Describing the population health burden of depression: health-adjusted life expectancy by depression status in Canada

Association between psychological distress and disability-free life expectancy in the older Japanese adults

BACKGROUND

Our study aimed to investigate the association between psychological distress and disability-free life expectancy (DFLE).

METHODS

In 2006, a cohort study was conducted of 12,365 Japanese individuals aged ≥65 years, who were followed-up for 13 years. Psychological distress was measured using the Kessler 6-item psychological distress scale and was categorized into no (0-4), mild (5-9), moderate (10-12), and serious distress (13-24). The number of participants was 1277 (22.4 %) for mild distress, 330 (5.8 %) for moderate, and 208 (3.6 %) for serious in men, and was 1635 (24.6 %), 467 (7.0 %), and 384 (5.8 %) in women. Sex-specific DFLE was defined as the mean years a person could expect to live without disability and calculated by Interpolated Markov Chain (IMaCh) software.

RESULTS

Compared to no distress, DFLE loss per person was 1.21, 2.61, and 4.43 years for mild, moderate, and serious distress respectively in men. At population level, DFEL loss (i.e., DFLE loss per person×number of participants) was 1545.17, 861.30, and 921.44 years for mild, moderate, and serious distress respectively in men. Accordingly, 46.4 % of the total DFLE loss was attributable to mild distress, 25.9 % to moderate, and 27.7 % to serious in men. Similarly, the results were 42.2 %, 25.4 %, and 32.4 % in women.

LIMITATIONS

Psychological distress was measured only once at baseline, and 2409 participants were excluded from the analysis because of missing data on exposure.

CONCLUSIONS

At population level, almost half of the total DFLE loss could be attributable to mild distress, underscoring the importance of population strategy for all levels of distress in promoting healthy aging.

Time trade-off health state utility values for depression: a systematic review and meta-analysis

PURPOSE

This study aims to systematically review the literature on health utility in depression generated by time trade-off (TTO) method and to compare health state vignettes.

METHODS

Systematic literature search was conducted following PRISMA guideline in 2020 November (updated in 2022 March) in Pubmed, Web of Science, PsycInfo, and Cochrane Database of Systematic Reviews. Random effect meta-analysis was conducted to pool vignette-based utility values of mild, moderate, and severe depression and to compare the preferences of depressed and nondepressed population.

RESULTS

Overall, 264 records were found, 143 screened by title and abstract after removing duplicates, 18 assessed full text, and 14 original publications included. Majority of the studies (n = 9) used conventional TTO method, and most of the studies (n = 8) applied 10-year timeframe. Eight studies evaluated self-experienced health (own-current depression). Six studies assessed vignette-based health states of remitted, mild, moderate, and severe depression, half of them applied McSad measure based health description. Altogether, 61 different utility values have been cataloged, mean utility of self-experienced depression states (n = 33) ranged between 0.89 (current-own depression) and 0.24 (worst experienced depression). Pooled utility estimates for vignette-based mild, moderate, and severe depression was 0.75, 0.66 and 0.50, respectively. Meta-regression showed that severe depression (β = -0.16) and depressed sample populations (β =  -0.13) significantly decrease vignette-based utility scores.

CONCLUSION

Our review revealed extent heterogeneity both in TTO methodology and health state vignette development. Patient's perception of depression health states was worse than healthy respondents.

The effect of depressive symptoms on disability-free survival in healthy older adults: A prospective cohort study

BACKGROUND

Gerontology and ageing research are increasingly focussing on healthy life span (healthspan), the period of life lived free of serious disease and disability. Late-life depression (LLD) is believed to impact adversely on physical health. However, no studies have examined its effect on healthspan. This study investigated the effect of LLD and subthreshold depression on disability-free survival, a widely accepted measure of healthspan.

METHODS

This prospective cohort study used data from the ASPirin in Reducing Events in the Elderly study. Participants were aged ≥70 years (or ≥65 years for African-American and Hispanic participants) and free of dementia, physical disability and cardiovascular disease. Depressive symptoms were measured using the 10-item Centre for Epidemiological Studies Depression Scale (CES-D-10). LLD and subthreshold depression were defined as CES-D-10 scores ≥8 and 3-7, respectively. Disability-free survival was defined as survival free of dementia and persistent physical disability.

RESULTS

A total of 19,110 participants were followed up for a maximum of 7.3 years. In female participants, LLD was associated with lower disability-free survival adjusting for sociodemographic and lifestyle factors, medical comorbidities, polypharmacy, physical function and antidepressant use (HR, 1.50; 95% CI, 1.23-1.82). In male participants, LLD was associated with lower disability-free survival adjusting for sociodemographic and lifestyle factors (HR, 1.30; 95% CI, 1.03-1.64). Subthreshold depression was also associated with lower disability-free survival in both sexes.

CONCLUSIONS

LLD may be a common and important risk factor for shortened healthspan.

Geriatric symptoms associated with healthy life expectancy in older people in Japan

BACKGROUND

We investigated the relationship between characteristic geriatric symptoms and healthy life expectancy in older adults in Japan. Additionally, we determined relationship predictors that would help formulate effective approaches toward promoting healthy life expectancy.

METHODS

The Kihon Checklist was used to identify older people at high risk of requiring nursing care in the near future. We evaluated the association of geriatric symptoms with healthy life expectancy while considering risk factors (frailty, poor motor function, poor nutrition, poor oral function, confinement, poor cognitive function, and depression). Data from the 2013 and 2019 Japan Gerontological Evaluation Studies were used. Healthy life expectancy was assessed using the multistate life table method.

