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Background: Subclinical depression is a risk factor for the development of major depression in older adults. We aimed to determine the effectiveness of pure self-help or self-help with minimal support to reduce depressive symptoms and to prevent the onset of major depression in this population.Methods: This was a systematic review and meta-analysis of trials that used self-administrated cognitive, behavioural or cognitive-behavioural interventions for older adults with subclinical depression compared to control groups. Medline, Embase, PsycInfo and Cochrane databases were searched for relevant studies.Results: We analysed eight trials involving 1449 participants. A small but significant effect favouring the intervention was found at short-term [d = 0.33; 95% CI (Confidence Interval): 0.20-0.47] and at long-term (d = 0.22; 95% CI: 0.04-0.40) for depressive symptoms. None of the studies looked at the preventive effect of self-help interventions in reducing the probability of a subsequent diagnosis of major depression.Limitations: The low number of studies meant that it was not possible to test for publication bias. The absence of pre-published protocols for many of the studies meant that there is a possibility of selective reporting bias for some of the primary studies.Conclusions: There is some evidence that cognitive-behavioural self-help interventions may reduce depressive symptoms in older adults with subclinical depression. However, no study examined whether the intervention had a preventative effect in reducing the likelihood of a subsequent diagnosis of major depression. [ABSTRACT FROM AUTHOR]

Importance: Socioeconomic factors are associated with the prevalence of depression, but their associations with prognosis are unknown. Understanding this association would aid in the clinical management of depression.Objective: To determine whether employment status, financial strain, housing status, and educational attainment inform prognosis for adults treated for depression in primary care, independent of treatment and after accounting for clinical prognostic factors.Data Sources: The Embase, International Pharmaceutical Abstracts, MEDLINE, PsycINFO, and Cochrane (CENTRAL) databases were searched from database inception to October 8, 2021.Study Selection: Inclusion criteria were as follows: randomized clinical trials that used the Revised Clinical Interview Schedule (CIS-R; the most common comprehensive screening and diagnostic measure of depressive and anxiety symptoms in primary care randomized clinical trials), measured socioeconomic factors at baseline, and sampled patients with unipolar depression who sought treatment for depression from general physicians/practitioners or who scored 12 or more points on the CIS-R. Exclusion criteria included patients with depression secondary to a personality or psychotic disorder or neurologic condition, studies of bipolar or psychotic depression, studies that included children or adolescents, and feasibility studies. Studies were independently assessed against inclusion and exclusion criteria by 2 reviewers.Data Extraction and Synthesis: Data were extracted and cleaned by data managers for each included study, further cleaned by multiple reviewers, and cross-checked by study chief investigators. Risk of bias and quality were assessed using the Quality in Prognosis Studies (QUIPS) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tools, respectively. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Individual Participant Data (PRISMA-IPD) reporting guidelines.Main Outcomes and Measures: Depressive symptoms at 3 to 4 months after baseline.Results: This systematic review and individual patient data meta-analysis identified 9 eligible studies that provided individual patient data for 4864 patients (mean [SD] age, 42.5 (14.0) years; 3279 women [67.4%]). The 2-stage random-effects meta-analysis end point depressive symptom scale scores were 28% (95% CI, 20%-36%) higher for unemployed patients than for employed patients and 18% (95% CI, 6%-30%) lower for patients who were homeowners than for patients living with family or friends, in hostels, or homeless, which were equivalent to 4.2 points (95% CI, 3.6-6.2 points) and 2.9 points (95% CI, 1.1-4.9 points) on the Beck Depression Inventory II, respectively. Financial strain and educational attainment were associated with prognosis independent of treatment, but unlike employment and housing status, there was little evidence of associations after adjusting for clinical prognostic factors.Conclusions and Relevance: Results of this systematic review and meta-analysis revealed that unemployment was associated with a poor prognosis whereas home ownership was associated with improved prognosis. These differences were clinically important and independent of the type of treatment received. Interventions that address employment or housing difficulties could improve outcomes for patients with depression. [ABSTRACT FROM AUTHOR]

Background and Aims: Admission to a smoke‐free setting presents a unique opportunity to encourage smokers to quit. However, risk of relapse post‐discharge is high, and little is known about effective strategies to support smoking cessation following discharge. We aimed to identify interventions that maintain abstinence following a smoke‐free stay and determine their effectiveness, as well as the probable effectiveness of behaviour change techniques (BCTs) used in these interventions. Methods: Systematic review and meta‐analyses of studies of adult smokers aged ≥ 18 years who were temporarily or fully abstinent from smoking to comply with institutional smoke‐free policies. Institutions included prison, inpatient mental health, substance misuse or acute hospital settings. A Mantel–Haenszel random‐effects meta‐analysis of randomized controlled trials (RCTs) was conducted using biochemically verified abstinence (7‐day point prevalence or continuous abstinence). BCTs were defined as 'promising' in terms of probable effectiveness (if BCT was present in two or more long‐term effective interventions) and feasibility (if BCT was also delivered in ≥ 25% of all interventions). Results: Thirty‐seven studies (intervention n = 9041, control n = 6195) were included: 23 RCTs (intervention n = 6593, control n = 5801); three non‐randomized trials (intervention n = 845, control n = 394) and 11 cohort studies (n = 1603). Meta‐analysis of biochemically verified abstinence at longest follow‐up (4 weeks–18 months) found an overall effect in favour of intervention [risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.08–1.49, I2 = 42%]. Nine BCTs (including 'pharmacological support', 'goal‐setting (behaviour)' and 'social support') were characterized as 'promising' in terms of probable effectiveness and feasibility. Conclusions: A systematic review and meta‐analyses indicate that behavioural and pharmacological support is effective in maintaining smoking abstinence following a stay in a smoke‐free institution. Several behaviour change techniques may help to maintain smoking abstinence up to 18 months post‐discharge. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care. Methods: We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted. Results: Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3–4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3–4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions. Conclusions: When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression. [ABSTRACT FROM AUTHOR]

