The relationship between mood instability and depression: Implications for studying and treating depression

Background

Most individuals with depressed mood report mood fluctuations (Mood Instability) within hours or days. This is not recognized in diagnostic criteria or standard rating scales for depression.

Hypothesis

That mood instability is a distinct component of the development of depression that has been omitted from criteria for depression because of reliance on retrospective recall and structured interviews. The inclusion of Mood Instability would enhance research into causes and treatment of depression.

Studies

We examined three datasets that used retrospective and prospective measures of depressed symptom ratings and mood instability to determine the relationship between the two. Study 1 used data from the 1991 UK Health and Lifestyle Surveys (HALS). Studies 2 and 3 used clinical samples. The scales used to assess mood instability were the mood instability factor from the Eysenck Personality Inventory Neuroticism Scale, the Affective Lability Scale (ALS), and the Visual Analogue Depression Scale (VAS). The depression scales (depressive symptoms) were the General Health Questionnaire (GHQ) depression factor, the Beck Depression Inventory IA (BDI) and the mean from the Visual Analogue Depression Scale (VAS). We used partial correlation analysis to assess the association between mood instability and depression and exploratory factor analysis to determine the factor structure of items pooled from the mood instability and depression scales from studies 1 and 2.

Results

Mood Instability was found to be moderately associated with depressive symptoms. The Pearson’s r-values ranged from 0.49 to 0.57. The correlation was lower when recalling mood in the past. The factor analytic solution supported the hypothesis that MI and depressive symptoms are related but distinct constructs.

Conclusions

Reliance exclusively on the retrospective assessment of depressive symptoms has occluded the widespread occurrence of mood instability. Including Mood Instability in diagnostic and assessment criteria would enhance causal and treatment research in depression.     

Probing for depression and finding diabetes: a mixed-methods analysis of depression interviews with adults treated for type 2 diabetes

Background

Depression has increased prevalence and consistently predicts poor health outcomes among patients with diabetes. The impact of stressors related to diabetes and its treatment on depression assessment is infrequently considered.

Methods

We used mixed methods to evaluate depressive symptoms in adults with type 2 diabetes. We categorized responses related to diabetes and its treatment during interviews (n=70) using the Montgomery–Åsberg Depression Rating Scale (MADRS) and administered questionnaires to measure diabetes-related distress and depressive symptoms.

Results

Participants (M age=56, SD=7; 67% female; 64% Black; 21% Latino) had mild depression on average (MADRS M=10, SD=9). Half of those with symptoms spontaneously mentioned diabetes context; 61% said diabetes contributed to their symptoms when questioned directly. Qualitative themes included: overlapping symptoms of diabetes and depression; burden of diabetes treatment; emotional impact of diabetes; and the bidirectional influence of depression and diabetes. Diabetes was mentioned more often at higher levels of depression severity (r=.38, p=.001). Higher HbA1c was associated with mentioning diabetes as a context for depressive symptoms (r=.32, p=.007). Insulin-users mentioned diabetes more often than those on oral medications only (p=.005).

Limitations

MADRS is not a traditional qualitative interview so themes may not provide an exhaustive view of the role of diabetes context in depression assessment.

Conclusions and clinical implications

The burden of type 2 diabetes and its treatment often provide an explanatory context for depressive symptoms assessed by structured clinical interviews, the gold standard of depression assessment. Diabetes context may influence accuracy of assessment and should inform intervention planning for those needing treatment.     

Cross-cultural validation of the Patient–Practitioner Orientation Scale (PPOS)

Objectives

Translate, adapt and validate the Patient–Practitioner Orientation Scale (PPOS) for use in Brazil.

Methods

The PPOS was translated to Portuguese using a modified Delphi technique. The final version was applied to 360 participants. Reliability (test–retest and internal consistency) and construct validity (explanatory and confirmatory factor analysis) were assessed.

