Effectiveness of Psychological and Educational Interventions to Prevent Depression in Primary Care: A Systematic Review and Meta-Analysis

A personalized intervention to prevent depression in primary care based on risk predictive algorithms and decision support systems: protocol of the e-predictD study

The predictD is an intervention implemented by general practitioners (GPs) to prevent depression, which reduced the incidence of depression-anxiety and was cost-effective. The e-predictD study aims to design, develop, and evaluate an evolved predictD intervention to prevent the onset of major depression in primary care based on Information and Communication Technologies, predictive risk algorithms, decision support systems (DSSs), and personalized prevention plans (PPPs). A multicenter cluster randomized trial with GPs randomly assigned to the e-predictD intervention + care-as-usual (CAU) group or the active-control + CAU group and 1-year follow-up is being conducted. The required sample size is 720 non-depressed patients (aged 18-55 years), with moderate-to-high depression risk, under the care of 72 GPs in six Spanish cities. The GPs assigned to the e-predictD-intervention group receive brief training, and those assigned to the control group do not. Recruited patients of the GPs allocated to the e-predictD group download the e-predictD app, which incorporates validated risk algorithms to predict depression, monitoring systems, and DSSs. Integrating all inputs, the DSS automatically proposes to the patients a PPP for depression based on eight intervention modules: physical exercise, social relationships, improving sleep, problem-solving, communication skills, decision-making, assertiveness, and working with thoughts. This PPP is discussed in a 15-min semi-structured GP-patient interview. Patients then choose one or more of the intervention modules proposed by the DSS to be self-implemented over the next 3 months. This process will be reformulated at 3, 6, and 9 months but without the GP-patient interview. Recruited patients of the GPs allocated to the control-group+CAU download another version of the e-predictD app, but the only intervention that they receive via the app is weekly brief psychoeducational messages (active-control group). The primary outcome is the cumulative incidence of major depression measured by the Composite International Diagnostic Interview at 6 and 12 months. Other outcomes include depressive symptoms (PHQ-9) and anxiety symptoms (GAD-7), depression risk (predictD risk algorithm), mental and physical quality of life (SF-12), and acceptability and satisfaction ('e-Health Impact' questionnaire) with the intervention. Patients are evaluated at baseline and 3, 6, 9, and 12 months. An economic evaluation will also be performed (cost-effectiveness and cost-utility analysis) from two perspectives, societal and health systems.

Trial registration

ClinicalTrials.gov, identifier: NCT03990792.

Effectiveness of interventions to prevent perinatal depression: An umbrella review of systematic reviews and meta-analysis

BACKGROUND

To date, dozens of systematic reviews (SRs) and meta-analyses (MAs) summarize the effectiveness of preventive interventions for perinatal depression. However, the results are inconclusive, making an urgent need to step up to higher levels of evidence synthesis.

AIMS

To summarize and compare the evidence from the SR&MA examining the effectiveness of all types of interventions for preventing perinatal depression.

METHOD

PubMed, PsycINFO, Cochrane Database of Systematic Reviews and OpenGrey were searched from inception to December 2022. We selected SR&MA of randomized controlled trials (RCTs) that compared all types of preventive interventions for perinatal depression with control groups whose outcome was the reduction of depressive symptoms and/or incidence of new cases of perinatal depression (PROSPERO: CRD42020173125).

RESULTS

A total of 19 SRs and MAs evaluated 152 unique RCTs that included 83,408 women from 26 countries and five continents. The median effect size for any intervention was SMD = 0.29 (95% CI: 0.20 to 0.38). Exercise/physical activity-based, psychological, and any type of intervention showed median effect sizes of 0.43, 0.28 and 0.36, respectively. The degree of overlap among RCTs was slight. According to AMSTAR-2, 79% of them were rated as low or critically low-quality. The strength of evidence, according to GRADE, was poorly reported and, in most cases, was low.

CONCLUSIONS

Exercise/physical activity-based and psychological interventions have a small-to-medium effect on reducing perinatal depressive symptoms. There is insufficient evidence to conclude that dietary supplements and pharmacological interventions are effective in preventing perinatal depression. There is a need for high-quality SR&MA of RCTs, mainly focusing on universal preventive interventions.

Effectiveness of social support-based interventions in preventing depression in people without clinical depression: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The evidence available on the association between social support and prevention of depression has been basically obtained from observational studies.

AIM

We evaluated the effectiveness of social support-based interventions for the prevention of depression in people without clinical depression.

METHODS

Systematic review and meta-analysis (SR/MA) of randomized controlled trials (RCT), which were searched for in MEDLINE, EMBASE, CENTRAL, WOS, PsycINFO, OpenGrey and other sources from the inception dates to June 8, 2022. We selected RCTs that assessed the effectiveness of social support-based interventions as compared to controls, included subjects without baseline clinical depression, and measured as results a reduction in depressive symptoms and/or the incidence of new cases of depression. Pooled standardized mean differences (SMDs) were calculated from random effects models.

