Web-Based Cognitive Behavior Therapy for Depression in People With Diabetes Mellitus: A Randomized Controlled Trial.

BACKGROUND: Depression is twice as common in diabetes mellitus (DM) as the general population and is associated with adverse health outcomes, but access to evidence-based therapies such as cognitive behavioral therapy (CBT) is limited in routine diabetes care. Past research has shown that generic Internet-based cognitive behavioral therapy (iCBT) is an effective treatment for depression in the general population, but it has never been evaluated in people with comorbid depression and DM. OBJECTIVE: The aim of our study was to examine the efficacy of a generic 6-lesson iCBT delivered over 10 weeks in people with major depressive disorder (MDD) and DM. METHODS: Participants with comorbid MDD and DM (type 1 or 2) were recruited online and randomized to an iCBT program with therapist support provided by phone and email (n=42) or a treatment as usual (TAU, n=49) control group. Outcomes were assessed through Web-based self-report questionnaires and the trial was Web-based with no face-to-face components. Primary outcomes were self-reported depression (patient health questionnaire-9, PHQ-9), diabetes-related distress (problem areas in diabetes, PAID), and self-reported glycemic control (hemoglobin A1c, HbA1c). Secondary outcomes were general distress (Kessler 10-item psychological distress scale, K-10) and disability (short form 12-item, SF-12), generalized anxiety (generalized anxiety disorder 7-item, GAD-7), and somatization (PHQ-15). The iCBT group was assessed at 3 months. RESULTS: A total of 27 participants (66%; 27/41) completed the iCBT program. Analyses indicated between-group superiority of iCBT over TAU at posttreatment on PHQ-9 (g=0.78), PAID (g=0.80), K-10 (g=1.06), GAD-7 (g=0.72), and SF-12 mental well-being scores (g=0.66), but no significant differences in self-reported HbA1c levels (g=0.14), SF-12 physical well-being, or PHQ-15 scores (g=0.03-0.21). Gains were maintained at 3-month follow-up in the iCBT group, and the 87% (27/31) of iCBT participants who were interviewed no longer met criteria for MDD. Clinically significant change following iCBT on PHQ-9 scores was 51% (21/41) versus 18% (9/49) in TAU. CONCLUSIONS: iCBT for depression is an efficacious, accessible treatment option for people with diabetes. Future studies should explore whether tailoring of iCBT programs improves acceptability and adherence, and evaluate the long-term outcomes following iCBT. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN): 12613001198718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365208&isReview=true (Archived by WebCite at http://www.webcitation.org/6qCR8Fi9V).

Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention.

Background: Borderline Personality Disorder (BPD) is a chronic, debilitating, and difficult to treat condition. BPD has recently been linked to steroid hormone dysregulation and medical conditions characterized by disturbed androgen metabolism. This study aimed to investigate cortisol and testosterone levels in BPD, and changes in hormones following psychological treatment. Methods: Participants with BPD (n = 33) completed a 12-week Dialectical Behavior Therapy group program. Pre and post salivary testosterone and cortisol were analyzed. Baseline hormones in the BPD group were compared to age-and-sex matched controls (n = 33). Non-parametric tests were utilized to investigate group differences, pre-post treatment hormone and symptom changes, and associations between symptoms and hormone levels. Results: Participants with BPD had significantly higher testosterone levels than controls. Mean testosterone levels in females with BPD were double that of female controls. Testosterone and cortisol levels were related, and some BPD symptoms were associated with with hormone levels. BPD symptoms reduced significantly with treatment, however pre to post hormone levels did not change. Conclusions: This study supports an association between BPD symptoms and neuroendocrine dysfunction at baseline, however we found no reduction in hormone dysfunction post treatment. Further research into relationships between stress signaling and neuroendocrine disturbances in BPD may inform aetiological and treatment models. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12618000477224. Registered on 3 April 2018.

Assessing the efficacy of a stepped-care group treatment programme for borderline personality disorder: study protocol for a pragmatic trial.

