A structured interview version of the Hamilton Depression Rating Scale: evidence of reliability and versatility of administration

The HAM-D6 through the lens of grief: Clinical considerations for administering the six-item Hamilton Depression Rating Scale in the context of bereavement

OBJECTIVES

Diagnosing mental health challenges in bereavement is controversial; however, regardless of one's position on this matter, assessments of bereaved individuals continue to occur in clinical and research contexts. It is critical for evaluations to account for contextual factors that are unique to bereavement. This paper summarizes considerations for diagnosing depression in bereaved individuals, focusing on use of the six-item Hamilton Depression Rating Scale (HAM-D6).

METHODS

Following a literature review of the Hamilton Depression Rating Scale (HAM-D) and various versions, we summarized decision rules we used in scoring the HAM-D6 in a study of parents bereaved by cancer. We expanded on existing scoring guidelines for each of the HAM-D6 items, including depressed mood, work and activities, general somatic symptoms, guilt, psychic anxiety, and psychomotor retardation, and illustrated clinical distinctions and probes for assessors to consider through case examples from our research with bereaved parents.

RESULTS

Considerations for assessing depressive symptoms and behavior changes in the context of bereavement were summarized. Symptoms that may be diagnostic of depression in some populations may reflect other factors in the bereaved, such as a change in priorities, social expectations surrounding grief, or avoidance of grief activators. Nuanced factors are important for assessors to consider when administering the HAM-D6 to bereaved individuals.

SIGNIFICANCE OF RESULTS

Our sharing of these considerations is not intended to promote diagnosis of depression in bereavement but to highlight the unique contextual factors that distinguish symptoms of depression from common experiences of grievers when applying an assessment tool such as the HAM-D6. While validated measures can be constraining, they can have clinical utility; they may increase standardization in research, help clinicians communicate with each other, advance the field more generally to understand the varying struggles bereaved individuals experience, and systemically facilitate access to services via managed care.

Perturbed gut microbiota is gender-segregated in unipolar and bipolar depression

OBJECTIVE

This study aimed to explore the gender specificity of gut microbiome in patients with unipolar and bipolar depression disorder by analyzing the data of gut microbiome in this two mental disorders and healthy people.

METHODS

A case-control study using 16S ribosomal RNA gene sequencing from fecal samples of MDD (male set, n = 43; female set, n = 77) and BD (male set, n = 82; female set, n = 83) compared with HCs (male set, n = 71; female set, n = 100) was conducted. Linear discriminant analysis was used to identify microbial characteristics. Through cooccurrence analysis, the potential correlations of the differential gut microbiota in different genders was explored. Finally, the gender-specific distinguishing microorganisms were identified as biomaker, and the diagnostic performance was verified by five-fold cross validation.

RESULTS

A specific cluster was found enriched only in female MDD set, including 4 Bacteroideae OTUs. Similarly, 3 Lachnospiraceae OTUs was found significantly increased in female BD compared with other groups. In addition, the consistent enrichment of Pseudomonadacea in male and female may be the characteristic disease-related gut microbiota of BD. Besides, the diagnostic potential of gender specific biomarker panel in male (male validation AUC: 0.758-0.874, accurancy: 0.693-0.792; female validation AUC: 0.727-0.883, accurancy: 0.678-0.781) and female (male validation AUC: 0.787-0.883, accurancy: 0.719-0.784; female validation AUC: 0.795-0.898, accurancy: 0.689-0.838) has also been identified and confirmed.

CONCLUSIONS

The microbiological changes in both MDD and BD are sex specific, and gender specific biomarker panel has better diagnostic performance, which provide a certain reference in sex difference for future clinical differentiation and microbial intervention.

The Association Between Sample and Treatment Characteristics and the Efficacy of Repetitive Transcranial Magnetic Stimulation in Depression: A Meta-analysis and Meta-regression of Sham-controlled Trials

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a form of non-invasive neuromodulation that is increasingly used to treat major depressive disorder (MDD). However, treatment with rTMS could be optimized by identifying optimal treatment parameters or characteristics of patients that are most likely to benefit. This meta-analysis and meta-regression aims to identify sample and treatment characteristics that are associated with change in depressive symptom level, treatment response and remission.

METHODS

The databases PubMed, Embase, Web of Science and Cochrane library were searched for randomized controlled trials (RCTs) reporting on the therapeutic efficacy of high-frequent, low-frequent, or bilateral rTMS for MDD compared to sham. Study and sample characteristics as well as rTMS parameters and outcome variables were extracted. Effect sizes were calculated for change in depression score and risk ratios for response and remission.

RESULTS

Sixty-five RCTs with a total of 2982 subjects were included in this meta-analysis. Active rTMS resulted in a larger depressive symptom reduction than sham protocol (Hedges' g = -0.791 95% CI -0.977; -0.605). Risk ratios for response and remission were 2.378 (95% CI 1.882; 3.005) and 2.450 (95% CI 1.779; 3.375), respectively. We found no significant association between sample and treatment parameters and rTMS efficacy.

CONCLUSIONS

rTMS is an efficacious treatment for MDD. No associations between sample or treatment characteristics and efficacy were found, for which we caution that publication bias, heterogeneity and lack of consistency in the definition of remission might bias these latter null findings. Our results are clinically relevant and support the use of rTMS as a non-invasive and effective treatment option for depression.

How Effective is a Web-Based Mental Health Intervention (Deprexis) in the Treatment of Moderate and Major Depressive Disorders when started during Routine Psychiatric Inpatient Treatment as an Adjunct Therapy? A Pragmatic Parallel-Group Randomized Controlled Trial

BACKGROUND

Internet-based self-help-programs like deprexis have been increasingly shown to reduce depressive symptoms if added to distinct, primarily outpatient-treatment-settings. There is limited information about the effectiveness of deprexis if started at routine psychiatric hospital inpatient treatment of moderate-to-severe major depressive disorder (MDD).

SUBJECTS AND METHODS

To examine, sixty-nine adult MDD-inpatients were randomly assigned to a 12-week-period of treatment-as-usual (TAU, N=33) or TAU plus guided deprexis (TAU-PLUS, N=36). The study was planned as a pragmatic approach considering psychiatric routine conditions, particularly, offering an instant and flexible discharge management when the patients felt stabilized enough for primary/secondary care. Therefore, there was no fixed time frame for the inpatient treatment duration. Post-discharge, patients were followed by structured telephone interviews up to study-endpoint, i. e., 12 weeks after deprexis-initiation. Primary (Beck-Depression-Inventory-II, BDI-II) and secondary outcome-measures (Hamilton-Depression-Scale, Clinical-Global-Impression-Severity, WHO-Well-Being-Index, Helping-Alliance-Questionnaire) were carried out at study entry and every 2 weeks. Furthermore, the working alliance with deprexis as well as the inpatient treatment duration, the daily activity and the utilization of post-hospital care after discharge were determined.

RESULTS

At week 12, modified ITT-analyses showed significant between-group differences of BDI-II scores in favor of the TAU-PLUS-patients (p=.03) corresponding to a medium effect size (d=-.73, 95% CI -1.4 to .06). TAU-PLUS-patients showed greater daily activity (p=.04, d=.70, 95% CI -.03 to 1.38) and had been discharged significantly earlier from inpatient treatment (p=.003). Post-discharge, the TAU-PLUS-group reported a lower rate of post-hospital care (p=.01) and re-admissions (p=.04). Secondary outcome-measures including the alliance with the therapists were not significantly different between the groups at study-endpoint. The patients´ working-alliance with deprexis significantly predicted MDD-improvement and wellbeing. Both groups (TAU and TAU plus deprexis) were comparable with regard to the prescribed antidepressant medication. Unfortunately, detailed data on the amount and actual duration of the psychotherapeutic and special therapeutic individual and group settings of the TAU were not collected CONCLUSION: TAU plus deprexis was superior to TAU in improving subjective depression-severity (BDI-II) and daily activity in patients having sought psychiatric inpatient MDD-treatment before. This beneficial effect appeared 12 weeks after inpatient deprexis-initiation, i. e. when the vast majority of patients were back in primary/secondary care. Adjunctive deprexis was associated with earlier discharges and a significant advantage for post-hospital stabilization. In this regard, it could be promising to include deprexis into inpatient treatment conditions, thereby also preparing its continuing outpatient use. We found no evidence that deprexis interfered negatively with the alliance between the patients and their therapists.

