Mental health service use by patients with dysthymic disorder: treatment use and dropout in a 7 1/2-year naturalistic follow-up study

Ethnic Identity and Mechanisms of Mental Health Service Engagement Among Young Adults with Serious Mental Illnesses

PURPOSE

Young adults from minoritized racial and ethnic groups have lower rates of engagement in treatment for serious mental illnesses (SMI). Previous research suggests a relationship between ethnic identity development and engagement in mental health services, but it remains unclear how a sense of belonging and attachment to one's racial and ethnic group influences participation in treatment among young adults with SMI.

METHODS

Bivariate analyses and structural equation modeling (SEM) were used to examine whether ethnic identity was associated with treatment engagement (attendance and investment in treatment) and how ethnic identity might influence engagement through theoretical proximal mediators. Eighty-three young adults with SMI (95% from minoritized racial and ethnic groups) were recruited from four outpatient psychiatric rehabilitation programs and assessed at least 3 months after initiating services.

RESULTS

Stronger ethnic identity was associated with greater investment in treatment but not with treatment attendance. The SEM analysis indicated that stronger ethnic identity may improve investment in treatment by enhancing hope (0.53, p < .05) and beliefs that mental health providers are credible (0.32, p < .05), and by increasing self-efficacy (-0.09, p < .05). Proximal mediators of engagement were associated with investment in treatment (hope and credibility, p < .05, and self-efficacy p = 0.055).

CONCLUSIONS

Findings provide preliminary evidence of an empirical and theoretical relationship between ethnic identity development and engagement in treatment among young adults with SMI. Assessment and strengthening of a young person's ethnic identity may be a promising approach for improving their engagement in services and reducing inequities in their care.

Racial and ethnic differences in suicidal behavior and mental health service use among US adults, 2009-2020

BACKGROUND

While suicide rates have recently declined for White individuals, rates among Black and Hispanic individuals have increased. Yet, little is known about racial/ethnic differences in precursors to suicide, including suicidal ideation (SI) and suicide attempts (SA).

METHODS

Data from 2009-2020 National Survey of Drug Use and Health (NSDUH) consisted of non-institutionalized US civilians aged ⩾18 (n = 426 008). We compared proportions of White, Black, and Hispanics among adults reporting no past-year suicidal thoughts/behavior, SI, and SA. Multivariable-adjusted analyses were used to evaluate the independence of observed racial/ethnic differences in past-year SI, SA, and mental health service use.

RESULTS

In the entire sample, 20 791 (4.9%) reported past-year SI only and 3661 (0.9%) reported a SA. Compared to White individuals, Black and Hispanic individuals were significantly less likely to report past-year SI [OR 0.73 (95% CI 0.69-0.77); OR 0.75 (95% CI 0.71-0.79), respectively], but more likely to report a past-year SA [OR 1.45 (95% CI 1.28-1.64); OR 1.19 (95% CI 1.04-1.37), respectively] even after multivariable adjustment. Black and Hispanic individuals were significantly less likely to use mental health services, but the lack of significant interactions between race/ethnicity and SI/SA in association with service use suggests differences in service use do not account for differences in SI or SA.

CONCLUSIONS

Black and Hispanic individuals are significantly less likely than White individuals to report SI but more likely to report SAs, suggesting differences in suicidal behavior across race/ethnicity that may be impacted by socio-culturally acceptable expressions of distress and structural racism in the healthcare system.

Does use of primary care-based behavioral health programs differ by race and ethnicity? Evidence from a multi-site collaborative care model

BACKGROUND

Collaborative care models (CoCM) that integrate mental health and primary care improve outcomes and could help address racial and ethnic mental health disparities. We examined whether use of these programs differs by race/ethnicity.

METHODS

This retrospective study examined two CoCM interventions implemented across primary care clinics in a large health system in Massachusetts: 1) a primary care-based behavioral health program for depression or anxiety (IMPACT model) and 2) referral to community-based specialty care services (Resource-finding). Outcomes included enrollment, non-completion, and symptom screening rates, and discharge status for Black, Hispanic and White patients referred for CoCM, 2017-2019.

RESULTS

Black and Hispanic vs. White patients referred to CoCM (n = 17,280) were more likely to live in high poverty ZIP codes (34% and 40% vs. 9%). Rates of program enrollment, non-completion, and symptom screening were similar across groups (e.g., 76%, 77%, and 75% of Black, Hispanic, and White patients enrolled). Hispanic vs. White patients were more likely to be enrolled in IMPACT (56%) vs. Resource-finding (43%). Among those completing IMPACT, Hispanic vs. White patients were more likely to be stepped to psychiatry vs. discharged to their primary care provider (51% vs. 20%, aOR = 1.55, 95% CI: 1.02-2.35).

CONCLUSIONS

Black and Hispanic patients referred to CoCM were similarly likely to use the program as White patients. Hispanic patients completing IMPACT were more frequently referred to psychiatry.

IMPLICATIONS

These results highlight the promise of CoCMs for engaging minority populations in mental healthcare. Hispanic patients may benefit from additional intervention or earlier linkage to specialty care.

