Cognitive behavioural interventions for depression in chronic neurological conditions: a systematic review

"It's knowing that there are other people and they've accepted it": Patients' experiences of an acceptance and commitment therapy group intervention for people with neurological conditions

Individuals living with neurological conditions often face chronic issues including motor and sensory impairments and cognitive deficits. These challenges can lead to significant psychological difficulties, including anxiety, depression, and post-traumatic stress. Acceptance and Commitment Therapy (ACT) is a psychotherapeutic approach which aims to enhance psychological flexibility and acceptance while promoting behavioural change. Although ACT groups have shown promise in supporting individuals with neurological conditions, the evidence on patients' experiences of attending them is sparse. This project explored the experiences of individuals with a range of neurological conditions who had attended ACT group sessions as part of routine clinical practice, with the aim to refine future iterations of the intervention and enhancing patient care. Ten individual qualitative semi-structured interviews were carried out and the data were analysed thematically. Three overarching themes emerged from the analysis: (1) Initial Barriers to Group Attendance and Engagement; (2) Building an Environment of Acceptance; (3) Developing an ACT toolkit. Overall, the results showed that the ACT group intervention led participants to develop stronger emotional connectedness, better knowledge of their difficulties, more effective psychological skills, and different mindsets regarding their condition. Implications for the refinement of future ACT groups, neuropsychological service development, and clinical practice are discussed.

The efficacy of cognitive behavioural therapy for depression and anxiety in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Adults with multiple sclerosis (MS) frequently experience symptoms of depression and anxiety, which pose significant challenges. However, psychological support for these symptoms remains a major unmet healthcare need.

OBJECTIVES

To inform the evidence base for the psychological management of adults with MS, this study examined the efficacy of cognitive behavioural therapy (CBT) interventions for improving symptoms of depression and anxiety. CBT interventions teach skills for improving the relationships between an individual's thoughts, feelings, and/or behaviours. The study also examined the role of intervention and study characteristics as moderators of treatment effects.

METHODS

Medline, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials were searched up to August 2024 for randomised control trials.

RESULTS

A meta-analysis of 15 clinical trials (1508 participants) was conducted, which found a medium significant treatment effect size for depression symptoms (g = 0.59, 95 % Confidence Interval [CI] [0.38, 0.80]) and a small significant treatment effect size for anxiety symptoms (g = 0.38 95 % CI [0.19, 0.57]). Moderator analyses revealed treatment effects for anxiety, but not depression, were significantly larger for studies conducted in non-Western countries compared to Western countries, and for those with smaller sample sizes.

CONCLUSIONS

CBT-based interventions appear efficacious for the management of depression and anxiety symptoms in adults with MS. However, future clinical trials with larger samples and more rigorous methodology are warranted. Further examination of intervention characteristics, including ways in which CBT is tailored and how this relates to outcomes, may help to refine interventions for people with MS.

Depression and anxiety as predictors of performance status and life satisfaction in older adult neurological patients: a cross-sectional cohort study

Neurological disorders are one of the leading causes of disability globally. Studies emphasise that the course and effectiveness of rehabilitation interventions may be influenced by emotional factors. The aim of the present study was to assess the prevalence of depressive and anxiety symptoms in patients with neurological disorders and examine whether depression and tendency to respond with anxiety are predictors of disability in these patients. The study included 229 individuals with neurological disorders aged over 55. Our findings show that stroke patients are more likely to experience depressive symptoms and are more likely to display trait anxiety as compared with patients with other neurological disorders. Advanced age, female sex, low level of education and the presence of trait anxiety are associated with a higher severity of depressive symptoms. Stroke survivors have significantly poorer ECOG performance scores and are more likely to be incapable for work. Both depression and trait anxiety are significant predictors of neurological patients' performance status, and the presence of depressive symptoms is a determinant of these patients' level of satisfaction with life. An understanding of psychological risk factors for poorer performance status in individuals with neurological disorders will make it possible to plan prophylactic interventions in order to minimise negative health impacts and facilitate access to mental health facilities.

Cognitive behavioral therapy for managing depressive and anxiety symptoms after brain injury: a meta-analysis

BACKGROUND

Individuals with traumatic brain injury (TBI) are at increased risk of depression and anxiety, leading to impaired recovery. While cognitive-behavioral therapy (CBT) addresses anxiety and depression maintenance factors, its efficacy among those with TBI has not been clearly demonstrated. This review aims to bridge this gap in the literature.

METHODS

Several databases, including Medline, PsycInfo and EMBASE, were used to identify studies published between 1990 and 2021. Studies were included if: (1) trials were randomized controlled trials (RCT) involving CBT-based intervention targeting anxiety and/or depression; (2) participants experienced brain injury at least 3-months previous; (3) participants were ≥18 years old. An SMD ± SE, 95% CI and heterogeneity were calculated for each outcome.

RESULTS

Thirteen RCTs were included in this meta-analysis. The pooled-sample analyses suggest that CBT interventions had small immediate post-treatment effects on reducing depression (SMD ± SE: 0.391 ± 0.126, p < 0.005) and anxiety (SMD ± SE: 0.247 ± 0.081, p < 0.005). Effects were sustained at a 3-months follow-up for depression. A larger effect for CBT was seen when compared with supportive therapy than control. Another sub-analysis found that individualized CBT resulted in a slightly higher effect compared to group-based CBT.

CONCLUSION

This meta-analysis provides substantial evidence for CBT in managing anxiety and depression post-TBI.

