Targeting mental health care attributes by diagnosis and clinical stage: the views of youth mental health clinicians

OBJECTIVES

To explore the potential utility of clinical stage and mental disorder categories as a basis for determining which attributes of youth mental health care should be offered to which groups of young people.

METHODS

In June 2017, we conducted an online survey of youth mental health clinicians that collected information on the participants' background and areas of expertise, then presented vignettes describing young people with different stages of six mental disorders (disorder-based vignettes were matched to participants' area of expertise). For each vignette, participants were asked to give a quantitative estimate of the proportion of young people with similar mental health problems they thought would clinically benefit from each of twelve attributes of mental health care (other than pharmacological or individual psychological therapies). Survey results were analysed as independent, disorder-based samples, using standard statistical tests of significance, and as a stratified sample using mixed-effects models.

RESULTS

A total of 412 clinicians working in 32 countries participated in both parts of the survey. Respondents represented a broad range of clinical disciplines, settings and areas of expertise. Their estimated proportions of young people who would benefit from the mental health care attributes varied by clinical stage and disorder (eg, a mean of 93% [interquartile range (IQR), 90%-100%] of young people with Stage 2 psychosis were estimated to benefit from case management with a multidisciplinary team; while only 15% [IQR, 1%-25%] of young people with Stage 1b generalised anxiety disorder were estimated to benefit from collection and processing of biological samples). Neither the background of the respondents nor the sex of the characters in the vignettes significantly influenced the results.

CONCLUSION

A combination of clinical stage and disorder information might be an appropriate basis for ensuring that the right attributes of early intervention mental health care are provided to the right young people at the right time. Policy and research priorities include trialling novel services, preferences research among young people, strengthening service responses to subthreshold disorders and promoting high-fidelity collection of clinical stage data in youth mental health settings.

Integrated (one-stop shop) youth health care: best available evidence and future directions

Although mental health problems represent the largest burden of disease in young people, access to mental health care has been poor for this group. Integrated youth health care services have been proposed as an innovative solution. Integrated care joins up physical health, mental health and social care services, ideally in one location, so that a young person receives holistic care in a coordinated way. It can be implemented in a range of ways. A review of the available literature identified a range of studies reporting the results of evaluation research into integrated care services. The best available data indicate that many young people who may not otherwise have sought help are accessing these mental health services, and there are promising outcomes for most in terms of symptomatic and functional recovery. Where evaluated, young people report having benefited from and being highly satisfied with these services. Some young people, such as those with more severe presenting symptoms and those who received fewer treatment sessions, have failed to benefit, indicating a need for further integration with more specialist care. Efforts are underway to articulate the standards and core features to which integrated care services should adhere, as well as to further evaluate outcomes. This will guide the ongoing development of best practice models of service delivery.

Comparative efficacy and acceptability of antidepressants, psychological interventions, and their combination for depressive disorder in children and adolescents: protocol for a network meta-analysis

INTRODUCTION

Depressive disorder is common in children and adolescents, with important consequences and serious impairments in terms of personal and social functioning. While both pharmacological and psychological interventions have been shown to be effective, there is still uncertainty about the balance between these and what treatment strategy should be preferred in clinical practice. Therefore, we aim to compare and rank in a network meta-analysis (NMA) the commonly used psychological, pharmacological and combined interventions for depressive disorder in children and adolescents.

METHODS AND ANALYSIS

We will update the literature search of two previous NMAs for the identification of trials of antidepressant and psychotherapy alone for depressive disorder in children and adolescents. For identification of trials of combination interventions, seven databases (PubMed, EMBASE, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science, PsycINFO, CINAHL, LiLACS) will be searched from date of inception. We will also search ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform and check relevant reports on the US Food and Drug Administration website for unpublished data. Building on our previous findings in the field, we will include any commonly prescribed oral antidepressants and any manualised or structured psychotherapies, as well as their combinations. Randomised controlled trials assessing any active intervention against active comparator or pill placebo/psychological controls in acute treatment for depressive disorder in children and adolescents will be included. The primary outcomes will be efficacy (mean change in depressive symptoms), and acceptability of treatment (dropout rate due to any cause). The secondary outcomes will be remission rate, tolerability of treatment (dropouts for adverse events), as well as suicide-related outcomes (suicidal behaviour or ideation). We will perform Bayesian NMAs for all relative outcome measures. Subgroup analyses and sensitivity analyses will be conducted to assess the robustness of the findings.

DISSEMINATION

This NMA will provide the most up to date and clinically useful information about the comparative efficacy and acceptability of antidepressants, psychological intervention and their combination in the acute treatment of children and adolescents with depressive disorder. This is the newest NMA and therefore these results are very important in terms of evidence-based medicine. The results will be disseminated through peer-reviewed publication.

PROTOCOL REGISTRATION

PROSPERO CRD42015020841.

Atypical antipsychotics for disruptive behaviour disorders in children and youths

BACKGROUND

This is an update of the original Cochrane Review, last published in 2012 (Loy 2012). Children and youths with disruptive behaviour disorders may present to health services, where they may be treated with atypical antipsychotics. There is increasing usage of atypical antipsychotics in the treatment of disruptive behaviour disorders.

