Paul R. Martin

A randomized controlled trial of psychological interventions for postnatal depression

OBJECTIVES First, to establish the efficacy of psychological interventions versus routine primary care for the management of postnatal depression (PND). Secondly, to provide a direct comparison of cognitive-behavioural therapy (CBT) versus counselling and, finally, to compare the relative value of group and individual delivery formats. DESIGN The study involved 192 depressed women drawn from a large community screening programme in Melbourne, Australia and allocated to cognitive behaviour therapy, counselling, or routine primary care. Baseline and post-intervention measures of depression and anxiety were collected in the form of validated self-report inventories. METHOD Women were screened in the community and diagnosis of depression confirmed with a standardized psychiatric interview. Interventions were of 12 weeks duration, including three partner sessions, and adhered to a structured manual. RESULTS Psychological intervention per se was superior to routine care in terms of reductions in both depression and anxiety following intervention. CONCLUSIONS For those women with PND, psychological intervention is a better option than routine care, leading to clinically significant reduction of symptoms. Counselling may be as effective as group cognitive behaviour therapy. The benefits of psychological intervention may be maximized by being delivered on a one-to-one basis.

Coping and caregivers of people with dementia

PURPOSE To critically review the research based on Lazarus and Folkmans (1984) stress and coping model, in respect to the coping of those caring for persons with dementia in the community, in an attempt to establish its implications for interventions aimed at improving caregiver adjustment. METHOD Published material on the coping of caregivers of persons with dementia was identified through computerized literature searches (Med-line, Psych-Info) to December 1999, employing search terms including Alzheimers disease, dementia, caregiving, caregiver burden, adaptation, psychological, coping, and stress. Studies were chosen to be considered in detail, based on the reviewers opinion that they would contribute to an understanding of the current state of the research and its clinical implications. This material was then critically reviewed against the tenets of Lazarus and Folkmans (1984) model. RESULTS Sixteen studies were selected to be included in the review, 12 cross-sectional and 4 longitudinal. Seven of the studies did not incorporate coping measures specific to caregiving and/or assess coping in respect of specific caregiver problems. Nine of the studies did do this. The research suggests that a general tendency towards problemsolving and acceptance styles of coping is likely to be advantageous to caregivers of people with dementia. CONCLUSIONS Despite this finding, it is concluded that the ability of the research to inform the clinician is severely limited. It is proposed that while longitudinal studies considered specific caregiver problems which incorporate coping measures specific to the caregiving task may improve understanding, a substantial revision of methodology and perspective may be required to produce findings that are likely to influence practice.

Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial

BACKGROUND Medical conditions are often complicated by major depression, with consequent additional impairment of quality of life. We aimed to compare the effectiveness of an integrated treatment programme for major depression in patients with cancer (depression care for people with cancer) with usual care. METHODS SMaRT Oncology-2 is a parallel-group, multicentre, randomised controlled effectiveness trial. We enrolled outpatients with major depression from three cancer centres and their associated clinics in Scotland, UK. Participants were randomly assigned in a 1:1 ratio to the depression care for people with cancer intervention or usual care, with stratification (by trial centre) and minimisation (by age, primary cancer, and sex) with allocation concealment. Depression care for people with cancer is a manualised, multicomponent collaborative care treatment that is delivered systematically by a team of cancer nurses and psychiatrists in collaboration with primary care physicians. Usual care is provided by primary care physicians. Outcome data were collected up until 48 weeks. The primary outcome was treatment response (≥50% reduction in Symptom Checklist Depression Scale [SCL-20] score, range 0-4) at 24 weeks. Trial statisticians and data collection staff were masked to treatment allocation, but participants could not be masked to the allocations. Analyses were by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN40568538. FINDINGS 500 participants were enrolled between May 12, 2008, and May 13, 2011; 253 were randomly allocated to depression care for people with cancer and 247 to usual care. 143 (62%) of 231 participants in the depression care for people with cancer group and 40 (17%) of 231 in the usual care group responded to treatment: absolute difference 45% (95% CI 37-53), adjusted odds ratio 8·5 (95% CI 5·5-13·4), p<0·0001. Compared with patients in the usual care group, participants allocated to the depression care for people with cancer programme also had less depression, anxiety, pain, and fatigue; and better functioning, health, quality of life, and perceived quality of depression care at all timepoints (all p<0·05). During the study, 34 cancer-related deaths occurred (19 in the depression care for people with cancer group, 15 in the usual care group), one patient in the depression care for people with cancer group was admitted to a psychiatric ward, and one patient in this group attempted suicide. None of these events were judged to be related to the trial treatments or procedures. INTERPRETATION Our findings suggest that depression care for people with cancer is an effective treatment for major depression in patients with cancer. It offers a model for the treatment of depression comorbid with other medical conditions. FUNDING Cancer Research UK and Chief Scientist Office of the Scottish Government.

Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data

BACKGROUND Major depression is an important complication of cancer. However, reliable data are lacking for the prevalence of depression in patients with cancer in different primary sites, the association of depression with demographic and clinical variables within cancer groupings, and the proportion of depressed patients with cancer receiving potentially effective treatment for depression. We investigated these questions with data from a large representative clinical sample. METHODS We analysed data from patients with breast, lung, colorectal, genitourinary, or gynaecological cancer who had participated in routine screening for depression in cancer clinics in Scotland, UK between May 12, 2008, and Aug 24, 2011. Depression screening was done in two stages (first, Hospital Anxiety and Depression Scale; then, major depression section of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition). Data for depression status were linked with demographic and clinical data obtained from the Scottish National Cancer Registry. FINDINGS We analysed data for 21 151 patients. The prevalence of major depression was highest in patients with lung cancer (13·1%, 95% CI 11·9-14·2%), followed by gynaecological cancer (10·9%, 9·8-12·1), breast cancer (9·3%, 8·7-10·0), colorectal cancer (7·0%, 6·1-8·0), and genitourinary cancer (5·6%, 4·5-6·7). Within these cancer groupings, a diagnosis of major depression was more likely in patients who were younger, had worse social deprivation scores, and, for lung cancer and colorectal cancer, female patients. 1130 (73%) of 1538 patients with depression and complete patient-reported treatment data were not receiving potentially effective treatment. INTERPRETATION Major depression is common in patients attending cancer clinics and most goes untreated. A pressing need exists to improve the management of major depression for patients attending specialist cancer services. FUNDING Cancer Research UK and Chief Scientist Office of the Scottish Government.

Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer

BACKGROUND The management of depression in patients with poor prognosis cancers, such as lung cancer, creates specific challenges. We aimed to assess the efficacy of an integrated treatment programme for major depression in patients with lung cancer compared with usual care. METHODS Symptom Management Research Trials (SMaRT) Oncology-3 is a parallel-group, multicentre, randomised controlled trial. We enrolled patients with lung cancer and major depression from three cancer centres and their associated clinics in Scotland, UK. Participants were randomly assigned in a 1:1 ratio to the depression care for people with lung cancer treatment programme or usual care by a database software algorithm that used stratification (by trial centre) and minimisation (by age, sex, and cancer type) with allocation concealment. Depression care for people with lung cancer is a manualised, multicomponent collaborative care treatment that is systematically delivered by a team of cancer nurses and psychiatrists in collaboration with primary care physicians. Usual care is provided by primary care physicians. The primary outcome was depression severity (on the Symptom Checklist Depression Scale [SCL-20], range 0-4) averaged over the patients time in the trial (up to a maximum of 32 weeks). Trial statisticians and data collection staff were masked to treatment allocation, but patients and clinicians could not be masked to the allocations. Analyses were by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN75905964. FINDINGS 142 participants were recruited between Jan 5, 2009, and Sept 9, 2011; 68 were randomly allocated to depression care for people with lung cancer and 74 to usual care. 43 (30%) of 142 patients had died by 32 weeks, all of which were cancer-related deaths. No intervention-related serious adverse events occurred. 131 (92%) of 142 patients provided outcome data (59 in the depression care for people with lung cancer group and 72 in the usual care group) and were included in the intention-to-treat primary analysis. Average depression severity was significantly lower in patients allocated to depression care for people with lung cancer (mean score on the SCL-20 1·24 [SD 0·64]) than in those allocated to usual care (mean score 1·61 [SD 0·58]); difference -0·38 (95% CI -0·58 to -0·18); standardised mean difference -0·62 (95% CI -0·94 to -0·29). Self-rated depression improvement, anxiety, quality of life, role functioning, perceived quality of care, and proportion of patients achieving a 12-week treatment response were also significantly better in the depression care for people with lung cancer group than in the usual care group. INTERPRETATION Our findings suggest that major depression can be treated effectively in patients with a poor prognosis cancer; integrated depression care for people with lung cancer was substantially more efficacious than was usual care. Larger trials are now needed to estimate the effectiveness and cost-effectiveness of this care programme in this patient population, and further adaptation of the treatment will be necessary to address the unmet needs of patients with major depression and even shorter life expectancy. FUNDING Cancer Research UK and Chief Scientist Office of the Scottish Government.