Cognitive behavioural therapy for neurologists

In neurological practice, we take pride in accurate diagnosis and using neuroscience to develop novel disease-modifying therapies, but we sometimes neglect symptom management and the treatment of distress. Most patients with neurological disorders report that their mental health needs are not being met. Of the many forms of psychological therapy, cognitive behavioural therapy (CBT) is the most likely to be available to our patients. This article sets out to answer the following questions: (1) What is CBT? (2) What will patients experience if they have CBT? (3) Is CBT effective for people with neurological disorders? (4) Who is most suitable for CBT? (5) How and where can a neurologist refer their patients for CBT? (6) Can we as neurologists use aspects of the CBT model in our own consultations?

The efficacy of telephone-delivered cognitive behavioral therapy in people with chronic illnesses and mental diseases: A meta-analysis

COVID-19 pandemic led to an increase of remote treatments, such as telephone-delivery cognitive behavioral therapy (T-CBT). To our knowledge, no meta-analyses studied the effect of T-CBT in chronic and/or mental illnesses on multiple psychological outcomes. Therefore, our study aims to evaluating the efficacy of T-CBT compared to other interventions (treatment as usual, TAU, or face-to-face CBT). Each effect size (ES) was calculated in Hedges' g and pooled together to produce a mean ES for each outcome (depression, anxiety, mental and physical QoL, worry, coping, and sleep disturbances). The meta-analysis included 33 studies with a randomized controlled trial design. A large ES was found when comparing the efficacy of T-CBT against TAU on depression (g = 0.84, p < 0.001), whereas a moderate ES was found on anxiety (g = 0.57; p < 0.001), and a small effect on mental quality of life (g = 0.33, p < 0.001), sleep disturbances (g = 0.37, p = 0.042), coping (g = 0.20, p = 0.016) and worry (g = 0.43, p = 0.001). The meta-analysis comparing the efficacy of T-CBT and CBT on depression revealed a not significant pooled ES (g = 0.06, p = 0.466). The results provided evidence that T-CBT could be to be more effective than TAU conditions in multiple psychological outcomes, and as efficient as face-to-face CBT in treating depression.

The wellbeing neuro course: a randomised controlled trial of an internet-delivered transdiagnostic psychological intervention for adults with neurological disorders

BACKGROUND

Mental health and functional difficulties are highly comorbid across neurological disorders, but supportive care options are limited. This randomised controlled trial assessed the efficacy of a novel transdiagnostic internet-delivered psychological intervention for adults with neurological disorders.

METHODS

221 participants with a confirmed diagnosis of epilepsy, multiple sclerosis, Parkinson's disease, or an acquired brain injury were allocated to either an immediate treatment group (n = 115) or treatment-as-usual waitlist control (n = 106). The intervention, the Wellbeing Neuro Course, was delivered online via the eCentreClinic website. The Course includes six lessons, based on cognitive behavioural therapy, delivered over 10 weeks with support from a psychologist via email and telephone. Primary outcomes were symptoms of depression (PHQ-9), anxiety (GAD-7) and disability (WHODAS 2.0).

RESULTS

215 participants commenced the trial (treatment n = 111; control n = 104) and were included in intention-to-treat analysis. At post-treatment, we observed significant between-group differences in depression (PHQ-9; difference = 3.07 [95% CI 2.04-4.11], g = 0.62), anxiety (GAD-7; difference = 1.87 [0.92-2.81], g = 0.41) and disability (WHODAS 2.0 difference = 3.08 [1.09-5.06], g = 0.31), that favoured treatment (all ps < 0.001). Treatment-related effects were maintained at 3-month follow-up. Findings were achieved with minimal clinician time (average of 95.7 min [s.d. = 59.3] per participant), highlighting the public health potential of this approach to care. No adverse treatment events were reported.

CONCLUSIONS

Internet-delivered psychological interventions could be a suitable model of accessible supportive care for patients with neurological disorders.

The Effectiveness of Cognitive Behavioral Therapy for Depression Among Individuals with Diabetes: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Depression is prevalent and common among individuals living with diabetes. The aim of this review is to systematically assess and meta-analyze the treatment effect of cognitive-behavioral therapy for depression (and other affective outcomes) among patients with diabetes.

RECENT FINDINGS

Earlier investigations found both psychosocial and pharmacological interventions, including cognitive-behavioral therapy, were promising in managing depression in patients with diabetes, though these findings remain inclusive due to poor study designs and a small number of trials included, which calls for a comprehensive systematic review and meta-analysis. A total of 33 studies (89 effect sizes) reported a moderate and statistically significant treatment effect of cognitive-behavioral therapy for depressive symptoms among individuals with diabetes (d = 0.301, 95% CI 0.115-0.487, p < 0.001). On average, cognitive-behavioral therapy was effective for psychological stress/distress outcomes but not for anxiety or physiological outcomes. The findings of the study confirmed CBT as an effective treatment option for depression among diabetes patients and identified important areas for future research.

Third wave cognitive behavioural therapies for people with multiple sclerosis: a scoping review

PURPOSE

Multiple sclerosis (MS) is a chronic condition linked to a wide range of psychological difficulties. While traditional cognitive behavioural therapy has been studied extensively with people with MS, much less is known about more recent "third wave" approaches.

METHODS

A scoping review was carried out by performing a systematic search across MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library up to January 2022.

