Clinical predictors of suicidal ideation, suicide attempts and suicide death in depressive disorder: a systematic review and meta-analysis.

Patients with depressive disorders are especially prone to suicide risk. Among the clinical predictors of suicidality, those specifically related to depressive disorders have not been accurately detailed. Our aim was to conduct a systematic review and meta-analysis of studies reporting longitudinal predictors of suicidal ideation, suicide attempts and suicide death within depression, including diagnostic subtypes, symptoms, clinical course, and assessment scales. A systematic search of the literature between 2001 and 2022 identified 4422 references, among which 19 studies providing 45 different predictors of suicidality met the inclusion criteria. Random effects meta-analyses were performed for 22 predictors, three for suicidal ideation, eleven for suicide attempts and eight for suicide death. Heterogeneity and publication bias were inspected through I2 tests and Egger's tests respectively. Meta-analysis results showed that severity of hopelessness predicted suicidal ideation and suicide attempts. History of suicide attempts, suicidal ideation, severe depression, and psychotic symptoms predicted subsequent suicide attempts and suicide death. Time to full remission and sleep disturbances were also found as relevant predictors of future suicide behaviours. This review specifies which predictors of suicidality within the clinical features of depression will help clinicians and policy makers to better prevent suicide risk in patients with depressive disorders. Further longitudinal studies are needed to reliably assess the predictive ability of our results and to analyse other possible clinical predictors to prevent suicidality, especially with regard to suicidal ideation.

Detection and treatment of depressive disorder in the spanish health system: a critical review.

Health care for depression is a major challenge. The aim of this review is to capture the status of the detection, diagno- sis and treatment of depression in the Spanish public health system. The data from the latest National Health Survey (ENSE 2017) have been analyzed and a non-systematic search for publications has been carried out in the PubMed and Scopus databases. We highlight the high specificity and low sensitivity in the detection of cases of major depression by Primary Care (PC) physicians in Spain. The detection of depression is supe- rior in specialized care compared to PC. The new healthcare systems based on the shared approach and the hierarchical model of screening, diagnosis and referral are reviewed and we present improvement proposals based on various programs and models of healthcare for depression.

Insomnia and sleep quality in healthcare workers fighting against COVID-19: a systematic review of the literature and meta-analysis.

The COVID-19 pandemic has the potential to significant- ly affect the mental health of healthcare workers, who stand in the frontline of this crisis. Insomnia is often related to exposure to stressful situations, such as the current health crisis, as well as other mental disorders, physical conditions and work-related problems. The objectives of this systematic review were: 1) to examine the impact of the current health pandemic produced by COVID-19 on insomnia and sleep quality of health professionals, and 2) to identify risk factors associated with insomnia. After a literature search in MEDLINE, EMBASE, and PsycINFO, 18 relevant studies were identified. The prevalence of insomnia estimated by random effects meta-analysis was 38% (95%CI= 37 to 39%), being slightly higher in women (29%, 95%CI= 27% to 30%) than in men (24%, 95%CI= 21 to 27%). The main risk factor associated with insomnia was working in a high-risk environment, followed by female sex and having a lower educational level. The high figures of self-reported insomnia and poor sleep quality observed indicate the need to develop interventions aimed at mitigating and caring for the mental health of healthcare workers fighting against this pandemic.

Efficacy of Three Low-Intensity, Internet-Based Psychological Interventions for the Treatment of Depression in Primary Care: Randomized Controlled Trial.

