Instrumental support to facilitate hepatitis C treatment adherence: working around shortfalls in shared-care.

Adherence to treatment for hepatitis C virus (HCV) infection is associated with the successful eradication of infection. However, patients often have difficulty adhering to HCV treatment because of factors such as the psychiatric side effects of regimens and social disadvantage. Commonly, health professionals including specialist physicians, nurses, social workers and psychologists work together under a multidisciplinary model of shared-care to support patients' adherence to HCV treatment. In some HCV treatment clinics, shared-care is not always available, or only partially implemented and this has implications for patient adherence. To explore the facilitators of adherence, an interview-based study was conducted in 2012 with a purposive sample of Australian physicians and nurses (N = 20). The findings reveal that when comprehensive shared-care was limited or unavailable, physicians and nurses filled in the gaps by assuming roles outside of their expertise to help patients adhere to HCV treatment. Physicians and nurses applied instrumental support strategies based on psychosocial interventions, namely patient advocacy, pragmatic problem-solving, treatment engagement and emotional support. These strategies were provided by dedicated physicians and nurses to address shortfalls in multidisciplinary shared-care. Although these interventions were reported to assist adherence, there is an increased risk of complications when physicians and nurses move beyond the bounds of their disciplinary training, for example, to assess and manage patients' psychiatric side effects or advocate on their behalf for social services. Future research should measure the effectiveness of instrumental support strategies on HCV treatment adherence, and explore the costs associated with physicians and nurses providing instrumental support in the absence of comprehensive multidisciplinary shared-care.

Cognitive behavior therapy for depression in people with epilepsy: a systematic review.

Cognitive behavioral therapy (CBT) is a recommended treatment for depression in people with epilepsy (PWE); however, a recent Cochrane review found that there was insufficient evidence that any psychological therapy is effective. This conclusion provides little help to clinicians who provide interventions for depressed PWE. The aim of this review was to systematically and qualitatively review the literature on the efficacy of CBT for depression in PWE based on randomized controlled trials (RCTs) and case series. We aim to determine patterns in the literature to inform the type of CBT, if any, that should be offered to PWE who are depressed. Databases MEDLINE, PsycINFO, and the Cochrane EBM Reviews were searched via OVID. Selection criteria included the following: (1) participants with epilepsy; (2) use of CBT; (3) valid depression outcome measure; and (4) published in peer-reviewed journal in English. Inclusions of studies were assessed by two independent researchers. We identified 14 outcome papers for 13 CBT trials including 6 randomized controlled trials (RCTs) and 7 case series. Positive effects of CBT on depression were reported in three of six RCTs. A review of their content revealed that all effective RCTs specifically tailored CBT to improve depression. Conversely, two of three RCTs that failed to find depression-related effects focused on improving seizure-control. This pattern was also observed in the case series. Although limited in number and having methodologic limitations, the treatment studies included in our review suggest that interventions tailored toward improving depression are possibly efficacious, whereas those that focus on improving seizure control do not appear to be. However, this review highlights that there is need for further RCTs in this area in order to confirm the possible efficacy of CBT for depression in PWE.

Psychological, lifestyle and social predictors of hepatitis C treatment response: a systematic review.

BACKGROUND: To increase cure rates for Hepatitis C, barriers to treatment adherence and completion must be identified and overcome. AIMS: This study systematically reviewed evidence on the psychological, lifestyle and social determinants of achieving viral eradication with antiviral therapy. METHODS: An electronic search strategy was used to identify relevant studies that examined psychological, lifestyle and social factors related to achieving a sustained virological response (SVR). RESULTS: Thirty-four studies that matched our criteria were identified. Of the factors that predict response to treatment, Asian ethnicity was an independent predictor of SVR. We found an indirect relationship between diet and SVR, with non-responders to treatment consuming more polyunsaturated fatty acids, fats and carbohydrates than those who attained SVR. The effect of alcohol consumption relied on the amount consumed; fewer than 30 grams daily had no effect on SVR, whereas >70 grams daily had an adverse impact on a patient's ability to achieve SVR, with termination rates up to 44% in those who drank >2 drinks a day. Patients with psychiatric illnesses had comparable SVR rates to controls if they continued psychological therapy (average 42%), although discontinuation rates were high with 11 studies reporting rates from 14 to 48%. CONCLUSIONS: There are major gaps in current knowledge of the impact of variables such as diet, exercise, attitudes and coping skills on cure rates in chronic Hepatitis C. Those who drink limited amounts of alcohol or have psychiatric disorders should be offered treatment for their disease, with adjunctive education and support to improve treatment completion.

