A randomized study on the effect of modified behavioral activation treatment for depressive symptoms in rural left-behind elderly

Effectiveness of digital modified behavioral activation treatment program for rural older adults with depressive symptoms in Western Hunan: study protocol for a multi-center randomized controlled trial

BACKGROUND

Rural older adults experience a high burden of depressive symptoms and significant barriers to accessing mental health services. The Modified Behavioral Activation Treatment (MBAT) has been verified to be effective among rural older adults in China. Due to its structured format and skill-based learning, it is well suited for digital-based delivery. However, only a few studies were from developed countries, and the evidence to support its application in rural China still needs to be provided. Thus, based on the fact that digital health technology has the potential to address the shortage of healthcare resources and the constraints of community mental health services in rural China, the effectiveness of the digital MBAT (D-MBAT) program among rural older adults is worth further evaluation.

METHODS

A multi-center randomized controlled trial will be conducted among 216 rural older adults from Huayuan County and Fenghuang County in Western Hunan. The intervention group will receive the D-MBAT program, while the control group will receive routine care. Depressive and anxiety symptoms, social health, quality of life, and satisfaction will be measured at baseline, one-month, and three-month follow-ups to evaluate the digital MBAT program's effectiveness.

DISCUSSION

Existing digital psychological intervention strategies seldom take into account the needs and preferences of the older adults in low-resource rural areas. Thus, this study aims to develop a D-MBAT program based on person-centered and community-engaged approach to maximize the mental health service of rural older adults with depressive symptoms.A successful D-MBAT program would be a feasible and scalable approach to the management of prevalent mental health conditions of rural older adults in resource-limited Western Hunan.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400091193. Registered on 23 October 2024.

Effectiveness of a modified behavioural activation treatment training program for primary medical staff to manage depressive symptoms among rural elderly in Hunan Province, China: study protocol for a cluster randomised controlled trial

INTRODUCTION

Depression is a major global health problem, with high prevalence rates of depressive symptoms observed among the elderly population in China, particularly exacerbating in rural areas. Due to a lack of professional mental health training and inadequate psychotherapy capacity within primary medical staff, rural elderly individuals grappling with depressive symptoms often encounter challenges in receiving timely diagnosis and treatment. In this landscape, the modified behavioural activation treatment (MBAT) emerges as a promising approach due to its practicality, ease of therapist training and application, patient acceptability, and broad applicability. However, existing evidence for MBAT mainly hails from developed countries, leaving a gap in its adaptation and implementation within rural China. This study aims to develop an MBAT training programme for primary medical staff to manage depressive symptoms among rural elderly and evaluate its effectiveness.

METHODS AND ANALYSIS

A cluster randomised controlled trial will be conducted in 10 randomly selected township hospitals in Lengshuijiang and Lianyuan, Hunan Province. We aim to recruit 150 participants, with 5 township hospitals selected for each group, each consisting of 15 participants. The intervention group will implement the MBAT training programme, while the control group will receive usual care training programme. Depressive symptoms, psychosocial functioning, quality of life and satisfaction will be measured at baseline, immediately post-intervention, and at 3 and 6 months post-intervention. Effectiveness will be assessed using linear or generalised linear mixed models.

ETHICS AND DISSEMINATION

This study has obtained approval from the Institutional Review Board of the Third Xiangya Hospital, Centre South University (No.: 2022-S261). Results will be disseminated through publication in international peer-reviewed journals and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300074544.

Effectiveness of psychological interventions among community-dwelling older adults with subthreshold depression: A systematic review and meta-analysis

BACKGROUND

Little is known about the effectiveness of psychological interventions among older adults with subthreshold depression in the community. This systematic review and meta-analysis aimed to examine the effectiveness of psychological interventions on depressive symptoms, anxiety symptoms and quality of life.

