Divergent Outcomes in Cognitive-Behavioral Therapy and Pharmacotherapy for Adult Depression

Is Self-Help Dangerous? Examination of Adverse Effects of a Psychological Internet-Based Self-Help Intervention for Body-Focused Repetitive Behavior (Free From BFRB)

Despite the proven effectiveness of psychotherapy for psychiatric disorders, adverse events or unwanted effects may occur. Unwanted effects, however, are rarely assessed. In self-help interventions, which usually are not supported by a therapist, such effects have received even less attention even though special caution is needed regarding unwanted effects such as those related to misapplication. For the present study, we present the newly developed Positive and Negative Effects of Psychotherapy Scale for Internet-Based Intervention (PANEPS-I) and examine possible unwanted effects of an internet-based self-help intervention in individuals with body-focused repetitive behaviors (BFRBs), aggregating three different techniques: habit reversal training (HRT), decoupling (DC), and decoupling in sensu (DC-is). Some HRT users have expressed concern that the suppression of the problematic behavior could lead to rebound effects, but this has not been examined rigorously. Following baseline assessment, 141 participants with at least one BFRB were randomly assigned to two intervention groups that differed only with respect to the delivery mode (video, manual); the content was the same. After 6 weeks, a post-assessment was conducted. Unwanted effects were assessed using the PANEPS-I. A total of 70% of the participants (both treatment groups combined) reported at least one positive effect of the intervention. Negative effects were reported by 14-92% of participants, depending on the effect. The highest agreement rates were found for "no positive goal orientation" (52.5%), "did not address personal problems" (48.8%), "time/performance pressure" (20.9%), shame (16.3%), and concerns about data privacy (14.3%). Participants in the manual intervention group reported unethical procedures (e.g., data privacy concerns) more often (Cohen's d = .44) than those in the video intervention group. Responders reported more positive effects and nonresponders more malpractice (|d| = .80, .54, respectively). HRT users (self-report) showed no significant differences compared to nonusers regarding negative effects. Stepwise hierarchical regression analyses indicated a dose-response relationship for reported positive effects and malpractice. Side effects may occur in any kind of intervention. Usage of HRT did not lead to more reported negative effects compared to nonusage. To improve the quality and effectiveness and ensure the safety of the user, especially those using digital self-help interventions, it is important to regularly assess unintended effects since there is no supervision of the patient in unguided self-help interventions.

Video-Delivered Family Therapy for Perinatal Women With Depressive Symptoms and Family Conflict: Feasibility, Acceptability, Safety, and Tolerability Results From a Pilot Randomized Trial

BACKGROUND

Although individual-level treatments exist for pregnant and postpartum women with depression, family conflict is a significant factor that can contribute to the development and severity of perinatal depressive symptoms. Yet, there is a lack of research on family therapy for perinatal women with moderate to severe depressive symptoms and family conflict. Further, research is needed on the feasibility, acceptability, safety, and tolerability of family therapies for perinatal depression that are delivered using Health Insurance Portability and Accountability Act-compliant videoconferencing technology (VCT).

OBJECTIVE

This paper describes the feasibility, acceptability, safety, and tolerability of a VCT-based family therapeutic intervention, Resilience Enhancement Skills Training (REST), for perinatal women with moderate to severe depressive symptoms and moderate to high conflict with their family members.

METHODS

This paper includes data from an ongoing randomized trial that compares an experimental family therapeutic intervention (REST) to standard of care (VCT-based problem-solving individual therapy) for the treatment of moderate to severe depressive symptoms in perinatal women with moderate to high family conflict. Both interventions were delivered by masters-level therapists using VCT. A total of 83 perinatal women and their adult family members (N=166 individuals) were recruited for participation in the study. Feasibility, defined as therapist adherence to ≥80% of REST session content, was assessed in audio-recorded sessions by 2 expert raters. Acceptability was defined as ≥80% of families completing REST, including completion of ≥80% homework assignments and family report of satisfaction with REST. Completion of REST was assessed by review of therapist session notes, and satisfaction was assessed by participant completion of a web-based questionnaire. The Beck Depression Inventory-Second Edition was administered to perinatal women by research assistants (blind to study group assignment) to assess safety, defined as a reduction in depressive symptoms during the treatment phase. The Family Environment Scale-Family Conflict subscale was administered by therapists to participants during the treatment phase to assess tolerability, defined as a reduction in family conflict during the treatment phase.

RESULTS

On average, the therapists achieved 90% adherence to REST session content. Of the families who started REST, 84% (32/38) of them completed REST, and on average, they completed 89% (8/9) of the homework assignments. Families reported satisfaction with REST. The results showed that REST is safe for perinatal women with moderate to severe depressive symptoms, and none discontinued due to worsened depressive symptoms. The results showed that REST is well tolerated by families, and no families discontinued due to sustained family conflict.