BACKGROUND: Primary care is a major access point for the initial treatment of depression, but the management of these patients is far from optimal. The lack of time in primary care is one of the major difficulties for the delivery of evidence-based psychotherapy. During the last decade, research has focused on the development of brief psychotherapy and cost-effective internet-based interventions mostly based on cognitive behavioral therapy (CBT). Very little research has focused on alternative methods of treatment for depression using CBT. Thus, there is a need for research into other therapeutic approaches. OBJECTIVE: This study aimed to assess the effectiveness of 3 low-intensity, internet-based psychological interventions (healthy lifestyle psychoeducational program [HLP], focused program on positive affect promotion [PAPP], and brief intervention based on mindfulness [MP]) compared with a control condition (improved treatment as usual [iTAU]). METHODS: A multicenter, 4-arm, parallel randomized controlled trial was conducted between March 2015 and March 2016, with a follow-up of 12 months. In total, 221 adults with mild or moderate major depression were recruited in primary care settings from 3 Spanish regions. Patients were randomly distributed to iTAU (n=57), HLP (n=54), PAPP (n=56), and MP (n=54). All patients received iTAU from their general practitioners. The main outcome was the Spanish version of the Patient Health Questionnaire-9 (PHQ-9) from pretreatment (time 1) to posttreatment (time 2) and up to 6 (time 3) and 12 (time 4) months' follow-up. Secondary outcomes included the visual analog scale of the EuroQol, the Short-Form Health Survey (SF-12), the Positive and Negative Affect Schedule (PANAS), and the Pemberton Happiness Index (PHI). We conducted regression models to estimate outcome differences along study stages. RESULTS: A moderate decrease was detected in PHQ-9 scores from HLP (ß=-3.05; P=.01) and MP (ß=-3.00; P=.01) compared with iTAU at posttreatment. There were significant differences between all intervention groups and iTAU in physical SF-12 scores at 6 months after treatment. Regarding well-being, MP and PAPP reported better PHI results than iTAU at 6 months post treatment. PAPP intervention significantly decreased PANAS negative affect scores compared with iTAU 12 months after treatment. CONCLUSIONS: The low-intensity, internet-based psychological interventions (HLP and MP) for the treatment of depression in primary care are more effective than iTAU at posttreatment. Moreover, all low-intensity psychological interventions are also effective in improving medium- and long-term quality of life. PAPP is effective for improving health-related quality of life, negative affect, and well-being in patients with depression. Nevertheless, it is important to examine possible reasons that could be implicated for PAPP not being effective in reducing depressive symptomatology; in addition, more research is still needed to assess the cost-effectiveness analysis of these interventions. TRIAL REGISTRATION: ISRCTN Registry ISRCTN82388279; http://www.isrctn.com/ISRCTN82388279. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12888-015-0475-0.

Suicidal risk and executive functions in major depressive disorder: a study protocol.

BACKGROUND: Suicide is a serious public health concern. Depression is the main gateway to suicidal behavior. The already established relationship between depression and suicidal risk should now focus on the investigation of more specific factors: recent studies have suggested an association between vulnerability to suicidal behavior and neurocognitive alterations, a nuclear symptom of depression. This project aims to identify alterations in the Executive Functions (EF) of patients suffering a first depressive episode that might constitute a risk factor for suicidal ideation, suicidal attempts and suicide, to allow for more adequate suicide prevention. METHODS: Prospective longitudinal design involving two groups (first depressive episodes with and without alterations in their EF) and four repeated measures (0, 6, 12 and 24 months). The estimated minimum sample size is 216 subjects. The variables and measurement instruments will include socio-demographic variables, clinical variables (age of illness onset, family and personal antecedents, psychopathological and medical comorbidity, suicidal ideation, suicide attempts and completed suicides, severity of depression, including melancholic or atypical, remission of the depressive episode), and neuropsychological variables (EF and decision-making processes evaluated through the Cambridge Neuropsychological Test Automated Battery (CANTAB)). DISCUSSION: First and foremost, the identification of clinical and neuropsychological risk factors associated with suicidal behavior will open the possibility to prevent such behavior in patients with a first depressive episode in the context of clinical practice. Secondly, interventions aimed at cognitive impairment (in particular: EF) derived from the study may be incorporated into strategies for the prevention of suicidal behavior. Finally, impaired neurocognitive function (even in early stages) could become an identifiable endophenotype or "marker" in clinical and neurobiological studies about suicidal behavior in depressive patients.

Efficacy of a blended low-intensity internet-delivered psychological programme in patients with multimorbidity in primary care: study protocol for a randomized controlled trial.

