The D*Phase-study: study protocol for a pragmatic two-phased, randomised controlled (non-inferiority) trial that addresses treatment non-response and compares cognitive behavioural therapy and short-term psychodynamic supportive psychotherapy for major depression

BACKGROUND

Several evidence-based psychotherapeutic treatment options are available for depression, but the treatment results could be improved. The D*Phase study directly compares short-term psychodynamic supportive psychotherapy (SPSP) and cognitive behavioural therapy (CBT) for Major Depressive Disorder (MDD). The objectives are 1. to investigate if, from a group level perspective, SPSP is not inferior to CBT in the treatment of major depressive disorder, 2. to build a model that may help predict the optimal type of treatment for a specific individual; and 3. to determine whether a change of therapist or a change of therapist and treatment method are effective strategies to deal with non-response. Furthermore (4.), the effect of the therapeutic alliance, treatment integrity and therapist allegiance on treatment outcome will be investigated.

METHOD

In this pragmatic randomised controlled trial, 308 patients with a primary diagnosis of MDD are being recruited from a specialised mental health care institution in the Netherlands. In the first phase, patients are randomised 1:1 to either SPSP or CBT. In case of treatment non-response, a second phase follows in which non-responders from treatment phase one are randomised 1:1:1 to one of three groups: continuing the initial treatment with the same therapist, continuing the initial treatment with another therapist or continuing the other type of treatment with another therapist. In both treatment phases, patients are offered sixteen twice-weekly psychotherapy sessions. The primary outcome is an improvement in depressive symptoms. Process variables, working alliance and depressive symptoms, are frequently measured. Comprehensive assessments take place before the start of the first phase (at baseline), in week one, two and four during the treatment, and directly after the treatment (week eight).

DISCUSSION

While the naturalistic setting of the study involves several challenges, we expect, by focusing on a large and diverse number of research variables, to generate important knowledge that may help enhance the effect of psychotherapeutic treatment for MDD.

TRIAL REGISTRATION

The study was registered on 26 August 2016 with the Netherlands Trial Register, part of the Dutch Cochrane Centre (NL5753), https://www.trialregister.nl/trial/5753.

Treating repetitive suicidal intrusions using eye movements: study protocol for a multicenter randomized clinical trial

BACKGROUND

Suicide is a major public health problem, and it remains unclear which processes link suicidal ideation and plans to the act of suicide. Growing evidence shows that the majority of suicidal patients diagnosed with major depression or bipolar disorder report repetitive suicide-related images and thoughts (suicidal intrusions). Various studies showed that vividness of negative as well as positive intrusive images may be reduced by dual task (e.g. eye movements) interventions taxing the working memory. We propose that a dual task intervention may also reduce frequency and intensity of suicidal imagery and may be crucial in preventing the transition from suicidal ideation and planning to actual suicidal behaviour. This study aims a) to evaluate the effectiveness of an Eye Movement Dual Task (EMDT) add-on intervention targeting suicidal imagery in depressed patients, b) to explore the role of potential moderators and mediators in explaining the effect of EMDT, and c) to evaluate the cost-effectiveness of EMDT.

METHODS

We will conduct a multi-center randomized clinical trial (RCT) evaluating the effects of EMDT in combination with usual care (n = 45) compared to usual care alone (n = 45). Participants will fill in multiple online batteries of self-report questionnaires as well as complete a semi-structured interview (Intrusion Interview), and online computer tasks. The primary outcome is the frequency and intrusiveness of suicidal imagery. Furthermore, the vividness, emotionality, and content of the suicidal intrusions are evaluated; secondary outcomes include: suicidal behaviour and suicidal ideation, severity of depression, psychological symptoms, rumination, and hopelessness. Finally, potential moderators and mediators are assessed.

DISCUSSION

If proven effective, EMDT can be added to regular treatment to reduce the frequency and vividness of suicidal imagery.

TRIAL REGISTRATION

The study has been registered on October 17th, 2018 at the Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR7563 ).

[Cognitive therapy and interpersonal psychotherapy for major depressive disorder: how do they work, how long, and for whom?]