OBJECTIVES

To evaluate the effect and safety of atypical antipsychotics, compared to placebo, for treating disruptive behaviour disorders in children and youths. The aim was to evaluate each drug separately rather than the class effect, on the grounds that each atypical antipsychotic has different pharmacologic binding profile (Stahl 2013) and that this is clinically more useful.

SEARCH METHODS

In January 2017, we searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers.

SELECTION CRITERIA

Randomised controlled trials of atypical antipsychotics versus placebo in children and youths aged up to and including 18 years, with a diagnosis of disruptive behaviour disorders, including comorbid ADHD. The primary outcomes were aggression, conduct problems and adverse events (i.e. weight gain/changes and metabolic parameters). The secondary outcomes were general functioning, noncompliance, other adverse events, social functioning, family functioning, parent satisfaction and school functioning.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors (JL and KS) independently collected, evaluated and extracted data. We used the GRADE approach to assess the quality of the evidence. We performed meta-analyses for each of our primary outcomes, except for metabolic parameters, due to inadequate outcome data.

MAIN RESULTS

We included 10 trials (spanning 2000 to 2014), involving a total of 896 children and youths aged five to 18 years. Bar two trials, all came from an outpatient setting. Eight trials assessed risperidone, one assessed quetiapine and one assessed ziprasidone. Nine trials assessed acute efficacy (over four to 10 weeks); one of which combined treatment with stimulant medication and parent training. One trial was a six-month maintenance trial assessing symptom recurrence.The quality of the evidence ranged from low to moderate. Nine studies had some degree of pharmaceutical support/funding. Primary outcomesUsing the mean difference (MD), we combined data from three studies (238 participants) in a meta-analysis of aggression, as assessed using the Aberrant Behaviour Checklist (ABC) ‒ Irritability subscale. We found that youths treated with risperidone show reduced aggression compared to youths treated with placebo (MD -6.49, 95% confidence interval (CI) -8.79 to -4.19; low-quality evidence). Using the standardised mean difference (SMD), we pooled data from two risperidone trials (190 participants), which used different scales: the Overt Aggression Scale ‒ Modified (OAS-M) Scale and the Antisocial Behaviour Scale (ABS); as the ABS had two subscales that could not be combined (reactive and proactive aggression), we performed two separate analyses. When we combined the ABS Reactive subscale and the OAS-M, the SMD was -1.30 in favour of risperidone (95% CI -2.21 to -0.40, moderate-quality evidence). When we combined the ABS Proactive subscale and OAS-M, the SMD was -1.12 (95% CI -2.30 to 0.06, moderate-quality evidence), suggesting uncertainty about the estimate of effect, as the confidence intervals overlapped the null value. In summary, there was some evidence that aggression could be reduced by risperidone. Data were lacking on other atypical antipsychotics, like quetiapine and ziprasidone, with regard to their effects on aggression.We pooled data from two risperidone trials (225 participants) in a meta-analysis of conduct problems, as assessed using the Nisonger Child Behaviour Rating Form ‒ Conduct Problem subscale (NCBRF-CP). This yielded a final mean score that was 8.61 points lower in the risperidone group compared to the placebo group (95% CI -11.49 to -5.74; moderate-quality evidence).We investigated the effect on weight by performing two meta-analyses. We wanted to distinguish between the effects of antipsychotic medication only and the combined effect with stimulants, since the latter can have a counteracting effect on weight gain due to appetite suppression. Pooling two trials with risperidone only (138 participants), we found that participants on risperidone gained 2.37 kilograms (kg) more (95% CI 0.26 to 4.49; moderate-quality evidence) than those on placebo. When we added a trial where all participants received a combination of risperidone and stimulants, we found that those on the combined treatment gained 2.14 kg more (95% CI 1.04 to 3.23; 3 studies; 305 participants; low-quality evidence) than those on placebo. Secondary outcomesOut of the 10 included trials, three examined general functioning, social functioning and parent satisfaction. No trials examined family or school functioning. Data on non-compliance/attrition rate and other adverse events were available from all 10 trials.

AUTHORS' CONCLUSIONS

There is some evidence that in the short term risperidone may reduce aggression and conduct problems in children and youths with disruptive behaviour disorders There is also evidence that this intervention is associated with significant weight gain.For aggression, the difference in scores of 6.49 points on the ABC ‒ Irritability subscale (range 0 to 45) may be clinically significant. It is challenging to interpret the clinical significance of the differential findings on two different ABS subscales as it may be difficult to distinguish between reactive and proactive aggression in clinical practice. For conduct problems, the difference in scores of 8.61 points on the NCBRF-CP (range 0 to 48) is likely to be clinically significant. Weight gain remains a concern.Caution is required in interpreting the results due to the limitations of current evidence and the small number of high-quality trials. There is a lack of evidence to support the use of quetiapine, ziprasidone or any other atypical antipsychotic for disruptive behaviour disorders in children and youths and no evidence for children under five years of age. It is uncertain to what degree the efficacy found in clinical trials will translate into real-life clinical practice. Given the effectiveness of parent-training interventions in the management of these disorders, and the somewhat equivocal evidence on the efficacy of medication, it is important not to use medication alone. This is consistent with current clinical guidelines.