Results

Only two items did not reach pre-established criteria agreement in Delphi technique. In pre-testing, seven items were modified. Internal consistency (Cronbach's alpha = 0.605) and test–retest reliability (intraclass correlation coefficient = 0.670) were adequate. In explanatory factor analysis, one item did not achieve a loading factor, one item was considered factorially complex and two items were inconsistent with a priori factors. Confirmatory factor analysis provided an acceptable adjustment for the observed variables (χ²/df = 2.33; GFI = 0.91; AGFI = 0.89; CFI = 0.84; NFI = 0.75; NNFI = 0.81; RMSEA = 0.062 (p = 0.016) and SRMR = 0.065).

Conclusions

The Brazilian version PPOS (B-PPOS) showed acceptable validity and adequate reliability.

Practice implications

The use of the B-PPOS in national and cross-cultural studies may contribute to the evaluation and monitoring of the attitudes of doctors, medical students and patients toward their professional relationships in research and practice.     

Validating the Medical Data Interpretation Test in a Dutch population

Objective

To validate the Dutch translation of the Medical Data Interpretation Test.

Methods

A test–retest design with a 2-week interval was used.

Results

The intraclass correlation coefficient (ICC = .82), the limits-of-agreement interval (LOA = −8.96 to 2.48) and the test–retest reliability (Pearson's r = 86) suggest that the Dutch translation has good reproducibility. Construct validity was tested by two hypotheses, both of which were confirmed. University participants had higher test scores than non-university participants (p = .02), and males did not score differently than females (p = .61).

Conclusion

The results suggest that the Dutch version of the Medical Data Interpretation Test is an adequate scale to assess ability to interpret medical data.

Practice implications

Assessing patients’ numeracy skills before a counseling session will enable the counselor to adjust subsequent communication accordingly and, as such, improve the session's effectiveness.     

A randomized double-blind comparison of fluoxetine augmentation by high and low dosage folic acid in patients with depressive episodes

Background

Though encouraging evidence exists for the use of folic acid as an augmenting agent to antidepressants, evidence regarding its optimal dosage is lacking.

Methods

Forty-two female out-patients with moderate (with or without somatic syndrome) or severe depressive episodes (without psychotic symptoms) diagnosed as per ICD-10 criteria, were randomized in a double-blind fashion to receive either 20 mg fluoxetine and a relatively low dose folic acid (1.5 mg/day; n=23; Group I) or 20 mg fluoxetine and high dose folic acid (5 mg/day; n=19; Group II). Primary outcome measures were weekly changes of scores on Hamilton Depression Rating Scale (HDRS) and Beck Depression Inventory (BDI) for 6 weeks.

Results

Group II patients showed greater improvement in both HDRS [Mean (SD) baseline HDRS score=21 (2.3) for group I and 20.0 (1.4) for group-II; time X group interaction effect: p=0.01] and BDI [Mean (SD) baseline BDI score=25.1 (5.2) for group-1 and 23.1 (2.7) for group-II; time X group interaction effect: p=0.01]. With regard to HDRS, 7 (36.8%) group II patients remitted compared to 2 (8.7%) group I patients (p=0.03); 9 (47.4%) patients of group II responded when compared to 6 (26.1%) from group I (p=0.15). When BDI was considered, 5 (26.3%) group II patients remitted when compared to 2 (8.7%) from group I (p=0.13); 10 patients (52.6%) from group II responded when compared to 5 (21.7%) from group I (p=0.04). No adverse effects were noted in either group.

Limitations

Lack of a placebo arm and small sample size.

Conclusion

Compared to folic acid 1.5 mg/day, augmentation with 5 mg/day may be more beneficial in female patients with depressive episodes taking fluoxetine 20 mg/day.     

Association between metabolic syndrome and depressive symptom profiles—Sex-specific?

Background

The association between depression and metabolic syndrome is becoming more obvious. Waist circumference (WC) might be the most important metabolic syndrome (MetS) feature in relation to late-life depression, with a possible mediating role for adiponectin.