Although the effectiveness of cognitive therapy (ct) and interpersonal psychotherapy (ipt) for depression has been well established, little is known about how, how long and for whom they work.<br/> AIM: To summarize findings from a large rct to the (differential) effects and mechanisms of change of ct/ipt for depression.<br/> METHOD: 182 adult depressed outpatients were randomized to ct (n = 76), ipt (n = 75), or a two-month wait-list-control condition (n = 31). Primary outcome was depression severity (bdi-ii). Other outcomes were quality of life, social and general psychological functioning and various potential process measures. Interventions were compared at the end of treatment, and up to 17 months follow-up.<br/> RESULTS: Overall, ct and ipt were both superior to the wait-list, but did not differ significantly from one another. However, the pathway through which therapeutic change occurred appeared to be different for ct and ipt, and many patients were predicted to have a clinically meaningful advantage in one of the two interventions. We did not find empirical support for the theoretical models of change.<br/> CONCLUSION: (Long-term) outcomes of ct and ipt appear to not differ significantly. The field would benefit from further refinement of research methods to disentangle mechanisms of change, and from advances in the field of personalized medicine.

Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects

BACKGROUND

The present meta-analysis aimed to examine to what extent combined pharmacotherapy with psychotherapy results in a different response to treatment compared to psychotherapy or pharmacotherapy alone in adults with major depression at six months or longer postrandomization.

METHODS

A systematic literature search resulted in 23 randomized controlled trials with 2184 participants. Combined treatment was compared to either psychotherapy or anti-depressant medication alone in both the acute phase and the maintenance phase. Odds ratios of a positive outcome were calculated for all comparisons.

RESULTS

In acute phase treatment, combined psychotherapy with antidepressants outperformed antidepressants alone at six months or longer postrandomization in patients with major depressive disorder (OR=2.93, 95%CI 2.15-3.99, p<0.001). Heterogeneity was zero (95%CI 0-57%, p>0.05). However, combined therapy resulted in equal response to treatment compared to psychotherapy alone at six months or longer postrandomization. As for the maintenance treatment, combined maintenance psychotherapy with antidepressants resulted in better-sustained treatment response compared to antidepressants at six months or longer postrandomization (OR=1.61, 95%CI 1.14-2.27, p<0.05). Heterogeneity was zero (95%CI 0-68%, p>0.05).

CONCLUSIONS

Combined therapy results in a superior enduring effect compared to antidepressants alone in patients with major depression. Psychotherapy is an adequate alternative for combined treatment in the acute phase as it is as effective as combined treatment in the long-term.

Predictors of treatment dropout in self-guided web-based interventions for depression: an 'individual patient data' meta-analysis

BACKGROUND

It is well known that web-based interventions can be effective treatments for depression. However, dropout rates in web-based interventions are typically high, especially in self-guided web-based interventions. Rigorous empirical evidence regarding factors influencing dropout in self-guided web-based interventions is lacking due to small study sample sizes. In this paper we examined predictors of dropout in an individual patient data meta-analysis to gain a better understanding of who may benefit from these interventions.

METHOD

A comprehensive literature search for all randomized controlled trials (RCTs) of psychotherapy for adults with depression from 2006 to January 2013 was conducted. Next, we approached authors to collect the primary data of the selected studies. Predictors of dropout, such as socio-demographic, clinical, and intervention characteristics were examined.

RESULTS

Data from 2705 participants across ten RCTs of self-guided web-based interventions for depression were analysed. The multivariate analysis indicated that male gender [relative risk (RR) 1.08], lower educational level (primary education, RR 1.26) and co-morbid anxiety symptoms (RR 1.18) significantly increased the risk of dropping out, while for every additional 4 years of age, the risk of dropping out significantly decreased (RR 0.94).

CONCLUSIONS

Dropout can be predicted by several variables and is not randomly distributed. This knowledge may inform tailoring of online self-help interventions to prevent dropout in identified groups at risk.

Clinical effectiveness of cognitive therapy v. interpersonal psychotherapy for depression: results of a randomized controlled trial

BACKGROUND

Although both cognitive therapy (CT) and interpersonal psychotherapy (IPT) have been shown to be effective treatments for major depressive disorder (MDD), it is not clear yet whether one therapy outperforms the other with regard to severity and course of the disorder. This study examined the clinical effectiveness of CT v. IPT in a large sample of depressed patients seeking treatment in a Dutch outpatient mental health clinic. We tested whether one of the treatments was superior to the other at post-treatment and at 5 months follow-up. Furthermore, we tested whether active treatment was superior to no treatment. We also assessed whether initial depression severity moderated the effect of time and condition and tested for therapist differences.