Negative health outcomes in depressed cardiac patients are associated with both low and high psychological well-being dimensions

Literature supports the positive effects of psychological well-being (P.W.B.) on health. However, most studies focused on the unitary construct of P.W.B., neglecting the different role played by distinct P.W.B. dimensions on health-related outcomes. The aim of this study was to determine whether unbalanced (i.e. low or high) levels of P.W.B. dimensions could differentially affect cardiac course after acute coronary syndrome (A.C.S.), in terms of participation in secondary prevention (S.P.) and/or survival. The sample included 136 depressed and/or demoralized A.C.S. patients referred for a S.P. program on lifestyle modification, in addition to routine cardiac visits provided by the hospital where they were admitted. Psychological assessment included validated interviews on depression and demoralization, Symptom Questionnaire and Psychological Well-Being scales. 100 patients joined the S.P. program, 36 did not. Logistic regression revealed that older age (B = 0.051; p < 0.05), higher autonomy (B = 0.070; p < 0.05) and lower personal growth (B = -0.073; p < 0.05) levels were associated with non-participation in S.P. Moreover, only among patients who did not join the program, those presenting with an impaired level of P.W.B. 'positive relations' dimension (i.e. below the 25^th percentile) showed a worse cardiac prognosis (Log Rank: χ²₍₁₎ = 4.654; p = 0.031). Negative health outcomes in depressed cardiac patients, such as non-participation in S.P. and worse cardiac course, are associated with both high and low levels of certain P.W.B. dimensions. Psychotherapeutic approaches geared to a balance in P.W.B. dimensions could represent promising new additions to S.P. programs.

Impact of a brief intervention to improve engagement in a recovery program for young adults with serious mental illness

OBJECTIVE

Serious mental illnesses (SMI) commonly emerge during young adulthood. Effective treatments for this population exist; however, engagement in treatment is a persistent challenge. This study examines the impact of Just Do You (JDY), an innovative intake-focused intervention designed to improve engagement in treatment and enhance personal recovery.

METHODS

The study used a parallel group randomized trial to examine if and how JDY improved recovery among 121 young adults with SMI from low-resourced communities referred to personalized recovery-oriented services (PROS). Measures of engagement (buy-in and attendance) and personal recovery in this pilot study were assessed at baseline and 3-month follow-up.

RESULTS

Participants in JDY reported more positive engagement outcomes; that is, relative to the control group they reported higher past two week attendance (b = 0.72, p < 0.05, Cohen's d = 0.56) and higher levels of buy-in to treatment (b = 2.42, p < 0.05, Cohen's d = 0.50). JDY also impacted young adults' personal recovery (b = 0.99, p < 0.05, Cohen's d = 1.15) and did so largely by increasing their level of buy-in to the treatment program.

CONCLUSION

This study suggests that an engagement intervention for young adults that orients, prepares, and empowers them to be active and involved in the larger treatment program makes a difference by improving engagement and enhancing recovery. Data also support conceptualizing and examining engagement beyond treatment attendance; in this study what mattered most for recovery was the level of buy-in to treatment among young adults.

Engagement intervention versus treatment as usual for young adults with serious mental illness: a randomized pilot trial

BACKGROUND

Young adults have elevated rates of mental health disorders, yet they often do not receive consistent care. The challenge of continuing to engage young adults has been pervasive worldwide. Few engagement interventions have been designed for young adults with serious mental illness. Just Do You is a theoretically guided engagement intervention. It uses innovative modalities (i.e., technology, expressive arts activities, narrative expression, mentoring) to engage participants in conversations about services and how they work, while simultaneously orienting them to treatment.

METHODS/DESIGN

This pilot and feasibility study utilizes a hybrid research design, examining feasibility, acceptability, and preliminary impact, alongside implementation. The study combines qualitative methods, a small pilot randomized trial, and a small cost-benefit analysis. Respondents are clinic staff and young adults who have made initial contact with the Personalized Recovery Oriented Services (PROS) program. Quantitative survey data are collected at baseline, 2 weeks (post-intervention), 1 month, and 3 months. The assessments focus on measuring feasibility, acceptability, engagement, and mental health outcomes. Medical record extraction will be used to triangulate self-report data. We will conduct single degree of freedom contrasts to examine whether Just Do You leads to improved outcomes relative to Treatment-As-Usual using robust regression for each outcome measure. We will examine whether changes in the proposed mediating variables occur across groups using a similar contrast strategy. In addition, we will use structural equation modeling to examine the contribution of mediators to ultimate outcomes. Finally, we will use constant comparison coding techniques for qualitative analyses.

DISCUSSION

The aim of this study is to examine the feasibility of a young adult engagement meta-intervention through an intensive preliminary pilot trial, learning through collaboration with stakeholders. Just Do You has the potential to fill a gap in the service system for young adults with serious mental illnesses, improving the seemingly intractable problem of disengagement. The program uses culturally responsive strategies, is recovery-oriented, and builds upon the best evidence to date. Our efforts align with local and national health care reform efforts embedding people with lived experience.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov (Identifier: NCT03423212) on April 18, 2018, as Protocol Record R34 MH111861-01, New York University, as the Just Do You Program for Young Adults with Serious Mental Illness.

