Wider, faster, more: Re-envisioning the treatment and research of depression to address its public health burden in the United States

Depression and other internalizing disorder symptoms are leading causes of disability in theUnited States. Although there are effective interventions, the burden of disability attributableto internalizing disorder symptoms is not decreasing. I review clinical and epidemiological datato identify solutions to the public health burden of internalizing disorder symptoms. Contemporary research efforts have a focus on treatment development and the identification of biomarkers of response. However, these solutions are not scalable because internalizing disorders are much more common than usually appreciated and there are substantial disparities in access to mental health care. Improving the dissemination of individual interventions may also be of limited value given data suggesting that high rates of symptom remission can only be achieved with multiple (e.g., 4-10) treatment steps. The logic of stepped care approaches for internalizing disorders is well-supported by these data, but initial treatments likely should be low-intensity and “stepping up” should occur more quickly than usually done in most trials. Efforts that promise to make an impact in the public health burden of internalizing disorder symptoms need to consider their high prevalence and heterogeneity in the level of care as well as in the mechanisms that treatments may need to engage.

Sharper Minds 2021 Pilot Report

Sharper Minds is a stepped care package designed by the researchers in collaboration with students and UQ Health Care providers to increase awareness and use of mental health prevention strategies among first year university students. The package was 'soft launched' in 2021, and this report presents findings from the pilot evaluation. The pilot adopted a non-randomised controlled design with 266 students (33% international students). Of these, 157 were in the INTERVENTION condition (students who participated in any aspect of the Sharper Minds package: app tracker or one of the short courses) and 109 were in the CONTROL condition (students who completed pre and post surveys only). Results showed a significantly greater benefit to students in the Intervention v Control on pre to post changes in % screening positive for mental health problems, and scores on measures of depression, wellbeing, and loneliness. Students in both conditions improved across semester on measures of anxiety, somatic symptoms, number of academic stressors and number of COVID-19 related stressors. The pilot also provided practical training for 15 Masters in Psychology students and 2 Masters in Dietetics students; and research thesis projects for 1 Masters in Clinical Psychology student; 21 Psychology Honours students; and 5 Exercise Physiology Honours students.

Identifying Primary Care Models of Dementia Care that Improve Quality of Life for People Living with Dementia and their Care Partners: An Environmental Scan

Dementia is a growing concern in Canada, affecting peoples’ health and raising the cost of care. Between June and October 2019, we conducted an environmental scan to identify primary care models, strategies, and resources for dementia care from 11 pre-selected countries and assess their impact on quality-of-life measures. Search strategies included a rapid scoping review, grey literature search, and discussions with stakeholders. Eighteen primary care-based models of dementia care were identified. Common factors include team-based care, centralized care/case coordination, individual treatment plans, a stepped-care approach, and support for care partners. Five provinces had released a dementia strategy. Evidence of positive outcomes supported primary care-based models for dementia care, although only one model demonstrated evidence of impact on quality of life. Although these findings are encouraging, further research is needed to identify primary care-based models of dementia care that demonstrably improve quality of life for people living with dementia and their care partners.

Barriers and Facilitators to Implementing a Stepped Care Cognitive-behavioral Therapy for Insomnia in Cancer Patients: a Qualitative Study.

Purpose: Insomnia affects 30-60% of cancer patients and tends to become chronic when left untreated. While cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment, this intervention is not readily accessible. This qualitative study investigated current practices in the assessment and management of insomnia in five hospitals offering cancer care and identified the barriers and facilitators to the implementation of a stepped care CBT-I (i.e., web-based CBT-I followed, if needed, by 1-3 booster sessions) in these settings. Methods: Nine focus groups composed of a total of 43 clinicians (e.g., physicians, nurses, technologists, psychologists), six administrators, and 10 cancer patients were held. The Consolidated Framework for Implementing Research (CFIR) was used to develop the semi-structured interview and analyze the data. Results: Sleep difficulties are not systematically discussed in clinical practice and when a treatment is offered, most often, it is a pharmacological one. Barriers and facilitators to the implementation of a stepped care CBT-I included individual characteristics (e.g., lack of knowledge about CBT-I); intervention characteristics (e.g., increased accessibility offered by a web-based format); inner setting characteristics (e.g., resistance to change); and process factors (e.g., motivation to offer a new service). Conclusions: This qualitative study confirms the need to better address insomnia in routine cancer care and suggests that, while some barriers were mentioned, the implementation of a stepped care CBT-I is feasible. Keys to a successful implementation include accessibility, training, inclusion of stakeholders in the process, and ensuring that they are supported throughout the implementation.