METHODS

We searched five databases from inception to 20th September 2022 and included RCTs that evaluated the effectiveness of psychological interventions among older adults with subthreshold depression in the community. Standardized mean difference (SMD) and 95 % confidence intervals (CI) were used to calculate the effect sizes of treatment outcomes in the meta-analysis, using RevMan 5.4.1 and Stata 16.0.

RESULTS

This meta-analysis included thirteen RCT studies involving 2079 participants. Psychological interventions could significantly reduce depressive symptoms (post-intervention time: SMD = -0.58, 95 % CI = -0.76 to -0.40; follow-up time: SMD = -0.31, 95 % CI = -0.41 to -0.22) and anxiety symptoms (post-intervention time: SMD = -0.33, 95 % CI = -0.49 to -0.17; follow-up time: SMD = -0.24, 95 % CI = -0.36 to -0.12) and improve quality of life (post-intervention time: SMD = 0.30, 95 % CI = 0.05 to 0.55; follow-up time: SMD = 0.15, 95 % CI = 0.01 to 0.28).

CONCLUSION

Evidence suggests that psychological interventions could significantly reduce depressive symptoms and anxiety symptoms, and improve quality of life among community-dwelling older adults with subthreshold depression.

Senescence Seclusion Syndrome: Appraising the Efficacy of Current Interventions

The proportion of senior citizens in the global population has been on a steady rise, and the current population is forecasted to double in a few decades. Against this backdrop, the prevalence of senescence seclusion syndrome, characterized by prolonged social isolation in the elderly, is increasing concurrently. Given the profound threats this syndrome poses to the mental, physical, and social well-being of this vulnerable demographic, implementing effective interventions is imperative to mitigate these threats and enhance the quality of life. This review aims to assess the efficacy of the interventional modalities critically. Studies were reviewed following comprehensive searches in databases such as PubMed, Scopus, and Google Scholar, and focusing on empirical studies from 2019 to 2024 that evaluated the efficacy of the major intervention categories - social, technological, psychological, and physical interventions. The findings indicate that initiatives that promote consistent social engagement, such as community-organized social events and structured group activities, significantly reduced loneliness and bolstered social connections. Furthermore, technological interventions, including artificial intelligence and virtual reality, have notably enhanced elderly connectivity with their communities. Additionally, psychological interventions, such as cognitive-behavioral therapy, have also been effective in alleviating symptoms of anxiety and depression associated with the syndrome, with group sessions enhancing social interaction and significantly diminishing isolation. Moreover, physical interventions involving group exercises and other activities have fostered improvements in the physical, mental, and social well-being of the elderly. This study underscores the importance of a multifaceted approach that is individualized according to preference and circumstance in addressing senescence seclusion syndrome.

Behavioral activation for depression in groups embedded in psychosomatic rehabilitation inpatient treatment: a quasi-randomized controlled study

Background

Behavioral activation (BA) and cognitive-behavioral therapy (CBT) have shown to be efficacious treatment methods for depression. Previous studies focused mostly on the outpatient treatment either in group or individual setting. The present study aimed at comparing the efficacy of group treatment BA vs. CBT, when embedded in inpatient psychosomatic rehabilitation treatment.

Methods

375 inpatients were randomly assigned to either BA (N = 174) or CBT (N = 201). We used established scales for depression such as the Beck Depression Inventory II (BDI-II, self-rating), the Quick Inventory of Depressive Symptomatology (QIDS; expert rating) and the Behavioral Activation for Depression Scale (BADS) to assess changes over the course of the treatment and at follow-up (4 to 6 months). In addition, we measured disability-related functioning with the Mini-ICF-APP, a rating scale built in reference to the International Classification of Functioning, Disability and Health (ICF). Multilevel models with repeated measures were conducted to examine the differences between groups in relation to change over time with patients' random effects.

