Digital interventions to promote psychological resilience: a systematic review and meta-analysis.

Societies are exposed to major challenges at an increasing pace. This underscores the need for preventive measures such as resilience promotion that should be available in time and without access barriers. Our systematic review summarizes evidence on digital resilience interventions, which have the potential to meet these demands. We searched five databases for randomized-controlled trials in non-clinical adult populations. Primary outcomes were mental distress, positive mental health, and resilience factors. Multilevel meta-analyses were performed to compare intervention and control groups at post-intervention and follow-up assessments. We identified 101 studies comprising 20,010 participants. Meta-analyses showed small favorable effects on mental distress, SMD = -0.24, 95% CI [-0.31, -0.18], positive mental health, SMD = 0.27, 95% CI [0.13, 0.40], and resilience factors, SMD = 0.31, 95% CI [0.21, 0.41]. Among middle-aged samples, older age was associated with more beneficial effects at follow-up, and effects were smaller for active control groups. Effects were comparable to those of face-to-face interventions and underline the potential of digital resilience interventions to prepare for future challenges.

Family health partners in regional network structures (NEST): A non-randomized controlled trial among parents of chronically ill and disabled children.

BACKGROUND: The overarching project goal is to evaluate the effectiveness of a cross-sectoral and cross-service provider offering professional support for families with chronically ill and disabled children: so-called Family Health Partners (in German: 'Familien-Gesundheits-Partner' or FGP). This needs-oriented service, which is anchored in regional networks, aims to provide 'holistic' support for families with children in need of care. METHODS: We are carrying out a non-randomized controlled trial with four points of measurement (t0-t3 in 18 months), beginning in January 2022. Both intervention and control group include 102 families. Primary outcome measure is the quality of life, secondary outcomes are resilience factors and associated measures as well as the access to care. Multilevel regression models will be used to analyze the longitudinal data. DISCUSSION: The strength of this study is that it looks at the health and resilience of all family members involved by examining how a FGP can influence the entire family system with regard to increasing quality of life, resilience and self-efficacy. The network structures of FGP also open up better to previously unknown regional supply offers. There are, however, a number of limitations (e.g. type of outcomes, sample size). TRIAL REGISTRATION: This study was first registered on the German Clinical Trials Register before enrolment of participants started (ID: DRKS00027465, 4 January 2022). In order to promote its dissemination, it was also retrospectively registered on ClinicalTrials.gov (ID: NCT05418205, 14 June 2022).

Effects of general and corona-specific stressors on mental burden during the SARS-CoV-2 pandemic in Germany.

The SARS-CoV-2 pandemic turned out to be a serious threat to mental and physical health. However, the relative contribution of corona-specific (DHs) and general stressors (DHg) on mental burden, and specific protective and risk factors for mental health are still not well understood. In a representative sample (N = 3,055) of the German adult population, mental health, potential risk, and protective factors as well as DHs and DHg exposure were assessed online during the SARS-CoV-2 pandemic (June and July 2020). The impact of these factors on mental health was analyzed using descriptive statistics, data visualizations, multiple regressions, and moderation analyses. The most burdensome DHg were financial and sleeping problems, respectively, and DHs corona-media reports and exclusion from recreational activities/important social events. 31 and 24% of total mental health was explained by DHg and DHs, respectively. Both predictors combined explained 36%, resulting in an increase in variance due to DHs of only 5% (R2 adjusted). Being female, older and a lower educational level were identified as general risk factors, somatic diseases as a corona-specific risk factor, and self-efficacy and locus of control (LOC) proved to be corona-specific protective factors. Further analyses showed that older age and being diagnosed with a somatic illness attenuated the positive influence of LOC, self-efficacy, and social support on resilience. Although the data showed that after the first easing restrictions, the stressor load was comparable to pre-pandemic data (with DHs not making a significant contribution), different risk and protective factors could be identified for general and corona-specific stressors. In line with observations from network analysis from other groups, the positive impact of resilience factors was especially diminished in the most vulnerable groups (elderly and somatically ill). This highlights the need to especially target these vulnerable groups to foster their resilience in upcoming waves of the corona pandemic.

Mental health and psychosocial support strategies in highly contagious emerging disease outbreaks of substantial public concern: A systematic scoping review.

