Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy

Clinical factors associated with relapse in depression in a sample of UK primary care patients who have been on long-term antidepressant treatment

BACKGROUND

This paper investigates whether age of onset of depression, duration of the last episode, number of episodes, and residual symptoms of depression and anxiety are associated with depression relapse in primary care patients who have been on long-term maintenance antidepressant treatment and no longer meet ICD10 criteria for depression.

METHODS

An observational cohort using data from ANTLER (N = 478), a double-blind placebo-controlled trial. The primary outcome was time to relapse using the retrospective CIS-R. Participants were followed for 12 months.

RESULTS

Primary outcome was available for 468 participants. Time to relapse in those with more than five previous episodes of depression was shorter, hazard ratio (HR) 1.84 (95% confidence interval [CI] 1.23-2.75) compared to people with two episodes; HR 1.57 (95% CI 1.01-2.43) after adjustment. The residual symptoms of depression at baseline were also associated with increased relapse: HR 1.05 (95% CI 1.01-1.09) and HR 1.06 (95% CI 1.01-1.12) in the adjusted model. There was evidence of reduced rate of relapse in older age of onset group: HR 0.86 (95% CI 0.78-0.95); HR attenuated after adjustment HR 0.91 (95% CI 0.81-1.02). There was no evidence of an association between duration of the current episode and residual anxiety symptoms with relapse.

CONCLUSIONS

The number of previous episodes and residual symptoms of depression were associated with increased likelihood of relapse. These factors could inform joint decision making when patients are considering tapering off maintenance antidepressant treatment or considering other treatments to prevent relapse.

An interdisciplinary multimodal integrative healthcare program for depressive and anxiety disorders

Objective

Although multimodal interventions are recommended in patients with severe depressive and/or anxiety disorders, available evidence is scarce. Therefore, the current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, for patients with (comorbid) depressive and/or anxiety disorders.

Methods

Participants were 3,900 patients diagnosed with a depressive and/or anxiety disorder. The primary outcome was Health-Related Quality of Life (HRQoL) measured with the Research and Development-36 (RAND-36). Secondary outcomes included: (1) current psychological and physical symptoms measured with the Brief Symptom Inventory (BSI) and (2) symptoms of depression, anxiety, and stress measured with the Depression Anxiety Stress Scale (DASS). The healthcare program consisted of two active treatment phases: main 20-week program and a subsequent continuation-phase intervention (i.e., 12-month relapse prevention program). Mixed linear models were used to examine the effects of the healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of 12-month relapse prevention program (T3).

Results

Results showed significant improvements from T0 to T2 for the primary variable (i.e., RAND-36) and secondary variables (i.e., BSI/DASS). During the 12-month relapse prevention program, further significant improvements were mainly observed for secondary variables (i.e., BSI/DASS) and to a lesser extent for the primary variable (i.e., RAND-36). At the end of the relapse prevention program (i.e., T3), 63% of patients achieved remission of depressive symptoms (i.e., DASS depression score ≤ 9) and 67% of patients achieved remission of anxiety symptoms (i.e., DASS anxiety score ≤ 7).

Conclusion

An interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, seems effective for patients suffering from depressive and/or anxiety disorders with regard to HRQoL and symptoms of psychopathology. As reimbursement and funding for interdisciplinary multimodal interventions in this patient group has been under pressure in recent years, this study could add important evidence by reporting on routinely collected outcome data from a large patient group. Future studies should further investigate the long-term stability of treatment outcomes after interdisciplinary multimodal interventions for patients suffering from depressive and/or anxiety disorders.

Examining the description of the concept "treatment as usual" for patients with depression, anxiety and stress-related mental disorders in primary health care research - A systematic review

BACKGROUND

In randomized controlled trials (RCTs) within medical research, applied interventions are compared to treatment-as-usual (TAU) as the control condition. The aim of the current study was to examine how the concept of TAU is described when used as control condition in RCTs evaluating treatments for depression, anxiety syndromes, and stress-related mental disorders in primary care.

METHOD

A systematic review of RCTs utilizing TAU as control group in the RCT in accordance with PRISMA standards was conducted. We used one multidisciplinary database (Scopus), one database focused on nursing (Cinahl), and one medical database (PubMed). The searches were conducted in November 2021 and May 2022.

RESULTS

The included 32 studies comprised of 7803 participants. The content of TAU was classified as follows: 1) Basic descriptions of TAU lacking a detailed account as well as reference to local or national guidelines, 2) Moderate description of TAU including reference to national or local guidelines or a detailed description 3) Advanced description of TAU including references to national guidelines and a detailed description containing five key concepts: early assessment, accessibility, psychological treatment, medication, somatic examination. 18 studies had basic, 11 moderate, and 3 advanced descriptions of TAU.

LIMITATIONS

The limitations were that only studies published in English were included.

CONCLUSIONS

The current study provides an assessment tool with three classification levels for TAU. The description of TAU is still insufficient in RCT studies conducted in primary care, which may affect the interpretation of results. In future research a detailed description of TAU is recommended.

A meta-analysis of CBT efficacy for depression comparing adults and older adults

INTRODUCTION

This meta-analysis investigates CBT treatment efficacy fordepression, and compares outcomes between adults (young and middle aged) and older adults (OA).

METHODOLOGY

Effect sizes (Hedges' g) were obtained from 37 peer-reviewed RCTs, 25 adult papers (participant n = 2948) and 12 OA papers (participant n = 551), and analysed with the random effects model.

RESULTS

No significant difference between age groups is reported in terms of CBT efficacy for depression compared to other treatments (Q_between (1) = 0.06, p = .89), with the overall effect favouring CBT over any other treatments (g = 0.48, 95 % CI = 0.29-0.68). The same pattern of results was found when restricting studies to those which used active control conditions (Q_between (1) = 0.03, p = .86) or passive control conditions (Q (1) = 2.45, p = .12).

DISCUSSION

No significant differences in efficacy for CBT treatment for depression are found when comparing adults and OA. CBT is as efficacious with OA as with adults.

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis

Objectives

The aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).

Methods

A systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.

Results

Thirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.

Conclusions

In patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.

Systematic review registration number

PROSPERO 2018: CRD42018103142.

Remission of symptoms is not equal to functional recovery: Psychosocial functioning impairment in major depression

The ultimate goal of depression treatment is to achieve functional recovery. Psychosocial functioning is the main component of functional impairment in depressed patients. The concept of psychosocial functioning has an early origin; however, its concept and connotation are still ambiguous, which is the basic and key problem faced by the relevant research and clinical application. In this study, we start from the paradox of symptoms remission and functional recovery, describe the concept, connotation, and characteristics of psychosocial functioning impairment in depressed patients, and re-emphasize its importance in depression treatment to promote research and clinical applications related to psychosocial functioning impairment in depressed patients to achieve functional recovery.

Perception and barriers to the use of cognitive-behavioral therapy in the treatment of depression in primary healthcare centers and family medicine clinics in Saudi Arabia

BACKGROUND

General practitioners (GPs) and family medicine physicians (FMPs) have a vital role to play in co-ordinating the care for mental disorders. The objective of this study was to determine the perception of GPs and FMPs on the use of cognitive-behavioral therapy (CBT) for depression in Saudi Arabia, and the barriers against the implementation of CBT in such settings.

