Psychoeducational treatment and prevention of depression: the "Coping with Depression" course thirty years later

Impact of a psychoeducational intervention on willingness to seek help for depression among African American young adults

Despite the success of psychoeducational interventions at improving willingness to seek professional help for mental illness, limited research explores the effect of culturally tailored psychoeducational interventions on African American (AA) college students. The objective of this study was to determine if exposure to a culturally relevant psychoeducational intervention impacted AA young adult attitudes, subjective norms, perceived behavioral control, depression stigma, disclosure and willingness to seek help for depression. We conducted a one-group pre- and post-test intervention study of AA college students (N = 75). The 2.5-h intervention featured presentations, large-group discussions, videos, and active learning exercises and was guided by applying a cultural adaptation framework to an existing psychoeducational intervention. The self-administered surveys were created using the Theory of Planned Behavior as a guide. Data were analyzed using paired t-tests. A total of 70 participants completed both pre- and post-test surveys. Overall, willingness, attitude, and disclosure significantly increased after the intervention (p < .001). Additionally, depression stigma significantly decreased after the intervention, indicating fewer stigmatizing beliefs about depression (p < .001). Willingness to seek help for depression among AA college students can be improved through culturally relevant and interactive psychoeducational interventions. These interventions can also improve negative attitudes and perceived behavioral control toward seeking help and decrease stigmatizing beliefs. More research is needed to explore the longitudinal impact of culturally relevant psychoeducational interventions and how they may affect actual help-seeking behavior among AA college students.

Development and initial evaluation of a treatment integrity measure for low-intensity group psychoeducational interventions

BACKGROUND

Despite the importance of assessing the quality with which low-intensity (LI) group psychoeducational interventions are delivered, no measure of treatment integrity (TI) has been developed.

AIMS

To develop a psychometrically robust TI measure for LI psychoeducational group interventions.

METHOD

This study had two phases. Firstly, the group psychoeducation treatment integrity measure-expert rater (GPTIM-ER) and a detailed scoring manual were developed. This was piloted by n=5 expert raters rating the same LI group session; n=6 expert raters then assessed content validity. Secondly, 10 group psychoeducational sessions drawn from routine practice were then rated by n=8 expert raters using the GPTIM-ER; n=9 patients also rated the quality of the group sessions using a sister version (i.e. GPTIM-P) and clinical and service outcome data were drawn from the LI groups assessed.

RESULTS

The GPTIM-ER had excellent internal reliability, good test-retest reliability, but poor inter-rater reliability. The GPTIM-ER had excellent content validity, construct validity, formed a single factor scale and had reasonable predictive validity.

CONCLUSIONS

The GPTIM-ER has promising, but not complete, psychometric properties. The low inter-rater reliability scores between expert raters are the main ongoing concern and so further development and testing is required in future well-constructed studies.

Facilitators and barriers to "Positive Outcomes" from cognitive-behavioral therapy, according to young people: A thematic synthesis

OBJECTIVE

This qualitative review sought to explore how young people (YP) conceptualize positive outcomes from cognitive-behavioral therapy (CBT) and what YP perceive to be the facilitators and barriers to positive outcomes.

METHODS

A systematic literature search was conducted in June 2021 using six online databases. Studies were included if qualitative data were collected from participants who were aged up to 25, had internalizing mental health difficulties, and had received in-person CBT from trained practitioners.

RESULTS

Nineteen studies were included. The Gough Weight of Evidence framework was used to assess methodological and topical quality and relevance. A thematic synthesis identified 34 conceptualizations of positive outcomes, 57 facilitators, and 49 barriers. Descriptive and analytical themes were identified. In line with the review's pragmatic perspective, the latter were worded as practice recommendations: acknowledge YP's perspectives on outcomes, teach tangible CBT techniques, balance autonomy and support, frame CBT as "upskilling," explore nuanced barriers to engagement, and consider the power of group dynamics.

CONCLUSIONS

This review established the range of YP's views about positive outcomes from CBT, as well as facilitators and barriers to achieving these. Findings should prompt CBT practitioners to reflect and consider how their practice might be shaped through reports from YP as experts by experience.

BEhavioral Health Stratified Treatment (B.E.S.T.) to optimize transition to adulthood for youth with intellectual and/or developmental disabilities

Youth with intellectual and/or developmental disabilities (IDD) often struggle with depression and anxiety, which adversely impacts transition to adulthood. Integrated behavioral health care coordination, wherein care coordinators and behavioral health specialists collaborate to provide systematic, cost-effective, patient-centered care, is a promising strategy to improve access to behavioral health services and address factors that impact transition to adulthood, including depression/anxiety symptoms. Current care coordination models (e.g., Title V Maternal and Child Health Bureau [MCHB]) do not include behavioral health services. The CHECK (Coordinated HealthCarE for Complex Kids) mental health model, hereby refined and renamed BEhavioral Health Stratified Treatment (B.E.S.T.), is a behavioral health intervention delivery program designed for integration into care coordination programs. This study aims to determine whether an integrated behavioral health care coordination strategy (i.e., MCHB care coordination plus B.E.S.T.) would be more acceptable and lead to better youth health and transition outcomes, relative to standard care coordination (i.e., MCHB care coordination alone). Results would guide future investment in improving outcomes for youth with IDD. This study is a two-arm randomized clinical trial of 780 transition-aged youth with IDD (13-20 years) to evaluate the comparable efficacy of MCHB Care Coordination alone vs. MCHB Care Coordination plus B.E.S.T. on the following outcomes: 1) decreased symptoms and episodes of depression and anxiety over time; 2) improved health behaviors, adaptive functioning and health related quality of life; 3) increased health care transition (HCT) readiness; and 4) improved engagement and satisfaction with care coordination among stakeholders.

Psychological treatment of depression: A systematic overview of a 'Meta-Analytic Research Domain'

BACKGROUND

Over the past 16 years, we have developed a 'Meta-analytic Research Domain' (MARD) of all randomized trials of psychological treatments of depression. A MARD is a living systematic review of a research field, that cannot be otherwise covered by one (network) meta-analysis and includes multiple PICOs. In this paper we give an overview of the findings of this MARD.

METHODS

A narrative review of the results of the 118 meta-analyses on psychotherapies for depression that were published within our MARD.

RESULTS

Most research has been conducted on cognitive-behavioral therapy (CBT), but several other psychotherapies are also effective, with few differences between therapies. They can be effectively delivered in individual, group, telephone and guided self-help format and are effective in many different target groups and across different age groups, although the effects are significantly smaller in children and adolescents. Psychotherapies have comparable effects as pharmacotherapy at the short term but are probably more effective at the longer term. Combined treatment is more effective than either psychotherapy or pharmacotherapy alone at the short, but also at the longer term.

LIMITATIONS

We did not summarize all published meta-analyses (protocols, methodological studies) and have not compared our results to those found in other meta-analyses on comparable subjects.

CONCLUSION

Psychotherapies can contribute considerably to a reduction of the disease burden of depression. MARDs are an important next step in the aggregation of knowledge from randomized controlled trials in psychological treatments of depression as well as in other healthcare sectors.

Effects of non-pharmacological interventions on depressive symptoms and risk of major depressive disorder in adults with subthreshold depression: A systematic review and meta-analysis

Subthreshold depression (StD) is a condition that significantly reduces the quality of life and increases the risk of developing major depressive disorder (MDD). In order to investigate the effectiveness of non-pharmacological interventions (NPIs) in preventing the onset of MDD and improving depressive symptoms in adults with StD (AStDs), we conducted a systematic search of nine databases and included a total of 15 studies. Standardized mean differences (SMDs) were calculated using random effects models. RoB2 tool and GRADEpro software were used to assess the methodological quality and evidence. Funnel plots, Egger's, and Begg's tests were used to analyze publication bias. Sensitivity, subgroup and meta-regression analyses were performed to explore potential sources of heterogeneity. The results showed that NPIs had a significant effect in preventing the onset of MDD and improving depressive symptoms. Subgroup analysis revealed that NPIs were particularly effective in general adult populations, during short-term follow-up (FU) periods, among pregnant women, and in universal prevention programs. The results were found to be robust and credible, as they were less sensitive to changes in the analysis method. Timely detection and treatment of StD is feasible and important, as it can effectively delay or prevent the onset of MDD.

