Major depression is often a relapsing disorder. It is therefore important to start its treatment with therapies that maximize the chance of not only getting the patients well but also keeping them well. We examined the associations between initial treatments and sustained response by conducting a network meta-analysis of randomized controlled trials (RCTs) in which adult patients with major depression were randomized to acute treatment with a psychotherapy (PSY), a protocolized antidepressant pharmacotherapy (PHA), their combination (COM), standard treatment in primary or secondary care (STD), or pill placebo, and were then followed up through a maintenance phase. By design, acute phase treatment could be continued into the maintenance phase, switched to another treatment or followed by discretionary treatment. We included 81 RCTs, with 13,722 participants. Sustained response was defined as responding to the acute treatment and subsequently having no depressive relapse through the maintenance phase (mean duration: 42.2±16.2 weeks, range 24-104 weeks). We extracted the data reported at the time point closest to 12 months. COM resulted in more sustained response than PHA, both when these treatments were continued into the maintenance phase (OR=2.

BackgroundInternet-based cognitive-behavioural therapy (iCBT) is effective for subthreshold depression. However, which skills provided in iCBT packages are more effective than others is unclear. Such knowledge can inform construction of more effective and efficient iCBT programmes.ObjectiveTo examine the efficacy of five components of iCBT for subthreshold depression.MethodsWe conducted an factorial trial using a smartphone app, randomly allocating presence or absence of five iCBT skills including self-monitoring, behavioural activation (BA), cognitive restructuring (CR), assertiveness training (AT) and problem-solving. Participants were university students with subthreshold depression. The primary outcome was the change on the Patient Health Questionnaire-9 (PHQ-9) from baseline to week 8. Secondary outcomes included changes in CBT skills.FindingsWe randomised a total of 1093 participants. In all groups, participants had a significant PHQ-9 reduction from baseline to week 8. Depression reduction was not significantly different between presence or absence of any component, with corresponding standardised mean differences (negative values indicate specific efficacy in favour of the component) ranging between −0.04 (95% CI −0.16 to 0.08) for BA and 0.06 (95% CI −0.06 to 0.18) for AT. Specific CBT skill improvements were noted for CR and AT but not for the others.ConclusionsThere was significant reduction in depression for all participants regardless of the presence and absence of the examined iCBT components.Clinical implicationWe cannot yet make evidence-based recommendations for specific iCBT components. We suggest that future iCBT optimisation research should scrutinise the amount and structure of components to examine.Trial registration numberUMINCTR-000031307.

BackgroundThere are many different skill components used in cognitive behavioural therapy (CBT). However, there is currently no comprehensive way of measuring these skills in patients.ObjectiveTo develop a comprehensive and brief measure of five main CBT skills: self-monitoring, behavioural activation, cognitive restructuring, assertiveness training and problem-solving.MethodsUniversity students (N=847) who participated in a fully factorial randomised controlled trial of smartphone CBT were assessed with the CBT Skills Scale, the Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 (GAD-7) and the short form of the Japanese Big Five Scale. Structural validity was estimated with exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and internal consistency evaluated with Cronbach’s α coefficients. Construct validity was evaluated with the correlations between each factor of the CBT Skills Scale, the PHQ-9, the GAD-7 and the Big Five Scale.FindingsThe EFA supported a five-factor solution based on the original instruments assessing each CBT skill component. The CFA showed sufficient goodness-of-fit indices for the five-factor structure. The Cronbach’s α of each factor was 0.75–0.81. Each CBT skills factor was specifically correlated to the PHQ-9, GAD-7, and the Big Five Scale.ConclusionsThe CBT Skills Scale has a stable structural validity and internal consistency with a five-factor solution and appropriate content validity concerning the relationship with depression, anxiety and personality.Clinical implicationsThe CBT Skills Scale will be potential predictor and effect modifier in studying the optimisation of CBT interventions.Trial registrationCTR-000031307.

The Japanese Big Five Scale Short Form (JBFS-SF), a 29-item self-report scale, has recently been used to measure the Big Five personality traits. However, the scale lacks psychometric validation. This study examined the validity and reliability of the JBFS-SF with data collected from 1,626 Japanese university students participating in a randomized controlled clinical trial. Structural validity was tested with exploratory and confirmatory factor analysis and measurement invariance tests were conducted across sex. Internal consistency was evaluated with McDonald’s omega. Additionally, construct validity was estimated across factors using the PHQ-9, GAD-7, AQ-J-10, and SSQ. EFA results showed that the JBFS-SF can be classified according to the expected five-factor structure, while three items had small loadings. Therefore, we dropped these three items and tested the reliability and validity of the 26-item version. CFA results found that a 26-item JBFS-FS has adequate structural validity (GFI = 0.907, AGFI = 0.886, CFI = 0.907, and RMSEA = 0.057). The omega of each factor was 0.74–0.85. Each JBFS-SF factor was specifically correlated with the PHQ-9, GAD-7, and SSQ. This research has shown that the JBFS-SF can be a clinically useful measure for assessing personality characteristics.

Background:The efficacy of brief intervention (BI) for unhealthy drug use in outpatient medical care has not been sufficiently substantiated through meta-analysis despite its ongoing global delivery. This study aims to determine the efficacy of BI for unhealthy drug use, the expected length of effects, and describe subgroup analyses by outpatient setting.Methods: Trials comparing BI with usual care controls were retrieved through four databases up to January 13, 2021. Two reviewers independently screened, selected, and extracted data. Primary outcomes included drug use frequency (days used) and severity on validated scales at 4-8 months and were analyzed using random-effects model meta-analysis. Results:In total, 20 studies with 9182 randomized patients were included. There was insufficient evidence to support the efficacy of BI for unhealthy drug use among all outpatient medical care settings for use frequency (SMD = -0.07, 95% CI = -0.17, 0.02, p = 0.12, I 2 = 37%, high certainty of evidence) and severity (SMD = -0.27, 95% CI = -0.78, 0.24, p = 0.30, I 2 = 98%, low certainty of evidence). However, post hoc subgroup analyses uncovered significant effects for use frequency by setting (interaction p = 0.02), with significant small effects only in emergency departments (SMD = -0.15, 95% CI = -0.25, -0.04, p < 0.01). Primary care, student health, women's health, and HIV primary care subgroups were nonsignificant. Primary care BI revealed nonsignificant greater average use in the treatment group compared to usual care.Discussion: BI for unhealthy drug use lacks evidence of efficacy among all outpatient medical settings. However, small effects found in emergency departments may indicate incremental benefits for some patients. Clinical decisions for SBI or specialty treatment program referrals should be carefully considered accounting for these small effects in emergency departments.