Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review

Association between first-line antidepressant use and risk of dementia in older adults: a retrospective cohort study

BACKGROUND

Prior studies suggested that antidepressant use is associated with an increased risk of dementia compared to no use, which is subject to confounding by indication. We aimed to compare the dementia risk among older adults with depression receiving first-line antidepressants (i.e., SSRI/SNRI) versus psychotherapy, which is also considered the first-line therapy for depression.

METHODS

This retrospective cohort study was conducted using the US Medical Expenditure Panel Survey from 2010 to 2019. We included adults aged ≥ 50 years diagnosed with depression who initiated SSRI/SNRI or psychotherapy. We excluded patients with a dementia diagnosis before the first record of SSRI/SNRI use or psychotherapy. The exposure was the patient's receipt of SSRI/SNRI (identified from self-report questionnaires) or psychotherapy (identified from the Outpatient Visits or Office-Based Medical Provider Visits files). The outcome was a new diagnosis of dementia within 2 years (i.e., survey panel period) identified using ICD-9/ICD-10 codes from the Medical Conditions file. Using a multivariable logistic regression model, we reported adjusted odds ratios (aORs) with 95% confidence intervals (CIs). We also conducted subgroup analyses by patient sex, age group, race/ethnicity, severity of depression, combined use of other non-SSRI/SNRI antidepressants, and presence of underlying cognitive impairment.

RESULTS

Among 2,710 eligible patients (mean age = 61 ± 8, female = 69%, White = 84%), 89% used SSRIs/SNRIs, and 11% received psychotherapy. The SSRI/SNRI users had a higher crude incidence of dementia than the psychotherapy group (16.4% vs. 11.8%), with an aOR of 1.36 (95% CI = 1.06-1.74). Subgroup analyses yielded similar findings as the main analyses, except no significant association for patients who were aged < 65 years (1.23, 95% CI = 0.93-1.62), male (1.34, 95% CI = 0.95-1.90), Black (0.76, 95% CI = 0.48-1.19), had a higher PHQ-2 (1.39, 95% CI = 0.90-2.15), and had underlying cognitive impairment (1.06, 95% CI = 0.80-1.42).

CONCLUSIONS

Our findings suggested that older adults with depression receiving SSRIs/SNRIs were associated with an increased dementia risk compared to those receiving psychotherapy.

Association between Antidepressants and Dementia Risk in Older Adults with Depression: A Systematic Review and Meta-Analysis

Depression, commonly treated with antidepressants, is associated with an increased risk of dementia, especially in older adults. However, the association between antidepressant use and dementia risk is unclear. We searched for randomized controlled trials and observational studies from PubMed, Embase, and Cochrane on 1 February 2022, restricting to full texts in English. Since dementia is a chronic disease requiring a long induction time, we restricted studies with ≥1 year follow-up. We extracted the relative risk (RR) adjusted for the most variables from each study and evaluated the heterogeneity using I square (I2). The protocol was registered in the PROSPERO International Register of Systematic Reviews (CRD42022338038). We included six articles in the systematic review, of which the sample size ranged from 716 to 141,740, and the median length of follow-up was 5 years. The pooled RR was 1.21 (95% CI = 1.12-1.29) with an I2 of 71%. Our findings suggest that antidepressant use was associated with an increased risk of dementia in older adults with depression, yet moderate to high heterogeneity existed across studies. Future work accounting for the depression progression is needed to differentiate the effect of depression and antidepressants on dementia risk.

Association between first-line antidepressant use and risk of dementia in older adults: a retrospective cohort study

Background

Prior studies suggested that antidepressant use is associated with an increased risk of dementia compared to no use, which is subject to confounding by indication. We aimed to compare the dementia risk among older adults with depression receiving first-line antidepressants (i.e., SSRI/SNRI) versus psychotherapy, which is also considered the first-line therapy for depression.

Methods

This retrospective cohort study was conducted using the US Medical Expenditure Panel Survey from 2010 to 2019. We included adults aged ≥50 years diagnosed with depression who initiated SSRI/SNRI or psychotherapy. We excluded patients with a dementia diagnosis before the first record of SSRI/SNRI use or psychotherapy. The exposure was the patient's receipt of SSRI/SNRI (identified from self-report questionnaires) or psychotherapy (identified from the Outpatient Visits or Office-Based Medical Provider Visits files). The outcome was a new diagnosis of dementia within 2 years (i.e., survey panel period) identified using ICD-9/ICD-10 codes from the Medical Conditions file. Using a multivariable logistic regression model, we reported adjusted odds ratios (aORs) with 95% confidence intervals (CIs). We also conducted subgroup analyses by patient sex, age group, race, severity of depression, combined use of other non-SSRI/SNRI antidepressants, and presence of underlying cognitive impairment.

Results

Among 2,710 eligible patients (mean age= 61±8, female=69%, white=84%), 89% used SSRIs/SNRIs, and 11% received psychotherapy. The SSRI/SNRI users had a higher crude incidence of dementia than the psychotherapy group (16.1% vs. 12.7%), with an aOR of 1.39 (95% CI=1.21-1.59). Subgroup analyses yielded similar findings as the main analyses, except no significant association for patients who were black (0.75, 95% CI=0.55-1.02), had a higher PHQ-2 (1.08, 95% CI=0.82-1.41), had concomitant non-SSRI/SNRI antidepressants (0.75, 95% CI=0.34-1.66), and had underlying cognitive impairment (0.84, 95% CI=0.66-1.05).

Conclusions

Our findings suggested that older adults with depression receiving SSRIs/SNRIs were associated with an increased dementia risk compared to those receiving psychotherapy.

Pattern breaking: a complex systems approach to psychedelic medicine

Recent research has demonstrated the potential of psychedelic therapy for mental health care. However, the psychological experience underlying its therapeutic effects remains poorly understood. This paper proposes a framework that suggests psychedelics act as destabilizers, both psychologically and neurophysiologically. Drawing on the 'entropic brain' hypothesis and the 'RElaxed Beliefs Under pSychedelics' model, this paper focuses on the richness of psychological experience. Through a complex systems theory perspective, we suggest that psychedelics destabilize fixed points or attractors, breaking reinforced patterns of thinking and behaving. Our approach explains how psychedelic-induced increases in brain entropy destabilize neurophysiological set points and lead to new conceptualizations of psychedelic psychotherapy. These insights have important implications for risk mitigation and treatment optimization in psychedelic medicine, both during the peak psychedelic experience and during the subacute period of potential recovery.