Factors Affecting Digital Tool Use in Client Interaction According to Mental Health Professionals: Interview Study

BACKGROUND

Digital tools and interventions are being increasingly developed in response to the growing mental health crisis, and mental health professionals (MHPs) considerably influence their adoption in client practice. However, how MHPs use digital tools in client interaction is yet to be sufficiently understood, which poses challenges to their design, development, and implementation.

OBJECTIVE

This study aimed to create a contextual understanding of how MHPs use different digital tools in clinical client practice and what characterizes the use across tools.

METHODS

A total of 19 Finnish MHPs participated in semistructured interviews, and the data were transcribed, coded, and inductively analyzed.

RESULTS

We found that MHP digital tool use was characterized by 3 distinct functions: communication, diagnosis and evaluation, and facilitating therapeutic change. The functions were addressed using analog tools, digitized tools that mimic their analog counterparts, and digital tools that use the possibilities native to digital. The MHP-client communication included various media alongside face-to-face meetings, the MHPs increasingly used digitized tools in client evaluation, and the MHPs actively used digitized materials to facilitate therapeutic change. MHP tool use was generally characterized by adaptability-it was negotiated in client interactions. However, there was considerable variance in the breadth of MHPs' digital toolbox. The existing clinical practices emphasized MHP-client interaction and invited incremental rather than radical developments, which challenged the achievement of the scalability benefits expected from digital tools.

CONCLUSIONS

MHPs use digitized and digital tools in client practice. Our results contribute to the user-centered research, development, and implementation of new digital solutions in mental health care by classifying them according to their function and medium and describing how MHPs use and do not use them.

Predicting Parental Mental Health During COVID-19: Economic Pressure, COVID-19 Stress, and Coping Strategies

As the COVID-19 pandemic continues, understanding connections between economic pressures and mental health experiences is critical in comprehending how stressful global events can affect families. Although economic pressures and stress can negatively impact mental health, approach coping strategies may provide reductions in negative mental health experiences for parents compared to avoidant coping strategies. Despite recent work showing that stress resulting from the pandemic can have negative implications for the mental health of parents with young children, there is little known about the mental health of parents with adolescents. This study utilized a longitudinal sample of 198 parents (194 biological parents; 103 Fathers, and 91 Mothers) of adolescents and examined the mediating impact of COVID-19 stress on the relationship between economic pressure and subsequent depressive and anxious symptoms. Additionally, approach and avoidant coping strategies were examined as potential moderators between COVID-19 stress and later mental health. Results indicated that parents who experienced economic pressure reported worsening mental health across the school semester, with COVID-19 stress mediating this pathway. Further, approach coping strategies moderated the association between COVID-19 stress and later anxiety symptoms such that higher levels of coping associated with greater rates of later anxiety symptoms, while lower levels of coping associated with less anxiety symptoms later. Avoidant coping strategies also moderated these associations, such that greater use associated with greater depressive and anxious symptomology later. These findings emphasize that parents are experiencing worsening mental health following the onset of the pandemic and that there is an urgent need for increased mental health services to assist families during this time.

Psychoeducation for breast cancer: A systematic review and meta-analysis

BACKGROUND

Psychoeducation has emerged as an intervention for women with breast cancer (BC). This meta-analysis evaluated the effectiveness of psychoeducation on adherence to diagnostic procedures and medical treatment, anxiety, depression, quality of life (QoL), and BC knowledge among patients with BC symptoms or diagnosis and BC survivors.

METHODS

A systematic literature search (in PubMed, Embase, PsycINFO and Cochrane) for randomised controlled trials (RCTs) comparing the effects of psychoeducation to control among patients with BC symptoms or diagnosis and BC survivors. Effects were expressed as relative risks (RRs) and standardized mean differences (SMDs) with their 95% confidence intervals.

RESULTS

Twenty-seven RCTs (7742 participants; 3880 psychoeducation and 3862 controls) were included. Compared with controls, psychoeducation had no significant effect on adherence to diagnostic procedures and medical treatment (RR 1.553; 95% CI 0.733 to 3.290, p = .16), but it significantly decreased anxiety (SMD -0.710, 95% CI -1.395 to -0.027, p = .04) and improved QoL with (SMD 0.509; 95% CI 0.096 to 0.923, p < .01). No effects were found for psychoeducation on depression (SMD -0.243, 95% CI -0.580 to 0.091, p = .14), or BC knowledge (SMD 0.718, 95% CI -0.800 to 2.236, p = .23).

CONCLUSION

We demonstrated that psychoeducation did not improve adherence to diagnostic procedures and treatment, depression and BC knowledge but was valuable for reducing anxiety and improving QoL. Future studies may explore the effectiveness of psychoeducation in promoting adherence across various types of cancer.

The Effect of the Imacoco Care Psychoeducation Website on Improving Psychological Distress Among Workers During the COVID-19 Pandemic: Randomized Controlled Trial

BACKGROUND

The prolonged COVID-19 pandemic has affected mental health among workers. Psychoeducational intervention via a website could be effective for primary prevention of mental illness among workers in the current COVID-19 pandemic.

OBJECTIVE

The aim of this randomized controlled trial is to examine the effect of a newly developed online psychoeducational website named Imacoco Care on reducing psychological distress and fear about COVID-19 infection among workers.

METHODS

Participants in the study were recruited from registered members of a web survey company in Japan. Participants who fulfilled the eligibility criteria were randomly allocated to the intervention or control group. Participants in the intervention group were invited to access the Imacoco Care program within a month after the baseline survey. The Kessler Psychological Distress Scale (K6) and the Fear of COVID-19 Scale (FCV-19S) scores were obtained at baseline and at 1- and 3-month follow-ups.

RESULTS

A total of 1200 workers were randomly allocated to the intervention and control groups (n=600 [50%] per group). The Imacoco Care intervention group showed a significant favorable effect on K6 scores (P=.03) with a small effect size (ES; Cohen d=-0.14) and an adverse effect on FCV-19S scores (P=.01) with a small ES (Cohen d=0.16) at 3-month follow-up. In the per protocol analysis (including only participants who had read the Imacoco Care content at least 1 time), the Imacoco Care intervention group also showed a significant favorable effect on reducing K6 scores (P=.03), while an adverse effect on FCV-19S scores was not significant (P=.06) in the intervention group at 3-month follow-up.

CONCLUSIONS

A web-based psychoeducation approach may be effective for improving psychological distress among workers; however, it may be important not only to distribute information but also to encourage active engagement with the content of the program to prevent adverse effects of psychoeducational intervention.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000042556; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048548.

Effects of a school-based intervention on levels of anxiety and depression: a cluster-randomized controlled trial of the MindPower program in ten high schools in Norway

BACKGROUND

The previous decades have shown increased symptoms of depression and anxiety among adolescents. To promote mental health and reduce mental illness, the government of Norway has, as in other countries, pledged that all schools must incorporate life-skills education. We report results from an evaluation of MindPower, a modification of the Coping With Depression (CWD) course, delivered universally in the classroom to secondary high school students, aged 15-16 years, in one county in Norway. The aim of the study was to evaluate the effect of MindPower on symptoms of depression and anxiety.

METHODS

We utilized a two-groups` delayed intervention design where 110 first year high school classes were randomized into one of two intervention groups (IG1 and IG2). IG1 participated in MindPower while IG2 served as a control group for four months until the intervention started also in this group. IG1 and IG2 responded to questionnaires before and after the eight weeks course, at the start of the first and the second booster session, and at the five months follow up. Questionnaires, including online versions of the Hopkins Symptom Checklist (SCL-8) and the Reynolds Adolescent Depression Scale (RADS-2:SF), were administered to 1673 out of a total of 2384 students. SCL-levels were also compared with those from a large population study (UngData).

RESULTS

According to mixed model analyses, SCL-8 and RADS-2:SF showed significant baseline differences between IG1 and IG2. In IG1 and IG2, both SCL-8 and RADS-2:SF showed a small but significant increase in mean scores throughout the study period, with markedly lower mean scores among boys. The SCL-levels were first lower for both girls and boys and then after the completion of MindPower the SCL-levels, equal to the SCL-levels in UngData.

CONCLUSIONS

No effects of the intervention were found. This large universal school-based trial suffered from considerable drop-out of participants. Experiences from implementation and evaluation of universal mental health promotion and preventive school interventions are thoroughly discussed, including, preparation, resources, support, time, realistic expectations, teacher selection and training, implementation, research designs and more. Several empirically based, practical advices are presented. Clinical Trial registration 27/08/2018. Registration number NCT03647826.