METHOD

Depressed adults (n = 182) were randomized to either CT (n = 76), IPT (n = 75) or a 2-month waiting list control (WLC) condition (n = 31). Main outcome was depression severity, measured with the Beck Depression Inventory - II (BDI-II), assessed at baseline, 2, 3, and 7 months (treatment phase) and monthly up to 5 months follow-up (8-12 months).

RESULTS

No differential effects between CT and IPT were found. Both treatments exceeded response in the WLC condition, and led to considerable improvement in depression severity that was sustained up to 1 year. Baseline depression severity did not moderate the effect of time and condition.

CONCLUSIONS

Within our power and time ranges, CT and IPT appeared not to differ in the treatment of depression in the acute phase and beyond.

Revealing the dynamic network structure of the Beck Depression Inventory-II

BACKGROUND

Structured interviews and questionnaires are important tools to screen for major depressive disorder. Recent research suggests that, in addition to studying the mean level of total scores, researchers should focus on the dynamic relations among depressive symptoms as they unfold over time. Using network analysis, this paper is the first to investigate these patterns of short-term (i.e. session to session) dynamics for a widely used psychological questionnaire for depression - the Beck Depression Inventory (BDI-II).

METHOD

With the newly developed vector autoregressive (VAR) multilevel method we estimated the network of symptom dynamics that characterizes the BDI-II, based on repeated administrations of the questionnaire to a group of depressed individuals who participated in a treatment study of an average of 14 weekly assessments. Also the centrality of symptoms and the community structure of the network were examined.

RESULTS

The analysis showed that all BDI-II symptoms are directly or indirectly connected through patterns of temporal influence. In addition, these influences are mutually reinforcing, 'loss of pleasure' being the most central item in the network. Community analyses indicated that the dynamic structure of the BDI-II involves two clusters, which is consistent with earlier psychometric analyses.

CONCLUSION

The network approach expands the range of depression research, making it possible to investigate the dynamic architecture of depression and opening up a whole new range of questions and analyses. Regarding clinical practice, network analyses may be used to indicate which symptoms should be targeted, and in this sense may help in setting up treatment strategies.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy

BACKGROUND

Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy.

METHOD

In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point.

RESULTS

Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037).

CONCLUSIONS

In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.

A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia

BACKGROUND

Interpersonal psychotherapy (IPT) seems to be as effective as cognitive behavioral therapy (CBT) in the treatment of major depression. Because the onset of panic attacks is often related to increased interpersonal life stress, IPT has the potential to also treat panic disorder. To date, a preliminary open trial yielded promising results but there have been no randomized controlled trials directly comparing CBT and IPT for panic disorder.

METHOD

This study aimed to directly compare the effects of CBT versus IPT for the treatment of panic disorder with agoraphobia. Ninety-one adult patients with a primary diagnosis of DSM-III or DSM-IV panic disorder with agoraphobia were randomized. Primary outcomes were panic attack frequency and an idiosyncratic behavioral test. Secondary outcomes were panic and agoraphobia severity, panic-related cognitions, interpersonal functioning and general psychopathology. Measures were taken at 0, 3 and 4 months (baseline, end of treatment and follow-up).

RESULTS

Intention-to-treat (ITT) analyses on the primary outcomes indicated superior effects for CBT in treating panic disorder with agoraphobia. Per-protocol analyses emphasized the differences between treatments and yielded larger effect sizes. Reductions in the secondary outcomes were equal for both treatments, except for agoraphobic complaints and behavior and the credibility ratings of negative interpretations of bodily sensations, all of which decreased more in CBT.

CONCLUSIONS

CBT is the preferred treatment for panic disorder with agoraphobia compared to IPT. Mechanisms of change should be investigated further, along with long-term outcomes.

Prediction of long-term sickness absence among employees with depressive complaints

INTRODUCTION

To study the properties of a screening instrument in predicting long-term sickness absence among employees with depressive complaints.

METHODS

Employees at high risk of future sickness absence were selected by the screening instrument Balansmeter (BM). Depressive complaints were assessed with the depression scale of the Hospital Anxiety and Depression Scale. The total study population consisted of 7,401 employees. Sickness absence was assessed objectively and analyzed at 12 and 18 months of follow-up using company registers on certified sick leave.