RESULTS

Nine RCTs involving 927 patients from North America, Asia and Europe were included. The pooled SMD was -0.43 [95% confidence interval (CI) -0.82 to -0.04; p = .031]. Sensitivity analyses confirmed the robustness of results. Heterogeneity was substantial [I² = 80% (95% CI: 64% to 89%)]. A meta-regression model that included usual care as comparator and the continent (Europe), explained 53% of heterogeneity. Eight RCTs had a moderate overall risk of bias and one had a high risk of bias. Follow-up was ⩾1 year in only three RCTs. There was no statistical evidence of publication bias. The quality of evidence, as measured on GRADE guidelines, was low.

CONCLUSION

Social support-based interventions had a small preventive effect on depression. Longer RCTs with a low risk of bias are necessary.

Depression Prevention in Pediatric Primary Care: Implementation and Outcomes of Interpersonal Psychotherapy-Adolescent Skills Training

This study evaluated the fidelity, feasibility, acceptability, and preliminary outcomes of a depression prevention program, interpersonal psychotherapy-adolescent skills training (IPT-AST), in urban pediatric primary care (PC) with a sample of primarily Black youth. Twenty-two adolescents with elevated depressive symptoms participated in this open clinical trial. Adolescents were identified through a screening questionnaire completed at well visits. Ratings of IPT-AST fidelity and session attendance were recorded. Youth and caregivers reported on their attitudes toward the intervention and completed measures of adolescents' symptoms and functioning pre- and post-intervention. Results demonstrated high levels of fidelity, attendance, and acceptability, despite some difficulties with recruitment. Adolescents and caregivers reported significant improvements in functioning. There were marginally significant reductions in self-reported depression, anxiety, and total mental health symptoms. Caregivers reported a significant decrease in total mental health symptoms. Findings provide preliminary information regarding the implementation and effects of IPT-AST when delivered in PC.

Effectiveness of psychological interventions in preventing postpartum depression in non-depressed women: a systematic review and meta-analysis of randomized controlled trials

Postpartum depression (PPD) is one of the most common disorders following childbirth. This systematic review and meta-analysis (SR/MA) aimed to assess the effectiveness of psychological interventions in preventing PPD in non-depressed women. PRISMA guidelines were followed. MEDLINE (Ovid and PubMed), PsycINFO, Web of Science, Scopus, CINAHL, CENTRAL, OpenGrey, Australian New Zealand Clinical Trial Registry and clinicaltrial.gov were searched. Randomized controlled trials (RCTs) conducted with pregnant or postpartum (up to 12 months) women who were non-depressed at baseline were selected. The outcomes were the incidence of PPD and/or the reduction of postpartum depressive symptoms. The standardized mean difference (SMD) using random-effect models was calculated. Sensitivity, sub-group and meta-regression analyses were performed. 17 RCTs were included in the SR and 15 in the MA, representing 4958 participants from four continents. The pooled SMD was -0.175 [95% confidence interval (CI) -0.266 to -0.083; p < 0.001] and sensitivity analyses confirmed the robustness of this result. Heterogeneity was low (I2 = 21.20%) and was fully explained by a meta-regression model including one variable (previous deliveries). The meta-regression model and MA stratified by previous deliveries indicated that interventions focused on primiparous women are more effective. There was no evidence of publication bias. Few RCTs had an overall low risk of bias. According to GRADE, the quality of evidence was moderate. Psychological interventions have very little effectiveness in preventing PPD in non-depressed women, although this effectiveness is greater in interventions focused on primiparous women. Further RCTs with a low risk of bias and more effective interventions are needed.

Primary prevention of depression: An umbrella review of controlled interventions

BACKGROUND

Primary prevention has the potential to modify the course of depression, but the consistency and magnitude of this effect are currently undetermined.

METHODS

PRISMA and RIGHT compliant (PROSPERO:CRD42020179659) systematic meta-review, PubMed/Web of Science, up to June 2020. Meta-analyses of controlled interventions for the primary prevention of depressive symptoms [effect measures: standardized mean difference (SMD)] or depressive disorders [effect measure: relative risk (RR)] were carried out. Results were stratified by: (i) age range; (ii) target population (general and/or at-risk); (iii) intervention type. Quality (assessed with AMSTAR/AMSTAR-PLUS content) and credibility (graded as high/moderate/low) were assessed. USPSTF grading system was used for recommendations.