BACKGROUND: The World Health Organization (WHO) has included comorbidity between depression and a chronic disease among the 10 leading global health priorities. Although there is a high prevalence of multimorbidity, health care systems are mainly designed for the management of individual diseases. Given the difficulty in delivering face-to-face psychological treatments, alternative models of treatment delivery have been proposed, emphasizing the role of technologies such as the Internet. The aim of this study is to assess the efficacy in Primary Care (PC) of a blended low-intensity psychological intervention applied using information and communication technologies (ICTs) for the treatment of multimorbidity in PC (depression and type 2 diabetes/low back pain) by means of a randomized controlled trial (RCT). Our main hypothesis is that improved usual care combined with psychological therapy applied using ICTs will be more efficacious for improvement in the symptomatology of multimorbidity, compared to a group with only improved treatment as usual six months after the end of treatment. METHODS: A protocol has been designed combining a face-to-face intervention with a supporting online programme that will be tested by an RCT conducted in three different regions (Andalusia, Aragon and the Balearic Islands). The RCT will evaluate three hundred participants diagnosed with depression and type 2 diabetes/low back pain. Four highly experienced research groups specializing in clinical psychology are involved in this trial, and there will be ample possibilities for translation and transfer to usual clinical practice. DISCUSSION: This clinical trial will lead to improvement in financial sustainability, maximizing the use of resources and responding to principles of efficiency and effectiveness. Furthermore, based on the evaluation of the feasibility of implementing this intervention in primary care facilities, we expect to be able to suggest the intervention for incorporation into public policy. In conclusion, positive results of this study could have a significant impact on one of the most important health-related problems, multimorbidity. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03426709 . Registered retrospectively on 08 February 2018.

Adherence predictors in an Internet-based Intervention program for depression.

Internet-delivered psychotherapy has been demonstrated to be effective in the treatment of depression. Nevertheless, the study of the adherence in this type of the treatment reported divergent results. The main objective of this study is to analyze predictors of adherence in a primary care Internet-based intervention for depression in Spain. A multi-center, three arm, parallel, randomized controlled trial was conducted with 194 depressive patients, who were allocated in self-guided or supported-guided intervention. Sociodemographic and clinical characteristics were gathered using a case report form. The Mini international neuropsychiatric interview diagnoses major depression. Beck Depression Inventory was used to assess depression severity. The visual analogic scale assesses the respondent's self-rated health and Short Form Health Survey was used to measure the health-related quality of life. Age results a predictor variable for both intervention groups (with and without therapist support). Perceived health is a negative predictor of adherence for the self-guided intervention when change in depression severity was included in the model. Change in depression severity results a predictor of adherence in the support-guided intervention. Our findings demonstrate that in our sample, there are differences in sociodemographic and clinical variables between active and dropout participants and we provide adherence predictors in each intervention condition of this Internet-based program for depression (self-guided and support-guided). It is important to point that further research in this area is essential to improve tailored interventions and to know specific patients groups can benefit from these interventions.

An Internet-Based Intervention for Depression in Primary Care in Spain: A Randomized Controlled Trial.

BACKGROUND: Depression is the most prevalent cause of illness-induced disability worldwide. Face-to-face psychotherapeutic interventions for depression can be challenging, so there is a need for other alternatives that allow these interventions to be offered. One feasible alternative is Internet-based psychological interventions. This is the first randomized controlled trial (RCT) on the effectiveness of an Internet-based intervention on depression in primary health care in Spain. OBJECTIVE: Our aim was to compare the effectiveness of a low-intensity therapist-guided (LITG) Internet-based program and a completely self-guided (CSG) Internet-based program with improved treatment as usual (iTAU) care for depression. METHODS: Multicenter, three-arm, parallel, RCT design, carried out between November 2012 and January 2014, with a follow-up of 15 months. In total, 296 adults from primary care settings in four Spanish regions, with mild or moderate major depression, were randomized to LITG (n=96), CSG (n=98), or iTAU (n=102). Research completers at follow-up were 63.5%. The intervention was Smiling is Fun, an Internet program based on cognitive behavioral therapy. All patients received iTAU by their general practitioners. Moreover, LITG received Smiling is Fun and the possibility of psychotherapeutic support on request by email, whereas CSG received only Smiling is Fun. The main outcome was the Beck Depression Inventory-II at 3 months from baseline. Mixed-effects multilevel analysis for repeated measures were undertaken. RESULTS: There was no benefit for either CSG [(B coefficient=-1.15; P=.444)] or LITG [(B=-0.71; P=.634)] compared to iTAU, at 3 months. There were differences at 6 months [iTAU vs CSG (B=-4.22; P=.007); iTAU vs LITG (B=-4.34; P=.005)] and 15 months [iTAU vs CSG (B=-5.10; P=.001); iTAU vs LITG (B=-4.62; P=.002)]. There were no differences between CSG and LITG at any time. Adjusted and intention-to-treat models confirmed these findings. CONCLUSIONS: An Internet-based intervention for depression combined with iTAU conferred a benefit over iTAU alone in the Spanish primary health care system. TRIAL REGISTRATION: Clinicaltrials.gov NCT01611818; https://register.clinicaltrials.gov/prs/app/action/SelectProtocol? selectaction=Edit&uid=U0001NPQ&ts=2&cx=gctdh2&sid=S0003KJ6 (Archived by WebCite at http://www.webcitation.org/6jbsUvUDz).