BACKGROUND: Acute disease outbreaks such as the COVID-19 pandemic cause a high burden of psychological distress in people worldwide. Interventions to enable people to better cope with such distress should be based on the best available evidence. We therefore performed a scoping review to systematically identify and summarize the available literature of interventions that target the distress of people in the face of highly contagious disease outbreaks. METHODS: MEDLINE, Cochrane CENTRAL, Web of Science (January 2000 to May 7, 2020), and reference lists were systematically searched and screened by two independent reviewers. Quantitative and qualitative studies investigating the effects of psychological interventions before, during, and after outbreaks of highly contagious emerging infectious diseases, such as SARS, MERS, Ebola, or COVID-19 were included. Study effects were grouped (e.g. for healthcare professionals, community members, people at risk) and intervention contents at the individual and organizational level summarized. We assessed the level of evidence using a modified scheme from the Oxford Centre for Evidence-based Medicine and the Australian National Health and Medical Research Council. RESULTS: Of 4030 records found, 19 studies were included (two RCTs). Most interventions were delivered during-exposure and face-to-face, focused on healthcare workers and crisis personnel, and combined psychoeducation with training of coping strategies. Based on two high-quality studies, beneficial effects were reported for resilience factors (e.g. positive cognitive appraisal) and professional attitudes of healthcare workers, with mixed findings for mental health (e.g. depression). Across all studies, there was positive qualitative feedback from participants and facilitators. We identified seven ongoing studies mostly using online- and mobile-based deliveries. CONCLUSIONS: There is preliminary evidence for beneficial effects of interventions to enable people to better cope with the distress of highly contagious emerging disease outbreaks. Besides the need for more high-quality studies, the summarized evidence may inform decision makers to plan interventions during the current pandemic and to develop pandemic preparedness plans.

Psychological interventions to foster resilience in healthcare students.

BACKGROUND: Resilience can be defined as maintaining or regaining mental health during or after significant adversities such as a potentially traumatising event, challenging life circumstances, a critical life transition or physical illness. Healthcare students, such as medical, nursing, psychology and social work students, are exposed to various study- and work-related stressors, the latter particularly during later phases of health professional education. They are at increased risk of developing symptoms of burnout or mental disorders. This population may benefit from resilience-promoting training programmes. OBJECTIVES: To assess the effects of interventions to foster resilience in healthcare students, that is, students in training for health professions delivering direct medical care (e.g. medical, nursing, midwifery or paramedic students), and those in training for allied health professions, as distinct from medical care (e.g. psychology, physical therapy or social work students). SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, waiting list, usual care, and active or attention control, in adults (18 years and older), who are healthcare students. Primary outcomes were resilience, anxiety, depression, stress or stress perception, and well-being or quality of life. Secondary outcomes were resilience factors. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only). MAIN RESULTS: We included 30 RCTs, of which 24 were set in high-income countries and six in (upper- to lower-) middle-income countries. Twenty-two studies focused solely on healthcare students (1315 participants; number randomised not specified for two studies), including both students in health professions delivering direct medical care and those in allied health professions, such as psychology and physical therapy. Half of the studies were conducted in a university or school setting, including nursing/midwifery students or medical students. Eight studies investigated mixed samples (1365 participants), with healthcare students and participants outside of a health professional study field. Participants mainly included women (63.3% to 67.3% in mixed samples) from young adulthood (mean age range, if reported: 19.5 to 26.83 years; 19.35 to 38.14 years in mixed samples). Seventeen of the studies investigated group interventions of high training intensity (11 studies; > 12 hours/sessions), that were delivered face-to-face (17 studies). Of the included studies, eight compared a resilience training based on mindfulness versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. universities, foundations), or a combination of various sources (four studies). Seven studies did not specify a potential funder, and three studies received no funding support. Risk of bias was high or unclear, with main flaws in performance, detection, attrition and reporting bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare students receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.43, 95% confidence interval (CI) 0.07 to 0.78; 9 studies, 561 participants), lower levels of anxiety (SMD -0.45, 95% CI -0.84 to -0.06; 7 studies, 362 participants), and lower levels of stress or stress perception (SMD -0.28, 95% CI -0.48 to -0.09; 7 studies, 420 participants). Effect sizes varied between small and moderate. There was little or no evidence of any effect of resilience training on depression (SMD -0.20, 95% CI -0.52 to 0.11; 6 studies, 332 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.15, 95% CI -0.14 to 0.43; 4 studies, 251 participants; very-low certainty evidence). Adverse effects were measured in four studies, but data were only reported for three of them. None of the three studies reported any adverse events occurring during the study (very-low certainty of evidence). AUTHORS' CONCLUSIONS: For healthcare students, there is very-low certainty evidence for the effect of resilience training on resilience, anxiety, and stress or stress perception at post-intervention. The heterogeneous interventions, the paucity of short-, medium- or long-term data, and the geographical distribution restricted to high-income countries limit the generalisability of results. Conclusions should therefore be drawn cautiously. Since the findings suggest positive effects of resilience training for healthcare students with very-low certainty evidence, high-quality replications and improved study designs (e.g. a consensus on the definition of resilience, the assessment of individual stressor exposure, more attention controls, and longer follow-up periods) are clearly needed.