BACKGROUND: Borderline personality disorder (BPD) is a high prevalence and serious mental health disorder that has historically challenged the finite resources of health services. Despite empirical evidence supporting structured psychological therapy as the first line of treatment, there remains significant barriers in providing timely access to evidence-based treatment for this population. The primary aim of this study is to evaluate the effectiveness of providing a stepped-care structured psychological group treatment to individuals with BPD within local mental health services. The secondary aims of the study are to identify the variables that predict the need to step up or down in care and the effectiveness of treatment on psychosocial functioning. METHODS: Participants seeking treatment at two community mental health services will be invited to participate. Randomised controlled trial assignment will be to either (i) group skills treatment or (ii) treatment as usual. Group treatment will be offered via a stepped-care pathway with participants initially attending a 12-week group with the option of a subsequent 16-week group. The criteria for inclusion in continuing treatment includes meeting > 4 BPD diagnostic criteria or severity on GAF (< 65) at the completion of the 12-week group. Data will be collected at baseline and at five follow-up time points over a 12-month period. DISCUSSION: This pragmatic trial will provide valuable information regarding the effectiveness of a progressive stepped-care group treatment for individuals with BPD in the real-world setting of a community mental health service. It will further the current understanding of variables that predict treatment dose and duration. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000477224 . Registered on 3 April 2018.

Issues concerning feedback about genetic testing and risk of depression.

BACKGROUND: Recent studies show that adverse life events have a significantly greater impact on depression onset for those with the s/s allele of the genotype for the 5-HT gene-linked promoter region. Research in genes related to risk of depression leads to the question of how this information is received by individuals. AIMS: To investigate factors related to the response to receiving one's own serotonin transporter genotype results. METHOD: Predictors of the impact of receiving individual genotype data were assessed in 128 participants in a study of gene-environment interaction in depression onset. RESULTS: Two-thirds decided to learn their individual genotype results (receivers) and prior to disclosure this decision was associated with a perception of greater benefit from receipt of the information (P=0.001). Receivers completing the 2-week (n=76) and 3-month follow-up (n=78) generally reported feeling pleased with the information and having had a more positive experience than distress. However, distress was related to genotype, with those with the s/s allele being most affected. CONCLUSIONS: There was high interest in, and satisfaction with, learning about one's serotonin transporter genotype. Participants appeared to understand that the gene conferred susceptibility to depression rather than a direct causal effect.

The long and the short of it: associations between 5-HTT genotypes and coping with stress.

OBJECTIVE: To examine whether the strategies people use to cope with stress were associated with differing serotonin transporter (5-HTT) genotypes. The short (s) variant of the 5-HTT promoter polymorphism has been associated with an increased likelihood of depression after significant life stress and greater emotional reactivity to fear-invoking stimuli. METHODS: Coping strategies were assessed within a longitudinal study in 1993. Ten years later, genomic DNA was obtained for 127 participants and genotypes for the 5-HTT promoter polymorphism were determined. Coping strategies were grouped into coping scales and also using an exploratory factor analysis. Using ordinal regression, associations were then examined between the coping scales and the 5-HTT genotype and gender. RESULTS: The short variant of the 5-HTT promoter polymorphism was associated with the use of fewer problem-solving strategies. This genotype effect differed significantly between the sexes and was greatest for males. CONCLUSIONS: Our results indicate that coping is influenced by 5-HTT genotype, gender, and their interaction. We raise the possibility that a gene-related disposition to greater emotional reactivity may preclude those with the short variant of the 5-HTT promoter polymorphism from drawing on problem-solving strategies to deal with stress.

Expressive writing for high-risk drug dependent patients in a primary care clinic: a pilot study.

BACKGROUND: Previous research has shown that expressive writing is beneficial in terms of both physical and emotional health outcomes. This study aimed to investigate the effectiveness and acceptability of a brief expressive writing intervention for high-risk drug dependent patients in a primary care clinic, and to determine the relationship between linguistic features of writing and health outcomes. METHODS: Participants completed four 15-minute expressive writing tasks over a week, in which they described their thoughts and feelings about a recent stressful event. Self-report measures of physical (SF-12) and psychological health (DASS-21) were administered at baseline and at a two-week follow-up. Fifty-three participants were recruited and 14 (26%) completed all measures. RESULTS: No statistically significant benefits in physical or psychological health were found, although all outcomes changed in the direction of improvement. The intervention was well-received and was rated as beneficial by participants. The use of more positive emotion words in writing was associated with improvements in depression and stress, and flexibility in first person pronoun use was associated with improvements in anxiety. Increasing use of cognitive process words was associated with worsening depressive mood. CONCLUSION: Although no significant benefits in physical and psychological health were found, improvements in psychological wellbeing were associated with certain writing styles and expressive writing was deemed acceptable by high-risk drug dependent patients. Given the difficulties in implementing psychosocial interventions in this population, further research using a larger sample is warranted.

Small groups for supporting GPs' professional development in mental health disease--an evaluation.