Internet-based cognitive behavioural therapy for young people with suicide-related behaviour (Reframe-IT): a randomised controlled trial

BACKGROUND

Suicide-related behaviours are common in young people and associated with a range of negative outcomes. There are few evidence-based interventions; however, cognitive behavioural therapy (CBT) shows promise. Internet delivery of CBT is popular, with potential to increase reach and accessibility.

OBJECTIVE

To test the effectiveness of an internet-based CBT program (Reframe-IT) in reducing suicide-related behaviours, depression, anxiety, hopelessness and improving problem solving and cognitive and behavioural skills in school students with suicide-related behaviours.

METHODS

A parallel randomised controlled trial testing the effectiveness of Reframe-IT plus treatment as usual (TAU) compared with TAU alone in reducing suicidal ideation, suicide attempts, depression, hopelessness, symptoms of anxiety, negative problem orientation and cognitive and behavioural skill acquisition was undertaken. We recruited students experiencing suicidal ideation from 18 schools in Melbourne, Australia, between August 2013 and December 2016. The intervention comprised eight modules of CBT delivered online over 10 weeks with assessments conducted at baseline, 10 weeks and 22 weeks.

FINDINGS

Only 50 of the planned 169 participants were recruited. There were larger improvements in the Reframe-IT group compared with the TAU group for the primary outcome of suicidal ideation (intervention -61.6, SD 41.6; control -47.1, SD 42.3, from baseline to 22-week follow-up intervention); however, differences were non-significant (p=0.593). There were no increases in distress in the majority of participants (91.1%) after completion of each module. Changes in depression and hopelessness partly mediated the effect of acquisition of CBT skills on suicidal ideation.

CONCLUSIONS

The trial was underpowered due to difficulties recruiting participants as a result of the complex recruitment procedures that were used to ensure safety of participants. Although there were no significant differences between groups, young people were safely and generally well engaged in Reframe-IT and experienced decreases in suicidal ideation and other symptoms as well as improvements in CBT skills. The study is the first online intervention trial internationally to include young people demonstrating all levels of suicide risk.

CLINICAL IMPLICATIONS

Integration of internet-delivered interventions for young people with suicide-related behaviour may result in reductions in these behaviours. Further research is needed, but researchers should feel more confident about being able to safely undertake research with young people who experience these behaviours.

TRIAL REGISTRATION NUMBER

ACTRN12613000864729.

Right choice, right time: Evaluation of an online decision aid for youth depression

BACKGROUND

Appropriate treatment for youth depression is an important public health priority. Shared decision making has been recommended, yet no decision aids exist to facilitate this.

OBJECTIVES

The main objective of this study was to evaluate an online decision aid for youth depression.

DESIGN

An uncontrolled cohort study with pre-decision, immediately post-decision and follow-up measurements.

SETTING AND PARTICIPANTS

Young people (n=66) aged 12-25 years with mild, mild-moderate or moderate-severe depression were recruited from two enhanced primary care services.

INTERVENTION

Online decision aid with evidence communication, preference elicitation and decision support components.

MAIN OUTCOME MEASURES

The main outcome measures were ability to make a decision; whether the decision was in line with clinical practice guidelines, personal preferences and values; decisional conflict; perceived involvement; satisfaction with decision; adherence; and depression scores at follow-up.

RESULTS

After using the decision aid, clients were more likely to make a decision in line with guideline recommendations (93% vs 70%; P=.004), were more able to make a decision (97% vs 79%; P=.022), had significantly reduced decisional conflict (17.8 points lower (95% CI: 13.3-22.9 points lower) on the Decisional Conflict Scale (range 0-100)) and felt involved and satisfied with their decision. At follow-up, clients had significantly reduced depression symptoms (2.7 points lower (95% CI: 1.3-4.0 points lower) on the Patient Health Questionnaire nine-item scale (range 0-27)) and were adherent to 88% (95% CI: 82%-94%) of treatment courses.

DISCUSSION AND CONCLUSIONS

A decision aid for youth depression can help ensure evidence-based, client-centred care, promoting collaboration in this often difficult to engage population.

The Youth Mood Clinic: an innovative service for the treatment of severe and complex depression

OBJECTIVE

Depression is the leading cause of disability for Australians from late adolescence through mid-adulthood, and effective treatments can positively impact subsequent life course trajectories. A treatment model for the management of complex youth depression, characterised by symptom severity, multi-morbidity and ongoing suicidality is presented.

CONCLUSIONS

The Youth Mood Clinic (YMC) provides multidisciplinary, team-based treatment for young people aged 15-25 years. The YMC model utilises a phased treatment approach, drawing on elements of cognitive and interpersonal psychotherapy embedded within case management and psychiatry review. Particular attention is given to developmental factors, engagement, assessment, suicide risk, caregiver input and pharmacotherapy. Key tasks of the YMC treatment phases are outlined, reflecting initial stages, recovery planning and treatment, continuation, consolidation and future planning.

Parents in prevention: A meta-analysis of randomized controlled trials of parenting interventions to prevent internalizing problems in children from birth to age 18

PURPOSE OF THE RESEARCH

Burgeoning evidence that modifiable parental factors can influence children's and adolescents' risk for depression and anxiety indicates that parents can play a crucial role in prevention of these disorders in their children. However, it remains unclear whether preventive interventions that are directed primarily at the parent (i.e. where the parent receives more than half of the intervention) are effective in reducing child internalizing (including both depression and anxiety) problems in the longer term.

