Meta-analysis of psychosocial interventions for people with dementia and anxiety or depression

Abstract

Objectives: Assess the effectiveness of psychosocial interventions for depression and anxiety in people with dementia (PWD) or mild cognitive impairment (MCI).

Method: OvidMedline, PsychInfo and Embase were searched for studies on the 5^th August 2017. The efficacy of the studies was estimated using meta-analyses.

Results: Eight RCTs were included. No RCTs were identified for people with MCI. Four RCTs found that psychosocial interventions (multicomponent intervention, Tai Chi, problem adaptation therapy and exercise/walking) were effective at reducing symptoms of depression in PWD who were depressed. One study (Tai Chi) found that these reductions were no longer evident at six-month follow-up. Another study, not included in the meta-analyses, found that pleasant events behaviour therapy and problem solving behaviour therapy improved depression symptoms and this effect remained significant at follow-up. Three RCTs found that psychosocial interventions (music therapy and cognitive behavioural therapy (CBT)) reduced symptoms of anxiety in PWD who were anxious. Evidence from two of these RCTs (music therapy and CBT) showed that these improvements were evident at three to six-month follow-up.

Conclusion: The identified psychosocial interventions are effective at reducing symptoms of depression or anxiety in PWD experiencing these symptoms. This review is limited by the quality of studies, small sample sizes and the heterogeneity of the interventions, therefore high quality studies with larger sample sizes are required to test the efficacy of specific interventions such as CBT.     

Identifying depression and anxiety in a 40-year epidemiological investigation: the Stirling County study

As a longitudinal investigation, the ‘Stirling County study’ involves a 40-year period beginning with the drawing of a sample in 1952 for a survey of psychiatric disorders. In 1970 a new sample was drawn and subjects from 1952 were followed, and in 1992 another new sample was drawn and all 1952 and 1970 subjects were followed. During these years, knowledge about psychiatric disorders has increased in the population at large; changes in everyday language about them have occurred and criteria for identifying them have been improved. This report describes adaptations of methods designed to overcome some of the problems inherent in such changes. A revised computerized algorithm named DPAX-2 (DP for depression and AX for anxiety) is described. The first version, DPAX-1, deals with a core set of questions that have been asked in identical fashion throughout the study. Early investigations of validity indicated that DPAX-1 appeared to be an adequate method for the period from 1952 through 1970. The revised version was constructed after data gathering for the 1990s phase of research documented that vocabulary changes had taken place. DPAX-2 addresses these changes by having more questions about states of sadness and apprehension. It also takes into account improvements introduced as ‘supplements’ that come after the core questions in the interview schedule. These improvements were available in the data collected for 1970 but have not thus far been utilized in reports about longitudinal findings because of their absence from the 1952 data. Evidence is presented that DPAX-1 and DPAX-2 were well correlated in 1970 and became considerably less so by 1992. This result, in conjunction with increased diagnostic sophistication in the responses of subjects to open-ended questions in the 1990s, suggests that the common parlance, especially about depression, began to change after 1970. It was also mainly after 1970 when antidepressant medications began to be widely used, a fact that may have influenced awareness about depression and the language for describing it. For comparison, depression and anxiety modules of the more recently developed Diagnostic Interview Schedule (DIS) were also part of the interview protocol in the 1990s. To explore validity, the Structured Clinical Interview for DSM-IIIR (SCID) was administered to a subsample. Agreement with the SCID results was better for DPAX-2 than for DPAX-1. Agreement with SCID was somewhat higher for the DIS, but DPAX-2 and the DIS showed almost equivalent sensitivity. In conclusion, the most satisfactory approach to studying the effects of ‘time's arrow’ in the Stirling County study will be to use DPAX-1 for the period 1952 to 1970 and DPAX-2 for the period 1970 to 1992. The level of articulation between the two versions will therefore be discernible at the middle phase of the study. Copyright © 1998 Whurr Publishers Ltd.     

Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators

Background  There is robust epidemiological and clinical evidence that a greater number of women than men experience depression and anxiety. This study investigated a number of socio-demographic, health and lifestyle, psychological and social factors as possible mediators for the gender difference in depression and anxiety in three cohorts (20–24, 40–44, 60–64). Methods  Responses were from a representative, community based survey (n = 7,485) conducted in Canberra and Queanbeyan (NSW), in Australia. Depression and anxiety were measured using the self-report Goldberg Anxiety and Depression Scales. The analyses initially identified gender differences in the potential mediators, followed by univariate and multivariate mediation models. Results  The results indicated several shared mediators for depression and anxiety across the three age groups including: childhood adversity, mastery, behavioural inhibition, ruminative style, neuroticism, physical health, physical activity, and perceived interpersonal and employment problems. There was a decrease in the number of social mediators as age increased. The multivariate models accounted for gender differences in both conditions for all age groups, except for anxiety in the 20–24 years old. This suggests further important unmeasured mediators for this age group. Conclusions  These findings add to the literature surrounding gender differences in depression and anxiety, and provide a basis for future research exploring variation in these gender disparities over the adult lifespan.     