BACKGROUND: Small groups provide opportunities for education, information sharing, development of clinical skills and peer support. They have been promoted in general practice in Australia, especially for mental health disease, and often by divisions of general practice. METHODS: Minutes from a series of small groups supervised by psychiatrists were analysed to observe the content and themes over 5 years. Additionally, focus groups of general practitioner participants were asked to comment on what they found most valuable. RESULTS: Forty-two GPs attended small groups (mean size 2-3) over 3 years, about half for 10-49 sessions. The most discussed diseases were depression (most frequently at 157 times), psychosis (137), personality disorders (79), drug and alcohol abuse (73), anxiety disorders (68) and suicide (42). Discussion of doctor-patient interpersonal and doctor self care issues increased from under 2% of all statements in 1995 to nearly 10% in 2000. Participating GPs found the small groups empowering, confidence increasing, and useful for addressing psychological and interpersonal issues at work. DISCUSSION: Participating GPs found small groups useful and provided helpful recommendations based on their experiences.

Internet-delivered cognitive behaviour therapy for depression in people with diabetes: study protocol for a randomised controlled trial.

INTRODUCTION: Depression substantially contributes to the personal burden and healthcare costs of living with diabetes mellitus (DM). Comorbid depression and DM are associated with poorer quality of life, poorer self-management and glycemic control, increased risk for DM complications and higher mortality rates, and higher health service utilization. Depression remains under-recognized and undertreated in people with DM, which may, in part, result from barriers associated with accessing face-to-face treatment. This study will examine the efficacy of an internet-based cognitive behaviour therapy programme for major depressive disorder (iCBT-MDD) in people with DM. METHODS AND ANALYSIS: A CONSORT 2010 compliant, registered randomised controlled trial of the intervention (iCBT-MDD) versus a treatment as usual control group will be conducted. The study will include 100 adults aged 18 years and over with a diagnosis of type 1 or type 2 DM and self-reported symptoms that satisfy MDD which will enable us to detect a statistically significant difference with a group effect size of 0.6 at a power of 80% and significance level of p=0.05. Participants will be randomised to receive the iCBT-MDD programme immediately, or to wait 10 weeks before accessing the programme. Primary outcomes will be self-reported depression severity, DM-related distress, and glycemic control (glycosylated hemoglobin). Secondary outcomes will be general distress and disability, generalized anxiety, lifestyle behaviours, somatization, eating habits, alcohol use, and acceptability of the iCBT programme to participants, and practicality for clinicians. Data will be analyzed with linear mixed models for each outcome measure. ETHICS AND DISSEMINATION: The Human Research Ethics Committee of St Vincent's Hospital Australia have given ethics approval (HREC/13/SVH/291). Results will be disseminated via peer-reviewed publication and social media channels of Australian Diabetes Consumer Representative Bodies. TRIAL REGISTRATION NUMBER: The trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12613001198718).

What can alert the general practitioner to people whose common mental health problems are unrecognised?

OBJECTIVES: To assess the characteristics of people with common mental health problems who are recognised by their general practitioner, and those who are not. DESIGN: Two different case-finding techniques (brief self-report and structured diagnostic interview) were compared with GPs' independent assessments of patients' presentations as psychological and/or medical. SETTING AND PARTICIPANTS: 371 patients in general practices in metropolitan Sydney and rural New South Wales, with follow-up telephone interview as soon as possible after the GP visit. The study was conducted from 2001 to 2003. MAIN OUTCOME MEASURES: Overall rates of disorder, measured by the 12-item Somatic and Psychological HEalth REport (SPHERE-12), and anxiety, depression and somatisation diagnostic categories of the Composite International Diagnostic Interview - Auto; rates of disability, assessed by the 12-item Short-Form (SF-12) General Health Survey's mental (MCS) and physical component scales; GP ratings of patients' psychological problems, and intended treatments. RESULTS: The SPHERE-12 showed the highest rate of case detection and greater agreement with GP assessments of psychological reasons for presentation. Patients who presented with somatic symptoms alone were most likely to be overlooked by GPs: none of the 57 patients identified by SPHERE-12 with a somatic disorder were identified by GPs as psychological presentations. Specificity for the SPHERE-12 psychological scale changed from 72% to 93%, and from 84% to 96% for the combined psychological and somatic scale, when the criterion of an SF-12 MCS score < or = 40 was added. CONCLUSION: Low rates of recognition of psychological problems by GPs, and infrequent treatment for those presenting with somatic symptoms, indicate a need for building GPs skills in the assessment and management of somatisation. The SPHERE-12 may be a useful screening tool for primary care if followed by further questioning and other methods to assess diagnosis and severity to target appropriate treatment.