Methods

Cross-sectional population based survey of 1277 participants (50–70 years). We measured all components of MetS, plasma adiponectin levels and depressive symptoms using Beck Depression Inventory (BDI). Principal components analysis on the BDI items revealed two factors, representing a cognitive-affective and a somatic-affective symptom-cluster. Multiple linear regression models with the BDI sum score and both depression symptom-clusters as dependent variables, respectively, were used to examine the association with each component of metabolic syndrome adjusted for confounders. We explored sex-differences as well as a hypothesised mediating effect of adiponectin.

Results

The presence of MetS as well as number of metabolic risk factors were significantly associated with BDI sum score. In men WC, triglycerides and HDL cholesterol explained variance in depressive symptoms, whereas in women this effect was confined to WC. Moreover, irrespective of sex, all associations were primarily driven by the somatic-affective symptom-cluster. Adiponectin neither mediated nor moderated any of the associations found.

Limitations

Cross-sectional design limits causal interpretation. Being a population-based survey, some selection bias might have occurred toward healthier part of population.

Conclusions

Although pathophysiological mechanisms underlying the association between metabolic disturbances and depression remains to be elucidated, our study points to sex-differences as well as a specific phenotype of depression that is associated with metabolic disturbances.     

Depression in medical students: Cluster symptoms and management

Background

Rates of depression among medical students have been shown to be high and related to year of study and other factors. We report on cluster of symptoms related to depression and their association with other difficulties in specific domains.

Methods

481 (Response rate=79.8%) medical students completed a questionnaire about areas of difficulty in the medical school (studies, leisure, colleagues, professors, and patients), and Beck Depression Inventory (BDI). We studied correlation among areas of difficulty and clusters of BDI along with year in the course.

Results

Two areas which contributed most difficulty were studies and leisure. The significant associations for studies were seen between somatic cluster of depressive symptoms and the level of the course. Difficulties associated with leisure activities and with colleagues were correlated with the affective cluster of symptoms of depression. Activities related to clinical matters especially working with patients in the internship year were associated with somatic clusters. The different associations confirmed that rather than relying on scores emphasis should be placed on clusters of symptoms.

Limitations

Sample from a single medical school.

Conclusions

Although the clusters are associated with specific difficulties, it is important that educators and health professionals are aware of streesors the medical students face. The correlations if confirmed in future studies with qualitative factors could guide the development of more specific therapeutic or curriculum interventions.     

Cross-cultural adaptation and validation of the health literacy assessment tool METER in the Portuguese adult population

Objective

We aimed to culturally adapt and validate METER in the Portuguese population, and to define cut-off values for adequate health literacy.

Methods

We used the standard procedure for the adaptation of the words and surveyed health professionals to select the non-words. The instrument was administered to a total sample of 249 participants and retested in a sub-sample of 45 after three months. Cut-offs were defined using the modified Angoff procedure. Construct validity was assessed through association with educational attainment and health-related occupation.

Results

Exploratory factor analysis revealed two dimensions of the instrument, one for words and another for non-words. METER showed a high degree of internal consistency, and acceptable test–retest reliability. Adequate health literacy was defined as scoring at least 35/40 in words and 18/30 in non-words. Physicians scored higher than any other group, followed by health researchers, researchers from other areas and by people with progressively lower levels of education (p < 0.001).

Conclusion

We culturally adapted a brief and simple instrument for health literacy assessment, and showed it was valid and reliable.

Practice implications

The Portuguese version of METER can be used to assess health literacy in Portuguese adults and to explore associations with health outcomes.     

rTMS for pharmacoresistant major depression in the clinical setting of a psychiatric hospital: Effectiveness and effects of age

Background

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive method of brain stimulation used in the treatment of drug-resistant major depressive disorder (MDD). It has been suggested that the efficacy of rTMS decreases with the age of the patient, but the data are contradictory. Here, we analyze in our clinical setting the efficacy of a 3-week rTMS treatment in drug-resistant MDD during a 3 month period and the potential influence of age on this efficacy.