Results

Both group formats showed substantial reduction in depressive symptoms at the end of treatment (d= 0.83 BA vs. d= 1.08 CBT; BDI-II) and at follow-up after 4 to 6 months (d = 0.97 BA vs. d = 1.33 CBT, BDI-II; and d = 1.17 BA vs. d = 1.09 CBT, QIDS). There were no significant differences between treatment approaches. At least 50% symptom reduction was achieved by 53.7% and 54.2% in BA vs. CBT respectively. Reported activation levels increased from pre- to posttreatment (d = 0.76 BA vs. d = 0.70CBT), while showing loss of increment between the end of the treatment until follow up in both formats (d = 0.28 BA vs. d = 0.29 CBT).

Discussion

Both modalities led to significant improvement of symptomatology and functioning at the end of the treatment and at follow-up, thus for the first time demonstrating the practicability of BA in rehabilitation clinics. Considering its lower requirements regarding cognitive abilities and its easier implementation, BA proved to be a good alternative to other psychotherapeutic treatments.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Efficacy of culturally adapted interventions for common mental disorders in people of Chinese descent: a systematic review and meta-analysis

BACKGROUND

Evidence suggests that culturally adapted psychological interventions have some benefits in treating diverse ethnic groups. However, the effect of such cultural adaptions specifically in Chinese ethnic groups has not been thoroughly reviewed. We aimed to systematically assess the evidence for the efficacy of different cultural adaptations in treating common mental disorders in people of Chinese descent (ie, ethnic Chinese populations).

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, CNKI, and WANFANG to identify randomised controlled trials published in English and Chinese from database inception to March 10, 2023. We included trials of culturally adapted psychological interventions in people of Chinese descent (with at least 80% of Han Chinese descent) aged 15 years or older with a diagnosis or subthreshold symptoms of common mental disorders, including depression, anxiety disorders, and post-traumatic stress disorder. We excluded studies that included participants with severe mental disorders (eg, schizophrenia, bipolar disorder), neurodevelopmental disorders, or dementia. Study selection and data extraction were done by two independent reviewers, who extracted data for study characteristics, cultural adaptations, and summary efficacy. The primary outcome was post-intervention change in symptoms (both self-reported and clinician-rated). We used random-effects models to calculate standardised mean differences. Quality was assessed using the Cochrane risk of bias tool. The study is registered with PROSPERO (CRD42021239607).

FINDINGS

We identified 32 791 records, 67 of which were included in our meta-analysis (60 done in mainland China, four in Hong Kong, and one each in Taiwan, Australia, and the USA). We included 6199 participants (mean age 39·32 years [range 16-84]), of whom 2605 (42%) were male and 3247 (52%) were female. Culturally adapted interventions had medium effect sizes in terms of reducing both self-reported (Hedges' g 0·77 [95% CI 0·61-0·94]; I² 84%) and clinician-rated (0·75 [0·54-0·96]; 86%) symptom severity across all disorders at end of treatment, irrespective of adaptation types. We noted no difference in efficacy between culturally modified interventions and culturally specific interventions. Subgroup analyses showed considerable heterogeneity. Inadequate reporting in included studies largely restricted risk-of-bias appraisals across all domains.

INTERPRETATION

Psychological interventions can be transported across cultures with appropriate modifications. Adaptations to interventions can be made by modifying evidence-based interventions, or in culturally specific ways that are rooted in the sociocultural context. However, findings are limited by the insufficient reporting of interventions and cultural adaptations.

FUNDING

None.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Attitudes toward depression among rural primary healthcare providers in hunan areas, China: a cross sectional study

BACKGROUND

Mental health services are not sufficient for depression patients in rural areas of China, training in mental health knowledge for primary healthcare providers has been encouraged, but the effect of this encouragement has rarely been reported.

METHODS

A cross-sectional survey was conducted in primary healthcare facilities that sought to include all the primary healthcare providers (registered physicians and nurses) in two cities in Hunan province, China by administering questionnaires that covered depression symptoms, typical depression cases, and the Revised Depression Attitude Questionnaire.

