Patient treatment preference as a predictor of response and attrition in treatment for chronic depression

How etiological beliefs contribute to the structure of depression symptom networks

OBJECTIVES

Each person possesses a unique view surrounding depressive symptomology and etiology that is shaped by idiosyncratic experiences. However, the influence that subjective etiological beliefs regarding a person's depressive symptoms have on actual symptom presentation and organization is seldom considered.

METHODS

The current study employed network analytic techniques to examine how subjective views surrounding the cause of depressive symptoms altered actual symptom presentation networks. Additionally, the interaction between depressive symptoms and various etiological beliefs was examined.

RESULTS

The results revealed that characterological beliefs, representing the idea that depression is caused by an internal sense of self, are strongly connected to a negative view of self, as well as a saddened mood. Additionally, the characterological beliefs node exhibited the greatest node predictability in its respective network, as well as in an omnibus network consisting of all depression symptoms and potential etiological beliefs. Whereas an achievement-based view of depression has a strong connection with concentration difficulties, a physical view of depression tends to form strong connections with physically based depressive symptoms.

CONCLUSION

Subjective views regarding the cause of depression have the potential to influence symptom presentation and organization within a network, which may influence a person's willingness to engage in treatment or specific treatment preferences.

Identifying subgroups with differential response to CBASP versus Escitalopram during the first eight weeks of treatment in outpatients with persistent depressive disorder

There exists little empirical evidence helping clinicians to select the most effective treatment for individual patients with persistent depressive disorder (PDD). This study identifies and characterizes subgroups of patients with PDD who are likely to benefit more from an acute treatment with psychotherapy than from pharmacotherapy and vice versa. Non-medicated outpatients with PDD were randomized to eight weeks of acute treatment with the Cognitive Behavioral Analysis System of Psychotherapy (CBASP; n = 29) or escitalopram plus clinical management (ESC/CM; n = 31). We combined several baseline variables to one composite moderator and identified two subgroups of patients: for 56.0%, ESC/CM was associated with a greater reduction in depression severity than CBASP, for the remaining 44.0%, it was the other way around. Patients likely to benefit more from ESC/CM were more often female, had higher rates of moderate-to-severe childhood trauma, more adverse life events and more previous suicide attempts. Patients likely to benefit more from CBASP were older, had more often an early illness onset and more previous treatments with antidepressants. Symptomatic response, remission, and reductions in symptom severity occurred more often in those patients treated with their likely more effective treatment condition. The findings suggest that the baseline phenotype of patients with PDD moderates their benefit from acute treatment with CBASP relative to ESC/CM. Once confirmed in an independent sample, these results could serve to guide the choice between primarily psychotherapeutic or pharmacological treatments for outpatients with PDD.

Exercise for the Prevention and Treatment of Depression

Depression is among the world's leading causes of disability and accounts for a significant loss of life. Despite large investments in research for antidepressants and psychotherapies, non-response, partial response, and small effects remain significant problems. Exercise and physical activity are two lifestyle behaviors that have been studied for well over half a century for the prevention and treatment of depression. The aim of this chapter is to summarize the current evidence base supporting the efficacy of exercise and physical activity in the prevention and treatment of depression, including evidence supporting exercise as a monotherapy and adjunct to antidepressant medication and psychotherapies. We conclude the chapter by outlining challenges to prescribing exercise for depression and general recommendations for encouraging behavioral adoption for individuals suffering from depression.

The impact of treatment preferences: A narrative review

Attending to treatment preferences is an element of person-centred care, reported as beneficial in improving treatment adherence, satisfaction, and outcome, in practice. The results of preference trials were inconsistent in supporting these benefits in intervention evaluation research. Informed by the conceptualisation of treatment preferences positing their indirect impact on outcomes, this narrative review aimed to summarise the evidence on the effects of preferences on enrolment; withdrawal or attrition; engagement, enactment, and satisfaction with treatment; and outcomes. The search yielded 72 studies (57 primary trials and 15 reviews). The results of vote counting indicated that (1) offering participants the opportunity to choose treatment enhances enrolment (reported in 87.5% of studies), and (2) providing treatments that match participants' preferences reduces attrition (48%); enhances engagement (67%), enactment (50%) and satisfaction with (43%) treatment; and improves outcomes (35%). The results are attributed to conceptual and methodological issues including less-than-optimal assessment of treatment preferences, which contributes to ill-identified preferences, accounting for withdrawal, low enactment, and limited satisfaction with treatment. These treatment processes, in turn, mediate the impact of treatment preferences on outcomes. It is important to refine and standardise the methods for assessing preferences and to examine their indirect impact (mediated by treatment processes) on outcomes in future preference trials to validly identify their benefits.

A Novel, Brief, Fully Automated Intervention to Extend the Antidepressant Effect of a Single Ketamine Infusion: A Randomized Clinical Trial

OBJECTIVE

Intravenous ketamine, which displays rapid antidepressant properties, is posited to reverse depression by rapidly enhancing neuroplasticity. The authors tested whether an automated, computer-based approach could efficiently leverage enhanced neuroplasticity to extend the durability of rapid clinical response.

METHODS

A total of 154 adults (ages 18-60) with treatment-resistant unipolar depression were randomized in a double-blind, parallel-arm design to receive an active/active treatment combination (ketamine plus active "automated self-association training" [ASAT]; N=53) or one of two control arms that lacked either the active drug component (saline plus active ASAT; N=51) or the active behavioral component (ketamine plus sham ASAT; N=50). One day after a single infusion of intravenous ketamine (0.5 mg/kg over 40 minutes) or inert placebo (saline), active ASAT-targeting self-worth through automated "evaluative conditioning" training delivered by computer-or sham ASAT (consisting of identical computer tasks that included no positive or self-referential stimuli) was given, delivered twice daily over 4 consecutive days (eight sessions, ≤20 minutes per session). The prespecified primary outcome measure throughout the main (30-day) study period was score on the Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

Ketamine rapidly and significantly reduced depression scores at 24 hours postinfusion (group-by-time interaction: standardized beta [β]=-1.30, 95% CI=-1.89, -0.70; t=-4.29, df=150). In intent-to-treat linear mixed models, depression scores in the ketamine+ASAT group remained significantly and stably low over the 30-day study period relative to those of the saline+ASAT group (β=-0.61, 95% CI=-0.95, -0.28; t=-3.62, df=148). By contrast, depression scores following ketamine+sham treatment followed a significant, increasing linear trajectory from 24 hours to 30 days, approaching the levels observed in the saline+ASAT group (group-by-time interaction relative to the saline+ASAT group: β=0.015, 95% CI=0.003, 0.03; t=2.35, df=568).

CONCLUSIONS

After priming the brain with ketamine, training positive self-associations could provide an efficient, low-cost, portable, noninvasive, and highly dissemination-ready strategy for leveraging and extending ketamine's rapid antidepressant effects.

