The Kimberley Assessment of Depression of Older Indigenous Australians: Prevalence of Depressive Disorders,Risk Factors and Validation of the KICA-dep Scale

Objective

This study aimed to develop a culturally acceptable and valid scale to assess depressive symptoms in older Indigenous Australians, to determine the prevalence of depressive disorders in the older Kimberley community, and to investigate the sociodemographic, lifestyle and clinical factors associated with depression in this population.

Methods

Cross-sectional survey of adults aged 45 years or over from six remote Indigenous communities in the Kimberley and 30% of those living in Derby, Western Australia. The 11 linguistic and culturally sensitive items of the Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep) scale were derived from the signs and symptoms required to establish the diagnosis of a depressive episode according to the DSM-IV-TR and ICD-10 criteria, and their frequency was rated on a 4-point scale ranging from ‘never’ to ‘all the time’ (range of scores: 0 to 33). The diagnosis of depressive disorder was established after a face-to-face assessment with a consultant psychiatrist. Other measures included sociodemographic and lifestyle factors, and clinical history.

Results

The study included 250 participants aged 46 to 89 years (mean±SD = 60.9±10.7), of whom 143 (57.2%) were women. The internal reliability of the KICA-dep was 0.88 and the cut-point 7/8 (non-case/case) was associated with 78% sensitivity and 82% specificity for the diagnosis of a depressive disorder. The point-prevalence of a depressive disorder in this population was 7.7%; 4.0% for men and 10.4% for women. Heart problems were associated with increased odds of depression (odds ratio = 3.3, 95% confidence interval = 1.2,8.8).

Conclusions

The KICA-dep has robust psychometric properties and can be used with confidence as a screening tool for depression among older Indigenous Australians. Depressive disorders are common in this population, possibly because of increased stressors and health morbidities.     

Are atypical depression,borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis?

The constructs of atypical depression, bipolar II disorder and borderline personality disorder (BPD) overlap. We explored the relationships between these constructs and their temperamental underpinnings. We examined 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features. Those who also met the DSM-IV criteria for BPD (BPD+), compared with those who did not (BPD-), had a significantly higher lifetime comorbidity for body dysmorphic disorder, bulimia nervosa, narcissistic, dependent and avoidant personality disorders, and cyclothymia. BPD+ also scored higher on the Atypical Depression Diagnostic Scale items of mood reactivity, interpersonal sensitivity, functional impairment, avoidance of relationships, other rejection avoidance, and on the Hopkins Symptoms Check List obsessive-compulsive, interpersonal sensitivity, anxiety, anger-hostility, paranoid ideation and psychoticism factors. Logistic regression revealed that cyclothymic temperament accounted for much of the relationship between atypical depression and BPD, predicting 6 of 9 of the defining DSM-IV attributes of the latter. Trait mood lability (among BPD patients) and interpersonal sensitivity (among atypical depressive patients) appear to be related as part of an underlying cyclothymic temperamental matrix.     

Depression Dimensions: Integrating Clinical Signs and Symptoms from the Perspectives of Clinicians and Patients

Background

Several studies have recognized that depression is a multidimensional construct, although the scales that are currently available have been shown to be limited in terms of the ability to investigate the multidimensionality of depression. The objective of this study is to integrate information from instruments that measure depression from different perspectives–a self-report symptomatic scale, a clinician-rated scale, and a clinician-rated scale of depressive signs–in order to investigate the multiple dimensions underlying the depressive construct.

Methods

A sample of 399 patients from a mood disorders outpatient unit was investigated with the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale (HDRS), and the Core Assessment of Psychomotor Change (CORE). Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were used to investigate underlying dimensions of depression, including item level analysis with factor loadings and item thresholds.

Results

A solution of six depression dimensions has shown good-fit to the data, with no cross-loading items, and good interpretability. Item-level analysis revealed that the multidimensional depressive construct might be organized into a continuum of severity in the following ascending order: sexual, cognitive, insomnia, appetite, non-interactiveness/motor retardation, and agitation.

Conclusion

An integration of both signs and symptoms, as well as the perspectives of clinicians and patients, might be a good clinical and research alternative for the investigation of multidimensional issues within the depressive syndrome. As predicted by theoretical models of depression, the melancholic aspects of depression (non-interactiveness/motor retardation and agitation) lie at the severe end of the depressive continuum.     