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Background: Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events.Methods and Findings: We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis.Conclusions: In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority. [ABSTRACT FROM AUTHOR]

Background: Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9. Methods: We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy. Results: 16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01). Conclusions: PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar. [ABSTRACT FROM AUTHOR]

Background: Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results.Objective: To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of ≥10.Methods: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview.Results: Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of ≥10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88).Conclusions: The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression. [ABSTRACT FROM AUTHOR]

Background: The health service delivery framework collaborative care is an effective intervention for depression. However, uncertainties remain about how to optimise its delivery at scale. Structured case management is a core component of collaborative care; its delivery via the telephone may improve access. Aims: To examine using meta-regression if telephone delivered case management diminishes the clinical effectiveness of collaborative care on depressive symptoms and anti-depressant use relative to face-to-face delivery methods. Methods: Randomised controlled trials were eligible if they included collaborative care interventions for adults with depression identified using self-report measures or diagnostic interviews and reported depression outcomes. Sociodemographics, intervention characteristics, depressive symptoms, and anti-depressant use were extracted. Random effects univariable and multivariable meta-regression analyses were used to examine the moderating effect of telephone delivered case-management on outcomes. Results: Ninety-four trials were identified comprising of 103 comparisons across 24, 132 participants with depression outcomes and 67 comparisons from 15,367 participants with anti-depressant use outcomes. Telephone delivered case management did not diminish the effects of collaborative care on depressive symptoms (β = -0.01, 95% CI -0.12 to 0.10; p = 0.86). Telephone delivered case management decreased anti-depressant medication use (relative risk 0.76, 95% CI 0.63 to 0.92; p = 0.005); this effect remained when assessed simultaneously alongside other study-level moderators of collaborative care. Conclusion: Using remote platforms such as the telephone to deliver case management may be a feasible way to implement collaborative care with no loss of effectiveness on depressive symptoms. However, adherence to anti-depressant medication may decrease when telephone case management is used. [ABSTRACT FROM AUTHOR]

Background: Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.Method: Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.Results: A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15-3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98-10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7-15) (OR = 0.96; 95% CI = 0.56-1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26-0.97).Conclusions: The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication. [ABSTRACT FROM AUTHOR]

In studies of diagnostic test accuracy, authors sometimes report results only for a range of cutoff points around data-driven "optimal" cutoffs. We assessed selective cutoff reporting in studies of the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. We compared conventional meta-analysis of published results only with individual-patient-data meta-analysis of results derived from all cutoff points, using data from 13 of 16 studies published during 2004-2009 that were included in a published conventional metaanalysis. For the "standard" PHQ-9 cutoff of 10, accuracy results had been published by 11 of the studies. For all other relevant cutoffs, 3-6 studies published accuracy results. For all cutoffs examined, specificity estimates in conventional and individual-patient-data meta-analyses were within 1% of each other. Sensitivity estimates were similar for the cutoff of 10 but differed by 5%-15% for other cutoffs. In samples where the PHQ-9 was poorly sensitive at the standard cutoff, authors tended to report results for lower cutoffs that yielded optimal results. When the PHQ-9 was highly sensitive, authors more often reported results for higher cutoffs. Consequently, in the conventional metaanalysis, sensitivity increased as cutoff severity increased across part of the cutoff range--an impossibility if all data are analyzed. In sum, selective reporting by primary study authors of only results from cutoffs that perform well in their study can bias accuracy estimates in meta-analyses of published results. [ABSTRACT FROM AUTHOR]

People with severe mental illness (SMI) have reduced life expectancy compared with the general population, which can be explained partly by their increased risk of diabetes. We conducted a meta-analysis to determine the clinical effectiveness of pharmacological and non-pharmacological interventions for improving glycaemic control in people with SMI (PROSPERO registration: CRD42015015558). A systematic literature search was performed on 30/10/2015 to identify randomised controlled trials (RCTs) in adults with SMI, with or without a diagnosis of diabetes that measured fasting blood glucose or glycated haemoglobin (HbA1c). Screening and data extraction were carried out independently by two reviewers. We used random effects meta-analysis to estimate effectiveness, and subgroup analysis and univariate meta-regression to explore heterogeneity. The Cochrane Collaboration’s tool was used to assess risk of bias. We found 54 eligible RCTs in 4,392 adults (40 pharmacological, 13 behavioural, one mixed intervention). Data for meta-analysis were available from 48 RCTs (n = 4052). Both pharmacological (mean difference (MD), -0.11mmol/L; 95% confidence interval (CI), [-0.19, -0.02], p = 0.02, n = 2536) and behavioural interventions (MD, -0.28mmol//L; 95% CI, [-0.43, -0.12], p<0.001, n = 956) were effective in lowering fasting glucose, but not HbA1c (pharmacological MD, -0.03%; 95% CI, [-0.12, 0.06], p = 0.52, n = 1515; behavioural MD, 0.18%; 95% CI, [-0.07, 0.42], p = 0.16, n = 140) compared with usual care or placebo. In subgroup analysis of pharmacological interventions, metformin and antipsychotic switching strategies improved HbA1c. Behavioural interventions of longer duration and those including repeated physical activity had greater effects on fasting glucose than those without these characteristics. Baseline levels of fasting glucose explained some of the heterogeneity in behavioural interventions but not in pharmacological interventions. Although the strength of the evidence is limited by inadequate trial design and reporting and significant heterogeneity, there is some evidence that behavioural interventions, antipsychotic switching, and metformin can lead to clinically important improvements in glycaemic measurements in adults with SMI. [ABSTRACT FROM AUTHOR]