Efficacy of low-intensity psychological intervention applied by ICTs for the treatment of depression in primary care: a controlled trial.

BACKGROUND: Depression is one of the most common disorders in Psychiatric and Primary Care settings and is associated with significant disability and economic costs. Low-intensity psychological interventions applied by Information and Communication Technologies (ICTs) could be an efficacious and cost-effective therapeutic option for the treatment of depression. The aim of this study is to assess 3 low-intensity psychological interventions applied by ICTs (healthy lifestyle, positive affect and mindfulness) in Primary Care; significant efficacy for depression treatment has previously showed in specialized clinical settings by those interventions, but ICTs were not used. METHOD: Multicenter controlled randomized clinical trial in 4 parallel groups. Interventions have been designed and on-line device adaptation has been carried out. Subsequently, the randomized controlled clinical trial will be conducted. A sample of N = 240 mild and moderate depressed patients will be recruited and assessed in Primary Care settings. Patients will be randomly assigned to a) healthy lifestyle psychoeducational program + improved primary care usual treatment (ITAU), b) focused program on positive affect promotion + ITAU c) mindfulness + ITAU or d) ITAU. The intervention format will be one face to face session and four ICTs on-line modules. Patients will be diagnosed with MINI psychiatric interview. Main outcome will be PHQ-9 score. They will be also assessed by SF-12 Health Survey, Client Service Receipt Inventory, EuroQoL-5D questionnaire, Positive and Negative Affect Scale, Five Facet Mindfulness Questionnaire and the Pemberton Happiness Index. Patients will be assessed at baseline, post, 6 and 12 post-treatment months. An intention to treat and per protocol analysis will be performed. DISCUSSION: Low-intensity psychological interventions applied by Information and Communication Technologies have been not used before in Spain and could be an efficacious and cost-effective therapeutic option for depression treatment. The strength of the study is that it is the first multicenter controlled randomized clinical trial of three low intensity and self-guided interventions applied by ICTs (healthy lifestyle psychoeducational program; focused program on positive affect promotion and brief intervention based on mindfulness) in Primary Care settings. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82388279 . Registered 16 April 2014.

Expectations among patients and health professionals regarding Web-based interventions for depression in primary care: a qualitative study.

BACKGROUND: One-quarter of the world's population will suffer from depression symptoms at some point in their lives. Mental health services in developed countries are overburdened. Therefore, cost-effective interventions that provide mental health care solutions such as Web-based psychotherapy programs have been proposed. OBJECTIVE: The intent of the study was to identify expectations regarding Web-based psychotherapy for the treatment of depression in primary care among patients and health professionals that might facilitate or hinder its effects. METHODS: The expectations of untreated patients and health professionals were examined by means of interviews and focus groups. There were 43 participants (20 patients with mild and moderate levels of depression, 11 primary care physicians, and 12 managers; 22 of them for interviews and 21 for groups). A thematic content analysis from the grounded theory for interviews, and an analysis of the discursive positions of participants based on the sociological model for groups were performed. Interpretations were achieved by agreement between three independent analysts. RESULTS: All participants showed a good general acceptance of Web-based psychotherapy, appreciating possible advantages and improvements. Patients, physicians, and managers shared the same conceptualization of their expectations, although highlighting different aspects. Patients focused on the need for individualized and personalized interaction, while professionals highlighted the need for the standardization of the program. Physicians were concerned with extra workload, while managers were worried about optimizing cost-effectiveness. CONCLUSIONS: Expectations of the different participants can conflict with each other. Finding a balanced position among them is needed if we are to harmoniously implement effective Web-based interventions for depression in routine clinical practice.