Designing Flexible Longitudinal Regimens: Supporting Clinician Planning for Discontinuation of Psychiatric Drugs

Clinical decision support tools have typically focused on one-time support for diagnosis or prognosis, but have the ability to support providers in longitudinal planning of patient care regimens amidst infrastructural challenges. We explore an opportunity for technology support for discontinuing antidepressants, where clinical guidelines increasingly recommend gradual discontinuation over abruptly stopping to avoid withdrawal symptoms, but providers have varying levels of experience and diverse strategies for supporting patients through discontinuation. We conducted two studies with 12 providers, identifying providers’ needs in developing discontinuation plans and deriving design guidelines. We then iteratively designed and implemented AT Planner, instantiating the guidelines by projecting taper schedules and providing flexibility for adjustment. Provider feedback on AT Planner highlighted that discontinuation plans required balancing interpersonal and infrastructural constraints and surfaced the need for different technological support based on clinical experience. We discuss the benefits and challenges of incorporating flexibility and advice into clinical planning tools.

Self-Inflicted Traumatic Bilateral Upper Extremity Amputation as a Suicidal Gesture?

Traumatic amputations are partial or complete dismemberment of part of the human body (usually one limb) due to an injury that involves a component of blunt force trauma. It is usually caused by accidental events and only very rarely due to suicidal events. A 37-year-old female with major depressive disorder attempted suicide by placing her forearms on a railroad track, resulting in traumatic bilateral upper extremity amputations. Emergency Department resuscitation was initiated as the patient was taken immediately to the operating room; however, restoration of the limbs was unfeasible, and the patient had successful debriding and fashioning a flap to the distal ends of the upper extremities after hemostasis was achieved. Depression may still be an undertreated clinical entity in our society, and many preventable causes of suicide are attempted each year. Evidence exists that suggests severe suicide attempts occur generally in men and minor suicide attempts, or so-called suicidal gestures, occur generally in women. This case questions this notion.

Lighten UP! A Community-Based Group Intervention to Promote Eudaimonic Well-Being in Older Adults: A Multi-Site Replication with 6 Month Follow-Up

Objectives: Eudaimonic well-being (EWB), increasingly recognized as a critical component of health, typically declines in later life, and there are no existing programs to sustain or increase EWB in older adults. Lighten UP! is an 8-week program to promote EWB through facilitated group sessions in community settings and at-home practice. Building on earlier pilot research, the current study assessed the effect of the Lighten UP! Program using a longitudinal, multi-site design. Methods: Men and women (N = 169) aged 60 and over were recruited from three Wisconsin communities. EWB, life satisfaction, depression, and diverse aspects of health were assessed before and after the program and at 6-month follow up. Results: Participants reported significantly increased EWB; these changes were maintained 6 months later. The specific EWB domains of self-acceptance, positive relations, and personal growth showed the most robust gains. Participants also showed significant and sustained declines in depressive symptoms, anxiety, and hostility. Conclusions: Lighten UP! Program confirmed its positive effects for enhancing EWB in older adults living in multiple community settings. Clinical Implications: Programs that sustain or enhance EWB in older adults can be expected to yield improvements in diverse aspects of mental and physical health.

Disruptive behavior scale for adolescents (DISBA): development and psychometric properties

BACKGROUND

Growing evidence indicates that if disruptive behavior is left unidentified and untreated, a significant proportion of these problems will persist and may develop into problems linked with delinquency, substance abuse, and violence. Research is needed to develop valid and reliable measures of disruptive behavior to assist recognition and impact of treatments on disruptive behavior. The aim of this study was to develop and evaluate the psychometric properties of a scale for disruptive behavior in adolescents.

METHODS

Six hundred high school students (50% girls), ages ranged 15-18 years old, selected through multi stage random sampling. Psychometrics of the disruptive behavior scale for adolescents (DISBA) (Persian version) was assessed through content validity, explanatory factor analysis (EFA) using Varimax rotation and confirmatory factor analysis (CFA). The reliability of this scale was assessed via internal consistency and test-retest reliability.

RESULTS

EFA revealed four factors accounting for 59% of observed variance. The final 29-item scale contained four factors: (1) aggressive school behavior, (2) classroom defiant behavior, (3) unimportance of school, and (4) defiance to school authorities. Furthermore, CFA produced a sufficient Goodness of Fit Index > 0.90. Test-retest and internal consistency reliabilities were acceptable at 0.85 and 0.89, respectively.

CONCLUSIONS

The findings from this study suggest that the Iranian version of DISBA questionnaire has content validity. Further studies are needed to evaluate stronger psychometric properties for DISBA.

Patients' comprehension and skill usage as a putative mediator of change or an engaged target in cognitive therapy: Preliminary findings

BACKGROUND

The skills that patients learn in cognitive therapy (CT) and use thereafter may mediate improvement in depression during and after intervention.

METHOD

We used a sequential, three-stage design: acute phase (523 outpatients received 12-14 weeks of CT); 8-month experimental phase (responders at higher risk were randomized to continuation phases: C-CT, C-fluoxetine or C-pill placebo); and 24 months of longitudinal, post-treatment follow-up. Path analyses estimated mediation by skill measured by the Skills of Cognitive Therapy (SoCT: Patient and Observer [Therapist] versions).

RESULTS

Better SoCT scores predicted lower depressive symptoms both in CT and C-CT. In CT depressive symptoms did not predict subsequent changes in skills. During CT and C-CT, when averaged across patients and therapists, skills predicted subsequent decreases in depressive symptoms.

LIMITATIONS

Generalization of findings may be limited by the trial's methodology.

CONCLUSION

Further rigorous investigation of the role of patient CT skills stands to increase understanding of mediators of change or engaged targets in psychosocial intervention.

Agomelatine versus fluoxetine in glycemic control and treating depressive and anxiety symptoms in type 2 diabetes mellitus subjects: a single-blind randomized controlled trial

BACKGROUND

Depressive and anxiety symptoms could seriously affect the quality of life of type 2 diabetes mellitus (T2DM) subjects. Currently, little is known about the efficacy and acceptability of agomelatine versus fluoxetine in treating these symptoms in T2DM subjects. Therefore, this study was performed to find out which one was better in treating these symptoms in T2DM subjects.

MATERIALS AND METHODS

T2DM subjects with depressive and anxiety symptoms were randomly assigned to receive either fluoxetine (30-40 mg/day) or agomelatine (25-50 mg/day). The treatment was continued for 12 weeks. The data of the Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS) were collected (at baseline and also at weeks 4, 8 and 12) to assess the depressive and anxiety symptoms, respectively. The metabolic parameters, including body mass index (BMI), fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c), were assessed at baseline and after 12 weeks of treatment. The treatment-related adverse events during the scheduled treatment period were recorded to compare the acceptability of these two drugs.

RESULTS

After 12 weeks of treatment, the average HDRS and HARS scores were significantly decreased in both groups. The average HDRS scores were not significantly different between the two groups, although the agomelatine group had a lower average HDRS score. The response and remission rates were similar between the two groups, and these two drugs had no significant effects on BMI and FPG. However, compared with the fluoxetine group, the agomelatine group had the significantly lower average HARS score (p=0.0017) and lower average HbA1c level (p<0.00001). Moreover, the incidence of adverse events was significantly lower in the agomelatine group than in the fluoxetine group (p=0.032).

