Effectiveness of supported self-help in recurrent depression: a randomized controlled trial in primary care

Background: The burden and economic consequences of depression are high, mostly due to its recurrent nature. Due to current budget and time restraints, a preventive, low-cost, accessible minimal intervention is much needed. In this study, we evaluated the effectiveness of a supported self-help preventive cognitive therapy (S-PCT) added to treatment as usual (TAU) in primary care, compared to TAU alone. Methods: We conducted a randomized controlled trial among 248 patients with a history of depression, currently in full or partial remission or recovery. Participants were randomized to TAU augmented with S-PCT (n = 124) or TAU alone (n = 124). S-PCT consisted of an 8-week self-help intervention, supported by weekly telephone guidance by a counselor. The intervention included a self-help book that could be read at home. The primary outcome was the incidence of relapse or recurrence and was assessed over the telephone by the Structured Clinical Interview for DSM-IV axis 1 disorders. Participants were observed for 12 months. Secondary outcomes were depressive symptoms, quality of life (EQ-5D and SF-12), comorbid psychopathology, and self-efficacy. These secondary outcomes were assessed by digital questionnaires. Results: In the S-PCT group, 44 participants (35.5) experienced a relapse or recurrence, compared to 62 participants (50.0) in the TAU group (incidence rate ratio = 0.71, 95 CI 0.52-0.97; risk difference = 14, 95 CI 2-24, number needed to treat = 7). Compared to the TAU group, the S-PCT group showed a significant reduction in depressive symptoms over 12 months (mean difference-2.18; 95 CI-3.09 to-1.27) and a significant increase in quality of life (EQ-5D) (mean difference 0.04; 95 CI 0.004-0.08). S-PCT had no effect on comorbid psychopathology, self-efficacy, and quality of life based on the SF-12. Conclusions: A supported self-help preventive cognitive therapy, guided by a counselor in primary care, proved to be effective in reducing the burden of recurrent depression

A supported self-help for recurrent depression in primary care; an economic evaluation alongside a multi-center randomised controlled trial

Background Major depression is a prevalent mental disorder with a high risk of relapse or recurrence. Only few studies have focused on the cost-effectiveness of interventions aimed at the prevention of relapse or recurrence of depression in primary care. Aim To evaluate the cost-effectiveness of a supported Self-help Preventive Cognitive Therapy (S-PCT) added to treatment-as-usual (TAU) compared with TAU alone for patients with a history of depression, currently in remission. Methods An economic evaluation alongside a multi-center randomised controlled trial was performed (n = 248) over a 12-month follow-up. Outcomes included relapse or recurrence of depression and quality-adjusted-life-years (QALYs) based on the EuroQol-5D. Analyses were performed from both a societal and healthcare perspective. Missing data were imputed using multiple imputations. Uncertainty was estimated using bootstrapping and presented using the cost-effectiveness plane and the Cost- Effectiveness Acceptability Curve (CEAC). Cost estimates were adjusted for baseline costs. Results S-PCT statistically significantly decreased relapse or recurrence by15% (95%CI 3;28) compared to TAU. Mean total societal costs were €2,114 higher (95%CI -112;4261). From a societal perspective, the ICER for recurrence of depression was 13,515. At a Willingness To Pay (WTP) of 22,000 €/recurrence prevented, the probability that S-PCT is cost-effective, in comparison with TAU, is 80%. From a healthcare perspective, the WTP at a probability of 80% should be 11,500 €/recurrence prevented. The ICER for QALYs was 63,051. The CEA curve indicated that at a WTP of 30,000 €/QALY gained, the probability that S-PCT is cost-effective compared to TAU is 21%. From a healthcare perspective, at a WTP of 30,000 €/QALY gained, the probability that S-PCT is cost-effective compared to TAU is 46%. Conclusions Though ultimately depending on the WTP of decision makers, we expect that for both relapse or recurrence and QALYs, S-PCT cannot be considered cost-effective compared to TAU

Supported self-help to prevent relapse or recurrence of depression: who benefits most?