Methods

Stimulation consisted of 15 sessions of rTMS over the dorsolateral prefrontal cortex. Clinical evaluations included the Hamilton Depression Rating Scale (HDRS), and the Beck Depression Inventory (BDI) at baseline, after 3 weeks of treatment, and 1 month and 3 months after the last session.

Results

Data from 93 patients issued from the 178 patients active file were analyzed. The antidepressant effect observed in the two age groups (<65 and ≥65) did not differ at the end of the treatment and 3 months later, with a comparable number of responders (50% decrease in HDRS score from baseline) (53.3% for age <65 versus 46.7% for age ≥65, p=0.51). The treatment had a significant effect over time. We found no evidence of the age affecting outcome at 3 months after the last session.

Limitations

Previous antidepressant treatments, and therapeutic drug use modifications after rTMS treatment, degree of pharmaco-resistance or duration of current episode are not reported.

Conclusion

RTMS of the DFPLC is effective as an add-on treatment for cases of pharmacologically refractory major depression, independent of the patient age.     

Treatment adherence in bipolar I and schizoaffective disorder,bipolar type

Background

Poor adherence rates in Bipolar Disorder type I (BDI) and Schizoaffective Disorder, bipolar type (SAD) may be high This study was aimed at comparing the clinical correlates of adherence to treatment and the course of illness in BDI and SAD patients.

Methods

75 SAD and 150 BDI DSM-IV outpatients were included. Adherence was assessed on the basis of patients’ and care-givers’ reports and serum levels, when available. Socio-demographic, clinical and treatment variables were collected and compared between diagnostic subsamples and then between goodly and poorly adherent patients. Multiple logistic regressions were performed, controlling for diagnostic subsample differences, to identify correlates of adherence in BDI and SAD groups.

Results

Poor adherence was highly prevalent both in BDI (32%) and in SAD patients (44%), with no significant differences between diagnostic categories. Presence of psychotic symptoms (p=0.029), higher number of manic relapses (p<0.001), comorbidity with personality disorders (p=0.002), and lithium therapy (p=0.003) were associated with poor adherence to treatment. Diagnostic subgroup analyses showed different predictive models, with the BDI poorly adherent subsample being more likely to include comorbid personality and manic recurrences and the SAD poorly adherent subsample being less clinically predictable.

Limitations

The cross-sectional nature of the study limits de capacity to ascertain the direction of the relationship between certain variables.

Conclusions

Rates of poor adherence to oral treatments are similar in SAD and BDI. BDI patients with comorbid personality and substance use disorders are likely to be poorly adherent. Treatment adherence may be more difficult to predict in SAD patients.     

Measuring depressive symptoms using the Patient Health Questionnaire-9 in Hong Kong Chinese subjects with type 2 diabetes

Background

Depression is common in type 2 diabetes although the prevalence in Chinese patients remains unclear. We validated the Patient Health Questionnaire(PHQ-9), a popular depression screening tool, in Chinese with type 2 diabetes, and documented the prevalence, demographic,and clinical characteristics associated with depression.

Methods

A consecutive cohort of 586 Hong Kong Chinese outpatients completed the PHQ-9 during comprehensive diabetes complication assessment. Within 2–4 weeks, 40 patients were retested via telephone survey. Ninety-nine randomly selected patients were interviewed by psychiatrists using the Mini International Neuropsychiatric Interview as a golden standard. Receiver operating characteristic curve was used to assess performance of the PHQ-9.

