Should treatment for depression be based more on patient preference?

Psychosocial factors associated with treatment preference in mental health

BACKGROUND

Studies examining the effects of incorporating patients' preferences into treatment outcomes highlight their impact on crucial aspects such as reduced dropout rates and enhanced effectiveness. Recognizing individuals' rights to participate in decisions about their treatments underscores the importance of studying treatment preferences and the factors influencing these choices.

AIM

This study aims to identify treatment preferences (psychological, pharmacological, or combined) among a sample of patients and to discern the psychosocial and clinical factors influencing these preferences.

METHODS

A total of 2,133 individuals receiving care at a community mental health unit completed assessments on anxious-depressive symptoms, social and occupational adjustment, and their treatment preference. Data analysis was conducted using SPSS, with descriptive statistics, Chi-square tests, and one-way ANOVA applied.

RESULTS

Preferences for treatments were distributed as follows: Combined (49.8%), psychological (33%), and pharmacological (10.6%). Factors such as diagnosis, severity of depressive and anxious symptoms, and functional impact were related to treatment preference with a moderate effect size. Meanwhile, various sociodemographic factors correlated with the selected treatment, though with a weak effect size.

CONCLUSIONS

There is a pronounced preference for combined treatments. The significance of psychological treatments is evident, as four out of five participants favored them in their choices. Addressing these preferences calls for an exploration within the broader context of prescription freedom in mental health.

Mental health services for German university students: acceptance of intervention targets and preference for delivery modes

Introduction

Most university students with mental disorders remain untreated. Evaluating the acceptance of intervention targets in mental health treatment, promotion, and prevention, as well as mental health service delivery modes is crucial for reducing potential barriers, increasing healthcare utilization, and efficiently allocating resources in healthcare services.

Aim

The study aimed to evaluate the acceptance of various intervention targets and delivery modes of mental health care services in German first-year university students.

Methods

In total, 1,376 first-year students from two German universities from the 2017-2018 multi-center cross-sectional cohort of the StudiCare project, the German arm of the World Mental Health International College Student Survey initiative, completed a web-based survey assessing their mental health. Mental disorder status was based on self-reported data fulfilling the DSM-IV criteria. We report frequencies of accepted delivery modes [categories: group or in-person therapy with on or off campus services, self-help internet- or mobile-based intervention (IMI) with or without coaching, or a combination of a in-person and IMI (blended)]. In a multinomial logistic regression, we estimate correlates of the preference for in-person vs. IMI vs. a combination of both modes (blended) modalities. Additionally, we report frequencies of intervention targets (disorder specific: e.g., social phobia, depressive mood; study-related: test anxiety, procrastination; general well-being: sleep quality, resilience) their association with mental disorders and sex, and optimal combinations of treatment targets for each mental illness.

Results

German university students' acceptance is high for in-person (71%-76%), moderate for internet- and mobile-based (45%-55%), and low for group delivery modes (31%-36%). In-person treatment (72%) was preferred over IMI (19%) and blended modalities (9%). Having a mental disorder [odds ratio (OR): 1.56], believing that digital treatments are effective (OR: 3.2), and showing no intention to use services (OR: 2.8) were associated with a preference for IMI compared to in-person modes. Students with prior treatment experience preferred in-person modes (OR: 0.46). In general, treatment targets acceptance was higher among female students and students with mental disorders. However, this was not true for targets with the highest (i.e., procrastination) and the lowest (i.e., substance-use disorder) acceptance. If only two intervention targets were offered, a combination of study-related targets (i.e., procrastination, stress, time management) would reach 85%-88% of the students.

Conclusion

In-person services are preferred, yet half of the students consider using IMI, preferably aiming for a combination of at least two study-related intervention targets. Student mental health care services should offer a combination of accepted targets in different delivery modes to maximize service utilization.

Digital health technologies and major depressive disorder

There is an urgent need to improve the clinical management of major depressive disorder (MDD), which has become increasingly prevalent over the past two decades. Several gaps and challenges in the awareness, detection, treatment, and monitoring of MDD remain to be addressed. Digital health technologies have demonstrated utility in relation to various health conditions, including MDD. Factors related to the COVID-19 pandemic have accelerated the development of telemedicine, mobile medical apps, and virtual reality apps and have continued to introduce new possibilities across mental health care. Growing access to and acceptance of digital health technologies present opportunities to expand the scope of care and to close gaps in the management of MDD. Digital health technology is rapidly evolving the options for nonclinical support and clinical care for patients with MDD. Iterative efforts to validate and optimize such digital health technologies, including digital therapeutics and digital biomarkers, continue to improve access to and quality of personalized detection, treatment, and monitoring of MDD. The aim of this review is to highlight the existing gaps and challenges in depression management and discuss the current and future landscape of digital health technology as it applies to the challenges faced by patients with MDD and their healthcare providers.

Specifying the Efficacy of Digital Therapeutic Tools for Depression and Anxiety: Retrospective, 2-Cohort, Real-World Analysis

BACKGROUND

Depression and anxiety are the main sources of work and social disabilities as well as health-related problems around the world. Digital therapeutic solutions using cognitive behavioral therapy have demonstrated efficacy in depression and anxiety. A common goal of digital health apps is to increase user digital engagement to improve outcomes. However, there is a limited understanding of the association between digital platform components and clinical outcomes.

OBJECTIVE

The aim of the study is to investigate the contribution of specific digital engagement tools to mental health conditions. We hypothesized that participation in coaching sessions and breathing exercises would be associated with a reduction in depression and anxiety.

METHODS

Depression and general anxiety symptoms were evaluated in real-world data cohorts using the digital health platform for digital intervention and monitoring change. This retrospective real-world analysis of users on a mobile platform-based treatment followed two cohorts of people: (1) users who started with moderate levels of depression and completed at least 2 depression assessments (n=519) and (2) users who started with moderate levels of anxiety and completed at least 2 anxiety assessments (n=474). Levels of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) were tracked throughout the first 16 weeks. A piecewise mixed-effects model was applied to model the trajectories of the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 mean scores in 2 segments (1-6 weeks and 7-16 weeks). Finally, simple slope analysis was used for the interpretation of the interactions probing the moderators: coaching sessions and breathing exercises in both depression and anxiety cohorts.

RESULTS

Analysis revealed a significant decrease in depression symptoms (β=-.37, 95% CI -0.46 to 0.28; P≤.001) during the period of weeks 1-6 of app use, which was maintained during the period of 7-16 weeks. Coach interaction significantly moderated the reduction in depression symptoms during the period of weeks 1-6 (β=-.03, 95% CI -0.05 to -0.001; P=.02). A significant decrease in anxiety symptoms (β=-.41, 95% CI -0.50 to -0.33; P≤.001) was revealed during the period of 1-6 weeks, which was maintained during the period of 7-16 weeks. Breathing exercises significantly moderated the reduction in anxiety symptoms during the period of 1-6 weeks (β=-.07, 95% CI -0.14 to -0.01; P=.04).

CONCLUSIONS

This study demonstrated general improvement followed by a period of stability of depression and anxiety symptoms associated with cognitive behavioral therapy-based digital intervention. Interestingly, engagement with a coaching session but not a breathing exercise was associated with a reduction in depression symptoms. Moreover, breathing exercise but not engagement with a coaching session was associated with a reduction of anxiety symptoms. These findings emphasize the importance of using a personalized approach to behavioral health during digital health interventions.