RESULTS

Forty-six meta-analyses (k=928 individual studies, n=286,429 individuals, mean age=22.4 years, 81.1% female) were included. Effect sizes were: SMD=0.08-0.53; for depressive symptoms; RR=0.90-0.28 for depressive disorders. Sensitivity analyses including only RCTs did not impact the findings. AMSTAR median=9 (IQR=8-9); AMSTAR-PLUS content median=4.25 (IQR=4-5). Credibility of the evidence was insufficient/low in 43 (93.5%) meta-analyses, moderate in two (4.3%), and high in one (2.2%): reduction of depressive symptoms using psychosocial interventions for young adults only, and a combination of psychological and educational interventions in primary care had moderate credibility; preventive administration of selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in individuals with a stroke had high credibility.

LIMITATIONS

Intervention heterogeneity and lack of long-term efficacy evaluation.

CONCLUSIONS

Primary preventive interventions for depression might be effective. Among them, clinicians may offer SSRIs post-stroke to prevent depressive disorders, and psychosocial interventions for children/adolescents/young adults with risk factors or during the prenatal/perinatal period.

Health-economic evaluation of psychological interventions for depression prevention: Systematic review

Psychological interventions have been proven to be effective to prevent depression, however, little is known on the cost-effectiveness of psychological interventions for the prevention of depression in various populations. A systematic review was conducted using PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Econlit, NHS Economic Evaluations Database, NHS Health Technology Assessment and OpenGrey up to January 2021. Only health-economic evaluations based on randomized controlled trials of psychological interventions to prevent depression were included. Independent evaluators selected studies, extracted data and assessed the quality using the Consensus on Health Economic Criteria and the Cochrane Risk of Bias Tool. Twelve trial-based economic evaluations including 5929 participants from six different countries met the inclusion criteria. Overall, the quality of most economic evaluations was considered good, but some studies have some risk of bias. Setting the willingness-to-pay upper limit to US$40,000 (2018 prices) for gaining one quality adjusted life year (QALY), eight psychological preventive interventions were likely to be cost-effective compared to care as usual. The likelihood of preventive psychological interventions being more cost-effective than care as usual looks promising, but more economic evaluations are needed to bridge the many gaps that remain in the evidence-base. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

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.

Universal and Selective Interventions to Prevent Poor Mental Health Outcomes in Young People: Systematic Review and Meta-analysis

BACKGROUND

Much is not known about the efficacy of interventions to prevent poor mental health outcomes in young people by targeting either the general population (universal prevention) or asymptomatic individuals with high risk of developing a mental disorder (selective prevention).

METHODS

We conducted a PRISMA/MOOSE-compliant systematic review and meta-analysis of Web of Science to identify studies comparing post-test efficacy (effect size [ES]; Hedges' g) of universal or selective interventions for poor mental health outcomes versus control groups, in samples with mean age <35 years (PROSPERO: CRD42018102143). Measurements included random-effects models, I2 statistics, publication bias, meta-regression, sensitivity analyses, quality assessments, number needed to treat, and population impact number.

RESULTS

295 articles (447,206 individuals; mean age = 15.4) appraising 17 poor mental health outcomes were included. Compared to control conditions, universal and selective interventions improved (in descending magnitude order) interpersonal violence, general psychological distress, alcohol use, anxiety features, affective symptoms, other emotional and behavioral problems, consequences of alcohol use, posttraumatic stress disorder features, conduct problems, tobacco use, externalizing behaviors, attention-deficit/hyperactivity disorder features, and cannabis use, but not eating-related problems, impaired functioning, internalizing behavior, or sleep-related problems. Psychoeducation had the highest effect size for ADHD features, affective symptoms, and interpersonal violence. Psychotherapy had the highest effect size for anxiety features.

CONCLUSION

Universal and selective preventive interventions for young individuals are feasible and can improve poor mental health outcomes.

Effectiveness of online psychological and psychoeducational interventions to prevent depression: Systematic review and meta-analysis of randomized controlled trials

Although evidence exists for the efficacy of interventions to prevent depression, little is known about its prevention through online interventions. We aim to assess the effectiveness of online psychological and psychoeducational interventions to prevent depression in heterogeneous populations. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted based on literature searches in eight electronic data bases and other sources from inception to 22 July 2019. Of the 4181 abstracts reviewed, 501 were selected for full-text review, and 21 RCTs met the inclusion criteria, representing 10,134 participants from 11 countries and four continents. The pooled SMD was -0·26 (95%CI: -0·36 to -0·16; p < 0.001) and sensitivity analyses confirmed the robustness of this result. We did not find publication bias but there was substantial heterogeneity (I² = 72%; 95%CI, 57% to 82%). A meta-regression including three variables explained 81% of the heterogeneity. Indicated prevention and interactive website delivery were statistically associated with higher effectiveness, and no association was observed with risk of bias. Online psychological and psychoeducational interventions have a small effect in reducing depressive symptoms in non-depressed and varied populations, and the quality of evidence is moderate. Given that these types of interventions are very accessible and can be applied on a wide scale, they should be further developed and implemented. Registration details: Registration number (PROSPERO): CRD42014014804.

