Effectiveness of cognitive behavioral therapy for depression in patients receiving disability benefits: a systematic review and individual patient data meta-analysis.

OBJECTIVES: To systematically summarize the randomized trial evidence regarding the relative effectiveness of cognitive behavioural therapy (CBT) in patients with depression in receipt of disability benefits in comparison to those not receiving disability benefits. DATA SOURCES: All relevant RCTs from a database of randomized controlled and comparative studies examining the effects of psychotherapy for adult depression (http://www.evidencebasedpsychotherapies.org), electronic databases (MEDLINE, EMBASE, PSYCINFO, AMED, CINAHL and CENTRAL) to June 2011, and bibliographies of all relevant articles. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTION: Adult patients with major depression, randomly assigned to CBT versus minimal/no treatment or care-as-usual. STUDY APPRAISAL AND SYNTHESIS METHODS: Three teams of reviewers, independently and in duplicate, completed title and abstract screening, full text review and data extraction. We performed an individual patient data meta-analysis to summarize data. RESULTS: Of 92 eligible trials, 70 provided author contact information; of these 56 (80%) were successfully contacted to establish if they captured receipt of benefits as a baseline characteristic; 8 recorded benefit status, and 3 enrolled some patients in receipt of benefits, of which 2 provided individual patient data. Including both patients receiving and not receiving disability benefits, 2 trials (227 patients) suggested a possible reduction in depression with CBT, as measured by the Beck Depression Inventory, mean difference [MD] (95% confidence interval [CI]) = -2.61 (-5.28, 0.07), p = 0.06; minimally important difference of 5. The effect appeared larger, though not significantly, in those in receipt of benefits (34 patients) versus not receiving benefits (193 patients); MD (95% CI) = -4.46 (-12.21, 3.30), p = 0.26. CONCLUSIONS: Our data does not support the hypothesis that CBT has smaller effects in depressed patients receiving disability benefits versus other patients. Given that the confidence interval is wide, a decreased effect is still possible, though if the difference exists, it is likely to be small.

Early signaling, referral, and treatment of adolescent chronic pain: a study protocol.

BACKGROUND: Chronic pain is prevalent among young people and negatively influences their quality of life. Furthermore, chronic pain in adolescence may persist into adulthood. Therefore, it is important early on to promote the self-management skills of adolescents with chronic pain by improving signaling, referral, and treatment of these youngsters. In this study protocol we describe the designs of two complementary studies: a signaling study and an intervention study. METHODS AND DESIGN: The signaling study evaluates the Pain Barometer, a self-assessed signaling instrument for chronic pain in adolescents. To evaluate the feasibility of the Pain Barometer, the experiences of youth-health care nurses will be evaluated in semi-structured interviews. Also, we will explore the frequencies of referral per health-care provider. The intervention study evaluates Move It Now, a guided self-help intervention via the Internet for teenagers with chronic pain. This intervention uses cognitive behavioural techniques, including relaxation exercises and positive thinking. The objective of the intervention is to improve the ability of adolescents to cope with pain. The efficacy of Move It Now will be examined in a randomized controlled trial, in which 60 adolescents will be randomly assigned to an experimental condition or a waiting list control condition. DISCUSSION: If the Pain Barometer is proven to be feasible and Move It Now appears to be efficacious, a health care pathway can be created to provide the best tailored treatment promptly to adolescents with chronic pain. Move It Now can be easily implemented throughout the Netherlands, as the intervention is Internet based. TRIAL REGISTRATION: Dutch Trial Register NTR1926.

The responsiveness of quality of life utilities to change in depression: a comparison of instruments (SF-6D, EQ-5D, and DFD).

BACKGROUND: Utilities are often a main outcome parameter in economic evaluations. Because depression has a large influence on quality of life, it is expected that utilities are responsive to changes in depression. OBJECTIVE: To evaluate the change in utility derived from different instruments in depression, including the Short Form 6D (SF-6D), the Euroqol based on the UK (EQ-5D(UK)), the Euroqol based on the Dutch tariff (EQ-5D(NL)), and utilities derived from Beck Depression Inventory Second Edition (BDI-II) using the Depression-Free-Day method. METHOD: This study evaluated the responsiveness, the minimally important difference, and the agreement in utility change derived from the different instruments. RESULTS: The SF-6D, EQ-5D(UK), and EQ-5D(NL) were responsive. The minimally important difference values are in line with previous studies, about 0.3. The Depression-Free-Day method nearly always resulted in positive utility changes, even for subgroups that had no change or deterioration in health status or depression. There was poor agreement between utility changes of the SF-6D, EQ-5D (either EQ-5D(UK) or EQ-5D(NL)), and DFDu. CONCLUSIONS: The SF-6D, EQ-5D(UK), and EQ-5D(NL) seem responsive and thus adequate for estimating utility in depression treatment. We do not recommend the use of the Depression-Fee-Day method. The low agreement between utility changes indicates that outcomes of the different instruments are incomparable.

Does the weather make us sad? Meteorological determinants of mood and depression in the general population.