Psychological interventions to foster resilience in healthcare professionals.

BACKGROUND: Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work-related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience-promoting training programmes. OBJECTIVES: To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists). SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results. SELECTION CRITERIA: Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, wait-list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well-being or quality of life. Secondary outcomes were resilience factors. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only). MAIN RESULTS: We included 44 RCTs (high-income countries: 36). Thirty-nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies). Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face-to-face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive-behavioural therapy) versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support. Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD -0.29, 95% CI -0.50 to -0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD -0.61, 95% CI -1.07 to -0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD -0.06, 95% CI -0.35 to 0.23; 5 studies, 231 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.14, 95% CI -0.01 to 0.30; 13 studies, 1494 participants; very-low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very-low certainty evidence). AUTHORS' CONCLUSIONS: For healthcare professionals, there is very-low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post-intervention. The paucity of medium- or long-term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high-quality replications and improved study designs.

[Interventions To Promote Resilience In Adults - A Narrative Review]. / Interventionen zur Resilienzförderung bei Erwachsenen.

Resilience refers to the phenomenon that many people maintain mental health despite exposure to psychological or physical adversity. Recent research suggests that resilience is dynamic and can be trained. Interventions to promote resilience aim at increasing well-being. The effects of such interventions have hardly been evaluated so far. This work is a narrative review of interventions to promote resilience in adults. We evaluated the results of 4 systematic reviews and meta-analyses on the topic and summarize the evidence from 44 randomized controlled trials. Overall, interventions to promote resilience achieved small to moderate effects regarding increasing resilience and improving mental health. Despite methodological shortcomings, the available evidence suggests that intervention programs to foster resilience can be effective and indicates that they could be a promising component of current preventive effort.

Interventions to Promote Resilience in Cancer Patients.

BACKGROUND: Resilience is the ability to maintain or rapidly regain mental health during or after stressful life experiences. Cancer is a major risk factor for stress- associated mental illness. In this review, we attempt to identify effective resilience- promoting interventions in adults with cancer. METHODS: The analysis was restricted to randomized, controlled trials of resilience- promoting interventions in adults with cancer in which training was provided for at least one psychosocial resilience factor. A selective search, with systematic compo- nents, for relevant publications was carried out in the PubMed and CENTRAL data- bases. Effect sizes (Hedges' g) were calculated wherever a fully reported dataset for resilience or post-traumatic growth was available. RESULTS: Twenty-two trials with a total of 2,912 patients were included in the analy- sis; the intervention was provided in an individual setting in five trials and in group format in 17. Beneficial effects on resilience and post-traumatic growth, some of them large, were observed in patients who were acutely ill with cancer and after in- terventions that were provided in more than 12 sessions. The effect size ranged from g = 0.33 to g = 1.45. Largely beneficial effects were achieved by interventions based on the concepts of positive psychology, supportive-expressive group therapy, behavioral therapy, or mindfulness, with considerable variation in individual effect sizes. CONCLUSION: Interventions that promote resilience should be made available to inter- ested and motivated cancer patients. These interventions should be provided, in as soon as the diagnosis is made and should ex- tend over more than 12 sessions whenever possible.

Early improvement of executive test performance during antidepressant treatment predicts treatment outcome in patients with Major Depressive Disorder.

