A 5-year prospective study of predictors for functional and work disability among primary care patients with depressive disorders

Functioning in patients with major depressive disorder in remission: A systematic review and meta-analysis

BACKGROUND

Major depressive disorder (MDD) is one of the leading causes of burden of disease globally. We aimed to investigate whether global functioning is impaired in patients with MDD in full or partial remission compared to healthy control individuals (HC).

METHODS

We conducted a systematic review and meta-analysis according to the PRISMA guideline. We searched the databases PubMed, EMBASE and PsycINFO from January 1st 1980 to February 1st 2023. We included studies of adults with a diagnosis/former diagnosis of MDD with assessment of global functioning performed during a state of full or partial remission. The methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. Standardised mean differences (SMD) using random-effects models were calculated as the summary measure. We further performed meta-analyses of the mean raw score in patients with MDD for individual functioning scales.

RESULTS

Forty-two studies, comprising 17,999 patients with MDD and 35,550 HC, were included, 14 of which included both patients with MDD in full or partial remission and HC. Global functioning was lower in patients with MDD in full or partial remission compared with HC (SMD -2.00, 95 % CI: -0.9 to -3.03, 15 comparisons, I2: 99.8 %).

LIMITATIONS

Important information about the study participants and setting was not reported for most studies, or the reporting was unclear.

CONCLUSION

Patients with MDD have lower levels of functioning compared with HC also when in full or partial remission. Assessment of functioning should be an essential component of managing patients with MDD, also during remission.

Comorbid substance use disorder, major depression, and associated disability in a nationally representative sample

BACKGROUND

Major depressive disorders (MDD) and substance use disorders (SUDs) are commonly linked to disability, but there is a lack of research on the risk of disability among individuals who have both SUDs and MD in the general population. This study aimed to investigate the associated risk of disability in people with comorbid SUDs- specifically cannabis use disorder, alcohol use disorder, other drug (except cannabis) use disorder, and a major depressive episode using a nationally representative sample.

METHODS

The 2012 Canadian Community Health Survey- Mental Health (CCHS-MH) data were analyzed using multilevel logistic regression models. The survey included a nationally representative sample of Canadians aged 15 years and older (n = 25,113) residing in the ten Canadian provinces from January to December 2012. The diagnoses of major depressive episodes (MDE) and the SUDs were derived from the DSM-IV diagnostic criteria using a modified WHO-CIDI instrument, while disability was assessed using the World Health Organization Disability Assessment Score (WHODAS) 2.0.

RESULTS

The strongest predictor of disability was found to be comorbidity. Individuals diagnosed with both a SUD and MDE were 4 to 9 times more likely to experience disability, depending on the substance used, compared to those without either diagnosis.

LIMITATIONS

The study's cross-sectional design limits causal inferences.

CONCLUSIONS

Our research discovered that individuals who have both SUD and MDE are at a significantly higher risk of experiencing disability. This highlights the importance of integrating mental health and addiction services to mitigate the risk of disability and improve overall treatment outcomes.

Sick leave and disability pension among TMD patients with musculoskeletal diseases, mental and behavioural disorders - a SWEREG-TMD population-based cohort study

BACKGROUND

Temporomandibular disorders (TMD) are associated with musculoskeletal diseases (MSD), mental and behavioural disorders (MBD), and patients with TMD have been shown to have 2-3 times more days of sick leave (SL) and disability pension (DP) than the general population. MSD and MBD are two of the most common causes for SL and DP, and the association between TMD and the influence of comorbidities on the need for SL and DP among TMD patients need further clarification. This study investigates the impact of MSD and MBD comorbidity on SL and DP among TMD patients diagnosed in a hospital setting and/or surgically treated.

