Cost-of-illness studies of depression: a systematic review

Economic evaluation of an e-mental health intervention for patients with retinal exudative diseases who receive intraocular anti-VEGF injections (E-PsEYE): protocol for a randomised controlled trial

INTRODUCTION

Because of the great potential of vascular endothelial growth factor inhibitors (anti-VEGF) for retinal exudative diseases, an increased number of patients receives this treatment. However, during this treatment, patients are subjected to frequent invasive intravitreal injections, and the effects on reversing the process of vision loss are uncertain, which may have negative consequences for patients' mental health. One in three patients experience at least mild symptoms of depression/anxiety. To support patients in dealing with these symptoms, an e-mental health intervention (called E-PsEYE) has been developed. E-PsEYE is based on cognitive-behavioural therapy (CBT) and contains nine modules. A stepped-care model with three steps will be used to deliver the intervention: (1) providing information and psychoeducation, (2) when symptoms of depression/anxiety persist, guided CBT is offered and supported by social workers from low vision rehabilitation services and (3) when symptoms still persist, patients are referred to their general practitioner.

METHODS AND ANALYSIS

An economic evaluation from a healthcare and societal perspective will be conducted alongside a multicentre randomised controlled trial in two parallel groups to evaluate whether E-PsEYE is cost-effective in comparison with usual care. Participants (n=174) will be 50 years or older, have retinal exudative diseases, receive anti-VEGF treatment and have mild symptoms of depression/anxiety (assessed prior to randomisation). Main outcome measures are: depression (Patient Health Questionnaire-9), anxiety (Hospital Anxiety and Depression Scale-Anxiety) and quality-adjusted life-years (determined with the Health Utility Index-3 and the EuroQol-5 dimensions). Five measurements take place: at baseline and after 3, 6, 9 and 12 months.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of the VU University Medical Centre Amsterdam. It will provide new and essential information on the cost-effectiveness of an innovative intervention for a vulnerable population. Outcomes will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

http://www.trialregister.nl, identifier: NTR6337.

The direct healthcare costs associated with psychological distress and major depression: A population-based cohort study in Ontario, Canada

The objective of our study was to estimate direct healthcare costs incurred by a population-based sample of people with psychological distress or depression. We used the 2002 Canadian Community Health Survey on Mental Health and Well Being and categorized individuals as having psychological distress using the Kessler-6, major depressive disorder (MDD) using DSM-IV criteria and a comparison group of participants without MDD or psychological distress. Costs in 2013 USD were estimated by linking individuals to health administrative databases and following them until March 31, 2013. Our sample consisted of 9,965 individuals, of whom 651 and 409 had psychological distress and MDD, respectively. Although the age-and-sex adjusted per-capita costs were similarly high among the psychologically distressed ($3,364, 95% CI: $2,791, $3,937) and those with MDD ($3,210, 95% CI: $2,413, $4,008) compared to the comparison group ($2,629, 95% CI: $2,312, $2,945), the population-wide excess costs for psychological distress ($441 million) were more than twice that for MDD ($210 million) as there was a greater number of people with psychological distress than depression. We found substantial healthcare costs associated with psychological distress and depression, suggesting that psychological distress and MDD have a high cost burden and there may be public health intervention opportunities to relieve distress. Further research examining how individuals with these conditions use the healthcare system may provide insight into the allocation of limited healthcare resources while maintaining high quality care.

Epidemiology of Major Depressive Disorder Disability in the US Military: FY 2007-2012

This study assesses the incidence of major depressive disorder (MDD) disability discharge and retirement in the Army, Navy, Marine Corps and Air Force and describes MDD comorbidity. Service members with a disability discharge for either MDD (n = 2,882) or any nonpsychiatric disability (n = 56,145), between fiscal years 2007 and 2012, were included in the study population. Those with MDD disability at first evaluation but not at last evaluation were excluded. The incidence of MDD disability discharge increased significantly in the Army and Air Force between fiscal years 2007 and 2012. MDD disability retirement significantly increased in the Army, Navy, and Air Force. Females, and those who experienced at least one deployment, had higher incidence rates of MDD disability discharge. All services included spinal diseases and posttraumatic stress disorder in their top five comorbid categories. Given the association between trauma and MDD, further research into the role of both combat exposure and injury on MDD is merited.

Time-Frequency Reward-Related Delta Prospectively Predicts the Development of Adolescent-Onset Depression

BACKGROUND

A blunted reward positivity (RewP), an event-related potential elicited by feedback indicating monetary gain relative to loss, was recently shown to prospectively predict the development of adolescent-onset depression. Time-frequency-based representations of this activity (e.g., reward-related delta) have also been associated with depression. This study is a reanalysis of the time-domain RewP investigation to examine the incremental value of time-frequency indices in the prediction of adolescent-onset depression.

METHODS

The sample included 444 13- to 15-year-old girls with no lifetime history of a depressive disorder. At baseline, adolescents completed a monetary guessing task, and both time-domain and time-frequency analyses were conducted on the event-related potential response to gain and loss feedback. Lifetime psychiatric history in the adolescent and a biological parent were evaluated with diagnostic interviews, and adolescents' current depressive symptoms were assessed using a self-report questionnaire. Adolescents were interviewed again approximately 18 months later to identify first-onset depressive disorder.

RESULTS

Blunted reward-related delta predicted first-onset depressive disorder 18 months later, independent of the time-domain RewP and psychosocial risk factors (i.e., adolescent baseline depressive symptoms, adolescent and parental psychiatric history). In contrast, loss-related theta did not predict the development of depression. Reward-related delta increased sensitivity (73.8% to 82.8%) and positive predictive value (45.0% to 70.9%) for first-onset depressive disorder when applied in parallel and in series, respectively, with baseline depressive symptoms and the time-domain RewP.

CONCLUSIONS

This study provides evidence that frequency-based representations of event-related potentials provide incremental value in the prediction of psychiatric disorders.

Economic evaluation of stepped-care versus usual care for depression and anxiety in older adults with vision impairment: randomized controlled trial

BACKGROUND

A stepped-care program was found effective in preventing depressive and anxiety disorders in older adults with vision impairment. However, before a decision can be made about implementation, the cost-effectiveness of this program should be investigated. Therefore, we aimed to compare the cost-effectiveness of stepped-care versus usual care within low vision rehabilitation.

METHODS

An economic evaluation from a societal perspective was performed alongside a multicenter randomized controlled trial. Data were collected by masked assessors during 24 months. Included were 265 older adults with vision impairment and subthreshold depression and/or anxiety. They were randomly assigned to stepped-care plus usual care (n = 131) or usual care alone (n = 134). Stepped-care comprised 1) watchful waiting, 2) guided self-help based on cognitive behavioral therapy, 3) problem solving treatment, and 4) referral to a general practitioner. Costs were based on direct healthcare costs and indirect non-healthcare costs. Main outcome measures were quality-adjusted life years (QALYs) and the cumulative incidence of major depressive, dysthymic and/or anxiety disorders. Secondary outcomes were symptoms of depression and anxiety.

RESULTS

Based on intention-to-treat, significant differences were found in the incidence of depressive/anxiety disorders (mean difference 0.17; 95% CI 0.06 to 0.29) and symptoms of anxiety (mean difference 1.43, 95% CI 0.10 to 2.77) in favor of stepped-care versus usual care; no significant difference was found for QALYs and symptoms of depression. Societal costs were non-significantly lower in the stepped-care group compared with the usual care group (mean difference: -€877; 95% confidence interval (CI): -8039 to 5489). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 95% or more at a willingness-to-pay of €33,000 per disorder prevented. The probability that stepped-care was cost-effective compared to usual care was 59% or more for a ceiling ratio of 0 €/QALY and increased to 65% at 20000 €/QALY.

CONCLUSIONS

This economic evaluation shows that stepped-care is dominant to usual care, with a probability of around 60%, due to its clinical superiority and its modest cost savings. However, it depends on the willingness-to-pay of decision makers whether or not stepped-care is considered cost-effective compared with usual care.

TRIAL REGISTRATION

identifier: NTR3296 , date: 13-02-2012.

