Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review

Baseline depression severity as moderator on depression outcomes in psychotherapy and pharmacotherapy

BACKGROUND

Evidence-based treatments for adult depression include psychotherapy and pharmacotherapy, yet little is known about how baseline depression severity moderates treatment outcome.

OBJECTIVES

We aimed to compare the effects of psychotherapy and pharmacotherapy for adult depression and to examine the association between baseline depression severity and treatment outcome, converting multiple baseline depression measures into the scores of the Beck Depression Inventory, second edition (BDI-II).

METHODS

We conducted systematic searches in bibliographical databases up to September 2022 to identify randomized controlled trials (RCTs) in which psychotherapy was compared with pharmacotherapy in the treatment of adult depression. Various meta-regressions using the baseline depression severity as predictor of the relative effects of psychotherapy and pharmacotherapy were performed.

RESULTS

We identified 65 RCTs including 7250 participants for the meta-analyses and 56 RCTs including 5548 participants for the meta-regression. We found no significant difference between psychotherapy and pharmacotherapy (g = -0.08, 95 % CI: -0.2 to 0.04, p = 0.193) and baseline depression severity was not significantly associated with the relative effects of psychotherapy and pharmacotherapy (B = 0.0032, SE = 0.0096, p = 0.74). Results were similar in several sensitivity analyses.

LIMITATIONS

Limitations included the low quality of the included studies, and the omission of long-term effects and within-study variability.

CONCLUSIONS

We found no indication for a moderation effect of baseline depression severity on the relative effects of psychotherapy and pharmacotherapy. Thus, other factors such as availability and patients' preference must be considered when deciding for treatment options.

Psychotherapy training in Brazil: Experiences of psychiatric trainees and early career psychiatrists

Understanding and skills in psychotherapy are fundamental aspects of clinical psychiatry practice. Learning about psychotherapy during the training of psychiatrists offers solid opportunities for developing high standards of psychiatric practice and providing better outcomes for patients. However, little is known about the extent that psychotherapy training is available to psychiatrists in America. This study aimed to analyze the status of psychotherapy training in Brazil through the experiences of early-career psychiatrists. This is a cross-sectional survey conducted between July and November 2021. A 16-item questionnaire was used to investigate: the quality of psychotherapy training; the organizational aspects of psychotherapy training; and satisfaction with training in psychotherapy. The majority of participants reported having mandatory training in psychotherapy, mainly in cognitive-behavioral therapy and psychodynamic therapy. However, only had some practical experience with psychotherapy training. This study highlights the frequent use of psychotherapy training among Brazilian early career psychiatrists. The consensus on the necessity of mandatory psychotherapy training underscores its importance in shaping psychiatric practice. While participants express satisfaction with psychotherapy supervision, the financial burden for advanced training raises concerns. These findings advocate for the improvement of the quality of psychotherapy training in Brazil.

Evaluating Clinical Outcomes in Patients Being Treated Exclusively via Telepsychiatry: Retrospective Data Analysis

BACKGROUND

Depression and anxiety are highly prevalent conditions in the United States. Despite the availability of suitable therapeutic options, limited access to high-quality psychiatrists represents a major barrier to treatment. Although telepsychiatry has the potential to improve access to psychiatrists, treatment efficacy in the telepsychiatry model remains unclear.

OBJECTIVE

Our primary objective was to determine whether there was a clinically meaningful change in 1 of 2 validated outcome measures of depression and anxiety-the Patient Health Questionnaire-8 (PHQ-8) or the Generalized Anxiety Disorder-7 (GAD-7)-after receiving at least 8 weeks of treatment in an outpatient telepsychiatry setting.

METHODS

We included treatment-seeking patients enrolled in a large outpatient telepsychiatry service that accepts commercial insurance. All analyzed patients completed the GAD-7 and PHQ-8 prior to their first appointment and at least once after 8 weeks of treatment. Treatments included comprehensive diagnostic evaluation, supportive psychotherapy, and medication management.

RESULTS

In total, 1826 treatment-seeking patients were evaluated for clinically meaningful changes in GAD-7 and PHQ-8 scores during treatment. Mean treatment duration was 103 (SD 34) days. At baseline, 58.8% (1074/1826) and 60.1% (1097/1826) of patients exhibited at least moderate anxiety and depression, respectively. In response to treatment, mean change for GAD-7 was -6.71 (95% CI -7.03 to -6.40) and for PHQ-8 was -6.85 (95% CI -7.18 to -6.52). Patients with at least moderate symptoms at baseline showed a 45.7% reduction in GAD-7 scores and a 43.1% reduction in PHQ-8 scores. Effect sizes for GAD-7 and PHQ-8, as measured by Cohen d for paired samples, were d=1.30 (P<.001) and d=1.23 (P<.001), respectively. Changes in GAD-7 and PHQ-8 scores correlated with the type of insurance held by the patients. Greatest reductions in scores were observed among patients with commercial insurance (45% and 43.9% reductions in GAD-7 and PHQ-8 scores, respectively). Although patients with Medicare did exhibit statistically significant reductions in GAD-7 and PHQ-8 scores from baseline (P<.001), these improvements were attenuated compared to those in patients with commercial insurance (29.2% and 27.6% reduction in GAD-7 and PHQ-8 scores, respectively). Pairwise comparison tests revealed significant differences in treatment responses in patients with Medicare versus commercial insurance (P<.001). Responses were independent of patient geographic classification (urban vs rural; P=.48 for GAD-7 and P=.07 for PHQ-8). The finding that treatment efficacy was comparable among rural and urban patients indicated that telepsychiatry is a promising approach to overcome treatment disparities that stem from geographical constraints.

CONCLUSIONS

In this large retrospective data analysis of treatment-seeking patients using a telepsychiatry platform, we found robust and clinically significant improvement in depression and anxiety symptoms during treatment. The results provide further evidence that telepsychiatry is highly effective and has the potential to improve access to psychiatric care.

Comparing the efficacy of electronic cognitive behavioral therapy to medication and combination therapy for generalized anxiety disorder: a quasi-experimental clinical trial

Background

Generalized anxiety disorder (GAD) is a debilitating mental health disorder with first-line treatments include cognitive behavioral therapy (CBT) and pharmacotherapy. CBT is costly, time-consuming, and inaccessible. Electronic delivery (e-CBT) is a promising solution to address these barriers. However, due to the novelty of this intervention, more research testing the e-CBT efficacy independently and in conjunction with other treatments is needed.

Objective

This study investigated the efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD.

Methods

This study employed a quasi-experimental design where patients selected their preferred treatment modality. Patients with GAD were enrolled in either e-CBT, medication, or combination arms. The 12-week e-CBT program was delivered through a digital platform. The medications followed clinical guidelines. The efficacy of each arm was evaluated using questionnaires measuring depression, anxiety, and stress severity, as well as quality of life.

Results

There were no significant differences between arms (N e-CBT = 41; N Medication = 41; N Combination = 33) in the number of weeks completed or baseline scores. All arms showed improvements in anxiety scores after treatment. The medication and combination arms improved depression scores. The e-CBT and Combination arms improved quality of life, and the combination arm improved stress scores. There were no differences between the groups in depression, anxiety, or stress scores post-treatment. However, the combination arm had a significantly larger improvement in quality of life. Gender and treatment arm were not predictors of dropout, whereas younger age was.

Conclusion

Incorporating e-CBT on its own or in combination with pharmaceutical interventions is a viable option for treating GAD. Treating GAD with e-CBT or medication appears to offer significant improvements in symptoms, with no meaningful difference between the two. Combining the treatments also offer significant improvements, while not necessarily superior to either independently. The findings suggest that all options are viable. Taking the patient's preferred treatment route based on their lifestyle, personality, and beliefs into account when deciding on treatment should be a priority for care providers.

