Problem solving treatment and group psychoeducation for depression: multicentre randomised controlled trial. Outcomes of Depression International Network (ODIN) Group

A translationally informed approach to vital signs for psychiatry: a preliminary proof of concept

The nature of data obtainable from the commercial smartphone - bolstered by a translational model emphasizing the impact of social and physical zeitgebers on circadian rhythms and mood - offers the possibility of scalable and objective vital signs for major depression. Our objective was to explore associations between passively sensed behavioral smartphone data and repeatedly measured depressive symptoms to suggest which features could eventually lead towards vital signs for depression. We collected continuous behavioral data and bi-weekly depressive symptoms (PHQ-8) from 131 psychiatric outpatients with a lifetime DSM-5 diagnosis of depression and/or anxiety over a 16-week period. Using linear mixed-effects models, we related depressive symptoms to concurrent passively sensed behavioral summary features (mean and variability of sleep, activity, and social engagement metrics), considering both between- and within-person associations. Individuals with more variable wake-up times across the study reported higher depressive symptoms relative to individuals with less variable wake-up times (B [95% CI] = 1.53 [0.13, 2.93]). On a given week, having a lower step count (-0.16 [-0.32, -0.01]), slower walking rate (-1.46 [-2.60, -0.32]), lower normalized location entropy (-3.01 [-5.51, -0.52]), more time at home (0.05 [0.00, 0.10]), and lower distances traveled (-0.97 [-1.72, -0.22]), relative to one's own typical levels, were each associated with higher depressive symptoms. With replication in larger samples and a clear understanding of how these components are best combined, a behavioral composite measure of depression could potentially offer the kinds of vital signs for psychiatric medicine that have proven invaluable to assessment and decision-making in physical medicine. Clinical Trials Registration: The data that form the basis of this report were collected as part of clinical trial number NCT03152864.

Psychometric evaluation of the patient health questionnaire stress scale

The "Patient Health Questionnaire (PHQ)" is a screening instrument, designed for time-efficient detection and severity assessment of depression, anxiety, and other syndromes in medical settings. Besides the questions on psychological symptoms, there are items on psychosocial functioning, on stressors and critical life events. However, for the stress items there are no psychometric properties available until now. The present study is thought to investigate item characteristics, internal consistency as well as factorial and construct validity of the stress scale of the PHQ. A representative sample of the general population of Germany was collected by a demography consulting company (USUMA, Berlin). Per random-route procedure, households and members of the households were selected. The sample was representative for the German community regarding age, gender, and education. In this investigation the following questionnaires were administered: PHQ-Stress, Questions on Life Satisfaction Modules (FLZ-M), Type-D Scale-14 (DS14). The sample included N = 2396 participants with mean age of 48.50 (SD = 17.75; range = 14 to 92) and 55.2 % being female. Reliability of the PHQ stress scale was acceptable (ω = 0.776), but some factor loadings were comparatively low. Model fit indices showed mixed results, some indicating unacceptable and some indicating acceptable fit of the 10-item stress scale of the PHQ. Correlations with related constructs demonstrated the scale's convergent validity. The results of this validation study indicate that the PHQ stress scale, which provides a one-dimensional total stress score, is a valid, good practical and reliable self-report instrument for assessing the severity of psychosocial stress.

In-person psychoeducational intervention to reduce rehospitalizations and improve the clinical course of major depressive disorder: a non-randomized pilot study

Background

Emerging issues in the management of major depressive disorder (MDD) comprise a nonadherence to treatment and treatment failures, depressive recurrence and relapses, misidentification of incoming exacerbated phases and consequently, a chronification of depression. While antidepressant drugs constitute the standard of care for MDD, effective psychosocial interventions are needed to reduce rehospitalizations and other adverse events. The present study primarily investigated the effects and impact of implementing a structured psychoeducational intervention on the clinical course of MDD.

Methods

A non-randomized comparative, pragmatic, pilot, single-center study of adults with nonpsychotic moderate or severe episode of MDD recently discharged from a psychiatric hospitalization. The consecutive subjects were allocated either to the intervention group (N=49) or to the attention control group (N=47), based on their preference. The psychoeducational intervention was based on a modified Munoz's Depression Prevention Course. Subjects were followed up prospectively for two years.

Results

The absolute changes in Beck anxiety inventory scale, Zung's depression questionnaire, and Montgomery and Äsberg depression rating scale (MADRS) total scores at 6-month follow-up were comparable between the two groups. There were lower rates of the rehospitalization within one year (2.1% vs. 16.7%; P<0.001) and less rehospitalizations after one year (6.3% vs. 25%; P<0.001), lower rates of the ongoing sickness absence (11.5% vs. 29.2%; P<0.001), less persons with disability due to MDD at 1-year follow-up (1% vs. 11.5%; P=0.002), and less nonadherent subjects who self-discontinued treatment (6.3% vs. 28.1%; P<0.001) among participants in the intervention group compared to the control group. The disability due to MDD at 1-year follow-up was predicted by the absence of the psychoeducational intervention (P=0.002) and by the MADRS total score at 6-month follow-up (OR 1.10; 95% CI 1.003-1.195; P=0.044). Qualitative data indicated the intervention was desired and appreciated by the participants, as well as being practical to implement in Slovakian clinical settings.

Conclusion

The results suggest the psychoeducational intervention based on a modified Munoz's Depression Prevention Course has beneficial effects in adults with MDD recently discharged from a psychiatric hospitalization. The findings implicate the psychoeducational intervention may offer a new approach to the prevention of depressive relapses.

Effectiveness of group cognitive behavioral therapy for depression in adults: a systematic review and meta-analysis of delivery by different healthcare professionals

This study addresses the gap in understanding the varied effectiveness of group cognitive behavioral therapy (gCBT) delivered by different professionals. This study aims to address this gap by conducting a systematic review of randomized controlled trials (RCTs) that evaluate gCBT and compare it to inactive controls in adults with a clinical diagnosis of depression. A total of 33 RCTs were included for analysis. In the overall analysis, 'profession of gCBT deliverer' was not a significant moderator in the meta-regression model (p = 0.57). For people without comorbidity, the overall effect size estimate was -0.69 (95% CI, -1.01. to -0.37, p = 0.03). Among gCBT deliverers, psychologists and nurses/psychiatric nurses demonstrated significant effectiveness, with psychologists showing a large effect size of -0.78 (95% CI, -1.25 to -0.30, p < 0.01) and nurses/psychiatric nurses showing a medium effect size of -0.45 (95% CI, -0.85 to -0.05, p = 0.03). The certainty of evidence for both professionals was moderate. These results have significant implications for the delivery of mental healthcare, as nurses/psychiatric nurses may be more accessible and cost-effective than psychologists in some settings. However, further research is necessary to determine the effectiveness of gCBT delivered by a broader range of healthcare professionals for patients with depression and other comorbidities.

Case report: A dual case study of how clinical feedback can be a communication aide and influence therapeutic work

Background

While routine outcome monitoring and clinical feedback may improve outcomes after psychotherapy, results from efficiency studies have been mixed. Moreover, how clinical feedback is implemented influences how it works for patients and clinicians, and working mechanisms are hitherto not thoroughly explored. Researchers have argued that inviting and using feedback from patients is best conceived of as a clinical skill. In this paper, we use case study methodology to explore and describe feedback's functions within three clinical skill themes: actualizing alliance work, concretizing change and stagnation and verbalizing the non-verbal.

Case presentation

Sonja is a young adult patient with a trauma background. She has a history of serious suicide attempts and distrust in relationships. She attended psychotherapy for eight months. Harald is a middle-aged man with a stable family. Traumatic events in his past has made him conceal own needs and developing depression. He attended psychotherapy for 19 months. Case material include the patient's clinical feedback over a range of life areas, medical health notes and the therapist's process notes.

Conclusion

Clinical feedback can be a positive supplement to the therapeutic work and process. The importance of making this as a joint tool between the client and the therapist is significant.

Perceived benefits from peer-support among family caregivers of people with amyotrophic lateral sclerosis and cognitive impairments in a palliative rehabilitation blended online learning programme

RATIONALE

Family caregivers of persons with amyotrophic lateral sclerosis and cognitive and/or behavioural impairments (PALS/CIs) experience various challenges and needs, including emotional and practical support from peers. Various forms of peer-support have shown different strengths and weaknesses; however, little is known about how family caregivers of PALS/CIs interact with and perceive virtual face-to-face peer-support.

