Comparative effectiveness of medication versus cognitive-behavioral therapy in a randomized controlled trial of low-income young minority women with depression

Primary Care Clinic Approaches to Facilitating Patient Health Behavior Change in Alabama

Background  Non-communicable chronic diseases (NCCDs), such as cardiovascular disease, diabetes, and cancer, are the leading cause of death and disability and the leading driver of healthcare costs in the U.S. It is estimated that 80% of chronic diseases and premature deaths are attributable to modifiable lifestyle factors related to smoking and alcohol intake, poor eating patterns, and physical inactivity. Inadequate sleep also plays a significant role. Among other directives, primary care providers (PCPs) have the opportunity to contribute to preventing and treating NCCD in their patients. Comprehensive, evidence-based behavioral counseling interventions are recommended to PCPs as a first-line approach to improving outcomes. However, presumably due to a lack of PCP time, training or resources, most patients report not receiving such services. Currently, the extent to which PCPs in Alabama offer or refer patients to health behavior change (HBC) services is unknown.  Objectives  This study aims to assess the following: (1) Alabama PCPs' current approaches in facilitating patient HBC in the domains of eating patterns, physical activity, sleep, and stress and (2) the likelihood of the Alabama PCPs referring patients to virtual HBC programs, once developed by an osteopathic medical school in the state.  Methods  Data were collected from clinic personnel who were knowledgeable regarding the clinic's approach to facilitating patient HBC via scripted telephone interviews and online surveys sent via email. The clinic list utilized for the study was derived from a list of VCOM-Auburn clinical preceptors. Primary care and specialty clinics were included. Data were analyzed descriptively to determine the number of clinics that (1) provide, recommend, or refer programs, services, or resources to patients to facilitate HBC related to eating patterns, physical activity, sleep, and stress management and (2) are likely to refer patients to free virtual HBC programs, once developed by an osteopathic medical school in the state. Results  Of the 198 clinics that were contacted, 75 were excluded, 46 were "no response," 53 agreed to participate, and 50 completed the survey. Of the 50 clinics that completed the survey, 33 indicated offering resources or referrals for diet, 29 stated they offered resources or referral services for physical activity, 33 indicated offering resources or referrals for sleep, and 28 indicated offering or recommending resources for stress management to patients. Most of the clinics (29/50) felt that their patients would benefit most from a program that facilitates improvement in eating patterns, and 41/50 clinics said that they are either "somewhat" or "extremely" likely to refer patients to a free VCOM-Auburn HBC program, once available.  Conclusions Findings indicate that a significant percentage of PCP clinics are not offering HBC resources to patients and that most PCP clinics would consider referring patients to free VCOM-Auburn HBC programs, once available. Phone data were significantly different from email data. The primary limitations were a low response rate and potential response bias.

Preliminary Effects of Mindfulness Training on Inflammatory Markers and Blood Pressure in Young Adult Survivors of Cancer: Secondary Analysis of a Pilot Randomized Controlled Trial

BACKGROUND

This was a secondary analysis of a pilot randomized controlled trial (RCT) of mindfulness-based stress reduction (MBSR) among young adult (YA) survivors of cancer, which showed preliminary evidence for improving psychosocial outcomes. Secondary outcomes assessed were the feasibility of collecting biological data from YAs and preliminary effects of MBSR on markers of inflammation and cardiovascular function.

METHOD

Participants were randomized to 8-week MBSR or a waitlist control condition. Participants provided whole blood spot samples for analysis of C-reactive protein (CRP) and interleukin (IL)-6 as well as blood pressure data in-person at baseline and 16-week follow-up. Feasibility was assessed with rates of providing biological data. Linear mixed effects modeling was used to evaluate preliminary effects of MBSR on inflammatory markers and blood pressure over time.