Barriers to and facilitators of using evidence-based, cognitive-behavioral anxiety interventions in integrated primary care practice

Cognitive-behavioral treatment for anxiety disorders and symptoms remains underutilized in integrated primary care (IPC), in part because the many treatments developed for specialty care are not readily translated to this unique setting. The objective of this study was to identify barriers and facilitators to behavioral health providers (BHPs) delivering evidence-based cognitive--behavioral anxiety interventions within IPC practice. We conducted semistructured interviews with a national sample of 18 BHPs (50% psychologists, 33% social workers, 17% registered nurses) working in IPC in the Veterans Health Administration. We assessed barriers to and facilitators of using psychoeducation, exposure, cognitive therapy, relaxation training, mindfulness/meditation, Acceptance and Commitment Therapy-based interventions, and problem-solving therapy. Qualitative coding and conventional content analysis revealed barriers and facilitators at three levels: IPC, provider, and patient. Themes suggested key barriers of poor fit with the IPC model, BHP training deficits, and lack of patient buy-in, and key facilitators of good perceived fit of the intervention (e.g., scope, duration) with the IPC model, BHPs feeling well equipped, and utility for patients. BHPs select interventions based on fit for the individual patient. Some results were consistent with prior work from specialty care, but the IPC model itself introduces significant implementation challenges. BHPs would benefit from flexible intervention options and training on IPC treatment goals and how to deliver the essence of evidence-based interventions in small doses. Our findings will help to inform adaptation of behavioral anxiety interventions to better fit IPC practice and development of beneficial training and resources for BHPs to reduce implementation challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychological treatment of adult depression in primary care compared with outpatient mental health care: A meta-analysis

BACKGROUND

It is not yet known whether psychological treatments of depression in primary care have comparable effects to treatments in specialized mental health care. We conducted a meta-analysis comparing randomized controlled trials in primary and specialized care.

METHODS

We selected studies from an existing database of randomized trials of psychological treatments of depression in adults, which was built through searches in PubMed, PsychINFO, Embase and the Cochrane Library. Random effects meta-analyses were conducted to examine the effects of therapies and mixed effects subgroup analyses were used to compare the effects in primary and specialized care.

RESULTS

We included 52 trials (7984 patients) in primary care and compared them with 50 trials (3685 patients) in specialized care. The main effect of therapies in primary care was g = 0.43 (95 % CI: 0.32; 0.53; PI: -0.18; 1.03). The overall effects were significantly smaller than those in specialized care (p = 0.006), but this was no longer significant after adjustment for differences between the two settings. The proportion of patients responding to treatment was comparable in primary (0.38; 95 % CI: 0.33; 0.43) and specialized care (0.34; 95 % CI: 0.28; 0.41; p = 0.41), but higher in control conditions in primary care (0.25; 95 % CI: 0.22; 0.28) compared to specialized care (0.16; 95 % CI: 0.12; 0.20; p < 0.001).

DISCUSSION

Psychological treatments are effective in primary care, but somewhat less than in specialized care. Response rates in control conditions in primary care are higher than in specialized care, which may point at a transient nature of depression in primary care.

Implementing digital mental health interventions at scale: one-year evaluation of a national digital CBT service in Ireland

BACKGROUND

In recent years, exponential growth in digital innovations and internet access has provided opportunities to deliver health services at a much greater scale than previously possible. Evidence-based technology-enabled interventions can provide cost-effective, accessible, and resource-efficient solutions for addressing mental health issues. This study evaluated the first year of a supported digital cognitive behavioral therapy (CBT) service provided by the national health service in Ireland, which has been accessible to individuals who receive a referral from one of five referring groups: General Practitioners, Primary Care Psychology, Counselling Primary Care, Community Mental Health, and Jigsaw (a nationwide youth mental health service).

METHODS

A retrospective, observational study examining data from the service between April 2021 to April 2022 was conducted. Descriptive statistics on referrals, account activations, user demographics, program usage, and user satisfaction were extracted, and pre-to-post clinical outcomes for depression measured by the Patient Health Questionnaire-9 and for anxiety measured by the Generalised Anxiety Disorder-7 were analysed using linear mixed effect models.

RESULTS

There were 5,298 referrals and 3,236 (61%) account activations within the year. Most users were female (72.9%) and aged between 18 and 44 years (75.4%). The CBT programs were associated with significant reductions in both depression (β = 3.34, 95% CI [3.03, 3.65], p < 0.001) and anxiety (β = 3.64, 95% CI [3.36, 3.93], p < 0.001), with large effect sizes (Cohen's d > 0.8). Time spent using the programs was also found to be a predictor of the variability in these clinical outcomes (p < 0.001), and accounting for this resulted in significantly better model fits (p < 0.001). User satisfaction ratings were also very high, exceeding 94%.

CONCLUSIONS

Efforts to improve the representation of male and older adult users are warranted. However, overall, the results demonstrate how digital CBT can be provided at scale and lead to symptom reductions with large effect sizes for patients seeking help for depression and anxiety. The findings substantiate the continued use and expansion of this service in Ireland and the more widespread implementation of similar services in other international public healthcare settings.

Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD.

METHODS

Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021.

RESULTS

The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently.

CONCLUSIONS

The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.

Trajectories of depression symptoms, anxiety symptoms and functional impairment during internet-enabled cognitive-behavioural therapy

Underlying classes capture differences between patient symptom trajectories during psychological therapy. This has not been explored for one-to-one internet-delivered therapy or functional impairment trajectories. Patients experiencing depression or anxiety received cognitive-behavioural therapy with a therapist using an online chat platform (N = 52,029). Trajectory classes of depression symptoms (PHQ9), anxiety symptoms (GAD7) and functional impairment (WSAS) were investigated using growth mixture modelling. Multinomial regressions tested associations between baseline variables and trajectory class. A four-class trajectory model was selected for each outcome, and these were highly similar. Each outcome showed three classes with initially moderate-severe symptoms or impairment: one demonstrated no change, one gradual improvement and one fast improvement. A fourth class had mild baseline scores and minimal improvement. In the moderate-severe classes, patients in the two with improvement were more likely to be employed and not to have obsessive-compulsive disorder. Fast improvement was likelier than gradual improvement or no change for patients with older age, no disability (e.g., physical, learning), or lower comorbid symptom or impairment scores. Associations with functional impairment classes were more similar to associations with depression classes than anxiety classes. Results were largely consistent with findings from face-to-face therapy. This study is an important step towards personalising therapy in terms of suitability and continuation.

Patients' perspectives of barriers and facilitators to accessing support through primary care for common mental health problems in England: A systematic review

BACKGROUND

Common mental disorders (CMDs) are prevalent throughout the population. Psychological therapy is often sought via primary care; however, equitable access is not commonplace. This review aims to investigate the barriers and facilitators adults experiencing CMDs perceive when accessing evidence-based psychological treatment in England.

METHODS

A qualitative systematic review with meta-synthesis was conducted (PROSPERO CRD42020227039). Seven electronic databases were searched for papers from 2008 to October 2022.

RESULTS

Searches identified 30 studies from which three themes were developed with seven subthemes. Stigma and patients' perceptions and understandings of CMDs impacted their help-seeking decision-making and engagement with services. This meant that services were not used as a first resort for help-seeking. Upon reaching services, patients appeared to perceive primary care as not prioritising mental health problems, nor as being the place where they would be supported, particularly as healthcare professionals did not appear to know about CMDs and therapy was seen as difficult to access. The interaction between healthcare professional and patients was seen as pivotal to whether patients accessed support or not.

LIMITATIONS

The review is limited to research conducted within England. Additionally, it only explores access barriers prior to treatment experiences.

CONCLUSION

Knowledge, attitudinal, systemic and relational barriers and facilitators were identified. Future research should focus on developing stigma reduction initiatives. Clinical implications include provision of standardised training across primary care HCP (healthcare professionals).

Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

Beliefs about mental health in incarcerated males: a qualitative interview study

Introduction

Beliefs about mental health are shaped by the sociocultural context. Prisons have unique environmental and social features, and the prevalence of mental health problems in incarcerated populations is exceptionally high. These features make prisons especially interesting settings for exploring health beliefs. The aim of this study was to explore the conceptualizations of mental health and coping preferences in a prison environment.

Methods

Individual in-depth interviews were conducted with fifteen incarcerated males from three prisons in Northern Norway. The design draws on central elements from Grounded Theory.

Results

Mental health was perceived as distinct from mental illness by many of the participants. They coped with the prison environment by focusing on the things that gave them a sense of meaning and autonomy - this also formed their conceptualization of mental health. Furthermore, social interaction and activities were perceived as important to enhance and maintain mental well-being, however there were institutional barriers to using these coping strategies. The prison environment was integrated in the participants conceptualizations of mental health problems, and psychosocial stressors were emphasized in causal attributions. Biological and dispositional factors were less frequently mentioned. The participants preferred non-medical management for mental health problems and most displayed a reserved attitude towards psychotropic medications. The exception was attention-deficit hyperactivity disorder, for which they held neurobiological causal beliefs, together with a corresponding preference for medication as treatment.