Evaluating the effectiveness and cost-effectiveness of British Sign Language Improving Access to Psychological Therapies: an exploratory study

Background

Improving Access to Psychological Therapies (IAPT) is a National Institute for Health and Care Excellence-approved approach to intervention for depression and/or anxiety. This exploratory study sets the groundwork for comparing psychological therapies for Deaf sign language users experiencing anxiety and/or depression, delivered in British Sign Language (BSL) by a Deaf therapist with usual access through an interpreter within the IAPT national programme.

Objectives

(1) To explore the following questions: (a) is BSL-IAPT more effective than standard IAPT for Deaf people with anxiety and/or depression? and (b) is any additional benefit from BSL-IAPT worth any additional cost to provide it? (2) To establish relevant BSL versions of assessment tools and methods to answer research questions (a) and (b). (3) To gauge the feasibility of a larger-scale definitive study and to inform its future design.

Design

A mixed-methods exploratory study combing an economic model to synthesise data from multiple sources; a qualitative study of understanding and acceptability of randomisation and trial terminology; statistical determination of clinical cut-off points of standardised assessments in BSL; secondary data analysis of anonymised IAPT client records; realist inquiry incorporating interviews with service providers and survey results.

Settings

IAPT service providers (NHS and private); the Deaf community.

Participants

Deaf people who use BSL and who are clients of IAPT services (n = 502); healthy Deaf volunteers (n = 104); IAPT service providers (NHS and private) (n = 118).

Interventions

IAPT at steps 2 and 3.

Main outcome measures

Reliable recovery and reliable improvement defined by IAPT; Deaf community views on the acceptability of randomisation; BSL terminology for trial-related language; clinical cut-off measurements for the BSL versions of the Patient Health Questionnaire-9 items (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7); a valid BSL version of the EuroQol-5 Dimensions five-level version (EQ-5D-5L); costs, quality-adjusted life-years and incremental cost-effectiveness ratios.

Data sources

IAPT service provider anonymised records of the characteristics and clinical outcomes of Deaf BSL users of BSL-IAPT and of standard IAPT; published literature.

Results

Randomisation may be acceptable to Deaf people who use IAPT if linguistic and cultural requirements are addressed. Specifications for effective information in BSL for recruitment have been established. A valid EQ-5D-5L in BSL has been produced. The clinical cut-off point for the GAD-7 BSL is 6 and for the PHQ-9 BSL is 8. No significant difference in rates of reliable recovery and reliable improvement between Deaf users of standard IAPT or BSL-IAPT has been found. Whether or not BSL-IAPT is more cost-effective than standard IAPT is uncertain.

Limitations

The small number of participating standard IAPT services who have seen Deaf clients means that there is statistical uncertainty in the comparable clinical outcome result. Clinical cut-off scores have not been verified through gold standard clinical interview methodology. Limited data availability means that whether or not BSL-IAPT is more cost-effective than standard IAPT is uncertain.

Conclusions

There is a lack of evidence to definitively compare reliable recovery and reliable improvement between Deaf users of standard IAPT and BSL-IAPT. Instrumentation and prerequisites for a larger-scale study have been established.

Future work

A prospective observational study for definitive results is justified.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effectiveness and cost-effectiveness of telephone-based cognitive-behavioural therapy in primary care: study protocol of TIDe - telephone intervention for depression

BACKGROUND

Despite the availability of evidence-based treatments for depression, a large proportion of patients remains untreated or adequate treatment is initiated with delay. This situation is particularly critical in primary care, where not only most individuals first seek help for their mental health problems, but also depressive disorders - particularly mild to moderate levels of severity - are highly prevalent given the high comorbidity of chronic somatic conditions and depression. Improving the access for evidence-based treatment, especially in primary care, is hence a priority challenge in the mental health care agenda. Telephone usage is widespread and has the potential of overcoming many barriers that individuals suffering from mental health problems are facing: Its implementation for treatment delivery presents an option for optimisation of treatment pathways and outcomes.

METHODS/DESIGN

This paper details the study protocol for a randomised controlled trial (RCT) evaluating the effectiveness of a telephone-administered short-term cognitive-behavioural therapy (T-CBT) for depression as compared to treatment as usual (TAU) in the Swiss primary care setting. The study aims at randomising a total of 216 mildly to moderately depressed patients, which are either identified by their General Practitioners (GPs) or who self-refer to the study programme in consultation with their GP. The trial will examine whether telephone-delivered, manualised treatment leads to clinically significant reduction in depression at follow-up. It will further investigate the cost-effectiveness and acceptability of the intervention in the primary care setting.

DISCUSSION

Conducting a low-intensity treatment on the telephone allows for greater flexibility for both patient and therapist, can grant more anonymity and can thus lead to less hesitation in the patient about whether to attempt treatment or not. In order to benefit from this approach, large-scale studies need to prove superior effectiveness and cost-effectiveness of telephone-delivered therapy over routine care for patients with mild to moderate depression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02667366 . Registered on 3 December 2015.

Paecilomyces tenuipes extract prevents depression-like behaviors in chronic unpredictable mild stress-induced rat model via modulation of neurotransmitters

The medicinal fungus Paecilomyces tenuipes exhibits a variety of pharmacological effects, including antidepressive effects. The chronic unpredictable mild stress (CUMS)‑induced rat model has served an important role in studies involving antidepressants screening. The aim of the present study was to evaluate the antidepressant‑like activity of P. tenuipes N45 aqueous extract (PTNE) in a CUMS‑induced rat model of behavioral despair depression. Following 4 weeks of PTNE treatment, behavioral tests were conducted to investigate the antidepressant‑like activities, and the levels of neurotransmitters and hormones in blood and hypothalamus were measured. The results demonstrated that PTNE treatment significantly increased movement in the forced running test, whereas the immobility time was reduced in the hotplate test and the forced swim test in depression‑model rats. PTNE treatment was able to normalize the levels of hormones and neurotransmitters in serum and hypothalamus of CUMS rats. The data demonstrated that PTNE treatment may be a potential pharmaceutical agent in treatment‑resistant depression, and the effects of PTNE may be partly mediated through normalizing the levels of neurotransmitters.

Dull to Social Acceptance Rather than Sensitivity to Social Ostracism in Interpersonal Interaction for Depression: Behavioral and Electrophysiological Evidence from Cyberball Tasks

Objectives: Impairments in interpersonal relationships in depression present as irritability, pessimism, and withdrawal, and play an important role in the onset and maintenance of the disorder. However, we know little about the neurological causes of this impaired interpersonal function. This study used the event-related brain potential (ERP) version of the Cyberball paradigm to investigate the emotions and neural activities in depressive patients during social inclusion and exclusion simultaneously to explore neuropsychological mechanisms.

Methods: Electrophysiological data were recorded when 27 depressed patients and 23 healthy controls (HCs) performed a virtual ball tossing game (Cyberball) during which the participants believed they were playing with two other co-players over the internet. The Cyberball paradigm included two other conditions; inclusion during which participants received the ball with the same probability as the other players to experience a feeling of acceptance, and exclusion during which the participants experienced a feeling of ostracism when the other two players threw the ball with each other. The Positive and Negative Affect Schedule (PANAS) was used as a baseline and after each block during the Cyberball to assess positive and negative effects. In addition, a brief Need-Threat Scale (NTS) was used to assess the fulfillment of basic needs of subjects after each block and 10 min after ostracism. Moreover, the relationship between the ERP data of depression and clinical symptoms was analyzed.

Results: Exclusion compared to inclusion Cyberball caused a decrease in positive affect and an increase in negative affect. The group differences were only found in the positive affect. Moreover, patients reported a lower level of basic needs than did HCs after social inclusion, but a similar level of basic needs after social exclusion. At the electrophysiological level, patients showed decreased P3 amplitudes compared to HCs in social inclusion, and P3 amplitudes were borderline negatively correlated with their scores of anhedonia symptoms.

Limitations: A limitation of our study was that the subjects' criteria were different.

Conclusions: The behavioral and electrophysiological results indicated that the interpersonal problems in depressive patients were mainly due to deficits in processing the pleasurable social stimuli rather than aversive social cues.