RESULTS

The relative risk (RR) for long-term sickness absence, for employees at high risk versus not at high risk, was 3.26 (95% CI 2.54-4.22) in men and 2.55 (1.98-3.35) in women, when the BM was applied in the total study population. The RR of long-term sickness absence of employees with depressive complaints compared with employees without depressive complaints was 3.13 (2.41-4.09) in men and 2.45 (2.00-3.00) in women. The RR of long-term sickness absence for the BM applied in employees with depressive complaints was 5.23 in men and 3.87 in women. When the BM with a cut-off point with a higher sensitivity was applied in employees with depressive complaints, the RR for long-term sickness absence was 4.88 in men and 3.80 in women.

CONCLUSIONS

The screening instrument Balansmeter is able to predict long-term sickness absence within employees with depressive complaints. The total prediction of long-term sickness absence proved better in employees with depressive complaints compared with employees of a general working population.

Improving adherence and effectiveness of computerised cognitive behavioural therapy without support for depression: a qualitative study on patient experiences

BACKGROUND

Several studies have evaluated the efficacy and effectiveness of computerized cognitive behavioural therapy (CCBT) for depression, but research on the patient perspective is limited.

AIMS

To gain knowledge on patient experiences with the online self-help CCBT program Colour Your Life (CYL) for depression, and find explanations for the low treatment adherence and effectiveness.

METHOD

Qualitative data were collected through semi-structured interviews with 18 patients. Interviewees were selected from a CCBT trial. An inductive, content analysis of the interviews was performed.

RESULTS

The main theme throughout the interviews concerns barriers and motivators experienced with CCBT. The most important barriers included experiences of a lack of identification with and applicability of CCBT-CYL, lack of support to adhere with the program or to gain deeper understanding, and inadequate computer/Internet skills, equipment, or location. Confusion between CCBT and Internet questionnaires resulted in no CCBT uptake of some study participants. Motivators included experiencing self-identification and improvement through CCBT-CYL, participating in a scientific study, and the freedom and anonymity associated with online computer self-help. The addition of support to CCBT was suggested as an improvement towards adherence and the course content.

CONCLUSION

The CCBT program CYL in its current form does not work for a large group of people with depressive symptoms. More tailoring, the provision of support (professional or lay) and good computer conditions could improve CCBT.

Economic evaluation of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial

BACKGROUND

Evidence about the cost-effectiveness and cost utility of computerised cognitive-behavioural therapy (CCBT) is still limited. Recently, we compared the clinical effectiveness of unsupported, online CCBT with treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus TAU) for depression. The study is registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).

AIMS

To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus TAU.

METHOD

Costs, depression severity and quality of life were measured for 12 months. Cost-effectiveness and cost-utility analyses were performed from a societal perspective. Uncertainty was dealt with by bootstrap replications and sensitivity analyses.

RESULTS

Costs were lowest for the CCBT group. There are no significant group differences in effectiveness or quality of life. Cost-utility and cost-effectiveness analyses tend to be in favour of CCBT.

CONCLUSIONS

On balance, CCBT constitutes the most efficient treatment strategy, although all treatments showed low adherence rates and modest improvements in depression and quality of life.

Ethical analysis of the justifiability of labelling with COPD for smoking cessation

BACKGROUND

Spirometry for early detection of chronic obstructive pulmonary disease (COPD) and smoking cessation is criticised because of the potential negative effects of labelling with disease.

AIM

To assess the effects of opinions of smokers with mild to moderate COPD on the effectiveness of spirometry for smoking cessation, the justification of early detection of airflow limitation in smokers and the impact of confrontation with COPD.

DESIGN

Qualitative study with data from a randomised controlled trial.

SETTING

General population of Dutch and Belgian Limburg.

METHODS

Semistructured ethical exit interviews were conducted with 205 smokers who were motivated to quit smoking and had no prior diagnosis of COPD but were detected with airflows limitation by means of spirometry. They received either (1) counselling, including labelling with COPD, plus with nortriptyline for smoking cessation, (2) counselling excluding labelling with COPD, plus nortriptyline for smoking cessation or (3) care as usual for smoking cessation by the general practitioner, without labelling with COPD.