RESULTS

From an initial return of 8306 citations, 35 studies were included, 20 of which were randomised controlled trials (RCTs). These showed that four third wave approaches have been investigated with people with MS to date: acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). MBSR and MBCT may be helpful to address a range of psychological difficulties up to three months post-intervention. However, MS-specific adaptations may be required, and more evidence is needed on longer-term effectiveness. Limited evidence is also available for DBT and ACT, but additional research is warranted before any recommendation can be made.

CONCLUSIONS

As third wave approaches keep being refined, further more rigorous investigations are needed to implement them to the benefit of people with MS. Implications for RehabilitationMultiple sclerosis is linked to a wide range of psychological difficulties in adults.Little is currently known on third wave psychotherapies for people with MS.Mindfulness-based stress reduction and mindfulness-based cognitive therapy may be helpful to address a wide range of difficulties in MS.Specific adaptations may be needed to deliver suitable therapies to people with MS.Additional research is warranted to build on preliminary findings for DBT and ACT.

Cognitive Behavioral Therapy: Principles, Science, and Patient Selection in Neurology

Cognitive behavioral therapy (CBT) is a widely used therapeutic modality in general psychiatric practice. In this review, we consider its application to neurological disorders. We examine the basic framework of CBT-that symptoms, emotions, thoughts, and behaviors are all interrelated and that therapeutic interventions that lead to change in thoughts or behavior may have the potential to reduce symptoms or emotional distress. We also outline specific methodological issues to consider when reading or planning studies of CBT interventions, highlighting important topics pertaining to quality control, control group selection, dropouts, and generalizability. We then review the evidence base for CBT's use across a range of neurological disorders. In doing so, we highlight where there is a clear evidence base, and where it is a technique with potential. The review is targeted at a general neurology audience as introduction to the topic not as an advanced guide for expert practitioners.

Neuropsychiatric Treatments for Parkinson's Disease: Nonpharmacological Approaches

Although diagnosed by characteristic motor features, Parkinson's disease and other movement disorders are frequently accompanied by a wide range of neuropsychiatric symptoms that require a multidisciplinary approach for treatment. Neuropsychiatric symptoms such as depression, anxiety and cognitive symptoms strongly influence quality of life, motor symptoms, and non-motor bodily symptoms. This review summarizes our current understanding of the neuropsychiatric symptoms in movement disorders and discusses the evidence base for treatments focusing on rehabilitation and nonpharmacological approaches. A practical approach is then proposed for patient selection for specific treatments based on disease stage. The article focuses mostly on Parkinson's disease as a prototypical movement disorder with the largest evidence base but the principles discussed herein are applicable to a range of other movement disorders.

Disability and life satisfaction in neurological disorders: The role of depression and perceived cognitive difficulties

BACKGROUND

This study assessed factors associated with disability and life satisfaction in a large cohort of 2246 Australian adults with neurological disorders who completed an online survey of mental health and wellbeing. It was hypothesised that depressive symptoms and perceived cognitive difficulties would be significantly associated with both outcomes, even after controlling for significant demographic/medical covariates (e.g., age, marital-status, employment, multi-morbidity, medication). Differences in profiles of four neurological subgroups (i.e., multiple sclerosis; n = 738, epilepsy; n = 672, Parkinson's disease; n = 263, and Acquired Bran Injury; n = 278) were explored.

METHODS

Multiple hierarchical linear regressions were run using cross-sectional data.

RESULTS

Depressive symptoms made a significant and large unique contribution to higher levels of disability (β = 0.333, p < .001), and poorer life satisfaction (β = -0.434, p < .001), in the overall sample and across all four neurological subgroups (β = 0.349 to 0.513, p < .001) Greater perceived cognitive difficulties were associated with disability in the overall sample (β = 0.318, p < .001) and across all neurological subgroups (β = 0.231 to 0.354, p < .001), but only life satisfaction in epilepsy (β = -0.107, p = 006).

CONCLUSIONS

The findings underscore the importance of managing psychological/neuropsychiatric comorbidities in neurological disorders.

Innovating Parkinson's Care: A Randomized Controlled Trial of Telemedicine Depression Treatment

BACKGROUND

For several decades, a myriad of factors have contributed to the inadequate diagnosis and management of depression in Parkinson's disease (PD), leaving up to 60% of significantly symptomatic patients untreated. Poor access to evidence-based neuropsychiatric care is one major barrier to achieving optimal Parkinson's outcomes.

OBJECTIVE

The goal of this study was to compare the efficacy of individual Parkinson's-informed, video-to-home cognitive-behavioral therapy (experimental group), to clinic-based treatment as usual (control group), for depression in PD.

METHOD

Ninety United States military veterans with clinical diagnoses of both depression and PD were computer-randomized (1:1) to either the experimental or control group; randomization was stratified by baseline antidepressant use and blind to all other baseline data. The acute treatment period spanned 10 weeks and was followed by a 6-month extension phase. The Hamilton Depression Rating Scale was the a priori primary outcome. Depression treatment response was defined as a score ≤2 on the Clinical Global Impression Improvement Scale. All statistical analyses were intent to treat.

RESULTS

Video-to-home cognitive-behavioral therapy outperformed clinic-based treatment as usual across three separate depression measures (P < 0.001). Effects were observed at the end of acute treatment and maintained through 6-month follow-up. Number needed to treat (based on treatment response classification) was 2.5 with an absolute risk reduction of 40%.