OXTR-Related Markers in Clinical Depression: a Longitudinal Case-Control Psychotherapy Study

We investigated stability and change of plasma and urinary oxytocin as well as OXTR DNA methylation patterns through psychotherapy. Furthermore, we explored the potential impact of inpatient psychotherapy on oxytocin-related biomarkers and vice versa by differentiating patients who remitted from depression versus non-remitters. Blood and urine samples were taken from 85 premenopausal women (aged 19–52), 43 clinically depressed patients from a psychosomatic inpatient unit, and 42 healthy control subjects matched for age and education at two points of time. Serum and urine oxytocin were measured using standard ELISA, and DNA methylation of the OXTR gene was assessed using bisulfite sequencing at the time of admission (baseline) and at discharge and from controls at matched time points. Oxytocin plasma levels were not associated with depression and were influenced by neither time in healthy controls nor psychotherapy in patients. Non-remitting depressed patients had significantly lower oxytocin urine levels before and after psychotherapy treatment. We found significantly lower exon 1 OTXR methylation in depressed patients over time and these differences were driven by patients remitting due to psychotherapy. A reverse pattern — higher levels of methylation in remitters — was found for exon 2 OXTR DNA methylation. Plasma oxytocin, urinary oxytocin, and OXTR DNA methylation patterns were intrapersonally relatively stable. OXTR-related factors were seemingly unaffected by inpatient psychotherapeutic treatment, but we found significant differences between remitting and non-remitting patients in urinary oxytocin and OXTR DNA methylation. If replicated, this suggests that OXTR-related markers may predict inpatient treatment outcomes of clinically depressed patients.

Effectiveness of a Guided Internet- and Mobile-Based Intervention for Patients with Chronic Back Pain and Depression (WARD-BP): A Multicenter, Pragmatic Randomized Controlled Trial

INTRODUCTION

There is neither strong evidence on effective treatments for patients with chronic back pain (CBP) and depressive disorder nor sufficiently available mental health care offers.

OBJECTIVE

The aim is to assess the effectiveness of internet- and mobile-based interventions (IMI) as a scalable approach for treating depression in a routine care setting.

METHODS

This is an observer-masked, multicenter, pragmatic randomized controlled trial with a randomization ratio of 1:1.Patients with CBP and diagnosed depressive disorder (mild to moderate severity) were recruited from 82 orthopedic rehabilitation clinics across Germany. The intervention group (IG) received a guided depression IMI tailored to CBP next to treatment-as-usual (TAU; including medication), while the control group (CG) received TAU. The primary outcome was observer-masked clinician-rated Hamilton depression severity (9-week follow-up). The secondary outcomes were: further depression outcomes, pain-related outcomes, health-related quality of life, and work capacity. Biostatistician blinded analyses using regression models were conducted by intention-to-treat and per protocol analysis.

RESULTS

Between October 2015 and July 2017, we randomly assigned 210 participants (IG, n = 105; CG, n = 105), mostly with only a mild pain intensity but substantial pain disability. No statistically significant difference in depression severity between IG and CG was observed at the 9-week follow-up (β = -0.19, 95% CI -0.43 to 0.05). Explorative secondary depression (4/9) and pain-related (4/6) outcomes were in part significant (p < 0.05). Health-related quality of life was significantly higher in the IG. No differences were found in work capacity.

CONCLUSION

The results indicate that an IMI for patients with CBP and depression in a routine care setting has limited impact on depression. Benefits in pain and health-related outcomes suggest that an IMI might still be a useful measure to improve routine care.

The Hamilton Rating Scales for Depression: A Critical Review of Clinimetric Properties of Different Versions

The format of the original Hamilton Rating Scale for Depression (HAM-D) was unstructured: only general instructions were provided for rating individual items. Over the years, a number of modified versions of the HAM-D have been proposed. They differ not only in the number of items, but also in modalities of administration. Structured versions, including item definitions, anchor points and semi-structured or structured interview questions, were developed. This comprehensive review was conducted to examine the clinimetric properties of the different versions of the HAM-D. The aim was to identify the HAM-D versions that best display the clinimetric properties of reliability, validity, and sensitivity to change. The search was conducted on MEDLINE, Scopus, Web of Science, and PubMed, and yielded a total of 35,473 citations, but only the most representative studies were included. The structured versions of the HAM-D were found to display the highest inter-rater and test-retest reliability. The Clinical Interview for Depression and the 6-item HAM-D showed the highest sensitivity in differentiating active treatment from placebo. The findings indicate that the HAM-D is a valid and sensitive clinimetric index, which should not be discarded in view of obsolete and not clinically relevant psychometric criteria. The HAM-D, however, requires an informed use: unstructured forms should be avoided and the type of HAM-D version that is selected should be specified in the registration of the study protocol and in the methods of the trial.

Adaptation and validation of a structured version of the Hamilton Depression Rating Scale for use by non-clinicians in South Africa (AFFIRM-HDRS)

RATIONALE, AIMS AND OBJECTIVES

The Hamilton depression rating scale (HDRS) is seen as an international gold standard for the measurement of depression. High rates of untreated depression, including perinatal depression, support the rationale to adapt and validate a structured version of the HDRS to be used by non-clinicians in low-income settings.

METHODS

Using previous structured versions of the HDRS as a foundation, the tool was adapted, translated, and then validated with an isiXhosa speaking perinatal population in South Africa (n = 187), using cognitive testing, test-retest reliability, and inter-rater assessments. The AFFIRM-HDRS was compared with the Edinburgh postnatal depression scale (EPDS) using the non-parametric Spearman Rho test to assess concurrent validity. Internal consistency was examined using Cronbach's Alpha, and inter-rater and test-retest reliability were assessed with the intra-class coefficient (ICC). Cohen's Kappa was used to assess the overall percentage agreement for each individual item of the AFFIRM-HDRS.

RESULTS

The AFFIRM-HDRS showed good construct and content validity had significant associations with the EPDS (Rho = 0.60 and 0.43, P < .001), and acceptable internal consistency (Cronbach's alpha = 0.74.). Inter-rater reliability and test-retest scores were excellent, with intraclass correlations ranging from 0.97 (0.94-0.99) to 0.98 (0.97-0.99) between raters, and test-retest reliability being 0.90 (95% CI: 0.86-0.93). The tool performed similarly to previous structured versions. Individual item-rest correlations suggest that the items "Weight loss or gain," "Insight," and "Libido" did not fit well with the overall instrument, but that the rest of the items performed well.

CONCLUSION

The AFFIRM-HDRS is adequately structured to be used by non-clinicians in an isiXhosa speaking perinatal population. It is hoped that this structured tool can be used to assist with identification and referral of these at-risk populations by non-clinicians in resource-constrained environments, thereby playing a role in addressing the treatment gap for perinatal depression in LMICs.

