Differential treatment effects of an integrated motivational interviewing and exercise intervention on depressive symptom profiles and associated factors: A randomised controlled cross-over trial among youth with major depression.

BACKGROUND: Exercise is increasingly recognised as an efficacious intervention for major depressive disorder (MDD) but to our knowledge differential treatment effects on depressive symptom profiles (cognitive, somatic and affective) and associated changes in psychological, physiological and behavioural factors have not been examined among youth with MDD. METHODS: Sixty-eight participants (mean age 20.8) meeting DSM-IV diagnostic criteria for MDD were randomised to an Immediate intervention or Control/delayed condition (n = 34 per group). The integrated intervention comprised an initial session of motivational interviewing (MI) followed by a 12-week, multi-modal exercise program. Changes in depressive symptom profiles were assessed with the Beck Depression Inventory-II (BDI-II) total score and factorial symptom subscales. RESULTS: There were significant differential improvements in BDI-II total scores post-treatment among intervention participants, which were also observed across the cognitive and affective subscales. Individual BDI-II items from the cognitive subscale showing significant differential improvement related to negative self-concept, while those from the affective subscale related to interest/activation; the energy item within the somatic subscale also revealed significant differential improvement. Significant differential improvements were also observed in exercise participation, negative automatic thoughts, behavioural activation and bench press repetitions among intervention participants, which correlated significantly with depression improvements. LIMITATIONS: The exercise intervention was delivered in a supervised, group format and potential social meditators of change cannot be excluded. CONCLUSIONS: Exercise differentially effects depressive symptom profiles with similar antidepressant effects as would be expected from psychological therapies improving negative cognition and emotional health.

Therapeutic Alliance, Client Need for Approval, and Perfectionism as Differential Moderators of Response to eHealth and Traditionally Delivered Treatments for Comorbid Depression and Substance Use Problems.

PURPOSE: This study sought to undertake an exploratory analysis of the impact of therapeutic alliance and dysfunctional attitudes (perfectionism and need for approval) on outcomes for participants receiving therapist-delivered and eHealth interventions for comorbid depression and alcohol/cannabis use problems. These factors have been shown in previous research to moderate response to psychological treatment for depression and related disorders. METHOD: Participants (N = 274) with concurrent depression and alcohol/cannabis misuse were randomized to 10 sessions of therapist-delivered cognitive behavior therapy/motivational interviewing (CBT/MI), computer-delivered CBT/MI with brief therapist assistance (SHADE CBT/MI), or supportive counseling (PCT). Follow-up occurred at 3, 6, and 12 months post-baseline. Exploratory moderator analyses examined changes in depression, alcohol use, and cannabis use over the 3-12-month follow-up timepoints, adjusting for baseline, as a function of treatment allocation, and the hypothesized moderators of therapeutic alliance, perfectionism, and need for approval. RESULTS: The sample size and number of comparisons in the analysis mean that the results are considered preliminary and need replication in larger trials. The analysis revealed that "client initiative," a subscale of therapeutic alliance, moderated change in depression scores between 3- and 12-month follow-up for the PCT group, with higher scores associated with decreases in depression over time. Higher therapeutic "bond" early in treatment for SHADE CBT/MI participants was associated with reduced cannabis use over time. Participants with higher "perfectionism" scores at baseline who received therapist CBT/MI reported increases in depression over the follow-up period, but reductions in depression if they received SHADE CBT/MI. Therapist CBT/MI participants high on "need for approval" at baseline reported better alcohol use outcomes over time. CONCLUSION: The preliminary nature of these results do not justify firm conclusions. However, the specific variables of perfectionism, need for approval, and client initiative show promise as moderators of treatment efficacy for comorbid depression and alcohol/cannabis use problems. Further research is justified to determine whether these factors can assist in tailoring the modality and strategies offered in the delivery of psychotherapy to this population.

Implementation of a recovery-oriented model in a sub-acute Intermediate Stay Mental Health Unit (ISMHU).