PRINCIPAL RESULTS

Compared to a range of comparison conditions, parenting interventions reduced child internalizing problems, at a minimum of 6months after the intervention was delivered. Mean effects were very small for measures of internalizing and depressive symptoms, and small for measures of anxiety symptoms. Pooled effects for anxiety diagnoses were significant and indicated a number needed to treat (NNT) of 10. Pooled effects for depression diagnoses approached significance but suggested a NNT of 11. These results were based on effects reported at the longest follow-up interval for each included study, which ranged from 6months up to 15years for internalizing measures, 5.5years for depressive measures, and 11years for anxiety measures.

MAJOR CONCLUSIONS

Our findings underscore the likely benefits of increasing parental involvement in preventing internalizing problems, particularly anxiety problems, in young people.

Comprehensive Online Self-Monitoring to Support Clinicians Manage Risk of Suicide in Youth Depression

BACKGROUND

Routine monitoring of depression symptoms and suicide risk is essential for appropriate treatment planning and risk management, but not well implemented by clinicians. We developed a brief online monitoring tool to address this issue.

AIMS

To investigate whether the online tool can feasibly improve monitoring; whether it is acceptable and useful for young people and their clinicians; and to determine whether a shorter tool could be implemented.

METHOD

In a naturalistic longitudinal cohort study, 101 young people with depression completed the online tool on a tablet, prior to their consultation. Their results were immediately available to their clinician. Clients and clinicians answered questionnaires about acceptability and usefulness.

RESULTS

The tool was feasible to implement. Young people and clinicians found the tool acceptable and useful for understanding symptoms and risk. A brief three-item suicidal ideation screening measure correlated well with a validated measure of suicidal ideation.

CONCLUSION

The online tool facilitates the quick exchange of key information about suicide risk, allowing clinicians to immediately address this. This level of responsiveness is likely to improve treatment outcomes. The brief version allows full integration into clinical practice to support clinicians managing those at risk of suicide.

Effective psychological and psychosocial approaches to reduce repetition of self-harm: a systematic review, meta-analysis and meta-regression

OBJECTIVE

To examine the efficacy of psychological and psychosocial interventions for reductions in repeated self-harm.

DESIGN

We conducted a systematic review, meta-analysis and meta-regression to examine the efficacy of psychological and psychosocial interventions to reduce repeat self-harm in adults. We included a sensitivity analysis of studies with a low risk of bias for the meta-analysis. For the meta-regression, we examined whether the type, intensity (primary analyses) and other components of intervention or methodology (secondary analyses) modified the overall intervention effect.

DATA SOURCES

A comprehensive search of MEDLINE, PsycInfo and EMBASE (from 1999 to June 2016) was performed.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of psychological and psychosocial interventions for adult self-harm patients.

RESULTS

Forty-five trials were included with data available from 36 (7354 participants) for the primary analysis. Meta-analysis showed a significant benefit of all psychological and psychosocial interventions combined (risk ratio 0.84; 95% CI 0.74 to 0.96; number needed to treat=33); however, sensitivity analyses showed that this benefit was non-significant when restricted to a limited number of high-quality studies. Meta-regression showed that the type of intervention did not modify the treatment effects.

CONCLUSIONS

Consideration of a psychological or psychosocial intervention over and above treatment as usual is worthwhile; with the public health benefits of ensuring that this practice is widely adopted potentially worth the investment. However, the specific type and nature of the intervention that should be delivered is not yet clear. Cognitive-behavioural therapy or interventions with an interpersonal focus and targeted on the precipitants to self-harm may be the best candidates on the current evidence. Further research is required.

Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis

BACKGROUND

Major depressive disorder is one of the most common mental disorders in children and adolescents. However, whether to use pharmacological interventions in this population and which drug should be preferred are still matters of controversy. Consequently, we aimed to compare and rank antidepressants and placebo for major depressive disorder in young people.

METHODS

We did a network meta-analysis to identify both direct and indirect evidence from relevant trials. We searched PubMed, the Cochrane Library, Web of Science, Embase, CINAHL, PsycINFO, LiLACS, regulatory agencies' websites, and international registers for published and unpublished, double-blind randomised controlled trials up to May 31, 2015, for the acute treatment of major depressive disorder in children and adolescents. We included trials of amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. Trials recruiting participants with treatment-resistant depression, treatment duration of less than 4 weeks, or an overall sample size of less than ten patients were excluded. We extracted the relevant information from the published reports with a predefined data extraction sheet, and assessed the risk of bias with the Cochrane risk of bias tool. The primary outcomes were efficacy (change in depressive symptoms) and tolerability (discontinuations due to adverse events). We did pair-wise meta-analyses using the random-effects model and then did a random-effects network meta-analysis within a Bayesian framework. We assessed the quality of evidence contributing to each network estimate using the GRADE framework. This study is registered with PROSPERO, number CRD42015016023.