Behavioral Management of Migraine Headache Triggers: Learning to Cope with Triggers

The literature on migraine triggers is reviewed, including the most common triggers, interactions between triggers, the research evidence related to the capacity of self-reported triggers to precipitate headaches, and the neurobiologic pathways by which triggers induce migraine attacks. An argument is developed against the standard advice to avoid migraine triggers as the best way of preventing attacks, based on conceptual and practical criticisms, and consideration of cognate literatures on chronic pain, stress, and anxiety. A small number of studies suggest that exposure to headache triggers has the same effect as exposure to anxiety-eliciting stimuli, with short exposure associated with increased pain response and prolonged exposure associated with decreased pain response. On the basis of this literature, “learning to cope with triggers” is advocated, where controlled exposure and approach/confront strategies are used to manage migraine triggers, except in cases where such an approach would probably be inappropriate.

Noise as a trigger for headaches : Relationship between exposure and sensitivity

Objective.—This study investigated how triggers acquire the capacity to precipitate headaches.

Screening participation in individuals with a family history of colorectal cancer: a review

Literature regarding screening behaviour in individuals with a family history of colorectal cancer was reviewed, in order to determine the prevalence of screening in this population and identify factors associated with screening participation. Four electronic databases were searched from 1994. Thirty papers met the inclusion criteria, including 3 community surveys, 13 studies on first-degree relatives of colorectal cancer patients, and 14 studies on genetic services for colorectal cancer risk assessment. Individuals with a family history of colorectal cancer, who have not received risk assessment, frequently have never had any form of screening for colorectal cancer. Uptake of endoscopic screening when offered to individuals identified as being at increased risk was generally high (often >60% participation). Having a medical recommendation to screen, a stronger family history and perceiving fewer barriers to screening were identified as predictors of screening behaviour. Existing data suggest that use of screening tests in individuals with a family history of colorectal cancer is variable, and our understanding of factors associated with screening behaviour is limited. A number of methodological problems in research to date were identified, and further research is needed in order to inform interventions to support sustained screening participation in this population.

Managing headache triggers: Think ‘coping’ not ‘avoidance’:

The standard clinical advice for individuals who suffer from recurrent headaches is that the best way to prevent headaches is to avoid the triggers. This editorial challenges that advice from a number of perspectives. First, there is little empirical support for such advice. Second, cognate literatures in the fields of chronic pain, stress and anxiety raise concerns about avoidance as a strategy. Third, studies have demonstrated that short exposure to a headache trigger results in increased sensitivity and prolonged exposure results in decreased sensitivity. Conclusions include that one aetiological pathway to developing a primary headache disorder may be via attempts to avoid triggers resulting in increased sensitivity to triggers. Also, clinicians need to become more flexible in the advice they give pertaining to triggers, namely they should think ‘coping with triggers’ rather than avoiding all triggers, as avoidance will sometimes be the preferred strategy, but often it will not be.

Mindfulness-based cognitive therapy for recurrent depression: A translational research study with 2-year follow-up

Objective: While mindfulness-based cognitive therapy (MBCT) has demonstrated efficacy in reducing depressive relapse/recurrence over 12–18 months, questions remain around effectiveness, longer-term outcomes, and suitability in combination with medication. The aim of this study was to investigate within a pragmatic study design the effectiveness of MBCT on depressive relapse/recurrence over 2 years of follow-up. Method: This was a prospective, multi-site, single-blind trial based in Melbourne and the regional city of Geelong, Australia. Non-depressed adults with a history of three or more episodes of depression were randomised to MBCT + depression relapse active monitoring (DRAM) (n=101) or control (DRAM alone) (n=102). Randomisation was stratified by medication (prescribed antidepressants and/or mood stabilisers: yes/no), site of usual care (primary or specialist), diagnosis (bipolar disorder: yes/no) and sex. Relapse/recurrence of major depression was assessed over 2 years using the Composite International Diagnostic Interview 2.1. Results: The average number of days with major depression was 65 for MBCT participants and 112 for controls, significant with repeated-measures ANOVA (F(1, 164)=4.56, p=0.03). Proportionally fewer MBCT participants relapsed in both year 1 and year 2 compared to controls (odds ratio 0.45, p<0.05). Kaplan-Meier survival analysis for time to first depressive episode was non-significant, although trends favouring the MBCT group were suggested. Subgroup analyses supported the effectiveness of MBCT for people receiving usual care in a specialist setting and for people taking antidepressant/mood stabiliser medication. Conclusions: This work in a pragmatic design with an active control condition supports the effectiveness of MBCT in something closer to implementation in routine practice than has been studied hitherto. As expected in this translational research design, observed effects were less strong than in some previous efficacy studies but appreciable and significant differences in outcome were detected. MBCT is most clearly demonstrated as effective for people receiving specialist care and seems to work well combined with antidepressants.