Diagnosing Depression in Chronic Pain Patients: DSM-IV Major Depressive Disorder vs. Beck Depression Inventory (BDI)

Background

Diagnosing depression in chronic pain is challenging due to overlapping somatic symptoms. In questionnaires, such as the Beck Depression Inventory (BDI), responses may be influenced more by pain than by the severity of depression. In addition, previous studies have suggested that symptoms of negative self-image, a key element in depression, are uncommon in chronic pain-related depression. The object of this study is to assess the relationship of the somatic and cognitive-emotional items of BDI with the diagnosis of depression, pain intensity, and disability.

Methods

One hundred consecutive chronic pain patients completed the Structured Clinical Interview for DSM Disorders (SCID) for the diagnosis of major depressive disorder (MDD) according to DSM-IV. Two subscales of BDI (negative view of self and somatic-physical function) were created according to the factor model presented by Morley.

Results

In the regression analysis, the somatic-physical function factor associated with MDD, while the negative view of self factor did not. Patients with MDD had higher scores in several of the BDI items when analysed separately. Insomnia and weight loss were not dependent on the depression diagnosis.

Limitations

The relatively small sample size and the selected patient sample limit the generalisability of the results.

Conclusions

Somatic symptoms of depression are also common in chronic pain and should not be excluded when diagnosing depression in pain patients. Regardless of the assessment method, diagnosing depression in chronic pain remains a challenge and requires careful interpretation of symptoms.     

Construct Validation of a Multidimensional Computerized Adaptive Test for Fatigue in Rheumatoid Arthritis

Objective

Multidimensional computerized adaptive testing enables precise measurements of patient-reported outcomes at an individual level across different dimensions. This study examined the construct validity of a multidimensional computerized adaptive test (CAT) for fatigue in rheumatoid arthritis (RA).

Methods

The ‘CAT Fatigue RA’ was constructed based on a previously calibrated item bank. It contains 196 items and three dimensions: ‘severity’, ‘impact’ and ‘variability’ of fatigue. The CAT was administered to 166 patients with RA. They also completed a traditional, multidimensional fatigue questionnaire (BRAF-MDQ) and the SF-36 in order to examine the CAT’s construct validity. A priori criterion for construct validity was that 75% of the correlations between the CAT dimensions and the subscales of the other questionnaires were as expected. Furthermore, comprehensive use of the item bank, measurement precision and score distribution were investigated.

Results

The a priori criterion for construct validity was supported for two of the three CAT dimensions (severity and impact but not for variability). For severity and impact, 87% of the correlations with the subscales of the well-established questionnaires were as expected but for variability, 53% of the hypothesised relations were found. Eighty-nine percent of the items were selected between one and 137 times for CAT administrations. Measurement precision was excellent for the severity and impact dimensions, with more than 90% of the CAT administrations reaching a standard error below 0.32. The variability dimension showed good measurement precision with 90% of the CAT administrations reaching a standard error below 0.44. No floor- or ceiling-effects were found for the three dimensions.

Conclusion

The CAT Fatigue RA showed good construct validity and excellent measurement precision on the dimensions severity and impact. The dimension variability had less ideal measurement characteristics, pointing to the need to recalibrate the CAT item bank with a two-dimensional model, solely consisting of severity and impact.     

Medical Decision-Making Incapacity among Newly Diagnosed Older Patients with Hematological Malignancy Receiving First Line Chemotherapy: A Cross-Sectional Study of Patients and Physicians

Background

Decision-making capacity to provide informed consent regarding treatment is essential among cancer patients. The purpose of this study was to identify the frequency of decision-making incapacity among newly diagnosed older patients with hematological malignancy receiving first-line chemotherapy, to examine factors associated with incapacity and assess physicians’ perceptions of patients’ decision-making incapacity.

Methods

Consecutive patients aged 65 years or over with a primary diagnosis of malignant lymphoma or multiple myeloma were recruited. Decision-making capacity was assessed using the Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory-Revised (SICIATRI-R). Cognitive impairment, depressive condition and other possible associated factors were also evaluated.

