Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: randomised controlled trial

Exploring digital health tools for depression management in primary health care: Systematic review and meta-analysis

BACKGROUND

Digital health tools are transforming mental health care, particularly in treating depression, which affects 5 % of the global population and is projected to be the top disease burden by 2030. In primary care, these tools improve accessibility and efficacy, addressing rising mental health demands, especially post-COVID-19.

OBJECTIVE

The aim of this study is to assess the efficacy of digital health tools for the management of depression within primary care.

METHODS

A systematic review followed PRISMA guidelines, focusing on digital health tools for reducing depressive symptoms. Controlled trials were included, with RCTs assessed via the Cochrane risk-of-bias tool and non-RCTs evaluated using the JBI checklist for quasi-experimental studies. Depressive symptom reduction was the primary outcome.

RESULTS

A total of 29 controlled trials met the inclusion criteria, identifying were web-based platforms, mobile apps, phone calls, text messages, and decision algorithms. The meta-analysis revealed that digital health tools had a significant effect on depressive symptoms (g = -0.22, 95 % CI: -0.37; -0.06, I2 = 79.64 %). At 6 to 12-month follow-up, the random effects meta-analysis showed that digital health tools had a significant effect on depressive symptoms (g = -0.19, 95%CI: -0.29; -0.09, I2 = 53.42 %).

CONCLUSIONS

Digital health tools are effective in reducing the symptoms of repression. Symptom severity does not predict suitability for digital treatment, emphasizing the need for gender-sensitive approaches and strategies for older adults. Integrating digital interventions into clinical guidelines requires studies like this to support their adoption in real-world practice.

Age Disparities in the Association Between Leisure-Time Physical Activity and Depression Among American Adults

BACKGROUND

This study aims to investigate the association between leisure-time physical activity (LTPA), age, and depressive symptoms.

METHODS

We included and analyzed data from 18,052 participants (age ≥ 20 years) from the cross-sectional National Health and Nutrition Examination Survey (NHANES) (2007-2014). Multivariable logistic regression was employed to assess the independent associations between physical activity and household income with depressive symptoms. Restricted cubic spline plots were utilized to analyze the non-linear relationship between LTPA and depression.

RESULTS

Among the 18,052 participants, 1,676 (9.28%) were defined as having depressive symptoms. We found: 1. Age exhibits a non-linear relationship with depression, with a turning point around 40 years. 2. Compared to those with no LTPA, individuals with higher levels of LTPA (Q3) in both younger and older age groups experienced the lowest risk of depression, with risk reductions of 53% (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.33-0.67) and 74% (OR 0.26, 95% CI 0.14-0.50), respectively. Conversely, in the middle-aged group, those with the highest level of LTPA (Q4) experienced the greatest reduction in depression risk, by 67% (OR 0.33, 95% CI 0.21-0.53). 3. A U-shaped relationship between LTPA and depression risk was observed in younger and older age groups.

CONCLUSION

The risk of depression peaks around the age of 40 in adults. For middle-aged individuals, greater engagement in LTPA is associated with reduced depression risk. Conversely, higher levels of LTPA in younger and older adults may not confer additional protective effects.

Are cognitive behavioural therapy, cognitive therapy, and behavioural activation for depression effective in primary care? A systematic review and meta-analysis

Cognitive behavioural therapy (CBT) is a recommended first-line treatment for depression. Evidence mainly derives from studies in secondary care, though most treatment occurs in primary care. This review examined efficacy of CBT, cognitive therapy (CT), or behavioural activation (BA) for depression within primary care. Databases were searched for trials up to 23rd July 2024. Risk of bias was assessed using the Cochrane risk-of-bias tool, version 2.0.44 studies were included. CBT, CT, and BA significantly reduced depression symptoms compared to inactive controls (k = 40, g = 0.44, p < .001), but not active comparators (other therapies, medication or exercise) (k = 9, g = -0.06, p = .24). Heterogeneity was significant in studies comparing CBT, CT, or BA to inactive controls, but not in studies using active comparators. Most studies were rated at high risk of bias (36 studies, 81.8 %), predominantly due to use of patient-rated outcome measures in non-blinded studies, lack of ITT analyses, and lack of pre-registering protocols, all of which may result in inflated effect sizes. Although CBT, CT, or BA appears effective for depression in primary care against usual care or waiting list controls, when compared to active comparators no significant difference is seen, likely a result of variability in the quality of the included studies. Large studies of improved quality (including use of blinded observer-rated outcome measures and ITT analyses) may be required to justify guideline recommendations for CBT over other interventions for depression specifically in primary care.

Individual patterns of activity predict the response to physical exercise as an intervention in mild to moderate depression

Physical exercise (PE) as antidepressive intervention is a promising alternative, as shown by multiple meta-analyses. However, there is no consensus regarding optimal intensity and duration of exercise, and there are no objective criteria available for personalized indication of treatment. The aims of this study were (1) to evaluate whether individual activity patterns before intervention can predict the response to treatment; and (2) to evaluate whether the patient outcome can be improved by using prior information on treatment efficacy at individual level. The study included subjects with mild to moderate depression randomized to three PE regimens as antidepressive intervention. Features extracted from actigraphy recordings were used for training linear regression ensembles to predict the response to treatment. The Bayesian analysis of coefficients yielded distinct signatures in enriched feature subsets for each PE regimen. Next, we used a counterfactual approach by virtually assigning each patient to the PE regimen predicted to yield best outcome. This procedure significantly increased the remission rates as compared to random assignment to treatment. Our data suggest that the analysis of individual patterns of activity can identify a PE regimen to yield the best results, and that assignment to PE regimen using this information would significantly increase remission rate.

Impact of combiner aerobic and resistance training on depression: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To summarize the existing literature and evaluate the efficacy of combined resistance and aerobic training in alleviating depressive symptoms among individuals with depression. Subgroup analyses were conducted based on study region, age, depression severity, intervention duration, intervention frequency, and whether the intervention was supervised or unsupervised.

METHODS

Five databases were thoroughly examined from database establishment until August 20, 2024, to find randomized controlled trials that investigated resistance combined aerobic training impact on depression.

RESULTS

Finally, 27 eligible studies were included, involving a total of 2,342 patients with depression. The outcomes indicated that resistance combined aerobic training notably improved signs of depression in these patients (SMD=-1.39, 95%CI=-1.80 to -0.96, p = 0.000). Subgroup analysis based on study area, age, severity of depressive symptoms, and exercise prescription revealed that resistance combined aerobic training had a particularly significant effect on middle-aged and elderly patients with depression, as well as on those with moderate depression. Additionally, moderate period (9-24 weeks), moderate frequency (3-4 times per week), a total weekly duration of more than 180 min and supervised training displayed the best results.

CONCLUSION

Resistance combined aerobic training serves as an efficient approach to relieve depression-related symptoms, particularly in middle-aged and elderly patients with depression and those with moderate depression. Moderate training intensity, duration, frequency, and total weekly duration offer the greatest benefit.

Exercise prior to cognitive behavior therapy sessions for depression: a feasibility pilot study

Exercise directly improves mood and cognition. Providing exercise immediately before cognitive behavior therapy (CBT) sessions may therefore enhance the clinical responsiveness to CBT. The present pilot study examined the feasibility and direction of effect of exercise+CBT versus CBT in depressed outpatients using a stepped wedged design. Thirty-three patients received either group-based CBT (12-16 weeks) or group-based exercise+CBT within specialized mental healthcare settings. Weekly therapist-supervised exercise sessions (45 min, moderate intensity, running/indoor cycling) were provided directly before the CBT sessions, with encouragement for home-exercise. Feasibility was assessed through recruitment, retention, and safety, alongside treatment adherence and treatment effects on clinically relevant outcomes. Recruitment yielded 37% of eligible patients with similar retention rates across conditions. No adverse events were reported. The exercise+CBT condition attended 63% of supervised exercise sessions (72% at moderate/vigorous intensity) and fewer CBT sessions (42%) compared to the CBT condition (54%). The conditions showed similar improvements in depressive symptoms, rumination, and CBT skills over time. Our study shows in a specialized mental health care routine practice population that providing exercise before CBT sessions is feasible, warranting a future randomized controlled trial.