Psychometric properties of Spanish version of QIDS-SR16 in depressive patients.

INTRODUCTION: Depression is a worldwide health problem. Thus, making the diagnosis with reliable and short tests is crucial. In this regard, the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16) has been validated in several countries. It was found that this instrument has a correct balance between time and reliability. This study has aimed to assess psychometric properties of QIDS-SR16 Spanish version, and to calculate several cutoffs to evaluate the depressive disorder severity. METHOD: The study was based on the data from the RESIST study that recruited 1595 depressive patients from 17 regional communities. Instruments used were Hamilton Depression Rating Scale (HDRS17) and Spanish version of QIDS-SR16. Statistical analyses included test-retest reliability and internal consistency calculation, and exploratory factor analysis. In addition, ROC curve was calculated in order to determine different cutoff values. RESULTS: QIDS-SR16 shows adequate test-retest reliability and high internal consistency (α=0.871), as well as ROC value of 0.946. Exploratory factor analysis showed a one factor model, which accounted for 46.80% of variance. Convergent validity and sensitivity to change were adequate. DISCUSSION: The results suggest that the QIDS-SR16 is a reliable test to assess depressive symptom severity in the Spanish population. The cutoff that shows the best sensitivity/specificity rate was a total score of 7.

Longitudinal associations between executive function impairments and suicide risk in patients with major depressive disorder: A 1-year follow-up study.

Impaired executive function (EF) is a key feature of patients with major depressive disorder (MDD) that several studies have linked to suicidal ideation and suicide attempts. This is the first longitudinal study to examine the association between impaired EF and suicide risk in adult patients with MDD. Longitudinal prospective study with 3 assessment points: baseline, 6 and 12 months. The Columbia-Suicide Severity Rating Scale (C-SSRS) was used to assess suicidality. The Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to assess EF. The association between EF impairments and suicidality was analyzed using mixed-effects models. Out of 167 eligible outpatients, 104 were included in the study. Of these, 72 were re-evaluated at 6 months and 60 at 12 months, obtaining 225 complete observations of the EF. Impaired decision-making and risk-taking behavior were associated with suicidal ideation. Difficulty in impulse control was related to suicidal ideation and to greater severity of suicidal ideation. Impaired spatial planning and working memory was linked to suicide attempts. Our results add to previous literature that the association between EF impairments and suicidality is maintained over the long term, supporting it as a longitudinal risk factor and a possible neurocognitive marker of suicide in patients with MDD.

Associations between unhealthy lifestyle and depression: Cross-sectional results from the Spanish National Health Survey.

INTRODUCTION: Depression usually worsens lifestyle habits, but previous evidence also suggests that an unhealthy lifestyle (UL) increases the risk of depression. Many studies have analyzed the association between lifestyle and depression in several nationally representative samples, but none have done so in the Spanish adult population. Our aim was to examine the associations between UL habits and depression in Spain. MATERIALS AND METHODS: Analysis of cross-sectional data from the latest National Health Survey published in 2018 (N=23,089). Data on depression and 4 lifestyle factors (diet, physical exercise, smoking, and alcohol consumption) were used. These factors were combined into an UL index ranging from 0 (healthiest lifestyle) to 4 (unhealthiest lifestyle). The prevalence of depression at different levels of the UL index, and the association between depression and both the cumulative UL index and the 4 UL factors was analyzed using parametric and non-parametric tests. RESULTS: Sedentarism was the most prevalent UL factor, followed by unhealthy diet, smoking and high-risk alcohol consumption. Having ≥1 UL factors was associated with a higher prevalence of depression compared to having 0 UL factors (2.5% vs. ≥5.2%), regardless of the cumulative number UL factors (1, 2, 3 or 4). Being physically inactive (OR=1.6) and a smoker (OR=1.3) increased the likelihood of depression. Being a high-risk wine drinker (OR=0.26) decreased the likelihood of depression. Dietary intake was not significant. CONCLUSIONS: The prevalence of depression changes depending on several modifiable lifestyle factors. Policy makers should therefore spare no resources in promoting strategies to encourage healthy lifestyles and prevent the acquisition of UL habits.

