Interventions for preventing relapse or recurrence of depression in primary health care settings: A systematic review

Strategies for antidepressant medications in the maintenance phase: A systematic review and network Meta-analysis

BACKGROUND

In the management of depression, achieving and maintaining remission is crucial. This study aims to compare and rank the effectiveness of several antidepressant medication strategies for patients with depression in the maintenance phase.

METHODS

We included randomized controlled trials (RCTs) by searching MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL, PubMed and Web of Science. We included studies comparing at least two of the five treatment strategies: continuing the current antidepressant at the same dose; reducing the antidepressant dose; increasing the antidepressant dose; switching to another antidepressant; stopping and replacing the antidepressant with placebo. A standard random-effects network meta-analysis (NMA) was used to synthesize data. The study protocol was registered with PROSPERO, number CRD42023417283.

RESULTS

A total of 24 studies with 6055 individuals were included for analysis. All strategies outperformed stopping medication in relapse prevention. Specifically, continuing the same dose (RR 0.54; 95 % CI, 0.48-0.60), reducing dose (RR 0.49; 95 % CI, 0.34-0.72), increasing dose (RR 0.53; 95 % CI, 0.34-0.82), and switching to another antidepressant (RR 0.64; 95 % CI, 0.48-0.84) demonstrated significant efficacy.

CONCLUSION

These results suggest that continuing and reducing dose may show good performance in terms of efficacy, tolerability, and acceptability for patients with depression in the maintenance phase. Increased dose doesn't reduce efficacy but patients are more likely to interrupt treatment. Switching has moderate efficacy and acceptability, but the risk of adverse events is higher. Due to the limited number of included studies, further research is needed to determine these results.

Incidence of Major Depressive Disorder Relapse and Effectiveness of Pharmacologic and Psychological Interventions in Primary Care: A Systematic Review and Meta-Analysis: Incidence de la rechute du trouble dépressif majeur et efficacité des interventions pharmacologiques et psychologiques en soins primaires : revue systématique et méta-analyse

ObjectiveThis research aims to investigate the relapse rates of major depressive disorder (MDD) within primary care and evaluate the efficacy of relapse prevention therapies. Despite primary care being the common point of contact for MDD patients, there are limited studies around this.MethodsWe included randomized controlled trials and observational studies examining MDD relapse incidence and the effect of pharmacological and non-pharmacological interventions in preventing relapse in primary care. Databases; Medline via Ovid, EMBASE, The Cochrane Library, PsycInfo (ebsco), and Clinical Trials.gov were searched from their inception until September 7, 2022. Joanna Briggs Institute (JBI) appraisal instrument for methodological quality assessment was used. A proportional data analysis estimated the MDD relapse incidence. Therapy effectiveness results were shown as odds ratios with 95% confidence intervals, with heterogeneity explored via subgroup analysis.ResultsOut of the reviewed studies, 35 met the eligibility criteria. Quality appraisal scores varied between 73% and 96%. MDD relapse incidence was divided into subgroups, revealing that both pharmacotherapy and non-pharmacotherapy led to a similar decrease in relapse rates with combination therapies showing further reduction in relapse. Subgroup analyses by study design, follow-up length, date of study and quality of study also yielded noteworthy findings.ConclusionOur findings showed that MDD relapse rates in primary care settings can be effectively reduced by pharmacotherapy, non-pharmacotherapy, or combination therapy. Some psychological interventions might also reduce relapse likelihood. More studies are needed on individual and combined treatments over longer periods to understand their long-term impacts on MDD relapse in primary care.

Web-enhanced return-to-work coordination for employees with common mental disorders: reduction of sick leave duration and relapse

BACKGROUND

Common mental disorders (CMDs) are highly prevalent in workplace settings, and have become a significant public health challenge. This study aims to assess the effectiveness of PRATICAdr, a web application facilitated by a Return-to-Work Coordinator (RTW-C), with a focus on reducing sick leave duration and preventing relapse in individuals with CMDs.

METHODS

PRATICAdr, designed to enhance collaboration among Return-to-Work (RTW) stakeholders and provide systematic support throughout the RTW process, was evaluated in a quasi-experimental study. Survival analyses were used to compare sick leave durations and relapses between the experimental group (PRATICAdr with RTW-C), and control groups (RTW-C only). Both conditions had equal distribution of 50% from large public health organizations (n = 35) and 50% from a large private financial organization (n = 35). Mixed linear models were used to observe changes in clinical symptoms over time, especially for the experimental group.