MATERIALS AND METHODS

All physicians working in Primary Healthcare Centers and Family Medicine Clinics in Saudi Arabia were targeted and invited to participate in this cross-sectional study. A self-administered online questionnaire was sent via E-mail through the Saudi Commission for Health Specialties and the Saudi Society of Family and Community Medicine. Data was collected using an existing validated questionnaire and was modified to fit the objectives of current study.

RESULTS

A total of 469 FMPs and GPs completed the survey; the mean age of respondents was 38 years. More than half of the FMPs' and GPs' (53%) showed a positive perception of the use of CBT in primary healthcare settings. Most participants (91.9%) were willing to use CBT if they had adequate education and training. More than half of the participants (59.5%) thought it was time-consuming, while 39% thought that CBT training was a very time-intensive process.

CONCLUSION

We conclude that more than half of the physicians clearly had a good perception of the effectiveness of CBT administration in primary healthcare settings. Younger physicians were more perceptive. The most agreed-on barrier to CBT implementation was the lack of training and education.

Single-Subject Research in Psychiatry: Facts and Fictions

Scientific evidence in the field of psychiatry is mainly derived from group-based ("nomothetic") studies that yield group-aggregated results, while often the need is to answer questions that apply to individuals. Particularly in the presence of great inter-individual differences and temporal complexities, information at the individual-person level may be valuable for personalized treatment decisions, individual predictions and diagnostics. The single-subject study design can be used to make inferences about individual persons. Yet, the single-subject study is not often used in the field of psychiatry. We believe that this is because of a lack of awareness of its value rather than a lack of usefulness or feasibility. In the present paper, we aimed to resolve some common misconceptions and beliefs about single-subject studies by discussing some commonly heard "facts and fictions." We also discuss some situations in which the single-subject study is more or less appropriate, and the potential of combining single-subject and group-based study designs into one study. While not intending to plea for single-subject studies at the expense of group-based studies, we hope to increase awareness of the value of single-subject research by informing the reader about several aspects of this design, resolving misunderstanding, and providing references for further reading.

Long-term effectiveness of two models of brief psychotherapy for depression: A three-year follow-up randomized clinical trial

Major depressive disorder (MDD) is a disease that severely impairs psychosocial functioning and decreases the subject's quality of life. Patients who received psychotherapy have a better long-term therapeutic response than those who have only been treated with antidepressants or have not been treated. There are few studies in the literature that follow the outcomes of psychotherapeutic treatments for depression for more than two years. The aim of this study is to compare the therapeutic response of two models of brief psychotherapy for MDD treatment (Cognitive Behavioral Therapy and Short-term Psychodynamic Psychotherapy) with naturalistic controls who received treatment as usual in a three-year follow-up. This is a sample of 75 outpatients, mostly women (82.7%), with a median age of 33 (27-44). The interventions took place in 50-minute sessions once a week for 14 to 16 weeks. Outcomes were assessed at baseline and three years after the intervention. Regarding depressive symptoms, the therapeutic response was maintained three years after the conclusion of the brief models of psychotherapy. Functional capacity long-term maintenance depended not only on the intervention but also on the education level, the work situation and the severity of depressive symptoms at the beginning of the treatment.

Anxiety and depression in general practice outpatients: the long-term change process

BACKGROUND AND OBJECTIVES

Patients who come for a consultation at a general practice clinic as outpatients often suffer from background anxiety and depression. The psychological state of such patients can alleviate naturally; however, there are cases when these symptoms persist. This study investigated the realities and factors behind anxiety/depression becoming prolonged.

METHODS

Participants were 678 adult patients, who came to Department of General Medicine at Chiba University Hospital within a 1-year period starting from April 2012 and who completed the Hospital Anxiety and Depression Scale (HADS) during their initial consultation. Participants whose Anxiety or Depression scores in the HADS, or both, were 8 points or higher were defined as being within the anxiety/depression group, with all other participants making up the control group. A telephone interview was also conducted with participants. Furthermore, age, sex, the period from the onset of symptoms to the initial consultation at our department, the period from the initial department consultation to the telephone survey, and the existence of mental illness at the final department diagnosis were investigated.

RESULTS

A total of 121 patients (17.8% response rate) agreed to the phone survey. The HADS score during the phone survey showed that the anxiety/depression group had a significantly higher score than the control group. The HADS scores obtained between the initial consultation and telephone survey showed a positive correlation. Logistic regression analysis extracted "age" and the "continuation of the symptoms during the initial consultation" as factors that prolonged anxiety/depression.

CONCLUSION

Anxiety and depression in general practice outpatients have the possibility of becoming prolonged for an extended period of time. Being aged 65 years or over and showing a continuation of symptoms past the initial consultation are the strongest factors associated with these prolonged conditions. When patients with anxiety and depression exhibit these risk factors, they should be further evaluated for treatment.

Seeing the signs: Using the course of residual depressive symptomatology to predict patterns of relapse and recurrence of major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is characterized by high relapse/recurrence rates. Predicting individual patients' relapse/recurrence risk has proven hard, possibly due to course heterogeneity among patients. This study aimed to (1) identify homogeneous data-driven subgroups with different patterns of relapse/recurrence and (2) identify associated predictors.

METHODS

For a year, we collected weekly depressive symptom ratings in 213 primary care MDD patients. Latent class growth analyses (LCGA), based on symptom-severity during the 24 weeks after no longer fulfilling criteria for the initial major depressive episode (MDE), were used to identify groups with different patterns of relapse/recurrence. Associations of baseline predictors with these groups were investigated, as were the groups' associations with 3- and 11-year follow-up depression outcomes.

RESULTS

LCGA showed that heterogeneity in relapse/recurrence after no longer fulfilling criteria for the initial MDE was best described by four classes: "quick symptom decline" (14.0%), "slow symptom decline" (23.3%), "steady residual symptoms" (38.7%), and "high residual symptoms" (24.1%). The latter two classes showed lower self-esteem at baseline, and more recurrences and higher severity at 3-year follow-up than the first two classes. Moreover, the high residual symptom class scored higher on neuroticism and lower on extraversion and self-esteem at baseline. Interestingly, the steady residual symptoms and high residual symptoms classes still showed higher severity of depressive symptoms after 11 years.

CONCLUSION

Some measures were associated with specific patterns of relapse/recurrence. Moreover, the data-driven relapse/recurrence groups were predictive of long-term outcomes, suggesting that patterns of residual symptoms could be of prognostic value in clinical practice.

Adult attachment predicts the seven-year course of recurrent depression in primary care

BACKGROUND

Attachment theory posits that attachment has a persistent, long-term impact on depression. Empirical data on associations between adult attachment and the long-term course of depression is, however, scarce. The present study addresses this omission.