Soft Drinks and Symptoms of Depression and Anxiety in Overweight Subjects: A Longitudinal Analysis of an European Cohort.

BACKGROUND: Studies about the association of carbonated/soft drinks, coffee, and tea with depression and anxiety are scarce and inconclusive and little is known about this association in European adults. Our aim was to examine the association between the consumption of these beverages and depressive and anxiety symptom severity. METHODS: A total of 941 European overweight adults (mean age, 46.8 years) with subsyndromal depression that participated in the MooDFOOD depression prevention randomized controlled trial (Clinical Trials.gov identifier: NCT2529423; date of the study: from 2014 to 2018) were analyzed. Depressive and anxiety symptom severity and beverage consumption were assessed using multilevel mixed-effects ordinal logistic regression models for each beverage consumption (carbonated/soft drink with sugar, carbonated/soft drink with non-nutritive sweeteners, coffee, and tea) with the three repeated measures of follow-up (baseline and 6 and 12 months). A case report form for participants' sociodemographic and clinical characteristics, the Food Frequency Questionnaire, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder 7-Item Scale, the MINI International Neuropsychiatric Interview 5.0, the Short Questionnaire to Assess Health-Enhancing Psychical Activity, and the Alcohol Use Disorders Identification Test were the research tools used. RESULTS: Daily consumption of carbonated/soft drinks with sugar was associated with a higher level of anxiety. Trends towards significance were found for associations between both daily consumption of carbonated/soft drinks with sugar and non-nutritive sweeteners and a higher level of depression. No relationship was found between coffee and tea consumption and the level of depression and anxiety. CONCLUSIONS: The high and regular consumption of carbonated/soft drink with sugar (amount of consumption: ≥1 unit (200 mL)/day) tended to be associated with higher level of anxiety in a multicountry sample of overweight subjects with subsyndromal depressive symptoms. It is important to point out that further research in this area is essential to provide valuable information about the intake patterns of non-alcoholic beverages and their relationship with affective disorders in the European adult population.

Impact of Smartphone App-Based Psychological Interventions for Reducing Depressive Symptoms in People With Depression: Systematic Literature Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Depression is a serious, disabling mental disorder that severely affects quality of life. Patients with depression often do not receive adequate treatment. App-based psychotherapy is considered to have great potential to treat depression owing to its reach and easy accessibility. OBJECTIVE: We aim to analyze the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. METHODS: We conducted a systematic literature review and meta-analysis. We searched Medline, Embase, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials from inception to December 23, 2020. We selected randomized controlled trials to examine the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Study selection, data extraction, and critical appraisal (using the Cochrane Risk of Bias tool for randomized studies and the ROBINS-I tool for nonrandomized studies) were conducted independently by 2 reviewers. Where possible, we pooled data using random effects meta-analyses to obtain estimates of the effect size of the intervention. We conducted post hoc meta-regression analyses to explore the factors associated with intervention success. RESULTS: After screening 3468 unique references retrieved from bibliographic searches and assessing the eligibility of 79 full texts, we identified 12 trials (2859 participants) evaluating 14 different interventions. Of 14 trials, 7 (58%) were conducted in the United States; 3 (25%) trials, in Asia (Japan, South Korea, and China); 1 (8%) trial, in Australia; and 1 (8%) trial, in Germany. Of the 12 trials, 5 (42%) trials presented a low risk of bias. The mean duration of the interventions was 6.6 (SD 2.8) weeks. Two-thirds of the interventions were based on cognitive behavioral therapy alone or included it in combination with cognitive control therapy, positive psychology, brief behavioral activation, or mindfulness- and acceptance-based therapy. With no evidence of publication bias, a pooled analysis of 83% (10/12) of the trials and 86% (12/14) of the interventions showed that app-based interventions, compared with a control group receiving usual care or minimal intervention, produced a moderate reduction in depressive symptoms (standardized mean difference [SMD] -0.51, 95% CI -0.69 to -0.33; 2018/2859, 70.58% of the participants; I2=70%). Our meta-regression analyses indicated that there was a greater reduction in symptoms of depression (P=.04) in trials that included participants with moderate to severe depression (SMD -0.67, 95% CI -0.79 to -0.55), compared with trials with participants exhibiting mild to moderate depression (SMD -0.15, 95% CI -0.43 to -0.12). CONCLUSIONS: App-based interventions targeted at people with depression produce moderate reductions in the symptoms of depression. More methodologically robust trials are needed to confirm our findings, determine which intervention features are associated with greater improvements, and identify those populations most likely to benefit from this type of intervention. TRIAL REGISTRATION: PROSPERO CRD42019145689; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=145689.

