The impact of phone calls on follow-up rates in an online depression prevention study.

BACKGROUND: Automated Internet intervention studies have generally had large dropout rates for follow-up assessments. Live phone follow-ups have been often used to increase follow-up completion rates. OBJECTIVE: To compare, via a randomized study, whether receiving phone calls improves follow-up rates beyond email reminders and financial incentives in a depression prevention study. METHOD: A sample of 95 participants (63 English-speakers and 32 Spanish-speakers) was recruited online to participate in a "Healthy Mood" study. Consented participants were randomized to either a Call or a No Call condition. All participants were sent up to three email reminders in one week at 1, 3, and 6 months after consent, and all participants received monetary incentives to complete the surveys. Those in the Call condition received up to ten follow-up phone calls if they did not complete the surveys in response to email reminders. RESULTS: The follow-up rates for Call vs. No Call conditions at 1, 3, and 6 months, respectively, were as follows: English speakers, 58.6% vs. 52.9%, 62.1% vs. 52.9%, and 68.9% vs. 47.1%; Spanish speakers, 50.0% vs. 35.7%, 33.3% vs. 21.4%, and 33.3% vs. 7.1%. The number of participants who completed follow-up assessments only after being called at 1-, 3- and 6 months was 2 (14.3%), 0 (0%), and 3 (25.0%) for English speakers, and 2 (18.9%), 0 (0%), and 1 (7.7%) for Spanish speakers. The number of phone calls made to achieve one completed follow-up was 58.8 in the English sample and 57.7 and Spanish-speaking sample. CONCLUSIONS: Adding phone call contacts to email reminders and monetary incentives did increase follow-up rates. However, the rate of response to follow-up was low and the number of phone calls required to achieve one completed follow-up raises concerns about the utility of adding phone calls. We also discuss difficulties with using financial incentives and their implications.

Quitting smoking does not increase the risk of major depressive episodes among users of Internet smoking cessation interventions.

BACKGROUND: Limited evidence has suggested that quitting smoking increases the incidence of major depressive episodes (MDEs), particularly for smokers with a history of depression. Further evidence for this increase would have important implications for guiding smoking cessation. METHOD: Spanish- and English-speaking smokers without a current MDE (n=3056) from an international, online smoking cessation trial were assessed for abstinence 1 month after their initial quit date and followed for a total of 12 months. Incidence of screened MDE was examined as a function of abstinence and depression history. RESULTS: Continued smoking, not abstinence, predicted MDE screened at 1 month [smoking 11.5% v. abstinence 7.8%, odds ratio (OR) 1.36, 95% confidence interval (CI) 1.04-1.78, p=0.02] but not afterwards (smoking 11.1% v. abstinence 9.8%, OR 1.05, 95% CI 0.77-1.45, p=0.74). Depression history predicted MDE screened at 1 month (history 17.1% v. no history 8.6%, OR 1.71, 95% CI 1.29-2.27, p<0.001) and afterwards (history 21.7% v. no history 8.3%, OR 3.87, 95% CI 2.25-6.65, p<0.001), although the interaction between history and abstinence did not. CONCLUSIONS: Quitting smoking was not associated with increased MDE, even for smokers with a history of depression, although a history of depression was. Instead, not quitting was associated with increased MDE shortly following a quit attempt. Results from this online, large, international sample of smokers converge with similar findings from smaller, clinic-based samples, suggesting that in general, quitting smoking does not increase the incidence of MDEs.

Therapeutic drug monitoring of nortriptyline in smoking cessation: a multistudy analysis.