The impact of treatment preferences: A narrative review

Attending to treatment preferences is an element of person-centred care, reported as beneficial in improving treatment adherence, satisfaction, and outcome, in practice. The results of preference trials were inconsistent in supporting these benefits in intervention evaluation research. Informed by the conceptualisation of treatment preferences positing their indirect impact on outcomes, this narrative review aimed to summarise the evidence on the effects of preferences on enrolment; withdrawal or attrition; engagement, enactment, and satisfaction with treatment; and outcomes. The search yielded 72 studies (57 primary trials and 15 reviews). The results of vote counting indicated that (1) offering participants the opportunity to choose treatment enhances enrolment (reported in 87.5% of studies), and (2) providing treatments that match participants' preferences reduces attrition (48%); enhances engagement (67%), enactment (50%) and satisfaction with (43%) treatment; and improves outcomes (35%). The results are attributed to conceptual and methodological issues including less-than-optimal assessment of treatment preferences, which contributes to ill-identified preferences, accounting for withdrawal, low enactment, and limited satisfaction with treatment. These treatment processes, in turn, mediate the impact of treatment preferences on outcomes. It is important to refine and standardise the methods for assessing preferences and to examine their indirect impact (mediated by treatment processes) on outcomes in future preference trials to validly identify their benefits.

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BACKGROUND

Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.

OBJECTIVE

To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.

DESIGN

Patient self-report surveys at treatment initiation linked to medical records.

SETTING

Veterans Health Administration (VA) clinics nationally, 2018-2020.

PARTICIPANTS

A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.

KEY RESULTS

More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.

CONCLUSIONS

Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

Predicting Medication Nonadherence in Older Adults With Difficult-to-Treat Depression in the IRL-GRey Randomized Controlled Trial

OBJECTIVE

Nonadherence to antidepressants interferes with optimal treatment of late-life depression. This analysis examines clinical and treatment factors predicting medication nonadherence in difficult-to-treat late-life depression.

METHODS

Secondary analysis of data from a clinical trial of antidepressant pharmacotherapy for Major Depressive Disorder in 468 adults aged 60+ years. All participants received venlafaxine XR for 12 weeks. Nonremitters were randomized to augmentation with either aripiprazole or placebo for 12 additional weeks. Medication adherence was assessed 14 times over 24 weeks. The analyses examined sociodemographic, clinical, and treatment factors that may predict antidepressant nonadherence during early (weeks 1-6), late (weeks 7-12), and augmentation (weeks 13--24) treatment.

RESULTS

Poor cognitive function and early response were predictive of early nonadherence. Poor cognitive function and prior nonadherence were predictive of late nonadherence. Living alone was associated with nonadherence both late and during augmentation treatment.

CONCLUSION

Future studies should consider the role of early response and cognitive function to improve antidepressant adherence, particularly among older adults who live alone.

Prevalence, progress, and subgroup disparities in pharmacological antidepressant treatment of those who screen positive for depressive symptoms: A repetitive cross-sectional study in 19 European countries

Background

The European Mental Health Action Plan (EMHAP) 2013–2020 promoted community-based mental health services. One potential success indicator is the provision of antidepressant medication to those needing it.

Methods

Public data from two surveys (Health Survey for England, UK; Survey of Health, Ageing and Retirement in Europe) covered 19 European countries across EMHAP phases one (2011–2015) and two (2015–2018). People screening positive for depressive symptoms by self-report were included. The primary outcome was antidepressant use: using country-specific weighted regression models, we estimated temporal trends and subgroup disparities in antidepressant receipt, with secondary analysis by country-level measures including healthcare expenditure.

Findings

Across 37,250 participants, after controlling for age, sex, wealth, and physical disability, antidepressant use (amongst those screening positive) increased significantly in 14/19 countries, with the smallest increase being in Slovenia (adjusted OR[AOR] for trend=1.68[1.20–2.36]) and the highest increase being in Germany (AOR for trend=10.07[7.54–13.46]) and Austria (AOR for trend=10.07[7.32–13.74]). The overall proportion using antidepressants was positively associated with national health expenditure (coefficient=5.43[1.62–9.25]), but not with gross national income per capita or the number of psychiatrists, general practitioners, or psychiatric hospital beds. In 15/19 countries, antidepressants were used less by ≥65-year-olds than 50–64-year-olds, with the smallest differential reported in Luxembourg (AOR=0.70[0.49, 0.98]) and the highest in Germany (AOR=0.28[0.21, 0.37]); this disparity widened in 12/15 countries. Men used antidepressants less than women in 8/19 countries, across phases. In 13/19 countries, people with physical disability were more likely to receive antidepressants, with the smallest gap in Italy (AOR=1.42[1.12–1.80]) and the largest in Israel (AOR=2.34[1.46–3.74]); this disparity narrowed in 5/13 countries. Disparity by wealth was found in 8/19 countries, but its temporal trend varied.

Interpretation

Usage of antidepressants by those with depressive symptoms has increased, with wide variation between countries and subgroups. Disparities across age, sex, and disability should prompt further research.

Funding

Medical Research Council (grants MC_PC_17213 and MR/W014386/1), UK National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) East of England, NIHR Cambridge Biomedical Research Centre (BRC-1215-20014).

Psychometric evaluation of a decision quality instrument for medication decisions for treatment of depression symptoms

BACKGROUND

A high quality treatment decision means patients are informed and receive treatment that matches their goals. This research examined the reliability and validity of the Depression Decision Quality Instrument (DQI), a survey to measure the extent to which patients are informed and received preferred treatment for depression.

METHODS

Participants were aged 18 and older from 17 US cities who discussed medication or counseling with a physician in the past year, and physicians who treated patients with depression who practiced in the same cities. Participants were mailed a survey that included the Depression-DQI, a tool with 10 knowledge and 7 goal and concern items. Patients were randomly assigned to either receive a patient decision aid (DA) on treatment of depression or no DA. A matching score was created by comparing the patient's preferred treatment to their self-reported treatment received. Concordant scores were considered matched, discordant were not. We examined the reliability and known group validity of the Depression-DQI.

RESULTS

Most patients 405/504 (80%) responded, 79% (320/405) returned the retest survey, and 60% (114/187) of physicians returned the survey. Patients' knowledge scores on the 10-item scale ranged from 14.6 to 100% with no evidence of floor or ceiling effects. Retest reliability for knowledge was moderate and for goals and concerns ranged from moderate to good. Mean knowledge scores differentiated between patients and physicians (M = 63 [SD = 15] vs. M = 81 [SD = 11], p < 0.001), and between patients who did and didn't receive a DA (M = 64 [SD = 16] vs. M = 61 [SD = 14], p = 0.041). 60.5% of participants received treatment that matched their preference. Based on the multivariate logistic regression, 'avoiding taking anti-depressants' was the only goal that was predictive of taking mediation (OR = 0.73 [0.66, 0.80], p < 0.01). Shared Decision Making Process scores were similar for those who matched their preference and those who didn't (M = 2.18 [SD = 0.97] vs. M = 2.06 [SD = 1.07]; t(320) =  - 1.06, p = 0.29). Those who matched had lower regret scores (matched M = 1.72 [SD = 0.74] vs. unmatched M = 2.32 [SD = 0.8]; t(301) =  - 6.6, p < .001).

CONCLUSIONS

The Depression DQI demonstrated modest reliability and validity. More work is needed to establish validity of the method to determine concordance.

