Control condition design and implementation features in controlled trials: a meta-analysis of trials evaluating psychotherapy for depression

Affect regulation training reduces symptom severity in depression - A randomized controlled trial

Deficits in general emotion regulation skills have been shown to be associated with various mental disorders. Thus, general affect-regulation training has been proposed as promising transdiagnostic approach to the treatment of psychopathology. In the present study, we aimed to evaluate the efficacy of a general affect-regulation as a stand-alone, group-based treatment for depression. For this purpose, we randomly assigned 218 individuals who met criteria for major depressive disorder (MDD) to the Affect Regulation Training (ART), to a waitlist control condition (WLC), or to a condition controlling for common factors (CFC). The primary outcome was the course of depressive symptom severity as assessed with the Hamilton Rating Scale for Depression and the Beck Depression Inventory. Multi-level analyses indicated that participation in ART was associated with a greater reduction of depressive symptom severity than was participation in WLC (d = 0.56), whereas the slight superiority of ART over CFC (d = 0.25) was not statistically significant. Mediation analyses indicated that changes in emotion regulation skills mediated the differences between ART/CFC and WLC. Thus, the findings provide evidence for enhancing emotion regulation skills as a common mechanism of change in psychological treatments for depression. The study was registered with ClinicalTrials.gov (NCT01330485) and was supported by grants from the German Research Association (DFG; BE 4510/3-1; HI 456/6-2). Future research should compare the (cost-) efficacy of ART with that of disorder-specific interventions.

Internet- and App-Based Stress Intervention for Distance-Learning Students With Depressive Symptoms: Protocol of a Randomized Controlled Trial

Background: Mental disorders are highly prevalent among university students. Distance-learning students are particularly burdened and have limited access to conventional university health services. Interventions for stress are sought after in distance learners and may help increase treatment coverage. Internet-based interventions have been shown to be effective in preventing and treating depression, but it remains unclear if interventions directed at academic stress also have this potential. Aim: The trial presented here investigates the effectiveness of an Internet- and App-based stress intervention in distance-learning students with elevated levels of depression. Methods: A sample of N = 200 students of a large German distance university with elevated levels of depression [Center for Epidemiological Studies' Depression Scale (CES-D) ≥ 16] will be randomly assigned to either an Internet- and App-based stress management intervention group (IG) or a control group (CG) receiving an Internet-based psychoeducational program for academic stress. The IG consists of eight Internet-based sessions promoting stress management skills using cognitive-behavioral and problem-solving techniques. A mobile App will be employed to facilitate training transfer. Self-report data will be assessed at baseline (T0), post-treatment (T1; 7 weeks), and 3-month follow-up (T2). Potential moderators will be assessed at baseline. The primary outcome is depression (CES-D) post-treatment. Secondary outcomes include mental health outcomes, modifiable risk and protective factors, and academic outcomes. Data will be analyzed on an intention-to-treat principle along with sensitivity analyses to assess the robustness of findings. Additional health economic analyses will be conducted. Discussion: Results will provide the basis to assess the acceptance and effectiveness of Internet-delivered stress interventions in distance-learning students with symptoms of depression. Ethics and dissemination: The study has been reviewed and approved by the University of Erlangen-Nuremberg ethics committee (Erlangen, Germany; 33_17 Bc). Results of the study will be disseminated through peer-reviewed publications. Trial Registration: German Clinical Trial Registration (DRKS), identifier DRKS00011800.

The Role of Common Factors in Psychotherapy Outcomes

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

Examining the "usual" in usual care: a critical review and recommendations for usual care conditions in psycho-oncology

PURPOSE

Within psycho-oncology clinical trials, usual care (UC) represents a common and important control condition. Yet recent shifts in oncology, coupled with insufficient description of such conditions, threaten to render UC increasingly difficult to define and interpret. This paper offers evidence of these shifts and recommendations for addressing them.

METHODS

The broader literature on usual care as a control condition in psychosocial/behavioral intervention trials was assessed, and usual care-controlled trials in psycho-oncology were selectively reviewed, toward to goal of conceptual synthesis.

RESULTS

We offer evidence that (1) UC control conditions are often insufficiently defined and assessed; and (2) the context of supportive care in oncology has shifted in a manner that contributes to this problem, with implications for interpreting and comparing findings across clinical trials. Three converging findings support these conclusions. First, the scientific literature increasingly documents the diversity in how "usual care" conditions are defined across psychosocial and behavioral trials, with important considerations for trial interpretation. Second, evidence suggests that the availability of psychosocial oncology care has increased over the past few decades. The increasing availability and variety of psychosocial care introduces potential confounds for UC conditions. Third, mental health care trends in the general population affect the supportive interventions available to oncology patients in UC conditions today versus in the past.