Objectives To identify subgroups for whom supported self-help preventive cognitive therapy (S-PCT) is more (cost)effective than treatment as usual (TAU) in preventing relapse and recurrence of major depression. Methods We conducted a randomized controlled trial in which 248 remitted, recurrently depressed participants were randomized to S-PCT (n=124) or TAU (n=124). Clinical outcome was relapse or recurrence of major depressive disorder (SCID-I). We tested the potential moderating effects on relapse or recurrence of age, gender, education level, residual depressive symptoms, number of previous episodes, age of onset, antidepressant medication, somatization, and self-efficacy with logistic regression analyses adjusted for baseline values of depressive symptoms. We examined moderating effects on costs using linear regression analyses adjusted for baseline costs. A stratified cost-effectiveness analysis was performed to tease out differences in cost-effectiveness between subgroups. Results We found no moderating effect on relapse or recurrence for any of the potential moderators. For costs, the number of previous depressive episodes was identified as a moderator. At a willingness-to-pay of 16,000€, the probability that S-PCT was cost-effective compared to TAU was 95% for participants with 2-3 previous episodes and 11% for participants with ≥4 episodes. Conclusions S-PCT was effective in preventing relapse or recurrence of depressive disorders in a broad range of participants, but is more likely to be cost-effective in participants with 2-3 episodes than with ≥4 episodes. This indicates that S-PCT can best be offered to participants with fewer previous depressive episodes

Treatment of chronically depressed patients: A multisite randomized controlled trial testing the effectiveness of 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) for chronic depressions versus usual secondary care

AbstractBackground'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) is a form of psychotherapy specifically developed for patients with chronic depression. In a study in the U.S., remarkable favorable effects of CBASP have been demonstrated. However, no other studies have as yet replicated these findings and CBASP has not been tested outside the United States. This protocol describes a randomized controlled trial on the effectiveness of CBASP in the Netherlands.Methods/DesignThe purpose of the present paper is to report the study protocol of a multisite randomized controlled trial testing the effectiveness of 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) for chronic depression in the Netherlands. In this study, CBASP in combination with medication, will be tested versus usual secondary care in combination with medication. The aim is to recruit 160 patients from three mental health care organizations. Depressive symptoms will be assessed at baseline, after 8 weeks, 16 weeks, 32 weeks and 52 weeks, using the 28-item Inventory for Depressive Symptomatology (IDS). Effect modification by co morbid anxiety, alcohol consumption, general and social functioning and working alliance will be tested. GEE analyses of covariance, controlling for baseline value and center will be used to estimate the overall treatment effectiveness (difference in IDS score) at post-treatment and follow up. The primary analysis will be by 'intention to treat' using double sided tests. An economic analysis will compare the two groups in terms of mean costs and cost-effectiveness from a societal perspective.DiscussionThe study will provide an answer to the question whether the favorable effects of CBASP can be replicated outside the US

Patients with a preference for medication do equally well in mindfulness-based cognitive therapy for recurrent depression as those preferring mindfulness

Item does not contain fulltextBACKGROUND: Previous studies have suggested that patients' treatment preferences may influence treatment outcome. The current study investigated whether preference for either mindfulness-based cognitive therapy (MBCT) or maintenance antidepressant medication (mADM) to prevent relapse in recurrent depression was associated with patients' characteristics, treatment adherence, or treatment outcome of MBCT. METHODS: The data originated from two parallel randomised controlled trials, the first comparing the combination of MBCT and mADM to MBCT in patients preferring MBCT (n=249), the second comparing the combination to mADM alone in patients preferring mADM (n=68). Patients' characteristics were compared across the trials (n=317). Subsequently, adherence and clinical outcomes were compared for patients who all received the combination (n=154). RESULTS: Patients with a preference for mADM reported more previous depressive episodes and higher levels of mindfulness at baseline. Preference did not affect adherence to either MBCT or mADM. With regard to treatment outcome of MBCT added to mADM, preference was not associated with relapse/recurrence (chi(2)=0.07; p=.80), severity of (residual) depressive symptoms during the 15-month follow-up period (beta=-0.08, p=.49), or quality of life. LIMITATIONS: The group preferring mADM was relatively small. The influence of preferences on outcome may have been limited in the current study because both preference groups received both interventions. CONCLUSIONS: The fact that patients with a preference for medication did equally well as those with a preference for mindfulness supports the applicability of MBCT for recurrent depression. Future studies of MBCT should include measures of preferences to increase knowledge in this area

