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Factors associated with increased  or decrease treatment use in with Major Depression

A.     The dataset used is National Epidemiologic Survey of Drug Use and Health.

B.     My topics of interest is “Factors associated with increased  or decrease treatment use in with Major Depression”

C.     A literature search on PubMed is conducted using terms: “Major Depression”, “Factor”, “Success”, “treatment”

D.     Seven relevant articles are identified:

1: Kraus C, Kadriu B, Lanzenberger R, Zarate CA Jr, Kasper S. Prognosis and

improved outcomes in major depression: a review. Transl Psychiatry. 2019 Apr

3;9(1):127. doi: 10.1038/s41398-019-0460-3. Review. PubMed PMID: 30944309; PubMed

Central PMCID: PMC6447556.

2: Kelley ME, Dunlop BW, Nemeroff CB, Lori A, Carrillo-Roa T, Binder EB, Kutner

MH, Rivera VA, Craighead WE, Mayberg HS. Response rate profiles for major

depressive disorder: Characterizing early response and longitudinal nonresponse.

Depress Anxiety. 2018 Oct;35(10):992-1000. doi: 10.1002/da.22832. Epub 2018 Sep

7. PubMed PMID: 30260539.

3: Heinz AJ, Meffert BN, Halvorson MA, Blonigen D, Timko C, Cronkite R.

Employment characteristics, work environment, and the course of depression over

23 years: Does employment help foster resilience? Depress Anxiety. 2018

Sep;35(9):861-867. doi: 10.1002/da.22782. Epub 2018 Jun 7. PubMed PMID: 29878482;

PubMed Central PMCID: PMC6123281.

4: Agabio R, Trogu E, Pani PP. Antidepressants for the treatment of people with

co-occurring depression and alcohol dependence. Cochrane Database Syst Rev. 2018

Apr 24;4:CD008581. doi: 10.1002/14651858.CD008581.pub2. Review. PubMed PMID:

29688573; PubMed Central PMCID: PMC6494437.

5: Dunlop BW, Kelley ME, Aponte-Rivera V, Mletzko-Crowe T, Kinkead B, Ritchie JC,

Nemeroff CB, Craighead WE, Mayberg HS; PReDICT Team. Effects of Patient

Preferences on Outcomes in the Predictors of Remission in Depression to

Individual and Combined Treatments (PReDICT) Study. Am J Psychiatry. 2017 Jun

1;174(6):546-556. doi: 10.1176/appi.ajp.2016.16050517. Epub 2017 Mar 24. PubMed

PMID: 28335624.

6: Hall CA, Reynolds-Iii CF. Late-life depression in the primary care setting:

challenges, collaborative care, and prevention. Maturitas. 2014 Oct;79(2):147-52.

doi: 10.1016/j.maturitas.2014.05.026. Epub 2014 Jun 7. Review. PubMed PMID:

24996484; PubMed Central PMCID: PMC4169311.

7: Marshall M, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H,

Roberts C, Hill E, Wiersma D, Bond GR, Huxley P, Tyrer P. Systematic reviews of

the effectiveness of day care for people with severe mental disorders: (1) acute

day hospital versus admission; (2) vocational rehabilitation; (3) day hospital

versus outpatient care. Health Technol Assess. 2001;5(21):1-75. Review. PubMed

PMID: 11532238.

E.      Abstracts and full articles are obtained. The abstracts are enclosed:

Transl Psychiatry. 2019 Apr 3;9(1):127. doi: 10.1038/s41398-019-0460-3.

Prognosis and improved outcomes in major depression: a review.

Kraus C1,2, Kadriu B2, Lanzenberger R1, Zarate CA Jr2, Kasper S3.