Implementation of a psychological online intervention for low to moderate depression in primary care: study protocol.

Background: Depression affects millions of people all over the world and implies a great socioeconomic burden. Despite there are different effective evidence-based interventions for treating depression, only a small proportion of these patients receives an appropriate treatment. In this regard, information and communication technologies (ICTs) can be used with therapeutic aims and this can contribute to make interventions more accessible. One example is "Smiling is fun", an internet-based treatment which has proved to be effective and cost-effective for treating depression in Spanish Primary Care (PC). However, the "know-do gap" between research and clinical settings implies that the actual implementation of such interventions could last up to 20 years. To overcome this obstacle, the implementation research establishes the methodology to implement the advances developed in the laboratories to the health care services maintaining the validity of the intervention and offering specific strategies for the implementation process. Objective: This is the protocol of an implementation study for the Internet-based program "Smiling is fun", which will be conducted on patients with mild-to-moderate depression of Spanish PC settings. In the implementation study, the feasibility, efficacy, cost-efficacy, acceptability, adoption, appropriateness, fidelity, penetration, normalization, and sustainability will be assessed. Methods: The current investigation is a Hybrid Effectiveness-Implementation Type II design. A Stepped Wedge randomized controlled trial design will be used, with a cohort of 420 adults diagnosed with depression (mild-to-moderate) who will undergo a first control phase (no treatment) followed by the intervention, which will last 16 weeks, and finishing with an optional use of the intervention. All patients will be assessed at baseline, during the treatment, and at post-treatment. The study will be conducted in three Spanish regions: Andalusia, Aragon, and the Balearic Islands. Two primary care centers of each region will participate, one located in the urban setting and the other in the rural setting. The primary outcome will be implementation success of the intervention assessing the reach, clinical effect, acceptability, appropriateness, adoption, feasibility, fidelity, penetration, implementation costs and sustainability services. Discussion: "Smiling is Fun", which has already been established as effective and cost-effective, will be adapted according to users' experiences and opinions, and the efficacy and cost-efficacy of the program will again be assessed. The study will point out barriers and facilitators to consider in the implementation process of internet-based psychological interventions in health services. The ultimate goal is to break the research-to-practice split, which would undoubtedly contribute to reduce the high burden of depression in our society. Trial registration: ClinicalTrials.gov, Identifier: NCT05294614.

Adherence to Lifestyle Interventions for Treatment of Adults with Depression: A Systematic Review and Meta-Analysis.

The aim of this systematic review was to determine the adherence to lifestyle interventions for adults with depression and to estimate the dropout rates in trials examining the impact of these interventions. A bibliographic search was conducted in PubMed, Embase, PsycINFO, the Cochrane library, and several sources of grey literature. We included randomised controlled trials examining the impact of multiple lifestyle interventions on depressive symptomatology in adults when compared to control or other active treatments. Two reviewers independently screened citations, extracted the relevant data, and assessed the risk of bias using Cochrane tools. A random effects meta-analysis of proportions was used to summarise the proportion of participants who completed the intervention and to determine the proportion of dropouts at post-treatment assessment. Multiple subgroup analyses were also carried out. We identified six trials. The meta-analysis of proportions showed that 53% (95%CI 49% to 58%) of the participants assigned to the intervention group fully adhered to the intervention program. The weighted mean proportion of completed intervention sessions was 66%. The pooled trial dropout rate was 22% (95%CI 20% to 24%). Around half of adults with depression adhere to lifestyle interventions. Future research is needed to develop interventions to support adherence to lifestyle interventions in depressive patients.

Predictors of Adherence in Three Low-Intensity Intervention Programs Applied by ICTs for Depression in Primary Care.

