Income and attrition in the treatment of depression: a STAR*D report

Does categorizing scale scores with cutoff points affect hypothesis-testing results?

BACKGROUND

The aim of this study is to evaluate the hypothesis test results after categorizing the scale scores with cut-off points and to assess whether similar results would be obtained in that best represent the categories.

METHODS

This cross-sectional study was conducted between March 15 and 20, 2023 via the Lime Survey. The questionnaire included questions about the sociodemographic and life characteristics of the participants and the Beck Depression Inventory II (BDI-II). Four groups (minimal, mild, moderate, severe depression) were formed using the cutoff points. Data analysis was performed with all participants and referred to as the conventional analysis group. Then, six subanalysis groups were determined to best represent the groups formed according to the BDI-II. In each BDI-II category, six subanalysis groups were created, including those between Q1-Q3 (IQR group), including those within ± 1 std, including those between 5p-95p (90% of the sample), including those between 2.5p-97.5p (95% of the sample). In addition, 100 different samples were randomly selected containing 50% of each group.

RESULTS

Of the 1950 participants, 84.7% (n = 1652) were female and 15.3% (n = 298) were male. In terms of depression, it was observed that the significance varied in the analysis groups for sex (p = 0.039), medication use (p = 0.009) and age (p = 0.010) variables. However, these variables were not significant in some of the subanalysis groups. On the other hand, a p < 0.001 value was obtained for income, physical activity, health perception, body shape perception, life satisfaction, and quality of life variables in terms of depression in the conventional analysis group, and it was seen that the significance continued in all subanalysis groups.

CONCLUSIONS

Our findings showed that variables with p < 0.001 in the conventional analysis group maintained their significance in the other analysis groups. In addition, as the p value got closer to 0.05, we observed that the significance changed according to different cutoff points in the analysis groups. In addition, 50% randomly selected samples support these results. At the end of our study, we reached results that support the necessity of secondary tests in the evaluation of scales. Although further studies are needed, we anticipate that our study will shed light on other studies.

Culturally appropriate psychotherapy and its retention: An example from Far North Queensland (Australia)

BACKGROUND

Culturally appropriate mental health care is essential in remote Australia. However, while associated with the development of an effective therapeutic alliance, current literature insufficiently reports the retention and psychotherapy outcomes of Indigenous adults. We aimed to describe the characteristics and retention of clients attending the Far North Mental Health and Wellbeing Service (FNS).

METHODS

We conducted a retrospective cross-sectional study on clients who received one or more psychotherapy consultations between 1st July 2019 and 31st December 2020. Population, entrance, and treatment characteristics were described, with retention compared between the major cultural groups. Entrance characteristics comprised referral pathway and reason for presentation and were investigated as alternative predictors of client retention.

FINDINGS

There were 186 non-Indigenous (68.3 % female) and 174 Indigenous (62.6 % female) clients, with a median number of 3.0 consultations (IQR 2.0-5.3). Indigenous status did not significantly predict retention. Referral pathway significantly predicted the number of consultations (Wald X2(6) = 17.67, p = .0071) and immediate discontinuation (Wald X2(6) = 12.94, p = .044), with self-referred clients having the highest retention. Initial presentation reason significantly predicted the number of consultations (Wald X2(5) = 13.83, p = .017), with clients with potential health hazards related to socioeconomic and psychosocial circumstances having the lowest retention. Significantly more Indigenous clients presented for this reason (20.1 % vs 4.3 %).

INTERPRETATION

Comparable retention of Indigenous clients suggests cultural appropriateness of the psychotherapy being delivered by the FNS. Services might use the described therapeutic approach as a guide for culturally appropriate care.

Income inequalities beyond access to mental health care: a Dutch nationwide record-linkage cohort study of baseline disease severity, treatment intensity, and mental health outcomes

BACKGROUND

Existing literature shows low and unequal access to mental health treatment globally, resulting in policy efforts to promote access for vulnerable groups. Yet, there is little evidence about how inequalities develop once individuals start treatment. The greater use of mental health care among individuals with low income, such as in the Dutch system, might be driven by differences in need and might not necessarily lead to better treatment outcomes. In this study, we aimed to examine income inequalities in four stages of the mental health treatment pathway while adjusting for need.

METHODS

We constructed a nationwide retrospective cohort study, examining all patients aged older than 18 years with a first specialist mental health treatment record in the Netherlands between 2011 and 2016, excluding those who did not receive any treatment minutes. We linked patient-level data from treatment records to administrative data on income, demographics from municipal registries, and health insurance claims. We used multivariate models to estimate adjusted associations between household income quintile (standardised for household size) and outcomes characterising four stages of mental health treatment: severity at baseline assessment based on the Global Assessment of Functioning (GAF) score, treatment minutes received, functional improvement by the end of the initial record, and additional treatment in a subsequent record. Estimates were adjusted for patient need (97 categories of primary diagnosis and severity at baseline assessment measured by GAF) and demographic covariates.

FINDINGS

Our study population consisted of 951 530 adults with a first specialist mental health treatment record in the Netherlands between Jan 1, 2011, and Dec 31, 2016. Patients in our cohort were on average aged 45·0 years (range 19-107) and mostly female (529 859 [55·7%] women and 421 671 [44·3%] men; no ethnicity data were available). First, we found that patients with the lowest income had the greatest initial therapist-assessed disease severity (5·545 GAF points), which was 0·353 GAF points (95% CI 0·347-0·360) lower than those in the highest income quintile. Second, we found that the negative association between income and treatment minutes was reversed once we adjusted for diagnosis and severity at baseline, with patients with the lowest income receiving 1·8% fewer treatment minutes (95% CI 1·1-2·4) than those in the highest quintile. Third, those in the highest income quintile were 17·3 percentage points (95% CI 17·0-17·6) more likely to have functional improvements by the end of the initial record, compared with 25·8% of patients with an improvement in the lowest income quintile. Fourth, while 35·7% of patients in the lowest income quintile received additional treatment in a subsequent record, this was only 3·0 percentage points (95% CI 2·7-3·3) lower for those in the highest quintile. None of these patterns were explained by diagnosis, severity at baseline, or treatment minutes received.