Background: There is interest in the use of very brief instruments to identify depression because of the advantages they offer in busy clinical settings. The PHQ-2, consisting of two questions relating to core symptoms of depression (low mood and loss of interest or pleasure), is one such instrument.Method: A systematic review was conducted to identify studies that had assessed the diagnostic performance of the PHQ-2 to detect major depression. Embase, MEDLINE, PsychINFO and grey literature databases were searched. Reference lists of included studies and previous relevant reviews were also examined. Studies were included that used the standard scoring system of the PHQ-2, assessed its performance against a gold-standard diagnostic interview and reported data on its performance at the recommended (≥3) or an alternative cut-off point (≥2). After assessing heterogeneity, where appropriate, data from studies were combined using bivariate diagnostic meta-analysis to derive sensitivity, specificity, likelihood ratios and diagnostic odds ratios.Results: 21 studies met inclusion criteria totalling N=11,175 people out of which 1529 had major depressive disorder according to a gold standard. 19 of the 21 included studies reported data for a cut-off point of ≥3. Pooled sensitivity was 0.76 (95% CI =0.68-0.82), pooled specificity was 0.87 (95% CI =0.82-0.90). However there was substantial heterogeneity at this cut-off (I(2)=81.8%). 17 studies reported data on the performance of the measure at cut-off point ≥2. Heterogeneity was I(2)=43.2% pooled sensitivity at this cut-off point was 0.91 (95% CI =0.85-0.94), and pooled specificity was 0.70 (95% CI =0.64-0.76).Conclusion: The generally lower sensitivity of the PHQ-2 at cut-off ≥3 than the original validation study (0.83) suggests that ≥2 may be preferable if clinicians want to ensure that few cases of depression are missed. However, in situations in which the prevalence of depression is low, this may result in an unacceptably high false-positive rate because of the associated modest specificity. These results, however, need to be interpreted with caution given the possibility of selectively reported cut-offs. [ABSTRACT FROM AUTHOR]

Aims To determine the effectiveness and safety of varenicline in treating tobacco dependence in patients with severe mental illness. Design A systematic reviewand meta-analysis of randomised controlled trials that compared varenicline with a placebo or an alternative intervention for smoking cessation or reduction. Setting Both in- and out-patient settings in any country. Participants Adult patients aged 18 years and over with any type of severe mental illness. The systematic review included eight studies comprising 398 participants. Measures Primary outcome measures were (1) smoking cessation, (2) smoking reduction measured by changes in the number of cigarettes smoked per day and (3) number of psychiatric adverse events, which were collected at the end of treatment. Findings The random-effect pooled estimates from the five studies that reported smoking-related outcomes found that varenicline is statistically superior to placebo in smoking cessation [risk ratios 4.33; 95% confidence interval (CI)=1.96-9.56], and smoking reduction was higher in varenicline groups (mean reduced daily cigarettes was 6.39; 95% CI=2.22-10.56). There is no significant difference regarding neuropsychiatric and other adverse events. Conclusions Varenicline appears to be significantly more effective than placebo in assisting with smoking cessation and reduction in people with severe mental illness. There appears to be no clear evidence that varenicline was associated with an increased risk of neuropsychiatric or other adverse events compared with placebo. [ABSTRACT FROM AUTHOR]

Importance: Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions.Objective: To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions.Data Sources: Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015.Study Selection: This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care.Data Extraction and Synthesis: Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed.Main Outcomes and Measures: Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures.Results: Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect.Conclusions and Relevance: There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis. [ABSTRACT FROM AUTHOR]

Background: Depression in older adults is often under recognised despite it being the most common mental health illness in this age group. An increasing older adult population highlights the need for improved diagnostic rates. Brief versions (15 items or less) of the Geriatric Depression Scale (GDS), which are suitable for busy clinical practice, could improve detection rates.Objective: Our aim is to establish the diagnostic accuracy of brief versions of the GDS.Methods: Twelve electronic databases of published and unpublished literature were searched. Study selection was in accordance with predefined inclusion and exclusion criteria. A recognised gold-standard diagnostic instrument was used as a comparator against data pertaining to the use of a brief version of the GDS in an older adult population. The QUADAS-II was utilised for quality assessment. Narrative analysis and, where possible, meta-analysis were performed.Results: Thirty-two studies were identified that provided diagnostic data regarding seven brief versions of the GDS (1, 4, 5, 7 8, 10 and 15-item versions). Pooled sensitivity was 0.89 (95% confidence interval (CI) 0.80-0.94), and specificity was 0.77 (95% CI 0.65-0.86) for the GDS-15 at the recommended cut-off score of 5. Meta-analysis of other brief versions was not possible because of an insufficient number of studies with standardised items.Conclusions: Results suggest the possibility of selective reporting of cut-off scores, and therefore, findings should be approached cautiously. Studies should report all cut-off scores, and all brief GDS versions should be compiled of standardised items. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective The Patient Health Questionnaire (PHQ-9) is a widely used screening tool for major depressive disorder (MDD), although there is debate surrounding its diagnostic properties. For the PHQ-9, we aimed to: 1. Establish the diagnostic performance at the standard cutoff point (10). 2. Compare the diagnostic performance at the standard cutoff point in different clinical settings. 3. Assess whether there is selective reporting of cutoff points other than 10. Methods We searched three databases — Embase, MEDLINE and PSYCHInfo — and performed a reverse citation search in Web of Science. We selected for inclusion studies of any design that assessed the PHQ-9 in adult populations against recognized gold-standard instruments for the diagnosis of either Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for major depression. Included studies had to report sufficient information to calculate 2*2 contingency tables. Data extraction and synthesis were performed independently by two researchers. For the included studies, we calculated pooled sensitivity, pooled specificity, positive likelihood, negative likelihood ratio and diagnostic odds ratio for cutoff points 7 to 15. Results Thirty-six studies (21,292 patients) met inclusion criteria. Pooled sensitivity for cutoff point 10 was 0.78 [95% confidence interval (CI), 0.70–0.84], and pooled specificity was 0.87 (95% CI, 0.84–0.90). At this cutoff, the PHQ-9 is a better screener in primary care than secondary care settings. No conclusions could be drawn at cutoff points other than 10 due to selective reporting of data. Conclusions For MDD, the PHQ-9 has acceptable diagnostic properties at cutoff point 10 in different settings. We recommend that future studies report the full range of cutoff points to allow exploration of optimal cutoff points in different settings. [ABSTRACT FROM AUTHOR]