RESULTS

In total, 315 primary healthcare providers agreed to participate in the study and finished the questionnaires, of which 12.1% had training in depression. In addition, 62.9% of the rural primary healthcare providers were able to recognize most general depression symptoms, and 8.3% were able to recognize all general depression symptoms. The primary healthcare providers in the survey held a neutral to slightly negative attitude towards depression as indicated by their professional confidence (mean scores 16.51 ± 4.30), therapeutic optimism/pessimism (mean scores 29.02 ± 5.98), and general perspective (mean scores 18.12 ± 3.12) scores. Fewer rural primary healthcare providers knew (28.3%) or applied (2.9%) psychological intervention in the clinic.

CONCLUSIONS

Our study indicated that primary healthcare providers knew about general depression symptoms, but lacked psychological intervention skills and held low confidence in and pessimistic attitudes toward depression care. We therefore speculate that existing psychological training for primary healthcare providers is insufficient in quantity and quality, making the need to explore more effective types of training urgently.

Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Mental health support is often scarce in low- and middle-income countries (LMIC), with mental health stigmatised. Older adults are some of the most vulnerable members of society and may require specific types of mental health support. The aim of this mixed-methods systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults (aged 60 + years) residing in LMIC.

METHODS

Six databases were searched in August 2021. Studies published since 2000 were included if they collected primary quantitative or qualitative data on community-based interventions for improving mental health for older adults residing in LMICs, focusing on improving mental health and well-being outcomes. Full texts were screened by two researchers.

RESULTS

From 24,378 citations identified, 40 studies met eligibility criteria. Across 12 countries, interventions were categorised into those focusing on (1) Established forms of psychological therapy; (2) Exercise; (3) Education; (4) Social engagement; (5) Multi-component. Most interventions were effective in reducing levels of depression, anxiety, and improving well-being, including reminiscence therapy, different types of socialising, and breathing and laughter exercises. Some interventions reported no benefits and those that did at times failed to report continued benefits at follow-up. Given the variations in intervention type and delivery, cultures, and outcome measures used, underpinning factors of intervention success or failure were difficult to establish.

CONCLUSIONS

Psychosocial interventions for older adults in LMIC need to be adapted to local contexts depending on culture and population needs. Existing interventions and their components can be used as a foundation to produce adapted and multi-component interventions, to tackle growing and inadequate mental health care provision in LMIC.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO [CRD42021271404].

Intelligent physical activity versus modified behavioral activation in adolescent and young adult cancer patients with psychological distress: A randomized, controlled pilot trial

BACKGROUND

More than 80% of adolescent and young adult cancer patients (AYACPs) experienced psychological distress. Physical activity and behavioral activation are effective to relieve the psychological distress in AYACPs.

METHODS

Participants aged 15-39 years diagnosed with malignant tumors were included. A total of 143 eligible AYACPs were randomly assigned to three groups. The treatment-as-usual group (N = 48) received routine care, the physical activity group (N = 47) received 8 weeks of physical activity program based on intelligent wearable devices, and the behavioral activation group (N = 48) received an internet-based modified behavioral activation program for 8 weeks. Objective outcome measures included salivary cortisol and testosterone.

RESULTS

Linear mixed-model analyses showed significant differences between treatment-as-usual, physical activity and behavioral activation in salivary cortisol, as well as total scores on depression and anxiety, physical activity, self-efficacy, and social support. Significantly stronger effect sizes for physical activity group compared with behavioral activation group were found on physical activity (d = 0.53) (1 week after intervention), moderate activity (d = 0.61), and walking activity (d = 0.57) (3-month follow-up).