CONCLUSION

Both fluoxetine and agomelatine could effectively reduce depressive and anxiety symptoms in T2DM subjects, but agomelatine might be more effective and acceptable. Future studies with more subjects are needed to support and validate our conclusion.

Preparing the workforce for integrated healthcare: A systematic review

Integrated healthcare is recommended to deliver care to individuals with co-occurring medical and mental health conditions. This literature review was conducted to identify the knowledge and skills required for behavioral health consultants in integrated settings. A review from 1999 to 2015 identified 68 articles. Eligible studies examined care to the U.S. adult population at the highest level of integration. The results provide evidence of specific knowledge of medical and mental health diagnoses, screening instruments, and intervention skills in integrated primary care, specialty medical, and specialty mental health. Further research is required to identify methods to develop knowledge/skills in the workforce.

Gathering Opinions on Depression Information Needs and Preferences: Samples and Opinions in Clinic Versus Web-Based Surveys

BACKGROUND

There has been limited research on the information needs and preferences of the public concerning treatment for depression. Very little research is available comparing samples and opinions when recruitment for surveys is done over the Web as opposed to a personal invitation to complete a paper survey.

OBJECTIVE

This study aimed to (1) to explore information needs and preferences among members of the public and (2) compare Clinic and Web samples on sample characteristics and survey findings.

METHODS

Web survey participants were recruited with a notice on three self-help association websites (N=280). Clinic survey participants were recruited by a research assistant in the waiting rooms of a family medicine clinic and a walk-in medical clinic (N=238) and completed a paper version of the survey.

RESULTS

The Clinic and Web samples were similar in age (39.0 years, SD 13.9 vs 40.2 years, SD 12.5, respectively), education, and proportion in full time employment. The Clinic sample was more diverse in demographic characteristics and closer to the demographic characteristics of the region (Winnipeg, Canada) with a higher proportion of males (102/238 [42.9%] vs 45/280 [16.1%]) and nonwhites (Aboriginal, Asian, and black) (69/238 [29.0%] vs 39/280 [13.9%]). The Web sample reported a higher level of emotional distress and had more previous psychological (224/280 [80.0%] vs 83/238 [34.9%]) and pharmacological (202/280 [72.1%] vs 57/238 [23.9%]) treatment. In terms of opinions, most respondents in both settings saw information on a wide range of topics around depression treatment as very important including information about treatment choices, effectiveness of treatment, how long it takes treatment to work, how long treatment continues, what happens when treatment stops, advantages and disadvantages of treatments, and potential side effects. Females, respondents with a white background, and those who had received or felt they would have benefited from therapy in the past saw more information topics as very important. Those who had received or thought they would have benefited in the past from medication treatment saw fewer topics as important. Participants in both groups expressed an interest in receiving information through discussion with a counselor or a physician, through written brochures, or through a recommended website.

CONCLUSIONS

The recruitment strategies were helpful in obtaining opinions from members of the public with different concerns and perspectives, and the results from the two methods were complementary. Persons coping with emotional distress and individuals not specifically seeking help for depression would be interested in information to answer a wide range of important questions about depression treatment. The Clinic sample yielded more cultural diversity that is a closer match to the population. The Web sample was less costly to recruit and included persons who were most interested in receiving information.

Treatment preferences for depression in the elderly

BACKGROUND

If patients are treated according to their personal preferences, depression treatment success is higher. It is not known which treatment options for late-life depression are preferred by patients aged 75 years and over and whether there are determinants of these preferences.

METHODS

The data were derived from the German "Late-life depression in primary care: needs, health care utilization, and costs (AgeMooDe)" study. Patients aged 75+ years (N = 1,230) were recruited from primary care practices. Depressive symptoms were determined using the Geriatric Depression Scale (GDS-15). Support for eight treatment options was determined.

RESULTS

Medication, psychotherapy, talking to friends and family, and exercise were the preferred treatment options. Having a GDS score ≥ 6 significantly lowered the endorsement of some treatment options. For each treatment option, the probability of choosing the indecisive category "I do not know" was significantly increased in participants with moderate depressive symptoms.

CONCLUSIONS

Depressive symptoms influence the preference for certain treatment options and also increase indecision in patients. The high preference for psychotherapy suggests a much higher demand for late-life psychotherapy in the future. Healthcare systems should begin to prepare to meet this anticipated need. Future studies should include previous experience with treatment methods as a confounding variable.

The Use of Antidepressants, Anxiolytics, and Hypnotics in People with Type 2 Diabetes and Patterns Associated with Use: The Hoorn Diabetes Care System Cohort

Objective. With depression being present in approximately 20% of people with type 2 diabetes mellitus (T2DM), we expect equally frequent prescription of antidepressants, anxiolytics, and hypnotics. Nevertheless, prescription data in people with T2DM is missing and the effect of depression on glycaemic control is contradictory. The aim of this study was to assess the prevalence of antidepressants, anxiolytics, and/or hypnotics use in a large, managed, primary care system cohort of people with T2DM and to determine the sociodemographic characteristics, comorbidities, T2DM medication, and metabolic control associated with its use. Method. The prevalence of antidepressants, anxiolytics, and/or hypnotics use in the years 2007-2012 was assessed in the Hoorn Diabetes Care System Cohort from the Netherlands. Results. From the 7016 people with T2DM, 500 people (7.1%) used antidepressants only, 456 people (6.5%) used anxiolytics and/or hypnotics only, and 254 people (3.6%) used a combination. Conclusion. We conclude that in our managed, primary care system 17% of all people with T2DM used antidepressants, anxiolytics, and/or hypnotics. Users of antidepressants, anxiolytics, and/or hypnotics were more often female, non-Caucasian, lower educated, and more often treated with insulin.

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.

The Effect of a Brief Intervention for Patients with Ischemic Stroke: A Randomized Controlled Trial

BACKGROUND

Depression and anxiety are common after stroke. There is inconclusive evidence of the benefit of psychotherapy for poststroke depression and anxiety. Here, we used a brief intervention, Neuro-Linguistic Programming (NLP) brief therapy plus health education, to evaluate the changes in patients with ischemic stroke.

METHODS

One hundred eighty patients were randomly allocated to receive 4 sessions of NLP plus health education (n = 90) or usual care (n = 90). A set of questionnaires was used preintervention and postintervention as well as at the 6-month follow-up. The primary outcomes were the prevalence of depression and anxiety, and the awareness of stroke knowledge.

RESULTS

More patients in the intervention group achieved remission of depressive (odds ratio [OR], 2.81; 95% confidence interval [CI], 1.41-5.59) and anxious symptoms (OR, 2.19; 95% CI, 1.15-4.18) after intervention. At the 6-month follow-up, we found no differences between groups in both the prevalence of depression and anxiety. After intervention, the intervention group had better awareness rates on most of the stroke knowledge items (P < .05). It also had better quality of life and physical function both after intervention and at the follow-up (P < .05).

