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1.
Contemp Clin Trials ; 99: 106184, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33091587

RESUMO

BACKGROUND: Programs such as the Pediatric Access Line in Washington state have shown decreases in antipsychotic medication use by youth with non-psychotic disorders. Program outcomes have been studied with observational designs. This manuscript describes the protocol for Targeted and Safer Use of Antipsychotics in Youth (SUAY), a randomized controlled trial of psychiatrist review of prescriptions and facilitated access to psychosocial care. The aim of the intervention is to reduce the number of person-days of antipsychotic use among participants. METHODS: Recruitment occurs at 4 health systems. Targeted enrollment is 800 youth aged 3-17 years. Clinicians are block randomized to intervention versus usual care prior to the study. Youth are nested within the arm of the prescribing clinician. Clinicians in the intervention group receive an EHR-based best practice alert with options to expedite access to psychosocial care and all medication orders are reviewed by a child and adolescent psychiatrist with feedback provided to the prescriber. The primary outcome is person-days of antipsychotic medication use in the 6 months following the initial order. All randomized individuals contribute data regardless of their level of participation (including declining all services). DISCUSSION: The trial has been approved by the institutional review boards at each of the 4 sites. The intervention has 4 novel design features including automated recruitment using a best practice alert, psychiatrist medication order review and consultation, telephone navigation to psychosocial care, and telemental health visits. Recruitment began in March of 2018 and will be completed in June 2020. Follow-up will be completed December 31, 2020. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03448575.

2.
JAMA Intern Med ; 2019 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-31633746

RESUMO

Importance: Patients with acute coronary syndrome (ACS) and elevated depressive symptoms are at increased risk for recurrent cardiovascular events and mortality, worse quality of life, and higher health care costs. These observational findings prompted multiple scientific panels to advise universal depression screening in survivors of ACS prior to evidence from randomized screening trials. Objective: To determine whether systematically screening for depression in survivors of ACS improves quality of life and depression compared with usual care. Design, Setting, and Participants: A 3-group multisite randomized trial enrolled 1500 patients with ACS from 4 health care systems between November 1, 2013, and March 31, 2017, with follow-up ending July 31, 2018. Patients were eligible if they had been hospitalized for ACS in the previous 2 to 12 months and had no prior history of depression. All analyses were performed on an intention-to-treat basis. Interventions: Patients with ACS were randomly assigned 1:1:1 to receive (1) systematic depression screening using the 8-item Patient Health Questionnaire, with notification of primary care clinicians and provision of centralized, patient-preference, stepped depression care for those with positive screening results (8-item Patient Health Questionnaire score ≥10; screen, notify, and treat, n = 499); (2) systematic depression screening, with notification of primary care clinicians for those with positive screening results (screen and notify, n = 501); and (3) usual care (no screening, n = 500). Main Outcomes and Measures: The primary outcome was change in quality-adjusted life-years. The secondary outcome was depression-free days. Adverse effects and mortality were assessed by patient interview and hospital records. Results: A total of 1500 patients (424 women and 1076 men; mean [SD] age, 65.9 [11.5] years) were randomized in the 18-month trial. Only 71 of 1000 eligible survivors of ACS (7.1%) had elevated 8-item Patient Health Questionnaire scores indicating depressive symptoms at screening. There were no differences in mean (SD) change in quality-adjusted life-years (screen, notify and treat, -0.06 [0.20]; screen and notify, -0.06 [0.20]; no screen, -0.06 [0.18]; P = .98) or cumulative mean (SD) depression-free days (screen, notify and treat, 343.1 [179.0] days; screen and notify, 351.3 [175.0] days; no screen, 339.0 [176.6] days; P = .63). Harms including death, bleeding, or sleep difficulties did not differ among groups. Conclusions and Relevance: In patients with ACS without a history of depression, systematic depression screening with or without providing depression treatment did not alter quality-adjusted life-years, depression-free days, or harms. Trial Registration: ClinicalTrials.gov identifier: NCT01993017.