RESULTS

The experimental group demonstrated significantly shorter sick leave durations and fewer relapses compared to the control group. Notably, the average absence duration was close to 3 months shorter in the experimental group. This difference was found when the RTW-C intervention (rehabilitation care) began 2 months after the onset of sick leave. Relapses occurred only in the control group (13.2%). The absence of relapses in the experimental group is noteworthy, along with the significant decrease in depressive and anxious symptoms over time.

CONCLUSIONS

The findings suggest that incorporating PRATICAdr into RTW-C intervention can lead to substantial cost savings by facilitating coordination among stakeholders and guiding the RTW process with validated tools. Initiation of RTW-C intervention alongside PRATICAdr within the first month of absence is recommended for optimal health and work outcomes.

Obstacles, Self-Efficacy, and Strategies for Returning to Work after Experiencing Burnout: Paving the Path to Sustainable Reintegration

PURPOSE

The objective of this study is twofold: (1) to better understand the Return-to-Work (RTW) process of employees on sick leave due to burnout by evaluating RTW obstacles and self-efficacy to overcome them, and (2) to investigate strategies implemented for maintaining employment following burnout.

METHOD

Fifty-one participants completed the online questionnaire titled "Return-to-Work Obstacles and Self-Efficacy Scale (ROSES)", and two focus groups were conducted with employees returning to work after experiencing burnout.

RESULTS

All the ROSES dimensions emerged as potential obstacles to returning to work after burnout. Several were particularly challenging to overcome, such as Fears of a relapse, Cognitive difficulties, and Loss of motivation to RTW. Qualitative analysis of verbatim from focus groups identified eight categories of strategies for overcoming these obstacles, such as Work involvement regulation strategies, Identity and anxiety regulation strategies, Seeking care and support from professionals, and Cognitive and metacognitive strategies, among the most often mentioned.

CONCLUSION

These findings pave the way for a more detailed analysis of the perceived obstacles individuals face during their RTW after burnout. Furthermore, the identification of strategies to overcome these obstacles may prove beneficial not only for the sustainable RTW of individuals, but also for the professionals who support them.

Effect of spiritual intelligence and employment status on the association between education and depressive symptoms among adults in rural Puducherry, India: A mediation analysis

BACKGROUND

Depression is a major global health concern, particularly in India, where it significantly impacts the population's well-being. The interplay of various factors, including education, employment status, and spiritual intelligence, contributes to the complex landscape of depressive symptoms among adults.

METHODOLOGY

A community-based cross-sectional study was conducted in the rural service areas of a tertiary care medical institution in rural India from March 2021 to September 2022. The study employed structured questionnaires and validated scales to assess depressive symptoms, spiritual intelligence, educational status, and occupational status among participants. Structural equation modelling was used for mediation analysis to evaluate the effect of spiritual intelligence and employment status on the association between education and depressive symptoms.

RESULTS

The study included 381 participants, with a prevalence of depressive symptoms at 14.4%. Higher educational attainment was associated with lower odds of depressive symptoms (aOR = 0.34, 95% CI [0.17, 0.67]). Employment status mediated the relationship between education and depression, with employed individuals exhibiting lower odds of depressive symptoms (aOR = 0.42, 95% CI [0.22, 0.82]). While spiritual intelligence was higher among those with formal education, its direct impact on depression was not statistically significant. The mediation analysis revealed that a significant portion (77.5%) of the total effect of education on depression was mediated through employment status and spiritual intelligence.

CONCLUSION

The study underscores the importance of education and employment opportunities in mitigating depressive symptoms among rural adults. It suggests targeted interventions that promote education and employment support to enhance mental health resilience. While spiritual intelligence may influence mental health outcomes, its exact role requires further investigation.

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: Protocol for a scoping review

INTRODUCTION

Patients with severe Major Depressive Disorder (MDD) have an increasing risk of new psychiatric hospitalizations following each new episode of depression highlighting the recurrent nature of the disorder. Furthermore, patients are not fully recovered at the end of their treatment in outpatient mental health services, and residual symptoms of depression might explain why patients with MDD have a high risk of relapse. However, evidence of methods to promote recovery after discharge from outpatient mental health services is lacking. The proposed scoping review aims to systematically scope, map and identify the evidence and knowledge gaps on interventions that aims to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care.