Gut Microbial Signatures Can Discriminate Unipolar from Bipolar Depression

Discriminating depressive episodes of bipolar disorder (BD) from major depressive disorder (MDD) is a major clinical challenge. Recently, gut microbiome alterations are implicated in these two mood disorders; however, little is known about the shared and distinct microbial characteristics in MDD versus BD. Here, using 16S ribosomal RNA (rRNA) gene sequencing, the microbial compositions of 165 subjects with MDD are compared with 217 BD, and 217 healthy controls (HCs). It is found that the microbial compositions are different between the three groups. Compared to HCs, MDD is characterized by altered covarying operational taxonomic units (OTUs) assigned to the Bacteroidaceae family, and BD shows disturbed covarying OTUs belonging to Lachnospiraceae, Prevotellaceae, and Ruminococcaceae families. Furthermore, a signature of 26 OTUs is identified that can distinguish patients with MDD from those with BD or HCs, with area under the curve (AUC) values ranging from 0.961 to 0.986 in discovery sets, and 0.702 to 0.741 in validation sets. Moreover, 4 of 26 microbial markers correlate with disease severity in MDD or BD. Together, distinct gut microbial compositions are identified in MDD compared to BD and HCs, and a novel marker panel is provided for distinguishing MDD from BD based on gut microbiome signatures.

Perinatal depressive symptoms among low-income South African women at risk of depression: trajectories and predictors

BACKGROUND

The aim of the study was to identify trajectories of perinatal depressive symptoms and their predictors among women living in a low-resource setting in South Africa, and who present with a risk of depression during pregnancy.

METHODS

This is a secondary analysis of a randomised controlled trial among 384 women living in Khayelitsha, a low income setting in South Africa, recruited at their first antenatal visit if they scored 13 or above on the Edinburgh Postnatal Depression Scale, were at least 18 years of age, less than 29 weeks pregnant and spoke isiXhosa. Participants were followed up at 8 months gestation, 3 and 12 months postpartum. Latent trajectories of depressive symptoms were identified using growth mixture modelling, based on the Hamilton Depression Rating Scale (HDRS). There were no differences in HDRS scores between the control and intervention arms, so all participants were assessed together. Health, social and economic predictors of trajectories were investigated to identify high-risk groups with greater or more chronic depressive symptoms, using univariate logistic regression.

RESULTS

Two trajectories were identified: antenatal only (91.4%), with moderate to severe symptoms at baseline which later subside; and antenatal and postnatal (8.6%), with severe depressive symptoms during pregnancy and later in the postpartum period, which subside temporarily to moderate levels at 3 months postpartum. Predictors for the antenatal and postnatal trajectory include severe food insecurity, intimate partner violence, lower social support, greater functional impairment, problematic drinking and suicide risk.

CONCLUSIONS

A small proportion of women who are at risk for depression antenatally remain at risk throughout the perinatal period, and can be differentiated from those who show a natural remission. Identification and referral strategies should be developed with these findings in mind, especially given the limited mental health resources in low-income settings.

A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial

BACKGROUND

Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions.

OBJECTIVES

This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes.

METHODS

User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum.

RESULTS

A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment.

CONCLUSIONS

Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy).

Urinary biomarker panel for diagnosing patients with depression and anxiety disorders

Available data indicate that patients with depression and anxiety disorders are likely to be at greater risk for suicide. Therefore, it is important to correctly diagnose patients with depression and anxiety disorders. However, there are still no empirical laboratory methods to objectively diagnose these patients. In this study, the multiple metabolomics platforms were used to profile the urine samples from 32 healthy controls and 32 patients with depression and anxiety disorders for identifying differential metabolites and potential biomarkers. Then, 16 healthy controls and 16 patients with depression and anxiety disorders were used to independently validate the diagnostic performance of the identified biomarkers. Finally, a panel consisting of four biomarkers-N-methylnicotinamide, aminomalonic acid, azelaic acid and hippuric acid-was identified. This panel was capable of distinguishing patients with depression and anxiety disorders from healthy controls with an area under the receiver operating characteristic curve of 0.977 in the training set and 0.934 in the testing set. Meanwhile, we found that these identified differential metabolites were mainly involved in three metabolic pathways and five molecular and cellular functions. Our results could lay the groundwork for future developing a urine-based diagnostic method for patients with depression and anxiety disorders.

Patterns of intimate partner violence among perinatal women with depression symptoms in Khayelitsha, South Africa: a longitudinal analysis

BACKGROUND

A combination of intimate partner violence (IPV) and depression is a common feature of the perinatal period globally. Understanding this association can provide indications of how IPV can be addressed or prevented during pregnancy. This paper aims to determine the prevalence and correlates of IPV among pregnant low-income women with depressive symptoms in Khayelitsha, South Africa, and changes in IPV reports during the course of the perinatal period.

METHODS

This study is a secondary analysis of data collected as part of a randomised controlled trial testing a psychosocial intervention for antenatal depression. IPV, socio-demographic measures, depression and other mental health measures were collected at recruitment (first antenatal visit), 8 months gestation, and 3 and 12 months postpartum. IPV was defined as a sexual or physical violence perpetrated by the participant's partner in the past 3 months. Descriptive statistics are reported.

RESULTS

Of 425 recruited depressed participants, 59 (13.9%) reported IPV at baseline, with physical IPV being the most frequently reported (69.5%). Reported IPV was associated with greater emotional distress, potentially higher food insecurity and higher rates of alcohol abuse. There were clear longitudinal trends in reported IPV with the majority of women no longer reporting IPV postpartum. However, some women reported IPV at later assessment points after not reporting IPV at baseline.

CONCLUSIONS

There is a strong association between IPV and depression in pregnancy. IPV reports remit over time for the women in this study, although the reason for this reduction is not clear and requires further investigation.

Evaluating the effects of rater and subject factors on measures of association

Large-scale agreement studies are becoming increasingly common in medical settings to gain better insight into discrepancies often observed between experts' classifications. Ordered categorical scales are routinely used to classify subjects' disease and health conditions. Summary measures such as Cohen's weighted kappa are popular approaches for reporting levels of association for pairs of raters' ordinal classifications. However, in large-scale studies with many raters, assessing levels of association can be challenging due to dependencies between many raters each grading the same sample of subjects' results and the ordinal nature of the ratings. Further complexities arise when the focus of a study is to examine the impact of rater and subject characteristics on levels of association. In this paper, we describe a flexible approach based upon the class of generalized linear mixed models to assess the influence of rater and subject factors on association between many raters' ordinal classifications. We propose novel model-based measures for large-scale studies to provide simple summaries of association similar to Cohen's weighted kappa while avoiding prevalence and marginal distribution issues that Cohen's weighted kappa is susceptible to. The proposed summary measures can be used to compare association between subgroups of subjects or raters. We demonstrate the use of hypothesis tests to formally determine if rater and subject factors have a significant influence on association, and describe approaches for evaluating the goodness-of-fit of the proposed model. The performance of the proposed approach is explored through extensive simulation studies and is applied to a recent large-scale cancer breast cancer screening study.

Cognitive Behavior Therapy for Anxiety in Parkinson's Disease: Outcomes for Patients and Caregivers

OBJECTIVE

Anxiety negatively impacts the quality of life of Parkinson's disease (PD) patients and caregivers. Despite high prevalence, there is a paucity of trials investigating effective treatments for anxiety in PD. This uncontrolled study investigated the use of a manualized and tailored Cognitive Behavior Therapy (CBT) for anxiety in PD.

METHODS

Participants completed 6 weekly CBT sessions. Pre-, post- and follow-up (3 and 6 months) assessments were made. Change in outcomes were analysed using t-tests and Reliability Change Index. Of 17 PD patients who agreed to CBT, 12 completed the intervention.

RESULTS

This study showed a significant reduction in Hamilton Anxiety Rating Scale scores in PD immediately post CBT (t(11) = 3.59, p < .01), maintained at 3-month (t(8) = 2.83, p = .02) and 6-month (t(7) = 2.07, p = .04) follow-up. A reduction in caregiver burden (t(11) = 2.68, p = .03) was observed post intervention. Improvements in motor disability (t(11) = 2.41, p = .04) and cognitive scores (t(11) = -2.92, p = .01) were also observed post intervention and at follow-up.