Racial and ethnic differences in mental healthcare utilization consistent with potentially effective care: The role of patient preferences

OBJECTIVE

Ethnic minorities are less likely than Whites to initiate and continue mental healthcare. Minorities also prefer non-medical approaches to address mental health issues. We evaluated sector-type as a modifier of the association of race/ethnicity with service utilization for mental health. We hypothesized that minorities utilize non-mental health sectors at rates consistent with guidelines and similar to Whites.

METHODS

We examined data from the Collaborative Psychiatric Epidemiologic Studies (CPES) (n=3803). We used logistic regression to assess the association of race/ethnicity with utilization consistent with potentially effective care across sectors-psychiatry, medical, non-medical mental health, human services, and spiritual.

RESULTS

Asians [OR: 0.56 CI: 0.39, 0.82] and Blacks [OR: 0.74 CI: 0.60, 0.92] had lower odds of having ≥1 visit compared to Whites. Blacks also had lower odds of ≥4 [OR: 0.66 CI: 0.50, 0.87] and ≥12 visits [OR: 0.58 CI: 0.41, 0.83]. Sector-type modified these associations. Compared to Whites, Asians [OR: 0.49 CI: 0.30, 0.82] and Blacks [OR: 0.71 CI: 0.54, 0.94] had lower odds of ≥1 visit to the medical sector. Asians had lower odds of seeing psychiatrists for ≥8 visits [OR: 0.15 CI: 0.04, 0.54] and ≥12 visits [OR: 0.21 CI: 0.06, 0.77]. Asians and Blacks demonstrated similar utilization to Whites in non-medical mental health and spiritual settings.

CONCLUSION

Racial/ethnic differences in utilization consistent with treatment guidelines are ameliorated in sectors preferred by minorities.

Cornerstone program for transition-age youth with serious mental illness: study protocol for a randomized controlled trial

Background

Transition-age youth have elevated rates of mental disorders, and they often do not receive services. This is a serious public health concern, as mental health conditions persist into adulthood. Continuing to engage this population has been a pervasive challenge for the mental health care system worldwide. Few mental health interventions have been developed for transition-age youth, and even fewer have been found to be effective over the transition to adulthood. Cornerstone, a theoretically guided intervention has shown promise for addressing the mental health and psychosocial needs of this population as they emerge into adulthood. Cornerstone provides case management, trauma-focused cognitive behavioral therapy, mentoring/peer support, community-based in vivo practice, and groups to address stigma, mistrust, and practical skill development to improve the transition to independence among transition-age youth with serious mental health conditions.

Methods/design

This study utilizes a hybrid research design and focuses on examining feasibility, acceptability and preliminary impact, along with factors that influence implementation, to maximize new knowledge. The study combines qualitative methods and a randomized controlled trial, using data to inform and refine protocols and manuals, while testing the preliminary impact of the intervention, compared to best available services (treatment as usual, TAU) at a partnering outpatient mental health clinic (n = 60). Contributors to the intervention development research (n = 20) are national experts on mental health services, clinic administrators and staff and young adults with direct experience. The intervention involves intensive staff training and 18 months of ongoing service provision, monitoring and supervision. Quantitative survey data will be collected at baseline, 3 months, 6 months, and 9 months measuring mental health and practical life outcomes via self-report measures. Medical records will be used to triangulate self-report data (i.e., primary diagnosis, treatment planning and attendance). Qualitative data focuses on the intervention development process and implementation research and will use constant comparison coding techniques. In this intention-to-treat analysis, we will conduct basic omnibus analyses to examine whether Cornerstone leads to improved outcomes relative to TAU utilizing t tests across treatment conditions for each outcome measure specified. We will likewise examine whether changes in the proposed mediating variables differ across groups.

Discussion

The aim of this study is to refine Cornerstone through an intensive preliminary trial, learning through collaboration with clinic staff, project team members, and leaders in New York State and nationwide on how to best serve transition-age youth with serious mental health conditions. Cornerstone has the potential to fill a large gap in the service system for transition-age youth with serious mental health conditions, and may enhance the menu of care options for those who have been recently diagnosed with a serious mental health condition, and yet, have a long life to live. The program is recovery-oriented, builds on the best evidence to date, and is in line with both local and national health care reform efforts.

Trial registration

This trial was registered with ClinicalTrials.gov (Identifier: NCT02696109) on 22 April 16 as Protocol Record R34-MH102525-01A1MRM, as New York University, Cornerstone program for transition-age youth with serious mental illness: study protocol for a randomized controlled trial.

Comparative Safety of Pharmacologic Treatments for Persistent Depressive Disorder: A Systematic Review and Network Meta-Analysis

We aimed to compare the safety of antidepressants for the treatment of persistent depressive disorder (PDD) with each other and with placebo. We conducted a systematic electronic search and included randomized controlled trials that investigated antidepressants for the treatment of PDD in adults. Outcomes were the incidence of experiencing any adverse event, specific adverse events and related treatment discontinuations. We analyzed the data using traditional and network meta-analyses. Thirty-four studies that comprised 4,769 patients and examined 20 individual agents in nine substance classes were included. Almost all analyzed substance classes were associated with higher discontinuation rates than placebo including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), antipsychotics, and the serotonin antagonist and reuptake inhibitor (SARI) trazodone. The odds of experiencing any adverse event were significantly higher for TCAs and serotonin noradrenaline reuptake inhibitors (SNRIs) compared to placebo. Pairwise comparisons among the substance classes revealed that more patients receiving TCAs or SNRIs experienced any adverse event and that more patients receiving TCAs or the SARI trazodone discontinued treatment. The complementary treatment with acetyl-l-carnitine showed lower rates of experiencing any adverse event and related discontinuations than all other comparators. TCAs were primarily associated with (anti-)cholinergic and sedating adverse events. SSRIs primarily showed gastrointestinal adverse events. Patients treated with the antipsychotic amisulpride were more likely to manifest weight gain and endocrine adverse events. The comparative evidence for further agents was insufficient or lacking. The identified safety differences may be used to inform the selection among the antidepressants.