Randomized Clinical Trial of an Internet-Based Adolescent Depression Prevention Intervention in Primary Care: Internalizing Symptom Outcomes

Approximately 20% of people will experience a depressive episode by adulthood, making adolescence an important developmental target for prevention. CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral, Humanistic, and Interpersonal Training), an online depression prevention intervention, has demonstrated efficacy in preventing depressive episodes among adolescents reporting elevated symptoms. Our study examines the effects of CATCH-IT compared to online health education (HE) on internalizing symptoms in adolescents at risk for depression. Participants, ages 13-18, were recruited across eight US health systems and were randomly assigned to CATCH-IT or HE. Assessments were completed at baseline, 2, 6, 12, 18, and 24 months. There were no significant differences between groups in change in depressive symptoms (b = -0.31 for CATCH-IT, b = -0.27 for HE, p = 0.80) or anxiety (b = -0.13 for CATCH-IT, b = -0.11 for HE, p = 0.79). Improvement in depressive symptoms was statistically significant (p < 0.05) for both groups (p = 0.004 for CATCH-IT, p = 0.009 for HE); improvement in anxiety was significant for CATCH-IT (p = 0.04) but not HE (p = 0.07). Parental depression and positive relationships with primary care physicians (PRPC) moderated the anxiety findings, and adolescents' externalizing symptoms and PRPC moderated the depression findings. This study demonstrates the long-term positive effects of both online programs on depressive symptoms and suggests that CATCH-IT demonstrates cross-over effects for anxiety as well.

[Common mental disorders in primary care: diagnostic and therapeutic difficulties, and new challenges in prediction and prevention. SESPAS Report 2020]

In primary health care only chronic pain surpass depression and anxiety in loss of quality-adjusted life years. More than 70% of people suffering from common mental disorders consulted their GPs for this reason. However, 'the declining halves rule' is a reality: less than 50% of primary care attendees with common mental disorders were correctly diagnosed, of these less than 50% received adequate treatment (pharmacological or psychological) and of these less than 50% patients were adherent. Collaborative models of common mental disorders care in primary health care have demonstrated their effectiveness through clinical trials; however, its implementation in a more general and real context is difficult and its effectiveness remains unclear. Risk algorithms have been developed and validated in primary health care to predict the onset and prognosis of common mental disorders; which are useful for their treatment and prevention. There is evidence that psychological and psychoeducational interventions (and possibly those of physical exercise) are effective for the primary prevention of common mental disorders, even in primary health care; although their effects are small or moderate. These interventions have a high potential to be scalable in schools, workplace and primary health care; in addition, when they are administered through information and communication technologies (e.g. by App), in self-guided or minimally guided programs, they have demonstrated their effectiveness for the treatment and prevention of common mental disorders. They are also very accessible, have low cost and contribute to the massive implementation of these interventions in different settings.

Moderators of psychological and psychoeducational interventions for the prevention of depression: A systematic review

Psychological and psychoeducational interventions have proven to be effective in preventing depression. However, the identification of the patients that benefit the most from each type of intervention has not yet been established. A systematic review was performed of the literature on moderators of preventive psychological and psychoeducational interventions for depression in all types of population. A search was performed on PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials and OpenGrey up to July 2019. Fulfillment of eligibility criteria, data collection, and study quality assessment were assessed by two independent researchers. Outcomes were moderators of the reduction of depressive symptoms or the incidence of depression. Twenty-seven moderator effect studies performed in 19 randomized controlled trials were included. Thirty-four potential sociodemographic, clinical, interpersonal, personality and life-event moderators were evaluated. Baseline depressive symptoms, gender, age, baseline parental depression and social support were the most frequently studied potential moderators. In interventions for children and adolescents, the moderator for which evidence was strongest was having parents free of depression at baseline. Psychological and psychoeducational interventions seem to be more effective in children and adolescents who exhibit a lower use of substances and whose parents do not have symptoms of depression at baseline. In adults, a lower age was associated with greater effects of preventive interventions. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

Factors Associated With Depressive Episode Recurrences in Primary Care: A Retrospective, Descriptive Study

Introduction and Objective

The early identification of depressive patients having a poor evolution, with frequent relapses and/or recurrences, is one of the priority challenges in this study of high prevalence mental disorders, and specifically in depression. So, this study aims to analyze the factors that may be associated with an increased risk of recurrence of major depression episodes in patients treated in primary care.