CONCLUSIONS

Shifts in psychosocial oncology and broader mental health care underscore the importance of carefully defining and assessing UC in psycho-oncology trials. Recommendations are offered for improving the design, evaluation, and interpretation of UC conditions, toward the ultimate goal of improving the quality of the evidence in psycho-oncology.

Network meta-analysis of randomised trials of pharmacological, psychotherapeutic, exercise and collaborative care interventions for depressive symptoms in patients with coronary artery disease: hybrid systematic review of systematic reviews protocol

BACKGROUND

Depression is common in patients with coronary artery disease (CAD) and is associated with poorer outcomes and higher costs. Several randomised controlled trials (RCTs) targeting depression, of various modalities (including pharmacological, psychotherapeutic and other approaches), have been conducted and summarised in pairwise meta-analytic reviews. However, no study has considered the cumulative evidence within a network, which can provide valuable indirect comparisons and information about the relative efficacy of interventions. Therefore, we will adopt a review of review methodology to develop a network meta-analysis (NMA) of depression interventions for depression in CAD.

METHODS

We will search relevant databases from inception for systematic reviews of RCTs of depression treatments for people with CAD, supplementing this with comprehensive searches for recent or ongoing studies. We will extract data from and summarise characteristics of individual RCTs, including participants, study characteristics, outcome measures and adverse events. Cochrane risk of bias ratings will also be extracted or if not present will be conducted by the authors. RCTs that compare depression treatments (grouped as pharmacological, psychotherapeutic, combined pharmacological/psychotherapeutic, exercise, collaborative care) to placebo, usual care, waitlist control or attention controls, or directly in head-to-head comparisons, will be included. Primary outcomes will be the change in depressive symptoms (summarised with a standardised mean difference) and treatment acceptability (treatment discontinuation: % of people who withdrew). Secondary outcomes will include change in 6-month depression outcomes, health-related quality of life (HRQoL), mortality, cardiovascular morbidity, health services use and adverse events. Secondary analyses will form further networks with individual anti-depressants and psychotherapies. We will use frequentist, random effects multivariate network meta-analysis to synthesise the evidence for depression intervention and to achieve a ranking of treatments, using Stata. Rankograms and surface under the cumulative ranking curves will be used for treatment ranking. Local and global methods will evaluate consistency. GRADE will be used to assess evidence quality for primary outcomes.

DISCUSSION

The present review will address uncertainties about the evidence in terms of depression management in CAD and may allow for a ranking of treatments, including providing important information for future research efforts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018108293.

Efficacy of an internet-based self-management intervention for depression or dysthymia - a study protocol of an RCT using an active control condition

BACKGROUND

The treatment of major depressive disorder, a highly prevalent disorder associated with pronounced burden, is a large challenge to healthcare systems worldwide. Internet based self-management interventions seem to be a cost effective way to complement the treatment of depressed patients, but the accumulating evidence is mainly based on the comparison to waitlist controls and treatment as usual, which might lead to an overestimation of effects. Furthermore, studies assessing long-term effects and possible negative outcomes are still rare.

METHODS/DESIGN

The proposed study evaluates the efficacy of the German version of the iFightDepression® tool in comparison to an active control condition. A total of 360 patients with mild to moderate depressive symptoms are included into a two-armed randomized controlled trial. They receive one of two six week interventions; either the iFightDepression® tool or progressive muscle relaxation serving as the control condition. Both intervention groups receive information material, weekly tasks via the internet and regular phone calls as part of the intervention. The primary outcome is change in depressive symptoms after the intervention period, as measured with the Inventory of Depressive Symptomatology. Satisfaction with the program, usability, changes in perceived quality of life, and possible negative effects are assessed as secondary outcomes.

DISCUSSION

This study represents the first randomized controlled trial on the iFightDepression® self-management tool in its German version, aiming at efficacy, but also at providing new insights into so far understudied aspects of E-mental health programs, namely the specificity of the treatment effect compared to an active control condition, it's continuity over a time course of 12 months, and possible negative effects of these internet based interventions.