MATERIALS AND METHODS

The proposed scoping review will follow the latest methodological guidance by the Joanna Briggs Institute (JBI) in tandem with the Preferred Reporting Items for Systematic reviews and Meta-Analysis-extension for Scoping Reviews (PRISMA-ScR) checklist. The review is ongoing. Four electronic databases (Medline via PubMed, PsycINFO, CINAHL, and Sociological Abstracts) were systematically searched from 20 January 2022 till 29 March 2022 using keywords and text words. The review team consists of three independent screeners. Two screeners have completed the initial title and abstract screening for all studies retrieved by the search strategy. Currently, we are in the full text screening phase. Reference lists of included studies will be screened, and data will be independently extracted by the review team. Results will be analyzed qualitatively and quantitatively.

DISCUSSION

The chosen methodology is based on the use of publicly available information and does not require ethical approval. Results will be published in an international peer reviewed scientific journal, at national and international conferences and shared with relevant authorities.

REGISTRATION

A pre-print has been registered at the medRxiv preprint server for health sciences (doi.org/10.1101/2022.10.06.22280499).

Recognition During the Return-to-Work Process in Workers with Common Mental Disorders

Purpose Considering worker's perspective, the purpose of this study was twofold: (1) to document the meaning of the experience of recognition in the return to work (RTW) process of work after a sick leave due to a common mental disorder (CMD) and (2) to investigate the phenomenon of recognition for workers in the process of RTW after a sick leave due to a CMD, by evaluating the presence or absence of marks of recognition from salient RTW stakeholders stemming from different systems. Methods The Relational Caring Inquiry phenomenological method was used to explore the meaning of recognition during the return-to-work process and marks of recognition in a group of 20 workers who returned to their employment after a sick leave due to a CMD. In depth individual interviews were conducted with each participant. Results The definition of recognition that emerged from workers experiencing the RTW process is related to the behaviours and attitudes of various stakeholders, stemming from the work, health, insurance and social systems that allow them to feel appreciated, valued and respected, throughout the RTW process. Recognition was most often described as showing support, trust, respect for recovery and pace, and providing positive feedback. Conclusion The findings from this study could serve as guidelines in organizations regarding the RTW process, and in particular clarifying the roles and actions that different stakeholders could take in the workplace to stimulate expressions of meaningful recognition.

Healthy Minds: Group Cognitive-Behavioral Intervention for Sustainable Return to Work After a Sick Leave Due to Depression

Background Depression is one of the major causes for sick leave and loss of productivity at work. Many studies have investigated return to work (RTW) interventions for people with common mental disorders. However, a paucity of studies has targeted depressive symptoms in the workplace, as well as work productivity. Objectives This study presents preliminary results on a novel group intervention based on cognitive behavioral principles in order to optimize sustainable RTW, by reducing clinical symptoms (anxiety and depression) and improving work productivity. Method This pilot study followed a quasi-experimental design, with participants randomly receiving the group intervention (N = 19) or only receiving usual services (N = 11, control group). The group intervention called Healthy Minds for Sustainable RTW consists of eight sessions based on cognitive behavioral therapy principles and techniques. Outcome measures on depressive and anxiety symptoms and work productivity were administered at baseline (i.e. the start of return-to-work or gradual RTW), as well 2 months later (post-intervention), and at 6-month follow-up. Results The results did not show a time × group interaction for symptoms of depression or anxiety (p = 0.07). Those who received the group intervention however did see a within-group reduction in anxiety and depressive symptoms over time, clinically significant for the group intervention only. A significant time × group interaction for work productivity was found, with those in the intervention group improving over time compared to the control condition. Conclusion Although replication is needed, these results suggest that a brief group cognitive-behavioral intervention specifically tailored to work-related issues is promising. Future studies are warranted, particularly with larger samples and remote webconferencing delivery.

Developing a collaborative and sustainable return to work program for employees with common mental disorders: a participatory research with public and private organizations

PURPOSE

To disentangle the key steps of the return to work (RTW) process and offer clearer recovery-focused and sustainable RTW for people on sick leave due to common mental disorders (CMDs).

METHODS

This participatory research involves two large Canadian organizations. In each organization, we established an advisory committee composed of RTW stakeholders. We collected information in semi-structured interviews from RTW stakeholders (n = 26) with each member of the advisory committee in each organization, as well as with employees who had recently experienced CMDs. The interviews examined the RTW process for employees on sick leave due to CMDs as well as RTW stakeholders' perceptions of barriers and facilitators. A thematic approach was used to synthesize the data, following which, results were discussed with the two advisory committees to identify solutions considering key RTW steps.

