Comparative effectiveness research trial for antidepressant incomplete and non-responders with treatment resistant depression (ASCERTAIN-TRD) a randomized clinical trial.

Further research is needed to help improve both the standard of care and the outcome for patients with treatment-resistant depression. A particularly critical evidence gap exists with respect to whether pharmacological or non-pharmacological augmentation is superior to antidepressant switch, or vice-versa. The objective of this study was to compare the effectiveness of augmentation with aripiprazole or repetitive transcranial magnetic stimulation versus switching to the antidepressant venlafaxine XR (or duloxetine for those not eligible to receive venlafaxine) for treatment-resistant depression. In this multi-site, 8-week, randomized, open-label study, 278 subjects (196 females and 82 males, mean age 45.6 years (SD 15.3)) with treatment-resistant depression were assigned in a 1:1:1 fashion to treatment with either of these three interventions; 235 subjects completed the study. 260 randomized subjects with at least one post-baseline Montgomery-Asberg Depression Rating (MADRS) assessment were included in the analysis. Repetitive transcranial magnetic stimulation (score change (standard error (se)) = -17.39 (1.3) (p = 0.015) but not aripiprazole augmentation (score change (se) = -14.9 (1.1) (p = 0.069) was superior to switch (score change (se) = -13.22 (1.1)) on the MADRS. Aripiprazole (mean change (se) = -37.79 (2.9) (p = 0.003) but not repetitive transcranial magnetic stimulation augmentation (mean change (se) = -42.96 (3.6) (p = 0.031) was superior to switch (mean change (se) = -34.45 (3.0)) on the symptoms of depression questionnaire. Repetitive transcranial magnetic stimulation augmentation was shown to be more effective than switching antidepressants in treatment-resistant depression on the study primary measure. In light of these findings, clinicians should consider repetitive transcranial magnetic stimulation augmentation early-on for treatment-resistant depression.Trial registration: ClinicalTrials.gov, NCT02977299.

Effectiveness of Mindful Self-Compassion Training Supported by Online Peer Groups in China: A Pilot Study.

Context: Self-compassion training involves the cultivation of feelings of warmth and safety, presence, and interconnectedness. Mindful Self-Compassion (MSC) training in a group setting has been found to increase self-compassion, mindfulness, and emotional well-being. Objective: The current study intended to examine the outcomes of live, online, videoconference-based MSC training with online peer-support for nonclinical populations in different cities in China. Design: The research team designed a pre-post pilot study. Setting: The study took place at Renmin University in Beijing, China. Participants: Participants were 253 Chinese individuals who were recruited from different regions in China through online advertisements. Intervention: Participants took part in online MSC training in a two-hour, group class each week for eight weeks and received support from online peer groups and through a half-day in-person retreat. Outcome Measures: Self-report outcomes were obtained at baseline and postintervention, using the Self Compassion Scale (SCS) and the Compassion for Others Scale (CS) for primary outcomes, and the Depression, Anxiety, and Stress Scale (DASS-21), the Fear of Compassion Scale (FOCS), the Satisfaction with Life Scale (SWLS), the Subjective Happiness Scale (SHS), and the Cognitive and Affective Mindfulness Scale (CAMS-R), for secondary outcomes. A fixed effects model was used to test for within-group changes in the scales. Results: The online MSC program yielded a high retention rate. Of the 206 first-time participants, 179 (86.9%) attended six or more of the eight MSC sessions, and 183 (88.8%) completed the assessments at both baseline and postintervention. Of the 183 retained participants, 97.8% were female, with an average age of 37.8 ± 7.9; 94% had college or higher education. For all scales, the within-person changes occurred in the expected direction; positive attributes and experiences increased, while negative attributes and experiences decreased. Conclusions: The study showed that first-time participants in China in an online MSC training that was supported by online peer groups had high attendance rates, high assessment completion, and favorable results. These preliminary outcomes suggest that future studies with more rigorous designs are warranted to further investigate online training with peer support as an effective and efficient approach to disseminate MSC training in China.

Four-Week Mentalizing Imagery Therapy for Family Dementia Caregivers: A Randomized Controlled Trial with Neural Circuit Changes.