Background The depression module of the Patient Health Questionnaire-9 (PHQ-9) is a widely used depression screening instrument in nonpsychiatric settings. The PHQ-9 can be scored using different methods, including an algorithm based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and a cut-off based on summed-item scores. The algorithm was the originally proposed scoring method to screen for depression. We summarized the diagnostic test accuracy of the PHQ-9 using the algorithm scoring method across a range of validation studies and compared the diagnostic properties of the PHQ-9 using the algorithm and summed scoring method at the proposed cut-off point of 10. Methods We performed a systematic review of diagnostic accuracy studies of the PHQ-9 using the algorithm scoring method to detect major depressive disorder (MDD). We used meta-analytic methods to calculate summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios for diagnosing MDD of the PHQ-9 using algorithm scoring method. In studies that reported both scoring methods (algorithm and summed-item scoring at proposed cut-off point of ≥ 10), we compared the diagnostic properties of the PHQ-9 using these methods. Results We found 27 validation studies that validated the algorithm scoring method of the PHQ-9 in various settings. There was substantial heterogeneity across studies, which makes the pooled results difficult to interpret. In general, sensitivity was low whereas specificity was good. Thirteen studies reported the diagnostic properties of the PHQ-9 for both scoring methods. Pooled sensitivity for algorithm scoring method was lower while specificities were good for both scoring methods. Heterogeneity was consistently high; therefore, caution should be used when interpreting these results. Interpretation This review shows that, if the algorithm scoring method is used, the PHQ-9 has a low sensitivity for detecting MDD. This could be due to the rating scale categories of the measure, higher specificity or other factors that warrant further research. The summed-item score method at proposed cut-off point of ≥ 10 has better diagnostic performance for screening purposes or where a high sensitivity is needed. [ABSTRACT FROM AUTHOR]

Background: Variability in patient-reported outcomes of psychological treatments has been partly attributed to therapists – a phenomenon commonly known as therapist effects. Meta-analytic reviews reveal wide variation in therapist-attributable variability in psychotherapy outcomes, with most studies reporting therapist effects in the region of 5% to 10% and some finding minimal to no therapist effects. However, all except one study to date have been conducted in high-intensity or mixed intervention groups; therefore, there is scarcity of evidence on therapist effects in brief low-intensity psychological interventions. Objective: To examine therapist effects in low-intensity interventions for depression and anxiety in a naturalistic setting. Data and Analysis: Session-by-session data on patient-reported outcome measures were available for a cohort of 1,376 primary care psychotherapy patients treated by 38 therapists. Outcome measures included PHQ-9 (sensitive to depression) and GAD-7 (sensitive to general anxiety disorder) measures. Three-level hierarchical linear modelling was employed to estimate therapist-attributable proportion of variance in clinical outcomes. Therapist effects were evaluated using the intra-cluster correlation coefficient (ICC) and Bayesian empirical predictions of therapist random effects. Three sensitivity analyses were conducted: 1) using both treatment completers and non-completers; 2) a sub-sample of cases with baseline scores above the conventional clinical thresholds for PHQ-9 and GAD-7; and 3) a two-level model (using patient-level pre- and post-treatment scores nested within therapists). Results: The ICC estimates for all outcome measures were very small, ranging between 0% and 1.3%, although most were statistically significant. The Bayesian empirical predictions showed that therapist random effects were not statistically significantly different from each other. Between patient variability explained most of the variance in outcomes. Conclusion: Consistent with the only other study to date in low intensity interventions, evidence was found to suggest minimal to no therapist effects in patient-reported outcomes. This draws attention to the more prominent source of variability which is found at the between-patient level. [ABSTRACT FROM AUTHOR]

Background: Depression is a common, disabling condition for which psychological treatments are recommended. Behavioural activation has attracted increased interest in recent years. It has been over 5 years since our meta-analyses summarised the evidence supporting and this systematic review updates those findings and examines moderators of treatment effect. Method: Randomised trials of behavioural activation for depression versus controls or anti-depressant medication were identified using electronic database searches, previous reviews and reference lists. Data on symptom level and study level moderators were extracted and analysed using meta-analysis, sub-group analysis and meta-regression respectively. Results: Twenty six randomised controlled trials including 1524 subjects were included in this meta-analysis. A random effects meta-analysis of symptom level post treatment showed behavioural activation to be superior to controls (SMD −0.74 CI −0.91 to −0.56, k = 25, N = 1088) and medication (SMD −0.42 CI −0.83 to-0.00, k = 4, N = 283). Study quality was low in the majority of studies and follow- up time periods short. There was no indication of publication bias and subgroup analysis showed limited association between moderators and effect size. Conclusions: The results in this meta-analysis support and strengthen the evidence base indicating Behavioural Activation is an effective treatment for depression. Further high quality research with longer term follow-up is needed to strengthen the evidence base. [ABSTRACT FROM AUTHOR]

