M.J.H. Huibers

Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data

Objective To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression. Design Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care. Setting Primary care and community settings. Participants 2470 patients with depression. Interventions Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions). Main outcome measures Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions. Results Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient −0.1 (95% CI −0.19 to −0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant. Conclusions The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

Psychological treatment of generalized anxiety disorder: a meta-analysis.

Recent years have seen a near-doubling of the number of studies examining the effects of psychotherapies for generalized anxiety disorder (GAD) in adults. The present article integrates this new evidence with the older literature through a quantitative meta-analysis. A total of 41 studies (with 2132 patients meeting diagnostic criteria for GAD) were identified through systematic searches in bibliographical databases, and were included in the meta-analysis. Most studies examined the effects of cognitive behavior therapy (CBT). The majority of studies used waiting lists as control condition. The pooled effect of the 38 comparisons (from 28 studies) of psychotherapy versus a control group was large (g=0.84; 95% CI: 0.71-0.97) with low to moderate heterogeneity. The effects based on self-report measures were somewhat lower than those based on clinician-rated instruments. The effects on depression were also large (g=0.71; 95% CI: 0.59-0.82). There were some indications for publication bias. The number of studies comparing CBT with other psychotherapies (e.g., applied relaxation) or pharmacotherapy was too small to draw conclusions about comparative effectiveness or the long-term effects. There were some indications that CBT was also effective at follow-up and that CBT was more effective than applied relaxation in the longer term.

Clinical effectiveness of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial

BACKGROUND Computerised cognitive-behavioural therapy (CCBT) might offer a solution to the current undertreatment of depression. AIMS To determine the clinical effectiveness of online, unsupported CCBT for depression in primary care. METHOD Three hundred and three people with depression were randomly allocated to one of three groups: Colour Your Life; treatment as usual (TAU) by a general practitioner; or Colour Your Life and TAU combined. Colour Your Life is an online, multimedia, interactive CCBT programme. No assistance was offered. We had a 6-month follow-up period. RESULTS No significant differences in outcome between the three interventions were found in the intention-to-treat and per protocol analyses. CONCLUSIONS Online, unsupported CCBT did not outperform usual care, and the combination of both did not have additional effects. Decrease in depressive symptoms in people with moderate to severe depression was moderate in all three interventions. Online CCBT without support is not beneficial for all individuals with depression.

Rumination and worrying as possible mediators in the relation between neuroticism and symptoms of depression and anxiety in clinically depressed individuals

Rumination and worrying are considered possible mediating variables that may explain the relation between neuroticism and symptoms of depression and anxiety. The current study sought to examine the mediational effects of rumination and worry in the relationships between neuroticism and symptoms of depression and anxiety in a sample of clinically depressed individuals (N=198). All patients completed a battery of questionnaires including measures of neuroticism, rumination, worrying, depression, and anxiety. Results showed that in subsequent analyses, rumination and worrying both mediated the relation between neuroticism and depression and anxiety. When rumination and worrying were simultaneously entered in the mediation analysis, only rumination was found to mediate the relation between neuroticism and symptoms of anxiety and depression. Two components of rumination (i.e., brooding and reflection) were also analyzed in the mediational analysis. Both reflection and brooding were significant mediators with respect to depressive symptoms, whereas brooding was the only significant mediator in relation to anxiety symptoms. The results are discussed in the light of current theories, previous research, and recent treatment developments. Clinical implications and suggestions for future research are provided.

Economic evaluation of online computerised cognitive–behavioural therapy without support for depression in primary care: randomised trial

BACKGROUND Evidence about the cost-effectiveness and cost utility of computerised cognitive-behavioural therapy (CCBT) is still limited. Recently, we compared the clinical effectiveness of unsupported, online CCBT with treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus TAU) for depression. The study is registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236). AIMS To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus TAU. METHOD Costs, depression severity and quality of life were measured for 12 months. Cost-effectiveness and cost-utility analyses were performed from a societal perspective. Uncertainty was dealt with by bootstrap replications and sensitivity analyses. RESULTS Costs were lowest for the CCBT group. There are no significant group differences in effectiveness or quality of life. Cost-utility and cost-effectiveness analyses tend to be in favour of CCBT. CONCLUSIONS On balance, CCBT constitutes the most efficient treatment strategy, although all treatments showed low adherence rates and modest improvements in depression and quality of life.

Psychological distress, fatigue and long-term sickness absence: prospective results from the Maastricht Cohort Study.