Evaluation of a Stepped Care Approach to Manage Depression and Diabetes Distress in Patients with Type 1 Diabetes and Type 2 Diabetes: Results of a Randomized Controlled Trial (ECCE HOMO Study)

<b><i>Introduction:</i></b> Depression is a common and serious complication of diabetes. Treatment approaches addressing the specific demands of affected patients are scarce. <b><i>Objective:</i></b> The aim of this work was to test whether a stepped care approach for patients with diabetes and depression and/or diabetes distress yields greater depression reduction than treatment-as-usual. <b><i>Methods:</i></b> Two-hundred and sixty patients with diabetes and elevated depressive symptoms (CES-D ≥16) and/or elevated diabetes distress (PAID ≥40) were randomized to stepped care for depression or diabetes treatment-as-usual. The primary outcome was the rate of meaningful depression reduction at the 12-month follow-up according to the HAMD (score &#x3c;9 or reduction by ≥50%). Secondary outcomes were changes in depression scores (HAMD/CES-D), diabetes distress (PAID), diabetes acceptance (AADQ), well-being (WHO-5), quality of life (EQ-5D/SF-36), self-care behavior (SDSCA/DSMQ), HbA_1c, and biomarkers of inflammation. <b><i>Results:</i></b> One-hundred and thirty-one individuals were assigned to stepped care and 129 to treatment-as-usual. Overall, 15.4% were lost to follow-up. Meaningful depression reduction was observed in 80.2 versus 51.2% in stepped care versus treatment-as-usual (<i>p</i> &#x3c; 0.001, intention-to-treat analysis). Of the secondary measures, the HAMD (∆ –3.2, <i>p</i> &#x3c; 0.001), WHO-5 (∆ 1.5, <i>p</i> = 0.007), and AADQ (∆ –1.0, <i>p</i> = 0.008) displayed significant treatment effects, while effects on CES-D (∆ –2.3, <i>p</i> = 0.065), PAID (∆ –3.5, <i>p</i> = 0.109), and SDSCA (∆ 0.20, <i>p</i> = 0.081) were not significantly different. Both groups showed comparable changes in EQ-5D/SF-36, DSMQ, HbA_1c, and biomarkers of inflammation (all <i>p</i> ≥ 0.19). <b><i>Conclusions:</i></b> The stepped care approach improved depression, well-being, and acceptance. The results support that increasing treatment intensity on demand is effective and can help provide more optimal treatment. The inclusion of diabetes-specific interventions may be beneficial for patients with diabetes and elevated depression.

Psychoeducational Group Intervention for Adults with Autism Spectrum Disorder and Their Close Relations (Prisma) – An Open Feasibility Study

Background: Autism spectrum disorder (ASD) in adulthood is associated with severe impairments in functioning and poor health, while ASD is also affecting close relations. Accessible first-line interventions addressing the complex clinical needs and care coordination are lacking. Methods: This study investigated the feasibility and preliminary effects of a new psychoeducational group intervention (Prisma) developed for intellectually able adults with ASD and their close relations in an outpatient setting. Results: Completion rate was 77% (n=71) of the 92 adults with ASD and 73% (n=69) of the 94 close relations. Participants considered Prisma to be an acceptable intervention and their feedback will be used to further improve the Prisma for an upcoming RCT. Preliminary analyses of effects showed promising results with an increase in knowledge of ASD. Conclusions: Overall, results indicate that the Prisma is a feasible first-line intervention in a stepped-care process in outpatient services. Trial registration: Clinicaltrials.org (NCT04460976).