3.
Contemp Clin Trials ; 84: 105826, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31419605

RESUMO

BACKGROUND: Elevated depressive symptoms among survivors of acute coronary syndromes (ACS) confer recurrent cardiovascular events and mortality, worse quality of life, and higher healthcare costs. While multiple scientific groups advise routine depression screening for ACS survivors, no randomized trials exist to inform this screening recommendation. We aimed to assess the effect of screening for depression on change in quality of life over 18 months among ACS patients. METHODS: The Comparison of Depression Identification after Acute Coronary Syndrome on Quality of Life and Cost Outcomes (CODIACS-QoL) trial is a pragmatic, 3-arm trial that randomized ACS patients to 1) systematic depression screening using the 8-item Patient Health Questionnaire (PHQ-8) and if positive screen (PHQ-8 ≥ 10), notification of primary care providers (PCPs) and invitation to participate in centralized, patient-preference, stepped depression care (Screen, Notify, and Treat, N = 499); 2) systematic depression screening and PCP notification only (Screen and Notify, N = 501); and 3) usual care (No Screen, N = 500). Adults hospitalized for ACS in the previous 2-12 months without prior history of depression were eligible for participation. Key outcomes will be quality-adjusted life years (primary), cost of health care utilization, and depression-free days across 18 months. RESULTS: A total of 1500 patients were randomized in the CODIACS-QOL trial (28.3% women; 16.3% Hispanic; mean age 65.9 (11.5) years). Only 7% of ACS survivors had elevated depressive symptoms. CONCLUSIONS: Using a novel randomization schema and pragmatic design principles, the CODIACS-QoL trial achieved its enrollment target. Eventual results of this trial will inform future depression screening recommendations in cardiac patients. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01993017).


Assuntos
Síndrome Coronariana Aguda/complicações , Depressão/diagnóstico , Depressão/etiologia , Programas de Rastreamento/métodos , Atenção Primária à Saúde/métodos , Síndrome Coronariana Aguda/psicologia , Fatores Etários , Idoso , Algoritmos , Antidepressivos/uso terapêutico , Análise Custo-Benefício , Aconselhamento/métodos , Depressão/terapia , Feminino , Nível de Saúde , Humanos , Masculino , Programas de Rastreamento/economia , Saúde Mental , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Atenção Primária à Saúde/economia , Qualidade de Vida , Encaminhamento e Consulta , Fatores Sexuais , Método Simples-Cego , Fatores Socioeconômicos
4.
Psychiatr Serv ; 70(4): 279-286, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30929618

RESUMO

OBJECTIVE: Youth depression can be prevented, yet few programs are offered. Decision makers lack cost information. This study evaluated the cost-effectiveness of a cognitive-behavioral prevention program (CBP) versus usual care. METHODS: A cost-effectiveness analysis was conducted with data from a randomized controlled trial of 316 youths, ages 13-17, randomly assigned to CBP or usual care. Youths were at risk of depression because of a prior depressive disorder or subthreshold depressive symptoms, or both, and had parents with a prior or current depressive disorder. Outcomes included depression-free days (DFDs), quality-adjusted life years (QALYs), and costs. RESULTS: Nine months after baseline assessment, youths in CBP experienced 12 more DFDs (p=.020) and .018 more QALYs (p=.007), compared with youths in usual care, with an incremental cost-effectiveness ratio (ICER) of $24,558 per QALY. For youths whose parents were not depressed at baseline, CBP youths had 26 more DFDs (p=.001), compared with those in usual care (ICER=$10,498 per QALY). At 33 months postbaseline, youths in CBP had 40 more DFDs (p=.05) (ICER=$12,787 per QALY). At 33 months, CBP youths whose parents were not depressed at baseline had 91 more DFDs (p=.001) (ICER=$13,620 per QALY). For youths with a currently depressed parent at baseline, CBP was not significantly more effective than usual care at either 9 or 33 months, and costs were higher. CONCLUSIONS: CBP produced significantly better outcomes than usual care and was particularly cost-effective for youths whose parents were not depressed at baseline. Depression prevention programs could improve youths' health at a reasonable cost; services to treat depressed parents may also be warranted.


Assuntos
Filho de Pais Incapacitados/psicologia , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo/prevenção & controle , Pais/psicologia , Adolescente , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Transtorno Depressivo/economia , Feminino , Seguimentos , Humanos , Masculino , Anos de Vida Ajustados por Qualidade de Vida , Análise de Regressão , Risco , Estados Unidos
5.
J ECT ; 34(4): 258-265, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29613944