METHODS

All incident TMD patients diagnosed or treated in a hospital setting between 1998 and 2016 and aged 23-59 were included. A non-exposed comparison cohort was collected from the general population. The cohorts were grouped based on the presence of comorbidity: No comorbidity (Group I); MSD comorbidity (Group II); MBD comorbidity (Group III); and combined MSD and MBD comorbidity (Group IV). Main outcomes were mean annual days of SL and DP, and statistical analysis was conducted using generalized estimated equations.

RESULTS

TMD subjects with no comorbidities (Group I) and with MSD/MBD comorbidity (Group II and III) were 2-3 times more often on SL and DP than the corresponding groups from the general population. However, in the group with both MSD and MBD comorbidity (Group IV), the difference between the TMD subjects and the general population was diminishing, suggesting an additive effect.

CONCLUSION

TMD patients are more dependent on SL and DP benefits compared to general population and the difference remains even after considering MSD and MBD comorbidity. In individuals with combined MSD and MBD comorbidity, concurrent TMD has less impact on the need for social insurance benefits. The results accentuate the impact TMD has on the patients' impaired ability to return to work and why TMD should be recognized as having a substantial impact on individual and economic suffering as well as on societal costs, with emphasis on the influence of comorbidities on patient suffering.

Predictors of Return to Work for People with Anxiety or Depression Participating in a Randomized Trial Investigating the Effect of a Supported Employment Intervention

Purpose Common mental disorders have a severe impact on society and individuals; rates of unemployment and disability pensions are high. Knowing which factors facilitate or hinder people's return to work is important when designing effective vocational rehabilitation interventions. Methods We conducted secondary analyses on data from 289 participants with depression or anxiety included in the Individual Placement and Support modified for people with mood and anxiety disorders (IPS-MA) trial. Associations of baseline characteristics and employment or education after 24 months were tested in univariate logistic regression analyses, variables with a p-value below 0.1 were included in multivariate analyses. Results In the univariate analyses, self-reported level of functioning (p = 0.032), higher age (p = 0.070), and higher level of readiness to change (p = 0.001) were associated with the outcome and included in the multivariate analysis. Only age (p = 0.030) and readiness to change (p = 0.003) remained significantly associated with return to work or education after 24 months in the multivariate analysis. Conclusion Higher age and lower readiness to change were associated with a lower chance of having returned to work or education. Factors modifying the effect of higher age should be identified, just as vocational rehabilitation should focus on improving factors related to people's readiness to change.

Fit for Work and Life—an eight-week program for improvement of functionality and quality of life

Background

The current two-stage study focused on work integration and quality of life of patients in an acute psychiatric day care unit. There is evidence that a longer absence from work due to illness negatively affects job retention, life satisfaction and clinical prognosis. Furthermore, there are individual supportive methods that proved to be effective in work integration. We therefore developed a specific group program Fit for Work and Life (FWL) for patients in an acute psychiatric day care unit focusing on work integration in the first labor market (in contrast to work in institutions for people with disabilities/second labor market).

Methods

Between 2018 and 2020, 62 patients (intervention group; IG) were enrolled in an 8‑week prospective job integration program and compared to 74 patients (control group; CG) who received treatment as usual (partly retrospective survey). Patients of both groups held a job when entering treatment. Main outcome was defined as their working status 4 weeks after the end of treatment as well as self-reported life satisfaction.

Results

At the end of treatment (i.e. the week prior to discharge), the IG participants reported higher overall life satisfaction as well as higher health-, self- and living condition-related satisfaction than controls. Functional and clinical improvement during treatment was linked to subsequently returning to work. Functional improvement was further linked to higher life satisfaction. Mediational analysis revealed an indirect path from functional improvement on life satisfaction via working status, i.e. the higher functional improvement during treatment, the higher the chance of successfully returning to work, which in turn increased life satisfaction.

Conclusion

Our findings suggest that programs such as FWL are useful interventions for employed patients to improve reintegration into work and life and to help to increase life satisfaction.