TRIAL REGISTRATION

International trial-registration took place through the "international clinical trials registry platform" (WHO) with the secondary ID 080-15-09032015. German Clinical Trial Registration: DRKS00009323 (DRKS.de, registered on 25 February 2016).

Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications

Mental disorders are highly prevalent and often remain untreated. Many limitations of conventional face-to-face psychological interventions could potentially be overcome through Internet-based and mobile-based interventions (IMIs). This chapter introduces core features of IMIs, describes areas of application, presents evidence on the efficacy of IMIs as well as potential effect mechanisms, and delineates how Artificial Intelligence combined with IMIs may improve current practices in the prevention and treatment of mental disorders in adults. Meta-analyses of randomized controlled trials clearly show that therapist-guided IMIs can be highly effective for a broad range of mental health problems. Whether the effects of unguided IMIs are also clinically relevant, particularly under routine care conditions, is less clear. First studies on IMIs for the prevention of mental disorders have shown promising results. Despite limitations and challenges, IMIs are increasingly implemented into routine care worldwide. IMIs are also well suited for applications of Artificial Intelligence and Machine Learning, which provides ample opportunities to improve the identification and treatment of mental disorders. Together with methodological innovations, these approaches may also deepen our understanding of how psychological interventions work, and why. Ethical and professional restraints as well as potential contraindications of IMIs, however, should also be considered. In sum, IMIs have a high potential for improving the prevention and treatment of mental health disorders across various indications, settings, and populations. Therefore, implementing IMIs into routine care as both adjunct and alternative to face-to-face treatment is highly desirable. Technological advancements may further enhance the variability and flexibility of IMIs, and thus even further increase their impact in people's lives in the future.

A pooled analysis of three studies of nonpharmacological interventions for menopausal hot flashes

OBJECTIVE

The aim of the study was to conduct a pooled analysis of three published trials of nonpharmacological interventions for menopausal hot flashes to compare the effectiveness of interventions.

METHODS

Data from three randomized controlled trials of interventions for hot flashes (two acupuncture trials, one yoga trial) were pooled. All three studies recruited perimenopausal or postmenopausal women experiencing ≥4 hot flashes/d on average. The primary outcome for all three studies was frequency of hot flashes as measured by the Daily Diary of Hot Flashes. Study 1 participants were randomly assigned to 8 weeks of acupuncture treatments (active intervention), sham acupuncture (attention control), or usual care. Study 2 participants were randomly assigned to 10 weeks of yoga classes, health and wellness education classes (attention control), or waitlist control. Study 3 randomly assigned participants to 6 months of acupuncture or waitlist control. To standardize the time frame for these analyses, only the first 8 weeks of intervention from all three studies were used.

RESULTS

The three active interventions and the two attention control groups had statistically similar trends in the percentage reduction of hot flashes over 8 weeks, ranging from 35% to 40%. These five groups did not differ significantly from each other, but all showed significantly greater reduction in hot flash frequency compared with the three usual care/waitlist groups.

CONCLUSION

Acupuncture, yoga, and health and wellness education classes all demonstrated statistically similar effectiveness in reduction of hot flash frequency compared with controls.

Randomised controlled trial of a self-guided online fatigue intervention in multiple sclerosis

OBJECTIVE

Fatigue is a major disabling symptom in many chronic diseases including multiple sclerosis (MS), but treatment options are limited.Here, we tested the effectiveness of a self-guided , interactive, online fatigue management programme (ELEVIDA) based on principles of cognitive behavioural therapy (CBT) and related psychotherapeutic approaches (eg, mindfulness) for reducing fatigue in MS.

METHODS

Patients with MS and self-reported fatigue were recruited via the website of the German MS Society and assigned via an automated randomisation generator (1:1, no blocking or stratification) to a 12-week online intervention (ELEVIDA, n=139, 82% female, mean age 40.8, median patient determined disease steps (PDDS) 3.0) or a waitlist control group (n=136, 79% female, mean age 41.9, median PDDS 3.0). The primary outcome was the Chalder Fatigue Scale. Outcomes were assessed at baseline, at week 12 (postintervention) and at follow-up (week 24).

RESULTS

Compared with the control group, significantly greater reductions in Chalder Fatigue Scale scores were seen in the ELEVIDA group at week 12 (primary endpoint, intention-to-treat analysis: between-group mean difference 2.74 points; 95% CI 1.16 to 4.32; p=0.0007; effect size d=0.53), with effects sustained at week 24 (intention-to-treat analysis: between-group mean difference 2.19 points; 95% CI 0.57 to 3.82; p=0.0080).

