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Understanding how and under what circumstances a highly effective psychological intervention, improved symptoms of depression is important to maximise its clinical effectiveness.
To address this complexity, we estimate the indirect effects of potentially important mediators to improve symptoms of depression (measured with the Patient Health Questionnaire (PHQ-9)) in the Healthy Activity Program trial.
Interventional in(direct) effects were used to decompose the total effect of the intervention on PHQ-9 scores into the direct and indirect effects. The following indirect effects were considered: characteristics of sessions, represented by the number of sessions and homework completed; behavioural activation, according to an adapted version of the Behavioural Activation for Depression Scale – Short Form; and extra sessions offered to participants who did not respond to the intervention.
Of the total effect of the intervention measured through the difference in PHQ-9 scores between treatment arms (mean difference: −2.1, bias-corrected 95% CI −3.2 to −1.5), 34% was mediated through improved levels of behavioural activation (mean difference: −0.7, bias-corrected 95% CI −1.2 to −0.4). There was no evidence to support the mediating role of characteristics of the sessions nor the extra sessions offered to participants who did not respond to the treatment.
Findings from our robust mediation analyses confirmed the importance of targeting behavioural activation. Contrary to published literature, our findings suggest that neither the number of sessions nor proportion of homework completed improved outcomes. Moreover, in this context, alternative treatments other than extra sessions should be considered for patients who do not respond to the intervention.
Digital technologies have been widely acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance is a key influence on outcomes in conventional psychotherapy, but little is known about therapists’ experiences of forming an effective working alliance in blended interventions that involve in-person psychotherapy and a digital programme.
To investigate psychological well-being practitioners’ (PWPs’) experiences of the working alliance in a trial of blended cognitive–behavioural therapy (b-CBT) for depression. Trial registration ISRCTN12388725.
Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared with face-to-face CBT. Thematic analysis was used to analyse the data.
Participants reported four facilitating factors when building and maintaining a working alliance in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT and receiving appropriate training and support. Participants also identified four barriers to building and maintaining a working alliance: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to patients’ needs and lack of confidence in delivering b-CBT.
Our study is the first specifically to investigate practitioners’ perceived facilitators and barriers to forming a working alliance in b-CBT for depression. Findings suggest that PWPs’ experiences of the working alliance can be improved by: accounting for the time required to deliver b-CBT in service workflows to reduce time pressures; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.
The Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory (BDI-II) and the Generalised Anxiety Disorder Assessment (GAD-7) are widely used in the evaluation of interventions for depression and anxiety. The smallest reduction in depressive symptoms that matter to patients is known as the Minimum Clinically Important Difference (MCID). Little empirical study of the MCID for these scales exists.
A prospective cohort of 400 patients in UK primary care were interviewed on four occasions, 2 weeks apart. At each time point, participants completed all three questionnaires and a ‘global rating of change’ scale (GRS). MCID estimation relied on estimated changes in symptoms according to reported improvement on the GRS scale, stratified by baseline severity on the Clinical Interview Schedule (CIS-R).
For moderate baseline severity, those who reported improvement on the GRS had a reduction of 21% (95% confidence interval (CI) −26.7 to −14.9) on the PHQ-9; 23% (95% CI −27.8 to −18.0) on the BDI-II and 26.8% (95% CI −33.5 to −20.1) on the GAD-7. The corresponding threshold scores below which participants were more likely to report improvement were −1.7, −3.5 and −1.5 points on the PHQ-9, BDI-II and GAD-7, respectively. Patients with milder symptoms require much larger reductions as percentage of their baseline to endorse improvement.
An MCID representing 20% reduction of scores in these scales, is a useful guide for patients with moderately severe symptoms. If treatment had the same effect on patients irrespective of baseline severity, those with low symptoms are unlikely to notice a benefit.
Mental, neurological and substance use (MNS) disorders are a leading, but neglected, cause of morbidity and mortality in sub-Saharan Africa. The treatment gap for MNS is vast with only 10% of people with MNS disorders in low-income countries accessing evidence-based treatments. Reasons for this include low awareness of the burden of MNS disorders and limited evidence to support development, adaptation and implementation of effective and feasible treatments. The overall goal of the African Mental Health Research Initiative (AMARI) is to build an African-led network of MNS researchers in Ethiopia, Malawi, South Africa and Zimbabwe, who are equipped to lead high quality mental health research programs that meet the needs of their countries, and to establish a sustainable career pipeline for these researchers with an emphasis on integrating MNS research into existing programs such as HIV/AIDS. This paper describes the process leading to the development of AMARI's objectives through a theory of change workshop, successes and challenges that have been faced by the consortium in the last 4 years, and the future role that AMARI could play in further building MNS research capacity by brining on board more institutions from low- and middle-income countries with an emphasis on developing an evidence-based training curriculum and a research-driven care service.
Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression.
To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression.
Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme – Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6).
There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI −4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar.
Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care.
Computerised cognitive–behavioural therapy (cCBT) for depression has the potential to be efficient therapy but engagement is poor in primary care trials.
We tested the benefits of adding telephone support to cCBT.
We compared telephone-facilitated cCBT (MoodGYM) (n = 187) to minimally supported cCBT (MoodGYM) (n = 182) in a pragmatic randomised trial (trial registration: ISRCTN55310481). Outcomes were depression severity (Patient Health Questionnaire (PHQ)-9), anxiety (Generalized Anxiety Disorder Questionnaire (GAD)-7) and somatoform complaints (PHQ-15) at 4 and 12 months.
Use of cCBT increased by a factor of between 1.5 and 2 with telephone facilitation. At 4 months PHQ-9 scores were 1.9 points lower (95% CI 0.5–3.3) for telephone-supported cCBT. At 12 months, the results were no longer statistically significant (0.9 PHQ-9 points, 95% CI −0.5 to 2.3). There was improvement in anxiety scores and for somatic complaints.
Telephone facilitation of cCBT improves engagement and expedites depression improvement. The effect was small to moderate and comparable with other low-intensity psychological interventions.
Reducing the global treatment gap for mental disorders requires treatments that are economical, effective and culturally appropriate.
To describe a systematic approach to the development of a brief psychological treatment for patients with severe depression delivered by lay counsellors in primary healthcare.
The treatment was developed in three stages using a variety of methods: (a) identifying potential strategies; (b) developing a theoretical framework; and (c) evaluating the acceptability, feasibility and effectiveness of the psychological treatment.
The Healthy Activity Program (HAP) is delivered over 6–8 sessions and consists of behavioral activation as the core psychological framework with added emphasis on strategies such as problem-solving and activation of social networks. Key elements to improve acceptability and feasibility are also included. In an intention-to-treat analysis of a pilot randomised controlled trial (55 participants), the prevalence of depression (Beck Depression Inventory II ⩾19) after 2 months was lower in the HAP than the control arm (adjusted risk ratio = 0.55, 95% CI 0.32–0.94, P = 0.01).
Our systematic approach to the development of psychological treatments could be extended to other mental disorders. HAP is an acceptable and effective brief psychological treatment for severe depression delivered by lay counsellors in primary care.
Some studies have found an association between elevated cortisol and
subsequent depression, but findings are inconsistent. The cortisol
awakening response may be a more stable measure of
hypothalamic–pituitary–adrenal function and potentially of stress
To investigate whether salivary cortisol, particularly the cortisol
awakening response, is associated with subsequent depression in a large
Young people (aged 15 years, n = 841) from the Avon
Longitudinal Study of Parents and Children (ALSPAC) collected salivary
cortisol at four time points for 3 school days. Logistic regression was
used to calculate odds ratios for developing depression meeting ICD-10
criteria at 18 years.
We found no evidence for an association between salivary cortisol and
subsequent depression. Odds ratios for the cortisol awakening response
were 1.24 per standard deviation (95% CI 0.93–1.66, P =
0.14) before and 1.12 (95% CI 0.73–1.72, P = 0.61) after
adjustment for confounding factors. There was no evidence that the other
cortisol measures, including cortisol at each time point, diurnal drop
and area under the curve, were associated with subsequent depression.
Our findings do not support the hypothesis that elevated salivary
cortisol increases the short-term risk of subsequent depressive illness.
The results suggest that if an association does exist, it is small and
unlikely to be of clinical significance.
To map the availability and types of depression and anxiety groups, to examine men's experiences and perception of this support as well as the role of health professionals in accessing support.
The best ways to support men with depression and anxiety in primary care are not well understood. Group-based interventions are sometimes offered but it is unknown whether this type of support is acceptable to men.
Interviews with 17 men experiencing depression or anxiety. A further 12 interviews were conducted with staff who worked with depressed men (half of whom also experienced depression or anxiety themselves). There were detailed observations of four mental health groups and a mapping exercise of groups in a single English city (Bristol).