Methodological Considerations in Social Cost Studies of Addictive Substances: A Systematic Literature Review

Background

Alcohol, tobacco, illicit drugs, and psychoactive pharmaceuticals’ use is associated with a higher likelihood of developing several diseases and injuries and, as a consequence, considerable health-care expenditures. There is yet a lack of consistent methodologies to estimate the economic impact of addictive substances to society. The aim was to assess the methodological approaches applied in social cost studies estimating the economic impact of alcohol, tobacco, illicit drugs, and psychoactive pharmaceuticals.

Methods

A systematic literature review through the electronic databases, Medline (PubMed) and Web of Science, was performed. Studies in English published from 1997 examining the social costs of the addictive substances alcohol, tobacco, illicit drugs, and psychoactive pharmaceuticals were eligible for inclusion.

Results

Twelve social cost studies met the inclusion criteria. In all studies, the direct and indirect costs were measured, but the intangible costs were seldom taken into account. A wide variety in cost items included across studies was observed. Sensitivity analyses to address the uncertainty around certain cost estimates were conducted in eight studies considered in the review.

Conclusion

Differences in cost items included in cost-of-illness studies limit the comparison across studies. It is clear that it is difficult to deal with all consequences of substance use in cost-of-illness studies. Future social cost studies should be based on sound methodological principles in order to result in more reliable cost estimates of the economic burden of substance use.

Preventing Depression in Adults With Subthreshold Depression: Health-Economic Evaluation Alongside a Pragmatic Randomized Controlled Trial of a Web-Based Intervention

Background

Psychological interventions for the prevention of depression might be a cost-effective way to reduce the burden associated with depressive disorders.

Objective

To evaluate the cost-effectiveness of a Web-based guided self-help intervention to prevent major depressive disorder (MDD) in people with subthreshold depression (sD).

Methods

A pragmatic randomized controlled trial was conducted with follow-up at 12 months. Participants were recruited from the general population via a large statutory health insurance company and an open access website. Participants were randomized to a Web-based guided self-help intervention (ie, cognitive-behavioral therapy and problem-solving therapy assisted by supervised graduate students or health care professionals) in addition to usual care or to usual care supplemented with Web-based psycho-education (enhanced usual care). Depression-free years (DFYs) were assessed by blinded diagnostic raters using the telephone-administered Structured Clinical Interview for DSM-IV Axis Disorders at 6- and 12-month follow-up, covering the period to the previous assessment. Costs were self-assessed through a questionnaire. Costs measured from a societal and health care perspective were related to DFYs and quality-adjusted life years (QALYs).

Results

In total, 406 participants were enrolled in the trial. The mean treatment duration was 5.84 (SD 4.37) weeks. On average, participants completed 4.93 of 6 sessions. Significantly more DFYs were gained in the intervention group (0.82 vs 0.70). Likewise, QALY health gains were in favor of the intervention, but only statistically significant when measured with the more sensitive SF-6D. The incremental per-participant costs were €136 (£116). Taking the health care perspective and assuming a willingness-to-pay of €20,000 (£17,000), the intervention’s likelihood of being cost-effective was 99% for gaining a DFY and 64% or 99% for gaining an EQ-5D or a SF-6D QALY.

Conclusions

Our study supports guidelines recommending Web-based treatment for sD and adds that this not only restores health in people with sD, but additionally reduces the risk of developing a MDD. Offering the intervention has an acceptable likelihood of being more cost-effective than enhanced usual care and could therefore reach community members on a wider scale.

Trial registration

German Clinical Trials Register: DRKS00004709; http://www.drks.de/DRKS00004709 (Archived by WebCite at http://www.webcitation.org/6kAZVUxy9)

Estimating the prevalence of depression associated with healthcare use in France using administrative databases

BACKGROUND

Quantitative indicators are needed in order to define priorities, plan policies and evaluate public health interventions in mental health. The aim of this study was to assess the contribution of a large and exhaustive French national administrative database to study and monitor treated depression by comparing the prevalence and characteristics of the population using significant healthcare resources for depression as identified by different estimation methods and sources and to discuss the advantages and drawbacks of these methods.

METHODS

This study included the French population covered by the main health insurance scheme in 2012 (Régime général, 86% of the insured French population). Data were extracted from the French health insurance claim database (SNIIRAM), which contains information on all reimbursements, including treatments and hospital stays in France. The following distinct sources of the SNIIRAM were used to select persons with depression: diagnoses of long-term or costly conditions, data from national hospital claims and data concerning all national health insurance reimbursements for drugs.

RESULTS

In 2012, we included 58,753,200 individuals covered by the main health insurance scheme; 271,275 individuals had full coverage for depression; 179,470 individuals had been admitted to a psychiatric hospital and 66,595 individuals admitted to a general hospital with a diagnosis of depression during a 2-year timeframe and 144,670 individuals had more than three reimbursements for antidepressants during the study year (with a history of hospitalisation for depression during the past 5 years). Only 16% of individuals were selected by more than one source.

CONCLUSIONS

We propose an algorithm that includes persons recently hospitalised for depression, or with a history of hospitalisation for depression and still taking antidepressants, or with full coverage for depression as a specific long-term or costly condition, yielding a prevalence estimate of 0.93% or 544,105 individuals. Changes in the case selection methodology have major consequences on the frequency count and characteristics of the selected population, and consequently on the conclusions that can be drawn from the data, emphasizing the importance of defining the characteristics of the target population before the study in order to produce relevant results.

The effect of depressive symptoms on social support one year following traumatic injury

BACKGROUND

Depression is a common mental health outcome after traumatic injury, negatively impacting physical outcomes and increasing the cost of care. Research shows that the presence and quality of support is a leading protective factor against depression post-injury; however, research is vague on the directional effects of both factors over the course of recovery.

METHODS

130 patients admitted to a Level I Trauma Center were recruited to a prospective study examining overall outcomes one-year after injury. Effects of social support and depression at baseline and 12-months post-injury were examined using correlational and cross-lagged path model analyses. Additional follow-up analyses were conducted for depression on specific types of social support.

RESULTS

Findings replicated previous research suggesting depression and social support were inversely related. Initial depression at time of traumatic injury was predictive of social support 12-months after their injury, but initial social support levels did not significantly predict depression at 12-months. Additionally, initial depression significantly predicted attachment, social integration, reassurance of worth, and guidance 12-months later.

LIMITATIONS

Findings of the analyses are limited by lack of experimentation and inability to control for other related variables.

CONCLUSIONS

Findings of the present study support the notion that initial depression predicts poorer social support in recovery, in lieu of prevailing theory (i.e., initial support buffers against later depression) in a sample of trauma patients. These findings highlight the need for medical staff to target specific factors during inpatient stay, such as addressing depressive symptoms and preparing family members and caregivers prior to discharge.

A Breathing-Based Meditation Intervention for Patients With Major Depressive Disorder Following Inadequate Response to Antidepressants: A Randomized Pilot Study

OBJECTIVE

To evaluate feasibility, efficacy, and tolerability of Sudarshan Kriya yoga (SKY) as an adjunctive intervention in patients with major depressive disorder (MDD) with inadequate response to antidepressant treatment.

METHODS

Patients with MDD (defined by DSM-IV-TR) who were depressed despite ≥ 8 weeks of antidepressant treatment were randomized to SKY or a waitlist control (delayed yoga) arm for 8 weeks. The primary efficacy end point was change in 17-item Hamilton Depression Rating Scale (HDRS-17) total score from baseline to 2 months. The key secondary efficacy end points were change in Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) total scores. Analyses of the intent-to-treat (ITT) and completer sample were performed. The study was conducted at the University of Pennsylvania between October 2014 and December 2015.

RESULTS

In the ITT sample (n = 25), the SKY arm (n = 13) showed a greater improvement in HDRS-17 total score compared to waitlist control (n = 12) (-9.77 vs 0.50, P = .0032). SKY also showed greater reduction in BDI total score versus waitlist control (-17.23 vs -1.75, P = .0101). Mean changes in BAI total score from baseline were significantly greater for SKY than waitlist (ITT mean difference: -5.19; 95% CI, -0.93 to -9.34; P = .0097; completer mean difference: -6.23; 95% CI, -1.39 to -11.07; P = .0005). No adverse events were reported.