BACKGROUND: An ongoing service evaluation project was initiated following the establishment of a new, purpose-built, 20-bed sub-acute Intermediate Stay Mental Health Unit (ISMHU). This paper: provides an overview of the targeted 6-week program, operating within an Integrated Recovery-oriented Model (IRM); characterises the clients admitted during the first 16 months; and documents their recovery needs and any changes. METHODS: A brief description of the unit's establishment and programs is initially provided. Client needs and priorities were identified collaboratively using the Mental Health Recovery Star (MHRS) and addressed through a range of in-situ, individual and group interventions. Extracted client and service data were analysed using descriptive statistics, paired t-tests examining change from admission to discharge, and selected correlations. RESULTS: The initial 154 clients (165 admissions, average stay = 47.86 days) were predominately male (72.1%), transferred from acute care (75.3%), with schizophrenia or related disorders (74.0%). Readmission rates within 6-months were 16.2% for acute and 3.2% for sub-acute care. Three MHRS subscales were derived, together with stage-of-change categories. Marked improvements in MHRS Symptom management and functioning were identified (z-change = -1.15), followed by Social-connection (z-change = -0.82) and Self-belief (z-change = -0.76). This was accompanied by a mean reduction of 2.59 in the number of pre-action MHRS items from admission to discharge (z-change = 0.98). Clinician-rated Health of the Nation Outcome Scales (HoNOS) improvements were smaller (z-change = 0.41), indicative of illness chronicity. Staff valued the elements of client choice, the holistic and team approach, program quality, review processes and opportunities for client change. Addressing high-levels of need in the 6-week timeframe was raised as a concern. CONCLUSIONS: This paper demonstrates that a recovery-oriented model can be successfully implemented at the intermediate level of care. It is hoped that ongoing evaluations support the enthusiasm, commitment and feedback evident from staff, clients and carers.

An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges.

BACKGROUND: Over past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered. DISCUSSION: This descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the person's changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed (remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations. CONCLUSIONS: Improved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: a randomised controlled trial.

OBJECTIVE: To compare computer-delivered and therapist-delivered treatments for people with depression and comorbid addictive disorders. DESIGN: Randomised controlled clinical trial. SETTING AND PARTICIPANTS: Our study was conducted between January 2005 and August 2007 at seven study clinics in rural and urban New South Wales. Participants were 274 people who had a Beck Depression Inventory II (BDI-II) score ≥ 17 and were using alcohol and/or cannabis at harmful levels in the month before baseline. They were self-referred or referred from other sources such as outpatient drug treatment clinics, general practices and non-government support agencies. INTERVENTIONS: Participants were randomly allocated to receive (1) integrated cognitive behaviour therapy and motivational interviewing (CBT/MI) delivered by a therapist; (2) integrated CBT/MI delivered by computer, with brief therapist assistance at the end of each session (clinician-assisted computerised [CAC] treatment), or (3) person-centred therapy (PCT), consisting of supportive counselling given by a therapist (the control group). All three treatments were delivered according to a manual developed specifically for the study. MAIN OUTCOME MEASURES: Changes in depression, alcohol use and cannabis use at 3 months after baseline; significant predictors of change in the primary outcome variables. RESULTS: Compared with computer- or therapist-delivered CBT/MI, PCT was associated with significantly less reduction in depression and alcohol consumption at 3 months. CAC therapy was associated with improvement at least equivalent to that achieved by therapist-delivered treatment, with superior results as far as reducing alcohol consumption. Change in depression was significantly predicted by change in alcohol use (in the same direction) and an ability to determine primacy, irrespective of whether this was for drug use or depression. Change in alcohol use was significantly predicted by changes in cannabis use and depression, and change in cannabis use by change in alcohol use. In the regression model, treatment allocation did not independently predict change, but was associated with significant reduction in depression and alcohol use at 3 months. CONCLUSIONS: Over a 3-month period, CBT/MI was associated with a better treatment response than supportive counselling. CAC therapy was associated with greater reduction in alcohol use than therapist-delivered treatment. TRIAL REGISTRATION NUMBER: ACTRN12610000274077.

Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy.