RESULTS

Of the participants, 177 (86%) agreed or completely agreed that it is justified to measure lung function in heavy smokers. These participants argued that measuring lung function raises consciousness of the negative effects of smoking, helps to prevent disease or increases motivation to stop smoking. Most of the 18 participants who disagreed argued that routinely measuring lung function in smokers would interfere with freedom of choice.

CONCLUSIONS

Labelling with disease is probably a less important issue in the discussion about the pros and cons of early detection of COPD.

Clinical effectiveness of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial

BACKGROUND

Computerised cognitive-behavioural therapy (CCBT) might offer a solution to the current undertreatment of depression.

AIMS

To determine the clinical effectiveness of online, unsupported CCBT for depression in primary care.

METHOD

Three hundred and three people with depression were randomly allocated to one of three groups: Colour Your Life; treatment as usual (TAU) by a general practitioner; or Colour Your Life and TAU combined. Colour Your Life is an online, multimedia, interactive CCBT programme. No assistance was offered. We had a 6-month follow-up period.

RESULTS

No significant differences in outcome between the three interventions were found in the intention-to-treat and per protocol analyses.

CONCLUSIONS

Online, unsupported CCBT did not outperform usual care, and the combination of both did not have additional effects. Decrease in depressive symptoms in people with moderate to severe depression was moderate in all three interventions. Online CCBT without support is not beneficial for all individuals with depression.

[Introducing the diagnostic inventory for depression in the Netherlands]

BACKGROUND

The Diagnostic Inventory for Depression (did) is a new self-report questionnaire based on the dsm-iv inclusion criteria for a major depressive disorder.

AIM

To analyse the Dutch translation of the did and examine the psychometric properties of the inventory. methods We conducted a large-scale internet-based screening among the general population. results Reliability, convergent validity and factor structure were good. The did-nl may classify participants accurately.

CONCLUSION

The results look promising and the did-nl can give added value to existing questionnaires. However, since the classification potential has not yet been sufficiently demonstrated, a clinical interview will still be needed.

Similarities, overlap and differences between burnout and prolonged fatigue in the working population

BACKGROUND

Burnout and prolonged fatigue are related but distinct concepts that have seldom been empirically compared.

AIM

To examine similarities, overlap and differences between burnout and prolonged fatigue.

DESIGN

Observational study.

METHODS

We analysed baseline data from the Maastricht Cohort Study on Fatigue at Work (n = 12 140). The discriminative abilities of the Checklist Individual Strength (CIS) and the Maslach Burnout Inventory-General Survey (MBI-GS) were evaluated using principal component analysis. Overlap, similarities and differences regarding health, work and demographic factors between subgroups were assessed.

RESULTS

The discriminative abilities of the CIS and MBI-GS appeared to be moderate. Prolonged fatigue and burnout cases overlapped considerably. The subgroup consisting of cases with concurrent fatigue and burnout tended to have poorer outcomes in terms of health and work factors than the subgroups with either prolonged fatigue or burnout. Similar patterns were found for subjective fatigue and exhaustion.

DISCUSSION

There appear to be some relevant differences between burnout and prolonged fatigue, with respect to work and health factors. Burnout and prolonged fatigue can occur both separately and simultaneously. Having both conditions simultaneously seems to be associated with worse outcomes than having either alone.

Family therapy for depression

BACKGROUND

People with depression often experience interpersonal problems. Family therapy for depression is a widely used intervention, but it is unclear whether this is an effective therapy for the treatment of depression.

OBJECTIVES

To assess the efficacy of family therapy for depression.

SEARCH STRATEGY

The following electronic databases were searched using a specific search strategy: CCDANCTR-Studies and CCDANCTR-References searched on 21/10/2005, The Cochrane Central Register of Controlled Trials, Medline (1966 to January 2005), EMBASE (1980 to January 2005), Psycinfo (1974 to January 2005). Reference lists of articles were also searched. Handsearches of relevant journals and bibliographies were conducted and first authors of included studies and experts in the field were contacted for further information.

SELECTION CRITERIA

Included studies were randomised controlled and controlled clinical trials comparing family therapy with no intervention or an alternative intervention in which depression symptomatology was a main outcome measure.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of the selected trials were independently extracted by three review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. It was not possible to perform meta-analyses because of the heterogeneity of the selected studies.