Evaluating the effectiveness of a multi-component lifestyle therapy program versus psychological therapy for managing mood disorders (HARMON-E): protocol of a randomised non-inferiority trial

BACKGROUND

Mood disorders, including unipolar and bipolar depression, contribute significantly to the global burden of disease. Psychological therapy is considered a gold standard non-pharmacological treatment for managing these conditions; however, a growing body of evidence also supports the use of lifestyle therapies for these conditions. Despite some clinical guidelines endorsing the application of lifestyle therapies as a first-line treatment for individuals with mood disorders, there is limited evidence that this recommendation has been widely adopted into routine practice. A key obstacle is the insufficient evidence on whether lifestyle therapies match the clinical and cost effectiveness of psychological therapy, particularly for treating those with moderate to severe symptoms. The HARMON-E Trial seeks to address this gap by conducting a non-inferiority trial evaluating whether a multi-component lifestyle therapy program is non-inferior to psychological therapy on clinical and cost-effectiveness outcomes over 8-weeks for adults with major depressive disorder and bipolar affective disorder.

METHODS

This trial uses an individually randomised group treatment design with computer generated block randomisation (1:1). Three hundred and seventy-eight adults with clinical depression or bipolar affective disorder, a recent major depressive episode, and moderate-to-severe depressive symptoms are randomised to receive either lifestyle therapy or psychological therapy (adjunctive to any existing treatments, including pharmacotherapies). Both therapy programs are delivered remotely, via a secure online video conferencing platform. The programs comprise an individual session and six subsequent group-based sessions over 8-weeks. All program aspects (e.g. session duration, time of day, and communications between participants and facilitators) are matched except for the content and program facilitators. Lifestyle therapy is provided by a dietitian and exercise physiologist focusing on four pillars of lifestyle (diet, physical activity, sleep, and substance use), and the psychological therapy program is provided by two psychologists using a cognitive behavioural therapy approach. Data collection occurs at baseline, 8-weeks, 16-weeks, and 6 months with research assistants blinded to allocation. The primary outcome is depressive symptoms at 8 weeks, measured using the Montgomery-Åsberg Depression Rating Scale (MADRS) (minimal clinically important difference = 1.6). A pre-specified within-trial economic evaluation will also be conducted.

DISCUSSION

Should lifestyle therapy be found to be as clinically and cost effective as psychological therapy for managing mood disorders, this approach has potential to be considered as an adjunctive treatment for those with moderate to severe depressive symptoms.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12622001026718, registered 22nd July 2022.

PROTOCOL VERSION

4.14, 26/06/2024.

Adjunctive use of mindfulness-based mobile application in depression: randomized controlled study

Mindfulness-based interventions (MBI) are effective in relapse prevention in Major Depressive Disorder (MDD). Internet-based interventions have been demonstrated to be effective in the treatment of MDD. Consequently, the integration of MBI through mobile applications emerges as a promising supplementary intervention for MDD, contributing to the augmentation of mental health services, particularly within ambulatory care contexts. The current randomized controlled study is designed to evaluate the efficacy of adjunctive MBI delivered via a mobile app in mitigating symptom severity and stress levels. This assessment involves a comparison with standard treatment practices in an ambulatory setting among individuals diagnosed with MDD. A total of 83 patients diagnosed with MDD (depressive episode, recurrent depression or depressive phase of bipolar disorder) were randomly allocated to the intervention (41 patients) or control condition (42 patients). The intervention consisted of the daily use of the mindfulness mobile application "Headspace" for thirty days. The control condition was treatment as usual (TAU) only. The symptom severity has been assessed by the Beck Depression Inventory (BDI-II) as well as the Hamilton Depression Rating Scale (HDRS-17). Blood pressure and resting heart rate have been assessed as secondary outcome. Upon hospital discharge, the mean scores on the Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HDRS) signaled partial remission of MDD in both treatment arms. In both groups, a subsequent decrease in both self-reported and expert-rated scores was evident after a 30-day period. However, the decrease in depression severity as measured by HDRS was significantly higher in the MBI group compared to the control group after 30 days. For secondary outcomes, systolic blood pressure was lower in the intervention group compared to control group. The total drop-out rate was 29%. Short term mindfulness intervention via mobile application (30 days) can be beneficial as adjunctive therapy to treatment as usual in patients with MDD.

Exercise and health-related quality of life and work-related outcomes in primary care patients with anxiety disorders - A randomized controlled study

BACKGROUND

Exercise interventions show promise in the treatment of anxiety disorders, but effects on health-related quality of life (HR-QoL), work ability, and sick leave are little studied. We investigated these outcomes in a 12-week randomized controlled trial with a 1-year follow-up.

METHODS

Patients aged 18-65 (n = 222) with anxiety disorders from primary care centers in Gothenburg were randomized to a control group or one of two 12-week exercise intervention groups (low-intensity, [LI] and moderate/high-intensity, [HI]); 148 were evaluated at 12-weeks and 113 completed the 1-year follow-up. The EuroQol 5D (EQ5D; index and the visual analogue scale [VAS]), work ability score (WAS), presenteeism, and self-reported sick leave were assessed at baseline, 12 weeks, and 1 year. Improvements were defined by binary cut-offs for each scale. Binary logistic regression with odds ratios (OR) and 95 % confidence intervals (CI) were reported.

RESULTS

There were improved scores for EQ5D and WAS in the HI group compared to controls after 12 weeks (EQ5D index: 4.74 [1.91-11.7], EQ5D-VAS 4.00, [1.65-9.72], WAS 3.41 [1.24-7.37]) and 1 year (EQ5D index: 3.05 [1.05-8.81], EQ5D-VAS 3.20 [1.16-8.84], WAS 5.50 [1.85-16.3]). Post-hoc analysis showed higher ORs in participants on antidepressants (n = 75) (12-week EQ5D index: OR 9.95 [2.85-34.8]) and significant improvements in EQ5D scores for both intervention groups after 1 year. There were no between-group differences for presenteeism or sick leave.

LIMITATIONS

Discontinuation was high, mostly early after randomization (n = 74), as is common for anxiety interventions.

CONCLUSIONS

HI Exercise improves HR-QoL and work ability in anxiety patients, especially when combined with antidepressants.

[Effects of a Motivational Intervention on the Effectiveness and Sustainability of Sports and Exercise Therapy in Inpatient Psychiatric Care]

OBJECTIVE

Reinforcement and sustainability of sports and exercise therapy in inpatient depression treatment.

METHODS

Randomized controlled study with 3 measurement times: t0 admission to the study, t1 after four weeks, t2 two months after discharge. 96 inpatients with depressive disorders (ICD-10 F32, F33) were randomly assigned to an intervention group (IG) or a control group (KG). In addition to sports and exercise therapy (KG), the IG received an educational and motivational session on the importance of sports and exercise, as well as a motivational final discussion.

RESULTS

Endurance performance and physical fitness improved more significantly in the IG than in the CG over the 3 measurement times. The motivational final discussion was rated as more helpful.

DISCUSSION

The intervention was well accepted by the patients and partially increased the effects of sports and exercise therapy. Not only psychological aspects of depression treatment were influenced, but also measurable physical effects.

CONCLUSION

The practical and time-efficient motivational intervention in inpatient psychiatric care can complement sports and exercise therapy for depressive patients.

Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis

Importance

While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary.

Objective

To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness.

Data Sources

A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials.

Study Selection

Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted.

Main Outcomes and Measures

Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs.

Results

The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46).

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.

Associations of device-measured and self-reported physical activity with alcohol consumption: Secondary analyses of a randomized controlled trial (FitForChange)

BACKGROUND

Physical activity (PA) is increasingly used as an adjunct treatment for alcohol use disorder (AUD). Previous studies have relied on self-report measures of PA, which are prone to measurement error. In the context of a randomized controlled trial of PA for AUD, we examined: (1) associations between device-measured and self-reported PA, (2) associations between PA measurements and alcohol use, and (3) the feasibility of obtaining device-measured PA data in this population.

METHOD

One-hundred and forty individuals with clinician-diagnosed AUD participated in a 12-week intervention comparing usual care (phone counselling) to yoga-based exercise and aerobic exercise. Device-measured PA (Actigraph GT3x), self-reported PA (International Physical Activity Questionnaire) and alcohol consumption (Timeline Follow Back Method) were assessed before and after the trial. Effects of the interventions on PA levels were assessed using linear mixed models.