TRIAL REGISTRATION

NCT01152307.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

Assessing the Care Modality Preferences and Predictors for Digital Mental Health Treatment Seekers in a Technology-enabled Stepped Care Delivery System: Cross-sectional Study

Background

Access to mental health services continues to be a systemic problem in the United States and around the world owing to a variety of barriers including the limited availability of skilled providers and lack of mental health literacy among patients. Individuals seeking mental health treatment may not be aware of the multiple modalities of digital mental health care available to address their problems (eg, self-guided and group modalities, or one-to-one care with a provider). In fact, one-to-one, in-person treatment is the dominant care model with a masters- or doctoral-level trained mental health provider, and it may or may not be the appropriate or preferred level of care for an individual. Technology-enabled mental health platforms may be one way to improve access to mental health care by offering stepped care, but more research is needed to understand the care modality preferences of digital mental health care seekers because additional modalities become increasingly validated as effective treatment options.

Objective

The purpose of this study was to describe and evaluate the predictors of care modality preferences among individuals enrolled in a technology-enabled stepped mental health care platform.

Methods

This exploratory, cross-sectional study used employee data from the 2021 Modern Health database, an employer-sponsored mental health benefit that uses a technology-enabled platform to optimize digital mental health care delivery. Chi-square tests and one-way analysis of variance (ANOVA) were conducted to evaluate associations among the categorical and continuous factors of interest and the preferred care modality. Bivariate logistic regression models were constructed to estimate the odds ratios (ORs) of preferring a one-on-one versus self-guided group, or no preference for digital mental health care modalities.

Results

Data were analyzed for 3661 employees. The most common modality preference was one-on-one care (1613/3661, 44.06%). Approximately one-fourth of the digital mental health care seekers (881/3661, 24.06%) expressed a preference for pursuing self-guided care, and others (294/3661, 8.03%) expressed a preference for group care. The ORs indicated that individuals aged 45 years and above were significantly more likely to express a preference for self-guided care compared to individuals aged between 18 and 24 years (OR 2.47, 95% CI 1.70-3.59; P<.001). Individuals screening positive for anxiety (OR 0.73, 95% CI 0.62-0.86; P<.001) or depression (OR 0.79, 95% CI 0.66-0.95; P=.02) were more likely to prefer one-on-one care.

Conclusions

Our findings elucidated that care modality preferences vary and are related to clinical severity factors and demographic variables among individuals seeking digital mental health care.

Understanding Treatment Preferences of Australian Patients Living with Treatment-Resistant Depression

BACKGROUND

There is evidence of improved adherence and treatment outcomes when patients' treatment preferences are considered, and shared decision making is utilized.

PURPOSE

We aimed to better understand treatment preferences among Australians with treatment-resistant depression (TRD), focusing on the specific treatment attributes that people value (such as effectiveness, risk of side effects and cost) and their relative importance. The risk-benefit trade-offs that characterize treatment choices were also examined.

PATIENTS AND METHODS

An online survey of 75 patients with experience of TRD was conducted, consisting of two discrete choice experiment (DCE) components - a medication DCE and a treatment plan DCE. Participants were able to prioritize and trade off different features of medications and treatment plans. Additional questions aimed to better define this population group, which in Australia is poorly understood.

RESULTS

In both DCEs, two distinct latent classes were identified. In the medication DCE, the classes were distinguished by willingness to consider new treatment alternatives. Participants in class 1 were reluctant to give up current treatment, while those in the slightly larger class 2 preferred new treatment options. In both classes, treatment effectiveness and cost were the greatest contributors to preference. Similar behavior was seen in the treatment plan DCE, with the larger class more likely to choose a new plan over their current treatment arrangement. Participants preferred medications that were low-cost, taken orally, had a high percentage improvement in mood symptoms, high rate of remission and low risk of weight gain. A similar result was found in preferences for treatment plans such that plans with the greatest effectiveness and lowest cost were most favorable.

CONCLUSION

Patient preferences should routinely be considered and discussed to guide informed decisions regarding the value of new and existing medications for TRD and how they sit in the context of treatment plans.

Effectiveness of psychological treatments for depressive symptoms among people living with HIV/AIDS in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Psychological treatments play a significant role in managing depressive symptoms. However, little is known about the most effective psychological treatments for depressive symptoms for people living with HIV/AIDS (PLWHA) in low- and middle-income countries (LMICs).

AIMS

To identify effective psychological treatments to manage depressive symptoms for adult PLWHA in LMICs and to estimate pooled effect sizes using a meta-analysis.

METHOD

Four databases were searched using key words and MeSH terms - PubMed, Scopus, Cochrane library and PsychINFO. The inclusion criteria were randomized controlled trials (RCTs) that examine psychological treatments that target depressive symptoms for adult PLWHA in LMICs. The Cochrane risk of bias tool was used to assess the risk of bias. A meta-analysis was done using RevMan-5.

RESULT

Nineteen studies were included in the systematic review and 14 of them were selected for meta-analysis. Eight (42%) of the trials used cognitive behavioural therapy (CBT). Pooled effect size of trials that used continuous outcomes was -0.61 (n = 12, 95%CI: -1.24, 0.02, I² = 95%) at post-treatment assessment. The pooled effect size changed to -1.41 (n = 8, 95%CI: -2.54, -0.28, I² = 98%) at six months post treatment.

LIMITATIONS

Studies varied in quality from low to high risk of bias and there was high heterogeneity across studies.

CONCLUSION

Trials used group support psychotherapy, interpersonal therapy, problem-solving therapy, and peer-support counselling were effective in reducing depressive symptoms. However, better powered studies with more consistent methodologies are needed to investigate whether specific therapies delivered by lay counsellors are effective for PLWHA in LMICs.

Illness narratives and preferences for treatment among older veterans living with treatment-resistant depression and insomnia

BACKGROUND

Despite the prevalence of comorbid late-life treatmentresistant depression (LLTRD) and insomnia in older adults, there is a gap in the literature describing patient factors, such as patients' beliefs about their illnesses and preferences for treatment, that can facilitate recovery. Therefore, we explored the perceptions and treatment preferences of older veterans with LLTRD and insomnia.

METHODS

Semi-structured interviews were completed with 11 older veterans. A thematic analysis of the interviews was conducted.

RESULTS

Four main themes were identified: 1. Insomnia and medical problems were considered to be significant contributors to depression, which was defined by low mood and anhedonia; 2. "Overthinking" was thought to be a cause of insomnia; 3. Participants' preference for psychotherapy was driven by their past experiences with therapy; and 4. Participants viewed patient education as a facilitator for compliance.

CONCLUSIONS

Older veterans with LLTRD and insomnia have a preference for behavioral interventions. However, they lack knowledge about available treatment options, such as behavioral interventions for sleep that can improve both their sleep and mood while being a good fit with their illness narratives, such as "overthinking." There is a need for patient education, which should be offered early and often during treatment.

Personalising psychotherapies for depression using a novel mixed methods approach: an example from Morita therapy

Background

Current quantitative methods for personalising psychotherapies for depression are unlikely to be able to inform clinical decision-making for hundreds of years. Novel alternative methods to generate hypotheses for prospective testing are therefore required, and we showcase mixed methods as one such approach. By exploring patients’ perspectives in depth, and integrating qualitative and quantitative data at the level of the individual, we may identify new potential psychosocial predictors of psychotherapy outcomes, potentially informing the personalisation of depression treatment in a shorter timeframe. Using Morita therapy (a Japanese psychotherapy) as an exemplar, we thus explored how Morita therapy recipients’ views on treatment acceptability explain their adherence and response to treatment.

