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Cognitive-behavioural therapy (CBT) is an effective treatment for depressed adults. CBT interventions are complex, as they include multiple content components and can be delivered in different ways. We compared the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT interventions for adult depression. We conducted a systematic review of randomised controlled trials in adults with a primary diagnosis of depression, which included a CBT intervention. Outcomes were pooled using a component-level network meta-analysis. Our primary analysis classified interventions according to the type of therapy and delivery mode. We also fitted more advanced models to examine the effectiveness of each content component or combination of components. We included 91 studies and found strong evidence that CBT interventions yielded a larger short-term decrease in depression scores compared to treatment-as-usual, with a standardised difference in mean change of −1.11 (95% credible interval −1.62 to −0.60) for face-to-face CBT, −1.06 (−2.05 to −0.08) for hybrid CBT, and −0.59 (−1.20 to 0.02) for multimedia CBT, whereas wait list control showed a detrimental effect of 0.72 (0.09 to 1.35). We found no evidence of specific effects of any content components or combinations of components. Technology is increasingly used in the context of CBT interventions for depression. Multimedia and hybrid CBT might be as effective as face-to-face CBT, although results need to be interpreted cautiously. The effectiveness of specific combinations of content components and delivery formats remain unclear. Wait list controls should be avoided if possible.

Abstract Background and Hypothesis Antipsychotics are first-line drug treatments for schizophrenia. When antipsychotic monotherapy is ineffective, combining two antipsychotic drugs is common although treatment guidelines warn of possible increases in side effects. Risks of metabolic side effects with antipsychotic polypharmacy have not been fully investigated. This study examined associations between antipsychotic polypharmacy and risk of developing diabetes, hypertension, or hyperlipidemia in adults with schizophrenia, and impact of co-prescription of first- and second-generation antipsychotics. Study Design A population-based prospective cohort study was conducted in the United Kingdom using linked primary care, secondary care, mental health, and social deprivation datasets. Cox proportional hazards models with stabilizing weights were used to estimate risk of metabolic disorders among adults with schizophrenia, comparing patients on antipsychotic monotherapy vs polypharmacy, adjusting for demographic and clinical characteristics, and antipsychotic dose. Study Results Median follow-up time across the three cohorts was approximately 14 months. 6.6% developed hypertension in the cohort assembled for this outcome, with polypharmacy conferring an increased risk compared to monotherapy, (adjusted Hazard Ratio = 3.16; P = .021). Patients exposed to exclusive first-generation antipsychotic polypharmacy had greater risk of hypertension compared to those exposed to combined first- and second-generation polypharmacy (adjusted HR 0.29, P = .039). No associations between polypharmacy and risk of diabetes or hyperlipidemia were found. Conclusions Antipsychotic polypharmacy, particularly polypharmacy solely comprised of first-generation antipsychotics, increased the risk of hypertension. Future research employing larger samples, follow-up longer than the current median of 14 months, and more complex methodologies may further elucidate the association reported in this study.

To investigate the effectiveness of combining mirtazapine with serotonin-noradrenaline reuptake inhibitor (SNRI) or selective serotonin reuptake inhibitor (SSRI) antidepressants for treatment resistant depression in primary care. Two parallel group multicentre phase III randomised placebo controlled trial. 106 general practices in four UK sites; Bristol, Exeter, Hull, and Keele/North Staffs, August 2013 to October 2015. 480 adults aged 18 or more years who scored 14 or more on the Beck depression inventory, second revision, fulfilled ICD-10 (international classification of diseases, 10th revision) criteria for depression, and had used an SSRI or SNRI for at least six weeks but were still depressed. 241 were randomised to mirtazapine and 239 to placebo, both given in addition to usual SSRI or SNRI treatment. Participants were stratified by centre and minimised by baseline Beck depression inventory score, sex, and current psychological therapy. They were followed up at 12, 24, and 52 weeks. 431 (89.8%) were included in the (primary) 12 week follow-up. Depressive symptoms at 12 weeks after randomisation, measured using the Beck depression inventory II score as a continuous variable. Secondary outcomes included measures of anxiety, quality of life, and adverse effects at 12, 24, and 52 weeks. Beck depression inventory II scores at 12 weeks were lower in the mirtazapine group after adjustment for baseline scores and minimisation or stratification variables, although the confidence interval included the null (mean (SD) scores at 12 weeks: 18.0 (12.3) in the mirtazapine group, 19.7 (12.4) in the placebo group; adjusted difference between means -1.83 (95% confidence interval -3.92 to 0.27); P=0.09). Adverse effects were more common in the mirtazapine group and were associated with the participants stopping the trial drug. This study did not find evidence of a clinically important benefit for mirtazapine in addition to an SSRI or SNRI over placebo in a treatment resistant group of primary care patients with depression. This remains an area of important unmet need where evidence of effective treatment options is limited. Current Controlled Trials ISRCTN06653773.

A bstract We examine values of the Adinkra Holoraumy-induced Gadget representation space metric over all possible four-color, four-open node, and four-closed node adinkras. Of the 1,358,954,496 gadget matrix elements, only 226,492,416 are non-vanishing and take on one of three values: −1/3, 1/3, or 1 and thus a subspace isomorphic to a description of a body-centered tetrahedral molecule emerges.