RESULTS

In total, 42% (n=59) of participants returned usable device-measured PA data (mean age= 56±10 years, 73% male). Device-measured and self-reported vigorous-intensity PA were correlated (β= -0.02, 95%CI= -0.03, -0.00). No associations were found for moderate-intensity PA. Compared to usual care, time spent in device-measured light-intensity PA increased in the aerobic exercise group (∆= 357, 95%CI= 709, 5.24). Increases in device-measured light-intensity PA were associated with fewer standard drinks (∆= -0.24, 95%CI= -0.03, -0.44), and fewer heavy drinking days (∆= -0.06, 95%CI=-0.01, -0.10).

CONCLUSION

Increases in light-intensity/habitual PA were associated with less alcohol consumption in adults with AUD. Self-reported PA data should be interpreted with caution. Incentives are needed to obtain device-measured PA data in AUD populations.

Evaluating the effect of exercise-based interventions on functioning in people with transdiagnostic depressive symptoms: A systematic review of randomised controlled trials

BACKGROUND

Depressive symptoms are associated with various conditions and can exacerbate the outcome of somatic diseases. Transdiagnostic symptom-based approaches provide treatment flexibility, and exercise has demonstrated benefits beyond clinical symptoms. This work aimed to synthesise and establish the effects of exercise-based interventions on global functioning and quality of life in adults with transdiagnostic depressive symptoms, as well as their impact on clinical symptoms.

METHODS

A systematic review was conducted following PRISMA guidelines. PubMed, Scopus and PsycINFO databases were searched from inception to April 2023. Eligibility criteria included randomised controlled trials involving adults with transdiagnostic depressive symptoms who received exercise-based interventions and provided details of the interventions. Comparators included treatment as usual or other active control groups. The Cochrane quality assessment tool was used for quality assessment.

RESULTS

Fifteen articles involving 2064 participants were included. Data on study design, sample, intervention characteristics, and outcomes were extracted. Several trials demonstrated the expected positive effects of exercise on functioning (7/15). Most results supported the benefits of adjunctive exercise interventions on illness outcomes.

LIMITATIONS

The studies had methodological limitations, including small sample sizes and an underrepresentation of somatic diseases.

CONCLUSIONS

The functional consequences of exercise-based interventions targeting depressive symptoms are often understudied. Incorporating exercise routinely as an add-on treatment for transdiagnostic depressive symptoms could improve overall functioning, quality of life, and symptom severity. There is a need to expand the focus of exercise-based interventions to incorporate functional outcomes. Future research should address the methodological limitations and include a wider range of participants, including those with somatic diseases.

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review

BACKGROUND

There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature.

OBJECTIVE

Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence.

METHODS

Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures.

RESULTS

A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics.

CONCLUSIONS

It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions.

Improving movement behavior in office workers: effects of two multi-level cluster-RCT interventions on mental health

BACKGROUND

We have previously reported on the design and efficacy of two cluster-randomized multi-level workplace interventions, attempting to decrease sedentary behavior (SED) or increase moderate to vigorous physical activity (MVPA) among office workers to improve mental health outcomes. The aim of this study was to investigate intervention effects on mental health outcomes, i.e., mental wellbeing, depression or anxiety symptoms, and stress immediately after the 6-month intervention period.

METHODS

Teams of 263 office workers were cluster-randomized to one of two interventions or a waitlist control group. The PA intervention (iPA) focused on increasing MVPA and the SED intervention (iSED) on reducing SED. Both multi-level interventions targeted individual office workers and their social, physical, and organizational work environment, incorporating counseling based on cognitive behavioral therapy and motivational interviewing. Mental health outcomes were assessed using validated questionnaires before and immediately after the intervention. Intervention effects were analyzed using linear mixed effects models.

RESULTS

Participants were mostly female and highly educated, with a mean age of 42 years and had favorable levels of mental health at baseline. Mental wellbeing improved for the iSED group (β = 8, 95% CI 1 to 15, p = 0.030) but not for the iPA group (β = 6, 95% CI -1 to 12, p = 0.072) compared to the control group. No effects were found for depression or anxiety symptoms or stress.

CONCLUSIONS

The multi-level interventions improved mental wellbeing among this population of office workers, reaching statistical significance in the iSED group. The size of the effect can be regarded meaningful, considering favorable mental health and high PA level at baseline. Thus, workplace interventions that provide support on multiple levels appear to have potential for improving mental wellbeing, but not reducing ill-health variables, among healthy office workers. More research is needed to understand the mechanisms through which such improvements can be achieved and to identify the most effective intervention components.

TRIAL REGISTRATION

ISRCTN92968402 (27 February 2018).

The Effect of Internet-Based Cognitive Behavioral Therapy on Major Depressive Disorder: Randomized Controlled Trial

BACKGROUND

Many people living with major depressive disorder (MDD) in China do not receive treatment owing to a lack of mental health services, along with significant stigma toward mental illness. Internet-based cognitive behavioral therapy (ICBT) has been proposed to increase access to mental health care for people with MDD.

OBJECTIVE

The aims of this study were to (1) evaluate the efficacy of ICBT for depressive symptoms in patients with MDD; (2) evaluate the effect of ICBT on anxiety symptoms, nonspecific psychological distress, general self-efficacy, depression stigma, social function, and health-related quality of life (HRQoL); and (3) explore the acceptability of and satisfaction with the ICBT program among participants.

METHODS

Patients with MDD were enrolled and randomized to the ICBT group or the waiting-list control (WLC) group. The ICBT group received ICBT delivered through a WeChat mini-program with general support by nonspecialists. Participants in the 2 groups were self-evaluated online at baseline and posttreatment for changes in the primary outcome (ie, depressive symptoms) and secondary outcomes (ie, anxiety symptoms, nonspecific psychological distress, general self-efficacy, depression stigma, social functional impairment, and HRQoL). Changes in outcomes were measured by changes in overall scores on respective scales, and response and remission rates were calculated based on depressive symptoms. The acceptability of and satisfaction with the ICBT program were measured by treatment adherence and participants' feelings (ie, modules seriously completed, perceived benefit, and satisfaction).

RESULTS

We included 40 patients who were randomly assigned to the ICBT group and 44 who were assigned to the WLC group. Compared with the WLC group, the ICBT group had fewer depressive symptoms, fewer anxiety symptoms, less nonspecific psychological distress, and greater general self-efficacy. Moreover, the ICBT group had higher response (18/31, 58%) and remission rates (17/31, 55%). The adherence rate in the ICBT group was 78% (31/40), and the majority of participants who completed all ICBT modules were satisfied with the ICBT program.

CONCLUSIONS

ICBT demonstrated greater improvements in depressive symptoms, anxiety symptoms, nonspecific psychological distress, and general self-efficacy among selected patients with MDD in comparison with the findings in waiting-list controls. The ICBT program in this study had good acceptability and satisfaction among participants.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100046425); https://tinyurl.com/bdcrj4zv.

Practical pathway for the management of depression in the workplace: a Canadian perspective

Major depressive disorder (MDD) and other mental health issues pose a substantial burden on the workforce. Approximately half a million Canadians will not be at work in any week because of a mental health disorder, and more than twice that number will work at a reduced level of productivity (presenteeism). Although it is important to determine whether work plays a role in a mental health condition, at initial presentation, patients should be diagnosed and treated per appropriate clinical guidelines. However, it is also important for patient care to determine the various causes or triggers including work-related factors. Clearly identifying the stressors associated with the mental health disorder can help clinicians to assess functional limitations, develop an appropriate care plan, and interact more effectively with worker's compensation and disability programs, as well as employers. There is currently no widely accepted tool to definitively identify MDD as work-related, but the presence of certain patient and work characteristics may help. This paper seeks to review the evidence specific to depression in the workplace, and provide practical tips to help clinicians to identify and treat work-related MDD, as well as navigate disability issues.

Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review

BACKGROUND

New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness.

OBJECTIVE

This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy.

METHODS

We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study.

RESULTS

This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability.

CONCLUSIONS

Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations.

Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression

OBJECTIVE

To estimate the efficacy of exercise on depressive symptoms compared with non-active control groups and to determine the moderating effects of exercise on depression and the presence of publication bias.