CONCLUSIONS

Intelligent, wearable, device-based physical activity program is more effective in alleviating anxiety and depression, reducing saliva cortisol, and improving physical activity in AYACPs than internet-based modified behavioral activation program. Intelligent, wearable, device-based physical activity program can reduce the time cost of AYACPs to ensure that the intervention is carried out.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Non-pharmacological interventions for older adults with depressive symptoms: a network meta-analysis of 35 randomized controlled trials

Objective: To assess the effectiveness of non-pharmacological interventions for seniors with depressive symptoms.Methods: A comprehensive literature search was performed. We conducted network meta-analysis in two ways, intervention classes (psychosocial, psychotherapy, physical activity, combined, treatment as usual) and individual intervention (11 categories). Whenever included studies used different scales, the different instruments were converted to the units of the scale most frequently used (the Geriatric Depression Scale), such that the effect size was reported as a mean difference (MD) with 95% confidence interval (CI). The risk of bias of RCTs included in this review was assessed according to the Cochrane Handbook. Bayesian NMA was conducted using R-3.4.0 software.Results: A total of 35 RCTs with 3,797 enrolled patients were included. Compared to conventional treatment, physical activity and psychotherapy resulted in significant improvements in depressive symptoms (MD: 2.25, 95%CrI: 0.99-3.56; SUCRA = 86.07%; MD: 1.75, 95% CrI: 0.90-2.64; SUCRA = 66.44%, respectively). Similar results were obtained for music (MD: 2.6; 95% CrI: 0.84-4.35;SUCRA = 80.53%), life review (MD:1.92; 95% CrI:0.71-3.14; SUCRA = 65.62%), cognitive behavioral therapy (MD: 1.27; 95% CrI: 0.23-2.38; SUCRA = 45.4%), aerobic (MD: 1.84; 95% CrI: 0.39-3.36; SUCRA = 63%) and resistance training (MD: 1.72; 95% CrI: 0.06-3.42; SUCRA = 59.24%). Network meta-regression showed that there were no statistically significant subgroup effects.Conclusions: Physical activity and psychotherapy demonstrated statistically significant superiority over conventional treatment. Music and life review therapy proved the most promising individual interventions. However, conclusions are limited by the lack of sufficient sample size and consensus regarding intervention categories and so an adequately powered study is necessary to consolidate these findings.

Effect of Two Interventions on Sleep Quality for Adolescent and Young Adult Cancer Survivors: A Pilot Randomized Controlled Trial

BACKGROUND

Sleep disturbance is common among adolescent and young adult (AYA) cancer survivors. Physical activity (PA) and behavioral activation (BA) therapy have been reported as enhancing sleep quality, but few studies exist on the effects of such interventions combined with technology to promote sleep quality in AYA cancer patients.

OBJECTIVE

The aim of this study was to investigate the feasibility and effects of intelligent wearable device-based PA therapy and internet-based modified BA therapy to improve sleep quality among AYA cancer patients.

METHODS

A randomized controlled trial with 143 AYA cancer patients was conducted. Participants were randomly assigned to a control group (n = 48), which performed routine care, a PA group (n = 47), which received 8-week PA therapy based on intelligent wearable devices, and a BA group (n = 48), which participated in internet-based modified BA therapy for 8 weeks.

RESULTS

At 1 week and 3 months after the intervention for sleep quality, there were statistically significant differences between the PA group and the control group (P = .020), but no statistically significant difference between the BA group and the control group.

CONCLUSIONS

The intelligent wearable device-based PA therapy has more advantages than internet-based modified BA therapy in improving the overall state of AYA cancer patients, and the intervention effect was sustained for at least 3 months.

IMPLICATIONS FOR PRACTICE

Developing and implementing PA plans for AYA cancer survivors can improve their sleep quality. Social media, intelligent wearable devices, and mobile health applications have unique advantages in promoting sleep quality for AYA cancer survivors.

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

Effectiveness of Behavioral Activation in Treating Thai Older Adults with Subthreshold Depression Residing in the Community

Background

In recent years, behavioral activation (BA) has attracted increased interest as an effective depression treatment. However, empirical evidence supporting its effectiveness in non-Western countries is currently limited.

Objective

To examine the effectiveness of BA in reducing depressive symptoms, stress, and anxiety among Thai older adults with subthreshold depression.