RESULTS

Ten common key steps within the three RTW phases emerged from the semi-structured interviews with RTW stakeholders and discussions with the two advisory committees: 1) At the beginning of sickness absence and involvement of disability management team (phase 1), we found 3 steps (e.g., taking charge of the file), 2) during the involvement in treatment rehabilitation with health professionals and preparation of the RTW (phase 2), 4 steps (e.g., RTW preparation), and finally 3) the RTW and follow-up (phase 3) consists of 3 steps (e.g., gradual RTW).

CONCLUSION

A participatory study involving RTW stakeholders helped identify 10 common key steps within three phases to support RTW sustainability of people with CMDs. Future research will need to address how RTW coordinators intervene in the RTW process of employees with CMDs within these steps.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals will benefit from a detailed description of the RTW process (10 steps spread out over 3 RTW phases), allowing them to standardize it while adopting a personalized approach for the employee on sick leave.Rehabilitation professionals are informed of stakeholders' role and actions required in the RTW process; as such the communication between RTW stakeholders should be improved.RTW coordinators will be able to tailor more precisely their intervention, considering the detailed RTW process and RTW stakeholders' role and actions, and thus will become the pivot occupational health specialists for the RTW process.

Factors Associated With Depressive Episode Recurrences in Primary Care: A Retrospective, Descriptive Study

Introduction and Objective

The early identification of depressive patients having a poor evolution, with frequent relapses and/or recurrences, is one of the priority challenges in this study of high prevalence mental disorders, and specifically in depression. So, this study aims to analyze the factors that may be associated with an increased risk of recurrence of major depression episodes in patients treated in primary care.

Methods

A retrospective, descriptive study of cases-controls was proposed. The cases consisted of patients who had been diagnosed with major depression and who had presented recurrences (n = 101), in comparison with patients who had experienced a single major depression episode with no recurrence (n = 99). The variables of the study are age at first episode; number of episodes; perception of severity of the depression episode suffered prior to recurrence; number of residual symptoms; physical and psychiatric comorbidity; history of anxiety disorders; family psychiatric history; high incidence of stressful life events (SLEs); and experiences of physical, psychological, or sexual abuse in childhood. The differences of the variables were compared between the case subjects and the control subjects, using the Mann-Whitney, chi-square, and Fisher's U statistics. A multivariate analysis (ordinary logistic regression) was performed.

Results

The average age of those suffering more than one depressive episode is significantly older (5 years), and a higher percentage of subjects who have experienced more than one depressive episode have a history of anxiety disorders. In the multivariate analysis, the variables that obtained a significant value in the logistic regression analysis were age (OR: 1.03; value: 0.007) and having suffered sexual abuse during childhood (OR: 1.64; value: 0.072).

Conclusion

These indicators should be considered by primary care physicians when attending patients suffering from major depression.

The role of relapse prevention for depression in collaborative care: A systematic review

BACKGROUND

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

METHODS

We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.

RESULTS

93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.

LIMITATIONS

We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.

CONCLUSION

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Predicting rehospitalization within 2 years of initial patient admission for a major depressive episode: a multimodal machine learning approach

Machine learning methods show promise to translate univariate biomarker findings into clinically useful multivariate decision support systems. At current, works in major depressive disorder have predominantly focused on neuroimaging and clinical predictor modalities, with genetic, blood-biomarker, and cardiovascular modalities lacking. In addition, the prediction of rehospitalization after an initial inpatient major depressive episode is yet to be explored, despite its clinical importance. To address this gap in the literature, we have used baseline clinical, structural imaging, blood-biomarker, genetic (polygenic risk scores), bioelectrical impedance and electrocardiography predictors to predict rehospitalization within 2 years of an initial inpatient episode of major depression. Three hundred and eighty patients from the ongoing 12-year Bidirect study were included in the analysis (rehospitalized: yes = 102, no = 278). Inclusion criteria was age ≥35 and <66 years, a current or recent hospitalisation for a major depressive episode and complete structural imaging and genetic data. Optimal performance was achieved with a multimodal panel containing structural imaging, blood-biomarker, clinical, medication type, and sleep quality predictors, attaining a test AUC of 67.74 (p = 9.99^-05). This multimodal solution outperformed models based on clinical variables alone, combined biomarkers, and individual data modality prognostication for rehospitalization prediction. This finding points to the potential of predictive models that combine multimodal clinical and biomarker data in the development of clinical decision support systems.