RESULTS

Overall, 8,956 individuals were included. For both men and women, healthy life expectancy was shorter in the symptomatic group than in the asymptomatic group for several domains of the Kihon Checklist. For men, the difference between individuals with risk factors and those with no risk factors was the maximum for confinement (3.83 years) and the minimum for cognitive function (1.51 years). For women, the difference between individuals with risk factors and those with no risk factors was the maximum for frailty (4.21 years) and the minimum for cognitive function (1.67 years). Healthy life expectancy tended to be shorter when the number of risk factors was higher. Specifically, the difference between individuals with ≥3 risk factors and those with no risk factors was 4.46 years for men and 5.68 years for women.

CONCLUSIONS

Healthy life expectancy was negatively associated with characteristic geriatric symptoms, with strong associations with frailty, physical functional decline, and depression. Therefore, comprehensive assessment and prevention of geriatric symptoms may increase healthy life expectancy.

The contribution of alcohol-related deaths to the life-expectancy gap between people with and without depression - a cross-country comparison

BACKGROUND

Alcohol-related deaths may be among the most important reasons for the shorter life expectancy of people with depression, yet no study has quantified their contribution. We quantify the contribution of alcohol-related deaths to the life-expectancy gap in depression in four European countries with differing levels of alcohol-related mortality.

METHODS

We used cohort data linking population registers with health-care and death records from Denmark, Finland, Sweden and Turin, Italy, in 1993-2007 (210,412,097 person years, 3046,754 deaths). We identified psychiatric inpatients with depression from hospital discharge registers in Denmark, Finland, and Sweden and outpatients with antidepressant prescriptions from prescription registers in Finland and Turin. We assessed alcohol-related and non-alcohol-related deaths using both underlying and contributory causes of death, stratified by sex, age and depression status. We quantified the contribution of alcohol-related deaths by cause-of-death decomposition of the life-expectancy gap at age 25 between people with and without depression.

RESULTS

The gap in life expectancy was 13.1-18.6 years between people with and without inpatient treatment for depression and 6.7-9.1 years between those with and without antidepressant treatment. The contribution of alcohol-related deaths to the life-expectancy gap was larger in Denmark (33.6%) and Finland (18.1-30.5%) - i.e., countries with high overall alcohol-related mortality - than in Sweden (11.9%) and Turin (3.2%), and larger among men in all countries. The life-expectancy gap due to other than alcohol-related deaths varied little across countries.

CONCLUSIONS

Alcohol contributes heavily to the lower life expectancy in depression particularly among men and in countries with high overall alcohol-related mortality.

The association between community-level socioeconomic status and depressive symptoms among middle-aged and older adults in China

BACKGROUND

There was little evidence concerning the association of community socioeconomic status (SES) and the cross-level interaction between community- and individual-level SES with depressive symptoms in China. This study aimed to investigate the association of community-level SES with depressive symptoms among Chinese middle-aged and older people and to examine whether individual-level SES moderates this relationship.

METHODS

Using data from the China Health and Retirement Longitudinal 2011-2018 Study, the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) short form was used to measure depressive symptoms in 35,546 Chinese individuals aged 45 years and older. Community SES was calculated as a sum of z scores of the average years of schooling and household income per capita, which were derived by aggregating the individual measures to the community level. Two-level hierarchical linear regression was used.

RESULTS

Community SES was negatively related to CES-D-10 scores (coef=-0.438). A 1-SD increase in individual SES was associated with lower CES-D-10 scores (coef=-0.490). The cross-level interaction on individual- and community-level SES was significantly associated with depressive symptoms, indicating that with the increase of individual-level SES, the effect of community-level SES on depression decreases. Stratified analyses observed robust associations of community SES with CES-D scores between urban and rural residents.

CONCLUSIONS

This study showed that individuals who live in lower-SES communities had more severe depressive symptoms, particularly individuals with low SES. Additional attention should be given to the community socioeconomic context of middle-aged and older adults with lower SES, which may be helpful to reduce SES inequalities in depressive symptoms in China.

The Role of Self-Care Activities (SASS-14) in Depression (PHQ-9): Evidence From Slovakia During the COVID-19 Pandemic

In the ongoing situation, when the world is dominated by coronavirus disease 2019 (COVID-19), the development of self-care programs appears to be insufficient, while their role in mental health may be crucial. The aim of the study was to evaluate the associations between self-care activities and depression in the general Slovak population, but also in its individual gender and age categories. This was achieved by validating the self-care screening instrument, assessing differences, and evaluating the associations using quantile regression analysis. The final research sample consisted of 806 participants [males: 314 (39%), females: 492 (61%)] and data were collected through an online questionnaire from February 12, 2021 to February 23, 2021. Patient Health Questionnaire (PHQ-9) for depression (α = 0.89) and Self-Care Activities Screening Scale (SASS-14) [health consciousness (HC) (α = 0.82), nutrition and physical activity (NPA) (α = 0.75), sleep quality (SLP) (α = 0.82), and interpersonal and intrapersonal coping strategies (IICS) (α = 0.58)] were used as screening measures. Mild depressive symptoms were found in 229 participants (28.41%), moderate depressive symptoms in 154 participants (19.11%), moderately severe depressive symptoms in 60 participants (7.44%) and severe depressive symptoms in 43 participants (5.33%). The main findings revealed the fact that individual self-care activities were associated with depression. This supported the idea that well-practiced self-care activities should be an immediate part of an individual's life in order to reduce depressive symptoms. Sleep quality played an important role, while HC indicated the need for increased attention. Other dimensions of self-care also showed significant results that should not be overlooked. In terms of depression, females and younger individuals need targeted interventions. The supportive educational intervention developed based on the self-care theory can help manage and maintain mental health during a stressful period, such as the COVID-19 pandemic. Health policy leaders should focus on health-promoting preventive self-care interventions, as the demand for them increases even more during the pandemic.