Methods

The Morita trial incorporated a pilot randomised controlled trial of Morita therapy versus treatment as usual for depression, and post-treatment qualitative interviews. We recruited trial participants from general practice record searches in Devon, UK, and purposively sampled data from 16 participants for our mixed methods analysis. We developed typologies of participants’ views from our qualitative themes, and integrated these with quantitative data on number of sessions attended and whether participants responded to treatment in a joint typologies and statistics display. We enriched our analysis using participant vignettes to demonstrate each typology.

Results

We demonstrated that (1) participants who could identify with the principles of Morita therapy typically responded to treatment, regardless of how many sessions they attended, whilst those whose orientation towards treatment was incompatible with Morita therapy did not respond to treatment, again regardless of treatment adherence and (2) participants whose personal circumstances impeded their opportunity to engage in Morita therapy attended the fewest sessions, though still benefitted from treatment if the principles resonated with them.

Conclusions

We identified new potential relationships between “orientation” and outcomes, and “opportunity” and adherence, which could not have been identified using existing non-integrative methods. This mixed methods approach warrants replication in future trials and with other psychotherapies to generate hypotheses, based on typologies (or profiles) of patients for whom a treatment is more or less likely to be suitable, to be tested in prospective trials.

Trial registration

Current Controlled Trials, ISRCTN17544090. Registered on 23 July 2015.

The (cost) effectiveness of guided internet-based self-help CBT for dialysis patients with symptoms of depression: study protocol of a randomised controlled trial

BACKGROUND

Only a minority of dialysis patients with depressive symptoms are diagnosed and receive treatment. Depressive symptoms are highly prevalent in this population and are associated with adverse clinical outcomes. Underlying factors for this undertreatment may be the lack of evidence for the safety and effectivity of antidepressant medication, the reluctance of patients to adhere to antidepressant medication, the lack of mental healthcare provision in somatic healthcare environments and end-stage renal disease (ESRD) related physical limitations that complicate face-to-face psychotherapy. Guided Internet-based self-help treatment has demonstrated to be effective for depressive symptoms in other chronic patient populations and may overcome these barriers. The aim of this study is to investigate the (cost) effectiveness of a guided Internet-based self-help intervention for symptoms of depression in dialysis patients.

METHODS

This study is a cluster randomized controlled trial (RCT) that investigates the effectiveness of a 5-week Internet-based self-help Problem Solving Therapy (PST) for depressive symptoms in dialysis patients. Depressive symptoms will be measured using the Beck Depression Inventory - second edition (BDI-II), with a cut-off score of ≥10. We aim to include 206 dialysis patients with depressive symptoms who will be cluster randomized to the intervention or the Care as Usual (CAU) control group. Secondary outcomes will include anxiety symptoms, quality of life, economic costs and clinical outcomes, such as inflammatory factors and hair cortisol levels. Assessments will take place at baseline (T0), 2 weeks after intervention (T1) and 6 months (T2), 12 months (T3) and 18 months (T4) after intervention. The control group will be measured at the same time points. Analysis will be based on the intention-to-treat principle. Mixed models will be used to assess the changes within each condition between pre-treatment and post-treatment.

DISCUSSION

If demonstrated to be (cost) effective, Internet-based PST will offer new possibilities to treat dialysis patients with depressive symptoms and to improve their quality of care.

TRIAL REGISTRATION

Dutch Trial Register: Trial NL6648 (NTR6834) (prospectively registered 13th November 2017).

The effect of causal attributions for depression on help-seeking and treatment preferences

BACKGROUND

Depression is a leading cause of ill-health and disability globally and encouraging help-seeking and treatment engagement is a key priority of health authorities worldwide. Causal attributions for mental illness have numerous attitudinal and behavioural consequences; however, limited research has explored their implications for attitudes to treatment. This study experimentally investigates the impact of causal attributions for depression on attitudes to specific help-seeking and treatment options.

METHODS

In an online study, 196 participants read a vignette that emphasised either biological, social or biopsychosocial causes of a character's depression. Participants rated several help-seeking and treatment options on how helpful or harmful they would be for the individual described in the vignette and for themselves personally.

RESULTS

The causal attribution manipulation significantly affected treatment attitudes. Relative to social attributions, emphasising biological causes of depression significantly decreased the perceived helpfulness of lifestyle-based treatments, but did not affect attitudes to psychotherapeutic or medical treatment options. Participants rated most help-seeking and treatment options as less helpful for themselves compared to the vignette character. Participants with personal experience of depression had lower confidence in informal sources of help-seeking and greater confidence in medical treatment.

LIMITATIONS

Limitations include reliance on self-report measures and low reliability of certain sub-scales.

CONCLUSIONS

These findings suggest emphasising the biological underpinnings of depression could deter people from engaging with lifestyle-based treatment options. Promoting biopsychosocial theories of depression could increase awareness about the multifactorial causes of depression without negatively impacting the perceived efficacy of any help-seeking or intervention options.

What format of treatment do patients with emotional disorders prefer and why? Implications for public mental health settings and policies

OBJECTIVE

We analyzed the preference of three psychological intervention formats-individual, group, and online-in a sample of 267 patients with a primary diagnosis of emotional disorder in Spanish public mental health settings.

METHOD

We studied patients' preferences considering sociodemographic characteristics, diagnoses, history of psychological treatments, number of sessions, and satisfaction with past interventions.

RESULTS

Most participants (85.4%) preferred psychological treatment in an individual format, 14.2% in group, and 0.4% online. When comparing the people who chose individual and group treatment, no demographic or clinical differences were found. The arguments against group format were the lack of privacy and expression difficulties. Regarding online format, these included being considered impersonal and ineffective.

CONCLUSION

The rejection of group and online psychotherapy formats allows us to define the actions we should carry out in public mental health settings to improve the acceptance of more cost-effective therapy formats.

Treatment credibility, expectancy, and preference: Prediction of treatment engagement and outcome in a randomized clinical trial of hatha yoga vs. health education as adjunct treatments for depression

BACKGROUND

Hatha yoga may be helpful for alleviating depression symptoms. The purpose of this analysis is to determine whether treatment program preference, credibility, or expectancy predict engagement in depression interventions (yoga or a control class) or depression symptom severity over time.

METHODS

This is a secondary analysis of a randomized controlled trial (RCT) of hatha yoga vs. a health education control group for treatment of depression. Depressed participants (n = 122) attended up to 20 classes over a period of 10 weeks, and then completed additional assessments after 3 and 6 months. We assessed treatment preference prior to randomization, and treatment credibility and expectancy after participants attended their first class. Treatment "concordance" indicated that treatment preference matched assigned treatment.

RESULTS

Treatment credibility, expectancy, and concordance were not associated with treatment engagement. Treatment expectancy moderated the association between treatment group and depression. Depression severity over time differed by expectancy level for the yoga group but not for the health education group. Controlling for baseline depression, participants in the yoga group with an average or high expectancy for improvement showed lower depression symptoms across the acute intervention and follow-up period than those with a low expectancy for improvement. There was a trend for a similar pattern for credibility. Concordance was not associated with treatment outcome.

LIMITATIONS

This is a secondary, post-hoc analysis and should be considered hypothesis-generating.

CONCLUSIONS

Results suggest that expectancy improves the likelihood of success only for a intervention thought to actively target depression (yoga) and not a control intervention.

Clinical and sociodemographic associations with treatment selection in major depression

OBJECTIVE

To investigate treatment selection in a naturalistic sample of MDD outpatients and the factors influencing treatment selection in specialized psychiatric care.

METHOD

Multinomial Logistic Regression analysis investigated associations between treatment selection and patients' sociodemographic and clinical characteristics, using retrospective chart review data and Routine Outcome Monitoring (ROM) data of MDD outpatients.