METHOD

Primary care patients with a history of depression (n = 103) completed the Experiences in Close Relationships questionnaire measuring adult attachment dimensions (avoidance and anxiety) and styles (secure, preoccupied, dismissing and fearful). The subsequent seven-year course of depression was assessed with the face-to-face administered Composite International Diagnostic Interview (CIDI) and a life-chart interview based on the Longitudinal Interval Follow-up Evaluation (LIFE). At the end of the seven-year follow-up severity of depression was additionally measured with the Beck Depression Inventory (BDI).

RESULTS

The attachment dimensions avoidance and anxiety both showed significant associations during the seven-year course with lower proportions of depressive symptom-free time and higher severity of depression (LIFE and BDI). The secure style predicted compared to preoccupied attachment a significantly higher proportion of symptom-free time (4.97 vs. 1.10 years), compared to dismissing attachment a higher proportion of symptom-free time (4.97 vs. 2.20 years) and lower severity of depression (LIFE: 1.65 vs. 2.14; BDI 6.04 vs. 9.52), and compared to fearful attachment a lower relapse/recurrence rate (45.7% vs. 76.9%), higher proportions of depression diagnosis-free time (7.31 vs. 6.65 years) and symptom-free time (4.97 vs. 0.29 years), and lower severity of depression (LIFE: 1.65 vs. 2.19; BDI 6.04 vs. 15.54).

LIMITATIONS

Sample size was restricted.

CONCLUSION

Insecure attachment predicts an unfavorable course of depression over a seven-year period.

The ten-year course of depression in primary care and long-term effects of psychoeducation, psychiatric consultation and cognitive behavioral therapy

BACKGROUND

While the majority of depressed patients are treated in primary care, long-term follow-up data on the naturalistic course of depression and treatment effectiveness in this setting are scarce. This study examined the ten-year course of depression in primary care patients who had participated in a randomized clinical trial aiming at enhancement of depression outcomes.

METHODS

Of the original sample (n=267), 166 patients participated in the ten-year follow-up; missingness was random. Four treatments were compared: (1) Care As Usual (CAU; n=51); (2) a Psychoeducational Prevention program (PEP; n=68); (3) Psychiatric Consultation followed by PEP (PC+PEP; n=21); and (4) brief Cognitive Behavioral Therapy followed by PEP (CBT+PEP; n=26). During the first three years interviews based on the Composite International Diagnostic Interview (CIDI) were three-monthly applied, the seven years thereafter were assessed with a once applied CIDI and a face-to-face life chart-based interview.

RESULTS

During the ten-year follow-up 76.5% of the patients developed a new depressive episode, 83.4% used antidepressants (median usage 3.1 years), median depression diagnosis-free time was 9.0 years, and median residual symptom-free time 3.8 years. Treatments did not significantly differ on these outcomes, only trends appeared for lower depression severity for CBT+PEP, and, along with PEP, a higher proportion of symptom-free time.

LIMITATIONS

Assessment with the once applied life chart interview (a valid and reliable instrument) is less precise than the three-monthly assessments during the first three years.

CONCLUSIONS

The long-term course of depression in primary care is unfavorable, whereas treatment effects over time seem absent or small.

Bidirectionality Between Sleep Symptoms and Core Depressive Symptoms and Their Long-Term Course in Major Depression

OBJECTIVE

To investigate the bidirectional dynamic relationship between sleep symptoms and core depressive symptoms and to identify subgroups differing with respect to their course.

METHODS

The weekly state of depressive symptoms in depressed primary care patients (N = 267) was assessed retrospectively every 3 months for 3 consecutive years. The bidirectional relationship between sleep and core symptoms was estimated by means of manifest Markov modeling. Data-driven subgroups were estimated with parallel processes-latent class growth analyses to identify differences in courses of sleep and core symptoms.

RESULTS

In total, core symptoms were associated with next-week development (odds = 1.42; 95% confidence interval [CI] = 1.20-1.67; p < .001) and remission of sleep symptoms (odds = 0.86; 95% CI 0.75 to 0.99, p = .033).Evidence was also found for a reverse pathway such that sleep symptoms were associated with the development (odds = 1.26; 95% CI = 1.05-1.50; p = .012) and remission of core symptoms (odds = 0.87; 95% CI = 0.76-0.99; p = .038). Three classes with different 3-year courses were derived. In class 1, the likelihood that core symptoms remitted was reduced if sleep symptoms were present, and symptoms remained present over 3 years. In class 2, symptoms were bidirectionally related and remitted over 3 years. In class 3, symptoms were not associated, and sleep symptoms declined less steeply than core depressive symptoms.

CONCLUSIONS

The results suggest that sleep symptoms should be treated alongside core depressive symptoms in patients with an asynchronic decrease of sleep and core symptoms and in patients that do not respond to treatment to increase the chance of complete remission.

Shared care across the interface between primary and specialty care in management of long term conditions

BACKGROUND

Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care.

OBJECTIVES

To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.Secondary questions include the following:1. Which shared care interventions or portions of shared care interventions are most effective?2. What do the most effective systems have in common?

SEARCH METHODS

We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015.

SELECTION CRITERIA

One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types.

MAIN RESULTS

We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty).

AUTHORS' CONCLUSIONS

This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.

THE LONG-TERM EFFICACY OF ACUTE-PHASE PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS OF RANDOMIZED TRIALS

BACKGROUND

Understanding the effectiveness of treatment for depression in both the short term and long term is essential for clinical decision making. The present meta-analysis examined treatment effects on depression and quality of life in acute-phase psychotherapeutic interventions compared to no treatment control groups for adult depression at 6 months or longer postrandomization.

METHODS

A systematic literature search resulted in 44 randomized controlled trials with 6,096 participants. Acute-phase psychotherapy was compared to control groups at 6-month or longer postrandomization. Odds ratios of a positive outcome were calculated.

RESULTS

Psychotherapy outperformed control groups at 6 months or longer postrandomization (OR = 1.92, 95% CI: 1.60-2.31, P < .001). Heterogeneity was moderate (I²: 65, 95% CI: 53-74, P < .001). However, effects significantly decreased with longer follow-up periods. Additionally, a small positive effect of psychotherapy was observed for quality of life, while similar effects were obtained in separate analyses of each type of psychotherapy, with the exception of nondirective supportive therapy. Studies that provided booster sessions had better treatment results compared with studies that did not provide any further sessions. Finally, we found that trials on psychotherapy aimed at major depressive disorder (MDD) had better outcomes than those that were aimed at elevated depressive symptoms.

CONCLUSIONS

There is substantial evidence that acute-phase psychotherapy results in a better treatment effects on depression and quality of life in the long term for adult patients with depression.

Predicting long-term depression outcome using a three-mode principal component model for depression heterogeneity

BACKGROUND

Depression heterogeneity has hampered development of adequate prognostic models. Therefore, more homogeneous clinical entities (e.g. dimensions, subtypes) have been developed, but their differentiating potential is limited because neither captures all relevant variation across persons, symptoms and time. To address this, three-mode Principal Component Analysis (3MPCA) was previously applied to capture person-, symptom- and time-level variation in a single model (Monden et al., 2015). This study evaluated the added prognostic value of such an integrated model for longer-term depression outcomes.