Medical Costs of Persons with Drug Use Disorders Among Medicaid Managed Care Beneficiaries in Puerto Rico : Comparison of the Direct Services Costs Incurred by Beneficiaries With and Without a Drug Use Disorder

Drug use disorders (DUDs) can substantially increase the costs of health care, especially when left untreated. Yet, not much is known about the specific types of medical services that give rise to these cost differences. This study aimed to estimate the medical costs of beneficiaries with DUDs enrolled in the Medicaid Managed Care (MMC) program in Puerto Rico using claims data. These were compared to those of a matched group of patients without DUDs. On average, each beneficiary with a DUD incurred in $4539 annually on medical services compared to $2601 in the matched comparison group, a cost differential of $1938. Close to half of these additional medical costs (43.4%) were generated in the physical health services sector. Counts of service claims were also higher for beneficiaries with DUDs than for beneficiaries without DUDs in all service types, except in outpatient and laboratory services for physical health. A host of access strategies and treatment modalities should be tested to assess the extent to which providing adequate access and adequate treatment for a DUD can contribute to cost savings.

Assessing racial/ethnic disparities in treatment across episodes of mental health care

OBJECTIVE

To investigate disparities in mental health care episodes, aligning our analyses with decisions to start or drop treatment, and choices made during treatment.

STUDY DESIGN

We analyzed whites, blacks, and Latinos with probable mental illness from Panels 9-13 of the Medical Expenditure Panel Survey, assessing disparities at the beginning, middle, and end of episodes of care (initiation, adequate care, having an episode with only psychotropic drug fills, intensity of care, the mixture of primary care provider (PCP) and specialist visits, use of acute psychiatric care, and termination).

FINDINGS

Compared with whites, blacks and Latinos had less initiation and adequacy of care. Black and Latino episodes were shorter and had fewer psychotropic drug fills. Black episodes had a greater proportion of specialist visits and Latino episodes had a greater proportion of PCP visits. Blacks were more likely to have an episode with acute psychiatric care.

CONCLUSIONS

Disparities in adequate care were driven by initiation disparities, reinforcing the need for policies that improve access. Many episodes were characterized only by psychotropic drug fills, suggesting inadequate medication guidance. Blacks' higher rate of specialist use contradicts previous studies and deserves future investigation. Blacks' greater acute mental health care use raises concerns over monitoring of their treatment.

Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010

BACKGROUND

A meta-analysis was conducted to identify the proportions of comorbid personality disorders (PD) in mood disorders.

METHODS

We found 122 empirical papers published in the period 1980-2010 on participants having mood disorders in addition to a comorbid PD. Mood disorders were classified as bipolar disorders (BD), major depressive disorders (MDD) and dysthymic disorders (DYS). Several moderators were coded as well.

RESULTS

The risk of having at least one comorbid PD (any PD) was high across all three mood disorders (BD=.42, MDD=.45), but highest in DYS (.60). Cluster B and C PDs were most frequent in BD, while cluster C PDs dominated in MDD and DYS. Among the specific PDs, the paranoid (.11 versus .07/.05), borderline (.16 versus .14/.13), histrionic (.10 versus .06/.06) and obsessive-compulsive (.18 versus .09/.12) PDs occurred more frequently in BD versus MDD/DYS, whereas the avoidant PD (.22 versus .12/.16) was most frequent in DYS versus BD/MDD. Moderator analyses showed higher comorbidity when diagnoses were based on questionnaires versus clinical interviews, DSM-III-R versus DSM-IV, more women were included or the duration of the disorder was longer. Age of onset yielded mixed results.

LIMITATIONS

Blind rating of diagnoses was recorded, but was employed in too few studies to be usable as an indication of diagnostic validity.

CONCLUSIONS

Personality disorders are common in mood disorders. Implications of the identified moderators as well as the new DSM-5 diagnostic system are considered.

Persistence of chronic major depression: a national prospective study

BACKGROUND

Chronic major depressive disorder (CMDD) is highly prevalent and associated with high personal and societal cost. Identifying risk factors for persistence and remission of CMDD may help in developing more effective treatment and prevention interventions.

METHODS

Prospective cohort study of individuals participating in the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1; n=43,093) and its 3-year follow-up (Wave 2; n=34,653) who met a diagnosis of CMDD at the Wave 1 assessment.

RESULTS

Among the 504 respondents who met criteria for present CMDD at Wave 1, only 63 (11.52%) of them continued to meet criteria of CMDD. A history of childhood sexual abuse, earlier onset of MDD, presence of comorbidity and a history of treatment-seeking for depression predicted persistence of CMDD three years after the baseline evaluation.