Background: Policy developments in recent years have led to important changes in the level of access to evidence-based psychological treatments. Several methods have been used to investigate the effectiveness of these treatments in routine care, with different approaches to outcome definition and data analysis. Aims: To present a review of challenges and methods for the evaluation of evidence-based treatments delivered in routine mental healthcare. This is followed by a case example of a benchmarking method applied in primary care. Method: High, average and poor performance benchmarks were calculated through a meta-analysis of published data from services working under the Improving Access to Psychological Therapies (IAPT) Programme in England. Pre-post treatment effect sizes (ES) and confidence intervals were estimated to illustrate a benchmarking method enabling services to evaluate routine clinical outcomes. Results: High, average and poor performance ES for routine IAPT services were estimated to be 0.91, 0.73 and 0.46 for depression (using PHQ-9) and 1.02, 0.78 and 0.52 for anxiety (using GAD-7). Data from one specific IAPT service exemplify how to evaluate and contextualize routine clinical performance against these benchmarks. Conclusions: The main contribution of this report is to summarize key recommendations for the selection of an adequate set of psychometric measures, the operational definition of outcomes, and the statistical evaluation of clinical performance. A benchmarking method is also presented, which may enable a robust evaluation of clinical performance against national benchmarks. Some limitations concerned significant heterogeneity among data sources, and wide variations in ES and data completeness. [ABSTRACT FROM AUTHOR]

Background: The brief Patient Health Questionnaire (PHQ-9) is commonly used to screen for depression with 10 often recommended as the cut-off score. We summarized the psychometric properties of the PHQ-9 across a range of studies and cut-off scores to select the optimal cut-off for detecting depression. Methods: We searched Embase, MEDLINE and PsycINFO from 1999 to August 2010 for studies that reported the diagnostic accuracy of PHQ-9 to diagnose major depressive disorders. We calculated summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios for detecting major depressive disorder at different cut-off scores and in different settings. We used random-effects bivariate meta-analysis at cutoff points between 7 and 15 to produce summary receiver operating characteristic curves. Results: We identified 18 validation studies (n = 7180) conducted in various clinical settings. Eleven studies provided details about the diagnostic properties of the questionnaire at more than one cut-off score (including 10), four studies reported a cut-off score of 10, and three studies reported cut-off scores other than 10. The pooled specificity results ranged from 0.73 (95% confidence interval [CI] 0.63-0.82) for a cut-off score of 7 to 0.96 (95% CI 0.94-0.97) for a cut-off score of 15. There was major variability in sensitivity for cut-off scores between 7 and 15. There were no substantial differences in the pooled sensitivity and specificity for a range of cut-off scores (8-11). Interpretation: The PHQ-9 was found to have acceptable diagnostic properties for detecting major depressive disorder for cut-off scores between 8 and 11. Authors of future validation studies should consistently report the outcomes for different cut-off scores. [ABSTRACT FROM AUTHOR]

Postnatal depression (PND) impacts on the mother and her partner, the family, mother-baby interaction and on the baby. This review synthesises the evidence from qualitative and quantitative research to determine whether screening for PND is acceptable to women and healthcare professionals. The research literature was systematically searched to retrieve articles available until February 2007. No language or geographical restrictions were applied. Studies were included if the acceptability of PND screening was assessed during the prenatal and postnatal period. Data were synthesised using the textual narrative approach. Fifteen of the 16 eligible studies focused on the acceptability of the Edinburgh Postnatal Depression Scale (EPDS). Screening for PND was generally found to be acceptable to women and healthcare professionals, although aspects of its administration were identified as being important. Specifically, a woman needs to feel comfortable about the screening process if she is to answer the questions honestly. This may be facilitated through forewarning and administration by a trusted person in her own home. Healthcare professionals need to be aware of differing cultural attitudes towards answering the questions, and the ambiguity of the question about self-harm. Further research into the acceptability of strategies other than EPDS is needed. [ABSTRACT FROM AUTHOR]

Background: Screening and case-finding has been proposed as a simple, quick and cheap method to improve the quality of care for depression. We sought to establish the effectiveness of screening in improving the recognition of depression, the management of depression and the outcomes of patients with depression. Methods: We performed a Cochrane systematic review of randomized controlled trials conducted in nonmental health settings that included case-finding or screening instruments for depression. We conducted a meta-analysis and explored heterogeneity using meta-regression techniques. Results: Sixteen studies with 7576 patients met our inclusion criteria. We found that the use of screening or case-finding instruments were associated with a modest increase in the recognition of depression by clinicians (relative risk [RR] 1.27, 95% confidence interval [CI] 1.02 to 1.59). Questionnaires, when administered to all patients and the results given to clinicians irrespective of baseline score, had no impact on recognition (RR 1.03, 95% CI 0.85 to 1.24). Screening or case finding increased the use of any intervention by a relative risk of 1.30 (95% CI 0.97 to 1.76). There was no evidence of influence on the prescription of antidepressant medications (RR 1.20, 95% CI 0.87 to 1.66). Seven studies provided data on outcomes of depression, and no evidence of an effect was found (standardized mean difference -0.02, 95% CI -0.25 to 0.20). Interpretation: If used alone, case-finding or screening questionnaires for depression appear to have little or no impact on the detection and management of depression by clinicians. Recommendations to adopt screening strategies using standardized questionnaires without organizational enhancements are not justified. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To examine whether cluster randomized trials (1) produce baseline imbalances between intervention and control conditions; (2) give results that are substantially different individually randomized trials; and (3) give different results when adjusted for unit of analysis error. Study Design and Setting: We used 14 cluster randomized trials and 20 individualized trials of the same intervention (collaborative care for depression). We conducted a random effects meta-analysis to examine imbalance in baseline depression scores. We used meta-regression to test for differential effect size and heterogeneity between clustered and individualized studies. Unit of analysis error was corrected using a range of plausible published intraclass correlation coefficients (ICCs). Results: There were no baseline imbalances in either cluster randomized (P =0.837) or individually randomized (P =0.737) studies. Cluster randomized studies gave almost identical estimates of effect size when compared to individually randomized studies (standardized mean difference, SMDcluster =0.25, 95% confidence interval [CI]: 0.17, 0.33; SMDindividual =0.24; 95% CI: 0.13, 0.36). Adjustment for clustering had minimal effect on clinical and statistical significance (pooled SMDICC 0.02 =0.249 [95% CI: 0.174, 0.325] to SMDICC 0.05 =0.258 [95% CI: 0.172, 0.345]). Conclusion: The additional effort and expense involved in cluster randomized trials needs to be justified when individualized studies might produce robust and believable results. [Copyright &y& Elsevier]