A Meta-Analysis of Mindfulness-Based Therapies for Insomnia and Sleep Disturbance Moving Toward Processes of Change

MBTs are increasingly being investigated as a viable treatment of insomnia or sleep disturbance. To date, 13 trials published since 2010 suggest that MBTs are efficacious for improving symptoms of insomnia and sleep quality relative to psychological placebos and inactive control conditions with medium to large effects. Limited evidence suggests that these effects are sustained at 3-month follow-up. Despite this, limited data were collected evaluating the empirically supported mechanisms or processes of change. The authors propose a testable model in the psychological process model of sleep that they hope will advance the next generation of research into MBTs for insomnia.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

METHODS

Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

DISCUSSION

The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

Patient Choice in Depression Psychotherapy: Outcomes of Patient-Preferred Therapy Versus Randomly Allocated Therapy

OBJECTIVE

Patient choice is recognized as a factor that influences clinical outcomes and treatment evaluation in mental health care. However, research on how having a choice affects patients with depression has been rare. This Dutch study examined whether patients randomly selected to choose between two types of depression psychotherapy benefited more from treatment than patients randomly assigned to an intervention.

METHODS

Data were derived from a trial of outpatients with depression who were randomly assigned to cognitive therapy (CT), interpersonal psychotherapy (IPT), or a 2-month waitlist control condition followed by the patient's choice of CT or IPT. Treatment groups were combined into a no-choice condition (N=151), with the waitlist as the choice condition (N=31). Multilevel regression was used to compare depression severity (measured with the Beck Depression Inventory-II [BDI-II]) and general psychological distress (measured with the Brief Symptom Inventory [BSI]) posttreatment and at the 5-month follow-up. Differences in patients' pretreatment expectations, beliefs about treatment credibility, and posttreatment evaluation were examined.

RESULTS

No significant differences in clinical outcomes were found between the choice and no-choice conditions (mean difference: BDI-II posttreatment=-0.55, 95% confidence interval [CI]=-5.25 to 4.15; follow-up=2.10, 95% CI=-4.01 to 8.20; BSI posttreatment=-1.89, 95% CI=-15.35 to 11.58; follow-up=3.13, 95% CI=-12.32 to 18.57). Patients in both groups reported comparable scores on pretreatment expectations, credibility beliefs, and posttreatment evaluation. Neither expectations nor credibility beliefs were predictive of clinical outcomes.

CONCLUSIONS

Our findings did not support the value of patient choice. Considering the exploratory nature of the trial, future studies designed to examine the effects of choice in depression treatment are recommended.

Impact of Mindfulness-Based Cognitive Therapy on Depressive Symptoms Reduction among Depressed Patients in Nigeria: A Randomized Controlled Trial

Depression is a common mental health disease with a high risk of relapse in people with a mental health condition. Mindfulness-based cognitive therapy (MBCT) showed higher efficacy in reducing depressive symptoms and prevent relapse for depressed patients. The study examined the effectiveness of MBCT versus the control group (CG) for the depression symptom reduction. A controlled trial was used to examine the effectiveness of MBCT or CG on depressive patients in Nigeria. Out of 357 screened subjects, 101 patients were randomized to receive either MBCT (n = 50) or CG (n = 51) and prospectively followed for 2 months. The intervention delivered according to the published manuals, and Beck Depression Inventory (BDI) was used to assess MDD severity among the patients. All assessments were conducted at three levels (baseline, 2 and 4 months). At the end of the 8 weeks of MBCT intervention, MBCT participants did not have significantly fewer depressive symptoms compared to those in the CG. However, the MBCT group had a significant depressive symptom reduction after 2 month follow up. The findings are in line with other studies, which show MBCT significantly decreased depression severity and improved treatment response rates after 2 months follow up, confirmed MBCT viability in the management of MDD.

Predictors of preference for cognitive-behavioral therapy (CBT) and yoga interventions among older adults

The purpose of this study was to examine factors that influence a person's choice of cognitive-behavioral therapy (CBT) or yoga, the stability of these preferences, and the impact of preference on engagement and process measures. We conducted a randomized preference trial of CBT and yoga in 500 adults ≥60 years with symptoms of worry. Participants reported their intervention preference, strength of preference, and factors impacting preference. Engagement in the intervention (session completion and dropout rates) was assessed. Process measures included satisfaction with the intervention, therapeutic alliance, and intervention expectancy. Neither intervention preference (48% and 52% chose CBT and yoga, respectively) nor strength of preference differed significantly between the two preference trial groups. Intervention expectancies at baseline among those in the preference trial were approximately 4.5 units (40-point scale) higher for their preferred intervention (p < .0001 within each group). A principal component analysis of factors influencing preference identified three constructs. Using logistic regression, components focused on attitudes about CBT or yoga were predictive of ultimate preference (odds ratio = 11.5, 95% C.I.6.3-21.0 per 1SD difference in component 1 for choosing CBT; odds ratio = 7.8, 95% CI4.3-13.9 per 1SD difference in component 2 for choosing yoga). There were no significant differences between the randomized and preference trials on intervention adherence, completion of assessments, intervention satisfaction, or working alliance. Receiving a preferred treatment had no significant effects on intervention outcomes through participant engagement or process measures. When options are limited, providers may have confidence in offering the most readily available non-pharmacological treatments.

Patient Choice in Depression Psychotherapy: Outcomes of Patient-Preferred Therapy Versus Randomly Allocated Therapy

OBJECTIVE

Patient choice is recognized as a factor that influences clinical outcomes and treatment evaluation in mental health care. However, research on how having a choice affects patients with depression has been rare. This Dutch study examined whether patients randomly selected to choose between two types of depression psychotherapy benefited more from treatment than patients randomly assigned to an intervention.

METHODS

Data were derived from a trial of outpatients with depression who were randomly assigned to cognitive therapy (CT), interpersonal psychotherapy (IPT), or a 2-month waitlist control condition followed by the patient's choice of CT or IPT. Treatment groups were combined into a no-choice condition (N=151), with the waitlist as the choice condition (N=31). Multilevel regression was used to compare depression severity (measured with the Beck Depression Inventory-II [BDI-II]) and general psychological distress (measured with the Brief Symptom Inventory [BSI]) posttreatment and at the 5-month follow-up. Differences in patients' pretreatment expectations, beliefs about treatment credibility, and posttreatment evaluation were examined.

RESULTS

No significant differences in clinical outcomes were found between the choice and no-choice conditions (mean difference: BDI-II posttreatment=-0.55, 95% confidence interval [CI]=-5.25 to 4.15; follow-up=2.10, 95% CI=-4.01 to 8.20; BSI posttreatment=-1.89, 95% CI=-15.35 to 11.58; follow-up=3.13, 95% CI=-12.32 to 18.57). Patients in both groups reported comparable scores on pretreatment expectations, credibility beliefs, and posttreatment evaluation. Neither expectations nor credibility beliefs were predictive of clinical outcomes.

CONCLUSIONS

Our findings did not support the value of patient choice. Considering the exploratory nature of the trial, future studies designed to examine the effects of choice in depression treatment are recommended.