Methods and Subjects

A clustered randomized controlled trial was conducted in two health promoting hospitals (HPHs) in the Samut Songkhram province of Thailand. One hospital was used for the intervention (BA+usual care group) and the other for the control (usual care-only group). Each HPH randomly selected 41 eligible older adults residing in their jurisdictions to take part in the study. Mental health outcomes were assessed using the Thai Geriatric Depression Scale (TGDS) and Depression Anxiety Stress Scales (DASS). The BA effectiveness was evaluated using generalized estimating equations (GEE) at a group level and the reliable change index (RCI) at the individual level.

Results

Over 9 months, the adjusted mean change in depression (TGDS) scores [−2.47 (95% CI: −3.84, −1.00)], mental health status (DASS), specifically depression and stress score [−1.47 and −1.87 (95% CI: −2.43, −0.50 and −2.94, −0.79, respectively)], improved significantly in the BA+usual care group compared to the usual care-only group, whereas anxiety score improved significantly only at 6 months [−0.87 (95% CI: −1.52, −0.23)]. Additional RCI analysis showed that BA was directly associated with 14.63 to 24.39% points increase in the reliable improvement of depressive outcome compared to the usual care-only group.

Conclusion

This study showed that the BA effectively improved depression, stress, and anxiety in older adults with subthreshold depression in a Thai community setting. Future research should evaluate the longer-term effectiveness of BA in diverse population groups.

Culturally adapted and lay-delivered cognitive behaviour therapy for older adults with depressive symptoms in rural China: a pilot trial

BACKGROUND

Late-life depression issues in developing countries are challenging because of understaffing in mental health. Cognitive behavioural therapy (CBT) is effective for treating depression.

AIM

This pilot trial examined the adherence and effectiveness of an eight-session adapted CBT delivered by trained lay health workers for older adults with depressive symptoms living in rural areas of China, compared with the usual care.

METHOD

Fifty with screen-positive depression were randomly assigned to the CBT arm or the care as usual (CAU) arm. The primary outcomes were the session completion of older adults and changes in depressive symptoms, assessed using the Geriatric Depression Scale (GDS).

RESULTS

The majority (19/24) of participants in the CBT arm completed all sessions. Mixed-effect linear regression showed that the CBT reduced more GDS scores over time compared with CAU.

CONCLUSION

Lay-delivered culturally adapted CBT is potentially effective for screen-positive late-life depression.

Behavioural activation therapy for depression in adults

BACKGROUND

Behavioural activation is a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment. Behavioural activation is increasingly receiving attention as a potentially cost-effective intervention for depression, which may require less resources and may be easier to deliver and implement than other types of psychotherapy.

OBJECTIVES

To examine the effects of behavioural activation compared with other psychological therapies for depression in adults. To examine the effects of behavioural activation compared with medication for depression in adults. To examine the effects of behavioural activation compared with treatment as usual/waiting list/placebo no treatment for depression in adults.

SEARCH METHODS

We searched CCMD-CTR (all available years), CENTRAL (current issue), Ovid MEDLINE (1946 onwards), Ovid EMBASE (1980 onwards), and Ovid PsycINFO (1806 onwards) on the 17 January 2020 to identify randomised controlled trials (RCTs) of 'behavioural activation', or the main elements of behavioural activation for depression in participants with clinically diagnosed depression or subthreshold depression. We did not apply any restrictions on date, language or publication status to the searches. We searched international trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of behavioural activation for the treatment of depression or symptoms of depression in adults aged 18 or over. We excluded RCTs conducted in inpatient settings and with trial participants selected because of a physical comorbidity. Studies were included regardless of reported outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles/abstracts and full-text manuscripts for inclusion. Data extraction and 'Risk of bias' assessments were also performed by two review authors in duplicate. Where necessary, we contacted study authors for more information.