CONCLUSIONS

NLP plus health education could reduce depression and anxiety immediately after intervention, but not at the 6-month follow-up. The intervention could also improve the awareness of stroke knowledge and benefit patients on quality of life and physical function.

Behavior medicine specialist

Total Health is a vision for the future and a strategy to prevent preventable disease, save lives, and make health care more affordable. Total Health means health of mind (behavior health) and health of body (physical health). To achieve Total Health we need healthy people in healthy communities. A behavior medicine specialist is a psychologist who works in the medical home with the primary care physician instead of in the Mental Health Department with a psychiatrist. The key to achieving Total Health will be to transform our current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavior medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home. The behavior medicine specialist will help improve outcomes in synergy with the primary care physician by universal screening of high-risk diseases, stepped care protocols, and efficient use of all resources available to care for patients in the medical home (health education classes, wellness coaches, and online social networking lifestyle management programs). These interventions should increase patient satisfaction, increase access to specialty care (psychiatry), and help us achieve Total Health.

Prevalence and functions of mental disability caused by mood disorders in China: A national sample

BACKGROUND

Mood disorders are common mental illness in China, but little was known about mental disability caused by mood disorders. In this study, we aimed to describe the prevalence rate of mental disability caused by mood disorders, and resulting impairment on physical and social functions.

METHODS

Data were derived from the 2006 second China National Survey on Disability (CNSD), and identification of mental disability caused by mood disorders were based on consensus manuals.

RESULTS

The prevalence rate of mental disability caused by mood disorders in China was 0.366‰ (95% CI=0.334-0.398). Prevalence rate of mental disability caused by mood disorders was higher among female, elderly people, illiterate population, people currently not married, and people with an annual family income equal or lower than national average. People with mental disability caused by mood disorders were less likely to have severe or extreme difficulty in all 6 aspects of functions.

CONCLUSIONS

This study revealed a lower prevalence rate of mental disability caused by mood disorders. The findings indicate that more studies are needed to obtain a precise overview of mood disorders in China, and intervention programs aimed at early identification and treatment for mood disorders should be developed.

Schizophrenia and Depression: A systematic Review of the Effectiveness and the Working Mechanisms Behind Acupuncture

OBJECTIVE

This systematic review assessed clinical evidence for the use of acupuncture as an add-on treatment in patients with depression and schizophrenia and for its underlying working mechanisms.

DATA SOURCES

Four databases (Medline, Scopus, ERIC, and the Cochrane Library) were searched with a cutoff date of March 31, 2014.

STUDY SELECTION

Systematic reviews and meta-analyses of acupuncture treatment for depression and schizophrenia were considered for inclusion. The scarcity of acupuncture research involving schizophrenia led to the inclusion of randomized controlled trials and case studies.

DATA EXTRACTION

The primary and secondary aims of this study were to evaluate the effects of acupuncture in treating patients with depression or schizophrenia and the possible working mechanisms underlying acupuncture through a systematic literature review.

DATA SYNTHESIS

The overall clinical results on using acupuncture to treat depression are promising, but only limited evidence for its effectiveness in treating schizophrenia was found. Acupuncture improves the quality of life, particularly that of sleep, in psychiatric patients. Brain research has revealed that acupuncture has a modulating and normalizing effect on the limbic-paralimbic-neocortical network (LPNN), including the default mode network. Because the LPNN is related to sleep and emotions, this might explain the improved qualities of life and sleep after acupuncture.

CONCLUSIONS

From the evidence found in this study, acupuncture seems to be an effective add-on treatment in patients with depression and, to a lesser degree, in patients with schizophrenia, but large well-designed studies are needed to confirm that evidence.

Randomized controlled trial of interpersonal psychotherapy versus enhanced treatment as usual for women with co-occurring depression and pelvic pain

OBJECTIVE

Our study assessed the effectiveness of Interpersonal Psychotherapy (IPT) tailored for biomedical patients with depression and pain. IPT was compared to enhanced treatment as usual (E-TAU) among women with co-occurring depression and chronic pain presenting for care at a women's health or family medicine practice. We hypothesized that women presenting to urban medical practices with depression and chronic pain would benefit from IPT tailored to address their needs to a greater degree than from E-TAU.

METHODS

We conducted a randomized controlled psychotherapy trial of 61 women from 2 urban medical practices who met criteria for major depressive disorder and chronic pelvic pain. Participants were assigned to receive either 8 sessions of IPT or a facilitated psychotherapy referral to a community mental health center, and assessed for depression, social interactions, and pain at 0-, 12-, 24-, and 36-weeks, with score on the Hamilton Rating Scale for Depression as the primary outcome. Both intent-to-treat (ITT) and causal modeling analyses correcting for treatment attendance were conducted.

RESULTS

ITT analyses were not significant. In causal modeling analyses, participants assigned to IPT showed significantly more improvement for depression and social interactions, but not for pain.

CONCLUSION

IPT may be a viable option as part of a comprehensive treatment program for women in medical practices with depression and chronic pain.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov, NCT00895999.

The cost-effectiveness of psychotherapy for the major psychiatric diagnoses

Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions. Psychotherapy can also lead to savings in other medical and societal costs. It is at times the firstline and most important treatment and at other times augments the efficacy of psychotropic medication. Many patients are in need of more prolonged and intensive psychotherapy, including those with personality disorders and those with chronic complex psychiatric conditions often with severe anxiety and depression. Many patients with serious and complex psychiatric illness have experienced severe early life trauma in an atmosphere in which family members or caretakers themselves have serious psychiatric disorders. Children and adolescents with learning disabilities and those with severe psychiatric disorders can also require more than brief treatment. Other diagnostic groups for whom psychotherapy is effective and cost-effective include patients with schizophrenia, anxiety disorders (including posttraumatic stress disorder), depression, and substance abuse. In addition, psychotherapy for the medically ill with concomitant psychiatric illness often lowers medical costs, improves recovery from medical illness, and at times even prolongs life compared to similar patients not given psychotherapy. While "cost-effective" treatments can yield savings in healthcare costs, disability claims, and other societal costs, "cost-effective" by no means translates to "cheap" but instead describes treatments that are clinically effective and provided at a cost that is considered reasonable given the benefit they provide, even if the treatments increase direct expenses. In the current insurance climate in which Mental Health Parity is the law, insurers nonetheless often use their own non-research and non-clinically based medical necessity guidelines to subvert it and limit access to appropriate psychotherapeutic treatments. Many patients, especially those who need extended and intensive psychotherapy, are at risk of receiving substandard care due to inadequate insurance reimbursement. These patients remain vulnerable to residual illness and the concomitant sequelae in lost productivity, dysfunctional interpersonal and family relationships, comorbidity including increased medical and surgical services, and increased mortality.

Effectiveness of collaborative care for depression in Italy. A randomized controlled trial

TRIAL DESIGN

This was a multicenter cluster-randomized controlled trial.