FINDINGS

We deemed 34 trials eligible, including 5260 participants and 14 antidepressant treatments. The quality of evidence was rated as very low in most comparisons. For efficacy, only fluoxetine was statistically significantly more effective than placebo (standardised mean difference -0·51, 95% credible interval [CrI] -0·99 to -0·03). In terms of tolerability, fluoxetine was also better than duloxetine (odds ratio [OR] 0·31, 95% CrI 0·13 to 0·95) and imipramine (0·23, 0·04 to 0·78). Patients given imipramine, venlafaxine, and duloxetine had more discontinuations due to adverse events than did those given placebo (5·49, 1·96 to 20·86; 3·19, 1·01 to 18·70; and 2·80, 1·20 to 9·42, respectively). In terms of heterogeneity, the global I(2) values were 33·21% for efficacy and 0% for tolerability.

INTERPRETATION

When considering the risk-benefit profile of antidepressants in the acute treatment of major depressive disorder, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated.

FUNDING

National Basic Research Program of China (973 Program).

Cognitive behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents

BACKGROUND

Depression is common in young people. It has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health. This is an update of a Cochrane review that was last updated in 2011.

OBJECTIVES

To determine whether evidence-based psychological interventions (including cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and third wave CBT)) are effective in preventing the onset of depressive disorder in children and adolescents.

SEARCH METHODS

We searched the specialised register of the Cochrane Common Mental Disorders Group (CCMDCTR to 11 September 2015), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched conference abstracts and reference lists of included trials and reviews, and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials of an evidence-based psychological prevention programme compared with any comparison control for young people aged 5 to 19 years, who did not currently meet diagnostic criteria for depression.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and rated their risk of bias. We adjusted sample sizes to take account of cluster designs and multiple comparisons. We contacted trial authors for additional information where needed. We assessed the quality of evidence for the primary outcomes using GRADE.

MAIN RESULTS

We included 83 trials in this review. The majority of trials (67) were carried out in school settings with eight in colleges or universities, four in clinical settings, three in the community and four in mixed settings. Twenty-nine trials were carried out in unselected populations and 53 in targeted populations.For the primary outcome of depression diagnosis at medium-term follow-up (up to 12 months), there were 32 trials with 5965 participants and the risk of having a diagnosis of depression was reduced for participants receiving an intervention compared to those receiving no intervention (risk difference (RD) -0.03, 95% confidence interval (CI) -0.05 to -0.01; P value = 0.01). We rated this evidence as moderate quality according to the GRADE criteria. There were 70 trials (73 trial arms) with 13,829 participants that contributed to the analysis for the primary outcome of depression symptoms (self-rated) at the post-intervention time point, with results showing a small but statistically significant effect (standardised mean difference (SMD) -0.21, 95% CI -0.27 to -0.15; P value < 0.0001). This effect persisted to the short-term assessment point (up to three months) (SMD -0.31, 95% CI -0.45 to -0.17; P value < 0.0001; 16 studies; 1558 participants) and medium-term (4 to 12 months) assessment point (SMD -0.12, 95% CI -0.18 to -0.05; P value = 0.0002; 53 studies; 11,913 participants); however, the effect was no longer evident at the long-term follow-up. We rated this evidence as low to moderate quality according to the GRADE criteria.The evidence from this review is unclear with regard to whether the type of population modified the overall effects; there was statistically significant moderation of the overall effect for depression symptoms (P value = 0.0002), but not for depressive disorder (P value = 0.08). For trials implemented in universal populations there was no effect for depression diagnosis (RD -0.01, 95% CI -0.03 to 0.01) and a small effect for depression symptoms (SMD -0.11, 95% CI -0.17 to -0.05). For trials implemented in targeted populations there was a statistically significantly beneficial effect of intervention (depression diagnosis RD -0.04, 95% CI -0.07 to -0.01; depression symptoms SMD -0.32, 95% CI -0.42 to -0.23). Of note were the lack of attention placebo-controlled trials in targeted populations (none for depression diagnosis and four for depression symptoms). Among trials implemented in universal populations a number used an attention placebo comparison in which the intervention consistently showed no effect.

AUTHORS' CONCLUSIONS

Overall the results show small positive benefits of depression prevention, for both the primary outcomes of self-rated depressive symptoms post-intervention and depression diagnosis up to 12 months (but not beyond). Estimates of numbers needed to treat to benefit (NNTB = 11) compare well with other public health interventions. However, the evidence was of moderate to low quality using the GRADE framework and the results were heterogeneous. Prevention programmes delivered to universal populations showed a sobering lack of effect when compared with an attention placebo control. Interventions delivered to targeted populations, particularly those selected on the basis of depression symptoms, had larger effect sizes, but these seldom used an attention placebo comparison and there are practical difficulties inherent in the implementation of targeted programmes. We conclude that there is still not enough evidence to support the implementation of depression prevention programmes.Future research should focus on current gaps in our knowledge. Given the relative lack of evidence for universal interventions compared with attention placebo controls and the poor results from well-conducted effectiveness trials of universal interventions, in our opinion any future such trials should test a depression prevention programme in an indicated targeted population using a credible attention placebo comparison group. Depressive disorder as the primary outcome should be measured over the longer term, as well as clinician-rated depression. Such a trial should consider scalability as well as the potential for the intervention to do harm.