RESUMO

BACKGROUND: Neurocognitive dysfunction is an understudied and undertreated aspect of psychiatric research and treatment. There is emerging evidence to suggest that repetitive transcranial magnetic stimulation (rTMS) may possess neurocognition-enhancing capabilities. METHODS: This study examined the neurocognitive data from a randomized, double-blind, sham-controlled trial of an investigational 2-coil rTMS device in antidepressant treatment or treatment-intolerant major depressive disorder patients. This device has the potential to stimulate deeper areas of the brain than the Food and Drug Administration-approved TMS devices, which primarily stimulate cortical brain areas and may therefore have different neurocognitive adverse effects. Patients received 20 daily rTMS treatments (10-Hz stimulation; either active or sham) with coil centers positioned over the left dorsolateral prefrontal cortex and dorsomedial prefrontal cortex. Neurocognitive safety was evaluated at baseline and within 72 hours of final treatment session with a computerized battery assessing aspects of attention and memory in 84 participants. RESULTS: There were no observed negative neurocognitive effects of the 2-coil rTMS device. A significant effect of active rTMS was observed on the quality of episodic memory. There were no observed effects for attention or working memory. Baseline quality of episodic memory predicted depression treatment response and remission, in that lower baseline episodic memory was associated with greater likelihood of depression response/remission. This was observed in logistic regression analyses controlling for treatment and baseline depressive symptoms. CONCLUSIONS: The 2-coil rTMS device is a cognitively safe treatment for treatment-resistant depression that may possess episodic memory-enhancing capabilities. Furthermore, baseline episodic memory may reflect an important predictor of subsequent depression treatment response/remission to rTMS.


Assuntos
Cognição , Transtorno Depressivo Maior/psicologia , Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana/métodos , Adolescente , Adulto , Idoso , Transtorno Depressivo Resistente a Tratamento/psicologia , Método Duplo-Cego , Feminino , Humanos , Masculino , Memória , Pessoa de Meia-Idade , Testes Neuropsicológicos , Córtex Pré-Frontal , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Estimulação Magnética Transcraniana/instrumentação , Resultado do Tratamento , Adulto Jovem
6.
Pediatrics ; 141(2)2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29351965

RESUMO

BACKGROUND AND OBJECTIVES: Adolescents with depression identified in primary care settings often have limited treatment options beyond antidepressant (AD) therapy. We assessed the cost-effectiveness of a brief cognitive behavioral therapy (CBT) program among depressed adolescents who declined or quickly stopped using ADs. METHODS: A total of 212 youth with depression were randomly assigned to treatment as usual (TAU) or TAU plus brief individual CBT. Clinical outcomes included depression-free days (DFDs) and estimated quality-adjusted life-years (QALYs). Costs were adjusted to 2008 US dollars. Incremental cost-effectiveness ratios (ICERs) comparing CBT to TAU were calculated over 12- and 24-month follow-up periods. RESULTS: Youth randomly assigned to CBT had 26.8 more DFDs (P = .044) and 0.067 more QALYs (P = .044) on average compared with TAU over 12 months. Total costs were $4976 less (P = .025) by the end of the 24-month follow-up among youth randomly assigned to CBT. Total costs per DFD were -$51 (ICER = -$51; 95% confidence interval [CI]: -$394 to $9) at 12 months and -$115 (ICER = -$115; 95% CI: -$1090 to -$6) at 24 months. Total costs per QALY were -$20 282 (ICER = -$20 282; 95% CI: -$156 741 to $3617) at 12 months and -$45 792 (ICER = -$45 792; 95% CI: -$440 991 to -$2731) at 24 months. CONCLUSIONS: Brief primary care CBT among youth declining AD therapy is cost-effective by widely accepted standards in depression treatment. CBT becomes dominant over TAU over time, as revealed by a statistically significant cost offset at the end of the 2-year follow-up.


Assuntos
Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Transtorno Depressivo/terapia , Adolescente , Antidepressivos/uso terapêutico , Criança , Transtorno Depressivo/economia , Feminino , Seguimentos , Humanos , Análise de Intenção de Tratamento , Masculino , Anos de Vida Ajustados por Qualidade de Vida
7.
Qual Life Res ; 27(2): 447-454, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29149441

