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It is well known that web-based interventions can be effective treatments for depression. However, dropout rates in web-based interventions are typically high, especially in self-guided web-based interventions. Rigorous empirical evidence regarding factors influencing dropout in self-guided web-based interventions is lacking due to small study sample sizes. In this paper we examined predictors of dropout in an individual patient data meta-analysis to gain a better understanding of who may benefit from these interventions.
A comprehensive literature search for all randomized controlled trials (RCTs) of psychotherapy for adults with depression from 2006 to January 2013 was conducted. Next, we approached authors to collect the primary data of the selected studies. Predictors of dropout, such as socio-demographic, clinical, and intervention characteristics were examined.
Data from 2705 participants across ten RCTs of self-guided web-based interventions for depression were analysed. The multivariate analysis indicated that male gender [relative risk (RR) 1.08], lower educational level (primary education, RR 1.26) and co-morbid anxiety symptoms (RR 1.18) significantly increased the risk of dropping out, while for every additional 4 years of age, the risk of dropping out significantly decreased (RR 0.94).
Dropout can be predicted by several variables and is not randomly distributed. This knowledge may inform tailoring of online self-help interventions to prevent dropout in identified groups at risk.
Although both cognitive therapy (CT) and interpersonal psychotherapy (IPT) have been shown to be effective treatments for major depressive disorder (MDD), it is not clear yet whether one therapy outperforms the other with regard to severity and course of the disorder. This study examined the clinical effectiveness of CT v. IPT in a large sample of depressed patients seeking treatment in a Dutch outpatient mental health clinic. We tested whether one of the treatments was superior to the other at post-treatment and at 5 months follow-up. Furthermore, we tested whether active treatment was superior to no treatment. We also assessed whether initial depression severity moderated the effect of time and condition and tested for therapist differences.
Depressed adults (n = 182) were randomized to either CT (n = 76), IPT (n = 75) or a 2-month waiting list control (WLC) condition (n = 31). Main outcome was depression severity, measured with the Beck Depression Inventory – II (BDI-II), assessed at baseline, 2, 3, and 7 months (treatment phase) and monthly up to 5 months follow-up (8–12 months).
No differential effects between CT and IPT were found. Both treatments exceeded response in the WLC condition, and led to considerable improvement in depression severity that was sustained up to 1 year. Baseline depression severity did not moderate the effect of time and condition.
Within our power and time ranges, CT and IPT appeared not to differ in the treatment of depression in the acute phase and beyond.
Structured interviews and questionnaires are important tools to screen for major depressive disorder. Recent research suggests that, in addition to studying the mean level of total scores, researchers should focus on the dynamic relations among depressive symptoms as they unfold over time. Using network analysis, this paper is the first to investigate these patterns of short-term (i.e. session to session) dynamics for a widely used psychological questionnaire for depression – the Beck Depression Inventory (BDI-II).
With the newly developed vector autoregressive (VAR) multilevel method we estimated the network of symptom dynamics that characterizes the BDI-II, based on repeated administrations of the questionnaire to a group of depressed individuals who participated in a treatment study of an average of 14 weekly assessments. Also the centrality of symptoms and the community structure of the network were examined.
The analysis showed that all BDI-II symptoms are directly or indirectly connected through patterns of temporal influence. In addition, these influences are mutually reinforcing, ‘loss of pleasure’ being the most central item in the network. Community analyses indicated that the dynamic structure of the BDI-II involves two clusters, which is consistent with earlier psychometric analyses.
The network approach expands the range of depression research, making it possible to investigate the dynamic architecture of depression and opening up a whole new range of questions and analyses. Regarding clinical practice, network analyses may be used to indicate which symptoms should be targeted, and in this sense may help in setting up treatment strategies.
Patients with depression often report impairments in social functioning. From a patient perspective, improvements in social functioning might be an important outcome in psychotherapy for depression. Therefore, it is important to examine the effects of psychotherapy on social functioning in patients with depression.
We conducted a meta-analysis on studies of psychotherapy for depression that reported results for social functioning at post-treatment. Only studies that compared psychotherapy to a control condition were included (31 studies with 2956 patients).
The effect size of psychotherapy on social functioning was small to moderate, before [Hedges' g = 0.46, 95% confidence interval (CI) 0.32–0.60] and after adjusting for publication bias (g = 0.40, 95% CI 0.25–0.55). Univariate moderator analyses revealed that studies using care as usual as a control group versus other control groups yielded lower effect sizes, whereas studies conducted in the USA versus other countries and studies that used clinician-rated instruments versus self-report yielded higher effect sizes. Higher quality studies yielded lower effect sizes whereas the number of treatment sessions and the effect size of depressive symptoms were positively related to the effect size of social functioning. When controlling for these and additional characteristics simultaneously in multivariate meta-regression, the effect size of depressive symptoms, treatment format and number of sessions were significant predictors. The effect size of social functioning remained marginally significant, indicating that improvements in social functioning are not fully explained by improvements in depressive symptoms.