MAIN RESULTS

Fifty-three studies with 5495 participants were included; 51 parallel group RCTs and two cluster-RCTs. We found moderate-certainty evidence that behavioural activation had greater short-term efficacy than treatment as usual (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.10 to 1.78; 7 RCTs, 1533 participants), although this difference was no longer evident in sensitivity analyses using a worst-case or intention-to-treat scenario. Compared with waiting list, behavioural activation may be more effective, but there were fewer data in this comparison and evidence was of low certainty (RR 2.14, 95% CI 0.90 to 5.09; 1 RCT, 26 participants). No evidence on treatment efficacy was available for behavioural activation versus placebo and behavioural activation versus no treatment. We found moderate-certainty evidence suggesting no evidence of a difference in short-term treatment efficacy between behavioural activation and CBT (RR 0.99, 95% CI 0.92 to 1.07; 5 RCTs, 601 participants). Fewer data were available for other comparators. No evidence of a difference in short term-efficacy was found between behavioural activation and third-wave CBT (RR 1.10, 95% CI 0.91 to 1.33; 2 RCTs, 98 participants; low certainty), and psychodynamic therapy (RR 1.21, 95% CI 0.74 to 1.99; 1 RCT,60 participants; very low certainty). Behavioural activation was more effective than humanistic therapy (RR 1.84, 95% CI 1.15 to 2.95; 2 RCTs, 46 participants; low certainty) and medication (RR 1.77, 95% CI 1.14 to 2.76; 1 RCT; 141 participants; moderate certainty), but both of these results were based on a small number of trials and participants. No evidence on treatment efficacy was available for comparisons between behavioural activation versus interpersonal, cognitive analytic, and integrative therapies. There was moderate-certainty evidence that behavioural activation might have lower treatment acceptability (based on dropout rate) than treatment as usual in the short term, although the data did not confirm a difference and results lacked precision (RR 1.64, 95% CI 0.81 to 3.31; 14 RCTs, 2518 participants). Moderate-certainty evidence did not suggest any difference in short-term acceptability between behavioural activation and waiting list (RR 1.17, 95% CI 0.70 to 1.93; 8 RCTs. 359 participants), no treatment (RR 0.97, 95% CI 0.45 to 2.09; 3 RCTs, 187 participants), medication (RR 0.52, 95% CI 0.23 to 1.16; 2 RCTs, 243 participants), or placebo (RR 0.72, 95% CI 0.31 to 1.67; 1 RCT; 96 participants; low-certainty evidence). No evidence on treatment acceptability was available comparing behavioural activation versus psychodynamic therapy. Low-certainty evidence did not show a difference in short-term treatment acceptability (dropout rate) between behavioural activation and CBT (RR 1.03, 95% CI 0.85 to 1.25; 12 RCTs, 1195 participants), third-wave CBT (RR 0.84, 95% CI 0.33 to 2.10; 3 RCTs, 147 participants); humanistic therapy (RR 1.06, 95% CI 0.20 to 5.55; 2 RCTs, 96 participants) (very low certainty), and interpersonal, cognitive analytic, and integrative therapy (RR 0.84, 95% CI 0.32 to 2.20; 4 RCTs, 123 participants). Results from medium- and long-term primary outcomes, secondary outcomes, subgroup analyses, and sensitivity analyses are summarised in the text.

AUTHORS' CONCLUSIONS

This systematic review suggests that behavioural activation may be more effective than humanistic therapy, medication, and treatment as usual, and that it may be no less effective than CBT, psychodynamic therapy, or being placed on a waiting list. However, our confidence in these findings is limited due to concerns about the certainty of the evidence. We found no evidence of a difference in short-term treatment acceptability (based on dropouts) between behavioural activation and most comparison groups (CBT, humanistic therapy, waiting list, placebo, medication, no treatment or treatment as usual). Again, our confidence in all these findings is limited due to concerns about the certainty of the evidence. No data were available about the efficacy of behaioural activation compared with placebo, or about treatment acceptability comparing behavioural activation and psychodynamic therapy, interpersonal, cognitive analytic and integrative therapies. The evidence could be strengthened by better reporting and better quality RCTs of behavioural activation and by assessing working mechanisms of behavioural activation.