CONCLUSIONS

Results of this randomized, waitlist-controlled pilot study suggest the feasibility and promise of an adjunctive SKY-based intervention for patients with MDD who have not responded to antidepressants.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02616549.

Online Positive Interventions to Promote Well-being and Resilience in the Adolescent Population: A Narrative Review

Numerous studies have shown an alarming prevalence of depression, anxiety, and behavior disorders in youth. Thus, prevention of psychological problems in this population becomes crucial. According to the World Health Organization (1), prevention should also include the promotion and development of the individual's strengths in order to reduce vulnerability to suffering from mental disorders. In addition, other key elements of prevention are the reach, adoption, implementation, and maintenance of interventions. The information and communication technologies, especially the Internet, have much to offer in terms of the prevention and promotion of positive mental health in adolescents. This paper reviews these fields of research-prevention, positive psychology, Internet, and adolescents-and discusses the potential of positive interventions delivered over the Internet as effective and sustainable health promotion tools. The paper provides a brief description of the systems developed so far and a summary of selected features of the studies detected in the literature review. The overall conclusions are that there is a need for more controlled studies with long-term follow-ups, the interventions should be designed considering the specific features of the target users and the specific contexts where the interventions will be delivered, and they could be enhanced by the use of other technologies, such as smartphones, sensors, or social networks.

Direct, indirect and intangible costs of acute hand and wrist injuries: A systematic review

BACKGROUND

Injuries sustained to the hand and wrist are common, accounting for 20% of all emergency presentations. The economic burden of these injuries, comprised of direct (medical expenses incurred), indirect (value of lost productivity) and intangible costs, can be extensive and rise sharply with the increase of severity.

OBJECTIVE

This paper systematically reviews cost-of-illness studies and health economic evaluations of acute hand and wrist injuries with a particular focus on direct, indirect and intangible costs. It aims to provide economic cost estimates of burden and discuss the cost components used in international literature.

MATERIALS AND METHODS

A search of cost-of-illness studies and health economic evaluations of acute hand and wrist injuries in various databases was conducted. Data extracted for each included study were: design, population, intervention, and estimates and measurement methodologies of direct, indirect and intangible costs. Reported costs were converted into US-dollars using historical exchange rates and then adjusted into 2015 US-dollars using an inflation calculator RESULTS: The search yielded 764 studies, of which 21 met the inclusion criteria. Twelve studies were cost-of-illness studies, and seven were health economic evaluations. The methodology used to derive direct, indirect and intangible costs differed markedly across all studies. Indirect costs represented a large portion of total cost in both cost-of-illness studies [64.5% (IQR 50.75-88.25)] and health economic evaluations [68% (IQR 49.25-73.5)]. The median total cost per case of all injury types was US$6951 (IQR $3357-$22,274) for cost-of-illness studies and US$8297 (IQR $3858-$33,939) for health economic evaluations. Few studies reported intangible cost data associated with acute hand and wrist injuries.

CONCLUSIONS

Several studies have attempted to estimate the direct, indirect and intangible costs associated with acute hand and wrist injuries in various countries using heterogeneous methodologies. Estimates of the economic costs of different acute hand and wrist injuries varied greatly depending on the study methodology, however, by any standards, these injuries should be considered a substantial burden on the individual and society. Further research using standardised methodologies could provide guidance to relevant policy makers on how to best distribute limited resources by identifying the major disorders and exposures resulting in the largest burden.

The Indirect Costs of Late-Life Depression in the United States: A Literature Review and Perspective

Late-life depression is a leading cause of disability in older adults and is associated with significant economic burden. This article draws from the existing literature and publicly available databases to describe the relative importance of the indirect costs associated with late-life depression. The authors found that unpaid caregiver costs represent the largest component of the indirect costs of late-life depression, with the highest level of economic burden attributed to the majority of care recipients who have fewer depressive symptoms. Other indirect costs, such as productivity losses related to early retirement, reduced ability to fulfill work and family functions and diminished financial success were mostly under-appreciated in the literature. Also, mortality cost estimates provided little clarity, employing variable methodologies and revealing mixed results. With respect to late-life suicide studies, studies approximated both economic costs and savings. More rigorous efforts to evaluate the indirect costs of late-life depression would afford a better understanding of the social and economic toll of this disorder and could influence the allocation of resources for research and treatment.

Investigating the (cost-) effectiveness of attention bias modification (ABM) for outpatients with major depressive disorder (MDD): a randomized controlled trial protocol

BACKGROUND

Despite the range of available, evidence-based treatment options for Major Depressive Disorder (MDD), the rather low response and remission rates suggest that treatment is not optimal, yet. Computerized attention bias modification (ABM) trainings may have the potential to be provided as cost-effective intervention as adjunct to usual care (UC), by speeding up recovery and bringing more patients into remission. Research suggests, that a selective attention for negative information contributes to development and maintenance of depression and that reducing this negative bias might be of therapeutic value. Previous ABM studies in depression, however, have been limited by small sample sizes, lack of long-term follow-up measures or focus on sub-clinical samples. This study aims at evaluating the long-term (cost-) effectiveness of internet-based ABM, as add-on treatment to UC in adult outpatients with MDD, in a specialized mental health care setting.

METHODS/DESIGN

This study presents a double-blind randomized controlled trial in two parallel groups with follow-ups at 1, 6, and 12 months, combined with an economic evaluation. One hundred twenty six patients, diagnosed with MDD, who are registered for specialized outpatient services at a mental health care organization in the Netherlands, are randomized into either a positive training (towards positive and away from negative stimuli) or a sham training, as control condition (continuous attentional bias assessment). Patients complete eight training sessions (seven at home) during a period of two weeks (four weekly sessions). Primary outcome measures are change in attentional bias (pre- to post-test), mood response to stress (at post-test) and long-term effects on depressive symptoms (up to 1-year follow-up). Secondary outcome measures include rumination, resilience, positive and negative affect, and transfer to other cognitive measures (i.e., attentional bias for verbal stimuli, cognitive control, positive mental imagery), as well as quality of life and costs.

DISCUSSION

This is the first study investigating the long-term effects of ABM in adult outpatients with MDD, alongside an economic evaluation. Next to exploring the mechanism underlying ABM effects, this study provides first insight into the effects of combining ABM and UC and the potential implementation of ABM in clinical practice.

TRIAL REGISTRATION

Trialregister.nl, NTR5285 . Registered 20 July 2015.

Long-Term Depressive Symptoms and Acculturative Stress Issues Among Immigrants From the Former Soviet Union

BACKGROUND

Previous studies regarding depressive symptoms and acculturative stress among immigrants have been limited to the initial period after immigration.

OBJECTIVE

The relationships between depressive symptoms, acculturation, and acculturative stress among immigrants from the former Soviet Union were examined in this descriptive study.

DESIGN

Eighty immigrants from the former Soviet Union who had immigrated within the past 20 years were recruited in various community locations.

RESULTS

Participants (N = 80), including recent and longer residing immigrants, reported elevated depressive symptoms and acculturative stress. Acculturative stress predicted depressive symptoms, controlling for dominant culture (American) immersion. However, length of time in the United States was not associated with depressive symptoms, ethnic culture immersion, or acculturative stress.

CONCLUSIONS

Our results suggest that elevated depressive symptoms are related to acculturative stress but are not confined to the initial adjustment period. Steps to decrease acculturative stress might help decrease depressive symptoms in immigrants regardless of the number of years lived in the United States.

Association between regular physical exercise and depressive symptoms mediated through social support and resilience in Japanese company workers: a cross-sectional study

BACKGROUND

Regular physical exercise has been reported to reduce depressive symptoms. Several lines of evidence suggest that physical exercise may prevent depression by promoting social support or resilience, which is the ability to adapt to challenging life conditions. The aim of this study was to compare depressive symptoms, social support, and resilience between Japanese company workers who engaged in regular physical exercise and workers who did not exercise regularly. We also investigated whether regular physical exercise has an indirect association with depressive symptoms through social support and resilience.