Mental Health Screening Needs and Preference in Treatment Types and Providers in African American and Asian American Older Adults

Older African Americans and Asian Americans in the U.S. underuse mental health services, despite their vulnerability to diverse mental health problems. This study examined their perspectives on the importance of various mental health problems, mental health treatment, and provider type preference. A total of 243 participants residing in Philadelphia were recruited through community-based organizations. Chi-square, ANOVA, and logistic regression were conducted to examine ethnic differences in demographic characteristics, mental health screening needs, and treatment preferences. African Americans were more likely to endorse the screening needs for depression (AOR: 3.77; 95% CI: 1.19-11.93, p < 0.05) and less likely to endorse the screening needs for suicide (AOR: 0.24; 95% CI: 0.08-0.76, p < 0.05) compared to Asian Americans. For treatment preferences, African Americans were more likely to seek help from primary care physicians (AOR: 8.26; 95% CI: 1.71-32.86, p < 0.01) and less likely to prefer medication as a treatment option (AOR: 0.36; 95% CI: 0.09-0.79, p < 0.05) than Asian Americans. African Americans and Asian Americans prioritized mental health screening needs differently and had different treatment preferences, indicating that matching community needs and preferences regarding mental health services is critical to improve mental service utilization rates in the targeted populations.

Ketamine treatment for depression: qualitative study exploring patient views

BACKGROUND

Ketamine is a new and promising treatment for depression but comes with challenges to implement because of its potential for abuse.

AIMS

We sought the views of patients to inform policy and practical decisions about the clinical use of ketamine before large-scale roll-out is considered.

METHOD

This qualitative study used three focus groups and three validation sessions from 14 patients with prior diagnoses of depression but no experience of ketamine treatment. Focus groups explored their views about clinical use of ketamine and the best way for ketamine to be administered and monitored. The qualitative data were analysed by three service-user researchers using thematic analysis.

RESULTS

Five themes were generated: changing public perceptions, risks, monitoring, privacy and data protection, and practical aspects. Participants were conscious of the stigma attached to ketamine as a street drug and wanted better public education, and evidence on the safety of ketamine after long-term use. They felt that monitoring was required to provide evidence for ketamine's safe use and administration, but there were concerns about the misuse of this information. Practical aspects included discussions about treatment duration, administration and accessibility (for example who would receive it, under what criteria and how).

CONCLUSIONS

Patients are enthusiastic about ketamine treatment but need more information before national roll-out. The wider societal impact of ketamine treatment also needs to be considered and patients need to be part of any future roll-out to ensure its success.

Impact of Baseline Characteristics on the Effectiveness of Disorder-Specific Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Supportive Psychotherapy in Outpatient Treatment for Persistent Depressive Disorder

Importance: In the treatment of persistent depressive disorder (PDD), disorder-specific Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has been shown to be superior to Supportive Psychotherapy (SP) in outpatients. It remains to clear which subgroups of patients benefit equally and differentially from both psychotherapies. Objective: To identify those patient-level baseline characteristics that predict a comparable treatment effectiveness of CBASP and SP and those that moderate the differential effectiveness of CBASP compared to SP. Design, setting and participants: In this analysis of a 48-week multicenter randomized clinical trial comparing CBASP to SP in adult antidepressant-free outpatients with early-onset PDD, we evaluated baseline variables from the following domains as potential predictors and moderators of treatment effectiveness: socio-demography, clinical status, psychosocial and global functioning, life quality, interpersonal problems, childhood trauma, treatment history, preference for psychotherapy, and treatment expectancy. Interventions: A 48-week treatment program with 32 sessions of either CBASP or SP. Main outcomes and measures: Depression severity measured by the 24-item Hamilton Rating Scale for Depression (HRSD-24) at week 48. Results: From N = 268 randomized outpatients, N = 209 completed the 48-week treatment program. CBASP completers had significantly lower post-treatment HRSD-24 scores than SP completers (meanCBASP=13.96, sdCBASP= 9.56; meanSP= 16.69, sdSP= 9.87; p = 0.04). A poor response to both therapies was predicted by higher baseline levels of clinician-rated depression, elevated suicidality, comorbid anxiety, lower social functioning, higher social inhibition, moderate-to-severe early emotional or sexual abuse, no preference for psychotherapy, and the history of at least one previous inpatient treatment. Moderator analyses revealed that patients with higher baseline levels of self-rated depression, comorbidity of at least one Axis-I disorder, self-reported moderate-to-severe early emotional or physical neglect, or at least one previous antidepressant treatment, had a significantly lower post-treatment depression severity with CBASP compared to SP (all p < 0.05). Conclusions and relevance: A complex multifactorial interaction between severe symptoms of depression, suicidality, and traumatic childhood experiences characterized by abuse, social inhibition, and anxiety may represent the basis of non-response to psychotherapy in patients with early onset PDD. Specific psychotherapy with CBASP might, however, be more effective and recommendable for a variety of particularly burdened patients compared to SP.

Quantitative and Qualitative Strategies to Strengthen Internal Validity in Randomized Trials

Although the randomized controlled trial (RCT) is the most reliable design to infer causality, evidence suggests that it is vulnerable to biases that weaken internal validity. In this paper, we review factors that introduce biases in RCTs and we propose quantitative and qualitative strategies for colleting relevant data to strengthen internal validity. The factors are related to participants' reactions to randomization, attrition, treatment perceptions, and implementation of the intervention. The way in which these factors operate is explained and pertinent empirical evidence is synthesized. Quantitative and qualitative strategies are described. Researchers can plan to assess these factors and examine their influence, providing evidence of what actually contributed to the interventions' causal impact.

Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications

Persistent depressive disorder is a chronic mood disorder that is common and often more disabling than episodic major depression. In DSM-5, the term subsumes several chronic depressive presentations, including dysthymia with or without superimposed major depressive episodes, chronic major depression, and recurrent major depression without recovery between episodes. Dysthymia can be difficult to detect in psychiatric and primary care settings until it intensifies in the form of a superimposed major depressive episode. Although information is scarce concerning the cause of persistent depressive disorder including dysthymia, the causation is likely to be multifactorial. In this narrative Review, we discuss current knowledge about the nosology and neurobiological basis of dysthymia and persistent depressive disorder, emphasising a dimensional perspective based on course for further research. We also review new developments in psychotherapy and pharmacotherapy for persistent depressive disorder, and propose a tailored, modular approach to accommodate its multifaceted nature.

Patients' and clinicians' perspectives on shared decision-making regarding treatment decisions for depression, anxiety disorders, and obsessive-compulsive disorder in specialized psychiatric care

RATIONALE, AIMS, AND OBJECTIVES

People worldwide are affected by psychiatric disorders that lack a "best" treatment option. The role of shared decision-making (SDM) in psychiatric care seems evident, yet remains limited. Research on SDM in specialized mental health is scarce, concentrating on patients with depressive disorder or psychiatric disorders in general and less on patients with anxiety and obsessive-compulsive disorder (OCD). Furthermore, recent research concentrates on the evaluation of interventions to promote and measure SDM rather than on the feasibility of SDM in routine practice. This study investigated patients' and clinicians' perspectives on SDM to treat depression, anxiety disorders, and OCD as to better understand SDM in specialized psychiatric care and its challenges in clinical practice.

