indicating that RF remains a reasonable treatment option for patients with recurrent symptoms of LFS.

Intrapersonal Factors Impact Advance Care Planning Among Cancer Patients

BACKGROUND

Cancer patients infrequently engage in advance care planning processes. Establishing preferences for future medical treatment without advance care planning may not be patient-centered, as it fails to consider important factors that influence these important decisions.

OBJECTIVE

The purpose of this study was to assess the influence of patient intrapersonal factors including race, religion, level of depression, and cancer stage on overall preferences for future medical treatment, including the presence of a (DNR), power of attorney, and advance directive.

DESIGN

A retrospective chart review design was used. Patients were included who were diagnosed with cancer at The Ohio State University James Comprehensive Cancer Center from 01/2015 to 08/2019.

RESULTS

A total of 3,463 patients were included. Median age was 59 years (IQR: 49, 67) and the majority of the patients was female (88.7%). Compared with no religious preference, patients who identified as religious had 61% higher odds (95%CI: 1.08-2.40) of having a DNR and approximately 30% higher odds of having a power of attorney (95%CI: 1.08-1.62) or advance directive (95%CI: 1.02-1.64). Patients with clinically relevant depression had more than twice the odds of having a DNR versus patients with no/lower levels of clinical depression (OR: 2.08; 95%CI: 1.40-3.10). White patients had higher odds of having a power of attorney (OR: 1.57; 95%CI: 1.16-2.13) and an advance directive (OR: 3.10; 95% CI: 1.95-4.93) than African-American/Black patients.

CONCLUSIONS

Understanding the factors that affect preferences for future medical treatment is necessary for medical professionals to provide proper care and support to patients diagnosed with cancer and their families.

Promotion of mental health in young adults via mobile phone app: study protocol of the ECoWeB (emotional competence for well-being in Young adults) cohort multiple randomised trials

BACKGROUND

Promoting well-being and preventing poor mental health in young people is a major global priority. Building emotional competence (EC) skills via a mobile app may be an effective, scalable and acceptable way to do this. However, few large-scale controlled trials have examined the efficacy of mobile apps in promoting mental health in young people; none have tailored the app to individual profiles.

METHOD/DESIGN

The Emotional Competence for Well-Being in Young Adults cohort multiple randomised controlled trial (cmRCT) involves a longitudinal prospective cohort to examine well-being, mental health and EC in 16-22 year olds across 12 months. Within the cohort, eligible participants are entered to either the PREVENT trial (if selected EC scores at baseline within worst-performing quartile) or to the PROMOTE trial (if selected EC scores not within worst-performing quartile). In both trials, participants are randomised (i) to continue with usual practice, repeated assessments and a self-monitoring app; (ii) to additionally receive generic cognitive-behavioural therapy self-help in app; (iii) to additionally receive personalised EC self-help in app. In total, 2142 participants aged 16 to 22 years, with no current or past history of major depression, bipolar disorder or psychosis will be recruited across UK, Germany, Spain, and Belgium. Assessments take place at baseline (pre-randomisation), 1, 3 and 12 months post-randomisation. Primary endpoint and outcome for PREVENT is level of depression symptoms on the Patient Health Questionnaire-9 at 3 months; primary endpoint and outcome for PROMOTE is emotional well-being assessed on the Warwick-Edinburgh Mental Wellbeing Scale at 3 months. Depressive symptoms, anxiety, well-being, health-related quality of life, functioning and cost-effectiveness are secondary outcomes. Compliance, adverse events and potentially mediating variables will be carefully monitored.

CONCLUSIONS

The trial aims to provide a better understanding of the causal role of learning EC skills using interventions delivered via mobile phone apps with respect to promoting well-being and preventing poor mental health in young people. This knowledge will be used to develop and disseminate innovative evidence-based, feasible, and effective Mobile-health public health strategies for preventing poor mental health and promoting well-being.

TRIAL REGISTRATION

ClinicalTrials.gov ( www.clinicaltrials.org ). Number of identification: NCT04148508 November 2019.

Depression screening using patient-targeted feedback in general practices: study protocol of the German multicentre GET.FEEDBACK.GP randomised controlled trial

INTRODUCTION

Approximately one out of six patients in primary care suffers from depression, which often remains undetected. Evidence regarding the efficacy of depression screening in primary care, however, is inconsistent. A previous single-centre randomised controlled trial (RCT) in cardiac patients, the DEPSCREEN-INFO trial, provided the first evidence that written feedback to patients following a positive depression screening reduces depression severity and leads to more comprehensive patient engagement in mental healthcare. To amplify these effects, the feedback should be tailored according to patients' needs and preferences. The GET.FEEDBACK.GP RCT will test the efficacy of this patient-targeted feedback intervention in primary care.

METHODS AND ANALYSIS

The multicentre three-arm GET.FEEDBACK.GP RCT aims to recruit a total of 1074 primary care patients from North, East and South Germany. Patients will be screened for depression using the Patient Health Questionnaire-9 (PHQ-9). In the case of a positive depression screening result (PHQ-9 score ≥10), the participant will be randomised into one of three groups to either receive (a) patient-targeted and general practitioner (GP)-targeted feedback regarding the depression screening results, (b) only GP-targeted feedback or (c) no feedback. Patients will be followed over a period of 12 months. The primary outcome is depression severity (PHQ-9) 6 months after screening. Secondary outcomes include patient engagement in mental healthcare, professional depression care and cost-effectiveness. According to a statistical analysis plan, the primary endpoint of all randomised patients will be analysed regarding the intention-to-treat principle.

ETHICS AND DISSEMINATION

The Ethics Committee of the Hamburg Medical Association approved the study. A clinical trial company will ensure data safety, monitoring and supervision. The multicentre GET.FEEDBACK.GP RCT is the first trial in primary care that tests the efficacy of a patient-targeted feedback intervention as an adjunct to depression screening. Its results have the potential to influence future depression guidelines and will be disseminated in scientific as well as patient-friendly language.

TRIAL REGISTRATION NUMBER

NCT03988985.

The psychological impact of fertility treatment suspensions during the COVID-19 pandemic

Purpose

To examine the psychological impact of fertility treatment suspensions resulting from the COVID-19 pandemic and to clarify psychosocial predictors of better or worse mental health.

Methods

92 women from Canada and the United States (ages 20–45 years) whose fertility treatments had been cancelled were recruited via social media. Participants completed a battery of questionnaires assessing depressive symptoms, perceived mental health impact, and change in quality of life related to treatment suspensions. Potential predictors of psychological outcomes were also examined, including several personality traits, aspects of social support, illness cognitions, and coping strategies.

Results

52% of respondents endorsed clinical levels of depressive symptoms. On a 7-point scale, participants endorsed a significant decline in overall quality of life (M(SD) = -1.3(1.3), p < .0001) as well as a significant decline in mental health related to treatment suspensions on a scale from -5 to +5 (M(SD) = -2.1(2.1), p < .001). Several psychosocial variables were found to positively influence these outcomes: lower levels of defensive pessimism (r = -.25, p < .05), greater infertility acceptance (r = .51, p < .0001), better quality social support (r = .31, p < .01), more social support seeking (r = .35, p < .001) and less avoidance of infertility reminders (r = -.23, p = .029).