CONCLUSIONS

The results show that REST is feasible, acceptable, safe, and tolerable for families. These findings will guide our interpretation of REST's preliminary effectiveness upon completion of outcome data collection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04741776; https://clinicaltrials.gov/ct2/show/NCT04741776.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Assessing in-session rumination and its effects on CBT for depression

The study evaluated if rumination of patients during therapy (i.e., in-session rumination) relates to whether or not they do less well in CBT treatment. We developed a reliably assessed in-session rumination observational measure and evaluated its relationship to depression over the course of CBT. Rated sessions came from 63 treatment-naïve patients with major depressive disorder who participated in CBT in the PReDICT study (Dunlop et al., 2017). In-session rumination was operationalized as repetitive, negative, and passive talking about depressive topics. Trained undergraduates rated the intensity and duration of in-session rumination occurring during 57 initial therapy sessions (i.e., session one) and 45 sessions in the middle of treatment (i.e., session eight). The observational ratings were sufficiently reliable (all ICCs > 0.69). Mixed model results indicated that greater intensity of in-session rumination during the initial treatment session predicted higher levels of subsequent clinician-rated depressive symptoms (p < .023). Regression results indicated that greater intensity and duration of in-session rumination at session 8 significantly predicted higher clinician-rated symptoms at end of treatment (p's < 0.02). In-session rumination intensity and duration were not, however, related to subsequent self-reported depressive symptoms. The results support efforts to identify which patients might benefit from rumination-specific interventions.

Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial

BACKGROUND

In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC).

METHODS

Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7).

OUTCOMES

change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation.

RESULTS

Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment.

CONCLUSION

As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.

Sequential Interventions for Major Depression and Heart Failure Self-Care: A Randomized Clinical Trial

BACKGROUND

Major depression and inadequate self-care are common in patients with heart failure (HF). Little is known about how to intervene when both problems are present. This study examined the efficacy of a sequential approach to treating these problems.

METHODS

Stepped Care for Depression in HF was a single-site, single-blind, randomized controlled trial of cognitive behavior therapy (CBT) versus usual care (UC) for major depression in patients with HF. The intensive phase of the CBT intervention lasted between 8 and 16 weeks, depending upon the rate of improvement in depression. All participants received a tailored HF self-care intervention that began 8 weeks after randomization. The intensive phase of the self-care intervention ended at 16 weeks post-randomization. The coprimary outcome measures were the Beck Depression Inventory (version 2) and the Maintenance scale of the Self-Care of HF Index (v6.2) at week 16.

RESULTS

One hundred thirty-nine patients with HF and major depression were enrolled; 70 were randomized to UC and 69 to CBT. At week 16, the patients in the CBT arm scored 4.0 points ([95% CI, -7.3 to -0.8]; P=0.02) lower on the Beck Depression Inventory, version 2 than those in the usual care arm. Mean scores on the Self-Care of HF Index Maintenance scale were not significantly different between the groups ([95% CI, -6.5 to 1.5]; P=0.22).

CONCLUSIONS

CBT is more effective than usual care for major depression in patients with HF. However, initiating CBT before starting a tailored HF self-care intervention does not increase the benefit of the self-care intervention.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02997865.

Rates and Predictors of Deterioration in a Trial of Internet-Delivered Cognitive Behavioral Therapy for Reducing Suicidal Thoughts

OBJECTIVE

It is necessary for suicide prevention interventions to demonstrate safety. One important aspect of safety is evidence that deterioration rates are low. No studies have examined deterioration of suicidal ideation in the context of an internet-based cognitive behavioral therapy (CBT) intervention to reduce suicidal ideation. A secondary analysis of the outcomes of an online trial was conducted to determine rates of deterioration in a CBT intervention called Living with Deadly Thoughts, relative to an attention control condition, and to identify factors associated with deterioration.

METHOD

The randomized controlled trial included 418 adults with suicidal ideation at baseline (77% females, mean age 40.6 years). Deterioration was defined in two ways: a reliable increase in Suicidal Ideation Attributes Scale (SIDAS score) of ≥6.0 units; or triggering the safety protocol during the trial as determined by high levels of suicidality. Analyses were repeated with multiply imputed data. Predictors of deterioration were identified using logistic regression analysis.

RESULTS

30 (14%) participants in the control group and 15 (7%) in the intervention group met criteria for reliable deterioration (Fisher's exact p = 0.027). In a fully adjusted logistic regression model, greater initial severity of suicidal thinking was associated with lower odds of deterioration, while intervention condition, demographics, psychological factors and mental health factors had no significant association with deterioration.