RESULTS

Of the patients included for analyses (N = 263), 34% received psychotherapy, 32% received an antidepressant (AD) and 35% received a combination. Men were more likely than women to receive AD with reference to psychotherapy (OR_AD = 5.57, 95% CI 2.38-13.00). Patients with severe depression and patients with AD use upon referral, prescribed by their general practitioner, were more likely to receive AD (OR_{severe depression} = 5.34, 95% CI 1.70-16.78/OR_{AD GP} = 9.26, 95% CI 2.53-33.90) or combined treatment (OR_{severe depression} = 6.32, 95% CI 1.86-21.49/OR_{AD GP} = 22.36, 95% CI 5.89-83.59) with respect to psychotherapy. More severe patients with AD upon referral received combined treatment less often compared to psychotherapy (OR = 0.14, 95% CI 0.03-0.68).

CONCLUSION

AD prescriptions in primary care, severity and gender influenced treatment selection for depressive disorders in secondary psychiatric care. Other factors such as the accessibility of treatment and patient preferences may have played a role in treatment selection in this setting and need further investigation.

Bridging the "digital divide": A comparison of use and effectiveness of an online intervention for depression between Baby Boomers and Millennials

BACKGROUND

Psychological online interventions (POIs) for depression have demonstrated promising effects. However, there are fewer randomized controlled studies on POIs among older adults with depression. The goal of the present study was to compare the use and efficacy of Deprexis, an online intervention for depression, among Millennials (18-35 years) and Baby Boomers (50-65 years).

METHODS

We completed a secondary data analysis on a subset (N = 577) of participants in the EVIDENT trial, a parallel-groups, pragmatic, randomized, controlled single-blind study, which compared a 12-week POI (Deprexis) to care as usual (CAU). Outcomes were assessed at baseline, 3 months (post-assessment) and 6 months (follow-up). The main outcome of interest was change on self-rated depression severity (PHQ-9).

RESULTS

Compared to Millennials, Boomers used the intervention significantly more often (d = 0.45) and for a longer duration (d = 0.46), and endorsed more positive attitudes towards POIs (d = 0.14). There was no significant Age Group by Intervention Group interaction for change in PHQ-9. The post-assessment between-group effect size (intervention vs. CAU control) for Millennials and Boomers were d = 0.26 and d = 0.39, respectively, and were stable at follow-up (d = 0.37 and d = 0.39).

LIMITATIONS

Age-based dichotomization may not accurately represent participants' experiences with and use of technology.

CONCLUSIONS

The POI examined in this trial was superior to CAU and was comparably effective among groups of adults defined as Millennials and Baby Boomers. Adults of the Baby Boomer generation who participate in POIs may have more positive attitudes towards POIs compared to their younger counterparts.

Positive Psychology for Overcoming Symptoms of Depression: A Pilot Study Exploring the Efficacy of a Positive Psychology Self-Help Book versus a CBT Self-Help Book

BACKGROUND

Depression is an extremely common mental health disorder, with prevalence rates rising. Low-intensity interventions are frequently used to help meet the demand for treatment. Bibliotherapy, for example, is often prescribed via books on prescription schemes (for example 'Reading Well' in England) to those with mild to moderate symptomology. Bibliotherapy can effectively reduce symptoms of depression (Naylor et al., 2010). However, the majority of self-help books are based on cognitive behavioural therapy (CBT), which may not be suitable for all patients. Research supports the use of positive psychology interventions for the reduction of depression symptoms (Bolier et al., 2013) and as such self-help books from this perspective should be empirically tested.

AIMS

This study aimed to test the efficacy of 'Positive Psychology for Overcoming Depression' (Akhtar, 2012), a self-help book for depression that is based on the principles of positive psychology, in comparison with a CBT self-help book that is currently prescribed in England as part of the Reading Well books on prescription scheme.

METHOD

Participants (n = 115) who were not receiving treatment, but had symptoms of depression, read the positive psychology or the CBT self-help book for 8 weeks. Depression and well-being were measured at baseline, post-test and 1-month follow-up.

RESULTS

Results suggest that both groups experienced a reduction in depression and an increase in well-being, with no differences noted between the two books.

CONCLUSIONS

Future directions are discussed in terms of dissemination, to those with mild to moderate symptoms of depression, via books on prescription schemes.

A Pilot Study of Metacognitive Training (D-MCT) for Older Adults with Depression

Abstract. Depression remains one of the most common psychological disorders among older adults. Their response to antidepressants: however, is often unsatisfactory, and despite the proven efficacy of psychotherapies, a large treatment gap remains. Metacognitive Training for Depression (D-MCT) is a low-threshold group intervention. This article examines the feasibility, acceptance, and effects of D-MCT as an add-on intervention among a group of older adults (55+ years; N = 116). Participants completed measures of depression and dysfunctional attitudes, and provided subjective appraisals of the training. Per protocol analyses (n = 55) revealed a significant decrease in depressive symptoms (d = 1.06) and cognitive biases (d = 0.33). The findings demonstrate the feasibility and acceptance of D-MCT among older adults with depression.

Patients' perspectives on treatment with Metacognitive Training for Depression (D-MCT): Results on acceptability

BACKGROUND

Our understanding of how patients perceive and evaluate treatment for depression is scarce. Because dropout rates are high among individuals in treatment for depression, it is necessary to expand the focus of research to patients' perspectives on the treatment they receive. The aim of the two studies presented was to evaluate patient acceptance of Metacognitive Training for Depression (D-MCT), a highly standardized group intervention.

METHODS

Acceptability was evaluated in an open case series (Study 1, N = 70) and a randomized controlled trial (RCT; Study 2, N = 84). In both studies, participants rated their subjective appraisal on a 15-item questionnaire after administration of eight D-MCT modules. In Study 1, a subsample of patients also evaluated modules individually after each session. In Study 2, ratings were compared to an active control intervention (walking and psychoeducation sessions), and assessment was repeated at 6-months follow-up.

RESULTS

High rates of acceptance of the D-MCT were demonstrated in both studies immediately after treatment (post-assessment). In addition, the RCT showed better evaluations for the D-MCT than for the control condition at post-assessment as well as at 6-months follow-up. Weekly session evaluations in Study 1 indicated good acceptance for individual modules.

LIMITATIONS

Evaluations could only be obtained from completers; blinding of patients and therapists was not possible.

CONCLUSIONS

Results of the two studies suggest that D-MCT represents a promising group treatment in terms of patient acceptance and provide an example of how patients' feedback may be used to improve treatment.

Effects of Patient Preferences on Outcomes in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) Study

OBJECTIVE

The Predictors of Remission in Depression to Individual and Combined Treatments [PReDICT] study aimed to identify clinical and biological factors predictive of treatment outcomes in major depressive disorder among treatment-naive adults. The authors evaluated the efficacy of cognitive-behavioral therapy (CBT) and two antidepressant medications (escitalopram and duloxetine) in patients with major depression and examined the moderating effect of patients' treatment preferences on outcomes.

METHOD

Adults aged 18-65 with treatment-naive major depression were randomly assigned with equal likelihood to 12 weeks of treatment with escitalopram (10-20 mg/day), duloxetine (30-60 mg/day), or CBT (16 50-minute sessions). Prior to randomization, patients indicated whether they preferred medication or CBT or had no preference. The primary outcome was change in the 17-item Hamilton Depression Rating Scale (HAM-D), administered by raters blinded to treatment.

