A meta-analysis of randomized trials of behavioural treatment of depression

Reproduced with permission of the publisher. Copyright © 2008 Cambridge University Press.Background. Depression is a common, disabling condition for which psychological treatments, in particular cognitive behavioural therapies are recommended. Promising results in recent randomized trials have renewed interest in behavioural therapy. This systematic review sought to identify all randomized trials of behavioural therapy for depression, determine the effect of such interventions and examine any moderators of such effect. Method. Randomized trials of behavioural treatments of depression versus controls or other psychotherapies were identified using electronic database searches, previous reviews and reference lists. Data on symptom-level, recovery/ dropout rate and study-level moderators (study quality, number of sessions, severity and level of training) were extracted and analysed using meta-analysis and meta-regression respectively. Results. Seventeen randomized controlled trials including 1109 subjects were included in this meta-analysis. A random-effects meta-analysis of symptom-level post-treatment showed behavioural therapies were superior to controls [standardized mean difference (SMD)-0.70, 95% CI -1.00 to -0.39, k=12, n=459], brief psychotherapy (SMD -0.56, 95% CI -1.0 to -0.12, k=3, n=166), supportive therapy (SMD -0.75, 95% CI -1.37 to -0.14, k=2, n=45) and equal to cognitive behavioural therapy (SMD 0.08, 95% CI -0.14 to 0.30, k=12, n=476). Conclusions. The results in this study indicate behavioural therapy is an effective treatment for depression with outcomes equal to that of the current recommended psychological intervention. Future research needs to address issues of parsimony of such interventions

Can we better understand severe mental illness through the lens of Syndemics?

Current health care systems do not sufficiently address contributors, also known as modifiable behavior factors, to severe mental illnesses (SMI). Instead treatment is focused on decreasing symptom-experience rather than reducing the detrimental effect of biological predisposition and behavioral influences on illness. Health care services and patients alike call for a more comprehensive, individual approach to mental health care, especially for people with SMI. A Syndemics framework has been previously used to identify ecological and social contributors to an HIV epidemic in the 1990s, and the same framework is transferable to mental health research to identify the relationship between contributing factors and the outcomes of SMI. Using this approach, a holistic insight into mental illness experience could inform more effective health care strategies that lessen the burden of disease on people with SMI. In this review, the components of a Syndemic framework, the scientific contributions to the topic so far, and the possible future of mental health research under the implementation of a Syndemic framework approach are examined

Outcomes measurement in psychiatry : a critical review of patient based outcomes measurement in psychiatric research and practice

SIGLEAvailable from British Library Document Supply Centre- DSC:DXN054482 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Loneliness, social isolation and social relationships: what are we measuring? A novel framework for classifying and comparing tools

OBJECTIVES: We present a novel way of classifying and comparing measures of social relationships to help readers interpret the growing literature on loneliness and social isolation and to provide researchers with a starting point to guide their choice of measuring tool. METHODS: Measures of social relationships used in epidemiological studies were identified from two systematic reviews—one review on the association between social relationships and health and social care service use, and a second review on the association between social relationships and health. Questions from each measure were retrieved and tabulated to derive a classification of social relationship measures. RESULTS: We present a classification of measures according to two dimensions: (1) whether instruments cover structural or functional aspects of social relationships and (2) the degree of subjectivity asked of respondents. We explain how this classification can be used to clarify the remit of the many questionnaires used in the literature and to compare them. CONCLUSIONS: Different dimensions of social relationships are likely to have different implications for health. Our classification of social relationship measures transcends disciplinary and conceptual boundaries, allowing researchers to compare tools that developed from different theoretical perspectives. Careful choice of measures is essential to further our understanding of the links between social relationships and health, to identify people in need of help and to design appropriate prevention and intervention strategies

Varenicline for smoking cessation and reduction in people with severe mental illnesses : systematic review and meta-analysis

AIMS: To determine the effectiveness and safety of varenicline in treating tobacco dependence in patients with severe mental illness. DESIGN: A systematic review and meta-analysis of randomised controlled trials that compared varenicline with a placebo or an alternative intervention for smoking cessation or reduction. SETTING: Both in-patient and out-patient settings in any country. PARTICIPANTS: Adult patients aged 18 and over with any type of severe mental illness. The systematic review included eight studies comprising 398 participants. MEASURES: Primary outcome measures were (1) smoking cessation (2) smoking reduction measured by changes in the number of cigarettes smoked per day and (3) number of psychiatric adverse events, which were collected at the end of treatment. FINDINGS: The random-effect pooled estimates from the five studies that reported smoking related outcomes found that varenicline is statistically superior to placebo in smoking cessation (risk ratios 4.33; 95% CI: 1.96-9.56), and smoking reduction was higher in varenicline groups (mean reduced daily cigarettes was 6.39; 95% CI: 2.22-10.56). There is no significant difference regarding neuropsychiatric and other adverse events. CONCLUSIONS: Varenicline appears to be significantly more effective than placebo in assisting with smoking cessation and reduction in people with severe mental illness. There appears to be no clear evidence that varenicline was associated with an increased risk of neuropsychiatric or other adverse events compared with placebo. This article is protected by copyright. All rights reserved

Are there researcher allegiance effects in diagnostic validation studies of the PHQ-9? : A systematic review and meta-analysis