INTERPRETATION

Disparities favourable to patients with a higher income persist through the different stages of mental health treatment. These differences highlight the limitations of solely focusing on improving access to care to reduce the mental health gap. Our findings call for a better understanding of the role of social environment and quality of care as complementary mechanisms explaining inequalities during mental health treatment.

FUNDING

Erasmus Initiative Smarter Choices for Better Health (Erasmus University Rotterdam), European Union's Horizon 2020, and Nederlandse Organisatie voor Wetenschappelijk Onderzoek (Dutch Research Council).

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

Dropout from treatment for mental disorders in six countries of the Americas: A regional report from the World Mental Health Surveys

OBJECTIVE

To estimate structural and attitudinal reasons for premature discontinuation of mental health treatment, socio-demographic and clinical correlates of treatment dropout due to these reasons, and to test country differences from the overall effect across the region of the Americas.

METHODS

World Health Organization-World Mental Health (WMH) surveys were carried out in six countries in the Americas: Argentina, Brazil, Colombia, Mexico, Peru and USA. Among the 1991 participants who met diagnostic criteria (measured with the Composite International Diagnostic Interview (WMHCIDI)) for a mental disorder and were in treatment in the prior 12-months, the 236 (12.2%) who dropped out of treatment before the professional recommended were included.

FINDINGS

In all countries, individuals more frequently reported attitudinal (79.2%) rather than structural reasons (30.7%) for dropout. Disorder severity was associated with structural reasons; those with severe disorder (versus mild disorder) had 3.4 (95%CI=1.1-11.1) times the odds of reporting a structural reason. Regarding attitudinal reasons, those with lower income (versus higher income) were less likely to discontinue treatment because of getting better (OR=0.4; 95%CI= 0.2-0.9). Country specific variations were found.

LIMITATIONS

Not all countries, or the poorest, in the region were included. Some estimations couldn´t be calculated due to cell size. Causality cannot be assumed.

CONCLUSION

Clinicians should in the first sessions address attitudinal factors that may lead to premature termination. Public policies need to consider distribution of services to increase convenience. A more rational use of resources would be to offer brief therapies to individuals most likely to drop out of treatment prematurely.

Study protocol for comparing Screening, Brief Intervention, and Referral to Treatment (SBIRT) to referral as usual for depression in African American churches

Background

Depression is a leading cause of disability worldwide. African American adults, compared to White adults, are half as likely to be screened for depression in primary care settings. Disparities in depression screening contribute to poor clinical outcomes, as African Americans with depression are more disabled and sicker longer compared to Whites. African American churches are trusted settings that provide access to supports for depression. Indeed, in the first study of its kind, the investigators found that 20% of adults in African American churches screened positive for depression using the Patient Health Questionnaire-9 (PHQ-9). However, no subjects with a positive screen (PHQ-9 ≥ 10) accepted a treatment referral when offered by research personnel. Community Health Workers, who are trusted paraprofessionals from the target community, may bridge the gap between depression screening and treatment. The investigators have trained and certified 112 Community Health Workers from 45 African American churches in New York City to deliver an evidence-based intervention called Screening, Brief Intervention, and Referral to Treatment (SBIRT). Thus, the aim of the current study is to test the impact of Community Health Worker-delivered depression screening in Black churches on engagement with clinical services.

Methods

Using a hybrid type 1 effectiveness-implementation design, we propose a 2-arm, mixed-methods cluster randomized controlled trial. Church study sites will be randomized to either SBIRT (intervention arm) or referral as usual (usual care arm). This trial will be conducted with 600 church members across 30 churches (300 intervention; 300 usual care). Our primary outcome is treatment engagement, defined as attending a depression-related clinical visit. Secondary outcomes will be changes in Mental Health-Related Quality of Life and depressive symptoms at 3 and 6 months post-screening. Lastly, we will conduct a concurrent, mixed-methods (qualitative-quantitative) process evaluation to assess contextual facilitators and barriers of screening and referral.

Discussion

This is the first randomized trial of a church-placed, community health worker-delivered intervention for depression in African American populations. This study may provide a novel and effective approach to increasing depression identification and treatment linkage in economically disadvantaged populations with high depression rates.

Trial registration

ClinicalTrials.govNCT04524767. Registered on 21 August 2020.

Patterns of care and dropout rates from outpatient mental healthcare in low-, middle- and high-income countries from the World Health Organization's World Mental Health Survey Initiative

BACKGROUND

There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.

METHODS

Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan-Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.

RESULTS

Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.

CONCLUSIONS

Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.

Relationships among illness representations and depressive symptom severity in predominantly African-American and Caribbean-American people with epilepsy

Objective: Depression is the most common psychiatric comorbidity among people with epilepsy (PWE) and tends to be more prevalent among people of color (POC) and those with intractable seizures. However, the extent to which illness-related perceptions are associated with depressive symptom severity among POC with intractable seizures is unclear. Method: This cross-sectional study examined relationships among illness representations and self-rated depressive symptoms in 55 PWE (M Age = 41; 61.8% female) with intractable seizures (M seizures per month = 2) who identified as Black/African-American (52.7%), Black/Caribbean-American (27.3%), and/or Hispanic/Latino (21.8%). Epilepsy-related illness perceptions were assessed with the Illness Perception Questionnaire-Revised and depression was measured via the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Results: Nearly half of the sample (41.8%) scored above the NDDI-E depression cut-off. PWE endorsing more severe depressive symptoms indicated that their epilepsy had more negative consequences, was hard to comprehend, was insufficiently controlled by treatment, and had a negative emotional impact (p's ≤ 0.02). Controlling for sex, these four illness representations accounted for 48% of the variance in depression severity. Interestingly, participants with probable major depressive episodes were more likely to endorse several psychological causes of seizures compared to non-depressed PWE. Conclusions: Worse depression symptom severity was associated with negative illness perceptions and a tendency to attribute one's epilepsy to psychological causes. Future research is needed to understand how the relationship between negative illness perceptions and depression symptoms unfold over time and whether interventions aimed at modifying illness representations reduce psychological distress in diverse PWE.