RESULTS

Of 126 total participants enrolled, 77% provided biological data at baseline (n = 48/67 MBSR, n = 49/59 control). At 16 weeks, 97% of the 76 retained participants provided follow-up biological data (n = 34/35 MBSR, n = 40/41 control). Relative to the control group, MBSR was associated with decreased systolic blood pressure (p = 0.042, effect sizes (ES) = 0.45) and decreased diastolic blood pressure (p = 0.017, ES = 0.64). There were no changes in CRP or IL-6.

CONCLUSION

This was the first study to explore the feasibility of collecting biological data from YA survivors of cancer and assess preliminary effects of MBSR on inflammatory and cardiovascular markers in an RCT. Minimally invasive biological data collection methods were feasible. Results provide preliminary evidence for the role of MBSR in improving cardiovascular outcomes in this population, and results should be replicated.

The Intricate Web of Fatigue in Women

The modern woman has taken her rightful place in society as a worker, a caregiver, a mother, and a world citizen. However, along with the privileges of these roles comes the great cost of stress and resultant exhaustion and fatigue. Psychosocial, physical, cultural, and disease-related realms of stress act as strands of a web that serve to bind and hinder women with chronic stress. New areas of research, such as exercise intervention, improved social programs (e.g., childcare), and supplementation are constantly evaluated for effectiveness alongside traditional remedies such as exercise. This review will highlight some of the key issues regarding stress in women and explore reports of new treatment modalities in light of the specific requirements of the modern woman.

Three Flavorings for a Soup to Cure what Ails Mental Health Services

With new tools from artificial intelligence and new perspectives on personalizing interventions, we could revolutionize the way mental health services are delivered and achieve major gains in improving the public's mental health. We examine Dr. Bickman's vision around these technological and paradigm changes that would usher in major scientific, workforce training, and societal cultural changes. We argue that additional efforts in research evaluations in implementation have the potential to scale up and adapt existing interventions and scale them out to diverse populations and service systems. The next stage of this work involves testing the effectiveness of personalized interventions that are preferred by the public and integrating these choices into sustainable service systems. We note cautions on the delivery of these programs as automated algorithmic recommendations are heretofore foreign to humans.

Association of cardiovascular health through early adulthood and health-related quality of life in middle age: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Previous studies have linked cardiovascular health (CVH) and health-related quality of life (HRQoL), but only in cross-sectional analyses where temporality cannot be established. The aim of this study was to determine trajectories of CVH from early adulthood to middle age, and examine their association with HRQoL in middle age. This analysis, conducted in 2018, included 3275 participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study who completed a year 30 follow-up exam in 2015/2016. Group-based trajectory modeling was used to create CVH trajectories, according to American Heart Association definitions, from baseline through follow-up year 20. HRQoL was assessed by the Medical Outcomes Study 12-Item Short Form Health Survey at year 30, which included the physical component summary score (PCS), the mental component summary score (MCS), and overall self-rated health (SRH). The mean (SD) age of the sample was 55.1 (3.6) years, 1868 (57%) were women, and 1541 (47%) were black. Five CVH trajectories were identified, 31% of CARDIA participants maintained ideal CVH during follow-up. Maintaining ideal CVH was associated with higher PCS and MCS, and lower odds of fair/poor SRH as compared to the other trajectory groups. Compared to the consistently low CVH group, those who maintained ideal CVH had on average a 5.9 point higher PCS (95% CI, 4.2-7.7), a 2.5-point higher MCS (95% CI, 0.5-4.4), and 84% lower odds of fair/poor SRH (95% CI, 0.09, 0.31). Our findings suggest that maintaining ideal CVH from early adulthood results in higher health-related quality of life in middle age.

Fasting glucose and insulin resistance trajectories during young adulthood and mid-life cardiac structure and function

AIMS

We assessed whether fasting glucose (FG) and insulin resistance (IR) trajectories during young adulthood are associated with changes in cardiac structure and function.