LIMITATIONS

Our sample is limited to adults, our follow-up period was only three-years and the diagnosis of CMDD at baseline was retrospective.

CONCLUSIONS

CMDD shows high rates of remission within three years of baseline assessment, although some specific risk factors predict a persistent course. Given the high personal and societal cost associated with CMDD, there is a need to develop and disseminate effective interventions for CMDD.

Controlled randomized clinical trial of spirituality integrated psychotherapy, cognitive-behavioral therapy and medication intervention on depressive symptoms and dysfunctional attitudes in patients with dysthymic disorder

BACKGROUND

Due to the controversy over efficacy of cognitive-behavioral therapy for chronic depression, recently, there has been an increasingly tendency toward therapeutic methods based on the cultural and spiritual approaches. The aim of this research was to compare efficacy of spiritual integrated psychotherapy (SIPT) and cognitive-behavioral therapy (CBT) on the intensity of depression symptoms and dysfunctional attitudes of patients with dysthymic disorder.

MATERIALS AND METHODS

This study had a mixed qualitative and quantitative design. In the first phase, SIPT model was prepared and, in the second phase, a double-blind random clinical trial was performed. Sixty-two patients with dysthymic disorder were selected from several centers include Nour and Alzahra Medical Center, Counseling Centers of Isfahan University of Medical Sciences and Goldis in Isfahan. The participants were randomly assigned to three experimental groups and one control group. The first group received 8 sessions treatment of SIPT, second groups also had 8 sessions of cognitive-behavioral therapy, which was specific to dysthymic disorder and third group were under antidepressant treatment. Beck depression inventory and dysfunctional attitudes scale were used to evaluate all the participants in four measurement stages. The data were analyzed using MANCOVA repeated measure method.

RESULTS

The results revealed that SIPT had more efficacy than medication based on both scales (P < 0.01); however, it was not different from CBT. SIPT was more effective on the modification of dysfunctional attitudes compared with CBT and medication (P < 0.05).

CONCLUSION

These findings supported the efficacy of psychotherapy enriched with cultural capacities and religious teachings.

Parameters of education and the course of depression: an analysis in the Turkish sociocultural context

BACKGROUND

Major depression (MD) is often marked by an unfavourable course. Education repeatedly was found to be associated with better mental health variables, but longitudinal data are scarce. This evaluation seeks to identify the predictive role of specific aspects of education on the course of depression in a socioculturally defined setting.

METHODS

A sample of 69 unipolar MD outpatients in university and primary health care in Antalya, Turkey were observed naturalistically for a mean 11-month period. The baseline examination included several psychosocial variables, among them the highest attained schooling degree (DEG), possible further but unfulfilled educational aspirations (UEA), and the participants' parental educational level (PEL). The depressive symptomatology was assessed with the HAM-D-17 at baseline and at four-monthly follow-ups. A binary variable differentiated 'non-remissive' from 'remissive' courses, the latter displaying at least temporal partial remissions.

RESULTS

Forty-two per cent of the sample displayed a non-remissive one-year course of MD. Half of the participants reported UEA. This was more prevalent among women, and qualitative information added causal gender-specific perceptions. In logistic regression, DEG proved prognostic impact, but was exceeded by the combination of UEA and PEL as the strongest predictor model (Cox & Snell R(2) = 0.217). This remained when controlled for place of examination, gender and initial severity of depression. As risk factors for low education, a pattern of female gender and large family size (itself predicted by rural descent) emerged.

CONCLUSIONS

Low education proved to be a risk factor for an unfavourable course of MD. Not only actual experienced schooling, but also unfulfilled academic aspirations and a low parental educational level appear to be of crucial impact.

Is treatment adherence consistent across time, across different treatments and across diagnoses?

OBJECTIVE

The objective was to examine consistency of adherence across depression treatments and consistency of adherence between depression treatments and treatments for chronic medical illness.

METHODS

For 25,456 health plan members beginning psychotherapy for depression between 2003 and 2008, health plan records were used to examine adherence to all episodes of psychotherapy, antidepressant medication, antihypertensive medication and lipid-lowering medication.

RESULTS

Within treatments, adherence to psychotherapy in one episode predicted approximately 20% greater likelihood of subsequent psychotherapy adherence [odds ratio (OR)=2.20, 95% confidence interval (CI) 1.83-2.64]. Similarly, adherence to antidepressant medication in one episode predicted approximately 20% greater likelihood of subsequent antidepressant adherence (OR=1.99, 95% CI 1.74-2.28). Across treatments, adherence to antidepressant medication predicted approximately 10% greater likelihood of concurrent or subsequent adherence to psychotherapy (OR=1.52, 95% CI 1.42-1.63), a 4% greater likelihood of adherence to antihypertensive medication (OR=1.24, 95% CI 1.14-1.37) and a 3% greater likelihood of adherence to lipid-lowering medication (OR=1.16, 95% CI 1.03-1.32). Adherence to psychotherapy predicted a 2% greater likelihood of concurrent or subsequent adherence to antihypertensive medication (OR=1.11, 95% CI 1.04-1.19) and was not a significant predictor of adherence to lipid-lowering medication (OR=0.99, 95% CI 0.90-1.18).