Primary prevention of depression: An umbrella review of controlled interventions

BACKGROUND

Primary prevention has the potential to modify the course of depression, but the consistency and magnitude of this effect are currently undetermined.

METHODS

PRISMA and RIGHT compliant (PROSPERO:CRD42020179659) systematic meta-review, PubMed/Web of Science, up to June 2020. Meta-analyses of controlled interventions for the primary prevention of depressive symptoms [effect measures: standardized mean difference (SMD)] or depressive disorders [effect measure: relative risk (RR)] were carried out. Results were stratified by: (i) age range; (ii) target population (general and/or at-risk); (iii) intervention type. Quality (assessed with AMSTAR/AMSTAR-PLUS content) and credibility (graded as high/moderate/low) were assessed. USPSTF grading system was used for recommendations.

RESULTS

Forty-six meta-analyses (k=928 individual studies, n=286,429 individuals, mean age=22.4 years, 81.1% female) were included. Effect sizes were: SMD=0.08-0.53; for depressive symptoms; RR=0.90-0.28 for depressive disorders. Sensitivity analyses including only RCTs did not impact the findings. AMSTAR median=9 (IQR=8-9); AMSTAR-PLUS content median=4.25 (IQR=4-5). Credibility of the evidence was insufficient/low in 43 (93.5%) meta-analyses, moderate in two (4.3%), and high in one (2.2%): reduction of depressive symptoms using psychosocial interventions for young adults only, and a combination of psychological and educational interventions in primary care had moderate credibility; preventive administration of selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in individuals with a stroke had high credibility.

LIMITATIONS

Intervention heterogeneity and lack of long-term efficacy evaluation.

CONCLUSIONS

Primary preventive interventions for depression might be effective. Among them, clinicians may offer SSRIs post-stroke to prevent depressive disorders, and psychosocial interventions for children/adolescents/young adults with risk factors or during the prenatal/perinatal period.

Are guided internet-based interventions for the indicated prevention of depression in green professions effective in the long run? Longitudinal analysis of the 6- and 12-month follow-up of a pragmatic randomized controlled trial (PROD-A)

OBJECTIVE

Evidence of long-term stability for positive mental health effects of internet-based interventions (IBIs) for depression prevention is still scarce. We evaluate long-term effectiveness of a depression prevention program in green professions (i.e. agriculture, horticulture, forestry).

METHODS

This pragmatic RCT (n = 360) compares a tailored IBI program to enhanced treatment as usual (TAU+) in green professions with at least subthreshold depression (PHQ ≥ 5). Intervention group (IG) received one of six IBIs shown previously to efficaciously reduce depressive symptoms. We report 6- and 12-month follow-up measures for depression, mental health and intervention-related outcomes. Intention-to-treat and per-protocol regression analyses were conducted for each measurement point and complemented by latent growth modeling.

RESULTS

After 6 months, depression severity (β = -0.30, 95%-CI: -0.52; -0.07), insomnia (β = -0.22, 95%-CI: -0.41; -0.02), pain-associated disability (β = -0.26, 95%-CI: -0.48; -0.04) and quality of life (β = 0.29, 95%-CI: 0.13; 0.45) in IG were superior to TAU+. Onset of possible depression was not reduced. After 12 months, no intervention effects were found. Longitudinal modeling confirmed group effects attenuating over 12 months for most outcomes. After 12 months, 55.56% of IG had completed at least 80% of their IBI.

CONCLUSIONS

Stability of intervention effects along with intervention adherence was restricted. Measures enhancing long-term effectiveness of IBIs for depression health promotion are indicated in green professions.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00014000. Registered: 09 April 2018.

Individuals' marital instability mediates the association of their perceived childhood parental affection predicting adulthood depression across 18 years

BACKGROUND

Parenting theories propose that lack of childhood parental affection confers increased vulnerability to heightened adulthood depression. However, only a few prospective studies have examined this topic, and no studies included mediators of the childhood parental affection-adulthood depression connection.

OBJECTIVE

This study examined parenting, and interpersonal theories by determining if participants' (n= 2,825) mid-life marital instability mediated their perceived childhood parental affection predicting depressive symptoms in adulthood across 18 years.

METHODS

Childhood maternal and paternal affection (Parental Support Scale) was measured at Time 1 (T1). Depressive symptoms (Composite International Diagnostic Interview-Short Form) were measured at T1, Time 2 (T2), and Time 3 (T3), spaced approximately nine years apart. Marital instability (Marital Instability Index) was measured at T1 and T2. Structural equation modeling analyses were conducted to test whether perceived childhood parental affection would independently negatively predict T3 depressive symptoms, and if participants' mid-life marital instability mediated those relations. All analyses adjusted for prior levels of mediator and outcome variables.

RESULTS

Lower perceived childhood maternal and paternal affection predicted higher T3 depressive symptoms. Lower childhood maternal and paternal affection predicted higher T2 marital instability. Greater marital instability in turn predicted elevated T3 depression. Individuals' marital instability mediated those associations, by accounting for 17-20% of the total effects.

CONCLUSION

Findings highlight the importance of perceived childhood parental affection to nurture a strong marital bond to reduce the odds of developing major depressive disorder in middle-to-late adulthood.

Development of a Novel Web Camera-Based Contact-Free Major Depressive Disorder Screening System Using Autonomic Nervous Responses Induced by a Mental Task and Its Clinical Application

Background

To increase the consultation rate of potential major depressive disorder (MDD) patients, we developed a contact-type fingertip photoplethysmography-based MDD screening system. With the outbreak of SARS-CoV-2, we developed an alternative to contact-type fingertip photoplethysmography: a novel web camera-based contact-free MDD screening system (WCF-MSS) for non-contact measurement of autonomic transient responses induced by a mental task.

Methods

The WCF-MSS measures time-series interbeat intervals (IBI) by monitoring color tone changes in the facial region of interest induced by arterial pulsation using a web camera (1920 × 1080 pixels, 30 frames/s). Artifacts caused by body movements and head shakes are reduced. The WCF-MSS evaluates autonomic nervous activation from time-series IBI by calculating LF (0.04-0.15 Hz) components of heart rate variability (HRV) corresponding to sympathetic and parasympathetic nervous activity and HF (0.15-0.4 Hz) components equivalent to parasympathetic activities. The clinical test procedure comprises a pre-rest period (Pre-R; 140 s), mental task period (MT; 100 s), and post-rest period (Post-R; 120 s). The WCF-MSS uses logistic regression analysis to discriminate MDD patients from healthy volunteers via an optimal combination of four explanatory variables determined by a minimum redundancy maximum relevance algorithm: HF during MT (HF _MT ), the percentage change of LF from pre-rest to MT (%ΔLF_(Pre-R⇒MT) ), the percentage change of HF from pre-rest to MT (%ΔHF_(Pre-R⇒MT) ), and the percentage change of HF from MT to post-rest (%ΔHF_{(MT⇒Post-R)} ). To clinically test the WCF-MSS, 26 MDD patients (16 males and 10 females, 20-58 years) were recruited from BESLI Clinic in Tokyo, and 27 healthy volunteers (15 males and 12 females, 18-60 years) were recruited from Tokyo Metropolitan University and RICOH Company, Ltd. Electrocardiography was used to calculate HRV variables as references.

Result

The WCF-MSS achieved 73% sensitivity and 85% specificity on 5-fold cross-validation. IBI correlated significantly with IBI from reference electrocardiography (r = 0.97, p < 0.0001). Logit scores and subjective self-rating depression scale scores correlated significantly (r = 0.43, p < 0.05).

Conclusion

The WCF-MSS seems a promising contact-free MDD screening apparatus. This method enables web camera built-in smartphones to be used as MDD screening systems.

Universal and Selective Interventions to Prevent Poor Mental Health Outcomes in Young People: Systematic Review and Meta-analysis

BACKGROUND

Much is not known about the efficacy of interventions to prevent poor mental health outcomes in young people by targeting either the general population (universal prevention) or asymptomatic individuals with high risk of developing a mental disorder (selective prevention).