Some men attend groups for support with depression and anxiety. There was a strong theme of isolated men, some reluctant to discuss problems with their close family and friends but attending groups. Peer support, reduced stigma and opportunities for leadership were some of the identified benefits of groups. The different types of groups may relate to different potential member audiences. For example, unemployed men with greater mental health and support needs attended a professionally led group whereas men with milder mental health problems attended peer-led groups. Barriers to help seeking were commonly reported, many of which related to cultural norms about how men should behave. General practitioners played a key role in helping men to acknowledge their experiences of depression and anxiety, listening and providing information on the range of support options, including groups. Men with depression and anxiety do go to groups and appear to be well supported by them. Groups may potentially be low cost and offer additional advantages for some men. Health professionals could do more to identify and promote local groups.
The prevalence and correlates of depression vary across countries. Contextual factors such as country-level income or income inequalities have been hypothesised to contribute to these differences.
To investigate associations of depression with socioeconomic factors at the country level (income inequality, gross national income) and individual (education, employment, assets and spending) level, and to investigate their relative contribution in explaining the cross-national variation in the prevalence of depression.
Multilevel study using interview data of 187 496 individuals from 53 countries participating in the World Health Organization World Health Surveys.
Depression prevalence varied between 0.4 and 15.7% across countries. Individual-level factors were responsible for 86.5% of this variance but there was also reasonable variation at the country level (13.5%), which appeared to increase with decreasing economic development of countries. Gross national income or country-level income inequality had no association with depression. At the individual level, fewer material assets, lower education, female gender, economic inactivity and being divorced or widowed were associated with increased odds of depression. Greater household spending, unlike material assets, was associated with increasing odds of depression (adjusted analysis).
The variance of depression prevalence attributable to country-level factors seemed to increase with decreasing economic development of countries. However, country-level income inequality or gross national income explained little of this variation, and individual-level factors appeared more important than contextual factors as determinants of depression. The divergent relationship of assets and spending with depression emphasise that different socioeconomic measures are not interchangeable in their associations with depression.
Farmers around the world are concerned about the effects of human-induced salinity on crop yield and quality. Therefore, researchers are actively testing wild relatives of cultivated plants to identify candidates to improve crop performance under salt stress. A study was conducted to understand the effects of salt stress (Sodium chloride, NaCl) on cultivated tomato species (Solanum lycopersicum var. cerasiforme L.) and a wild tomato relative (Solanum chilense Dun.) from the Northern part of Chile. Plants were cultivated hydroponically under controlled environmental conditions for 112 days with nutrient solution containing 0 mM (3 dS m−1), 40 mM (6 dS m−1) and 80-mM (9 dS m−1) NaCl. Salt stress reduced the shoot biomass in S. lycopersicum but not in S. chilense. Both species were able to maintain the leaf water content; however, the cultivated S. lycopersicum showed osmotic adjustment, while S. chilense did not. Salt stress reduced the total fruit yield in S. lycopersicum based on a decrease in the mean fruit weight, but it had no impact on the number of fruits per plant. In contrast, salt stress had no significant impact on the fruit yield in S. chilense. Salt stress increased the total soluble solids content in S. lycopersicum and the titratable acidity in S. chilense. It was concluded that S. chilense displays a contrasting behaviour in response to prolonged exposure to moderate salinity compared with S. lycopersicum, and that this related species could be an interesting plant for breeding purposes.
High-quality evidence on morale in the mental health workforce is
To describe staff well-being and satisfaction in a multicentre UK
National Health Service (NHS) sample and explore associated factors.
A questionnaire-based survey (n = 2258) was conducted in
100 wards and 36 community teams in England. Measures included a set of
frequently used indicators of staff morale, and measures of perceived job
characteristics based on Karasek's demand–control–support model.
Staff well-being and job satisfaction were fairly good on most
indicators, but emotional exhaustion was high among acute general ward
and community mental health team (CMHT) staff and among social workers.
Most morale indicators were moderately but significantly intercorrelated.
Principal components analysis yielded two components, one appearing to
reflect emotional strain, the other positive engagement with work. In
multilevel regression analyses factors associated with greater emotional
strain included working in a CMHT or psychiatric intensive care unit
(PICU), high job demands, low autonomy, limited support from managers and
colleagues, age under 45 years and junior grade. Greater positive
engagement was associated with high job demands, autonomy and support
from managers and colleagues, Black or Asian ethnic group, being a
psychiatrist or service manager and shorter length of service.
Potential foci for interventions to increase morale include CMHTs, PICUs
and general acute wards. The explanatory value of the
demand–support–control model was confirmed, but job characteristics did
not fully explain differences in morale indicators across service types
Psychological therapies have been shown to be effective in the treatment of depression. However, evidence is focused on individually delivered therapies, with less evidence for group-based therapies.