RESUMO

PURPOSE: To examine the longitudinal construct validity in the assessment of changes in depressive symptoms of widely used utility and generic HRQL instruments in teens. METHODS: 392 teens enrolled in the study and completed HRQL and diagnostic measures as part of the baseline interview. HRQL measures included EuroQol (EQ-5D-3L), Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), Quality of Well-Being Scale (QWB), Pediatric Quality of Life Inventory (PEDS-QL), RAND-36 (SF-6D), and Quality of Life in Depression Scale (QLDS). Youth completed follow-up interviews 12 weeks after baseline. Sixteen youth (4.1%) were lost to follow-up. We examined correlations between changes in HRQL instruments and the Children's Depression Rating Scale-Revised (CDRS-R) and assessed clinically meaningful change in multi-attribute utility HRQL measures using mean change (MC) and standardized response mean (SRM) among youth showing at least moderate (20%) improvement in depression symptomology. RESULTS: Spearman's correlation coefficients demonstrated moderate correlation between changes in CDRS-R and the HUI2 (r = 0.38), HUI3 (r = 0.42), EQ-5D-3L (r = 0.36), SF-6D (r = 0.39), and PEDS-QL (r = 0.39) and strong correlation between changes in CDRS-R and QWB (r = 0.52) and QLDS (r = - 0.71). Effect size results are also reported. Among multi-attribute utility measures, all showed clinically meaningful improvements in the sample of youth with depression improvement (HUI2, MC = 0.20, SRM = 0.97; HUI3, MC = 0.32, SRM = 1.17; EQ-5D-3L, MC = 0.08, SRM = 0.51; QWB, MC = 0.11, SRM = 0.86; and SF-6D, MC = 0.12, SRM = 1.02). CONCLUSIONS: Findings support the longitudinal construct validity of included HRQL instruments for the assessment of change in depression outcomes in teens. Results of this study can help inform researchers about viable instruments to include in economic evaluations for this population.


Assuntos
Depressão/diagnóstico , Qualidade de Vida/psicologia , Adolescente , Depressão/psicologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Inquéritos e Questionários
8.
BMJ Open Diabetes Res Care ; 6(1): e000604, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30687505

RESUMO

Objective: To determine the possible association between insomnia and risk of type 2 diabetes mellitus (T2DM) in the naturalistic clinical setting. Research design and methods: We conducted a retrospective cohort study to examine the risk of developing T2DM among patients with pre-diabetes with and without insomnia. Participants with pre-diabetes (identified by a physician or via two laboratory tests) between January 1, 2007 and December 31, 2015 and without sleep apnea were followed until December 31, 2016. Patients were determined to have T2DM when two of the following occurred within a 2-year window: physician-entered outpatient T2DM diagnosis (International Classification of Diseases [ICD]-9 250.00; ICD-10 E11), dispensing of an antihyperglycemia agent, and hemoglobin A1c (A1c) >6.5% (48 mmol/mol) or fasting plasma glucose (FPG) >125 mg/dL. One hospital inpatient stay with an associated T2DM diagnosis was also sufficient for classification of T2DM. Results: Our cohort consisted of 81 233 persons with pre-diabetes, 24 146 (29.7%) of whom had insomnia at some point during the 4.3-year average observation period. After adjustment for traditional risk factors, those with insomnia were 28% more likely to develop T2DM than those without insomnia (HR 1.28; 95% CI 1.24 to 1.33). The estimate was essentially unchanged after adjusting for baseline A1c level (HR 1.32; 95% CI 1.25 to 1.40) or FPG (HR 1.28; 95% CI 1.23 to 1.33). Conclusions: Insomnia imparts an increased risk of T2DM comparable with that conferred by traditional risk factors (eg, overweight, non-white race, cardiovascular risk factors). This association could have clinical importance because it suggests a new potentially modifiable risk factor that could be targeted to prevent diabetes.

9.
Brain Stimul ; 10(5): 926-933, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28642024

RESUMO

BACKGROUND: Therapeutic repetitive Transcranial Magnetic Stimulation (rTMS) has emerged as a standard of care for individuals with major depressive disorder (MDD) who do not benefit from, or are unable to tolerate, antidepressant pharmacotherapy. Depth of stimulation is limited with currently approved figure-eight coils and larger coils capable of deeper penetration may be associated with loss of stimulation focality and undesired recruitment of motor cortex. A second generation 2-coil array rTMS system was designed to target converging brain pathways for potentially deeper prefrontal cortex stimulation. METHODS: A randomized, double-blind, sham-controlled trial examined the safety and efficacy of an investigational 2-coil rTMS device. Antidepressant treatment-resistant or treatment-intolerant MDD patients (n = 92) received 20 daily rTMS treatments with coil centers positioned over left dorsolateral prefrontal cortex (dlPFC) and dorsomedial prefrontal cortex (dmPFC). 10 Hz stimulation (maximum summated power for both coils ≤ 120% motor threshold) was delivered. Primary efficacy endpoint was change in HAMD-24 score from baseline to the conclusion of treatments. RESULTS: Data from n = 75 (per-protocol sample) showed significantly greater improvement (mean HAMD-24 change) over time for the active (n = 38) versus sham (n = 37) group after 20 sessions (F = 7.174; p = 0.008) and also at the one-month follow-up (F = 6.748; p = 0.010). Response rates were 55.3% (active) versus 32.4% (sham) (p = 0.063); remission rates were 26.3% versus 18.9% (p > 0.05). Other secondary outcomes were generally supportive. CONCLUSIONS: The results confirmed safety and acute efficacy of the 2-coil rTMS device. Despite modest sample size, primary outcome was clinically and statistically significant, and the effect size was comparable with those reported for regulatory trials with FDA-cleared devices.