Psychotherapy for depression results in small to moderate improvements in social functioning. These improvements are strongly associated with, but not fully explained by, improvements in depressive symptoms.
Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy.
In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point.
Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037).
In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.
Interpersonal psychotherapy (IPT) seems to be as effective as cognitive behavioral therapy (CBT) in the treatment of major depression. Because the onset of panic attacks is often related to increased interpersonal life stress, IPT has the potential to also treat panic disorder. To date, a preliminary open trial yielded promising results but there have been no randomized controlled trials directly comparing CBT and IPT for panic disorder.
This study aimed to directly compare the effects of CBT versus IPT for the treatment of panic disorder with agoraphobia. Ninety-one adult patients with a primary diagnosis of DSM-III or DSM-IV panic disorder with agoraphobia were randomized. Primary outcomes were panic attack frequency and an idiosyncratic behavioral test. Secondary outcomes were panic and agoraphobia severity, panic-related cognitions, interpersonal functioning and general psychopathology. Measures were taken at 0, 3 and 4 months (baseline, end of treatment and follow-up).
Intention-to-treat (ITT) analyses on the primary outcomes indicated superior effects for CBT in treating panic disorder with agoraphobia. Per-protocol analyses emphasized the differences between treatments and yielded larger effect sizes. Reductions in the secondary outcomes were equal for both treatments, except for agoraphobic complaints and behavior and the credibility ratings of negative interpretations of bodily sensations, all of which decreased more in CBT.
CBT is the preferred treatment for panic disorder with agoraphobia compared to IPT. Mechanisms of change should be investigated further, along with long-term outcomes.
Evidence about the cost-effectiveness and cost utility of computerised
cognitive–behavioural therapy (CCBT) is still limited. Recently, we
compared the clinical effectiveness of unsupported, online CCBT with
treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus
TAU) for depression. The study is registered at the Netherlands Trial
Register, part of the Dutch Cochrane Centre (ISRCTN47481236).
To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus
Costs, depression severity and quality of life were measured for 12
months. Cost-effectiveness and cost-utility analyses were performed from
a societal perspective. Uncertainty was dealt with by bootstrap
replications and sensitivity analyses.
Costs were lowest for the CCBT group. There are no significant group
differences in effectiveness or quality of life. Cost-utility and
cost-effectiveness analyses tend to be in favour of CCBT.
On balance, CCBT constitutes the most efficient treatment strategy,
although all treatments showed low adherence rates and modest
improvements in depression and quality of life.
Computerised cognitive–behavioural therapy (CCBT) might offer a solution
to the current undertreatment of depression.
To determine the clinical effectiveness of online, unsupported CCBT for
depression in primary care.
Three hundred and three people with depression were randomly allocated to
one of three groups: Colour Your Life; treatment as usual (TAU) by a
general practitioner; or Colour Your Life and TAU combined. Colour Your
Life is an online, multimedia, interactive CCBT programme. No assistance
was offered. We had a 6-month follow-up period.
No significant differences in outcome between the three interventions
were found in the intention-to-treat and per protocol analyses.
Online, unsupported CCBT did not outperform usual care, and the
combination of both did not have additional effects. Decrease in
depressive symptoms in people with moderate to severe depression was
moderate in all three interventions. Online CCBT without support is not
beneficial for all individuals with depression.
Fatigue is a common complaint that may lead to long-term sick leave and work disability.
To assess the efficacy of cognitive–behavioural therapy by general practitioners for unexplained, persistent fatigue among employees.
A randomised controlled trial, using a pre-randomisation design in primary care, investigated 151 employees on sick leave with fatigue. Participants in the experimental group were offered five to seven 30 min sessions of cognitive–behavioural therapy by a general practitioner; those in the control group were offered no treatment. Main outcome measures (fatigue severity self-reported absenteeism, registered absenteeism and clinical recovery) were assessed at 4 months, 8 months and 12 months.
At baseline, 44% of the patients already met research criteria for chronic fatigue syndrome. There was no significant difference between the experimental group and the control group on primary or secondary outcomes at any point.
Cognitive–behavioural therapy by general practitioners for unexplained, persistent fatigue did not prove to be an effective intervention. Since these doctors were unable to deliver this therapy effectively under ideal circumstances, it is unlikely that doctors in routine practice would be more successful in doing so.
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