DESIGN

Systematic review and meta-analysis with meta-regression.

DATA SOURCES

The Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, Embase, SPORTDiscus, PsycINFO, Scopus and Web of Science were searched without language restrictions from inception to 13 September2022 (PROSPERO registration no CRD42020210651).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials including participants aged 18 years or older with a diagnosis of major depressive disorder or those with depressive symptoms determined by validated screening measures scoring above the threshold value, investigating the effects of an exercise intervention (aerobic and/or resistance exercise) compared with a non-exercising control group.

RESULTS

Forty-one studies, comprising 2264 participants post intervention were included in the meta-analysis demonstrating large effects (standardised mean difference (SMD)=-0.946, 95% CI -1.18 to -0.71) favouring exercise interventions which corresponds to the number needed to treat (NNT)=2 (95% CI 1.68 to 2.59). Large effects were found in studies with individuals with major depressive disorder (SMD=-0.998, 95% CI -1.39 to -0.61, k=20), supervised exercise interventions (SMD=-1.026, 95% CI -1.28 to -0.77, k=40) and moderate effects when analyses were restricted to low risk of bias studies (SMD=-0.666, 95% CI -0.99 to -0.34, k=12, NNT=2.8 (95% CI 1.94 to 5.22)).

CONCLUSION

Exercise is efficacious in treating depression and depressive symptoms and should be offered as an evidence-based treatment option focusing on supervised and group exercise with moderate intensity and aerobic exercise regimes. The small sample sizes of many trials and high heterogeneity in methods should be considered when interpreting the results.

Effects of Acute Exercise on Affect, Anxiety, and Self-Esteem in Poly-Substance Dependent Inpatients

INTRODUCTION

Negative affect and anxiety frequently precede the onset of drug use in those with substance use disorder (SUD). Low self-esteem may increase the risk of relapse. We examined the short-term effects of exercise on affect, anxiety, and self-esteem in inpatients with poly-SUD.

METHODS

This is a multicenter randomized control trial (RCT) with a crossover design. Thirty-eight inpatients (37.3 ± 6.4 years; 84% male) from three clinics participated in 45 min of soccer, circuit training, and control condition (psychoeducation) in a random order. Positive and negative affect (PANAS), state anxiety (single item), and self-esteem (Rosenberg SE-scale) were measured immediately before, immediately after, 1-h, 2-h, and 4-h post-exercise. Heart rate and ratings of perceived exertion were taken. Effects were assessed using linear mixed effects models.

RESULTS

Compared to the control condition, there were significant post-exercise improvements in positive affect (β = 2.99, CI = 0.39: 5.58), self-esteem (β = 1.84, CI = 0.49: 3.20), and anxiety (β = -0.69, CI = -1.34: -0.04) after circuit training (shown) and soccer. Effects persisted 4-h post-exercise. Reductions in negative affect were observed 2-h (circuit training: β = -3.39, CI = -6.35: -1.51) and 4-h (soccer: β = -3.71, CI = -6.03: -1.39) post-exercise, respectively.

CONCLUSION

Moderately strenuous exercise undertaken in naturalistic settings may improve mental health symptoms in poly-SUD inpatients for up to 4-h post-exercise.

Personalization strategies in digital mental health interventions: a systematic review and conceptual framework for depressive symptoms

Introduction

Personalization is a much-discussed approach to improve adherence and outcomes for Digital Mental Health interventions (DMHIs). Yet, major questions remain open, such as (1) what personalization is, (2) how prevalent it is in practice, and (3) what benefits it truly has.

Methods

We address this gap by performing a systematic literature review identifying all empirical studies on DMHIs targeting depressive symptoms in adults from 2015 to September 2022. The search in Pubmed, SCOPUS and Psycinfo led to the inclusion of 138 articles, describing 94 distinct DMHIs provided to an overall sample of approximately 24,300 individuals.

Results

Our investigation results in the conceptualization of personalization as purposefully designed variation between individuals in an intervention's therapeutic elements or its structure. We propose to further differentiate personalization by what is personalized (i.e., intervention content, content order, level of guidance or communication) and the underlying mechanism [i.e., user choice, provider choice, decision rules, and machine-learning (ML) based approaches]. Applying this concept, we identified personalization in 66% of the interventions for depressive symptoms, with personalized intervention content (32% of interventions) and communication with the user (30%) being particularly popular. Personalization via decision rules (48%) and user choice (36%) were the most used mechanisms, while the utilization of ML was rare (3%). Two-thirds of personalized interventions only tailored one dimension of the intervention.

Discussion

We conclude that future interventions could provide even more personalized experiences and especially benefit from using ML models. Finally, empirical evidence for personalization was scarce and inconclusive, making further evidence for the benefits of personalization highly needed.

Systematic Review Registration

Identifier: CRD42022357408.

Examining the description of the concept "treatment as usual" for patients with depression, anxiety and stress-related mental disorders in primary health care research - A systematic review

BACKGROUND

In randomized controlled trials (RCTs) within medical research, applied interventions are compared to treatment-as-usual (TAU) as the control condition. The aim of the current study was to examine how the concept of TAU is described when used as control condition in RCTs evaluating treatments for depression, anxiety syndromes, and stress-related mental disorders in primary care.

METHOD

A systematic review of RCTs utilizing TAU as control group in the RCT in accordance with PRISMA standards was conducted. We used one multidisciplinary database (Scopus), one database focused on nursing (Cinahl), and one medical database (PubMed). The searches were conducted in November 2021 and May 2022.

RESULTS

The included 32 studies comprised of 7803 participants. The content of TAU was classified as follows: 1) Basic descriptions of TAU lacking a detailed account as well as reference to local or national guidelines, 2) Moderate description of TAU including reference to national or local guidelines or a detailed description 3) Advanced description of TAU including references to national guidelines and a detailed description containing five key concepts: early assessment, accessibility, psychological treatment, medication, somatic examination. 18 studies had basic, 11 moderate, and 3 advanced descriptions of TAU.

LIMITATIONS

The limitations were that only studies published in English were included.

CONCLUSIONS

The current study provides an assessment tool with three classification levels for TAU. The description of TAU is still insufficient in RCT studies conducted in primary care, which may affect the interpretation of results. In future research a detailed description of TAU is recommended.

Dr Amir Mohammadamini The effect of exercise on suicidal behaviors: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although exercise may positively impact those with mental or other medical illnesses, there is a lack of understanding on how it influences suicidal ideation or risk.

METHODS

We conducted a PRISMA 2020-compliant systematic review searching MEDLINE, EMBASE, Cochrane, and PsycINFO from inception to June 21, 2022. Randomized controlled trials (RCTs) investigating exercise and suicidal ideation in subject with mental or physical conditions were included. Random-effects meta-analysis was conducted. The primary outcome was suicidal ideation. We assessed bias of studies with risk of bias tool 2.

RESULTS

We identified 17 RCTs encompassing 1021 participants. Depression was the most included condition (71 %, k = 12). Mean follow up was 10.0 weeks (SD = 5.2). Post-intervention suicidal ideation (SMD = -1.09, CI -3.08-0.90, p = 0.20, k = 5) was not significantly different between exercise and control groups. Suicide attempts were significantly reduced in participants randomized to exercise interventions as compared to inactive controls (OR = 0.23, CI 0.09-0.67, p = 0.04, k = 2). Fourteen studies (82 %) were at high risk of bias.

LIMITATIONS

This meta-analysis is limited by few, and underpowered and heterogenous studies.

CONCLUSION

Overall, our meta-analysis did not find a significant decrease in suicidal ideation or mortality between exercise and control groups. However, exercise did significantly decrease suicide attempts. Results should be considered preliminary, and more and larger studies assessing suicidality in RCTs testing exercise are needed.

Internet-delivered psychological treatment as an add-on to treatment as usual for common mental disorders: A systematic review with meta-analysis of randomized trials

BACKGROUND

Psychological treatments for common mental disorders are increasingly being delivered remotely via the internet. Evidence suggests that internet-delivered cognitive behavioural therapy (iCBT) is superior to waitlist. However, the benefits are unclear of using this treatment modality as an add-on to treatment as usual (TAU) in regular healthcare.