MAIN RESULTS

Three high-quality and three low-quality studies, involving 519 people with depression, were identified. The studies were very heterogeneous in terms of interventions, participants, and measuring instruments. Despite fairly good methodological quality and positive findings of some studies, evidence for the effectiveness of family therapy for depression did not exceed level 3 (limited or conflicting evidence), except for moderate evidence (level 2), based on the non-combined findings from three studies, indicating that family therapy is more effective than no treatment or waiting list condition on decreasing depression, and on increasing family functioning.

AUTHORS' CONCLUSIONS

The current evidence base is too heterogeneous and sparse to draw conclusions on the overall effectiveness of family therapy in the treatment of depression. At this point, use of psychological interventions for the treatment of depression for which there is already an evidence-base would seem to be preferable to family therapy. Further high quality trials examining the effectiveness and comparative effectiveness of explicitly defined forms of family therapy are required.

Psychosocial interventions by general practitioners

BACKGROUND

Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective than usual care. However, these interventions were mostly performed by health professionals other than the GP.

OBJECTIVES

To examine the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies.

SEARCH STRATEGY

The search was conducted using the CCDANCTR-Studies and CCDANCTR-References on 20/10/2005, The Cochrane Library, reference lists of relevant studies for citation tracking and personal communication with experts.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before November 2005 were eligible for entry.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of selected trials were independently extracted by two review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed.

MAIN RESULTS

Ten studies were included in the review. Selected studies addressed different psychosocial interventions for five distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, cognitive behavioural therapy for unexplained fatigue, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting.

AUTHORS' CONCLUSIONS

In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression may offer promise, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.

[Aetiology of prolonged fatigue among workers. An overview of findings from the Maastricht Cohort Study]

BACKGROUND

Considerable attention is being given to prolonged fatigue among workers because it occurs so frequently and is alleged to have serious consequences.

AIM

To present an overview of the magnitude, causes and consequences of prolonged fatigue in the workplace with a view to preventing its occurrence.

METHOD

On the basis of of the articles written as part of the Maastricht Cohort Study we present an overview of this study, a prospective cohort study (n=12,140) that covered a period of 4 years. results Prolonged fatigue seems to occur frequently among workers. Risk factors in the aetiology of prolonged fatigue were found in subjective and objective work-related factors, as well as in factors related to the health and private situation of the employee.

CONCLUSION

The assumed multifactorial aetiology of prolonged fatigue was confirmed by means of prospective analyses in the Maastricht Cohort Study. The observed risk factors can be applied as tools for the development of effective preventive measures against prolonged fatigue.

[Course, consequences and treatment of prolonged fatigue among workers: an overview of findings from the Maastricht Cohort Study]

summary background Although prolonged fatigue is a common complaint among workers, relatively little is known about its course and consequences.

AIM

To present an overview of the course, consequences and treatment of prolonged fatigue in the work force.

METHOD

We present an overview of the findings from the Maastricht Cohort Study, which was a prospective cohort (n=12.140) that covered a period of 4 years. results Fatigue runs an unfavourable course. In many workers symptoms of fatigue are present for a long time, and in some workers the symptoms even develop into those of chronic fatigue syndrome. The consequences of prolonged fatigue are also serious and are manifested in various ways: sick leave, work disability, accidents, immunological effects and reduction in work participation. A brief cognitive behaviour therapy administered by general practitioners to employees with prolonged fatigue proved ineffective.

CONCLUSION

The severe consequences of prolonged fatigue and the current lack of effective therapies underline the importance of preventing the development of fatigue complaints, for which the Maastricht Cohort Study may provide the basic tools.

Chronic fatigue syndrome-like caseness as a predictor of work status in fatigued employees on sick leave: four year follow up study

OBJECTIVE

To assess whether CFS-like caseness (meeting the criteria for chronic fatigue syndrome (CFS)) predicts work status in the long term.

METHODS

Prospective study in a sample of fatigued employees absent from work. Data were collected at baseline and four years later, and included CFS-like caseness and work status (inactive work status and full work incapacity).

RESULTS

CFS-like cases at baseline were three times more likely to be unable to work at follow up than fatigued employees who did not meet CFS criteria at baseline (ORs 3-3.3). These associations grew even stronger when demographic and clinical confounders were controlled for (ORs 3.4-4.4).