CONCLUSIONS

Participation in an online suicide prevention intervention was associated with lower prevalence of reliable deterioration than participation in an attention-control intervention, providing further evidence that internet-based CBT interventions do not cause harm.HighlightsFirst study to assess deterioration in an internet suicide prevention interventionRates of reliable deterioration were higher in control (14%) than intervention (7%)No psychological or demographic factors were robustly associated with deteriorationFindings provide further evidence that internet based CBT programs are not harmful.

Out of sight, out of mind? High discrepancy between observer- and patient-reported outcome after routine inpatient treatment for depression

BACKGROUND

Divergent outcomes of treatment for depression occur regularly, but often go undetected by clinical judgment alone. To date, no comprehensive studies are available on what the detection rate of divergent outcomes is in routine care.

METHOD

We analyzed a large (N = 20,882) database of clinician-rated and patient-reported outcomes from routine inpatient treatment for depression.

RESULTS

There was little agreement (57.7% on the GAF, 7.8% on the CGI-I) between clinician ratings and patients not showing clinically significant change. There was virtually no agreement (0.6% on the GAF, 2% on the CGI-I) between clinician ratings and self-report scales in deteriorated patients. Multiple regression showed that clinician ratings of change were influenced primarily by symptom severity at discharge, rather than change from admission.

LIMITATIONS

Only symptom scales were available as patient-reported outcomes, although clinician ratings may be based on other sources of information. In addition, no information was available on clinicians' experience with the rating scales used, nor is it clear how carefully the ratings were made.

DISCUSSION

It can be concluded that failure to achieve treatment success and worsening after routine treatment for depression often go undetected on clinical rating scales, suggesting that such cases frequently remain undetected. Clinicians should generally obtain patient-reported outcomes during treatment to detect these cases.

The Contribution of “Individual Participant Data” Meta-Analyses of Psychotherapies for Depression to the Development of Personalized Treatments: A Systematic Review

While randomized trials typically lack sufficient statistical power to identify predictors and moderators of outcome, ”individual participant data” (IPD) meta-analyses, which combine primary data of multiple randomized trials, can increase the statistical power to identify predictors and moderators of outcome. We conducted a systematic review of IPD meta-analyses on psychological treatments of depression to provide an overview of predictors and moderators identified. We included 10 (eight pairwise and two network) IPD meta-analyses. Six meta-analyses showed that higher baseline depression severity was associated with better outcomes, and two found that older age was associated with better outcomes. Because power was high in most IPD meta-analyses, non-significant findings are also of interest because they indicate that these variables are probably not relevant as predictors and moderators. We did not find in any IPD meta-analysis that gender, education level, or relationship status were significant predictors or moderators. This review shows that IPD meta-analyses on psychological treatments can identify predictors and moderators of treatment effects and thereby contribute considerably to the development of personalized treatments of depression.

Frequency analysis of symptomatic worsening following ketamine infusions for treatment resistant depression in a real-world sample: Results from the canadian rapid treatment center of excellence

Antidepressants are associated with symptomatic worsening in a subgroup of patients. Replicated evidence has demonstrated rapid and robust antidepressant effects with intravenous (IV) ketamine in treatment resistant depression (TRD); however, the risk of ketamine worsening depressive symptoms in a subgroup of patients remains unknown. Herein we report a retrospective analysis on the rates of symptomatic worsening during an acute course of IV ketamine in individuals with unipolar (n = 142) and bipolar (n = 22) TRD. Adults (N = 164; mean age = 45.97) with TRD underwent four sub-anesthetic infusions (0.5-0.75 mg/kg over 40 min) of IV ketamine over two weeks, and were assessed with the Quick Inventory for Depression Symptomatology-Self Report-16 (QIDS-SR₁₆) at baseline and after each infusion. The primary outcome was the proportion of patients experiencing clinically significant worsening of depressive symptoms (≥20% increase on the QIDS-SR₁₆) at each time point relative to baseline. Secondary analyses explored trends in the results. The frequency of clinically significant worsening fluctuated between 1.83% to 5.49%, with no identifiable trend across time. Zero individuals with bipolar TRD reported symptomatic worsening. Limitations include the single-centered, uncontrolled, retrospective nature of this study. Rates of symptomatic worsening associated with IV ketamine therapy for TRD appear to be very low and similar to conventional antidepressants.

What works for mental health problems in youth? Survey of real-world experiences of treatments and side effects

AIM

Despite youth being the most common age group for onset of mental disorders, there is less knowledge on the benefits and harms of treatments in young people. In addition, efficacy data from randomized controlled trials may not generalize to how treatment works outside of research settings. This study aimed to investigate young people's perceived effectiveness of different treatments for mental health problems, the professionals who delivered these, and the experience of negative effects.