Author information

Abstract

Treatment outcomes for major depressive disorder (MDD) need to be improved. Presently, no clinically relevant tools have been established for stratifying subgroups or predicting outcomes. This literature review sought to investigate factors closely linked to outcome and summarize existing and novel strategies for improvement. The results show that early recognition and treatment are crucial, as duration of untreated depression correlates with worse outcomes. Early improvement is associated with response and remission, while comorbidities prolong course of illness. Potential biomarkers have been explored, including hippocampal volumes, neuronal activity of the anterior cingulate cortex, and levels of brain-derived neurotrophic factor (BDNF) and central and peripheral inflammatory markers (e.g., translocator protein (TSPO), interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor alpha (TNFα)). However, their integration into routine clinical care has not yet been fully elucidated, and more research is needed in this regard. Genetic findings suggest that testing for CYP450 isoenzyme activity may improve treatment outcomes. Strategies such as managing risk factors, improving clinical trial methodology, and designing structured step-by-step treatments are also beneficial. Finally, drawing on existing guidelines, we outline a sequential treatment optimization paradigm for selecting first-, second-, and third-line treatments for acute and chronically ill patients. Well-established treatments such as electroconvulsive therapy (ECT) are clinically relevant for treatment-resistant populations, and novel transcranial stimulation methods such as theta-burst stimulation (TBS) and magnetic seizure therapy (MST) have shown promising results. Novel rapid-acting antidepressants, such as ketamine, may also constitute a paradigm shift in treatment optimization for MDD.

PMID: 30944309 PMCID: PMC6447556 DOI: 10.1038/s41398-019-0460-3

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2.

Depress Anxiety. 2018 Oct;35(10):992-1000. doi: 10.1002/da.22832. Epub 2018 Sep 7.

Response rate profiles for major depressive disorder: Characterizing early response and longitudinal nonresponse.

Kelley ME1, Dunlop BW2, Nemeroff CB3, Lori A2, Carrillo-Roa T4, Binder EB2,4, Kutner MH1, Rivera VA5, Craighead WE2,6, Mayberg HS1,7.

Author information

Abstract

BACKGROUND:

Definition of response is critical when seeking to establish valid predictors of treatment success. However, response at the end of study or endpoint only provides one view of the overall clinical picture that is relevant in testing for predictors. The current study employed a classification technique designed to group subjects based on their rate of change over time, while simultaneously addressing the issue of controlling for baseline severity.

METHODS:

A set of latent class trajectory analyses, incorporating baseline level of symptoms, were performed on a sample of 344 depressed patients from a clinical trial evaluating the efficacy of cognitive behavior therapy and two antidepressant medications (escitalopram and duloxetine) in patients with major depressive disorder.

RESULTS:

Although very few demographic and illness-related features were associated with response rate profiles, the aggregated effect of candidate genetic variants previously identified in large pharmacogenetic studies and meta-analyses showed a significant association with early remission as well as nonresponse. These same genetic scores showed a less compelling relationship with endpoint response categories. In addition, consistent nonresponse throughout the study treatment period was shown to occur in different subjects than endpoint nonresponse, which was verified by follow-up augmentation treatment outcomes.

CONCLUSIONS:

When defining groups based on the rate of change, controlling for baseline depression severity may help to identify the clinically relevant distinctions of early response on one end and consistent nonresponse on the other.

© 2018 Wiley Periodicals, Inc.

KEYWORDS:

CBT/cognitive behavior therapy; antidepressants; depression; genetics; treatment

PMID: 30260539 DOI: 10.1002/da.22832

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3.

Depress Anxiety. 2018 Sep;35(9):861-867. doi: 10.1002/da.22782. Epub 2018 Jun 7.

Employment characteristics, work environment, and the course of depression over 23 years: Does employment help foster resilience?

Heinz AJ1,2, Meffert BN1, Halvorson MA3, Blonigen D2,4, Timko C2,4, Cronkite R2,5,6.

Author information

Abstract

BACKGROUND:

Depression is the leading cause of disability and represents a significant challenge to stable employment and professional success. Importantly, employment may also operate as a protective factor against more chronic courses of depression as it can function as a form of behavioral activation and scaffold recovery by facilitating community integration. The current study examined work-related characteristics as protective or risk factors for subsequent long-term depression trajectories.

METHODS:

Relations between employment characteristics and lifetime course of depression were examined among 424 adults in the community who entered treatment for depression. The sample was followed for 23 years with assessments at 1, 4, 10, and 23 years post baseline. At baseline, participants were asked about employment history and status along with work-related events and aspects of their work environments. Depression was measured at each assessment, and three different life course trajectories of depression were identified.

RESULTS:

Employment at baseline was associated with lower levels of depression at baseline and less severe life courses of depression. Among employed participants, higher occupational prestige, a more supportive work environment (greater involvement, cohesion, and perceived support), and lower work stress (less pressure and more control, role clarity, and autonomy) may protect against more severe, intractable depression over time and may have bolstered functioning.

