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BACKGROUND: Treatment-resistant depression (TRD) is the inability of a patient with major depressive disorder (MDD) to accomplish or achieve remission after an adequate trial of antidepressant treatments. Several combinations and augmentation treatment strategies for TRD exist, including the use of repetitive transcranial magnetic stimulation (rTMS), and new therapeutic options are being introduced. Text4Support, a text message-based form of cognitive behavioral therapy that allows patients with MDD to receive daily supportive text messages for correcting or altering negative thought patterns through positive reinforcement, may be a useful augmentation treatment strategy for patients with TRD. It is however currently unknown if adding the Text4Support intervention will enhance the response of patients with TRD to rTMS treatment. OBJECTIVE: This study aims to assess the initial comparative clinical effectiveness of rTMS with and without the Text4Support program as an innovative patient-centered intervention for the management of patients diagnosed with TRD. METHODS: This study is a multicenter, prospective, parallel-design, 2-arm, rater-blinded randomized controlled pilot trial. The recruitment process is scheduled to last 12 months. It will involve active treatment for 6 weeks, observation, and a follow-up period of 6 months for participants in the study arms. In total, 200 participants diagnosed with TRD at rTMS care clinics in Edmonton, Alberta, and rTMS clinics in Halifax, Nova Scotia will be randomized to 1 of 2 treatment arms (rTMS sessions alone or rTMS sessions plus Text4Support intervention). Participants in each group will be made to complete evaluation measures at baseline, and 1, 3, and 6 months. The primary outcome measure will be the mean change in the scores of the Patient Health Questionnaire-9 (PHQ-9). The secondary outcome measures will involve the scores of the 7-item Generalized Anxiety Disorders Scale (GAD-7), Columbia-Suicide Severity Rating Scale (CSSRS), and World Health Organization-Five Well-Being Index (WHO-5). Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses. Qualitative data will be analyzed using the thematic analysis framework. RESULTS: The results of the study are expected to be available 18 months from the start of recruitment. We hypothesize that participants enrolled in the rTMS plus Text4Support intervention treatment arm of the study will achieve superior outcomes compared with the outcomes of participants enrolled in the rTMS alone arm. CONCLUSIONS: The application of the combination of rTMS and Text4Support has not been investigated previously. Therefore, we hope that this study will provide a concrete base of data to evaluate the practical application and efficacy of using the novel combination of these 2 treatment modalities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/46830.
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Background: The transition from hospital to community settings for most mental health service users is often hindered by challenges that affect community adjustment and continuity of care. The first few weeks and days after discharge from mental health inpatient units represent a critical phase for many service users. This paper aims to evaluate the changes in the resilience, personal recovery, and quality of life status of individuals with mental health challenges recently discharged from acute mental health care into the community. Methods: Data for this study were collected as part of a pragmatic stepped-wedge cluster-randomized, longitudinal approach in Alberta. A paired sample t-test and Chi-squared/Fisher test were deployed to assess changes from baseline to six weeks in the recovery assessment scale (RAS), brief resilience scale (BRS), and EuroQol-5d (EQ-5D), using an online questionnaire. Results: A total of 306 service users were recruited and 88 completed both baseline and six weeks, giving a response rate of 28.8%. There was no statistically significant change in the level of resilience, recovery and quality of life as measured with the brief resilience scale, recovery assessment scale and EQ-5D from baseline to six weeks (p > 0.05). Conclusions: The study showed that there was neither an improvement nor deterioration in resilience, recovery, or quality of life status of service users six weeks post-discharge from inpatient mental health care. The lack of further progress calls into question whether the support available in the community when patient's leave inpatient care is adequate to promote full recovery. The results justify investigations into the effectiveness of innovative and cost-effective programs such as peer and text-based supportive interventions for service users discharged from inpatient psychiatric care.