CONCLUSION

A CFS-like status (compared to non-CFS fatigue) proved to be a strong predictor of an inactive work status and full work incapacity in the long term. Since little is known about effective interventions that prevent absenteeism and work incapacity or facilitate return to work in subjects with chronic fatigue, there is a great need for powerful early interventions that restore or preserve the ability to work, especially for workers who meet criteria for CFS.

Associations of depressive symptoms with gender, body mass index and dyspnea in primary care COPD patients

BACKGROUND

It has been suggested that severe COPD is associated with depressive symptoms, possibly linked to exacerbations, dyspnea and hospitalisation. However, scarce data are available in primary care where most patients suffer from mild or moderate disease.

OBJECTIVE

We aimed to reveal associations of depressive symptoms with demographic and clinical characteristics in mild to moderate COPD.

METHODS

Cross-sectional data on lung function measurements, exacerbation frequency, dyspnea, comorbidity, smoking behaviour, body mass index (BMI), age, gender and depressive symptoms (Beck Depression Inventory) of 147 primary care patients were assessed in multiple logistic regression analyses.

RESULTS

Patients suffered from mild to moderate obstruction (FEV1 63.6% pred, range 45.1% to 82.1%). Female gender (OR 4.8, 95% CI 2.1 to 10.8), BMI > 25 (OR 0.4, 95% CI 0.2 to 0.8) and current smoking (OR 2.3, 95% CI 1.01 to 5.3) were univariately associated with depressive symptoms, while in a multivariate logistic model only female gender (OR 4.0, 95% CI 1.6 to 9.9), BMI > 25 (OR 0.3, 95% CI 0.1 to 0.7) and dyspnea (OR 1.8, 95% CI 1.1 to 2.9) were independently associated with depressive symptoms. Conclusion. These data suggest that in primary care depressive symptoms in COPD seem to be related with female gender, BMI and dyspnea. In this study, lung function, exacerbation rate, smoking behaviour, age and comorbidity are not independently associated with depressive symptoms in COPD of mild to moderate severity.

Efficacy of Bupropion and Nortriptyline for Smoking Cessation Among People at Risk for or With Chronic Obstructive Pulmonary Disease

BACKGROUND

The observations that smokers with chronic obstructive pulmonary disease (COPD) are at increased risk of depression and that nicotine may have antidepressant effects and regulate mood provide a rationale for the use of antidepressant drugs for smoking cessation in patients with COPD. No clinical trial has studied the efficacy of bupropion hydrochloride and nortriptyline hydrochloride for smoking cessation in this patient population, to our knowledge.

METHODS

In a placebo-controlled double-dummy randomized trial, 255 adults at risk for COPD or with COPD were prescribed sustained-release bupropion (bupropion SR) (150 mg twice daily) or nortriptyline (75 mg once daily) for 12 weeks. All patients received smoking cessation counseling. The main outcome measure was prolonged abstinence from smoking from week 4 to week 26 after the target quit date.

RESULTS

The use of bupropion SR and nortriptyline resulted in higher prolonged abstinence rates compared with placebo, although only the difference between bupropion SR and placebo was statistically significant (differences with placebo, 13.1% [95% confidence interval, 1.2%-25.1%] for bupropion SR and 10.2% [95% confidence interval, -1.7% to 22.2%] for nortriptyline). In patients with COPD, bupropion SR and nortriptyline seem efficacious in achieving prolonged abstinence (differences with placebo, 18.9% [95% confidence interval, 3.6%-34.2%] for bupropion SR and 12.9% [95% confidence interval, -0.8% to 26.4%] for nortriptyline). In participants at risk for COPD, no statistically significant differences with placebo in prolonged abstinence rates were found.

CONCLUSIONS

Bupropion SR treatment is an efficacious aid to smoking cessation in patients with COPD. Nortriptyline treatment seems to be a useful alternative.

Prevalence of chronic fatigue syndrome-like caseness in the working population: results from the Maastricht cohort study

AIM

To determine the prevalence of chronic fatigue syndrome (CFS)-like caseness in the working population.

METHODS

Using data from the prospective Maastricht Cohort Study on Fatigue at Work, the prevalence and incidence of CFS-like cases (employees meeting research criteria for CFS) were determined among 5499 employees who responded to the follow up assessment 3 years and 8 months after baseline.