INTRODUCTION: Family caregivers of patients with dementia suffer a high burden of depression and reduced positive emotions. Mentalizing imagery therapy (MIT) provides mindfulness and guided imagery skills training to improve balanced mentalizing and emotion regulation. OBJECTIVE: Our aims were to test the hypotheses that MIT for family caregivers would reduce depression symptoms and improve positive psychological traits more than a support group (SG), and would increase dorsolateral prefrontal cortex (DLPFC) connectivity and reduce subgenual anterior cingulate cortex (sgACC) connectivity. METHODS: Forty-six caregivers participated in a randomized controlled trial comparing a 4-week MIT group (n = 24) versus an SG (n = 22). Resting state neuroimaging was obtained at baseline and post-group in 28 caregivers, and questionnaires completed by all participants. The primary outcome was change in depression; secondary measures included anxiety, mindfulness, self-compassion, and well-being. Brain networks with participation of DLPFC and sgACC were identified. Connectivity strengths of DLPFC and sgACC with respective networks were determined with dual regression. DLPFC connectivity was correlated with mindfulness and depression outcomes. RESULTS: MIT significantly outperformed SG in improving depression, anxiety, mindfulness, self-compassion, and well-being, with moderate to large effect sizes. Relative to SG, participants in MIT showed significant increases in DLPFC connectivity - exactly replicating pilot study results - but no change in sgACC. DLPFC connectivity change correlated positively with mindfulness and negatively with depression change. CONCLUSIONS: In this trial, MIT was superior to SG for reducing depression and anxiety symptoms and improving positive psychological traits. Neuroimaging results suggested that strengthening DLPFC connectivity with an emotion regulation network might be mechanistically related to MIT effects.

How family dementia caregivers perceive benefits of a 4-week Mentalizing Imagery Therapy program: a pilot study.

Background: Family caregivers of dementia patients experience high levels of interpersonal stress that often results in elevated anxiety, and depression, and negative impacts on interpersonal relationships. Changes in behaviors and the structure of relationships with the care recipient (CR) and others in the social milieu challenge the caregivers' ability to mentalize, or understand the links between mental states and behaviors. This study investigates the experiences and perceived benefits of family dementia caregivers who underwent Mentalizing Imagery Therapy (MIT), a treatment aiming to improve balanced self-other mentalizing and reduce psychological symptoms. Methods: Purposeful sampling was used to select 11 family dementia caregivers who underwent a 4-week pilot trial of MIT. Semi-structured interviews were completed post-intervention to identify subjective benefits, putative psychological mediators and perceived active components. Results: Caregivers reported improvements in well-being, mood, anxiety, and sleep, and a majority stated MIT helped with forming and maintaining healthier relationships. Some participants noted benefits extending to how they reacted to their social environment and perceived themselves more objectively from others' perspectives. Specific elements of MIT, including self-compassion, self-care, and the ability to reflect on emotionally arousing challenges, might have mediated these improvements. Conclusion: Family dementia caregivers perceived salutary benefits of MIT on multiple domains of well-being. The self reports suggest MIT holds promise for improving well-being, reducing non-mentalizing patterns of thought, and facilitating improvements in balanced mentalization within the caregivers' relationships.

Use of the Move to Emptiness Technique, A Mind-Body Exercise for Treating Trauma and Post-Traumatic Stress Disorder: A Case Report.

CONTEXT: The paper reports a case of trauma treated by the Move to Emptiness Technique (MET), which is a therapy to alleviate patient's physical or psychological symptom related to trauma by combining Qigong with imagery, metaphor and suggestions. OBJECTIVE: To introduce MET and report treating a patient with trauma using MET. INTERVENTION: The patient was guided to visualize a symbolic object that represented the physical or psychological symptom of the traumatic experience, and visualize moving the symbolic object to the farthest possible space of "emptiness", where the object became imperceptible. At the same time, the patient embodied the physical and emotional sensations of the symbolic object and its container, and focused on the changes in his sensations when moving them. OUTCOME MEASURES: A self-assessment was used to score the patient's distress form 0 to 10, 10 being the worst before and after intervention. RESULTS: The score of distress dropped form 8/10 to 2/10. The patient improved a lot and was better able to manage his emotions and communicate with his parents after resolving his conflict. CONCLUSIONS: MET may be an alternative to commonly used trauma-focused treatments. It is safe and easy to learn for therapists and patients.