CONCLUSIONS

Our trial provides evidence for the effectiveness of a self-guided , internet-based intervention to reduce fatigue in MS. Interventions such as ELEVIDA may be a suitable low barrier, cost-effective treatment option for MS fatigue.

TRIAL REGISTRATION NUMBER

ISRCTN registry (number ISRCTN25692173).

Tutorial for Using Control Systems Engineering to Optimize Adaptive Mobile Health Interventions

BACKGROUND

Adaptive behavioral interventions are individualized interventions that vary support based on a person's evolving needs. Digital technologies enable these adaptive interventions to function at scale. Adaptive interventions show great promise for producing better results compared with static interventions related to health outcomes. Our central thesis is that adaptive interventions are more likely to succeed at helping individuals meet and maintain behavioral targets if its elements can be iteratively improved via data-driven testing (ie, optimization). Control systems engineering is a discipline focused on decision making in systems that change over time and has a wealth of methods that could be useful for optimizing adaptive interventions.

OBJECTIVE

The purpose of this paper was to provide an introductory tutorial on when and what to do when using control systems engineering for designing and optimizing adaptive mobile health (mHealth) behavioral interventions.

OVERVIEW

We start with a review of the need for optimization, building on the multiphase optimization strategy (MOST). We then provide an overview of control systems engineering, followed by attributes of problems that are well matched to control engineering. Key steps in the development and optimization of an adaptive intervention from a control engineering perspective are then summarized, with a focus on why, what, and when to do subtasks in each step.

IMPLICATIONS

Control engineering offers exciting opportunities for optimizing individualization and adaptation elements of adaptive interventions. Arguably, the time is now for control systems engineers and behavioral and health scientists to partner to advance interventions that can be individualized, adaptive, and scalable. This tutorial should aid in creating the bridge between these communities.

A cluster randomized controlled platform trial comparing group MEmory specificity training (MEST) to group psychoeducation and supportive counselling (PSC) in the treatment of recurrent depression

Impaired ability to recall specific autobiographical memories is characteristic of depression, which when reversed, may have therapeutic benefits. This cluster-randomized controlled pilot trial investigated efficacy and aspects of acceptability, and feasibility of MEmory Specificity Training (MEST) relative to Psychoeducation and Supportive Counselling (PSC) for Major Depressive Disorder (N = 62). A key aim of this study was to determine a range of effect size estimates to inform a later phase trial. Assessments were completed at baseline, post-treatment and 3-month follow-up. The cognitive process outcome was memory specificity. The primary clinical outcome was symptoms on the Beck Depression Inventory-II at 3-month follow-up. The MEST group demonstrated greater improvement in memory specificity relative to PSC at post-intervention (d = 0.88) and follow-up (d = 0.74), relative to PSC. Both groups experienced a reduction in depressive symptoms at 3-month follow-up (d = 0.67). However, there was no support for a greater improvement in depressive symptoms at 3 months following MEST relative to PSC (d = -0.04). Although MEST generated changes on memory specificity and improved depressive symptoms, results provide no indication that MEST is superior to PSC in the resolution of self-reported depressive symptoms. Implications for later-phase definitive trials of MEST are discussed.

Internet- and Mobile-Based Psychological Interventions: Applications, Efficacy, and Potential for Improving Mental Health

Abstract. The majority of mental health disorders remain untreated. Many limitations of traditional psychological interventions such as limited availability of evidence-based interventions and clinicians could potentially be overcome by providing Internet- and mobile-based psychological interventions (IMIs). This paper is a report of the Taskforce E-Health of the European Federation of Psychologists’ Association and will provide an introduction to the subject, discusses areas of application, and reviews the current evidence regarding the efficacy of IMIs for the prevention and treatment of mental disorders. Meta-analyses based on randomized trials clearly indicate that therapist-guided stand-alone IMIs can result in meaningful benefits for a range of indications including, for example, depression, anxiety, insomnia, or posttraumatic stress disorders. The clinical significance of results of purely self-guided interventions is for many disorders less clear, especially with regard to effects under routine care conditions. Studies on the prevention of mental health disorders (MHD) are promising. Blended concepts, combining traditional face-to-face approaches with Internet- and mobile-based elements might have the potential of increasing the effects of psychological interventions on the one hand or to reduce costs of mental health treatments on the other hand. We also discuss mechanisms of change and the role of the therapist in such approaches, contraindications, potential limitations, and risk involved with IMIs, briefly review the status of the implementation into routine health care across Europe, and discuss confidentiality as well as ethical aspects that need to be taken into account, when implementing IMIs. Internet- and mobile-based psychological interventions have high potential for improving mental health and should be implemented more widely in routine care.