METHODS

The Beck Depression Inventory (BDI) was administered quarterly for two years to major depressive disorder outpatients participating in a randomized controlled trial. A previously developed 3MPCA model decomposed the data into 2 symptom-components ('somatic-affective', 'cognitive'), 2 time-components ('recovering', 'persisting') and 3 person-components ('severe non-persisting depression', 'somatic depression' and 'cognitive depression'). The predictive value of the 3MPCA model for BDI scores at 3-year (n=136) and 11-year follow-up (n=145) was compared with traditional latent variable models and traditional prognostic factors (e.g. baseline BDI component scores, personality).

RESULTS

3MPCA components predicted 41% and 36% of the BDI variance at 3- and 11-year follow-up, respectively. A latent class model, growth mixture model and other known prognostic variables predicted 4-32% and 3-24% of the BDI variance at 3- and 11-year follow-up, respectively.

LIMITATIONS

Only primary care patients were included. There was no independent validation sample.

CONCLUSION

Accounting for depression heterogeneity at the person-, symptom- and time-level improves longer-term predictions of depression severity, underlining the potential of this approach for developing better prognostic models.

Major depressive disorder as a nonlinear dynamic system: bimodality in the frequency distribution of depressive symptoms over time

BACKGROUND

A defining characteristic of Major Depressive Disorder (MDD) is its episodic course, which might indicate that MDD is a nonlinear dynamic phenomenon with two discrete states. We investigated this hypothesis using the symptom time series of individual patients.

METHODS

In 178 primary care patients with MDD, the presence of the nine DSM-IV symptoms of depression was recorded weekly for two years. For each patient, the time-series plots as well as the frequency distributions of the symptoms over 104 weeks were inspected. Furthermore, two indicators of bimodality were obtained: the bimodality coefficient (BC) and the fit of a 1- and a 2-state Hidden Markov Model (HMM).

RESULTS

In 66% of the sample, high bimodality coefficients (BC>.55) were found. These corresponded to relatively sudden jumps in the symptom curves and to highly skewed or bimodal frequency distributions. The results of the HMM analyses classified 90% of the symptom distributions as bimodal.

CONCLUSIONS

A two-state pattern can be used to describe the course of depression symptoms in many patients. The BC seems useful in differentiating between subgroups of MDD patients based on their life course data.

Simultaneous Decomposition of Depression Heterogeneity on the Person-, Symptom- and Time-Level: The Use of Three-Mode Principal Component Analysis

Although heterogeneity of depression hinders research and clinical practice, attempts to reduce it with latent variable models have yielded inconsistent results, probably because these techniques cannot account for all interacting sources of heterogeneity at the same time. Therefore, to simultaneously decompose depression heterogeneity on the person-, symptom and time-level, three-mode Principal Component Analysis (3MPCA) was applied to data of 219 Major Depression patients, who provided Beck Depression Inventory assessments every three months for two years. The resulting person-level components were correlated with external baseline clinical and demographic variables. The 3MPCA extracted two symptom-level components (‘cognitive’, ‘somatic-affective’), two time-level components (‘improving’, ‘persisting’) and three person-level components, characterized by different interaction-patterns between the symptom- and time-components (‘severe non-persisting’, ‘somatic depression’ and ‘cognitive depression’). This model explained 28% of the total variance and 65% when also incorporating the general trend in the data). Correlations with external variables illustrated the content differentiation between the person-components. Severe non-persisting depression was positively correlated with psychopathology (r=0.60) and negatively with quality of life (r=-0.50). Somatic depression was negatively correlated with physical functioning (r=-0.45). Cognitive depression was positively correlated with neuroticism (r=0.38) and negatively with self-esteem (r=-0.47). In conclusion, 3MPCA decomposes depression into homogeneous entities, while accounting for the interactions between different sources of heterogeneity, which shows the utility of the technique to investigate the underlying structure of complex psychopathology data and could help future development of better empirical depression subtypes.

Symptom-specific course trajectories and their determinants in primary care patients with Major Depressive Disorder: Evidence for two etiologically distinct prototypes

BACKGROUND

The course-heterogeneity of Major Depressive Disorder (MDD) hampers development of better prognostic models. Although latent class growth analyses (LCGA) have been used to explain course-heterogeneity, such analyses have failed to also account for symptom-heterogeneity of depressive symptoms. Therefore, the aim was to identify more specific data-driven subgroups based on patterns of course-trajectories on different depressive symptom domains.

METHODS

In primary care MDD patients (n=205), the presence of the MDD criterion symptoms was determined for each week during a year. Weekly 'mood/cognition' (MC) and 'somatic' (SOM) scores were computed and parallel processes-LCGA (PP-LCGA) was used to identify subgroups based on the course on these domains. The classes׳ associations with baseline predictors and 2-/3-year outcomes were investigated.

RESULTS

PP-LCGA identified four classes: quick recovery, persisting SOM, persisting MC, and persisting SOM+MC (chronic). Persisting SOM was specifically predicted by higher baseline somatic symptomatology and somatization, and was associated with more somatic depressive symptomatology at long-term follow-up. Persisting MC was specifically predicted by higher depressive severity, thinking insufficiencies, neuroticism, loneliness and lower self-esteem, and was associated with lower mental health related quality of life and more mood/cognitive depressive symptomatology at follow-up.

LIMITATIONS

The sample was small and contained only primary care MDD patients. The weekly depression assessments were collected retrospectively at 3-month intervals.

CONCLUSIONS

The results indicate that there are two specific prototypes of depression, characterized by either persisting MC or persisting SOM, which have different sets of associated prognostic factors and long-term outcomes, and could have different etiological mechanisms.

Effectiveness of psychological interventions in preventing recurrence of depressive disorder: meta-analysis and meta-regression

BACKGROUND

Major depression is probably best seen as a chronically recurrent disorder, with patients experiencing another depressive episode after remission. Therefore, attention to reduce the risk of relapse or recurrence after remission is warranted. The aim of this review is to meta-analytically examine the effectiveness of psychological interventions to reduce relapse or recurrence rates of depressive disorder.

METHODS

We systematically reviewed the pertinent trial literature until May 2014. The random-effects model was used to compute the pooled relative risk of relapse or recurrence (RR). A distinction was made between two comparator conditions: (1) treatment-as-usual and (2) the use of antidepressants. Other sources of heterogeneity in the data were explored using meta-regression.

RESULTS

Twenty-five randomised trials met inclusion criteria. Preventive psychological interventions were significantly better than treatment-as-usual in reducing the risk of relapse or recurrence (RR=0.64, 95% CI=0.53-0.76, z=4.89, p<0.001, NNT=5) and also more successful than antidepressants (RR=0.83, 95% CI=0.70-0.97, z=2.40, p=0.017, NNT=13). Meta-regression showed homogeneity in effect size across a range of study, population and intervention characteristics, but the preventive effect of psychological intervention was usually better when the prevention was preceded by treatment in the acute phase (b=-1.94, SEb=0.68, z=-2.84, p=0.005).

LIMITATIONS

Differences between the primary studies in methodological design, composition of the patient groups and type of intervention may have caused heterogeneity in the data, but could not be evaluated in a meta-regression owing to poor reporting.