The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months' follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, -9.2 ± 0.8 95% CI -10.9, -7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

Increased prevalence of depression in South Korea from 2002 to 2013

South Korea has one of the highest suicide rates among countries. However, the prevalence of depression in South Korea has been reported to be much lower than in other countries. The current study aims to estimate the prevalence of major depressive disorder using a large representative sample of the South Korean population. The prevalence of depression in a sampled population of one million individuals increased from 2.8% in 2002 to 5.3% in 2013; it was found to increase with the age of the population, and was higher in females than in males for most age groups. A Cox's proportional hazard model showed that suicide risk was significantly higher in people with depression (hazard ratio [HR] 3.79, 95% CI 3.14-4.58) than those without depression. It was also significantly higher in older people (HR 1.52, 95% CI 1.36-1.70) than in younger people, and in males (HR 2.45, 95% CI 2.02-2.96) than in females. Furthermore, higher income groups were at lower suicide risk as compared to lower income groups (HR 0.88, 95% CI 0.80-0.95). This study using the large representative sample data provided evidence that increased prevalence of depression contributed to the increased risk of suicide in South Korea during the recent decade.

Social inequalities in antidepressant treatment outcomes: a systematic review

PURPOSE

To identify, review and synthesize evidence on whether social disadvantage moderates antidepressant treatment outcomes, even when access to treatment is not a consideration.

METHODS

The systematic review was done in accordance with PRIMSA guidelines. An a priori systematic search strategy was used to search databases (MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Trials Library) from their earliest entries through December 31, 2018. A two-step screening procedure was followed, and all experimental studies of antidepressant treatment in ICD/DSM diagnosed cases of depression were included. Studies with subjects < 18 years or investigating other modalities of treatment were excluded.

RESULTS

Thirteen papers reporting analyses from nine studies met inclusion criteria. There was heterogeneity in sample sizes, target populations, treatment settings, clinical outcomes and definition of SES indices. The primary outcome was the relative effect of socioeconomic status (SES) (as measured by income, employment status and level of education)-on antidepressant treatment outcomes.

CONCLUSIONS

The evidence from this review suggests that lower SES may lead to social inequalities in antidepressant treatment outcomes even in the context of clinical trials in which all participants have equal access to the same high-quality, standardized care. The review calls for more careful consideration of the choice and operationalization of SES indicators, and the need to "employ sampling methods that ensure ample representation of individuals from a wide range of social worlds". The review concludes with tentative suggestions about how to reduce social inequalities in antidepressant treatment outcomes at the level of individuals and populations.

Effect of income level on adherence to antidepressant treatment in first onset depression outpatients

Clinical guidelines for depression management recommend continuous antidepressant medication; however, poor adherence to medication is commonly seen in the treatment of depression. Income is an important factor influencing antidepressant medication adherence. The purpose of this study was to investigate the relationship between income level and adherence to antidepressant medication in outpatients with depression. This was a retrospective cohort study using National Health Insurance claim data for services provided between January 1 and December 31, 2012. We examined data from a total of 142,336 individuals aged 18 years or older who were continuously enrolled in treatment after a new episode of major depression and who had initiated antidepressant treatment. The operational definition of adherence to antidepressant treatment was medication being dispensed to the patient at least 80% of the time during 3 and 6 months (ie. MPR ≥80%). To investigate the relationship between income level and adherence to antidepressants, we estimated adjusted odds ratios and 95% confidence intervals using hierarchical logistic regression analysis, adjusting for sociodemographic, clinical, and medical use characteristics. A total of 22.64% and 15.13% of depression patients showed adherence to antidepressants during 3 and 6 months, respectively. A statistically significant association was found between income level and adherence to antidepressants over 3 and 6 months for individuals with employee and self-employed subscribers. In addition, adherence to antidepressants was lower among those with a lower income than those with a higher income. We confirmed that social disparities exist in adherence to antidepressant treatment by income level in this Korean population-based retrospective cohort of depression outpatients.

Attrition in treatment-resistant depression: predictors and clinical impact

The aim of this study was to investigate attrition (dropout) during a second antidepressant trial in treatment-resistant depression. Three hundred forty-two outpatients with major depressive disorder and lack of response to a prior antidepressant were treated with venlafaxine for 6 weeks. Sociodemographic and clinical characteristics were compared between the attrition and non-attrition groups. Attrition was reported in 65 patients (19%), of whom 30 patients (46%) dropped out within week 4. The characteristics of dropout patients included a longer duration of depressive episode (P = 0.011) and lower antidepressant doses (P < 0.0001) as a consequence of a faster decrease (week 2) in depressive symptoms (P = 0.028). However, by controlling for early improvement, dropout subjects were associated with a smaller probability of antidepressant response (odds ratio = 0.16▪.83). A decrease of at least 30% in Montgomery Asberg Depression Rating Scale on day 14 predicted subsequent dropout with high specificity (81.9%▪1.0%) but lower sensitivity (19.6%▪2.8%) for clinical use. Patients who have been depressed for a longer period and show an initial improvement of symptoms after changing their antidepressant may be at increased risk for drop out. Further studies are necessary to ascertain the usefulness of these characteristics for predicting attrition.

Short- and Long-Term Antidepressant Clinical Trials for Major Depressive Disorder in Youth: Findings and Concerns

The diagnosis of major depressive disorder (MDD) in U.S. youth is increasing as is the rate of antidepressant medication (ADM) treatment for the disorder. Fluoxetine and escitalopram are FDA approved for the short term and maintenance treatment of MDD in youth. Placebo-controlled short-term ADM trials represent the basis for Food and Drug Administration (FDA) approval. Meta-analyses in 2007 and 2016 revealed that short-term ADM treatment of youth diagnosed with MDD resulted in no meaningful benefit for children and only marginal benefit for adolescents. Placebo substitution trials of ADM short-term responders represent the basis for FDA approval of ADM maintenance treatment. These ADM placebo substitution maintenance trials for youth with MDD are characterized by high dropout rates, a rapid withdrawal that often can follow the switch to placebo, and relapse rates that are not dissimilar from those in the natural course of the disorder. Without the evidence from problematic ADM placebo substitution trials, there is no acceptable support for the inclusion of ADM in maintenance treatment for MDD in youth.