Results

Among 139 eligible patients registered for this study, 114 completed the survey. Of these, 28 (25%, 95% confidence interval [CI]: 17%-32%) were judged as having some extent of decision-making incompetency according to SICIATRI-R. Higher levels of cognitive impairment and increasing age were significantly associated with decision-making incapacity. Physicians experienced difficulty performing competency assessment (Cohen’s kappa -0.54).

Conclusions

Decision-making incapacity was found to be a common and under-recognized problem in older patients with cancer. Age and assessment of cognitive impairment may provide the opportunity to find patients that are at a high risk of showing decision-making incapacity.     

The Effects of a Problem Solving-Based Intervention on Depressive Symptoms and HIV Medication Adherence Are Independent

Depression and depressive symptoms predict poor adherence to medical therapy, but the association is complex, nonspecific, and difficult to interpret. Understanding this association may help to identify the mechanism explaining the results of interventions that improve both medical therapy adherence and depressive symptoms as well as determine the importance of targeting depression in adherence interventions. We previously demonstrated that Managed Problem Solving (MAPS) focused on HIV medication adherence improved adherence and viral load in patients initiating a new antiretroviral regimen. Here, we assessed whether MAPS improved depressive symptoms and in turn, whether changes in depressive symptoms mediated changes in adherence and treatment outcomes. We compared MAPS to usual care with respect to presence of depressive symptoms during the trial using logistic regression. We then assessed whether MAPS’ effect on depressive symptoms mediated the relationship between MAPS and adherence and virologic outcomes using linear and logistic regression, respectively. Mediation was defined by the disappearance of the mathematical association between MAPS and the outcomes when the proposed mediator was included in regression models. Although MAPS participants had a lower rate of depressive symptoms (OR = 0.45, 95% confidence interval 0.21–0.93), there was no evidence of mediation of the effects of MAPS on adherence and virological outcome by improvements in depression. Thus, interventions for medication adherence may not need to address depressive symptoms in order to impact both adherence and depression; this remains to be confirmed, however, in other data.     

Hell Is Other People? Gender and Interactions with Strangers in the Workplace Influence a Person’s Risk of Depression

We suggest that interactions with strangers at work influence the likelihood of depressive disorders, as they serve as an environmental stressor, which are a necessary condition for the onset of depression according to diathesis-stress models of depression. We examined a large dataset (N = 76,563 in K = 196 occupations) from the German pension insurance program and the Occupational Information Network dataset on occupational characteristics. We used a multilevel framework with individuals and occupations as levels of analysis. We found that occupational environments influence employees’ risks of depression. In line with the quotation that ‘hell is other people’ frequent conflictual contacts were related to greater likelihoods of depression in both males and females (OR = 1.14, p<.05). However, interactions with the public were related to greater likelihoods of depression for males but lower likelihoods of depression for females (OR_intercation = 1.21, p<.01). We theorize that some occupations may involve interpersonal experiences with negative emotional tones that make functional coping difficult and increase the risk of depression. In other occupations, these experiences have neutral tones and allow for functional coping strategies. Functional strategies are more often found in women than in men.     

Development and Validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for Primary Care Patients with Type 2 Diabetes

Objectives

To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes.

Research Design and Method

Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach’s alpha.

Results

Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett’s Test of Sphericity (P<0.001). Using exploratory factor analysis with varimax rotation, 10 factors were generated onto which 26 items loaded with loading scores > 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach’s alpha coefficients for the first four factors were ≥0.6 identifying four sub-scales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: ‘Self-image and stigmatization’; ‘Factors promoting self-efficacy; ‘Fear of pain or needles’; and ‘Time and family support’.

Conclusion

The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin.     

Prevalence,Recurrence, and Incidence of Current Depressive Symptoms among People Living with HIV in Ontario,Canada: Results from the Ontario HIV Treatment Network Cohort Study