Rates of DSM-IV mood, anxiety disorders, and suicidality in Australian adult epilepsy outpatients: a comparison of well-controlled versus refractory epilepsy.

Despite recent research into the impact of seizure control on mood disorders in epilepsy, it is often assumed that rates of psychiatric disorders are higher in people with refractory rather than well-controlled epilepsy. We assessed the point prevalence of mood and anxiety disorders and suicide risk using the Mini International Neuropsychiatric Interview (MINI) in a consecutive sample of epilepsy outpatients from a tertiary referral center. One hundred and thirty patients, whose epilepsy was categorized as well-controlled versus drug-treatment-refractory epilepsy (69; 53% well-controlled epilepsy) were recruited. High rates of mood disorders (n = 34; 26%), anxiety disorders (n = 37; 29%) and suicide risk (n = 43; 33%) were found. However, there was no difference in rates of disorders or suicide risk for those with refractory versus well-controlled epilepsy. These results underscore the importance of assessment and management of psychopathology in all people with epilepsy, regardless of their seizure control.

Anxiety in epilepsy: a neglected disorder.

OBJECTIVE: Anxiety disorders and symptoms are highly prevalent and problematic comorbidities in people with epilepsy (PWE), yet they remain poorly understood and often go undetected. This research aimed to further our understanding about anxiety in PWE. METHODS: Study 1 assessed the effectiveness of the commonly utilised yet unvalidated measure (Hospital Anxiety Depression Scale-Anxiety subscale; HADS-A) to identify DSM-IV anxiety disorders in 147 adult epilepsy outpatients. RESULTS: This study found that although the HADS-A had reasonable specificity (75%), its poor sensitivity (61%) and inadequate area under the curve (.68) deemed it unreliable as a screener for anxiety disorders in this population. METHODS: Study 2 aimed to further our understanding of the relationship between anxiety disorders, as defined by clinical interview, and psychosocial correlates in PWE. One hundred and twenty-two participants from Study 1 completed a battery of psychosocial measures. RESULTS: Multivariate analysis revealed that the presence of an anxiety disorder was associated with unemployment, which was found to be the only independent predictor. That is, despite the fact that psychosocial factors together contributed to the variance in anxiety disorders none were revealed to be significant independent predictors. CONCLUSION: These findings add to the literature indicating that the HADS may indicate distress, but does not adequately identify people with anxiety disorders and highlights the urgent need for the development of a reliable anxiety screening measure for PWE. Further, the results suggest that anxiety disorders in PWE are likely to be multiply determined with respect to psychosocial factors and require further investigation.

The Pain Course: a randomised controlled trial examining an internet-delivered pain management program when provided with different levels of clinician support.

The present study evaluated an internet-delivered pain management program, the Pain Course, when provided with different levels of clinician support. Participants (n = 490) were randomised to 1 of 4 groups: (1) Regular Contact (n = 143), (2) Optional Contact (n = 141), (3) No Contact (n = 131), and (4) a treatment-as-usual Waitlist Control Group (n = 75). The treatment program was based on the principles of cognitive behaviour therapy and comprised 5 internet-delivered lessons provided over 8 weeks. The 3 Treatment Groups reported significant improvements (between-group Cohen's d; avg. reduction) in disability (ds ≥ 0.50; avg. reduction ≥ 18%), anxiety (ds ≥ 0.44; avg. reduction ≥ 32%), depression (ds ≥ 0.73; avg. reduction ≥ 36%), and average pain (ds ≥ 0.30; avg. reduction ≥ 12%) immediately posttreatment, which were sustained at or further improved to 3-month follow-up. High treatment completion rates and levels of satisfaction were reported, and no marked or consistent differences were observed between the Treatment Groups. The mean clinician time per participant was 67.69 minutes (SD = 33.50), 12.85 minutes (SD = 24.61), and 5.44 minutes (SD = 12.38) for those receiving regular contact, the option of contact, and no clinical contact, respectively. These results highlight the very significant public health potential of carefully designed and administered internet-delivered pain management programs and indicate that these programs can be successfully administered with several levels of clinical support.