AIMS AND OBJECTIVES

The aim of this study was to understand how caregivers of PALS/CIs interact with and perceive virtual face-to-face peer-support in a palliative rehabilitation programme designed to promote targeted palliative rehabilitation initiatives for caregivers of PALS/CIs.

METHOD

A qualitative design using participant observations of 17 recorded virtual group-facilitated meetings from two rounds of a 4-month intervention was performed. The Medical Research Council framework, the inductive interpretive description methodology and the theoretical framework of Sense of Coherence guided the study. Nineteen participants, divided into four groups, were included.

RESULTS

Three themes emerged: 'Relating my situation to others', 'Making room for forbidden thoughts' and 'Longing for normalcy'. The themes reflected the various ways participants interacted in online group meetings and how the interactions evolved around practical, emotional and forbidden thoughts. Sharing personal and sorrowful concerns and frustrations engendered feelings of trust and a sense of belonging, which empowered the participants to address their genuine wish and longing for normalcy with all the trivialities of which ALS/CIs had robbed them.

CONCLUSION

Virtual face-to-face peer-support can enable caregivers of PALS/CIs to share experiences of everyday life challenges that cannot always be shared elsewhere. Being able to relate to and learn from other's experiences alleviated feelings of loneliness, frustration, and concerns and thereby enhanced comprehensibility, manageability and meaningfulness. Online palliative rehabilitation interventions should provide an opportunity for caregivers to meet regularly in interactive group meetings. Familiarization takes time online and is necessary to improve their sense of feeling safe to share their deepest thoughts. Such group interventions, facilitated by trained healthcare professionals, offer a means to support dynamic group interactions and discussion of sensitive topics.

A cross-sectional evaluation of acceptability of an online palliative rehabilitation program for family caregivers of people with amyotrophic lateral sclerosis and cognitive and behavioral impairments

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a progressive fatal neurodegenerative disease. Around half of the population with ALS develop cognitive and/or behavioral impairment. Behavioral changes in persons with ALS are perceived as the strongest predictor of psychosocial distress among family caregivers. Interventions aiming to support family caregivers are emphasized as important in relation to reducing psychological distress among family caregivers. Successful healthcare interventions depend on the participants' acceptance of the intervention. Therefore, this study aims to evaluate the acceptability of a new online palliative rehabilitation blended learning program (EMBRACE) for family caregivers of people with ALS and cognitive and/or behavioral impairments.

METHODS

A qualitative cross-sectional design using the theoretical framework of acceptability to evaluate acceptance of the intervention based on data collected through individual in-depth interviews and participant observations. Individual interviews were conducted in 10 participants post-intervention and participant observations were recorded during virtual group meetings among 12 participants. A deductive retrospective analysis was used to code both datasets in relation to the seven constructs of the theoretical framework of acceptability: affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy. The theory of sense of coherence by Antonovsky informed the development and design of the intervention and interviews. The study adheres to the COREQ (consolidated criteria for reporting qualitative research) guidelines.

RESULTS

Within the seven constructs we found that affective attitude addressed the meaning and importance of peer support and focused on the participants' needs and challenges. Burden referred to technology challenges, time pressure, and frequent interruptions during meetings. Ethicality concerned transparency about personal experiences and the exposure of the affected relative. Intervention coherence referred to a shared destiny among participants when they shared stories. Opportunity costs primary concerned work-related costs. Perceived effectiveness referred to the usefulness and relevance of peer support and the meetings that brought up new ideas on how to approach current and future challenges. Self-efficacy involved the motivation to learn more about ALS and ways to cope that were accommodated by the convenient online format.

CONCLUSIONS

The findings showed that the participants favored peer support and the videos that reduced feelings of loneliness and frustration but also confronted them and provided knowledge on future challenges. Further research should explore the benefits of the program and the meaning of online peer support among caregivers of people with ALS and cognitive and/or behavioral impairments.

TRIAL REGISTRATION

Retrospectively registered on November 20th, 2020. ID no. NCT04638608 .

The role of personality disorder in ‘difficult to reach’ patients with depression: Findings from the ODIN study

Individuals with personality disorders (especially paranoid personality disorder) tend to be reluctant to engage in treatment. This paper aimed to elucidate the role of personality disorder in predicting engagement with psychological treatment for depression. The Outcomes of Depression International Network (ODIN) involves six urban and three rural study sites throughout Europe at which cases of depression were identified through a two-stage community survey. One patient in seven who was offered psychological treatment for depression had a comorbid diagnosis of personality disorder (most commonly paranoid personality disorder). Forty-five percent of patients who were offered psychological treatment for depression did not complete treatment. The odds of completion were higher for patients with a comorbid diagnosis of personality disorder, especially paranoid, anxious or dependent personality disorder. The relatively low number of cases with some specific personality disorders (e.g. schizoid personality disorder) limited the study's power to reach conclusions about these specific disorders. This study focused on a community-based sample which may lead to apparently lower rates of engagement when compared to studies based on treatment-seeking populations. Episodes of depression in the context of personality disorder may represent a valuable opportunity to engage with patients who might otherwise resist engagement.

Problem solving therapies for depression: A meta-analysis

Purpose

In the past decades, the effects of problem-solving therapy (PST) for depression have been examined in several randomized controlled studies. However, until now no meta-analysis has tried to integrate the results of these studies.

Methods

We conducted a systematic literature search and identified 13 randomized studies examining the effects of PST, with a total of 1133 subjects. The quality of studies varied.

Results

The mean standardized effect size was 0.34 in the fixed effects model and 0.83 in the random effects model, with very high heterogeneity. Subgroup analyses indicated significantly lower effects for individual interventions in studies with subjects who met criteria for major depression, studies in which intention-to-treat analyses were conducted instead of completers-only analyses, and studies with pill placebo and care-as-usual control groups. Heterogeneity was high, and the subgroup analyses did not result in clear indications of what caused this high heterogeneity. This indicates that PST has varying effects on depression, and that it is not known to date what determines whether PST has larger of smaller effects.

Conclusion

Although there is no doubt that PST can be an effective treatment for depression, more research is needed to ascertain the conditions and subjects in which these positive effects are realized.

Relations Between Frequency and Volume of Leisure-Time Physical Activity and Body Composition in Police Officers

Purpose: Leisure-time physical activity (LTPA) has always been very important for the maintenance and improvement of body composition. Thus, the aim of this study was to examine if the frequency and volume of LTPA (F-LTPA and V-LTPA) were related to indices of body composition in police officers. Method: A physical activity questionnaire was used to collect data from 346 male police officers regarding their F-LTPA and V-LTPA. They were divided into four groups relative to the frequency, and four groups relative to the volume of LTPA, labeled as inactive, seldom active, moderately active and very active for each LTPA indicator. Percent body fat (PBF), skeletal muscle mass (PSMM), skeletal muscle mass index (SMMI) and body fat mass index (BFMI) were assessed. Correlation analyses investigated associations and multivariate analysis of variance analysed the differences between body composition and LTPA, with significance set at p < .05. Results: The F-LTPA correlated (p < .001) to PBF (r = -0.306), BFMI (r = -0.289), PSMM (r = 0.309) and SMMI (r = -0.138, p = .010). The V-LTPA correlated (p < .001) to PBF (r = -0.370), BFMI (r = -0.348), PSMM (r = 0.311), and SMMI (r = -0.106, p = .049). The differences that occurred between more and less active police officers, whereby those who were very active had lower values of PBF and BFMI and higher values of PSMM and SMMI regardless of the frequency and volume of LTPA. PBF and PSMM were more affected by LTPA than SMMI and BFMI. Conclusions: F-LTPA and V-LTPA were considered important for police officers, whereby F-LTPA was related to muscle and V-LTPA to fat parameters of body composition.

Group interventions for amyotrophic lateral sclerosis caregivers in Ireland: a randomised controlled trial protocol

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a rapid and fatal motor disease marked by progressive physical impairment due to muscle weakness and wasting. It is multidimensional with many patients presenting with cognitive and/or behavioural impairment. Caregivers of patients with ALS, commonly non-paid immediate family members, often take primary responsibility for the complex care needs of patients in non-medicalised setting, and many as a consequence experience caregiver burden, anxiety, and/or depression.