Conclusion

Fertility treatment suspensions have had a considerable negative impact on women’s mental health and quality of life. However, these findings point to several protective psychosocial factors that can be fostered in the future to help women cope.

A Pilot Evaluation of a Smartphone Application for Workplace Depression

Interventions delivered via mobile apps show particular promise in tackling the burden of common mental disorders. Appropriately targeting these interventions to at-risk populations is critical to their success. This pilot study aimed to assess the usability, feasibility, acceptability, and preliminary effects of an app-based intervention designed to target depressive symptoms in a stressed working population. Anchored, a smartphone app including a 30-day program of mindfulness and cognitive and behavioural therapeutic components, was tested in a pre-post pilot study with participants recruited via social media advertisements. Eligible participants (N = 81) were Australian adults who were employed and reported elevated stress levels on a single-item screening measure. Follow-up assessment occurred 5 weeks after baseline. The primary outcome measure was change in depressive symptoms, with secondary outcomes measuring change in anxiety, wellbeing, stress, resilience, exercise, alcohol use, absenteeism, and work performance. User feedback and in-app data were analysed to assess engagement and intervention adherence. At follow-up, there were significant reductions in depressive symptoms (t₆₁ = 6.35; p < 0.001) and anxiety symptoms (t₆₀ = 7.35; p < 0.001), along with significantly reduced cases of likely new onset depression compared to baseline (24% vs. 6%, p = 0.012). Significant improvements were also seen in wellbeing (t₆₀ = -5.64; p < 0.001), resilience (t₆₀ = -3.89; p < 0.001), stress (t₆₁ = 11.18; p < 0.001), and alcohol use (t₆₀ = 3.40; p = 0.001). Participants reported no significant changes in work performance, absenteeism or exercise. There were satisfactory levels of app usability, feasibility, and acceptability. Most participants found the app easy to use (93.2%), understood the app content well (83.0%), and rated the app highly or very highly overall (72.9%). User feedback suggestions were predominantly focused on improving app navigation and user interface. This pilot study provides encouraging evidence that Anchored has potentially beneficial effects, and is usable, feasible, and acceptable as an app-based intervention for the working population experiencing elevated stress. Further testing of Anchored in a randomised controlled trial is required to investigate its efficacy as an intervention for workplace mental ill-health.

Postpartum depression and associated factors among postpartum women in Ethiopia: a systematic review and meta-analysis, 2020

Introduction

The postpartum period is recognized as a high-risk period for the development of various mood disorders like postpartum depression. Globally, postnatal depression is a serious public health problem that has a negative impact on the mother’s health and child development, especially in developing countries. In Ethiopia, even though there are different primary studies conducted on postpartum depression, there is no nationally representative evidence. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence and associated factors of postpartum depression in Ethiopia.

Methods

Published and unpublished articles from various electronic databases and digital libraries were accessed. This systematic review included studies that were conducted on the magnitude and factors associated with postpartum depression among postnatal women in Ethiopia. A random-effect model was used to estimate the pooled magnitude of postpartum depression with a 95% confidence interval (CI). Inverse variance (I²) was used to visualize the presence of heterogeneity, and forest plot was used to estimate the pooled magnitude of postpartum depression. Publication bias was assessed by funnel plots and Egger’s statistical tests. A meta-regression and subgroup analysis were computed to minimize underlying heterogeneity.

Result

Initially, a total of 764 studies were accessed. Twenty-eight full articles were assessed for eligibility criteria, of which twelve studies fulfilled inclusion criteria were included in the final meta-analysis. The overall pooled magnitude of postpartum depression was 22.89% (95% CI 17.75%, 28.03%) with the lowest (12.20%) and highest (33.82%) in the Southern nations region. Unplanned pregnancy, domestic violence, lack of social support, previous history of depression, infant loss, and dissatisfaction in marriage showed a statistically significant association with postpartum depression.

Conclusions

In the current analysis, the prevalence of postpartum depression was high as compared with other developing countries. Routine screening of mothers in the postpartum period and integrating mental health with maternal health care is highly recommended.

[Validation of the Short-Form-Health-Survey-12 (SF-12 Version 2.0) assessing health-related quality of life in a normative German sample]

Validation of the Short-Form-Health-Survey-12 (SF-12 Version 2.0) assessing health-related quality of life in a normative German sample Objectives: Convergent and divergent validation of the Short-Form-Health-Survey-12 assessing HRQoL by analyzing its associations with depressiveness (PHQ-9), social support (OSS-3) and satisfaction with life (SWLS). Methods: A normative German sample (N = 2.524) was analyzed using correlation, regression as well as confirmatory factor analysis and structural equation modelling for ordinal data. Results: The SF-12-scale Mental Health is associated most strongly with the validation criteria (PHQ: r[scales/constructs] = -.73/-.88, OSS-3: r = .35/.55, SWLS: r = .47/.62). Mental Health (β = .36) and Social Support (OSS-3; β = .25) allow to explain a significant amount of variance of the SWLS (R2 = .28). On construct level Emotional Role Functioning (β = .28) proved to be significant additionally. Conclusions: The SF-12 scales are associated with the validation criteria as expected. The SF- 12 proved to be suitable for modelling core components of HRQoL within a biopsychosocial framework aiming at predicting satisfaction with life.

Evaluation of Mental Health Factors among People with Systemic Lupus Erythematosus during the SARS-CoV-2 Pandemic

There are considerable psychological and psychiatric consequences of the pandemic. Researchers have started to take into account the real or perceived sense of social threats that may be expressed, such as anxiety, depression, and sleep disorders. However, analyses on pandemic-related anxiety, depression, and sleep disorders mostly rarely addresses the situation of people with autoimmune diseases. Therefore, the aim of this study was to assess the mental health factors among people with systemic lupus erythematosus by quantifying the severity of anxiety, depression, and sleep disorders during the SARS-CoV-2 pandemic. In total, 723 people took part in the study. The study group consisted of 134 individuals with a systemic lupus erythematosus. The control group consisted of 589 people without systemic lupus erythematosus. The regression adjusted by age, gender, and diagnosis of other chronic diseases showed individuals with systemic lupus erythematosus were at a much higher risk of elevated symptoms of anxiety on the GAD-7 scale (OR = 3.683; p < 0.001), depression on the PHQ-9 scale (OR = 4.183; p < 0.001), and sleep disorders on the Insomnia Severity Index (ISI) scale (OR = 6.781; p < 0.001). Therefore, the mental health of patients with systemic lupus erythematosus in the times of the SARS-CoV-2 pandemic is not only an extremely important medical problem but also a social one and must require special attention.

Evaluation of an Adapted Collaborative Care Model for Older Adult Depression Severity Reduction and Quality of Life Improvement

PURPOSE

The purpose of this clinical study was to evaluate the efficacy of a collaborative care model in the reduction of depression severity and the improvement of quality of life (QOL) of older adults.

METHODS

Individual participant encounters were conducted approximately every 2 weeks over 4 months with nineteen participants. Average participant age was 73 years. A pre-experimental single pretest-posttest group was conducted in which the Patient Health Questionnaire 9 (PHQ-9) and Quality of Life Assessment (QOLA) scores respectively measured depression severity and QOL of participants.