The psychosocial correlates of depressive disorders and suicide risk in people with epilepsy.

OBJECTIVE: Despite considerable effort to identify correlates of psychopathology in people with epilepsy (PWE), research has yet to identify consistent predictors. We tested the association between factors predicted by a model of adjustment to illness and psychopathology in PWE. METHODS: In 123 PWE recruited from a tertiary referral centre, we examined the cross-sectional relationship between psychosocial factors (illness representations, coping, self-illness enmeshment and self-efficacy) with depression and suicide risk, while controlling for condition-related and demographic factors. RESULTS: Multivariate analyses confirmed previous findings showing that condition-related and demographic variables did not consistently account for unique variance in depression although employment status was found to be a significant predictor of suicide risk. In multivariate analyses escape-avoidance coping and the illness consequences subscale of the illness representation questionnaire predicted unique variance in both depression and suicide risk. CONCLUSION: The results provided partial support for a model of adjustment to illness. Specifically, those who believed epilepsy was serious and coped through avoidance were more likely to be depressed and report a current level of suicide risk. These results suggest that interventions that target coping strategies and illness representations may be warranted for PWE with psychopathology.

The Pain Course: a randomised controlled trial of a clinician-guided Internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being.

The present study evaluated the efficacy of a clinician-guided Internet-delivered cognitive behaviour therapy (iCBT) program, the Pain Course, to reduce disability, anxiety, and depression associated with chronic pain. Sixty-three adults with chronic pain were randomised to either a Treatment Group or waitlist Control Group. Treatment consisted of 5 iCBT-based lessons, homework tasks, additional resources, weekly e-mail or telephone contact from a Clinical Psychologist, and automated e-mails. Twenty-nine of 31 Treatment Group participants completed the 5 lessons during the 8-week program, and posttreatment and 3-month follow-up data were collected from 30/31 and 29/31 participants, respectively. Treatment Group participants obtained significantly greater improvements than Control Group participants in levels of disability, anxiety, depression, and average pain levels at posttreatment. These improvements corresponded to small to large between-groups effect sizes (Cohen's d) at posttreatment for disability (d = .88), anxiety (d = .38), depression (d = .66), and average pain (d = .64), respectively. These outcomes were sustained at follow-up and participants rated the program as highly acceptable. Overall, the clinician spent a total mean time of 81.54 minutes (SD 30.91 minutes) contacting participants during the program. The results appear better than those reported in iCBT studies to date and provide support for the potential of clinician-guided iCBT in the treatment of disability, anxiety, and depression for people with chronic pain.

Psychosocial predictors of depression and anxiety in patients with epilepsy: a systematic review.

BACKGROUND: People with epilepsy (PWE) have a high chance of experiencing depression and anxiety disorders over their lifetime. However, those most at risk are unknown. Psychosocial variables have been suggested as potentially important risk factors. A systematic review was conducted in order to critically assess available evidence regarding the psychosocial predictors of depression and anxiety in adults with epilepsy. METHODS: Electronic databases searched were MEDLINE, PsycINFO and Web of Science. Studies were included if they assessed depressive or anxiety symptoms using a validated questionnaire, and controlled for the role of potentially important epilepsy factors. Eleven studies were identified and assessed for research standards using the Quality Index Scale (QIS). RESULTS: Ten of the eleven studies found at least one significant predictor of depression and all six studies that assessed anxiety found one or more significant predictors. LIMITATIONS: Overall QIS score was only 7.5 out of 15, indicating significant design limitations of many included studies. There was also large variability between studies in measures used to assess psychosocial variables. CONCLUSION: Studies did not support the importance of attributional theory and stigma in the development of depression in epilepsy. There was inconsistent support for the role of illness representations but likely support for the role of stress and self-efficacy. Consistent support was found for the role of coping strategies and perceived social support. Given that psychosocial factors are potentially modifiable, a better understanding of their role in the development of depression in people with epilepsy is urgently needed to guide effective treatments.

Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials.