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Background: Treatment-resistant depression (TRD) is considered one of the major clinical challenges in the field of psychiatry. An estimated 44% of patients with major depressive disorder (MDD) do not respond to two consecutive antidepressant therapies, and 33% do not respond to up to four antidepressants. Over 15% of all patients with MDD remain refractory to any treatment intervention. rTMS is considered a treatment option for patients with TRD. Likewise, iCBT is evidence-based, symptom-focused psychotherapy recommended for the treatment of TRD. Objective: This study aimed to evaluate the initial comparative clinical effectiveness of rTMS treatment with and without iCBT as an innovative intervention for the treatment of participants diagnosed with TRD. Methods: This study is a prospective two-arm randomized controlled trial. Overall, 78 participants diagnosed with TRD were randomized to one of two treatment interventions: rTMS sessions alone and rTMS sessions plus iCBT. Participants in each group were made to complete evaluation measures at baseline, and 6 weeks (discharge) from treatment. The primary outcome measure was baseline to six weeks change in mean score for the 17-item Hamilton depression rating scale (HAMD-17). Secondary outcomes included mean baseline to six-week changes in the Columbia suicide severity rating scale (CSSRS) for the rate of suicidal ideations, the QIDS-SR16 for subjective depression, and the EQ-5D-5L to assess the quality of health in participants. Results: A majority of the participants were females 50 (64.1%), aged ≥ 40 39 (50.0%), and had college/university education 54 (73.0%). After adjusting for the baseline scores, the study failed to find a significant difference in the changes in mean scores for participants from baseline to six weeks between the two interventions under study on the HAMD-17 scale: F (1, 53) = 0.15, p = 0.70, partial eta squared = 0.003, CSSRS; F (1, 56) = 0.04 p = 0.85, partial eta squared = 0.001, QIDS-SR16 scale; F (1, 53) = 0.04 p = 0.61, partial eta squared = 0.005, and EQ-5D-VAS; F (1, 51) = 0.46 p = 0.50, and partial eta squared = 0.009. However, there was a significant reduction in means scores at week six compared to baseline scores for the combined study population on the HAMD-17 scale (42%), CSSRS (41%), QIDS-SR16 scale (35%), and EQ-VAS scale (62%). Conclusion: This study did not find that combined treatment of TRD with rTMS + iCBT (unguided) was superior to treatment with rTMS alone. Our findings do not support the use of combined treatment of rTMS + iCBT for the management of TRD disorders.
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Background: Appropriate and adequate treatment of psychiatric conditions in the community or at first presentation to the hospital may prevent rehospitalization. Information about hospital readmission factors may help to reduce readmission rates. This scoping review sought to examine the readmission of patients to acute psychiatric hospitals to determine predictors and interventions to reduce psychiatric readmission rates. Method: A scoping review was conducted in eleven bibliographic databases to identify the relevant peer-reviewed studies. Two reviewers independently assessed full-text articles, and a screening process was undertaken to identify studies for inclusion in the review. PRISMA checklist was adopted, and with the Covidence software, 75 articles were eligible for review. Data extraction was conducted, collated, summarized, and findings reported. Result: 75 articles were analyzed. The review shows that learning disabilities, developmental delays, alcohol, drug, and substance abuse, were crucial factors that increased the risk of readmission. Greater access to mental health services in residential treatment and improved crisis intervention in congregate care settings were indicated as factors that reduce the risk of readmission. Conclusion: High rates of readmission may adversely impact healthcare spending. This study suggests a need for focused health policies to address readmission factors and improve community-based care.
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Background: The flood in Fort McMurray (FMM) which occurred between April 26 and May 2, 2020, is known to have displaced an estimated population of 1,500 people, and destroyed or damaged about 1,230 buildings. In all, it is estimated to have caused about $228 million in losses. Objective: This study aims to identify the prevalence and determinants of likely Generalized Anxiety disorder (GAD) in among respondents 12-months after the 2020 flooding. Methods: Data for the study were collected through a cross-sectional survey sent through REDCap and hosted online from the 24th of April to the 2nd of June 2021. The self-administered questionnaire was emailed to respondents using community, government, school, and occupational platforms. Demographic, flooding-related variables, and clinical data were collected. A validated instrument, the GAD-7 was used to collect information on likely GAD. Consent was implied by completing the survey forms, and the University of Alberta Health Research Ethics Committee approved the study. Results: Of the 249 residents surveyed, 74.7% (186) respondents completed the online survey, 81.6% (80) were above 40 years, 71% (132) were in a relationship, 85.5% (159) were females, and 94.1% (175) were employed. The prevalence of likely GAD was 42.5% in our study. Predictors of likely GAD among respondents included positive employment status (OR = 30.70; 95% C.I. 2.183-423.093), prior diagnosis of depression (OR = 3.30; 95% C.I. 1.157-9.43), and the perceived need to have mental health counseling (OR = 6.28; 95% C.I. 2.553-15.45). Conclusion: This study showed that there was an increased magnitude of moderate to high anxiety symptoms among respondents following the natural disaster particularly the flood in 2020. The predictors of likely GAD include positive employment status, history of depression diagnosis, and the need to have mental health counseling. Policymakers may mitigate the rise of anxiety after flooding in vulnerable areas by addressing these and other factors.