Depression is one of the most common disorders in psychiatric and primary care settings, and is associated with disability, loss in quality of life, and economic costs. Internet-based psychological interventions have been shown to be effective in depression treatment but present problems with a low degree of adherence. The main aim of this study is to analyze the adherence predictors in three low-intensity interventions programs applied by Information and Communication Technologies (ICTs) for depression. A multi-center, randomized, controlled clinical trial was conducted with 164 participants with depression, who were allocated to: Healthy Lifestyle Program, Positive Affect Promotion Program or Mindfulness Program. Sociodemographic characteristics, Patient Health Questionnaire-9, Visual Analog Scale, Short Form Health Survey, Positive and Negative Affect Schedule, Five Facets Mindfulness Questionnaire, Pemberton Happiness Index and Treatment Expectancy Questionnaire were used to study adherence. Results showed that positive affect resulted in a predictor variable for Healthy Lifestyle Program and Positive Affect Promotion Program. Perceived health was also a negative adherence predictor for the Positive Affect Promotion Program. Our findings demonstrate that there are differences in clinical variables between treatment completers and non-completers and we provide adherence predictors in two intervention groups. Although new additional predictors have been examined, further research is essential in order to improve tailored interventions and increase adherence treatment.

Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review was to evaluate the effectiveness of telephone-administered psychotherapy for depression in adults when compared to control conditions or other active treatments, and to determine adherence to telephone-administered psychotherapy. METHODS: A bibliographic search was conducted in MEDLINE, Embase, PsycINFO, the Cochrane library, and a number of sources of grey literature. We included randomised controlled trials (RCTs) examining the impact of telephone-administered psychotherapy on depressive symptomatology. Two reviewers independently screened citations, extracted the relevant data, and assessed risk of bias using Cochrane tools. Random effects meta-analyses were used to determine the average effect of the interventions on depressive symptomatology: main analysis including randomised trials only, and several exploratory subgroup and sensitivity analyses. RESULTS: We identified ten trials. Telephone-administered psychotherapy showed beneficial effects on depression severity when compared to control conditions ((standardized mean difference [SMD]= -0.85 (95% CI -1.56 to -0.15)). When compared to active comparators, the meta-analysis showed a non-significant small effect size (SMD= -0.18 (95% CI -0.45 to 0.09)), in favour of telephone-administered psychotherapy. Total weighted mean adherence was 73%. LIMITATIONS: Some of the included studies presented a small sample size. Due to variations in time points follow-ups among the studies, it was not possible to determine long term post intervention effects. CONCLUSIONS: Available evidence suggests that telephone-delivered psychotherapy may be an effective strategy to reduce depression symptoms when compared to control conditions, and shows an adequate treatment adherence. Future research is needed to determine its cost-effectiveness and long-term effects.

Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis.

BACKGROUND: This study aimed at examining the impact of providing healthcare during health emergencies caused by viral epidemic outbreaks on healthcare workers' (HCWs) mental health; to identify factors associated with worse impact, and; to assess the available evidence base regarding interventions to reduce such impact. METHOD: Rapid systematic review. We searched MEDLINE, Embase, and PsycINFO (inception to August 2020). We pooled data using random-effects meta-analyses to estimate the prevalence of specific mental health problems, and used GRADE to ascertain the certainty of evidence. RESULTS: We included 117 studies. The pooled prevalence was higher for acute stress disorder (40% (95%CI 39 to 41%)), followed by anxiety (30%, (30 to 31%)), burnout (28% (26 to 31%)), depression (24% (24 to 25%)), and post-traumatic stress disorder (13% (13 to 14%)). We identified factors associated with the likelihood of developing those problems, including sociodemographic (younger age and female gender), social (lack of social support, stigmatization), and occupational (working in a high-risk environment, specific occupational roles, and lower levels of specialised training and job experience) factors. Four studies reported interventions for frontline HCW: two educational interventions increased confidence in pandemic self-efficacy and in interpersonal problems solving (very low certainty), whereas one multifaceted intervention improved anxiety, depression, and sleep quality (very low certainty). LIMITATIONS: We only searched three databases, and the initial screening was undertaken by a single reviewer. CONCLUSION: Given the very limited evidence regarding the impact of interventions to tackle mental health problems in HCWs, the risk factors identified represent important targets for future interventions.