METHODS

We conducted a PRISMA/MOOSE-compliant systematic review and meta-analysis of Web of Science to identify studies comparing post-test efficacy (effect size [ES]; Hedges' g) of universal or selective interventions for poor mental health outcomes versus control groups, in samples with mean age <35 years (PROSPERO: CRD42018102143). Measurements included random-effects models, I2 statistics, publication bias, meta-regression, sensitivity analyses, quality assessments, number needed to treat, and population impact number.

RESULTS

295 articles (447,206 individuals; mean age = 15.4) appraising 17 poor mental health outcomes were included. Compared to control conditions, universal and selective interventions improved (in descending magnitude order) interpersonal violence, general psychological distress, alcohol use, anxiety features, affective symptoms, other emotional and behavioral problems, consequences of alcohol use, posttraumatic stress disorder features, conduct problems, tobacco use, externalizing behaviors, attention-deficit/hyperactivity disorder features, and cannabis use, but not eating-related problems, impaired functioning, internalizing behavior, or sleep-related problems. Psychoeducation had the highest effect size for ADHD features, affective symptoms, and interpersonal violence. Psychotherapy had the highest effect size for anxiety features.

CONCLUSION

Universal and selective preventive interventions for young individuals are feasible and can improve poor mental health outcomes.

Effectiveness and dissemination of computer-based cognitive behavioral therapy for depressed adolescents: Effective and accessible to whom?

BACKGROUND

The aim of this study was to investigate the effectiveness of a Computer-based Cognitive Behavioral Therapy (CCBT) and identify the characteristics of depressed adolescents that participated in the CCBT program.

METHODS

Screening tests for depression and help-seeking variables were conducted in school-aged Korean adolescents (n= 376, mean age=15.71 years, 53.7% female). The number of adolescents that scored above the threshold for mild depression (PHQ-9, CES-D) was 139. Fifty adolescents agreed to participate in the randomized controlled trial (RCT) of CCBT program. Twenty-five adolescents were randomly assigned to the treatment group, and the other 25 to the waitlist control group. The treatment group engaged in CCBT with therapeutic support. To identify variables affecting the outcomes, the quality of their homework compliance also was assessed.

RESULTS

Participants (n=50) who agreed to participate in the CCBT program demonstrated different help-seeking attitudes - a greater recognition of the need for help and lower interpersonal openness - compared to the adolescents (n=87) who did not participate (t = -2.93, p < .01; t = 3.50, p < .001). The treatment group showed significant improvements in depression, self-esteem, and quality of life compared to the waitlist group. Adolescents with high homework compliance showed a significant decrease in the depression scores compared to adolescents with low homework compliance.

LIMITATIONS

Small sample size, no follow-up assessments.

CONCLUSION

CCBT could be an effective alternative for depressed adolescents, especially those who tend to have low interpersonal openness. To improve the effects of CCBT, therapeutic support needs to be provided.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Defining the Assessment and Treatment Competencies to Deliver Low-Intensity Cognitive Behavior Therapy: A Multi-Center Validation Study

Despite the vastly increased dissemination of the low-intensity (LI) version of cognitive behavior therapy (CBT) for the treatment of anxiety and depression, no valid and reliable indices of the LI-CBT clinical competencies currently exist. This research therefore sought to develop and evaluate two measures: the low-intensity assessment competency scale (LIAC) and the low-intensity treatment competency scale (LITC). Inductive and deductive methods were used to construct the competency scales and detailed rating manuals were prepared. Two studies were then completed. The first study used a quantitative, fully-crossed design and the second a multi-center, quantitative longitudinal design. In study one, novice, qualified, and expert LI-CBT practitioners rated an LI-CBT assessment session (using the LIAC) and an LI-CBT treatment session (using the LITC). Study two used the LIAC and LITC across four training sites to analyze the competencies of LI-CBT practitioners over time, across raters, and in relation to the actor/patients' feedback concerning helpfulness, the alliance, and willingness to return. Both the LIAC and LITC were found to be single factor scales with good internal, test-retest reliability and reasonable inter-rater reliability. Both measures were sensitive to measuring change in clinical competence. The LIAC had good concurrent, criterion, discriminant, and predictive validity, while the LITC had good concurrent, criterion, and predictive validity, but limited discriminant validity. A score of 18 accurately delineated a minimum level of competence in LI-CBT assessment and treatment practice, with incompetent practice associated with patient disengagement. These observational ratings scales can contribute to the clinical governance of the burgeoning use of LI-CBT interventions for anxiety and depression in routine services and also in the methods of controlled studies.

Utilizing placebos to leverage effects of cognitive-behavioral therapy in patients with depression

BACKGROUND

Patients with depression often experience difficulties with completing homework assignments during cognitive-behavioral therapy (CBT). In the present study, we investigated the effects of a specific placebo which aimed at improving the practice of a daily relaxation exercise during a four-week outpatient program.

METHODS

A total of 126 patients diagnosed with major depressive disorder were randomly assigned to one of three groups: 'Coping with Depression' course, 'Coping with Depression' course with additional daily placebo treatment, and waiting-list group. The placebo (sunflower oil) was introduced as a natural medicine to help the patients focus on their inner strengths and to mobilize their bodies' natural healing powers. The placebo was taken orally before the daily relaxation exercise.

RESULTS

The placebo improved homework quantity and quality (both p < .001). The placebo group practiced more often and experienced greater relaxation effects than the no-placebo group. Additionally, the placebo group showed a greater reduction of depression symptoms (p < .001).

LIMITATIONS

The primary limitation of the study is the lack of a psychophysiological measure of relaxation.

CONCLUSIONS

Placebos can be used to leverage CBT effects in patients with depression.

Effectiveness and moderators of individual cognitive behavioral therapy versus treatment as usual in clinically depressed adolescents: a randomized controlled trial

We examined if manualized cognitive behavioral therapy (CBT) was more effective than Treatment As Usual (TAU) for clinically depressed adolescents within routine care. This multisite Randomized controlled trail included 88 clinically depressed adolescents (aged 12-21 years) randomly assigned to CBT or TAU. Multiple assessments (pre-, post treatment and six-month follow-up) were done using semi-structured interviews, questionnaires and ratings and multiple informants. The primary outcome was depressive or dysthymic disorder based on the KSADS. Completers, CBT (n = 19) and TAU (n = 26), showed a significant reduction of affective diagnoses at post treatment (76% versus 76%) and after six months (90% versus 79%). Intention-to-treat analyses on depressive symptoms showed that 41.6% within CBT and 31.8% within the TAU condition was below clinical cut-off at post treatment and after six-months, respectively 61.4% and 47.7%. No significant differences in self-reported depressive symptoms between CBT and TAU were found. No prediction or moderation effects were found for age, gender, child/parent educational level, suicidal criteria, comorbidity, and severity of depression. We conclude that CBT did not outperform TAU in clinical practice in the Netherlands. Both treatments were found to be suitable to treat clinically referred depressed adolescents. CBT needs further improvement to decrease symptom levels below the clinical cut-off at post treatment.

Effects of waiting patiently as coping strategy for an interpersonal stressor on depressive symptoms

Background: Coping behavior is known to moderate the effect of stressors on depressive symptoms. Increased reassessing coping, that is, waiting patiently for an appropriate opportunity to handle a stressful relationship, as coping strategy for interpersonal stressors is associated with lower depressive symptoms. Objectives: We hypothesized that higher reassessing coping would be associated with lower depressive symptoms in individuals with higher coping flexibility. Coping flexibility is the ability to discontinue a coping strategy that produces undesirable outcomes by monitoring and evaluating stressful situations and the effects of coping strategies. Methods: Two studies involving approximately 1,800 college students were conducted, one using a cross-sectional design (n = 281) and another a longitudinal design (n = 1,468). Results: In both studies, hierarchical multiple regression analyses showed that the interaction between reassessing coping and coping flexibility scores was predictive of a significant depressive symptom score. This indicates that higher levels of reassessing coping are associated with lower levels of depressive symptoms when coping flexibility is higher, whereas reassessing coping is not associated with depressive symptoms when coping flexibility is lower. Conclusions: These results were consistent with our hypothesis in both studies.

Adherence to Established Treatment Guidelines Among Unguided Digital Interventions for Depression: Quality Evaluation of 28 Web-Based Programs and Mobile Apps

Background

Web-based interventions for depression have been widely tested for usability and functioning. However, the few studies that have addressed the therapeutic quality of these interventions have mainly focused on general aspects without consideration of specific quality factors related to particular treatment components. Clinicians and scientists are calling for standardized assessment criteria for web-based interventions to enable effective and trustworthy patient care. Therefore, an extensive evaluation of web-based interventions at the level of individual treatment components based on therapeutic guidelines and manuals is needed.