METHODS

Transcripts of eight focus groups with 17 outpatients and 33 clinicians were coded, and SDM-related codes were analysed using thematic analyses.

RESULTS

Motivators, responsibilities, and preconditions regarding SDM were defined. Patients thought SDM should be common practice given the autonomy they have over their own bodies and felt responsible for their treatments. Clinicians value SDM for obtaining patients' consent, promoting treatment adherence, and establishing a good patient-clinician relationship. Patients and clinicians thought clinicians assumed the most responsibility regarding the initiation and achievement of SDM in clinical practice. According to clinicians, preconditions were often not met, were influenced by illness severity, and formed important barriers (eg, patient's decision-making capacity, treatment availability, and clinicians' preferences), leading to paternalistic decision-making. Patients recognized these difficulties, but felt none of these preclude the implementation of SDM. Personalized information and more consultation time could facilitate SDM.

CONCLUSIONS

Patients and clinicians in specialized psychiatric care value SDM, but adapting it to daily practice remains challenging. Clinicians are vital to the implementation of SDM and should become versed in how to involve patients in the decision-making process, even when this is difficult.

Association of Patient Treatment Preference With Dropout and Clinical Outcomes in Adult Psychosocial Mental Health Interventions: A Systematic Review and Meta-analysis

IMPORTANCE

Receiving a preferred treatment has previously been associated with lower dropout rates and better clinical outcomes, but this scenario has not been investigated specifically for psychosocial interventions for patients with a mental health diagnosis.

OBJECTIVE

To assess the association of patient treatment preference with dropout and clinical outcomes in adult psychosocial mental health interventions via a systematic review and meta-analysis.

DATA SOURCES

The Cochrane Library, Embase, PubMed, PsychINFO, Scopus, Web of Science, Nice HDAS (Healthcare Databases Advanced Search), Google Scholar, BASE (Bielefeld Academic Search Engine), Semantic Scholar, and OpenGrey were searched from inception to July 20, 2018, and updated on June 10, 2019.

STUDY SELECTION

Studies were eligible if they (1) were a randomized clinical trial; (2) involved participants older than 18 years; (3) involved participants with mental health diagnoses; (4) reported data from a group of participants who received their preferred treatment and a group who received their nonpreferred treatment or who were not given a choice; and (5) offered at least 1 psychosocial intervention.

DATA EXTRACTION AND SYNTHESIS

Two researchers extracted study data for attendance, dropout, and clinical outcomes independently. Both assessed the risk of bias according to the Cochrane tool. Data were pooled using random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

The following 7 outcomes were examined: attendance, dropout, therapeutic alliance, depression and anxiety outcomes, global outcomes, treatment satisfaction, and remission.

RESULTS

A total of 7341 articles were identified, with 34 eligible for inclusion. Twenty-nine articles were included in the meta-analyses comprising 5294 participants. Receiving a preferred psychosocial mental health treatment had a medium positive association with dropout rates (relative risk, 0.62; 0.48-0.80; P < .001; I2 = 44.6%) and therapeutic alliance (Cohen d = 0.48; 0.15-0.82; P = .01; I2 = 20.4%). There was no evidence of a significant association with other outcomes.

CONCLUSIONS AND RELEVANCE

This is the first review, to our knowledge, examining the association of receiving a preferred psychosocial mental health treatment with both engagement and outcomes for patients with a mental health diagnosis. Patients with mental health diagnoses who received their preferred treatment demonstrated a lower dropout rate from treatment and higher therapeutic alliance scores. These findings underline the need to accommodate patient preference in mental health services to maximize treatment uptake and reduce financial costs of premature dropout and disengagement.

Treatment preference and recruitment to pediatric RCTs: A systematic review

BACKGROUND

Recruitment to pediatric randomised controlled trials (RCTs) can be a challenge, with ethical issues surrounding assent and consent. Pediatric RCTs frequently recruit from a smaller pool of patients making adequate recruitment difficult. One factor which influences recruitment and retention in pediatric trials is patient and parent preferences for treatment.

PURPOSE

To systematically review pediatric RCTs reporting treatment preference.

METHODS

Database searches included: MEDLINE, CINAHL, EMBASE, and COCHRANE.Qualitative or quantitative papers were eligible if they reported: pediatric population, (0-17 years) recruited to an RCT and reported treatment preference for all or some of the participants/parents in any clinical area. Data extraction included: Number of eligible participants consenting to randomisation arms, number of eligible patients not randomised because of treatment preference, and any further information reported on preferences (e.g., if parent preference was different from child).

RESULTS

Fifty-two studies were included. The number of eligible families declining participation in an RCT because of preference for treatment varied widely (between 2 and 70%) in feasibility, conventional and preference trial designs. Some families consented to trial involvement despite having preferences for a specific treatment. Data relating to 'participant flow and recruitment' was not always reported consistently, therefore numbers who were lost to follow-up or withdrew due to preference could not be extracted.

CONCLUSIONS

Families often have treatment preferences which may affect trial recruitment. Whilst children appear to hold treatment preferences, this is rarely reported. Further investigation is needed to understand the reasons for preference and the impact preference has on RCT recruitment, retention and outcome.

A meta-analytic examination of attrition in virtual reality exposure therapy for anxiety disorders

A proposed advantage of virtual reality exposure therapy for anxiety disorders is that people will be less likely to drop out of treatment prematurely if the treatment involves facing one's fear in a virtual world rather than the real world, but this has yet to be empirically tested. The present meta-analyses assess the odds of dropout from virtual reality exposure therapy compared to in vivo exposure therapy, estimate the overall rate of dropout from virtual reality exposure treatment, and test potential moderating variables. The odds ratio meta-analysis indicated that there was no significant difference in the likelihood of attrition from virtual reality exposure therapy relative to in vivo exposure therapy. The overall attrition rate for virtual reality exposure therapy across 46 studies with a combined sample size of 1057 participants was 16%. This rate is slightly lower than other estimates of dropout from in vivo therapy and from cognitive-behavioral therapy for anxiety disorders. Incorporation of between-session intervention (i.e., homework) was identified as a moderator; specifically, inclusion of between-session interventions in the treatment was associated with better retention. Overall, the findings of the present study indicate that virtual reality exposure and in vivo exposure therapy show similar rates of attrition.

Clinical and sociodemographic associations with treatment selection in major depression

OBJECTIVE

To investigate treatment selection in a naturalistic sample of MDD outpatients and the factors influencing treatment selection in specialized psychiatric care.

METHOD

Multinomial Logistic Regression analysis investigated associations between treatment selection and patients' sociodemographic and clinical characteristics, using retrospective chart review data and Routine Outcome Monitoring (ROM) data of MDD outpatients.