Assuntos
Transtorno Depressivo Resistente a Tratamento/fisiopatologia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana/métodos , Adulto , Transtorno Depressivo Resistente a Tratamento/diagnóstico , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Córtex Motor/fisiopatologia , Córtex Pré-Frontal/fisiologia , Estudos Prospectivos , Estimulação Magnética Transcraniana/efeitos adversos , Resultado do Tratamento
10.
Med Care ; 54(12): 1089-1097, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27261639

RESUMO

PURPOSE: To provide empirical evidence on the performance of common measures in assessing health-related quality of life (HRQL) in depressed and nondepressed youth. These measures can be used in research trials, cost-effectiveness studies, and to help develop policy for treating youth depression. BACKGROUND: Depression is one of the most common mental disorders among adolescents, with a chronic, episodic course marked by considerable impairment. Data on HRQL for teens with depression could more fully demonstrate the burden of depression and help to evaluate the comparative effectiveness of teen depression services, which in turn can be used to inform public and clinical policies. METHODS: We collected data on depression and HRQL from 392 depressed and nondepressed teens aged 13-17. RESULTS: Generic mental health, disease-specific, and generic preference-based measures of HRQL all do a reasonable job of distinguishing teens with and without depression and between teens with differing levels of depression. Generic mental health and disease-specific measures provide valuable information on burden of disease and perform well. For the purpose of economic evaluation, the HUI-3 and EQ-5D perform somewhat better than other preference-based measures. These results can aid future research on teens with depression by helping to guide which HRQL instruments are most useful in this population and can help to quantify the burden of depression in teens for policy and clinical planning.


Assuntos
Depressão/psicologia , Psicologia do Adolescente , Qualidade de Vida , Adolescente , Depressão/diagnóstico , Feminino , Humanos , Entrevista Psicológica , Masculino , Escalas de Graduação Psiquiátrica , Psicologia do Adolescente/estatística & dados numéricos , Qualidade de Vida/psicologia , Inquéritos e Questionários
11.
J Am Acad Child Adolesc Psychiatry ; 55(3): 219-26, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26903255

RESUMO

OBJECTIVE: To assess predictors and moderators of a cognitive-behavioral prevention (CBP) program for adolescent offspring of parents with depression. METHOD: This 4-site randomized trial evaluated CBP compared to usual community care (UC) in 310 adolescents with familial (parental depression) and individual (youth history of depression or current subsyndromal symptoms) risk for depression. As previously reported by Garber and colleagues, a significant prevention effect favored CBP through 9 months; however, outcomes of CBP and UC did not significantly differ when parents were depressed at baseline. The current study expanded on these analyses and examined a range of demographic, clinical, and contextual characteristics of families as predictors and moderators and used recursive partitioning to construct a classification tree to organize clinical response subgroups. RESULTS: Depression onset was predicted by lower functioning (hazard ratio [HR] = 0.95, 95% CI = 0.92-0.98) and higher hopelessness (HR = 1.06, 95% CI = 1.01-1.11) in adolescents. The superior effect of CBP was diminished when parents were currently depressed at baseline (HR = 6.38, 95% CI = 2.38-17.1) or had a history of hypomania (HR = 67.5, 95% CI = 10.9-417.1), or when adolescents reported higher depressive symptoms (HR = 1.04, 95% CI = 1.00-1.08), higher anxiety (HR = 1.05, 95% CI = 1.01-1.08), higher hopelessness (HR = 1.10, 95% CI = 1.01-1.20), or lower functioning (HR = 0.94, 95% CI = 0.89-1.00) at baseline. Onset rates varied significantly by clinical response cluster (0%-57%). CONCLUSION: Depression in adolescents can be prevented, but programs may produce superior effects when timed at moments of relative wellness in high-risk families. Future programs may be enhanced by targeting modifiable negative clinical indicators of response. CLINICAL TRIAL REGISTRATION INFORMATION: Prevention of Depression in At-Risk Adolescents; http://clinicaltrials.gov/; NCT00073671.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Depressão/prevenção & controle , Transtorno Depressivo/prevenção & controle , Adolescente , Causalidade , Filho de Pais Incapacitados/psicologia , Depressão/psicologia , Transtorno Depressivo/diagnóstico , Família/psicologia , Feminino , Humanos , Masculino , Pais/psicologia , Fatores de Risco
12.
JAMA Psychiatry ; 72(11): 1110-8, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26421861