Effectiveness of an Internet- and App-Based Intervention for College Students With Elevated Stress: Randomized Controlled Trial

Background

Mental health problems are highly prevalent among college students. Most students with poor mental health, however, do not receive professional help. Internet-based self-help formats may increase the utilization of treatment.

Objective

The aim of this randomized controlled trial was to evaluate the efficacy of an internet-based, app-supported stress management intervention for college students.

Methods

College students (n=150) with elevated levels of stress (Perceived Stress Scale 4-item version, PSS-4 ≥8) were randomly assigned to either an internet- and mobile-based stress intervention group with feedback on demand or a waitlist control group. Self-report data were assessed at baseline, posttreatment (7 weeks), and 3-month follow-up. The primary outcome was perceived stress posttreatment (PSS-4). Secondary outcomes included mental health outcomes, modifiable risk and protective factors, and college-related outcomes. Subgroup analyses were conducted in students with clinically relevant symptoms of depression (Center for Epidemiological Studies’ Depression Scale >17).

Results

A total of 106 participants (76.8%) indicated that they were first-time help-seekers, and 77.3% (intervention group: 58/75; waitlist control group: 58/75) showed clinically relevant depressive symptoms at baseline. Findings indicated significant effects of the intervention compared with the waitlist control group for stress (d=0.69; 95% CI 0.36-1.02), anxiety (d=0.76; 95% CI 0.43-1.09), depression (d=0.63; 95% CI 0.30-0.96), college-related productivity (d=0.33; 95% CI 0.01-0.65), academic work impairment (d=0.34; 95% CI 0.01-0.66), and other outcomes after 7 weeks (posttreatment). Response rates for stress symptoms were significantly higher for the intervention group (69%, 52/75) compared with the waitlist control group (35%, 26/75, P<.001; number needed to treat=2.89, 95% CI 2.01-5.08) at posttest (7 weeks). Effects were sustained at 3-month follow-up, and similar findings emerged in students with symptoms of depression.

Conclusions

Internet- and mobile-based interventions could be an effective and cost-effective approach to reduce consequences of college-related stress and might potentially attract students with clinically relevant depression who would not otherwise seek help.

Trial Registration

German Clinical Trial Register DRKS00010212; http://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010212 (Archived by WebCite at http://www.webcitation.org/6w55Ewhjd)

Efficacy of a web-based intervention with and without guidance for employees with risky drinking: results of a three-arm randomized controlled trial

AIMS

To test the efficacy of a web-based alcohol intervention with and without guidance.

DESIGN

Three parallel groups with primary end-point after 6 weeks.

SETTING

Open recruitment in the German working population.

PARTICIPANTS

Adults (178 males/256 females, mean age 47 years) consuming at least 21/14 weekly standard units of alcohol (SUA) and scoring ≥ 8/6 on the Alcohol Use Disorders Identification Test.

INTERVENTION

Five web-based modules including personalized normative feedback, motivational interviewing, goal setting, problem-solving and emotion regulation during 5 weeks. One intervention group received an unguided self-help version (n=146) and the second received additional adherence-focused guidance by eCoaches (n=144). Controls were on a waiting list with full access to usual care (n=144).

MEASUREMENTS

Primary outcome was weekly consumed SUA after 6 weeks. SUA after 6 months was examined as secondary outcome, next to numbers of participants drinking within the low-risk range, and general and work-specific mental health measures.

FINDINGS

All groups showed reductions of mean weekly SUA after 6 weeks (unguided: -8.0; guided: -8.5; control: -3.2). There was no significant difference between the unguided and guided intervention (P=0.324). Participants in the combined intervention group reported significantly fewer SUA than controls [B=-4.85, 95% confidence interval (CI)=-7.02 to -2.68, P < 0.001]. The intervention groups also showed significant reductions in SUA consumption after 6 months (B=-5.72, 95% CI=-7.71 to -3.73, P < 0.001) and improvements regarding general and work-related mental health outcomes after 6 weeks and 6 months.

CONCLUSIONS

A web-based alcohol intervention, administered with or without personal guidance, significantly reduced mean weekly alcohol consumption and improved mental health and work-related outcomes in the German working population.