Trends in happy life expectancy in Russia, 1994-2015

Although the physical health status of the Russian population has improved over time, limited attention has been paid to the role of subjective well-being (SWB), and even less is known about its relationship with objective health conditions. Using the concept of health expectancy, this study estimates the number of years expected to be satisfied with life (happy life expectancy [LE]) for Russian men and women aged 50 years and older between 1994 and 2015. Data on age-specific prevalence rates of life satisfaction were obtained from the Russian Longitudinal Study of Higher School of Economics (RLMS-HSE), and the life tables were from the Human Life Table Database. We also tested the correlation between macroeconomic indicators and happy LE at age 50. Results based on the Sullivan method demonstrated substantial increases in happy LE at age 50 for both genders during the study period. Changes in happy LE and the percentage of happy life were significant for both genders. Furthermore, happy LE fluctuated during the 1990s but increased in the early 2000s. Importantly, the results from more recent years show stagnation and slight declines in happy LE for men and women. We also noted correlations between happy LE at age 50 and macroeconomic indicators, including gross domestic product (GDP), inflation, unemployment, and poverty rates. Taken together, the findings suggest that Russian men and women are becoming more satisfied with life as they live longer. While health has mainly been measured by mortality and morbidity in the Russian context, the finding suggests the importance of focusing more on the positive aspect of population health.

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The role of subjective well-being in the physical health of the Russian population remains to be addressed.

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Russian people are becoming happier as they enjoy longer lives.

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Trends for life expectancy (LE) and happy LE differed between 1994 and 2015.

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There is evidence of stagnation and slight declines in happy LE in more recent years.

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More attention should be directed toward the positive aspects of population health, including happiness.

The impact of long-term conditions on disability-free life expectancy: A systematic review

Although leading causes of death are regularly reported, there is disagreement on which long-term conditions (LTCs) reduce disability-free life expectancy (DFLE) the most. We aimed to estimate increases in DFLE associated with elimination of a range of LTCs. This is a comprehensive systematic review and meta-analysis of studies assessing the effects of LTCs on health expectancy (HE). MEDLINE, Embase, HMIC, Science Citation Index, and Social Science Citation Index were systematically searched for studies published in English from July 2007 to July 2020 with updated searches from inception to April 8, 2021. LTCs considered included: arthritis, diabetes, cardiovascular disease including stroke and peripheral vascular disease, respiratory disease, visual and hearing impairment, dementia, cognitive impairment, depression, cancer, and comorbidity. Studies were included if they estimated HE outcomes (disability-free, active or healthy life expectancy) at age 50 or older for individuals with and without the LTC. Study selection and quality assessment were undertaken by teams of independent reviewers. Meta-analysis was feasible if three or more studies assessed the impact of the same LTC on the same HE at the same age using comparable methods, with narrative syntheses for the remaining studies. Studies reporting Years of Life Lost (YLL), Years of Life with Disability (YLD) and Disability Adjusted Life Years (DALYs = YLL+YLD) were included but reported separately as incomparable with other HE outcomes (PROSPERO registration: CRD42020196049). Searches returned 6072 unique records, yielding 404 eligible for full text retrieval from which 30 DFLE-related and 7 DALY-related were eligible for inclusion. Thirteen studies reported a single condition, and 17 studies reported on more than one condition (two to nine LTCs). Only seven studies examined the impact of comorbidities. Random effects meta-analyses were feasible for a subgroup of studies examining diabetes (four studies) or respiratory diseases (three studies) on DFLE. From pooled results, individuals at age 65 without diabetes gain on average 2.28 years disability-free compared to those with diabetes (95% CI: 0.57-3.99, p<0.01, I2 = 96.7%), whilst individuals without respiratory diseases gain on average 1.47 years compared to those with respiratory diseases (95% CI: 0.77-2.17, p<0.01, I2 = 79.8%). Eliminating diabetes, stroke, hypertension or arthritis would result in compression of disability. Of the seven longitudinal studies assessing the impact of multiple LTCs, three found that stroke had the greatest effect on DFLE for both genders. This study is the first to systematically quantify the impact of LTCs on both HE and LE at a global level, to assess potential compression of disability. Diabetes, stroke, hypertension and arthritis had a greater effect on DFLE than LE and so elimination would result in compression of disability. Guidelines for reporting HE outcomes would assist data synthesis in the future, which would in turn aid public health policy.

Better together: How group-based physical activity protects against depression

Against the backdrop of evidence that physical activity can protect against depression, there has been growing interest in the mechanisms through which this relationship operates (e.g., biological adaptations), and the factors that might moderate it (e.g., physical activity intensity). However, no attempt has been made to examine whether, or through what mechanisms, depression-related benefits might arise from belonging to groups that engage in physical activity. Across two studies, we addressed these shortcomings by (a) examining whether engaging in physical activity specifically in the context of sport or exercise groups protects against depression and (b) testing two pathways through which benefits might arise: greater physical activity and reduced loneliness. Study 1 (N = 4549) used data from three waves of a population study of older adults residing in England. Sport or exercise group membership predicted fewer depression symptoms four years later. This relationship was underpinned by sport or exercise group members engaging in physical activity more frequently and feeling less lonely. Clinical depression rates were almost twice as high among non-group members than group members. Study 2 (N = 635) included Australian adults who were members of sport and exercise groups, recruited during the enforced suspension of all group-based sport and exercise due to COVID-19 restrictions. The more sport or exercise groups participants had lost physical access to, the more severe their depression symptoms. Clinical depression rates were over twice as high among those who had lost access to >2 groups compared to those who had lost access to <2 groups. The relationship between number of groups lost and depression symptom severity was mediated by greater loneliness, but not by overall physical activity. Overall, findings suggest that belonging to groups that engage in physical activity can protect against depression, and point to the value of initiatives that aim to promote people's engagement in such groups.