RESUMO

IMPORTANCE: Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known. OBJECTIVE: To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation. DESIGN, SETTING, AND PARTICIPANTS: A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015. INTERVENTIONS: The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment. MAIN OUTCOMES AND MEASURES: The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood. RESULTS: Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program's overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program's benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program's effect on depression-free days. CONCLUSIONS AND RELEVANCE: The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier:NCT00073671.


Assuntos
Filho de Pais Incapacitados/psicologia , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo/prevenção & controle , Pais/psicologia , Adolescente , Adulto , Feminino , Seguimentos , Humanos , Masculino , Risco , Resultado do Tratamento , Adulto Jovem
13.
JAMA Psychiatry ; 70(11): 1161-70, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24005242

RESUMO

IMPORTANCE: Adolescent offspring of depressed parents are at high risk for experiencing depressive disorders themselves. OBJECTIVE: To determine whether the positive effects of a group cognitive-behavioral prevention (CBP) program extended to longer-term (multiyear) follow-up. DESIGN: A 4-site randomized clinical trial with 33 months of follow-up was conducted. Recruitment of participants was from August 2003 through February 2006. SETTING: The study settings included a health maintenance organization, university medical centers, and a community mental health center. PARTICIPANTS: Three hundred sixteen adolescent (aged 13-17 years) offspring of parents with current and/or prior depressive disorders; adolescents had histories of depression, current elevated depressive symptoms, or both but did not currently meet criteria for a depressive disorder. INTERVENTIONS: The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Adolescents were randomly assigned to either the CBP program or usual care (UC). MAIN OUTCOMES AND MEASURES: The primary outcome was a probable or definite episode of depression (Depression Symptom Rating score ≥4) for at least 2 weeks through the month 33 follow-up evaluation. RESULTS: Over the 33-month follow-up period, youths in the CBP condition had significantly fewer onsets of depressive episodes compared with those in UC. Parental depression at baseline significantly moderated the intervention effect. When parents were not depressed at intake, CBP was superior to UC (number needed to treat, 6), whereas when parents were actively depressed at baseline, average onset rates between CBP and UC were not significantly different. A 3-way interaction among intervention, baseline parental depression, and site indicated that the impact of parental depression on intervention effectiveness varied across sites. CONCLUSIONS AND RELEVANCE: The CBP program showed significant sustained effects compared with UC in preventing the onset of depressive episodes in at-risk youth over a nearly 3-year period. Important next steps will be to strengthen the CBP intervention to further enhance its preventive effects, improve intervention outcomes when parents are currently depressed, and conduct larger implementation trials to test the broader public health impact of the CBP program for preventing depression in youth. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00073671.


Assuntos
Comportamento do Adolescente/psicologia , Filho de Pais Incapacitados/psicologia , Terapia Cognitivo-Comportamental , Transtorno Depressivo/prevenção & controle , Transtorno Depressivo/terapia , Adolescente , Humanos , Pais/psicologia , Psicoterapia de Grupo , Método Simples-Cego
14.
J Pediatr Psychol ; 38(10): 1070-80, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23860262

RESUMO

OBJECTIVES: This study (1) examines fatigue over 1 year in adolescents with chronic pain (n = 61) and depressive disorders (n = 51) compared with healthy adolescents (n = 60), (2) identifies longitudinal risk factors, and (3) tests sleep disturbances as a mediator between depression and fatigue. METHODS: Adolescents completed questionnaires at baseline, 6, and 12 months. Mixed effects models examined associations between risk factors and fatigue; structural equation modeling assessed contemporaneous and longitudinal mediation. RESULTS: Results revealed fatigue persisted at 1 year follow-up, with adolescents in the clinical samples experiencing greater fatigue than healthy youth at all time points (ps < .001). Age, baseline depression, and baseline sleep disturbances predicted longitudinal fatigue for the total sample (ps < .05), with variation in predictors by subgroup. Sleep quality mediated the contemporaneous effects of depression on fatigue in the clinical samples (ps < .05). CONCLUSIONS: Findings underscore the longitudinal course of fatigue and suggest that improving sleep disturbances may reduce fatigue in clinical samples.