RESULTS

Of the patients included for analyses (N = 263), 34% received psychotherapy, 32% received an antidepressant (AD) and 35% received a combination. Men were more likely than women to receive AD with reference to psychotherapy (OR_AD = 5.57, 95% CI 2.38-13.00). Patients with severe depression and patients with AD use upon referral, prescribed by their general practitioner, were more likely to receive AD (OR_{severe depression} = 5.34, 95% CI 1.70-16.78/OR_{AD GP} = 9.26, 95% CI 2.53-33.90) or combined treatment (OR_{severe depression} = 6.32, 95% CI 1.86-21.49/OR_{AD GP} = 22.36, 95% CI 5.89-83.59) with respect to psychotherapy. More severe patients with AD upon referral received combined treatment less often compared to psychotherapy (OR = 0.14, 95% CI 0.03-0.68).

CONCLUSION

AD prescriptions in primary care, severity and gender influenced treatment selection for depressive disorders in secondary psychiatric care. Other factors such as the accessibility of treatment and patient preferences may have played a role in treatment selection in this setting and need further investigation.

Extractive from Hypericum ascyron L promotes serotonergic neuronal differentiation in vitro

BACKGROUND

Plant natural products have many different biological activities but the precise mechanisms underlying these activities remain largely unknown. Hypericum longistylum has long been recorded in Chinese medicine as a cure for depression and related disorders, but how it repairs neural lineages has not been addressed.

METHODS

We extracted compounds from Hypericum longistylum and determined their effect on neural differentiation of embryonic stem cells (ESCs) in vitro by using the Pax6-GFP reporter system. The amount of serotonin released during differentiation was measured by HPLC. The tail suspension test and forced swimming test was performed for determining the effect of compounds on depression-like behaviors in mice.

RESULTS

We found that one of the phloroglucinol derivatives not only facilitated differentiation of neural progenitor cells, but also increased the efficiency of differentiation into serotonergic neurons. This compound also improved the behaviors of mice placed in a stressful environment and reduced signs of depression.

CONCLUSIONS

This is the first use of Chinese herb derived-natural products to promote neurogenesis of ESCs, including the generation of serotonergic neurons, and the first attempt to identify the active compound in Hypericum longistylum responsible for its beneficial effects on depressive diseases.

Group-based multicomponent treatment to reduce depressive symptoms in women with co-morbid psychiatric and psychosocial problems during pregnancy: A randomized controlled trial

BACKGROUND

Depressive symptoms in pregnant women, which are common and debilitating, are often co-morbid with other mental disorders (e.g. anxiety and personality disorders), and related to low socioeconomic status (SES). This situation may hamper treatment outcome, which has often been neglected in previous studies on the treatment of depression during pregnancy. We developed a new group-based multicomponent treatment (GMT) comprising cognitive behavioral therapy, psycho-education and body-oriented therapy and compared the effect on depressive symptoms with individual counseling (treatment as usual, TAU) in a heterogeneous group of pregnant women with co-morbid mental disorders and/or low SES.

METHODS

An outpatient sample from a university hospital of 158 pregnant women who met DSM-IV criteria for mental disorders were included and 99 participants were randomized to GMT or TAU from January 2010 until January 2013. The Edinburgh Depression Scale (EDS) was used at baseline, every 5 weeks during pregnancy and as the primary outcome measure of depressive symptoms at 6 weeks postpartum. Secondary outcome measures included the clinician-reported Hamilton Depression Rating Scale (HDRS), obstetric outcomes and a 'Patient Satisfaction' questionnaire.

RESULTS

155 participants were included the intention-to-treat (ITT)-analysis. GMT was not superior above TAU according to estimated EDS (β = 0.13, CI = - 0.46-0.71, p = 0.67) and HDRS scores (β = - 0.39, CI = - 0.82-0.05, p = 0.08) at 6 weeks postpartum. There were no differences in secondary outcomes between the GMT and TAU, nor between the randomized condition and patient-preference condition.

LIMITATIONS

The ability to detect an effect of GMT may have been limited by sample size, missing data and the ceiling effect of TAU.

CONCLUSIONS

GMT is an acceptable treatment for a heterogeneous group of pregnant women with depressive symptoms and co-morbid mental disorders and/or low SES, but not superior to TAU. Further research should focus on understanding and treating co-morbid disorders and psychosocial problems during pregnancy.

CLINICAL TRIALS REGISTRATION

Dutch trial registry, www.trialregister.nl under reference number: NTR3015.

Preferences for Depression Treatment Including Internet-Based Interventions: Results From a Large Sample of Primary Care Patients

Background: To date, little is known about treatment preferences for depression concerning new media. This study aims to (1) investigate treatment preferences for depression including internet-based interventions and (2) examine subgroup differences concerning age, gender and severity of depression as well as patient-related factors associated with treatment preferences. Methods: Data were derived from the baseline assessment of the @ktiv-trial. Depression treatment preferences were assessed from n = 641 primary care patients with mild to moderate depression regarding the following treatments: medication, psychotherapy, combined treatment, alternative treatment, talking to friends and family, exercise, self-help literature, and internet-based interventions. Depression severity was specified by GPs according to ICD-10 criteria. Ordinal logistic regression models were conducted to identify associated factors of treatment preferences. Results: Patients had a mean age of 43.9 years (SD = 13.8) and more than two thirds (68.6%) were female. About 43% of patients had mild depression while 57% were diagnosed with moderate depression. The majority of patients reported strong preferences for psychotherapy, talking to friends and family, and exercise. About one in five patients was very likely to consider internet-based interventions in case of depression. Younger patients expressed significantly stronger treatment preferences for psychotherapy and internet-based interventions than older patients. The most salient factors associated with treatment preferences were the patients' education and perceived self-efficacy. Conclusions: Patients with depression report individually different treatment preferences.Our results underline the importance of shared decision-making within primary care. Future studies should investigate treatment preferences for different types of internet-based interventions.

Effect of Cognitive Behavioral Therapy Versus Interpersonal Psychotherapy in Patients with Major Depressive Disorder: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Practice guidelines have recommended cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as the treatment of choice for major depression disorder (MDD). However, whether one therapy is better than the other remains inconclusive. The aim of this study was to compare the treatment efficacy of the two treatment approaches for MDD.

METHODS

Using the terms "cognitive behavior therapy or cognitive therapy or CBT or CT or cognitive behavioral therapy" and "interpersonal psychotherapy or IPT," we systematically searched PubMed, Psyclnfo and Chinese National Knowledge Infrastructure databases up to February 2017. The language was restricted to be English and Chinese. Therapeutic outcomes, characteristics, and research quality were then extracted and analyzed independently. In accessing the included studies, we followed the criteria suggested by the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Data for 946 patients from 10 randomized controlled trials were included in the study. Methodological quality was not optimal in most trials. Meta-analysis showed a mean difference (MD) of -1.31, 95% confidence interval (CI) (-2.49, -0.12) (P < 0.05) in favor of CBT according to the Beck Depression Inventory (BDI), and however, we did not found any statistically significant difference between CBT and IPT on the Hamilton Rating Scale for depression (HRSD) (MD -0.90, 95% CI [-2.18, 0.38]). Subgroup analyses for the studies in which patients were treated only by psychotherapy (MD -1.26, 95% CI [-2.78, 0.35]) and for those which offered more sessions of therapies (MD -0.82, 95% CI [-2.23, 0.59]) showed there was no significant difference between CBT and IPT according to BDI.

