Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health.

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

A measure of cognitions specific to seasonal depression: Development and validation of the Seasonal Beliefs Questionnaire.

We introduce the Seasonal Beliefs Questionnaire (SBQ), a self-report inventory of maladaptive thoughts about the seasons, light availability, and weather conditions, proposed to constitute a unique cognitive vulnerability to winter seasonal affective disorder (SAD; Rohan, Roecklein, & Haaga, 2009). Potential items were derived from a qualitative analysis of self-reported thoughts during SAD-tailored cognitive-behavioral therapy (CBT-SAD) and subsequently refined based on qualitative feedback from 48 SAD patients. In the psychometric study (N = 536 college students), exploratory and confirmatory factor analyses pruned the items to a 26-item scale with a 5-factor solution, demonstrating good internal consistency, convergent and divergent validity, and 2-week test-retest reliability. In a known groups comparison, the SBQ discriminated SAD patients (n = 86) from both nonseasonal major depressive disorder (MDD) patients (n = 30) and healthy controls (n = 110), whereas a generic measure of depressogenic cognitive vulnerability (the Dysfunctional Attitudes Scale [DAS]) discriminated MDD patients from the other groups. In a randomized clinical trial comparing CBT-SAD with light therapy (N = 177), SBQ scores improved at twice the rate in CBT-SAD than in light therapy. Greater change in SBQ scores during CBT-SAD, but not during light therapy, was associated with a lower risk of depression recurrence 2 winters later. In contrast, DAS scores improved comparably during CBT-SAD and light therapy, and DAS change was unrelated to recurrence following either treatment. These results support using the SBQ as a brief assessment tool for a SAD-specific cognitive vulnerability and as a treatment target in CBT-SAD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A protocol for the Hamilton Rating Scale for Depression: Item scoring rules, Rater training, and outcome accuracy with data on its application in a clinical trial.

BACKGROUND: We present a fully articulated protocol for the Hamilton Rating Scale for Depression (HAM-D), including item scoring rules, rater training procedures, and a data management algorithm to increase accuracy of scores prior to outcome analyses. The latter involves identifying potentially inaccurate scores as interviews with discrepancies between two independent raters on the basis of either scores >=5-point difference) or meeting threshold for depression recurrence status, a long-term treatment outcome with public health significance. Discrepancies are resolved by assigning two new raters, identifying items with disagreement per an algorithm, and reaching consensus on the most accurate scores for those items. METHODS: These methods were applied in a clinical trial where the primary outcome was the Structured Interview Guide for the Hamilton Rating Scale for Depression-Seasonal Affective Disorder version (SIGH-SAD), which includes the 21-item HAM-D and 8 items assessing atypical symptoms. 177 seasonally depressed adult patients were enrolled and interviewed at 10 time points across treatment and the 2-year followup interval for a total of 1589 completed interviews with 1535 (96.6%) archived. RESULTS: Inter-rater reliability ranged from ICCs of .923-.967. Only 86 (5.6%) interviews met criteria for a between-rater discrepancy. HAM-D items "Depressed Mood", "Work and Activities", "Middle Insomnia", and "Hypochondriasis" and Atypical items "Fatigability" and "Hypersomnia" contributed most to discrepancies. LIMITATIONS: Generalizability beyond well-trained, experienced raters in a clinical trial is unknown. CONCLUSIONS: Researchers might want to consider adopting this protocol in part or full. Clinicians might want to tailor it to their needs.

Outcomes One and Two Winters Following Cognitive-Behavioral Therapy or Light Therapy for Seasonal Affective Disorder.

OBJECTIVE: The central public health challenge for winter seasonal affective disorder (SAD) is recurrence prevention. Preliminary studies suggest better long-term outcomes following cognitive-behavioral therapy tailored for SAD (CBT-SAD) than light therapy. The present study is a large, randomized head-to-head comparison of these treatments on outcomes one and two winters after acute treatment. METHOD: Community adults with major depression, recurrent with seasonal pattern (N=177) were followed one and two winters after a randomized trial of 6 weeks of CBT-SAD (N=88) or light therapy (N=89). Prospective follow-up visits occurred in January or February of each year, and major depression status was assessed by telephone in October and December of the first year. The primary outcome was winter depression recurrence status on the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorder Version (SIGH-SAD). Other outcomes were depression severity on the SIGH-SAD and the Beck Depression Inventory-Second Edition (BDI-II), remission status based on severity cutoff scores, and major depression status from tracking calls. RESULTS: The treatments did not differ on any outcome during the first year of follow-up. At the second winter, CBT-SAD was associated with a smaller proportion of SIGH-SAD recurrences (27.3% compared with 45.6%), less severe symptoms on both measures, and a larger proportion of remissions defined as a BDI-II score ≤8 (68.3% compared with 44.5%) compared with light therapy. Nonrecurrence at the next winter was more highly associated with nonrecurrence at the second winter among CBT-SAD participants (relative risk=5.12) compared with light therapy participants (relative risk=1.92). CONCLUSIONS: CBT-SAD was superior to light therapy two winters following acute treatment, suggesting greater durability for CBT-SAD.

