Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

<b>Objective</b>: Antidepressant drugs and cognitive&ndash;behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness &ndash; Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.<br /><br /><b>Method</b>: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.<br /><br /><b>Results</b>: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.<br /><br /><b>Conclusions</b>: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.<br />

Prevalence of psychological distress, anxiety and depression in rural communities in Australia

<b>Objective</b>: To describe the prevalence of psychological distress, depression and anxiety in three Australian rural settings and to identify the levels of risk by gender and age.<br /><br /><b>Design and setting</b>: Three cross-sectional surveys in the Greater Green Triangle area covering the south-east of South Australia (Limestone Coast), and south-west (Corangamite Shire) and north-west (Wimmera) of Victoria.<br /><br /><b>Participants</b>: A total of 1563 people, aged 25&ndash;74 years, randomly selected from the electoral roll.<br /><br /><b>Main outcome measures</b>: Psychological distress assessed by the Kessler 10, and anxiety and depression assessed by the Hospital Anxiety and Depression Scale.<br /><br /><b>Results</b>: The prevalence of psychological distress was 31% for both men and women with two-thirds reporting moderate and one-third high levels of psychological distress. The prevalence of depression and anxiety was approximately 10%. The highest rate of psychological distress, anxiety and depression occurred in the 45&ndash;54 years age group. There were no consistent gender or area differences in the prevalence of psychological distress, depression or anxiety.<br /><br /><b>Conclusions</b>: A third of the rural population reported psychological distress, with the highest prevalence observed in middle-aged men and women. Thus, health professionals should attend not only to physical health, but also to mental health status in this age group. It is also important to target prevention strategies at the 20% who reported moderate levels of psychological distress in order to prevent the development of more serious conditions. <br />

Identifying depression in patients following admission for acute coronary syndrome

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Treatment of depression in low-level residential care facilities for the elderly

<b>Background: </b>The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels).<br /><br /><b>Method:</b> The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression.<br /><br /><b>Results:</b> An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed.<br /><br /><b>Conclusion:</b> There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.<br />

The prevalence and recognition of major depression among low-level aged care residents with and without cognitive impairment

Previous research has demonstrated a high level of depression in nursing homes. The current study was designed to determine the prevalence of depression, using a structured diagnostic interview, among older people with and without mild-moderate cognitive impairment residing in low-level care facilities. The results demonstrated that, consistent with previous research in nursing homes, 16.9% of older people were diagnosed with major depressive disorder. Less than half of these cases had been detected or treated. Individuals with moderate cognitive impairment were more likely to be depressed, but cognitive impairment did not appear to act as a strong impediment to the detection of depression by general practitioners. A low awareness of their use of antidepressant medications was demonstrated among older people prescribed this treatment, including those with normal cognitive function. Reasons for the poor recognition of depression among older people are discussed.

Health behaviors among individuals with schizophrenia and depression

This article presents findings from a study that evaluated the utility of Protection Motivation Theory to explain cardiovascular health behaviors among people with schizophrenia (n = 83) and depression (n = 70). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were greater among people with a mental illness compared to individuals without a mental illness. Major predictors were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, limited social support and psychiatric symptoms. Implications of these results are discussed in designing education and preventive health programs for individuals with schizophrenia and Mental Depressive Disorder (MDD).

Early detection of depression and associated risk factors in adults with mild/moderate intellectual disability

The aim of this study was to determine the presentation and risk factors for depression in adults with mild/moderate intellectual disability (ID). A sample of 151 adults (83 males and 68 females) participated in a semi-structured interview. According to results on the Beck Depression Inventory II, 39.1% of participants evinced symptoms of depression (2 severe, 14 moderate, and 43 mild). Sadness, self-criticism, loss of energy, crying, and tiredness appeared to be the most frequent indicators of depression or risk for depression. A significant difference was found between individuals with and without symptoms of depression on levels of automatic negative thoughts, downward social comparison and self-esteem. Automatic negative thoughts, quality and frequency of social support, self-esteem, and disruptive life events significantly predicted depression scores in people with mild/moderate ID, accounting for 58.1% of the variance.<br /><br />