A Possible Antidepressive Effect of Dietary Interventions: Emergent Findings and Research Challenges

Purpose

Despite recent advancements in the treatment of depression, the prevalence of affected individuals continues to grow. The development of new strategies has been required and emerging evidence has linked a possible antidepressant effect with dietary interventions. In this review, we discuss recent findings about the possible antidepressant effect of dietary interventions with an emphasis on the results of randomized controlled trials.

Recent findings

A high consumption of refined sugars and saturated fat and a low dietary content of fruits and vegetables has been associated with the development of depression. There is evidence supporting a small to moderate beneficial effect of a Mediterranean-type diet in depression. In addition, new dietary protocols are being studied for their use as possible interventions, such as the ketogenic diet, Nordic diet, and plant-based diet.

Summary

Lifestyle interventions surrounding diet and nutrition are a relatively affordable way to enhance response to treatment and to be employed as an adjunct in mental health care. Most studies, however, are limited by the difficulty in controlling for the placebo effect. Mediterranean-style diets seem to be the most promising as an adjunctive treatment for mood disorders. Larger randomized controlled trials that could assess predictors of response to dietary interventions are needed to establish a clear positive effect of diet and guide clinical care and nutritional recommendations concerning mental health care.

The Early Burden of Disability in Individuals With Mood and Other Common Mental Disorders in Ontario, Canada

IMPORTANCE

Large population-based data on the trajectory to disability after the first diagnosis of a mood disorder are lacking.

OBJECTIVE

To assess the time between an incident mood disorder diagnosis and the receipt of disability services during a follow-up period of as long as 20 years.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used health administrative and social service data from ICES for 1 902 792 adults aged 18 to 59 years living in Ontario, Canada. A narrow cohort of individuals who had a new diagnosis of a mood disorder between October 1, 1997, and March 31, 2007, matched by sex and age to individuals with no history of mood disorder, included 278 296 participants. A broader cohort of individuals who had a new diagnosis of other common mental disorders during the same period, matched by sex and age to individuals with no history of mental disorder diagnosis, included 1 624 496 individuals. All individuals were followed up to a maximum end date of March 31, 2017. Data analysis was conducted from November 2017 to June 2018.

EXPOSURE

Incident diagnosis of mood or common mental disorder.

MAIN OUTCOMES AND MEASURES

Disability outcomes were as follows: (1) entry into the Ontario Disability Support Program (ODSP), signifying long-term inability to work because of a disability, and (2) admission into a long-term care (LTC) residence, signifying the inability to live in independent housing. Cox proportional hazards models were used.

RESULTS

In the full cohort of 1 902 792 individuals, 278 296 participants (14.6%) were included in the mood disorder cohort (mean [SD] age, 37.5 [11.9] years; 157 386 [56.6%] women), and 1 624 496 participants (85.4%) were included in the common mental disorder cohort (mean [SD], 36.5 [11.8] years; 932 545 [57.4%] women). The incidence of ODSP initiation was greater among individuals with mood disorders than those without (51.5 per 10 000 person-years vs 25.5 per 10 000 person-years; adjusted hazard ratio [aHR], 2.03; 95% CI, 1.95-2.11) and for those with common mental disorders (45.0 per 10 000 person-years vs 27.6 per 10 000 person-years; aHR, 1.57; 95% CI, 1.55-1.60). The aHR for admission to LTC was also higher among individuals with mood disorders compared with those without (aHR, 2.20; 95% CI, 1.80-2.69) and those with common mental disorders compared with those without (aHR, 1.21; 95% CI, 1.14-1.29). Individuals with bipolar disorders had greater ODSP rates than individuals with major depressive disorders (crude rate ratio: 4.31 [95% CI, 3.56-5.17] vs 1.82 [95% CI, 1.36-2.43]).

CONCLUSIONS AND RELEVANCE

This cohort study found that mood disorders were associated with elevated and early rates of disability services. Effective early intervention strategies targeting functional impairment in this population are encouraged.