CONCLUSION

Video-to-home cognitive-behavioral therapy may be an effective intervention to bypass access barriers to specialized, evidence-based depression care in PD and to address the unmet neuropsychiatric treatment needs of the Parkinson's community. © 2021 International Parkinson and Movement Disorder Society.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

A feasibility trial of an internet-delivered psychological intervention to manage mental health and functional outcomes in neurological disorders

OBJECTIVE

Mental health and cognitive difficulties are highly prevalent across neurological disorders and significantly contribute to poorer patient outcomes. Unfortunately, access to effective psychological services for these comorbidities are limited. To determine whether a novel transdiagnostic internet-delivered psychological intervention, the Wellbeing Neuro Course, was feasible, acceptable and efficacious a single-group feasibility open trial was employed.

METHODS

The Wellbeing Neuro Course, targets mental health and cognitive difficulties, across a variety of neurological disorders. It is comprised of six online lessons, based on Cognitive Behavioural Therapy and Compensatory Cognitive Rehabilitation, delivered over 10 weeks and provided with weekly support from a mental health professional via email and telephone. 105 adults with diagnoses of either epilepsy, multiple sclerosis, Parkinson's disease and/or acquired brain injury, underwent the intervention.

RESULTS

The intervention was found to be highly acceptable with high intervention completion and levels of satisfaction (>95%). There was evidence of clinically significant improvements in primary outcomes (within-group Cohen's d; average reductions) of depression (d = 0.93; avg. reduction ≥36%), anxiety (ds = 0.66, avg. reduction ≥36%), and disability (ds ≥ 0.49; avg. reduction ≥23%) at post-intervention, maintained at 3-month follow-up. For secondary outcomes there were significant improvements in fatigue severity and perceived cognitive difficulties of attention, planning and prospective memory. Findings were achieved with minimal clinician time, highlighting its public health potential.

CONCLUSION

This open trial provides preliminary evidence the Wellbeing Neuro Course is acceptable and reduces symptoms of depression, anxiety and disability in neurological disorders. Future controlled trials of the intervention are now needed.

TRIAL REGISTRATION

ACTRN12617000581369.

Telephone-based cognitive behavioral therapy for depression in Parkinson disease: A randomized controlled trial

Objective

To determine whether, for patients with depression and Parkinson disease (PD), telephone-based cognitive-behavioral treatment (T-CBT) alleviates depressive symptoms significantly more than treatment as usual (TAU), we conducted a randomized controlled trial to evaluate the efficacy of a 10-session T-CBT intervention for depression in PD, compared to TAU.

Methods

Seventy-two people with PD (PWP) were randomized to T-CBT + TAU or TAU only. T-CBT tailored to PWPs’ unique needs was provided weekly for 3 months, then monthly during 6-month follow-up. CBT targeted negative thoughts (e.g., “I have no control”; “I am helpless”) and behaviors (e.g., social withdrawal, excessive worry). It also trained care partners to help PWP practice healthy habits. Blind raters assessed outcomes at baseline, midtreatment, treatment end, and 1 and 6 months post-treatment. Analyses were intent to treat.

Results

T-CBT outperformed TAU on all depression, anxiety, and quality of life measures. The primary outcome (Hamilton Depression Rating Scale score) improved significantly in T-CBT compared to TAU by treatment end. Mean improvement from baseline was 6.53 points for T-CBT and −0.27 points for TAU (p < 0.0001); gains persisted over 6-month follow-up (p < 0.0001). Improvements were moderated by a reduction in negative thoughts in the T-CBT group only, reflecting treatment target engagement.

Conclusions

T-CBT may be an effective depression intervention that addresses a significant unmet PD treatment need and bypasses access barriers to multidisciplinary, evidence-based care.

Clinicaltrials.gov identifier

NCT02505737.

Classification of evidence

This study provides Class I evidence that for patients with depression and PD, T-CBT significantly alleviated depressive symptoms compared to usual care.

Differences in Incidence and Risks of Suicide Attempt and Suicidal Drug Overdose between Patients with Epilepsy with and without Comorbid Depression

Objective: To determine the differences in the incidences and risks of suicide attempt (SA) and suicidal drug overdose (SDO) between patients with epilepsy with and without comorbid depression by using data from Taiwan’s National Health Insurance Research Database. Methods: We analyzed data of patients (≥20 years) who had received epilepsy diagnoses between 2000 and 2012; the diagnosis date of epilepsy was defined as the index date. The epilepsy patients were divided into the cohorts, with and without comorbid depression, and compared against a cohort from the non-affected population. We calculated adjusted hazard ratios and the corresponding 95% confidence intervals for SA and SDO in the three cohorts after adjustment for age, sex, and comorbidities. Results: The incidences of SA and SDO in the cohort with epilepsy and depression were 42.9 and 97.4 per 10,000 person-years, respectively. The epilepsy with depression cohort had 21.3 times of SA risk; and 22.9 times of SDO risk than did the comparison cohort had a 6.03-fold increased risk of SA and a 2.56-fold increased risk of SDO than did the epilepsy patients without depression. Moreover, patients’ age <65 years, and female sex would further increase the risk of SA in patients with epilepsy and comorbid depression. Conclusion: Risks of SA and SDO in patients with epilepsy are proportionally increased when depression is coexisted. Our findings provide crucial information for clinicians and the government for suicide prevention and to question whether prescribing a large number of medications to patients with epilepsy and depression is safe.