CONCLUSIONS:

Findings have potential to be harnessed for clinical translation to better inform vocational rehabilitation counseling and human resources programs. Specifically, clinician assessment of work setting can guide patient decision making about how to reduce vulnerability to depression and foster resilience via employment.

© 2018 Wiley Periodicals, Inc.

KEYWORDS:

depression; employment; occupational prestige; resilience; work environment

PMID: 29878482 PMCID: PMC6123281 DOI: 10.1002/da.22782

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4.

Cochrane Database Syst Rev. 2018 Apr 24;4:CD008581. doi: 10.1002/14651858.CD008581.pub2.

Antidepressants for the treatment of people with co-occurring depression and alcohol dependence.

Agabio R1, Trogu E, Pani PP.

Author information

Abstract

BACKGROUND:

Alcohol dependence is a major public health problem characterized by recidivism, and medical and psychosocial complications. The co-occurrence of major depression in people entering treatment for alcohol dependence is common, and represents a risk factor for morbidity and mortality, which negatively influences treatment outcomes.

OBJECTIVES:

To assess the benefits and risks of antidepressants for the treatment of people with co-occurring depression and alcohol dependence.

SEARCH METHODS:

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to July 2017. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA:

Randomized controlled trials and controlled clinical trials comparing antidepressants alone or in association with other drugs or psychosocial interventions (or both) versus placebo, no treatment, and other pharmacological or psychosocial interventions.

DATA COLLECTION AND ANALYSIS:

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS:

We included 33 studies in the review (2242 participants). Antidepressants were compared to placebo (22 studies), psychotherapy (two studies), other medications (four studies), or other antidepressants (five studies). The mean duration of the trials was 9.9 weeks (range 3 to 26 weeks). Eighteen studies took place in the USA, 12 in Europe, two in Turkey, and one in Australia. The antidepressant included in most of the trials was sertraline; other medications were amitriptyline, citalopram, desipramine, doxepin, escitalopram, fluoxetine, fluvoxamine, imipramine, mianserin, mirtazepine, nefazodone, paroxetine, tianeptine, venlafaxine, and viloxazine. Eighteen studies were conducted in an outpatient setting, nine in an inpatient setting, and six in both settings. Psychosocial treatment was provided in 18 studies. There was high heterogeneity in the selection of outcomes and the rating systems used for diagnosis and outcome assessment.Comparing antidepressants to placebo, low-quality evidence suggested that antidepressants reduced the severity of depression evaluated with interviewer-rated scales at the end of trial (14 studies, 1074 participants, standardized mean difference (SMD) -0.27, 95% confidence interval (CI) -0.49 to -0.04). However, the difference became non-significant after the exclusion of studies with a high risk of bias (SMD -0.17, 95% CI -0.39 to 0.04). In addition, very low-quality evidence supported the efficacy of antidepressants in increasing the response to the treatment (10 studies, 805 participants, risk ratio (RR) 1.40, 95% Cl 1.08 to 1.82). This result became non-significant after the exclusion of studies at high risk of bias (RR 1.27, 95% CI 0.96 to 1.68). There was no difference for other relevant outcomes such as the difference between baseline and final score, evaluated using interviewer-rated scales (5 studies, 447 participants, SMD 0.15, 95% CI -0.12 to 0.42).Moderate-quality evidence found that antidepressants increased the number of participants abstinent from alcohol during the trial (7 studies, 424 participants, RR 1.71, 95% Cl 1.22 to 2.39) and reduced the number of drinks per drinking days (7 studies, 451 participants, mean difference (MD) -1.13 drinks per drinking days, 95% Cl -1.79 to -0.46). After the exclusion of studies with high risk of bias, the number of abstinent remained higher (RR 1.69, 95% CI 1.18 to 2.43) and the number of drinks per drinking days lower (MD -1.21 number of drinks per drinking days, 95% CI -1.91 to -0.51) among participants who received antidepressants compared to those who received placebo. However, other outcomes such as the rate of abstinent days did not differ between antidepressants and placebo (9 studies, 821 participants, MD 1.34, 95% Cl -1.66 to 4.34; low-quality evidence).Low-quality evidence suggested no differences between antidepressants and placebo in the number of dropouts (17 studies, 1159 participants, RR 0.98, 95% Cl 0.79 to 1.22) and adverse events as withdrawal for medical reasons (10 studies, 947 participants, RR 1.15, 95% Cl 0.65 to 2.04).There were few studies comparing one antidepressant versus another antidepressant or antidepressants versus other interventions, and these had a small sample size and were heterogeneous in terms of the types of interventions that were compared, yielding results that were not informative.