CONCLUSIONS

We conclude that there is supporting evidence that preventive psychological interventions reduce the risk of relapse or recurrence in major depression.

Collaborative care for depression in European countries: a systematic review and meta-analysis

OBJECTIVES

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries.

METHODS

A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure.

RESULTS

The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care.

CONCLUSIONS

The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.

Relapse rates after psychotherapy for depression - stable long-term effects? A meta-analysis

BACKGROUND

Depression is the most common mental disorder. Effective psychotherapeutic treatments for depression exist; however, data on their long-term effectiveness beyond a time span of two years is still scarce. Our aim was to perform a meta-analysis, investigating (a) overall rates of relapse more than two years after psychotherapy (meta-analysis 1), and (b) if psychotherapy has more enduring effects than non-psychotherapeutic comparison conditions (e.g. pharmacotherapy, treatment as usual), again beyond a time span of two years post-therapy (meta-analysis 2).

METHODS

We searched electronic databases Medline, PsycINFO and the COCHRANE Library. Main selection criteria were (i) RCT of psychotherapy with follow-up interval of more than 2 years, (ii) primary diagnosis of depression, assessed by observer ratings, (iii) report of relapse at follow-up.

RESULTS

We identified 11 studies, 6 of which included a non-psychotherapeutic comparison condition. Together they comprised long-term data of 966 patients. Mean follow-up duration was 4.4 years. The overall relapse rate at long-term follow-up was 0.39 (95% CI 0.29, 0.50). Psychotherapy resulted in significantly less relapses (53.1% vs. 71.1%, OR 0.51; 95% CI 0.32, 0.82, p=0.005) than comparison treatments. This finding corresponded to a number needed to treat (NNT) of 5.55.

LIMITATIONS

Results can only be preliminary as data was sparse and studies differed methodologically. Heterogeneity in the first meta-analysis was high (I(2)=82%). Results indicated publication bias.

CONCLUSIONS

The relapse rate more than two years after psychotherapy is relatively high, but significantly lower compared to non-psychotherapeutic treatments. Multiannual follow-ups should routinely be included in future psychotherapy RCTs.

Data-driven course trajectories in primary care patients with major depressive disorder

BACKGROUND

The chronic nature of MDD has been acknowledged as one of the key determinants of the burden associated with depression. Unfortunately, so far described prognostic factors have been inconsistent, possibly due to used course outcomes that are often based on arbitrary criteria/cut-offs. Therefore, the aim of the current study was to use data-driven trajectory groups based on closely spaced weekly severity ratings, as outcomes in prognostic research.

METHODS

The sample consisted of primary care patients with MDD (n = 153), who were followed up for a year with 52 consecutive weekly ratings of the nine DSM-IV MDD criterion symptoms. Growth Mixture Modeling (GMM) was used to reduce the interpersonal growth variation to an optimal set of clinically interpretable trajectory groups. Next, baseline course predictors were investigated and the prognostic (added) value of course-group membership was investigated for clinical outcomes after 1, 2, and 3 years.

RESULTS

GMM resulted in four trajectory groups: "early remission" (40.2%), "late remission" (9.8%), "remission and recurrence" (17.0%), and "chronic" (33.0%). Multivariate predictors of "chronic" group membership were a prior suicide attempt, comorbid dysthymia, and lower levels of somatic depressive symptoms. Group membership predicted differences in depression severity and/or quality of life after 1, 2, and 3 years.

CONCLUSIONS

The used data-driven approach provided a parsimonious and clinically informative way to describe course variation across MDD patients. Using the trajectory groups to investigate prognostic factors of MDD provided insight in potentially useful prognostic factors. Importantly, trajectory-group membership was itself a strong predictor of future mental well-being.

Cognitive behavioral therapy for treatment of primary care patients presenting with psychological disorders

Mental disorders affect a great number of people worldwide. Four out of the 10 leading causes of disability in the world are mental disorders. Because of the scarcity of specialists around the world and especially in developing countries, it is important for primary care physicians to provide services to patients with mental disorders. The most widely researched and used psychological approach in primary care is cognitive behavioral therapy. Due to its brief nature and the practical skills it teaches, it is convenient for use in primary care settings. The following paper reviews the literature on psychotherapy in primary care and provides some practical tips for primary care physicians to use when they are faced with patients having mental disorders.

Unique and shared techniques in cognitive-behavioural and short-term psychodynamic psychotherapy: a content analysis of randomised trials on depression

Randomised controlled trials (RCTs) of psychotherapeutic interventions assume that specific techniques are used in treatments, which are responsible for changes in the client's symptoms. This assumption also holds true for meta-analyses, where evidence for specific interventions and techniques is compiled. However, it has also been argued that different treatments share important techniques and that an upcoming consensus about useful treatment strategies is leading to a greater integration of treatments. This makes assumptions about the effectiveness of specific interventions ingredients questionable if the shared (common) techniques are more often used in interventions than are the unique techniques. This study investigated the unique or shared techniques in RCTs of cognitive-behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP). Psychotherapeutic techniques were coded from 42 masked treatment descriptions of RCTs in the field of depression (1979-2010). CBT techniques were often used in studies identified as either CBT or STPP. However, STPP techniques were only used in STPP-identified studies. Empirical clustering of treatment descriptions did not confirm the original distinction of CBT versus STPP, but instead showed substantial heterogeneity within both approaches. Extraction of psychotherapeutic techniques from the treatment descriptions is feasible and could be used as a content-based approach to classify treatments in systematic reviews and meta-analyses.

Depression self-management support: a systematic review

OBJECTIVE

To systematically review empirical evidence regarding the efficacy of depression self-management support (SMS) interventions for improving depression symptomatology and preventing relapse.

METHODS

Pubmed and PsycINFO databases were searched for relevant articles on depression SMS interventions. Scanning of references in the articles and relevant reviews and communications with field experts yielded additional articles. Two independent reviewers analyzed the articles for inclusion and data was extracted from the selected articles.

RESULTS

13 papers met the inclusion criteria and reported the results of six separate studies, including three pilot studies. The results were mostly positive. A majority of the trials assessing depression severity changes found SMS to be superior to care as usual. SMS interventions were found to improve self-management behaviors and self-efficacy. Mixed results were found concerning relapse rates. Promising results were found on assessments of functional status. Based on the findings, cost-effectiveness remains unclear.

CONCLUSION

SMS has been mostly examined through pilot studies with insufficient power. The results are promising, but larger randomized controlled trials are needed.

PRACTICE IMPLICATIONS

SMS interventions can be administered by non-physician professionals and are well accepted by patients, but more research is needed before we can recommend implementing specific depression SMS approaches in primary care.

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

Background

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

Method

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

Results

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

Conclusions

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

[Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part II: General Aspects of Treatment, Management of the Acute Phase, Continuation and Maintenance of Patients with a Depression Diagnosis]

INTRODUCTION

This article presents recommendations based on evidence gathered to answer a series of clinical questions concerning the depressive episode and the recurrent depressive disorder, with emphasis on general treatment aspects, treatment in the acute phase and management of the continuation/maintenance, all intended to grant health care parameters based on the best and more updated available evidence for achieving minimum quality standards with adult patients thus diagnosed.