Objective

The objective of this study was to evaluate the quality of unguided web-based interventions for depression at the level of individual treatment components based on their adherence to current gold-standard treatment guidelines and manuals.

Methods

A comprehensive online search of popular app stores and search engines in January 2018 revealed 11 desktop programs and 17 smartphone apps that met the inclusion criteria. Programs and apps were included if they were available for German users, interactive, unguided, and targeted toward depression. All programs and apps were tested by three independent researchers following a standardized procedure with a predefined symptom trajectory. During the testing, all web-based interventions were rated with a standardized list of criteria based on treatment guidelines and manuals for depression.

Results

Overall interrater reliability for all raters was substantial with an intraclass correlation coefficient of 0.73 and Gwet AC1 value of 0.80. The main features of web-based interventions included mood tracking (24/28, 86%), psychoeducation (21/28, 75%), cognitive restructuring (21/28, 75%), crisis management (20/28, 71%), behavioral activation (19/29, 68%), and relaxation training (18/28, 64%). Overall, therapeutic meaningfulness was rated higher for desktop programs (mean 4.13, SD 1.17) than for smartphone apps (mean 2.92, SD 1.46).

Conclusions

Although many exercises from manuals are included in web-based interventions, the necessary therapeutic depth of the interventions is often not reached, and risk management is frequently lacking. There is a need for further research targeting general principles for the development and evaluation of therapeutically sound web-based interventions for depression.

Stigma for common mental disorders in racial minorities and majorities a systematic review and meta-analysis

BACKGROUND

There is a strong stigma attached to mental disorders preventing those affected from getting psychological help. The consequences of stigma are worse for racial and/or ethnic minorities compared to racial and/or ethnic majorities since the former often experience other social adversities such as poverty and discrimination within policies and institutions. This is the first systematic review and meta-analysis summarizing the evidence on the impact of differences in mental illness stigma between racial minorities and majorities.

METHODS

This systematic review and meta-analysis included cross-sectional studies comparing mental illness stigma between racial minorities and majorities. Systematic searches were conducted in the bibliographic databases of PubMed, PsycINFO and EMBASE until 20th December 2018. Outcomes were extracted from published reports, and meta-analyses, and meta-regression analyses were conducted in CMA software.

RESULTS

After screening 2787 abstracts, 29 studies with 193,418 participants (N = 35,836 in racial minorities) were eligible for analyses. Racial minorities showed more stigma than racial majorities (g = 0.20 (95% CI: 0.12 ~ 0.27) for common mental disorders. Sensitivity analyses showed robustness of these results. Multivariate meta-regression analyses pointed to the possible moderating role of the number of studies with high risk of bias on the effect size. Racial minorities have more stigma for common mental disorders when compared with majorities. Limitations included moderate to high risk of bias, high heterogeneity, few studies in most comparisons, and the use of non-standardized outcome measures.

CONCLUSIONS

Mental illness stigma is higher among ethnic minorities than majorities. An important clinical implication of these findings would be to tailor anti-stigma strategies related with mental illnesses according to specific racial and/or ethnic backgrounds with the intention to improve mental health outreach.

The importance of physical and mental health in explaining health-related academic role impairment among college students

Research consistently documents high rates of mental health problems among college students and strong associations of these problems with academic role impairment. Less is known, though, about prevalence and effects of physical health problems in relation to mental health problems. The current report investigates this by examining associations of summary physical and mental health scores from the widely-used Short-Form 12 (SF-12) Health Survey with self-reported academic role functioning in a self-report survey of 3,855 first-year students from five universities in the northeastern United States (US; mean age 18.5; 53.0% female). The mean SF-12 physical component summary (PCS) score (55.1) was half a standard deviation above the benchmark US adult population mean. The mean SF-12 mental component summary (MCS) score (38.2) was more than a full standard deviation below the US adult population mean. Two-thirds of students (67.1%) reported at least mild and 10.5% severe health-related academic role impairment on a modified version of the Sheehan Disability Scale. Both PCS and MCS scores were significantly and inversely related to these impairment scores, but with nonlinearities and interactions and much stronger associations involving MCS than PCS. Simulation suggests that an intervention that improved the mental health of all students with scores below the MCS median to be at the median would result in a 61.3% reduction in the proportion of students who experienced severe health-related academic role impairment. Although low-cost scalable interventions exist to address student mental health problems, pragmatic trials are needed to evaluate the effectiveness of these interventions in reducing academic role impairment.

Willingness to Seek Help for Depression in Young African American Adults: Study Protocol

Background

In the United States, among those living with mental illness, 81% of African American (AA) young adults do not seek treatment compared with 66% of their white counterparts. Although the literature has identified unique culturally related factors that impact help seeking among AAs, limited information exists regarding the development and evaluation of interventions that incorporate these unique factors.

Objective

This study aims to describe a study protocol designed to develop a culturally relevant, theory-based, psychoeducational intervention for AA young adults; to determine if exposure to the intervention impacts AA young adults’ willingness to seek help; and to determine whether cultural factors and stigma add to the prediction of willingness to seek help.

Methods

The Theory of Planned Behavior (TPB) and Barrera and Castro’s framework for cultural adaptation of interventions were used as guiding frameworks. In stage 1 (information gathering), a literature review and three focus groups were conducted to identify salient cultural beliefs. Using stage 1 results, the intervention was designed in stage 2 (preliminary adaptation design), and in stage 3 (preliminary adaptation tests), the intervention was tested using pretest, posttest, and 3-month follow-up surveys. An experimental, mixed methods, prospective one-group intervention design was employed, and the primary outcomes were participants’ willingness and intention to seek help for depression and actual help-seeking behavior.

Results

This study was funded in May 2016 and approved by the University of Texas at Austin institutional review board. Data were collected from November 2016 to March 2016. Of the 103 students who signed up to participate in the study, 70 (67.9%) completed the pre- and posttest surveys. The findings are expected to be submitted for publication in 2020.

Conclusions

The findings from this research are expected to improve clinical practice by providing empirical evidence as to whether a culturally relevant psychoeducational intervention is useful for improving help seeking among young AAs. It will also inform future research and intervention development involving the TPB and willingness to seek help by identifying the important factors related to willingness to seek help. Advancing this field of research may facilitate improvements in help-seeking behavior among AA young people and reduce the associated mental health disparities that apparently manifest early on.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16267

Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial

BACKGROUND

Innovative solutions are required to provide mental health support at scale in low-resource humanitarian contexts. We aimed to assess the effectiveness of a facilitator-guided, group-based, self-help intervention (Self-Help Plus) to reduce psychological distress in female refugees.

METHODS

We did a cluster randomised trial in rural refugee settlements in northern Uganda. Participants were female South Sudanese refugees with at least moderate levels of psychological distress (cutoff ≥5 on the Kessler 6). The intervention comprised access to usual care and five 2-h audio-recorded stress-management workshops (20-30 refugees) led by briefly trained lay facilitators, accompanied by an illustrated self-help book. Villages were randomly assigned to either intervention (Self-Help Plus or enhanced usual care) on a 1:1 basis. Within 14 villages, randomly selected households were approached. Screening of women in households continued until 20-30 eligible participants were identified per site. The primary outcome was individual psychological distress, assessed using the Kessler 6 symptom checklist 1 week before, 1 week after, and 3 months after intervention, in the intention-to-treat population. All outcomes were measured at the individual (rather than cluster) level. Secondary outcomes included personally identified problems, post-traumatic stress, depression symptoms, feelings of anger, social interactions with other ethnic groups, functional impairment, and subjective wellbeing. Assessors were masked to allocation. This trial was prospectively registered at ISRCTN, number 50148022.

FINDINGS

Of 694 eligible participants (331 Self-Help Plus, 363 enhanced usual care), 613 (88%) completed all assessments. Compared with controls, we found stronger improvements for Self-Help Plus on psychological distress 3 months post intervention (β -1·20, 95% CI -2·33 to -0·08; p=0·04; d -0·26). We also found larger improvements for Self-Help Plus 3 months post-intervention for five of eight secondary outcomes (effect size range -0·30 to -0·36). Refugees with different trauma exposure, length of time in settlements, and initial psychological distress benefited similarly. With regard to safety considerations, the independent data safety management board responded to six adverse events, and none were evaluated to be concerns in response to the intervention.