Multi-gene Pharmacogenomic Testing That Includes Decision-Support Tools to Guide Medication Selection for Major Depression: A Health Technology Assessment

BACKGROUND

Major depression is a substantial public health concern that can affect personal relationships, reduce people's ability to go to school or work, and lead to social isolation. Multi-gene pharmacogenomic testing that includes decision-support tools can help predict which depression medications and dosages are most likely to result in a strong response to treatment or to have the lowest risk of adverse events on the basis of people's genes.We conducted a health technology assessment of multi-gene pharmacogenomic testing that includes decision-support tools for people with major depression. Our assessment evaluated effectiveness, safety, cost-effectiveness, the budget impact of publicly funding multi-gene pharmacogenomic testing, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias Tool and the Risk of Bias Assessment Tool for Nonrandomized studies (RoBANS) and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.We performed a systematic literature search of the economic evidence to review published cost-effectiveness studies on multi-gene pharmacogenomic testing that includes a decision-support tool in people with major depression. We developed a state-transition model and conducted a probabilistic analysis to determine the incremental cost of multi-gene pharmacogenomic testing versus treatment as usual per quality-adjusted life-year (QALY) gained for people with major depression who had inadequate response to one or more antidepressant medications. In the reference case (with GeneSight-guided care), we considered a 1-year time horizon with an Ontario Ministry of Health perspective. We also estimated the 5-year budget impact of publicly funding multi-gene pharmacogenomic testing for people with major depression in Ontario.To contextualize the potential value of multi-gene pharmacogenomic testing that includes decision-support tools, we spoke with people who have major depression and their families.

RESULTS

We included 14 studies in the clinical evidence review that evaluated six multi-gene pharmacogenomic tests. Although all tests included decision-support tools, they otherwise differed greatly, as did study design, populations included in studies, and outcomes reported. Little or no improvement was observed on change in HAM-D17 depression score compared with treatment as usual for any test evaluated (GRADE: Low-Very Low). GeneSight- and NeuroIDgenetix-guided medication selection led to statistically significant improvements in response (GRADE: Low-Very Low) and remission (GRADE: Low-Very Low), while treatment guided by CNSdose led to significant improvement in remission rates (GRADE: Low), but the study did not report on response. Results were inconsistent and uncertain for the impact of Neuropharmagen, and no significant improvement was observed for Genecept or another unspecified test for either response or remission (GRADE: Low-Very Low). Neuropharmagen may reduce adverse events and CNSDose may reduce intolerability to medication, while no difference was observed in adverse events with GeneSight, Genecept, or another unspecified test (GRADE: Moderate-Very Low). No studies reported data on suicide, treatment adherence, relapse, recovery, or recurrence of depression symptoms.Our review included four model-based economic studies and found that multi-gene pharmacogenomic testing was associated with greater effectiveness and cost savings than treatment as usual, over long-term (i.e., 3-,5-year and lifetime) time horizons. Since none of the included studies was fully applicable to the Ontario health care system, we conducted a primary economic evaluation.Our reference case analysis over the 1-year time horizon found that multi-gene pharmacogenomic testing (with GeneSight) was associated with additional QALYs (0.03, 95% credible interval [CrI]: 0.005; 0.072) and additional costs ($1,906, 95% Crl: $688; $3,360). An incremental cost-effectiveness ratio was $60,564 per QALY gained. The probability of the intervention being cost-effective (vs. treatment as usual) was 36.8% at a willingness-to-pay amount of $50,000 per QALY (i.e., moderately likely not to be cost-effective), rising to 70.7% at a willingness-to-pay amount of $100,000 per QALY (i.e., moderately likely to be cost-effective). Evidence informing economic modeling of the reference case with GeneSight and other multi-gene pharmacogenomic tests was of low to very low quality, implying considerable uncertainty or low confidence in the effectiveness estimates. The price of the test, efficacy of the intervention on remission, time horizon, and analytic perspective were major determinants of the cost-effectiveness results. If the test price were assumed to be $2,162 (compared with $2,500 in the reference case), the intervention would be cost-effective at a willingness-to-pay amount of $50,000 per QALY; moreover, if the price decreased to $595, the intervention would be cost saving (or dominant) compared with treatment as usual.At an increasing uptake of 1% per year and a test price of $2,500, the annual budget impact of publicly funding multi-gene pharmacogenomic testing in Ontario over the next 5 years ranged from an additional $3.5 million in year 1 (at uptake of 1%) to $16.8 million in year 5. The 5-year budget impact was estimated at about $52 million.People with major depression and caregivers generally supported multi-gene pharmacogenomic testing because they believed it could provide guidance that fit their values. They hoped such guidance would speed symptom relief, would reduce side effects and help inform their medication choices. Some patients expressed concerns over maintaining confidentiality of test results and the possibility that physicians would sacrifice patient-centred care to follow pharmacogenomic guidance.