Results

The internal consistency of the PHQ-9 was 0.86 and test–retest reliability was 0.70. The 3 somatic items explained 53.6% of the PHQ-9 score. The optimal cutoff value was 7 with 82.6% sensitivity and 73.7% specificity, giving a depression prevalence of 18.3% (n=107). Of these, 18.7% had been previously diagnosed with depression. Depression was more prevalent in women than men. After controlling for confounders, patients with depression had higher HbA1c (7.80±1.86% versus 7.43±1.29%, [61.7±20.4 versus 57.8±14.1 mmol/mol], P<0.05), reduced likelihood of achieving HbA1c target of <7.0% (33.6% versus 41.8%, P<0.05), and were more likely to have self-reported hypoglycemia in the previous 3 months (18.7% versus 6.7%, P<0.01).

Limitation

A small sample was used in the criterion validation and the cross-sectional design precludes causal inference.

Conclusions

PHQ-9 is a validated tool for screening for depression, which is common and frequently undiagnosed in Chinese type 2 diabetic patients and is associated with suboptimal glycemic control, hypoglycemia, and somatization.     

Venlafaxine alters microvascular perfusion, [I]-beta-CIT binding and BDI scores in flushing postmenopausal women

Background

Although 70% of postmenopausal women suffer from hot flashes the pathophysiology is poorly understood. The serotonin and noradrenaline reuptake inhibitor (SNRI) venlafaxine provides relief of flushing although the mechanism is unknown and could involve a central effect and/or a peripheral effect. Using single photon emission computed tomography (SPECT) we studied the central serotonin transporter (SERT) in vivo using [¹²³I]-beta-carbomethoxy-3-β-(4-iodophenyl)tropane (beta-CIT) and, as previous studies have shown that reactivity of the skin blood vessels is enhanced in those who flush, we examined cutaneous microvascular perfusion.

Methods

Cutaneous microvascular perfusion was assessed in 31 postmenopausal women, with flushing, using laser Doppler imaging with iontophoresis (LDI + ION), before and after 8 weeks of treatment with venlafaxine. A sub-group of 14 of these women also had SPECT imaging at both time points to evaluate the availability of SERT in the brain. Flush frequency and score was recorded, and Beck Depression Inventory (BDI) II scores were assessed before and after treatment.

Results

Following treatment with venlafaxine, there was a significant reduction in the [¹²³I]-beta-CIT binding ratio, BDI scores, flushing and endothelial dependent perfusion response. [¹²³I]-Beta-CIT reduction was associated with BDI reduction (r² = 0.54; F = 8.8; p = 0.004), but not flushing reduction or perfusion reduction.

Conclusions

Venlafaxine resulted in a decrease in BDI II scores with an associated reduction in [¹²³I]-beta-CIT binding in a group of non-depressed women. It also improved flush frequency and severity which may be as a result of decreases seen in enhanced cutaneous microvascular perfusion.     

Further validation of the 5-item Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) scale in patients with osteoarthritis

Objective

To examine the structural validity, internal consistency, test–retest reliability, and construct validity of the 5-item Perceived Efficacy in Patient–Physician Interactions (PEPPI-5) scale in patients with osteoarthritis (OA).

Methods

A cross-sectional sample of 224 outpatients with OA completed a survey containing the Dutch PEPPI-5 and other standardized measures assessing perceived health-management skills, general self-efficacy, social support, and health-related quality of life. A subsample of 100 patients completed the PEPPI-5 again approximately 3 weeks later.

Results

Confirmatory factor analysis demonstrated good fit for a unidimensional model of the PEPPI-5. Additionally, the scale showed high internal consistency (α = 0.92) and fair test–retest reliability (ICC = 0.68). As hypothesized, the PEPPI-5 was strongly correlated with perceived health-management skills, moderately with social support and psychosocial aspects of health, and not with physical aspects of health. Contrary to expectations, however, it was not correlated with general self-efficacy.

Conclusion

The Dutch PEPPI-5 demonstrated adequate validity and reliability in patients with OA.