METHODOLOGY

A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from NICE90 and CANMAT guides were adopted and updated so as to answer the questions posed while de novo questions were developed.

RESULTS

Recommendations 5-22 corresponding to management of depression are presented.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

Symptom profiles of DSM-IV-defined remission, recovery, relapse, and recurrence of depression: the role of the core symptoms

BACKGROUND

Depression outcomes in research and clinical practice are commonly defined by the concepts of remission, recovery, relapse, and recurrence. Despite their widespread use, there has been little empirical examination of these concepts. Therefore, we investigated profiles of individual symptoms during each of these phases of depression.

METHODS

In a 3-year prospective study of 267 depressed primary care patients, we established the presence or absence of the individual DSM-IV depressive symptoms week-by-week during DSM-IV-defined remissions, recoveries, relapses, and recurrences. We measured symptoms in 12 quarterly assessments using the Composite International Diagnostic Interview.

RESULTS

Remissions were characterized by double the proportion of time that the core symptoms were present compared to the initial phase of recoveries after a major depressive episode (MDE; 59 versus 32%; Z = -3.03; P = .002). Before a relapse, remissions again showed elevated levels of core symptoms in comparison to the final phase of recoveries before a recurrence (58 versus 26%; Z = -2.99; P = .003).

CONCLUSIONS

Compared with the initial and final phases of recoveries, remissions showed a consistently higher level of core symptoms. Clinically, this means that unresolved core symptoms in the direct aftermath of a MDE seem to constitute a risk for relapse and should be the target of preventive or augmented interventions.

Effectiveness of cognitive behavioural therapy in primary health care: a review

BACKGROUND

Depression and anxiety are highly prevalent disorders causing substantial impairment in daily life. Cognitive behavioural therapy (CBT) delivered face-to-face or as self-help has shown to be an effective treatment for these disorders. Such treatments may be suitable for delivery in primary health care.

AIM

The aim of the article was to review research on the effectiveness of CBT for depression and anxiety disorders delivered in primary care by primary care therapists.

METHODS

A literature search of quantitative studies of the effectiveness of CBT delivered in primary care was conducted on multiple electronic databases. A total of 17 studies were included in the review.

RESULTS

Eight studies of supported Internet- or computer-based CBT, six of which were randomized controlled trials (RCTs), indicate that this treatment is effective for mild to moderate depression and anxiety. Five studies suggest that this treatment may be more effective than usual care for mild to moderate but not for more severe symptoms. Results of four RCTs of brief therapies using written self-help material suggest that while such interventions are effective, no particular approach outperformed any other, including usual care. Five RCTs of CBT delivered face-to-face show that this treatment can be effective when delivered by therapists highly educated in the mental health field. However, many primary care therapists may find such interventions too time consuming.

CONCLUSIONS

CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists.

Counselling for mental health and psychosocial problems in primary care

BACKGROUND

The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care.

SEARCH STRATEGY

To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011).

SELECTION CRITERIA

Randomised controlled trials of counselling for mental health and psychosocial problems in primary care.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events.

MAIN RESULTS

Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions.

AUTHORS' CONCLUSIONS

Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

Optimal duration of combined psychotherapy and pharmacotherapy for patients with moderate and severe depression: a meta-analysis

BACKGROUND

To investigate the most effective duration of combined psychotherapy and pharmacotherapy for achieving remission and preventing relapse in depressive patients as compared to pharmacotherapy alone.

METHODS

A systematic review of English articles using PubMed, EMBASE, Web of Science, the Cochrane Library, and PsychINFO was performed in September 2009. Clinical studies comparing pharmacotherapy alone with pharmacotherapy in combination with a psychological intervention for depression treatment that reported response, remission or relapse as outcomes were included in the analysis. For each of the studies, clinical binary outcomes such as response, remission or relapse were extracted.

RESULTS

All pooled analyses were based on random-effects models. Twenty-one article describing the influence of additional psychotherapy on remission and 15 articles reporting the influence on relapse in depression were included in the analysis. Patients receiving combined treatment experienced remission more often than those receiving pharmacotherapy alone, with the highest odds ratio OR, 2.36; 95% CI, 1.58-3.55 observed at 4months after commencing the treatment. Patients receiving pharmacotherapy alone also demonstrated a higher risk for relapse compared to those receiving combined treatment.

LIMITATIONS

We restricted our search to only English language publications. Studies investigating relapse or recurrence rates are often of small size.

CONCLUSION

Pharmacotherapy enhanced with psychotherapy is associated with a higher probability of remission and a lower risk of relapse, as compared to antidepressants alone for depression treatment. Receiving psychotherapy in both the acute and continuation phases is the most effective option. Further research is needed to investigate the influence of additional psychotherapy on different patients.

Presence of individual (residual) symptoms during depressive episodes and periods of remission: a 3-year prospective study

BACKGROUND

Residual depressive symptomatology constitutes a substantial risk for relapse in depression. Treatment until full remission is achieved is therefore implicated. However, there is a lack of knowledge about the prevalence of (1) residual symptoms in general and (2) the individual residual symptoms in particular.

METHOD

In a 3-year prospective study of 267 initially depressed primary care patients we established per week the presence/absence of the individual DSM-IV depressive symptoms during subsequent major depressive episodes (MDEs) and episodes of (partial) remission. This was accomplished by means of 12 assessments at 3-monthly intervals with the Composite International Diagnostic Interview (CIDI).

RESULTS

In general, residual depressive symptomatology was substantial, with on average two symptoms present during remissions. Three individual symptoms (cognitive problems, lack of energy and sleeping problems) dominated the course of depression and were present 85-94% of the time during depressive episodes and 39-44% of the time during remissions.

CONCLUSIONS

Residual symptoms are prevalent, with some symptoms being present for almost half of the time during periods of remission. Treatment until full remission is achieved is not common practice, yet there is a clear need to do so to prevent relapse. Several treatment suggestions are made.

Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: a randomized pilot study

BACKGROUND

The only psychotherapy specifically designed and evaluated for the treatment of chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), has never been directly compared to another depression-specific psychological method.

METHODS

Thirty patients with early-onset chronic depression were randomized to 22 sessions of CBASP or Interpersonal Psychotherapy (IPT) provided in 16 weeks. Primary outcome was the score on the 24-item Hamilton Rating Scale for Depression (HRSD) assessed posttreatment by an independent blinded evaluator. Secondary endpoints were, among others, remission (HRSD≤8) rates and the Beck Depression Inventory (BDI). The study included a prospective naturalistic 12-month follow-up.

RESULTS

Intent-to-treat analyses of covariance (ANCOVA) revealed that there was no significant difference in posttreatment HRSD scores between the CBASP and the IPT condition, but in self-rated BDI scores. We found significantly higher remission rates in the CBASP (57%) as compared to the IPT (20%) group. One year posttreatment, no significant differences were found in the self-reported symptom level (BDI) using ANCOVA.