Pannexin-1 in the CNS: Emerging concepts in health and disease.

Pannexin-1 (Panx1) is a large pore membrane channel with unique conduction properties ranging from non-selective ion permeability to the extracellular release of signalling molecules. The release of ATP by Panx1 has been particularly well-characterized with implications in purine signalling across a variety of biological contexts. Panx1 activity is also important in inflammasome formation and the secretion of pro-inflammatory molecules such as interleukin-1ß. Within the central nervous system (CNS), Panx1 is expressed on both neurons and glia, and is thought to mediate crosstalk between these cells. A growing body of literature now supports the pathological activity of Panx1 in contributing to disease processes including seizure, stroke, migraine headache and chronic pain. Emerging evidence also reveals a physiological function of Panx1 in regulating neural stem cell survival, neuronal maturation and synaptic plasticity, with possible relevance to normal cognitive functioning. The aim of this review is to summarize the current evidence regarding the roles of Panx1 in the CNS, with emphasis on how putative signalling properties and activation mechanisms of this channel contribute to various physiological and pathophysiological processes.

Qigong for the Prevention, Treatment, and Rehabilitation of COVID-19 Infection in Older Adults.

The elderly are at high risk of contracting respiratory infectious diseases, including COVID-19 infection. The recent pandemic has the potential to cause significant physical and mental damage in older adults. Similarly to other mind-body exercises in Traditional Chinese medicine, Qigong features regulation of breath rhythm and pattern, body movement and posture, and meditation. Given these traits, Qigong has the potential to play a role in the prevention, treatment, and rehabilitation of respiratory infections, such as COVID-19. Potential mechanisms of action include stress reduction, emotion regulation, strengthening of respiratory muscles, reduction of inflammation, and enhanced immune function. Three forms of Qigong; abdominal breathing, Ba Duan Jin and Liu Zi Jue, all of which are gentle, smooth, and simple for the elderly to practice, are recommended in this context.

Cultural Humility and the Practice of Consultation-Liaison Psychiatry.

BACKGROUND: Cultural competency has long been the gold standard for clinicians who treat patients of different races and/or cultural backgrounds than their own. However, in recent years, there has been increasing criticism of the cultural competency framework because of its reliance on stereotypes and an overemphasis on knowledge acquisition. OBJECTIVE: We review this transition, including the critiques of cultural competency. We highlight trends in psychiatrist diversity, education, and training on cultural humility, including how consultation-liaison psychiatrists can incorporate advances in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, regarding the role of culture in clinical diagnosis, treatment, and management. METHODS: We review the transition from cultural competency to cultural humility, including the critiques of cultural competency. We highlight trends in psychiatrist diversity, education, and training on cultural humility. RESULTS: We illustrate how consultation-liaison psychiatrists can incorporate advances in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, regarding the role of culture in clinical diagnosis, treatment, and management. CONCLUSIONS: Cultural humility, which minimizes the power imbalance between clinicians and patients and emphasizes patient-focused interviewing and care, is a useful approach for consultation-liaison psychiatrists working with diverse patients and with diverse multidisciplinary teams in the general hospital.

Persistence and remission of depressive symptoms and psycho-social correlates in Chinese early adolescents.

BACKGROUND: This study aimed to investigate a one-year course of persistent/remitted depressive symptoms and associated demographic and psychosocial factors that predict persistent/remitted depressive symptoms in Chinese high school students. METHODS: One thousand five hundred forty-four Grade 7 students provided data for the first wave. Of the initially recruited students, 483 who were classified as depressed (CESD score ≥ 16) at baseline were then tracked and invited to fill in the questionnaire for a second time (Grade 8) after 1 year. Finally, 435 of them were successfully matched. RESULTS: Two hundred two (46.4%) of the subset categorized as depressed in the first survey (N = 435) remained with depressive symptoms, while 233 (53.6%) recovered from depression 1 year later. Having siblings, a lower level of positive youth development, non-intact family status, and poor family functioning at baseline significantly predicted a higher likelihood of persistent depression, while those with fathers having higher educational qualifications (bachelor's degree or higher) at baseline showed a significantly higher probability of remitting from depression. CONCLUSIONS: The findings indicated that the prevalence of persistent depressive symptoms was generally high, and promoting aspects of positive youth development and family functioning for adolescents could be promising in preventing or reducing these symptoms.