Conclusion

The main finding was a firm integration of the prison context in in the participants' beliefs about mental health. We theorize that fusion of prison conditions and mental health beliefs were brought on by the processes of prisonization, observing mental distress in peers and attempts to protect self-esteem by externalizing the causes for mental health problems. Access to activities, social time, and "someone to talk to" were perceived to be crucial for improving and preserving mental health.

Supporting antidepressant discontinuation using mindfulness plus monitoring versus monitoring alone: A cluster randomized trial in general practice

Discontinuing antidepressant medication (ADM) can be challenging for patients and clinicians. In the current study we investigated if Mindfulness-Based Cognitive Therapy (MBCT) added to supported protocolized discontinuation (SPD) is more effective than SPD alone to help patients discontinue ADM. This study describes a prospective, cluster-randomized controlled trial (completed). From 151 invited primary care practices in the Netherlands, 36 (24%) were willing to participate and randomly allocated to SPD+MBCT (k = 20) or SPD (k = 16). Adults using ADM > 9 months were invited by GPs to discuss tapering, followed by either MBCT+SPD, or SPD alone. Exclusion criteria included current psychiatric treatment; substance use disorder; non-psychiatric indication for ADM; attended MBCT within past 5 years; cognitive barriers. From the approximately 3000 invited patients, 276 responded, 119 participated in the interventions and 92 completed all assessments. All patients were offered a decision aid and a personalized tapering schedule (with GP). MBCT consisted of eight group sessions of 2.5 hours and one full day of practice. SPD was optional and consisted of consultations with a mental health assistant. Patients were assessed at baseline and 6, 9 and 12 months follow-up, non-blinded. In line with our protocol, primary outcome was full discontinuation of ADM within 6 months. Secondary outcomes were depression, anxiety, withdrawal symptoms, rumination, well-being, mindfulness skills, and self-compassion. Patients allocated to SPD + MBCT (n = 73) were not significantly more successful in discontinuing (44%) than those allocated to SPD (n = 46; 33%), OR 1.60, 95% CI 0.73 to 3.49, p = .24, number needed to treat = 9. Only 20/73 allocated to MBCT (27%) completed MBCT. No serious adverse events were reported. In conclusion, we were unable to demonstrate a significant benefit of adding MBCT to SPD to support discontinuation in general practice. Actual participation in patient-tailored interventions was low, both for practices and for patients. (Trial registration: ClinicalTrials.gov PRS ID: NCT03361514 registered December 2017).

Adjunctive cognitive training with exposure enhances fear and neural outcomes in social anxiety

Exposure-based cognitive behavioral therapy (CBT) is the gold standard for treating social anxiety disorder (SAD), yet response is not universal. CBT is thought to operate via extinction-related learning during exposure, which in turn relies on cognitive processes such as working memory. The present proof-of-concept study investigates the potential for training working memory to improve anxiety related outcomes following exposure. Thirty-three adults with elevated social anxiety were randomized to complete a working memory training or sham training condition. Post-training, participants completed a working memory assessment, speech exposure session, and two fMRI tasks. Participants who received working memory training demonstrated lower distress ratings by the end of the speech exposures and better performance on the fMRI working memory task than those in sham. Working memory training completers had greater neural activation in frontoparietal regions during an in-scanner working memory task and exhibited less neural activation in the fusiform gyrus in response to an emotional face processing task than those in sham. Adding working memory training to exposure procedures could strengthen functioning of frontoparietal regions and alter emotional processing - key mechanisms implicated in extinction learning. Findings provide preliminary evidence that training working memory in conjunction with exposure may enhance exposure success.

Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology: Clinical practice guideline for social anxiety disorder (2021)

The development of clinical practice guidelines for social anxiety disorder began in March 2018 when the Joint Clinical Practice Guideline Development Committee for Anxiety and Obsessive-Compulsive Disorders was formed by the Japanese Society of Anxiety and Related Disorders and Japanese Society of Neuropsychopharmacology to jointly develop guidelines for anxiety and obsessive-compulsive disorders. Based on the universal concept of evidence-based medicine, three clinical questions (CQs) about pharmacotherapy and psychotherapy were developed for clinical guidelines for social anxiety disorder, panic disorders, and obsessive-compulsive disorder in accordance with the Minds "Manual for Guidelines Development 2017 by the Japan Council for Quality Health Care: CQ1-"What is the recommended pharmacotherapy for social anxiety disorder in adults?"; CQ2-"What is the recommended psychotherapy (psychological intervention) for social anxiety disorder in adults?"; and CQ3-"What are the recommendations regarding monotherapy and combination therapy for social anxiety disorder in adults in terms of pharmacotherapy and psychotherapy (psychological interventions)?" Summarized recommendations for social anxiety disorder in adults are selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitor for CQ1, cognitive behavioral therapy for CQ2, and there are no recommendations regarding monotherapy and combination therapy for CQ3. These were answered by considering the balance between benefits and harms based on systematic reviews of each. The aim of this brief guideline for the standard-of-care (i.e., medical treatment) for social anxiety disorder in adults (18 years and older) was to help "shared decision making," in which medical professionals, including physicians, and patients share scientific evidence to decide on a course of treatment.

Changes to healthcare utilisation and symptoms for common mental health problems over the first 21 months of the COVID-19 pandemic: parallel analyses of electronic health records and survey data in England

Background

Few studies have investigated the effect of the COVID-19 pandemic on mental health beyond 2020. This study quantifies changes to healthcare utilisation and symptoms for common mental health problems over the pandemic's first 21 months.

Methods

Parallel cohort studies using primary care database and survey data for adults (≥16 years) in England from January 2015 to December 2021: 16,551,842 from the Clinical Practice Research Datalink (CPRD) and 40,699 from the UK Household Longitudinal Survey (UKHLS). Interrupted time-series models estimated changes in monthly prevalence of presentations and prescribed medications for anxiety and depression (CPRD); and self-reported psychological distress (UKHLS). The pandemic period was divided into five phases: 1st Wave (April-May 2020); post-1st Wave (June-September 2020); 2nd Wave (October 2020-February 2021); post 2nd Wave (March-May 2021); 3rd Wave (June-December 2021).

Findings

Primary care presentations for depression or anxiety dropped during the first wave (4.6 fewer monthly appointments per 1000 patients, 4.4-4.8) and remained lower than expected throughout follow-up. Self-reported psychological distress exceeded expected levels during the first (Prevalence Ratio = 1.378, 95% CI 1.289-1.459) and second waves (PR = 1.285, 1.189-1.377), returning towards expected levels during the third wave (PR = 1.038, 0.929-1.154). Increases in psychological distress and declines in presentations were greater for women. The decrease in primary care presentations for depression and anxiety exceeded that for physical health conditions (rheumatoid arthritis, diabetes, urinary tract infections). Anxiety and depression prescriptions returned to pre-pandemic levels during the second wave due to increased repeat prescriptions.

Interpretation

Despite periods of distress during the pandemic, we did not find an enduring effect on common mental health problems. The fall in primary care presentations for anxiety or depression suggests changing healthcare utilisation for mental distress and a potential treatment gap.

Funding

National Institute for Health and Care Research (NIHR).

The 2023 Impact of Inflammatory Bowel Disease in Canada: Mental Health and Inflammatory Bowel Disease

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn's disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.

Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis

Importance

Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD.

Objective

To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD.

Data Sources

For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial.

Study Selection

Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD.

Data Extraction and Synthesis

Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models.

Main Outcomes and Measures

The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS.

Results

A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD).

Conclusions and Relevance

In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.

Development of a model to predict antidepressant treatment response for depression among Veterans

BACKGROUND

Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA).

METHODS

A 2018-2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample.

RESULTS

In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors.

CONCLUSIONS

Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.

Associations between psychological therapy outcomes for depression and incidence of dementia

BACKGROUND

Depression is an important, potentially modifiable dementia risk factor. However, it is not known whether effective treatment of depression through psychological therapies is associated with reduced dementia incidence. The aim of this study was to investigate associations between reduction in depressive symptoms following psychological therapy and the subsequent incidence of dementia.

METHODS

National psychological therapy data were linked with hospital records of dementia diagnosis for 119808 people aged 65+. Participants received a course of psychological therapy treatment in Improving Access to Psychological Therapies (IAPT) services between 2012 and 2019. Cox proportional hazards models were run to test associations between improvement in depression following psychological therapy and incidence of dementia diagnosis up to eight years later.