CONCLUSIONS

Multi-gene pharmacogenomic testing that includes decision-support tools to guide medication selection for depression varies widely. Differences between individual tests must be considered, as clinical utility observed with one test might not apply to other tests. Overall, effectiveness was inconsistent among the six multi-gene pharmacogenomic tests we identified. Multi-gene pharmacogenomic tests may result in little or no difference in improvement in depression scores compared with treatment as usual, but some tests may improve response to treatment or remission from depression. The impact on adverse events is uncertain. The evidence, however, is uncertain, and therefore our confidence that these observed effects reflect the true effects is low to very low.For the management of major depression in people who had inadequate response to at least one medication, some multi-gene pharmacogenomic tests that include decision support tools are associated with additional costs and QALYs over the 1-year time horizon, and maybe be cost-effective at the willingness-to-pay amount of $100,000 per QALY. Publicly funding multi-gene pharmacogenomic testing in Ontario would result in additional annual costs of between $3.5 million and $16.8 million, with a total budget impact of about $52 million over the next 5 years.People with major depression and caregivers generally supported multi-gene pharmacogenomic testing because they believed it could provide guidance that fit their values. They hoped such guidance would speed symptom relief, would reduce side and help inform their medication choices. Some patients expressed concerns over maintaining confidentiality of test results and the possibility that physicians would sacrifice patient-centred care to follow pharmacogenomic guidance.

Repetitive Transcranial Magnetic Stimulation for People With Treatment-Resistant Depression: A Health Technology Assessment

BACKGROUND

Major depression is one of the most diagnosed mental illnesses in Canada. Generally, people are treated successfully with antidepressants or psychotherapy, but some people do not respond to these treatments (called treatment-resistant depression [TRD]). Repetitive transcranial magnetic stimulation (rTMS) delivers magnetic pulses to stimulate the areas of the brain associated with mood regulation. Several modalities of rTMS exist (e.g., high frequency rTMS, intermittent theta burst stimulation [iTBS], deep transcranial magnetic stimulation). We conducted a health technology assessment of rTMS for people with TRD, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding rTMS, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Risk of Bias in Systematic Reviews (ROBIS) tool and Cochrane Risk of Bias for Randomized Controlled Trials and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 3-year horizon from a public payer perspective. We also analyzed the 5-year budget impact of publicly funding rTMS for people with TRD in Ontario. To assess the potential value of rTMS, we spoke with people who have TRD. Seven rTMS modalities were considered: low-frequency (1 Hz) stimulation, high-frequency (10-20 Hz) stimulation, unilateral stimulation, bilateral stimulation, iTBS, continuous theta burst stimulation, and deep transcranial magnetic stimulation.

RESULTS

We included 58 primary studies, 9 systematic reviews, and 1 network meta-analysis in the clinical evidence review. Most rTMS modalities were more effective than sham treatment for all outcomes (GRADE: Moderate to High). All rTMS modalities were similar to one another in response and remission rates (GRADE: not reported) and were similar to electroconvulsive therapy (ECT) in response and remission rates (GRADE: Moderate). Moreover, in both the reference case and scenario analyses, two rTMS modalities (rTMS or iTBS), followed by ECT when patients did not respond to initial treatment, were less expensive and more effective than ECT alone. They were cost-effective compared with pharmacotherapy alone at a willingness-to-pay amount of $50,000 per quality-adjusted life-year (QALY). The annual budget impact of publicly funding rTMS would range from $9.3 million in year 1 to $15.76 million in year 5, for a total of $63.2 million over the next 5 years. People with TRD we spoke with reported that their experiences were generally favourable, and their attitudes toward rTMS were positive. Similarly, psychiatrists had positive attitudes toward and acceptance of rTMS. Our quantitative literature review on preferences revealed some gaps in psychiatrists' knowledge of rTMS, which could have been influenced by their level of training on rTMS.

CONCLUSIONS

Most rTMS modalities are likely more effective than sham rTMS on all outcomes. All rTMS modalities are similar to ECT and to one another in response and remission rates. Compared with ECT alone, two rTMS modalities (high-frequency rTMS and iTBS), followed by ECT when necessary in a stepped care pathway, were less costly and more effective for managing adults with TRD. These types of rTMS (high-frequency rTMS and iTBS) were cost-effective compared with pharmacotherapy alone at a willingness-to-pay amount of $50,000 per QALY. Publicly funding rTMS (high-frequency rTMS and iTBS) for the treatment of adults with TRD in Ontario over the next 5 years would add $63.2 million in total costs. People with TRD had positive experiences and attitudes toward rTMS.

Depression and Anxiety-Free Life Expectancy by Sex and Urban-Rural Areas in Jiangxi, China in 2013 and 2018

Objective: To quantitatively estimate life expectancy (LE) and depression and anxiety-free life expectancy (DAFLE) for the years 2013 and 2018 in Jiangxi Province, China, by sex and urban–rural areas. Additionally, to compare the discrepancy of DAFLE/LE of different sexes and urban-rural areas over various years. Methods: Based on the summary of the health statistics of Jiangxi Province in 2013 and 2018 and the results of the 5th and 6th National Health Service Surveys in Jiangxi Province, the model life table is used to estimate the age-specific mortality rate by sex and urban–rural areas. Sullivan’s method was used to calculate DAFLE. Results: Data from 2013 indicate that those aged 15 can expect to live 56.20 years without depression and anxiety for men and 59.67 years without depression and anxiety for women. Compared to 2013, DAFLE had not fluctuated significantly in 2018. The proportion of life expectancy without depression and anxiety (DAFLE/LE) declined between 2013 and 2018. DAFLE/LE in urban areas was higher than in rural areas. Men had higher DAFLE/LE than women. From 2013 to 2018, the DAFLE aged 15 decreased by 0.18 years for urban men and decreased by 0.52 years for urban women, rural areas also decreased to varying degrees. Conclusions: Even if women had a longer life span than men, they would spend more time with depression or anxiety. DAFLE did not increase with the increase in LE from 2013 to 2018, suggesting an absolute expansion of the burden, especially in rural areas. Depression and anxiety health services in Jiangxi, China will face more serious obstacles and challenges, which may lead to more disability. This requires more attention and more effective measures from the public, medical departments and the government.