CONCLUSIONS

Adherence is moderately consistent across episodes of depression treatment. Depression treatment adherence is a statistically significant, but relatively weak, predictor of adherence to antihypertensive or lipid-lowering medication.

Early dropout from psychotherapy for depression with group- and network-model therapists

Administrative data were used to examine early dropout among 16,451 health plan members calling to request psychotherapy for depression. Compared to members referred to group-model therapists, those referred to network-model therapists were more likely to drop out before the initial visit (OR 2.33, 95% CI 2.17-2.50) but less likely to drop out after the first visit (OR 0.45, 95% CI 0.43-0.48). These differences were unaffected by adjustment for neighborhood income and educational attainment, antidepressant use, or generosity of insurance coverage. Efforts to increase the effectiveness of psychotherapy may required different strategies in group- and network-model practice.

Cognitive behaviour therapy and supportive therapy for bipolar disorders: relapse rates for treatment period and 2-year follow-up

BACKGROUND

The efficacy of adjunctive psychosocial interventions such as cognitive behaviour therapy (CBT) for bipolar disorder (BD) has been demonstrated in several uncontrolled and controlled studies. However, these studies compared CBT to either a waiting list control group, brief psycho-education or treatment as usual (TAU). Our primary aim was to determine whether CBT is superior to supportive therapy (ST) of equal intensity and frequency in preventing relapse and improving outcome at post-treatment. A secondary aim was to look at predictors of survival time.

METHOD

We conducted a randomized controlled trial (RCT) at the Department of Psychology, University of Tübingen, Germany (n=76 patients with BD). Both CBT and ST consisted of 20 sessions over 9 months. Patients were followed up for a further 24 months.

RESULTS

Although changes over time were observed in some variables, they were not differentially associated with CBT or ST. CBT showed a non-significant trend for preventing any affective, specifically depressive episode during the time of therapy. Kaplan-Meier survival analyses revealed that 64.5% of patients experienced a relapse during the 33 months. The number of prior episodes, the number of therapy sessions and the type of BD predicted survival time.

CONCLUSIONS

No differences in relapse rates between treatment conditions were observed, suggesting that certain shared characteristics (e.g. information, systematic mood monitoring) might explain the effects of psychosocial treatment for BD. Our results also suggest that a higher number of prior episodes, a lower number of therapy sessions and a diagnosis of bipolar II disorder are associated with a shorter time before relapse.

Epidemiology of chronic and nonchronic major depressive disorder: results from the national epidemiologic survey on alcohol and related conditions

BACKGROUND

Burden related to major depressive disorder (MDD) derives mostly from long-term occurrence of symptoms. This study aims to examine the prevalence, sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization of chronic major depressive disorder (CMDD) compared to nonchronic major depressive disorder.

METHODS

Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).

RESULTS

The 12-month and lifetime prevalence of CMDD within the population meeting criteria for MDD was 26.5% and 24.0%, respectively. Individuals reporting a chronic course of MDD were socioeconomically and educationally disadvantaged, tended to be older, report loss of spouse or history of divorce, live in rural areas, have public assistance, low self-esteem, worse overall health and more likely to report comorbidities, most importantly dysthymia, generalized anxiety disorder, avoidant, and dependant personality disorder. Individuals with chronic MDD were more likely to report familial but not childhood onset risk factors for MDD. Those suffering CMDD were more likely to seek and receive mental health care than other forms of MDD, even though it took longer to start treatment.

CONCLUSION

Chronic course of MDD is related to still worse socioeconomic conditions, educational achievement, more comorbidities, and family risk factors, although other courses of MDD carried greater risk of unmet treatment.

Quality of life and menopause: Developing a theoretical model based on meaning in life, self-efficacy beliefs, and body image

GOAL

There are various views on variables that influence quality of life, such as meaning in life, self-efficacy, and body image (including body area satisfaction, health evaluation, and appearance evaluation), in menopausal women. This study looked at the relationships among these variables both in terms of their codetermination and intensity of relationship to quality of life.

METHODS

The research study included menopausal women (45-55 years old) who lived in the city of Tehran and had at least a high school education. The sample consisted of 349 women selected at random from the attendees of cultural centers in the city of Tehran during June 2009-December 2009. Each participant completed four questionnaires, including a questionnaire on meaning in life [Salehi, M. (1994). Evaluating the issue of adolescents and the youth from the view of humanistic psychologists (Psychology PhD dissertation). Islamic Azad University, Research and Sciences Campus, Tehran.], general self-efficacy, multidimensional relation of self and body, and quality of life (sf-36). Structural equation modeling was used to analyze the relationships among variables. Path analysis was used to study the direct and indirect effects of variables as cause. A primary hypothetical model was developed that included the expected relationships among the variables. Confirmation or rejection of the expected relationships in the model was determined after executing the questionnaires and scoring the data.

RESULTS

The model fitness was analyzed using various methods. Results showed that there is a significant direct relationship between quality of life and meaning in life, self-efficacy, body area satisfaction, and health evaluation. In addition, the model predicted 33% of quality of life variance in menopausal women. The best predictors were body area satisfaction, health evaluation, and self-efficacy. Step-by-step regression analysis confirmed the results.

CONCLUSION

Based on our results, there is a direct and meaningful relationship between the independent variables of this study and the quality of life. Therefore, in order to improve the quality of life in menopausal women, one or all of these variables needs to be improved.