Risk and risk factors for disability pension among patients with treatment resistant depression- a matched cohort study

BACKGROUND

Treatment resistant depression (TRD) is common among patients with depression, and is associated with clinical and functional disability. However, the risk and risk factors for being granted disability pension (DP) among patients with TRD have not been investigated.

METHODS

All antidepressant initiators in Sweden with a diagnosis of depression in specialized care were identified in nationwide registers 2006-2013 and followed regarding treatment trials. TRD was defined as the start of a third sequential trial. Patients with TRD who were not on DP (N = 3204) were matched by age, sex, history of depression, calendar year, and time for treatment start with 3204 comparators with depression and ongoing antidepressant treatment. A proportional Cox Regression was performed with DP as outcome, adjusted for various sociodemographic and clinical covariates.

RESULTS

Compared to the comparison cohort, TRD was associated with a doubled risk for all-cause DP (aHR 2.07; 95%CI 1.83-2.35), DP due to depression (2.28; 1.82-2.85) and to any mental disorder (2.24; 1.95-2.57) but not due to somatic diagnoses (1.25; 0.84-1.86). Among significant risk factors for DP in TRD were female sex, being > 29 years of age, unemployment and a diagnosis of comorbid personality disorder (ICD-10 codes F60.0-9).

CONCLUSION

TRD is associated with an elevated risk for DP compared to other patients with depression, with large potential costs for the affected patients and for society. Clinical and therapeutic implications for patients with TRD who are granted DP should be further investigated.

LIMITATION

No clinical data, e.g. type of depression or reason for treatment switch, was available for this study.

Measuring Primary Health Care Clinicians' Skills for Depression Management

Introduction: Primary health care clinicians play an important role in the management of depression. Thus, it is very important to have a valid and reliable assessment of the competences needed to manage depression in primary health care, with the use of clinical simulation providing such an opportunity. Objective: The present study describes the assessment of primary health care clinicians' depression-related skills through a series of objective structured clinical examination stations. Material and Methods: Clinicians from multi-professional teams for the management of depression at two primary health care clinics in Santiago, Chile, went through seven objective structured clinical examination stations, lasting 10 to 20 min each, to assess their depression-related skills. The clinical and communicative skills measured were in accordance with clinical guidelines. Standardized patients portrayed cases usually encountered in clinical practice, while expert raters evaluated clinicians' performance with standardized checklists. Results: Psychosocial clinicians performed better than biomedical clinicians in the assessed skills. The most notable results were as follows: a high level of accomplishment in the relationship with patient, medical anamnesis, health checkup, and lab test requests; heterogeneous performance in patient management according to screening results, feedback to the patient, and registration in clinical records; and major deficiencies in the differential diagnosis of bipolar disorder. Discussion: The objective structured clinical examinations administered provided an opportunity to perform an in-depth examination of the depression-related skills of primary health care clinicians, where flaws in the screening and diagnosis procedures used by biomedical clinicians were detected. Given the significant involvement of these types of clinicians in depression management, undergraduate-level and continuing health education opportunities are needed.

Trajectories of Return to Work Among People on Sick Leave with Mood or Anxiety Disorders: Secondary Analysis from a Randomized Controlled Trial

Purpose The return to work (RTW) of people with mood and anxiety disorders is a heterogeneous process. We aimed to identify prototypical trajectories of RTW over a two-year period in people on sick leave with mood and anxiety disorders, and investigate if socio-demographic or clinical factors predicted trajectory membership. Methods We used data from the randomized IPS-MA trial (n = 283), evaluating a supported employment intervention for participants with recently diagnosed mood or anxiety disorders. Information on "weeks in employment in the past 6 months" was measured after 1/2, 1, 1 ½ and 2 years, using data from a nationwide Danish register (DREAM). Latent growth mixture modelling analysis was carried out to identify trajectories of RTW and logistic regression analyses were used to estimate predictors for trajectory membership. Results Four trajectory classes of RTW were identified; non-RTW [70% (196/283)] (practically no return to work); delayed-RTW [19% (56/283)] (6 months delay before full RTW); rapid-unstable-RTW [7% (19/283)] (members rapidly returned to work, but only worked half the time); and the smallest class, rapid-RTW [4% (12/283)] (members rapidly reached full employment, but later experienced a decrease in weeks of employment). Self-reported disability score according to the SDS, not living with a partner, and readiness to change on the CQ scale were found to be significantly associated with RTW. Conclusion The trajectories identified support that many do not benefit from vocational rehabilitation, or experience difficulties sustaining employment; enhanced support of this patient group is still warranted.Trial registration: http://www.clinicaltrials.gov (Identifier: NCT01721824).