METHODS AND ANALYSIS

This randomised controlled trial (RCT) will use randomisation to allocate n=75 caregivers of patients with ALS from the national ALS clinic into three groups with an equal distribution. The RCT consists of two intervention groups and a wait list control (treatment as usual [TAU]) group. The intervention arms of the trial consist of a 'mindfulness-based stress reduction' and 'building better caregivers' manualised group-based intervention, with 9 and 6 weekly sessions, respectively. The TAU group will have access to intervention at the end of the trial period. Primary outcomes are self-report questionnaires on anxiety and depression symptoms, with caregiver burden and quality of life considered secondary outcomes. Assessment will commence at baseline, immediately following the intervention period, and after a period of 12 weeks to assess the effectiveness and efficacy of participating in an intervention. Patient cognitive and behavioural data will also be considered. Means of treatment and control groups at Time 0 and 1 will be analysed using mixed model multivariate analysis of variance followed by analysis of variance, and treatment effect-sizes will be calculated. This RCT protocol is pre-results and has been registered with an international database resulting in an International Standard Randomised Controlled Trials Number (ISRCTN53226941).

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Beaumont Hospital Medical Research Ethics Committee. Results of the main trial will be submitted for publication in a peer-reviewed journal.

Sleep problems as a risk factor for suicide: Are certain specific sleep domains associated with increased suicide risk?

OBJECTIVES

The purpose of this study was to examine the relationship between sleep problems and suicidal ideation in depressive patients.

BACKGROUND AND AIMS

Evidence from diverse settings and populations indicates that sleep problems are associated with suicidal ideation. However, relationships between them are not well defined. This study was conducted in order to explore whether poor sleep was associated with suicidal ideation above and beyond depression and whether specific domains of sleep were related to suicidal ideation. We also determined whether the association between sleep problems and suicidal ideation was mediated by depression.

MATERIALS AND METHODS

Patients aged 18-65 years from an outpatient clinic at Seoul St. Mary's Hospital were recruited for this study. From September 2010 to November 2017, a total of 909 participants were included in the final sample. The Beck Depression Inventory (BDI) and Pittsburgh Sleep Quality Index (PSQI) were used to assess psychiatric symptoms. Independent samples t-test, chi-square test, Pearson correlation analyses, hierarchical multiple regression analyses, and mediation analyses were performed using SPSS PROCESS macro.

RESULTS

The majority of participants with suicidal ideation also had sleep problems (94.9%). After controlling for age, marital status, and depressive symptoms, total sleep problems estimated by the PSQI global score were also significant associated with suicidal ideation. Among seven sleep components derived from the PSQI, several components including cough or snore loudly, have bad dreams, and use sleep medication were associated with increased suicide risk. Also, the relationship between sleep problems and suicidal ideation was mediated by depressive symptoms indirectly. There was no convincing direct relationship between sleep problems and suicidal ideation.

CONCLUSIONS

Investigating the pathways which connect sleep problems and suicidality is fundamental to the development of suicide prevention. While it might be premature to suggest specific interventions, it would be important for clinicians to consider evaluating and managing sleep problems in the context of suicidality.

Is psychotherapy effective? A re-analysis of treatments for depression

AimsThe aim of this study was to reanalyse the data from Cuijpers et al.'s (2018) meta-analysis, to examine Eysenck's claim that psychotherapy is not effective. Cuijpers et al., after correcting for bias, concluded that the effect of psychotherapy for depression was small (standardised mean difference, SMD, between 0.20 and 0.30), providing evidence that psychotherapy is not as effective as generally accepted.

METHODS

The data for this study were the effect sizes included in Cuijpers et al. (2018). We removed outliers from the data set of effects, corrected for publication bias and segregated psychotherapy from other interventions. In our study, we considered wait-list (WL) controls as the most appropriate estimate of the natural history of depression without intervention.

RESULTS

The SMD for all interventions and for psychotherapy compared to WL controls was approximately 0.70, a value consistent with past estimates of the effectiveness of psychotherapy. Psychotherapy was also more effective than care-as-usual (SMD = 0.31) and other control groups (SMD = 0.43).

CONCLUSIONS

The re-analysis reveals that psychotherapy for adult patients diagnosed with depression is effective.

The Role of Common Factors in Psychotherapy Outcomes

Psychotherapies may work through techniques that are specific to each therapy or through factors that all therapies have in common. Proponents of the common factors model often point to meta-analyses of comparative outcome studies that show all therapies have comparable effects. However, not all meta-analyses support the common factors model; the included studies often have several methodological problems; and there are alternative explanations for finding comparable outcomes. To date, research on the working mechanisms and mediators of therapies has always been correlational, and in order to establish that a mediator is indeed a causal factor in the recovery process of a patient, studies must show a temporal relationship between the mediator and an outcome, a dose–response association, evidence that no third variable causes changes in the mediator and the outcome, supportive experimental research, and have a strong theoretical framework. Currently, no common or specific factor meets these criteria and can be considered an empirically validated working mechanism. Therefore, it is still unknown whether therapies work through common or specific factors, or both.

The Use of Problem-Solving Therapy for Primary Care to Enhance Complex Decision-Making in Healthy Community-Dwelling Older Adults

Some older adults who are cognitively healthy have been found to make poor decisions. The vulnerability of such older adults has been postulated to be the result of disproportionate aging of the frontal lobes that contributes to a decline in executive functioning abilities among some older adults. The purpose of this study was to investigate whether decision-making performance in older adults can be enhanced by a psychoeducational intervention. Twenty cognitively and emotionally intact persons aged 65 years and older were recruited and randomized into two conditions: psychoeducational condition [Problem-Solving Therapy for Primary Care (PST-PC)] and no-treatment Control group. Participants in the psychoeducational condition each received four 45-min sessions of PST-PC across a 2-week period. The Iowa Gambling Task (IGT) was administered as the outcome measure to the treatment group, while participants in the Control group completed the IGT without intervention. A significant interaction effect was observed between group status and the trajectory of score differences across trials on the IGT. Particularly, as the task progressed to the last 20% of trials, participants in the PST-PC group significantly outperformed participants in the Control group in terms of making more advantageous decisions. These findings demonstrated that a four-session problem-solving therapy can reinforce aspects of executive functioning (that may have declined as a part of healthy aging), thereby enhancing complex decision-making in healthy older adults.

Psychoeducation against depression, anxiety, alexithymia and fibromyalgia: a pilot study in primary care for patients on sick leave

OBJECTIVES

Feasibility testing of a psychoeducational method -The Affect School and Script Analyses (ASSA) - in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS).

DESIGN

Pilot study.

SETTING

Three Swedish primary care centers serving 20,000 people.

INTERVENTION

8 weekly 2-hour sessions with a 5-7 participant group led by two instructors - followed by 10 individual hour-long sessions.

SUBJECTS

Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia.

OUTCOME MEASURES

Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS.

RESULTS

The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p < .05 after correction for multiple testing for 9 of 11 measures (depression, anxiety, alexithymia, MUPS, general health, self-affirmation, self-love, self-blame, and self-hate); 18 months post intervention the results remained significantly favorable for 15 respondents for 7 of 11 measures (depression, alexithymia, MUPS, general health, self-affirmation, self-love, and self-hate).

CONCLUSIONS

A psychoeducational method previously untested in primary care for mostly women patients on sick-leave due to depression, anxiety, or fibromyalgia had >80% participation rates, and clear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting. Key Points  A pilot study of a psychoeducational intervention - The Affect School and Script Analyses (ASSA) - was performed in primary care   • The intervention showed feasibility for patients on sick-leave due to depression, anxiety, or fibromyalgia   • 92% completed the 8 weeks/16 hours Affect School and 83% completed the entire 26-hour ASSA intervention   • 9 of 11 self-reported measures improved significantly one-week post intervention   • 7 of 11 self-reported measures improved significantly 18 months post-intervention.

Problem-solving therapy for adult depression: An updated meta-analysis

BACKGROUND

Problem-solving therapy (PST) is one of the best examined types of psychotherapy for adult depression. No recent meta-analysis has examined the effects of PST compared to control groups or to other treatments. We wanted to verify whether PST is effective, whether effects are comparable to those of other treatments, and whether we could identify the possible sources of high heterogeneity that was found in earlier meta-analyses.

METHODS

We conducted systematic searches in bibliographical databases, including PubMed, PsycInfo, Embase and the Cochrane database of randomized trials.

