Web-Based Cognitive Behavior Therapy for Depression in People With Diabetes Mellitus: A Randomized Controlled Trial.

BACKGROUND: Depression is twice as common in diabetes mellitus (DM) as the general population and is associated with adverse health outcomes, but access to evidence-based therapies such as cognitive behavioral therapy (CBT) is limited in routine diabetes care. Past research has shown that generic Internet-based cognitive behavioral therapy (iCBT) is an effective treatment for depression in the general population, but it has never been evaluated in people with comorbid depression and DM. OBJECTIVE: The aim of our study was to examine the efficacy of a generic 6-lesson iCBT delivered over 10 weeks in people with major depressive disorder (MDD) and DM. METHODS: Participants with comorbid MDD and DM (type 1 or 2) were recruited online and randomized to an iCBT program with therapist support provided by phone and email (n=42) or a treatment as usual (TAU, n=49) control group. Outcomes were assessed through Web-based self-report questionnaires and the trial was Web-based with no face-to-face components. Primary outcomes were self-reported depression (patient health questionnaire-9, PHQ-9), diabetes-related distress (problem areas in diabetes, PAID), and self-reported glycemic control (hemoglobin A1c, HbA1c). Secondary outcomes were general distress (Kessler 10-item psychological distress scale, K-10) and disability (short form 12-item, SF-12), generalized anxiety (generalized anxiety disorder 7-item, GAD-7), and somatization (PHQ-15). The iCBT group was assessed at 3 months. RESULTS: A total of 27 participants (66%; 27/41) completed the iCBT program. Analyses indicated between-group superiority of iCBT over TAU at posttreatment on PHQ-9 (g=0.78), PAID (g=0.80), K-10 (g=1.06), GAD-7 (g=0.72), and SF-12 mental well-being scores (g=0.66), but no significant differences in self-reported HbA1c levels (g=0.14), SF-12 physical well-being, or PHQ-15 scores (g=0.03-0.21). Gains were maintained at 3-month follow-up in the iCBT group, and the 87% (27/31) of iCBT participants who were interviewed no longer met criteria for MDD. Clinically significant change following iCBT on PHQ-9 scores was 51% (21/41) versus 18% (9/49) in TAU. CONCLUSIONS: iCBT for depression is an efficacious, accessible treatment option for people with diabetes. Future studies should explore whether tailoring of iCBT programs improves acceptability and adherence, and evaluate the long-term outcomes following iCBT. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN): 12613001198718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365208&isReview=true (Archived by WebCite at http://www.webcitation.org/6qCR8Fi9V).

Prevalence, comorbidities, and correlates of challenging behavior among community-dwelling adults with severe traumatic brain injury: a multicenter study.

OBJECTIVE: Investigate the prevalence, comorbidities, and correlates of challenging behaviors among clients of the New South Wales Brain Injury Rehabilitation Program. SETTING: All community-based rehabilitation services of the statewide program. PARTICIPANTS: Five hundred seven active clients with severe traumatic brain injury. DESIGN: Prospective multicenter study. MAIN MEASURES: Eighty-eight clinicians from the 11 services rated clients on the Overt Behaviour Scale, Disability Rating Scale, Sydney Psychosocial Reintegration Scale-2, Care and Needs Scale, and Health of the Nation Outcome Scale-Acquired Brain Injury. RESULTS: Overall prevalence rate of challenging behaviors was 54%. Inappropriate social behavior (33.3%), aggression (31.9%), and adynamia (23.1%) were the 3 most common individual behaviors, with 35.5% of the sample displaying more than 1 challenging behavior. Significant associations were found between increasing levels of challenging behavior and longer duration of posttraumatic amnesia, increasing functional disability, greater restrictions in participation, increased support needs, and greater degrees of psychiatric disturbance, respectively (P < 0.004). Multivariate binomial logistic regression found that premorbid alcohol abuse, postinjury restrictions in participation, and higher levels of postinjury psychiatric disturbance were independent predictors of challenging behavior. CONCLUSIONS: Challenging behaviors are widespread among community-dwelling adults with severe traumatic brain injury. Services need to deliver integrated anger management, social skills, and motivational treatments.

Association between serotonin transporter promoter polymorphisms and psychological distress in a diabetic population.

Investigations into serotonin transporter and anxiety and depression have shown an association between stress, depression onset and genotype. We investigated the relationship between 5-HTTLPR genotype and depression and anxiety in a population with diabetes mellitus, a condition associated with high rates of stress and depression. Participants were classified according to 'S' and 'L' alleles as well as the modification of the single nucleotide polymorphism (SNP) rs25531. The 5-HTTLPR low-expression genotype group (S or L(G) allele carriers) had significantly higher psychological distress (K10) scores (N=234, P=0.047). Subsequent analysis revealed that the effect of genotype was related to anxiety symptoms rather than depression symptoms. Furthermore, the main effect of genotype was not observed when the modification of the SNP polymorphism was not taken into account. Findings suggest that 5-HTTLPR/rs25531 genotype is associated with psychological distress in a sample of subjects with diabetes.

The ins and outs of an online bipolar education program: a study of program attrition.

BACKGROUND: The science of eHealth interventions is rapidly evolving. However, despite positive outcomes, evaluations of eHealth applications have thus far failed to explain the high attrition rates that are associated with some eHealth programs. Patient adherence remains an issue, and the science of attrition is still in its infancy. To our knowledge, there has been no in-depth qualitative study aimed at identifying the reasons for nonadherence to-and attrition from- online interventions. OBJECTIVE: This paper explores the predictors of attrition and participant-reported reasons for nonadherence to an online psycho-education program for people newly diagnosed with a bipolar disorder. METHODS: As part of an ongoing randomized controlled trial (RCT) evaluating an online psycho-education program for people newly diagnosed with a bipolar disorder, we undertook an in-depth qualitative study to identify participants' reasons for nonadherence to, and attrition from, the online intervention as well as a quantitative study investigating predictors of attrition. Within the RCT, 370 participants were randomly allocated to 1 of 2 active interventions or an attention control condition. Descriptive analyses and chi-square tests were used to explore the completion rates of 358 participants, and standard regression analysis was used to identify predictors of attrition. The data from interviews with a subsample of 39 participants who did not complete the online program were analyzed using "thematic analysis" to identify patterns in reported reasons for attrition. RESULTS: Overall, 26.5% of the sample did not complete their assigned intervention. Standard multiple regression analysis revealed that young age (P= .004), male gender (P= .001), and clinical recruitment setting (P= .001) were significant predictors of attrition (F(7,330)= 8.08, P< .001). Thematic analysis of interview data from the noncompleter subsample revealed that difficulties associated with the acute phases of bipolar disorder, not wanting to think about one's illness, and program factors such as the information being too general and not personally tailored were the major reasons for nonadherence. CONCLUSIONS: The dropout rate was equivalent to other Internet interventions and to face-to-face therapy. Findings from our qualitative study provide participant-reported reasons for discontinuing the online intervention, which, in conjunction with the quantitative investigations about predictors, add to understanding about Internet interventions. However, further research is needed to determine whether there are systematic differences between those who complete and those who do not complete eHealth interventions. Ultimately, this may lead to the identification of population subgroups that most benefit from eHealth interventions and to informing the development of strategies to improve adherence. TRIAL REGISTRATION: ACTRN12608000411347; http://www.anzctr.org.au/ACTRN12608000411347.aspx (Archived by WebCite at http://www.webcitation.org/5uX4uYwVN).