PARTICIPANTS

A total of 227 patients ≥18 years old with a new onset of depressive symptoms who screened positive on the first two items of the Patient Health Questionnaire-9 (PHQ-9) were recruited by primary care physicians (PCPs) of eight health districts of three Italian regions from September 2009 to June 2011.

INTERVENTION

PCPs of the intervention group received a specific collaborative care program including 2 days of intensive training, implementation of a stepped care protocol, depression management toolkit and scheduled meetings with a dedicated consultant psychiatrist.

OBJECTIVE

The objective was to determine whether a collaborative care program for depression management in primary care leads to higher remission rate than usual PCP care.

OUTCOMES

Outcome was clinical remission as expressed on PHQ-9 <5 at 3 months.

RANDOMIZATION

An independent researcher used computer-generated randomization to assign involved primary care groups to the two alternative arms.

BLINDING

PCPs and research personnel were not blinded.

RESULTS

The 223 PCPs enrolled recruited 227 patients (128 in collaborative care arm, 99 in the usual care arm). At 3 months (n=210), the proportion of patients who achieved remission was higher, though the difference was not statistically significant, in the collaborative care group. The effect size was of 0.11. When considering only patients with minor/major depression, collaborative care appeared to be more effective than usual care (P=.015).

CONCLUSIONS

The present intervention for managing depression in primary care, designed to be applicable to the Italian context, appears to be effective and feasible.

Primary care physicians' perspective on the management of anxiety and depressive disorders: a cross-sectional survey in Emilia Romagna Region

Background

Evidences from literature suggest that Primary Care Physicians’ (PCPs) knowledge and attitude about psychological and pharmacological treatments of anxiety and depressive disorders could influence their clinical practice. The aim of the study is double: 1) to assess PCPs’ opinions about antidepressants (ADs) and psychotherapy for the management of anxiety and depressive disorders; 2) to evaluate the influence of PCPs’ gender, age, duration of clinical practice, and office location on their opinions and attitudes.

Methods

This cross-sectional multicentre survey involved 816 PCPs working in four Local Health Units of the Emilia Romagna Region. Participating PCPs were asked to complete a questionnaire during educational meetings between October 2006 and December 2008.

Results

The response rate was 65.1%. Eighty-five percent of PCPs agreed on the effectiveness of ADs for depressive disorder whereas lower agreement emerged for anxiety disorder and on psychotherapy for both anxiety and depression. Forty percent of PCPs reported to feel “very/extremely confident” in recognizing depression and 20.0% felt equally confident in treating it with pharmacotherapy. Considering anxiety disorder, these proportions increased. Female PCPs and those located in the rural/mountain areas reported to adopt more psycho-educational support compared to male and suburban colleagues.

Conclusions

Our results suggest that an effort should be made to better disseminate recent evidences about the management of anxiety and depressive disorders in Primary Care. In particular, the importance of psychological interventions and the role of drugs for anxiety disorder should be addressed.

A randomized double-blind, placebo-controlled trial of venlafaxine-extended release for co-occurring cannabis dependence and depressive disorders

AIM

To evaluate whether venlafaxine-extended release (VEN-XR) is an effective treatment for cannabis dependence with concurrent depressive disorders.

DESIGN

This was a randomized, 12-week, double-blind, placebo-controlled trial of out-patients (n = 103) with DSM-IV cannabis dependence and major depressive disorder or dysthymia. Participants received up to 375 mg VEN-XR on a fixed-flexible schedule or placebo. All patients received weekly individual cognitive-behavioral psychotherapy that primarily targeted marijuana use.

SETTINGS

The trial was conducted at two university research centers in the United States.

PARTICIPANTS

One hundred and three cannabis-dependent adults participated in the trial.

MEASUREMENTS

The primary outcome measures were (i) abstinence from marijuana defined as at least two consecutive urine-confirmed abstinent weeks and (ii) improvement in depressive symptoms based on the Hamilton Depression Rating Scale.

FINDINGS

The proportion of patients achieving a clinically significant mood improvement (50% decrease in Hamilton Depression score from baseline) was high and did not differ between groups receiving VEN-XR (63%) and placebo (69%) (χ1 (2)  = 0.48, P = 0.49). The proportion of patients achieving abstinence was low overall, but was significantly worse on VEN-XR (11.8%) compared to placebo (36.5%) (χ1 (2)  = 7.46, P < 0.01; odds ratio = 4.51, 95% confidence interval: 1.53, 13.3). Mood improvement was associated with reduction in marijuana use in the placebo group (F1,179  = 30.49, P < 0.01), but not the VEN-XR group (F1,186  = 0.02, P = 0.89).

CONCLUSIONS

For depressed, cannabis-dependent patients, venlafaxine-extended release does not appear to be effective at reducing depression and may lead to an increase in cannabis use.

[Depression in old age: challenge for aging societies]

Depression in old age is common and has severe consequences. The paper reviews the most recent results of population-based and primary care-based studies reporting the prevalence, course and risk factors for depression in old age. Consequences of late life depression for the individual and for the society in terms of costs of illness are outlined. Studies of health service utilization and costs showed homogeneously that healthcare costs for depressive elderly individuals are one third higher compared to non-depressive individuals even though most do not receive depression-specific treatment. Late life depression is underrecognized and undertreated and data from Germany are rare. Improvement strategies, such as collaborative care models are discussed; however, adaptation and implementation to the German context are still pending. Future demographic changes will facilitate mental health service research into late life depression.

The effectiveness of Internet cognitive behavioural therapy (iCBT) for depression in primary care: a quality assurance study

Background

Depression is a common, recurrent, and debilitating problem and Internet delivered cognitive behaviour therapy (iCBT) could offer one solution. There are at least 25 controlled trials that demonstrate the efficacy of iCBT. The aim of the current paper was to evaluate the effectiveness of an iCBT Program in primary care that had been demonstrated to be efficacious in two randomized controlled trials (RCTs).

Method

Quality assurance data from 359 patients prescribed the Sadness Program in Australia from October 2010 to November 2011 were included.

Results

Intent-to-treat marginal model analyses demonstrated significant reductions in depressive symptoms (PHQ9), distress (K10), and impairment (WHODAS-II) with medium-large effect sizes (Cohen's d = .51–1.13.), even in severe and/or suicidal patients (Cohen's d = .50–1.49.) Secondary analyses on patients who completed all 6 lessons showed levels of clinically significant change as indexed by established criteria for remission, recovery, and reliable change.

Conclusions

The Sadness Program is effective when prescribed by primary care practitioners and is consistent with a cost-effective stepped-care framework.

Depression care and treatment in a chronically ill Medicare population

OBJECTIVE

The purpose of this study is to examine depression care among chronically ill Medicare Advantage beneficiaries.