METHODS

We developed a consumer report website where young people who were ever diagnosed with a mental disorder provided ratings on the helpfulness or harmfulness of different types of professionals, mental health treatments (medical, psychological complementary/alternative) and self-help strategies, and whether they had experienced particular negative effects.

RESULTS

Here, 557 young people aged 12-25 years, who were recruited from English-speaking, high-income countries, provided 1258 ratings of treatments. All treatments showed varied perceptions of effectiveness. Medical and psychological treatments were rated moderately helpful on average with low rates of harmfulness. Self-help strategies were rated as being as helpful as professional treatments. Side effects related to the head or mind (e.g., concentration difficulties, inability to feel emotions, depression and irritability) were the most common across all types of medicines. For psychological treatments, treatment being too expensive and feeling worse at the end of a session were the most commonly reported negative effects.

CONCLUSIONS

Study findings may be a useful guide to clinicians, researchers, young people and their families about what is likely to work in real-world settings.

Negative effects in internet-based interventions for depression: A qualitative content analysis

An increasing number of studies is proving the efficacy of Internet-based interventions (IBI) for treating depression. While the focus of most studies is thereby lying on the potential of IBI to alleviate emotional distress and enhance well-being, few studies are investigating possible negative effects that might be encountered by participants. The current study was therefore exploring self-reported negative effects of participants undergoing a cognitive-behavioral IBI targeting mild to moderate depression over 6 weeks. Data from the client pool of a German insurance company (n = 814, 68% female) revealed that 8.6% of the participants reported the experience of negative effects. Qualitative content analysis yielded two broad categories and five subcategories for the nature of participants' experiences of negative effects: participant-related negative effects (insight and symptom) and program-related negative effects (online format, contact, and implementation). By using both, qualitative and quantitative methods, results did not only shed light on the characteristics of negative effects but analyses also found that working alliance was a predictor for the experience of negative effects. Monitoring the occurrences of negative effects as well as working alliance throughout treatment was considered essential to help prevent negative effects and attrition among participants undergoing IBI for depression.

Efficacy of Cognitive Behavioral Therapy on Mood Disorders, Sleep, Fatigue, and Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis

Objective: The aim of this study was to perform a quantitative analysis to evaluate the efficacy of cognitive behavioral therapy (CBT) on mood disorders, sleep, fatigue, and its impact on quality of life (QOL) in Parkinson's Disease (PD). Methods: We searched for randomized controlled trials in three electronic databases. Fourteen studies, including 507 patients with PD, met the inclusion criteria. We determined the pooled efficacy by standard mean differences and 95% confidence intervals, using I ² to reveal heterogeneity. Results: The result showed CBT had a significant effect on depression [-0.93 (95%CI, -1.19 to -0.67, P < 0.001)] and anxiety [-0.76 (95%CI, -0.97 to -0.55, P < 0.001)]. Moderate effect sizes were noted with sleep disorders [-0.45 (95% CI, -0.70 to -0.20, P = 0.0004)]. There was no evident impact of CBT on fatigue or QOL. We found an intervention period >8 weeks was advantageous compared with <8 weeks, and CBT implemented in non-group was more effective than in group. Between the delivery methods, no significant difference was found. Conclusion: We found that CBT in patients with PD was an efficacious therapy for some non-motor symptoms in PD, but not efficacious for fatigue and QOL. These results suggest that CBT results in significant improvement in PD and should be used as a conventional clinical intervention.

One (effect) size does not fit at all: Interpreting clinical significance and effect sizes in depression treatment trials

The efficacy of antidepressants in major depressive disorder has been continually questioned, mainly on the basis of studies using the sum-score of the Hamilton Depression Rating Scale as a primary outcome parameter. On this measure antidepressants show a standardised mean difference of around 0.3, which some authors suggested is below the cut-off for clinical significance. Prompted by a recent review that, using this argument, concluded antidepressants should not be used for adults with major depressive disorder, we (a) review the evidence in support of the cut-off for clinical significance espoused in that article (a Hamilton Depression Rating Scale standardised mean difference of 0.875); (b) discuss the limitations of average Hamilton Depression Rating Scale sum-score differences between groups as measure of clinical significance; (c) explore alternative measures of clinical importance; and (d) suggest future directions to help overcome disagreements on how to define clinical significance. We conclude that (a) the proposed Hamilton Depression Rating Scale cut-off of 0.875 has no scientific basis and is likely misleading; (b) there is no agreed upon way of delineating clinically significant from clinically insignificant; (c) evidence suggests the Hamilton Depression Rating Scale sum-score underestimates antidepressant efficacy; and (d) future clinical trials should consider including measures directly reflective of functioning and wellbeing, in addition to measures focused on depression psychopathology.