Practice implications

The PEPPI-5 is a brief and appropriate tool for measuring self-efficacy of patients with OA to interact with their physicians. Additional research into its sensitivity to change is needed before it can be confidently recommended as an outcome measure in intervention studies.     

Relationship between the clinical global impression of severity for schizoaffective disorder scale and established mood scales for mania and depression

Background

This analysis explored the relationship between ratings on HAM-D-17 or YMRS and those on the depressive or manic subscale of CGI-S for schizoaffective disorder (CGI-S-SCA).

Methods

This post hoc analysis used the database (N=614) from two 6-week, randomized, placebo-controlled studies of paliperidone ER versus placebo in symptomatic subjects with schizoaffective disorder assessed using HAM-D-17, YMRS, and CGI-S-SCA scales. Parametric and nonparametric regression models explored the relationships between ratings on YMRS and HAM-D-17 and on depressive and manic domains of the CGI-S-SCA from baseline to the 6-week end point. A clinically meaningful improvement was defined as a change of 1 point in the CGI-S-SCA score. No adjustment was made for multiplicity.

Results

Multiple linear regression models suggested that a 1-point change in the depressive domain of CGI-S-SCA corresponded to an average 3.6-point (SE=0.2) change in HAM-D-17 score. Similarly, a 1-point change in the manic domain of CGI-S-SCA corresponded to an average 5.8-point (SE=0.2) change in YMRS score. Results were confirmed using local and cumulative logistic regression models in addition to equipercentile linking.

Limitations

Lack of subjects scoring over the complete range of possible scores may limit broad application of the analyses.

Conclusion

Clinically meaningful score changes in depressive and manic domains of CGI-S-SCA corresponded to approximately 4- and 6-point score changes on HAM-D-17 and YMRS, respectively, in symptomatic subjects with schizoaffective disorder.     

Trajectories of individual symptoms in remitters versus non-remitters with depression

Background

It remains unclear regarding the contribution of each individual symptom in predicting the outcome in major depressive disorder (MDD). The objective of this analysis was to evaluate trajectories of individual symptoms over time to identify which specific depressive item(s) could predict subsequent clinical response.

Methods

The data of 2874 outpatients with nonpsychotic MDD who received citalopram for up to 14 weeks in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial were analyzed. Average trajectories of individual symptoms over time were estimated for remitters and non-remitters. Moreover, specific symptoms whose improvement at week 2 predicted remission were identified, using binary logistic regression analysis.

Results

Trajectories were significantly different between remitters and non-remitters in all depressive symptoms. All depressive symptoms in the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR₁₆) in the two groups, except for hypersomnia and weight change in non-remitters, substantially improved within 2 weeks and gradually continued to improve thereafter throughout the 14 weeks. Early improvements in the following five symptoms, in order of magnitude, in the QIDS-SR₁₆ were significantly associated with remission: sad mood, negative self-view, feeling slowed down, low energy, and restlessness (P<0.001, P<0.001, P=0.001, P=0.004, P=0.021).

Limitations

The participants were limited to the nonpsychotic MDD outpatients who received citalopram. Further, symptomatology was not evaluated at the very beginning of treatment.

Conclusions

While the data pertain to citalopram and replication is necessary for other antidepressants, early improvements in certain core depressive symptoms may serve as a predictor of subsequent remission.     

The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder,and nondepressed controls

Background

Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression.

Methods

Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder.

Results

Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment.

Limitations

Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based.

Conclusions

Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.     

Poor Sleep Quality is Associated with Depressive Symptoms in Patients with Heart Disease

Background

Depression in cardiac patients has gained importance due to increased mortality. Although sleep disturbances are a core symptom of depression, the prevalence and patterns of sleep disturbances in heart disease have hardly been examined regarding depression.

Purpose

This cross-sectional study aims to examine sleep disturbances and depressive symptoms in consecutively admitted cardiac patients and depressed patients.