Executive dysfunctions frequently occur in patients with Major Depressive Disorder and have been shown to improve during effective antidepressant treatment. However, the time course of improvement and its relationship to treatment outcome is unknown. The aim of the study was to assess the test performance and clinical outcome by repetitive assessments of executive test procedures during antidepressant treatment. Executive test performance was assessed in 209 -patients with Major Depressive Disorder (mean age 39.3 ± 11.4 years) and 84 healthy controls five times in biweekly intervals from baseline to week 8. Patients were treated by a defined treatment algorithm within the early medication change study (EMC trial; ClinicalTrials.gov NCT00974155), controls did not receive any intervention. Cognitive domains were processing speed, cognitive flexibility, phonemic and semantic verbal fluency. Intelligence was assessed at baseline. Depression severity was tested once a week by the Hamilton Depression Rating Scale (HAMD17). 130 patients (62%) showed executive dysfunctions in at least one of four tests at baseline. Linear mixed regression models revealed that the course of depression severity was associated to the course of cognitive flexibility (p = 0.004) and semantic verbal fluency (p = 0.020). Cognitive flexibility and semantic verbal fluency may be candidates easily to apply for therapy response prediction in clinical routine, which should be tested in further prospective studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT00974155 EudraCT: 2008-008280-96.

Population-based validation of a German version of the Brief Resilience Scale.

Smith and colleagues developed the Brief Resilience Scale (BRS) to assess the individual ability to recover from stress despite significant adversity. This study aimed to validate the German version of the BRS. We used data from a population-based (sample 1: n = 1.481) and a representative (sample 2: n = 1.128) sample of participants from the German general population (age ≥ 18) to assess reliability and validity. Confirmatory factor analyses (CFA) were conducted to compare one- and two-factorial models from previous studies with a method-factor model which especially accounts for the wording of the items. Reliability was analyzed. Convergent validity was measured by correlating BRS scores with mental health measures, coping, social support, and optimism. Reliability was good (α = .85, ω = .85 for both samples). The method-factor model showed excellent model fit (sample 1: χ2/df = 7.544; RMSEA = .07; CFI = .99; SRMR = .02; sample 2: χ2/df = 1.166; RMSEA = .01; CFI = 1.00; SRMR = .01) which was significantly better than the one-factor model (Δχ2(4) = 172.71, p < .001) or the two-factor model (Δχ2(3) = 31.16, p < .001). The BRS was positively correlated with well-being, social support, optimism, and the coping strategies active coping, positive reframing, acceptance, and humor. It was negatively correlated with somatic symptoms, anxiety and insomnia, social dysfunction, depression, and the coping strategies religion, denial, venting, substance use, and self-blame. To conclude, our results provide evidence for the reliability and validity of the German adaptation of the BRS as well as the unidimensional structure of the scale once method effects are accounted for.

Randomized controlled study of early medication change for non-improvers to antidepressant therapy in major depression--The EMC trial.

Patients with Major Depressive Disorder (MDD) and no improvement after two weeks of antidepressant pharmacotherapy have a high risk of treatment failure. The aim of the study was to determine whether an early medication change (EMC) strategy is superior to a guideline-based treatment in MDD patients without improvement after two weeks of antidepressant pharmacotherapy. Eight-hundred-and-eighty-nine patients with MDD were enrolled, 879 patients received the SSRI escitalopram. Of those, 192 patients had no improvement, defined as a reduction of < 20% on the Hamilton Depression Rating Scale (HAMD-17) after 14 days of treatment, and were randomly assigned to open treatment with the EMC strategy (n = 97; venlafaxine XR for study days 15-56; in case of sustained non-improvement on day 28, lithium augmentation for days 29-56) or TAU (n = 95; escitalopram continuation; non-responders on day 28 were switched to venlafaxine XR for four weeks, i.e. days 29-56). The primary outcome was remission (HAMD-17 ≤ 7) after 8 weeks of treatment as assessed by blinded raters. Remission rates were 24% for EMC and 16% for TAU, which was not significantly different (p = 0.2056). Sensitivity analyses for the primary and secondary effectiveness endpoints consistently showed favorable results for patients randomized to EMC. The results confirm data from post-hoc analyses of clinical trials showing that early non-improvement identifies patients who likely need alternate interventions. However, the herein used two-step switch/augmentation strategy for this risk group was not more effective than the control intervention. Alternate strategies and other design aspects are discussed in order to support researchers addressing the same research question.

Hamilton depression rating subscales to predict antidepressant treatment outcome in the early course of treatment.