METHODS

This study includes 5898 Medicare Advantage members with a depression diagnosis enrolled between 2008 and 2010 in a care management program. Two depression care indicators were created: (a) any depression care (≥ 1 antidepressant prescription or ≥ 1 specialty mental health visit) and (b) among those receiving any depression care, those receiving an antidepressant prescription for ≥ 90 days or ≥ 2 specialty visits. Multivariable analysis using logistic regression was used to examine correlates of depression care.

RESULTS

Among those <65 years old, 72% received any depression care with 75% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. Among ≥ 65 years old, 65% received any depression care with 67% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. For both age groups, female gender, medical comorbidities and dual eligibility were positively associated with an antidepressant prescription. In the older group, female gender was positively associated with at least a 90-day supply of an antidepressant prescription, while substance use disorders were negatively associated with receiving a minimum of 90 days of an antidepressant. Regional differences and certain psychiatric comorbidities were also associated with receiving depression care.

CONCLUSION

Two thirds of the depressed patients in this Medicare Advantage population received depression care. Further studies are needed to examine the effects of quality improvement efforts in the context of care management programs for chronically ill older adults.

Multidisciplinary cognitive-behavioral therapy training for the veterans affairs primary care setting

OBJECTIVE

Current research highlights the need to embed evidence-based psychotherapies such as cognitive-behavioral therapy (CBT) within primary care settings. Few studies have examined CBT training procedures, and no studies have examined the impact of CBT training in the primary care setting. The current study sought to describe and assess the feasibility and effectiveness of a focused CBT training program for a diverse sample of primary care mental health providers in the Department of Veterans Affairs (VA).

METHOD

A multidisciplinary group of 28 mental health clinicians from 6 VA medical centers and 15 community-based outpatient clinics received an intensive 1½-day CBT workshop, held in Houston, Texas, in May 2008, including didactic presentations, expert modeling, and small-group role plays. CBT experts also provided biweekly follow-up group telephone consultation calls for participants over 12 weeks to aid in development of CBT skills. Participant program evaluation surveys and self-reported CBT knowledge, ability, and utilization were measured preworkshop, postworkshop, and 3 months postworkshop. Analyses compared mean change scores at baseline to those at 3-month follow-up. Wilcoxon signed rank tests were completed, and Cohen d effect-size calculations were also computed.

RESULTS

Statistical analyses found that participant self-reported CBT knowledge (P < .01, effect size [ES] = 0.49) was significantly improved postworkshop and maintained at 3-month follow-up. Self-reported abilities were also improved (P = .07, ES = 0.40). The potency of the training experience appeared to be enhanced by the multimodal nature of the program.

CONCLUSION

Although challenges exist, focused and intensive training in CBT appears feasible for multidisciplinary mental health practitioners in the primary care setting.

Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design

BACKGROUND

Despite the availability of evidence-based psychotherapies for depression and anxiety, they are underused in non-mental health specialty settings such as primary care. Hybrid effectiveness-implementation designs have the potential to evaluate clinical and implementation outcomes of evidence-based psychotherapies to improve their translation into routine clinical care practices.

METHODS

This protocol article discusses the study methodology and implementation strategies employed in an ongoing, hybrid, type 2 randomized controlled trial with two primary aims: (1) to determine whether a brief, manualized cognitive behavioral therapy administered by Veterans Affairs Primary Care Mental Health Integration program clinicians is effective in treating depression and anxiety in a sample of medically ill (chronic cardiopulmonary diseases) primary care patients and (2) to examine the acceptability, feasibility, and preliminary outcomes of a focused implementation strategy on improving adoption and fidelity of brief cognitive behavioral therapy at two Primary Care-Mental Health Integration clinics. The study uses a hybrid type 2 effectiveness/implementation design to simultaneously test clinical effectiveness and to collect pilot data on a multifaceted implementation strategy that includes an online training program, audit and feedback of session content, and internal and external facilitation. Additionally, the study engages the participation of an advisory council consisting of stakeholders from Primary Care-Mental Health Integration, as well as regional and national mental health leaders within the Veterans Administration. It targets recruitment of 320 participants randomized to brief cognitive behavioral therapy (n = 200) or usual care (n = 120). Both effectiveness and implementation outcomes are being assessed using mixed methods, including quantitative evaluation (e.g., intent-to-treat analyses across multiple time points) and qualitative methods (e.g., focus interviews and surveys from patients and providers). Patient-effectiveness outcomes include measures of depression, anxiety, and physical health functioning using blinded independent evaluators. Implementation outcomes include patient engagement and adherence and clinician brief cognitive behavioral therapy adoption and fidelity.

CONCLUSIONS

Hybrid designs are needed to advance clinical effectiveness and implementation knowledge to improve healthcare practices. The current article describes the rationale and challenges associated with the use of a hybrid design for the study of brief cognitive behavioral therapy in primary care. Although trade-offs exist between scientific control and external validity, hybrid designs are part of an emerging approach that has the potential to rapidly advance both science and practice.

TRIAL REGISTRATION

NCT01149772 at http://www.clinicaltrials.gov/ct2/show/NCT01149772.

Combination of pharmacotherapy and psychotherapy in the treatment of chronic depression: a systematic review and meta-analysis

BACKGROUND

Chronic depression represents a substantial portion of depressive disorders and is associated with severe consequences. This review examined whether the combination of pharmacological treatments and psychotherapy is associated with higher effectiveness than pharmacotherapy alone via meta-analysis; and identified possible treatment effect modifiers via meta-regression-analysis.

METHODS

A systematic search was conducted in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ISI Web of Science, BIOSIS, PsycINFO, and CINAHL. Primary efficacy outcome was a response to treatment; primary acceptance outcome was dropping out of the study. Only randomized controlled trials were considered.

RESULTS

We identified 8 studies with a total of 9 relevant comparisons. Our analysis revealed small, but statistically not significant effects of combined therapies on outcomes directly related to depression (BR = 1.20) with substantial heterogeneity between studies (I² = 67%). Three treatment effect modifiers were identified: target disorders, the type of psychotherapy and the type of pharmacotherapy. Small but statistically significant effects of combined therapies on quality of life (SMD = 0.18) were revealed. No differences in acceptance rates and the long-term effects between combined treatments and pure pharmacological interventions were observed.

CONCLUSIONS

This systematic review could not provide clear evidence for the combination of pharmacotherapy and psychotherapy. However, due to the small amount of primary studies further research is needed for a conclusive decision.

Open trial of brief behavioral activation psychotherapy for depression in an integrated veterans affairs primary care setting

OBJECTIVE

Major depressive disorder (MDD) is highly prevalent and impairing and highly likely to present in primary care settings. Recent efforts by the Department of Veterans Affairs (VA) have sought to integrate mental health services into primary care settings, leading to new specialty pharmacotherapy and psychotherapy treatment options for primary care patients. However, little is known about the effectiveness of these new services in primary care patients with MDD. The present study investigated the effectiveness of a brief, easy-to-administer, evidence-based psychotherapy behavioral activation in an integrated mental health/primary care setting in a southeastern VA medical center during the first year of the program.