RESULTS

The average PHQ-9 score (0-27; higher indicates worse depression) decreased from 14 pre-intervention to 8.3 post-intervention (p < .001), while the average QOLA score (0-10; higher indicates better QOL) increased from 5.7 pre-intervention to 6.5 post-intervention (p = .342).

CONCLUSION

The adapted collaborative care model provided an affordable, effective method of older adult depression management within the contexts of this clinical study.

Optimizing a self-directed mobile mindfulness intervention for improving cardiorespiratory failure survivors' psychological distress (LIFT2): Design and rationale of a randomized factorial experimental clinical trial

INTRODUCTION

Although as many as 75% of the >2 million annual intensive care unit (ICU) survivors experience symptoms of psychological distress that persist for months to years, few therapies exist that target their symptoms and accommodate their unique needs. In response, we developed LIFT, a mobile app-based mindfulness intervention. LIFT reduced distress symptoms more than either a telephone-based mindfulness program or education control in a pilot randomized clinical trial (LIFT1).

OBJECTIVE

To describe the methods of a factorial experimental clinical trial (LIFT2) being conducted to aid in the development and implementation of the version of the LIFT intervention that is optimized across domains of effect, feasibility, scalability, and costs.

METHODS AND ANALYSIS

The LIFT2 study is an optimization trial conceptualized as a component of a larger multiphase optimization strategy (MOST) project. The goal of LIFT2 is to use a 2 × 2 × 2 factorial experimental trial involving 152 patients to determine the ideal components of the LIFT mobile mindfulness program for ICU survivors across factors including (1) study introduction by call from a therapist vs. app only, (2) response to persistent or worsening symptoms over time by therapist vs. app only, and (3) high dose vs. low dose. The primary trial outcome is change in depression symptoms 1 month from randomization measured by the PHQ-9 instrument. Secondary outcomes include anxiety, post-traumatic stress disorder, and physical symptoms; measures of feasibility, acceptability, and usability; as well as themes assessed through qualitative analysis of semi-structured interviews with study participants conducted after follow up completion. We will use general linear models to compare outcomes across the main effects and interactions of the factors.

Trauma, posttraumatic stress disorder severity, and positive memories

Positive memories play an important role in the aetiology and maintenance of posttraumatic stress disorder (PTSD). However, most trauma research/clinical work has focused solely on the role of traumatic memories. Thus, we examined the relationship between count of retrieved positive memories and PTSD severity, factors associated with count of retrieved positive memories (i.e., rumination, negative/positive emotion dysregulation, fear of positive emotions), and the relationship between positive memory phenomenological domains and PTSD severity. The sample included 185 trauma-exposed participants recruited through Amazon's Mechanical Turk (Mage = 35.69 years; 63.80% female). Results of linear/hierarchical regressions showed that (1) PTSD severity did not predict count of (specific) positive memories; (2) greater positive emotion dysregulation predicted fewer retrieved positive memories controlling for PTSD severity; and (3) greater PTSD severity predicted more negative valence, less vividness, less coherence, less accessibility, less clear time perspective, fewer sensory details, and greater distancing ratings of the retrieved positive memory, controlling for sleep quantity/quality. Findings add to the literature by informing PTSD theoretical perspectives; enhancing an understanding of positive memories in PTSD/trauma treatments; and highlighting potential clinical targets (e.g., positive emotion regulation), when integrating a focus on positive memories into PTSD intervention.

Selecting Patient-Reported Outcome Measures to Contribute to Primary Care Performance Measurement: a Mixed Methods Approach

New models of primary care include patient-reported outcome measures (PROMs) to promote patient-centered care. PROMs provide information on patient functional status and well-being, can be used to enhance care quality, and are proposed for use in assessing performance. Our objective was to identify a short list of candidate PROMs for use in primary care practice and to serve as a basis for performance measures (PMs). We used qualitative and quantitative methods to identify relevant patient-reported outcome (PRO) domains for use in performance measurement (PRO-PM) and their associated PROMs. We collected data from key informant groups: patients (n = 13; one-on-one and group interviews; concept saturation analysis), clinical thought leaders (n = 9; group discussions; thematic analysis), primary care practices representatives (n = 37; six focus groups; thematic analysis), and primary care payer representatives (n = 10; 12-question survey; frequencies of responses). We merged the key informant group information with findings from environmental literature scans. We conducted a targeted evidence review of measurement properties for candidate PROMs. We used a scoping review and key informant groups to identify PROM evaluation criteria, which were linked to the National Quality Forum measure evaluation criteria. We developed a de novo schema to score candidate PROMs against our criteria. We identified four PRO domains and 10 candidate PROMs: 3 for depressive symptoms, 2 for physical function, 3 for self-efficacy, 2 for ability to participate. Five PROMs met ≥ 70% of the evidence criteria for three PRO domains: PHQ-9 or PROMIS Depression (depression), PF-10 or PROMIS-PF (physical functioning), and PROMIS Self-Efficacy for Managing Treatments and Medications (self-efficacy). The PROMIS Ability to Participate in Social Roles and Activities met 68% of our criteria and might be considered for inclusion. Existing evidence and key informant data identified 5 candidate PROMs to use in primary care. These instruments can be used to develop PRO-PMs.

Longitudinal Assessment of Depressive Symptoms After Sport-Related Concussion in a Cohort of High School Athletes

BACKGROUND

The long-term effect of sport-related concussion on mood in adolescent athletes is largely unknown.

HYPOTHESIS

Longitudinal measures of depression will worsen acutely after sport-related concussion and improve with concussion symptom resolution.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A population-based sample of 2160 high school athletes from 31 urban, suburban, and rural high schools completed preseason baseline concussion symptom evaluation and Patient Health Questionnaire-9 (PHQ-9) assessments over 2 years. Athletic trainers recorded onset of sport-related concussion, and concussed athletes completed the PHQ-9 assessment within 24 to 72 hours, 7 days, date of return to sport, 3 months, 6 months, and 12 months after sport-related concussion. Scores at each time point were compared to baseline with mixed-effects models and repeated-measures analysis of variance. Sex-based differences were assessed using mixed-effect models.

RESULTS

Of the 2160 athletes enrolled in the study, 125 (5.8%; 80 males, 45 females) sustained a sport-related concussion. PHQ-9 scores worsened from baseline at 24 to 72 hours (+1.05; 95% CI, 0.26-1.84; P = 0.003) and 7 days (+0.91; 95% CI, 0.23-1.60; P = 0.006). However, PHQ-9 scores improved from baseline to date of return to sport (-1.38; 95% CI, -2.20 to -0.55; P < 0.001), 3 months (-1.08; 95% CI, -1.88 to -0.28; P = 0.003), 6 months (-1.19; 95% CI, -2.04 to -0.34; P = 0.001), and 12 months after sport-related concussion (-0.76; 95% CI, -1.43 to -0.08; P = 0.028). Female athletes reported more severe concussion symptoms 24 to 72 hours after sport-related concussion compared with male athletes (female, 20.5 [interquartile range (IQR), 10.0-36.2]; male, 9.0 [IQR, 4.0-19.5]; P = 0.003). Neither PHQ-9 scores nor change in PHQ-9 scores differed between male and female athletes at any time point.