BACKGROUND: Hamilton depression rating scale (HAMD) subscales provide an economic alternative for the full scale; however, their ability to detect onset of improvement in the early course of treatment (EI) has not yet been researched. The present study investigated in patients with major depression (MD) whether the subscales are a comparable option to predict treatment remission in the early course of treatment. METHODS: Based on data from 210 MD patients of a 6-week randomised, placebo-controlled trial comparing mirtazapine (MIR) and paroxetine (PAR), the discriminative and predictive validity of EI for (stable) remission at treatment end was evaluated for seven subscales and the HAMD17 in the total and in treatment subgroups (MIR vs. PAR). Receiver operating characteristics (ROC) curves (at week 2) and the Clinical Global Impression scales (CGI) (at study endpoint) were used to validate the 20% EI criterion for the subscales. RESULTS: Only the Evans6 and Toronto7 subscale had almost the same predictive value as the HAMD17 (e.g., sensitivities stable remission Evans6/Toronto7: 96/95% vs. 96% HAMD17). The optimal cut-off for EI to predict remission was just below 20% for most subscales and slightly over 20% for stable remission. LIMITATIONS: Study sample representativeness, non-independence of subscales, missing external validation criterion, lack of control group. CONCLUSIONS: The Evans6 and Toronto7 subscales are valuable alternatives in situations, where economic aspects play a larger role. A sum score reduction of ≥20% as definition for EI seems also appropriate for the HAMD subscales, in the total as well as in the antidepressant subgroups.

A meta-analysis of cognitive functions in children and adolescents with major depressive disorder.

The cumulative prevalence rates of major depressive disorders (MDD) in children and adolescents averages 9.5 %. The majority of adults with MDD suffer from significant cognitive deficits, but the available neuropsychological data on the cognitive performance of children and adolescents with MDD yielded mixed results. Meta-analytic methods were used to assess the severity of cognitive deficits in children and adolescents with MDD as compared to healthy children and adolescents. We identified 17 studies comparing the intelligence, executive functions, verbal memory and attention of 447 patients with DSM-IV MDD and 1,347 healthy children and adolescents. Children and adolescents with MDD performed 0.194-0.772 (p < 0.001) standard mean differences worse than healthy control subjects in neuropsychological test procedures. The most pronounced deficits of children and adolescents with MDD were seen in inhibition capacity (STD = 0.772; p = 0.002), phonemic verbal fluency (STD = 0.756; p = 0.0001), sustained attention (STD = 0.522; p = 0.000), verbal memory (STD = 0.516; p = 0.0009) and planning (STD = 0.513; p = 0.014). We revealed cognitive deficits of children and adolescents with MDD in various cognitive domains. Long-term studies should investigate how the cognitive deficits of depressed youth affect their academic and social functioning, and whether age, comorbidity and depression severity play a role in this process.

Sensitivity to changes during antidepressant treatment: a comparison of unidimensional subscales of the Inventory of Depressive Symptomatology (IDS-C) and the Hamilton Depression Rating Scale (HAMD) in patients with mild major, minor or subsyndromal depression.

In the efficacy evaluation of antidepressant treatments, the total score of the Hamilton Depression Rating Scale (HAMD) is still regarded as the 'gold standard'. We previously had shown that the Inventory of Depressive Symptomatology (IDS) was more sensitive to detect depressive symptom changes than the HAMD17 (Helmreich et al. 2011). Furthermore, studies suggest that the unidimensional subscales of the HAMD, which capture the core depressive symptoms, outperform the full HAMD regarding the detection of antidepressant treatment effects. The aim of the present study was to compare several unidimensional subscales of the HAMD and the IDS regarding their sensitivity to changes in depression symptoms in a sample of patients with mild major, minor or subsyndromal depression (MIND). Biweekly IDS-C28 and HAMD17 data from 287 patients of a 10-week randomised, placebo-controlled trial comparing the effectiveness of sertraline and cognitive-behavioural group therapy in patients with MIND were converted to subscale scores and analysed during the antidepressant treatment course. We investigated sensitivity to depressive change for all scales from assessment-to-assessment, in relation to depression severity level and placebo-verum differences. The subscales performed similarly during the treatment course, with slight advantages for some subscales in detecting treatment effects depending on the treatment modality and on the items included. Most changes in depressive symptomatology were detected by the IDS short scale, but regarding the effect sizes, it performed worse than most subscales. Unidimensional subscales are a time- and cost-saving option in judging drug therapy outcomes, especially in antidepressant treatment efficacy studies. However, subscales do not cover all facets of depression (e.g. atypical symptoms, sleep disturbances), which might be important for comprehensively understanding the nature of the disease depression. Therefore, the cost-to-benefit ratio must be carefully assessed in the decision for using unidimensional subscales.