LIMITATIONS

The study used only a small sample size and no placebo control. The generalizability of the results may be limited to patients with a preference for psychological treatment.

CONCLUSIONS

While the primary outcome was not significant, secondary measures showed relevant benefits of CBASP over IPT. We found preliminary evidence that in early-onset chronic depression, an approach specifically designed for this patient population was superior to a method originally developed for the treatment of acute depressive episodes. Long-term results suggest that chronically depressed patients may need extended treatment courses.

Integrating care for people with depression: developments in the Netherlands

Introduction

In this article we describe the history and present state of integrated care for people with depression in the Netherlands. The central question is: what are the developments in integrated care for people with depression in the Netherlands?

Methods

We describe these developments from the role of an observer, and make use of several sources: important Dutch policy documents and research documents, our own national survey carried out in 2007, a number of reports and project descriptions and searches in PubMed and Google. Also key people were contacted to supply additional information.

Results

In the Netherlands two separate phases can be distinguished within integrated care for people with depression. From the beginning of the 1990s, specialized secondary Mental Health Care (MHC) began to develop care programmes, including programmes for people with depression. The implementation of these care programmes has taken years. Mass usage of care programmes only went ahead once the large-scale mergers between ambulatory and clinical MHC organizations around 2000 had taken effect. An analysis of these programmes shows, that they did not lead to integration with primary care. This changed in the second phase from around 2000. Then attention was directed more towards strengthening the GP within the treatment of depression, collaboration between primary and specialized care and the development of collective integrated care packages.

Discussion

We relate these developments to projects in other countries and discuss the scientific basis by using evidence of international literature reviews and metastudies. Some general recommendations are given about functional costing, the physical presence of MHC specialists in the primary care sector and the use of a common national standard for both primary care and specialized MHC.

Duration of subsequent episodes and periods of recovery in recurrent major depression

BACKGROUND

Little is known about the duration of subsequent depressive episodes and periods of recovery, and much is based on potentially biased retrospective data. We therefore prospectively assessed whether duration of depressive episodes and recoveries is correlated within subjects and across episodes, and whether duration of subsequent depressive episodes and recoveries increases or decreases over time.

METHODS

From a sample of 267 depressed primary care patients enrolled in a RCT, we identified 279 depressive episodes and 455 recovery periods during a 3-year follow-up. We correlated durations of depressive episodes and of recovery within subjects, and compared within subjects the duration of first depressive episodes after index depression with second and third episodes, and similarly with recovery periods.

RESULTS

No significant correlations were found between duration of depressive episodes or between recovery periods within subjects (Rs ranging from -0.17 to 0.08; all Ps >0.05). Median duration of first and second depressive episodes was 11 (IQR 6-19) and 9 weeks (IQR 5-14). Median duration of first and second recovery periods was 16.5 (IQR 7-31) and 17.5 weeks (IQR 9-32). No significant increase or decrease was observed in duration of consecutive depressive episodes, nor in recovery periods across episodes (all Ps >0.05).

CONCLUSIONS

In this prospective study, we found no correlation between duration of depressive episodes or between recovery periods within subjects. Moreover, we found no support for an increase or decrease in subsequent duration of depressive episodes or a decrease in recovery periods across episodes. These findings do not support the notion that experiencing multiple depressive episodes results in a growing vulnerability.

What is the role of consultation-liaison psychiatry in the management of depression in primary care? A systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of consultation-liaison services, involving mental health professionals working to advise and support primary care professionals in the management of depression.

METHODS

Studies of consultation-liaison for depression in primary care were identified from a systematic search of electronic databases, augmented by identification of papers from reference lists, published reviews and from hand searching. Data on study quality, intervention characteristics and outcomes were extracted by two reviewers, and outcome data were meta-analyzed.

RESULTS

Five studies met the criteria. There was no significant effect of consultation-liaison on antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or depression outcomes in the short- (standardized mean difference -0.04, 95% CI -0.21 to 0.14) or long-term (standardized mean difference 0.06, 95% CI -0.13 to 0.26).

CONCLUSIONS

Evidence concerning consultation-liaison for depression in primary care remains limited, but the existing studies do not suggest it is more effective than usual care. Further research is required to explore the mechanisms by which consultation-liaison might be made more effective, including the potential role of consultation-liaison in combination with other models of care, and in other patient populations.

Subjektive Krankheitskonzepte bei depressiven Störungen

Zusammenfassung. Depressive Störungen sind ein weit verbreitetes und oft chronisches Gesundheitsproblem mit erheblichem Leiden des Individuums und hohen Gesundheitskosten. Die subjektiven Wahrnehmungen einer solchen Erkrankung korrelieren mit deren Bewältigung. Dies kann insbesondere für depressive Störungen angenommen werden, da bei Depressionen die dysfunktionalen kognitiven Bewertungsprozesse sowohl ätiologisch relevant sind als auch die Krankheitsbewältigung ungünstig beeinflussen. Diese Studie hat zum Ziel, Zusammenhänge zwischen Dimensionen der Krankheitskonzepte von Patientinnen und Patienten, der depressiven Symptomatik und positivem Affekt zu untersuchen. Dazu wurden 60 Patientinnen und Patienten einer stationären psychosomatischen Rehabilitationsmaßnahme sowohl im Quer- als auch im Längsschnitt bis zur dreimonatigen Katamnese nach Entlassung befragt. Die Studienteilnehmer wurden weiterhin randomisiert einer Expressiven Schreib- oder einer Kontrollbedingung zugeteilt, um die Effekte dieser Minimalintervention als adjunkte Maßnahme zu untersuchen. Die Ergebnisse zeigen, dass die Wahrnehmung des zeitlichen Verlaufs und des Schwergrads der Depression sowie die emotionalen Repräsentationen der eigenen Erkrankung mit vermehrten depressiven Symptomen assoziiert sind. Im Längsschnitt zeigt sich, dass die Ausprägung kontrollbezogener subjektiver Krankheitskonzepte mit unterschiedlichen Verläufen der depressiven Symptomatik und des Wohlbefindens über einen Zeitraum von 3 Monaten nach Beendigung des stationären Aufenthalts im Zusammenhang stehen. Die subjektiv erlebte Kohärenz des Krankheitskonzepts war nur mit dem Wohlbefinden, aber nicht mit Depression verbunden. Expressives Schreiben konnte in dieser kleinen Gruppe zusätzlich zum stationären Aufenthalt zwar keine signifikanten Verbesserungen erzielen, jedoch zeigt sich, dass Personen mit einer stark ausgeprägten Neigung zu emotionalen Repräsentationen tendenziell mehr vom Schreiben profitieren und dass sich dieser Effekt über die Zeit zu verstärken scheint.

Recurrent depression and the role of adult attachment: a prospective and a retrospective study

BACKGROUND

Recurrent depression is associated with interpersonal dysfunctioning which is related to underlying insecure attachment. In this study we examined associations between adult attachment and the long-term course of depression in depressed primary care patients.