The Beneficial Effects of Mind-Body Exercises for People With Mild Cognitive Impairment: a Systematic Review With Meta-analysis.

OBJECTIVE: To objectively evaluate the most common forms of mind-body exercise (MBE) (tai chi, yoga, qigong) on cognitive function among people with mild cognitive impairment (MCI). DATA SOURCES: We searched 6 electronic databases (Scopus, PubMed, PsycINFO, WanFang, Web of Science, CNKI) from inception until September 2018. STUDY SELECTION: Nine randomized controlled trials and 3 nonrandomized controlled trials were included for meta-analysis. DATA EXTRACTION: Two researchers independently performed the literature searches, study selection, data extraction, and methodological quality assessment using the revised Physiotherapy Evidence Database (PEDro) scale. DATA SYNTHESIS: The pooled effect size (standardized mean difference [SMD]) was calculated while random-effect model was selected. Overall results of the meta-analysis (N=1298 people with MCI) indicated that MBE significantly improved attention (SMD=0.39, 95% confidence interval [CI] 0.07-0.71, P=.02, I2=31.6%, n=245), short-term memory (SMD=0.74, 95% CI 0.57-0.90, P<.001, I2=0%, n=861), executive function (SMD=-0.42, 95% CI -0.63 to -0.21, P<.001, I2=38.54%, n=701), visual-spatial/executive function (SMD=0.35, 95% CI 0.07-0.64, P<.05, I2=0%, n=285), and global cognitive function (SMD=0.36, 95% CI 0.2-0.52, P<.001, I2=15.12%, n=902). However, the significant positive effect on cognitive processing speed was not observed following MBE interventions (SMD=0.31, 95% CI -0.01 to 0.63, P=.054, I2=28.66%, n=233). CONCLUSIONS: Study findings of this meta-analysis suggest that MBE have the potential to improve various cognitive functions in people with MCI.

Effects of Tai Chi on Lower Limb Proprioception in Adults Aged Over 55: A Systematic Review and Meta-Analysis.

OBJECTIVE: To summarize and critically evaluate the effects of Tai Chi on lower limb proprioception in adults older than 55. DATA SOURCES: Seven databases (Scopus, PubMed, Web of Science, SPORTDiscus, Cochrane Library, Wanfang, CNKI) were searched from inception until April 14, 2018. STUDY SELECTION: Eleven randomized controlled trials were included for meta-analysis. DATA EXTRACTION: Two independent reviewers screened potentially relevant studies based on the inclusion criteria, extracted data, and assessed methodological quality of the eligible studies using the Physiotherapy Evidence Database (PEDro). DATA SYNTHESIS: The pooled effect size (standardized mean difference [SMD]) was calculated while the random-effects model was selected. Physiotherapy Evidence Database scores ranged from 5 to 8 points (mean=6.7). The study results showed that Tai Chi had significantly positive effects on lower limb joint proprioception. Effect sizes were moderate to large, including ankle plantar flexion (SMD=-0.55; 95% confidence interval [95% CI], -0.9 to -0.2; P=.002; I2=0%; n=162), dorsiflexion (SMD=-0.75; 95% CI, -1.11 to -0.39; P<.001; I2=0%; n=162), nondominant or left knee flexion (SMD=-0.71; 95% CI, -1.10 to -0.41; P<.001; I2=25.1%; n=266), dominant or right knee flexion (SMD=-0.82; 95% CI, -1.06 to -0.58; P<.001; I2=33.8%; n=464). CONCLUSIONS: There is moderate to strong evidence that suggests that Tai Chi is an effective intervention to maintain and improve lower limb proprioception in adults older than 55. More robust multicenter studies including oldest-old participants, with longer follow-ups and validated outcome measures, are needed before a definitive conclusion is drawn.