CONCLUSIONS

Differences in treatment efficacy seem to vary according to different outcome measures. CBT shows an advantage over IPT for MDD according to BDI, and there is no significant difference between the two according to HRSD. These results should be interpreted with caution.

Effects of Patient Preferences on Outcomes in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) Study

OBJECTIVE

The Predictors of Remission in Depression to Individual and Combined Treatments [PReDICT] study aimed to identify clinical and biological factors predictive of treatment outcomes in major depressive disorder among treatment-naive adults. The authors evaluated the efficacy of cognitive-behavioral therapy (CBT) and two antidepressant medications (escitalopram and duloxetine) in patients with major depression and examined the moderating effect of patients' treatment preferences on outcomes.

METHOD

Adults aged 18-65 with treatment-naive major depression were randomly assigned with equal likelihood to 12 weeks of treatment with escitalopram (10-20 mg/day), duloxetine (30-60 mg/day), or CBT (16 50-minute sessions). Prior to randomization, patients indicated whether they preferred medication or CBT or had no preference. The primary outcome was change in the 17-item Hamilton Depression Rating Scale (HAM-D), administered by raters blinded to treatment.

RESULTS

A total of 344 patients were randomly assigned, with a mean baseline HAM-D score of 19.8 (SD=3.8). The mean estimated overall decreases in HAM-D score did not significantly differ between treatments (CBT: 10.2, escitalopram: 11.1, duloxetine: 11.2). Last observation carried forward remission rates did not significantly differ between treatments (CBT: 41.9%, escitalopram: 46.7%, duloxetine: 54.7%). Patients matched to their preferred treatment were more likely to complete the trial but not more likely to achieve remission.

CONCLUSIONS

Treatment guidelines that recommend either an evidence-based psychotherapy or antidepressant medication for nonpsychotic major depression can be extended to treatment-naive patients. Treatment preferences among patients without prior treatment exposure do not significantly moderate symptomatic outcomes.

Effectiveness of a decision aid for patients with depression: A randomized controlled trial

Background

Shared decision making is an important component of patient‐centred care and decision aids are tools designed to support patients' decision making and help patients with depression to make informed choices.

Objective

The study aim was to assess the effectiveness of a web‐based decision aid for patients with unipolar depression.

Design

Randomized controlled trial.

Setting and participants

Adults diagnosed with a major depressive disorder and recruited in primary care centres were included and randomized to the decision aid (n=68) or usual care (n=79).

Intervention

Patients in the decision aid group reviewed the decision aid accompanied by a researcher.

Outcome measures

Knowledge about treatment options, decisional conflict, treatment intention and preference for participation in decision making. We also developed a pilot measure of concordance between patients' goals and concerns about treatment options and their treatment intention.

Results

Intervention significantly improved knowledge (P<.001) and decisional conflict (P<.001), and no differences were observed in treatment intention, preferences for participation, or concordance. One of the scales developed to measure goals and concerns showed validity issues.

Conclusion

The decision aid “Decision making in depression” is effective improving knowledge of treatment options and reducing decisional conflict of patients with unipolar depression. More research is needed to establish a valid and reliable measure of concordance between patients' goals and concerns regarding pharmacological and psychological treatment, and the choice made.

The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials

BACKGROUND

Chronic depression is a severe and disabling condition. Compared to an episodic course, chronic depression has been shown to be less responsive to psychopharmacological and psychological treatments. The cognitive behavioral analysis system of psychotherapy (CBASP) has been developed as a specific psychotherapy for chronic depression. However, conflicting results concerning its efficacy have been reported in randomized-controlled trials (RCT). Therefore, we aimed at examining the efficacy of CBASP using meta-analytical methods.

METHODS

Randomized-controlled trials assessing the efficacy of CBASP in chronic depression were identified by searching electronic databases (PsycINFO, PubMed, Scopus, Cochrane Central Register of Controlled Trials) and by manual searches (citation search, contacting experts). Searching period was restricted from the first available entry to October 2015. Identified studies were systematically reviewed. The standardized mean difference Hedges' g was calculated from posttreatment and mean change scores. The random-effects model was used to compute combined overall effect sizes. A risk of publication bias was addressed using fail-safe N calculations and trim-and-fill analysis.

RESULTS

Six studies comprising 1.510 patients met our inclusion criteria. The combined overall effect sizes of CBASP versus other treatments or treatment as usual (TAU) pointed to a significant effect of small magnitude (g = 0.34-0.44, P < 0.01). In particular, CBASP revealed moderate-to-high effect sizes when compared to TAU and interpersonal psychotherapy (g = 0.64-0.75, P < 0.05), and showed similar effects when compared to antidepressant medication (ADM) (g = -0.29 to 0.02, ns). The combination of CBASP and ADM yielded benefits over antidepressant monotherapy (g = 0.49-0.59, P < 0.05).

LIMITATIONS

The small number of included studies, a certain degree of heterogeneity among the study designs and comparison conditions, and insufficient data evaluating long-term effects of CBASP restrict generalizability yet.

CONCLUSIONS

We conclude that there is supporting evidence that CBASP is effective in the treatment of chronic depression.

Testing of a Statewide Initiative to Enhance Depression Care in Older Home Care Patients

Late-life depression is becoming increasingly prevalent among older adults in the United States and is predictive of a wide range of negative health-related outcomes. Fourteen home care agencies participated in a quasi-experimental, pre-test, post-test design of a depression screening training program nested within a two-cycle, phased introduction of the intervention. The primary aim of this study was to evaluate the effects of the program at three levels of outcomes: the trainers, the trainees, and the agencies. There was a significant increase in the knowledge and self-efficacy of the trainers and trainees and a trend toward decreased hospitalization.

Treating Depression: What Patients Want; Findings From a Randomized Controlled Trial in Primary Care

OBJECTIVE

To highlight clinical and sociodemographic factors associated with patients' preference in the treatment of depression, we conducted a randomized controlled trial comparing the efficacy of selective serotonin reuptake inhibitors and interpersonal counseling in patients with a major depressive episode.

METHODS

Patients, recruited from a psychiatric consultation service in the primary care setting, were asked to express their preference for the type of treatment before randomization to one of the 2 intervention arms. Severity of depressive symptoms and functional impairment was assessed using the 21-item Hamilton Rating Scale for Depression and the Work and Social Adjustment Scale, respectively.