METHODS

We used data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (baseline: 1985-1986). Echocardiography was performed after 25 (Y25) and 30 years of follow-up. Group-based modeling was used to determine 25-year trajectories in FG and IR. We assessed differences at Y25 and 5-year longitudinal change in cardiac structure and function after adjustment for demographics, cumulative exposure to traditional cardiovascular risk factors, and baseline FG or IR.

RESULTS

We identified five FG trajectory groups among 2414 individuals and three IR trajectory groups among 2358 individuals. Moderate-increasing FG trajectory was associated with lower lateral E' velocity (difference: -0.9 cm/s, 95%CI: -0.3, -1.5) and with greater left ventricular (LV) mass index (difference: 2.7 g/m2.7, 95%CI: 0.7, 4.7) at Y30 compared to low-stable FG. High-increasing IR trajectory was associated with lower lateral E' velocity and septal E' velocity at Y30 compared to low-decreasing IR trajectory.

CONCLUSIONS

Trajectories in FG and IR over 25 years before the development of diabetes are associated with unfavorable differences in LV structure and diastolic function beyond single values of FG and IR.

Initial severity-dependent longitudinal model with application to a randomized controlled trial of women with depression

The assessment of initial severity of a disease is arguably one of the most important factors in identifying appropriate therapies. In this paper, we propose an initial severity-dependent longitudinal model to account for the influence of the initial severity of a disease on the posttreatment severity and the efficacy of medical treatments. The proposed model has the flexibility of nonparametric modeling, as it allows coefficients to vary with the initial severity of the disease. It also provides attractive and practical patient-specific interpretation of initial severity-dependent coefficients. As a result, the proposed model enables patient-specific modeling and treatment recommendations consistent with the assessment of the patient's initial severity, and thus, it can be used as a decision support tool for clinicians. A new empirical likelihood approach is employed for efficient estimation and statistical inference about the initial severity-dependent coefficients. In contrast to the literature on marginal regression models, the proposed estimation procedure allows nuisance parameters associated with the working correlation matrix and the error variances to vary smoothly with the initial severity. The effectiveness of the proposed procedure is demonstrated via simulation studies. We further apply the proposed method by analyzing a data set arising from a randomized controlled trial of women with depression and discover an interesting phenomenon; antidepressant medication intervention is effective for patients with moderate or severe depression, whereas psychotherapy intervention using manual-guided cognitive behavior therapy is effective for patients with a severe case of depression.

A Randomized Comparison of Medication and Cognitive Behavioral Therapy for Treating Depression in Low-Income Young Minority Women

BACKGROUND Longitudinal data arise frequently in biomedical science and health studies where each subject is repeatedly measured over time. We compared the effectiveness of medication and cognitive behavioral therapy on depression in predominantly low-income young minority women. MATERIAL AND METHODS The treatment effects on patients with low-level depression may differ from the treatment effects on patients with high-level depression. We used a quantile regression model for longitudinal data analysis to determine which treatment is most beneficial for patients at different stress levels over time. RESULTS The results confirm that both treatments are effective in reducing the depression score over time, regardless of the depression level. CONCLUSIONS Compared to cognitive behavioral therapy, treatment with medication more often effective, although the size of the effect differs. Thus, no matter how severe a patient's depression symptoms are, antidepressant medication is effective in decreasing depression symptoms.

Testing moderation in network meta-analysis with individual participant data

Meta-analytic methods for combining data from multiple intervention trials are commonly used to estimate the effectiveness of an intervention. They can also be extended to study comparative effectiveness, testing which of several alternative interventions is expected to have the strongest effect. This often requires network meta-analysis (NMA), which combines trials involving direct comparison of two interventions within the same trial and indirect comparisons across trials. In this paper, we extend existing network methods for main effects to examining moderator effects, allowing for tests of whether intervention effects vary for different populations or when employed in different contexts. In addition, we study how the use of individual participant data may increase the sensitivity of NMA for detecting moderator effects, as compared with aggregate data NMA that employs study-level effect sizes in a meta-regression framework. A new NMA diagram is proposed. We also develop a generalized multilevel model for NMA that takes into account within-trial and between-trial heterogeneity and can include participant-level covariates. Within this framework, we present definitions of homogeneity and consistency across trials. A simulation study based on this model is used to assess effects on power to detect both main and moderator effects. Results show that power to detect moderation is substantially greater when applied to individual participant data as compared with study-level effects. We illustrate the use of this method by applying it to data from a classroom-based randomized study that involved two sub-trials, each comparing interventions that were contrasted with separate control groups. Copyright © 2016 John Wiley & Sons, Ltd.