The 7-year course of depression and anxiety in the general population

Rhebergen D, Batelaan NM, de Graaf R, Nolen WA, Spijker J, Beekman ATF, Penninx BWJH. The 7‐year course of depression and anxiety in the general population. Objective: Insight into the long‐term course of depression and anxiety. Method: Data were derived from Netherlands Mental Health Survey and Incidence Study/Netherlands Study of Depression and Anxiety, epidemiologic surveys in the adult population in the Netherlands. Three hundred and three respondents with depressive and/or anxiety Composite International Diagnostic Interview (CIDI) disorder were interviewed, examining the 7‐year course of depression (n = 141), anxiety (n = 102) and the comorbid state (n = 60) and possible prognostic factors. Outcomes were CIDI diagnostic status after 7 years and percentage of time during 7 years with depressive and/or anxiety symptoms, retrospectively assessed by the Life Chart Interview (LCI). Results: After 7 years, 60.7% of the subjects were free from a 12‐month CIDI depression or anxiety diagnosis. The odds were higher for subjects with anxiety and comorbidity compared to subjects with depression. Low physical functioning and high neuroticism predicted the presence of a diagnosis after 7 years. During 7‐year follow‐up, 37.3% of the subjects were free from depressive and anxiety symptoms according to the LCI, 51.8% had symptoms <50% of the time, and 10.9%≥50% of the time. (Comorbid) anxiety resulted in a poorer course. High neuroticism and childhood adversity predicted more follow‐up time with symptoms. Conclusion: Course trajectories were more favorable than expected, although comorbidity resulted in poorer course. Neuroticism, physical functioning, and childhood adversity predicted an unfavorable course.     

The association of psychosocial factors and depression with hypertension among older adults

OBJECTIVE: To examine the relationship between depression and hypertension in an elderly population and how psychosocial variables influence this relationship. METHODS: The study included 293 subjects, who met DSM-IV criteria for unipolar depression, and 151 subjects with no psychiatric disorder. All subjects were over the age of 58. Participants were administered the Duke Depression Evaluation Schedule at baseline and at yearly intervals for 3 years. RESULTS: Cross-sectional analyses of baseline data showed that hypertensive patients were more likely to be depressed and of non-white race. Bivariate analyses provided evidence that hypertension was associated with higher amounts of total stressors and lower social support. No differences in the prevalence of hypertension were found between men and women. In addition, there was no evidence of change in hypertension status over time. CONCLUSION: Patients, especially minorities, who experience depression, stress, or a lack of social support, are at an increased likelihood of having hypertension and clinicians should consider this risk when treating this population.     

The role of autonomy-connectedness in depression and anxiety

The relationship between autonomy-connectedness, and depression and anxiety was investigated in 94 primary mental health care patients and 95 psychology students. All participants completed the Autonomy-Connectedness Scale-30 (ACS-30), the Beck Depression Inventory (BDI), and the Symptom Checklist-90 (SCL-90). Results indicated that the primary mental health care group compared with the control group scored lower in Self-Awareness and Capacity for Managing New Situations, and higher in Sensitivity to Others. Women compared with men had higher levels of self-reported Sensitivity to Others. Regression analyses showed that both (low) Self-Awareness and (high) Sensitivity to Others predicted depression, as well as anxiety; also, (low) educational level had predictive value. These results indicate that low autonomy-connectedness might be a risk factor for depression and anxiety.     

No association of depression and anxiety with the metabolic syndrome: the Norwegian HUNT study

Objective: To examine the associations of depression and anxiety with the metabolic syndrome. Method: Cross‐sectional study of 9571 participants aged 20–89 years in the Nord‐Trøndelag Health Study (HUNT 2). We assessed anxiety and depression with the Hospital Anxiety and Depression Scale and the metabolic syndrome with the International Diabetes Federation criteria. Results: Despite generous statistical power and use of both continuous and categorical approaches, we found no association between anxiety or depression and the metabolic syndrome in models adjusted for age, gender, educational level, smoking, physical activity and pulse rate. When adjusted for age and gender only, we found a weak positive association for depression when a continuous measure was used, but not at the case level. The findings were similar across sexes, and robust for exclusion of cardiovascular disease and antidepressants. Conclusion: In this largest study to date we found no association of anxiety and depression with the metabolic syndrome.     