Objective: To summarize the psychometric properties of the PHQ2 and PHQ9 as screening instruments for depression.Interventions: We identified 17 validation studies conducted in primary care; medical outpatients; and specialist medical services (cardiology, gynecology, stroke, dermatology, head injury, and otolaryngology). Electronic databases from 1994 to February 2007 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane registers) plus study reference lists have been used for this study. Translations included US English, Dutch, Italian, Spanish, German and Arabic). Summary sensitivity, specificity, likelihood and diagnostic odds ratios (OR) against a gold standard (DSM-IV) Major Depressive Disorder (MDD) were calculated for each study. We used random effects bivariate meta-analysis at recommended cut points to produce summary receiver-operator characteristic (sROC) curves. We explored heterogeneity with metaregression.Measurements and Main Results: Fourteen studies (5,026 participants) validated the PHQ9 against MDD: sensitivity = 0.80 (95% CI 0.71-0.87); specificity = 0.92 (95% CI 0.88-0.95); positive likelihood ratio = 10.12 (95% CI 6.52-15.67); negative likelihood ratio = 0.22 (0.15 to 0.32). There was substantial heterogeneity (Diagnostic Odds Ratio heterogeneity I2 = 82%), which was not explained by study setting (primary care versus general hospital); method of scoring (cutoff > or = 10 versus "diagnostic algorithm"); or study quality (blinded versus unblinded). The diagnostic validity of the PHQ2 was only validated in 3 studies and showed wide variability in sensitivity.Conclusions: The PHQ9 is acceptable, and as good as longer clinician-administered instruments in a range of settings, countries, and populations. More research is needed to validate the PHQ2 to see if its diagnostic properties approach those of the PHQ9. [ABSTRACT FROM AUTHOR]

Objective: The extent of disagreement between large and smaller randomized, controlled trials on mental health issues is unknown. The authors aimed to compare the results of large versus smaller trials on mental health-related interventions. Method: The authors screened 161 Cochrane and 254 Database of Abstracts of Reviews of Effectiveness systematic reviews on mental health-related interventions. They identified 16 meta-analyses with at least one "large" randomized trial with sample size >800 and at least one "smaller" trial. Effect sizes were calculated separately for large and smaller trials. Heterogeneity was assessed between all studies, within each group (large and smaller studies), and between large and smaller studies. Results: Significant between-study heterogeneity was seen in five meta-analyses. By random-effects calculations, the results of large and smaller trials differed beyond chance in four meta-analyses (25%). In three of these disagreements (effect of day care on IQ, discontinuation of antidepressants, risperidone versus typical antipsychotics for schizophrenia), the smaller trials showed greater effect sizes than the large trials. The inverse was seen in one case (olanzapine versus typical antipsychotics for schizophrenia). With fixed- effects models, disagreements beyond chance occurred in five cases (31%). In four meta-analyses, the effect size differed over twofold between large and smaller trials. Various quality and design parameters were identified as potential explanations for some disagreements. Conclusions: Large trials are uncommon in mental health. Their results are usually comparable with the results of smaller studies, but major disagreements do occur. Both large and smaller trials should be scrutinized as they offer a continuum of randomized evidence. [ABSTRACT FROM AUTHOR]

Objective: Publication bias threatens the validity of published research, although this topic has received little attention in psychiatry. The purpose of this article is to produce a systematic overview of the causes and consequences of publication bias and to summarize the available methods with which it is detected and corrected. Method: Empirical evidence for the existence of publication bias is reviewed and the following methods are applied to an illustrative case example from psychiatry: funnel plot analysis; the ‘file drawer method’; linear regression techniques; rank correlation; ‘trim and fill’. Results: Small studies are particularly susceptible to publication and related bias. All methods to detect publication bias depend upon the availability of a number of individual studies with a range of sample sizes. Unfortunately, large numbers of studies of varying sample size are not always available in many areas of psychiatric research. Conclusion: Where possible researchers should always test for the presence of publication bias. The problem of publication bias will not be solved by anything other than a prospective trials register. [ABSTRACT FROM AUTHOR]

The article discusses a study question about influence of initial severity of depression on effectiveness of low intensity interventions. The study found that patients with more severe depression show at least as much clinical benefit from low intensity interventions as less depressed patients. However, patients with more severe depres¬sion are more likely to continue to show clinically signifi¬cant levels of distress after low intensity treatments and may require additional care.