RESULTS

A total of 344 patients were randomly assigned, with a mean baseline HAM-D score of 19.8 (SD=3.8). The mean estimated overall decreases in HAM-D score did not significantly differ between treatments (CBT: 10.2, escitalopram: 11.1, duloxetine: 11.2). Last observation carried forward remission rates did not significantly differ between treatments (CBT: 41.9%, escitalopram: 46.7%, duloxetine: 54.7%). Patients matched to their preferred treatment were more likely to complete the trial but not more likely to achieve remission.

CONCLUSIONS

Treatment guidelines that recommend either an evidence-based psychotherapy or antidepressant medication for nonpsychotic major depression can be extended to treatment-naive patients. Treatment preferences among patients without prior treatment exposure do not significantly moderate symptomatic outcomes.

Method of Treatment Allocation: Does It Affect Adherence to Behavioural Therapy for Insomnia?

Adherence to treatment is critical in determining the effects of behavioural therapy and may be affected by participants' preference for treatment. The purpose of this study was to determine the extent to which method of allocation to treatment (random vs. preference-based) influences adherence (exposure and enactment) to behavioural therapy. Participants received behavioural therapy for the management of insomnia randomly or by preference. Exposure was assessed as attendance at the treatment sessions, enactment as self-reported application of treatment recommendations. Participants (N = 262) attended a mean of 5.6 treatment sessions, applied the treatment recommendations frequently, and reported high levels of overall compliance. There was no difference between the random and preference groups in terms of exposure to and enactment of treatment. Randomization to the preferred treatment, dissatisfaction with the allocated treatment, and self-report bias could play a role in the findings and should be explored in future research.

Helpful Factors in the Treatment of Depression from the Patient's, Carer's and Professional's Perspective: A Concept Map Study

OBJECTIVE

Depression research has resulted in knowledge about neurobiology, pharmacological strategies and short-term cost-effective treatments. However, more than two-thirds of all depressed patients experience insufficient improvement. Therefore, a better understanding of what patients, carers and professionals perceive as most helpful in the treatment of depression is needed.

METHODS

Concept mapping, a mixed-method design, was used to identify the patients (n = 33), carers (n = 22) and professionals (n = 50) perspectives. In six brainstorm sessions, the patients, carers and professionals generated 795 ideas, which were condensed into 55 unique statements. Subsequently, 100 participants prioritized and sorted these statements, which were analysed by multidimensional scaling and cluster analysis and visualized as a two-dimensional map.

RESULTS

The 55 statements were clustered in 10 factors and further grouped into four main-factors (meta-clusters): 'Professional therapist', 'Treatment content', 'Structured treatment process' and 'Treatment organisation'. Patients and carers prioritized 'Treatment organisation' higher than professionals, but overall there was considerable agreement about the factors of treatment the participants perceived as most helpful including factors related to the therapeutic relationship and the 'creation of hope'.

CONCLUSIONS

Our study identified factors of depression treatment perceived as helpful according to patients, carers and professionals. Findings suggest that in a scientific era with emphasis on biological psychiatry, not only patients and carers, but also professionals consider aspecific factors the most helpful. Further studies might show that factors we found to be helpful in the treatment for depression, can be generalized to mental health treatment in general.

A questionnaire-based qualitative study of therapist views on computerized CBT

Few studies have explored therapists’ views on computerized cognitive behavioural therapy (cCBT) and this study aimed to provide an in-depth understanding of accredited therapists’ views on cCBT's role in treating depression. Twelve therapists constituted this self-selected sample (eight female, four male). Mean age was 52 years (range 46–61). The data obtained from a semi-structured questionnaire were analysed using thematic analysis. Three themes were identified and discussed: (1) the standardized nature of cCBT for depression, (2) the importance of the therapeutic relationship in cCBT, and (3) the pros and cons with cCBT as an alternative to CBT. The therapists in this study emphasized that innovations in CBT delivery formats (e.g. internet-based, computerized) show promise. However, participants expressed some views that clash with the evidence-based viewpoint. More work is needed to improve the implementation of evidence-based practice and policy.

Short-term effects of a peer co-led educational programme delivered before mental health treatment: A randomised controlled trial

OBJECTIVE

To investigate the 1-month effects of an educational programme co-led by peers delivered before treatment on treatment preferences, self-management knowledge and motivation in comparison to usual care.

METHODS

Adults referred to a community mental health centre were randomised to either a control group (n=48) or a peer co-led educational programme (intervention group, n=45). The programme consisted of an 8-hour group education session followed by an individual pretreatment planning session. The main topics of the educational programme were treatment options, patients' rights, self-management, the importance of patient activation and participation.

RESULTS

At 1-month follow-up, a significantly larger proportion of the patients in the intervention group knew which type of treatment they preferred (76.7% vs. 32.5%, p<0.001). The intervention group had significantly higher self-management knowledge (p<0.001). There was no effect on treatment motivation (p=0.543).

CONCLUSION

At 1-month following the delivery of a pretreatment educational programme, we found that participants' knowledge of treatment preferences and self-management had improved.

PRACTICE IMPLICATIONS

Educational interventions co-led by peers can optimise the process of informing and educating outpatients, thereby helping patients to clarify their treatment preferences.

Treatment-related decisional conflict in patients with depressive and anxious disorders

PURPOSE

To determine the level of treatment-related decisional conflict in patients with emotional disorders and to establish its relationship with sociodemographic and clinical variables.

METHODS

We conducted a cross-sectional survey on a convenience sample of 321 consecutive psychiatric outpatients with emotional disorders. All patients completed self-report questionnaires assessing sociodemographic and clinical variables, patients' preference of participation in decision making, perceived decisional conflict about treatment, adherence to prescribed treatment, and satisfaction with the psychiatric care provided. Multiple correspondences analysis was used to investigate relationships of decisional conflict with the variables of interest.

RESULTS

Approximately, two-thirds of psychiatric outpatients self-reported decisional conflict regarding their treatment. Interestingly, the presence of decisional conflict did not influence significantly patients' preferences of participation or their adherence to prescribed treatment. Patients without decisional conflict registered significantly higher satisfaction. Multiple correspondences analysis evidenced two clear profiles: patients without decisional conflict received the treatment they preferred, mainly psychotherapy or combined treatment, had been under psychiatric treatment for longer than 5 years, and self-reported high satisfaction with health care received; on the other hand, patients with decisional conflict did not receive the treatment they preferred, were treated with pharmacotherapy alone for a period of time between 1 and 5 years, and self-reported medium satisfaction with received health care.

CONCLUSION

The high level of decisional conflict found in patients with depression and anxiety attending a secondary care service could be an important driving force when personalizing and tailoring information and teaching skills to patients about their illnesses and their treatments.

Treating Depression: What Patients Want; Findings From a Randomized Controlled Trial in Primary Care

OBJECTIVE

To highlight clinical and sociodemographic factors associated with patients' preference in the treatment of depression, we conducted a randomized controlled trial comparing the efficacy of selective serotonin reuptake inhibitors and interpersonal counseling in patients with a major depressive episode.

METHODS

Patients, recruited from a psychiatric consultation service in the primary care setting, were asked to express their preference for the type of treatment before randomization to one of the 2 intervention arms. Severity of depressive symptoms and functional impairment was assessed using the 21-item Hamilton Rating Scale for Depression and the Work and Social Adjustment Scale, respectively.