RESULTS

Improvements in depression following treatment were associated with reduced rates of dementia diagnosis up to 8 years later (HR = 0.88, 95% CI 0.83-0.94), after adjustment for key covariates. Strongest effects were observed for vascular dementia (HR = 0.86, 95% CI 0.77-0.97) compared with Alzheimer's disease (HR = 0.91, 95% CI 0.83-1.00).

CONCLUSIONS

Reliable improvement in depression across psychological therapy was associated with reduced incidence of future dementia. Results are consistent with at least two possibilities. Firstly, psychological interventions to improve symptoms of depression may have the potential to contribute to dementia risk reduction efforts. Secondly, psychological therapies may be less effective in people with underlying dementia pathology or they may be more likely to drop out of therapy (reverse causality). Tackling the under-representation of older people in psychological therapies and optimizing therapy outcomes is an important goal for future research.

Randomized trial of brief interpersonal psychotherapy and cognitive behavioral therapy for depression delivered both in-person and by telehealth

BACKGROUND

Expert consensus guidelines recommend Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT), interventions that were historically delivered face-to-face, as first-line treatments for Major Depressive Disorder (MDD). Despite the ubiquity of telehealth following the COVID-19 pandemic, little is known about differential outcomes with CBT versus IPT delivered in-person (IP) or via telehealth (TH) or whether working alliance is affected.

METHODS

Adults meeting DSM-5 criteria for MDD were randomly assigned to either 8 sessions of IPT or CBT (group). Mid-trial, COVID-19 forced a change of therapy delivery from IP to TH (study phase). We compared changes in Hamilton Rating Scale for Depression (HRSD-17) and Working Alliance Inventory (WAI) scores for individuals by group and phase: CBT-IP (n = 24), CBT-TH (n = 11), IPT-IP (n = 25) and IPT-TH (n = 17).

RESULTS

HRSD-17 scores declined significantly from pre to post treatment (pre: M = 17.7, SD = 4.4 vs. post: M = 11.7, SD = 5.9; p < .001; d = 1.45) without significant group or phase effects. WAI scores did not differ by group or phase. Number of completed therapy sessions was greater for TH (M = 7.8, SD = 1.2) relative to IP (M = 7.2, SD = 1.6) (Mann-Whitney U = 387.50, z = -2.24, p = .025).

LIMITATIONS

Participants were not randomly assigned to IP versus TH. Sample size is small.

CONCLUSIONS

This study provides preliminary evidence supporting the efficacy of both brief IPT and CBT, delivered by either TH or IP, for depression. It showed that working alliance is preserved in TH, and delivery via TH may improve therapy adherence. Prospective, randomized controlled trials are needed to definitively test efficacy of brief IPT and CBT delivered via TH versus IP.

Breakthrough for Trauma Treatment: Safety and Efficacy of MDMA-Assisted Psychotherapy Compared to Paroxetine and Sertraline

Unsuccessfully treated posttraumatic stress disorder (PTSD) is a serious and life-threatening disorder. Two medications, paroxetine hydrochloride and sertraline hydrochloride, are approved treatments for PTSD by the Food and Drug Administration (FDA). Analyses of pharmacotherapies for PTSD found only small to moderate effects when compared with placebo. The Multidisciplinary Association for Psychedelic Studies (MAPS) obtained Breakthrough Therapy Designation (BTD) from the FDA for 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for treatment of PTSD on the basis of pooled analyses showing a large effect size for this treatment. This review covers data supporting BTD. In this treatment, MDMA is administered with psychotherapy in up to three monthly 8-h sessions. Participants are prepared for these sessions beforehand, and process material arising from the sessions in follow-up integrative psychotherapy sessions. Comparing data used for the approval of paroxetine and sertraline and pooled data from Phase 2 studies, MAPS demonstrated that MDMA-assisted psychotherapy constitutes a substantial improvement over available pharmacotherapies in terms of safety and efficacy. Studies of MDMA-assisted psychotherapy had lower dropout rates compared to sertraline and paroxetine trials. As MDMA is only administered under direct observation during a limited number of sessions, there is little chance of diversion, accidental or intentional overdose, or withdrawal symptoms upon discontinuation. BTD status has expedited the development of MAPS phase 3 trials occurring worldwide, leading up to a planned submission seeking FDA approval in 2021. Appeared originally in Front Psychiatry 2019; 10:650.

A low-intensity behavioral intervention for depression in older adults delivered by lay coaches: proof-of-concept trial

OBJECTIVES

A broader workforce is necessary to expand U.S. geriatric mental health services. We examined (1) feasibility of training undergraduate students to deliver Do More, Feel Better (DMFB), an evidence-informed program for depression; and (2) feasibility, acceptability, and outcomes in a single-arm proof-of-concept trial.

METHOD

In Study 1, we taught DMFB to 18 upper-level undergraduate students and assessed fidelity using role plays. In Study 2, four students delivered six weekly DMFB sessions to 12 community-dwelling older adults (M = 66.83 years old, SD = 10.39) with depression (PHQ ≥ 10). Patient outcomes were change in pre- to post-treatment depressive symptoms, disability, and the target mechanism of increased activity.

RESULTS

Fidelity was high in the course (Study 1; 82.4% of role plays rated as 'passing') and the trial (Study 2; 100% of 24 sessions rated as 'passing'). The majority (83.3%) of patients were retained and evidenced statistically and clinically significant improvement in depressive symptoms (Hamilton Rating Scale for Depression [HAM-D]), disability (World Health Organization's Disability Assessment Schedule 2.0 [WHODAS 2.0], and activity (Behavioral Activation for Depression Scale [BADS]).

CONCLUSION

It is feasible to train bachelor's-level students to deliver a brief, structured intervention for depression. Future research should consider implementation strategies and stakeholder feedback.

Effects of digital cognitive behavioral therapy for depression on suicidal thoughts and behavior: Protocol for a systematic review and meta-analysis of individual participant data

INTRODUCTION

Digital cognitive behavioral therapy (i-CBT) interventions for the treatment of depression have been extensively studied and shown to be effective in the reduction of depressive symptoms. However, little is known about their effects on suicidal thoughts and behaviors (STB). Information on the impact of digital interventions on STB are essential for patients' safety because most digital interventions are self-help interventions without direct support options in case of a suicidal crisis. Therefore, we aim to conduct a meta-analysis of individual participant data (IPDMA) to investigate the effects of i-CBT interventions for depression on STB and to explore potential effect moderators.

METHODS

Data will be retrieved from an established and annually updated IPD database of randomized controlled trials investigating the effectiveness of i-CBT interventions for depression in adults and adolescents. We will conduct a one-stage and a two-stage IPDMA on the effects of these interventions on STB. All types of control conditions are eligible. STB can be measured using specific scales (e.g., Beck scale suicide, BSS) or single items from depression scales (e.g., item 9 of the PHQ-9) or standardized clinical interviews. Multilevel linear regression will be used for specific scales, and multilevel logistic regression will be used for treatment response or deterioration, operationalized as a change in score by at least one quartile from baseline. Exploratory moderator analyses will be conducted at participant, study, and intervention level. Two independent reviewers will assess the risk of bias using the Cochrane Risk of Bias Tool 2.

CONCLUSION

This IPDMA will harness the available data to assess the effects (response and deterioration) of i-CBT interventions for depression interventions on STB. Information about changes in STB is essential to estimate patients' safety when engaging in digital treatment formats.

TRIAL REGISTRATION

We will pre-register this study with the open science framework after article acceptance to ensure consistency between online registration and the published trial protocol.

Behavioral activation for depression in patients with advanced cancer: study protocol for a multicenter randomized controlled trial

BACKGROUND

Though behavioral activation (BA) has been shown to be effective for depression, evidence in patients with advanced cancer has not been established. This study aimed to examine the effectiveness of a BA program on depression in this population.

METHODS

A randomized controlled trial with a wait-list control group (waiting group) of 38 patients with advanced cancer and depression will be conducted at three sites in Japan. The BA program consists of seven sessions. Outcome measures will be evaluated at three times in the intervention group; at the entry, at the end of the intervention and 4 months after the end of the intervention and four times in the waiting group: at the entry, before the intervention, at the end of the intervention, and 4 months after the end of the intervention. Primary outcome is Beck Depression Inventory-II (BDI-II) score. To examine the main effect of the intervention, two-way repeated measures analysis of variance (ANOVA) will be conducted, with timing and intervention status as the independent variables and BDI-II score as the dependent variable. One-way repeated measures ANOVA will be conducted to combine data from the intervention and control groups and examine changes in BDI-II scores by timing in both groups. Secondary endpoints (anxiety, quality of life, spirituality, degree of behavioral activation, value, and pain) will be evaluated with rating scales. Two-way repeated measures ANOVA will be conducted to examine whether there are differences between the groups before and after the intervention, with timing and intervention status as the independent variables and scores on each rating scale as the dependent variables.