RESULTS

We included 30 randomized controlled trials on PST (with 3530 patients), in which PST was compared to control conditions, with other therapies, and with pharmacotherapy. We could compare these 30 trials on PST also with 259 trials on other psychotherapies for adult depression. The effect size of PST versus control groups was g=0.79 (0.57-1.01) with very high heterogeneity (I²=84; 95% CI: 77-88). The effect size from the 9 studies with low risk of bias was g=0.34 (95% CI: 0.22-0.46) with low heterogeneity (I²=32; 95% CI: 0-68), which is comparable to the effects of other psychotherapies. PST was a little more effective than other therapies in direct comparisons, but that may be explained by the considerable number of studies with researcher allegiance towards PST. In meta-regression analyses of all controlled studies, no significant difference between PST and other therapies was found.

CONCLUSION

PST is probably an effective treatment for depression, with effect sizes that are small, but comparable to those found for other psychological treatments of depression.

Should community health workers offer support healthcare services to survivors of sexual violence? a systematic review

Background

Sexual violence is widespread, yet relatively few survivors receive healthcare or complete treatment. In low and middle-income countries, community health workers (CHWs) have the potential to provide support services to large numbers of survivors. The aim of this review was to document the role of CHWs in sexual violence services. We aimed to: 1) describe existing models of CHWs services including characteristics of CHWs, services delivered and populations served; 2) explore acceptability of CHWs’ services to survivors and feasibility of delivering such services; and 3) document the benefits and challenges of CHW-provided sexual violence services.

Methods

Quantitative and qualitative studies reporting on CHWs and other community-level paraprofessional volunteer services for sexual violence were eligible for inclusion. CHWs and sexual violence were defined according to WHO criteria. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Quality of included studies was assessed using two quality assessment tools for quantitative, and, the methodology checklist by the National Institute for Health and Clinical Excellence for qualitative studies. Data were extracted and analysed separately for quantitative and qualitative studies and results integrated using a framework approach.

Results

Seven studies conducted in six countries (Democratic Republic of Congo, Rwanda, Burma, United States of America, Scotland, Israel) met the inclusion criteria. Different models of care had diverse CHWs roles including awareness creation, identifying, educating and building relationships with survivors, psychosocial support and follow up. Although sociocultural factors may influence CHWs’ performance and willingness of survivors to use their services, studies often did not report on CHWs characteristics. Few studies assessed acceptability of CHWs’ to survivors or feasibility of delivery of services. However, participants mentioned a range of benefits including decreased incidence of violence, CHWs being trusted, approachable, non-judgmental and compassionate. Challenges identified were high workload, confidentiality issues and community norms influencing performance.

Conclusions

There is a dearth of research on CHWs services for sexual violence. Findings suggest that involving CHWs may be beneficial, but potential challenges and harms related to CHW-provided services exist. No different models of CHW-provided care have been robustly evaluated for effects on patient outcomes. Further research to establish survivors’ views on these services, and, their effectiveness is desperately needed.

Electronic supplementary material

The online version of this article (10.1186/s12914-017-0137-z) contains supplementary material, which is available to authorized users.

The efficacy of psychoeducation on recurrent depression: a randomized trial with a 2-year follow-up

BACKGROUND

The efficacy of psychoeducation is well documented in the treatment of relapse prevention of schizophrenia, and recently also in bipolar disorder; however, for recurrent depression only few controlled studies focusing on the efficacy of psychoeducation have been conducted.

AIMS

This randomized study tests the efficacy of treatment-as-usual supplemented with a psychoeducative programme for patients with recurrent depression, treated at Community Mental Health Centres (CMHC) in Denmark. The primary outcome measurements concern was decline in consumption of psychiatric inpatient services and decline in Beck's Depression Inventory (BDI).

METHODS

Eighty patients were randomized, either to the psychoeducative programme (consisting of eight sessions, each of 2 hours duration) and 2-year outpatient follow-up (42 cases), or only to 2-year outpatient follow-up (38 controls). The patients were monitored during 2 years after randomization. Data were collected from interviews including BDI, drug treatment and social measurements, and register data concerning use of psychiatric services.

RESULTS

At 2-year follow-up, a significant reduction in the consumption of psychiatric inpatient services and in BDI was found; however, it was uniform for case and control patients. Drop-out/non-compliance was significantly more frequent among patients randomized to the control group. Furthermore, during follow-up the case group got a significant stronger attachment to the Labour market than the control group.

CONCLUSIONS

The primary hypothesis could not be confirmed. Secondary outcome measurements concerning drop-out/non-compliance and attachment to the Labour market were significantly in favour of cases.

Effect of psychotherapy for depression on quality of life: meta-analysis

BACKGROUND

Several meta-analyses have shown that psychotherapy is effective for reducing depressive symptom severity. However, the impact on quality of life (QoL) is as yet unknown.

AIMS

To investigate the effectiveness of psychotherapy for depression on global QoL and on the mental health and physical health components of QoL.

METHOD

We conducted a meta-analysis of 44 randomised clinical trials comparing psychotherapy for adults experiencing clinical depression or elevated depressive symptoms with a control group. We used subgroup analyses to explore the influence of various study characteristics on the effectiveness of treatment.

RESULTS

We detected a small to moderate effect size (Hedges' g = 0.33, 95% CI 0.24-0.42) for global QoL, a moderate effect size for the mental health component (g = 0.42, 95% CI 0.33-0.51) and, after removing an outlier, a small but statistically significant effect size for the physical health component (g = 0.16, 95% CI 0.05-0.27). Multivariate meta-regression analyses showed that the effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component.

CONCLUSIONS

Psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.

Estimating treatment effects from randomized clinical trials with noncompliance and loss to follow-up: the role of instrumental variable methods

Perfectly implemented randomized clinical trials, particularly of complex interventions, are extremely rare. Almost always they are characterized by imperfect adherence to the randomly allocated treatment and variable amounts of missing outcome data. Here we start by describing a wide variety of examples and then introduce instrumental variable methods for the analysis of such trials. We concentrate mainly on situations in which compliance is all or nothing (either the patient receives the allocated treatment or they do not - in the latter case they may receive no treatment or a treatment other than the one allocated). The main purpose of the review is to illustrate the use of latent class (finite mixture) models, using maximum likelihood, for complier-average causal effect estimation under varying assumptions concerning the mechanism of the missing outcome data.

Are all psychotherapies equally effective in the treatment of adult depression? The lack of statistical power of comparative outcome studies

More than 100 comparative outcome trials, directly comparing 2 or more psychotherapies for adult depression, have been published. We first examined whether these comparative trials had sufficient statistical power to detect clinically relevant differences between therapies of d=0.24. In order to detect such an effect size, power calculations showed that a trial would need to include 548 patients. We selected 3 recent meta-analyses of psychotherapies for adult depression (cognitive behaviour therapy (CBT), interpersonal psychotherapy and non-directive counselling) and examined the number of patients included in the trials directly comparing other psychotherapies. The largest trial comparing CBT with another therapy included 178 patients, and had enough power to detect a differential effect size of only d=0.42. None of the trials in the 3 meta-analyses had enough power to detect effect sizes smaller than d=0.34, but some came close to the threshold for detecting a clinically relevant effect size of d=0.24. Meta-analyses may be able to solve the problem of the low power of individual trials. However, many of these studies have considerable risk of bias, and if we only focused on trials with low risk of bias, there would no longer be enough studies to detect clinically relevant effects. We conclude that individual trials are heavily underpowered and do not even come close to having sufficient power for detecting clinically relevant effect sizes. Despite this large number of trials, it is still not clear whether there are clinically relevant differences between these therapies.

PSYCHOLOGICAL TREATMENT OF DEPRESSION IN COLLEGE STUDENTS: A METAANALYSIS

BACKGROUND

Expanded efforts to detect and treat depression among college students, a peak period of onset, have the potential to bear high human capital value from a societal perspective because depression increases college withdrawal rates. However, it is not clear whether evidence-based depression therapies are as effective in college students as in other adult populations. The higher levels of cognitive functioning and IQ and higher proportions of first-onset cases might lead to treatment effects being different among college students relative to the larger adult population.

METHODS

We conducted a metaanalysis of randomized trials comparing psychological treatments of depressed college students relative to control groups and compared effect sizes in these studies to those in trials carried out in unselected populations of depressed adults.