Methods

A retrospective, descriptive study of cases-controls was proposed. The cases consisted of patients who had been diagnosed with major depression and who had presented recurrences (n = 101), in comparison with patients who had experienced a single major depression episode with no recurrence (n = 99). The variables of the study are age at first episode; number of episodes; perception of severity of the depression episode suffered prior to recurrence; number of residual symptoms; physical and psychiatric comorbidity; history of anxiety disorders; family psychiatric history; high incidence of stressful life events (SLEs); and experiences of physical, psychological, or sexual abuse in childhood. The differences of the variables were compared between the case subjects and the control subjects, using the Mann-Whitney, chi-square, and Fisher's U statistics. A multivariate analysis (ordinary logistic regression) was performed.

Results

The average age of those suffering more than one depressive episode is significantly older (5 years), and a higher percentage of subjects who have experienced more than one depressive episode have a history of anxiety disorders. In the multivariate analysis, the variables that obtained a significant value in the logistic regression analysis were age (OR: 1.03; value: 0.007) and having suffered sexual abuse during childhood (OR: 1.64; value: 0.072).

Conclusion

These indicators should be considered by primary care physicians when attending patients suffering from major depression.

Effectiveness of universal multiple-risk lifestyle interventions in reducing depressive symptoms: Systematic review and meta-analysis

Though many studies have explored the association between single-risk lifestyle interventions and depression, unhealthy lifestyle factors often co-occur, with adults engaging in two or more risk behaviours. To date, little is known about the effectiveness of universal multiple-risk lifestyle interventions to reduce depressive symptoms. We conducted a SR/MA to assess the effectiveness of universal multiple-risk lifestyle interventions (by promoting a healthy diet, physical activity and/or smoking cessation) to reduce depressive symptoms in adults. We searched MEDLINE, Scopus, CENTRAL, PsycINFO, WOS, OpenGrey, the ICTRP and other sources from inception to 16 September 2019. We selected only randomized controlled trials, with no restrictions on language or setting. Our outcome was the reduction of depressive symptoms. We calculated the standardized mean difference using random-effect models. Sensitivity, sub-group and meta-regression analyses were performed. Of the 9386 abstracts reviewed, 311 were selected for full-text review. Of these, 23 RCTs met the inclusion criteria, including 7558 patients from four continents. Twenty RCTs provided valid data for inclusion in the meta-analysis. The pooled SMD was -0.184 (95% CI, -0.311 to -0.057; p = 0.005). We found no publication bias, but heterogeneity was substantial (I² = 72%; 95% CI: 56% to 82%). The effectiveness disappeared when only studies with a low risk of bias were included. The quality of evidence according GRADE was low. Although a small preventive effect was found, the substantial heterogeneity and RCTs with lower risk of bias suggested no effectiveness of universal multiple-risk lifestyle interventions in reducing depressive symptoms in a varied adult population. Further evidence is required.

Mediators in psychological and psychoeducational interventions for the prevention of depression and anxiety. A systematic review

Although efforts have been undertaken to determine how psychological interventions exert their effects, research on mediators and mechanisms of change remains limited, especially in the field of prevention. We aimed to assess available evidence on mediators of psychological and psychoeducational interventions for the prevention of depression and anxiety in varied populations. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and the Cochrane Central Register of Controlled Trials was performed. Two independent reviewers assessed the eligibility criteria of all articles, extracted data, determined the risk of bias in randomized controlled trials, and the requirements for mediators. The outcomes were mediators of the incidence of depression or anxiety and/or the reduction of symptoms of depression or anxiety. We identified 28 nested mediator studies within randomized controlled trials involving 7442 participants. Potential cognitive, behavioral, emotional and interpersonal mediators were evaluated in different psychological and psychoeducational interventions to prevent depression and anxiety. The effects were mediated mainly by cognitive variables, which were the most commonly assessed factors. For depression, the mediator with the strongest empirical support was negative thinking in adults. Cognitive change is an important mediator in preventive psychological and psychoeducational interventions for both anxiety and depression. REGISTRATION DETAILS: Registration number (PROSPERO): CRD42018092393.

Depression: more treatment but no drop in prevalence: how effective is treatment? And can we do better?

PURPOSE OF REVIEW

Since the 70s, treatment of depression, especially pharmacologically, has expanded enormously. However, epidemiological studies show that 12-month population prevalence rates have not dropped. This observation raises multiple questions. How good are treatments of depression actually? Do they improve long-term outcomes? Have the treatment gaps narrowed? And how can we make mental healthcare more effective at the population level?

RECENT FINDINGS

Recent publications suggest some answers. Controlled treatment trials show that effectiveness of specific treatments (pharmacological, psychological) is modest and probably overestimated owing to substantial spontaneous recovery and nonspecific therapeutic effects. Treatment gaps are still substantial and prevention has unclear long-term effects and is not structurally embedded. Future relevance of genetic information for better personalized treatment is potentially high but uncertain. Increasingly, the potential of treatment to improve long-term outcome is being questioned.