IntroductionCurrent studies of depression among people living with HIV focus on describing its point prevalence. Given the fluctuating nature of depression and its profound impacts on clinical and quality-of-life outcomes, this study aimed to examine the prevalence, recurrence and incidence of current depressive symptoms and its underlying catalysts longitudinally and systematically among these individuals.MethodsWe conducted a prospective cohort study between October 1, 2007 and December 31, 2012 using longitudinal linked data sources. Current depressive symptoms was identified using the Centre for Epidemiologic Studies Depression Scale or the Kessler Psychological Distress Scale, first at baseline and again during follow-up interviews. Multivariable regressions were used to characterize the three outcomes.ResultsOf the 3,816 HIV-positive participants, the point prevalence of depressive symptoms was estimated at 28%. Of the 957 participants who were identified with depressive symptoms at baseline and who had at least two years of follow-up, 43% had a recurrent episode. The cumulative incidence among 1,745 previously depressive symptoms free participants (at or prior to baseline) was 14%. During the five-year follow-up, our multivariable models showed that participants with greater risk of recurrent cases were more likely to feel worried about their housing situation. Participants at risk of developing incident cases were also likely to be younger, gay or bisexual, and unable to afford housing-related expenses.ConclusionsDepressive symptoms are prevalent and likely to recur among people living with HIV. Our results support the direction of Ontario’s HIV/AIDS Strategy to 2026, which addresses medical concerns associated with HIV (such as depression) and the social drivers of health in order to enhance the overall well-being of people living with or at risk of HIV. Our findings reinforce the importance of providing effective mental health care and demonstrate the need for long-term support and routine management of depression, particularly for individuals at high risk.     

Major depression and recent physical or sexual abuse increase readmissions among high-utilising primary care patients

Objective To investigate whether current major depression and past physical/sexual victimisation is associated with recurrent general hospital admissions.Method Ninety-six inner-city primary care patients with a history of high medical service utilisation completed the PRIME-MD and the Abuse Assessment Screen; medical records were reviewed to assess reasons for re-hospitalisations. We compared hospitalisation rates over the preceding 12 months between those subjects with and without major depression and those with and without histories of abuse.Results Compared to non-abused subjects, patients with past-year abuse showed significantly increased past-year hospitalisations (3.2 versus 1.8, P = 0.007). Re-admissions were related to chronic disease management and were not because of acute physical effects of trauma. Analysis of variance revealed that major depressive disorder and past-year abuse history interacted to increase an association with re-admissions.Conclusions Past-year abuse was independently associated with increased hospital admissions. Psychological effects of recent abuse combined with depression may particularly increase rates of medical/surgical hospitalisations.     

Tool for Rapid & Easy Identification of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic Foot Screening Tool

Background

Most diabetic foot amputations are caused by ulcers on the skin of the foot i.e. diabetic foot ulcers. Early identification of patients at high risk for diabetic foot ulcers is crucial. The ‘Simplified 60-Second Diabetic Foot Screening Tool’ has been designed to rapidly detect high risk diabetic feet, allowing for timely identification and referral of patients needing treatment. This study aimed to determine the clinical performance and inter-rater reliability of ‘Simplified 60 Second Diabetic Foot Screening Tool’ in order to evaluate its applicability for routine screening.

Methods and Findings

The tool was independently tested by n=12 assessors with n=18 Guyanese patients with diabetes. Inter-rater reliability was assessed by calculating Cronbach’s alpha for each of the assessment items. A minimum value of 0.60 was considered acceptable. Reliability scores of the screening tool assessment items were: ‘monofilament test’ 0.98; ‘active ulcer’ 0.97; ‘previous amputation’ 0.97; ‘previous ulcer’ 0.97; ‘fixed ankle’ 0.91; ‘deformity’ 0.87; ‘callus’ 0.87; ‘absent pulses’ 0.87; ‘fixed toe’ 0.80; ‘blisters’ 0.77; ‘ingrown nail’ 0.72; and ‘fissures’ 0.55. The item ‘stiffness in the toe or ankle’ was removed as it was observed in only 1.3% of patients. The item ‘fissures’ was also removed due to low inter-rater reliability. Clinical performance was assessed via a pilot study utilizing the screening tool on n=1,266 patients in an acute care setting in Georgetown, Guyana. In total, 48% of patients either had existing diabetic foot ulcers or were found to be at high risk for developing ulcers.

Conclusions

Clinicians in low and middle income countries such as Guyana can use the Simplified 60-Second Diabetic Screening Tool to facilitate early detection and appropriate treatment of diabetic foot ulcers. Implementation of this screening tool has the potential to decrease diabetes related disability and mortality.     