METHODS

Depressed primary care patients were 3-monthly assessed during a prospective 3-year follow-up regarding: (1) severity of depression (BDI); and proportions of: (2) depression-free time; (3) depressive symptom-free time; and (4) time on antidepressants (all CIDI interview). Attachment style was assessed by the Experiences in Close Relationships questionnaire at two points in time: (1) one year before the end of follow-up (1-year prospectively followed subsample; n=68); and (2) at the end of the 3-year follow-up (3-year retrospective subsample; n=145). Mixed model analyses and non-parametric tests were used to determine whether different attachment styles were associated with different courses of depression.

RESULTS

Fearfully attached patients in the prospective sample reported a statistically significant worse depression course compared with securely attached patients (adjusted mean BDI 12.7 v. 6.8 respectively; F=3.22; p=0.029), which was confirmed in the retrospective sample (adjusted mean BDI 15.7 v. 8.8; F=7.86; p<0.001). They reported significantly more prior depressive episodes and residual symptoms, longer use of antidepressants, and worse social functioning as well.

LIMITATIONS

Size of the prospective sample was restricted.

CONCLUSION

Fearfully attached subjects constitute a particularly vulnerable category of depressed patients. Information on their attachment style may provide GPs with indications regarding intensity, goals and approach of treatment.

Psychological treatment of depression in primary care: a meta-analysis

BACKGROUND

Although most depressive disorders are treated in primary care and several studies have examined the effects of psychological treatment in primary care, hardly any meta-analytic research has been conducted in which the results of these studies are integrated.

AIM

To integrate the results of randomised controlled trials of psychological treatment of depression in adults in primary care, and to compare these results to psychological treatments in other settings.

DESIGN OF STUDY

A meta-analysis of studies examining the effects of psychological treatments of adult depression in primary care.

SETTING

Primary care.

METHOD

An existing database of studies on psychological treatments of adult depression that was built on systematic searches in PubMed, PsychINFO, EMBASE, and Dissertation Abstracts International was used. Randomised trials were included in which the effects of psychological treatments on adult primary care patients with depression were compared to a control condition.

RESULTS

In the 15 included studies, the standardised mean effect size of psychological treatment versus control groups was 0.31 (95% CI = 0.17 to 0.45), which corresponds with a numbers-needed-to-treat (NNT) of 5.75. Studies in which patients were referred by their GP for treatment had significantly higher effect sizes (d = 0.43; NNT = 4.20) than studies in which patients were recruited through systematic screening (d = 0.13, not significantly different from zero; NNT = 13.51).

CONCLUSIONS

Although the number of studies was relatively low and the quality varied, psychological treatment of depression was found to be effective in primary care, especially when GPs refer patients with depression for treatment.

Cognitive-behavioural therapy v. usual care in recurrent depression

We examined in a primary care sample whether acute-phase cognitive-behavioural therapy (CBT) would be more effective than usual care for patients with multiple prior episodes of depression. Depression outcome was based on a 3-monthly administered Beck Depression Inventory (BDI) during a 2-year follow-up. We confirmed that in patients with four or more prior episodes, CBT outperformed usual care by four points on the BDI, but not in patients with three or fewer prior episodes. Subsequent analyses suggested that CBT may be able to tackle cognitive problems related to rumination in patients with recurrent depression.

Content validation of the depressive symptom assessment for older adults

The goal of this study was to evaluate the content validity of the Depressive Symptom Assessment for Older Adults (DSA), an interviewer-rated instrument designed to comprehensively measure depression in older adults regardless of their cognitive status. Seniors who were not currently depressed but had been either previously depressed or had an older adult family member who was depressed (n = 7) served as content validation experts for this two phased study. In Phase 1 of the content validation process, 19 of the questions had 100% agreement, 20 of the questions had 86% agreement, 13 of the questions had 71% agreement, 5 of the questions had 57% agreement, and 2 of the questions had 43% agreement. In Phase 2 of the content validation process, 42 of the questions had 100% agreement, 11 of the questions had 86% agreement, and 1 of the questions had 71% agreement. The DSA provides mental health nurses with a comprehensive instrument to assess older adults for depression.

Efficacy of Interpersonal Psychotherapy plus pharmacotherapy in chronically depressed inpatients

BACKGROUND

Clinical guidelines recommend the combination of pharmaco- and psychotherapy for the treatment of chronic depression, although there are only a few studies supporting an additive effect of psychotherapy.

METHODS

Forty-five inpatients with a chronic Major Depressive Disorder were randomized to 5 weeks of either Interpersonal Psychotherapy (IPT) modified for an inpatient setting (15 individual and 8 group sessions) plus pharmacotherapy or to medication plus Clinical Management (CM). The 17-item Hamilton Rating Scale for Depression was the primary outcome measure. The study included a prospective naturalistic follow-up, 3- and 12-months after discharge.

RESULTS

Intent-to-treat analyses revealed a significantly greater reduction of depressive symptoms as well as better global functioning of patients treated with IPT compared to the CM group at week 5. Response and sustained response rates differed significantly between the two treatment conditions, favouring the IPT group. Remission rates were considerably higher for IPT patients who completed the treatment (67% vs. 32%). Patients who initially responded to IPT exhibited greater treatment gains at 12 months since only 7% of these subjects relapsed compared with 25% of the CM subjects. In the long-term, additional IPT led to a lower symptom level and higher global functioning.

LIMITATIONS

The study uses data of a subset of patients from a larger trial. Both treatment groups did not receive comparable amounts of therapeutic attention. Extrapolating the data from this inpatient study to chronically depressed outpatients may not be possible.

CONCLUSIONS

Intensive combined treatment provides superior acute and long-term effects over standard treatment in chronically depressed inpatients.

Prediction of the three-year course of recurrent depression in primary care patients: different risk factors for different outcomes

BACKGROUND

The objectives of this study are: (1) identification of predictors for the three-year course of recurrent depression in the rarely studied, but relevant sample of primary care patients, and (2) investigation whether different outcome indicators, time to recurrence, proportion depression-free time and mean severity of depressive symptoms during follow-up, are associated with different risk factors.

METHODS

Depression course was established by assessing 110 patients three-monthly with the Composite International Diagnostic Interview and the BDI, during a three-year period. Eight (groups of) predictors, assessed at baseline, were examined: socio-demographics, parental depression, history and severity of depression, anxiety, coping potential, social dysfunctioning and physical functioning.

RESULTS

Time to recurrence was predicted by number of previous episodes (OR=1.91). Both proportion depressive disorder-free time and mean depression severity during follow-up were predicted by: severity of depression (B=-.19 and .21 respectively), anxiety (B=-.32 and .33), social dysfunctioning (B=-.21 and .22) and physical functioning (B=.24 and -.39). Mean severity was additionally predicted by: educational level (B=-.21), duration of the longest prior episode (B=.32), and coping potential (B=-.40). Coping potential and number of previous episodes were marginally significant predictors for all three outcomes.

LIMITATIONS

Although substantial, sample size was restricted.

CONCLUSION

Different outcome variables are predicted by different risk factors. Restriction to one outcome may lead to missing important determinants of the depression course. Number of prior episodes and coping potential seem to warrant special attention from the GP.