METHOD

Thirty-five veterans with MDD (DSM-IV criteria) completed an initial clinical intake, were given the Mini International Neuropsychiatric Interview, and began a 4-week behavioral activation program. Patients also completed the Hospital Anxiety and Depression Scale (HADS) at intake, posttreatment, and at 1-month follow-up. The study was conducted from November 2009 to November 2010.

RESULTS

Sixty percent (n = 21) of patients completed the brief behavioral activation. Treatment completers demonstrated significant reductions in symptoms of both anxiety and depression on the HADS at posttreatment (t values > 5.2, P values < .001, d values > 1.16, g values > 1.02) and follow-up (t values > 4.0, P values < .01, d values > 1.74, g values > 1.67) when compared to pretreatment levels.

CONCLUSIONS

The present findings support the use of behavioral activation as an effective treatment for patients with MDD in a primary care setting. These findings suggest that new integrated primary care settings should incorporate behavioral activation to offer brief, evidence-based treatments that provide reliable symptom reductions in addition to possible reductions in treatment needs and better management of related physical health conditions.

Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies

BACKGROUND

Depressive symptoms are correlated with poor health outcomes in adults with chronic kidney disease (CKD). The prevalence, severity, and treatment of depressive symptoms and potential risk factors, including level of kidney function, in diverse populations with CKD have not been well studied.

STUDY DESIGN

Cross-sectional analysis.

SETTINGS & PARTICIPANTS

Participants at enrollment into the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies. CRIC enrolled Hispanics and non-Hispanics at 7 centers in 2003-2007, and H-CRIC enrolled Hispanics at the University of Illinois in 2005-2008.

MEASUREMENT

Depressive symptoms measured by Beck Depression Inventory (BDI).

PREDICTORS

Demographic and clinical factors.

OUTCOMES

Elevated depressive symptoms (BDI score ≥11) and antidepressant medication use.

RESULTS

Of 3,853 participants, 27.4% had evidence of elevated depressive symptoms and 18.2% were using antidepressant medications; 31.0% of persons with elevated depressive symptoms were using antidepressants. The prevalence of elevated depressive symptoms varied by level of kidney function: 23.6% for participants with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m(2) and 33.8% of those with eGFR <30 mL/min/1.73 m(2). Lower eGFR (OR per 10-mL/min/1.73 m(2) decrease, 1.10; 95% CI, 1.04-1.17), and non-Hispanic black race (OR, 1.42; 95% CI, 1.16-1.74) were each associated with increased odds of elevated depressive symptoms after controlling for other factors. In regression analyses incorporating BDI score, whereas female sex was associated with greater odds of antidepressant use, Hispanic ethnicity, non-Hispanic black race, and higher urine albumin levels were associated with decreased odds of antidepressant use (P < 0.05 for each).

LIMITATIONS

Absence of clinical diagnosis of depression and use of nonpharmacologic treatments.

CONCLUSIONS

Although elevated depressive symptoms were common in individuals with CKD, use of antidepressant medications is low. Individuals of racial and ethnic minority background and with more advanced CKD had a greater burden of elevated depressive symptoms and lower use of antidepressant medications.

The effect of changes in depressive symptoms on disability status in patients with diabetes

OBJECTIVE

To examine the association between changes in depressive symptoms and disability status in patients with diabetes.

METHODS

This 5-year prospective cohort study included 2733 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study who had completed depression and activities of daily living questionnaires at baseline and 5 years. Four depression groups were created using changes in depression scores over 5 years: no depression, improved depression, persistent depression, and development of depression. After controlling for sociodemographic and clinical characteristics, we examined the association between changes in depressive symptoms and incident disability at 5 years using Poisson regression.

RESULTS

In patients nondisabled at baseline (n = 2155), the improved depression group had a risk of disability comparable to the no depression reference group [relative risk (RR): 0.70, 95% CI (0.44-1.12)]. The development of depression and persistent depression groups were significantly more likely to develop disability compared with the no depression group [RR: 2.86, 95% CI (2.12-3.86) and RR: 2.16, 95% CI (1.47-3.18), respectively]. Among those who were disabled at baseline, there was no significant change in the disability status of the three depression groups compared with disabled patients with no depressive symptoms at either time point.

CONCLUSIONS

Among initially nondisabled patients with diabetes, those whose depression improved had functional outcomes comparable to those who were nondepressed at baseline and 5 years. Patients who developed depression and had persistent depression were more likely to experience disability at 5 years than those who were nondepressed at baseline and 5 years.

Major depressive disorder: new clinical, neurobiological, and treatment perspectives

In this Seminar we discuss developments from the past 5 years in the diagnosis, neurobiology, and treatment of major depressive disorder. For diagnosis, psychiatric and medical comorbidity have been emphasised as important factors in improving the appropriate assessment and management of depression. Advances in neurobiology have also increased, and we aim to indicate genetic, molecular, and neuroimaging studies that are relevant for assessment and treatment selection of this disorder. Further studies of depression-specific psychotherapies, the continued application of antidepressants, the development of new treatment compounds, and the status of new somatic treatments are also discussed. We address two treatment-related issues: suicide risk with selective serotonin reuptake inhibitors, and the safety of antidepressants in pregnancy. Although clear advances have been made, no fully satisfactory treatments for major depression are available.

When she says "no" to medication: psychotherapy for antepartum depression

Many women suffering from major depressive disorder during pregnancy are hesitant to initiate or continue antidepressant treatment during preconception planning, conception, pregnancy, and lactation (perinatal period). Over the past few decades, various psychotherapeutic approaches have been found to be efficacious for depression in general population research. Several observational and quasi-experimental studies also suggest that psychotherapy can be a safe first-line treatment for perinatal women with mild to moderate depression. This article summarizes findings to date regarding the use of psychotherapy for depression occurring during pregnancy and describes the adaptations made to tailor the treatment to the unique needs of women in the perinatal period.

Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study

BACKGROUND

There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement.

METHODS

This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records.

RESULTS

721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes.

CONCLUSION

The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Suicide attempts: prevention of repetition

OBJECTIVE

To present an overview of promising strategies to prevent repetition of suicidal behaviours.

METHOD

This literature review on tertiary preventive interventions of suicide attempts was produced using the computerized databases PubMed and PsycINFO from January 1966 to September 2010, using French- and English-language limits and the key words: suicid* or deliberate self-harm and treatment* or therapy or intervention* or management.