INTERPRETATION

Self-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees.

FUNDING

Research for Health in Humanitarian Crises (R2HC) Programme.

Can Cognitive-Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico

This is a longitudinal randomized control trial on the impact of adding a parent psychoeducation intervention (TEPSI) as part of cognitive-behavioral therapy (CBT) for adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample. We tested the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reducing depressive symptoms, MDD diagnosis, and improving family functioning. Participants (n = 121) were randomized to individual CBT with or without TEPSI. No main group effects were found for most patient domains including depression symptoms, as well as presence of adolescent's MDD diagnosis at posttreatment. Results did show a main effect of CBT over time for depression symptoms, suicide ideation, family criticism, and the presence of MDD diagnosis decreasing from pre- to postintervention. A year post treatment, almost 70% of adolescents in both conditions (CBT and CBT + TEPSI) remained in remission. A main effect was obtained for treatment in the adolescent's perception of familism and family emotional involvement. The primary hypothesis that family psychoeducation would optimize CBT for depression in adolescents was not supported. Both conditions yielded similar clinical end points. The culturally adapted CBT was found effective with Latino/a adolescents showing clinically significant improvements from pretreatment to posttreatment and remained stable at a 1-year follow-up. Regarding family outcomes, adolescents in CBT + TEPSI remained stable from pretreatment to posttreatment on family emotional involvement, while adolescents in CBT-alone showed an increase. The implication of these findings is discussed.

Predicting optimal interventions for clinical depression: Moderators of outcomes in a positive psychological intervention vs. cognitive-behavioral therapy

Identifying differences in the clinical response to specific interventions is an important challenge in the field of Clinical Psychology. This is especially true in the treatment of depression where many treatments appear to have comparable outcomes. In a controlled trial, we compared a positive psychology group intervention, the Integrative Positive Psychological Intervention for Depression (IPPI-D; n = 62) to a cognitive-behavioral therapy group intervention (CBT; n = 66) for depression. No statistically or clinically-significant differences between the treatments were found, but a slight advantage was observed, on average, for IPPI-D. The aim of the present study was to identify and combine moderators of the differential efficacy of these two psychological interventions for clinical depression. For this purpose, a secondary analysis using the Personalized Advantage Index (PAI) was performed to identify the intervention predicted to produce the better outcome for each patient. Six of the 21 potential moderators were found to predict differential efficacy between the treatments. IPPI-D was predicted to be the optimal treatment for 73% of the sample. Baseline features that characterized these individuals were: mental and physical comorbidity, prior antidepressant medication, higher levels of negative thoughts, and higher personal growth. The 27% who were predicted to achieve better outcomes in CBT than in IPPI-D tended to have these baseline features: no comorbidities, no prior antidepressant medication, lower levels of negative thoughts, and lower personal growth.

Preventing depression in the community by voluntary sector providers (PERSUADE): intervention development and protocol for a parallel randomised controlled feasibility trial

INTRODUCTION

Depression is now the most common illness worldwide affecting more than 300 million people. Studies modelling the impact of depression interventions have shown that the burden of depression cannot be minimised by more than 35% with existing treatments. There is a need to develop better preventative interventions. The overall aim of this programme of work is to develop interventions to reduce depression symptom scores and prevent development of depression in people with subthreshold depression. The objectives are to adapt a low intensity community-based depression prevention intervention, establish the acceptability and uptake of this model and conduct a parallel randomised controlled feasibility trial to inform a full-scale trial.

METHODS AND ANALYSIS

Focus groups will be run with members of the public, voluntary sector providers and researchers to inform the adaptation of an existing depression prevention course. Sixty-four people with subthreshold depression, as represented by a score of between 5 and 9 on the Patient Health Questionnaire-9 depression measure, will be recruited to take part in the feasibility trial. Participants will be randomised equally to the intervention or usual care control groups. Participants in the intervention group will receive the new revised manual and attend a 1-day workshop delivered by voluntary sector service providers. Outcome measures will be completed 3 months after baseline. Quantitative data on recruitment, randomisation, attendance, retention, questionnaire completion rates will be collected. Primary analyses will be descriptive and a process evaluation will be conducted to assess the processes involved in implementing the intervention. Interviews will be conducted to explore acceptability and framework analysis will be used to analyse the data.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by NHS Research and Ethics Committee: NW-Greater Manchester East. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, the internet and community engagement activities.

TRIAL REGISTRATION NUMBER

ISRCTN23278208;Pre-results.

A Primary Care Prevention System for Behavioral Health: The Behavioral Health Annual Wellness Checkup

Behavioral health problems are involved in the majority of primary care visits. These behavior disorders (e.g., depression, anxiety, smoking, insomnia, etc.) are costly, burdensome to both the patient and the healthcare system, and result in greater medical utilization/cost and poorer future health outcomes. Integrated behavioral healthcare has been proposed as a model for more efficiently addressing the burden of behavioral health problems. While this model has demonstrated some promise in the treatment of behavioral health problems, as well as in the reduction in costs and improvement in healthcare outcomes, the primary prevention of behavioral health problems in this delivery model has been relatively neglected. The present paper discusses the potential value of incorporating the prevention of behavioral health problems into the annual physical/wellness checkup and proposes a detailed system for how this might be accomplished. Limitations, future research, and costs associated with increased prevention in a primary care context are discussed.

Effects of an internet-based cognitive behavioral therapy (iCBT) intervention on improving depressive symptoms and work-related outcomes among nurses in Japan: a protocol for a randomized controlled trial

BACKGROUND

Depression is a major problem among nurses; hence, it is important to develop a primary prevention strategy to manage depression among nurses. This randomized controlled trial (RCT) study aims to investigate the effects of a newly developed internet-based cognitive behavioral therapy (iCBT) program on depressive symptoms, measured at baseline and three- and six-month follow-ups, among nurses in Japan.

METHODS

Nurses working at three university hospitals, one public hospital, and twelve private hospitals who meet inclusion criteria will be recruited and randomized either to the intervention group or the control group (planned N = 525 for each group). The newly developed iCBT program for nurses consists of six modules, which cover different components of cognitive behavioral therapy (CBT); transactional stress model (in module 1), self-monitoring skills (in module 2), behavioral activation skills (in module 3), cognitive restructuring skills (in modules 4 and 5), relaxation skills (in module 5), and problem-solving skills (in module 6). Participants in the intervention group will be asked to read these modules within 9 weeks. The primary outcome will be depressive symptoms as assessed by the Beck Depression Inventory-II (BDI-II) at baseline, three-, and six-month follow-ups.

DISCUSSION

The greatest strength of this study is that it is the first RCT to test the effectiveness of the iCBT program in improving depressive symptoms among nurses. A major limitation is that all measurements, including major depressive episodes, are self-reported and may be affected by situational factors at work and participants' perceptions.

TRIAL REGISTRATION

This trial was registered at the University Hospital Medical Information Network clinical trials registry (UMIN-CTR; ID =  UMIN000033521 ) (Date of registration: August 1, 2018).

Mediation analyses of Internet-facilitated cognitive behavioral intervention for maternal depression

This study evaluated the putative mediating mechanisms of an Internet-facilitated cognitive-behavioral therapy (CBT) intervention for depression tailored to economically disadvantaged mothers of preschool-age children. The CBT mediators were tested across two previously published randomized controlled trials which included the same measures of behavioral activation, negative thinking, and savoring of positive events. Trial 1 included 70 mothers with elevated depressive symptoms who were randomized to either the eight-session, Internet-facilitated intervention (Mom-Net) or to treatment as usual. Trial 2 included 266 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to a motivational interviewing and referral to services condition. Simple mediation models tested each putative mediator independently followed by tests of multiple mediation that simultaneously included all three mediators in the model to assess the salient contributions of each mediator. The pattern of results for the mediating effects were systematically replicated across the two trials and suggest that behavioral activation and negative thinking are salient mediators of the Mom-Net intervention; significant mediating effects for savoring were obtained only in the simple mediation models and were not obtained in the multiple mediation models.