DISCUSSION

This multicenter randomized controlled trial is the first study to assess the effectiveness of BA on depression in patients with advanced cancer. Our findings will provide evidence about the effectiveness of BA on depression and provide an intervention option that is acceptable and feasible for the treatment of depression in this population. The results of this study will lead to improved mood and rebuilding to regain life purpose and value in this vulnerable population.

TRIAL REGISTRATION NUMBER

jRCT, jRCT1030210687, Registered 22 March 2022, https://jrct.niph.go.jp/en-latest-detail/jRCT1030210687 .

Psychological therapies for depression and cardiovascular risk: evidence from national healthcare records in England

AIMS

People with depression are up to 72% more at risk to develop cardiovascular disease (CVD) in their lifetime. Evidence-based psychotherapies are first-line interventions for the treatment of depression and are delivered nationally in England through the National Health Service via the Improving Access to Psychological Therapy (IAPT) primary care programme. It is currently unknown whether positive therapy outcomes may be associated with cardiovascular risk reduction. This study aimed to examine the association between psychotherapy outcomes for depression and incident CVD.

METHODS AND RESULTS

A cohort of 636 955 individuals who have completed a course of psychotherapy was built from linked electronic healthcare record databases of national coverage in England: the national IAPT database, the Hospital Episode Statistics (HES) database, and the HES-ONS (Office of National Statistics) mortality database. Multivariable Cox models adjusting for clinical and demographic covariates were run to estimate the association between reliable improvement from depression and the risk of subsequent incidence of cardiovascular events. After a median follow-up of 3.1 years, reliable improvement from depression symptoms was associated with a lower risk of new onset of any CVD [hazard ratio (HR): 0.88, 95% confidence interval (CI): 0.86, 0.89], coronary heart disease (HR: 0.89, 95% CI: 0.86, 0.92), stroke (HR: 0.88, 95% CI: 0.83, 0.94), and all-cause mortality (HR: 0.81, 95% CI: 0.78, 0.84). This association was stronger in the under 60 compared with the over 60 for all outcomes. Results were confirmed in sensitivity analyses.

CONCLUSION

Management of depression through psychological interventions may be associated with reduced risk of CVD. More research is needed to understand the causality of these associations.

Preliminary Evaluation of Translated and Culturally Adapted Internet-Delivered Cognitive Therapy for Social Anxiety Disorder: Multicenter, Single-Arm Trial in Japan

BACKGROUND

Internet-delivered cognitive therapy for social anxiety disorder (iCT-SAD), which is a therapist-guided modular web-based treatment, has shown strong efficacy and acceptability in English-language randomized controlled trials in the United Kingdom and Hong Kong. However, it is not yet known whether iCT-SAD can retain its efficacy following linguistic translation and cultural adaptation of treatment contents and implementation in other countries such as Japan.

OBJECTIVE

This study aimed to examine the preliminary efficacy and acceptability of the translated and culturally adapted iCT-SAD in Japanese clinical settings.

METHODS

This multicenter, single-arm trial recruited 15 participants with social anxiety disorder. At the time of recruitment, participants were receiving usual psychiatric care but had not shown improvement in their social anxiety and required additional treatment. iCT-SAD was provided in combination with usual psychiatric care for 14 weeks (treatment phase) and for a subsequent 3-month follow-up phase that included up to 3 booster sessions. The primary outcome measure was the self-report version of the Liebowitz Social Anxiety Scale. The secondary outcome measures examined social anxiety-related psychological processes, taijin kyofusho (the fear of offending others), depression, generalized anxiety, and general functioning. The assessment points for the outcome measures were baseline (week 0), midtreatment (week 8), posttreatment (week 15; primary assessment point), and follow-up (week 26). Acceptability was measured using the dropout rate from the treatment, the level of engagement with the program (the rate of module completion), and participants' feedback about their experience with the iCT-SAD.

RESULTS

Evaluation of the outcome measures data showed that iCT-SAD led to significant improvements in social anxiety symptoms during the treatment phase (P<.001; Cohen d=3.66), and these improvements were maintained during the follow-up phase. Similar results were observed for the secondary outcome measures. At the end of the treatment phase, 80% (12/15) of participants demonstrated reliable improvement, and 60% (9/15) of participants demonstrated remission from social anxiety. Moreover, 7% (1/15) of participants dropped out during treatment, and 7% (1/15) of participants declined to undergo the follow-up phase after completing the treatment. No serious adverse events occurred. On average, participants completed 94% of the modules released to them. Participant feedback was positive and highlighted areas of strength in treatment, and it included further suggestions to improve suitability for Japanese settings.

CONCLUSIONS

Translated and culturally adapted iCT-SAD demonstrated promising initial efficacy and acceptability for Japanese clients with social anxiety disorder. A randomized controlled trial is required to examine this more robustly.

Assessment and Monitoring of the Quality of Clinical Pathways in Patients with Depressive Disorders: Results from a Multiregional Italian Investigation on Mental Health Care Quality (the QUADIM Project)

Ensuring adequate quality of care to patients with severe mental disorders remains a challenge. The implementation of clinical indicators aimed at assessing the quality of health care pathways delivered is crucial for the improvement of mental health services (MHS). This study aims to evaluate the quality of care delivered to patients who are taken-into-care with depressive disorders by MHS. Thirty-four clinical indicators concerning accessibility, appropriateness, continuity, and safety were estimated using health care utilization databases from four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). A total of 78,924 prevalent patients treated for depressive disorders in 2015 were identified, of whom 15,234 were newly engaged by MHS. During the year of follow-up, access to psychotherapeutic interventions was low, while the intensity was adequate; 5.1% of prevalent patients received at least one hospitalization in a psychiatric ward (GHPW), and 3.3% in the cohort of newly engaged in services. Five-out-of-10 patients had contact with community services within 14 days after GHPW discharge, but less than half of patients were persistent to antidepressant drug therapy. Furthermore, prevalent patients showed an excess of mortality compared to the general population (SMR = 1.35; IC 95%: 1.26-1.44). In conclusion, the quality of health care is not delivered in accordance with evidence-based mental health standards. Evaluation of health interventions are fundamental strategies for improving the quality and equity of health care.

Depression and anxiety among college students: Understanding the impact on grade average and differences in gender and ethnicity

Objective: Psychiatric disorders, such as depression and anxiety, can hinder academic performance among college-age individuals. Participants: Mental health among college students is a growing public health concern, with some scholars describing collegiate mental health as a crisis (Chen et al., Psychiatr Serv. 2019;70(6):442-449). Methods: This study analyzes data from four annual administrations of the American College Health Association (ACHA)'S NCHA (n = 117,430). Results: Overall, anxiety and depression were the most common conditions, at 9.2% and 8.7%, respectively. Of students reporting the focal symptom, 17.87% were treated for depression and 12.91% were treated for anxiety. Compared to not-treated students, diagnosed only students, had significantly lower grade averages, with effect sizes of -0.30 and -0.20 for depression and anxiety, respectively. Conclusions: Given the prevalence of depression and anxiety among college-aged students, continued research into help seeking behaviors and their effects on outcomes like grade average is an essential part of understanding the toll these disorders take.

Characteristics of effective teletherapy for major depression: A systematic review

BACKGROUND

People would prefer to have psychotherapy as treatment over medication for major depression. There is evidence that psychotherapy does not require in-person delivery to be effective. Other modes of delivery, such as videoconferencing teletherapy, may make it a more accessible treatment.

METHOD

The aim of this review was to identify the characteristics of effective psychotherapy delivered by videoconference for adults in primary care with a primary diagnosis of depression. A quantitative systematic review was conducted and reported according to PRISMA guidelines.

RESULTS

There were 8 studies included in the review. The therapies studied were tele problem-solving therapy, behavioural activation and cognitive behavioural therapy. All studies had a medium to high risk of bias. Six were randomized controlled trials, one was a pragmatic retrospective cohort study and one was an open-label design. Four studies found similar outcomes to the in-person comparators, one study found tele problem-solving therapy was more effective than behavioural activation, and one study found cognitive behavioural therapy to be similar to usual care.