The effects of cognitive behavioral and mindfulness-based therapies on psychological distress in patients with multiple sclerosis, Parkinson's disease and Huntington's disease: Two meta-analyses

OBJECTIVE

Psychological distress has a high impact on quality of life in patients with multiple sclerosis (MS), Parkinson's disease (PD), and Huntington's disease (HD). Studies have shown that cognitive behavioral therapy (CBT) and mindfulness-based therapies (MBTs) are successful in reducing psychological distress in patients with anxiety, depressive, and chronic somatic disorders. We aimed to investigate the effectiveness of these therapies in MS, PD, and HD patients.

METHODS

We performed a comprehensive literature search in PubMed, PsycINFO, Embase and the Cochrane Central Register of Controlled Trials up to March 2018. Randomized controlled trials (RCTs) investigating a CBT or MBT and reporting psychological outcome measures were included. Two separate meta-analyses were performed; one on studies comparing psychological therapy with a treatment as usual or waitlist condition and one on studies with active treatment control conditions.

RESULTS

The first meta-analysis (N = 12 studies, 8 in MS and 4 in PD populations) showed a significant effect size of g = 0.51 in reducing psychological distress. The second meta-analysis (N = 7 studies, in MS populations) showed a mean effect size of g = 0.36. No RCTs were found in HD populations. The overall quality of the included studies was low and considerable heterogeneity was found. No evidence was found for publication bias.

CONCLUSION

CBT and MBTs have a small to moderate effect on reducing psychological distress in patients with PD and MS. However, more research with better methodological quality and larger study samples is warranted, especially in HD patient populations.

Third-Wave Therapies for Long-Term Neurological Conditions: A Systematic Review to Evaluate the Status and Quality of Evidence

Background: Adults with long-term neurological conditions can face complex challenges including anxiety and depression. Emerging research suggests the utility of third-wave approaches (the third development of psychotherapies) in working transdiagnostically with these difficulties.

Aims: This systematic review sought to summarise and appraise the quality of published empirical studies using third-wave therapies such as Compassion Focused Therapy; Acceptance and Commitment Therapy; and Mindfulness-Based Cognitive Therapy or Mindfulness-Based Stress Reduction.

Method: Review procedures followed PRISMA guidelines, with 437 abstracts screened, 24 full-text articles retrieved and 19 studies found to meet inclusion criteria. Six out of seven randomised studies had unclear or high risk of bias, whilst the majority of non-randomised studies were considered moderate quality.

Results: Overall, studies reported a statistically significant reduction in emotional distress. Of the 13 studies that used model-specific process measures, 10 found statistically significant improvements in transdiagnostic factors.

Discussion: The findings indicate that third-wave therapies show promise in addressing transdiagnostic difficulties within neurological conditions. A number of methodological and conceptual issues for the included studies were highlighted during the quality appraisal process. Clinical implications include consideration of intervention length and use of outcome measures. Research implications are discussed by considering the progressive stages of development for behavioural treatments.

Sleep and fatigue after TBI

BACKGROUND

Whilst post traumatic brain injury fatigue (PTBIF) and sleep disturbance are common sequelae following brain injury, underlying mechanisms, and the potential for targeted interventions remain unclear.

OBJECTIVE

To present a review of recent studies exploring the epidemiology of PTBIF and sleep disturbance, the relationship and neuropsychological correlates of these issues, potential approaches to intervention, and implications for neurorehabilitation.

METHODS

A review of relevant literature was undertaken, with a focus on PTBIF relating to sleep disturbance, the neuropsychological correlates of these issues and implications for neurorehabilitation. This paper does not set out to provide a systematic review.

RESULTS

Multidimensional approaches to assessment and treatment of sleep disturbance and PTBIF are required.

CONCLUSIONS

There is a need for more robust findings in determining the complex nature of relationships between PTBIF, sleep disturbance, and correlates. Longitudinal prospective data is required to increase our understanding of the nature and course of PTBIF and sleep disturbance post TBI. Large scale clinical trials are required in evaluating the potential benefits of interventions.

Dopaminergic Lesion in the Olfactory Bulb Restores Olfaction and Induces Depressive-Like Behaviors in a 6-OHDA Model of Parkinson's Disease

Olfactory impairments and depressive behavior are commonly reported by individuals with Parkinson's disease (PD) being observed before motor symptoms. The mechanisms underlying these clinical manifestations are not fully elucidated. However, the imbalance in dopaminergic neurotransmission seems to play an important role in this context. In patients and animal models of PD, an increase in the dopaminergic interneurons of the glomerular layer in olfactory bulb (OB-gl) is observed, which may contribute to the olfactory impairment. In addition, neuronal imbalance in OB is related to depressive symptoms, as demonstrated by chemical olfactory bulbectomy. In view of that, we hypothesized that a reduction in the number or density of dopaminergic neurons present in OB could promote an olfactory improvement and, in contrast, would accentuate the depressive-like behaviors in the 6-hydroxydopamine (6-OHDA) model of PD. Therefore, we performed single or double injections of 6-OHDA within the substantia nigra pars compacta (SNpc) and/or in the OB-gl. We observed that, after 7 days, the group with nigral lesion exhibited olfactory impairment, as well as the group with the lesion in the OB-gl. However, the combination of the lesions prevented the occurrence of hyposmia. In relation to depressive-like behaviors, we observed that the SNpc injury promoted depressive-like behavior, being accentuated after a double injury. Our results demonstrated the importance of the dopaminergic neurons of the OB-gl in different non-motor features of PD, since the selective reduction of these periglomerular neurons was able to induce olfactory impairment and depressive-like behaviors.