Potential applications of attention bias modification (ABM) for acute and chronic pain patients are investigated. In study 1, 54 acute back pain patients (46 of whom completed the study) were recruited at their initial physiotherapy session and randomised to receive 1 session of ABM or placebo. Patients were followed up 3 months later. Participants who were randomised to receive ABM reported less average (P=0.001) and current pain (P=0.008) and experienced pain for fewer days (P=0.01) than those who received placebo. In study 2, 34 chronic pain patients were recruited and randomly assigned to receive either 4 sessions of ABM (n=22) or placebo (n=12), followed by 8 sessions of cognitive behavioural treatment (CBT). After ABM, there was a significant group-by-time effect for disability. By 6-month follow-up, differences had emerged between the 2 training groups, such that the ABM group had shown greater reductions in anxiety sensitivity and disability than the placebo group. Although the results of these studies show that there is potential in the application of ABM to pain conditions, the mechanisms of treatment could not be established. Neither group showed an initial bias towards the word stimuli or a training effect, and only in the acute pain group were changes in biases related to outcome. Nonetheless, the fact that 2 independent samples showed a positive effect of ABM on clinical outcomes suggests that ABM is worthy of future study as an intervention for pain patients.

Assessing the efficacy of 2 screening measures for depression in people with epilepsy.

OBJECTIVES: The aim of this study was to compare the efficacy of the Neurological Depressive Disorders Inventory for Epilepsy (NDDI-E) and the depression component of the Hospital Anxiety Depression Scale (HADS-D) for identifying depression and suicide risk in adults with epilepsy. METHODS: A total of 147 (87 female [59% ]) outpatients attending a tertiary epilepsy center in Sydney Australia completed the NDDI-E and HADS-D. They then completed the depression and suicide sections of the Mini International Neuropsychiatric Inventory (MINI) with a clinician blind to symptom measure scores. Receiver operator characteristic analysis was performed for the clinical cutoff scores for depression on the NDDI-E ≥ 15 and HADS-D ≥ 8 to identify MINI-determined depression and suicidality. RESULTS: The NDDI-E indicated strong sensitivity (84%) and acceptable specificity (78%), whereas the HADS-D had poor sensitivity (42%) but good specificity (97%) for identifying depression. For identifying suicide risk, the NDDI-E indicated strong sensitivity (81%) and reasonable specificity (66%), whereas the HADS-D had poor sensitivity (43%) but acceptable specificity (90%). Area under the curve comparisons for these measures were not significant. CONCLUSION: In clinical practice, it is essential that screening measures have the highest possible sensitivity values to limit the chances of false-negative results. In accordance with these guidelines, the NDDI-E was a superior screening measure compared with the HADS-D. Our results demonstrate the efficacy of the NDDI-E for identifying both major and minor depression and serious suicide risk. The poor sensitivity of the HADS-D suggests that it should not be used as a screen for depression or suicidality in adults with epilepsy.

Comparison of a pain management program with usual care in a pain management center for people with spinal cord injury-related chronic pain.

OBJECTIVE: To evaluate the effectiveness of a specifically modified group-based, multidisciplinary cognitive-behavioral pain management program (PMP) in comparison to usual care in a clinical sample of people with spinal cord injury (SCI)-related chronic pain. METHOD: Changes over time on a range of measures, including usual pain intensity, pain catastrophizing and self-efficacy, mood, SCI acceptance and self-efficacy, and interference due to pain were examined in 2 groups with SCI-related chronic pain after a multidisciplinary pain assessment. One group (n=19) attended the PMP, and the other (n=17) received standard care on an individualized basis in a pain management center. RESULTS: The groups were significantly different at baseline, with the PMP group scoring more negatively on a number of the measures, including usual pain intensity. The PMP group showed an overall improvement in mood and life interference due to pain at the end of the PMP when compared with the usual care group. Within the PMP group, there was a significant improvement over time in anxiety and pain catastrophizing. No changes in SCI-related psychologic variables (acceptance and self-efficacy) were observed in either group. DISCUSSION: This study demonstrates that a PMP may offer benefits to clinical populations with SCI-related chronic pain in a pain management center. The reported improvements were of a magnitude to be clinically significant. However, some of the initial benefits reported were not maintained at the nine month follow-up. The interventions may need to be augmented to address the effects of SCI-related psychologic variables that may impact upon the individual's ability to benefit from a PMP.