Omega 3 fatty acids and the brain : review of studies in depression

The brain is a lipid-rich organ containing mostly complex polar&nbsp; phospholipids, sphingolipids, gangliosides and cholesterol. These lipids are involved in the structure and function of cell membranes in the brain. The glycerophospholipids in the brain contain a high proportion of&nbsp; polyunsaturated fatty acids (PUFA) derived from the essential fatty acids, linoleic acid and alpha-linolenic acid. The main PUFA in the brain are docosahexaenoic acid (DHA, all <i>cis</i> 4,7,10,13,16,19-22:6) derived from the omega 3 fatty acid, alpha-linolenic acid, and arachidonic acid (AA, all <i>cis</i> 5,8,11,14-20:4) and docosatetraenoic acid (all <i>cis</i> 7,10,13,16-22:4), both derived from the omega 6 fatty acid, linoleic acid. Experimental studies in animals have shown that diets lacking omega 3 PUFA lead to substantial disturbances in neural function, which in most circumstances can be restored by the inclusion of omega 3 PUFA in the diet. In the past 10 years there has been an emerging interest in treating neuropsychological&nbsp; disorders (depression and schizophrenia) with omega 3 PUFA. This paper discusses the clinical studies conducted in the area of depression and omega 3 PUFA and the possible mechanisms of action of these PUFA. It is clear from the literature that DHA is involved in a variety of processes in neural cells and that its role is far more complex than simply influencing cell membrane properties.<br />

Depression, anxiety and stress in women following acute coronary syndrome: implications for secondary prevention

<b>Objective</b><br />To document incidence of depression, anxiety, and stress in women more than 6 months following an acute coronary syndrome.<br /><br /><b>Design</b><br />Participants were identified from a coronary care unit database. The Depression Anxiety Stress Scales 21 (DASS 21) was sent to potential participants via postal survey.<br /><br /><b>Setting</b><br />A metropolitan teaching hospital in Melbourne, Australia.<br /><br /><b>Participants</b><br />The cohort of women was aged between 55 and 70 years. They had been admitted to hospital with a diagnosis of acute coronary syndrome (ACS) between 6 and 14 months prior to participating in this study.<br /><br /><b>Main outcome measures</b><br />Scores on Depression, Anxiety, and Stress Scale (DASS 21).<br /><br /><b>Results</b><br />Of the 117 posted questionnaires, 39 women with a mean age of 63 (S.D. 4.97) responded to the survey, representing a response rate of 33.3%. Most participants scored within normal levels of depression (66.7%), anxiety (60.5%), and stress (70.3%), however, mild to extremely severe levels of each construct (33.4%, 39.6%, and 29.7%, respectively) were found.<br /><br /><b>Conclusions</b><br />The reporting of elevated levels of depression, anxiety and stress in a subset of women more than 6 months following an ACS event underscores the importance of ongoing screening for risk factors impacting on psychological well-being and the inclusion of this information in education and counseling strategies in both the inpatient and outpatient settings. Based on these pilot data, consideration of a screening system in the immediate post discharge period for women at risk and an education or support service are recommended.<br />

Does interpersonal psychotherapy improve clinical care for adolescents with depression attending a rural child and adolescent mental health service? Study protocol for a cluster randomised feasibility trial

<b>Background</b>: Depression amongst adolescents is a costly societal problem. Little research documents the effectiveness of public mental health services in mapping this problem. Further, it is not clear whether usual care in such services can be improved via clinician training in a relevant evidence based intervention. One such intervention, found to be effective and easily learned amongst novice clinicians, is Interpersonal Psychotherapy (IPT). The study described in the current paper has two main objectives. First, it aims to investigate the impact on clinical care of implementing Interpersonal Psychotherapy for Adolescents for the treatment of adolescent depression within a rural mental health service compared with Treatment as Usual (TAU). The second objective is to record the process and challenges (i.e. feasibility, acceptability, sustainability) associated with implementing and evaluating an evidence-based intervention within a community service. This paper outlines the study rationale and design for this community based research trial.<br /><br /><b>Methods/design</b>: The study involves a cluster randomisation trial to be conducted within a Child and Adolescent Mental Health Service in rural Australia. All clinicians in the service will be invited to participate.&nbsp; Participating clinicians will be randomised via block design at each of four sites to (a) training and delivery of IPT, or (b) TAU. The primary measure of impact on care will be a clinically significant change in depressive&nbsp; symptomatology, with secondary outcomes involving treatment satisfaction and changes in other symptomatology. Participating adolescents with significant depressive symptomatology, aged 12 to 18 years, will complete assessment measures at Weeks 0, 12 and 24 of treatment. They will also complete a depression inventory once a month during that period. This study aims to recruit 60 adolescent participants and their parent/guardian/s. A power analysis is not indicated as an intra-class correlation coefficient will be calculated and used to inform sample size calculations for subsequent large-scale trials. Qualitative data regarding process implementation will be collected quarterly from focus groups with participating clinicians over 18 months, plus phone interviews with participating adolescents and parent/guardians at 12 weeks and 24 weeks of treatment. The focus group qualitative data will be analysed using a Fourth Generation Evaluation methodology that includes a constant comparative cyclic analysis method.<br /><b><br />Discussion</b>: This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting cluster randomised trials within community practice such as mental health services.<br />