Relationships between activity and well-being in people with parkinson's disease

OBJECTIVES

The complex symptomatology of Parkinson' disease (PD) usually goes along with reduced physical activity. Previous studies have indicated positive effects of activating therapies on patients' well-being. This study, therefore, examined how activity in daily life is related to patients' subjective condition.

MATERIALS AND METHODS

Twenty-one PD patients rated their condition every two hours during two routine days and documented the duration and type of their activities (based on the PRISCUS-Physical Activity Questionnaire) during the respective time intervals. They were furthermore assessed regarding motor and nonmotor symptoms, personality factors, and coping strategies.

RESULTS

Patients spent on average 8.59 ± 2.93 hr per day at physical rest and 5.47 ± 2.93 hr physically active. We found highly significant associations between positive condition ratings (such as happiness, motivation, and concentration) and the duration of subsequent physical activities (adj.r²  = .689) as well as between the duration of these activities and a subsequent improvement in the subjective condition (adj.r²  = .545). This was strongest in patients using active coping strategies and showing agreeable and conscientious personality traits (adj.r²  = .380). Nonmotor symptom severity was weakly inversely related to the daily amount of activities (adj.r²  = .273), whereas no significant association with motor symptom severity was found.

CONCLUSIONS

The results suggest a feedback process between a positive subjective condition and physical activities in PD patients. This appears to depend on the use of active coping strategies and nonmotor symptoms rather than on motor symptom severity. The results should encourage physicians to address the importance of everyday physical activities and to provide patients with behavioral advice.

The neuropsychiatry of multiple sclerosis

Multiple sclerosis (MS), an immune-mediated demyelinating condition, is the most common neurological disease affecting young adults in the UK. It has a high psychiatric comorbidity and over half of patients have some degree of cognitive impairment that adds to the burden of disability. This article reviews the psychiatric and cognitive manifestations of MS and their detection and treatment. Recent advances in the treatment of the disease are briefly reviewed and the impact of disease-modifying therapies on psychiatric morbidity and cognitive impairment is discussed.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Cognitive rehabilitation, self-management, psychotherapeutic and caregiver support interventions in progressive neurodegenerative conditions: A scoping review

BACKGROUND

Despite its potentially significant impact, cognitive disability may be overlooked in a number of progressive neurodegenerative conditions, as other difficulties dominate the clinical picture.

OBJECTIVE

We examined the extent, nature and range of the research evidence relating to cognitive rehabilitation, self-management, psychotherapeutic and caregiver support interventions in Parkinsonian disorders, multiple sclerosis (MS), frontotemporal dementias (FTD), motor neuron disease and Huntington's disease.

METHODS

Scoping review based on searches of MEDLINE and CINAHL up to 15 March 2016.

RESULTS

We included 140 eligible papers. Over half of the studies, and almost all the randomised controlled trials, related to MS, while a number of single case studies described interventions for people with FTD. CR interventions addressed functional ability, communication and interaction, behaviour or memory. The majority of psychotherapy interventions involved cognitive behavioural therapy for depression or anxiety. Self-management interventions were mainly available for people with MS. There were few reports of interventions specific to caregivers. Numerous methodological challenges were identified.

CONCLUSIONS

The limited range of studies for all conditions except MS suggests a need firstly to synthesise systematically the available evidence across conditions and secondly to develop well-designed studies to provide evidence about the effectiveness of CR and other psychological interventions.

Relation of depressive symptoms to outcome of CI movement therapy after stroke

OBJECTIVE

Depressive symptoms after stroke have been associated with negative outcomes, including poorer functional ability, less efficient use of rehabilitation services, decreased quality of life, and increased mortality. It has been anecdotally noted that depressive symptoms do not limit motor recovery in patients who undergo Constraint-Induced Movement Therapy (CIMT), an efficacious intervention for chronic poststroke hemiparesis. Here we analyze depressive symptom and motor scores from 40 participants who received CIMT in 2 previously published studies.

METHOD

Adults more than 1-year after stroke with mild to moderate upper-extremity hemiparesis completed the Zung Self-Rating Depression Scale and Motor Activity Log (MAL) before and after CIMT. We used regression analysis to test whether Zung scores predicted response to CIMT and paired t tests to test whether depressive symptoms changed from pre- to posttreatment.

RESULTS

Pretreatment Zung score did not predict outcome on the MAL Arm Use scale, ΔR2 (1, 30) = 0.004, p = .19, after controlling for pretreatment MAL scores. Additionally, participants had a small but statistically significant decrease in Zung score, t(39) = 3.0, p = .005, mean change = -3.6.

CONCLUSION

These results suggest that depressive symptoms do not significantly limit motor recovery in patients treated with CIMT for chronic poststroke hemiparesis. Additionally, treatment with CIMT may improve depressive symptoms. (PsycINFO Database Record

A qualitative study of cognitive behavioural therapy in multiple sclerosis: experiences of psychotherapists

Purpose: To investigate how psychotherapists experience using individual, face-to-face cognitive behavioural therapy (CBT) aimed at alleviating depressive symptoms in persons with multiple sclerosis (MS).

Method: Semi-structured interviews with three psychotherapists were conducted after CBT with 12 participants with MS, and analysed using qualitative content analysis.

Results: Two main themes emerged: Trusting their expertise as psychotherapists whilst lacking MS-specific knowledge, and The process of exploring the participants’ readiness for CBT with modifications of content and delivery. The psychotherapists perceived it difficult to know whether a symptom was attributable to depression or to MS, and for some participants the CBT needed to be adapted to a more concrete content.