RESULTS

Of the 5499 employees, 199 (3.6%) were identified as CFS-like cases. By deleting possible CFS-like cases at baseline, the annual incidence of CFS-like caseness was estimated to be 85 per 10 000. Twenty employees (0.36%) reported having been diagnosed with CFS by a physician.

CONCLUSIONS

The prevalence of CFS-like cases (3.6%) was considerably higher than the prevalence of CFS reported in previous studies (0.006-3%). These findings suggest that the CFS-like caseness may be underdetected in the working population and perhaps in other populations as well.

Social support and the persistence of complaints in chronic fatigue syndrome

BACKGROUND

Several studies suggested that the surroundings of chronic fatigue syndrome (CFS) patients are of importance in the persistence of complaints. Contrary to what was expected, participation in support groups has not led to clinical improvement. The purpose of the present study was to describe social support in CFS patients as compared with other fatigued and non-fatigued groups. Further, changes in social support and the influence of social support on the course of CFS over a period of more than 1 year were studied in patients with and without treatment.

METHODS

Baseline data were assessed in 270 CFS patients, 150 disease-free breast cancer patients, 151 fatigued employees on sick-leave and 108 healthy subjects using the Social Support List and Significant Others Scale. CFS patients were followed in cognitive behaviour therapy (CBT), guided support groups and natural course at 8 and 14 months.

RESULTS

CFS patients and fatigued employees reported more negative interactions and insufficiency of supporting interactions than cancer patients and healthy controls. No differences in frequency of supporting interactions were found. Negative interactions decreased significantly after treatment with CBT, but did not change in support groups or natural course. In the natural course, higher fatigue severity at 8 months was predicted by more negative interactions at baseline.

CONCLUSIONS

In CFS patients and fatigued employees, social support is worse than in disease-free cancer patients and healthy controls. Lack of social support was identified as a new factor in the model of perpetuating factors of fatigue severity and functional impairment in CFS.

Fatigue, burnout, and chronic fatigue syndrome among employees on sick leave: do attributions make the difference?

BACKGROUND

Persistent fatigue among employees, burnout, and chronic fatigue syndrome (CFS) are three fatigue conditions that share some characteristics in theory. However, these conditions have not been compared in empirical research, despite conceptual similarities.

METHODS

This cross sectional study aimed to investigate relations between persistent fatigue, burnout, and CFS by describing the clinical features of a sample of 151 fatigued employees on sick leave. Using validated instruments, subgroups based on research criteria for CFS and burnout within the sample of fatigued employees and a reference group of 97 diagnosed CFS patients were compared. Analyses of covariance were performed.

RESULTS

A total of 66 (43.7%) fatigued employees met research criteria for CFS (except symptom criteria) and 76 (50.3%) met research criteria for burnout. "CFS-like employees" (fatigued employees who met CFS criteria) reported stronger somatic attributions than "non-CFS-like employees". Burnt out CFS-like employees were more depressed and distressed than CFS-like employees who were not burnt out. Burnout cases among the non-CFS-like employees had stronger psychological attributions than fatigued employees who were not burnt out. Compared to diagnosed CFS patients, CFS-like employees merely had a shorter duration of fatigue complaints. Burnt out CFS-like employees had stronger psychological attributions and were more distressed than CFS patients.

CONCLUSIONS

Fatigued employees shared many important characteristics with CFS patients, regardless of burnout status, and many fatigued employees met CFS criteria and/or burnout criteria. Differences however concerned the causal attributions that were made. This raises questions about the role of causal attributions: are they modified by fatigue complaints or do they determine illness outcome?

The effectiveness of psychosocial interventions delivered by general practitioners

BACKGROUND

Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective that usual care. However, these interventions were mostly performed by health professionals other than the GP.

OBJECTIVES

To present a systematic review of the literature addressing the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies.

SEARCH STRATEGY

The literature search was conducted using the CCDAN Trials Register, the Cochrane Library and reference lists of relevant studies for citation tracking. Also, personal communication with experts took place.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before January 2002 were eligible for entry.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently be assessed by two reviewers using the Maastricht-Amsterdam Criteria List and the CCDAN Quality Rating Scale. The qualitative and quantitative characteristics of selected trials were independently extracted by two reviewers using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed.

MAIN RESULTS

Eight studies were included in the review. Selected studies addressed different psychosocial interventions for four distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting.

REVIEWER'S CONCLUSIONS

In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression seems the most promising tool for GPs, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.