SUMMARY

To reduce prevalence, it is essential to narrow the treatment gaps, provide timely interventions and high-quality treatment, eradicate waiting lists, prescribe antidepressants more cautiously and better managed, consider psychological alternatives, and provide more psychosocial treatment in primary care with physician-assistants. In addition, research is needed on long-term outcome of different treatment modalities, and least but not last the value of structurally socially embedded preventive interventions.

Family physicians' views on participating in prevention of major depression. The predictD-EVAL qualitative study

Background

The predictD intervention, a multicomponent intervention delivered by family physicians (FPs), reduced the incidence of major depression by 21% versus the control group and was cost-effective. A qualitative methodology was proposed to identify the mechanisms of action of these complex interventions.

Purpose

To seek the opinions of these FPs on the potential successful components of the predictD intervention for the primary prevention of depression in primary care and to identify areas for improvement.

Method

Qualitative study with FPs who delivered the predictD intervention at 35 urban primary care centres in seven Spanish cities. Face-to-face semi-structured interviews adopting a phenomenological approach. The data was triangulated by three investigators using thematic analysis and respondent validation was carried out.

Results

Sixty-seven FPs were interviewed and they indicated strategies used to perform the predictD intervention, including specific communication skills such as empathy and the activation of patient resources. They perceived barriers such as lack of time and facilitators such as prior acquaintance with patients. FPs recognized the positive consequences of the intervention for FPs, patients and the doctor-patient relationship. They also identified strategies for future versions and implementations of the predictD intervention.

Conclusions

The FPs who carried out the predictD intervention identified factors potentially associated with successful prevention using this program and others that could be improved. Their opinions about the predictD intervention will enable development of a more effective and acceptable version and its implementation in different primary health care settings.

Effectiveness of complex multiple-risk lifestyle interventions in reducing symptoms of depression: a study protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Many studies have explored the impact of lifestyle interventions on depression. However, little is known about the effectiveness of complex multiple-risk lifestyle interventions in reducing symptoms of depression. Our objective is to assess the effectiveness of complex multiple-risk lifestyle interventions in reducing depressive symptoms in the adult population by the acquisition of at least two healthy habits-healthy diet, physical activity and/or smoking cessation. For such purpose, a systematic review and meta-analysis of randomised controlled trials will be conducted.

METHOD AND ANALYSIS

MEDLINE (through Ovid and PubMed), Scopus, Cochrane Central Register of Controlled Trials, Web of Science, PsycINFO, OpenGrey Register (System for Information on Grey Literature in Europe) and the International Clinical Trials Registry Platform will be searched for relevant articles. Additionally, a supplementary manual search will be performed using lists of references, references to expert authors and other systematic reviews and/or meta-analyses. Study selection, data extraction (target habits, country, target populations, conditions and statistical data to name a few) and assessment of the risk of bias will be performed separately by two independent researchers. The primary outcome measure will be the reduction of depression symptoms, as measured by validated instruments. We will calculate pooled standardised mean differences and 95% CIs using random-effect models. Heterogeneity, sensitivity and publication bias will be assessed, and sub-group analysis will be performed. Heterogeneity will be explored by random-effects meta-regression analysis.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The results of this systematic review and meta-analysis will be presented in relevant conferences and published in a peer-review journal. The findings of this study could have important clinical and scientific implications for the improvement of symptoms of depression.

PROSPERO REGISTRATION NUMBER

CRD42018100253; Pre-results.

Effectiveness of online interventions in preventing depression: a protocol for systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Although evidence exists for the efficacy of psychosocial interventions in preventing depression, little is known about its prevention through online interventions. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials assessing the effectiveness of online interventions in preventing depression in heterogeneous populations.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis of randomised controlled trials that will be identified through searches of PubMed, PsycINFO, WOS, Scopus, OpenGrey, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and Australia New Zealand Clinical Trials Register . We will also search the reference lists provided in relevant studies and reviews. Experts in the field will be contacted to obtain more references. Two independent reviewers will assess the eligibility criteria of all articles, extract data and determine their risk of bias (Cochrane Collaboration Tool). Baseline depression will be required to have been discarded through standardised interviews or validated self-reports with standard cut-off points. The outcomes will be the incidence of new cases of depression and/or the reduction of depressive symptoms as measured by validated instruments. Pooled standardised mean differences will be calculated using random-effect models. Heterogeneity and publication bias will be estimated. Predefined sensitivity and subgroup analyses will be performed. If heterogeneity is relevant, random-effect meta-regression will be performed.

ETHICS AND DISSEMINATION

The results will be disseminated through peer-reviewed publication and will be presented at a professional conference. Ethical assessment is not required as we will search and assess existing sources of literature.

TRIAL REGISTRATION NUMBER

CRD42014014804; Results.

Effect of Internet-based Cognitive Behavioral Humanistic and Interpersonal Training vs. Internet-based General Health Education on Adolescent Depression in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Although 13-20% of American adolescents experience a depressive episode annually, no scalable primary care model for adolescent depression prevention is currently available.