LIMITATIONS

The search identified only 8 studies. Due to the heterogeneity of outcome measures and comparators, a meta-analysis could not be conducted.

CONCLUSIONS

No definitive conclusions can be drawn about the effectiveness of teletherapy in primary care based on this review, however, there is emerging evidence to suggest it has similar outcomes to in-person therapy for people with a primary diagnosis of depression. There is no evidence regarding the superiority of one model of therapy over the others.

Limited impacts of biogenetic messaging on neural correlates of cognitive control and beliefs about depression

During the past 60 years, perceptions about the origins of mental illness have shifted toward a biomedical model, depicting depression as a biological disorder caused by genetic abnormalities and/or chemical imbalances. Despite benevolent intentions to reduce stigma, biogenetic messages promote prognostic pessimism, reduce feelings of agency, and alter treatment preferences, motivations, and expectations. However, no research has examined how these messages influence neural markers of ruminative activity or decision-making, a gap this study sought to fill. In this pre-registered, clinical trial (NCT03998748), 49 participants with current or past depressive experiences completed a sham saliva test and were randomly assigned to receive feedback that they either have (gene-present; n = 24) or do not have (gene-absent; n = 25) a genetic predisposition to depression. Before and after receiving the feedback, resting-state activity and neural correlates of cognitive control (error-related negativity [ERN] and error positivity [Pe]) were measured using high-density electroencephalogram (EEG). Participants also completed self-report measures of beliefs about the malleability and prognosis of depression and treatment motivation. Contrary to hypotheses, biogenetic feedback did not alter perceptions or beliefs about depression, nor did it alter EEG markers of self-directed rumination nor neurophysiological correlates of cognitive control. Explanations of these null findings are discussed in the context of prior studies.

App-Delivered Mindfulness Training to Reduce Anxiety in People with HIV Who Smoke: A One-Armed Feasibility Trial

INTRODUCTION

People with HIV (PWH) who smoke have reported that managing anxiety is a barrier to making a quit attempt and maintaining abstinence post-quit. This study examined the feasibility and acceptability of an app-based mindfulness intervention, Unwinding Anxiety, to reduce anxiety prior to a quit attempt in PWH who were not planning to quit in the next 30 days.

METHODS

Sixteen PWH (mean age 51.5 [SD = 13.2]; mean cigarettes per day 11.4 [SD = 5.4]) were enrolled and followed for eight weeks. A smartphone-based app with 30 modules designed to reduce anxiety was introduced at baseline; participants were encouraged to complete one module daily for four weeks. Symptoms of anxiety and readiness to quit smoking were measured at baseline and weeks 4 and 8. The mean number of modules completed, session attendance, and number of study completers were examined. Generalized estimating equations (GEE) were used to examine changes in self-reported anxiety and readiness to quit at baseline, week 4, and week 8. A brief qualitative interview was conducted at week 4 to explore the acceptability of the app.

RESULTS

Feasibility was high, with 93% of participants completing the study. The mean number of study sessions completed was 2.7 (SD = 0.59), and the mean number of modules completed was 16.0 (SD 16.8). Anxiety was high at baseline (M = 14.4, SD = 3.9), but lower at week 4 (b = -5.5; CI: [-9.4, -1.7]; p = 0.004) and week 8 (b = -5.1; CI: [-8.8, -1.3]; p = 0.008), and stable between weeks 4 and 8 (b = 0.48; CI: [-2.0, 3.0]; p = 0.706). Readiness to quit significantly increased from baseline M = 5.5 (SD = 1.6) to week 4 (b = 0.56; CI: [0.20, 0.91]; p = 0.002) but was not significantly different from baseline at week 8 (b = 0.34; CI: [-0.30, 1.0]; p = 0.30). Ad-hoc moderation analyses found that anxiety had a small significantly positive association with readiness to quit at baseline (main effect: b = 0.10; SE = 0.03; p < 0.001) and significantly attenuated the increase in readiness to quit observed at week 4 (anxiety by week 4 interaction: b = -0.08; SE = 0.03; p = 0.009).

CONCLUSIONS

App-based mindfulness training appears to be feasible and acceptable for PWH who smoke and report baseline anxiety. At week 4, anxiety was reduced and readiness to quit was increased, perhaps a key time point for a smoking cessation attempt.

Aerobic exercise in the treatment of PTSD: An examination of preclinical and clinical laboratory findings, potential mechanisms, clinical implications, and future directions

Posttraumatic stress disorder (PTSD) is associated with heightened emotional responding, avoidance of trauma related stimuli, and physical health concerns (e.g., metabolic syndrome, type 2 diabetes, cardiovascular disease). Existing treatments such as exposure-based therapies (e.g., prolonged exposure) aim to reduce anxiety symptoms triggered by trauma reminders, and are hypothesized to work via mechanisms of extinction learning. However, these conventional gold standard psychotherapies do not address physical health concerns frequently presented in PTSD. In addition to widely documented physical and mental health benefits of exercise, emerging preclinical and clinical evidence supports the hypothesis that precisely timed administration of aerobic exercise can enhance the consolidation and subsequent recall of fear extinction learning. These findings suggest that aerobic exercise may be a promising adjunctive strategy for simultaneously improving physical health while enhancing the effects of exposure therapies, which is desirable given the suboptimal efficacy and remission rates. Accordingly, this review 1) encompasses an overview of preclinical and clinical exercise and fear conditioning studies which form the basis for this claim; 2) discusses several plausible mechanisms for enhanced consolidation of fear extinction memories following exercise, and 3) provides suggestions for future research that could advance the understanding of the potential importance of incorporating exercise into the treatment of PTSD.

Mind-Body Intervention for Dysfunctional Breathing in Chronic Obstructive Pulmonary Disease: Feasibility Study and Lessons Learned

Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).

Meta-Analysis: Relapse Prevention Strategies for Depression and Anxiety in Remitted Adolescents and Young Adults

OBJECTIVE

Depression and anxiety cause a high burden of disease and have high relapse rates (39%-72%). This meta-analysis systematically examined effectiveness of relapse prevention strategies on risk of and time to relapse in youth who remitted.

METHOD

PubMed, PsycInfo, Embase, Cochrane, and ERIC databases were searched up to June 15, 2021. Eligible studies compared relapse prevention strategies to control conditions among youth (mean age 13-25 years) who were previously depressed or anxious or with ≥30% improvement in symptoms. Two reviewers independently assessed titles, abstracts, and full texts; extracted study data; and assessed risk of bias and overall strength of evidence. Random-effects models were used to pool results, and mixed-effects models were used for subgroup analyses. Main outcome was relapse rate at last follow-up (PROSPERO ID: CRD42020149326).

RESULTS

Of 10 randomized controlled trials (RCTs) that examined depression, 9 were eligible for analysis: 4 included psychological interventions (n = 370), 3 included antidepressants (n = 80), and 2 included combinations (n = 132). No RCTs for anxiety were identified. Over 6 to 75 months, relapse was half as likely following psychological treatment compared with care as usual conditions (k = 6; odds ratio 0.56, 95% CI 0.31 to 1.00). Sensitivity analyses including only studies with ≥50 participants (k = 3), showed similar results. Over 6 to 12 months, relapse was less likely in youth receiving antidepressants compared with youth receiving pill placebo (k = 3; OR 0.29, 95% CI 0.10 to 0.82). Quality of studies was suboptimal.

CONCLUSION

Relapse prevention strategies for youth depression reduce risk of relapse, although adequately powered, high-quality RCTs are needed. This finding, together with the lack of RCTs on anxiety, underscores the need to examine relapse prevention in youth facing these common mental health conditions.

Geriatric Depression

Late-life depression is common but underrecognized and undertreated leading to significant morbidity and mortality, including from suicide. The presence of comorbidities necessitates screening followed by a careful history in order to make the diagnosis of depression. Because older adults tend to take longer to respond to treatment and have higher relapse rates than younger patients, they benefit most from persistent, attentive therapy. Although both pharmacotherapy and psychosocial treatments, or a combination of the two, are considered as the first-line therapy for late-life depression, most data support a combined, biopsychosocial treatment approach provided by an interdisciplinary team.

Patient factors associated with receipt of psychological and pharmacological treatments among individuals with common mental disorders in a Swedish primary care setting

BACKGROUND

Psychological and pharmacological therapies are the recommended first-line treatments for common mental disorders (CMDs) but may not be universally accessible or utilised.