Why Uptake of Blended Internet-Based Interventions for Depression Is Challenging: A Qualitative Study on Therapists' Perspectives

(1) Background: Blended cognitive behavioral therapy (bCBT; online and face-to-face sessions) seems a promising alternative alongside regular face-to-face CBT depression treatment in specialized mental health care organizations. Therapists are key in the uptake of bCBT. This study focuses on therapists' perspectives on usability, satisfaction, and factors that promote or hinder the use of bCBT in routine practice; (2) Methods: Three focus groups (n = 8, n = 7, n = 6) and semi-structured in-depth interviews (n = 15) were held throughout the Netherlands. Beforehand, the participating therapists (n = 36) completed online questionnaires on usability and satisfaction. Interviews were analyzed by thematic analysis; (3) Results: Therapists found the usability sufficient and were generally satisfied with providing bCBT. The thematic analysis showed three main themes on promoting and hindering factors: (1) therapists' needs regarding bCBT uptake, (2) therapists' role in motivating patients for bCBT, and (3) therapists' experiences with bCBT; (4) Conclusions: Overall, therapists were positive; bCBT can be offered by all CBT-trained therapists and future higher uptake is expected. Especially the pre-set structure of bCBT was found beneficial for both therapists and patients. Nevertheless, therapists did not experience promised time-savings-rather, the opposite. Besides, there are still teething problems and therapeutic shortcomings that need improvement in order to motivate therapists to use bCBT

Patients' preferences in the treatment of depressive disorder in primary care

Patients' preferences in the treatment of depression are important in clinical practice and in research. Antidepressant medication is often prescribed, but adherence is low. This may be caused by patients preferring psychotherapy, which is often not available in primary care. In randomized clinical trials, patients' preferences may affect the external validity. The aim of this article is to study patients' preferences regarding psychotherapy and antidepressant medication and the impact of these preferences on treatment outcome. A systematic review of the literature was performed. The majority of patients preferred psychotherapy in all available studies. Antidepressants were often regarded as addictive and psychotherapy was assumed to solve the cause of depression. Discussing and supporting preferences as part of a quality improvement program of depression care, resulted in more patients receiving the treatment that was most suitable to them. In two patient-preference trials, preferences did not influence treatment outcome. It can be concluded that a substantial percentage of well-informed patients prefer psychotherapy. Patients with strong preferences, mostly for psychotherapy, are likely not to enter antidepressant treatment or randomized clinical trials if their preferences are not supported

Depression, anxiety and 6-year risk of cardiovascular disease

Objective: Depression and anxiety are considered etiological factors in cardiovascular disease (ND), though their relative contribution and differentiation by clinical characteristics have not been studied intensively. We examined 6-year associations between depressive and anxiety disorders, clinical characteristics and newly-developed ND. Methods: DSM-IV diagnoses were established in 2510 DID-free participants of the Netherlands Study of Depression and Anxiety. Data on subtype, severity, and psychoactive medication were collected. The 6-year incidence of ND was assessed using Cox regression analyses adjusted for sociodemographic, health and lifestyle factors. Results: One-hundred-six subjects (4.2%) developed CVD. Having both current depressive and anxiety disorders (HR = 2.86, 95%CI 1.49-5.49) or current depression only (HR = 230; 95%CI 1.10-4.80) was significantly associated with increased ND incidence, whereas current anxiety only (HR = 1.48; 95%CI 0.74-2.96) and remitted disorders (HR = 1.48; 95%CI 0.80-2.75) were not associated. Symptom severity was associated with increased ND onset (e.g., Inventory of Depressive Symptomatology per SD increase: HR = 1.51; 95%CI 125-1.83). Benzodiazepine use was associated with additional ND risk (HR = 1.95; 95%CI 1.16-331). Conclusions: Current depressive (but not anxiety) disorder independently contributed to CVD in our sample of initially DID-free participants. DID incidence over 6 years of follow-up was particularly increased in subjects with more symptoms, and in those using benzodiazepines. (C) 2014 Elsevier Inc. All rights reserved