CONCLUSIONS

Tailored CBT can be used to treat anxiety in PD.

CLINICAL IMPLICATIONS

This study provides preliminary evidence suggesting that tailored CBT reduces anxiety in PD with persisting benefits, and lowers caregiver burden.

Suicidality in Bipolar Disorder: The Role of Emotion-Triggered Impulsivity

A growing body of research suggests that impulsive responses to emotion more robustly predict suicidality than do other forms of impulsivity. This issue has not yet been examined within bipolar disorder, however. Participants diagnosed with bipolar I disorder (n = 133) and control participants (n = 110) diagnosed with no mood or psychotic disorder completed self-report measures of emotion-triggered impulsivity (Negative and Positive Urgency Scales) and interviews concerning lifetime suicidality. Analyses examined the effects of emotion-triggered impulsivity alone and in combination with gender, age of onset, depression severity, comorbid anxiety, comorbid substance use, and medication. A history of suicide ideation and attempts, as well as self-harm, were significantly more common in the bipolar disorder group compared with the control group. Impulsive responses to positive emotions related to suicide ideation, attempts, and self-harm within the bipolar group. Findings extend research on the importance of emotion-triggered impulsivity to a broad range of key outcomes within bipolar disorder. The discussion focuses on limitations and potential clinical implications.

Affective Instability and Reactivity in Depressed Patients With and Without Borderline Pathology

The quality of depression in borderline personality disorder (BPD) was reported to differ from that in patients with major depressive disorder (MDD) only. However, little is known about affect dynamics in "borderline-depression." The authors assessed affective instability and reactivity in 20 MDD patients with BPD and in 21 MDD patients without BPD by Ambulatory Assessment. Participants reported on current affect, daily events, and attribution of affective states to events five times per day over a 7-day period. The results do not indicate higher affective instability in MDD patients with BPD comorbidity. Depressed patients with BPD reported less subjectively perceived affective reactivity, while observed associations between events and affect were not different between groups, except for one finding: In depressed patients with BPD, overall mood was lower after being alone. These findings suggest impaired attribution of mood changes and less tolerance of being alone as specific for depression in BPD.

A study in persons later after stroke of the relationships between social participation, environmental factors and depression

OBJECTIVE

To explore the impacts of social participation and the environment on depression among people with stroke.

DESIGN

Cross-sectional survey.

SETTING

Structured interviews in the participants' homes.

SUBJECTS

Community-dwelling persons with stroke in the rural areas of China ( N = 639).

INTERVENTIONS

Not applicable.

MAIN MEASURES

Depression (Hamilton Rating Scale for Depression-6), activity and social participation (Chinese version of the World Health Organization's Disability Assessment Schedule 2.0), environmental barriers (Craig Hospital Inventory of Environmental Factors), neurological function (Canadian Neurological Scale).

RESULTS

A total of 42% of the variance in depression was explained by the environmental barriers, neurological function, activity, and social participation factors studied. Social participation, services/assistance, and attitudes/support were directly related to depression; their standardized regression coefficients were 0.530, 0.162, and 0.092, respectively ( p ⩽ 0.01). The physical environment, policies, and neurological function indirectly impacted depression. Depression influences social participation in turn, with a standardized regression coefficient of 0.29 ( p ⩽ 0.01).

CONCLUSIONS

Depression and social participation are inversely related. The physical environment, services/assistance, attitudes/support, and policies all impact post-stroke depression.

A preliminary report on a skills-based telephone-administered peer support programme for patients with multiple sclerosis

Objective: Peer-support interventions have shown no statistically significant or clinically meaningful effect on quality of life (QOL) or depressive symptoms for multiple sclerosis (MS) patients. Peer-support interventions for MS generally provide support but no skills training. The aim of this study was to evaluate a brief telephone-administered skills-training model of peer-support for patients with MS. Methods: Sixteen patients with MS showing signs of moderate distress received eight sessions of telephone-administered peer support (TAPS). TAPS is a manualized programme administered by peer-support counsellors diagnosed with MS. Using a workbook, peer-support counsellors teach skills to manage distress and MS symptoms. Subjective depression was assessed using the Center for Epidemiological Studies Depression Scale while objective depression was rated using the Hamilton Rating Scale for Depression. QOL was measured preand post-treatment using the SF-36. Results: The participants showed significant improvements on both the CESD (p=0.04) and the HRSD (p=0.01). Overall QOL improved significantly (p=0.045), however this was not reflected in either the Physical Health composite score or the Mental Health Composite Scale (p-0.17). Conclusions: These findings suggest that TAPS may prove to be an efficacious peer-support model for patients with MS.

Gut microbiome remodeling induces depressive-like behaviors through a pathway mediated by the host's metabolism

Major depressive disorder (MDD) is the result of complex gene-environment interactions. According to the World Health Organization, MDD is the leading cause of disability worldwide, and it is a major contributor to the overall global burden of disease. However, the definitive environmental mechanisms underlying the pathophysiology of MDD remain elusive. The gut microbiome is an increasingly recognized environmental factor that can shape the brain through the microbiota-gut-brain axis. We show here that the absence of gut microbiota in germ-free (GF) mice resulted in decreased immobility time in the forced swimming test relative to conventionally raised healthy control mice. Moreover, from clinical sampling, the gut microbiotic compositions of MDD patients and healthy controls were significantly different with MDD patients characterized by significant changes in the relative abundance of Firmicutes, Actinobacteria and Bacteroidetes. Fecal microbiota transplantation of GF mice with 'depression microbiota' derived from MDD patients resulted in depression-like behaviors compared with colonization with 'healthy microbiota' derived from healthy control individuals. Mice harboring 'depression microbiota' primarily exhibited disturbances of microbial genes and host metabolites involved in carbohydrate and amino acid metabolism. This study demonstrates that dysbiosis of the gut microbiome may have a causal role in the development of depressive-like behaviors, in a pathway that is mediated through the host's metabolism.

Telephone-Administered Interpersonal Psychotherapy by Nurse-Midwives for Postpartum Depression

INTRODUCTION

Postpartum depression (PPD) affects 7% to 13% of childbearing women. Access to care may be limited by maternal time constraints and fears of being judged, labeled as mentally ill, and having their infants taken away. The study's objective was to test the feasibility, effectiveness, and acceptability of certified nurse-midwife telephone-administered interpersonal psychotherapy (CNM-IPT) as a treatment for PPD.

METHODS

A prospective cohort study was conducted from 2010 to 2014. A sample of women meeting Diagnostic and Statistical Manual of Mental Disorders, Version 4, Text Revision (DSM-IV-TR) criteria for depression was recruited from 8 obstetric practices employing CNMs in the United States. Forty-one women in the treatment group received up to eight 50-minute CNM-IPT sessions, and 20 in the control group were referred to mental health professionals. The main outcome measure was the Hamilton Rating Scale for Depression. Secondary outcomes included maternal and marital functioning, mother-infant bonding, social support, and client satisfaction.

RESULTS

The Hamilton Rating Scale for Depression at 8 and 12 weeks was significantly lower among women in the treatment group compared to the control group (Week 8, P = .047; Week 12, P = .029). Client satisfaction was high in both groups. While only 5 out of 8 CNM-IPT counselors continued the intervention until the study's conclusion, CNM-IPT counselor protocol adherence was high.

DISCUSSION

CNM-IPT is effective and acceptable as a method of reducing the severity of PPD symptoms. Careful assessment of CNM availability is critical to intervention feasibility. Future research is needed to evaluate translation of this intervention into practice.

Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma

OBJECTIVE

Low attendance in psychotherapy, particularly among individuals with comorbid disorders, is a pervasive challenge. The present study examined predictors of treatment attendance in a sample of veterans with depression, substance use disorder, and trauma.

METHODS

This is an analysis of data collected as part of a larger clinical trial involving outpatients at a Veterans Administration dual diagnosis clinic. Individuals were excluded if they had significant memory deficits, schizophrenia, bipolar disorder, or substantial travel constraints. Participants (N = 146) received 12 weeks of group-delivered integrated cognitive behavioral therapy for depression and substance use, followed by randomization to 12 additional weeks of individually delivered cognitive behavioral therapy (n = 62) or cognitive processing therapy (n = 61) modified to address substance use and trauma. Participants, therapists, and researchers were not blinded to group assignment. For this study, we included only the 123 participants who were randomized into the second phase, analyzing predictors of treatment attendance categorized into predisposing factors, enabling factors, and need factors.

RESULTS

Participants were primarily male (89%) and Caucasian (76%) and averaged 47 years old (SD = 12). Forty-four percent had alcohol use disorder, 16% had drug use disorder, and 40% had polysubstance use disorder. Most met criteria for PTSD (82%), with 44% having combat-related trauma, 33% sexual trauma, and 28% other trauma. Treatment attendance did not differ between groups. More education was associated with increased group (r = .19, p = .04) and individual session attendance (r = .28, p = .002). Individuals with chronic housing problems attended fewer group sessions (r = -.19, p = .04), while individuals with sexual trauma, compared to those with other traumas, attended more individual sessions (r = .23, p = .01). Number of group sessions attended was positively associated with individual session attendance.

CONCLUSIONS

Few variables were significantly predictive of treatment attendance, possibly due to the complex nature of comorbid disorders. Including a focus on trauma was not associated with lower attendance. Special consideration may need to be given to education level, homelessness, and trauma when trying to engage and retain patients with comorbid disorders in treatment. This clinical trial is registered at www.clinicaltrials.gov as NCT00958217.

Attentional bias in euthymic bipolar I disorder

Little is known about the nature of the relation between information-processing biases and affective traits in bipolar disorder. The present study was designed to investigate whether attentional biases are evident in persons diagnosed with bipolar disorder when they are in a positive mood state, and whether biases are related to indices of emotion regulation and to prior history of mood episodes. Ninety adults diagnosed with bipolar I disorder and 81 controls with no lifetime mood disorder underwent a positive mood induction and then completed an emotion face dot-probe task; participants in the bipolar disorder group also completed a self-report measure of responses to positive affect. Attentional bias was not related to a diagnosis of bipolar disorder or to symptom severity. Consistent with hypotheses, analyses within the bipolar group indicated that greater dampening of positive affect related to significantly less attention paid to the positively valenced faces. Discussion focuses on the potential role of affective traits in shaping attentional bias in bipolar disorder.

Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial

IMPORTANCE

Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.

OBJECTIVE

To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study.

INTERVENTIONS

The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week.

MAIN OUTCOMES AND MEASURES

Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D).

RESULTS

The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005).

CONCLUSION AND RELEVANCE

Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01979302.

The Assessment of Poststroke Depression

Poststroke depression (PSD) is a common clinical consequence of stroke. PSD is associated with poor functional and social outcomes, reduced quality of life, the presence of cognitive impairment, and increased mortality. Despite the potential benefit associated with the identification and treatment of PSD, it often remains unrecognized and undertreated. The present study provides a critical review and synthesis of measurement properties for 10 instruments used in the assessment of depression following stroke. Assessment considerations specific to PSD are addressed, and tools are reviewed within the context of stroke. To facilitate the timely detection, diagnosis, and initiation of treatment for PSD, a two-step assessment process is recommended, thereby taking strategic advantage of the strengths and limitations associated with self-report and observer-rating assessment tools.

How do you feel? Detection of recurrent Major Depressive Disorder using a single-item screening tool

Mood is a key element of Major Depressive Disorder (MDD), and is perceived as a highly dynamic construct. The aim of the current study was to examine whether a single-item mood scale can be used for mood monitoring. One hundred thirty remitted out-patients were assessed using the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I), Visual Analogue Mood Scale (VAMS), 17-item Hamilton Depression Rating Scale (HAM-D17), and Inventory of Depressive Symptomatology-Self Report (IDS-SR). Of all patients, 13.8% relapsed during follow-up assessments. Area under the curves (AUCs) for the VAMS, HAM-D17 and IDS-SR were 0.94, 0.91, and, 0.86, respectively. The VAMS had the highest positive predictive value (PPV) without any false negatives at score 55 (PPV=0.53; NPV=1.0) and was the best predictor of current relapse status (variance explained for VAMS: 60%; for HAM-D17: 49%; for IDS-SR: 34%). Only the HAM-D17 added significant variance to the model (7%). Assessing sad mood with a single-item mood scale seems to be a straightforward and patient-friendly avenue for life-long mood monitoring. Using a diagnostic interview (e.g., the SCID) in case of a positive screen is warranted. Repeated assessment of the VAMS using Ecological Momentary Assessment (EMA) might reduce false positives.

Comparison of the hospital anxiety and depression scale and the center for epidemiological studies depression scale for detecting depression in women with breast or gynecologic cancer

OBJECTIVE

Depression is common in cancer patients but frequently undetected. Consensus regarding validity and optimal thresholds of screening measures is lacking. We investigated the validity of the Hospital Anxiety and Depression Scale (HADS-D) and Center for Epidemiological Studies Depression Scale (CES-D) relative to a referent diagnostic standard in women with breast or gynecologic cancer.

METHOD

Participants were 100 patients who completed the CES-D and HADS-D within a larger study. The Mini International Neuropsychiatric Interview was the criterion standard. Sensitivity, specificity, predictive values and likelihood ratios for various thresholds were calculated using receiver operating characteristics. Participants were assigned to two diagnostic groups: 'major depressive disorder' or 'any depressive disorder'.

RESULTS

Separate analyses were conducted whereby participants found to be receiving depression/anxiety treatment at the time of validation (n=28) were excluded. Both measures had good internal consistency and criterion validity. There were no statistical differences in global accuracy between the measures for detecting either group. For optimal sensitivity and specificity in both groups, generally recommended thresholds were lowered for the HADS-D. For the CES-D, the threshold was lowered for 'any depressive disorder' and raised for 'major depressive disorder'. Negative predictive values associated with our recommended cutoffs were excellent, but positive predictive values were poor.

CONCLUSIONS

The HADS-D and CES-D have acceptable properties and are equivalent for detecting depression in this population. Depending on the purpose of screening, the CES-D may be more suitable for identifying major depression. Threshold choice may have serious implications for screening program effectiveness, and the use of generally recommended thresholds should be cautious.

Psychopathological profile and health-related quality of life (HRQOL) in patients with hepatocellular carcinoma (HCC) and cirrhosis

In some tumors, psychosocial interventions may enhance health-related quality of life (HRQOL) of patients. The effects of psychological variables on HRQOL in hepatocellular carcinoma (HCC) patients have been rarely assessed. The aim of this work is to evaluate the psychopathological profile of HCC and cirrhotic patients and its effect on HRQOL. Twenty-four HCC patients (median age 71, Child A 21, Child B 3), 22 cirrhotic patients (median age 68, Child A 20, Child B 2) and 20 control subjects were included in this study. Each subject completes four questionnaires: medical outcomes study short form-36 (SF-36, HRQOL evaluation); Hamilton-D (quantitative evaluation of depression; positive ≥8); symptom check list 90-revised (SCL 90-R, general psychopathological profile; nine domains, each positive >1); Toronto alexithymia scale (TAS 20) (positive ≥60). SCL 90-R: cirrhotic patients differ from HCC subjects for somatization (SOM) (M ± SD 1.09 ± 0.6 vs 0.65 ± 0.6; p = 0.01) and anxiety (M ± SD 0.85 ± 0.46 vs 0.58 ± 0.38; p = 0.01) items. TAS 20: positive in 50% of HCC patients, in 54% of cirrhotic patients (p = n.s.) and in none of controls. Hamilton-D: higher scores in cirrhotic patients than in the HCC group (86 vs 46%; p = 0.005). SF-36: each item, except bodily pain, is lower in both group of patients in comparison with controls. Pearson correlation analysis shows negative correlations on HRQOL of depression, SOM and anxiety both in cirrhotic and HCC subjects, also of obsessive-compulsive and hostility items in HCC. This is the first report on the psychopathological profile of HCC patients: the results open questions on the role of psychological interventions that may improve HRQOL of patients before treatment and in the follow-up.

