Annet Kleiboer

A Meta-Analysis of Cognitive-Behavioural Therapy for Adult Depression, Alone and in Comparison With Other Treatments.

Objective: No recent meta-analysis has examined the effects of cognitive-behavioural therapy (CBT) for adult depression. We decided to conduct such an updated meta-analysis. Methods: Studies were identified through systematic searches in bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane library). We included studies examining the effects of CBT, compared with control groups, other psychotherapies, and pharmacotherapy. Results: A total of 115 studies met inclusion criteria. The mean effect size (ES) of 94 comparisons from 75 studies of CBT and control groups was Hedges g = 0.71 (95% CI 0.62 to 0.79), which corresponds with a number needed to treat of 2.6. However, this may be an overestimation of the true ES as we found strong indications for publication bias (ES after adjustment for bias was g = 0.53), and because the ES of higher-quality studies was significantly lower (g = 0.53) than for lower-quality studies (g = 0.90). The difference between high- and low-quality studies remained significant after adjustment for other study characteristics in a multivariate meta-regression analysis. We did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy. Combined treatment was significantly more effective than pharmacotherapy alone (g = 0.49). Conclusions: There is no doubt that CBT is an effective treatment for adult depression, although the effects may have been overestimated until now. CBT is also the most studied psychotherapy for depression, and thus has the greatest weight of evidence. However, other treatments approach its overall efficacy.

Comprehensive Meta-Analysis of Excess Mortality in Depression in the General Community Versus Patients With Specific Illnesses

OBJECTIVE Several hundred studies have shown that depression is associated with an elevated risk of dying at follow-up. It is not clear, however, whether the mechanisms for this association are disease specific, leading to higher mortality in specific patient groups, or generic, resulting in comparable mortality rates in all patient groups as well as in community samples. The authors conducted a comprehensive meta-analysis of prospective studies of community as well as patient samples associating depression at baseline with excess mortality at follow-up. METHOD The authors conducted systematic searches of PubMed, PsycINFO, and Embase. Studies were included if depression was measured with a standardized instrument and mortality was reported for both depressed and nondepressed participants at follow-up. RESULTS A total of 293 studies including 1,813,733 participants (135,007 depressed and 1,678,726 nondepressed) from 35 countries were included. The overall unadjusted relative risk of mortality in depressed relative to nondepressed participants was 1.64 (95% CI=1.56-1.76), with high heterogeneity (I2=83, 95% CI=80-84). After adjustment for publication bias, the overall relative risk was reduced to 1.52 (95% CI=1.45-1.59). No strong indications were found that the pooled relative risk was different across the relatively healthy community samples and specific patient samples with heart disease, cancer, kidney disease, or other disease, except for a significantly higher risk in patients with chronic obstructive pulmonary disease (p<0.05). Also, the relative risk was lower when the follow-up period was longer and when the quality of the study was higher. CONCLUSIONS The authors could confirm the presence of a significant association between depression and excess mortality, although this association may have been overestimated because of publication bias and low study quality. Few indications were found that this association is stronger in community or specific patient samples.

Differential mortality rates in major and subthreshold depression: meta-analysis of studies that measured both

BACKGROUND Although the association between depression and excess mortality has been well established, it is not clear whether this is greater in major depression than in subthreshold depression. AIMS To compare excess mortality in major depression with that in subthreshold depression. METHOD We searched bibliographic databases and included prospective studies in which both major and subthreshold depression were examined at baseline and mortality was measured at follow-up. RESULTS A total of 22 studies were included. People with major depression had a somewhat increased chance of dying earlier than people with subthreshold depression but this difference was not significant, although there was a trend (relative risk 1.13, 95% CI 0.98-1.30, P = 0.1). The population attributable fraction was 7% for major depression and an additional 7% for subthreshold depression. CONCLUSIONS Although excess mortality may be somewhat higher in major than in subthreshold depression, the difference is small and the overall impact on excess mortality is comparable.

Screening for major depression in cancer outpatients: the diagnostic accuracy of the 9-item patient health questionnaire.

Systematic screening for depression has been recommended for patients who have medical conditions like cancer. The 9‐item Patient Health Questionnaire (PHQ‐9) is becoming widely used, but its diagnostic accuracy has not yet been tested in a cancer patient population. In this article, the authors report on the performance of the PHQ‐9 as a screening instrument for major depressive disorder (MDD) in patients with cancer.

Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data

Importance Self-guided internet-based cognitive behavioral therapy (iCBT) has the potential to increase access and availability of evidence-based therapy and reduce the cost of depression treatment. Objectives To estimate the effect of self-guided iCBT in treating adults with depressive symptoms compared with controls and evaluate the moderating effects of treatment outcome and response. Data Sources A total of 13 384 abstracts were retrieved through a systematic literature search in PubMed, Embase, PsycINFO, and Cochrane Library from database inception to January 1, 2016. Study Selection Randomized clinical trials in which self-guided iCBT was compared with a control (usual care, waiting list, or attention control) in individuals with symptoms of depression. Data Extraction and Synthesis Primary authors provided individual participant data from 3876 participants from 13 of 16 eligible studies. Missing data were handled using multiple imputations. Mixed-effects models with participants nested within studies were used to examine treatment outcomes and moderators. Main Outcomes and Measures Outcomes included the Beck Depression Inventory, Center for Epidemiological Studies–Depression Scale, and 9-item Patient Health Questionnaire scores. Scales were standardized across the pool of the included studies. Results Of the 3876 study participants, the mean (SD) age was 42.0 (11.7) years, 2531 (66.0%) of 3832 were female, 1368 (53.1%) of 2574 completed secondary education, and 2262 (71.9%) of 3146 were employed. Self-guided iCBT was significantly more effective than controls on depressive symptoms severity (&bgr; = −0.21; Hedges g  = 0.27) and treatment response (&bgr; = 0.53; odds ratio, 1.95; 95% CI, 1.52-2.50; number needed to treat, 8). Adherence to treatment was associated with lower depressive symptoms (&bgr; = −0.19; P = .001) and greater response to treatment (&bgr; = 0.90; P < .001). None of the examined participant and study-level variables moderated treatment outcomes. Conclusions and Relevance Self-guided iCBT is effective in treating depressive symptoms. The use of meta-analyses of individual participant data provides substantial evidence for clinical and policy decision making because self-guided iCBT can be considered as an evidence-based first-step approach in treating symptoms of depression. Several limitations of the iCBT should be addressed before it can be disseminated into routine care.

Mobile Web-Based Monitoring and Coaching: Feasibility in Chronic Migraine

Background The Internet can facilitate diary monitoring (experience sampling, ecological momentary assessment) and behavioral coaching. Online digital assistance (ODA) is a generic tool for mobile Web-based use, intended as an adjuvant to face-to-face or Internet-based cognitive behavioral treatment. A current ODA application was designed to support home-based training of behavioral attack prevention in chronic migraine, focusing on the identification of attack precursors and the support of preventive health behaviour. Objective The aim was to establish feasibility of the ODA approach in terms of technical problems and participant compliance, and ODA acceptability on the basis of ratings of user-friendliness, potential burden, and perceived support of the training for behavioral attack prevention in migraine. Methods ODA combines mobile electronic diary monitoring with direct human online coaching of health behavior according to the information from the diary. The diary contains three parts covering the following: (1) migraine headache and medication use, (2) attack precursors, and (3) self-relaxation and other preventive behavior; in addition, menstruation (assessed in the evening diary) and disturbed sleep (assessed in the morning diary) is monitored. The pilot study consisted of two runs conducted with a total of five women with chronic migraine without aura. ODA was tested for 8.5 days (range 4-12 days) per participant. The first test run with three participants tested 4-5 diary prompts per day. The second run with another three participants (including one subject who participated in both runs) tested a reduced prompting scheme (2-3 prompts per day) and minor adaptations to the diary. Online coaching was executed twice daily on workdays. Results ODA feasibility was established on the basis of acceptable data loss (1.2% due to the personal digital assistant; 5.6% due to failing Internet transmission) and good participant compliance (86.8% in the second run). Run 1 revealed some annoyance with the number of prompts per day. Overall ODA acceptability was evident by the positive participant responses concerning user-friendliness, absence of burden, and perceived support of migraine attack prevention. The software was adapted to further increase the flexibility of the application. Conclusions ODA is feasible and well accepted. Tolerability is a sensitive issue, and the balance between benefit and burden must be considered with care. ODA offers a generic tool to combine mobile coaching with diary monitoring,independently of time and space. ODA effects on improvement of migraine remain to be established.