Disparities in antidepressant use in pregnancy

OBJECTIVE

The American College of Obstetricians and Gynecologists and the American Psychiatric Association both recommend pharmacotherapy for perinatal depression when the benefits outweigh the risks. While minority adults are less likely to use antidepressant medications compared with non-Hispanic Whites, whether this pattern occurs among pregnant women is unclear. We sought to determine the frequency of antidepressant medication use reported during ambulatory care visits for pregnant women and whether these rates varied by race.

STUDY DESIGN

We combined the 2006-2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to obtain nationally representative estimates of outpatient preventive care visits for pregnant women. We then obtained estimates of the prevalence of reported depression and antidepressant use during outpatient visits for pregnant women. To determine whether these estimates varied by race, we used multivariable logistic regression analyses accounting for survey design using SAS 9.2 (PROC SURVEYLOGISTIC) to estimate odds ratios of reported antidepressant use after adjustment for age, insurance status and region of the country.

RESULT

Antidepressant use was reported during 2.2% of all outpatient visits for pregnant women. Providers indicated a depression diagnosis in 4.5% of visits. Among visits for depressed pregnant women, providers reported antidepressant use 25.4% of the time for all visits. Antidepressant use during pregnancy varied significantly by race/ethnicity. Among visits for non-Hispanic White women, 3.1% included a code for antidepressant use vs just 1.0% for non-White women (P<0.0001). After adjustment for age, insurance status and region of the country, this association persisted with non-Hispanic White (vs non-White) pregnant women having higher odds of antidepressant use (adjusted OR 3.3, 95% confidence intervals 2.1, 5.3).

CONCLUSION

Non-Hispanic White women were more likely than non-White women to be using antidepressants during pregnancy. Whether differences in antidepressant use by race/ethnicity indicates over-treatment of non-Hispanic White women or under-treatment of minorities remains unclear. This disparity warrants investigation with the goal of optimizing maternal mental health while minimizing potential adverse sequelae of antidepressants on developing fetuses.

Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents

BACKGROUND

Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning.

OBJECTIVES

To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 June 2014. The register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales.

MAIN RESULTS

We included eleven studies, involving 1307 participants in this review. We also identified one ongoing study, and two additional ongoing studies that may be eligible for inclusion. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, just under half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However, some trials measured suicidal ideation using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 0.26, 95% CI 0.07 to 0.98), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes.

AUTHORS' CONCLUSIONS

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

Predictors of prevention failure in college students participating in two indicated depression prevention programs

The purpose of this study was to identify subgroups of university students with the highest likelihood of remaining at elevated levels of depressive symptoms six months following the receipt of a depressive prevention intervention on the basis of known risk factors and participation in one of two depression prevention programs. Data from a randomized controlled trial evaluating depression prevention among 133 college students with elevated depressive symptoms were analyzed. Participants were randomized to a cognitive-behavioral or relaxation training group preventive intervention. Classification tree analysis showed that older age was the strongest risk factor for persistently elevated depression. Additional risk factors were: (1) for younger students, fewer daily pleasant activities; (2) for those with higher level of pleasant activities, higher level of stressful events; and (3) for those with higher level of stressful events, lower assertiveness. Results offer directions for prevention foci, identify specific subgroups of college students to target for depression prevention efforts, and suggest that research aim to help older, non-traditional students or graduating students manage the transition from college to the work force.