AIMS

To determine the extent to which primary care patients with CMDs receive treatment and the impact of sociodemographic, work-related and clinical factors on treatment receipt.

METHOD

National registers were used to identify all Stockholm County residents aged 19-64 years who had received at least one CMD diagnosis (depression, anxiety, stress-related) in primary care between 2014 and 2018. Individuals were followed from the date of their first observed CMD diagnosis until the end of 2019 to determine treatment receipt. Associations between patient factors and treatment group were examined using multinomial logistic regression.

RESULTS

Among 223 271 individuals with CMDs, 30.6% received pharmacotherapy only, 16.5% received psychological therapy only, 43.1% received both and 9.8% had no treatment. The odds of receiving any treatment were lower among males (odds ratio (OR) range = 0.76 to 0.92, 95% CI_{[minimum, maximum]} 0.74 to 0.95), individuals born outside of Sweden (OR range = 0.67 to 0.93, 95% CI_{[minimum, maximum]} 0.65 to 0.99) and those with stress-related disorders only (OR range = 0.21 to 0.51, 95% CI_{[minimum, maximum]} 0.20 to 0.53). Among the patient factors examined, CMD diagnostic group, prior treatment in secondary psychiatric care and age made the largest contributions to the model (R² difference: 16.05%, 1.72% and 1.61%, respectively).

CONCLUSIONS

Although over 90% of primary care patients with CMDs received pharmacological and/or psychological therapy, specific patient groups were less likely to receive treatment.

A randomized controlled trial of surf and hike therapy for U.S. active duty service members with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is the most prevalent mental health disorder worldwide, including among U.S. service members. In addition to evidence-based treatments, activity-based approaches have been shown to effectively treat depressive symptoms, particularly when they occur in the natural environment.

METHODS

This study compared two activity-based interventions, Surf Therapy and Hike Therapy, on depression outcomes among 96 active duty service members with MDD. Participants were randomized to 6 weeks of Surf or Hike Therapy. Clinician-administered and self-report measures were completed at preprogram, postprogram, and 3-month follow-up. A brief depression/anxiety measure was completed before and after each activity session.

RESULTS

Multilevel modeling results showed that continuous depression outcomes changed significantly over time (ps < .001). Although service members in Hike Therapy reported higher average depression scores than those in Surf Therapy, the trajectory of symptom improvement did not significantly differ between groups. Regarding MDD diagnostic status, there were no significant differences between the groups at postprogram (p = .401), but Surf Therapy participants were more likely to remit from MDD than were those in Hike Therapy at the 3-month follow-up (p = .015).

LIMITATIONS

The sample consisted of service members, so results may not generalize to other populations. Most participants received concurrent psychotherapy or pharmacotherapy, and, although statistically accounted for, results should be interpreted in this context.

CONCLUSIONS

Both Surf and Hike Therapies appear to be effective adjunctive interventions for service members with MDD. Research is needed to examine the effectiveness of these therapies as standalone interventions.

TRIAL REGISTRATION

Clinical trials registration number NCT03302611; First registered on 05/10/2017.

Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments : A Rapid Review

BACKGROUND

Developers of clinical practice guidelines need to take patient values and preferences into consideration when weighing benefits and harms of treatment options for depressive disorder.

PURPOSE

To assess patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder.

DATA SOURCES

MEDLINE (Ovid) and PsycINFO (EBSCO) were searched for eligible studies published from 1 January 2014 to 30 November 2022.

STUDY SELECTION

Pairs of reviewers independently screened 30% of search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts.

DATA EXTRACTION

One reviewer extracted data and assessed the certainty of evidence, and a second reviewer checked for completeness and accuracy. Two reviewers independently assessed risk of bias.

DATA SYNTHESIS

The review included 11 studies: 4 randomized controlled trials, 5 cross-sectional studies, and 2 qualitative studies. In 1 randomized controlled trial, participants reported at the start of therapy that they expected supportive-expressive psychotherapy and antidepressants to yield similar improvements. A cross-sectional study reported that non-Hispanic White participants and men generally preferred antidepressants over talk therapy, whereas Hispanic and non-Hispanic Black participants and women generally did not have a preference. Another cross-sectional study reported that the most important nonserious adverse events for patients treated with antidepressants were insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. For other comparisons and outcomes, no conclusions could be drawn because of the insufficient certainty of evidence.

LIMITATIONS

The main limitation of this review is the low or insufficient certainty of evidence for most outcomes. No evidence was available on second-step depression treatment or differences in values and preferences based on gender, race/ethnicity, age, and depression severity.

CONCLUSION

Low-certainty evidence suggests that there may be some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence is lacking or insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42020212442).

Entertain Me Well: An Entertaining, Tailorable, Online Platform Delivering CBT for Depression

Depression prevalence is high, impacting approximately 20% of Americans during their lifetime, and on the rise due to stress and loss associated with the COVID-19 pandemic. Despite the high prevalence of depression, unacceptable treatment access disparities persist. When depression goes untreated, it leads to substantial negative impacts in multiple life domains. Cognitive behavioral therapy (CBT), the gold-standard psychosocial treatment for depression, remains largely unavailable to individuals living with depression, particularly individuals who are members of underrepresented groups in our society. Digital mental health interventions (DMHI) have led to important advances in extending the reach of CBT for depression; however, they are underutilized and treatment engagement remains low. We sought to address some of the current gaps in DMHI by developing an online platform for delivering CBT for depression that is entertaining, simple and straightforward, and tailorable. First, this article introduces our online platform, Entertain Me Well (EMW) and its key innovations, including the use of an engaging, character-driven storyline presented as "episodes" within each session, as well as customizable content that allows for tailoring of text, images, and examples to create content most relevant to the target client population, context, or setting. Next, we describe two EMW depression treatment programs that have been tailored: one for delivery in the rural church setting, called Raising Our Spirits Together, and one tailored for delivery in dialysis centers, called Doing Better on Dialysis. Finally, we discuss future directions for the EMW platform, including the ability to create programs for other common mental health and health conditions, the development of additional character-driven storylines with greater treatment personalization, translation of content in multiple languages, and the use of additional technological innovation, such as artificial intelligence like natural language processing, to enhance platform interactivity.

Predictors and significance of rapid response to behaviorally based treatment of binge eating disorder

OBJECTIVE

This study examined baseline predictors of rapid response and its prognostic significance in a clinical trial of behaviorally based weight loss treatment (BBWLT) for binge eating disorder in patients with obesity.

METHODS

One hundred ninety-one participants receiving BBWLT were assessed at baseline, throughout treatment, and at posttreatment (6 months) by independent assessors. Rapid response was defined as ≥ 65% reduction in binge eating by the fourth treatment week. Patients with versus without rapid response were compared on demographic features, a broad range of current/past clinical and psychiatric variables, and treatment attitudes. Rapid response was used to prospectively predict posttreatment outcomes.

RESULTS

Rapid response, which characterized 63% (N = 120) of participants, was not associated significantly with any demographic features or with any current/past clinical and psychiatric variables. Higher ratings (at week one) regarding the logic of BBWLT and greater confidence that treatment would help with binge eating and weight loss were associated significantly with rapid response (at week four). Rapid response was prospectively associated with significantly better binge eating and weight loss outcomes.

CONCLUSIONS

These findings indicate that rapid response to BBWLT for binge eating disorder prospectively predicts superior clinical outcomes in both binge eating and weight loss. Treatment attitudes, rather than patient demographic or clinical severity variables, are prospectively associated with rapid response.

Symptom-specific effects of counselling for depression compared to cognitive-behavioural therapy

BACKGROUND

Cognitive-behavioural therapy (CBT) and counselling for depression (CfD) are recommended first-line treatments for depression. While they approach change differently, there is little understanding of the impact those approaches have on change during treatment.

OBJECTIVES

This study aimed to identify whether CBT and CfD target different symptoms and explore the implications of modelling choices when quantifying change during treatment.

METHODS

Symptom-specific effects of treatment were identified using moderated network modelling. This was a retrospective cohort study of 12 756 individuals who received CBT or CfD for depression in primary/community care psychological therapy services in England. Change was modelled several ways within the whole sample and a propensity score matched sample (n=3446).