RESULTS

The 15 trials on college students satisfying study inclusion criteria included 997 participants. The pooled effect size of therapy versus control was g = 0.89 (95% CI: 0.66∼1.11; NNT = 2.13) with moderate heterogeneity (I(2) = 57; 95% CI: 23∼72). None of these trials had low risk of bias. Effect sizes were significantly larger when students were not remunerated (e.g. money, credit), received individual versus group therapy, and were in trials that included a waiting list control group. No significant difference emerged in comparing effect sizes among college students versus adults either in simple mean comparisons or in multivariate metaregression analyses.

CONCLUSIONS

This metaanalysis of trials examining psychological treatments of depression in college students suggests that these therapies are effective and have effect sizes comparable to trials carried out among depressed adults.

THE LONG-TERM EFFICACY OF ACUTE-PHASE PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS OF RANDOMIZED TRIALS

BACKGROUND

Understanding the effectiveness of treatment for depression in both the short term and long term is essential for clinical decision making. The present meta-analysis examined treatment effects on depression and quality of life in acute-phase psychotherapeutic interventions compared to no treatment control groups for adult depression at 6 months or longer postrandomization.

METHODS

A systematic literature search resulted in 44 randomized controlled trials with 6,096 participants. Acute-phase psychotherapy was compared to control groups at 6-month or longer postrandomization. Odds ratios of a positive outcome were calculated.

RESULTS

Psychotherapy outperformed control groups at 6 months or longer postrandomization (OR = 1.92, 95% CI: 1.60-2.31, P < .001). Heterogeneity was moderate (I²: 65, 95% CI: 53-74, P < .001). However, effects significantly decreased with longer follow-up periods. Additionally, a small positive effect of psychotherapy was observed for quality of life, while similar effects were obtained in separate analyses of each type of psychotherapy, with the exception of nondirective supportive therapy. Studies that provided booster sessions had better treatment results compared with studies that did not provide any further sessions. Finally, we found that trials on psychotherapy aimed at major depressive disorder (MDD) had better outcomes than those that were aimed at elevated depressive symptoms.

CONCLUSIONS

There is substantial evidence that acute-phase psychotherapy results in a better treatment effects on depression and quality of life in the long term for adult patients with depression.

Preventing Perinatal Depression in High Risk Women: Moving the Mothers and Babies Course from Clinical Trials to Community Implementation

A growing research literature highlights the public health need for preventive interventions to reduce symptoms and incidence of perinatal depression among vulnerable populations. The Mothers and Babies (MB) course is a cognitive-behavioral intervention designed to teach mood regulation skills to English- and Spanish-speaking low-income women at high risk for perinatal depression. We describe the development of the MB course and evaluate the extent to which research findings support efficacy, effectiveness, and dissemination based on the Society for Prevention Research Standards Committee's standards of evidence. Our review of research and implementation activities suggests that the MB intervention demonstrates promising evidence for efficacy in reducing depressive symptoms; empirical support for prevention of major depressive episodes is still preliminary. Work is in progress to evaluate program effectiveness and prepare for broad dissemination and implementation. The MB course shows promise as an intervention for low-income women at risk for perinatal mood issues. Spanish and English intervention materials have been developed that can be delivered in different settings (hospitals, home visiting), in different dosages (6, 8, or 12 sessions), and via different modalities (group, individual). Evaluating the MB course against current standards is intended to inform other prevention intervention development research.

Rehabilitation staff perspectives on training for problem-solving therapy for primary care in a low vision service

Vision rehabilitation staff were trained to deliver problem-solving therapy for primary care (PST-PC) over the telephone to adults with depressive symptoms and low vision. Training was a 2-day workshop, completion of training cases, and assessment of treatment fidelity. Staff perspectives of training and challenges in PST-PC delivery were explored. Telephone-administered semi-structured interviews were conducted pre- and post-workshop and following PST-PC competency. In all, 14 staff (mean age = 47.64 years, SD = 12.68 years, 93% females) achieved competency and 6 withdrew. Results showed an increased understanding of PST-PC from pre- to post-workshop ( Z = −2.71, p = .007) and pre-workshop to post-competency ( Z = −3.09, p = .002). A high level of satisfaction with training was reported. Staff challenges included the clients’ ability to define problems and brainstorm solutions. Training enabled staff to competently deliver PST-PC and may serve as a model for integrating depression care into vision rehabilitation services recommended by international guidelines.

Effectiveness of the first French psychoeducational program on unipolar depression: study protocol for a randomized controlled trial

BACKGROUND

Major Depressive Disorder (MDD) is highly prevalent and was associated with greater morbidity, mortality (including suicide), and healthcare costs. By 2030, MDD will become the leading cause of disability in high-income countries. Notably, among patients with a previous experience of a major depressive episode, it was indeed estimated that up to 85 % of those patients will suffer from relapse. Two main factors were associated with a significantly higher risk of relapse: poor medication adherence and low self-efficacy in disease management. Interestingly, these issues could become the targets of psychoeducational programs for chronic diseases. Indded psychoeducational program for depression are recommended in international guidelines, but have not yet been proposed in France.

METHODS/DESIGN

We propose to evaluate the first French psychoeducational program for depression "ENVIE" in a multicenter randomized controlled trial. The group intervention will include 9 weekly sessions. Its aim is to educate patients on the latest knowledge on depression and effective treatments through didactic and interactive sessions. Patients will experiment the latest innovating psychological skills (from acceptance and commitment therapy) to cope with depressive symptoms and maintain motivation in behavioral activation. In total, 332 unipolar non-chronic (<2 years) outpatients with moderate to severe depression, without psychotic features, will be randomly allocated to the add-on ENVIE program (N = 166) or to a waiting list (N = 166). The follow-up will last 15 months and include 5 assessment visits. The primary endpoint will be the remission rate of the index episode at 15 months post-inclusion, defined by a Montgomery and Asberg Depression Rating Scale (MADRS) score ≤ 12 over an 8-week period, and without relapse during follow-up. We will also assess the response rate and relapse at 15 months post-inclusion, hospitalization rate and adherence to treatment during the follow-up period, quality of life and global functioning upon inclusion and at 9 and 15 months post inclusion.

DISCUSSION

If the proposed trial shows the effectiveness of the intervention, but also an increased remission rate in depressed outpatients at 15-months post-inclusion, in addition to improved treatment adherence in patients, it will further promotes arguments in favor of a wide dissemination of psychoeducational programs for depression.

TRIAL REGISTRATION

This trial is registered under number 2015-A00249-40 (PURE clinical trial: NCT02501226 ) (June 30th, 2015).

ADAPTA: A pilot randomised controlled trial of an alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting

AIM

To examine the relative feasibility, acceptability, applicability, effectiveness and explore cost-effectiveness of a healthy living focused intervention (HL) compared to an alcohol-focused intervention (AF) for problem drinkers identified in hospital.

METHODS

A pragmatic, randomised, controlled, open pilot trial. Feasibility and acceptability were measured by recruitment, attrition, follow-up rates and number of treatment sessions attended. Effectiveness was measured using the Alcohol Use Disorders Identification Test score at six months. Additional economic and secondary outcome measures were collected.

RESULTS

Eighty-six participants were randomised and 72% (n=62) were retained in full participation. Forty-one participants attended at least one treatment session (48%). A greater proportion in the HL group attended all four treatment sessions (33% vs 19%). Follow-up rates were 29% at six months and 22% at twelve months. There was no evidence of a difference in AUDIT score between treatment groups at six months. Mean cost of health care and social services, policing and the criminal justice system use decreased while EQ-5D scores indicated minor improvement in both arms. However, this pilot trial was not powered to detect differences in either measure between groups.

CONCLUSIONS

While no treatment effect was observed, this study demonstrated a potential to engage patients drinking at harmful or dependent levels in a healthy living intervention. However, recruitment proved challenging and follow-up rates were poor. Better ways need to be found to help these patients recognise the harms associated with their drinking and overcome the evident barriers to their engagement with specialist treatment.