Mental and personality disorders in infertile women with polycystic ovary: a case-control study

Background

Polycystic Ovarian Syndrome (PCOS) is one of the most common causes of infertility in women.

Objective

The current study investigated mental and personality disorders in infertile women with and without PCOS.

Methods

This case-control study evaluated 400 infertile women who referred to the Infertility Center in Babol city (North of Iran). Participants were categorized into the case group (201 PCOS) and the control group (199 without PCOS). All of the participants completed the Millon Clinical Multi-axial Inventory-III (MCMI-III).

Results

The mean scores for clinical personality patterns were significantly higher for six personality disorders (schizoid, avoidant, antisocial, depressive, sadistic, and negativistic) and for three classes of severe personality disorder patterns (schizotypal, borderline, and paranoid) in infertile women with PCOS than in women without PCOS. The mean scores for eight clinical disorders (somatoform, manic disorder, dysthymia, alcohol-dependence, drug-dependence, post-trauma stress disorder, major depression, and delusion disorder) were also higher in infertile women with PCOS than in women without PCOS.

Conclusion

The scores of many mental and personality disorders are higher in infertile women with PCOS than in women without PCOS. Thus, clinicians should prioritize recognizing and treating psychological problems of infertile women with PCOS.

Concordance between clinician-rated and patient reported outcome measures of depressive symptoms in treatment resistant depression

BACKGROUND

Calls to implement measurement-based care (MBC) in psychiatry are increasing. A recent Cochrane meta-analysis concluded that there is insufficient evidence that routine application of patient reported outcomes (PROs) improves treatment outcomes for common psychiatric disorders. There is a particular paucity of this information in patients with treatment resistant depression (TRD).

METHODS

A TRD sample (n = 302) and a treatment-naïve sample with major depression (n = 344) were assessed for the level of agreement in depression severity between two PROs (the Beck Depression Inventory, BDI, and the Quick Inventory of Depressive Symptomatology Self-report, QIDS-SR) and two Clinician Rated (CRs) measures (Hamilton Depression Rating Scale, HDRS, and the Montgomery-Asberg Depression Rating Scale, MADRS).

RESULTS

Correlations between CR and PRO total scores in the TRD sample ranged from 0.57 (HDRS-QIDS-SR) to 0.68 (MADRS-BDI), reflecting a moderate-to-strong relationship between assessment tools. Correlations in the treatment naïve sample were non-significantly lower for most comparisons, ranging from 0.51 (HDRS-QIDS-SR) to 0.64 (MADRS-BDI). Few predictors of discordance between CRs and PROs were identified, though chronicity of the current episode in treatment-naïve patients was associated with greater agreement.

LIMITATIONS

Inter-rater reliability of the clinician interviews was conducted separately within the two studies so we could not determine the reliability between the two groups of raters used in the studies.

CONCLUSION

Findings generally supported acceptably high levels of agreement between patient and clinician ratings of baseline depression severity. More work is needed to determine the extent to which PROs can improve outcomes in MBC for depression and, more specifically, TRD.

Whose depression deteriorates during acute phase antidepressant treatment?

BACKGROUND

Few studies have investigated the proportion of patients with depression who experience worsening of depression symptoms during adequate antidepressant treatment. The current study aimed to investigate the proportion and predictors of worsening depression during antidepressant treatment in a multi-center randomized trial involving patients with major depression.

METHODS

We defined the deterioration of depression using depression symptom severity evaluated by total Patient Health Questionnaire (PHQ-9) score increases from week 0 to week 9 during acute phase antidepressant treatment. Patients' baseline demographic and clinical data, change in PHQ-9 scores from week 0 to week 3, and side effects at week 3 were evaluated as potential predictors of subsequent deterioration of depression.

RESULTS

Of 1,647 patients, 99 (6.0%) exhibited deterioration of depression, and this proportion was smaller when reliable change index criteria were applied. Logistic regression analysis revealed that the following factors were significantly associated with deterioration of depression: younger age at onset of first episode of major depressive disorder, current older age, and greater increase in PHQ-9 scores between week 0 and week 3.

LIMITATIONS

The time of the primary endpoint might not have been sufficiently long. The present study did not include a placebo arm, and potentially relevant predictors might not have been comprehensively investigated.

CONCLUSIONS

A small proportion of patients may experience deterioration of depression during acute phase antidepressant treatment. Age at onset at first depressive episode, current age, and early negative response to antidepressants may be useful predictors of subsequent worsening of depression.