METHODS

The literature was systematically searched up to August 2021 for randomized trials of internet-delivered psychological treatments using TAU as the comparator. Eligible participants were diagnosed with depressive, anxiety, obsessive-compulsive, or trauma- and stress-related disorders. Outcomes of interest were symptoms, functioning, quality of life, healthcare utilization, and negative effects. Results were synthesized using random-effects meta-analyses. Quality of evidence was assessed using GRADE.

RESULTS

The included studies evaluated iCBT for adults with depression (k = 9), depressive or anxiety disorders (k = 4), and post-traumatic stress disorder (k = 2) and were conducted in primary care or similar settings. For depression, low-certainty evidence suggested beneficial short-term effects on symptoms (g = -0.23; 95 % CI: = -0.37, -0.09), response rate (OR = 2.46; 1.31, 4.64), and remission (OR = 1.70; 1.19, 2.42;). The certainty of evidence was very low for long-term effects, other outcomes, and other disorders.

LIMITATIONS

TAU varied across studies and was often insufficiently described.

CONCLUSIONS

iCBT as a complement to usual care for adult with depression may result in a small incremental effect, which potentially could be clinically important. Studies are lacking for several common disorders and for children, adolescents, and the elderly. More robust studies of long-term effects are also needed, to better inform clinical decision-making.

The role of exercise in the treatment of depression: biological underpinnings and clinical outcomes

Globally, depression is a leading cause of disability and has remained so for decades. Antidepressant medications have suboptimal outcomes and are too frequently associated with side effects, highlighting the need for alternative treatment options. Although primarily known for its robust physical health benefits, exercise is increasingly recognized for its mental health and antidepressant benefits. Empirical evidence indicates that exercise is effective in treating individuals with depression; however, the mechanisms by which exercise exerts anti-depressant effects are not fully understood. Acute bouts of exercise have been shown to transiently modulate circulating levels of serotonin and norepinephrine, brain-derived neurotrophic factor, and a variety of immuno-inflammatory mechanisms in clinical cohorts with depression. However, exercise training has not been demonstrated to consistently modulate such mechanisms, and evidence linking these putative mechanisms and reductions in depression is lacking. The complexity of the biological underpinnings of depression coupled with the intricate molecular cascade induced by exercise are significant obstacles in the attempt to disentangle exercise's effects on depression. Notwithstanding our limited understanding of these effects, clinical evidence uniformly argues for the use of exercise to treat depression. Regrettably, exercise remains underutilized despite being an accessible, low-cost alternative/adjunctive intervention that can simultaneously reduce depression and improve overall health. To address the gaps in our understanding of the clinical and molecular effects of exercise on depression, we propose a model that leverages systems biology and multidisciplinary team science with a large-scale public health investment. Until the science matches the scale of complexity and burden posed by depression, our ability to advance knowledge and treatment will continue to be plagued by fragmented, irreproducible mechanistic findings and no guidelines for standards of care.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Exercise and yoga during pregnancy and their impact on depression: a systematic literature review

It is well established that exercise can improve depressive symptoms in the general population; however, it is not clear if these benefits are also seen in pregnancy. This review aimed to synthesize the evidence that examines whether exercise during pregnancy impacts depressive and associated symptoms (e.g. anxiety) during the perinatal period. The review was conducted in accordance with PRISMA guidelines and reporting criteria; literature was searched using PubMed, Scopus and Web of Science database engines. Clinical trials published in English evaluating the effects of a defined exercise protocol during pregnancy on depressive and/or anxiety symptoms during the perinatal period were included. Studies without a control group were excluded. Risk of bias was conducted by Cochrane assessment to appraise the quality of the included studies. Twenty-seven articles, between 1994 and 2019, were included. Of these, only 5 specifically recruited women with depression (n = 334), which all assessed a yoga-based intervention; 4 of these studies showed a statistically significant improvement in depressive and/or anxiety symptoms in the intervention group compared to baseline; however, 2 of these studies also showed an improvement in the control group. The remaining 22 studies used various exercise interventions in pregnant women (n = 4808) with 20 studies reporting that exercise during pregnancy has the ability to improve depressive and/or anxiety measures in the perinatal period compared to either baseline or control. The evidence suggests that exercise of various types in pregnancy can reduce depressive and/or anxiety symptoms in the perinatal period in otherwise healthy women. Specifically in women with antenatal depression, the incorporation of yoga in pregnancy can improve depressive/anxiety symptoms in the perinatal period; however, this is based on a small number of studies, and it is not clear whether this is superior to non-exercise controls. Further studies are needed to determine the potential therapeutic effects of exercise of various types during pregnancy on symptoms of antenatal depression.

Web-based exercise interventions for patients with depressive and anxiety disorders: a systematic review of randomized controlled trials

OBJECTIVE

The number of people suffering from depression and/or anxiety has increased steadily due to the coronavirus disease 2019 (COVID-19) pandemic. In this context, web-based exercise interventions have emerged as a potential treatment strategy. The objective of this study was to synthetize evidence from randomized controlled trials regarding the effects of web-based exercise interventions on patients with depressive and/or anxiety disorders.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Six databases were searched (Cochrane Library, EBSCO, PubMed, SciELO, Scopus, and Web of Science), and eligible articles were identified according to a PICOS inclusion-exclusion approach (participants with depressive or anxiety disorders; web-based exercise interventions; active or passive control group; assessment of changes in depressive or anxiety disorders; randomized design). Primary outcomes were depressive and/or anxiety symptoms. The quality of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 7,846 search results, three studies met the inclusion criteria (172 participants between 18 and 65 years of age, 95.9% women). The web-based exercise interventions lasted 8-12 weeks and involved endurance training, yoga, or combined endurance and strength training. The comparators involved non-exercise controls or active controls. Compliance rates were low. Web-based exercise interventions were not superior to controls regarding anxiety symptoms, and only one study found benefits for depressive symptoms (p ≤ 0.05). The quality of the cumulative evidence was low.

CONCLUSION

The available data regarding the effects of web-based exercise interventions on depression and/or anxiety symptoms is scarce, the risk of bias is high, and the quality of the cumulative results is low. Currently, no clear recommendations can be provided.

REGISTRATION NUMBER

PROSPERO CRD42021225938.

Digital interventions to address mental health needs in colleges: Perspectives of student stakeholders

Objective

The need for clinical services in U.S. colleges exceeds the supply. Digital Mental health Interventions (DMHIs) are a potential solution, but successful implementation depends on stakeholder acceptance. This study investigated the relevance of DMHIs from students' perspectives.

Methods

In 2020-2021, an online cross-sectional survey using mixed methods was conducted with 479 students at 23 colleges and universities. Respondents reported views and use of standard mental health services and DMHIs and rated the priority of various DMHIs to be offered through campus services. Qualitative data included open-ended responses.

Findings

Among respondents, 91% reported having experienced mental health problems, of which 91% reported barriers to receiving mental health services. Students highlighted therapy and counseling as desired and saw flexible access to services as important. With respect to DMHIs, respondents had the most experience with physical health apps (46%), mental health questionnaires (41%), and mental well-being apps (39%). Most were unaware of or had not used apps or self-help programs for mental health problems. Students were most likely to report the following DMHIs as high priorities: a crisis text line (76%), telehealth (66%), websites for connecting to services (62%), and text/messaging with counselors (62%). They considered a self-help program with coach support to be convenient but some also perceived such services to be possibly less effective than in-person therapy.

Conclusions

Students welcome DMHIs on campus and indicate preference for mental health services that include human support. The findings, with particular focus on characteristics of the DMHIs prioritized, and students' awareness and perceptions of scalable DMHIs emphasized by policymakers, should inform schools looking to implement DMHIs.

Effects of yoga and aerobic exercise on wellbeing in physically inactive older adults: randomized controlled trial (FitForAge)

OBJECTIVE

To compare the effects of yoga and aerobic exercise (AE) on wellbeing in physically inactive, but otherwise healthy older adults. A secondary objective was to assess and compare the frequency of adverse events associated with yoga and AE.

DESIGN

Twelve-week, three-group, parallel randomized controlled trial with blinded follow-up assessment.

INTERVENTIONS

Participants were supported to complete ≥3 Hatha yoga classes/week or ≥3 AE sessions/week. A wait-list control (WLC) group continued usual daily activities.