RESULTS

A total of 170 patients were evaluated, 87 (51.2%) patients expressed their preference for interpersonal counseling and 83 (48.8%) for selective serotonin reuptake inhibitors. Depression severity and treatment preference showed significant correlations. Preference for interpersonal counseling was related to mild depression and greater functional impairment, whereas patients with moderate or severe depression were more likely to prefer medication. Remission rates and functional level were not related to treatment preference at the end of the study.

CONCLUSION

Treatment preference is a critical factor, influenced by clinical and sociodemographic characteristics, and further studies are needed to improve its clinical relevance.

Cognitive-Behavioural Analysis System of Psychotherapy (CBASP), a drug, or their combination: differential therapeutics for persistent depressive disorder: a study protocol of an individual participant data network meta-analysis

INTRODUCTION

Despite important advances in psychological and pharmacological treatments of persistent depressive disorders in the past decades, their responses remain typically slow and poor, and differential responses among different modalities of treatments or their combinations are not well understood. Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) is the only psychotherapy that has been specifically designed for chronic depression and has been examined in an increasing number of trials against medications, alone or in combination. When several treatment alternatives are available for a certain condition, network meta-analysis (NMA) provides a powerful tool to examine their relative efficacy by combining all direct and indirect comparisons. Individual participant data (IPD) meta-analysis enables exploration of impacts of individual characteristics that lead to a differentiated approach matching treatments to specific subgroups of patients.

METHODS AND ANALYSIS

We will search for all randomised controlled trials that compared CBASP, pharmacotherapy or their combination, in the treatment of patients with persistent depressive disorder, in Cochrane CENTRAL, PUBMED, SCOPUS and PsycINFO, supplemented by personal contacts. Individual participant data will be sought from the principal investigators of all the identified trials. Our primary outcomes are depression severity as measured on a continuous observer-rated scale for depression, and dropouts for any reason as a proxy measure of overall treatment acceptability. We will conduct a one-step IPD-NMA to compare CBASP, medications and their combinations, and also carry out a meta-regression to identify their prognostic factors and effect moderators. The model will be fitted in OpenBUGS, using vague priors for all location parameters. For the heterogeneity we will use a half-normal prior on the SD.

ETHICS AND DISSEMINATION

This study requires no ethical approval. We will publish the findings in a peer-reviewed journal. The study results will contribute to more finely differentiated therapeutics for patients suffering from this chronically disabling disorder.

TRIAL REGISTRATION NUMBER

CRD42016035886.

Patients with a preference for medication do equally well in mindfulness-based cognitive therapy for recurrent depression as those preferring mindfulness

BACKGROUND

Previous studies have suggested that patients' treatment preferences may influence treatment outcome. The current study investigated whether preference for either mindfulness-based cognitive therapy (MBCT) or maintenance antidepressant medication (mADM) to prevent relapse in recurrent depression was associated with patients' characteristics, treatment adherence, or treatment outcome of MBCT.

METHODS

The data originated from two parallel randomised controlled trials, the first comparing the combination of MBCT and mADM to MBCT in patients preferring MBCT (n=249), the second comparing the combination to mADM alone in patients preferring mADM (n=68). Patients' characteristics were compared across the trials (n=317). Subsequently, adherence and clinical outcomes were compared for patients who all received the combination (n=154).

RESULTS

Patients with a preference for mADM reported more previous depressive episodes and higher levels of mindfulness at baseline. Preference did not affect adherence to either MBCT or mADM. With regard to treatment outcome of MBCT added to mADM, preference was not associated with relapse/recurrence (χ(2)=0.07; p=.80), severity of (residual) depressive symptoms during the 15-month follow-up period (β=-0.08, p=.49), or quality of life.

LIMITATIONS

The group preferring mADM was relatively small. The influence of preferences on outcome may have been limited in the current study because both preference groups received both interventions.

CONCLUSIONS

The fact that patients with a preference for medication did equally well as those with a preference for mindfulness supports the applicability of MBCT for recurrent depression. Future studies of MBCT should include measures of preferences to increase knowledge in this area.

SECOND-STAGE TREATMENTS FOR RELATIVE NONRESPONDERS TO COGNITIVE BEHAVIORAL THERAPY (CBT) FOR PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA-CONTINUED CBT VERSUS SSRI: A RANDOMIZED CONTROLLED TRIAL

BACKGROUND

Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT.

METHOD

The current trial is a second-step stratified randomized design comparing two treatment conditions-selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively.

RESULTS

Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms.

CONCLUSIONS

These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

A Randomized Controlled Trial of Mindfulness-Based Cognitive Therapy for Treatment-Resistant Depression

BACKGROUND

Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD.

METHODS

This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission.

RESULTS

We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes.

CONCLUSIONS

MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.

Patients׳ perspectives on how treatment can impede their recovery from depression

BACKGROUND

More than 50% of all major depressive disorder (MDD) patients experience insufficient improvement from the available treatment options. There is emerging evidence that patients׳ beliefs and experiences about MDD treatment influence treatment outcomes. The aim was to explore patients׳ perspectives on impeding characteristics of professional treatment for the recovery of MDD.

METHODS

In-depth interviews in a purposive sample with 27 recovered MDD patients who had received professional treatment. Data were qualitatively analyzed using constant comparison.

RESULTS

Participants׳ accounts yielded four major impeding themes: lack of clarity and consensus about the nature of the participants׳ MDD and the content of their treatment; precarious relationship with the clinician; unavailability of mental health care; and insufficient involvement of significant others.

LIMITATIONS

The external generalizability may be limited due to missed other subgroups within depression.

CONCLUSIONS

This study identified a comprehensive overview of impeding characteristics in MDD treatment from patients׳ perspectives. This may help clinicians to understand how patients experience MDD treatment, and to incorporate patients׳ perspectives about treatment into their joint decision-making. This can lead towards increased treatment adherence, motivation and finally success.

Are there racial/ethnic disparities in VA PTSD treatment retention?

BACKGROUND

Chronic posttraumatic stress disorder (PTSD) can result in significant social and physical impairments. Despite the Department of Veterans Affairs' (VA) expansion of mental health services into primary care clinics to reach larger numbers of Veterans with PTSD, many do not receive sufficient treatment to clinically benefit. This study explored whether the odds of premature mental health treatment termination varies by patient race/ethnicity and, if so, whether such variation is associated with differential access to services or beliefs about mental health treatments.

METHODS

Prospective national cohort study of VA patients who were recently diagnosed with PTSD (n = 6,788). Self-administered surveys and electronic VA databases were utilized to examine mental health treatment retention across racial/ethnic groups in the 6 months following the PTSD diagnosis controlling for treatment need, access factors, age, gender, treatment beliefs, and facility factors.

RESULTS

African American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and African American Veterans were less likely to receive a minimal trial of any treatment in the 6 months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino but not African American Veterans. Access factors did not contribute to treatment retention disparities.

CONCLUSIONS

Even in safety-net healthcare systems like VA, racial and ethnic disparities in mental health treatment occur. To improve treatment equity, clinicians may need to more directly address patients' treatment beliefs. More understanding is needed to address the treatment disparity for African American Veterans.