Evaluation of the Effectiveness of a Psychoeducational Intervention in Treatment-Naïve Patients with Antidepressant Medication in Primary Care: A Randomized Controlled Trial

Background. There is evidence supporting the effectiveness of psychoeducation (PE) in patients with symptoms of depression in primary care (PC), but very few studies have assessed this intervention in antidepressant-naïve patients. The aim of this study is to assess the effectiveness of a PE program in these patients, since the use of antidepressant (AD) medication may interfere with the effects of the intervention. Methods. 106 participants were included, 50 from the PE program (12 weekly 1.5-hour sessions) and 56 from the control group (CG) that received the usual care. Patients were assessed at baseline and at 3, 6, and 9 months. The main outcome measures were the Beck Depression Inventory (BDI) and remission based on the BDI. The analysis was carried out on an intention-to-treat basis. Results. The PE program group showed remission of symptoms of 40% (P = 0.001) posttreatment and 42% (P = 0.012) at 6 months. The analysis only showed significant differences in the BDI score posttreatment (P = 0.008; effect size Cohen's d′ = 0.55). Conclusions. The PE intervention is an effective treatment in the depressive population not treated with AD medication. Before taking an AD, psychoeducational intervention should be considered.

Counselling versus low-intensity cognitive behavioural therapy for persistent sub-threshold and mild depression (CLICD): a pilot/feasibility randomised controlled trial

BACKGROUND

Persistent depressive symptoms below the threshold criteria for major depression represent a chronic condition with high risk of progression to a diagnosis of major depression. The evidence base for psychological treatments such as Person-Centred Counselling and Low-Intensity Cognitive Behavioural Therapy for sub-threshold depressive symptoms and mild depression is limited, particularly for longer-term outcomes.

METHODS

This study aimed to test the feasibility of delivering a randomised controlled trial into the clinical and cost effectiveness of Low-Intensity Cognitive Behavioural Therapy versus Person-Centred Counselling for patients with persistent sub-threshold depressive symptoms and mild depression. The primary outcome measures for this pilot/feasibility trial were recruitment, adherence and retention rates at six months from baseline. An important secondary outcome measure was recovery from, or prevention of, depression at six months assessed via a structured clinical interview by an independent assessor blind to the participant's treatment condition. Thirty-six patients were recruited in five general practices and were randomised to either eight weekly sessions of person-centred counselling each lasting up to an hour, or up to eight weeks of cognitive-behavioural self-help resources with guided telephone support sessions lasting 20-30 minutes each.

RESULTS

Recruitment rate in relation to the number of patients approached at the general practices was 1.8 %. Patients attended an average of 5.5 sessions in both interventions. Retention rate for the 6-month follow-up assessments was 72.2 %. Of participants assessed at six months, 71.4 % of participants with a diagnosis of mild depression at baseline had recovered, while 66.7 % with a diagnosis of persistent subthreshold depression at baseline had not developed major depression. There were no significant differences between treatment groups for both recovery and prevention of depression at six months or on any of the outcome measures.

CONCLUSIONS

It is feasible to recruit participants and successfully deliver both interventions in a primary care setting to patients with subthreshold and mild depression; however recruiting requires significant input at the general practices. The evidence from this study suggests that short-term Person-Centred Counselling and Low-Intensity Cognitive Behaviour Therapy are potentially effective and their effectiveness should be evaluated in a larger randomised controlled study which includes a health economic evaluation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN60972025 .

Caregiving across the lifespan: comparing caregiver burden, mental health, and quality of life

BACKGROUND

Care can be considered a lifelong process, but caring for a child is different from caring for an older adult. The present study aims to compare the caregiving process from infancy through old age by evaluating differences in caregiver burden, mental health, and quality of life and to describe the factors that could impact these outcomes.

METHODS

To compare different groups of caregivers, we included 300 caregivers recruited from admissions to a tertiary acute hospital: 100 caregivers of children, 100 caregivers of adults, and 100 caregivers of older adults. A self-administered questionnaire was used that covered the following: sociodemographics, depression (Beck Depression Inventory), anxiety (Beck Anxiety Inventory), quality of life (Short Form Health Survey (SF-36)), religiosity (Duke Religion Index) and caregiver burden (Zarit Caregiver Burden Interview).

RESULTS

A comparison between groups was performed (through χ² and anova), and a linear regression analysis was used to assess the related factors. We found that children's caregivers had more depressive symptoms (higher Beck Depression Inventory scores), better physical health (SF-36: physical functioning and SF-36: Physical Component Summary), and lower pain (SF-36: bodily pain) than other caregivers. We found that caregivers of adults had better mental health (SF-36: mental health and SF-36: Mental Component Summary) than other caregivers and that caregivers of older adult had a higher caregiver burden (Zarit Caregiver Burden Interview scores) than other caregivers. After we controlled for baseline characteristics, only depressive symptoms and caregiver burden remained statistically significant.

CONCLUSION

In conclusion, there are important differences between caregiving across the lifespan. Caregiving for children was associated with more depressive symptoms, and caregiving for older adults was associated with higher caregiver burden. Further studies are needed to replicate these findings in other settings.

Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke

Objective:

To enhance participation post stroke through a structured, community-based program.

Design:

A controlled trial with random allocation to immediate or four-month delayed entry.

Setting:

Eleven community sites in seven Canadian cities.

Subjects:

Community dwelling persons within five years of stroke onset, cognitively intact, able to toilet independently.

Interventions:

Evidence-based program delivered in three 12-week sessions including exercise and project-based activities, done as individuals and in groups.

Main measures:

Hours spent per week in meaningful activities outside of the home and Reintegration to Normal Living Index; Stroke-Specific Geriatric Depression Scale, Apathy Scale, gait speed, EuroQuol EQ-5D, and Preference-Based Stroke Index. All measures were transformed to a scale from 0 to 100. Assessments prior to randomization, after the first session at three months, six months, 12 months, and 15 months.

Results:

A total of 186 persons were randomized. The between-group analysis showed no disadvantage to waiting and so groups were combined and a within-person analysis was carried out at three time points. There were statistically significant increases in all study outcomes on average over all persons. Over 45% of people met or exceeded the pre-specified target of a three hour per week increase in meaningful activity and this most often took a full year of intervention to achieve. Greatest gains were in satisfaction with community integration (mean 4.78; 95% CI: 2.01 to 7.55) and stroke-specific health-related quality of life (mean 4.14; 95% CI: 2.31 to 5.97).

Conclusions:

Community-based programs targeting participation are feasible and effective, but stroke survivors require time to achieve meaningful gains.

The effect of psychotherapy for depression on improvements in social functioning: a meta-analysis

BACKGROUND

Patients with depression often report impairments in social functioning. From a patient perspective, improvements in social functioning might be an important outcome in psychotherapy for depression. Therefore, it is important to examine the effects of psychotherapy on social functioning in patients with depression.

METHOD

We conducted a meta-analysis on studies of psychotherapy for depression that reported results for social functioning at post-treatment. Only studies that compared psychotherapy to a control condition were included (31 studies with 2956 patients).

RESULTS

The effect size of psychotherapy on social functioning was small to moderate, before [Hedges' g = 0.46, 95% confidence interval (CI) 0.32-0.60] and after adjusting for publication bias (g = 0.40, 95% CI 0.25-0.55). Univariate moderator analyses revealed that studies using care as usual as a control group versus other control groups yielded lower effect sizes, whereas studies conducted in the USA versus other countries and studies that used clinician-rated instruments versus self-report yielded higher effect sizes. Higher quality studies yielded lower effect sizes whereas the number of treatment sessions and the effect size of depressive symptoms were positively related to the effect size of social functioning. When controlling for these and additional characteristics simultaneously in multivariate meta-regression, the effect size of depressive symptoms, treatment format and number of sessions were significant predictors. The effect size of social functioning remained marginally significant, indicating that improvements in social functioning are not fully explained by improvements in depressive symptoms.

CONCLUSIONS

Psychotherapy for depression results in small to moderate improvements in social functioning. These improvements are strongly associated with, but not fully explained by, improvements in depressive symptoms.

Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis

OBJECTIVE

Various control conditions have been employed in psychotherapy trials, but there is growing suspicion that they may lead to different effect size estimates. The present study aims to examine the differences among control conditions including waiting list (WL), no treatment (NT) and psychological placebo (PP).

METHOD

We comprehensively searched for all randomized controlled trials (RCTs) comparing cognitive-behaviour therapies (CBT) against various control conditions in the acute phase treatment of depression, and applied network meta-analysis (NMA) to combine all direct and indirect comparisons among the treatment and control arms.