The Green Card Clinic: overview of a brief patient-centred intervention following deliberate self-harm.

OBJECTIVES: The aim of this study was to present an overview of the Green Card Clinic, a novel brief intervention service for patients presenting to the emergency department following deliberate self-harm (DSH) or with suicidal ideation, to examine its effectiveness in terms of service utilization, and patient and clinician feedback, and to explore the correlates of repeated DSH. METHOD: The aims and structure of the Green Card Clinic are described. We highlight our patient-centred approach involving self-identification of difficulties from a list of problem areas, coupled with tailored intervention strategies. Relevant data are presented and characteristics of repeat DSH patients are compared to the first-episode group. RESULTS: Between 1998 and 2005, 456 DSH patients were referred to the clinic. Of these, 75% (n = 344) attended the first session, 43% (n = 197) the second session, 26% (n = 117) the third session, and 16% (n = 73) completed a 3-15 month follow-up. Clinic attenders (mean age 31.6 years, 57% female) reported a diverse range of self-identified problems and repeat DSH patients reported worse depression, poorer health-related behaviours, and a greater number of problems than those presenting after first-episode DSH. CONCLUSIONS: The clinic achieved high rates of first session attendance. This may have been attributable to the use of a few specific strategies aimed at increasing compliance, such as the green card, next-day appointments and assertive follow-up of non-attenders. For repeat self-harmers, we advocate an approach aimed at 'lifestyle change' rather than based on current psychological stressors. The Green Card Clinic service, involving a range of interventions tailored to meet the multitude of presenting needs, appears to be an acceptable and flexible approach to brief intervention for DSH.

Life events, first depression onset and the serotonin transporter gene.

BACKGROUND: A relationship between the serotonin transporter gene, adverse events and onset of major depression has been reported. AIMS: To replicate a gene x environment interaction in a cohort with longitudinal data for life events, experience of depression, parental bonding and neuroticism. METHOD: At the 25-year follow-up, genomic DNA was obtained from 127 cohort members (mean age 48 years) to determine the genotype of the serotonin transporter gene-linked promoter region (5-HTTLPR). Associations were investigated between the 5-HTTLPR genotype, positive and adverse life events and the gene x environment interaction, and also between the 5-HTTLPR genotype and risk factors for depression. RESULTS: No relationship was found between 5-HTTLPR genotype and either risk factors for depression or positive life events. Adverse life events had a significantly greater impact on the onset of depression for individuals with the s/s genotype. CONCLUSIONS: The 5-HTTLPR genotype is a significant predictor of onset of major depression following multiple adverse events. This is one of the more robust findings concerning specific biological risk factors for depression.

Work and mental health.

BACKGROUND: Studies investigating the psychological correlates of types of occupation have focused on such disorders as stress, depression, suicide and substance abuse. There have also been some models proposed to allow understanding of factors common to different types of occupations. We sought to provide an overview of research related to work and mental health and consider future research directions. METHODS: A literature search was conducted using the Medline, PsycInfo, Embase and PubMed databases. The key words "occupation" or "work" were searched in combination with the key words "mental health", "risk factors", "disorders", "depression", "suicide", "trauma", "stress" or "substance use". RESULTS: Studies of "stress" tend to be more applicable to specific workplace issues. While some of the studies relating to onset of depression, suicide, substance abuse and trauma pertain to specific occupational issues and results are often not generalizable, they have progressed our understanding of risk factors to those disorders. There are workplace factors involving exposure to danger and crisis that lead to posttraumatic stress disorder (PTSD), substance abuse (including stimulants) and depersonalization. Workplace risk factors for depression involve situations promoting lack of autonomy, and involving "caring" for others as part of the work role, particularly where there is dependence on others for their livelihood. Risk factors for alcohol abuse include workplaces with access to alcohol and where use of alcohol is sanctioned. There appears to be a bi-directional relationship between personality and work, so that people are drawn to particular occupations, but the occupations then have an effect on them. An interactional model is proposed to consider this. CONCLUSION: The research questions pertaining to mental health are varied and will determine what mental health issues are of interest and the models of work applicable. There need to be more longitudinal studies and consideration of factors which the worker brings to the workplace (psychosocial issues, personality traits), as well as interpersonal issues and consideration of systemic, organizational, political and economic factors, including leadership styles.