CONCLUSION

Sport-related concussion did not worsen longitudinal measures of depressed mood in this cohort of high school athletes.

CLINICAL RELEVANCE

Emotional symptoms are common after sport-related concussion, but typically resolve by return to sport.

Assessment of Mental Health Factors among Health Professionals Depending on Their Contact with COVID-19 Patients

It seems that the medical personnel in contact with patients infected with SARS-CoV-2 are at an especially high risk of adverse psychological effects. Therefore, the aim of this study was to assess the mental health factors among healthcare workers by quantifying the severity of anxiety, depression, and sleep disorders during the current SARS-CoV-2 pandemic, while taking into account coexisting diseases. The study involved 441 healthcare professionals including 206 healthcare workers at emergency wards, infectious wards, and intensive care units. The control group consisted of 235 healthcare workers working in wards other than those where individuals from the study group worked. Regression adjusted by age, gender, the occurrence of hypertension, diabetes mellitus, dyslipidemia, asthma, autoimmune diseases, and cigarette smoking showed the elevated risk of anxiety on the Generalized Anxiety Disorder (GAD-7) scale (OR = 1.934; p < 0.001), depression on the Patient Health Questionnaire (PHQ-9) scale (OR = 2.623; p < 0.001), and sleep disorders on the Insomnia Severity Index (ISI) scale (OR = 3.078; p < 0.001). Our study showed that healthcare workers who are exposed to SARS-CoV-2-infected patients at emergency wards, infectious wards, and intensive care units are at a much higher risk of showing symptoms of anxiety, depression, and sleep disorders than healthcare workers working in other wards.

Application of High-Intensity Functional Resistance Training in a Skilled Nursing Facility: An Implementation Study

OBJECTIVE

Rehabilitation in skilled nursing facilities (SNFs) is under scrutiny to deliver high-quality care and superior outcomes in less time. High-intensity resistance training demonstrates functional improvements in community-dwelling and long-term care populations but has not been generalized to the SNF population. The purpose of this study was to evaluate implementation issues including safety and feasibility and to provide preliminary information on effectiveness of rehabilitation focused on high-intensity functional resistance training in an SNF.

METHODS

The implementation study design consisted of 2 nonrandomized independent groups (usual care and high intensity) that were staged within a single SNF. The i-STRONGER program (IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE Residents) integrates principles of physiologic tissue overload into rehabilitation. Physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate the implementation process. An observational checklist and documentation audits were used to assess treatment fidelity. Regression analyses evaluated the response of functional change by group.

RESULTS

No treatment-specific adverse events were reported. Treatment fidelity was high at >99%, whereas documentation varied from 21% to 50%. Patient satisfaction was greater in i-STRONGER, and patient refusals to participate in therapy sessions trended downward in i-STRONGER. Patients in i-STRONGER exhibited a 0.13 m/s greater change in gait speed than in the usual care group. Although not significant, i-STRONGER resulted in a 0.64-point greater change in the Short Physical Performance Battery than usual care, and average SNF length of stay was 3.5 days shorter for i-STRONGER patients.

CONCLUSION

The findings from this study indicate that implementation of a high-intensity resistance training framework in SNFs is safe and feasible. Furthermore, results support a signal effectiveness of improving function and satisfaction, although the heterogeneity of the population necessitates a larger implementation study to confirm.

IMPACT STATEMENT

This pragmatic study demonstrates that high-intensity resistance training in medically complex older adults is safe and favorable in SNFs. This work supports the need to fundamentally change the intensity of rehabilitation provided to this population to promote greater value within post-acute care. Furthermore, this study supports the application of implementation science to rehabilitation for rapid and effective translation of evidence into practice.

Evaluation of the teaching recovery techniques community-based intervention for accompanied refugee children experiencing post-traumatic stress symptoms (Accompanied refugeeS In Sweden Trial; ASsIST): study protocol for a cluster randomised controlled trial

BACKGROUND

Refugee children have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue for years after resettlement. The Accompanied refugeeS In Sweden Trial (ASsIST) aims to evaluate a community-based intervention, called 'Teaching Recovery Techniques' (TRT), for accompanied refugee minors experiencing PTSD symptoms.

METHODS/DESIGN

A cluster randomised controlled trial will be conducted in which participants will be randomly allocated to one of the two possible arms: the intervention arm (n=113) will be offered the TRT programme and the waitlist-control arm (n=113) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; c.8 weeks after randomisation) and follow-up (T3; c.20 weeks after randomisation).

ETHICS AND DISSEMINATION

Ethical approval was granted by the Regional Ethical Review Board in Uppsala (Ref. 2018/382) (24^th February 2019). Results will be published in scientific journals.

TRIAL REGISTRATION DETAILS

ISRCTN17754931. Prospectively registered on 4^th June 2019.

A trauma medical home, evaluating collaborative care for the older injured patient: study protocol for a randomized controlled trial

Background

It is estimated that 55 million adults will be 65 years and older in the USA by 2020. These older adults are at increased risk for injury and their recovery is multi-faceted. A collaborative care model may improve psychological and functional outcomes of the non-neurologically impaired older trauma patient and reduce health care costs.

Methods

This is a randomized controlled trial of 430 patients aged 50 and older who have suffered a non-neurologic injury and are admitted to a level one trauma center in Indianapolis, IN, or Madison, WI. Participants will be assigned to either the Trauma Medical Home (TMH) intervention or usual care. The TMH intervention is a collaborative care model that includes validated protocols addressing the multi-faceted needs of this population, with the help of care coordination software and a mobile office concept. The primary outcome is self-reported physical recovery at 6- and 12-month follow-up. Secondary outcomes include self-reported psychological recovery, acute health care utilization, and cost-effectiveness of the intervention at 6 and 12 months. The TMH collaborative care model will be delivered by a registered nurse care coordinator. The assessments will be completed by trained blinded research assistants.

Discussion

The proposed study will evaluate a collaborative care model to help maximize psychological and functional recovery for non-neurologically injured older patients at four level one trauma centers in the Midwest.

Trial registration

Clinical Trials. NCT03108820. Registered on 11 April 2017.

Protocol Version 6: Study # 1612690852. April 12, 2019.

Sponsor: Indiana University. Human subjects and IRB contact information: irb@iu.edu

Prospectively registered in the WHO ICTRP on 4 June 2017.

Changes in patient health questionnaire (PHQ-9) scores in adults with medical authorization for cannabis

Background

Legal access to medical cannabis is increasing world-wide. Despite this, there is a lack of evidence surrounding its efficacy on mental health outcomes, particularly, on depression. This study assesses the effect of medical cannabis on Patient Health Questionnaire (PHQ-9) scores in adult patients between 2014 and 2019 in Ontario and Alberta, Canada.

Methods

An observational cohort study of medically authorized cannabis patients in Ontario and Alberta. Overall change in PHQ-9 scores from baseline to follow-up were evaluated (mean change) over a time period of up to 3.2 years.