Conclusions: Psychotherapists may need more MS-specific knowledge and an insight into the individual’s functioning. The content of CBT in terms of concrete home assignments and behavioural activation needs to be individualised.

Mind the gap: Exploring information gaps for the development of an online resource hub for epilepsy and depression

PURPOSE

Depression is common in epilepsy, and is often under-detected and under-treated. The motivation to create a depression eHub for persons with epilepsy is to connect them to the best available online resources to effectively manage their depression. The study sought to: 1) identify facilitators and barriers to accessing resources related to management of epilepsy and/or depression and 2) discuss gaps in available resources (free and in the public domain) and 3) identify suggestions for future content.

METHODS

Semi-structured interviews were conducted with ten patients with epilepsy and a history of depression. Using inductive analysis, two team members engaged in a process of textual open-coding utilizing a conventional content analysis approach whereby content was conceptually clustered based on the research questions. A phenomenological framework was applied to describe the phenomenon of online health resource access and utilization from the perspective of people with epilepsy.

RESULTS

Facilitators to the use of online resources included information credibility, thoughtful organization, and accessibility of resources. Barriers included difficulties finding and piecing together information from many different sites. Patients reported difficulty having the motivation to seek out resources while depressed, which was compounded by feelings of stigma, social isolation, and lack of control. Gaps in resources included a lack of information about living with epilepsy day-to-day and resources for family and friends. Suggested content included information to raise awareness about epilepsy and depression; questionnaires to screen for symptoms of depression; stories of other patients with epilepsy and depression via video or moderated forums; current research and news; local community resources; and tools and strategies to manage depression in epilepsy.

CONCLUSIONS

There is a gap in accessible resources for patients with epilepsy and depression as well as barriers that include epilepsy-related restrictions, depression-related impairments, lack of awareness, and stigmatization. These results should be used to guide the development of e-Health resources for patients with epilepsy.

Current Pharmaceutical Treatments and Alternative Therapies of Parkinson's Disease

Over the decades, pharmaceutical treatments, particularly dopaminergic (DAergic) drugs have been considered as the main therapy against motor symptoms of Parkinson's disease (PD). It is proposed that DAergic drugs in combination with other medications, such as monoamine oxidase type B inhibitors, catechol-O-methyl transferase inhibitors, anticholinergics and other newly developed non-DAergic drugs can make a better control of motor symptoms or alleviate levodopa-induced motor complications. Moreover, non-motor symptoms of PD, such as cognitive, neuropsychiatric, sleep, autonomic and sensory disturbances caused by intrinsic PD pathology or drug-induced side effects, are gaining increasing attention and urgently need to be taken care of due to their impact on quality of life. Currently, neuroprotective therapies have been investigated extensively in pre-clinical studies, and some of them have been subjected to clinical trials. Furthermore, non-pharmaceutical treatments, including deep brain stimulation (DBS), gene therapy, cell replacement therapy and some complementary managements, such as Tai chi, Yoga, traditional herbs and molecular targeted therapies have also been considered as effective alternative therapies to classical pharmaceutics. This review will provide us updated information regarding the current drugs and non-drugs therapies for PD.

Affective disorders and functional (non-epileptic) seizures in persons with epilepsy

OBJECTIVE

This paper aims to describe the prevalence, assessment and management of affective disorders as well as functional (non-epileptic) seizures in people with epilepsy.

METHOD

This paper comprises a selective review of the literature of the common affective manifestations of epilepsy.

RESULTS

Affective disorders are the most common psychiatric comorbidity seen in people with epilepsy and assessment and management parallels that of the general population. Additionally, people with epilepsy may experience higher rates of mood instability, irritability and euphoria, classified together as a group, interictal dysphoric disorder and resembling an unstable bipolar Type II disorder. Functional seizures present unique challenges in terms of identification of the disorder and a lack of specific management.

CONCLUSIONS

Given their high prevalence, it is important to be able to recognise affective disorders in people with epilepsy. Management principles parallel those in the general population with specific caution exercised regarding the potential interactions between antidepressant medications and antiepileptic drugs. Functional seizures are more complex and require a coordinated approach involving neurologists, psychiatrists, general practitioners, nursing and allied health. There is very limited evidence to guide psychological and behavioural interventions for neurotic disorders in epilepsy and much more research is needed.

Diagnosing and treating depression in epilepsy

At least one third of patients with active epilepsy suffer from significant impairment of their emotional well-being. A targeted examination for possible depression (irrespective of any social, financial or personal burdens) can identify patients who may benefit from medical attention and therapeutic support. Reliable screening instruments such as the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) are suitable for the timely identification of patients needing help. Neurologists should be capable of managing mild to moderate comorbid depression but referral to mental health specialists is mandatory in severe and difficult-to-treat depression, or if the patient is acutely suicidal. In terms of the therapeutic approach, it is essential first to optimize seizure control and minimize unwanted antiepileptic drug-related side effects. Psychotherapy for depression in epilepsy (including online self-treatment programs) is underutilized although it has proven effective in ten well-controlled trials. In contrast, the effectiveness of antidepressant drugs for depression in epilepsy is unknown. However, if modern antidepressants are used (e.g. SSRI, SNRI, NaSSA), concerns about an aggravation of seizures and or problematic interactions with antiepileptic drugs seem unwarranted. Epilepsy-related stress ("burden of epilepsy") explains depression in many patients but acute and temporary seizure-related states of depression or suicidality have also been reported. Limbic encephalitits may cause isolated mood alteration without any recognizable psychoetiological background indicating a possible role of neuroinflammation. This review will argue that, overall, a bio-psycho-social model best captures the currently available evidence relating to the etiology and treatment of depression as a comorbidity of epilepsy.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) has revised its 2009 guidelines for the management of major depressive disorder (MDD) in adults by updating the evidence and recommendations. The target audiences for these 2016 guidelines are psychiatrists and other mental health professionals.