AUTHORS' CONCLUSIONS:

We found low-quality evidence supporting the clinical use of antidepressants in the treatment of people with co-occurring depression and alcohol dependence. Antidepressants had positive effects on certain relevant outcomes related to depression and alcohol use but not on other relevant outcomes. Moreover, most of these positive effects were no longer significant when studies with high risk of bias were excluded. Results were limited by the large number of studies showing high or unclear risk of bias and the low number of studies comparing one antidepressant to another or antidepressants to other medication. In people with co-occurring depression and alcohol dependence, the risk of developing adverse effects appeared to be minimal, especially for the newer classes of antidepressants (such as selective serotonin reuptake inhibitors). According to these results, in people with co-occurring depression and alcohol dependence, antidepressants may be useful for the treatment of depression, alcohol dependence, or both, although the clinical relevance may be modest.

PMID: 29688573 PMCID: PMC6494437 DOI: 10.1002/14651858.CD008581.pub2

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5.

Am J Psychiatry. 2017 Jun 1;174(6):546-556. doi: 10.1176/appi.ajp.2016.16050517. Epub 2017 Mar 24.

Effects of Patient Preferences on Outcomes in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) Study.

Dunlop BW1, Kelley ME1, Aponte-Rivera V1, Mletzko-Crowe T1, Kinkead B1, Ritchie JC1, Nemeroff CB1, Craighead WE1, Mayberg HS1; PReDICT Team1.

Author information

Abstract

OBJECTIVE:

The Predictors of Remission in Depression to Individual and Combined Treatments [PReDICT] study aimed to identify clinical and biological factors predictive of treatment outcomes in major depressive disorder among treatment-naive adults. The authors evaluated the efficacy of cognitive-behavioral therapy (CBT) and two antidepressant medications (escitalopram and duloxetine) in patients with major depression and examined the moderating effect of patients' treatment preferences on outcomes.

METHOD:

Adults aged 18-65 with treatment-naive major depression were randomly assigned with equal likelihood to 12 weeks of treatment with escitalopram (10-20 mg/day), duloxetine (30-60 mg/day), or CBT (16 50-minute sessions). Prior to randomization, patients indicated whether they preferred medication or CBT or had no preference. The primary outcome was change in the 17-item Hamilton Depression Rating Scale (HAM-D), administered by raters blinded to treatment.

RESULTS:

A total of 344 patients were randomly assigned, with a mean baseline HAM-D score of 19.8 (SD=3.8). The mean estimated overall decreases in HAM-D score did not significantly differ between treatments (CBT: 10.2, escitalopram: 11.1, duloxetine: 11.2). Last observation carried forward remission rates did not significantly differ between treatments (CBT: 41.9%, escitalopram: 46.7%, duloxetine: 54.7%). Patients matched to their preferred treatment were more likely to complete the trial but not more likely to achieve remission.

CONCLUSIONS:

Treatment guidelines that recommend either an evidence-based psychotherapy or antidepressant medication for nonpsychotic major depression can be extended to treatment-naive patients. Treatment preferences among patients without prior treatment exposure do not significantly moderate symptomatic outcomes.

KEYWORDS:

Antidepressants; Cognitive Therapy; Mood Disorders-Unipolar; Outcome Studies

Comment in

Engaging Depressed Patients: An Essential Step in Optimizing Care. [Am J Psychiatry. 2017]

PMID: 28335624 DOI: 10.1176/appi.ajp.2016.16050517

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6.

Maturitas. 2014 Oct;79(2):147-52. doi: 10.1016/j.maturitas.2014.05.026. Epub 2014 Jun 7.

Late-life depression in the primary care setting: challenges, collaborative care, and prevention.

Hall CA1, Reynolds-Iii CF2.