The role of inflammation and the gut microbiome in depression and anxiety

The study of the gut microbiome has increasingly revealed an important role in modulating brain function and mental health. In this review, we underscore specific pathways and mechanisms by which the gut microbiome can promote the development of mental disorders such as depression and anxiety. First, we review the involvement of the stress response and immune system activation in the development of depression and anxiety. Then, we examine germ-free murine models used to uncover the role of the gut microbiome in developing and modulating pertinent activity in the brain and the immune system. We also document multiple pathways by which stress-induced inflammation harms brain function and ultimately affects mental health, and review how probiotic and prebiotic treatments have shown to be beneficial. Lastly, we provide an overview of gut microbiome-derived compounds (short-chain fatty acids, tryptophan catabolites, microbial pattern recognition) and related mechanisms (vagal nerve activity and fecal microbiota transplants) involved in mediating the influence of the gut microbiome to mental health. Overall, a picture of the gut microbiome playing a facilitating role between stress response, inflammation, and depression, and anxiety is emerging. Future research is needed to firmly establish the microbiome's causal role, to further elucidate the mechanisms by which gut microbes influence brain function and mental health, and to possibly develop treatments that improve mental health through microbiotic targets.     

The role of atypical antipsychotics in bipolar depression and anxiety disorders

Abstract:  Bipolar disorder is a complex condition that includes symptoms of mania, depression, and often anxiety. Diagnosing and treating bipolar depression is challenging, with the disorder often being diagnosed as unipolar depression. In addition, comorbid anxiety can be a significant detractor to successful outcomes, increasing symptom severity, frequency of episodes and suicide rates, and decreasing response to antidepressant therapy. Anxiety often precedes and hastens the onset of bipolar disorder, and a shared genetic etiology has been suggested. Studies have demonstrated the efficacy of atypical antipsychotics for the acute and maintenance treatment of mania. Evidence from studies in patients with treatment-resistant major depressive disorder and bipolar depression indicate that these agents may also have antidepressant effects. In open trials in patients with bipolar mania, risperidone therapy has led to significant reductions in depression scores compared with baseline. Reductions in depression scores in patients with bipolar mania have been significantly greater with olanzapine compared with placebo. In patients with bipolar depression, the combination of olanzapine and fluoxetine resulted in significant improvement in depression compared with olanzapine alone or placebo. Although little data are available on the effects of these agents on comorbid anxiety in patients with bipolar disorder, some atypical antipsychotics have demonstrated efficacy in patients with anxiety disorders, including obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder. Thus, atypical antipsychotics represent an important therapeutic option for the treatment of bipolar disorder, providing improvements in manic, depressive, and anxiety symptoms.     

Recurrence of depression during pregnancy: psychosocial and personal functioning correlates

Background: This study examined psychosocial and personal functioning during pregnancy in women at risk for depression recurrence based on having had at least one major depressive episode (MDE) preceding the pregnancy. Methods: Three groups of women, who differed in recurrence of depression during pregnancy, were compared: (1) women who had at least one recurrent episode meeting diagnostic criteria for a MDE (n=23), (2) women who had a recurrence of clinically significant levels of depressive symptoms but did not meet criteria for a MDE (n=18), and (3) women who had no recurrence of depression (n=38) during pregnancy. Results: Results indicated that recurrences of depression during pregnancy are associated with a range of psychosocial and personal functioning correlates. Furthermore, the correlates of depression during pregnancy were the same for women who met diagnostic criteria for MDE and women who had subthreshold levels of depression. Conclusions: The findings support extending psychosocial models of depression to depression recurrence during pregnancy with an emphasis on the broader context within which depression occurs. The findings also have implications for understanding subclinical depression during pregnancy as being associated with problems in functioning equal in severity and breadth to episodes of major depression. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

The association between depression, anxiety, and cognitive function in the elderly general population--the Hordaland Health Study

OBJECTIVES: To examine the association between depression and/or anxiety and cognitive function in the elderly general population. SUBJECTS: Non-demented participants from the general population (n = 1,930) aged 72-74 years. METHODS: Symptoms and caseness of depression and anxiety disorder were assessed using the Hospital Anxiety and Depression Scale (HADS). Cognitive function was assessed by the Digit Symbol Test (modified version), the Kendrick Object Learning Test, and the 'S'-task from the Controlled Oral Word Association Test. RESULTS: There was a significant association between depression and reduced cognitive function. The inverse association between anxiety and reduced cognitive performance was explained by adjustment for co-morbid depression. The inverse association between depressive symptoms and cognitive function was found to be close to linear, and was also present in the sub-clinical symptom range. Males were more affected cognitively by depressive symptoms than females. CONCLUSION: The inverse association between depression and cognitive function is not only a finding restricted to severely ill patient samples, but it can also be found in the elderly general population.     