Results

37,338 patients from the cohort had an initial PHQ-9 score recorded with 5103 (13.7%) patients having follow-up PHQ-9 scores. The average age was 54 yrs. (SD 15.7), 46% male, 50% noted depression at baseline. The average PHQ-9 score at baseline was 10.5 (SD 6.9), following a median follow-up time of 196 days (IQR: 77–451) the average final PHQ-9 score was 10.3 (SD 6.8) with a mean change of − 0.20 (95% CI: − 0.26, − 0.14, p-value < 0.0001). Overall, 4855 (95.1%) had no clinically significant change in their PHQ-9 score following medical cannabis use while 172 (3.4%) reported improvement and 76 (1.5%) reported worsening of their depression symptoms.

Conclusions

Although the majority showed no clinically important changes in PHQ-9 scores, a number of patients showed improvement or deteriorations in PHQ-9 scores. Future studies should focus on the parallel use of screening questionnaires to control for PHQ-9 sensitivity and to explore potential factors that may have attributed to the improvement in scores pre- and post- 3-6 month time period.

Health economic evaluation of an internet intervention for depression (deprexis), a randomized controlled trial

BACKGROUND

Depressive disorders often remain undiagnosed or are treated inadequately. Online-based programs may reduce the present treatment gap for depressive disorders and reduce disease-related costs. This study aimed to examine the potential of the internet intervention "deprexis" to reduce the total costs of statutory health insurance. Changes in depression severity, health-related quality of life and impairment in functioning were also examined.

METHOD

A total of 3805 participants with, at minimum, mild depressive symptoms were randomized to either a 12-week online intervention (deprexis) or a control condition. The primary outcome measure was statutory health insurance costs, estimated using health insurers' administrative data. Secondary outcomes were: depression severity, health-related quality of life, and impairment in functioning; assessed on patient's self-report at baseline, post-treatment, and three-months' and nine-months' follow-up.

RESULTS

In both groups, total costs of statutory health insurance decreased during the study period, but changes from baseline differed significantly. In the intervention group total costs decreased by 32% from 3139€ per year at baseline to 2119€ in the study year (vs. a mean reduction in total costs of 13% in the control group). In comparison to the control group, the intervention group also showed a significantly greater reduction in depression severity, and impairment in functioning and a significantly greater increase in health-related quality of life.

CONCLUSION

The study underlines the potential of innovative internet intervention programs in treating depressive disorders. The results suggest that the use of deprexis over a period of 12 weeks leads to a significant improvement in symptoms with a simultaneous reduction in the costs of statutory health insurance.

Depression in Rural Communities and Primary Care Clinics in Chiapas, Mexico

Depression is a leading cause of disability worldwide and can be diagnosed and treated in primary care clinics. No studies to date have demonstrated the prevalence of depression in rural, primary care settings in Mexico. The objective of this study is to describe the prevalence of visits for depression in primary care settings in one group of rural communities within Chiapas, Mexico. We performed a cross-sectional, retrospective study of depression prevalence in primary care clinics in the Sierra region of Chiapas, Mexico during the calendar year of 2014. We determined the average depression prevalence is 7.9% (6 community clinics, n = 4555). The prevalence of depression in rural Chiapas, Mexico is much higher than the Mexican national average of 4.0–4.5% found in a home-based survey. Further efforts to understand the causes, develop improved mental health services in primary care, and reduce the higher burden of depression in rural communities in Mexico are urgently needed.

Patient-reported outcomes predict return to work and health-related quality of life six months after cardiac rehabilitation: Results from a German multi-centre registry (OutCaRe)

BACKGROUND

Multi-component cardiac rehabilitation (CR) is performed to achieve an improved prognosis, superior health-related quality of life (HRQL) and occupational resumption through the management of cardiovascular risk factors, as well as improvement of physical performance and patients' subjective health. Out of a multitude of variables gathered at CR admission and discharge, we aimed to identify predictors of returning to work (RTW) and HRQL 6 months after CR.

DESIGN

Prospective observational multi-centre study, enrolment in CR between 05/2017 and 05/2018.

METHOD

Besides general data (e.g. age, sex, diagnoses), parameters of risk factor management (e.g. smoking, hypertension), physical performance (e.g. maximum exercise capacity, endurance training load, 6-min walking distance) and patient-reported outcome measures (e.g. depression, anxiety, HRQL, subjective well-being, somatic and mental health, pain, lifestyle change motivation, general self-efficacy, pension desire and self-assessment of the occupational prognosis using several questionnaires) were documented at CR admission and discharge. These variables (at both measurement times and as changes during CR) were analysed using multiple linear regression models regarding their predictive value for RTW status and HRQL (SF-12) six months after CR.

RESULTS

Out of 1262 patients (54±7 years, 77% men), 864 patients (69%) returned to work. Predictors of failed RTW were primarily the desire to receive pension (OR = 0.33, 95% CI: 0.22-0.50) and negative self-assessed occupational prognosis (OR = 0.34, 95% CI: 0.24-0.48) at CR discharge, acute coronary syndrome (OR = 0.64, 95% CI: 0.47-0.88) and comorbid heart failure (OR = 0.51, 95% CI: 0.30-0.87). High educational level, stress at work and physical and mental HRQL were associated with successful RTW. HRQL was determined predominantly by patient-reported outcome measures (e.g. pension desire, self-assessed health prognosis, anxiety, physical/mental HRQL/health, stress, well-being and self-efficacy) rather than by clinical parameters or physical performance.

CONCLUSION

Patient-reported outcome measures predominantly influenced return to work and HRQL in patients with heart disease. Therefore, the multi-component CR approach focussing on psychosocial support is crucial for subjective health prognosis and occupational resumption.

TRIAL REGISTRATION

The study was registered at the German Clinical Trial Registry and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (DRKS00011418; http://www.drks.de/DRKS00011418, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00011418).

Clinical trial testing in-home multidisciplinary care management for older adults with cognitive vulnerability: Rationale and study design

Care management approaches are being widely tested in the Medicare-eligible population to manage chronic conditions, but few have focused on cognitive vulnerability as the pathway to optimizing independence in the community-dwelling older population. Cognitive vulnerability refers to living with dementia, depression, and/or a history of delirium. Many studies have shown that cognitive vulnerability is associated with poor health-related outcomes in community-dwelling older adults, raising the health policy importance of finding evidence-based approaches to improve outcomes for this target population. Moreover, very little is known about effects of care management approaches in the rapidly growing Medicare Advantage population. In response to these knowledge gaps, we are testing the efficacy of an in-home, nurse practitioner-led care management team for adults age ≥ 65 with cognitive vulnerability in a Medicare Advantage population. Older adults and family caregivers randomized either to this multidisciplinary care management team, or to a telephonic care management program routinely offered by our Medicare Advantage partner. The intervention period is 12 months and the primary outcome is any emergency department visit or hospitalization over the 12-month period. In this paper, we report on the rationale for testing a multidisciplinary care management intervention for this target population, and explain how a university-based research team collaborated with a Medicare Advantage insurer to conceptualize and implement the clinical trial. We also provide details on study design, and on components of the in-home and telephonic care management interventions. We conclude with a synopsis of recruitment progress along with selected baseline characteristics of the study cohort.