Redefining Therapeutic Outcomes of Depression Treatment

Responses to evidence-based interventions for depression are divergent: Some patients benefit more than others during treatment and some do not benefit at all or even deteriorate. Tailoring interventions to the individual may improve outcomes. However, such personalization of evidence-based treatment in depression requires investigation of individual outcomes and the individual trajectories towards these outcomes. This theoretical paper provides a critical reflection on individual outcomes of depression treatment. First, it is argued that outcomes should be broadened, from a focus on mainly depressive symptomatology to recovery in different domains. It is acknowledged that recovery from depression reflects a personal journey that differs from person to person. Second, outcome measures should be lengthened beyond the acute treatment phase, taking a lifetime perspective on depression. The challenge then is to discover which trajectories of what measures during what interventions result in personalized sustainable recovery and for whom. Routine outcome monitoring systems may be used to inform this quest towards assessment of personalized sustainable therapeutic outcomes. Adaptations to broaden and lengthen measurements in routine outcome monitoring systems are proposed to identify predictors of personalized sustainable recovery. Routine outcome monitoring systems may eventually be used to implement personalized treatments for depression that result in personalized sustainable recovery.

Targets and outcomes of psychotherapies for mental disorders: an overview

It is not yet clear what mental disorders are and what are the causal pathways that lead to them. That makes it difficult to decide what the targets and outcomes of psychotherapies should be. In this paper, the main types of targets and outcomes of psychotherapies are described, and a brief overview is provided of some of the main results of research on these types. These include symptom reduction, personal targets and outcomes from the patient's perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes to be avoided, and economic outcomes. In line with the dominance of the DSM and ICD systems for diagnoses, most research has been focused on symptom reduction. This considerable body of research, with hundreds of randomized trials, has shown that for most mental disorders effective psychotherapies are available. There is also research showing that psychotherapies can result in improvement of quality of life in most mental disorders. However, relatively little research is available on patient-defined outcomes, intermediate outcomes, negative outcomes and economic outcomes. Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes of psychotherapies. The perspective of patients should have more priority in research, and a standardization of outcome measures across trials is much needed.

Stress, Depression, Sexual Function, and Alexithymia in Infertile Females with and without Polycystic Ovary Syndrome: A Case-Control Study

Background

Infertile females experience some types of distress such as social stress, depression, and sexual dysfunction that may be exacerbated by polycystic ovary syndrome (PCOS). The current study aimed at comparing psychological profile of infertile females with PCOS with that of women without PCOS with respect to four domains: infertility stress, depression, sexual dysfunction, and alexithymia.

Materials and Methods

The current case-control study was conducted on 240 infertile females (120 with PCOS and 120 without PCOS) in Fatemeh Azahra Infertility and Reproductive Health Research Center (Babol, Iran) from 2016 to 2017. The following questionnaires were used to collect data: the fertility problem inventory (FPI), the female sexual function index (FSFI), the Beck depression inventory-II (BDI-II), and the Toronto alexithymia scale (TAS-20).

Results

Females with PCOS had higher FPI total scores than the ones without PCOS (120.68 ± 29.42 vs. 112.83 ± 30.94). Of the subscales of infertility stress, the mean scores of social stress and rejection of a future life without a child were higher in females with PCOS than the ones without PCOS (P<0.05). Also, the mean total scores of alexithymia symptoms (TAS-20) in females with PCOS were significantly higher than those of the ones without PCOS (59.83 ± 11.36 vs. 55.69 ± 11.52). There was no significant difference between the two groups regarding the mean scores of depression symptoms and sexual function.

Conclusion

Infertile females with PCOS experienced higher levels of infertility stress and inability to distinguish and describe their feelings compared with the ones without PCOS. It is suggested that infertility care providers should provide more psychosocial support for infertile females with PCOS.

Estimating outcome probabilities from early symptom changes in cognitive therapy for recurrent depression

OBJECTIVE

Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD) producing benefits comparable to pharmacotherapy, but not all patients respond or remit. The purpose of the current analyses was to estimate CT patients' probability of nonresponse and remission from symptom improvement early in treatment.

METHOD

Data from 2 clinical trials of acute-phase CT for recurrent depression were pooled for analysis (N = 679). Adult outpatients received 16- or 20-session CT protocols. Symptoms were measured repeatedly with the clinician-report Hamilton Rating Scale for Depression (HRSD) and Inventory of Depressive Symptomatology-Self-Report (IDS-SR). Outcomes at exit from CT were nonresponse (<50% reduction in HRSD scores) and remission (no MDD and HRSD score ≤6).

RESULTS

The nonresponse rate was 45.7%, and the remission rate was 33.4%. In logistic regression models, improvements on the HRSD or IDS-SR from intake to CT Sessions 3, 5, 7, 9, or 11 significantly predicted both outcomes, with prediction gaining in accuracy in later sessions. Clinician and self-report assessments yielded similar results. Prediction of outcomes replicated across data sets. Patients with no symptom improvement by CT Session 9 (Week 5) had ≤10% probability of remission and >75% probability of nonresponse.

