How are guide profession and routine care setting related to adherence and symptom change in iCBT for depression? - an explorative log-data analysis.

BACKGROUND: While the antidepressant efficacy of guided digital interventions has been proven in randomized controlled trials, findings from routine care are less clear. Low adherence rates are common and limit the potential effectiveness. Adherence has been linked to sociodemographic variables and the amount of guidance, but the role of the guide's profession and their work setting has not yet been studied for routine care. METHODS: Routinely collected log data from a digital intervention for depressed patients (iFightDepression tool) were analyzed in an exploratory manner. The sample is a convenience sample from routine care, where guidance is provided by general practitioners (GP), certified psychotherapists (PT) or medical doctors specialized in mental health. Log data from 2184 patients were analyzed and five usage parameters were extracted to measure adherence (first-to-last login, time on tool, number of sessions, workshops completed and minimal dose). Multiple logistic regression was used to analyze relations between the guide's profession and clinical context as well as other covariates and adherence and symptom change on a brief depression questionnaire (PHQ-9). RESULTS: The analyses showed a significant relation of guide profession and adherence. Guidance by PT was associated to the highest adherence scores (reference category). The odds ratios (ORs) of scoring above the median in each usage parameter for patients guided by GPs were 0.50-0.63 (all ps < 0.002) and 0.61-0.80 (p = .002-0.197) for MH. Higher age, initial PHQ-9 score and self-reported diagnosis of depression were also significantly associated with higher adherence scores. In a subsample providing enough data on the PHQ-9 (n = 347), no association of guide profession with symptom reduction was found. Instead, a greater reduction was observed for patients with a higher baseline PHQ-9 (ß = -0. 39, t(341.75) = -8.814, p < .001) and for those who had achieved minimal dose (ß = -2.42, t(340.34) = -4.174, P < .001) and those who had achieved minimal dose and scored high on time on tool (ß = 0.22, t(341.75) = 1.965, P = .050). CONCLUSION: Being guided by PT was associated with the highest adherence. The lowest adherence was observed in patients who were guided by GP. While no association of guide profession and symptom reduction was found in a subsample, greater adherence was associated with symptom reduction.

[How frequently are depressive disorders recognized in primary care patients? : A cross-sectional epidemiological study in Germany]. / Wie häufig werden Patienten mit depressiven Störungen in der hausärztlichen Praxis erkannt? : Eine epidemiologische Querschnittsstudie.

BACKGROUND: Primary care physicians (PCPs) play a crucial role for guideline-oriented intervention in patients with depression. OBJECTIVES: Based on a diagnostic screening questionnaire, this study investigates the sensitivity of PCPs to recognize patients with depression as well as the factors facilitating recognition and concordant diagnostic decisions. METHOD: In a cross-sectional epidemiological study in six regions of Germany, 3563 unselected patients filled in questionnaires on mental and physical complaints and were diagnostically evaluated by their PCP (N = 253). The patient reports on an established Depression-Screening-Questionnaire (DSQ), which allows the approximate derivation of an ICD-10 depression diagnosis, were compared with the physician diagnosis (N = 3211). In a subsample of discordant cases a comprehensive standardized clinical-diagnostic interview (DIA-X/CIDI) was applied. RESULTS: On the study day, the prevalence of ICD-10 depression was 14.3% according to the DSQ and 10.7% according to the physician diagnosis. Half of the patients identified by DSQ were diagnosed with depression by their physician and two thirds were recognized as mental disorder cases. More severe depression symptomatology and the persistent presence of main depression symptoms were related to better recognition and concordant diagnostic decisions. Diagnostic validation interviews confirmed the DSQ diagnosis in the majority of the false-negative cases. Indications for at least a previous history of depression were found in up to 70% of false-positive cases. CONCLUSION: Given the high prevalence of depression in primary care patients, there is continued need to improve the recognition and diagnosis of these patients to assure guideline-oriented treatment.

Antipsychotic combinations vs monotherapy in schizophrenia: a meta-analysis of randomized controlled trials.

CONTEXT: Despite lacking evidence for its safety and efficacy, antipsychotic cotreatment is common in schizophrenia. OBJECTIVE: To evaluate therapeutic and adverse effects of antipsychotic cotreatment vs monotherapy in schizophrenia. DATA SOURCES: Cochrane Schizophrenia Group register and hand searches of relevant journals/conference proceedings. STUDY SELECTION: Randomized controlled trials comparing antipsychotic monotherapy to cotreatment with a second antipsychotic. DATA EXTRACTION AND ANALYSIS: Two authors independently extracted data. For homogenous dichotomous data, we calculated random effects, relative risk (RR), 95% confidence intervals (CIs), and numbers needed to treat (NNT). For continuous data, weighted mean differences were calculated. RESULTS: In 19 studies (1229 patients) with 28 monotherapy and 19 cotreatment arms, antipsychotic cotreatment was superior to monotherapy regarding 2 a priori defined coprimary outcomes: less study-specific defined inefficacy (N = 22, n = 1202, RR = 0.76, CI = 0.63-0.90, P = .002, NNT = 7, CI = 4-17, P = .0008, I(2) = 78.9%) and all-cause discontinuation (N = 20, n = 1052, RR = 0.65, CI = 0.54-0.78, P < .00001). Results were consistent using Clinical Global Impressions thresholds of less than much (P = .006) and less than minimally (P = .01) improved. Specific psychopathology and adverse event data were insufficient to yield meaningful results. In sensitivity analyses, 5 efficacy moderators emerged: concurrent polypharmacy initiation, clozapine combinations, trial duration >10 weeks, Chinese trials, and second-generation + first-generation antipsychotics. In a meta-regression, similar dose combinations, second-generation + first-generation antipsychotics and concurrent polypharmacy initiation remained significant. CONCLUSIONS: In certain clinical situations, antipsychotic cotreatment may be superior to monotherapy. However, the database is subject to possible publication bias and too heterogeneous to derive firm clinical recommendations, underscoring the need for future research.