It is a common and well-spread belief that people feel more depressed when the weather is bad. However, whether meteorological factors such as temperature, sunshine and rainfall can actually account for variations in the prevalence of depression in the general population has yet to be investigated. We aimed to assess the influence of weather conditions on the seasonal variation of depression observed in the general population. We used data from a large-scale depression-screening programme in the south of the Netherlands. Seasonal prevalence of DSM-IV classified major depression and sad mood in a sample of 14,478 participants from the general population was calculated, and linked to mean daily temperature, duration of sunshine and duration of rainfall in logistic regression analyses. The prevalence of major depression and sad mood showed seasonal variation, with peaks in the summer and fall. Weather conditions were not associated with mood, and did not explain the seasonal variation we found. We conclude that, contrary to popular belief, weather conditions and sad mood or depression do not seem to be associated. Future studies might use daily measures of well-being as outcome.

Minor and major depression in the general population: does dysfunctional thinking play a role?

BACKGROUND: Although most research suggests that minor depression is part of a depression continuum, conflicting results have also been found. Moreover, little is known about dysfunctional thinking in minor depression and how this varies along the continuum. Especially, research on the form of dysfunctional thinking (ie, extreme responding) is lacking. We have addressed these issues by reporting results from a large community sample. METHODS: Demographic, clinical, and cognitive factors (ie, content and form of dysfunctional thinking) were compared between minor depression (ie, 2-4 symptoms), major depression with 5 to 6 symptoms, and major depression with 7 to 9 symptoms. A large community sample (N = 1129) was used. Differences between the 3 subgroups were examined as well as linear relations between number of symptoms and factors marking the severity. RESULTS: Most demographic variables did not distinguish the 3 depression status categories from each other. Clinical and cognitive factors acted in synchrony with the depression continuum. CONCLUSIONS: Minor depression should be considered as part of continuum together with major depression. Not only the content but also the form of dysfunctional thinking seems to play a major role in depression. Extreme positive responding is more prominent in mild depression, whereas more severely depressed individuals have a general tendency toward extreme negative responding. This finding, if replicated, may have important implications for the cognitive theory of depression.

Predicting outcome in computerized cognitive behavioral therapy for depression in primary care: A randomized trial.

OBJECTIVE: To explore pretreatment and short-term improvement variables as potential moderators and predictors of 12-month follow-up outcome of unsupported online computerized cognitive behavioral therapy (CCBT), usual care, and CCBT combined with usual care for depression. METHOD: Three hundred and three depressed patients were randomly allocated to (a) unsupported online CCBT, (b) treatment as usual (TAU), or (c) CCBT and TAU combined (CCBT&TAU). Potential predictors and moderators were demographic, clinical, cognitive, and short-term improvement variables. Outcomes were the Beck Depression Inventory-II score at 12 months of follow-up and reliable change. RESULTS: Those with higher levels of extreme (positive) responding had a better outcome in CCBT compared with TAU, whereas those having a parental psychiatric history or a major depressive disorder diagnosis had a better outcome in CCBT&TAU compared with TAU. Predictors regardless of treatment type included current employment, low pretreatment illness severity, and short-term improvement on clinical variables. CONCLUSIONS: Optimistic patients, holding approach-oriented coping strategies, might benefit most from CCBT, whereas CCBT&TAU might be the most suitable option for those with more severe vulnerability characteristics. Those with the least impairment improve the most, regardless of treatment type.

Measuring Dysfunctional Attitudes in the General Population: The Dysfunctional Attitude Scale (form A) Revised.

The Dysfunctional Attitude Scale (DAS) was designed to measure the intensity of dysfunctional attitudes, a hallmark feature of depression. Various exploratory factor analytic studies of the DAS form A (DAS-A) yielded mixed results. The current study was set up to compare the fit of various factor models. We used a large community sample (N = 8,960) to test the previously proposed factor models of the DAS-A using confirmatory factor analysis. The retained model of the DAS-A was subjected to reliability and validity analyses. All models showed good fit to the data. Finally, a two-factor solution of the DAS-A was retained, consisting of 17 items. The factors demonstrated good reliability and convergent construct validity. Significant associations were found with depression. Norm-scores were presented. We advocate the use of a 17-item DAS-A, which proved to be useful in measuring dysfunctional beliefs. On the basis of previous psychometric studies, our study provides solid evidence for a two-factor model of the DAS-A, consisting of 'dependency' and 'perfectionism/performance evaluation'.

Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome.

BACKGROUND: In a recent randomized trial, we were unable to confirm the previously reported high effectiveness of CCBT. Therefore, the aim of the current study was to have a closer look at usage and acceptability (i.e. expectancy, credibility, and satisfaction) of the intervention. METHODS: Depressed participants (N=200) were given login codes for unsupported online CCBT. A track-and-trace system tracked which components were used. We used a 9-month follow-up period. RESULTS: Uptake was sufficient, but dropout was high. Many usage indices were positively associated with short-term depressive improvement, whereas only homework was related to long-term improvement. Acceptability was good and expectancy could predict long-term, but not short-term outcome. LIMITATIONS: Associations between use of CCBT and improvement are merely correlational. Our sample was too depressed in relation to the scope of the intervention. We relied on online self-report measures. Analyses were exploratory in nature. CONCLUSIONS: Although CCBT might be a feasible and acceptable treatment for depression, means to improve treatment adherence are needed for moderately to severely depressed individuals.

Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: design of a randomised trial.

BACKGROUND: Major depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care. METHODS/DESIGN: In a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18-65) will be recruited in the general population by means of a large-scale Internet-based screening (N = 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life. DISCUSSION: Although computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed. TRIAL REGISTRATION: The study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).