To conduct a systematic review and meta-analysis of the efficacy of group-based psychological therapies for depression in primary care and the community.
We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials and the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group database from inception to July 2010. The Cochrane risk of bias methodology was applied.
Twenty-three studies were included. The majority showed considerable risk of bias. Analysis of group cognitive–behavioural therapy (CBT) v. usual care alone (14 studies) showed a significant effect in favour of group CBT immediately post-treatment (standardised mean difference (SMD) −0.55 (95% CI −0.78 to −0.32)). There was some evidence of benefit being maintained at short-term (SMD =–0.47 (95% CI −1.06 to 0.12)) and medium- to long-term follow-up (SMD =–0.47 (95% CI – 0.87 to −0.08)). Studies of group CBT v. individually delivered CBT therapy (7 studies) showed a moderate treatment effect in favour of individually delivered CBT immediately post-treatment (SMD = 0.38 (95% CI 0.09–0.66)) but no evidence of difference at short- or medium- to long-term follow-up. Four studies described comparisons for three other types of group psychological therapies.
Group CBT confers benefit for individuals who are clinically depressed over that of usual care alone. Individually delivered CBT is more effective than group CBT immediately following treatment but after 3 months there is no evidence of difference. The quality of evidence is poor. Evidence about group psychological therapies not based on CBT is particularly limited.
Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare.
To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders.
Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with clinicaltrials.gov (NCT00446407).
A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53–0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59–0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR = 0.64, 95% CI 0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities.
Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities.
Non-communicable diseases are growing rapidly and mental problems represent a large proportion of this group. Most mental health burden is to be found in the community and at primary health care. There are large disparities in prevalence rates between and within countries. Latin American countries have consistently shown higher prevalence rates than most other countries in the world.
A population-based cohort study investigated postnatal depression in
Brazilian women who attempted an abortion. Participants' views and actions
on abortion were assessed during pregnancy and postnatal depression was
evaluated with the Edinburgh Postnatal Depression Scale. An unsuccessful
abortion attempt was associated with postnatal depression (adjusted OR =
1.6, 95% CI 1.0–2.5). In Brazil abortion is illegal under most
In 2001, an initiative to provide effective treatment for people with depressive disorders in primary care clinics was introduced in Chile, the Programme for Screening, Diagnosis and Comprehensive Treatment of Depression (PSDCTD) (Ministerio de Salud, 2001). It was extended to all primary care clinics in the country 4 years later.
A growing number of studies suggest a link between timing of menarche and risk of depressive symptoms in adolescence, but few have prospectively examined the emergence of depressive symptoms from late childhood into adolescence.
To examine whether girls who experience earlier menarche than their peers have higher levels of depressive symptoms in adolescence.
The study sample comprised 2184 girls from the Avon Longitudinal Study of Parents and Children. The association between timing of menarche and depressive symptoms at 10.5, 13 and 14 years was examined within a structural equation model.
Girls with early menarche (<11.5 years) had the highest level of depressive symptoms at 13 (P = 0.007) and 14 years (P<0.001) compared with those with normative and late timing of menarche.
Early maturing girls are at increased risk of depressive symptoms in adolescence and could be targeted by programmes aimed at early intervention and prevention.
In a representative sample of the UK population we found that common mental disorders (as a group and in ICD–10 diagnostic categories) and subthreshold psychiatric symptoms at baseline were both independently associated with new-onset functional disability and significant days lost from work at 18-month follow-up. Subthreshold symptoms contributed to almost half the aggregate burden of functional disability and over 32 million days lost from work in the year preceding the study. Leaving these symptoms unaccounted for in surveys may lead to gross underestimation of disability related to psychiatric morbidity.
Low- and middle-income countries lack information on contextualised mental health interventions to aid resource allocation decisions regarding healthcare.
To undertake a cost-effectiveness analysis of treatments for depression contextualised to Chile.
Using data from studies in Chile, we developed a computer-based Markov cohort model of depression among Chilean women to evaluate the cost-effectiveness of usual care or improved stepped care.
The incremental cost-effectiveness ratio (ICER) of usual care was I$113 per quality-adjusted life-year (QALY) gained, versus no treatment, whereas stepped care had an ICER of I$468 per QALY versus usual care. This compared favourably with Chile's per-capita GDP. Results were most sensitive to variation in recurrent episode coverage, marginally sensitive to cost of treatment, and insensitive to changes in health-state utility of depression and rate of recurrence.
Our results suggest that treatments for depression in lowand middle-income countries may be more cost-effective than previously estimated.