Multiple, controlled clinical trials support the efficacy of nortriptyline as a smoking cessation agent. Although therapeutic plasma nortriptyline concentrations (PNCs) are known for the treatment of depression, little is known about PNCs in smoking cessation treatment. PNCs from three randomized, placebo-controlled smoking cessation trials (N=244) were analyzed both separately and pooled. PNCs normalized for dose and weight were associated with cigarettes per day and race, but not with sex or age. Greater smoking was associated with decreased normalized PNCs. In addition, both Asian and black populations had significantly higher normalized PNCs than the white populations. Weak and inconsistent associations between PNCs and self-reported side effects were observed. PNCs were linearly related to end of treatment and long-term biochemically verified smoking abstinence. Maximum therapeutic effects were observed over a range of plasma concentrations somewhat lower than those found effective for the treatment of depression.

Psychology over the Internet: On-Line Experiences.

The "International Symposium on Psychology over the Internet: On-Line Experiences" was held in Lima, Peru, July 2003, at the 29th InterAmerican Congress of Psychology. The main topic was the advantages and disadvantages of using this technology in the applied field of psychology. The Internet has been considered a new alternative for teaching-learning processes (virtual classroom); vocational assessment; counseling and orientation (virtual psychological consultation); and intervention focused on specific health-related problems. These experiences of on-line psychological services and their conclusions are briefly described herein.

Differential item functioning in a Spanish translation of the Beck Depression Inventory.

Brief and culturally compatible measures of depression are necessary, yet most depression scales are translated without regard for cultural biases. In this study, 292 medical outpatients completed an English or a Spanish-translated and back-translated version of the Beck Depression Inventory (BDI). The BDI items were analyzed for bias between Spanish and English-speaking patients to determine the equivalence of the scale. A Differential Item Function (DIF) using a Mantel Haenszel Approach for Ordered Response Categories was used to analyze how likely subjects in the two ethnic groups were to endorse each response category. The results suggest that regardless of level of depression, Latinos are more likely to endorse items reflecting tearfulness and punishment, and less likely to endorse inability to work. Cultural interpretations and recommendations for use of the BDI are discussed.

Development of major depression after treatment for smoking cessation.

OBJECTIVE: Case studies suggest cigarette abstinence may precipitate a major depressive episode. This study examined the incidence and predictors of major depression in the 12 months after treatment for smoking cessation. METHOD: Participants (N=304, 172 women) were recruited from two trials of smoking cessation. Both trials provided psychological group intervention, but one group received treatment with nicotine gum and the other was given nortriptyline or placebo. The incidence of major depressive episodes was identified by the Inventory to Diagnose Depression, which was administered at follow-up assessments. RESULTS: The 12-month incidence of major depression after treatment for smoking cessation was 14.1% (N=43). Multiple logistic regression analyses indicated that history of depression, baseline Beck Depression Inventory score, college education, and age at smoking initiation were significant predictors of major depression after treatment. Abstinence at the end of treatment did not significantly predict major depression. CONCLUSIONS: Patients who achieved abstinence from smoking showed a risk of developing depressive episodes similar to those who failed to achieve abstinence. As expected, patients who had a history of depression were more likely to experience depressive episodes after treatment for smoking cessation. The 12-month incidence of major depression in this study group was higher than that observed in the general population, but reasons for the elevation were not clear.

Depression screening in a women's clinic: using automated Spanish- and English-language voice recognition.

Clinical depression is frequently unrecognized, even in health care settings. This study (a) reports high levels of major depressive episodes (MDEs) and depressive symptoms in a public sector women's clinic, (b) compares computerized voice recognition with live interviews, and (c) compares Spanish and English versions of the depression-screening instruments. Patients (N = 104) completed face-to-face interviews and/or computerized voice recognition interviews in counterbalanced order; 38% scored positive for current MDE, and 67% scored positive for lifetime MDE. The mean score on the Center for Epidemiological Studies Depression scale (CES-D) was 22.1 (SD = 12.1), with 68% scoring 16 or above. No differences were found on either measure between English and Spanish speakers. Overall agreement between computer and live interviews was as follows: kappa = .82 for both current and lifetime MDE and r = .89 for CES-D scores. Kappas between the MDE Screener developed for this study and the Primary Care Evaluation of Mental Disorders were .75 for live interviews and .81 for the computerized version. Depression screening with computerized voice recognition methods yielded results comparable with those of live interviews in both English and Spanish.

Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking.

BACKGROUND: A history of major depressive disorder (MDD) predicts failure to quit smoking. We determined the effect of nortriptyline hydrochloride and cognitive-behavioral therapy on smoking treatment outcome in smokers with a history of MDD. The study also addressed the effects of diagnosis and treatment condition on dysphoria after quitting smoking and the effects of dysphoria on abstinence. METHODS: This was a 2 (nortriptyline vs placebo) x 2 (cognitive-behavioral therapy vs control) x 2 (history of MDD vs no history) randomized trial. The participants were 199 cigarette smokers. The outcome measures were biologically verified abstinence from cigarettes at weeks 12, 24, 38, and 64. Mood, withdrawal, and depression were measured at 3, 5, and 8 days after the smoking quit date. RESULTS: Nortriptyline produced higher abstinence rates than placebo, independent of depression history. Cognitive-behavioral therapy was more effective for participants with a history of depression. Nortriptyline alleviated a negative affect occurring after smoking cessation. Increases in the level of negative affect from baseline to 3 days after the smoking quit date predicted abstinence at later assessments for MDD history-negative smokers. There was also a sex-by-depression history interaction; MDD history-positive women were less likely to be abstinent than MDD history-negative women, but depression history did not predict abstinence for men. CONCLUSIONS: Nortriptyline is a promising adjunct for smoking cessation. Smokers with a history of depression are aided by more intensive psychosocial treatments. Mood and diagnosis interact to predict relapse. Increases in negative affect after quitting smoking are attenuated by nortriptyline.

Cortisol and response to dexamethasone as predictors of withdrawal distress and abstinence success in smokers.

BACKGROUND: Glucocorticoids have been linked to self-administration of a wide range of drugs in animals and are increased endogenously by chronic nicotine intake. Corticosteroids have also been shown to regulate nicotine receptor sensitivity and to be involved in behavioral sensitization to nicotine. METHODS: Cortisol levels and cortisol suppression in response to dexamethasone were measured in a sample of smokers participating in a smoking cessation treatment trial. RESULTS: Cortisol levels dropped significantly during the early quitting process (2 weeks post-quit) and returned to a level below baseline 1 month post-quit. The magnitude of the initial drop in cortisol was strongly related to post-quit distress and marginally predictive of abstinence. Neither baseline nor post-quit changes in percent cortisol suppression after dexamethasone were related to abstinence success or withdrawal distress. CONCLUSIONS: Withdrawal from cigarette smoking is marked by a reduction in cortisol levels that appears to be related to the degree of distress experienced during the early quitting period. Further work is needed to determine whether withdrawal-related cortisol changes or distress are predictive of abstinence success.

Mood management mail intervention increases abstinence rates for Spanish-speaking Latino smokers.

A self-administered mood management intervention program for smoking cessation provided through the mail to Spanish-speaking Latinos resulted in a 23% abstinence rate at 3 months compared to an 11% abstinence rate for a smoking cessation guide alone. Participants (N = 136) were randomly assigned to receive either the cessation guide (the Guía), or the Guía plus a mood management intervention (Tomando Control de su Vida) presented in writing and in audiotape format. At 3 months after random assignment, 16 out of 71 of those assigned to the Guía-plus-mood management condition reported being abstinent (not smoking for at least 7 days) compared to 7 out of 65 in the Guía-only condition (z = 1.8; p = .04, one-tailed). Moreover, those with a history of major depressive episodes, but not currently depressed, reported an even higher abstinence rate in the Guía-plus-mood management condition, compared to the Guía-only condition (31 vs. 11%, z = 1.8, p = .04, one-tailed). We conclude that the mood management mail intervention substantially increases abstinence rates, especially for those with a history of major depressive episodes.

Institute of Medicine report on prevention of mental disorders. Summary and commentary.