Trajectories of work disability and unemployment among young adults with common mental disorders

BACKGROUND

Labour-market marginalisation (LMM) and common mental disorders (CMDs) are serious societal problems. The aims were to describe trajectories of LMM (both work disability and unemployment) among young adults with and without CMDs, and to elucidate the characteristics associated with these trajectories.

METHODS

The study was based on Swedish registers and consisted of all individuals 19-30 years with an incident diagnosis of a CMD in year 2007 (n = 7245), and a matched comparison group of individuals without mental disorders during the years 2004-07 (n = 7245). Group-based trajectory models were used to describe patterns of LMM both before, and after the incident diagnosis of a CMD. Multinomial logistic regressions investigated the associations between sociodemographic and medical covariates and the identified trajectories.

RESULTS

Twenty-six percent (n = 1859) of young adults with CMDs followed trajectories of increasing or constant high levels of work disability, and 32 % (n = 2302) followed trajectories of increasing or constant high unemployment. In the comparison group, just 9 % (n = 665) followed increasing or constant high levels of work disability and 21 % (n = 1528) followed trajectories of increasing or constant high levels of unemployment. A lower share of young adults with CMDs followed trajectories of constant low levels of work disability (n = 4546, 63%) or unemployment (n = 2745, 38%), compared to the level of constant low work disability (n = 6158, 85%) and unemployment (n = 3385, 50%) in the comparison group. Remaining trajectories were fluctuating or decreasing. Around 50% of young adults with CMDs had persistent levels of LMM at the end of follow-up. The multinomial logistic regression revealed that educational level and comorbid mental disorders discriminated trajectories of work disability, while educational level, living area and age determined differences in trajectories of unemployment (R2difference = 0.02-0.05, p < 0.001).

CONCLUSIONS

A large share, nearly 50%, of young adults with CMDs, substantially higher than in the comparison group of individuals without mental disorders, display increasing or high persistent levels of either work disability or unemployment throughout the follow-up period. Low educational level, comorbidity with other mental disorders and living in rural areas were factors that increased the probability for LMM.

Determinants of Sickness Absence and Return to Work Among Employees with Common Mental Disorders: A Scoping Review

Purpose To present an overview of the existing evidence on prognostic factors of (recurrent) sickness absence (SA) and return to work (RTW) among workers with a common mental disorder (CMD). This scoping review provides information about determinants for SA and RTW, which could be used to develop better interventions aimed at the prevention of SA and promotion of RTW among workers with a CMD. Methods Relevant articles were identified in PubMed, Embase, PsycINFO, PSYNDEX, and SINGLE up to October 2016. In order to be included, studies should provide insight into prognostic factors of SA or RTW of workers with a CMD. We classified all factors according to the domains of the International Classification of Functioning, Disability and Health. Results Our searches identified 2447 possible relevant articles, of which 71 were included for data extraction. There is consistent evidence in ≥3 studies that previous episodes of CMD, higher symptom severity, previous absenteeism, co-morbidity, high job demands, low job control, high job strain, female gender, lower educational level, smoking behavior, and low perceived general health are predictors of SA in people with CMDs. Earlier RTW is consistently predicted by lower symptom severity, having no previous absenteeism, younger age, and positive expectations concerning sick-leave duration or RTW. Conclusions The amount of research on determinants for SA and RTW in workers with CMD has increased dramatically in recent years, although most studies are from the Netherlands and Scandinavia. There are some research gaps identified in this scoping review that need further attention in primary and secondary studies. Based on the summary of the evidence, we provide guidance for policy, practice and research.