Paroxetine versus Venlafaxine and Escitalopram in Korean Patients with Major Depressive Disorder: A Randomized, Rater-blinded, Six-week Study

Objective

The purpose of this study was to compare the efficacy and safety of escitalopram, paroxetine and venlafaxine in Korean patients with major depressive disorder (MDD).

Methods

A total of 449 Korean MDD patients were recruited in a six-week, randomized, rater-blinded, active-controlled trial and were evenly randomized to paroxetine, venlafaxine, or escitalopram treatment.

Results

When comparing the mean difference for the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Hamilton Depression Rating Scale (HDRS) total scores during six weeks, paroxetine (−6.4±0.4, and −5.4±0.4, respectively) was found to be significantly superior to escitalopram (−3.7±0.5 and −3.1±0.4, respectively). Venlafaxine had a significantly lower MADRS total score (−5.4±0.4) than escitalopram. When adjusting baseline variables, the response, according to the MADRS and HDRS scores, in the paroxetine group was greater than that for the escitalopram group (odds ratio [OR]=2.43, 95% confidence interval [CI]=1.42–4.16 for MADRS; and OR=2.32, 95% CI=1.35–3.97 for HDRS) and the venlafaxine group (OR=1.94, 95% CI=1.17–3.21 for MADRS; and OR=1.71, 95% CI=1.03–2.83 for HDRS). Despite that the overall tolerability was high and similar among the three groups, a total of 268 subjects (59.7%) prematurely discontinued treatment, representing the main limitation of the present study.

Conclusion

Although a low study completion rate limits generalizability, our findings suggest that paroxetine might be superior to escitalopram in Korean MDD patients. Further studies should be conducted to draw a definite conclusion.

Citalopram amplifies the influence of living conditions on mood in depressed patients enrolled in the STAR*D study

Selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed antidepressant drugs, have a variable and incomplete efficacy. In order to better understand SSRI action, we explored the hypothesis that SSRIs do not affect mood per se but amplify the influence of the living conditions on mood. To this aim, we exploited the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) data set, selected a subpopulation of 591 patients with an overlapping clinical history and analyzed treatment outcome according to dosage -20 or 40 mg per day of citalopram. We found that sociodemographic characteristics affected treatment response in the same direction in the two dose groups, but these effects reached statistical significance only in the 40 mg per day dose group. In the latter, higher improvement rate was associated with having a working employment status (P=0.0219), longer education (P=0.0053), high income (P=0.01) or a private insurance (P=0.0031), and the higher remission rate was associated with having a working employment status (P=0.0326) or longer education (P=0.0484). Moreover, the magnitude of the effect of the sociodemographic characteristics on mood, measured as the percent of patients showing a positive outcome when exposed to favorable living conditions, was much greater-up to 37-fold-in the 40 compared to the 20 mg per day dose group. Overall, our results indicate that citalopram amplifies the influence of the living conditions on mood in a dose-dependent manner. These findings provide a potential explanation for the variable efficacy of SSRIs and might lead to the development of personalized strategies aimed at enhancing their efficacy.

Treatment disparities among African American men with depression: implications for clinical practice

A decade has passed since the National Institute of Mental Health initiated its landmark Real Men Real Depression public education campaign. Despite increased awareness, depressed African American men continue to underutilize mental health treatment and have the highest all-cause mortality rates of any racial/ethnic group in the United States. We review a complex array of socio-cultural factors, including racism and discrimination, cultural mistrust, misdiagnosis and clinician bias, and informal support networks that contribute to treatment disparities. We identify clinical and community entry points to engage African American men. We provide specific recommendations for frontline mental health workers to increase depression treatment utilization for African American men. Providers who present treatment options within a frame of holistic health promotion may enhance treatment adherence. We encourage the use of multidisciplinary, community-based participatory research approaches to test our hypotheses and engage African American men in clinical research.

Brexpiprazole as an adjunctive treatment in young adults with major depressive disorder who are in a school or work environment

BACKGROUND

Major depressive disorder (MDD) is a common, debilitating disorder with substantial socioeconomic burden. Many patients with MDD experience symptoms that impair functioning and productivity, often negatively affecting work or educational pursuits. This Phase 3b open-label study evaluated adjunctive brexpiprazole in young adults with MDD, who were in work or study.

METHODS

Young patients (18-35 years) with MDD (inadequate responders to 1-3 antidepressant treatments [ADT] for their current episode) received brexpiprazole 1-3mg/day (target dose, 2mg/day) adjunctive to the same stable dose of ADT for 12 weeks.

RESULTS

Depressive symptoms improved during treatment with adjunctive brexpiprazole (primary endpoint, least squares [LS] mean change from baseline in Montgomery-Åsberg Depression Rating Scale [MADRS] total score, -18.1 [p<0.0001]). Reductions from baseline in Sheehan Disability Scale Score (SDS; LS mean change -11.2 [p<0.0001]) and Work Limitations Questionnaire (WLQ; p<0.0001) indicated improvements in the effects of patients' symptoms on functioning (work/school, social life, and home responsibilities). Changes from baseline in additional measures supported improvements in patient functioning and depression symptoms. The most common adverse events were headache (21.3%), weight increase (17.0%), and somnolence (17.0%); reported rates of akathisia were low (6.4%). Clinically relevant increases in weight (≥7%) occurred in 10.5% of patients.

LIMITATIONS

Open-label design; absence of comparator.

CONCLUSIONS

Brexpiprazole may represent an effective therapy for adjunctive treatment strategy of young adults with MDD who are working or studying. The observed improvements in work/school functioning in patients with MDD, whose depression was treated with ADT+brexpiprazole, suggests potential to reduce socioeconomic burden.