Reliability of three alternate forms of the trail making tests a and B.

The majority of patients with Major Depressive Disorder (MDD) suffer from significant executive dysfunctions. To investigate the time course of executive functions during antidepressant treatment, repeated measures of executive functions are necessary. In order to avoid practice effects, the assessment of alternate forms is suggested. The aim of this study was to compare the processing times of four alternate versions of the Trail Making Test (TMT) A and B in patients with MDD. Fifty-five subjects with DSM-IV MDD were included in the study. We analyzed mean processing times and retest reliability of the four versions of TMT A and B. Mean processing times did not differ between the four tested versions of TMT A and B. Retest reliability of TMT A and B was between 0.76 and 0.89 and between 0.86 and 0.94, respectively. Because of their identical difficulty and high reliability, the herein described versions of the TMT A and B are suitable for sequential testing of executive functioning.

The Inventory Of Depressive Symptomatology (IDS-C(28)) is more sensitive to changes in depressive symptomatology than the Hamilton Depression Rating Scale (HAMD(17)) in patients with mild major, minor or subsyndromal depression.

Depression rating scales play a decisive role in the assessment of the severity of depression and the evaluation of the efficacy of antidepressant treatments. The Hamilton Depression Rating Scale (HAMD) is regarded as the 'gold standard'; nevertheless, studies suggest that the Inventory of Depressive Symptomatology (IDS) is more sensitive to detect symptom changes. The aim of the present study was to investigate whether the IDS is more sensitive in detecting changes in depression symptoms in patients with mild major, minor or subsyndromal depression (MIND). Biweekly IDS-C(28) and HAMD(17) data from 340 patients of a 10-week randomized, placebo-controlled trial comparing the effectiveness of sertraline and cognitive-behavioural therapy in patients with MIND were analysed. We investigated sensitivity to change for both scales (1) from assessment-to-assessment, (2) in relation to depression severity level, and (3) in relation to DSM-IV depression criterion symptoms. The IDS-C(28) was more sensitive in detecting changes in depression symptomatology over the treatment course as well as for different severity levels, especially in patients with a low depression severity. It assesses the DSM-IV criteria more thoroughly, is better able to track the change of cognitive symptoms and to identify residual symptoms. Both scales are well able to assess depressive symptomatology. However, the IDS-C(28) surpasses the HAMD(17) in detecting small changes especially in the core symptoms of depression. This is important for an optimal treatment by capturing early improvements, enabling prompt reactions and detecting residual symptoms.

Early improvement is a predictor of treatment outcome in patients with mild major, minor or subsyndromal depression.

BACKGROUND: There is substantial evidence that early improvement (EI) under antidepressant treatment is a clinically useful predictor of later treatment outcome in patients with major depressive disorders. The aim of this study was to test whether EI can also be used as a predictor for treatment outcome in patients with mild major, minor or subsyndromal depression, i.e. patients, who are typically treated by general practitioners. METHODS: Analyses were carried out using data from 223 patients of a 10-weeks randomized, placebo-controlled trial comparing the effectiveness of sertraline and cognitive-behavioural therapy (CBT) in patients with mild major, minor or subsyndromal depression. EI was defined as a reduction of > or =20% on the 17-item Hamilton Rating Scale for Depression (HAMD-17) compared with baseline within the first 2 weeks of treatment. The predictive value of EI for stable response at week 8 and 10 (> or =50% HAMD-17 sum score reduction at weeks 8 and 10) and stable remission (HAMD-17 sum score < or =7 at weeks 8 and 10) was evaluated. RESULTS: In both the sertraline- and CBT-treatment group, EI was a highly sensitive predictor for later stable response (76% and 82%, respectively) and stable remission (70% and 75%, respectively). In patients without EI, only a small proportion of sertraline or CBT-treated patients achieved stable response (20.9% and 5.9%, respectively) or stable remission (18.6% and 8.8%, respectively). Patients with EI were by far more likely to achieve stable response or stable remission than patients without as indicated by high odds ratios (95% confidence interval) of 8.1 (3.0-21.8) and 3.8 (1.4-10.1) for sertraline, and 11.1 (2.1-58.4) and 7.2 (1.7-30.8) for CBT-treated patients, respectively. LIMITATIONS: Sample sizes were relatively low in different treatment groups. CONCLUSION: The identification of early improvement might be useful in clinical decision making in the early course of treatment of patients with mild major, minor and subthreshold depression.