Common Psychosocial Factors Predicting Return to Work After Common Mental Disorders, Cardiovascular Diseases, and Cancers: A Review of Reviews Supporting a Cross-Disease Approach

Purpose This systematic review aimed at identifying the common psychosocial factors that facilitate or hinder the return to work (RTW) after a sick leave due to common mental disorders (CMDs), cardiovascular diseases (CVDs), or cancers (CAs). Methods We conducted a review of reviews searching 13 databases from 1994 to 2016 for peer-reviewed, quantitative, cohort studies investigating factors influencing RTW after a CMD, CVD, or CA. Then, for each disease we identified additional cohort studies published after the date of the latest review included. Data were extracted following a three steps best-evidence synthesis method: the extraction of results about each predictor from studies within each single review and in the additional papers; the synthesis of results across the reviews and additional papers investigating the same disease; and the synthesis of results across the diseases. Results The search strategy identified 1029 unique records from which 27 reviews and 75 additional studies underwent comprehensive review. 14 reviews and 32 additional cohort studies met eligibility criteria. Specific predictors of RTW with different levels of evidence are provided for each disease. We found four common facilitators of RTW (job control, work ability, perceived good health and high socioeconomic status), and six barriers of RTW (job strain, anxiety, depression, comorbidity, older age and low education). Conclusion This is the first review to systematically analyze commonalities in RTW after CMDs, CVDs, or CAs. The common factors identified indicate that the RTW process presents many similarities across various diseases, thus supporting the validity of a cross-disease approach.

Delineating the trajectories of social and occupational functioning of young people attending early intervention mental health services in Australia: a longitudinal study

OBJECTIVES

Mental disorders typically emerge during adolescence and young adulthood and put young people at risk for prolonged socioeconomic difficulties. This study describes the longitudinal course of social and occupational functioning of young people attending primary care-based, early intervention services.

DESIGN

A longitudinal study of young people receiving mental healthcare.

SETTING

Data were collected between January 2005 and August 2017 from a designated primary care-based mental health service.

PARTICIPANTS

554 young people (54% women) aged 12-32 years.

MEASURES

A systematic medical file audit collected clinical and functional information at predetermined time intervals (ie, 3 months to 5+ years) using a clinical pro forma. Group-based trajectory modelling (GBTM) was used to identify distinct trajectories of social and occupational functioning over time (median number of observations per person=4; median follow-up time=23 months).

RESULTS

Between first clinical contact and time last seen, 15% of young people had reliably deteriorated, 23% improved and 62% did not demonstrate substantive change in function. Of the whole cohort, 69% had functional scores less than 70 at time last seen, indicative of ongoing and substantive impairment. GBTM identified six distinct functional trajectories whereby over 60% had moderate-to-serious functional impairment at entry and remained chronically impaired over time; 7% entered with serious impairment and deteriorated further; a quarter were mildly impaired at entry and functionally recovered and only a small minority (4%) presented with serious impairments and functionally improved over time. Not being in education, employment or training, previous hospitalisation and a younger age at baseline emerged as significant predictors of these functional trajectories.

CONCLUSION

Young people with emerging mental disorders have significant functional impairment at presentation for care, and for the majority, it persists over the course of clinical care. In addition to providing clinical care earlier in the course of illness, these data suggest that more sophisticated and more intensive individual-level and organisational strategies may be required to achieve significant and sustained functional improvements.