Religiosity and Mental Health Service Utilization Among African-Americans

African-Americans are approximately half as likely as their white counterparts to use professional mental health services. High levels of religiosity among African-Americans may lend to a greater reliance on religious counseling and coping when facing a mental health problem. This study investigates the relationship between three dimensions of religiosity and professional mental health service utilization among a large (n = 3570), nationally representative sample of African-American adults. African-American adults who reported high levels of organizational and subjective religiosity were less likely than those with lower levels of religiosity to use professional mental health services. This inverse relationship was generally consistent across individuals with and without a diagnosable Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, anxiety, mood, or substance use disorder. No association was found between nonorganizational religiosity and professional mental health service use. Seeking professional mental health care may clash with sociocultural religious norms and values among African-Americans. Strategic efforts should be made to engage African-American clergy and religious communities in the conceptualization and delivery of mental health services.

Patient-reported outcomes before and after treatment of major depressive disorder

Patient reported outcomes (PROs) of quality of life (QoL), functioning, and depressive symptom severity are important in assessing the burden of illness of major depressive disorder (MDD) and to evaluate the impact of treatment. We sought to provide a detailed analysis of PROs before and after treatment of MDD from the large Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. This analysis examines PROs before and after treatment in the second level of STAR*D. The complete data on QoL, functioning, and depressive symptom severity, were analyzed for each STAR*D level 2 treatment. PROs of QoL, functioning, and depressive symptom severity showed substantial impairments after failing a selective serotonin reuptake inhibitor trial using citalopram (level 1). The seven therapeutic options in level 2 had positive statistically (P values) and clinically (Cohen's standardized differences [Cohen's d]) significant impact on QoL, functioning, depressive symptom severity, and reduction in calculated burden of illness. There were no statistically significant differences between the interventions. However, a substantial proportion of patients still suffered from patient-reported QoL and functioning impairment after treatment, an effect that was more pronounced in nonremitters. PROs are crucial in understanding the impact of MDD and in examining the effects of treatment interventions, both in research and clinical settings.

Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy

Relative to non-Latino Whites, Latinos in the United States with major depressive disorder (MDD) show low engagement in antidepressant therapy, whether engagement is defined as pharmacotherapy access, medication initiation, pill-taking, or treatment retention. One potential reason for this disparity in depression care is the low cultural congruence of pharmacotherapy for this population. To examine Latinos' views of depression and antidepressant therapy, we conducted qualitative interviews with 30 Latino outpatients initiating antidepressants prior to their first treatment visit using the semistructured Treatment Adherence and Retention Questionnaire. These baseline interviews were randomly selected from data collected for a randomized controlled trial testing a novel intervention to enhance engagement by depressed Latino outpatients. Participant narratives were analyzed using open coding and the iterative analytical approach derived from grounded theory. Patient views about depression addressed stigmatizing views held by others in their social circle. Most participants directly refuted these views by providing alternate explanations to depression experiences. Antidepressant therapy narratives also revealed marked stigmatization, but participants tended not to refute these views. Instead, patients expressed concerns about antidepressants and showed marked ambivalence about seeking psychiatric care. Participants, however, did suggest ways in which clinicians and patients might collaborate to address their concerns about antidepressants. Some cultural views, such as concerns about addiction to or dependence on medication, may be negotiable barriers to treatment. Prescribing clinicians should address cultural views and concerns in order to improve Latino engagement in antidepressant therapy.

Quality of life in major depressive disorder before/after multiple steps of treatment and one-year follow-up

OBJECTIVE

This study examines the impact of major depressive disorder (MDD) and its treatment on quality of life (QOL).

METHOD

From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, we analyzed complete data of 2280 adult MDD out-patients at entry/exit of each level of antidepressant treatments and after 12 months of entry to follow-up. QOL was measured using the QOL Enjoyment and Satisfaction Questionnaire (Q-LES-Q). The proportions of patients scoring 'within-normal' QOL (within 10% of Q-LES-Q community norms) and those with 'severely impaired' QOL (>2 SD below Q-LES-Q community norms) were analyzed.

RESULTS

Before treatment, no more than 3% of MDD patients experienced 'within-normal' QOL. Following treatment, statistically significant improvements were detected; however, the proportion of patients achieving 'within-normal' QOL did not exceed 30%, with >50% of patients experiencing 'severely impaired' QOL. Although remitted patients had greater improvements compared with non-remitters, 32-60% continued to experience reduced QOL. 12-month follow-up data revealed that the proportion of patients experiencing 'within-normal' QOL show a statistically significant decrease in non-remitters.

CONCLUSION

Symptom-focused treatments of MDD may leave a misleading impression that patients have recovered when, in fact, they may be experiencing ongoing QOL deficits. These findings point to the need for investigating specific interventions to ameliorate QOL in MDD.

Recovery and recurrence of mental sickness absence among production and office workers in the industrial sector

BACKGROUND

Manual workers in the public sector have previously been found to be at risk of mental sickness absence (SA). As the impact of mental illness differs across economic sectors, this study investigated mental SA in the industrial sector, differentiating between office and production workers.

METHODS

Ten-year observational cohort study including 14 369 (8164 production and 6205 office) workers with a total of 101 118 person years. SA data were retrieved from an occupational health register. Mental SA episodes were medically certified as emotional disturbances [10th version of the International Classification of Diseases (ICD-10 R45)] or mental and behavioural disorders (ICD-10 F00-F99). The first mental SA episode since baseline was called index mental SA. Recurrences were defined as any mental SA episode occurring >28 days after recovery from index mental SA.

RESULTS

The incidence of mental SA was higher in production workers than in office workers, but office workers needed longer time to recover from mental SA. Mental SA recurred as frequently in production workers as in office workers. The median time to recurrence was 15.9 months and tangibly shorter in office workers (14.9 months) than in production workers (16.7 months). Production and office workers aged >55 years were at increased risk of recurrent mental SA within 12 months of recovery from index mental SA.

CONCLUSIONS

The incidence of mental SA was higher in production workers than in office workers, whereas recurrence rates did not differ between them. Occupational health providers should pay special attention to older workers as they are at increased risk of recurrent mental SA.