MAIN OUTCOME MEASURE

Change in wellbeing, assessed using the Satisfaction with Life Scale (SWLS) and Life Satisfaction Index-Z (LSI),at baseline and at 12-week follow up.

RESULTS

In total, 82 adults (mean age 72.5 years, range 65-85, 77% female) were recruited. Of these, 27 were randomized to yoga, 29 to aerobic exercise and 26 to wait-list control. Medium-magnitude treatment effects (Hedges' g) were seen for yoga versus WLC and AE versus WLC(SWLS, g = 0.65 and 0.56; LSI, g = 0.54 and 0.54, respectively). In per-protocol analyses, larger effect sizes were found (SWLS, g = 0.72 and 0.66; LSI, g = 0.76 and 0.76, respectively). Adverse events were less frequent in the yoga group (6/27; 22%) compared to AE (10/27; 37%).

CONCLUSIONS

Among physically inactive older adults, participation in yoga or AE was associated with beneficial effects on subjective wellbeing when compared to a non-active control group. Yoga was associated with fewer injuries and may be especially suitable for older adults (DRKS 00015093).

Utilization of healthcare and prescription medicines after non-pharmacological interventions for depression - A 3-year register follow-up of an RCT in primary care

•

A 3-year register follow-up of an RCT for depression interventions was conducted.

•

Healthcare utilization and dispensed medicines were used as register outcomes.

•

The interventions had no effect on consultations for mental illness during follow-up.

•

Both interventions are appropriate additions to mild-moderate depression care.

Depression is a common, recurrent disorder. There is a need for readily available treatments with few negative side effects, that demands little resources and that are effective both in the short- and long term.

Our aim was to investigate the long-term effectiveness of two different interventions; physical exercise and internet-based cognitive behavioural therapy (internet-CBT), compared to usual care in patients with mild to moderate depression in a Swedish primary care setting.

We performed a register-based 3-year follow-up study of participants in the randomized controlled trial REGASSA (n = 940) using healthcare utilization and dispensed medicines as outcomes.

We found no difference between the three groups regarding proportion of participants consulting healthcare due to mental illness or pain during follow-up. Regarding number of consultations, there was no difference between the groups, except for consultations related to pain. For this outcome both treatment arms had significantly fewer consultations compared to usual care, during year 2–3, the risk ratio (RR) for physical exercise and internet-CBT was 0.64 (95% CI = 0.43–0.95) and 0.61 (95% CI = 0.41–0.90), respectively.

A significantly lower proportion of patients in both treatment arms were dispensed hypnotics and sedatives year 2–3 compared to the usual care arm, RR for both physical exercise and internet-CBT was 0.72 (95% CI = 0.53–0.98). No other differences between the groups were found.

In conclusion, considering long-term effects, both physical exercise and internet-CBT, being resource-efficient treatments, could be considered as appropriate additions for patients with mild to moderate depression in primary care settings.

Trial registration: The original RCT was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).

Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression.

OBJECTIVES

To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020.

INTERVENTIONS

CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded.

MAIN OUTCOMES AND MEASURES

The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8.

RESULTS

The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02700009.

Actigraphy monitoring in anxiety disorders: A mini-review of the literature

Sleep disturbances and changes of activity patterns are not uncommon in anxiety disorders, but they are rarely the object of attention. Actigraphic monitoring of day and night activity patterns could provide useful data to detect symptom worsening, prevent risk periods, and evaluate treatment efficacy in those disorders. Thus, we have conducted a systematic search of the scientific literature to find any original study using actigraphic monitoring to investigate activity and sleep patterns in patients affected by any type of anxiety disorder according to the definition of the DSM-5. We found only six studies fulfilling these criteria. Three studies report significant findings in patients suffering from anxiety disorders. Overall, the samples and methods are heterogeneous. Although the authors support the interest of actigraphic monitoring in anxiety disorders, the evidence to date is very limited.

Effect of online aerobic exercise training in patients with bipolar depression: Protocol of a randomized clinical trial

INTRODUCTION

Bipolar disorder (BD) is a common and debilitating mental illness that affects about 400 million people worldwide, decreasing their functionality and quality of life. Medication and psychotherapy are recommended for treatment of BD, while some evidence indicates that exercise could improve the clinical outcome of BD. This study aims to investigate whether exercise intervention could reduce the mood symptoms and inflammation level of BD.

METHODS

This is a longitudinal, interventional, randomized, and single-blind trial. We plan to recruit 94 patients diagnosed with BD in depression episode. Patients will be randomly assigned to treatment as usual + aerobic exercise group (intervention group) and treatment as usual (TAU) only group, at a ratio of 1:1. The intervention group will undergo 40-min aerobic exercise training twice a week for eight weeks. The primary outcome of this study is the mean change of Hamilton Depression Rating Scale 17 (HAMD 17) scores from baseline to week 8. The Young Manic Rating Scale (YMRS), Self-Rating Depression Scale (SDS), and Interleukin-6 (IL-6), Tumor necrosis factor-α (TNF-α) and C-reactive protein (CRP) levels will also be measured. The measurements will be performed at baseline, immediately after intervention and two months after intervention.

DISCUSSION

Aerobic exercise training + treatment is expected to bring more benefits to BD patients than TAU only. This trial might provide stronger evidence of physical exercise efficacy for BD treatment.

CLINICAL TRIAL REGISTRATION

This study was approved by the Chinese Clinical Trial Registry (Registration Code: ChiCTR2200057159). Registered on 1 March 2022.

The Self-Absorptive Trait of Dissociative Experience and Problematic Internet Use: A National Birth Cohort Study

Functional and excessive use of internet are hard to distinguish from each other, and internet use can affect adolescents’ development of self-identity. The aim of our study was to investigate the associated relationships between the risk and protective factors for internet use, including parental monitoring, the absorptive dissociative trait, having been bullied, exercise, self-perceived depressive mood, and happiness of 12-year-old adolescents. The Taiwan Birth Cohort Study dataset, which used a national household probability sampling method and included 17,694 12-year-old adolescents, was used for this study. Our results showed that 5.3% of adolescents reported spending more than five hours online during school days. Additionally, adolescents that spent more than five hours online during school days tended to have a higher absorptive trait, perceived less care from mothers, were more likely to have been bullied, and expressed a higher level of depressed mood, which led to a lower level of perceived happiness. Adolescents that spent more than five hours online during school days, compared to those that spent less than an hour online, were more likely to have been bullied, which effected their level of happiness, showing that they may be a group of higher concern. Therefore, spending more than five hours per day online maybe a clinical prevention indicator for problematic internet use.

Effectiveness of a mindfulness-based mobile application for the treatment of depression in ambulatory care: study protocol for a randomized controlled trial (Preprint)

Background

Patients with major depressive disorder (MDD) often experience relapses despite regular treatment with pharmacotherapy and psychotherapy. Further, long waiting lists and more demand than treatment capacity characterize ambulatory settings. Mindfulness-based interventions proved to be effective in relapse prevention in MDD. Next, mindfulness-based interventions in the form of free mobile applications can be an effective augmentation of the treatment as usual and can fill a gap in ambulatory care.

Objective

Given this background, the aim of this randomized controlled study is to assess the effectiveness of additional MBI via a mobile app on the symptom severity and stress levels, compared to treatment as usual.

Methods

A total of 140 individuals with MDD will be randomly allocated to the intervention or control condition. The intervention consists of the daily use of the mindfulness mobile application Headspace for thirty days (up to 10 minutes a day). The control condition will be treatment as usual. At baseline and four weeks later, the following key outcome dimensions will be assessed: self-rated (Beck Depression Inventory) and experts’ rated symptoms of MDD (Hamilton Depression Rating Scale); secondary outcome variables will be blood pressure, heart rate, and respiratory rate and changes in tobacco and alcohol consumption and medication as a proxy of perceived stress.

Results

This study was funded in February 2021 and approved by the institutional review board on April 15, 2021, and it started in May 2021. As of December 2021, we enrolled 30 participants. The findings are expected to be published in spring 2023.

Conclusions

We hypothesize that compared to the control conditions, individuals with MDD of the mobile app-condition will have both lower self- and experts’ rated symptoms of MDD and more favorable stress-related levels. While the risk for medical events is low, the immediate benefit for participants could be a decrease in symptom severity and reduction of the stress level.