CONCLUSIONS

Outcomes of CT for depression are predictable from early symptom changes. Clinicians may find nonresponse and remission probability estimates useful in the informed consent process and in choosing whether to continue, augment, or switch treatments for CT patients with recurrent MDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The role of long-term psychodynamic psychotherapy in improving attachment patterns, defense styles, and alexithymia in patients with depressive/anxiety disorders

INTRODUCTION

Long-term psychodynamic psychotherapy (LTPP) emphasizes the centrality of intrapsychic and unconscious conflicts and their relation to development. Although there is evidence supporting the efficacy of LTPP in mental disorders, little research has been published on the efficacy of LTPP for depressive and anxiety disorders.

OBJECTIVE

To examine whether patients with anxiety and depressive disorders demonstrate improvement in their attachment styles, defense styles, psychiatric symptoms, anxiety/depressive symptoms, and alexithymia with LTPP.

METHODS

In this retrospective, descriptive study, the psychological outcomes of patients who were treated at the psychoanalytic clinic of Babol University of Medical Sciences were assessed. Fourteen patients diagnosed with depressive or anxiety disorder participated in the study of LTPP using the self-psychology approach. The Beck Depression Inventory II, Beck Anxiety Inventory, Adult Attachment Scale, 40-item Defense Style Questionnaire, and the 20-item Toronto Alexithymia Scale were administered at pre-treatment, post-treatment, and 6-month follow-up. Generalized estimating equations were used to analyze changes in psychological outcomes after each of the three assessments.

RESULTS

The mean scores of depression and anxiety and secure attachment improved significantly after LTPP with self-psychology approach from baseline to post-treatment and follow-up. Also, the mean scores of neurotic and immature defenses, difficulty in identifying feelings, difficulty in describing feelings, externally oriented thinking, and total alexithymia scores decreased significantly from baseline to post-treatment and follow-up.

CONCLUSION

Symptoms of anxiety disorders, depressive disorders, insecure attachment styles, alexithymia, and neurotic/immature defense styles improved after the LTPP with self-psychology approach. Moreover, the improvements persisted at the 6-month follow-up.

Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates

BACKGROUND

The risk for deterioration in patients receiving psychotherapy for adult depression has not been examined extensively and it is not clear whether psychotherapy reduces this risk or may even increase it in some patients. We conducted a meta-analysis of trials comparing these psychotherapies with control conditions that report deterioration rates.

METHODS

We used an existing database of randomized trials on psychotherapies for adult depression which was updated up to 1/1/2017, through systematic searches in bibliographic databases. We included trials that reported clinically significant deterioration rates.

RESULTS

We included 18 studies with 23 comparisons between therapy and control groups. The pooled risk ratio of deterioration was 0.39 (95% CI: 0.27∼0.57), indicating that patients in the psychotherapy groups have a 61% lower chance to deteriorate than patients in the control groups. We found that 20 patients need to be treated with psychotherapy in order to avoid one case of deterioration, compared to the control conditions. The median deterioration rate in the therapy groups was 4%, and in some studies more than 10%, indicating that clinicians should always be aware of the risk of deterioration.

LIMITATIONS

The results should be considered with caution because most studies had at least some risk of bias. Only 6% of all trials comparing psychotherapy with a control condition reported deterioration rates, using different ways to define deterioration which made pooling the prevalence rates across treatments and control groups impossible.

CONCLUSIONS

Psychological treatments of adult depression may reduce the risk for deterioration, compared to control groups, but this should be considered with caution because of the small proportion of studies reporting deterioration rates.

The potential of predictive analytics to provide clinical decision support in depression treatment planning

PURPOSE OF REVIEW

To review progress developing clinical decision support tools for personalized treatment of major depressive disorder (MDD).

RECENT FINDINGS

Over the years, a variety of individual indicators ranging from biomarkers to clinical observations and self-report scales have been used to predict various aspects of differential MDD treatment response. Most of this work focused on predicting remission either with antidepressant medications versus psychotherapy, some antidepressant medications versus others, some psychotherapies versus others, and combination therapies versus monotherapies. However, to date, none of the individual predictors in these studies has been strong enough to guide optimal treatment selection for most patients. Interest consequently turned to decision support tools made up of multiple predictors, but the development of such tools has been hampered by small study sample sizes. Design recommendations are made here for future studies to address this problem.

SUMMARY

Recommendations include using large prospective observational studies followed by pragmatic trials rather than smaller, expensive controlled treatment trials for preliminary development of decision support tools; basing these tools on comprehensive batteries of inexpensive self-report and clinical predictors (e.g., self-administered performance-based neurocognitive tests) versus expensive biomarkers; and reserving biomarker assessments for targeted studies of patients not well classified by inexpensive predictor batteries.