A comprehensive report mandated by the U.S. Congress on the state of the science of prevention recommends a stricter definition of the term prevention; summarizes specific preventive intervention research programs across the life span; and specifies funding, personnel, and coordination priorities to build a national prevention research infrastructure. A major conceptual recommendation is a focus on reducing risk for mental disorders, which has been a fruitful strategy in the prevention of physical illness. The report argues that the prevention field should also draw from advances in mental disorder treatment research and from the major contributions to the knowledge base occurring in the behavioral and biological core sciences. Relevant advances in neuroscience, genetics, epidemiology, and developmental psychopathology are examined in detail. Five major disorders are chosen to illustrate possible approaches to prevention: conduct disorder, depressive disorders, alcohol abuse and dependence, schizophrenia, and Alzheimer's disease.

Recruiting and retaining low-income Latinos in psychotherapy research.

This article offers suggestions for recruiting and retaining low-income Latinos in treatment studies. Because Latinos underuse traditional mental health services, places such as medical centers or churches with large Latino constituents are suggested as useful alternative sources. To keep Latinos in research protocols, providing culturally sensitive treatments are necessary. Culturally sensitive treatments should incorporate families as part of recruitment efforts, particularly older men in the family. In addition, showing respect is an important aspect of traditional Latino culture that includes using formal titles and taking time to listen carefully. Finally, traditional Latinos tend to like interactions with others that are more warm and personal than is generally part of a research atmosphere.

Mood management and nicotine gum in smoking treatment: a therapeutic contact and placebo-controlled study.

Earlier research indicated that a 10-session mood management (MM) intervention was more effective than a 5-session standard intervention for smokers with a history of major depressive disorder (MDD). In a 2 x 2 factorial design, the present study compared MM intervention to a contact-equivalent health education intervention (HE) and 2 mg to 0 mg of nicotine gum for smokers with a history of MDD. Participants were 201 smokers, 22% with a history of MDD. Contrary to the earlier findings, the MM and HE interventions produced similar abstinence rates: 2 mg gum was no more effective than placebo. History-positive participants had a greater increase in mood disturbance after the quit attempt. Independent of depression diagnosis, increases in negative mood immediately after quitting predicted smoking. No treatment differences were found in trends over time for measures of mood, withdrawal symptoms, pleasant activities and events, self-efficacy, and optimism and pessimism. History-positive smokers may be best treated by interventions providing additional support and contact, independent of therapeutic content.

Prevention of depression with primary care patients: a randomized controlled trial.

The prevention of major depression is an important research goal which deserves increased attention. Depressive symptoms and disorders are particularly common in primary care patients and have a negative impact on functioning and well-being comparable with other major chronic medical conditions. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial to demonstrate the feasibility of implementing such research in a public sector setting serving low-income, predominantly minority individuals: 150 primary care patients free from depression or other major mental disorders were randomized to an experimental cognitive-behavioral intervention or to a control condition. The experimental intervention group reported a significantly greater reduction in depressive levels. Decline in depressive levels was significantly mediated by decline in the frequency of negative conditions. Group differences in the number of new episodes (incidence) of major depression did not reach significance during the 1-year trial. We conclude that depression prevention trials in public sector primary care settings are feasible, and that depressive symptoms can be reduced even in low-income, minority populations. To conduct randomized prevention trials that can test effects on incidence with sufficient statistical power, subgroups at greater imminent risk have to be identified.

Cognitive-behavioral intervention increases abstinence rates for depressive-history smokers.

This article describes the test of the hypothesis that a cognitive-behavioral mood management intervention would be effective for smokers with a history of major depressive disorder (MDD). The method was randomized trial; the assessments occurred at Weeks 0, 8, 12, 26, and 52. Ss were 149 smokers; 31% had a history of MDD. All received 2 mg of nicotine gum. Mood management was provided in 10 group sessions over 8 weeks. Standard treatment was provided in 5 group sessions over 8 weeks. Outcome was continuous abstinence. History-positive Ss were more likely to be abstinent when treated with mood management. Treatment condition differences were not significant for history-negative Ss. For history-positive Ss, less anger at baseline predicted abstinence. For history-negative Ss, more years smoked and higher baseline carbon monoxide (CO) predicted abstinence. Cognitive-behavioral therapy did not affect mood after quitting. Abstinence predictors differed as a function of baseline diagnosis.