Patient and physician perspectives of a smartphone application for depression: a qualitative study

BACKGROUND

Despite an increasing number of smartphone apps, such therapeutic tools have not yet consistently demonstrated their efficacy and many suffer from low retention rates. To ensure the development of efficient apps associated with high adherence, we aimed to identify, through a user-centred design approach, patient and physician expectations of a hypothetical app dedicated to depression.

METHODS

We conducted semi-structured interviews with physicians (psychiatrists and general practitioners) and patients who had experienced a major depressive episode during the last 12 months using the focus group method. The interviews were audio recorded, transcribed and analysed using qualitative content analysis to define codes, categories and emergent themes.

RESULTS

A total of 26 physicians and 24 patients were included in the study. The focus groups showed balanced sex and age distributions. Most participants owned a smartphone (83.3% of patients, 96.1% of physicians) and were app users (79.2% of patients and 96.1% of physicians). The qualitative content analysis revealed 3 main themes: content, operating characteristics and barriers to the use of the app. Expected content included the data collected by the app, aiming to provide information about the patient, data provided by the app, gathering psychoeducation elements, therapeutic tools and functionalities to help with the management of daily life and features expected for this tool. The "operating characteristics" theme gathered aims considered for the app, its potential target users, considered modalities of use and considerations around its accessibility and security of use. Finally, barriers to the use of the app included concerns about potential app users, its accessibility, safety, side-effects, utility and functioning. All themes and categories were the same for patients and physicians.

CONCLUSIONS

Physician and patient expectations of a hypothetical smartphone app dedicated to depression are high and confirmed the important role it could play in depression care. The key points expected by the users for such a tool are an easy and intuitive use and a personalised content. They are also waiting for an app that gives information about depression, offers a self-monitoring functionality and helps them in case of emergency.

Perceived Effectiveness and Motivations for the Use of Web-Based Mental Health Programs: Qualitative Study

BACKGROUND

The prevalence of depression is high and has been stable despite increased treatment, research, and dissemination. People encounter barriers to seeking traditional mental health services, which could be mitigated by using web-based prevention methods.

OBJECTIVE

This study aims to understand what people at high risk for depression perceive as effective aspects of web-based mental health programs and what motivates people at high risk for depression to use web-based mental health programs.

METHODS

We conducted an inductive content analysis using telephone interview data from 77 participants at high risk for depression who were recruited from 2 randomized controlled trials (RCTs). Participants from the first RCT were working men who had been randomly assigned to 1 of the following 3 groups: control group, who had access to general depression information from a website called BroMatters; intervention group 1, who had access to the BroMatters website along with the associated BroHealth web-based mental health program; and intervention group 2, who had access to the BroMatters website, the BroHealth web-based mental health program, and telephone sessions with a life coach. Participants from the second RCT were men and women who had been assigned to the intervention group, who received access to the HardHat web-based mental health program, or the control group, who only received access to the HardHat web-based mental health program following completion of the RCT. Participants for this inductive content analysis study were recruited from the intervention groups in both RCTs. Two groups of participants (n=41 and n=20) were recruited from the BroHealth RCT, and a third group comprised 16 participants that were recruited from the HardHat RCT.

RESULTS

We generated four categories regarding the perceived effectiveness of web-based programs and five categories related to what motivates the use of web-based programs. Participants identified awareness, program medium and functionality, program content, and coaches as categories related to the effectiveness of the programs. Categories of motivators to use web-based programs included providing reminders or incentives, promotion of the programs, providing appropriate medium and functionality, appropriate content, and perceived need. The final category related to motivators reflects perceptions of participants who were either unsure about what motivates them or believed that there is no way to motivate use.

CONCLUSIONS

Conflicting evidence was obtained regarding the perceived effectiveness of aspects of the content and functionality of web-based programs. In general, web-based mental health programs were perceived to help increase mental health awareness, especially when it includes live access to a coach. However, the results also revealed that it is difficult to motivate people to begin using web-based mental health programs. Strategies that may motivate the use of such programs include perceived personal need, effective promotion, providing incentives and reminders, and improving functionality.

Cost–effectiveness of combinatorial pharmacogenomic testing for depression from the Canadian public payer perspective

Aim: Evaluate the cost–effectiveness of combinatorial pharmacogenomic (PGx) testing, versus treatment as usual (TAU), to guide treatment for patients with depression, from the Canadian public healthcare system perspective. Materials & methods: Clinical and economic data associated with depression were extracted from published literature. Clinical (quality-adjusted life years; QALYs) and economic (incremental cost–effectiveness ratio) outcomes were modeled using combinatorial PGx and TAU treatment strategies across a 5-year time horizon. Results: With the combinatorial PGx strategy to guide treatment, patients were projected to gain 0.14–0.19 QALYs versus TAU. Accounting for test price, combinatorial PGx saved CAD $1,687–$3,056 versus TAU. Incremental cost–effectiveness ratios ranged from -$11,861 to -$16,124/QALY gained. Conclusion: Combinatorial PGx testing was more efficacious and less costly compared with the TAU for depression.