OBJECTIVES: To investigate whether an authorship effect is found that leads to better performance in studies conducted by the original developers of the Patient Health Questionnaire (PHQ-9) (allegiant studies). DESIGN: Systematic review with random effects bivariate diagnostic meta-analysis. Search strategies included electronic databases, examination of reference lists and forward citation searches. INCLUSION CRITERIA: Included studies provided sufficient data to calculate the diagnostic accuracy of the PHQ-9 against a gold standard diagnosis of major depression using the algorithm or the summed item scoring method at cut-off point 10. DATA EXTRACTION: Descriptive information, methodological quality criteria and 2×2 contingency tables. RESULTS: Seven allegiant and 20 independent studies reported the diagnostic performance of the PHQ-9 using the algorithm scoring method. Pooled diagnostic OR (DOR) for the allegiant group was 64.40, and 15.05 for non-allegiant studies group. The allegiance status was a significant predictor of DOR variation (p<0.0001).Five allegiant studies and 26 non-allegiant studies reported the performance of the PHQ-9 at recommended cut-off point of 10. Pooled DOR for the allegiant group was 49.31, and 24.96 for the non-allegiant studies. The allegiance status was a significant predictor of DOR variation (p=0.015).Some potential alternative explanations for the observed authorship effect including differences in study characteristics and quality were found, although it is not clear how some of them account for the observed differences. CONCLUSIONS: Allegiant studies reported better performance of the PHQ-9. Allegiance status was predictive of variation in the DOR. Based on the observed differences between independent and non-independent studies, we were unable to conclude or exclude that allegiance effects are present in studies examining the diagnostic performance of the PHQ-9. This study highlights the need for future meta-analyses of diagnostic validation studies of psychological measures to evaluate the impact of researcher allegiance in the primary studies

Making the journey with me : a qualitative study of experiences of a bespoke mental health smoking cessation intervention for service users with serious mental illness

BACKGROUND: Smoking is one of the major modifiable risk factors contributing to early mortality for people with serious mental illness. However, only a minority of service users access smoking cessation interventions and there are concerns about the appropriateness of generic stop-smoking services for this group. The SCIMITAR (Smoking Cessation Intervention for Severe Mental Ill-Health Trial) feasibility study explored the effectiveness of a bespoke smoking cessation intervention delivered by mental health workers. This paper reports on the nested qualitative study within the trial. METHODS: Qualitative semi-structured interviews were conducted with 13 service users receiving the intervention and 3 of the MHSCPs (mental health smoking cessation practitioners) delivering the intervention. Topic guides explored the perceived acceptability of the intervention particularly in contrast to generic stop-smoking services, and perceptions of the implementation of the intervention in practice. Transcripts were analysed using the Constant Comparative Method. RESULTS: Generic services were reported to be inappropriate for this group, due to concerns over stigma and a lack of support from health professionals. The bespoke intervention was perceived positively, with both practitioners and service users emphasising the benefits of flexibility and personalisation in delivery. The mental health background of the practitioners was considered valuable not only due to their increased understanding of the service users' illness but also due to the more collaborative relationship style they employed. Challenges involved delays in liaising with general practitioners and patient struggles with organisation and motivation, however the MHSCP was considered to be well placed to address these problems. CONCLUSION: The bespoke smoking cessation intervention was acceptable to service users and the both service users and practitioners reported the value of a protected mental health worker role for delivering smoking cessation to this group. The results have wider implications for understanding how to achieve integrated and personalised care for this high-risk population and further underscore the need for sensitised smoking cessation support for people with serious mental illness. TRIAL REGISTRATION: Current Controlled Trials ISRCTN79497236 . Registered 3(rd) July 2009

What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression.

Reproduced with permission of the publisher. © 2007 Cambridge University Press.Background. Although self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators. Method. Randomized trials of the effectiveness of self-help interventions versus controls in the treatment of depressive symptoms were identified using previous reviews and electronic database searches. Data on moderators (i.e. patient populations, study design, intervention content) and outcomes were extracted and analysed using meta-regression. Results. Thirty-four studies were identified with 39 comparisons. Study design factors associated with greater effectiveness were unclear allocation concealment, observer-rated outcome measures and waiting-list control groups. Greater effectiveness was also associated with recruitment in non-clinical settings, patients with existing depression (rather than those ‘at risk ’), contact with a therapist (i.e. guided self-help) and the use of cognitive behavioural therapy (CBT) techniques. However, only guided self-help remained significant in the multivariate analysis [regression coefficient 0.36, 95% confidence interval (CI) 0.05–0.68, p=0.03]. In the subset of guided studies, there were no significant associations between outcomes and the session length, content, delivery mode or therapist background. Conclusions. The results provide some insights into moderators of self-help interventions, which might assist in the design of future interventions. However, the present study did not provide a comprehensive description, and other research methods might be required to identify factors associated with the effectiveness of self-help

Sudden gains in behavioural activation for depression

Sudden gains have been linked to improved outcomes in cognitive behaviour therapy for depression. The relationship between sudden gains and outcome is less clear in other treatment modalities, including interpersonal psychotherapy and supportive expressive therapy, which may indicate different mechanisms of change between treatment modalities. The current study examined sudden gains in adults meeting diagnostic criteria for depression (N = 40) offered up to 12 sessions of behavioural activation treatment. Sudden gains were found in 42.5% of the sample. Sudden gains occurred early (median pre-gain session 2) and were related to outcome: those who experienced a sudden gain had significantly lower post-treatment scores on the PHQ-9. Furthermore, the proportion meeting the reliable and clinically significant change criteria at end of treatment was higher in the sudden gain group. These findings highlight the importance of understanding the mechanisms by which sudden gains relate to therapy outcome in behavioural activation