Youth depression alleviation: the Fish Oil Youth Depression Study (YoDA-F): A randomized, double-blind, placebo-controlled treatment trial

AIM

US authorities have recommended 'black-box' warnings for antidepressants because of the increased risk of suicidality for individuals up to age 25. There is thus a clinical and ethical imperative to provide effective treatment for youth depression with an acceptable risk-benefit balance. Long-chain omega-3 polyunsaturated fatty acids (PUFAs) play an important role in a range of physiological processes in living organisms. Supplementation with omega-3 PUFAs has been shown to have a range of beneficial effects on both physical and mental health, and results of previous trials suggest that omega-3 PUFAs may be a safe and effective treatment for depression. However, conclusions from these trials have been limited by their relatively small sample sizes.

METHODS

This trial will test the effectiveness of a 12-week parallel group, double-blind, randomized, placebo-controlled trial of 1.4 g day(-1) omega-3 PUFAs in help seeking 15- to 25-year-olds (N = 400) presenting with major depressive disorder. The primary hypothesis is that young people will show greater improvement of depressive symptoms after 12 weeks of treatment with omega-3 PUFAs plus cognitive behavioural case management compared with treatment with placebo plus cognitive behavioural case management.

CONCLUSION

Because of using a large sample, results from this study will provide the strongest evidence to date to inform the use of omega-3 PUFAs as first-line therapy in young people presenting with major depressive disorder. The study also heralds an important step towards indicated prevention of persistent depression, which may reduce the burden, stigmatization, disability and economic consequences of this disorder.

Subjective ratings of neurocognitive functioning in depressed young people undergoing treatment: utility of a brief screening tool

AIMS

To determine how young people with depression rate their neurocognitive functioning during treatment, and whether these ratings are affected by depression severity, age, suicidal ideation and antidepressant status.

METHODS

Fifty young people (12-25 years) engaged in psychological therapy completed the Neuropsychological Symptoms Self-Report rating their neurocognitive functioning in a range of domains.

RESULTS

In two domains, working memory/multitasking and motivation, more than 40% of the sample rated their functioning as improved, since commencing treatment. Ratings of neurocognitive functioning were affected by depression severity and suicidal ideation, particularly in the areas of wakefulness, attention and concentration, working memory/multitasking, and motivation. However, there were few differences related to age or antidepressant status.

CONCLUSIONS

The Neuropsychological Symptoms Self-Report - a rapid measure of subjective neurocognitive functioning - can provide a snapshot of subjective changes in neurocognitive functioning during treatment for depression. This information may guide treatment approaches.

The effectiveness of simple psychological and physical activity interventions for high prevalence mental health problems in young people: A factorial randomised controlled trial

BACKGROUND

The prevalence and burden of disease of depression and anxiety disorders in young people necessitates effective early intervention strategies. The aim of this study was to evaluate the effectiveness of low-intensity interventions (problem solving therapy (PST) and physical activity promotion) in young people (15-25 years) with mild-moderate depression and/or anxiety.

METHOD

A 2×2 factorial randomised controlled trial (RCT) with factors of PST versus supportive counselling (control) and behavioural activation physical activity versus lifestyle psychoeducation (control). Help-seeking participants (n=176) were randomised to receive up to 6 manualised intervention sessions. Primary outcomes were post-intervention depressive symptoms (Beck Depression Inventory-II (BDI-II), anxiety symptoms (Beck Anxiety Inventory), and Montgomery-Åsberg Depression Rating Scale (MADRS)). Trial registration ACTRN12608000550303.

RESULTS

Depression symptoms were significantly reduced in the physical activity group compared to psychoeducation (BDI-II: d=0.41 (95% CI: 0.07-0.76); MADRS: d=0.48 (95% CI: 0.13-0.82), but not post-intervention anxiety symptoms. PST was not superior to supportive counselling, nor were any interactions between interventions significant.

LIMITATIONS

As self reported levels of physical activity did not significantly differ between baseline and end-point in those randomised to the physical activity intervention, it is unclear as to whether some form of physical activity not measured in the trial may have led to the difference in depression symptoms.

CONCLUSIONS

PST was not superior to supportive counselling in reducing depression and anxiety symptoms in young people. Participants who received the physical activity intervention reported the greatest reduction in depression symptoms, however further research is required to establish the mechanism of action and to determine its effectiveness as an adjunct intervention in routine clinical practice.

Consultation liaison in primary care for people with mental disorders

Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary healthcare has been identified as essential to improving the delivery of mental healthcare. Consultation liaison is a model of mental healthcare where the primary care provider maintains the central role in the delivery of mental healthcare, with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental healthcare in the primary care setting and, in turn, improve outcomes for people with a mental disorder.

Antiglucocorticoid and related treatments for psychosis

BACKGROUND

Hypothalamic-pituitary-adrenal (HPA) axis dysregulation has been implicated in the development and relapse of psychotic disorders. Elevated cortisol secretion has been positively linked with symptom severity in people with psychosis. Antiglucocorticoid and related drugs that target the HPA axis may be useful for the treatment of individuals with psychosis.

OBJECTIVES

1. To determine the effects of antiglucocorticoid and related drugs for the treatment of psychosis, when used alone or in combination with antipsychotic medication.2. To determine whether the effects of these medications differs between those in a prodromal phase or first episode of psychosis, and those with more established illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (August 2009 and April 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antiglucocorticoid and related drugs compared to placebo (either as a sole treatment or as an adjunct to atypical antipsychotics, typical antipsychotics, antidepressants or other combination treatment) for people with a primary diagnosis of a psychotic disorder, or for individuals at high risk of developing a psychotic disorder.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials, assessed methodological quality and extracted data. We used a fixed-effect meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) and standardised mean differences (SMDs) with 95% CIs for continuous measures. We assessed risk of bias for included studies and used GRADE (Grading of Recommendations Assessment, Development and Evaluation) to create a 'Summary of findings' table.