Methods

Two hundred four inpatients (113 male, 91 female) were examined: 94 cardiac inpatients (mean age 49.3?±?14.3?years) with different heart diseases and 110 psychiatric inpatients (mean age 41.6?±?13.0?years) with depressive disorders (DP). A depressive episode according to International Classification of Diseases (ICD)-10 was also diagnosed in 14 of the cardiac patients (DCP). The Pittsburgh Sleep Quality Index (PSQI) and the Beck Depression Inventory (BDI) were used to assess subjective sleep quality and severity of depressive symptoms.

Results

Poor sleep quality (PSQI?>?5) was reported in all comorbid DCP (PSQI 12.00?±?3.53, BDI 17.86?±?4.28), in 60% of the 80 non-DCP (PSQI 5.59?±?3.73, BDI 4.47?±?3.07), and in 86.4% of the DP (PSQI 11.76?±?4.77, BDI 27.11?±?10.54). The cardiac inpatients showed a significant correlation between increased depressive symptoms and the PSQI components subjective sleep quality (r?=?0.40) and daytime dysfunction (r?=?0.34). Both sleep components were significant predictors of self-rated depression (R2?=?0.404).

Conclusions

Most cardiac patients experience poor sleep quality. Self-reported sleep disturbances in heart disease could serve as predictors of clinical or subclinical comorbid depression outside of a psychiatric setting in cardiology and other fields, and such patients should be referred to consultation-liaison psychiatry or polysomnography where sleep disorders like sleep apnea are suspected.     

A pilot randomized controlled trial of a depression and disease management program delivered by phone

Background

Depression in medically ill patients occurs at twice the rate found in the general population. Though pharmacologic and psychotherapeutic interventions for depression are effective, response to treatment and access to care are barriers for this population. A multidimensional telehealth intervention was designed to focus on these barriers by delivering a phone based intervention that addressed managing one's illness and coping emotionally.

Methods

Veterans with diabetes, hypertension, or chronic pain and depressive symptoms were randomized to one of three conditions: Usual Care (n=23), Illness Management Only (n=31), or Combined Psychotherapy and Illness Management (n=29). Those randomized to the Combined or Illness Management Only intervention group received 10 phone visits. Veterans in the Combined group received all aspects of the illness management program plus a manualized depression intervention. Subjects completed assessments at baseline, week 5, and 10 to test the main hypothesis that veterans in the Combined condition would have a greater decline in depressive symptoms.

Results

The Combined intervention yielded a significant decline in depressive symptoms when compared with Usual Care. However, the there was no significant difference between the Combined and Illness Management Only groups.

Limitations

This is a pilot study with a small sample size relative to a standard randomized controlled trial in psychotherapy.

Conclusions

This telephone-based intervention succeeded in reducing depressive symptoms in veterans with chronic illness. It adds to the building evidence base for providing phone-delivered mental health services.     

Improving communication in general practice when mental health issues appear: Piloting a set of six evidence-based skills

Objective

To test a communication skills training program teaching general practitioners (GPs) a set of six evidence-based mental health related skills.

Methods

A training program was developed and tested in a pilot test–retest study with 21 GPs. Consultations were videotaped and actors used as patients. A coding scheme was created to assess the effect of training on GP behavior. Relevant utterances were categorized as examples of each of the six specified skills. The GPs’ self-perceived learning needs and self-efficacy were measured with questionnaires.

Results

The mean number of GP utterances related to the six skills increased from 13.3 (SD 6.2) utterances before to 23.6 (SD 7.2) utterances after training; an increase of 77.4% (P < 0.001). Effect sizes varied from 0.23 to 1.37. Skills exploring emotions, cognitions and resources, and the skill Promote coping, increased significantly. Self-perceived learning needs and self-efficacy did not change significantly.

Conclusion

The results from this pilot test are encouraging. GPs enhanced their use on four out of six mental health related communication skills significantly, and the effects were medium to large.

Practice implications

This training approach appears to be an efficacious approach to mental health related communication skills training in general practice.