Lithium in the episode and suicide prophylaxis and in augmenting strategies in patients with unipolar depression

BACKGROUND

Depressive disorders are a leading cause of the global burden of disease and are associated with high recurrent often continuing morbidity and high excess mortality by suicide and cardiovascular disease. Whilst there are established, effective and cost-effective treatments for depression, their long-term management is often neglected: there is continuing controversy over the case of need for long-term treatment including lifelong treatment and safety issues.

OBJECTIVE AND METHODS

In this narrative review, we critically examine the evidence for the effectiveness and safety of lithium salts in the long-term management of unipolar depression. We refer to existing recent international guidelines as well as the scientific literature selectively and against the background of our longstanding experience with patients suffering from unipolar depression who are often under treated or inappropriately treated.

RESULTS AND DISCUSSION

According to many studies mostly dating back to the 1970/1980s, lithium is efficacious in the prophylaxis of unipolar depression particularly depression with melancholia and delusional depression and showing a clearly episodic course. Also the efficacy of lithium maintenance treatment following recovery by ECT has been clearly shown. Moreover, convincing evidence exists that lithium has added value and benefit for its unique anti-suicidal effects as well as reducing mortality by other causes. The anti-suicidal effect has been convincingly demonstrated in bipolar as well as in unipolar patients. Nevertheless its use in the management of patients with unipolar depression has not been properly recognized by a majority of textbooks and guidelines. Whilst it has been well considered as an effective treatment for depression that has not responded to antidepressants as an adjunct treatment, also called augmentation, it has been much less recommended for the prevention of recurrent episodes of unipolar depression. One of the reasons for this neglect is the blurring of the diagnosis "unipolar depression" by modern diagnostic tools. Lithium will hardly work in a patient with "unipolar depression spectrum disease".

CONCLUSIONS

We conclude that lithium is an effective prophylactic treatment for carefully selected patients with unipolar depression and is safe when prescribed in recommended doses/plasma lithium levels and with regular, careful monitoring. We propose that lithium prophylaxis can be indicated in patients with unipolar depression and that the occurrence of 2 episodes of depression within 5 years is a practical criterion for starting lithium prophylaxis particularly in severe depression with psychotic features and high suicidal risk. Furthermore, an indication might be considered especially in unipolar patients in whom a bipolar background is suspected. In some cases, lithium prophylaxis may be recommended after a single episode of depression that is severe with high suicidal risk and continued life-long.

Imagine your mood: Study design and protocol of a randomized controlled micro-trial using app-based experience sampling methodology to explore processes of change during relapse prevention interventions for recurrent depression

Background

Relapse prevention strategies include continuation of antidepressant medication and preventive psychological interventions. This study aims to gain understanding that may inform tailoring of relapse prevention to individual differences, to improve their effects. Such treatment personalization may be based on repeated assessments within one individual, using experience sampling methodology. As a first step towards informing decisions based on this methodology, insight is needed in individual differences in risk of relapse and response to treatment, and how relapse prevention strategies may differentially target vulnerability for relapse.

Methods

The smartphone application ‘Imagine your mood’ has been developed specifically for this study to assess emotions, imagery, cognitions, and behaviors in daily life. Parallel to the randomized controlled trial ‘Disrupting the rhythm of depression’, 45 remitted recurrently depressed individuals taking continuation antidepressant medication will be randomly assigned to either continuing antidepressant medication (n = 15), continuing antidepressant medication combined with an eight-session preventive cognitive therapy (n = 15), or tapering of antidepressant medication in combination with preventive cognitive therapy (n = 15). Relapse and return of depressive symptomatology over a 24-month follow-up will be assessed. Additionally, matched never depressed individuals (n = 15) will be recruited as controls.

Discussion

This innovative study combines the strengths of a randomized controlled trial and experience sampling methodology in a micro-trial to explore individual differences in risk of relapse and what works for whom to prevent relapse. Results may ultimately pave the way for therapists to tailor relapse prevention strategies to individual (affective) vulnerability.

Trial registration

ISRCTN15472145, retrospectively registered.