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Abstract

Late-life depression is highly prevalent worldwide. In addition to being a debilitating illness, it is a risk factor for excess morbidity and mortality. Older adults with depression are at risk for dementia, coronary heart disease, stroke, cancer and suicide. Individuals with late-life depression often have significant medical comorbidity and, poor treatment adherence. Furthermore, psychosocial considerations such as gender, ethnicity, stigma and bereavement are necessary to understand the full context of late-life depression. The fact that most older adults seek treatment for depression in primary care settings led to the development of collaborative care interventions for depression. These interventions have consistently demonstrated clinically meaningful effectiveness in the treatment of late-life depression. We describe three pivotal studies detailing the management of depression in primary care settings in both high and low-income countries. Beyond effectively treating depression, collaborative care models address additional challenges associated with late-life depression. Although depression treatment interventions are effective compared to usual care, they exhibit relatively low remission rates and small to medium effect sizes. Several studies have demonstrated that depression prevention is possible and most effective in at-risk older adults. Given the relatively modest effects of treatment in averting years lived with disability, preventing late-life depression at the primary care level should be highly prioritized as a matter of health policy.

Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

KEYWORDS:

Collaborative care; Depression prevention; Late-life depression; Primary care; Treatment of depression

PMID: 24996484 PMCID: PMC4169311 DOI: 10.1016/j.maturitas.2014.05.026

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7.

Health Technol Assess. 2001;5(21):1-75.

Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care.

Marshall M1, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H, Roberts C, Hill E, Wiersma D, Bond GR, Huxley P, Tyrer P.

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Abstract

***ACUTE DAY HOSPITAL VERSUS ADMISSION FOR ACUTE PSYCHIATRIC DISORDERS***

BACKGROUND:

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVE:

The aim of this review was to assess the effectiveness and feasibility of day hospital versus inpatient care for people with acute psychiatric disorders.

METHODS - STUDY SELECTION:

Eligible studies were randomised controlled trials of day hospital versus inpatient care for people with acute psychiatric disorders. Studies were excluded if they were primarily concerned with elderly people, children, or patients with a diagnosis of organic brain disease or substance abuse. METHODS - DATA SOURCES: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: Data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise the data. Individual patient data were therefore sought so that outcomes could be re-analysed using a common format.

RESULTS:

Nine trials met the inclusion criteria (involving 1568 randomised patients and 2268 assessed for suitability of day hospital treatment). Individual patient data were obtained for four trials (involving 594 people). A sensitivity analysis of combined data suggested that day hospital treatment was feasible for at worst 23.2% (n = 2268; 95% CI, 21.2 to 25.2) and at best 37.5% (n = 1768; 95% CI, 35.2 to 39.8) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital (combining day hospital days and inpatient days) between day hospital patients and controls (n = 465; weighted mean difference (WMD) = -0.38 days/ month; 95% CI, -1.32 to 0.55). However, compared with controls, patients randomised to day hospital care spent significantly more days in day hospital care (n = 265; WMD = 2.34 days/month; 95% CI, 1.97 to 2.70) and significantly fewer days in inpatient care (n = 265; WMD = -2.75 days/month; 95% CI, -3.63 to -1.87). There was no difference between readmission rates for day hospital and control patients (n = 667; RR = 0.91; 95% CI, 0.72 to 1.15). Individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n = 407; c2 = 9.66; p = 0.002), but not social functioning (n = 295; c2 = 0.006; p = 0.941) amongst day hospital patients. Four of five trials demonstrated that day hospital care was cheaper than inpatient care (with overall cost reductions ranging from 20.9% to 36.9%).

CONCLUSIONS:

Acute day hospitals are an attractive option in situations where demand for inpatient care is high and facilities exist that are suitable for conversion. They are a less attractive option when demand for inpatient care is low and where effective alternatives already exist. The interpretation of day hospital research would be enhanced if future trials made use of the common set of outcome measures used in this review. It is important to examine how acute day hospital care can be most effectively integrated into a modern community-based psychiatric service. ***VOCATIONAL REHABILITATION FOR PEOPLE WITH SEVERE MENTAL DISORDERS***

BACKGROUND:

People who are disabled by severe mental disorders experience high rates of unemployment, but most want to work. Prevocational training (PVT) is the traditional approach to helping such people to return to work. PVT assumes that a period of preparation is required before those with a severe mental disorder can enter into competitive employment. Supported Employment (SEm) is a new approach that places clients in competitive employment without extended preparation. Both PVT and SEm are widely practised, but it is unclear which is the most effective.