OBJECTIVE

To study whether CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training) reduces the hazard for depression in at-risk adolescents identified in primary care, as compared to a general health education attention control (HE).

DESIGN

The Promoting AdolescenT Health (PATH) study compares CATCH-IT and HE in a phase 3 single-blind multicenter randomized attention control trial. Participants were enrolled from 2012 to 2016 and assessed at 2, 6, 12, 18, and 24 months post-randomization.

SETTING

Primary care.

PARTICIPANTS

Eligible adolescents were 13-18 years with subsyndromal depression and/or history of depression and no current depression diagnosis or treatment. Of 2,250 adolescents screened for eligibility, 446 participants completed the baseline interview and 369 were randomized into CATCH-IT (n=193) and HE (n=176).

INTERVENTIONS

CATCH-IT is a 20-module (15 adolescent modules, 5 parent modules) online psychoeducation course that includes a parent program, supported by three motivational interviews.

MAIN OUTCOMES AND MEASURES

Time-to-event for depressive episode; depressive symptoms at 6 months.

RESULTS

Mean age was 15.4 years, and 68% were female; 28% had both a past episode and subsyndromal depression; 12% had a past episode only, 59% had subsyndromal depression only, and 1% had borderline subsyndromal depression. The outcome of time-to-event favored CATCH-IT but was not significant with intention-to-treat analyses (N=369; unadjusted HR=0.59; 95% CI 0.27, 1.29; p=0.18; adjusted HR=0.53; 95% CI 0.23, 1.23, p=0.14). Adolescents with higher baseline CES-D₁₀ scores showed a significantly stronger effect of CATCH-IT on time-to-event relative to those with lower baseline scores (p=0.04). For example, for a CES-D₁₀ score of 15 (significant sub-syndromal depression), HR=0.20 (95% CI 0.05, 0.77), compared to CES-D₁₀ of 5 (no sub-syndromal depression), HR=1.44 (95% CI, 0.41, 5.03). In both CATCH-IT and HE groups, depression symptoms declined and functional scores increased.

CONCLUSIONS AND RELEVANCE

CATCH-IT may be better than HE for preventing depressive episodes for at-risk adolescents with sub-syndromal depression. CATCH-IT may be a scalable approach to prevent depressive episodes in adolescents in primary care.

The utility of neuropsychological consultation in identifying medical inpatients with suspected cognitive impairment at risk for greater hospital utilization

OBJECTIVE

This was a retrospective study designed to examine the relationship between inpatient neuropsychological status and future utilization costs.

METHODS

We completed a retrospective chart review of 280 patients admitted to a large academic medical center who were referred for bedside neuropsychological evaluation. Patients were grouped based on neuropsychological recommendation regarding level of supportive needs post-discharge (low, moderate, high). Level of support was used as a gross surrogate indicator of cognitive status in this heterogeneous sample. We also included patients who refused assessment. Outcome variables included time to readmission, number of emergency department visits, inpatient admissions, length of hospitalization, and total costs of hospitalizations, 30 days and 1 year following discharge.

RESULTS

Multivariate analysis indicated patients who refused assessment had higher inpatient service utilization (number of ED visits, number of admissions, and total cost of hospitalization) compared to those with moderate needs. Also, high needs patients had higher total cost of hospitalization at 1 year, and those with low needs used the ED more, compared to those with moderate needs.

CONCLUSIONS

Our findings replicate prior studies linking refusal of neuropsychological evaluation to higher service utilization costs, and suggest a nonlinear relationship between cognitive impairment severity and future costs for medical inpatients (different groups incur different types of costs). Results preliminarily highlight the potential utility of inpatient neuropsychological assessment in identifying patients at risk for greater hospital utilization, which may allow for the development of appropriate interventions for these patients.

Recent advances in the prevention of mental disorders

PURPOSE

Prevention of mental disorders is a rapidly growing area of research with substantial potential benefits for population health. This paper reviews the evidence base for prevention of depression, anxiety, and schizophrenia.

METHODS

We synthesized evidence from recent systematic reviews and meta-analyses published between 2013 and 2018 on prevention of depression, anxiety, and first-episode psychosis. We included reviews of randomized controlled trials testing psychological, psychosocial, and pharmacological preventive interventions.

RESULTS

There is good evidence that depression and anxiety can be prevented, although effect sizes are generally small. Indicated prevention of first-episode psychosis appears promising. Economic evaluations provide support for prevention of depression, anxiety, and first-episode psychosis, but more studies evaluating costs and benefits are needed to strengthen the knowledge base, particularly regarding long-term outcomes, which include chronicity of the prevented disorder, as well as later occurence of important comorbid mental and physical health problems. Promising areas for further development include internet- or computer-based prevention strategies, mindfulness-based interventions, and integration of prevention programs within occupational settings.