Trial Registration

Clinical Trials.gov NCT05060393; https://clinicaltrials.gov/ct2/show/NCT05060393.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33423

Low and high doses of oxandrolone promote pathological cardiac remodeling in young male rats

Oxandrolone (OXA) used in clinical practice, however, its misuse is frequent, including by adolescents pursuing an aesthetic goal. However, the impacts of noxious doses on the cardiovascular system remain unknown.

AIM

To investigate cardiac effects of OXA in low (LD) and high (HD) doses.

METHODS

Male Wistar prepubescent rats were separated into 3 experimental groups: control (CON), LD, and HD. Only the CON group received the carrier (carboxymethylcellulose, 0.5%), while the LD and HD groups received, respectively, 2.5 and 37.5 mg/kg/day of OXA via gavage for 4 weeks. The hemodynamic parameters (+dP/dtmax, -dP/dtmin, and Tau) and cardiac autonomic tonus were assessed. Hearts were retrieved for histological analyses and oxidative stress evaluation. Expression levels of calcium-handling proteins were measured by western blot.

RESULTS

The OXA treatment changed neither the cardiac contractility nor the cardiac autonomic tonus. However, cardiac hypertrophy, collagen deposition, and increased angiotensin-converting enzyme (ACE) expression were observed in a dose-dependent way. Also, the p-phospholamban (p-PLB)/PLB ratio was observed to decrease and increase, respectively, in the LD and HD groups; the sarcoplasmic/endoplasmic reticulum calcium ATPase 2a (SERCA2a)/PLB ratio being higher in both groups. OXA increased SOD1 expression and decreased catalase expression only in the LD group, and protein oxidation was increased in HD.

CONCLUSION

Both doses of OXA could promote pathological cardiac remodeling, probably via increased ACE, and these effects were exacerbated in the HD treatment, but cardiac contractility was not affected regardless of the dose.

Associations between antidepressant therapy, work ability, and sick leave for patients with common mental disorders within a two-year perspective - A longitudinal observational cohort study in Swedish primary care

Background

An increasing number of patients are on sick leave because of common mental disorders (CMD), with or without antidepressant therapy. There is a lack of long-term follow-up studies in the primary care context, where most of the patients are treated. The importance of identifying potential factors associated with work ability for CMD patients is increasingly in focus.

Objective

To investigate the associations between using antidepressants, sick leave duration, reported work ability and psychological symptoms among patients with CMD during a two-year observation period in the primary care context.

Methods

Longitudinal observational cohort study at 28 Primary Care Centers in Region Västra Götaland, Sweden, including 182 patients with an employment and on sick leave for CMD. The following outcomes were assessed: work ability measured with WAI, depressive symptoms with MADRS-S, anxiety symptoms with BAI, fatigue symptoms with KEDS, quality of life with EQ-5D, and days of sick leave. The data were compared between the groups that used and did not use antidepressants, during the 24-months observation period.

Results

Work ability and health-related quality of life increased over time in both groups. A steeper decrease of depressive symptoms, anxiety symptoms as well as an increased health-related quality of life at 3, 6 and 12 months was found in the group without antidepressants, although both groups levelled off at 24 months. In both groups, a higher work ability at baseline was associated with less two-year sick leave.

Conclusion

Our study indicates that a high work ability at baseline has a strong association with a lower total net and gross sick leave duration during the entire two-year follow-up period for patients with CMD in primary health care, irrespective of use of antidepressants. Using WAI in primary health care could therefore be helpful in predicting return to work. Use of antidepressants during the CMD episode could indicate initially a more pronounced overall symptom pattern, motivating introduction of antidepressants, rather than prolonging the sick leave period.

[Sport and physical exercise in unipolar depression : Prevention, therapy, and neurobiological mechanisms of action]

There is increasing consensus on the relevance of exercise interventions for the treatment and prevention of unipolar depression. The present review article aims to provide a practitioner-friendly overview of recent insights into the underlying neurobiological mechanisms of exercise interventions in depression in order to enhance their dissemination and acceptance. Exercise has proven antidepressive efficacy in major depressive disorders. Furthermore, it has demonstrated a protective effect on the development of depressive symptoms. Neurobiological research has shown that exercise increases the volume of gray matter in the brain, improves the microstructure of white matter and leads to a higher functional connectivity in brain regions implicated in major depressive disorders. On a molecular level, preliminary findings indicate that exercise has anti-inflammatory, neuroplastic and antioxidative effects, which could represent the basis for the effects observed on a brain structural and functional level. Exercise interventions should be recommended as an adjunct therapy for all patients with major depressive disorder.

Discovering Common Elements of Empirically Supported Self-Help Interventions for Depression in Primary Care: a Systematic Review

BACKGROUND

Although the efficacy of self-help cognitive-behavioral therapy (CBT) for depression has been well established, its feasibility in primary care settings is limited because of time and resource constraints. The goal of this study was to identify common elements of empirically supported (i.e., proven effective in controlled research) self-help CBTs and frameworks for effective use in practice.

METHODS

Randomized controlled trials (RCTs) for self-help CBTs for depression in primary care were systematically identified in Pubmed, PsycINFO, and CENTRAL. The distillation and matching model approach was used to abstract commonly used self-help techniques (practice elements). Study contexts associated with unique combinations of intervention elements were explored, including total human support dose (total face-to-face, telephone, and personalized email contact time recommended by the protocol), effective symptom domain (depression vs. general psychological distress), and severity of depression targeted by the study. Relative contribution to intervention success was estimated for individual elements and human support by conditional probability (CP, proportion of the number of times each element appeared in a successful intervention to the number of times it was used in the interventions identified by the review).

RESULTS

Twenty-one interventions (12 successful) in 20 RCTs and 21 practice elements were identified. Cognitive restructuring, behavioral activation, and homework assignment were elements appearing in > 80% of successful interventions. The dose of human support was positively associated with the proportion of interventions that were successful in a significant linear fashion (CPs: interventions with no support, 0.20; 1-119 min of support, 0.60; 120 min of support, 0.83; p = 0.042). In addition, human support increased the probability of success for most of the extracted elements. Only social support activation, homework assignment, and interpersonal skills were highly successful (CPs ≥ 0.60) when minimal support was provided.

DISCUSSION

These findings suggest that human support is an important component in creating an evidence-informed brief self-help program compatible with primary care settings.

Italia Ti Ascolto [Italy, I am listening]: an app-based group psychological intervention during the COVID-19 pandemic

The onset of the coronavirus disease 2019 (COVID-19) pandemic impacted individuals' psychological wellbeing resulting in heightened perceived stress, anxiety, and depression. However, a significant issue in accessing psychological care during a lockdown is the lack of access to in-person interventions. In this regard, research has shown the efficacy and utility of psychological app-based interventions. 'Italia Ti Ascolto' (ITA) has been developed as a population tailored internet-based intervention to offer an online professional solution for psychological support needs. The ITA app is available on iOS and Android systems. Users completed a baseline assessment on emotion regulation strategies (cognitive reappraisal and expressive suppression), psychological stress, anxiety, depression, and perceived social support. Participants could select among several one-hour long clinical groups held by expert psychotherapists. After every session, people were asked to complete a quick users' satisfaction survey. Our contribution presents ITA's intervention protocol and discusses preliminary data on psychological variables collected at baseline. Data showed significant associations between emotion regulation strategies, symptoms of depression and anxiety, and level of stress. Moreover, the role of perceived social support is considered. Future developments and implications for clinical practice and treatment are discussed.

Delivery Approaches Within Exercise Referral Schemes: A Survey of Current Practice in England

BACKGROUND

Exercise referral schemes in England offer referred participants an opportunity to take part in an exercise prescription in a nonclinical environment. The aim of these schemes is to effect clinical health benefits, yet there is limited evidence of schemes' effectiveness, which could be due to the heterogeneity in design, implementation, and evaluation. Additionally, there has been no concerted effort to map program characteristics.

OBJECTIVE

To understand what key delivery approaches are currently used within exercise referral schemes in England.

METHODS

Across England, a total of 30 schemes with a combined total of 85,259 exercise referral scheme participants completed a Consensus on Exercise Reporting Template-guided questionnaire. The questionnaire explored program delivery, nonexercise components, and program management.