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This study explores differences in stress, anxiety, and depression experienced by different ethnic groups during the COVID-19 pandemic. This was a cross-sectional online survey of subscribers of the COVID-19 Text4Hope text messaging program in Alberta. Stress, anxiety, and depression were measured among Caucasian, Indigenous, Asian, and other ethnic groups using the Perceived Stress Scale (PSS)-10, Generalized Anxiety Disorder (GAD)-7, and Patient Health Questionnaire (PHQ)-9 scales, respectively. The burden of depression and stress were significantly higher in Indigenous populations than in both Caucasian and Asian ethnic groups. The mean difference between Indigenous and Caucasian for PHQ-9 scores was 1.79, 95% CI of 0.74 to 2.84, p < 0.01 and for PSS-10 it was 1.92, 95% CI of 0.86 to 2.98, p < 0.01). The mean difference between Indigenous and Asian for PHQ-9 scores was 1.76, 95% CI of 0.34 to 3.19, p = 0.01 and for PSS-10 it was 2.02, 95% CI of 0.63 to 3.41, p < 0.01. However, Indigenous participant burden of anxiety was only significantly higher than Asian participants' (mean difference for GAD-7 was 1.91, 95% CI of 0.65 to 3.18, p < 0.01). Indigenous people in Alberta have higher burden of mental illnesses during the COVID-19 pandemic. These findings are helpful for service planning and delivery.
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BACKGROUND: Major depression is a severe, disabling, and potentially lethal clinical disorder. Only about half of patients respond to an initial course of antidepressant pharmacotherapy. At least 15% of all patients with major depressive disorder (MDD) remain refractory to any treatment intervention. By the time that a patient has experienced 3 definitive treatment failures, the likelihood of achieving remission with the fourth treatment option offered is below 10%. Repetitive transcranial magnetic stimulation (rTMS) is considered a treatment option for patients with MDD who are refractory to antidepressant treatment. It is not currently known if the addition of internet-delivered cognitive-behavioral therapy (iCBT) enhances patients' responses to rTMS treatments. OBJECTIVE: This study will evaluate the initial comparative clinical effectiveness of rTMS with and without iCBT as an innovative patient-centered intervention for the treatment of participants diagnosed with treatment-resistant depression (TRD). METHODS: This study is a prospective, two-arm randomized controlled trial. In total, 100 participants diagnosed with resistant depression at a psychiatric care clinic in Edmonton, Alberta, Canada, will be randomized to one of two conditions: (1) enrolment in rTMS sessions alone and (2) enrolment in the rTMS sessions plus iCBT. Participants in each group will complete evaluation measures (eg, recovery, general symptomatology, and functional outcomes) at baseline, 1 month, 3 months, and 6 months. The primary outcome measure will be the mean change to scores on the Hamilton Depression Rating Scale. Patient service utilization data and clinician-rated measures will also be used to gauge patient progress. Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses. RESULTS: We expect the results of the study to be available in 24 months. We hypothesize that participants enrolled in the study who receive rTMS plus iCBT will achieve superior outcomes in comparison to participants who receive rTMS alone. CONCLUSIONS: The concomitant application of psychotherapy with rTMS has not been investigated previously. We hope that this project will provide us with a concrete base of data to evaluate the practical application and efficacy of using a novel combination of these two treatment modalities (rTMS plus iCBT). TRIAL REGISTRATION: ClinicalTrials.gov NCT0423965; https://clinicaltrials.gov/ct2/show/NCT04239651. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/18843.