RESULTS

We identified 49 RCTs (2730 participants) comparing WL, NT, PP and CBT. This network of evidence was consistent, and the effect size estimates for CBT were substantively different depending on the control condition. The odds ratio of response for NT over WL was statistically significant at 2.9 (95% CI: 1.3-5.7). However, the quality of evidence, including publication bias, was less than ideal and none of the preplanned sensitivity analyses limiting to high-quality studies could be conducted, while findings of significant differences did not persist in post hoc sensitivity analyses trying to adjust for publication bias.

CONCLUSION

There may be important differences in control conditions currently used in psychotherapy trials.

Linkages between insomnia and suicidality: prospective associations, high-risk subgroups and possible psychological mechanisms

Insomnia can be lethal, increasing the risk of suicide and accidental death by overdose. In this review we present a synthesis of the literature investigating the insomnia-suicide link and the psychological mechanisms underpinning the association. Specifically, we review the findings of prospective epidemiological studies demonstrating the insomnia-suicide link in adult and adolescent community populations. Robust associations between insomnia and suicide are observed in clinically depressed and anxious populations, and there are indications across a number of cross-sectional and longitudinal studies that these linkages are attributable to a disrupted sleep pattern, dysfunctional beliefs about sleep and nightmares, independent of depression and anxiety symptoms. Borderline personality disorder (BPD) and chronic pain (CP) are highlighted as high-risk subgroups given the elevated rates of insomnia and suicidality in both conditions. Aside from the influence of comorbid depression and anxiety symptoms, emerging evidence has identified impulsivity and emotional dysregulation as possible mechanisms driving the insomnia-suicide link in BPD, and catastrophizing and the sense of defeat/entrapment as potential cognitive pathways through which insomnia aggravates suicidality in CP. Screening for, and interventions that tackle, insomnia and these associated psychological mechanisms, offer a novel avenue for reducing suicidality across a range of clinical and non-clinical populations.

Problem solving styles among people who use alcohol and other drugs in South Africa

The present study examines the relationship between problem-solving styles, socio-demographic variables and risk of alcohol and other drug (AOD)-related problems among a South African population. The Social Problem-Solving Inventory-Revised, Center for Epidemiologic Studies Depression Scale (CES-D) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were administered to a convenience sample of 1000 respondents. According to the ASSIST, 32% and 49% of respondents met criteria for moderate to high risk of alcohol use and illicit drug use respectively. After adjusting for the effects of other variables in the model, respondents who were of "Coloured" ancestry (PR=1.20, 95% CI 1.0-1.4), male (PR=1.19, 95% CI 1.04-1.37), older (PR=1.01, 95% CI 1.00-1.02), who adopted an avoidance style of coping with problems (PR=1.03, 95% CI 1.01-1.05) and who met criteria for depression (PR=1.42, 95% CI 1.12-1.79) were more likely to be classified as having risky AOD use. This suggests that interventions to improve problem solving and provide people with cognitive strategies to cope better with their problems may hold promise for reducing risky AOD use.

Methylenetetrahydrofolate reductase (MTHFR) genetic variation and major depressive disorder prognosis: A five-year prospective cohort study of primary care attendees

Methylenetetrahydrofolate reductase (MTHFR) genetic variation has been associated with the diagnosis of major depressive disorder (MDD) but no study to date has examined the effect MTHFR variation has on MDD prognosis. We sought to examine the prospective effects of two common MTHFR variants (C677T and A1298C) as well as seven haplotype-tagging single nucleotide polymorphisms (htSNPs) on MDD prognosis over a 5-year (60-month) period. Participants were 147 depressed primary care attendees enrolled in the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) prospective cohort study. Prognosis of MDD was measured using three methods: (1) DSM-IV criteria, (2) Primary Care Evaluation of Mental Disorders Patient Health Questionnaire-9 (PHQ-9), and (3) Center for Epidemiologic Studies Depression Scale (CESD). DSM-IV criteria for MDD was assessed using the Composite International Diagnostic Interview at baseline and 24, 36, 48, and 60 months post-baseline; whereas, PHQ-9 and CESD measures were employed at baseline and 12, 24, 36, 48, and 60 months post-baseline. Repeated measures analysis of variance showed that PHQ-9 symptom severity trajectories differed by C677T genotype (F = 3.34, df = 2,144, P = 0.038), with 677CC genotype showing the most severe symptom severity course over the 60 months of observation. Neither the A1298C polymorphism nor any of the htSNPs were associated with MDD prognosis regardless of measure used. Our results suggest that the MTHFR C677T polymorphism may serve as a marker for MDD prognosis pending independent replication.

Psychoeducation for major depressive disorders: a randomised controlled trial

Various psychological therapies have been shown to be effective for the treatment of mood disorders. Among them, family psychoeducation has demonstrated efficacy in reducing symptom severity and extending the time to relapse. We tested the efficacy of adding psychoeducation focussed on how to deal with the family's expressed emotion to treatment as usual (TAU) to prevent relapse among patients with remitted major depression. A total of 34 patients with major depressive disorders in full or partial remission were randomised to receive either group psychoeducation over six sessions, each consisting of a didactic lecture and group problem-solving (n=19), plus TAU or TAU alone (n=15). The primary outcome was relapse by Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria. Masked raters administered the Hamilton Rating Scale for Depression-17 (HRSD-17). As many as 18 patients in the intervention group and 14 patients in the control group completed the study. Time to relapse was significantly longer in the intervention group than in the control group, with a risk ratio (RR) of relapse by 9 months of 0.12. At 9 months, there was a significantly greater decrease in the HRSD-17 score in the intervention group than in the control group. We demonstrated the effectiveness of patient psychoeducation on the course and outcome of major depressive disorders.

Effectiveness of psychoeducation for depression: a systematic review

OBJECTIVE

Pharmacological treatment is considered indispensable to major depressive disorder. In spite of this, a significant number of patients do not respond adequately to treatment based only on medication, presenting high relapse and recurrence rates. Therefore, psychosocial interventions, such as psychoeducation, have been increasingly recognized as an essential component in the treatment of depression, associated with pharmacological strategies. Thus, the aim of the present systematic review was to evaluate the effectiveness of psychoeducation for patients with unipolar depression, analyzing the evidence from the literature.

METHOD

Searches were undertaken from April to October 2012 in LILACS, PsycINFO, PubMed, SCOPUS and ISI Web of Knowledge with keywords including 'psychoeducation', 'psychoeducational intervention' and 'depression', with no restriction regarding publishing dates.

RESULTS

Fifteen studies were included in the review, 13 of which evaluated the effectiveness of psychoeducation for patients with depression: 10 papers evaluated in-person psychoeducation approaches and three papers evaluated long-distance approaches. In addition to these 13 papers, one evaluated psychoeducational interventions for patients' families and patients' responses and another evaluated psychoeducational interventions for patients' families and families' responses. Findings suggest that increased knowledge about depression and its treatment is associated with better prognosis in depression, as well as with the reduction of the psychosocial burden for the family.

CONCLUSIONS

Psychoeducation is a psychosocial treatment that has been well documented as an adjunct to pharmacological therapy. However, there are only a few studies regarding its effectiveness on adult patients with major depressive disorder. Although the publications in this area are still very limited, the articles selected in this review suggest that psychoeducation is effective in improving the clinical course, treatment adherence, and psychosocial functioning of depressive patients.

Antidepressant and Group Psychosocial Treatment for Depression: A Rater Blind Exploratory RCT from a Low Income Country

Background: Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. Aim: To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. Method: This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. Results: More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. Conclusion: Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

How much psychotherapy is needed to treat depression? A metaregression analysis

BACKGROUND

Although psychotherapies are effective in the treatment of adult depression it is not clear how this treatment effect is related to amount, frequency and intensity of therapy.

METHODS

To fill this gap in knowledge, the present metaregression analysis examined the association between the effects of psychotherapy for adult depression and several indicators of amount, frequency and intensity of therapy. The analysis included 70 studies (92 comparisons) with 5403 patients, in which individual psychotherapy was compared with a control group (e.g. waiting list, care-as-usual).

RESULTS

There was only a small association between number of therapy sessions and effect size, and this association was no longer significant when the analysis adjusted for other characteristics of the studies. The multivariable analyses also found no significant association with the total contact time or duration of the therapy. However, there was a strong association between number of sessions per week and effect size. An increase from one to two sessions per week increased the effect size with g=0.45, while keeping the total number of treatment sessions constant.