Risk factors for chronic depression--a systematic review

BACKGROUND

One of five patients with an acute depressive episode develops chronic depression. Risk factors for a current depressive episode to become chronic are insufficiently known. This review was conducted to examine which factors represent a risk factor for the development of chronic depression for patients diagnosed with a depressive episode.

METHOD

Medline, Psycinfo, ISI Web of Science, CINHAL and BIOSIS Previews were searched up until September 2007, complemented by handsearching in the December 1987 to December 2007 issues of Journal of Affective Disorders and investigating reference lists of included articles and existing reviews. On the basis of a formal checklist, two investigators independently decided which studies to include or exclude.

RESULTS

25 relevant primary studies with a total of 5192 participants were included in the systematic review. Overall the methodological quality of the included studies was found to be sufficient. Data synthesis was performed via vote counting. The following risk factors were identified: younger age at onset, longer duration of depressive episode, and family history of mood disorders. Psychological comorbidity i.e. anxiety disorders, personality disorders and substance abuse, low level of social integration, negative social interaction and lower severity of depressive symptoms repeatedly appeared concurrently with chronic depression.

LIMITATIONS

Most included studies were cross-sectional thus drawing causal conclusions with regard to risk factors proved to be difficult.

CONCLUSION

Risk factors for a current depressive episode to become chronic were identified. To date only few significant longitudinal studies on this topic are available.

Predictors of treatment utilization in major depression

Suicide attempters with major depression are at risk for repeat attempts and often do not utilize treatment. Identifying predictors of treatment non-utilization could inform interventions to motivate treatment use and reduce suicide risk in major depression. Two hundred and seventy three participants with a major depressive episode as part of a major depressive disorder or bipolar disorder, were assessed for socio-demographic and clinical characteristics at baseline and again 1 year later to identify predictors of treatment utilization. Treatment utilization rate was high 1 year after initial evaluation (72.5%). Severity of baseline depression, baseline treatment status, and education were associated with treatment utilization at 1 year. Interventions focused on increasing knowledge about depression and treatment efficacy may improve treatment adherence when treating depression.

Treatment goals of depressed outpatients: a qualitative investigation of goals identified by participants in a depression treatment trial

Treatment goals and preferences of depressed patients are important, but they are rarely empirically studied. Although clinicians are likely to discuss goals with individual patients, research that clarifies overall patterns in the treatment goals of depressed patients could be useful in informing new interventions for depression. Such research could also potentially help address problems such as poor adherence and psychotherapy drop-out. In this preliminary qualitative investigation, we examined treatment goals established by depressed outpatients in the context of a trial of behaviorally oriented psychotherapy. The treatment goals that were most commonly articulated included improving social and family relationships, increasing physical health behaviors, finding a job, and organizing one's home. These results underscore the fact that, in addition to improvement in the symptoms of depression, functional improvements are viewed as key treatment goals by depressed individuals.

Retention in depression treatment among ethnic and racial minority groups in the United States

BACKGROUND

Premature discontinuation of psychiatric treatment among ethnic-racial minorities is a persistent concern. Previous research on identifying factors associated with ethnic-racial disparities in depression treatment has been limited by the scarcity of national samples with adequate representation of minority groups and especially non-English speakers. In this article, we aim to identify variations in the likelihood of retention in depression treatment among ethnic-racial minority groups in the United States as compared to non-Latino whites. Second, we aim to identify the factors that are related to treatment retention.

METHODS

We use data from the Collaborative Psychiatric Epidemiology Surveys to examine differences and correlates of depression treatment retention among a representative sample (n=564) of non-Latino whites, Latinos, African-American, and Asian respondents with last 12-month depressive disorder and who report receiving formal mental health treatment in the last year. We define retention as attending at least four visits or remaining in treatment during a 12-month period.

RESULTS

Being seen by a mental health specialist as opposed to being seen by a generalist and having received medication are correlates of treatment retention for the entire sample. However, after adjusting for demographics, clinical factors including number of co-occurring psychiatric disorders and level of disability, African-Americans are significantly less likely to be retained in depression treatment as compared to non-Latino whites.

CONCLUSIONS

Availability of specialized mental health services or comparable treatment within primary care could improve treatment retention. Low retention suggests persistent problems in the delivery of depression treatment for African-Americans.

Stability and Change in Personality Disorder

The standard view of personality disorder is that it is a maladaptive expression of personality traits, which are relatively stable and unchanging. Thus, personality disorder has been considered to have its roots in childhood and adolescence, to persist in adulthood, and to be difficult to change. However, recent research has challenged this view, revealing that personality continues to change, albeit more slowly, well into adulthood, and that the maladaptive manifestations of personality disorder are much less stable than previously believed. These research findings are described, and factors that influence stability and change in personality disorder are discussed. The emerging view of personality disorder has important implications for diagnosis, assessment, and treatment of personality pathology.