Race, genetic ancestry and response to antidepressant treatment for major depression

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study revealed poorer antidepressant treatment response among black compared with white participants. This racial disparity persisted even after socioeconomic and baseline clinical factors were taken into account. Some studies have suggested genetic contributions to this disparity, but none have attempted to disentangle race and genetic ancestry. Here we used genome-wide single-nucleotide polymorphism (SNP) data to examine independent contributions of race and genetic ancestry to citalopram response. Secondary data analyses included 1877 STAR*D participants who completed an average of 10 weeks of citalopram treatment and provided DNA samples. Participants reported their race as White (n=1464), black (n=299) or other/mixed (n=114). Genetic ancestry was estimated by multidimensional scaling (MDS) analyses of about 500 000 SNPs. Ancestry proportions were estimated by STRUCTURE. Structural equation modeling was used to examine the direct and indirect effects of observed and latent predictors of response, defined as change in the Quick Inventory of Depressive Symptomatology (QIDS) score from baseline to exit. Socioeconomic and baseline clinical factors, race, and anxiety significantly predicted response, as previously reported. However, direct effects of race disappeared in all models that included genetic ancestry. Genetic African ancestry predicted lower treatment response in all models. Although socioeconomic and baseline clinical factors drive racial differences in antidepressant response, genetic ancestry, rather than self-reported race, explains a significant fraction of the residual differences. Larger samples would be needed to identify the specific genetic mechanisms that may be involved, but these findings underscore the importance of including more African-American patients in drug trials.

Retention and attrition among African Americans in the STAR*D study: what causes research volunteers to stay or stray?

BACKGROUND

High attrition rates among African-Americans (AA) volunteers are a persistent problem that makes clinical trials less representative and complicates estimation of treatment outcomes. Many studies contrast AA with other ethnic/racial groups, but few compare the AA volunteers who remain in treatment with those who leave. Here, in addition to comparing patterns of attrition between African Americans and Whites, we identify predictors of overall and early attrition among African Americans.

METHOD

Sample comprised non-Hispanic African-American (n = 673) and White (n = 2,549) participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Chi-square tests were used to examine racial group differences in reasons for exit. Multivariate logistic regression was used to examine predictors of overall attrition, early attrition (by level 2) and top reasons cited for attrition among African Americans.

RESULTS

Both African-American and White dropouts most commonly cited noncompliance reasons for attrition during the earlier phases of the study, while citing reasons related to efficacy and medication side effects later in the study. Satisfaction with treatment strongly predicted overall attrition among African Americans independent of socioeconomic, clinical, medical or psychosocial factors. Early attrition among African American dropouts was associated with less psychiatric comorbidity, and higher perceived physical functioning but greater severity of clinician-rated depression.

CONCLUSIONS

Compliance, efficacy, and side effects are important factors that vary in relative importance during the course of a clinical trial. For African Americans in such trials, retention strategies should be broadened to emphasize patient engagement and satisfaction during the critical periods immediately following enrollment and treatment initiation.

Prevalence and clinical characteristics of remission during treatment in generalized anxiety

OBJECTIVE

Although the remission criteria for generalized anxiety are well defined, there is not much data available on the point prevalence of remission. The Measuring Impact of Remission in Anxiety Disorders in Belgium (MIRABEL) study is a naturalistic study designed to document the point prevalence of remission in patients treated for general anxiety and potential factors affecting this prevalence.

METHODS

The study population consisted of 618 adult outpatients being treated for generalized anxiety. The sample is defined by the key symptoms of generalized anxiety disorder rather than by fulfilling the exact DSM-IV-TR diagnostic criteria. Remission was defined as a Hamilton Anxiety Scale (HAM-A) score of less than or equal to 7. To reduce the interrater reliability, the HAM-A was assessed by the attending physicians who had no specific training. Factors investigated as possibly related to remission included sociodemographic, disease and treatment characteristics.

RESULTS

The point prevalence of remission in the study population was estimated at 13.3%. Remission prevalence varied with occupational status and severity of the current anxiety episode. Remission prevalence was lower in the presence of comorbidity and was proportional to the number of comorbid symptoms. Remitters took fewer medications but were treated longer. Remission prevalence was higher in patients who were taking antidepressants, but was lower in patients who were taking sedatives.

CONCLUSIONS

These findings underline the poor prognosis of generalized anxiety.

Economic inequalities in the effectiveness of a primary care intervention for depression and suicidal ideation

BACKGROUND

Economic disadvantage is associated with depression and suicide. We sought to determine whether economic disadvantage reduces the effectiveness of depression treatments received in primary care.

METHODS

We conducted differential-effects analyses of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial, a primary-care-based randomized, controlled trial for late-life depression and suicidal ideation conducted between 1999 and 2001, which included 514 patients with major depression or clinically significant minor depression.

RESULTS

The intervention effect, defined as change in depressive symptoms from baseline, was stronger among persons reporting financial strain at baseline (differential effect size = -4.5 Hamilton Depression Rating Scale points across the study period [95% confidence interval = -8.6 to -0.3]). We found similar evidence for effect modification by neighborhood poverty, although the intervention effect weakened after the initial 4 months of the trial for participants residing in poor neighborhoods. There was no evidence of substantial differences in the effectiveness of the intervention on suicidal ideation and depression remission by economic disadvantage.

CONCLUSIONS

Economic conditions moderated the effectiveness of primary-care-based treatment for late-life depression. Financially strained individuals benefited more from the intervention; we speculate this was because of the enhanced treatment management protocol, which led to a greater improvement in the care received by these persons. People living in poor neighborhoods experienced only temporary benefit from the intervention. Thus, multiple aspects of economic disadvantage affect depression treatment outcomes; additional work is needed to understand the underlying mechanisms.