A systematic review of anxiety interventions in stroke and acquired brain injury: Efficacy and trial design

OBJECTIVE

There is little randomized controlled trial (RCT) evidence to guide treatment for anxiety after stroke. We systematically reviewed RCTs of anxiety interventions in acquired brain injury (ABI) conditions including stroke and traumatic brain injury (TBI) in order to summarize efficacy and key aspects of trial design to help guide future RCTs.

METHODS

We searched the Cochrane trial register, Medline, Embase, PsychInfo and CINAHL systematically up to August 2017. Two independent reviewers systematically selected studies and extracted data. We summarized the effect size, key study characteristics and sources of potential bias in trial design.

RESULTS

14 studies (12 stroke; one stroke & TBI; one TBI) with 928 participants were included. Meta-analysis of five psychotherapy comparisons favoured intervention over control (standardized mean difference (SMD): -0.41 [-0.79, -0.03], I2=28%); Overall effect size of pharmacotherapy comparisons favoured intervention over control (SMD: -2.12 [-3.05, -1.18], I2=89%). One comparison of mixed pharmacotherapy and psychotherapy favoured intervention over usual care (SMD: -4.79 [-5.87, -3.71]). One comparison favoured forest therapy versus urban control (SMD: -2.00 [-2.59, -1.41]). All positive studies carried high or unclear risk of bias. Sample sizes were small in all included studies.

CONCLUSIONS

There is low quality evidence to suggest that psychotherapy and pharmacotherapy may be effective interventions in the treatment of anxiety after stroke based on underpowered studies that carried high risk of bias. Large-scale well-designed definitive trials are needed to establish whether pharmacological or psychotherapy works. Our review highlighted key considerations for investigators wishing to design high quality trials to evaluate treatments for anxiety after stroke.

CBT-I and HT-I group therapy for adults with insomnia in comparison to those with insomnia and comorbid depression - a pilot study

PURPOSE

The aim of this study was to examine the effectiveness of a combined cognitive-behavioral therapy for insomnia (CBT-I) and hypnotherapy for insomnia (HT-I) program for insomnia patients with or without additional depression regarding depressive symptoms and various sleep parameters.

PATIENTS AND METHODS

A sample of 63 patients suffering from insomnia received a six-session sleep intervention, which combined cognitive-behavioral and hypnotherapeutical elements. Due to violating exclusion criteria, data of 37 patients were analyzed. Ten patients had insomnia comorbid with depression, whereas 27 patients had insomnia only. Sleep diaries were implemented to measure various sleep parameters, whereas depressive symptomatology was assessed with the anxiety and depression scale and Symptom-Checklist-90-R at baseline, before and after the intervention, as well as at 3-months follow-up.

RESULTS

Depressive symptoms decreased from pre to post measurement and follow-up for patients with insomnia comorbid with depression, whereas scores of patients with only insomnia remained relatively on a low level. Both groups showed a significant increase of sleep efficiency and a significant decrease of the duration of wake after sleep onset. However, only patients with insomnia and depression revealed a significant reduction of sleep-onset latency and a higher level of regeneration. Nondepressive insomniacs, on the other hand, showed a significant increase of performance from post measurement to follow-up. For both groups, no change over time was found for number of wake after sleep onset, total sleep time, mood in the morning and evening.

CONCLUSION

Combining CBT-I and HT-I is effective in reducing depressive symptoms and improving sleep. Therefore, nonresponders to other forms of therapy, eg, pharmacological, interpersonal, or cognitive-behavioral therapy, might benefit from the combined CBT-I/HT-I intervention.

Control conditions for randomised trials of behavioural interventions in psychiatry: a decision framework

In psychiatry, comparative analyses of therapeutic options and the aggregation of data from clinical trials across different therapeutic approaches play an important role in clinical decision making, treatment guidelines, and health policy. This approach assumes that trials of pharmacological and behavioural therapies generally produce the same level of evidence when properly designed. However, trial design for behavioural interventions has some unique characteristics and control groups vary widely, which influence the effects observed in any given trial. In this Personal View, we review various control conditions typically used in psychiatry, outline their effect on the internal validity and expected effect size of a trial, and propose a decision framework for choosing a control condition depending on the risk to the patient population and the stage of development of the therapeutic intervention. We argue that the choice of control group and its justification need to be taken into consideration when comparing behavioural and pharmacological therapies.