Assuntos
Dor Crônica/fisiopatologia , Transtorno Depressivo/fisiopatologia , Fadiga/fisiopatologia , Transtornos do Sono-Vigília/fisiopatologia , Adolescente , Fatores Etários , Dor Crônica/epidemiologia , Comorbidade , Transtorno Depressivo/epidemiologia , Fadiga/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Valor Preditivo dos Testes , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Transtornos do Sono-Vigília/epidemiologia , Tempo
15.
Cogn Behav Pract ; 20(2): 147-161, 2013 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-23645978

RESUMO

There is a need for treatment interventions to address the high prevalence of disordered eating throughout adolescence and early adulthood. We developed an adolescent-specific manualized CBT protocol to treat female adolescents with recurrent binge eating and tested its efficacy in a small, pilot randomized controlled trial. We present lessons learned in recruiting adolescents, a description of our treatment approach, acceptability of the treatment for teens and parents, as well as results from the pilot trial. Participants in the CBT group had significantly fewer posttreatment eating binges than those in a treatment as usual/delayed treatment (TAU-DT) control group; 100% of CBT participants were abstinent at follow-up. Our results provide preliminary support for the efficacy of this adolescent adaptation of evidence-based CBT for recurrent binge eating. The large, robust effect size estimate observed for the main outcome (NNT=2) places this among the larger effects observed for any mental health intervention.

16.
J Am Acad Child Adolesc Psychiatry ; 52(4): 370-7, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23582868

RESUMO

OBJECTIVE: To examine the bidirectional relationship between parent-child discord and treatment outcome for adolescent treatment-resistant depression. METHOD: Depressed youth who had not responded to an adequate course of a selective serotonin reuptake inhibitor (SSRI) were randomized to either a switch to another SSRI or venlafaxine, with or without the addition of cognitive behavior therapy (CBT) in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. The Conflict Behavior Questionnaire was used to assess adolescent (CBQ-A) and parent-reported (CBQ-P) parent-child discord. The impact of remission on parent-child conflict, and the differential impact of medication and CBT on the CBQ-A and CBQ-P, were assessed using generalized linear models. RESULTS: Although there were no differential treatment effects on parent or adolescent-report of conflict, remission was associated with improvement in the CBQ-P. In general, intake family conflict did not predict remission, except in the sub-group of participants whose parents reported clinically significant parent-child conflict at intake, for whom high levels of parent-reported conflict predicted a lower likelihood of remission. Conflict also did not moderate treatment response. CONCLUSIONS: Remission of depression may be sufficient to reduce parent-reported parent-child conflict. However, higher parent-reported conflict, in the clinically significant range, predicts a lower likelihood of remission from depression. Clinical trial registration information-Treatment of SSRI-Resistant Depression in Adolescents (TORDIA); http://clinicaltrials.gov/; NCT00018902.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Conflito Psicológico , Cicloexanóis/farmacologia , Relações Pais-Filho , Inibidores de Captação de Serotonina/farmacologia , Adolescente , Criança , Terapia Combinada , Cicloexanóis/administração & dosagem , Transtorno Depressivo Resistente a Tratamento , Feminino , Humanos , Masculino , Inibidores de Captação de Serotonina/administração & dosagem , Resultado do Tratamento , Cloridrato de Venlafaxina
17.
J Clin Psychopharmacol ; 31(1): 92-7, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21192150

RESUMO

This paper examines the relationship between plasma concentration of antidepressant and both clinical response and adverse effects in treatment-resistant depressed adolescents. Adolescents (n = 334) with major depression who had not responded to a selective serotonin reuptake inhibitor (SSRI) were randomized to 1 of 4 treatments: switch to another SSRI (fluoxetine, citalopram, or paroxetine), switch to venlafaxine, switch to SSRI plus cognitive behavior therapy, or switch to venlafaxine plus cognitive behavior therapy. Adolescents who did not improve by 6 weeks had their dose increased. Plasma concentrations of medication and metabolites were measured at 6 weeks in 244 participants and at 12 weeks in 204 participants. Adolescents treated with citalopram whose plasma concentration was equal to or greater than the geometric mean (GM) showed a higher response rate compared to those with less than the GM, with parallel but nonsignificant findings for fluoxetine. A dose increase of citalopram or fluoxetine at week 6 was most likely to result in response when it led to a change in concentration from less than the GM at 6 weeks to the GM or greater at week 12. Plasma levels of paroxetine, venlafaxine, or O-desmethylvenlafaxine were not related to clinical response. Exposure was associated with more cardiovascular and dermatologic side effects in those receiving venlafaxine. Antidepressant concentration may be useful in optimizing treatment for depressed adolescents receiving fluoxetine or citalopram.