DISCUSSION

More research is needed to establish the robustness of this finding. Based on these findings, it may be advisable to concentrate psychotherapy sessions within a brief time frame.

Pragmatic trials of complex psychosocial interventions: methodological challenges

Having first introduced the pragmatic health care trial, the discussion then focuses on a selected list of technical problems that are important for the design, analysis and inference from such trials. The first is lack of independence of participants' outcomes do to clustering either arising from a cluster randomized design or to the way treatment is delivered (therapist and group effects). The second and third concern the implications of non-adherence to treatment and subsequent loss to follow-up, particularly, when non-adherence is associated with missing outcome data. Finally, it is argued that pragmatism and a desire for a scientific explanation should not be regarded as mutually exclusive.

Effectiveness of cognitive behavioral therapy: An evaluation of therapies provided by trainees at a university psychotherapy training center

At the psychotherapy training center at Karlstad University, a study was carried out to examine the levels of symptom change and satisfaction with therapy in a heterogeneous population of clients treated using cognitive behavioral therapy (CBT) by less experienced trainee therapists with limited theoretical education. The clients received an average of 11 therapy sessions. The results suggested that CBT performed by less experienced trainee therapists can be effective. According to client estimations, a statistically significant reduction in symptoms, measured using the Symptoms Checklist, was achieved for seven of nine variables (p ≤ .006), as well as a significant increase in satisfaction with life (p ≤ .001). Also, the pre- and posttherapy measurements using the Montgomery–Åsberg Depression Rating Scale showed a statistically significant improvement in the clients’ condition. According to the therapists’ estimations, 64% (SD = 32.01) of the clients experienced a significant improvement in their condition. In addition, the results of a survey of client satisfaction demonstrated that the clients were very pleased with the therapy received. Also the therapists were, to a great extent, satisfied with the treatment process itself, including the supervision received, and very satisfied with the client alliance. A correlation analysis between the clients’ perceived level of improvement and therapist satisfaction showed a strong correlation between the two variables (r = .50, p < .005). By including the Comparative Psychotherapy Process Scale (CPPS) in our study it was possible to measure trueness to therapy form. An analysis of the CPPS results confirmed that the form of therapy used at the training site was more strongly CBT than psychodynamic interpersonal treatment (p ≤ .001). The CBT subscale score indicated that the therapy was characteristic of CBT, confirming that the interventions used in the therapy belong to the CBT genre.

Effectiveness of a psycho-educational group program for major depression in primary care: a randomized controlled trial

BACKGROUND

Studies show the effectiveness of group psychoeducation in reducing symptoms in people with depression. However, few controlled studies that have included aspects of personal care and healthy lifestyle (diet, physical exercise, sleep) together with cognitive-behavioral techniques in psychoeducation are proven to be effective.The objective of this study is to assess the effectiveness of a psychoeducational program, which includes aspects of personal care and healthy lifestyle, in patients with mild/moderate depression symptoms in Primary Care (PC).

METHODS

In a randomized, controlled trial, 246 participants over 20 years old with ICD-10 major depression were recruited through nurses/general practitioners at 12 urban Primary Care Centers (PCCs) in Barcelona. The intervention group (IG) (n=119) received a group psychoeducational program (12 weekly, 1.5 h sessions led by two nurses) and the control group (CG) (n=112) received usual care. Patients were assessed at baseline and at, 3, 6 and 9 months. The main outcome measures were the BDI, EQ-5D and remission based upon the BDI.

RESULTS

231 randomized patients were included, of whom 85 had mild depression and 146 moderate depression. The analyses showed significant differences between groups in relation to remission of symptoms, especially in the mild depression group with a high rate of 57% (p=0.009) at post-treatment and 65% (p=0.006) at 9 month follow up, and only showed significant differences on the BDI at post-treatment (p=0.016; effect size Cohen's d'=.51) and at 6 and 9 month follow-up (p= 0.048; d'=.44).In the overall and moderate sample, the analyses only showed significant differences between groups on the BDI at post-treatment, p=0.02 (d'=.29) and p=0.010 (d'=.47), respectively.The psychoeducation group improved significantly on the EQ-5D at short and long-term.

CONCLUSIONS

This psychoeducational intervention is a short and long-term effective treatment for patients with mild depression symptoms. It results in a high remission rate, is recommended in PC and can be carried out by nurses with previous training. In moderate patients, group psychoeducation is effective in the short-term.

TRIAL REGISTRATION

Clinical Trials.gov identifier NCT00841737.

Cost-effectiveness of problem-solving treatment in comparison with usual care for primary care patients with mental health problems: a randomized trial

BACKGROUND

Mental health problems are common and are associated with increased disability and health care costs. Problem-Solving Treatment (PST) delivered to these patients by nurses in primary care might be efficient. The aim of this study was to evaluate the cost-effectiveness of PST by mental health nurses compared with usual care (UC) by the general practitioner for primary care patients with mental health problems.

METHODS

An economic evaluation from a societal perspective was performed alongside a randomized clinical trial. Patients with a positive General Health Questionnaire score (score ≥ 4) and who visited their general practitioner at least three times during the past 6 months were eligible. Outcome measures were improvement on the Hospital Anxiety and Depression Scale and QALYs based on the EQ-5D. Resource use was measured using a validated questionnaire. Missing cost and effect data were imputed using multiple imputation techniques. Bootstrapping was used to analyze costs and cost-effectiveness of PST compared with UC.

RESULTS

There were no statistically significant differences in clinical outcomes at 9 months. Mean total costs were €4795 in the PST group and €6857 in the UC group. Costs were not statistically significantly different between the two groups (95% CI -4698;359). The cost-effectiveness analysis showed that PST was cost-effective in comparison with UC. Sensitivity analyses confirmed these findings.

CONCLUSIONS

PST delivered by nurses seems cost-effective in comparison with UC. However, these results should be interpreted with caution, since the difference in total costs was mainly caused by 3 outliers with extremely high indirect costs in the UC group.

TRIAL REGISTRATION

Nederlands Trial Register ISRCTN51021015.

[Psychoeducation and quality of life: an amplification of the evaluation study in Graz (Part 1). Psychoeducation with psychotic patients]

BACKGROUND

This study is an amplification of the evaluation study in Graz and aimed at evaluating the effects of psychoeducation (PE) on psychotic patients.

METHODS

26 psychotic patients participated in nine PE-group sessions and observer as well as self-rating scales were completed before and after PE.

RESULTS

A significant increase in psychological wellbeing, in psychosis-related knowledge and a reduction of psychopathology was found. The degree of psychopathology influenced life-quality and psychosis - related knowledge but still patients with severe psychopathology benefit from PE. Using regression analyses further variables fostering the PE-success were tried to be identified.

CONCLUSION

A multidimensional consideration of the lifequality-concept is necessary for evaluation of PE. In clinical practice PE groups with patients suffering from different psychotic diseases can be well implemented and are very effective. The results underline the relevance of PE in an inpatient psychiatric setting.

Recruitment strategies for caregivers of children with mental health problems

PURPOSE

The aim of this study was to describe strategies for recruiting participants into an intervention study that focused on improving problem-solving skills in caregivers of children with mental health problems.

BACKGROUND

Caregivers of children with mental health problems report feeling physically and psychologically overwhelmed and have high rates of depression because of the demands of caregiving. Research on the needs of these caregivers and interventions to ameliorate their stress is needed. However, recruiting this population can be particularly difficult because of the stigma of mental illness. Available literature on recruitment of caregivers of persons with physical illness cannot be transferred to caregivers of children with mental health problems because of the different caregiving situations. There is a need to identify effective recruitment strategies to reduce cost and answer research questions. Clinical nurse specialists have the skills to facilitate the recruitment of research participants. We revised and expanded health system referrals, community outreach, and recruiting advertisement (ads). When these strategies did not increase recruitment, radio ads were used. The Andersen's Behavioral Model of Health Services Utilization was selected as a guiding framework.

OUTCOME

Radio ads were the most effective strategy for recruiting caregivers of children with mental health problems for this study.

CONCLUSION

Recruitment was ultimately successful because we were flexible and made decisions consistent with the Andersen's Behavioral Model of Health Services Utilization.

IMPLICATIONS

Clinical nurse specialists who study this population of caregivers should really consider the use of radio ads and systematically track which recruitment strategies lead to the greatest number of participants screened, eligible, and enrolled into studies.