Rejection Sensitivity is Associated with Quality of Life, Psychosocial Outcome, and the Course of Depression in Euthymic Patients with Bipolar I Disorder

Rejection sensitivity has been found to predict the course of unipolar depression as well as key outcomes, but has not yet been considered within bipolar disorder. The present study investigated the effects of rejection sensitivity on outcome in bipolar disorder. Fifty-three participants diagnosed with bipolar I disorder in remission using the Structured Clinical Interview for DSM-IV were compared to 44 controls with no history of mood disorder. A subset of 38 bipolar participants completed follow-up interviews using standard symptom severity measures at 6 months. People with bipolar I disorder reported higher rejection sensitivity scores than did controls. Within the bipolar sample, rejection sensitivity at baseline predicted increases in depression, but not mania, over the following 6 months; heightened rejection sensitivity was also correlated with poorer quality of life, social support, and psychological well-being. Findings highlight the importance of interpersonal-cognitive factors for treating depression and improving outcome within bipolar I disorder.

Chronic stressors and trauma: prospective influences on the course of bipolar disorder

BACKGROUND

Exposure to life stress is known to adversely impact the course of bipolar disorder. Few studies have disentangled the effects of multiple types of stressors on the longitudinal course of bipolar I disorder. This study examines whether severity of chronic stressors and exposure to trauma are prospectively associated with course of illness among bipolar patients.

METHOD

One hundred and thirty-one participants diagnosed with bipolar I disorder were recruited through treatment centers, support groups and community advertisements. Severity of chronic stressors and exposure to trauma were assessed at study entry with in-person interviews using the Bedford College Life Event and Difficulty Schedule (LEDS). Course of illness was assessed by monthly interviews conducted over the course of 24 months (over 3000 assessments).

RESULTS

Trauma exposure was related to more severe interpersonal chronic stressors. Multiple regression models provided evidence that severity of overall chronic stressors predicted depressive but not manic symptoms, accounting for 7.5% of explained variance.

CONCLUSIONS

Overall chronic stressors seem to be an important determinant of depressive symptoms within bipolar disorder, highlighting the importance of studying multiple forms of life stress.

Synchronous telehealth technologies in psychotherapy for depression: a meta-analysis

BACKGROUND

Many patients suffering from depression lack immediate access to care. The use of synchronous telehealth modalities to deliver psychotherapy is one solution to this problem. This meta-analysis examined differences in treatment efficacy for psychotherapy administered via synchronous telehealth as compared to standard nontelehealth approaches.

METHOD

We located 14 articles that met inclusion criteria of the use of a synchronous telehealth modality for treatment compared to a standard nontelehealth modality comparison group.

RESULTS

Overall, a statistically significant systematic difference between modes of delivery was not identified (g = 0.14, SE = 0.08, 95% CI = [-0.03, 0.30], P = .098, I(2) = 49.74%). Stratification methods and metaregression were used to analyze the contributions of type of comparison group, intervention modality, and targeted mental health outcome to moderation of effect size (ES) estimates and heterogeneity. Type of comparison group (face-to-face versus care-as-usual) had the strongest influence on observed heterogeneity and moderated the summary ES. The only detectable difference in efficacy was restricted to studies that used care-as-usual as the comparison group (g = 0.29, SE = 0.06, 95% CI = [0.16, 0.41], P < .001, I(2) = 5.14%).

CONCLUSIONS

Overall, we found no evidence to suggest that the delivery of psychotherapy via synchronous telehealth modalities is less effective than nontelehealth means in reducing depression symptoms.

Tobacco smoking predicts depression and poorer quality of life in heart disease

Background

We report on the prospective association between smoking and depression and health-related quality of life (HRQOL) in patients with coronary artery disease (CAD).

Methods

Prospective study of 193 patients with assessment of depression occurring 3-, 6- and 9- months (T1, 2, and 3, respectively) following discharge from hospital for a cardiac event. HRQOL was assessed at T3. T1 depression was assessed by clinical interview; T2 and T3 depression was assessed by self-report. Smoking at time of cardiac event was assessed by self-report. Multivariate analyses controlled for known demographic, psychosocial and clinical correlates of depression.

Results

Smoking at the time of index cardiac event increased the likelihood of being diagnosed with Major Depressive Disorder (MDD) at T1 by 4.30 [95% CI, 1.12-16.46; p < .05]. The likelihood of receiving a diagnosis of minor depression, dysthymia or MDD as a combined group was increased by 8.03 [95% CI, 2.35-27.46; p < .01]. Smoking did not reliably predict depression at T2 or T3 and did not reliably predict persistent depression. Smoking increased the likelihood of being classified as depressed according to study criteria at least once during the study period by 5.19 [95% CI, 1.51-17.82; p < .01]. Smoking independently predicted worse mental HRQOL.

Conclusions

The findings support a role for smoking as an independent predictor of depression in CAD patients, particularly in the first 3 months post-cardiac event. The well-established imperative to encourage smoking cessation in these patients is augmented and the findings may add to the evidence for smoking cessation campaigns in the primary prevention of depression.

Psychometric properties of the Quick Inventory of Depressive Symptomatology (QIDS-SR) in UK primary care

It is widely believed that severity of depressive disorder should guide treatment selection and many guidelines emphasise this factor. The Quick Inventory of Depressive Symptomatology (QID-SR16) is a self-complete measure of depression severity which includes all DSM-IV criterion symptoms for major depressive disorder. The object of this study was to assess the psychometric properties of the QIDS-SR16 in a primary care sample. Adult primary care patients completed the QIDS-SR16 and were assessed by a psychiatrist (blind to QIDS-SR16) with the 17-item Hamilton Rating Scale for Depression (GRID-HAMD). Internal consistency, homogeneity and convergent and discriminant validity of the QIDS-SR16 were assessed. Severity cut-off scores for QIDS-SR16 were assessed for convergence with HRSD-17 cut-offs. Published methods for converting scores to HRSD-17 were also assessed. Two hundred and eighty-six patients participated: mean age = 49.5 (s.d. = 13.8), 68% female, mean HRSD-17 = 12.6 (s.d. = 7.6). The QIDS-SR16 exhibited acceptable internal consistency (Cronbach's alpha = 0.86), a robust factor structure indicating one underlying dimension and correlated highly with the HRSD-17 (r = 0.79) but differed significantly in how it categorised the severity of depression relative to the HRSD-17 (Wilcoxon Signed Rank Test p < 0.001). Using published methods to convert QIDS-SR16 scores to HRSD-17 scores did not result in alignment of severity categorisation. In conclusion, psychometric properties of the QIDS-SR16 were found to be strong in terms of internal consistency, factor structure and convergent and discriminant validity. Using conventional scoring and conversion methods the scale was found not to concur with the HRSD-17 in categorising the severity of depressive symptoms.