RESULTS

A total of 170 patients were evaluated, 87 (51.2%) patients expressed their preference for interpersonal counseling and 83 (48.8%) for selective serotonin reuptake inhibitors. Depression severity and treatment preference showed significant correlations. Preference for interpersonal counseling was related to mild depression and greater functional impairment, whereas patients with moderate or severe depression were more likely to prefer medication. Remission rates and functional level were not related to treatment preference at the end of the study.

CONCLUSION

Treatment preference is a critical factor, influenced by clinical and sociodemographic characteristics, and further studies are needed to improve its clinical relevance.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects

BACKGROUND

The present meta-analysis aimed to examine to what extent combined pharmacotherapy with psychotherapy results in a different response to treatment compared to psychotherapy or pharmacotherapy alone in adults with major depression at six months or longer postrandomization.

METHODS

A systematic literature search resulted in 23 randomized controlled trials with 2184 participants. Combined treatment was compared to either psychotherapy or anti-depressant medication alone in both the acute phase and the maintenance phase. Odds ratios of a positive outcome were calculated for all comparisons.

RESULTS

In acute phase treatment, combined psychotherapy with antidepressants outperformed antidepressants alone at six months or longer postrandomization in patients with major depressive disorder (OR=2.93, 95%CI 2.15-3.99, p<0.001). Heterogeneity was zero (95%CI 0-57%, p>0.05). However, combined therapy resulted in equal response to treatment compared to psychotherapy alone at six months or longer postrandomization. As for the maintenance treatment, combined maintenance psychotherapy with antidepressants resulted in better-sustained treatment response compared to antidepressants at six months or longer postrandomization (OR=1.61, 95%CI 1.14-2.27, p<0.05). Heterogeneity was zero (95%CI 0-68%, p>0.05).

CONCLUSIONS

Combined therapy results in a superior enduring effect compared to antidepressants alone in patients with major depression. Psychotherapy is an adequate alternative for combined treatment in the acute phase as it is as effective as combined treatment in the long-term.

Predicting Optimal Outcomes in Cognitive Therapy or Interpersonal Psychotherapy for Depressed Individuals Using the Personalized Advantage Index Approach

Introduction

Although psychotherapies for depression produce equivalent outcomes, individual patients respond differently to different therapies. Predictors of outcome have been identified in the context of randomized trials, but this information has not been used to predict which treatment works best for the depressed individual. In this paper, we aim to replicate a recently developed treatment selection method, using data from an RCT comparing the effects of cognitive therapy (CT) and interpersonal psychotherapy (IPT).

Methods

134 depressed patients completed the pre- and post-treatment BDI-II assessment. First, we identified baseline predictors and moderators. Second, individual treatment recommendations were generated by combining the identified predictors and moderators in an algorithm that produces the Personalized Advantage Index (PAI), a measure of the predicted advantage in one therapy compared to the other, using standard regression analyses and the leave-one-out cross-validation approach.

Results

We found five predictors (gender, employment status, anxiety, personality disorder and quality of life) and six moderators (somatic complaints, cognitive problems, paranoid symptoms, interpersonal self-sacrificing, attributional style and number of life events) of treatment outcome. The mean average PAI value was 8.9 BDI points, and 63% of the sample was predicted to have a clinically meaningful advantage in one of the therapies. Those who were randomized to their predicted optimal treatment (either CT or IPT) had an observed mean end-BDI of 11.8, while those who received their predicted non-optimal treatment had an end-BDI of 17.8 (effect size for the difference = 0.51).

Discussion

Depressed patients who were randomized to their predicted optimal treatment fared much better than those randomized to their predicted non-optimal treatment. The PAI provides a great opportunity for formal decision-making to improve individual patient outcomes in depression. Although the utility of the PAI approach will need to be evaluated in prospective research, this study promotes the development of a treatment selection approach that can be used in regular mental health care, advancing the goals of personalized medicine.

Examining the influence of treatment preferences on attrition, adherence and outcomes: a protocol for a two-stage partially randomized trial

Background

Empirical evidence pertaining to the influence of treatment preferences on attrition, adherence and outcomes in intervention evaluation trials is inconsistent. The inconsistency can be explained by the method used for allocating treatment and measuring preferences. The current methodological study is designed to address these factors by implementing the two-stage partially randomized or preference trial design, and administering a validated measure to assess participants’ preferences for the treatments under evaluation. It aims to compare attrition, adherence and outcomes for participants allocated randomly or by preference to treatment. The study is in its final stages of data collection; its protocol is presented in this paper.

Methods/Design

A partially randomized clinical or preference trial is used. Eligible participants are randomized to two trial arms. First is the random arm involving random assignment to treatments, and second is the preference arm involving allocation to the chosen treatment. Participants with chronic insomnia are targeted. Two behavioral treatments are offered, stimulus control therapy and sleep restriction therapy, in the same format (small group) and dose (two sessions given over a 4-week period). A participant log is used to collect data on attrition. Adherence is evaluated in terms of exposure and enactment of treatment. Sleep-related outcomes (sleep parameters and perceived insomnia severity) are measured at pretest, posttest, 6 and 12 month follow-up. Treatment preferences, adherence and outcomes are assessed with reliable and valid measures.

Discussion

The advantages and limitations of the preference trial design are highlighted. The challenges in implementing the trial are discussed relative to the distribution of participants in the groups defined by treatment received and method of treatment allocation.

Trial registration

ClinicalTrials.gov Registry NCT02513017

Differences in patients' perceived helpfulness of depression treatment provided by general medical providers and specialty mental health providers

OBJECTIVE

This study examined the differences in the level of perceived helpfulness of treatments received for a major depressive episode (MDE) from a general medical provider only, a specialty mental health provider only or both.

METHOD

This study examined a sample of 8900 respondents from the 2008-2012 National Survey on Drug Use and Health aged 18-64 who had past 12-month MDE (based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition) and received treatment for depression. Generalized ordered logistic regression analyses were conducted to estimate the association between the type of treatment providers and perceived helpfulness of depression treatment.

RESULTS

Adults who received depression treatment from either specialty mental health providers alone or from both specialty mental health providers and general medical providers in the past year were more likely to report that treatment helped them. The differences persisted after adjusting for sociodemographic characteristics, comorbid health conditions, receipt of depression medication and severity of depression (adjusted odds ratios across level of perceived helpfulness ranged from 1.63 to 3.96).

CONCLUSIONS

This finding calls for greater attention to factors associated with provider type and organizational context that may contribute to differences in perceived helpfulness of depression treatment.

Patients׳ perspectives on how treatment can impede their recovery from depression

BACKGROUND

More than 50% of all major depressive disorder (MDD) patients experience insufficient improvement from the available treatment options. There is emerging evidence that patients׳ beliefs and experiences about MDD treatment influence treatment outcomes. The aim was to explore patients׳ perspectives on impeding characteristics of professional treatment for the recovery of MDD.

METHODS

In-depth interviews in a purposive sample with 27 recovered MDD patients who had received professional treatment. Data were qualitatively analyzed using constant comparison.

RESULTS

Participants׳ accounts yielded four major impeding themes: lack of clarity and consensus about the nature of the participants׳ MDD and the content of their treatment; precarious relationship with the clinician; unavailability of mental health care; and insufficient involvement of significant others.

LIMITATIONS

The external generalizability may be limited due to missed other subgroups within depression.

CONCLUSIONS

This study identified a comprehensive overview of impeding characteristics in MDD treatment from patients׳ perspectives. This may help clinicians to understand how patients experience MDD treatment, and to incorporate patients׳ perspectives about treatment into their joint decision-making. This can lead towards increased treatment adherence, motivation and finally success.