RESULTS

Results found that program delivery varied, though many schemes were typically 12 weeks in length, offering participants 2 exercise sessions in a fitness gym or studio per week, using a combination of exercises. Adherence was typically measured through attendance, with nonexercise components and program management varying by scheme.

CONCLUSION

This research provides a snapshot of current delivery approaches and supports the development of a large-scale mapping exercise to review further schemes across the whole of the United Kingdom in order to provide evidence of best practice and delivery approaches nationwide.

A very brief self-report scale for measuring insomnia severity using two items from the Insomnia Severity Index - development and validation in a clinical population

OBJECTIVE

To develop a very brief scale with selected items from the Insomnia Severity Index (ISI), and to investigate the psychometric properties of the proposed scale in a psychiatric sample.

METHODS

Patient data from seven Cognitive Behavioral Therapy (CBT) for insomnia trials and from regular care were used in psychometric analyses (N = 280-15 653). The samples included patients screening (N = 6936) or receiving treatment (N = 1725) for insomnia and other psychiatric conditions. Six criteria relating to component structure, sensitivity to change and clinical representativeness were used to select items. Psychometric analyses for the proposed very brief scale were performed.

RESULTS

One item representing satisfaction/dissatisfaction with current sleep pattern and one item representing interferences with daily functioning, were selected to create the 2-item ISI version. Correlations with the full scale were high at screening, pre and post, and for change (0.82-0.94). Categorical omega was ⍵_C = 0.86. With a cut-off of 6 points, the scale could detect Insomnia Disorder with a sensitivity of 84% and a specificity of 76%, which was close to the full ISI showing 86% and 80% respectively.

CONCLUSIONS

The systematic psychometric evaluation based on a large sample from different contexts makes the proposed 2-item ISI version (ISI-2) a strong candidate for a very brief scale measuring insomnia, both for detecting cases and for measuring change during CBT with an overall high discriminative validity. ISI-2 is especially useful in clinical settings or population studies where there is a need to measure more than one condition at a time without overburdening patients.

CLINICAL TRIALS

Trials used in this analysis: ClinicalTrials.gov identifier: NCT01105052 (https://www.clinicaltrials.gov/ct2/show/NCT01105052) (sample b), ClinicalTrials.gov identifier: NCT01256099 (https://clinicaltrials.gov/ct2/show/NCT01256099) (sample c and d), German clinical trial (DRKS), registration ID: DRKS00008745 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008745) (sample e), ClinicalTrials.gov identifier: NCT01663844 (https://clinicaltrials.gov/ct2/show/NCT01663844) (sample f and g), ClinicalTrials.gov Identifier: NCT02743338 (https://clinicaltrials.gov/ct2/show/NCT02743338) (sample h).

Circulating Extracellular Vesicles: The Missing Link between Physical Exercise and Depression Management?

Depression is associated with an increased risk of aging-related diseases. It is also seemingly a common psychological reaction to pandemic outbreaks with forced quarantines and lockdowns. Thus, depression represents, now more than ever, a major global health burden with therapeutic management challenges. Clinical data highlights that physical exercise is gaining momentum as a non-pharmacological intervention in depressive disorders. Although it may contribute to the reduction of systemic inflammation associated with depression, the mechanisms underlying the beneficial physical exercise effects in emotional behavior remain to be elucidated. Current investigations indicate that a rapid release of extracellular vesicles into the circulation might be the signaling mediators of systemic adaptations to physical exercise. These biological entities are now well-established intercellular communicators, playing a major role in relevant physiological and pathophysiological functions, including brain cell-cell communication. We also reviewed emerging evidence correlating depression with modified circulating extracellular vesicle surfaces and cargo signatures (e.g., microRNAs and proteins), envisioned as potential biomarkers for diagnosis, efficient disease stratification and appropriate therapeutic management. Accordingly, the clinical data summarized in the present review prompted us to hypothesize that physical exercise-related circulating extracellular vesicles contribute to its antidepressant effects, particularly through the modulation of inflammation. This review sheds light on the triad "physical exercise-extracellular vesicles-depression" and suggests new avenues in this novel emerging field.

Intervention Effect of Long-Term Aerobic Training on Anxiety, Depression, and Sleep Quality of Middle School Students With Depression After COVID-19

Objective: To explore the effects of using RPE exercise intensity monitoring methods and 12-week mid- and low-intensity team aerobic training on anxiety, depression and sleep quality of depressed middle school students after the COVID-19 epidemic. Methods: All study participants were all from a boarding middle school in Chongqing, China. All study participants were screened by the self-rating depression scale and reached the diagnostic criteria for depression. The study subjects were divided into a control group (N = 35) and an exercise group (N = 34). The exercise group performed 30-min night aerobic running four times a week. Use the Borg 6-20 rating of perceived exertion scale (RPE) as a monitoring tool for exercise intensity, and control the exercise intensity at RPE = 11-14. And the control group studied and lived normally. The experiment lasted 12 weeks in total. After the experiment, there were 34 people in the control group and 23 people in the exercise group. The subjects' anxiety, depression and Pittsburgh sleep quality were scored before and after the experiment. Results: After intervention, the depression index (p < 0.01) of the exercise group was significantly lower than that of the control group. Conclusion: Using the RPE exercise intensity monitoring method for 12 weeks of mid- and low-intensity team aerobic training can improve the depressive symptoms of depressed middle school students, and it is beneficial to improve the students' mental health.

The Effects and Mechanisms of Exercise on the Treatment of Depression

Background: It is necessary to seek alternative therapies for depression, because side effects of medications lead to poor adherence and some patients do not achieve a clinical treatment effect. Recently the role of exercise as a low-cost and easy-to-use treatment for depression has gained attention with a number of studies showing that exercise is effective at reducing depressive symptoms and improving body functions such as cardiorespiratory system and cognitive function. Because of the heterogeneity of exercise therapy programs, there is no standardized and unified program. Few studies have summarized the specific properties of exercise programs (type, intensity, duration, and frequency) and clinical prescriptions for exercise are not mentioned in most articles. Aims: This study aimed to investigate the feasibility and efficacy of exercise therapy for patients with depression, in order to appraise the evidence and outline accepted guidelines to direct individualized treatment plans for patients with depression based on their individual situations. Methods: A systematic review of English language literature including papers published from 2010 to present in PubMed was performed. Given the feasibility of prescribing exercise therapy for patients with depression, nearly 3 years of clinical studies on the treatments of depressive symptoms with exercise were first reviewed, comparing the exercise programs utilized. Conclusions: Exercise has therapeutic effects on depression in all age groups (mostly 18-65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression. Moderate intensity exercise is enough to reduce depressive symptoms, but higher-dose exercise is better for overall functioning. Exercise therapy has become more widely used because of its benefits to the cardiovascular system, emotional state, and systemic functions. Recommendations: Aerobic exercise/mind-body exercise (3-5 sessions per week with moderate intensity lasting for 4-16 weeks) is recommended. Individualized protocols in the form of group exercise with supervision are effective at increasing adherence to treatment.

Suicide risk management in research on internet-based interventions for depression: A synthesis of the current state and recommendations for future research

BACKGROUND

The number of studies examining internet-based interventions (IBIs) for depression is increasing. Although many individuals with depression experience suicidal ideation, there is only insufficient information available on how to manage and support individuals at risk of suicide in IBI trials. Here, we examined the current practice regarding the management of individuals experiencing suicidal thoughts or behaviors in studies of IBIs for depression.

METHODS

Information pertaining to the management of suicidality was extracted from 24 studies. Additionally, researchers in the field completed a questionnaire (n = 13) before being interviewed (n = 11) about their procedures and considerations regarding the management of suicidality.

RESULTS

In most trials (N = 17; 71%), individuals at risk of suicide were excluded based on varying criteria. N = 7 studies used structured interviews and N = 5 studies used single items of self-report questionnaires for assessing suicidality. The nature and degree of support provided to individuals at risk of suicide varied and only one intervention comprised suicide-specific content.

LIMITATIONS

Most experts referred to research on interventions with some level of human support (e.g. written feedback) which might limit the representativeness of the results of the interviews for unguided interventions.

CONCLUSIONS

Suicidality is often treated more as an exclusion criterion rather than a treatable condition in research on IBIs for depression. This paper provides an overview of the current practice and gives recommendations for the design of future trials.