Randomized Trial of Cognitive-Behavioral Therapy Versus Light Therapy for Seasonal Affective Disorder: Acute Outcomes.

OBJECTIVE: Whereas considerable evidence supports light therapy for winter seasonal affective disorder (SAD), data on cognitive-behavioral therapy for SAD (CBT-SAD) are promising but preliminary. This study estimated the difference between CBT-SAD and light therapy outcomes in a large, more definitive test. METHOD: The participants were 177 adults with a current episode of major depression that was recurrent with a seasonal pattern. The randomized clinical trial compared 6 weeks of CBT-SAD (N=88) and light therapy (N=89). Light therapy consisted of 10,000-lux cool-white florescent light, initiated at 30 minutes each morning and adjusted according to a treatment algorithm based on response and side effects. CBT-SAD comprised 12 sessions of the authors' SAD-tailored protocol in a group format and was administered by Ph.D. psychologists in two 90-minute sessions per week. Outcomes were continuous scores on the Structured Interview Guide for the Hamilton Rating Scale for Depression-SAD Version (SIGH-SAD, administered weekly) and Beck Depression Inventory-Second Edition (BDI-II, administered before treatment, at week 3, and after treatment) and posttreatment remission status based on cut points. RESULTS: Depression severity measured with the SIGH-SAD and BDI-II improved significantly and comparably with CBT-SAD and light therapy. Having a baseline comorbid diagnosis was associated with higher depression scores across all time points in both treatments. CBT-SAD and light therapy did not differ in remission rates based on the SIGH-SAD (47.6% and 47.2%, respectively) or the BDI-II (56.0% and 63.6%). CONCLUSIONS: CBT-SAD and light therapy are comparably effective for SAD during an acute episode, and both may be considered as treatment options.

A longitudinal study of depression, fatigue, and sleep disturbances as a symptom cluster in women with breast cancer.

CONTEXT: Depression, fatigue, and sleep disturbances have been identified as a symptom cluster among breast cancer patients. However, few longitudinal studies have examined the temporal relations between these symptoms surrounding diagnosis and treatment. OBJECTIVES: The present study investigated the co-occurrence of and interrelations between nonsomatic depressive symptoms, fatigue, and sleep disturbances in breast cancer patients at three time points: before, after, and six to eight months following adjuvant chemotherapy treatment. METHODS: Separate samples of premenopausal (n = 67) and postmenopausal (n = 67) breast cancer patients completed self-report measures of depression, fatigue, and sleep disturbances at all three time points. Path analysis was used to explore within- and cross-symptom paths across time. RESULTS: Depression, fatigue, and sleep disturbances were correlated within each time point. Continuity paths, whereby prior levels of symptom severity tended to predict subsequent severity of the same symptom at the subsequent time point, were significant in both samples, except for depression in the premenopausal sample. Instead, significant cross-symptom paths emerged whereby baseline fatigue predicted postchemotherapy depression, and postchemotherapy fatigue predicted depression at follow-up in the premenopausal patients. No significant cross-symptom paths emerged for the postmenopausal sample. CONCLUSION: Findings supported the notion that depression, fatigue, and sleep disturbances manifest as a symptom cluster. Fatigue may precede nonsomatic symptoms of depression among premenopausal breast cancer patients and represents a potential intervention target.

Cognitive-behavioral therapy vs. light therapy for preventing winter depression recurrence: study protocol for a randomized controlled trial.

BACKGROUND: Seasonal affective disorder (SAD) is a subtype of recurrent depression involving major depressive episodes during the fall and/or winter months that remit in the spring. The central public health challenge in the management of SAD is prevention of winter depression recurrence. Light therapy (LT) is the established and best available acute SAD treatment. However, long-term compliance with daily LT from first symptom through spontaneous springtime remission every fall/winter season is poor. Time-limited alternative treatments with effects that endure beyond the cessation of acute treatment are needed to prevent the annual recurrence of SAD. METHODS/DESIGN: This is an NIMH-funded R01-level randomized clinical trial to test the efficacy of a novel, SAD-tailored cognitive-behavioral group therapy (CBT) against LT in a head-to-head comparison on next winter outcomes. This project is designed to test for a clinically meaningful difference between CBT and LT on depression recurrence in the next winter (the primary outcome). This is a concurrent two-arm study that will randomize 160 currently symptomatic community adults with major depression, recurrent with seasonal pattern, to CBT or LT. After 6 weeks of treatment in the initial winter, participants are followed in the subsequent summer, the next winter, and two winters later. Key methodological issues surround timing study procedures for a predictably recurrent and time-limited disorder with a focus on long-term outcomes. DISCUSSION: The chosen design answers the primary question of whether prior exposure to CBT is associated with a substantially lower likelihood of depression recurrence the next winter than LT. This design does not test the relative contributions of the cognitive-behavioral treatment components vs. nonspecific factors to CBT's outcomes and is not adequately powered to test for differences or equivalence between cells at treatment endpoint. Alternative designs addressing these limitations would have required more patients, increased costs, and reduced power to detect a difference in the primary outcome. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01714050.