Improving Diagnosis of Depression With XGBOOST Machine Learning Model and a Large Biomarkers Dutch Dataset (n = 11,081)

Machine Learning has been on the rise and healthcare is no exception to that. In healthcare, mental health is gaining more and more space. The diagnosis of mental disorders is based upon standardized patient interviews with defined set of questions and scales which is a time consuming and costly process. Our objective was to apply the machine learning model and to evaluate to see if there is predictive power of biomarkers data to enhance the diagnosis of depression cases. In this research paper, we aimed to explore the detection of depression cases among the sample of 11,081 Dutch citizen dataset. Most of the earlier studies have balanced datasets wherein the proportion of healthy cases and unhealthy cases are equal but in our study, the dataset contains only 570 cases of self-reported depression out of 11,081 cases hence it is a class imbalance classification problem. The machine learning model built on imbalance dataset gives predictions biased toward majority class hence the model will always predict the case as no depression case even if it is a case of depression. We used different resampling strategies to address the class imbalance problem. We created multiple samples by under sampling, over sampling, over-under sampling and ROSE sampling techniques to balance the dataset and then, we applied machine learning algorithm “Extreme Gradient Boosting” (XGBoost) on each sample to classify the mental illness cases from healthy cases. The balanced accuracy, precision, recall and F1 score obtained from over-sampling and over-under sampling were more than 0.90.

Predictors of Functional Change in a Skilled Nursing Facility Population

BACKGROUND AND PURPOSE

Inability to obtain sufficient gains in function during a skilled nursing facility (SNF) stay impacts patients' functional trajectories and susceptibility to adverse events. The purpose of this study was to identify predictors of functional change in patients temporarily residing in an SNF following hospitalization.

METHODS

One hundred forty patients admitted to a single SNF from the hospital who had both evaluation and discharge measures of physical function documented were included. Data from the Minimum Data Set 3.0 and electronic medical record were extracted to record clinical and demographic characteristics. The Short Physical Performance Battery (SPPB) was administered by rehabilitation therapists at evaluation and discharge. The SPPB consists of balance tests, gait speed, and a timed 5-time sit-to-stand test.

RESULTS AND DISCUSSION

The Patient Health Questionnaire (PHQ-9) Screening Tool for Depression was the only significant predictor of change in gait speed over an SNF stay. Eighty-seven percent of patients achieved a clinically meaningful change in the SPPB of 1 point or greater from evaluation to discharge, with 78% demonstrating a clinically meaningful change of 0.1 m/s or greater on gait speed. However, 69% of patients demonstrated SPPB scores of 6 points or less and 57% ambulated less than 0.65 m/s at the time of discharge from the SNF, which indicates severe disability.

CONCLUSIONS

Poor physical function following an SNF stay places older adult at significant risk for adverse events including rehospitalization, future disability, and institutionalization. Understanding the predictors of functional change from evaluation to discharge may direct efforts toward developing innovative and effective interventions to improve function trajectories for older adults following an acute hospitalization.

Minimally important differences and severity thresholds are estimated for the PROMIS depression scales from three randomized clinical trials

BACKGROUND

Patient Reported Outcomes Measurement Information Systems (PROMIS) scales are increasingly being used to measure symptoms in research and practice. The purpose of this study was to determine the minimally important difference (MID) and severity thresholds (cut-points) for the four fixed-length PROMIS depression scales.

METHODS

The study sample was adult participants in three randomized clinical trials (N=651). MID was estimated using multiple distribution- and anchor-based approaches including assessing correspondence between Patient Health Questionnaire (PHQ-9) and PROMIS depression scores.

RESULTS

The best MID estimate was a PROMIS depression T-score of 3.5 points with most methods producing an MID in the 3 to 4 point range across all three samples. MID estimates were similar for all four PROMIS scales. A PHQ-9 1-point change equated to a PROMIS 1.25-point T-score change. PROMIS T-scores of 55, 60, 65, and 70 appeared to be reasonable thresholds for mild, moderate, moderately severe, and severe depression, respectively.

LIMITATIONS

The study sample was predominantly male veterans with either chronic pain (2 trials) or previous stroke (1 trial). The severity of depression was mild to moderate.

CONCLUSION

A T-score of 3 to 4 points is a reasonable MID for PROMIS depression scales and can be used to assess treatment effects in both practice and research as well to calculate sample sizes for clinical trials. Severity cut-points can help interpret the meaning of scores and action thresholds for treatment decisions.

Effects of intense assessment on statistical power in randomized controlled trials: Simulation study on depression

Smartphone-based devices are increasingly recognized to assess disease symptoms in daily life (e.g. ecological momentary assessment, EMA). Despite this development in digital psychiatry, clinical trials are mainly based on point assessments of psychopathology. This study investigated expectable increases in statistical power by intense assessment in randomized controlled trials (RCTs). A simulation study, based on three scenarios and several empirical data sets, estimated power gains of two- or fivefold pre-post-assessment. For each condition, data sets of various effect sizes were generated, and AN(C)OVAs were applied to the sample of interest (N = 50-N = 200). Power increases ranged from 6% to 92%, with higher gains in more underpowered scenarios and with higher number of repeated assessments. ANCOVA profited from a more precise estimation of the baseline covariate, resulting in additional gains in statistical power. Fivefold pre-post EMA resulted in highest absolute statistical power and clearly outperformed traditional questionnaire assessments. For example, ANCOVA of automatized PHQ-9 questionnaire data resulted in absolute power of 55 (for N = 200 and d = 0.3). Fivefold EMA, however, resulted in power of 88.9. Non-parametric and multi-level analyses resulted in comparable outcomes. Besides providing psychological treatment, digital mental health can help optimizing sensitivity in RCT-based research. Intense assessment appears advisable whenever psychopathology needs to be assessed with high precision at pre- and post-assessment (e.g. small sample sizes, small treatment effects, or when applying optimization problems like machine learning). First empiric studies are promising, but more evidence is needed. Simulations for various effects and a short guide for popular power software are provided for study planning.

Evaluating a group-based Yoga of Stress Resilience programme: a pragmatic before-after interventional study protocol

INTRODUCTION

Rates of mental health illnesses and burnout are increasing internationally. Therapeutic yoga is increasingly used to improve and maintain physical, mental and emotional well-being and general health. This protocol describes a study to evaluate the effectiveness of an existing primary care group-based therapeutic yoga programme, the Yoga of Stress Resilience programme, which combines yoga and psychotherapeutic techniques, in improving mental health and decreasing burnout. Implementation factors will also be evaluated for potential scale-up.

METHODS AND ANALYSIS

A pragmatic before-after interventional trial design will be used to study changes in occupational participation and mental health outcomes, including anxiety, depression, burnout, functional impairment, insomnia, perceived stress, loneliness, self-compassion and readiness for change in adults experiencing anxiety and burnout. Repeated measures analysis of variance will be used to determine changes in outcome measures over time. Regression and multivariate analyses will be conducted to examine relationships between participant characteristics and outcomes and among various outcomes. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework will be used to guide the analyses.

ETHICS AND DISSEMINATION

Approval from the Hamilton Integrated Research Ethics Board has been waived: project number 7082 (full review waived). Informed consent will be obtained prior to enrolling any participant into the study. All data will be kept confidential. Peer-reviewed publications and presentations will target researchers and health professionals.

TRIAL REGISTRATION NUMBER

The ClinicalTrials.gov registry (NCT03973216).