Blood pressure trajectories in early adulthood and subclinical atherosclerosis in middle age

IMPORTANCE

Single measures of blood pressure (BP) levels are associated with the development of atherosclerosis; however, long-term patterns in BP and their effect on cardiovascular disease risk are poorly characterized.

OBJECTIVES

To identify common BP trajectories throughout early adulthood and to determine their association with presence of coronary artery calcification (CAC) during middle age.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort data from 4681 participants in the CARDIA study, who were black and white men and women aged 18 to 30 years at baseline in 1985-1986 at 4 urban US sites, collected through 25 years of follow-up (2010-2011). We examined systolic BP, diastolic BP, and mid-BP (calculated as [SBP+DBP]/2, an important marker of coronary heart disease risk among younger populations) at baseline and years 2, 5, 7, 10, 15, 20, and 25. Latent mixture modeling was used to identify trajectories in systolic, diastolic, and mid-BP over time.

MAIN OUTCOMES AND MEASURES

Coronary artery calcification greater than or equal to Agatston score of 100 Hounsfield units (HU) at year 25.

RESULTS

We identified 5 distinct mid-BP trajectories: low-stable (21.8%; 95% CI, 19.9%-23.7%; n=987), moderate-stable (42.3%; 40.3%-44.3%; n=2085), moderate-increasing (12.2%; 10.4%-14.0%; n=489), elevated-stable (19.0%; 17.1%-20.0%; n=903), and elevated-increasing (4.8%; 4.0%-5.5%; n=217). Compared with the low-stable group, trajectories with elevated BP levels had greater odds of having a CAC score of 100 HU or greater. Adjusted odds ratios were 1.44 (95% CI, 0.83-2.49) for moderate-stable, 1.86 (95% CI, 0.91-3.82) for moderate-increasing, 2.28 (95% CI, 1.24-4.18), for elevated-stable, and 3.70 (95% CI, 1.66-8.20) for elevated-increasing groups. The adjusted prevalence of a CAC score of 100 HU or higher was 5.8% in the low-stable group. These odds ratios represent an absolute increase of 2.7%, 5%, 6.3%, and 12.9% for the prevalence of a CAC score of 100 HU or higher for the moderate-stable, moderate-increasing, elevated-stable and elevated-increasing groups, respectively, compared with the low-stable group. Associations were not altered after adjustment for baseline and year 25 BP. Findings were similar for trajectories of isolated systolic BP trajectories but were attenuated for diastolic BP trajectories.

CONCLUSIONS AND RELEVANCE

Blood pressure trajectories throughout young adulthood vary, and higher BP trajectories were associated with an increased risk of CAC in middle age. Long-term trajectories in BP may assist in more accurate identification of individuals with subclinical atherosclerosis.

Practitioner review: maternal mood in pregnancy and child development--implications for child psychology and psychiatry

BACKGROUND

The empirical base suggesting a link between prenatal maternal anxiety, stress or depression and cognitive, behavioral, and biological outcomes in the infant and child has increased dramatically in the past 10 years.

METHODS

In this review, we consider the relevance of prenatal maternal mood for child mental health practitioners; the empirical base for a likely causal impact of the link between prenatal anxiety, depression, or stress and child outcomes; the degree to which the available evidence is sufficient for informing or altering clinical practice; and the possible role of prenatal interventions for promoting child health and development. A selective review of PubMed, Cochrane Library and other sources was undertaken.

FINDINGS

Clinically significant links between maternal prenatal distress and child behavioral and cognitive outcomes have been reported; predictions to stress physiology, immunology, and neurodevelopment have been reported but the effect sizes and clinical significance is less clear. Several candidate mechanisms have been proposed, with some supporting evidence. Many behavioral treatments for prenatal maternal distress exist, but their application to promoting child health is largely unknown.

CONCLUSIONS

Research on maternal prenatal distress is a good example of translational research and offers a strong paradigm for promoting interdisciplinary clinical research on child health and development.