Une intervention cognitive comportementale de groupe pour prévenir les rechutes chez les employés en processus de retour au travail à la suite d’une dépression : protocole et faisabilité

La dépression est une des causes d’absence maladie (ou arrêt maladie) les plus fréquentes en milieu organisationnel. Plusieurs études se sont intéressées aux facteurs individuels, organisationnels, et ceux relatifs aux interventions qui peuvent prédire le retour au travail des personnes ayant vécu une dépression. Toutefois, peu d’études s’intéressent à la prévention des rechutes de dépression à la suite d’un retour au travail, alors que plus de la moitié des personnes ayant vécu une première dépression est à risque de faire une rechute dans un délai assez court.

Objectif Cet article présente le protocole de recherche relatif à une intervention de groupe novatrice, d’orientation cognitive comportementale, en vue d’optimiser la santé mentale des employés lors de leur retour au travail et ainsi diminuer d’éventuelles rechutes. Nous visons aussi à présenter la faisabilité de cette approche.

Méthode L’étude consiste en un essai pilote randomisé avec groupe contrôle dont la moitié des participants (n= 25) suit l’intervention de groupe et l’autre moitié (n = 25) reçoit les services/interventions usuels. Les bases théoriques et empiriques soutenant l’intervention proposée ainsi qu’une description de l’intervention et des objectifs de l’étude sont ici présentées.

RésultatsNous décrirons succinctement les propos tenus par les participants des deux premières cohortes concernant leur appréciation à l’égard de l’intervention de groupe.

ConclusionEnfin, les retombées d’une telle intervention seront aussi évoquées.

Stratégies de retour au travail d’employés ayant fait l’expérience d’une dépression : perspectives des employeurs et des cadres des ressources humaines

La dépression majeure est l’une des premières causes d’incapacité au travail dans le monde et a de nombreuses conséquences tant sur l’employé concerné qu’auprès des acteurs du milieu de travail.

ObjectifNous visons à documenter, selon la perspective des employeurs et des cadres des ressources humaines, les stratégies que ces acteurs préconisent dans leur organisation pour faciliter le retour au travail (RaT) d’employés en absence maladie due à une dépression.

MéthodeDeux cent dix-neuf employeurs et cadres de ressources humaines (n = 219) ont accepté de répondre à une entrevue semi-structurée téléphonique. La question abordée dans cet article était : « Selon vous, quelles sont les stratégies les plus efficaces pour aider un employé ayant reçu un diagnostic de dépression à retourner au travail ? » La codification duverbatima été effectuée à partir d’études empiriques et de théories existantes.

RésultatsTrente-quatre (34) stratégies réparties sur six grands principes ont émergé : 1) Contact avec l’employé en absence maladie (10 stratégies) ; 2) Évaluation et planification du RaT sans précipitation (6) ; 3) Formation des gestionnaires et du collectif de travail à la problématique de la santé mentale au travail (4) ; 4) Concertation des acteurs clés du RaT (4) ; 5) RaT progressif avec aménagements (4) ; 6) Suivi de la santé de l’employé et de son travail (6).

ConclusionCes principes articulés autour de 34 stratégies du RaT vont au-delà d’un processus étapiste de nature chronologique. Articulés dans un programme de RaT, ils devront être testés afin d’évaluer leurs retombées dans les organisations, notamment sur la gestion de l’incapacité au travail.

The self-management of longer-term depression: learning from the patient, a qualitative study

BACKGROUND

Depression is a common mental health condition now viewed as chronic or long-term. More than 50 % of people will have at least one further episode of depression after their first, and therefore it requires long-term management. However, little is known about the effectiveness of self-management in depression, in particular from the patients' perspective. This study aimed to understand how people with longer-term depression manage the condition, how services can best support self-management and whether the principles and concepts of the recovery approach would be advantageous.

METHODS

Semi-structured in depth interviews were carried out with 21 participants, recruited from a range of sources using maximum variation sampling. Interpretative Phenomenological Analysis was used by a diverse team comprised of service users, practitioners and academics.

RESULTS

Four super-ordinate themes were found: experience of depression, the self, the wider environment, self-management strategies. Within these, several prominent sub-themes emerged of importance to the participants. These included how aspects of themselves such as hope, confidence and motivation could be powerful agents; and how engaging in a wide range of chosen activities could contribute to their emotional, mental, physical, social, spiritual and creative wellbeing.

CONCLUSIONS

Services in general were not perceived to be useful in specifically facilitating self-management. Increased choice and control were needed and a greater emphasis on an individualised holistic model. Improved information was needed about how to develop strategies and locate resources, especially during the first episode of depression. These concepts echoed those of the recovery approach, which could therefore be seen as valuable in aiding the self-management of depression.