Novel Risk Factors for Posttraumatic Stress Disorder Symptoms in Family Members of Acute Respiratory Distress Syndrome Survivors

OBJECTIVES

Family members of ICU survivors report long-term psychologic symptoms of posttraumatic stress disorder. We describe patient- and family-member risk factors for posttraumatic stress disorder symptoms among family members of survivors of acute respiratory distress syndrome.

DESIGN

Prospective cohort study of family members of acute respiratory distress syndrome survivors.

SETTING

Single tertiary care center in Seattle, Washington.

SUBJECTS

From 2010 to 2015, we assembled an inception cohort of adult acute respiratory distress syndrome survivors who identified family members involved in ICU and post-ICU care. One-hundred sixty-two family members enrolled in the study, corresponding to 120 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Family members were assessed for self-reported psychologic symptoms 6 months after patient discharge using the Posttraumatic Stress Disorder Checklist-Civilian Version, the Patient Health Questionnaire 9-item depression scale, and the Generalized Anxiety Disorder 7-item scale. The primary outcome was posttraumatic stress disorder symptoms, and secondary outcomes were symptoms of depression and anxiety. We used clustered multivariable logistic regression to identify patient- and family-member risk factors for psychologic symptoms. Posttraumatic stress disorder symptoms were present in 31% (95% CI, 24-39%) of family participants. Family member risk factors for posttraumatic stress disorder symptoms included preexisting mental health disorders (adjusted odds ratio, 3.22; 95% CI, 1.42-7.31), recent personal experience of serious physical illness (adjusted odds ratio, 3.07; 95% CI, 1.40-6.75), and female gender (adjusted odds ratio, 5.18; 95% CI, 1.74-15.4). Family members of previously healthy patients (Charlson index of zero) had higher frequency of posttraumatic stress disorder symptoms (adjusted odds ratio, 2.25; 95% CI, 1.06-4.77). Markers of patient illness severity were not associated with family posttraumatic stress disorder symptoms.

CONCLUSIONS

The prevalence of long-term posttraumatic stress disorder symptoms among family members of acute respiratory distress syndrome survivors is high. Family members with preexisting mental health disorders, recent experiences of serious physical illness, and family members of previously healthy patients are at increased risk for posttraumatic stress disorder symptoms.

Pain inhibition is not affected by exercise-induced pain

Introduction:

Offset analgesia (OA) and conditioned pain modulation (CPM) are frequently used paradigms to assess the descending pain modulation system. Recently, it was shown that both paradigms are reduced in chronic pain, but the influence of acute pain has not yet been adequately examined.

Objectives:

The aim of this study is to investigate OA and CPM after exercise-induced pain to evaluate whether these tests can be influenced by delayed-onset muscle soreness (DOMS) at a local or remote body site.

Methods:

Forty-two healthy adults were invited to 3 separate examination days: a baseline appointment, the consecutive day, and 7 days later. Participants were randomly divided into a rest (n = 21) and an exercise group (n = 21). The latter performed a single intensive exercise for the lower back. Before, immediately after, and on the following examination days, OA and CPM were measured at the forearm and the lower back by blinded assessor.

Results:

The exercise provoked a moderate pain perception and a mild delayed-onset muscle soreness on the following day. Repeated-measurements analysis of variance showed no statistically significant main effect for either OA or CPM at the forearm or lower back (P > 0.05).

Conclusion:

Delayed-onset muscle soreness was shown to have no effect on the inhibitory pain modulation system neither locally (at the painful body part), nor remotely. Thus, OA and CPM are robust test paradigms that probably require more intense, different, or prolonged pain to be modulated.

Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7)

BACKGROUND

Effective treatment requires regular follow-up and monitoring of symptoms. We investigated sensitivity to change and minimal clinically important difference of the Generalized Anxiety Disorder Scale (GAD-7).

METHODS

This study included all participants from a multisite trial of chronic depression. Baseline and follow-up (12 and 48 weeks) data were used to assess treatment response. Effect sizes (ES) and standardized response means (SRM) of pre- and post-GAD-7 mean changes were calculated for subgroups of patients, who did or did not improve according to ratings in the Hamilton Rating Scale for Depression (HRSD-24).

RESULTS

N = 261 patients were included in the analyses. In the subgroup of patients who improved according to HRSD-24, GAD-7 scores were significantly lower after 12 weeks (t = -6.31, df = 120, p < .001; ES = -0.51, SRM = -0.57), and 48 weeks of treatment (t = -12.68, df = 141, p < .001; ES = -1.0, SRM = -1.7), when compared to admission. In the group who worsened, GAD-7 scores were significantly higher after 12 weeks (t = 2.96, df = 41, p = .005; ES = 0.30, SRM = 0.46), and increased after 48 weeks (t = 1.99, df = 21, p = .059; ES = 0.37, SRM = 0.43), when compared to baseline. The unchanged group showed no significant difference between baseline and follow-up. MCID was estimated 4 points on the GAD-7 total score.

LIMITATIONS

Confirmation of these findings and further investigation of the GAD-7 in populations and trials focusing on anxiety-specific treatment is highly recommended.

CONCLUSIONS

Results show that the GAD-7 is sensitive to detect change in psychopathology over the course of treatment.

Impact of Removing Nonprescription Codeine in Australia: Protocol for a Prospective Cohort Study

Background

On February 1, 2018, Australia rescheduled codeine to a prescription-only medication. Many concerns were associated with this change, including increased financial costs, reduced service accessibility, the potential for poorer pain management, and a decline in physical and mental health if codeine could not be accessed. In the research literature, there is limited knowledge about the long-term consequences of rescheduling pharmaceutical opioids and, as Australia has followed many countries in implementing a restriction on codeine, further study of these consequences is critical.

Objective

The goal of this study was to examine the impact of rescheduling codeine from an over-the-counter (OTC) product to a prescription-only medicine on the primary measures of codeine use and dependence in a prospective cohort of people who are frequent consumers of OTC codeine. Secondary measures included pain and self-efficacy, health service use, and mental health.

Methods

The Codeine Cohort study aimed to recruit 300 participants in Australia who regularly (at least a few times per week for the past 6 months) used OTC codeine. Using an online survey, participants were followed up at three time points (February 2018, June 2018, and February 2019) after codeine was rescheduled.

Results

All four waves of data collection are complete, with the final round of data collection finalized in August 2019. Data analyses are yet to be completed. Information on demographics, codeine use and dependence, physical and mental health, medication use, and health service use will be analyzed using mixed models.

Conclusions

Results of this study will provide insight into the effectiveness of regulatory restriction in curtailing nonmedical use of and harms associated with codeine. Additionally, results will explore positive and negative outcomes of codeine rescheduling for individual patients, which informs health professionals who support patients who use codeine and further community education.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15540

Retinal correlates of psychiatric disorders

Diagnosis and monitoring of psychiatric disorders rely heavily on subjective self-reports of clinical symptoms, which are complicated by the varying consistency of accounts reported by patients with an impaired mental state. Hence, more objective and quantifiable measures have been sought to provide clinicians with more robust methods to evaluate symptomology and track progression of disease in response to treatments. Owing to the shared origins of the retina and the brain, it has been suggested that changes in the retina may correlate with structural and functional changes in the brain. Vast improvements in retinal imaging, namely optical coherence tomography (OCT) and electrodiagnostic technology, have made it possible to investigate the eye at a microscopic level, allowing for the investigation of potential biomarkers in vivo. This review provides a summary of retinal biomarkers associated with schizophrenia, bipolar disorder and major depression, demonstrating how retinal biomarkers may be used to complement existing methods and provide structural markers of pathophysiological mechanisms that underpin brain dysfunction in psychiatric disorders.