Effects of transcranial photobiomodulation with near-infrared light on sexual dysfunction.

OBJECTIVES: Transcranial photobiomodulation (t-PBM) consists of the delivery of near-infrared (NIR) or red light to the scalp designed to penetrate to subjacent cortical areas of the brain. NIR t-PBM has recently emerged as a potential therapy for brain disorders. This study assessed the efficacy of repeated sessions of NIR t-PBM on sexual dysfunction. METHODS: We performed a secondary analysis of a double-blind clinical trial on t-PBM for major depressive disorder (MDD). Twenty individuals received NIR t-PBM (n = 9) or sham therapy (n = 11) twice a week for 8 weeks. Sexual desire, arousal, and orgasm were assessed using the Systematic Assessment for Treatment-Emergent Effects-Specific Inquiry (SAFTEE-SI). RESULTS: The mean improvement in sexual function (decrease in SAFTEE sex total score) in subjects receiving t-PBM in NIR-mode was significantly greater than in subjects receiving sham-mode in the whole sample (NIR [n = 9] -2.55 ± 1.88 vs. sham [n = 11] -0.45 ± 1.21; z = 2.548, P = 0.011]) and in the completers (NIR [n = 5] -3.4 ± 1.95 vs. sham [n = 7] -0.14 ± 1.21; z = 2.576, P = 0.010]). CONCLUSION: This exploratory study with a small sample size indicates that repeated sessions of NIR t-PBM may be associated with therapeutic effects on sexual dysfunction. The latter appeared unrelated to the antidepressant effect of t-PBM in our cohort. Lasers Surg. Med. 51:127-135, 2019. © 2018 Wiley Periodicals, Inc.

The Effects of Tai Chi Chuan Versus Core Stability Training on Lower-Limb Neuromuscular Function in Aging Individuals with Non-Specific Chronic Lower Back Pain.

Objectives: For this paper, we aimed to investigate the effects of Tai Chi Chuan (TCC) versus the Core Stability Training (CST) program on neuromuscular function (NF) in the lower extremities among aging individuals who suffered from non-specific chronic lower back pain (NLBP). Regarding the design, during a 12-week intervention, a single-blinded randomized controlled trial was used to compare two intervention groups with a control group on the parameters of NF. Methods: Forty-three Chinese community-dwellers were randomly assigned into two intervention groups (three sessions per week, with each session lasting 60 min in TCC and CST) and a control group. The patient-based Visual Analogue Scale (VAS) was used to measure the level of perceived pain, while parameters of NF as primary outcomes were measured by the Biodex System 3 Isokinetic Dynamometer. Results: For the knee joint, we observed significant differences in the endurance of left extension at a speed of 60°/s: (1) between TCC and control groups (p < 0.01); (2) between CST and control groups (p < 0.01). For the ankle joint, significant differences between CST and control groups were observed on the peak torque of left dorsiflexion (p < 0.05) and the endurance of the left plantar flexion at a speed of 60°/s (p < 0.05). In addition, we observed a significant difference between TCC and control groups in the endurance of the right plantar flexion (p < 0.05). Conclusions: Chen-style TCC and CST were found to have protective effects on NF in aging individuals with NLBP, while alleviating non-specific chronic pain.

Patient primary language in a culturally focused intervention for Latino Americans with depression.

BACKGROUND: This study examined whether a culturally focused psychiatric consultation program (CFP) for Latino Americans was equally effective in reducing depressive symptoms in English-speaking and Spanish-speaking patients. METHODS: The CFP utilizes the Engagement Interview Protocol (EIP), a semi-standardized protocol eliciting patient narratives about illness beliefs. The sample included 118 Latino American patients presenting with depressive symptoms. Patient-preferred primary language was examined as a moderator for the effect of CFP participation vs usual care on change in depressive symptoms. RESULTS: Multiple regression analysis revealed that the interaction effect of primary language and treatment arm on depressive symptoms, as measured by the Quick Inventory of Depressive Symptomatology-Self Report was not statistically significant at 6-month follow-up (B = -2.89, t = -1.35, P = .180). CONCLUSIONS: The findings suggest that the CFP was equally effective in both Spanish and English-speaking Latino Americans. The trend in the results toward greater reduction in depressive symptoms in primary Spanish-speaking Latino Americans as compared with primary English-speaking Latino Americans suggests the importance of receiving language-concordant care.