AIMS: To evaluate computer- versus therapist-delivered psychological treatment for people with comorbid depression and alcohol/cannabis use problems. DESIGN: Randomized controlled trial. SETTING: Community-based participants in the Hunter Region of New South Wales, Australia. PARTICIPANTS: Ninety-seven people with comorbid major depression and alcohol/cannabis misuse. INTERVENTION: All participants received a brief intervention (BI) for depressive symptoms and substance misuse, followed by random assignment to: no further treatment (BI alone); or nine sessions of motivational interviewing and cognitive behaviour therapy (intensive MI/CBT). Participants allocated to the intensive MI/CBT condition were selected at random to receive their treatment 'live' (i.e. delivered by a psychologist) or via a computer-based program (with brief weekly input from a psychologist). MEASUREMENTS: Depression, alcohol/cannabis use and hazardous substance use index scores measured at baseline, and 3, 6 and 12 months post-baseline assessment. FINDINGS: (i) Depression responded better to intensive MI/CBT compared to BI alone, with 'live' treatment demonstrating a strong short-term beneficial effect which was matched by computer-based treatment at 12-month follow-up; (ii) problematic alcohol use responded well to BI alone and even better to the intensive MI/CBT intervention; (iii) intensive MI/CBT was significantly better than BI alone in reducing cannabis use and hazardous substance use, with computer-based therapy showing the largest treatment effect. CONCLUSIONS: Computer-based treatment, targeting both depression and substance use simultaneously, results in at least equivalent 12-month outcomes relative to a 'live' intervention. For clinicians treating people with comorbid depression and alcohol problems, BIs addressing both issues appear to be an appropriate and efficacious treatment option. Primary care of those with comorbid depression and cannabis use problems could involve computer-based integrated interventions for depression and cannabis use, with brief regular contact with the clinician to check on progress.

Cognitive-behavioural therapy for substance use disorders in people with psychotic disorders: Randomised controlled trial.

BACKGROUND: Few randomised controlled trials have been aimed specifically at substance use reduction among people with psychotic disorders. AIMS: To investigate whether a 10-session intervention consisting of motivational interviewing and cognitive-behavioural therapy (CBT) was more efficacious than routine treatment in reducing substance use and improving symptomatology and general functioning. METHOD: A community sample of people with a psychotic disorder and who reported hazardous alcohol, cannabis and/or amphetamine use during the preceding month was recruited. Participants were randomly allocated to motivational interviewing/CBT (n = 65) or treatment as usual (n = 65), and were assessed on multiple outcomes at baseline, 15 weeks, 6 months and 12 months. RESULTS: There was a short-term improvement in depression and a similar trend with regard to cannabis use among participants who received the motivational interviewing/CBT intervention, together with effects on general functioning at 12 months. There was no differential benefit of the intervention on substance use at 12 months, except for a potentially clinically important effect on amphetamine use. CONCLUSIONS: The motivational interviewing/CBT intervention was associated with modest improvements.

The 'co-morbidity roundabout': a framework to guide assessment and intervention strategies and engineer change among people with co-morbid problems.

This paper describes the nature and consequences of co-morbidity, as applied to co-occurring mental health and alcohol/other drug (AOD) use problems. The 'co-morbidity roundabout' is introduced as a useful metaphor for conceptualizing the current experiences of people with co-occurring mental health and AOD use problems. In order to successfully negotiate the 'roundabout', the 'drivers' (people with co-morbid mental health and AOD use problems) must consider a range of internal and external conditions (knowledge about services, support from family, friends, health providers, motivation to change, etc.), account for their vehicle's characteristics (other conditions and demands, including social/legal/financial issues), keep their travel itinerary in mind (plans for change including treatment) and navigate through the many detours and dead-ends that they may confront (eligibility for services, accessibility of treatments, etc.). Co-morbidity is a major contributing factor in 'drivers' failing to successfully negotiate, or even becoming 'stuck' on, the 'roundabout'. A summary of relevant treatment research is also presented, including descriptions of brief interventions and more intensive treatment approaches. Finally, the 'co-morbidity roundabout' metaphor is expanded to assist clinicians to translate the findings from this treatment research into clinical practice. Further suggestions are made for improved navigation through and exit from the 'roundabout', including recommendations for the use of a stepped-care approach to the assessment and treatment of clients with co-morbid mental health and AOD use problems.