OBJECTIVES:

The overall objective of this review was to assess the effectiveness of PVT and SEm relative to each other and to standard care (in hospital or the community) for people with severe mental disorders. In addition, the review examined the effectiveness of: (1) special types of PVT ("clubhouse" model) and SEm (individual placement and support model); and (2) modifications for enhancing PVT (e.g. payment or psychological interventions).

METHODS - STUDY SELECTION:

Eligible studies were randomised controlled trials (RCTs) examining the effectiveness of vocational rehabilitation approaches (PVT and SEm or modifications) for people of working age and suffering from a severe mental disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Schizophrenia Group's specialised register, MEDLINE, EMBASE, CINAHL and PsycLIT, and the reference lists of all identified studies and review articles. Researchers who were active in the field were approached in order to identify unpublished studies. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. Continuous data were excluded if they were collected by using an unpublished scale or were based on a subset of items from a scale. METHODS - DATA SYNTHESIS: For all comparisons, the primary outcome was the number of clients who were in competitive employment at various time points. Secondary outcomes were: other employment outcomes, clinical outcome and costs. The relative risk (RR) and number-needed-to-treat (NNT) were calculated for the relevant categorical outcomes. Continuous data were either presented as in the original trial reports or, where possible, combined across trials as a standardised mean difference score.

RESULTS:

Eighteen RCTs of reasonable quality were identified: PVT versus hospital controls, three RCTs, n = 172; PVT versus community controls, five RCTs, n = 1204; modified PVT, four RCTs, n = 423; SEm versus community controls, one RCT, n = 256; and SEm versus PVT, five RCTs, n = 491). The main finding was that, on the primary outcome (number in competitive employment), SEm was significantly more effective than PVT at all time points (e.g. at 12 months, SEm 34% employed, PVT 12% employed; RR of not being in competitive employment = 0.76, 95% confidence interval 0.69 to 0.84, NNT = 4.5). Clients in SEm also earned more and worked more hours per month than those in PVT.

CONCLUSIONS:

The main finding was that SEm was more effective than PVT for patients suffering from a severe mental disorder who wanted to work. There was no evidence that PVT was more effective than standard community care or hospital care. The implication of these findings is that people suffering from mental disorders who want to work should be offered the option of SEm. Commissioning agencies would be justified in encouraging vocational rehabilitation (VR) providers to develop more SEm schemes. From a research perspective, the cost-effectiveness of SEm should be examined in larger multicentre trials, both within and outside the USA. There is a case for countries outside the USA to survey their existing VR services to determine the extent to which the most effective interventions are being offered. ***DAY HOSPITAL VERSUS OUTPATIENT CARE FOR PATIENTS WITH PSYCHIATRIC DISORDERS***

BACKGROUND:

This review considers the use of day hospitals as an alternative to outpatient care. Two typesof day hospital provision are covered: "day treatment programmes" and "day care centres". Day treatment programmes are day hospitals that are used to enhance the treatment of patients with anxiety or depressive disorders who have failed to respond to outpatient care. Day care centres are day hospitals that offer structured support to patients with long-term severe mental disorders who would otherwise be treated in an outpatient clinic.

OBJECTIVES:

There were two objectives: first, to assess the effectiveness of day treatment programmes versus outpatient care for people with non-psychotic disorders; and, secondly, to assess the effectiveness of day care centres versus outpatient care for people with severe long-term disorders.

METHODS - STUDY SELECTION:

Eligible studies were randomised controlled trials comparing day hospital care (either a day treatment programme or a day care centre) with outpatient care. Studies were ineligible if they were largely restricted to patients who were aged under 18 or over 65 years or who had a primary diagnosis of substance abuse or organic brain disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of all identified studies and review articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risks and 95% confidence intervals were calculated for dichotomous data. Standardised mean differences were calculated for continuous data.

RESULTS:

There was evidence from two of the five trials identified suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence to suggest that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable or on costs. (ABSTRACT TRUNCATED)