MAIN RESULTS

We included 11 studies that randomly assigned 509 people with schizophrenia, schizoaffective disorder or psychotic depression. No trials were conducted in patients at their first episode of psychotic illness and none included populations at high risk for developing psychosis. Our pre-stated outcomes of interest were mental state, global state, general functioning, adverse effects and quality of life.Two trials compared antiglucocorticoid drugs (mifepristone) versus placebo as sole treatment. Limited data from one trial showed no difference in the proportion responding to mifepristone when mental state was assessed immediately post intervention using the Brief Psychiatric Rating Scale (BPRS) (n = 5, 1 RCT, MD -5.20, 95% CI -17.91 to 7.51; very low-quality evidence); depressive symptoms (Hamilton Rating Scale for Depression (HAMD) total) were also similar between groups (n = 5, 1 RCT, MD 1.67, 95% CI -16.44 to 19.78; very low-quality evidence). However, a significant difference favoured treatment at short-term follow-up for global state (30% reduction in total BPRS, n = 221, 1 RCT, RR 0.58, 95% CI 0.38 to 0.89; low-grade quality evidence). This effect was also seen for short-term positive psychotic symptoms (50% reduction in BPRS positive symptom subscale, n = 221, 1 RCT, RR 0.60, 95% CI 0.43 to 0.84; low-grade quality evidence). Participants receiving mifepristone experienced a similar overall number of adverse effects as those receiving placebo (n = 226, 2 RCTs, RR 0.92, 95% CI 0.77 to 1.09; moderate-quality evidence). No data on general functioning or quality of life were available.One trial compared an antiglucocorticoid, dehydroepiandrosterone (DHEA), as an adjunct to atypical antipsychotic treatment to adjunctive placebo. Data for main outcomes of interest were of low quality, and analysis of useable data showed no significant effects of treatment on mental state or adverse effects. Data on global state, general functioning and quality of life were not available.Data from six trials comparing antiglucocorticoid drugs as an adjunct to combination treatment versus adjunctive placebo showed no significant differences between groups in mean endpoint scores for overall psychotic symptoms (n = 171, 6 RCTs, SMD 0.01, 95% CI - 0.29 to 0.32) or positive psychotic symptoms (n = 151, 5 RCTs, SMD -0.07, 95% CI - 0.40 to 0.25). Data from three trials showed no differences between groups in mean endpoint scores for negative symptoms (n = 94, 3 RCTs, MD 2.21, 95% CI -0.14 to 4.55). One study found improvements in global state that were similar between groups (n = 30, 1 RCT, RR 0.58, 95% CI 0.32 to 1.06; very low-quality evidence). In this comparison, pooled results showed that antiglucorticoids caused a greater overall number of adverse events (n = 199, 7 RCTs, RR 2.66, 95% CI 1.33 to 5.32; moderate quality evidence), but no quality of life data were available.

AUTHORS' CONCLUSIONS

Good evidence is insufficient to conclude whether antiglucocorticoid drugs provide effective treatment for psychosis. Some global state findings suggest a favourable effect for mifepristone, and a few overall adverse effect findings favour placebo. Additional large randomised controlled trials are needed to justify findings.

Consultation liaison in primary care for people with mental disorders

BACKGROUND

Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder.

OBJECTIVES

To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care.

SEARCH METHODS

We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information.We collected and analysed data for all follow-up periods: up to and including three months following the start of treatment; between three and 12 months; and more than 12 months following the start of therapy.We used a random-effects model to calculate the risk difference (RD) for binary data and number needed to treat for an additional beneficial outcome (NNTB), if differences between groups were significant. The mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data.

MAIN RESULTS

There were 8203 citations identified from database searches and reference lists. We included 12 trials with 2605 consumer participants and more than 905 primary care practitioner participants. Eleven trials compared consultation liaison to standard care and one compared consultation liaison to collaborative care, with a case manager co-ordinating mental health care. People with depression were included in eight trials; and one trial each included people with a variety of disorders: depression, anxiety and somatoform disorders; medically unexplained symptoms; and drinking problems. None of the included trials reported separate data for children or older people.There was some evidence that consultation liaison improved mental health up to three months following the start of treatment (two trials, n = 445, NNTB 8, 95% CI 5 to 25) but there was no evidence of its effectiveness between three and 12 months. Consultation liaison also appeared to improve consumer satisfaction (up to three months: one trial, n = 228, NNTB 3, 95% CI 3 to 5; 3 to 12 months: two trials, n = 445, NNTB 8, 95% CI 5 to 17) and adherence (3 to 12 months: seven trials, n = 1251, NNTB 6, 95% CI 4 to 13) up to 12 months. There was also an improvement in the primary care provider outcomes of providing adequate treatment between three to 12 months (three trials, n = 797, NNTB 7, 95% CI 4 to 17) and prescribing pharmacological treatment up to 12 months (four trials, n = 796, NNTB 13, 95% CI 7 to 50). There was also some evidence that consultation liaison may not be as effective as collaborative care in regards to symptoms of mental disorder, disability, general health status, and provision of treatment.The quality of these findings were low for all outcomes however, apart from consumer adherence from three to 12 months, which was of moderate quality. Eight trials were rated a high risk of performance bias because consumer participants were likely to have known whether or not they were allocated to the intervention group and most outcomes were self reported. Bias due to attrition was rated high in eight trials and reporting bias was rated high in six.