Dismantling the relative effectiveness of core components of cognitive behavioural therapy in preventing depression in adolescents: protocol of a cluster randomized microtrial

BACKGROUND

Both depressive disorder and subclinical depressive symptoms during adolescence are a major public health concern. Therefore, it is important that depression is detected at an early stage and is treated preventively. Prevention based on the principles of Cognitive Behavioural Therapy (CBT) has proven to be the most effective, however research has mainly focused on the effectiveness of "prevention packages" consisting of multiple CBT-components, rather than on the distinct CBT-components. This study will evaluate the relative effectiveness of four core components of CBT (cognitive restructuring (CR), behavioural activation (BA), problem solving (PS) and relaxation (RE)). In addition the relative (cost-)effectiveness of four different sequences of these components will be evaluated: (1) CR - BA - RE - PS, (2) BA - CR - RE - PS, (3) PS - GA - CR - RE and (4) RE - PS - BA - CR.

METHODS

We will perform a non-blinded multisite cluster randomized prevention microtrial with four parallel conditions consisting of the four sequences. The four sequences of components will be offered in groups of high school students with elevated depressive symptoms. For each CBT-component a module of three sessions is developed. Assessments will be conducted at baseline, after each CBT-component, prior to each session, at post-intervention and at 6-month follow-up. Potential moderators and mediators will be evaluated exploratively to shed light on for whom the (sequences of) CBT-components are most effective and how effects are mediated.

DISCUSSION

The potential value of the study is insight in the relative effectiveness of the four most commonly used CBT-components and four different sequences, and possible moderators and mediators in the prevention of depression among adolescents. This knowledge can be used to optimize and personalize CBT-programs.

TRIAL REGISTRATION

The study is registered in the Dutch Trial Register (Trial NL5584 / NTR6176) on October 13, 2016.

Effectiveness of a psychoeducation group intervention conducted by primary healthcare nurses in patients with depression and physical comorbidity: study protocol for a randomized, controlled trial

BACKGROUND

Depressive disorders are the third leading cause of consultation in primary care, mainly in patients with chronic physical illnesses. Studies have shown the effectiveness of group psychoeducation in reducing symptoms in depressive individuals. Our primary aim is to evaluate the effectiveness of an intervention based on a psychoeducational program, carried out by primary care nurses, to improve the remission/response rate of depression in patients with chronic physical illness. Secondarily, to assess the cost-effectiveness of the intervention, its impact on improving control of the physical pathology and quality of life, and intervention feasibility.

METHODS/DESIGN

A multicenter, randomized, clinical trial, with two groups and one-year follow-up evaluation. Economic evaluation study.

SUBJECTS

We will assess 504 patients (252 in each group) aged > 50 years assigned to 25 primary healthcare centers (PHC) from Catalonia (urban, semi-urban, and rural). Participants suffer from major depression (Beck depression inventory: BDI-II 13-28) and at least one of the following: type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma, and/or ischemic cardiopathy. Patients with moderate/severe suicide risk or severe mental disorders are excluded. Participants will be distributed randomly into the intervention group (IG) and control (CG).

INTERVENTION

The IG will participate in the psychoeducational intervention: 12 sessions of 90 min, once a week led by two Primary Care (PC) nurses. The sessions will consist of health education regarding chronic physical illness and depressive symptoms.

MAIN MEASUREMENTS

Clinical remission of depression and/or response to intervention (BDI-II).

SECONDARY MEASUREMENTS

Improvement in control of chronic diseases (blood test and physical parameters), drug compliance (Morinsky-Green test and number of containers returned), quality of life (EQ-5D), medical service utilization (appointments and hospital admissions due to complications), and feasibility of the intervention (satisfaction and compliance). Evaluations will be blinded, and conducted at baseline, post-intervention, and 12 months follow-up.

DISCUSSION

Results could be informative for efforts to prevent depression in patients with a chronic physical illness.

TRIAL REGISTRATION

NCT03243799 (registration date August 9, 2017).

Guidelines for the diagnosis and treatment of depressive disorders in China: The second edition

BACKGROUND

The recent guidelines for depressive disorders in China are based on both the first edition published in 2003, and new scientific evidence reviewed until the end of 2014. The purpose of the guidelines is to provide a comprehensive overview of the scientific evidence for the diagnosis and treatment of depressive disorders for Chinese patients.

METHODS

The data used in the guidelines were extracted from the recent literature, and various international treatment guidelines.

RESULTS

The current (second) guidelines are based on both evidence-based and measurement-based approaches. Comprehensive and regular assessments with standard instruments are recommended in the acute, continuation, and maintenance treatment phases, and the stage prior to the termination of treatment. In order to reduce the risk of relapse, the new guidelines are extended to the entire course of treatment. Recommendations for pharmacotherapeutic and other treatment modalities are described in detail.

CONCLUSIONS

Although major advances have been made compared to the 2003 edition of the guidelines, more intensive research is needed to optimize diagnosis and treatment of depressive disorders in China. The new guidelines provide only recommendations for diagnosis and treatment, therefore clinicians should develop individualized treatment plans along the lines of the comprehensive information obtained from patients and their families.

Cognitive behavioral treatment for depressed adolescents: results from a cluster randomized controlled trial of a group course

BACKGROUND

The group-based CBT intervention, the Adolescent Coping with Depression Course (ACDC), has previously been evaluated within a quasi-experimental design, showing reduction in depressive symptoms compared to a benchmark of similar studies. The aim of our study was to investigate the effectiveness of ACDC within a randomized controlled (RCT) design.

METHOD

Thirty-five course/control leaders randomly assigned to provide ACDC or usual care (UC) recruited 133 adolescents allocated to ACDC and 95 to UC. ACDC participants received eight weekly sessions and two follow-up sessions about 3 and 6 weeks after the last session. UC participants received usual care as implemented at the different sites. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale for adolescents (CES-D), perfectionism with the revised version of the Dysfunctional Attitude Scale (DAS), and rumination with the revised version of the Ruminative Responses Scale (RRS). Attrition was considered missing at random (MAR) and handled with a full information maximum likelihood (FIML) procedure.

RESULTS

Intention to treat analysis (ITT), including baseline scores and predictors of missing data as control or auxiliary variables, showed a small to medium reduction in depressive symptoms for the ACDC group compared to UC (d = -.31). Changes in perfectionism and rumination in favor of the intervention were also significant. Sensitivity analyses confirmed the findings from the ITT analyses.

CONCLUSIONS

The current study supports the effectiveness of this group-based CBT intervention. The intervention can hopefully result in clinically significant reductions in symptoms associated with depression among adolescents.

TRIAL REGISTRATION

ISRCTN registry ISRCTN19700389 . Registered 6 October 2015.

Effectiveness and cost-effectiveness of Self-Help Plus (SH+) for preventing mental disorders in refugees and asylum seekers in Europe and Turkey: study protocols for two randomised controlled trials

INTRODUCTION

This article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In these trials SH+ is being tested as a preventative intervention to lower the incidence of mental disorders in asylum seekers and refugees with psychological distress resettled in Europe and Turkey.

METHODS AND ANALYSIS

Two prospective, multicentre, randomised, rater-blinded, parallel-group studies will follow participants over a period of 12 months. One trial will be conducted in Europe and one in Turkey. In each trial, 600 asylum seekers and refugees screening positive on the General Health Questionnaire (≥3), but without a formal diagnosis of any mental disorders according to the Mini International Neuropsychiatric Interview, will be randomly allocated to SH+or to enhanced treatment-as-usual. The primary outcome will be a lower incidence of mental disorders at 6 month follow-up. Secondary outcomes will include the evaluation of psychological symptoms, functioning, well-being, treatment acceptability and indicators of intervention cost-effectiveness.

ETHICS AND DISSEMINATION

The two trials received ethical clearance from the local Ethics Committees of the participating sites (seven sites), as well as from the WHO Ethics Committee. All participants will provide informed consent before screening and before study inclusion (a two-step procedure). The results of the trials will be disseminated in agreement with a dissemination plan that includes publication(s) in peer-reviewed journals and presentations at relevant national and international conferences and meetings.

TRIALS REGISTRATION NUMBERS

NCT03571347, NCT03587896.

Randomized controlled trial of a facilitated online positive emotion regulation intervention for dementia caregivers

OBJECTIVE

To test the effects of Life Enhancing Activities for Family Caregivers (LEAF), a 6-week positive emotion regulation intervention, on outcomes of positive emotion, depression, anxiety, and physical health as measured by the Patient-Reported Outcomes Measurement Information System® (PROMIS®).