METHODS

Participants were 715 Japanese employees at six worksites. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression (CES-D) scale, social support with the short version of the Social Support Questionnaire (SSQ), and resilience with the 14-item Resilience Scale (RS-14). A self-report questionnaire, which was extracted from the Japanese version of the Health-Promoting Lifestyle Profile, was used to assess whether participants engage in regular physical exercise, defined as more than 20 min, three or more times per week. The group differences in CES-D, SSQ, and RS-14 scores were investigated by using analysis of covariance (ANCOVA). Mediation analysis was conducted by using Preacher and Hayes' bootstrap script to assess whether regular physical exercise is associated with depressive symptoms indirectly through resilience and social support.

RESULTS

The SSQ Number score (F = 4.82, p = 0.03), SSQ Satisfaction score (F = 6.68, p = 0.01), and RS-14 score (F = 6.01, p = 0.01) were significantly higher in the group with regular physical exercise (n = 83) than in the group without regular physical exercise (n = 632) after adjusting for age, education, marital status, and job status. The difference in CES-D score was not significant (F = 2.90, p = 0.09). Bootstrapping revealed significant negative indirect associations between physical exercise and CES-D score through the SSQ Number score (bias-corrected and accelerated confidence interval (BCACI) = -0.61 to -0.035; 95 % confidence interval (CI)), SSQ Satisfaction score (BCACI = -0.92 to -0.18; 95 % CI), and RS-14 score (BCACI = -1.89 to -0.094; 95 % CI).

CONCLUSION

Although we did not find a significant direct association between exercise and depressive symptoms, exercise may be indirectly associated with depressive symptoms through social support and resilience. Further investigation is warranted.

Covariates of depression and high utilizers of healthcare: Impact on resource use and costs

OBJECTIVE

To characterize healthcare costs, resource use, and treatment patterns of survey respondents with a history of depression who are high utilizers (HUds) of healthcare and to identify factors associated with high utilization.

METHODS

Adults with two or more depression diagnoses identified from the HealthCore Integrated Research Database were invited to participate in the CODE study, which links survey data with 12-month retrospective claims data. Patient surveys provided data on demographics, general health, and symptoms and/or comorbidities associated with depression. Similar clinical conditions also were identified from the medical claims. Factors associated with high utilization were identified using logistic regression models.

RESULTS

Of 3132 survey respondents, 1921 were included, 193 of whom were HUds (defined as those who incurred the top 10% of total all-cause costs in the preceding 12months). Mean total annual healthcare costs were eightfold greater for HUds than for non-HUds ($US56,145 vs. $US6,954; p<.0001). HUds incurred more inpatient encounters (p<.0001) and emergency department (p=.01) and physician office visits (p<.0001). Similar findings were observed for mental healthcare costs/resource use. HUds were prescribed twice as many medications (total mean: 16.86 vs. 8.32; psychotropic mean: 4.11 vs. 2.61; both p<.0001). HUds reported higher levels of depression severity, fatigue, sleep difficulties, pain, high alcohol consumption, and anxiety. Predictors of becoming a HUd included substance use, obesity, cardiovascular disease, comorbidity severity, psychiatric conditions other than depression, and pain.

CONCLUSION

Focusing on pain, substance use, and psychiatric conditions beyond depression may be effective approaches to reducing high costs in patients with depression.

Attitudes towards depression, psychiatric medication and help-seeking intentions amid financial crisis: Findings from Athens area

BACKGROUND

The financial crisis has yielded adverse effects on the population worldwide, as evidenced by elevated rates of major depression. International recommendations for offsetting the mental health impact of the recession highlight the need for effective treatment, including reduction in the stigma attached to the disorder.

AIMS

This study endeavoured to explore lay attitudes to depression and psychiatric medication during a period of financial crisis and to identify their correlates. Furthermore, it investigated their link to help-seeking intentions.

METHOD

A random and representative sample of 621 respondents from Athens area participated in the study (Response Rate = 81.7%). The telephone interview schedule consisted of the Personal Stigma Scale, a self-constructed scale tapping attitudes to psychiatric medication and one question addressing help-seeking intentions.

RESULTS

The preponderant stigmatising belief about depression pertains to perceiving the disorder as a sign of personal weakness. In addition, stereotypes of unpredictability and dangerousness were popular among the sample. Nonetheless, stigmatising beliefs are much stronger with regard to psychiatric medication; perceived as addictive, capable of altering one's personality, less effective than homeopathic remedies and doing more harm than good. Help-seeking intentions were predicted by education, unemployment and attitudes to psychiatric medication solely.

CONCLUSION

Research on the mental health effects of the global recession should encompass studies investigating the stigma attached to mental disorders and its implications.

The attributable annual health costs of U.S. occupational lead poisoning

BACKGROUND

U.S. occupational lead standards have not changed for decades, while knowledge about lead's health effects has grown substantially.

OBJECTIVE

The objective of this analysis was twofold: to estimate the attributable annual societal costs of health damages associated with occupationally lead-exposed U.S. workers and, more broadly, to develop methods for a fuller valuation of health damages.

METHODS

I combined data voluntarily reported to NIOSH on the number of highly exposed workers with published literature on the health effects of lead in adults to estimate the potential health benefits of lowering the U.S. occupational limit. I developed simple algorithms for monetizing more fully both the direct medical and indirect (productivity) damages associated with those high lead exposures.

RESULTS

I estimated direct medical costs of $141 million (2014US$) per year for 16 categories of health endpoints, and combined direct and indirect costs of over $392 million (2014US$) per year for the 10,000 or so U.S. workers with high occupational lead exposures.

CONCLUSIONS

Reducing allowable occupational lead limits produces annual societal benefits of almost $40,000 per highly exposed worker. Given underreporting of actual exposures and the omission of important health effects, this is likely a severe underestimate.

Clinical and economic impact of non-adherence to antidepressants in major depressive disorder: A systematic review

BACKGROUND

Medication non-adherence is one of the major challenges in treating patients with depression. This systematic review aims to determine the clinical and economic outcomes of non-adherence in depression.

METHODS

A systematic search was performed across the following databases: PubMed, EMBASE, DARE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews; from database inception to March 31, 2015. Studies must report on the association between adherence and outcomes, and English full texts needed to be available. The quality of each study was assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 11 articles were included, with eight reporting on clinical outcomes, two reporting on economic outcomes, and one reporting on both. The majority of studies were retrospective cohort studies. The mean quality of all included studies was 7, with a range from 3 to 9. Results clearly indicate that patients who were non-adherent were more likely to experience increased risks of relapse and/or recurrence, emergency department visits, and hospitalization rates; increased severity of depression, and a decrease in response and remission rates. The worsening of clinical outcomes in patients who were non-adherent subsequently translated to an increase in healthcare utilization and charges.

LIMITATIONS

No standardized adherence measurement tools were used, and few studies looked at the economic impact of non-adherence in depression.

CONCLUSION

There is a strong association between non-adherence to antidepressants and a worsening of patients' clinical and economic outcomes. Cost-effective interventions should be directed to this group of patients to improve medication adherence.

Depression-related treatment and costs in Germany: Do they change with comorbidity? A claims data analysis

BACKGROUND

Existing diverse bottom-up estimations of direct costs associated with depression in Germany motivated a detailed patient-level analysis of depression-related treatment (DRT), -costs (DRC) and Comorbidity.

METHODS

A large sickness fund's claims data was used to retrospectively identify patients aged 18-65 years with new-onset depression treatment between January 1st and February 15th 2010, and follow them until December 31st 2010, describe DRT, estimate associated DRC, and predict DRC with a generalised linear model.

RESULTS

A total of 18,139 patients were analysed. Mean direct DRC were €783. Predictors of DRC regarding psychiatric comorbidities were: "Delusion, psychotic disorders and personality disorders" (DRC-ratio 1.72), "Alcohol/drug addiction" (1.82), "abuse of alcohol/drugs" (1.57). Predictors of DRC regarding medical comorbidities were: "Rheumatoid arthritis" (0.77), "atherosclerosis" (0.65), "pregnancy" (0.66), and "Osteoarthritis" (1.87). Of all patients, 60.8% received their most intense/specialised DRT from a general practitioner, a medical specialist (23.7%), a psychotherapist (8.0%), a medical specialist and psychotherapist (2.9%), or in hospital (4.6%). Serious psychiatric comorbidity nearly tripled depression-related hospitalisation rates.