Knowledge,Practices, and Perceived Barriers Regarding Cancer Pain Management Among Physicians and Nurses In Korea: A Nationwide Multicenter Survey

Purpose

Medical professionals’ practices and knowledge regarding cancer pain management have often been cited as inadequate. This study aimed to evaluate knowledge, practices and perceived barriers regarding cancer pain management among physicians and nurses in Korea.

Methods

A nationwide questionnaire survey was administered to physicians and nurses involved in the care of cancer patients. Questionnaire items covered pain assessment and documentation practices, knowledge regarding cancer pain management, the perceived barriers to cancer pain control, and processes perceived as the major causes of delay in opioid administration.

Results

A total of 333 questionnaires (149 physicians and 284 nurses) were analyzed. Nurses performed pain assessment and documentation more regularly than physicians did. Although physicians had better knowledge of pain management than did nurses, both groups lacked knowledge regarding the side effects and pharmacology of opioids. Physicians working in the palliative care ward and nurses who had received pain management education obtained higher scores on knowledge. Physicians perceived patients’ reluctance to take opioids as a barrier to pain control, more so than did nurses, while nurses perceived patients’ tendency to under-report of pain as a barrier, more so than did physicians. Physicians and nurses held different perceptions regarding major cause of delay during opioid administration.

Conclusions

There were differences between physicians and nurses in knowledge and practices for cancer pain management. An effective educational strategy for cancer pain management is needed in order to improve medical professionals’ knowledge and clinical practices.     

A Depressive Endophenotype of Mild Cognitive Impairment and Alzheimer’s Disease

Background

Alzheimer’s disease (AD) is a devastating public health problem that affects over 5.4 million Americans. Depression increases the risk of Mild Cognitive Impairment (MCI) and AD. By understanding the influence of depression on cognition, the potential exists to identify subgroups of depressed elders at greater risk for cognitive decline and AD. The current study sought to: 1) clinically identify a sub group of geriatric patients who suffer from depression related cognitive impairment; 2) cross validate this depressive endophenotype of MCI/AD in an independent cohort.

Methods and Findings

Data was analyzed from 519 participants of Project FRONTIER. Depression was assessed with the GDS30 and cognition was assessed using the EXIT 25 and RBANS. Five GDS items were used to create the Depressive endophenotype of MCI and AD (DepE). DepE was significantly negatively related to RBANS index scores of Immediate Memory (B=-2.22, SE=.37, p<0.001), visuospatial skills (B=-1.11, SE=0.26, p<0.001), Language (B=-1.03, SE=0.21, p<0.001), Attention (B=-2.56, SE=0.49, p<0.001), and Delayed Memory (B=-1.54, SE = 037, p<0.001), and higher DepE scores were related to poorer executive functioning (EXIT25; B=0.65, SE=0.19, p=0.001). DepE scores significantly increased risk for MCI diagnosis (odds ratio [OR] = 2.04; 95% CI=1.54-2.69). Data from 235 participants in the TARCC (Texas Alzheimer’s Research & Care Consortium) were analyzed for cross-validation of findings in an independent cohort. The DepE was significantly related to poorer scores on all measures, and a significantly predicted of cognitive change over 12- and 24-months.

Conclusion

The current findings suggest that a depressive endophenotype of MCI and AD exists and can be clinically identified using the GDS-30. Higher scores increased risk for MCI and was cross-validated by predicting AD in the TARCC. A key purpose for the search for distinct subgroups of individuals at risk for AD and MCI is to identify novel treatment and preventative opportunities.     

The Effect of Self-Care Education on the Awareness,Attitude, and Adherence to Self-Care Behaviors in Hospitalized Patients Due to Heart Failure with and without Depression

Background

Cardiovascular diseases are among somatic disorders and psychological factors affect their onset, exacerbation, and treatment. This study was conducted on the hospitalized patients who had heart failure with and without depression. The study criteria was to evaluate the effect of self-care education on awareness, attitude, and adherence to self-care behaviors on these patients.