Abstract: Objective: To examine whether randomized economic evaluations report clinical effectiveness estimates that are unrepresentative of the totality of the research literature. Study Design and Setting: From 36 studies (12,294 patients) of enhanced care for depression, we compared pooled clinical effect sizes in studies with a concurrent economic evaluation to those in studies that did not publish a concurrent economic evaluation, using metaregression. Results: The pooled clinical effect size of studies publishing an economic evaluation was almost twice as large as that of studies that did not publish an economic evaluation (pooled standardized mean difference [SMD] in randomized controlled trials [RCTs] with an economic evaluation=0.34; 95% confidence interval [CI]=0.23–0.46; pooled SMD in RCTs without an economic evaluation=0.17; 95% CI=0.10–0.25). This difference was statistically significant (SMD between group difference=−0.17; 95% CI: −0.31 to −0.02; P =0.02). Conclusion: Publication of an economic evaluation of enhanced care for depression was associated with a larger clinical effect size. Cost-effectiveness estimates should be interpreted with caution, and the representativeness of the clinical data on which they are based should always be considered. Further research is needed to explore this observed association and potential bias in other areas. [Copyright &y& Elsevier]

The seven-item Hospital Anxiety and Depression Scale Depression subscale (HADS-D) and the total score of the 14-item HADS (HADS-T) are both used for major depression screening. Compared to the HADS-D, the HADS-T includes anxiety items and requires more time to complete. We compared the screening accuracy of the HADS-D and HADS-T for major depression detection. We conducted an individual participant data meta-analysis and fit bivariate random effects models to assess diagnostic accuracy among participants with both HADS-D and HADS-T scores. We identified optimal cutoffs, estimated sensitivity and specificity with 95% confidence intervals, and compared screening accuracy across paired cutoffs via two-stage and individual-level models. We used a 0.05 equivalence margin to assess equivalency in sensitivity and specificity. 20,700 participants (2,285 major depression cases) from 98 studies were included. Cutoffs of ≥7 for the HADS-D (sensitivity 0.79 [0.75, 0.83], specificity 0.78 [0.75, 0.80]) and ≥15 for the HADS-T (sensitivity 0.79 [0.76, 0.82], specificity 0.81 [0.78, 0.83]) minimized the distance to the top-left corner of the receiver operating characteristic curve. Across all sets of paired cutoffs evaluated, differences of sensitivity between HADS-T and HADS-D ranged from −0.05 to 0.01 (0.00 at paired optimal cutoffs), and differences of specificity were within 0.03 for all cutoffs (0.02–0.03). The pattern was similar among outpatients, although the HADS-T was slightly (not nonequivalently) more specific among inpatients. The accuracy of HADS-T was equivalent to the HADS-D for detecting major depression. In most settings, the shorter HADS-D would be preferred. Public Significance Statement: The present study suggests that the accuracy of 14-item Hospital Anxiety and Depression Scale (HADS-D) and the seven-item HADS Depression subscale (HADS-D) are equivalent for detecting major depression. Using the seven-item HADS-D for depression screening instead of the full 14-item HADS-T has minimal influence on performance of the measure but would reduce patient and participant burden in most clinical and research settings. [ABSTRACT FROM AUTHOR]

Objective: To investigate associations between major life events and prognosis independent of treatment type: (1) after adjusting for clinical prognostic factors and socio-demographics; (2) amongst patients with depressive episodes at least six-months long; and (3) patients with a first life-time depressive episode.Methods: Six RCTs of adults seeking treatment for depression in primary care met eligibility criteria, individual patient data (IPD) were collated from all six (n = 2858). Participants were randomized to any treatment and completed the same baseline assessment of life events, demographics and clinical prognostic factors. Two-stage random effects meta-analyses were conducted.Results: Reporting any major life events was associated with poorer prognosis regardless of treatment type. Controlling for baseline clinical factors, socio-demographics and social support resulted in minimal residual evidence of associations between life events and treatment prognosis. However, removing factors that might mediate the relationships between life events and outcomes reporting: arguments/disputes, problem debt, violent crime, losing one's job, and three or more life events were associated with considerably worse prognoses (percentage difference in 3-4 months depressive symptoms compared to no reported life events =30.3%(95%CI: 18.4-43.3)).Conclusions: Assessing for clinical prognostic factors, social support, and socio-demographics is likely to be more informative for prognosis than assessing self-reported recent major life events. However, clinicians might find it useful to ask about such events, and if they are still affecting the patient, consider interventions to tackle problems related to those events (e.g. employment support, mediation, or debt advice). Further investigations of the efficacy of such interventions will be important. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the effectiveness of newer atypical antipsychotic drugs in comparison to clozapine for schizophrenia. Publications in all languages were searched from all relevant databases and all randomized controlled trials comparing clozapine with newer atypical drugs were included. The review and meta-analysis includes eight studies, most of them short in duration. Newer atypical drugs were broadly similar to clozapine when improvement was measured using a psychosis symptom rating scale or a global index. There was a trend for clozapine to be more effective than the comparators for positive symptoms, and less effective for the negative symptoms. The adverse effect profile of clozapine and newer atypical drugs was dissimilar: while clozapine produced more fatigue, hypersalivation, and orthostatic dizziness, new atypical drugs, with the exception of olanzapine, produced more extrapyramidal symptoms. As these results were obtained from few studies and a relatively small amount of patients, the equal effectiveness and tolerability of new atypical drugs in comparison with clozapine is not yet demonstrated. More trials of sufficient power, with longer duration, and measuring clinically important outcomes are urgently needed. [Copyright &y& Elsevier]

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects. We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747. We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, −0.11 [95%CI, −0.15 to −0.08]; I2, 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, −0.15 [95%CI -0.19 to −0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, − 0.18 [95%CI -0.25 to −0.11]). Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most. [ABSTRACT FROM AUTHOR]