Attitudes and Preferences towards Self-help Treatments for Depression in Comparison to Psychotherapy and Antidepressant Medication

Background: Self-help is an effective treatment for depression. Less is known, however, about how acceptable people find different self-help treatments for depression. Aims: To investigate preferences and attitudes toward different self-help treatments for depression in comparison to psychotherapy and antidepressants. Method:N = 536 people who were not actively seeking treatment for depression were randomly assigned to read about one of five treatment options (bibliotherapy, Internet-based self-help, guided self-help, antidepressants, or psychotherapy) before rating how acceptable they found the treatment. Participants also ranked the treatments in order of preference. Results: Psychotherapy and guided self-help were found to be the most acceptable and preferred treatment options. Antidepressants and bibliotherapy were found to be the least acceptable treatments, with antidepressants rated as the most likely to have side effects. Preference data reflected the above findings – psychotherapy and guided self-help were the most preferred treatment options. Conclusions: The findings highlight differences in attitudes and preferences between guided and unguided self-help interventions; and between self-help interventions and psychotherapy. Future research should focus on understanding why unguided self-help interventions are deemed to be less acceptable than guided self-help interventions for treating depression.

The effects of amount of home meditation practice in Mindfulness Based Cognitive Therapy on hazard of relapse to depression in the Staying Well after Depression Trial

Few empirical studies have explored the associations between formal and informal mindfulness home practice and outcome in Mindfulness-based Cognitive Therapy (MBCT). In this study ninety-nine participants randomised to MBCT in a multi-centre randomised controlled trial completed self-reported ratings of home practice over 7 treatment weeks. Recurrence of Major Depression was assessed immediately after treatment, and at 3, 6, 9, and 12-months post-treatment. Results identified a significant association between mean daily duration of formal home practice and outcome and additionally indicated that participants who reported that they engaged in formal home practice on at least 3 days a week during the treatment phase were almost half as likely to relapse as those who reported fewer days of formal practice. These associations were independent of the potentially confounding variable of participant-rated treatment plausibility. The current study identified no significant association between informal home practice and outcome, although this may relate to the inherent difficulties in quantifying informal home mindfulness practice. These findings have important implications for clinicians discussing mindfulness-based interventions with their participants, in particular in relation to MBCT, where the amount of participant engagement in home practice appears to have a significant positive impact on outcome.

•

We examine the relation between home practice and outcome in people receiving MBCT.

•

Formal home practice is negatively associated with hazard of relapse to depression.

•

Those who engage in such practice at least three days/week approximately halve hazard of relapse.

•

Informal home practice was unrelated to risk of relapse to major depression.

•

Effects of formal home practice on outcome are not confounded with treatment plausibility.

Client preferences affect treatment satisfaction, completion, and clinical outcome: a meta-analysis

We conducted a meta-analysis on the effects of client preferences on treatment satisfaction, completion, and clinical outcome. Our search of the literature resulted in 34 empirical articles describing 32 unique clinical trials that either randomized some clients to an active choice condition (shared decision making condition or choice of treatment) or assessed client preferences. Clients who were involved in shared decision making, chose a treatment condition, or otherwise received their preferred treatment evidenced higher treatment satisfaction (ESd=.34; p<.001), increased completion rates (ESOR=1.37; ESd=.17; p<.001), and superior clinical outcome (ESd=.15; p<.0001), compared to clients who were not involved in shared decision making, did not choose a treatment condition, or otherwise did not receive their preferred treatment. Although the effect sizes are modest in magnitude, they were generally consistent across several potential moderating variables including study design (preference versus active choice), psychoeducation (informed versus uninformed), setting (inpatient versus outpatient), client diagnosis (mental health versus other), and unit of randomization (client versus provider). Our findings highlight the clinical benefit of assessing client preferences, providing treatment choices when two or more efficacious options are available, and involving clients in treatment-related decisions when treatment options are not available.

The influence of patients' preference/attitude towards psychotherapy and antidepressant medication on the treatment of major depressive disorder

BACKGROUND AND OBJECTIVES

Preferences and attitudes patients hold towards treatment are important, as these can influence treatment outcome. In depression research, the influence of patients' preference/attitudes on outcome and dropout has mainly been studied for antidepressant medication, and less for psychological treatments. We investigated the effects of patients' preference and attitudes towards psychological treatment and antidepressant medication on treatment outcome and dropout, and tested specificity of effects.

METHODS

Data are based on a randomized trial testing the effectiveness of behavioural activation (BA) vs antidepressant medication (ADM) for major depression (MDD) in Iran. Patients with MDD (N = 100) were randomized to BA (N = 50) or ADM (N = 50). Patients' preference/attitudes towards psychotherapy and ADM were assessed at baseline and associated with dropout and treatment outcome using logistic regression and multilevel analysis.

RESULTS

High scores on psychotherapy preference/attitude and low scores on ADM preference/attitude predicted dropout from ADM, while no association between dropout and preference/attitude was found in BA. Psychotherapy preference/attitude moderated the differential effect of BA and ADM on one outcome measure, but the association disappeared after one year.

LIMITATIONS

Because in Iran most patients have only access to ADM, offering a psychological treatment for depression could attract especially those patients that prefer this newly available treatment.

CONCLUSIONS

Patients' preferences and attitudes towards depression treatments influence dropout from ADM, and moderate the short-term difference in effectiveness between BA and ADM. The fact that dropout from BA was not affected by preference/attitude speaks for its acceptability among patients.

Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans

There is considerable public and professional concern about the mental health status of veterans deployed to Iraq and Afghanistan as well as how to engage and retain symptomatic veterans in treatment. This study examined demographic, psychiatric, and psychosocial determinants of prospective initiation and retention in mental health services among symptomatic Iraq/Afghanistan veterans. One hundred thirty-seven symptomatic veterans who were referred to mental health screening completed a survey at the time of their first mental health visit. Associations between survey variables and subsequent Veterans Affairs service utilization were evaluated. The most consistent determinants of mental health service initiation and retention were severity of posttraumatic stress disorder (PTSD) and depressive symptoms. Notably, whereas PTSD-related re-experiencing symptoms were independently associated with initiation of mental health treatment, PTSD-related numbing symptoms were independently associated with retention in treatment. Stigma, barriers to care, and beliefs about mental health treatment were not associated with either mental health initiation or retention.

Should treatment for depression be based more on patient preference?

Patient treatment preferences are of growing interest to researchers, clinicians, and patients. In this review, an overview of the most commonly recommended treatments for depression is provided, along with a brief review of the evidence supporting their efficacy. Studies examining the effect of patient treatment preferences on treatment course and outcome are summarized. Existing literature on what treatment options patients tend to prefer and believe to be helpful, and what factors may affect these preferences, is also reviewed. Finally, clinical implications of research findings on patient preferences for depression management are discussed. In summary, although our knowledge of the impact of patient preferences on treatment course and outcome is limited, knowing and considering those preferences may be clinically important and worthy of greater study for evidence-based practice.