Objective: Little is known about psychological distress as a risk factor for the onset of long-term sickness absence and even less about the influence of fatigue in this relationship. Methods: We examined the relationship between psychological distress and the onset of long-term sickness absence during 18 months of follow-up while considering fatigue. Analyses were based on 6403 employees participating in the Maastricht Cohort Study. Results: Psychological distress was related to the onset of long-term sickness absence (women relative risk 1.45, 95% confidence interval = 1.23–1.72; men 1.33, 1.21–1.46). Adjustment for fatigue weakened the associations, particularly in women. Caseness analyses revealed different effects of psychological distress and fatigue in the onset of long-term sickness absence in men and women. Conclusion: The findings underline the need for interventions aiming at psychological distress and, depending on the gender, also at fatigue, to reduce the risk of long-term sickness absence.

Efficacy of confronting smokers with airflow limitation for smoking cessation

The objective of the present study was to test whether confronting smokers with previously undetected chronic obstructive pulmonary disease (COPD) increases the rate of smoking cessation. In total, 296 smokers with no prior diagnosis of COPD were detected with mild-to-moderate airflow limitation by means of spirometry and randomly allocated to: confrontational counselling by a nurse with nortriptyline for smoking cessation (experimental group); regular counselling by a nurse with nortriptyline (control group 1); or “care as usual” for smoking cessation by the general practitioner (control group 2). Only the experimental group was confronted with their abnormal spirometry (mean forced expiratory volume in one second (FEV1) post-bronchodilator 80.5% predicted, mean FEV1/forced vital capacity post-bronchodilator 62.5%). There was no difference in cotinine-validated prolonged abstinence rate between the experimental group (11.2%) and control group 1 (11.6%) from week 5–52 (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.43–2.18). The abstinence rate was approximately twice as high in the experimental group compared with control group 2 (5.9%), but this difference was not statistically significant (OR 2.02, 95% CI 0.63–6.46). The present study did not provide evidence that the confrontational approach increases the rate of long-term abstinence from smoking compared with an equally intensive treatment in which smokers were not confronted with spirometry. The high failure rates (≥88%) highlight the need for treating tobacco addiction as a chronic relapsing disorder.

How much psychotherapy is needed to treat depression? A metaregression analysis

BACKGROUND Although psychotherapies are effective in the treatment of adult depression it is not clear how this treatment effect is related to amount, frequency and intensity of therapy. METHODS To fill this gap in knowledge, the present metaregression analysis examined the association between the effects of psychotherapy for adult depression and several indicators of amount, frequency and intensity of therapy. The analysis included 70 studies (92 comparisons) with 5403 patients, in which individual psychotherapy was compared with a control group (e.g. waiting list, care-as-usual). RESULTS There was only a small association between number of therapy sessions and effect size, and this association was no longer significant when the analysis adjusted for other characteristics of the studies. The multivariable analyses also found no significant association with the total contact time or duration of the therapy. However, there was a strong association between number of sessions per week and effect size. An increase from one to two sessions per week increased the effect size with g=0.45, while keeping the total number of treatment sessions constant. DISCUSSION More research is needed to establish the robustness of this finding. Based on these findings, it may be advisable to concentrate psychotherapy sessions within a brief time frame.

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.

Fatigue, burnout, and chronic fatigue syndrome among employees on sick leave: do attributions make the difference?

Background: Persistent fatigue among employees, burnout, and chronic fatigue syndrome (CFS) are three fatigue conditions that share some characteristics in theory. However, these conditions have not been compared in empirical research, despite conceptual similarities. Methods: This cross sectional study aimed to investigate relations between persistent fatigue, burnout, and CFS by describing the clinical features of a sample of 151 fatigued employees on sick leave. Using validated instruments, subgroups based on research criteria for CFS and burnout within the sample of fatigued employees and a reference group of 97 diagnosed CFS patients were compared. Analyses of covariance were performed. Results: A total of 66 (43.7%) fatigued employees met research criteria for CFS (except symptom criteria) and 76 (50.3%) met research criteria for burnout. “CFS-like employees” (fatigued employees who met CFS criteria) reported stronger somatic attributions than “non-CFS-like employees”. Burnt out CFS-like employees were more depressed and distressed than CFS-like employees who were not burnt out. Burnout cases among the non-CFS-like employees had stronger psychological attributions than fatigued employees who were not burnt out. Compared to diagnosed CFS patients, CFS-like employees merely had a shorter duration of fatigue complaints. Burnt out CFS-like employees had stronger psychological attributions and were more distressed than CFS patients. Conclusions: Fatigued employees shared many important characteristics with CFS patients, regardless of burnout status, and many fatigued employees met CFS criteria and/or burnout criteria. Differences however concerned the causal attributions that were made. This raises questions about the role of causal attributions: are they modified by fatigue complaints or do they determine illness outcome?