Materials and Methods

In this quasi-experimental study, seventy patients with heart failure that met the inclusion criteria were recruited through purposive sampling method. They were assigned in to two equal size groups regarding their depression status. First, the eligible patients were selected; then Beck Depression Inventory was done on the patients followed by examination by the clinical psychologist. Patients with average and higher scores were classified in the depressed group and others who got lower than average scores were classified as the non -depressed group. A questionnaire containing items related to awareness, attitude, and adherence to self-care behaviors was used to collect the data. First, self-care behavior was determined and then a four-sessions of educational intervention were held individually for both groups. The second round of questionnaires were completed at patients’ home twelve weeks after the discharge. The Collected data was analyzed using independent-samples and paired-sample t tests, Chi square, and statistical analysis of covariance (ANCOVA) tests through SPSS (version 21, SPSS Inc., Chicago, IL, USA).

Results

After the educational sessions, the statistical analysis showed significant differences in the mean scores of awareness, attitude, and adherence to self-care behaviors between the two groups (P<0.0001).

Conclusion

Self-care behavior education had lower effects on the depressed patients with heart failure. Therefore, before providing education for these patients, it is necessary to consider their psychological problems such as depression.     

Clinical Patterns and Treatment Outcome in Patients with Melancholic,Atypical and Non-Melancholic Depressions

Objective

To assess sociodemographic, clinical and treatment factors as well as depression outcome in a large representative clinical sample of psychiatric depressive outpatients and to determine if melancholic and atypical depression can be differentiated from residual non-melancholic depressive conditions.

Subjects/Materials and Method

A prospective, naturalistic, multicentre, nationwide epidemiological study of 1455 depressive outpatients was undertaken. Severity of depressive symptoms was assessed by the Hamilton Depression Rating Scale (HDRS) and the Self Rated Inventory of Depressive Symptomatology (IDS-SR₃₀). IDS-SR₃₀ defines melancholic and atypical depression according to DSM-IV criteria. Assessments were carried out after 6–8 weeks of antidepressant treatment and after 14–20 weeks of continuation treatment.

Results

Melancholic patients (16.2%) were more severely depressed, had more depressive episodes and shorter episode duration than atypical (24.7%) and non-melancholic patients. Atypical depressive patients showed higher rates of co-morbid anxiety disorders and substance abuse. Melancholic patients showed lower rates of remission.

Conclusion

Our study supports a different clinical pattern and treatment outcome for melancholic and atypical depression subtypes.     

The Method Quality of Cross-Over Studies Involved in Cochrane Systematic Reviews

Background

It is possible that cross-over studies included in current systematic reviews are being inadequately assessed, because the current risk of bias tools do not consider possible biases specific to cross-over design. We performed this study to evaluate whether this was being done in cross-over studies included in Cochrane Systematic Reviews (CSRs).

Methods

We searched the Cochrane Library (up to 2013 issue 5) for CSRs that included at least one cross-over trial. Two authors independently undertook the study selection and data extraction. A random sample of the CSRs was selected and we evaluated whether the cross-over trials in these CSRs were assessed according to criteria suggested by the Cochrane handbook. In addition we reassessed the risk of bias of these cross-over trials by a checklist developed form the Cochrane handbook.

Results

We identified 688 CSRs that included one or more cross-over studies. We chose a random sample of 60 CSRs and these included 139 cross-over studies. None of these CSRs undertook a risk of bias assessment specific for cross-over studies. In fact items specific for cross-over studies were seldom considered anywhere in quality assessment of these CSRs. When we reassessed the risk of bias, including the 3 items specific to cross-over trials, of these 139 studies, a low risk of bias was judged for appropriate cross-over design in 110(79%), carry-over effects in 48(34%) and for reporting data in all stages of the trial in 114(82%).Assessment of biases in cross-over trials could affect the GRADE assessment of a review’s findings.

Conclusion

The current Cochrane risk of bias tool is not adequate to assess cross-over studies. Items specific to cross-over trials leading to potential risk of bias are generally neglected in CSRs. A proposed check list for the evaluation of cross-over trials is provided.     

Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Youth: A Meta-Analysis of Randomized Controlled Outcome Trials

Background

Anxiety and depression in children and adolescents are undertreated. Computer- and Internet-based cognitive behavioral treatments (cCBT) may be an attractive treatment alternative to regular face-to-face treatment.This meta-analysis aims to evaluate whether cCBT is effective for treating symptoms of anxiety and depression in youth.