The effect of treatment as usual on major depressive disorder: A meta-analysis

BACKGROUND

Health-economic models are used to evaluate the long-term cost-effectiveness of an intervention and typically include treatment as usual (TAU) as comparator. Part of the data used for these models are acquired from the literature and thus valid information is needed on the effects of TAU on depression. The aim of the current meta-analysis was to examine positive and negative outcomes of major depression for patients receiving TAU.

METHODS

We conducted a systematic literature search in PubMed, EMBASE, PsycInfo, and the Cochrane Central Register of Controlled Trials. Eligible studies were randomized controlled trials including a TAU group for depression. The quality of the included studies was assessed using the criteria described in the "Risk of bias assessment tool". Four separate meta-analyses were performed to estimate remission, response, reliable change and deterioration rates at short-term (≤6 months from baseline).

RESULTS

Thirty-eight studies including 2099 patients in the TAU were identified. Nine studies (24%) met five or six quality criteria, 17 studies (44%) met three or four quality criteria and 12 studies (32%) met one or two quality criteria. After adjusting for publication bias, the first meta-analysis (n=33) showed that 33% of the patients remitted from depression. The second meta-analysis (n=13) demonstrated that 27% of the patients responded to treatment, meaning that their depressive symptom decreased at least 50% from baseline to follow-up measurement. The third meta-analysis (n=7) indicated that 31% of the patients showed a reliable change, meaning that their depressive symptoms improved more than expected by random variation alone. Finally, 12% of the patients deteriorated, meaning that their depressive symptoms became more severe.

LIMITATIONS

Statistical heterogeneity was substantial in most analyses and was not fully explained by subgroup analyses. The quality of the included studies was moderate. This may result in overestimation of the true effects.

CONCLUSIONS

The treatments labelled as TAU for depression were clinically and statistically heterogeneous. We demonstrated that a few patients benefited from TAU and a small number of patients suffered from worsened depressive symptoms at the short term. The results can be included in health-economic models that compare depression treatments to TAU.

How to prove that your therapy is effective, even when it is not: a guideline

AIMS

Suppose you are the developer of a new therapy for a mental health problem or you have several years of experience working with such a therapy, and you would like to prove that it is effective. Randomised trials have become the gold standard to prove that interventions are effective, and they are used by treatment guidelines and policy makers to decide whether or not to adopt, implement or fund a therapy.

METHODS

You would want to do such a randomised trial to get your therapy disseminated, but in reality your clinical experience already showed you that the therapy works. How could you do a trial in order to optimise the chance of finding a positive effect?

RESULTS

Methods that can help include a strong allegiance towards the therapy, anything that increases expectations and hope in participants, making use of the weak spots of randomised trials (risk of bias), small sample sizes and waiting list control groups (but not comparisons with existing interventions). And if all that fails one can always not publish the outcomes and wait for positive trials.

CONCLUSIONS

Several methods are available to help you show that your therapy is effective, even when it is not.

Internet-based treatment for depression in multiple sclerosis: A randomized controlled trial

Background:

Depression in multiple sclerosis (MS) patients is common but may stay untreated. Physical limitations impede face-to-face treatment. Internet-based treatment is therefore a promising tool for treating depression in MS.

Objectives:

To investigate effectiveness of a guided Internet-based problem-solving treatment (IPST) for depressed MS patients.

Methods:

MS patients with moderate or severe depressive symptoms were randomly assigned to IPST or a wait list control. Primary outcome was the change in depressive symptoms defined by a change in sum score on the Beck Depression Inventory Second Edition (BDI-II). Assessments took place at baseline (T0), within a week after the intervention (T1), and at 4 months follow-up (T2). Analyses were based on the intention-to-treat principle.

Results:

A total of 171 patients were randomized to IPST ( n = 85) or a wait list control ( n = 86). T1 was completed by 152 (89%) and T2 by 131 patients (77%). The IPST group and wait list control showed large significant improvements in depressive symptoms, but no differences were found between groups at T1 ( d = 0.23; 95% confidence interval (CI) = (−4.03, 1.08); p = 0.259) and T2 ( d = 0.01; 95% CI = (−2.80, 2.98); p = 0.953).

Conclusion:

We found no indication that IPST for MS patients with moderate or severe depression is effective in reducing depressive symptoms compared to a waiting list. Large improvements in the wait list control were unexpected and are discussed.