Examining the benefits and harms of Alzheimer's disease screening for family members of older adults: study protocol for a randomized controlled trial

BACKGROUND

Multiple national expert panels have identified early detection of Alzheimer's disease and related dementias (ADRD) as a national priority. However, the United States Preventive Services Task Force (USPSTF) does not currently support screening for ADRD in primary care given that the risks and benefits are unknown. The USPSTF stresses the need for research examining the impact of ADRD screening on family caregiver outcomes.

METHODS

The Caregiver Outcomes of Alzheimer's Disease Screening (COADS) is a randomized controlled trial that will examine the potential benefits or harms of ADRD screening on family caregivers. It will also compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening. COADS will enroll 1800 dyads who will be randomized into three groups (n = 600/group): the 'Screening Only' group will receive ADRD screening at baseline and disclosure of the screening results, with positive-screen participants receiving a list of local resources for diagnostic follow-up; the 'Screening Plus' group will receive ADRD screening at baseline coupled with disclosure of the screening results, with positive-screen participants referred to a dementia collaborative care program for diagnostic evaluation and potential care; and the control group will receive no screening. The COADS trial will measure the quality of life of the family member (the primary outcome) and family member mood, anxiety, preparedness and self-efficacy (the secondary outcomes) at baseline and at 6, 12, 18 and 24 months. Additionally, the trial will examine the congruence of depressive and anxiety symptoms between older adults and family members at 6, 12, 18 and 24 months and compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening between the two groups randomized to screening (Screening Only versus Screening Plus).

DISCUSSION

We hypothesize that caregivers in the screening arms will express higher levels of health-related quality of life, lower depressive and anxiety symptoms, and better preparation for caregiving with higher self-efficacy at 24 months. Results from this study will directly inform the National Plan to Address Alzheimer's Disease, the USPSTF and other organizations regarding ADRD screening and early detection policies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03300180. Registered on 3 October.

Assessing the Relative Impact of Diverse Stressors among Public Safety Personnel

Public Safety Personnel (PSP; e.g., correctional workers and officers, firefighters, paramedics, police officers, and public safety communications officials (e.g., call center operators/dispatchers)) are regularly exposed to potentially psychologically traumatic events (PPTEs). PSP also experience other occupational stressors, including organizational (e.g., staff shortages, inconsistent leadership styles) and operational elements (e.g., shift work, public scrutiny). The current research quantified occupational stressors across PSP categories and assessed for relationships with PPTEs and mental health disorders (e.g., anxiety, depression). The participants were 4820 PSP (31.7% women) responding to established self-report measures for PPTEs, occupational stressors, and mental disorder symptoms. PPTEs and occupational stressors were associated with mental health disorder symptoms (ps < 0.001). PSP reported substantial difficulties with occupational stressors associated with mental health disorder symptoms, even after accounting for diverse PPTE exposures. PPTEs may be inevitable for PSP and are related to mental health; however, leadership style, organizational engagement, stigma, sleep, and social environment are modifiable variables that appear significantly related to mental health.

Prenatal Depression and Diet Quality During Pregnancy

BACKGROUND

Maternal nutrition during pregnancy has a significant effect on the health of the offspring and mother, highlighting the need for identifying factors that may affect diet during pregnancy. Research in nonpregnant and pregnant populations suggest depression may play a role.

OBJECTIVE

To investigate the relationship between prenatal depression and diet quality during pregnancy overall and by race/ethnicity and to explore the relationships between prenatal depression and the 12 Healthy Eating Index 2010 dietary components.

DESIGN

A cross-sectional secondary analysis of a cohort study of Kaiser Permanente Northern California women entering prenatal care between October 2011 and April 2013.

PARTICIPANTS/SETTING

Participants included 1,160 adult pregnant women.

MAIN OUTCOME MEASURES

Poor diet quality was defined as a Healthy Eating Index 2010 score in the lowest quartile.

STATISTICAL ANALYSES PERFORMED

Logistic regression was used to assess the relationship between prenatal depression (defined as a depression diagnosis, Patient Health Questionnaire score of 10 or greater or antidepressant medication dispensing between the last menstrual period and completion of the food frequency questionnaire) and poor diet quality overall and by race/ethnicity. Relationships between prenatal depression and each of the 12 Healthy Eating Index 2010 dietary components were assessed using t-tests and linear regression analyses.

RESULTS

One hundred fifty-nine (14%) participants had prenatal depression. Women with prenatal depression had nearly two times the odds of poor diet quality (odds ratio 1.80, 95% CI 1.23 to 2.60) compared with women without prenatal depression, after adjusting for potential confounders. Differences emerged by race/ethnicity; after adjusting for potential confounders the adjusted odds of poor diet quality were significant only among Hispanic women. Hispanic women with prenatal depression had an increased odds of poor diet quality compared with Hispanic women without prenatal depression (odds ratio 2.66, 95% CI 1.15 to 6.06). Women with prenatal depression had a higher consumption of empty calories (from solid fats, alcohol, and added sugars; threshold for counting alcohol >13 g/1,000 kcal) (P=0.01) and lower consumption of greens and beans (P<0.05), total fruit (P<0.01), and whole fruit (P<0.01), compared with women without prenatal depression. Except for empty calories, these findings remained after adjusting for potential confounders.

CONCLUSIONS

Study findings suggest that women with prenatal depression are at a higher risk of poor diet quality compared with women without prenatal depression, and the relationship is stronger among Hispanic women. Nutrition counseling interventions for women with depression should consider the use of culturally sensitive materials and target limiting empty calories from solid fats, alcohol, and added sugars and encourage eating more greens, beans, and fruit.

Using the Personalized Advantage Index for Individual Treatment Allocation to Blended Treatment or Treatment as Usual for Depression in Secondary Care

A variety of effective psychotherapies for depression are available, but patients who suffer from depression vary in their treatment response. Combining face-to-face therapies with internet-based elements in the sense of blended treatment is a new approach to treatment for depression. The goal of this study was to answer the following research questions: (1) What are the most important predictors determining optimal treatment allocation to treatment as usual or blended treatment? and (2) Would model-determined treatment allocation using this predictive information and the personalized advantage index (PAI)-approach result in better treatment outcomes? Bayesian model averaging (BMA) was applied to the data of a randomized controlled trial (RCT) comparing the efficacy of treatment as usual and blended treatment in depressive outpatients. Pre-treatment symptomatology and treatment expectancy predicted outcomes irrespective of treatment condition, whereas different prescriptive predictors were found. A PAI of 2.33 PHQ-9 points was found, meaning that patients who would have received the treatment that is optimal for them would have had a post-treatment PHQ-9 score that is two points lower than if they had received the treatment that is suboptimal for them. For 29% of the sample, the PAI was five or greater, which means that a substantial difference between the two treatments was predicted. The use of the PAI approach for clinical practice must be further confirmed in prospective research; the current study supports the identification of specific interventions favorable for specific patients.