[Treatment preferences of elderly patients with mental disorders]

BACKGROUND

Successful treatment in psychosomatic medicine requires intrinsic motivation of the patient and the belief that the chosen therapeutic option can help. Depression, somatization disorder and generalized anxiety disorder (GAD) are frequent mental disorders in the elderly population. Finding a suitable and successful treatment for elderly people with mental disorders is often difficult. Undertreatment and the utilization of inappropriate healthcare services are frequent.

OBJECTIVE

Treatment preferences of elderly patients with mental disorders were ascertained in order to evaluate the motivation for psychotherapy or other therapeutic measures.

MATERIAL AND METHODS

The data were derived from the 8-year follow-up of the epidemiological study on chances of prevention, early recognition and optimized therapy of chronic diseases in the elderly population (ESTHER), a population-based cohort study in Saarland, Germany. A total of 3124 patients aged 55-84 years were included in this analysis. The treatment preferences were documented using a questionnaire with 12 different answer categories. The occurrence of depression, somatization disorder and GAD was collated using the patient health questionnaire (PHQ-D).

RESULTS

Physiotherapy and inpatient rehabilitation were the most frequently named treatment preferences in all three subgroups of patients with mental disorders. Psychotherapy was the preferred treatment for 18.3 % of depressive patients, for 15.0 % of somatization patients and for 15.7 % of GAD patients.

CONCLUSION

Mentally ill elderly patients in Germany preferred physical treatment techniques, such as physiotherapy and inpatient rehabilitation over psychotherapy. Discussion is needed over the reasons for these findings and the clinical implications.

Gender differences in suicide prevention responses: implications for adolescents based on an illustrative review of the literature

Background: There are well-documented gender differences in adolescent suicidal behavior; death by suicide is more common in males, while nonfatal suicide attempts are more common among females. Over the past three decades, researchers have documented the effectiveness of a myriad of suicide prevention initiatives. However, there has been insufficient attention to which types of suicide prevention interventions are effective in changing attitudes and behaviors for young males and females. In this review of the literature, we consider common examples of primarily universal suicide prevention programs from three implementation settings: school-based, community-based, and healthcare-based. Our purpose is to delineate how the potential gender bias in such strategies may translate into youth suicide prevention efforts. Methods: Research in which gender was found to moderate program success was retrieved through online databases. Results: The results that feature programming effects for both males and females are provocative, suggesting that when gender differences are evident, in almost all cases, females seem to be more likely than males to benefit from existing prevention programming. Conclusions: We conclude by considering recommendations that may benefit males more directly. Implications for adolescent suicide prevention in particular are discussed. Personalization of suicide intervention is presented as a promising solution to reduce suicide rates.

Depressed patients' preferences for type of psychotherapy: a preliminary study

BACKGROUND

The treatment recommendations for depressed patients by the American Psychiatric Association encourage a focus on the patient's preferences. The focus of this study was the preference of depressed inpatients for the type of psychotherapy.

METHODS

Twenty-nine subjects of both sexes who were hospitalized with a major depressive episode were interviewed at 5-day intervals with the same questions after the depressive episode resolved, as indicated by a score less than 7 on the Hamilton Depression Rating Scale (HDRS). The selection of items was performed by expert consensus.

RESULTS

The supportive psychotherapy scores were the highest, followed by psychodynamic psychotherapy and cognitive behavioral therapy. The two sessions conducted at 5-day intervals showed no significant difference, which reflected the stability of choices and preferences of patients.

CONCLUSION

In this study, the patients preferred supportive psychotherapy as first-line therapy compared to psychodynamic psychotherapy and cognitive behavioral therapy.

Confirmation bias in web-based search: a randomized online study on the effects of expert information and social tags on information search and evaluation

BACKGROUND

The public typically believes psychotherapy to be more effective than pharmacotherapy for depression treatments. This is not consistent with current scientific evidence, which shows that both types of treatment are about equally effective.

OBJECTIVE

The study investigates whether this bias towards psychotherapy guides online information search and whether the bias can be reduced by explicitly providing expert information (in a blog entry) and by providing tag clouds that implicitly reveal experts' evaluations.

METHODS

A total of 174 participants completed a fully automated Web-based study after we invited them via mailing lists. First, participants read two blog posts by experts that either challenged or supported the bias towards psychotherapy. Subsequently, participants searched for information about depression treatment in an online environment that provided more experts' blog posts about the effectiveness of treatments based on alleged research findings. These blogs were organized in a tag cloud; both psychotherapy tags and pharmacotherapy tags were popular. We measured tag and blog post selection, efficacy ratings of the presented treatments, and participants' treatment recommendation after information search.

RESULTS

Participants demonstrated a clear bias towards psychotherapy (mean 4.53, SD 1.99) compared to pharmacotherapy (mean 2.73, SD 2.41; t173=7.67, P<.001, d=0.81) when rating treatment efficacy prior to the experiment. Accordingly, participants exhibited biased information search and evaluation. This bias was significantly reduced, however, when participants were exposed to tag clouds with challenging popular tags. Participants facing popular tags challenging their bias (n=61) showed significantly less biased tag selection (F2,168=10.61, P<.001, partial eta squared=0.112), blog post selection (F2,168=6.55, P=.002, partial eta squared=0.072), and treatment efficacy ratings (F2,168=8.48, P<.001, partial eta squared=0.092), compared to bias-supporting tag clouds (n=56) and balanced tag clouds (n=57). Challenging (n=93) explicit expert information as presented in blog posts, compared to supporting expert information (n=81), decreased the bias in information search with regard to blog post selection (F1,168=4.32, P=.04, partial eta squared=0.025). No significant effects were found for treatment recommendation (Ps>.33).

CONCLUSIONS

We conclude that the psychotherapy bias is most effectively attenuated-and even eliminated-when popular tags implicitly point to blog posts that challenge the widespread view. Explicit expert information (in a blog entry) was less successful in reducing biased information search and evaluation. Since tag clouds have the potential to counter biased information processing, we recommend their insertion.

Aripiprazole augmentation, antidepressant combination or switching therapy in patients with major depressive disorder who are partial- or non-responsive to current antidepressants: a multi-center, naturalistic study

There has been no studies comparing the clinical benefits of aripiprazole augmentation (AT), antidepressant combination (AC), and switching to a different antidepressant (SW) in patients with major depressive disorder (MDD) patients partially or not responding to an initial antidepressant. AT, AC, or SW was chosen by patients. The primary efficacy measure was the proportion of patients showing an improvement in the Clinical Global Impression-Clinical Benefit (CGI-CB) score at week 8. Secondary efficacy measures included changes in CGI-CB, CGI-Severity (S) and subjective satisfaction scores. Remission and responder analysis were also employed. A total of 295 patients were enrolled. The most preferred strategy was AT (n = 156, 52.9%), followed by AC (n = 93, 31.5%) and SW (n = 46, 15.6%). The improver was significantly higher in AT (74.1%) compared with AC (48.1%; p < 0.001) and similar to SW (73.5%, p = 0.948), whereas no significant difference was found between AC and SW. Similar results were also found in the most secondary endpoint measures proving a superiority of AT over AC without differences between AT and SW. Tolerability profiles were similar across the three groups; however, the mean weight gain for SW (-0.1 kg) was significantly less than that for AC (1.3 kg, p < 0.05). Patients preferred AT to AC or SW when an antidepressant was ineffective in treating their depression. Among the three treatment strategies, overall AT yielded greater clinical benefit than did AC and SW. Adequately powered, well-controlled clinical trials are strongly warranted to confirm our findings due to methodological shortcomings.