Predictors of treatment dropout in self-guided web-based interventions for depression: an 'individual patient data' meta-analysis

BACKGROUND It is well known that web-based interventions can be effective treatments for depression. However, dropout rates in web-based interventions are typically high, especially in self-guided web-based interventions. Rigorous empirical evidence regarding factors influencing dropout in self-guided web-based interventions is lacking due to small study sample sizes. In this paper we examined predictors of dropout in an individual patient data meta-analysis to gain a better understanding of who may benefit from these interventions. METHOD A comprehensive literature search for all randomized controlled trials (RCTs) of psychotherapy for adults with depression from 2006 to January 2013 was conducted. Next, we approached authors to collect the primary data of the selected studies. Predictors of dropout, such as socio-demographic, clinical, and intervention characteristics were examined. RESULTS Data from 2705 participants across ten RCTs of self-guided web-based interventions for depression were analysed. The multivariate analysis indicated that male gender [relative risk (RR) 1.08], lower educational level (primary education, RR 1.26) and co-morbid anxiety symptoms (RR 1.18) significantly increased the risk of dropping out, while for every additional 4 years of age, the risk of dropping out significantly decreased (RR 0.94). CONCLUSIONS Dropout can be predicted by several variables and is not randomly distributed. This knowledge may inform tailoring of online self-help interventions to prevent dropout in identified groups at risk.

Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms

Importance Self-guided internet-based cognitive behavioral therapy (iCBT) has the potential to increase access and availability of evidence-based therapy and reduce the cost of depression treatment. Objectives To estimate the effect of self-guided iCBT in treating adults with depressive symptoms compared with controls and evaluate the moderating effects of treatment outcome and response. Data Sources A total of 13 384 abstracts were retrieved through a systematic literature search in PubMed, Embase, PsycINFO, and Cochrane Library from database inception to January 1, 2016. Study Selection Randomized clinical trials in which self-guided iCBT was compared with a control (usual care, waiting list, or attention control) in individuals with symptoms of depression. Data Extraction and Synthesis Primary authors provided individual participant data from 3876 participants from 13 of 16 eligible studies. Missing data were handled using multiple imputations. Mixed-effects models with participants nested within studies were used to examine treatment outcomes and moderators. Main Outcomes and Measures Outcomes included the Beck Depression Inventory, Center for Epidemiological Studies–Depression Scale, and 9-item Patient Health Questionnaire scores. Scales were standardized across the pool of the included studies. Results Of the 3876 study participants, the mean (SD) age was 42.0 (11.7) years, 2531 (66.0%) of 3832 were female, 1368 (53.1%) of 2574 completed secondary education, and 2262 (71.9%) of 3146 were employed. Self-guided iCBT was significantly more effective than controls on depressive symptoms severity (&bgr; = −0.21; Hedges g  = 0.27) and treatment response (&bgr; = 0.53; odds ratio, 1.95; 95% CI, 1.52-2.50; number needed to treat, 8). Adherence to treatment was associated with lower depressive symptoms (&bgr; = −0.19; P = .001) and greater response to treatment (&bgr; = 0.90; P < .001). None of the examined participant and study-level variables moderated treatment outcomes. Conclusions and Relevance Self-guided iCBT is effective in treating depressive symptoms. The use of meta-analyses of individual participant data provides substantial evidence for clinical and policy decision making because self-guided iCBT can be considered as an evidence-based first-step approach in treating symptoms of depression. Several limitations of the iCBT should be addressed before it can be disseminated into routine care.

What is a psychological intervention? A metareview and practical proposal

Objective: What do we mean by a ‘psychological intervention’ in the context of cancer care? It is critical to know what treatments are included under this term, if data from diverse treatment trials are to be summarized in order to inform clinical practice. We, therefore, aimed to determine how the term ‘psychological intervention’ has been defined and used to group and compare interventions in reviews of cancer care.

Screening for suicidality in cancer patients using Item 9 of the nine-item patient health questionnaire; does the item score predict who requires further assessment?

OBJECTIVE To determine whether a higher score on Item 9 of the Patient Health Questionnaire-9 (range zero to three) was more likely to indicate suicidality as determined at subsequent clinical interview in cancer outpatients. METHOD Analysis of anonymized data (with ethical approval) obtained from the routine clinical administration of self-report questionnaires and telephone interviews to patients attending a cancer centre in the UK. RESULTS Complete data were available on 330 patients. Those with higher scores on the item were more likely to be suicidal at interview. However, a substantial number of those (54/235; 23%) who scored only one on the item were also found to be suicidal. CONCLUSIONS A higher score on Item 9 of the PHQ-9 indicates a greater likelihood that the patient is suicidal. However, even patients who score only 1 may be suicidal and consequently also require further assessment.