The multiple sclerosis depression rating scale

Depression is a troublesome issue in the lives of people with multiple sclerosis (MS). However, there are many questions about how to measure depression in people with MS. Depression is a syndrome that is characterized by emotional, cognitive and somatic symptoms. Depression scales are usually designed to cover each of these domains but in MS there is concern that cognitive deficits and somatic symptoms related to the illness itself may inflate depressive symptom scores, potentially leading to false-positive ratings. Such misclassification may consume excessive resources in screening programs due to the triggering of unnecessary clinical assessments. In research, such misclassification could lead to bias. In an effort to address these issues, the authors of the article under evaluation have recently developed a new scale, the Multiple Sclerosis Depression Rating Scale.

Measuring depression severity in general practice: discriminatory performance of the PHQ-9, HADS-D, and BDI-II

BACKGROUND

The UK Quality and Outcomes Framework (QOF) rewards practices for measuring symptom severity in patients with depression, but the endorsed scales have not been comprehensively validated for this purpose.

AIM

To assess the discriminatory performance of the QOF depression severity measures.

DESIGN AND SETTING

Psychometric assessment in nine Scottish general practices.

METHOD

Adult primary care patients diagnosed with depression were invited to participate. The HADS-D, PHQ-9, and BDI-II were assessed against the HRSD-17 interview. Discriminatory performance was determined relative to the HRSD-17 cut-offs for symptoms of at least moderate severity, as per criteria set by the American Psychiatric Association (APA) and NICE. Receiver operating characteristic curves were plotted and area under the curve (AUC), sensitivity, specificity, and likelihood ratios (LRs) calculated.

RESULTS

A total of 267 were recruited per protocol, mean age = 49.8 years (standard deviation [SD] = 14.1), 70% female, mean HRSD-17=12.6 (SD = 7.62, range = 0-34). For APA criteria, AUCs were: HADS-D = 0.84; PHQ-9 = 0.90; and BDI-II = 0.86. Optimal sensitivity and specificity were reached where HADS-D ≥9 (74%, 76%); PHQ-9 ≥12 (77%, 79%), and BDI-II ≥23 (74%, 75%). For NICE criteria: HADS-D AUC = 0.89; PHQ-9 AUC = 0.93; and BDI-II AUC = 0.90. Optimal sensitivity and specificity were reached where HADS-D ≥10 (82%, 75%), PHQ-9 ≥15 (89%, 83%), and BDI-II ≥28 (83%, 80%). LRs did not provide evidence of sufficient accuracy for clinical use.

CONCLUSION

As selecting treatment according to depression severity is informed by an evidence base derived from trials using HRSD-17, and none of the measures tested aligned adequately with that tool, they are inappropriate for use.

Cognitive Bias Modification Using Mental Imagery for Depression: Developing a Novel Computerized Intervention to Change Negative Thinking Styles

Why do some people see their glass as half-empty rather than half-full or even imagine that the glass will be filled in the future? Experimental methods can illuminate how individual differences in information processing style can profoundly impact mood or even result in disorders such as depression. A computerized cognitive bias modification intervention targeting interpretation bias in depression via positive mental imagery (CBM-I) was evaluated by investigating its impact on mental health and cognitive bias compared with a control condition. Twenty-six depressed individuals completed either positive imagery-focussed CBM-I or a control condition daily at home over one week. Outcome measures were collected pre-treatment and post-treatment and at two-week follow-up. Individuals in the positive condition demonstrated significant improvements from pre-treatment to post-treatment in depressive symptoms, cognitive bias and intrusive symptoms compared with the control condition. Improvements in depressive symptoms at two-week follow-up were at trend level. The results of this first controlled comparison of positive imagery-focussed CBM-I for depression further support the clinical potential of CBM-I and the development of a novel computerized treatment that could help patients imagine a more positive future. Broader implications concern the modification of individual differences in personality variables via their interaction with key information processing targets. Copyright © 2011 John Wiley & Sons, Ltd.

Reliability of the Hamilton Rating Scale for Depression: a meta-analysis over a period of 49 years

The aim of this study was to provide a comprehensive meta-analytic review of the reliability of the Hamilton Rating Scale for Depression (HRSD) for the period 1960-2008, taking into consideration all three types of reliability: internal consistency, inter-rater, and test-retest reliability. This is the first such meta-analytic study of a clinician-administered psychiatric scale. A thorough literature search was conducted using MEDLINE and PsycINFO. The total number of collected articles was 5548, of which 409 reported one or more reliability coefficients. The effect size was obtained by the z-transformation of reliability coefficients. The meta-analysis was performed separately for internal consistency, inter-rater and test-retest reliability. A pooled mean for alpha coefficient in random effects model was 0.789 (95%CI 0.766-0.810). The meta-regression analysis revealed that higher alpha coefficients were associated with higher variability of the HRSD total scores. With regard to inter-rater reliability, pooled means in random effects model were 0.937 (95%CI 0.914-0.954) for the intraclass correlation coefficient, 0.81 (95%CI 0.72-0.88) for the kappa coefficient, 0.94 (95%CI 0.90-0.97) for the Pearson correlation coefficient, and 0.91 (95%CI 0.78-0.96) for the Spearman rank correlation coefficient. A meta-regression analysis showed positive association between inter-rater reliability and publication year. Test-retest reliability of HRSD ranged between 0.65 and 0.98 and generally decreased with extending the interval between two measurements (Spearman r between the duration of interval and test-retest reliability figures=-0.74). Results suggest that HRSD provides a reliable assessment of depression. Figures indicate good overall levels of internal consistency, inter-rater and test-retest reliability, but some HRSD items (e.g., "loss of insight") do not appear to possess a satisfactory reliability.

The effect of telephone-administered cognitive-behavioral therapy on quality of life among patients with multiple sclerosis

BACKGROUND

Past research has found that a variety of physical, psychological, and social factors can affect quality of life (QOL). These previous findings suggest that interventions that address these factors could potentially improve QOL.

PURPOSE

The purpose of this study was to examine whether cognitive behavioral therapy (CBT) can improve QOL, and if so, explore which factors might mediate this effect.

METHODS

This is a secondary analysis of a randomized controlled trial. One hundred twenty-seven participants with multiple sclerosis and depression were randomly assigned to either a telephone-administered CBT (T-CBT) or telephone-administered supportive emotion-focused therapy (T-SEFT) intervention.

RESULTS

Patients assigned to T-CBT showed significantly greater improvements in QOL compared with those assigned to T-SEFT. The greater improvement in QOL among T-CBT recipients was mediated by improvements in depression and positive affect. There was also inconsistent support for the superior effect of CBT on QOL being mediated by improvement in fatigue.

CONCLUSIONS

T-CBT provided greater QOL benefits compared with T-SEFT, which controlled for non-specific treatment components. This study further suggests that T-CBT procedures specific to the management of depression and positive affect were uniquely useful in improving QOL.

Early patterns of symptom change signal remission with interpersonal psychotherapy for depressed adolescents

BACKGROUND

This study examined whether reductions in depression symptoms at different time points over the course of therapy predict remission for depressed adolescents treated with interpersonal psychotherapy (IPT-A) or treatment as usual (TAU) delivered in school-based health clinics.

METHODS

Participants were 63 adolescents (ages 12-18) drawn from a randomized controlled clinical trial examining the effectiveness of IPT-A Mufson et al. [2004; Archives of General Psychiatry 61:577-584]. Adolescents were randomized to receive IPT-A or TAU delivered by school-based mental health clinicians. Assessments were completed at baseline and weeks 4, 8, 12, and 16 (or at early termination) and included the Hamilton Rating Scale for Depression (HRSD; Hamilton [1967; British Journal of Social and Clinical Psychology 6:278-2962]).