FINDINGS

CBT for depression directly affected excessive worry, trouble relaxing and apprehensive expectation and had a stronger influence on changes between suicidal ideation and concentration. CfD had a stronger direct influence on thoughts of being a failure and on the associated change between being an easily annoyed and apprehensive of expectation. There were inconsistencies when modelling change using the first and second appointments as the baseline. Residual score models produced more conservative findings than models using difference scores.

CONCLUSIONS

CfD and CBT for depression have differential effects on symptoms demonstrating specific mechanisms of change.

CLINICAL IMPLICATIONS

CBT was uniquely associated with changes in symptoms associated with anxiety and may be better suited to those with anxiety symptoms comorbid to their depression. When assessing change, the baseline should be the first therapy session, not the pretreatment assessment. Residual change scores should be preferred over difference score methods.

Facilitating Mental Health Treatment Through Proactive Screening and Concierge Services in the Workplace

OBJECTIVE

The aim of this study is to determine if a proactive employer-sponsored mental health program closed gaps in detection and treatment of mental health conditions.

METHODS

Of n = 56,442 eligible, n = 8170 (14.5%) participated in the optional screening. Participants with mental health risk were offered care concierge services including support, care planning, and connection to care. Difference in behavioral health care utilization, diagnoses, and prescriptions were evaluated postintervention through claims analysis.

RESULTS

Compared with controls (n = 2433), those receiving concierge services (n = 369) were more likely to fill mental health prescriptions (adjusted hazards ratio [HR], 1.2; 1.0-1.5; P = 0.042), use professional mental health services (adjusted HR, 1.4; 1.1-1.8; P = 0.02), and use new mental health services (adjusted HR, 1.9; 1.2-2.8; P = 0.004) in the following 6 months.

CONCLUSIONS

This proactive mental health program with care concierge services identified risk, connected individuals to mental health care, and facilitated mental health treatment, among program participants.

The experience of 'treatment-resistant' depression: A qualitative meta-synthesis

While antidepressants may be effective in treating depression for some people, a third of people do not have an improvement in mood after a trial of two different antidepressants for an adequate duration. These people are diagnosed as having 'treatment-resistant' depression which situates the problem as part of their biological or psychological makeup. We conducted a search of studies that examined this problem from the perspective of people whose depression did not improve on antidepressants. Nine studies were included in a qualitative meta-synthesis that identified four themes across these studies: feeling trapped, disconnection, loss of self, and questioning. The participants experienced considerable distress associated with the constant presence of depression in their lives. While antidepressants may help some people, there is a need for more innovative approaches to the treatment of depression. There is a strong argument for trialling appropriate evidence-based psychotherapy before a person is categorized as having treatment-resistant depression. It is perhaps better to describe the issue as inadequate efficacy of antidepressants to situate the problem with the treatment provided rather than with the person.

Factors associated with past-year medication use and psychotherapy in adults with suicidal ideation in France

BACKGROUND

The objective of the study is to assess the sociodemographic and clinical factors associated with past-year medication use and/or psychotherapy among adults with suicidal ideation in the past 12 months.

METHODS

Data were drawn from the 2017 Health Barometer survey, a large computer-assisted telephone survey on a representative sample of the general population aged 18 to 75 years living in metropolitan France (n = 25,319). Logistic and multinomial regression analyses were used to study past-year medication use and/or psychotherapy as a function of sociodemographic and clinical factors. Analyses were restricted to individuals reporting suicidal ideation in the past year (n = 1,148).

RESULTS

Overall, 43.6% of adults with suicidal ideation reported no treatment for a mental health reason in the past year; 36.6% reported using medication only, 4.8% psychotherapy only, and 15.0% both. Sociodemographic and clinical factors associated with increased probability of treatment varied as a function of the type of treatment received. Adjusting for key factors including clinical factors, older adults with suicidal ideation were more likely than younger adults to receive medication only.

CONCLUSIONS

The findings point to differential inequalities in access to medication and psychotherapy among adults with suicidal ideation in the general population of France.

Racial-Ethnic Disparities in Outpatient Mental Health Care in the United States

OBJECTIVE

The authors aimed to compare national rates and patterns of use of outpatient mental health care among Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

METHODS

Data from the 2018-2019 Medical Expenditure Panel Survey, a nationally representative survey of U.S. households, were analyzed, focusing on use of any outpatient mental health care service by non-Hispanic White (N=29,126), non-Hispanic Black (N=7,965), and Hispanic (N=12,640) individuals ages ≥4 years (N=49,731). Among individuals using any mental health care, analyses focused on those using psychotropic medications, psychotherapy, or both and on receipt of minimally adequate mental health care.

RESULTS

The annual rate per 100 persons of any outpatient mental health service use was more than twice as high for White (25.3) individuals as for Black (12.2) or Hispanic (11.4) individuals. Among those receiving outpatient mental health care, Black (69.9%) and Hispanic (68.4%) patients were significantly less likely than White (83.4%) patients to receive psychotropic medications, but Black (47.7%) and Hispanic (42.6%) patients were significantly more likely than White (33.3%) patients to receive psychotherapy. Among those treated for depression, anxiety, attention-deficit hyperactivity disorder, or disruptive behavior disorders, no significant differences were found in the proportions of White, Black, or Hispanic patients who received minimally adequate treatment.

CONCLUSIONS

Large racial-ethnic gaps in any mental health service use and smaller differences in patterns of treatment suggest that achieving racial-ethnic equity in outpatient mental health care delivery will require dedicated efforts to promote greater mental health service access for Black and Hispanic persons in need.

The development and internal evaluation of a predictive model to identify for whom Mindfulness-Based Cognitive Therapy (MBCT) offers superior relapse prevention for recurrent depression versus maintenance antidepressant medication

Depression is highly recurrent, even following successful pharmacological and/or psychological intervention. We aimed to develop clinical prediction models to inform adults with recurrent depression choosing between antidepressant medication (ADM) maintenance or switching to Mindfulness-Based Cognitive Therapy (MBCT). Using data from the PREVENT trial (N=424), we constructed prognostic models using elastic net regression that combined demographic, clinical and psychological factors to predict relapse at 24 months under ADM or MBCT. Only the ADM model (discrimination performance: AUC=.68) predicted relapse better than baseline depression severity (AUC=.54; one-tailed DeLong's test: z=2.8, p=.003). Individuals with the poorest ADM prognoses who switched to MBCT had better outcomes compared to those who maintained ADM (48% vs. 70% relapse, respectively; superior survival times [z=-2.7, p=.008]). For individuals with moderate-to-good ADM prognosis, both treatments resulted in similar likelihood of relapse. If replicated, the results suggest that predictive modeling can inform clinical decision-making around relapse prevention in recurrent depression.

Acupuncture and other traditional Chinese medicine therapies in the treatment of children's tic syndrome: A network meta-analysis

Background

Tic disorders (TD) are a kind of neuropsychiatric disease that frequently occur among preschool and school-age children, mainly characterized by motor tics or sometimes accompanied by vocal tics, and its pathogenesis is still unclear. The clinical manifestations are mainly characterized by chronic multiple movements, rapid muscle twitching, involuntary occurrence, and language disorder. Acupuncture, tuina, traditional Chinese medicine, and other methods are commonly used in clinical treatments, which have unique therapeutic advantages but have not been recognized and accepted by the international community. This study conducted a quality evaluation and meta-analysis of the currently published randomized controlled trials (RCTs) of acupuncture for TD in children in order to provide reliable evidence-based medical evidence for acupuncture for TD.

Methods

All the randomized controlled trials (RCTs) using the intervention methods acupuncture + traditional Chinese medical herbs, acupuncture + tuina, and acupuncture, and the control group using Western medicine were included in the analysis. The main outcomes were obtained by using the Yale Global Tic Severity Scale (YGTSS), the Traditional Chinese medicine (TCM) syndrome score scale, and clinical treatment efficiency. Secondary outcomes included adverse events. The risk of bias in the included studies was assessed according to the tool recommended by Cochrane 5.3. The risk of bias assessment chart, risk of bias summary chart, and evidence chart in this study will be produced using R and Stata software.

Results

There were 39 studies that met the inclusion criteria, including 3,038 patients. In terms of YGTSS, the TCM syndrome score scale changes and shows a clinically effective rate, and we found that acupuncture combined with Chinese medicine is the best treatment.

Conclusion

Acupuncture + traditional Chinese medical herbs may be the best therapy to improve TD in children. At the same time, compared with Western medicine commonly used in clinical practice, acupuncture and acupuncture combined with tuina therapy have better effects on improving TD in children.