Psychological interventions to improve psychological well-being in people with dementia or mild cognitive impairment: systematic review and meta-analysis protocol

INTRODUCTION

Dementia and mild cognitive impairment are associated with an increased risk of depression, anxiety, psychological distress and poor mental health-related quality of life. However, there is a lack of research examining the evidence base for psychological interventions targeting general psychological well-being within this population. Furthermore, there is little research relating to the design of randomised controlled trials examining psychological interventions for dementia and mild cognitive impairment, such as effective recruitment techniques, trial eligibility and appropriate comparators.

METHODS AND ANALYSIS

Systematic review of electronic databases (CINAHL; EMBASE; PsychInfo; MEDLINE; ASSIA and CENTRAL), supplemented by expert contact, reference and citation checking, and grey literature searches. Published and unpublished studies will be eligible for inclusion with no limitations placed on year of publication. Primary outcomes of interest will be standardised measurements of depression, anxiety, psychological distress or mental health-related quality of life. Eligibility and randomisation proportions will be calculated as secondary outcomes. If data permits, meta-analytical techniques will examine: (1) overall effectiveness of psychological interventions for people with dementia or mild cognitive impairment in relation to outcomes of depression, anxiety, psychological distress or mental health-related quality of life; (2) clinical and methodological moderators associated with effectiveness; (3) proportions eligible, recruited and randomised.

ETHICS AND DISSEMINATION

Ethical approval is not required for the present systematic review. Results will inform the design of a feasibility study examining a new psychological intervention for people with dementia and depression, with dissemination through publication in peer-reviewed journals and presentations at relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42015025177.

The effects of blinding on the outcomes of psychotherapy and pharmacotherapy for adult depression: A meta-analysis

BACKGROUND

Randomized trials with antidepressants are often run under double blind placebo-controlled conditions, whereas those with psychotherapies are mostly unblinded. This can introduce bias in favor of psychotherapy when the treatments are directly compared. In this meta-analysis, we examine this potential source of bias.

METHODS

We searched Pubmed, PsycInfo, Embase and the Cochrane database (1966 to January 2014) by combining terms indicative of psychological treatment and depression, and limited to randomized trials. We included 35 trials (with 3721 patients) in which psychotherapy and pharmacotherapy for adult depression were directly compared with each other. We calculated effect sizes for each study indicating the difference between psychotherapy and pharmacotherapy at post-test. Then, we examined the difference between studies with a placebo condition and those without in moderator analyses.

RESULTS

We did not find a significant difference between the studies with and those without a placebo condition. The studies in which a placebo condition was included indicated no significant difference between psychotherapy and pharmacotherapy (g=-0.07; NNT=25). Studies in which no placebo condition was included (and patients and clinicians in both conditions were not blinded), resulted in a small, but significant difference between psychotherapy and pharmacotherapy in favor of pharmacotherapy (g=-0.13; NNT=14).

CONCLUSIONS

Studies comparing psychotherapy and pharmacotherapy in which both groups of patients (and therapists) are not blinded (no placebo condition is included) result in a very small, but significantly higher effect for pharmacotherapy.

Managing depression in older age: psychological interventions

The number of studies on psychological treatments of depression in older adults has increased considerably in the past years. Therefore, we conducted an updated meta-analysis of these studies. A total of 44 studies comparing psychotherapies to control groups, other therapies or pharmacotherapy could be included. The overall effect size indicating the difference between psychotherapy and control groups was g=0.64 (95% CI: 0.47-0.80), which corresponds with a NNT of 3. These effects were maintained at 6 months or longer post randomization (g=0.27; 95%CI: 0.16-0.37). Specific types of psychotherapies that were found to be effective included cognitive behavior therapy (g=0.45; 95% CI: 0.29-0.60), life review therapy (g=0.59; 95% CI: 0.36-0.82) and problem-solving therapy (g=0.46; 95% CI: 0.18-0.74). Treatment compared to waiting list control groups resulted in larger effect sizes than treatments compared to care-as-usual and other control groups (p<0.05). Studies with lower quality resulted in higher effect sizes than high-quality studies (p<0.05). Direct comparisons between different types of psychotherapy suggested that cognitive behavior therapy and problem-solving therapy may be more effective than non-directive counseling and other psychotherapies may be less effective than other therapies. This should be considered with caution, however, because of the small number of studies. There were not enough studies to examine the long-term effects of psychotherapies and to compare psychotherapy with pharmacotherapy or combined treatments. We conclude that it is safe to assume that psychological therapies in general are effective in late-life depression, and this is especially well-established for cognitive behavior therapy and problem-solving therapy.