Exploring Asian American attitudes regarding mental health treatment in primary care: A qualitative study.

BACKGROUND: In this exploratory study, we examined attitudes regarding mental health treatment among 10 Asian American patients in an urban primary care setting to better understand contextual barriers to care. METHODS: Ten semi-structured telephone interviews were conducted with Asian Americans recruited from primary care practices in an urban medical center. RESULTS: The study's qualitative data suggest that focusing on specific cultural concerns is essential for increasing mental health access for Asian Americans. Although few participants initially expressed interest in a culturally focused mental health program themselves, when phrased as being part of their primary care practice, 8 expressed interest. Furthermore, most felt that the program could help family or friends. Many participants preferred to seek care initially from social systems and alternative and complementary medicine before seeking psychiatric care. CONCLUSIONS: Because Asian Americans face notable barriers to seeking mental health treatment, addressing cultural concerns by providing culturally sensitive care could help make mental health treatment more acceptable, particularly among less acculturated individuals. To our knowledge, this is the first qualitative study exploring barriers to Asian Americans accessing integrated mental health services in primary care.

Cultural Humility for Consultation-Liaison Psychiatrists.

BACKGROUND: Case presentation and analysis is a useful way to revisit key clinical themes, broad concepts, and teach others, especially when it comes to cross-cultural clinical issues. Patients from different cultural backgrounds tend to have different explanatory models of illnesses and related help seeking behaviors. Ineffective communication between clinicians and patients from nonmajority cultural groups may lead to less satisfaction with care and disparities in access to health care and in treatment outcomes. CONCLUSIONS: To address health disparities, psychiatrists need to be able to understand the illness beliefs of all patients, particularly those from diverse cultural backgrounds. Using cultural humility to work with patients from all cultures by understanding the patients' values and preferences is a key attitude for successful cross-cultural clinical encounters.

The Effects of Tai Chi on Sleep Quality in Chinese American Patients With Major Depressive Disorder: A Pilot Study.

OBJECTIVE: This pilot study evaluated the effects of Tai Chi training on sleep quality (primary outcomes), and depression and social functioning levels (secondary outcomes) among patients with depression. PARTICIPANTS: Sixteen depressed Chinese patients. METHODS: Participants received 1-hr Tai Chi training sessions 2 times per week for 10 weeks. Patients' subjective sleep quality ratings, objective sleep quality measurements, and depression and social functioning levels were measured before, during, and after the intervention. RESULTS: Sleep quality and depression outcomes improved significantly. Patients reported improved Pittsburgh Sleep Quality Index (PSQI) scores (9.6 ± 3.3 to 6.6 ± 5.2, p = 0.016), and cardiopulmonary coupling (CPC) analysis of electrocardiogram (ECG) showed decreased stable sleep onset latency (75.7 ± 100.6 to 20.9 ± 18.0, p = 0.014), increased stable sleep percentages (31.5 ± 18.7 to 46.3 ± 16.9, p = 0.016), and decreased unstable sleep percentages (45.3 ± 20.1 to 30.6 ± 16.5, p = 0.003). Patients also reported decreased Hamilton Rating Scale for Depression (HAM-D-17; 20.1 ± 3.7 to 7.8 ± 5.9, p < 0.001) and Beck Depression Inventory (BDI) scores (22.3 ± 9.1 to 11.1 ± 10.6, p = 0.006). Significant correlations were found between the changes in subjective sleep assessments ΔPSQI and ΔHAM-D-17 (r = 0.6, p = 0.014), and ΔPSQI and ΔBDI (r = 0.62, p = 0.010). Correlations between changes in objective sleep measurements and changes in depression symptoms were low and not significant. CONCLUSIONS: Tai Chi training improved sleep quality and mood symptoms among depressed patients.

Selective Cutoff Reporting in Studies of Diagnostic Test Accuracy: A Comparison of Conventional and Individual-Patient-Data Meta-Analyses of the Patient Health Questionnaire-9 Depression Screening Tool.