RESULTS

Receiver operating characteristic analysis was used to identify the time point and degree of reduction in HRSD that best predicted remission (HRSD <7) at the end of the trial (week 16). Week 4 was the best time point for classifying adolescents as likely to remit or not likely to remit for both IPT-A and TAU. A 16.2% reduction in HRSD from baseline represented the best combined sensitivity and specificity in predicting week 16 remission status for adolescents treated with IPT-A. A 24.4% reduction in depressive symptoms represented the best combined sensitivity and specificity in predicting remission status for TAU.

CONCLUSIONS

These findings provide preliminary evidence of one early marker of remission with IPT-A. Replication with larger samples would suggest that depressed adolescents who have not demonstrated at least a 16.2% reduction in their depressive symptoms after 4 weeks of IPT-A may benefit from a change in the treatment plan.

Relationship between depression, fatigue, subjective cognitive impairment, and objective neuropsychological functioning in patients with multiple sclerosis

OBJECTIVE

This study explored the influence of depression and fatigue on subjective cognitive complaints and objective neuropsychological impairment in patients with multiple sclerosis (MS).

METHODS

Data for this study were taken from a randomized controlled trial, comparing 16 weeks of telephone-administered cognitive-behavioral therapy and telephone-administered supportive emotion focused therapy for the treatment of depression. The sample includes 127 patients with MS. The following self-report measures were collected pre- and posttreatment: Perceived Deficits Questionnaire, Beck Depression Inventory-II, and Modified Fatigue Impact Scale. Measures of objective cognitive functioning and the Hamilton Rating Scale for Depression were administered over the telephone.

RESULTS

Our results showed that changes in depression and fatigue significantly predicted changes in subjective cognitive complaints from pre- to posttreatment, with patients perceiving fewer cognitive problems at posttreatment (beta = .36, p < .001 and beta = .61, p < .001, respectively). Changes in depression and fatigue were not significantly related to changes in objective neuropsychological performance. Improvements in depression and fatigue also predicted improved accuracy in perceiving cognitive abilities from pre- to posttreatment (OR = .77, p < .001 and OR = .90, p < .001, respectively).

CONCLUSIONS

The results of this study suggest that improvements in depression and fatigue through treatment do not influence objective neuropsychological performance in MS patients, but do relate to changes in subjective impairment. Furthermore, these changes improve patients' abilities to accurately perceive their cognitive functioning.

A Framework for Assessing Broad Sense Agreement Between Ordinal and Continuous Measurements

Conventional agreement studies have been confined to addressing the sense of reproducibility, and therefore are limited to assessing measurements on the same scale. In this work, we propose a new concept, called "broad sense agreement," which extends the classical framework of agreement to evaluate the capability of interpreting a continuous measurement in an ordinal scale. We present a natural measure for broad sense agreement. Nonparametric estimation and inference procedures are developed for the proposed measure along with theoretical justifications. We also consider longitudinal settings which involve agreement assessments at multiple time points. Simulation studies have demonstrated good performance of the proposed method with small sample sizes. We illustrate our methods via an application to a mental health study.

Multimodal e-mental health treatment for depression: a feasibility trial

BACKGROUND

Internet interventions for depression have shown less than optimal adherence. This study describes the feasibility trial of a multimodal e-mental health intervention designed to enhance adherence and outcomes for depression. The intervention required frequent brief log-ins for self-monitoring and feedback as well as email and brief telephone support guided by a theory-driven manualized protocol.

OBJECTIVE

The objective of this feasibility trial was to examine if our Internet intervention plus manualized telephone support program would result in increased adherence rates and improvement in depression outcomes.

METHODS

This was a single arm feasibility trial of a 7-week intervention.

RESULTS

Of the 21 patients enrolled, 2 (9.5%) dropped out of treatment. Patients logged in 23.2 ± 12.2 times over the 7 weeks. Significant reductions in depression were found on all measures, including the Patient Health Questionnaire depression scale (PHQ-8) (Cohen's d = 1.96, P < .001), the Hamilton Rating Scale for Depression (d = 1.34, P < .001), and diagnosis of major depressive episode (P < .001).

CONCLUSIONS

The attrition rate was far lower than seen either in Internet studies or trials of face-to-face interventions, and depression outcomes were substantial. These findings support the feasibility of providing a multimodal e-mental health treatment to patients with depression. Although it is premature to make any firm conclusions based on these data, they do support the initiation of a randomized controlled trial examining the independent and joint effects of Internet and telephone administered treatments for depression.

Impact of psychotherapy on insomnia symptoms in patients with depression and multiple sclerosis

The purpose of the study was to evaluate the prevalence of insomnia in multiple sclerosis patients with comorbid depression, associations between psychological symptoms, multiple sclerosis symptoms and insomnia, and to test effects of a 16-week protocol-based psychotherapy intervention for depression on insomnia symptoms. Participants with multiple sclerosis and depression (n = 127) were randomized to telephone administered cognitive behavioral therapy and telephone administered supportive emotion-focused therapy. Multiple sclerosis functional limitation was measured at baseline. Depression, insomnia, anxiety and quality of life were evaluated at pre treatment, mid treatment (8 weeks), and post treatment (16 weeks). Prevalence of insomnia ≥3 times per week was 78% at pre treatment and 43% at post treatment. Insomnia at baseline was associated with depression, multiple sclerosis related mood symptoms and anxiety. Middle of the night awakenings were associated with swallowing and speech problems. Improvements in insomnia were associated with improvement in depression and anxiety. Participants with residual insomnia were more likely to have major depressive disorder, greater multiple sclerosis severity, elevated anxiety and lower mental components of quality of life. Results demonstrate rates of insomnia in patients with comorbid multiple sclerosis and depression are higher than those reported in the general multiple sclerosis population and additional insomnia treatment is indicated beyond the treatment of comorbid psychological disorders.

Comorbid anxiety disorders and treatment of depression in people with multiple sclerosis

OBJECTIVE

Anxiety is highly comorbid with depression, but little is known about the impact of anxiety disorders on the effectiveness of empirically supported psychotherapies for depression. We examined such outcomes for people with Multiple Sclerosis (MS) and depression, with versus without comorbid anxiety disorders.

DESIGN

Participants with MS (N = 102) received 16 weeks of telephone-administered psychotherapy for depression and were followed for one year post-treatment.

RESULTS

Participants with comorbid anxiety disorders improved to a similar degree during treatment as those without anxiety disorders. Outcomes during follow-up were mixed, and thus we divided the anxiety diagnoses into distress and fear disorders. The distress disorder (GAD) was associated with elevated anxiety symptoms during and after treatment. In contrast, fear disorders (i.e., panic disorder, agoraphobia, social phobia, specific phobia) were linked to depression, specifically during follow-up, across 3 different measures.

CONCLUSIONS

People with GAD receiving treatment for depression may benefit from additional services targeting anxiety more specifically, while those with comorbid fear disorders may benefit from services targeting maintenance of gains after treatment.

Sleep debt and depression in female college students

The objective of the study was to evaluate relationships between sleep habits and depressive symptoms. Pilot study data were collected about sleep schedules, related factors and depression in female college students to find whether their sleep schedules correlate with affective symptoms. In the subsequent main study, similar information was collected under more controlled conditions. Depression was measured using the CES-D (Center for Epidemiologic Studies Depression Scale) and HAM-D-3 (modified Hamilton Depression Rating Scale). Response rates were 31.3% of eligible students for the pilot survey and 71.6% for the main study. Both studies showed that about 20% of students reported weekday sleep debts of greater than 2 h and about 28% reported significantly greater sleep debt and had significantly higher depression scores (P<0.0001) than other students. Melancholic symptoms indicated by high CES-D scores (>24), were observed in 24% of students. Sleep problems explained 13% of the variance for both the CESD scale and the HAM-D-3 scale. Among female college students, those who report a sleep debt of at least 2 h or significant daytime sleepiness have a higher risk of reporting melancholic symptoms than others.