Post disaster resilience: Racially different correlates of depression symptoms among hurricane Katrina-Rita volunteers

The present analyses examined the differential risks of and protective factors against depressive symptoms of African American and Non-Hispanic White American student volunteers, respectively after Hurricanes Katrina and Rita (H-KR). A total sample of 554 student volunteers were recruited from mental health professional programs at five universities located in the Deep South, namely areas severely impacted by H-KR during fall semester 2005. The response rate was 91% (n = 505). African American respondents (n = 299) and Non-Hispanic White Americans (n = 206) completed the survey questionnaires. Respondents retrospectively provided information on peritraumatic emotional reactions and previous trauma that were recalled by H-KR and H-KR stressors. African American respondents reported higher levels of depressive symptoms (65.2%) than their Non-Hispanic White counterparts (34.8%). Hierarchical regression analyses revealed that disaster related stressors affected African Americans (p < 0.001), but not Non-Hispanic Whites. However, African Americans who experienced peritraumatic positive emotions had lower depression levels. Lower rates of recollection of prior traumas during H-KR were reported by African American respondents, whereas previous trauma recollections predicted symptoms among Non-Hispanic White Americans (p < 0.05). Exhibiting more optimism had lower depression levels among Non-Hispanic White Americans. Peritraumatic negative emotion was the only shared risk for depressive symptoms of both groups. Findings underscore racially different levels of depressive symptoms that may contribute to varying degrees of resilience among student volunteers. Future research and practice may address these racial differences by understanding the risk factors for depressive symptoms to develop appropriate interventions for racial groups, and cultivating the protective factors that contribute to resilience from traumatic experiences.

The role of personal attributes in the genesis and progression of lung disease and cigarette smoking

OBJECTIVES

We examined early maladaptive personal attributes (e.g., depression), later lung disease, and later maladaptive personal attributes over a significant part of a woman's life.

METHODS

We gathered longitudinal data on a prospective cohort of community-dwelling women (n = 498) followed from young adulthood to late midlife. Results. We used structural equation modeling to assess the interrelations of maladaptive personal attributes, cigarette smoking, lung disease, and financial strain. The results supported a mediational model through which early maladaptive personal attributes were associated with smoking (b = 0.17, P < .001), which in turn predicted later lung disease (b = 0.33, P < .001), and lung disease was related to later family financial difficulties (b = 0.09, P < .05), which in turn were associated with later maladaptive personal attributes (b = 0.35, P < .001).

CONCLUSIONS

Our results address a number of important public health and clinical issues. An understanding of the interrelations of smoking, underlying mental health conditions, financial stress, and later mental health conditions on the part of physicians and other health care providers can be critical in managing patients with lung disease.

Comprehensive review of factors implicated in the heterogeneity of response in depression

BACKGROUND

Heterogeneity in overall response and outcomes to pharmacological treatment has been reported in several depression studies but with few sources that integrate these results. The goal of this study was to review the literature and attempt to identify nongenetic factors potentially predictive of overall response to depression treatments.

METHODS

A comprehensive review of the literature from the last 10 years was performed using three key databases (PubMed, EMBASE, and Cochrane). All relevant studies that met the inclusion criteria were selected and scored for their levels of evidence using the NICE scoring method. A subjective assessment of the strength of evidence for each factor was performed using predefined criteria.

RESULTS

Our broad search yielded 76 articles relevant to treatment heterogeneity. Sociodemographic factors, disease characteristics, and comorbidities were the most heavily researched areas. Some of the factors associated with more favorable overall response include being married, other social support, and low levels of baseline depressive symptoms. Evidence relating to baseline disease severity as a factor predictive of antidepressant response was particularly convincing among the factors reviewed. The presence of comorbid anxiety and pain contributed to worse antidepressant treatment outcomes.

CONCLUSIONS

Several factors either predictive of or associated with overall response to antidepressant treatment have been identified. Inclusion of factors predictive of response in the design of future trials may help tailor treatments to depression patients presenting to the average clinical practice, resulting in improved outcomes.

Addiction treatment trials: how gender, race/ethnicity, and age relate to ongoing participation and retention in clinical trials

Introduction

Historically, racial and ethnic minority populations have been underrepresented in clinical research, and the recruitment and retention of women and ethnic minorities in clinical trials has been a significant challenge for investigators. The National Drug Abuse Treatment Clinical Trials Network (CTN) conducts clinical trials in real-life settings and regularly monitors a number of variables critical to clinical trial implementation, including the retention and demographics of participants.

Purpose

The examination of gender, race/ethnicity, and age group differences with respect to retention characteristics in CTN trials.

Methods

Reports for 24 completed trials that recruited over 11,000 participants were reviewed, and associations of gender, race/ethnicity, and age group characteristics were examined along with the rate of treatment exposure, the proportion of follow-up assessments obtained, and the availability of primary outcome measure(s).

Results

Analysis of the CTN data did not indicate statistical differences in retention across gender or race/ethnicity groups; however, retention rates increased for older participants.

Conclusion

These results are based on a large sample of patients with substance use disorders recruited from a treatment-seeking population. The findings demonstrate that younger participants are less likely than older adults to be retained in clinical trials.

Conducting research with racial/ethnic minorities: methodological lessons from the NIDA Clinical Trials Network

BACKGROUND

Multiple studies in the National Institute on Drug Abuse Clinical Trials Network (CTN) demonstrate strategies for conducting effective substance abuse treatment research with racial/ethnic minorities (REMs).

OBJECTIVES

The objectives of this article are to describe lessons learned within the CTN to (1) enhance recruitment, retention, and other outcomes; (2) assess measurement equivalence; and (3) use data analytic plans that yield more information.

METHOD

This article includes background information and examples from multiple CTN studies on inclusion, measurement, and data analysis.

RESULTS AND CONCLUSIONS

Seven recommendations are included for conducting more effective research on REMs.

Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer

OBJECTIVE

The generalizability of palliative care intervention research is often limited by high rates of study attrition. This study examined factors associated with attrition from a randomized controlled trial comparing meaning-centered group psychotherapy (MCGP), an intervention designed to help advanced cancer patients sustain or enhance their sense of meaning to the supportive group psychotherapy (SGP), a standardized support group.

METHODS

Patients with advanced solid tumor cancers (n = 153) were randomized to eight sessions of either the MCGP or SGP. They completed assessments of psychosocial, spiritual, and physical well-being pretreatment, midtreatment, and 2 months post-treatment. Attrition was assessed in terms of the percent of participants who failed to complete these assessments, and demographic, psychiatric, medical, and study-related correlates of attrition were examined for the participants in each of these categories.