LIMITATIONS

Seasonal affective disorder and missing psychiatric outpatient clinic data must be considered.

CONCLUSIONS

Estimated DRC are significantly below the assessment of the German national guideline. Differing definitions of observation period and cost attribution might explain differing German DRC results. Signs of hospital psychiatric comorbidity bias indicate overestimation of hospital DRC. Identified associations of DRC with certain medical diseases in older adults warrant further research. Up to one quarter of patients with severe depression diagnosis might lack specialist treatment.

[Collaborative and stepped care for depression: Development of a model project within the Hamburg Network for Mental Health (psychenet.de)]

BACKGROUND

Depression is one of the most widespread mental disorders in Germany and causes a great suffering and involves high costs. Guidelines recommend stepped and interdisciplinary collaborative care models for the treatment of depression.

OBJECTIVES

Stepped and collaborative care models are described regarding their efficacy and cost-effectiveness. A current model project within the Hamburg Network for Mental Health exemplifies how guideline-based stepped diagnostics and treatment incorporating innovative low-intensity interventions are implemented by a large network of health care professionals and clinics.

MATERIALS AND METHODS

An accompanying evaluation using a cluster randomized controlled design assesses depressive symptom reduction and cost-effectiveness for patients treated within "Health Network Depression" ("Gesundheitsnetz Depression", a subproject of psychenet.de) compared with patients treated in routine care.

RESULTS

Over 90 partners from inpatient and outpatient treatment have been successfully involved in recruiting over 600 patients within the stepped care model. Communication in the network was greatly facilitated by the use of an innovative online tool for the supply and reservation of treatment capacities. The participating professionals profit from the improved infrastructure and the implementation of advanced training and quality circle work.

CONCLUSIONS

New treatment models can greatly improve the treatment of depression owing to their explicit reference to guidelines, the establishment of algorithms for diagnostics and treatment, the integration of practices and clinics, in addition to the implementation of low-intensity treatment alternatives. These models could promote the development of a disease management program for depression.

Association between eating alone and depressive symptom in elders: a cross-sectional study

Background

Depression is one of the main health concerns in elders which could lead to many negative outcomes. Eating alone is an emerging issue in elders in China and would become more serious along with the fast course of industrialization and urbanization, as well as population aging. However, their relationship was seldom researched.

Methods

Using a two-stage cluster sampling strategy, an investigation was conducted in 2014 among 9,361 permanent residents aged 60 years and above in Zhejiang Province, China. Totally, 7,968 cognitively normal elders were included in our analysis. Multilevel logistic regression was used to explore the association between eating arrangement (number of companions in mealtime) and depressive symptom as well as the association between eating alone and depressive symptom in relation to living alone.

Results

In our sample, 17.1 % of the elders ate alone and 8.7 % had depressive symptom. We observed a distinct inverse association between eating arrangement (number of companions in mealtime) and geriatric depressive symptom (female: OR = 1.12, P = 0.027; aged 60–74 years: OR = 1.16, P = 0.002), after adjustment for demography, socioeconomic status, social relation, health behaviors, underlying conditions and living alone. We then introduced a combined variable of eating alone and living alone and examined its relationship with depressive symptom. We found that compared with elders who ate and lived with others, those who ate alone but lived with others had a significant increased odds of depressive symptom (female: OR = 1.62, P = 0.027; aged 60–74 years: OR = 1.59, P = 0.025).

Conclusions

Our results suggested that a lack of companionship in mealtime might be independently associated with geriatric depressive symptom for females and those aged 60–74 years. What’s more, eating alone might be a stronger factor associated with depressive symptom than living alone. We recommend interventions to be performed in encouraging elders especially females and those aged 60–74 years to eat with others. Longitudinal studies in different populations which focus on this topic are required to better understand this issue.

Major depression treatment in Germany-descriptive analysis of health insurance fund routine data and assessment of guideline-adherence

BACKGROUND

Guideline oriented treatment strategies of Major depressive disorder (MDD) improve treatment outcomes and reduce risks of chronicity and recurrence.

AIMS

Description of routine treatment reality and analysis of guideline fidelity in first episode MDD in Germany. Indicators: patients with severe or psychotic depression or severe psychiatric comorbidities' treatment by specialists, adequate antidepressant pharmacotherapy, permanent treatment with more than one antidepressant, long-term benzodiazepine treatment and provision of psychotherapy.

METHOD

Descriptive analysis of routine data of the German statutory health insurance fund Barmer GEK in the index year 2011 that covers a population of 7,501,110.

RESULTS

236,843 patients were diagnosed a depressive episode. 53.0% of the patients with severe depression, 34.4% with psychotic depression and 50.9% with severe psychiatric comorbidities were treated by specialists; of the patients treated by a general practitioner 48.1% with severe and 47.3% with psychotic depression received an antidepressant; 9.7% of all patients with MDD got two antidepressants simultaneously; 8.3% received longterm benzodiazepine prescriptions; 26.1% got psychotherapy.

LIMITATIONS

the analyses depends on the indicators definitions that cannot cope with the variety of individual treatment path; comparison with guidelines was complicated by a large fraction of patients with recurrent MDD that was wrongly diagnosed with first episode depression; due to the data structure, not all guideline recommendations could be examined

CONCLUSIONS

Routine practice was oriented upon the guidelines recommendations. However some aspects could be identified that bear potential for improvements.

Association Between Cognitive Function and Health Care Costs 3 Months and 6 Months After Initiating Antidepressant Medication for Depressive Disorders

BACKGROUND

Major depressive disorder is one of the most common and disabling mental health disorders and is associated with substantial costs in terms of direct health care utilization and workplace productivity. Cognitive dysfunction, which alone substantially increases health care costs, is commonly associated with major depressive disorder. However, the health care costs of cognitive dysfunction in the context of depressive disorder are unknown. Recovery from mood symptoms is not always associated with resolution of cognitive dysfunction. Thus, cognitive dysfunction may contribute to health care burden even with successful antidepressant therapy. 

OBJECTIVE

To compare health care utilization and costs for patients with a depressive disorder with and without cognitive dysfunction, at 3 and 6 months after initiation of antidepressant medication. 

METHODS

This was an observational study, combining a cross-sectional patient survey, administered during a telephone interview, with health care claims data from a large, geographically diverse U.S. health plan. Included patients had at least 1 pharmacy claim for an antidepressant medication between August 1 and September 30, 2012, and no claim for any antidepressant during the 6 months prior to the index date. In addition to other criteria assessed in the claims data, patients confirmed a diagnosis of depression or major depressive disorder and the absence of any exclusionary neurological diagnoses possibly associated with cognitive impairment. Eligible patients were administered validated cognitive function assessments of verbal episodic memory (Hopkins Verbal Learning Test-Revised, Delayed and Total); attention (Digit Span Forward Maximum Sequence Length); working memory (Digit Span Backward Maximum Sequence Length); and executive function (D-KEFS-Letter Fluency Test). Based on comparison of scores with normative data, patients were assigned to cognitive dysfunction or cognitive normal cohorts. All-cause (all diagnoses) and depressive disorder-related health care utilization and costs (all from a payer perspective) were assessed 6 months prior (baseline) to antidepressant initiation and 3 months and 6 months after (follow-up) initiation of antidepressant medication. Health care utilization and costs included ambulatory (office and hospital outpatient), emergency room, inpatient hospital, pharmacy, other medical (e.g., laboratory and diagnostics), and total (all categories combined). All-cause and depressive disorder-related total costs during the 3- and 6-month follow-up periods were modeled with generalized linear modeling with gamma distribution and log link, while adjusting for potential confounders (age, race, gender, education, employment, and comorbidities).