AUTHORS' CONCLUSIONS

There is evidence that consultation liaison improves mental health for up to three months; and satisfaction and adherence for up to 12 months in people with mental disorders, particularly those who are depressed. Primary care providers were also more likely to provide adequate treatment and prescribe pharmacological therapy for up to 12 months. There was also some evidence that consultation liaison may not be as effective as collaborative care in terms of mental disorder symptoms, disability, general health status, and provision of treatment. However, the overall quality of trials was low particularly in regards to performance and attrition bias and may have resulted in an overestimation of effectiveness. More evidence is needed to determine the effectiveness of consultation liaison for people with mental disorders particularly for those with mental disorders other than depression.

Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis

Previous meta-analyses of psychotherapies for child and adolescent depression were limited because of the small number of trials with direct comparisons between two treatments. A network meta-analysis, a novel approach that integrates direct and indirect evidence from randomized controlled studies, was undertaken to investigate the comparative efficacy and acceptability of psychotherapies for depression in children and adolescents. Systematic searches resulted in 52 studies (total N=3805) of nine psychotherapies and four control conditions. We assessed the efficacy at post-treatment and at follow-up, as well as the acceptability (all-cause discontinuation) of psychotherapies and control conditions. At post-treatment, only interpersonal therapy (IPT) and cognitive-behavioral therapy (CBT) were significantly more effective than most control conditions (standardized mean differences, SMDs ranged from -0.47 to -0.96). Also, IPT and CBT were more beneficial than play therapy. Only psychodynamic therapy and play therapy were not significantly superior to waitlist. At follow-up, IPT and CBT were significantly more effective than most control conditions (SMDs ranged from -0.26 to -1.05), although only IPT retained this superiority at both short-term and long-term follow-up. In addition, IPT and CBT were more beneficial than problem-solving therapy. Waitlist was significantly inferior to other control conditions. With regard to acceptability, IPT and problem-solving therapy had significantly fewer all-cause discontinuations than cognitive therapy and CBT (ORs ranged from 0.06 to 0.33). These data suggest that IPT and CBT should be considered as the best available psychotherapies for depression in children and adolescents. However, several alternative psychotherapies are understudied in this age group. Waitlist may inflate the effect of psychotherapies, so that psychological placebo or treatment-as-usual may be preferable as a control condition in psychotherapy trials.

Where to go from here? An exploratory meta-analysis of the most promising approaches to depression prevention programs for children and adolescents

OBJECTIVE

To examine the overall effect of individual depression prevention programs on future likelihood of depressive disorder and reduction in depressive symptoms. In addition, we have investigated whether Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT) and other therapeutic techniques may modify this effectiveness.

METHODS

This study is based on and includes the trial data from meta-analyses conducted in the Cochrane systematic review of depression prevention programs for children and adolescents by Merry et al. (2011). All trials were published or unpublished English language randomized controlled trials (RCTs) or cluster RCTs of any psychological or educational intervention compared to no intervention to prevent depression in children and adolescents aged 5-19 years.

RESULTS

There is some evidence that the therapeutic approach used in prevention programs modifies the overall effect. CBT is the most studied type of intervention for depression prevention, and there is some evidence of its effectiveness in reducing the risk of developing a depressive disorder, particularly in targeted populations. Fewer studies employed IPT, however this approach appears promising. To our knowledge, this is the first study to have explored how differences in the approach taken in the prevention programs modify the overall treatment effects of prevention programs for children and adolescents.

CONCLUSIONS

More research is needed to identify the specific components of CBT that are most effective or indeed if there are other approaches that are more effective in reducing the risk of future depressive episodes. It is imperative that prevention programs are suitable for large scale roll-out, and that emerging popular modes of delivery, such as online dissemination continue to be rigorously tested.

Back to basics: could behavioural therapy be a good treatment option for youth depression? A critical review

AIM

Recent findings from systematic reviews and primary research studies have shown more modest effects of cognitive behavioural therapy (CBT) for youth depression than previously shown, highlighting the need to further enhance the effectiveness of this intervention, or components of this intervention. Therefore, the aim of this review is to summarize the work that has been done to identify the different components of CBT and their varying effectiveness for young people with depression.

METHODS

Narrative overview of English language reviews/meta-analyses and primary intervention studies retrieved from searches of computerized databases as well as ancestry searches.

RESULTS

Reviews of intervention studies of adults as well as young people with depression have shown that behavioural approaches are equally as effective as cognitive approaches in reducing depression symptoms. Post-hoc analyses of large studies in youth depression have also shown that behavioural approaches might be more suitable for young people.

CONCLUSIONS

Behaviourally based approaches appear promising in treating youth depression; however, further research is required. This research will represent an essential step towards refining interventions for youth depression, and enabling interventions to be targeted to particular subgroups, to optimize their effectiveness.