RESULTS

The rates of attrition at these time points were 28.1%, 17.7%, and 11.1%, respectively; 43.1% of the participants (66 of 153) completed the entire study. The most common reason for dropout was patients feeling too ill. Attrition rates did not vary significantly between study arms. The participants who dropped out pretreatment reported less financial concerns than post-treatment dropouts, and the participants who dropped out of the study midtreatment had poorer physical health than treatment completers. There were no other significant associations between attrition and any demographic, medical, psychiatric, or study-related variables.

CONCLUSIONS

These findings highlight the challenge of maintaining advanced cancer patients in longitudinal research and suggest the need to consider alternative approaches (e.g., telemedicine) for patients who might benefit from group interventions but are too ill to travel.

Influences of income and employment on psychological distress and depression treatment in Japanese adults

OBJECTIVES

Psychological distress is a health issue of critical importance, especially in people of working age in developed countries, including Japan. This study examined the relationships of income and employment arrangement with psychological distress and treatment of depression in a national sample of Japanese adults.

METHODS

Data for 10,959 men and 11,655 women 25-59 years of age, obtained from the Comprehensive Survey of the Living Conditions of People on Health and Welfare in 2007, were examined. Health outcomes were psychological distress measured by the Japanese version of the K6, subjective complaints and medical treatment of depression. Explanatory variables included marital status, employment arrangement, and household income. The relationships between health outcomes and explanatory variables were examined using multiple logistic regression analyses.

RESULTS

Lower income and unemployment were associated with a higher prevalence of psychological distress and treatment of depression. The association between psychological distress and income showed a threshold: the lowest income quintile had an especially high prevalence, while other quintiles had similar prevalences. The prevalence of depression treatment in those with psychological distress was significantly lower in the highest income quintile than in all the other income groups, and the prevalence was also significantly lower in employed than in unemployed respondents.

CONCLUSIONS

This study showed clear relationships of lower income and unemployment with psychological distress and depression treatment. It has been suggested that people with higher socioeconomic status and full-time work may be reluctant to consult professionals and receive medical treatment, despite their psychological distress. Comprehensive mental health interventions are required to prevent psychological distress in all socioeconomic strata of the population.

Predictors of 12-week remission in a nationwide cohort of people with depressive disorders: the CRESCEND study

OBJECTIVE

To estimate the 12-week remission rate of patients with depressive disorders and predictors of this in a naturalistic clinical setting in South Korea.

METHODS

For people with DSM-IV depressive disorders about to receive treatment at 18 hospitals, data on sociodemographic and health status were obtained. A free choice of clinical interventions was allowed and naturalistic follow-up took place at 1, 2, 4, 8, and 12 weeks later. Remission was defined as a Hamilton Depression Rating Scale score of ≤7 sustained to 12 weeks or last follow-up, if earlier.

RESULTS

For 723 participants, the 12-week remission rate was 31.4%. Remission was more likely in women, and in patients without a prior history of suicide attempt, and those with lower baseline anxiety.

CONCLUSIONS

Remission associated with unrestricted clinical interventions was comparable to STAR*D estimates for citalopram alone. Comorbid anxiety and previous suicide attempt were markers of worse outcome.

Association between major depression, depressive symptoms and personal income in US adults with diabetes

OBJECTIVE

Although the association between diabetes and depression outcomes has been well studied, very little is known about the association between depression and personal income in adults with diabetes. We examined the association between major depression, number of depressive symptoms and personal income among individuals with diabetes.

METHODS

We used the two-stage Heckman procedure to estimate adjusted personal income by major depression status and number of depressive symptoms for 1818 adults with diabetes from the nationally representative 2006 Medical Expenditure Panel Survey. STATA V.10 was used for statistical analysis to account for the complex survey design.

RESULTS

In a fully adjusted model with major depression as a binary variable, major depression was associated with $2838 lower personal income. In a separate model with depressive symptoms as a continuous variable, each additional symptom was associated with $1235 lower personal income. Compared with being white/non-Hispanic, being black/non-Hispanic (-$4640) was associated with decreased personal income. Compared with excellent health status, fair health status (-$12,172) and poor health status (-$13,835) were associated with lower income. Relative to private insurance, public insurance only (-$8413) and being uninsured (-$9600) were associated with decreased income.

CONCLUSIONS

Among adults with diabetes, major depression and depressive symptoms are associated with lower personal income, after adjusting for relevant confounders. This finding suggests that aggressively diagnosing and treating depression as well as keeping people free of depressive symptoms can have huge human capital savings over the employment lifetime of individuals with diabetes and depression.

Factors Associated with Attrition from Mindfulness-Based Cognitive Therapy in Patients with a History of Suicidal Depression

We report data from a randomised controlled trial of mindfulness-based cognitive therapy to pilot procedures for people with a history of suicidal ideation or behaviour, focusing in particular on the variables that distinguish those who complete an adequate ‘dose’ of treatment, from those who drop out. Sixty-eight participants were randomised to either immediate treatment with mindfulness-based cognitive therapy (MBCT) (n = 33) or to the waitlist (n = 36) arm of the trial. In addition to collecting demographic and clinical information, we assessed participants’ cognitive reactivity using the means end problem-solving task, completed before and after a mood induction procedure. Ten participants dropped out of treatment, and eight dropped out of the waitlist condition. Those who dropped out of MBCT were significantly younger than those who completed treatment, less likely to be on antidepressants, had higher levels of depressive rumination and brooding and showed significantly greater levels of problem-solving deterioration following mood challenge. None of these factors distinguished participants in the waiting list condition who remained in the study from those who dropped out. Our results suggest that individuals with high levels of cognitive reactivity, brooding and depressive rumination may find it particularly difficult to engage with MBCT, although paradoxically they are likely to have the most to gain from the development of mindfulness skills if they remain in class. Addressing how such patients can be best prepared for treatment and supported to remain in treatment when difficulties arise is an important challenge.