Background: Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.Methods: We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.Results: 93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.Limitations: We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.Conclusion: Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A broad array of transdiagnostic psychological treatments for depressive and anxiety disorders have been evaluated, but existing reviews of this literature are restricted to face-to-face cognitive behavioural therapy (CBT) protocols. The current meta-analysis focused on studies evaluating clinician-guided internet/computerised or face-to-face manualised transdiagnostic treatments, to examine their effects on anxiety, depression and quality of life (QOL). Results from 50 studies showed that transdiagnostic treatments are efficacious, with large overall mean uncontrolled effects (pre- to post-treatment) for anxiety and depression ( g s = .85 and .91 respectively), and medium for QOL ( g = .69). Uncontrolled effect sizes were stable at follow-up. Results from 24 RCTs that met inclusion criteria showed that transdiagnostic treatments outperformed control conditions on all outcome measures (controlled ESs: g s = .65, .80, and .46 for anxiety, depression and QOL respectively), with the smallest differences found compared to treatment-as-usual (TAU) control conditions. RCT quality was generally poor, and heterogeneity was high. Examination of the high heterogeneity revealed that CBT protocols were more effective than mindfulness/acceptance protocols for anxiety (uncontrolled ESs: g s = .88 and .61 respectively), but not depression. Treatment delivery format influenced outcomes for anxiety (uncontrolled ESs: group: g = .70, individual: g = .97, computer/internet: g = .96) and depression (uncontrolled ESs: group: g = .89, individual: g = .86, computer/internet: g = .96). Preliminary evidence from 4 comparisons with disorder-specific treatments suggests that transdiagnostic treatments are as effective for reducing anxiety, and may be superior for reducing depression. These findings show that transdiagnostic psychological treatments are efficacious, but higher quality research studies are needed to explore the sources of heterogeneity amongst treatment effects. [ABSTRACT FROM AUTHOR]

Abstract: Background: Depression will be the second largest cause of disease burden by 2020. It is commonly associated with long term physical health conditions resulting in worsened clinical outcome and increased costs. Nurses would appear ideally placed to facilitate depression management in those people with long term health problems within health care clinics. This article reviews the evidence to support such a clinical approach. Method: A systematic review and meta-analysis of randomised trials of nurse led management of depression in patients with long term health problems. Databases were searched between December 2011 and May 2012, data were extracted and analysed using Comprehensive Meta Analysis software. Subgroup analysis and meta-regression were used to explore the impact of study level moderators of effect. Results: Nurse delivered collaborative care was compared to usual care in 14 studies including 4440 participants. The mean effect size at follow-up was d=0.43 95% CI 0.34 to 0.52 p<0.001 NNT 4.23, representing a moderate impact on depression severity. Results were consistent across studies and maintained at longer term follow up. Limitations: Data were only available on depression outcomes and with most studies being USA based generalizability is somewhat limited. To date only one study reported cost effectiveness outcomes. Conclusions: Based upon the research literature nurse led depression management provides effective treatment across a range of long term health conditions. Nurses are ideally placed to deliver such interventions and further research is required to examine the cost utility of the approach and its durability outside of the USA. [Copyright &y& Elsevier]

Abstract: Objective: To quantify the accuracy of the Hospital Anxiety and Depression Scale (HADS) as a case-finding instrument for anxiety and depressive disorders. Method: MEDLINE, PSYCHINFO, EMBASE, CINAHL, BNI, and AMED were searched from January 1983 to June 2006. Studies were included that administered the HADS, used a standardized psychiatric interview to establish a diagnosis of anxiety or depression, and provided sufficient data on sensitivity and specificity (N=41). Summary sensitivity, specificity, likelihood ratios, and diagnostic odds ratios were calculated for each study. Random effects meta-analytic pooling across studies at the recommended clinical (7/8) and research (10/11) cutoff points was undertaken and summary receiver operating characteristic curves constructed. Results: For major depressive disorders, a cut point of ≥8 gave a sensitivity of 0.82 (95% CI, 0.73–0.89) and a specificity of 0.74 (95% CI, 0.60–0.84) and a cut point ≥11 gave a sensitivity of 0.56 (95% CI, 0.40–0.71) and a specificity of 0.92 (95% CI, 0.79–0.97). Conclusions: Many studies have shown that the HADS is a useful screening tool to identify emotional distress in nonpsychiatric patients. However, it does not appear to be superior to other screening instruments in terms of identifying specific mental disorders in physical health settings. [Copyright &y& Elsevier]

Objective: Two previous individual participant data meta-analyses (IPDMAs) found that different diagnostic interviews classify different proportions of people as having major depression overall or by symptom levels. We compared the odds of major depression classification across diagnostic interviews among studies that administered the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D).Methods: Data accrued for an IPDMA on HADS-D diagnostic accuracy were analysed. We fit binomial generalized linear mixed models to compare odds of major depression classification for the Structured Clinical Interview for DSM (SCID), Composite International Diagnostic Interview (CIDI), and Mini International Neuropsychiatric Interview (MINI), controlling for HADS-D scores and participant characteristics with and without an interaction term between interview and HADS-D scores.Results: There were 15,856 participants (1942 [12%] with major depression) from 73 studies, including 15,335 (97%) non-psychiatric medical patients, 164 (1%) partners of medical patients, and 357 (2%) healthy adults. The MINI (27 studies, 7345 participants, 1066 major depression cases) classified participants as having major depression more often than the CIDI (10 studies, 3023 participants, 269 cases) (adjusted odds ratio [aOR] = 1.70 (0.84, 3.43)) and the semi-structured SCID (36 studies, 5488 participants, 607 cases) (aOR = 1.52 (1.01, 2.30)). The odds ratio for major depression classification with the CIDI was less likely to increase as HADS-D scores increased than for the SCID (interaction aOR = 0.92 (0.88, 0.96)).Conclusion: Compared to the SCID, the MINI may diagnose more participants as having major depression, and the CIDI may be less responsive to symptom severity. [ABSTRACT FROM AUTHOR]