Association between depressive symptoms and poor sleep quality among Han and Manchu ethnicities in a large, rural, Chinese population

Objectives

To estimate the relationship between sleep quality and depression, among Han and Manchu ethnicities, in a rural Chinese population.

Methods

A sample of 8,888 adults was selected using a multistage cluster and random sampling method. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). Depressive symptoms were assessed via the Center for Epidemiological Survey, Depression Scale (CES-D). Logistic regression was conducted to assess associations between sleep quality and depression.

Results

The prevalence of poor sleep quality and depression in the Manchus (20.74% and 22.65%) was significantly lower than that in the Hans (29.57% and 26.25%), respectively. Depressive participants had higher odds ratios of global and all sub PSQI elements than non-depressive participants, both among the Hans and the Manchus. Additive interactions were identified between depressive symptoms and ethnicity with global and four sub-PSQI elements, including subjective sleep quality, sleep disturbance, use of sleep medication and daytime dysfunction.

Conclusions

The findings revealed that the prevalence of poor sleep quality and depression among the Hans was greater than among the Manchus. Depression was associated with higher odds of poor sleep quality.

Patterns of comorbidities in women with breast cancer: a Canadian population-based study

PURPOSE

Improving the understanding of co-existing chronic diseases prior to and after the diagnosis of cancer may help to facilitate therapeutic decision making in clinical practice. This study aims to examine patterns of comorbidities in Canadian women with breast cancer.

METHODS

We conducted a retrospective cohort study using provincial linked administrative health datasets from British Columbia, Canada, between 2000 and 2013. Women diagnosed with breast cancer between 2005 and 2009 were identified. The index date was defined as the date of diagnosis of breast cancer. Subsets of the breast cancer cohort were identified based on the absence of individual type of comorbidity of interest within 5 years prior to breast cancer diagnosis. For each subset, cases were then individually matched by year of birth at 1:2 ratios with controls without a history of cancer and the individual type of comorbidity of interest within 5 years prior to the assigned index year, matching with the year of breast cancer diagnosis of the corresponding case. Baseline comorbidities were measured over a 1-year period prior to the index date using two comorbidity indices, Rx-Risk-V and Aggregated Diagnosis Groups (ADG). Cox regression model was used to assess the development of seven specific comorbidities after the index date between women with breast cancer and non-cancer women.

RESULTS

The most prevalent baseline comorbidity in the breast cancer cohort measured using the Rx-Risk-V model was cardiovascular conditions (39.0%), followed by pain/pain-inflammation (34.8%). The most prevalent category measured using the ADG model was major signs or symptoms (71.8%), followed by stable chronic medical conditions (52.2%). The risks of developing ischemic heart disease, heart failure, depression, diabetes, osteoporosis, and hypothyroidism were higher in women with breast cancer compared to women without cancer, with the hazard ratios ranging from 1.09 (95 CI% 1.03-1.16) for ischemic heart disease to 2.10 (95% CI 1.99-2.21) for osteoporosis in the model adjusted for baseline comorbidity measured using Rx-Risk-V score.

CONCLUSION

Women with breast cancer had a higher risk of developing new comorbidities than women without cancer. Development of coordinated care models to manage multiple chronic diseases among breast cancer patients is warranted.

Age- and sex-specific Canadian utility norms, based on the 2013-2014 Canadian Community Health Survey

BACKGROUND

Although many Canadian studies have provided disease-specific or patient group-specific utility scores, the utility score norms currently available for the general Canadian population are outdated. Canadian guideline recommendations for the economic evaluation of health technologies advocate for utilities reflecting those of the general population and for stratified analyses when results are heterogeneous; as such, there is also a need for age-, sex- and jurisdiction-specific utility score norms.

METHODS

We used data from the 2013-2014 Canadian Community Health Survey. We used the Health Utilities Index Mark 3 to calculate utility scores. We estimated means (with 95% confidence intervals [CIs]) and medians (with interquartile ranges [IQRs]) for utility scores. In addition to Canadian-level measures, we stratified all utility score norms by respondents' age, sex, and province or territory of residence. We weighted respondents' answers and computed 95% CIs using sampling weights and bootstrap weights provided by Statistics Canada to extrapolate the study findings to the Canadian population.

RESULTS

Respondents to the 2013-2014 Canadian Community Health Survey represented 30 014 589 community-dwelling Canadians 12 years of age and older (98% of the Canadian population); half of the respondents were female (50.6%), and the weighted average age was 44.8 (95% CI 44.7-44.9) years. The mean and median self-reported utility scores for Canadians were estimated at 0.863 (95% CI 0.861-0.865) and 0.927 (IQR 0.838-0.972), respectively.

INTERPRETATION

This study provides utility score norms for several age-, sex-and jurisdiction-specific strata in Canada. These results will be useful for future cost-utility analyses and could serve as benchmark values for comparisons with future studies.

Incidence of Depression Among Community Dwelling Healthy Elderly and the Predisposing Socio-environmental Factors

Introduction

The average life expectancy is increasing with better medical facilities and evolving technology. The ratio of the geriatric population is increasing, which drives a need to invest more in the physical and psychological health of older people. The aim of this study was to assess the incidence of depression in community-dwelling healthy older adults. 

Methods

Geriatric Depression Scale-15 (GDS-15) was utilized in this study. Community-dwelling older adults (age 65+ years) were approached in parks, mosques, grocery stores, and waiting areas of banks. Demographic information including age, gender, education, marital status, employment, and financial status, and family structure was recorded. Data were entered and analyzed using SPSS v. 22.0.