Assuntos
Antidepressivos/administração & dosagem , Antidepressivos/sangue , Transtorno Depressivo Maior/sangue , Transtorno Depressivo Maior/tratamento farmacológico , Adolescente , Fatores Etários , Citalopram/administração & dosagem , Citalopram/sangue , Transtorno Depressivo Maior/psicologia , Feminino , Fluoxetina/administração & dosagem , Fluoxetina/sangue , Humanos , Masculino , Resultado do Tratamento
18.
JAMA ; 301(21): 2215-24, 2009 Jun 03.
Artigo em Inglês | MEDLINE | ID: mdl-19491183

RESUMO

CONTEXT: Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings. OBJECTIVE: To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression. DESIGN, SETTING, AND PARTICIPANTS: A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase. INTERVENTION: Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone. MAIN OUTCOME MEASURE: Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers. RESULTS: Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67). CONCLUSION: The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00073671.


Assuntos
Filho de Pais Incapacitados , Terapia Cognitivo-Comportamental , Transtorno Depressivo , Psicoterapia de Grupo , Adolescente , Transtorno Depressivo/prevenção & controle , Feminino , Humanos , Masculino , Escalas de Graduação Psiquiátrica , Fatores de Risco
19.
Clin Psychol Rev ; 29(5): 449-58, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19450912

RESUMO

The "Coping with Depression" course (CWD) is by the far the best studied psychoeducational intervention for the treatment and prevention of depression, and is used in routine practice in several countries. The CWD is a highly structured cognitive-behavioral intervention, which has been adapted for several goals, contexts, and target populations. The efficacy of the CWD has been examined in 25 randomized controlled trials. We conducted a meta-analysis of these studies. The 6 studies aimed at the prevention of new cases of major depression were found to result in a reduced risk of getting major depression of 38% (incidence rate ratio was 0.62). The 18 studies examining the CWD as a treatment of depression found a mean effect size (Cohen's d) of 0.28. Direct comparisons with other psychotherapies did not result in any indication that the CWD was less efficacious. The CWD is a flexible treatment which can easily be adapted for different populations and this may have led researchers to use this intervention for complex target groups, which in turn may have resulted in a lower mean effect size. The CWD has contributed considerably to the development and innovation of prevention and treatment of depression in many target populations.


Assuntos
Adaptação Psicológica , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo/terapia , Educação de Pacientes como Assunto/métodos , Transtorno Depressivo/prevenção & controle , Transtorno Depressivo Maior/prevenção & controle , Transtorno Depressivo Maior/terapia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
Am J Prev Med ; 31(6 Suppl 1): S143-51, 2006 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17175409

RESUMO

BACKGROUND: Depression in childhood and adolescence creates significant burden to individuals, families, and societies by increasing morbidity, increasing mortality, and negatively affecting quality of life during times of significantly depressed mood. Several studies have estimated the cost of depression in the United States and elsewhere, but none have included the costs associated with depression in children or younger adolescents. This paper reviews data currently available on the cost of depression in childhood and the cost effectiveness of interventions to treat and prevent depression in this population. METHODS: A systematic review was conducted of published literature related to the cost of depression in children and adolescents and of economic evaluations of interventions to treat or prevent depression in this population. RESULTS: Five articles were identified that included any type of data related to the cost of depression in childhood; four articles were identified that conducted economic evaluations of interventions to treat or prevent depression in children or adolescents. CONCLUSIONS: Little information on the economic burden of depression in childhood is currently available. Future research in this area needs to include a broad range of costs; long-term outcomes; and costs relevant to decision makers in public and private agencies, such as implementation costs and costs of sustaining intervention fidelity over time.


Assuntos
Efeitos Psicossociais da Doença , Depressão/economia , Transtorno Depressivo/economia , Adolescente , Criança , Depressão/terapia , Transtorno Depressivo/epidemiologia , Transtorno Depressivo/terapia , Humanos
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