RESULTS

Of the 13,537 patients who were mailed an invitation, 824 (6%) were eligible and agreed to participate. Of these, 563 patients provided informed consent, completed the interview, maintained eligibility, and were included in the 3-month calculations. Among these, 255 (45%) were classified as having cognitive dysfunction. Mean patient age was 41.3 (± 12.5) years; 80% were female. Most patients were white and employed. More patients in the cognitive normal cohort were white (P  less than  0.001) and employed full time (P = 0.029), had higher education attainment (P  less than    0.001), and had fewer comorbidities (P = 0.007) than those in the cognitive dysfunction cohort. Over the first 3 months, patients with cognitive dysfunction had higher adjusted all-cause costs ($3,309 vs. $2,157, P = 0.002) and higher adjusted depressive disorder-related costs ($718 vs. $406, P  less than  0.001) than patients without cognitive dysfunction. At 6 months, data from 4 patients were removed from the analysis because of exclusionary diagnoses. Over 6 months, patients with cognitive dysfunction had higher adjusted all-cause costs ($4,793) than patients without cognitive dysfunction ($3,683, P = 0.034). Over 6 months, depressive disorder-related costs did not significantly differ between patients with ($771) and without cognitive dysfunction ($594, P = 0.071). The main drivers of all-cause costs were office visits, outpatient hospital visits, and inpatient costs, and the main driver of depressive disorder-related costs was inpatient costs.

CONCLUSIONS

Cognitive dysfunction was associated with higher adjusted all-cause and depressive disorder-related costs 3 months after initiation of an antidepressant medication. This difference persisted for all-cause costs through 6 months. Identification and treatment of cognitive dysfunction in patients with depressive disorder might reduce health care costs.

Fish consumption and resilience to depression in Japanese company workers: a cross-sectional study

BACKGROUND

Depression is a common disorder that is influenced by psychosocial factors in the workplace. Increasing resilience, the ability to cope with stress in the face of adversity, is considered an important strategy to prevent depression. It has been suggested that consumption of fish, which is a major source of long chain n-3 polyunsaturated fatty acids (LC n-3 PUFA), may prevent depression. However, associations between depression, resilience, and fish consumption have not been documented. The aim of the study is to investigate the association between fish consumption and resilience to depression.

METHODS

Participants were 527 Japanese employees at three worksites of a large company. The Center for Epidemiologic Studies Depression (CES-D) Scale was administered to assess depressive symptoms, and the 14-item Resilience Scale (RS-14) was administered to assess resilience. A self-report questionnaire extracted from the Food Frequency Questionnaire was used to measure fish consumption frequency. Regression analyses were conducted to assess a mediation model based on a statistical analysis framework defined by Baron and Kenny. The indirect association of resilience was calculated with the bootstrapping method. Each analysis was adjusted by age, sex, marital status, work position, and educational background.

RESULTS

The association between fish consumption frequency and total CES-D score was significant (B=-0.94; p=0.011). The association between fish consumption frequency and total RS-14 score was significant (B=1.4; p=0.010), as was association total RS-14 score and the total CES-D score (B=-0.34; p<0.001). When controlling for total RS-14 score, there was no longer a significant association between fish consumption frequency and total CES-D score. The bootstrapping results revealed that significant indirect association though fish consumption frequency and total CES-D score (bias corrected and accelerated confidence interval=-0.83 to -0.13; 95% confidence interval) through total RS-14 score.

CONCLUSIONS

Fish consumption might be associated with resilience to depression. Further studies are needed, particularly double blind randomized placebo controlled intervention trials on the potential preventative effect of LC n-3 PUFA on resilience to depression.

Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: a systematic review

BACKGROUND

For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care.

PURPOSE

To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care.

METHODS

A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP).

RESULTS

In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562.

CONCLUSION

Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Complex coevolution of depression and health-related quality of life in old age

PURPOSE

To investigate the coevolution of depression and health-related quality of life (HRQoL) in old age.

METHODS

In a representative survey of the German general population aged 75 years and older, the course of HRQoL and depression was observed over 4.5 years (3 waves). HRQoL was assessed by the Visual Analogue Scale (EQ VAS) of the EQ-5D instrument, while the Geriatric Depression Scale was used to measure depression. A panel vector autoregressive model was used to account for the complex coevolution of depression and HRQoL. Unobserved heterogeneity was taken into account by taking the first differences.

RESULTS

We revealed a robust negative association between an initial change in HRQoL and a subsequent change in depression score, with substantial sex differences: In women there was a robust association, while in men the significance of this association depended on the model specification. Surprisingly, in the total sample and in both sexes, no robust association between an initial increase in depression and a subsequent change in HRQoL was found.

CONCLUSION

Findings indicate that the direction of evolution from HRQoL to depression deserves more attention. Furthermore, treatment of depression in late life should aim at improving HRQoL in which remission of depressive symptoms is necessary but not sufficient.

Effect of newly synthesized 1,2,4-triazino[5,6-b]indole-3-thione derivatives on olfactory bulbectomy induced depression in rats

OBJECTIVE

To study the derivatives of 1,2,4-triazino[5,6-b]indole-3-thione for antidepressant activity in olfactory bulbectomized (OBX) rats. Out of various derivatives tested for acute tail suspension test, the two derivatives showing prominent action were selected for bilateral olfactory bulbectomy model of chronic depression in rats.

METHODS

The sub acute effects of 14-day oral pretreatment of two derivatives labeled as 3a (70 mg/kg) and 3r (70 mg/kg), imipramine (20 mg/kg), fluoxetine (30 mg/kg) and moclobemide (15 mg/kg) were evaluated on bilateral bulbectomy induced rise in body weight, hyperphagia, hyperactivity, and on sexual dysfunction. The serum sodium concentration, body temperature, and heart rate were also recorded.

RESULTS

The derivatives 3a and 3r showed reversal of drop in body weight, reversed OBX induced hyperactivity, normalized body temperature, heart rate, and serum sodium concentration. In elevated maze test, moclobemide, 3a, 3r treatment significantly reduced time spent in open arm as compared to OBX rats. 3a and 3r also improved sexual behavior parameters.

CONCLUSIONS

The present study shows promising antidepressant action and provides a proof of concept for the chronic treatment of 3a, 3r to treat depression.

Commentary on "Disability but not social support predicts cognitive deterioration in late-life depression"

It is well established that depression is common in late life and associated with a range of consequences for the individual and those close to them. These consequences include higher use of health services and declines in functional ability (Luppa et al., 2007), not to mention negative subjective experiences, such as reduced engagement with, and enjoyment of day-to-day activities. Depression in late life is a heterogeneous condition made more complex by the links between depression, cognitive decline and dementia. The “Vascular Depression Hypothesis” suggests that a subset of late life depressive disorders are caused by cerebrovascular disease (Taylor, 2014), but questions about the relationships between depression and cognitive decline remain unanswered. The paper chosen as the paper of the month in this issue of International Psychogeriatrics addresses one of these questions, namely, whether we can identify clinical signs and symptoms that predict cognitive decline in individuals diagnosed with depression. This question is of great clinical relevance, as not all patients and clinicians will have access to the neuroimaging or detailed neuropsychological assessment that could cast light on risk for cognitive deterioration.

Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms. A randomized controlled trial

BACKGROUND

Internet-based interventions (IBI) are effective in treating depression. However, uptake rates in routine care are still limited. Hence, this study aimed to (1) assess the acceptance of IBIs in primary care patients with depressive symptoms and to (2) examine the effects of a brief acceptance facilitating intervention in the form of an informational video on patients' acceptance of IBIs.

METHODS

Primary care patients (N=128) with Minor or Major Depression were randomly assigned to an intervention (IG) or control group (CG). Patients in the IG were shown a brief informational video about IBIs before receiving a questionnaire that assessed their acceptance of IBIs and other secondary outcomes. Patients of the CG filled out the questionnaire immediately.

RESULTS

Baseline acceptance of IBIs in the CG was high for 6.3%, moderate for 53.1% and low for 40.6% of patients. Acceptance of IBIs was significantly higher in the IG when compared to the CG (d=.71, 95%-CI:.09-2.91). Except for social influence and the general attitude towards psychological treatment, all secondary outcomes were also significantly improved (e.g. effort- (d=.40) and performance-expectancy: d=.65; knowledge about Internet interventions d=.35).

LIMITATIONS

Depression of the participants was only assessed using a self-report measure (PHQ-9).

CONCLUSION

Primary care patients' acceptance of IBIs for depressive symptoms was low but could be increased significantly using a brief acceptance facilitating intervention on the basis of an informational video. Future studies should further examine the potential of acceptance facilitating interventions for patients and health care providers to exploit the public health impact of IBIs.