RESULTS

Thirteen of the 35 included studies showed statistically significant effects of fewer repeated attempts or suicides in the experimental condition. Overall, 22 studies focused on more traditional approaches, that is, pharmacological or psychological approaches. Only 2 of the 6 pharmacological treatments proved significantly superior to a placebo- a study of lithium with depression and flupenthixol with personality disorders. Eight out of 16 psychological treatments proved superior to treatment as usual or another approach: cognitive-behavioural therapy (CBT) (n = 4), (including dialectical behaviour therapy [n = 2]); psychodynamic therapy (n = 2); mixed (CBT plus psychodynamic therapy [n = 1]); and motivational approach and change in therapist (n = 1). Among the 8 studies using visit, postal, or telephone contact or green-token emergency card provision, 2 were significant: one involving telephone follow-up and the other telephone follow-up or visits. Hospitalization was not related to fewer attempts, and 1 of the 4 outreach approaches had significant results: a program involving individualized biweekly treatment. The rationale behind these single or multiple approaches still needs to be clarified. There were methodological flaws in many studies and some had very specific limited samples.

CONCLUSIONS

There is a need for more research addressing the problem in definitions of outcomes and measurement of the dependent variables, gender-specific effects, and inclusion of high-risk groups. There is a need for the development and evaluation of new approaches that support collaboration with community resources and more careful assessment and comparisons of existing treatments with different populations.

The costs of guideline-concordant care and of care according to patients' needs in anxiety and depression

AIM

To describe the direct and indirect costs for people with anxiety and depressive disorders where guidelines are adhered to and patients' perceived needs are fully met.

METHOD

Data were derived from the Netherlands Study of Depression and Anxiety. At baseline, adult patients were interviewed and they completed questionnaires to measure DSM-IV diagnoses, socio-demographic characteristics and perceived need for care. Actual care data were also derived from electronic medical records. Criteria for guideline adherence were based on general practice guidelines, issued by the Dutch College of General Practitioners. Direct and indirect costs were inferred from the Perceived Need for Care Questionnaire administered at baseline, and the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness administered at 1-year follow-up.

RESULTS

For 568 patients with a current anxiety or depressive disorder a complete dataset on health care use and absenteeism was available. Guideline adherence was significantly associated with increased care use and corresponding costs, while fully met perceived need was unrelated to costs. Socio-demographic characteristics, severity of symptoms and guideline adherence all affected the societal costs of patients with fully met perceived needs compared with patients with perceived unmet needs.

CONCLUSION

It appears that guideline-concordant care for anxiety and depression costs more than non-concordant care, while care that has fulfilled all of a patient's needs seems not to be more expensive than care that has not met all perceived needs. However, randomized controlled trials should first confirm this conclusion.

Examination of the utility of psychotherapy for patients with treatment resistant depression: a systematic review

OBJECTIVE

To examine the utility of psychotherapy in managing treatment resistant depression.

DATA SOURCES

PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies.

REVIEW METHODS

Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted.

RESULTS

Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy.

CONCLUSIONS

Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.

Training primary care staff to deliver a computer-assisted cognitive-behavioral therapy program for anxiety disorders

OBJECTIVES

This paper describes the training approach used with primary care staff to deliver an evidence-based computer-assisted cognitive-behavioral therapy (CBT) program for anxiety disorders within a collaborative care treatment delivery model.

METHODS

We describe the training and proficiency evaluation procedures utilized in the Coordinated Anxiety Learning and Management (CALM) study, a large multisite study of collaborative care for anxiety disorders in primary care. Training incorporated readings, didactic presentations, video demonstrations of CBT skills, role-plays, computer-assisted practice, CBT training cases and ongoing group supervision provided by study psychologists.

RESULTS

Proficiency training case data from 15 clinicians are presented. The anxiety clinical specialists (ACSs) were highly proficient at delivering the CBT component of the CALM intervention. The ACSs also provided Likert-scale ratings and open-ended responses about their experiences with the training. Overall, the training was rated very positively and was described as very thorough, indicating a high level of acceptability to clinicians. Recommendations for future training are described.

CONCLUSIONS

Primary care staff with none or minimal prior CBT experience can be trained to deliver a computer-assisted, evidence-based treatment for anxiety disorders. The implications for dissemination and transportability of evidenced-based interventions are discussed.

Depression in primary care: interpersonal counseling vs selective serotonin reuptake inhibitors. The DEPICS Study. A multicenter randomized controlled trial. Rationale and design

BACKGROUND

Depression is a frequently observed and disabling condition in primary care, mainly treated by Primary Care Physicians with antidepressant drugs. Psychological interventions are recommended as first-line treatment by the most authoritative international guidelines but few evidences are available on their efficacy and effectiveness for mild depression.

METHODS/DESIGN

This multi-center randomized controlled trial was conducted in 9 Italian centres with the aim to compare the efficacy of Inter-Personal Counseling, a brief structured psychological intervention, to that of Selective Serotonin Reuptake Inhibitors. Patients with depressive symptoms referred by Primary Care Physicians to psychiatric consultation-liaison services were eligible for the study if they met the DSM-IV criteria for major depression, had a score ≥ 13 on the 21-item Hamilton Depression Rating Scale, and were at their first or second depressive episode. The primary outcome was remission of depressive symptoms at 2-months, defined as a HDRS score ≤ 7. Secondary outcome measures were improvement in global functioning and recurrence of depressive symptoms at 12-months. Patients who did not respond to Inter-Personal Counseling or Selective Serotonin Reuptake Inhibitors at 2-months received augmentation with the other treatment.

DISCUSSION

This trial addresses some of the shortcomings of existing trials targeting major depression in primary care by evaluating the comparative efficacy of a brief psychological intervention that could be easily disseminated, by including a sample of patients with mild/moderate depression and by using different outcome measures.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12608000479303.

Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study

Background

Although for more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low. A significant need exists to identify simple but effective implementation strategies to adopt complex practices within complex systems of care. Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practices. The current pilot examined the use of external facilitation for adoption of cognitive behavioral therapy (CBT) in 20 Department of Veteran Affairs (VA) clinics.

Methods

The 20 clinics were paired on facility characteristics, and 23 clinicians from these were trained in CBT. A clinic in each pair was randomly selected to receive external facilitation. Quantitative methods were used to examine the extent of CBT implementation in 10 clinics that received external facilitation compared with 10 clinics that did not, and to better understand the relationship between individual providers' characteristics and attitudes and their CBT use. Costs of external facilitation were assessed by tracking the time spent by the facilitator and therapists in activities related to implementing CBT. Qualitative methods were used to explore contextual and other factors thought to influence implementation.

Results

Examination of change scores showed that facilitated therapists averaged an increase of 19% [95% CI: (2, 36)] in self-reported CBT use from baseline, while control therapists averaged a 4% [95% CI: (-14, 21)] increase. Therapists in the facilitated condition who were not providing CBT at baseline showed the greatest increase (35%) compared to a control therapist who was not providing CBT at baseline (10%) or to therapists in either condition who were providing CBT at baseline (average 3%). Increased CBT use was unrelated to prior CBT training. Barriers to CBT implementation were therapists' lack of control over their clinic schedule and poor communication with clinical leaders.

Conclusions

These findings suggest that facilitation may help clinicians make complex practice changes such as implementing an evidence-based psychotherapy. Furthermore, the substantial increase in CBT usage among the facilitation group was achieved at a modest cost.