Pre-post effect sizes should be avoided in meta-analyses

Aims The standardised mean difference (SMD) is one of the most used effect sizes to indicate the effects of treatments. It indicates the difference between a treatment and comparison group after treatment has ended, in terms of standard deviations. Some meta-analyses, including several highly cited and influential ones, use the pre-post SMD, indicating the difference between baseline and post-test within one (treatment group).

METHODS

In this paper, we argue that these pre-post SMDs should be avoided in meta-analyses and we describe the arguments why pre-post SMDs can result in biased outcomes.

RESULTS

One important reason why pre-post SMDs should be avoided is that the scores on baseline and post-test are not independent of each other. The value for the correlation should be used in the calculation of the SMD, while this value is typically not known. We used data from an 'individual patient data' meta-analysis of trials comparing cognitive behaviour therapy and anti-depressive medication, to show that this problem can lead to considerable errors in the estimation of the SMDs. Another even more important reason why pre-post SMDs should be avoided in meta-analyses is that they are influenced by natural processes and characteristics of the patients and settings, and these cannot be discerned from the effects of the intervention. Between-group SMDs are much better because they control for such variables and these variables only affect the between group SMD when they are related to the effects of the intervention.

CONCLUSIONS

We conclude that pre-post SMDs should be avoided in meta-analyses as using them probably results in biased outcomes.

Individual patient data meta-analysis of combined treatments versus psychotherapy (with or without pill placebo), pharmacotherapy or pill placebo for adult depression: a protocol

INTRODUCTION

There are many proven treatments (psychotherapy, pharmacotherapy or their combination) for the treatment of depression. Although there is growing evidence for the effectiveness of combination treatment (psychotherapy + pharmacotherapy) over pharmacotherapy alone, psychotherapy alone or psychotherapy plus pill placebo, for depression, little is known about which specific groups of patients may respond best to combined treatment versus monotherapy. Conventional meta-analyses techniques have limitations when tasked with examining whether specific individual characteristics moderate the effect of treatment on depression. Therefore, this protocol outlines an individual patient data (IPD) meta-analysis to explore which patients, with which clinical characteristics, have better outcomes in combined treatment compared with psychotherapy (alone or with pill placebo), pharmacotherapy and pill placebo.

METHODS AND ANALYSIS

Study searches are completed using an established database of randomised controlled trials (RCTs) on the psychological treatment of adult depression that has previously been reported. Searches were conducted in PubMed, PsycInfo, Embase and the Cochrane Central Register of Controlled Trials. RCTs comparing combination treatment (psychotherapy + pharmacotherapy) with psychotherapy (with or without pill placebo), pharmacotherapy or pill placebo for the treatment of adult depression will be included. Study authors of eligible trials will be contacted and asked to contribute IPD. Conventional meta-analysis techniques will be used to examine differences between studies that have contributed data and those that did not. Then, IPD will be harmonised and analysis using multilevel regression will be conducted to examine effect moderators of treatment outcomes.

DISSEMINATION

Study results outlined above will be published in peer-reviewed journals. Study results will contribute to better understanding whether certain patients respond best to combined treatment or other depression treatments and provide new information on moderators of treatment outcome that can be used by patients, clinicians and researchers.

TRIAL REGISTRATION NUMBER

CRD42016039028.

The Effects of Mindfulness-Based Cognitive Therapy on Depression and Anxiety in Women with Premenstrual Syndrome

Objective. Little research has been done regarding the role of psychotherapy in the treatment of Premenstrual Syndrome (PMS). The aim of this study was to examine the effect of mindfulness-based cognitive therapy (MBCT) on the PMS symptoms and depression and anxiety symptoms in women with PMS. Design. In a randomized controlled trial, a total of 60 students at Mazandaran University with mild to moderate PMS who had depressive symptoms (Beck depression scores 16-47) were randomly allocated to either an experimental (n = 30) or a control (n = 30) group. The experimental group received MBCT in eight group sessions (120 min each) over 8 weeks. The control group received no intervention. All participants completed the Premenstrual Assessment Scale (PAS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) at the beginning and the end of the study. Repeated-measure ANOVA was used to analyze the data. Results. At the end of study, the experimental and control groups showed the following scores, respectively (mean ± SD): depression, 15.73 ± 6.99 and 25.36 ± 7.14; anxiety, 16.96 ± 7.78 and 26.60 ± 9.38; and total PAS, 42.86 ± 8.02 and 58.93 ± 8.47. MBCT improved depression and anxiety symptoms and total PAS score. Conclusion. MBCT intervention is acceptable and potentially beneficial in women with PMS symptoms. Psychotherapy should be considered as a treatment option for mild to moderate PMS in women with depressive symptoms.