The association between age and depression in the general population: a multivariate examination

Objective: In a large general population study we found a close to linear rise with age in the mean score and prevalence of self‐reported symptoms of depression. The aim of this study was to examine if this linear relation prevailed when controlled for multiple variables and to examine factors that eventually explained the association. Method: Among individuals aged 20–89 years living in Nord‐Trøndelag County of Norway, 60 869 filled in valid ratings of the Hospital Anxiety and Depression Scale as well as many other variables. Covariates were grouped into a multivariate model with six blocks. Logistic regression was used to model the blocks and variables with caseness of depression as the dependent variable. Results: The model explains a considerable part of the age‐related pattern on depression. The pattern became less distinct in the age groups above 50 years. Variables within the blocks of somatic diagnoses and symptoms, as well as impairment, had most explanatory power. Conclusion: Because of our large sample we were able to control for more relevant variables than earlier studies. In contrast to most other studies, we found that an age‐related increase of the prevalence of depression persisted after control for multiple variables.     

Work stress and depression among direct support professionals: the role of work support and locus of control

Background Although work stress can impede the capacity of direct support professionals and contribute to mental health challenges, external (i.e. work social support) and internal resources (i.e. an internal locus of control) have been shown to help DSPs cope more actively. We examined how work stress was associated with depression, with a particular focus on the role of resources. Method Direct support professionals (n = 323) who serve adults with intellectual and developmental disabilities from five community‐based organisations completed a cross‐sectional, self‐administered survey which measured work stress, work support, locus of control, and depression. Results Multiple regression analyses demonstrated that work stress was positively associated with depression, while resources were negatively associated with depression. In particular, work support moderated the effects of client disability stress, supervisory support lessened the effects of role conflict, and locus of control moderated the effects of workload. Conclusions Such findings suggest the importance of external and internal resources for staff mental health. This research underscores the need for strong work social support systems and interventions to help staff manage work stressors.     

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

Objectives: Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke.

Method: The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up.

Results: One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was ?1.32 (95% confidence interval: ?2.61, ?0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19).

Conclusion: A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.     

A 4-year follow-up study of syndromal and sub-syndromal anxiety and depression symptoms in the general population

Background Our aims were to examine the stability of self-rated anxiety and depression symptoms and the predictors for change in case-level status after 4 years in a general population sample. Methods Prospective cohort study. Based on the total score on the Hospital Anxiety and Depression rating scale (HADS-T) in HUNT 2 (1995–1997), three groups were identified: Level 3 (n = 654, score ≥ 25 points), Level 2 (n = 654, score 19–24 points), and Level 1 (n = 1,308, score < 19 points). The groups were followed up with a mailed questionnaire after 4 years. Results Among the 1,326 (53% response rate) who participated in the follow-up, 816 (62%) had not changed symptom level. The number of participants that had crossed the HADS-T caseness level (19 points) was the same in both directions. In non-cases at baseline (Level 1), lack of friends (OR 2.34, 95% CI 1.28–4.27, P = 0.006) and previous episodes of depression (OR 2.90, 95% CI 1.76–4.78, P < 0.001) predicted HADS-T caseness at follow-up, while higher educational level (OR 0.66, 95% CI 0.46–0.96, P = 0.028) protected from developing caseness level of anxiety and depression. In HADS-T cases (Levels 2 and 3) at baseline, previous episode(s) of depression (OR 0.36, 95% CI 0.19–0.68, P = 0.002) and being unemployed (OR 0.58, 95% CI 0.34–1.00, P = 0.050) predicted HADS-T caseness at follow-up, whereas a higher educational level (OR 1.83, 95% CI 1.24–2.70, P = 0.002) was associated with remission from HADS-T caseness after 4 years. Conclusions Though symptom fluctuation was considerable, conventional HADS-T caseness (≥19 points) was a reliable and valid predictor for high long-term symptom stability of anxiety and depression in our general population sample.