Employment Status of Depressed Individuals in an 11-Year Follow-up: Results From the Finnish Health 2011 Survey

OBJECTIVES

The aim of this study was to describe the employment and mental health status of persons with depressive disorders after an 11-year follow-up, and identify individual and work-related factors that predict adverse outcomes.

METHODS

Two nationally representative health surveys, Health 2000 and its follow-up, Health 2011 were used, and persons with depressive disorders at baseline (n = 275) were re-interviewed after 11 years.

RESULTS

Information on employment status was available for all 263 participants in 2011. About 15.7% had been granted disability pension by 2011, while 55.5% were employed and 18.2% on old-age pension. High job control was the only statistically significant predictor of lower probability of disability pension (adjusted odds ratio 0.42, 95% confidence interval [95% CI] 0.23 to 0.77). Being unmarried (adjusted odds ratio 2.99, 95% CI 1.19 to 7.52) was associated with persistent depressive disorder.

CONCLUSIONS

Job control emerged as an important predictor of long-term employment outcomes among depressed individuals.

The Dark Side of Top Level Sport: An Autobiographic Study of Depressive Experiences in Elite Sport Performers

The general and sport psychology research converge to point to a complex relationship between depressive experiences and human performance. The purpose of this study was to explore the depressive experiences of top level athletes and the relationship of such experiences with sport performance. Twelve autobiographies of elite athletes representing eight sports were analyzed. The autobiographical analysis was informed by narrative tradition, using three types of narrative analysis: categorical content, categorical form, and holistic content. The analysis revealed a temporal aspect to the depressive experiences that the athletes reported. Initially, sport represented a form of escape from the depressive symptoms which had been exacerbated by both external stressors (e.g., experiencing bereavement) and internal stressors (e.g., low self-esteem). However, in time, the athletes typically reached a stage when the demands of their sport shifted from being facilitative to being debilitative in nature with an intensification of their depressive symptoms. This was accompanied by deliberations about continuing their engagement in sport and an acceptance that they could no longer escape from their symptoms, with or without sport. The findings extend the extant literature by suggesting a reciprocal relationship between depressive experiences and sport performance, and they support the general psychology literature relating to the negative impact of depression on performance. The applied implications of these findings are discussed emphasizing the importance of early identification of depressive symptoms and the adoption of a proactive approach in the prevention and management of symptoms.

Treatment received and treatment adequacy of depressive disorders among young adults in Finland

BACKGROUND

Under-treated depression may be especially harmful in early adulthood. The aims of this study are to describe treatments received for depressive disorders, to define factors associated with treatment adequacy and dropouts from treatment in a Finnish general population sample of young adults.

METHODS

A nationally representative two-stage cluster sample of 1894 Finns aged 19 to 34 years was sent a questionnaire containing several mental health screens. All screen positives and a random sample of screen negatives were invited to participate in a mental health assessment including a SCID interview. Case records from mental health treatments for the same sample were obtained for the final diagnostic assessment. Based on all available information, receiving antidepressant pharmacotherapy for at least two months with at least four visits with any type of physician or at least eight sessions of psychotherapy within 12 months or at least four days of hospitalization were regarded as minimally adequate treatment. Treatment dropout was rated if the treatment strategy was assessed to be adequate according to the case records but the patient discontinued the visits.

RESULTS

Of participants with depressive disorders (n = 142), 40.9% received minimally adequate treatment. In multiple logistic regression models, substance use disorder and female gender were associated with at least one visit with a physician, while having major depressive disorder was associated with visits with a physician at least 4 times a year. Women had higher odds of having received any psychotherapy and psychotherapy lasting for at least 8 sessions in a year. Low education and a history of suicide attempt were associated with increased odds of treatment dropout. None of the factors explained the final outcome of minimally adequate treatment.

CONCLUSIONS

Treatment adequacy in the present study was better than previously seen, but more efforts are needed to provide adequate treatment for young adults, especially those with low education and suicidality.