Results

Out of the 367 elderly participants, there were 165 (45%) men and 202 (55%) women. Depression was reported in 37% (n = 136) individuals; 29.7% (n = 109) were suggestive of depression, while 33.2% (n = 122) were not depressed. Risk factors for the development of depression included female gender, not living with a spouse (separated/spouse died/single), being financially dependent, being employed, and living alone (not in a joint or nuclear family).

Conclusion

The incidence of depression is high among healthy community-dwelling elderly individuals in Pakistan. Geriatric health should be taken into consideration. There should be strategies and guidelines to screen the geriatric population for psycho-social symptoms and provide them with psychological counseling.

Association Between Perceived Social Support and Depressive Symptoms Among Community-Dwelling Older Chinese Americans

Purpose: This study examined the association between social support and depressive symptoms among U.S. Chinese older adults. Methods: Data were from the Population Study of Chinese Elderly in Chicago (PINE) study. Independent variables were positive and negative perceived social support (PSS). Dependent variable was depressive symptoms. Multinomial logistic regression analyses were performed. Results: A total of participants were 3,157 Chinese older adults with the mean age of 72.8 years (range 60-105 years). After controlling for confounding factors, Chinese older adults with higher positive PSS were 12% (odds ratio [OR] = 0.88, 95% confidence interval [CI] = [0.85, 0.92]) and 18% (OR = 0.82, 95% CI = [0.79, 0.86]) less likely to report mild and moderate-severe depressive symptoms, respectively, compared to reporting minimal depressive symptoms; On the contrary, Chinese older adults with higher negative PSS were 34% (OR = 1.34, 95% CI = [1.24, 1.46]) and 38% (OR = 1.38, 95% CI = [1.26, 1.52]) more likely to report mild and moderate-severe depressive symptoms, respectively. Discussion: The study findings corroborate previous research that social support is significantly associated with depressive symptoms. Our findings reinforce the importance of developing strategies to utilize positive social support and limit negative support in practice for the depressed older adults. Further studies should be conducted to better understand the associations between different dimensions of social support and depression among U.S. Chinese older adults.

The role of new antidepressants in clinical practice in Canada: a brief review of vortioxetine, levomilnacipran ER, and vilazodone

Although many branded and generic antidepressants are approved for the treatment of major depressive disorder (MDD) in Canada, efficacy and tolerability differ among patients, and new treatment options are needed. Symptom types (eg, fatigue, energy/motivation, cognition, and functioning), medication type, treatment duration, and the need for maintenance therapy are factors that may influence treatment effectiveness. Three antidepressants, vortioxetine, levomilnacipran extended-release (ER), and vilazodone have recently become available in Canada. The aim of this review is to contextualize differences in their mechanistic and clinical profiles, thereby providing practitioners with knowledge to support treatment decisions. In trials versus placebo, each drug improved depressive symptoms in adult patients with MDD. The antidepressant effect of vortioxetine may be related to enhanced serotonergic activity via reuptake inhibition and agonism and/or antagonism of various serotonin receptors. Vortioxetine may also improve cognitive functioning in MDD, and has proven efficacious in relapse prevention. Nausea was the most commonly reported adverse event (AE); rates of sexual dysfunction were low and abrupt discontinuation was well tolerated. Levomilnacipran ER, a serotonin norepinephrine reuptake inhibitor, demonstrated greater improvement versus placebo in functional impairment as well as depressive symptoms; in post hoc analyses, improvement in symptoms of motivation and energy were observed. Nausea was the most commonly reported AE; gradual discontinuation is recommended to avoid discontinuation syndrome. Vilazodone is a serotonin reuptake inhibitor and partial serotonergic 5-HT1A receptor agonist. In addition to improvement in depressive symptoms, evidence suggests that vilazodone may be particularly well suited for depressed patients with high anxiety levels. Diarrhea, nausea, and headache were the most common AEs; low rates of sexual dysfunction were reported. The 2016 Canadian Network for Mood and Anxiety Treatments guidelines for MDD includes vortioxetine as a first-line treatment; levomilnacipran ER and vilazodone are considered as second-line treatments due to lack of relapse prevention data at the time of approval.

Health status, activity limitations, work-related restrictions and level of disability among Canadians with mood and/or anxiety disorders

INTRODUCTION

This study provides the first overview of the perceived general and mental health, activity limitations, work-related restrictions and level of disability, as well as factors associated with disability severity, among Canadian adults with mood and/or anxiety disorders, using a population-based household sample.

METHODS

We used data from the 2014 Survey on Living with Chronic Diseases in Canada- Mood and Anxiety Disorders Component. The sample consists of Canadians aged 18 years and older with self-reported mood and/or anxiety disorders from the 10 provinces (n = 3361; response rate 68.9%). We conducted descriptive and multinomial multivariate logistic regression analyses.

RESULTS

Among Canadian adults with mood and/or anxiety disorders, over one-quarter reported "fair/poor" general (25.3%) and mental (26.1%) health; more than one-third (36.4%) reported one or more activity limitations; half (50.3%) stated a job modification was required to continue working; and more than one-third (36.5%) had severe disability. Those with concurrent mood and anxiety disorders reported poorer outcomes: 56.4% had one or more activity limitations; 65.8% required a job modification and 49.6% were severely disabled. Upon adjusting for individual characteristics, those with mood and/or anxiety disorders who were older, who had a household income in the lowest or lower-middle adequacy quintile or who had concurrent disorders were more likely to have severe disability.

CONCLUSION

Findings from this study affirm that mood and/or anxiety disorders, especially concurrent disorders, are associated with negative physical and mental health outcomes. Results support the role of public health policy and programs aimed at improving the lives of people living with these disorders, in particular those with concurrent disorders.