Methods and Findings

We conducted systematic searches in bibliographical databases (Pubmed, Cochrane controlled trial register, PsychInfo) up to December 4, 2013. Only randomized controlled trials in which a computer-, Internet- or mobile-based cognitive behavioral intervention targeting either depression, anxiety or both in children or adolescents up to the age of 25 were compared to a control condition were selected. We employed a random-effects pooling model in overall effect analyses and a mixed effect model for sub-group analyses. Searches resulted in identifying 13 randomized trials, including 796 children and adolescents that met inclusion criteria. Seven studies were directed at treating anxiety, four studies at depression, and two were of a transdiagnostic nature, targeting both anxiety and depression. The overall mean effect size (Hedges’ g) of cCBT on symptoms of anxiety or depression at post-test was g=0.72 (95% CI:0.55-0.90, numbers needed to be treated (NNT)=2.56). Heterogeneity was low (I²=20.14%, 95% CI: 0-58%). The superiority of cCBT over controls was evident for interventions targeting anxiety (g=0.68; 95% CI: 0.45-0.92; p < .001; NNT=2.70) and for interventions targeting depression (g=0.76; 95% CI: 0.41-0.12; p < .001; NNT=2.44) as well as for transdiagnostic interventions (g=0.94; 95% CI: 0.23-2.66; p < .001; NNT=2.60).

Conclusions

Results provide evidence for the efficacy of cCBT in the treatment of anxiety and depressive symptoms in youth. Hence, such interventions may be a promising treatment alternative when evidence based face-to-face treatment is not feasible. Future studies should examine long-term effects of treatments and should focus on obtaining patient-level data from existing studies, to perform an individual patient data meta-analysis.     

Bourdieu’s Cultural Capital in Relation to Food Choices: A Systematic Review of Cultural Capital Indicators and an Empirical Proof of Concept

Objective

Unhealthy food choices follow a socioeconomic gradient that may partly be explained by one’s ‘cultural capital’, as defined by Bourdieu. We aim 1) to carry out a systematic review to identify existing quantitative measures of cultural capital, 2) to develop a questionnaire to measure cultural capital for food choices, and 3) to empirically test associations of socioeconomic position with cultural capital and food choices, and of cultural capital with food choices.

Design

We systematically searched large databases for the key-word ‘cultural capital’ in title or abstract. Indicators of objectivised cultural capital and family institutionalised cultural capital, as identified by the review, were translated to food choice relevant indicators. For incorporated cultural capital, we used existing questionnaires that measured the concepts underlying the variety of indicators as identified by the review, i.e. participation, skills, knowledge, values. The questionnaire was empirically tested in a postal survey completed by 2,953 adults participating in the GLOBE cohort study, The Netherlands, in 2011.

Results

The review yielded 113 studies that fulfilled our inclusion criteria. Several indicators of family institutionalised (e.g. parents’ education completed) and objectivised cultural capital (e.g. possession of books, art) were consistently used. Incorporated cultural capital was measured with a large variety of indicators (e.g. cultural participation, skills). Based on this, we developed a questionnaire to measure cultural capital in relation to food choices. An empirical test of the questionnaire showed acceptable overall internal consistency (Cronbach’s alpha of .654; 56 items), and positive associations between socioeconomic position and cultural capital, and between cultural capital and healthy food choices.

Conclusions

Cultural capital may be a promising determinant for (socioeconomic inequalities in) food choices.     

Depression and subjective quality of life among outpatients with diabetes mellitus at a teaching hospital in Nigeria

Objective To determine the relationship between depression and the subjective assessment of quality of life (QoL) in a sample of patients with diabetes mellitus (DM) attending outpatient clinics at a regional university teaching hospital in Nigeria.Methods A cross-section of 200 patients were administered the depression module of the Schedule for the Clinical Assessment in Neuropsychiatry (SCAN) and the World Health Organization Quality of Life assessment - brief version (WHOQoL-Bref) over a two-month study period.Results A major depressive disorder (MDD) was diagnosed in 30% of patients. MDD was significantly associated with lower mean scores on the facets of overall QoL (p<0.01) and health satisfaction (p<0.01), but not in the domains of physical health (p=0.67), psychological health (p=0.59), environment (p=0.70), or social relations (p=0.58) of the WHOQoL-Bref.Conclusion Depression is associated with a poorer subjective assessment of QoL among DM patients in Nigeria.