METHOD

A randomized controlled trial (N = 170) comparing LEAF (N = 86) to an emotion reporting/waitlist condition (N = 84) in dementia caregivers. LEAF was individually delivered online by trained facilitators. Participants in the control condition completed daily online emotion reports and then crossed over into the intervention condition after 6 weeks. The study was registered with Clinicaltrials.gov (NCT01825681) and funded by R01NR014435.

RESULTS

Analyses of difference in change from baseline to 6 weeks demonstrated significantly greater decreases in PROMIS® depression (d = -.25; p = .02) and Quality of Life in Neurological Disorders (NeuroQOL) anxiety (d = -.33; p < .01), as well as improvements in PROMIS® physical health (d = .24; p = .02) in the intervention condition compared to the emotion reporting/waitlist control. The intervention also showed greater improvements in positive emotion (d = .58; p < .01) and positive aspects of caregiving (d = .36; p < .01). Increases in positive emotion significantly mediated the effect of LEAF on depression over time.

CONCLUSIONS

This randomized controlled trial of the online-facilitated positive emotion regulation intervention in dementia caregivers demonstrated small to medium effect sizes on caregiver well-being and shows promise for remotely delivered programs to improve psychological well-being in caregivers of people with dementia and other chronic illnesses. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Self Help Plus: study protocol for a cluster-randomised controlled trial of guided self-help with South Sudanese refugee women in Uganda

BACKGROUND

Exposure to armed conflict and forced displacement constitute significant risks for mental health. Existing evidence-based psychological interventions have limitations for scaling-up in low-resource humanitarian settings. The WHO has developed a guided self-help intervention, Self Help Plus (SH+), which is brief, implemented by non-specialists, and designed to be delivered to people with and without specific mental disorders. This paper outlines the study protocol for an evaluation of the SH+ intervention in northern Uganda, with South Sudanese refugee women.

METHODS

A two-arm, single-blind cluster-randomised controlled trial will be conducted in 14 villages in Rhino Camp refugee settlement, with at least 588 women experiencing psychological distress. Villages will be randomly assigned to receive either SH+ with enhanced usual care (EUC), or EUC alone. SH+ is a five-session guided self-help intervention delivered in workshops with audio-recorded materials and accompanying pictorial guide. The primary outcome is reduction in overall psychological distress over time, with 3 months post-treatment as the primary end-point. Secondary outcomes are self-defined psychosocial concerns, depression and post-traumatic stress disorder symptoms, hazardous alcohol use, feelings of anger, interethnic relations, psychological flexibility, functional impairment and subjective wellbeing. Psychological flexibility is a hypothesised mediator, and past trauma history and intervention attendance will be explored as potential moderators.

DISCUSSION

This trial will provide important information on the effectiveness of a scalable, guided self-help intervention for improving psychological health and wellbeing among people affected by adversity.

TRIAL REGISTRATION

ISRCTN50148022; registered 13/03/2017.

Differences in the Effect of Internet-Based Cognitive Behavioral Therapy for Improving Nonclinical Depressive Symptoms Among Workers by Time Preference: Randomized Controlled Trial

Background

Previous randomized controlled trials (RCTs) have shown a significant intervention effect of internet-based computerized cognitive behavioral therapy (iCBT) on improving nonclinical depressive symptoms among healthy workers and community residents in a primary prevention setting. Time preference is one’s relative valuation for having a reward (eg, money) at present than at a later date. Time preference may affect the effectiveness of cognitive behavioral therapy.

Objective

This RCT aimed to test the difference of intervention effect of an iCBT program on improving nonclinical depressive symptoms between two subgroups classified post-hoc on the basis of time preference among workers in Japan.

Methods

All workers in one corporate group (approximate n=20,000) were recruited. Participants who fulfilled the inclusion criteria were randomly allocated to either intervention or control groups. Participants in the intervention group completed 6 weekly lessons and homework assignments within the iCBT program. The Beck Depression Inventory-II (BDI-II) and Kessler’s Psychological Distress Scale (K6) measures were obtained at baseline and 3-, 6-, and 12-month follow-ups. Two subgroups were defined by the median of time preference score at baseline.

Results

Only few (835/20,000, 4.2%) workers completed the baseline survey. Of the 835 participants, 706 who fulfilled the inclusion criteria were randomly allocated to the intervention or control group. Participants who selected irrational time preference options were excluded (21 and 18 participants in the intervention and control groups, respectively). A three-way interaction (group [intervention/control] × time [baseline/follow-up] × time preference [higher/lower]) effect of iCBT was significant for BDI-II (t_1147.42=2.33, P=.02) and K6 (t_1254.04=2.51, P=.01) at the 3-month follow-up, with a greater effect of the iCBT in the group with higher time preference. No significant three-way interaction was found at the 6- and 12-month follow-ups.

Conclusions

The effects of the iCBT were greater for the group with higher time preference at the shorter follow-up, but it was leveled off later. Workers with higher time preference may change their cognition or behavior more quickly, but these changes may not persist.

Trial Registration

UMIN Clinical Trials Registry UMIN000014146; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000016466 (Archived by WebCite at http://www.webcitation.org/70o2rNk2V)

The Family Check-Up Online Program for Parents of Middle School Students: Protocol for a Randomized Controlled Trial

Background

Research has established that skillful family management during adolescence protects youth from a variety of mental health and behavioral problems. Interventions associated with this research have focused on parenting skills as the mediator that links early risk factors with a profile of later behavioral risk, including problem behavior, substance use, and school failure. Fortunately, positive changes in family management skills have been linked to meaningful improvements in adolescent behavior, and these improvements have been significant across a variety of cultural groups.

Objective

We describe the background, research design, and intervention components of an electronic health version of the Family Check-Up program that is targeting middle school children and is being evaluated in a randomized controlled trial for its usability, feasibility, and efficacy.

Methods

We used an iterative formative research process to develop an electronic health version of the Family Check-Up program. In our ongoing randomized controlled trial, eligible families are randomly assigned to 1 of 3 conditions: Family Check-Up Online-only (n≈100), Family Check-Up Online + Coach (n≈100), and a waitlist control condition (middle school as usual; n≈100). We are conducting assessments at baseline, 3 months following randomization (posttest), and at follow-ups scheduled for 6 months and 12 months.

Results

This randomized controlled trial project was funded in 2015. Participant recruitment was completed in spring 2018 and enrollment is ongoing. Follow-up assessments will be completed in 2019.

Conclusions

The innovative Family Check-Up Online program has the potential to help address many of the barriers that more traditional school-based behavioral mental health implementation strategies have yet to solve, including staffing and resources to implement family-centered support within schools.

Trial Registration

ClinicalTrials.gov NCT03060291; https://clinicaltrials.gov/ct2/show/NCT03060291 (Archived by WebCite at http://www.webcitation.org/70f8keeN4)

Trial Registration

RR1-10.2196/11106

Cultural Adaptations: Conceptual, Ethical, Contextual, and Methodological Issues for Working with Ethnocultural and Majority-World Populations

Mayor advancements have been achieved in research on the cultural adaptation of prevention and treatment interventions that are conducted with diverse ethnocultural groups. This commentary addresses conceptual, ethical, contextual, and methodological issues related to cultural adaptations. The articles in this special issue represent a major contribution to the study of cultural adaptations in prevention science. We frame our analysis of fidelity to core intervention components using a conceptual approach that examines (a) the propositional model (theory of change), (b) the procedural model (theory of action, methods), and (c) the philosophical assumptions that undergird these models. Regarding ethics, we caution against imposing the norms, values, and world views of the Western dominant society onto vulnerable populations such as ethnocultural groups. Given that the assumption of universality in behavioral science has been questioned, and as randomized clinical trials (RCTs) seldom examine the ecological validity of evidence-based interventions and treatments (EBI/T), imposing such interventions onto ethnocultural groups is problematic since these interventions contain values, norms, beliefs, and worldviews that may be contrary to those held by many ethnocultural groups. Regarding methods, several innovative designs are discussed that serve as alternatives to the RCT and represent an important contribution to prevention science. Also, we discuss guidelines for conducting cultural adaptations. Finally, the articles in this special issue make a major contribution to the growing field of cultural adaptation of preventive interventions with ethnocultural groups and majority-world populations.