METHODS

Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Psychological Treatments" is the second of six sections of the 2016 guidelines.

RESULTS

Evidence-informed responses were developed for 25 questions under 5 broad categories: 1) patient characteristics relevant to using psychological interventions; 2) therapist and health system characteristics associated with optimizing outcomes; 3) descriptions of major psychotherapies and their efficacy; 4) additional psychological interventions, such as peer interventions and computer- and technology-delivered interventions; and 5) combining and/or sequencing psychological and pharmacological interventions.

CONCLUSIONS

First-line psychological treatment recommendations for acute MDD include cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and behavioural activation (BA). Second-line recommendations include computer-based and telephone-delivered psychotherapy. Where feasible, combining psychological treatment (CBT or IPT) with antidepressant treatment is recommended because combined treatment is superior to either treatment alone. First-line psychological treatments for maintenance include CBT and mindfulness-based cognitive therapy (MBCT). Patient preference, in combination with evidence-based treatments and clinician/system capacity, will yield the optimal treatment strategies for improving individual outcomes in MDD.

Electroencephalographic findings in patients with major depressive disorder during cognitive or emotional tasks: a systematic review

Objective:

Major depressive disorder (MDD) is a prevalent psychiatric condition characterized by multiple symptoms that cause great distress. Uncovering the brain areas involved in MDD is essential for improving therapeutic strategies and predicting response to interventions. This systematic review discusses recent findings regarding cortical alterations in depressed patients during emotional or cognitive tasks, as measured by electroencephalography (EEG).

Methods:

A search of the MEDLINE/PubMed and Cochrane databases was carried out using the keywords EEG and depression, confined to article title.

Results:

The studies identified reveal the frontal cortex as an important brain structure involved in the complex neural processes associated with MDD. Findings point to disorganization of right-hemisphere activity and deficient cognitive processing in MDD. Depressed individuals tend to ruminate on negative information and respond with a pattern of relatively higher right frontal activity to emotional stimuli associated with withdrawal and isolation.

Conclusion:

Patients with MDD may have altered dynamic patterns of activity in several neuroanatomical structures, especially in prefrontal and limbic areas involved in affective regulation. Identification of these alterations might help predict the response of patients to different interventions more effectively and thus maximize the effects both of pharmacotherapeutic and of psychotherapeutic strategies.

Self-Management Interventions to Prevent Depression in People with Mobility Limitations

Introduction

This focused review reports on the impact of self-management interventions on depression in people with a mobility disability.

Method

There were two phases to the search including a comprehensive scoping review of the literature examining multiple secondary conditions impacted by self-management programs (Phase 1) and a focused review of the literature detailing the impact of self-management interventions on depression (Phase 2). CINAHL, PubMed, and PsyclNFO were searched for articles published between January 1988 through August 2014 and studies were screened by the first author based on specific inclusion and exclusion criteria.

Results

Twenty-five studies met criteria with results, demonstrating a mixed effect of self-management programs on depression. Sixteen studies included an intervention and control/comparison group, of which eight (50%) had a significant effect on depression. A further nine studies did not include a control/comparison group and five found significant changes in depression and four found no change. Eighteen out of 25 studies (72%) were rated as having moderate-to-high bias and nine different outcome measures were used across studies.

Discussion

Based on the mixed findings and varied approaches adopted for intervention and outcome assessment, future research should adopt a more rigorous methodological approach to examine self-management interventions on depression.

The clinical effectiveness of cognitive behavior therapy and an alternative medicine approach in reducing symptoms of depression in adolescents

The main aim of the study was to investigate the effectiveness of two psychotherapeutic approaches, cognitive behavioral therapy (CBT) and a complementary medicine method Reiki, in reducing depression scores in adolescents. We recruited 188 adolescent patients who were 12-17 years old. Participants were randomly assigned to CBT, Reiki or wait-list. Depression scores were assessed before and after the 12 week interventions or wait-list. CBT showed a significantly greater decrease in Child Depression Inventory (CDI) scores across treatment than both Reiki (p<.001) and the wait-list control (p<.001). Reiki also showed greater decreases in CDI scores across treatment relative to the wait-list control condition (p=.031). The analyses indicated a significant interaction between gender, condition and change in CDI scores, such that male participants showed a smaller treatment effect for Reiki than did female participants. Both CBT and Reiki were effective in reducing the symptoms of depression over the treatment period, with effect for CBT greater than Reiki. These findings highlight the importance of early intervention for treatment of depression using both cognitive and complementary medicine approaches. However, research that tests complementary therapies over a follow-up period and against a placebo treatment is required.

Recognition and treatment of neuropsychiatric disturbances in Parkinson's disease

The non-motor symptoms of Parkinson's disease (PD) have been attracting increasing attention due to their ubiquitous nature and their often devastating effects on the quality of life. Behavioral problems in PD include dementia, depression, apathy, fatigue, anxiety, psychosis, akathisia, personality change, sleep disorders and impulse control disorders. Some of these are intrinsic to the neuropathology while others occur as an interplay between pathology, psychology and pharmacology. While few data exist for guiding therapy, enough is known to guide therapy in a rational manner.