On the AHCPR depression in primary care guidelines. Further considerations for practitioners. Agency for Health Care Policy and Research.AHCPR.

The majority of cases of clinical depression go unrecognized and untreated, despite the fact that depression is an eminently treatable disorder. The Agency for Health Care Policy and Research (AHCPR) recently published a set of clinical practice guidelines focused on depression in primary care settings. The review of the literature on which the guidelines are based is thorough and appropriate and should enhance the detection of depression and the quality of pharmacotherapy for depression. However, the guidelines encourage primary care physicians to provide pharmacotherapy to their depressed patients as the first line of treatment. The wisdom of this recommendation is questioned and revisions to the guidelines are suggested. Specifically, patients should be informed of the broad array of treatment options available and provided with a more balanced presentation of the potential benefits of psychotherapy for depression. Patients should decide which treatment alternative they wish to undergo.

Nicotine, negative affect, and depression.

Depression, whether conceptualized as a trait, symptom, or as a diagnosable disorder, is overrepresented among smokers. Depressed smokers appear to experience more withdrawal symptoms on quitting, are less likely to be successful at quitting, and are more likely to relapse. This article documents these relationships and explores several potential links between smoking and depression. The potential efficacy of antidepressant therapy, cognitive-behavioral therapy, and nicotine replacement therapy for smokers with depressive disorders or traits is discussed. Clinical implications and the role of patient treatment matching are also discussed.

Somatization, psychiatric disorder, and stress in utilization of ambulatory medical services.

Examined the prediction from Mechanic's (1972) attribution theory of somatization that somatizers who are under stress will overuse ambulatory medical services. Two hundred fourteen volunteer patients from university ambulatory care clinics completed the Diagnostic Interview Schedule and the Life Experiences Inventory. We examined somatization, psychiatric diagnoses, and life stress-and the interaction of these factors-in predicting frequency of medical visits during the preceding year, after controlling for need (active medical problems) and predisposing factors. As hypothesized, life stress interacted with somatization in predicting number of medical visits; somatizers who were under stress made more visits to the clinics than did nonsomatizers or somatizers who were not under stress. Although stress affected somatizers most, stress was predictive of increased medical utilization for all patients. These results suggest that psychological services intended to reduce overutilization of outpatient medical services might best focus on stress reduction and be most beneficial to somatizers.

Depression in medical outpatients. Underrecognition and misdiagnosis.

Depression is a common problem in medical outpatients, yet primary care physicians recognize the disorder in only about half of their depressed patients. We compared physician recognition of depression (defined by chart notation or prescription of antidepressants) with diagnoses generated by the Diagnostic Interview Schedule (DIS) in 265 medical outpatients. Using DIS criteria, diagnoses of major depression in the past year or dysthymia (chronic minor depression) were made in 70 patients. Physicians recognized as depressed only 25 (35.7%) of the 70 DIS-depressed patients. However, 36 patients who were not depressed according to DIS were "recognized" as depressed by physicians. Patients misdiagnosed as depressed by physicians were older, less educated, had more outpatient visits, and were prescribed more medications. Receiver operating characteristic curves of two self-report depression scales suggest that these scales may assist physicians in recognizing depressed outpatients. We conclude that physicians underrecognize and misdiagnose depression in medical outpatients.

Visceral leishmaniasis as an opportunistic infection in the acquired immunodeficiency syndrome.

We describe the case of a woman aged 34 years infected with the human immunodeficiency virus and whose illness was complicated by visceral leishmaniasis that ultimately led to her death.