CONCLUSIONS

A number of interventions to prevent mental disorders are efficacious. While intervention effect sizes are generally small for prevention of depression and anxiety, they may nonetheless be of significant population benefit. Using the growing evidence base to inform policy and dissemination of evidence-based prevention programs is critical for moving prevention science into real-world settings.

A personalized intervention to prevent depression in primary care: cost-effectiveness study nested into a clustered randomized trial

BACKGROUND

Depression is viewed as a major and increasing public health issue, as it causes high distress in the people experiencing it and considerable financial costs to society. Efforts are being made to reduce this burden by preventing depression. A critical component of this strategy is the ability to assess the individual level and profile of risk for the development of major depression. This paper presents the cost-effectiveness of a personalized intervention based on the risk of developing depression carried out in primary care, compared with usual care.

METHODS

Cost-effectiveness analyses are nested within a multicentre, clustered, randomized controlled trial of a personalized intervention to prevent depression. The study was carried out in 70 primary care centres from seven cities in Spain. Two general practitioners (GPs) were randomly sampled from those prepared to participate in each centre (i.e. 140 GPs), and 3326 participants consented and were eligible to participate. The intervention included the GP communicating to the patient his/her individual risk for depression and personal risk factors and the construction by both GPs and patients of a psychosocial programme tailored to prevent depression. In addition, GPs carried out measures to activate and empower the patients, who also received a leaflet about preventing depression. GPs were trained in a 10- to 15-h workshop. Costs were measured from a societal and National Health care perspective. Qualityadjustedlife years were assessed using the EuroQOL five dimensions questionnaire. The time horizon was 18 months.

RESULTS

With a willingness-to-pay threshold of €10,000 (£8568) the probability of cost-effectiveness oscillated from 83% (societal perspective) to 89% (health perspective). If the threshold was increased to €30,000 (£25,704), the probability of being considered cost-effective was 94% (societal perspective) and 96%, respectively (health perspective). The sensitivity analysis confirmed these results.

CONCLUSIONS

Compared with usual care, an intervention based on personal predictors of risk of depression implemented by GPs is a cost-effective strategy to prevent depression. This type of personalized intervention in primary care should be further developed and evaluated.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01151982. Registered on June 29, 2010.

Effectiveness of Psychological and/or Educational Interventions in the Prevention of Anxiety: A Systematic Review, Meta-analysis, and Meta-regression

Importance

To our knowledge, no systematic reviews or meta-analyses have been conducted to assess the effectiveness of preventive psychological and/or educational interventions for anxiety in varied populations.

Objective

To evaluate the effectiveness of preventive psychological and/or educational interventions for anxiety in varied population types.

Data Sources

A systematic review and meta-analysis was conducted based on literature searches of MEDLINE, PsycINFO, Web of Science, EMBASE, OpenGrey, Cochrane Central Register of Controlled Trials, and other sources from inception to March 7, 2017.

Study Selection

A search was performed of randomized clinical trials assessing the effectiveness of preventive psychological and/or educational interventions for anxiety in varying populations free of anxiety at baseline as measured using validated instruments. There was no setting or language restriction. Eligibility criteria assessment was conducted by 2 of us.

Data Extraction and Synthesis

Data extraction and assessment of risk of bias (Cochrane Collaboration's tool) were performed by 2 of us. Pooled standardized mean differences (SMDs) were calculated using random-effect models. Heterogeneity was explored by random-effects meta-regression.

Main Outcomes and Measures

Incidence of new cases of anxiety disorders or reduction of anxiety symptoms as measured by validated instruments.

Results

Of the 3273 abstracts reviewed, 131 were selected for full-text review, and 29 met the inclusion criteria, representing 10 430 patients from 11 countries on 4 continents. Meta-analysis calculations were based on 36 comparisons. The pooled SMD was -0.31 (95% CI, -0.40 to -0.21; P < .001) and heterogeneity was substantial (I2 = 61.1%; 95% CI, 44% to 73%). There was evidence of publication bias, but the effect size barely varied after adjustment (SMD, -0.27; 95% CI, -0.37 to -0.17; P < .001). Sensitivity analyses confirmed the robustness of effect size results. A meta-regression including 5 variables explained 99.6% of between-study variability, revealing an association between higher SMD, waiting list (comparator) (β = -0.33 [95% CI, -0.55 to -0.11]; P = .005) and a lower sample size (lg) (β = 0.15 [95% CI, 0.06 to 0.23]; P = .001). No association was observed with risk of bias, family physician providing intervention, and use of standardized interviews as outcomes.

Conclusions and Relevance

Psychological and/or educational interventions had a small but statistically significant benefit for anxiety prevention in all populations evaluated. Although more studies with larger samples and active comparators are needed, these findings suggest that anxiety prevention programs should be further developed and implemented.