Dysthymic disorder and double depression: prediction of 10-year course trajectories and outcomes

We sought to identify baseline predictors of 10-year course trajectories and outcomes in patients with dysthymic disorder and double depression. Eighty-seven outpatients with early-onset (<21 years) dysthymic disorder, with or without superimposed major depression, were assessed five times at 30-month intervals for 10 years. Baseline evaluations included semi-structured diagnostic interviews for Axis I and II psychopathology and childhood adversity. Direct interview and family history data were collected on first-degree relatives. Follow-up assessments included the Longitudinal Follow-up Evaluation and Hamilton Depression Rating Scale. Using mixed effects growth curve models, univariate predictors of depression severity and functional impairment at 10-year outcome included older age, less education, concurrent anxiety disorder, greater familial loading for chronic depression, a history of a poorer maternal relationship in childhood, and a history of childhood sexual abuse. In addition, longer duration of dysthymic disorder also predicted greater impairment 10 years later. Predictors of a poorer trajectory of depressive symptoms over time included ethnicity and personality disorders; predictors of a poorer trajectory of social functioning included familial loading of chronic depression and quality of the childhood maternal relationship. Thus, demographic, clinical, family history, and early adversity variables all contribute to predicting the long-term trajectory and outcome of DD. These variables should be routinely assessed in clinical evaluations and can provide clinicians with valuable prognostic information.

Evaluation of a patient activation and empowerment intervention in mental health care

BACKGROUND

Evidence suggests that minority populations have lower levels of attendance and retention in mental health care than non-Latino whites. Patient activation and empowerment interventions may be effective in increasing minority patients' attendance and retention.

OBJECTIVES

This study developed and evaluated a patient self-reported activation and empowerment strategy in mental health care.

RESEARCH DESIGN

The Right Question Project-Mental Health (RQP-MH) trainings consisted of 3 individual sessions using a pre/post test comparison group design with patients from 2 community mental health clinics. The RQP-MH intervention taught participants to identify questions that would help them consider their role, process and reasons behind a decision; and empowerment strategies to better manage their care.

SUBJECTS

A total of 231 participated, completing at least the pretest interview (n = 141 intervention site, 90 comparison site).

MEASURES

Four main outcomes were linked to the intervention: changes in self-reported patient activation; changes in self-reported patient empowerment; treatment attendance; and retention in treatment.

RESULTS

Findings show that intervention participants were over twice as likely to be retained in treatment and over 3 times more likely than comparison participants to have scheduled at least 1 visit during the 6-month follow-up period. Similarly, intervention participants demonstrated 29% more attendance to scheduled visits than comparison patients. There was no evidence of an effect on self-reported patient empowerment, only on self-reported patient activation.

CONCLUSIONS

Results demonstrate the intervention's potential to increase self-reported patient activation, retention, and attendance in mental health care for minority populations. By facilitating patient-provider communication, the RQP-MH intervention may help minorities effectively participate in mental health care.

Barriers in the help-seeking process: a multiple-case study of early-onset dysthymia in Sweden

The aim of this study was to investigate barriers to diagnosis and adequate treatment of patients with early-onset dysthymia by studying how understandings of illness by patients and providers have evolved and how treatments have been negotiated over time. A theory-testing and explorative multiple-case study design was used with developmental cognitive theory as framework. Data pertaining 10 non-remission dysthymic patients were analyzed using five sources: 1) case records, 2) interviews, 3) self-report questionnaires, 4) observations, and 5) life-charting, eliciting life events, course and treatments. The analysis comprised qualitative content analysis and a coding scheme of knowledge structures. Barriers could be explained by misunderstandings as patients mainly expressed illness in concrete, perceptually bound knowledge structures and providers focused on one aspect, instead of on the complexity of concurrent aspects. Another barrier, associated to comorbid personality disorder, was a core pattern of concealing due to fear of rejection and mistrust. Other barriers were connected to providers' attitudes and contextual factors such as access problems and lack of follow-up. A theoretical model that involves patients' understanding of illness in preoperational thinking and providers' cognitive errors can explain communication barriers. Means of shared understanding and treatment planning are suggested. Future treatment research could elucidate the impact of the core belief of rejection with associated strategy of concealing by assessing these variables as predictors and as targets for change.

Behavioral activation system deficits predict the six-month course of depression

BACKGROUND

Behavioral activation system (BAS) deficits are hypothesized to increase risk for depression. This study tested the hypothesis that BAS deficits, measured with both self-report and electrophysiological methods, would predict the six-month course of depression.

METHODS

67 participants with major depressive disorder (MDD) with or without pre-existing dysthymia were assessed at baseline with Carver and White's [Carver, C.S., White, T.L., 1994. Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment: the BIS/BAS scales. J. Pers. Soc. Psychol. 67, 319-333.] BIS/BAS scales and resting EEG. The week-by-week course of their depressive symptoms was assessed six months later with the Longitudinal Interval Follow-up Evaluation (LIFE).

RESULTS

Baseline self-reported BAS sensitivity predicted depression diagnosis (MDD or dysthymia) at follow-up, number of MDD symptoms at follow-up, average weekly level of depression, and time to recovery. These effects persisted after controlling for baseline clinical variables associated with a worse course. Baseline resting EEG alpha asymmetry did not significantly predict the course of depression.

LIMITATIONS

Although BAS sensitivity predicted the subsequent course of depression, we cannot determine whether it played a causal role in maintaining depression.

CONCLUSIONS

Lower self-reported BAS sensitivity predicts a worse course of depression but EEG asymmetries do not.