In studies of diagnostic test accuracy, authors sometimes report results only for a range of cutoff points around data-driven "optimal" cutoffs. We assessed selective cutoff reporting in studies of the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. We compared conventional meta-analysis of published results only with individual-patient-data meta-analysis of results derived from all cutoff points, using data from 13 of 16 studies published during 2004-2009 that were included in a published conventional meta-analysis. For the "standard" PHQ-9 cutoff of 10, accuracy results had been published by 11 of the studies. For all other relevant cutoffs, 3-6 studies published accuracy results. For all cutoffs examined, specificity estimates in conventional and individual-patient-data meta-analyses were within 1% of each other. Sensitivity estimates were similar for the cutoff of 10 but differed by 5%-15% for other cutoffs. In samples where the PHQ-9 was poorly sensitive at the standard cutoff, authors tended to report results for lower cutoffs that yielded optimal results. When the PHQ-9 was highly sensitive, authors more often reported results for higher cutoffs. Consequently, in the conventional meta-analysis, sensitivity increased as cutoff severity increased across part of the cutoff range-an impossibility if all data are analyzed. In sum, selective reporting by primary study authors of only results from cutoffs that perform well in their study can bias accuracy estimates in meta-analyses of published results.

A comparison of bivariate, multivariate random-effects, and Poisson correlated gamma-frailty models to meta-analyze individual patient data of ordinal scale diagnostic tests.

Individual patient data (IPD) meta-analyses are increasingly common in the literature. In the context of estimating the diagnostic accuracy of ordinal or semi-continuous scale tests, sensitivity and specificity are often reported for a given threshold or a small set of thresholds, and a meta-analysis is conducted via a bivariate approach to account for their correlation. When IPD are available, sensitivity and specificity can be pooled for every possible threshold. Our objective was to compare the bivariate approach, which can be applied separately at every threshold, to two multivariate methods: the ordinal multivariate random-effects model and the Poisson correlated gamma-frailty model. Our comparison was empirical, using IPD from 13 studies that evaluated the diagnostic accuracy of the 9-item Patient Health Questionnaire depression screening tool, and included simulations. The empirical comparison showed that the implementation of the two multivariate methods is more laborious in terms of computational time and sensitivity to user-supplied values compared to the bivariate approach. Simulations showed that ignoring the within-study correlation of sensitivity and specificity across thresholds did not worsen inferences with the bivariate approach compared to the Poisson model. The ordinal approach was not suitable for simulations because the model was highly sensitive to user-supplied starting values. We tentatively recommend the bivariate approach rather than more complex multivariate methods for IPD diagnostic accuracy meta-analyses of ordinal scale tests, although the limited type of diagnostic data considered in the simulation study restricts the generalization of our findings.

Health and well-being benefits of spending time in forests: systematic review.

BACKGROUND: Numerous studies have reported that spending time in nature is associated with the improvement of various health outcomes and well-being. This review evaluated the physical and psychological benefits of a specific type of exposure to nature, forest therapy. METHOD: A literature search was carried out using MEDLINE, PubMed, ScienceDirect, EMBASE, and ProQuest databases and manual searches from inception up to December 2016. Key words: "Forest" or "Shinrin -Yoku" or "Forest bath" AND "Health" or "Wellbeing". The methodological quality of each randomized controlled trials (RCTs) was assessed according to the Cochrane risk of bias (ROB) tool. RESULTS: Six RCTs met the inclusion criteria. Participants' ages ranged from 20 to 79 years. Sample size ranged from 18 to 99. Populations studied varied from young healthy university students to elderly people with chronic disease. Studies reported the positive impact of forest therapy on hypertension (n = 2), cardiac and pulmonary function (n = 1), immune function (n = 2), inflammation (n = 3), oxidative stress (n = 1), stress (n = 1), stress hormone (n = 1), anxiety (n = 1), depression (n = 2), and emotional response (n = 3). The quality of all studies included in this review had a high ROB. CONCLUSION: Forest therapy may play an important role in health promotion and disease prevention. However, the lack of high-quality studies limits the strength of results, rendering the evidence insufficient to establish clinical practice guidelines for its use. More robust RCTs are warranted.