The costs and benefits of reducing racial-ethnic disparities in mental health care

OBJECTIVE

Previous studies have found that timely mental health treatment can result in savings in both mental health and general medical care expenditures. This study examined whether reducing racial-ethnic disparities in mental health care offsets costs of care.

METHODS

Data were from a subsample of 6,206 individuals with probable mental illness from the 2004-2010 Medical Expenditure Panel Survey (MEPS). First, disparities in mental health treatment were analyzed. Second, two-year panel data were used to determine the offset of year 1 mental health outpatient and pharmacy treatment on year 2 mental and general medical expenditures. Third, savings were estimated by combining results from steps 1 and 2.

RESULTS

Compared with whites, blacks and Latinos with year 1 outpatient mental health care spent less on inpatient and emergency general medical care in year 2. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care. Reducing racial-ethnic disparities in mental health care and in psychotropic drug use led to savings in acute medical care expenditures.

CONCLUSIONS

Savings in acute care expenditures resulting from eliminating disparities in racial-ethnic mental health care access were greater than costs in some but not all areas of acute mental health and general medical care. For blacks and Latinos, the potential savings from eliminating disparities in inpatient general medical expenditures are substantial (as much as $1 billion nationwide), suggesting that financial and equity considerations can be aligned when planning disparity reduction programs.

Reward dysfunction in major depression: multimodal neuroimaging evidence for refining the melancholic phenotype

Reward dysfunction is thought to play a core role in the pathophysiology of major depressive disorder (MDD). Event-related potential (ERP) and functional magnetic resonance imaging (fMRI) studies have identified reward processing deficits in MDD, but these methods have yet to be applied together in a single MDD sample. We utilized multimodal neuroimaging evidence to examine reward dysfunction in MDD. Further, we explored how neurobiological reward dysfunction would map onto subtypes of MDD. The feedback negativity (FN), an ERP index of reward evaluation, was recorded in 34 unmedicated depressed individuals and 42 never-depressed controls during a laboratory gambling task. Ventral striatal (VS) activation to reward was recorded in a separate fMRI session, using an identical task, among a subgroup of 24 depressed individuals and a comparison group of 18 non-depressed controls. FN amplitude was blunted in MDD. This effect was driven by a MDD subgroup characterized by impaired mood reactivity to positive events, a core feature of melancholic MDD. A similar pattern was observed for VS activation, which was also blunted among the MDD subgroup with impaired mood reactivity. Neither FN amplitude nor VS activation was related to the full, DSM-defined melancholic or atypical MDD subtypes. Across the MDD sample, FN amplitude and VS activation were correlated, indicating convergence across methods. These results indicate that not all MDD is characterized by reward dysfunction, and that there is meaningful heterogeneity in reward processing within MDD. The current study offers neurobiological evidence that impaired mood reactivity is a key phenotypic distinction for subtyping MDD, and further suggests that the existing melancholic phenotype may require further refinement.

Germaine-Smith C, Metcalfe A, Patten SB, Beck CA. Systematic review and assessment of validated case definitions for depression in administrative data

BACKGROUND

Administrative data are increasingly used to conduct research on depression and inform health services and health policy. Depression surveillance using administrative data is an alternative to surveys, which can be more resource-intensive. The objectives of this study were to: (1) systematically review the literature on validated case definitions to identify depression using International Classification of Disease and Related Health Problems (ICD) codes in administrative data and (2) identify individuals with and without depression in administrative data and develop an enhanced case definition to identify persons with depression in ICD-coded hospital data.

METHODS

(1) Systematic review: We identified validation studies using ICD codes to indicate depression in administrative data up to January 2013. (2) VALIDATION: All depression case definitions from the literature and an additional three ICD-9-CM and three ICD-10 enhanced definitions were tested in an inpatient database. The diagnostic accuracy of all case definitions was calculated [sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV)].

RESULTS

(1) Systematic review: Of 2,014 abstracts identified, 36 underwent full-text review and three met eligibility criteria. These depression studies used ICD-9 and ICD-10 case definitions. (2) VALIDATION: 4,008 randomly selected medical charts were reviewed to assess the performance of new and previously published depression-related ICD case definitions. All newly tested case definitions resulted in Sp >99%, PPV >89% and NPV >91%. Sensitivities were low (28-35%), but higher than for case definitions identified in the literature (1.1-29.6%).

CONCLUSIONS

Validating ICD-coded data for depression is important due to variation in coding practices across jurisdictions. The most suitable case definitions for detecting depression in administrative data vary depending on the context. For surveillance purposes, the most inclusive ICD-9 & ICD-10 case definitions resulted in PPVs of 89.7% and 89.5%, respectively. In cases where diagnostic certainty is required, the least inclusive ICD-9 and -10 case definitions are recommended, resulting in PPVs of 92.0% and 91.1%. All proposed case definitions resulted in suboptimal levels of sensitivity (ranging from 28.9%-35.6%). The addition of outpatient data (such as pharmacy records) for depression surveillance is recommended and should result in improved measures of validity.

Cost-of-illness studies of diabetes mellitus: a systematic review

BACKGROUND

Diabetes mellitus (DM) is recognised as a major health problem.

OBJECTIVES

The aims of this study are two-fold: (1) to describe the methods used in the identified cost-of-illness (COI) studies of DM and (2) to summarise their study findings regarding the economic impact of DM.

METHODS

This is a systematic review of MEDLINE and Scopus journal articles reporting the cost of type 1 and/or 2 DM that were published in English from 2007 to 2011. Costs reported in the included studies were converted to US dollars.

RESULTS

The systematic search yielded 30 articles. The studies varied considerably in their study design, perspective and included cost categories. Estimates for the total annual costs of DM ranged from US$141.6 million to US$174 billion; direct costs ranged from US$150 to US$14,060 per patient per year (pppy) whereas indirect costs ranged from US$39.6 to US$7,164 pppy. Inpatient cost was the major contributor to direct cost in half of the studies that included inpatient costs, physician services and medications.

CONCLUSION

There is a considerable economic burden associated with DM. Future research should focus on improving methods of estimating costs, enhancing the interpretation of study findings and facilitating comparisons between studies.

Adult depression screening in Saudi primary care: prevalence, instrument and cost

BACKGROUND

By the year 2020 depression would be the second major cause of disability adjusted life years lost, as reported by the World Health Organization. Depression is a mental illness which causes persistent low mood, a sense of despair, and has multiple risk factors. Its prevalence in primary care varies between 15.3-22%, with global prevalence up to 13% and between 17-46% in Saudi Arabia. Despite several studies that have shown benefit of early diagnosis and cost-savings of up to 80%, physicians in primary care setting continue to miss out on 30-50% of depressed patients in their practices.

METHODS

A cross sectional study was conducted at three large primary care centers in Riyadh, Saudi Arabia aiming at estimating point prevalence of depression and screening cost among primary care adult patients, and comparing Patient Health Questionnaires PHQ-2 with PHQ-9. Adult individuals were screened using Arabic version of PHQ-2 and PHQ-9. PHQ-2 scores were correlated with PHQ-9 scores using linear regression. A limited cost-analysis and cost saving estimates of depression screening was done using the Human Capital approach.

RESULTS

Patients included in the survey analysis were 477, of whom 66.2% were females, 77.4% were married, and nearly 20% were illiterate. Patients exhibiting depressive symptoms on the basis of PHQ9 were 49.9%, of which 31% were mild, 13.4% moderate, 4.4% moderate-severe and 1.0% severe cases. Depression scores were significantly associated with female gender (p-value 0.049), and higher educational level (p-value 0.002). Regression analysis showed that PHQ-2 & PHQ-9 were strongly correlated R = 0.79, and R2 = 0.62. The cost-analysis showed savings of up to 500 SAR ($133) per adult patient screened once a year.

CONCLUSION

The point prevalence of screened depression is high in primary care visitors in Saudi Arabia. Gender and higher level of education were found to be significantly associated with screened depression. Majority of cases were mild to moderate, PHQ-2 was equivocal to PHQ 9 in utility and that screening for depression in primary care setting is cost saving.