Smoking rates in people with depression and anxiety are twice as high as in the general population, even though people with depression and anxiety are motivated to stop smoking. Most healthcare professionals are aware that stopping smoking is one of the greatest changes that people can make to improve their health. However, smoking cessation can be a difficult topic to raise. Evidence suggests that smoking may cause some mental health problems, and that the tobacco withdrawal cycle partly contributes to worse mental health. By stopping smoking, a person's mental health may improve, and the size of this improvement might be equal to taking antidepressants. In this article we outline ways in which healthcare professionals can compassionately and respectfully raise the topic of smoking to encourage smoking cessation. We draw on evidence-based methods such as cognitive–behavioural therapy (CBT) and outline approaches that healthcare professionals can use to integrate these methods into routine care to help their patients stop smoking.

Background Engaging clients in psychotherapy by managing their expectations is important for therapeutic success. Initial moments in first sessions of therapy are thought to afford an opportunity to establish a shared understanding of how therapy will proceed. However, there is little evidence from analysis of actual sessions of therapy to support this. Objective This study utilised recorded session logs to examine how therapists manage clients’ expectations during the first two sessions of online Cognitive Behavioural Therapy (CBT). Methods Expectation management was investigated through conversation analysis of sessions from 176 client‐therapist dyads involved in online CBT. The primary focus of analysis was expectation management during the initial moments of first sessions, with a secondary focus on expectations at subsequent points. Analysis Clients’ expectations for therapy were most commonly managed during the initial moments of first sessions of therapy. At this point, most therapists either produced a description outlining the tasks of the first and subsequent sessions (n = 36) or the first session only (n = 108). On other occasions (n = 32), no attempt was made to manage clients’ expectations by outlining what would happen in therapy. Observations of the interactional consequences of such an absence suggest clients may struggle to engage with the therapeutic process in the absence of appropriate expectation management by therapists. Conclusion Clients may more readily engage from the outset of therapy when provided with an explanation that manages their expectation of what is involved. Therapists can accomplish this by projecting how therapy will proceed, particularly beyond the initial session.

Background: Engaging clients from the outset of psychotherapy is important for therapeutic success. However, there is little research evaluating therapists’ initial attempts to engage clients in the therapeutic process. This article reports retrospective analysis of data from a trial of online cognitive behavioural therapy (CBT) for depression. Qualitative and quantitative methods were used to evaluate how therapists manage clients’ expectations at the outset of therapy and its relationship with client retention in the therapeutic intervention. Aims: To develop a system to codify expectation management in initial sessions of online CBT and evaluate its relationship with retention. Method: Initial qualitative research using conversation analysis identified three communication practices used by therapists at the start of first sessions: no expectation management, some expectation management, and comprehensive expectation management. These findings were developed into a coding scheme that enabled substantial inter-rater agreement (weighted Kappa = 0.78; 95% CI: 0.52 to 0.94) and was applied to all trial data. Results: Adjusting for a range of client variables, primary analysis of data from 147 clients found comprehensive expectation management was associated with clients remaining in therapy for 1.4 sessions longer than those who received no expectation management (95% CI: -0.2 to 3.0). This finding was supported by a sensitivity analysis including an additional 21 clients (1.6 sessions, 95% CI: 0.2 to 3.1). Conclusions: Using a combination of qualitative and quantitative methods, this study suggests a relationship between expectation management and client retention in online CBT for depression, which has implications for professional practice. A larger prospective study would enable a more precise estimate of retention.

Prevalence of Diabetes Is Higher Among Female than Male Zuni Indians Marina Scavini , MD 1 2 , Christine A. Stidley , PHD 1 3 , Vallabh O. Shah , PHD 4 , Andrew S. Narva , MD 5 , Francesca Tentori , MD 4 6 , David S. Kessler , MD 7 , Arlene Bobelu , BS 1 , Carleton P. Albert , BS 4 , Jeanette Bobelu , BSN 4 , Eunice Jamon , LPN 4 , Kathy Natachu 4 , Donica Neha , BSN 4 , Mildred Waikaniwa 4 , Thomas K. Welty , MD 4 , Jean W. MacCluer , PHD 8 and Philip G. Zager , MD 4 1 Dialysis Clinic, Inc., Albuquerque, New Mexico 2 H. San Raffaele Scientific Institute, Milan, Italy 3 Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico 4 Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico 5 Kidney Disease Program, Indian Health Service, Albuquerque, New Mexico 6 Universita’ degli Studi di Milano, Scuola di Specializzazione in Nefrologia, Milan, Italy 7 Zuni Indian Hospital, Zuni Pueblo, New Mexico 8 Southwest Foundation for Biomedical Research, San Antonio, Texas Abstract OBJECTIVE —Test the hypothesis that diabetes and related risk factors are more common among female than male Zuni Indians. RESEARCH DESIGN AND METHODS —We conducted a population-based, cross-sectional survey of the Zuni Indians aged ≥5 years. We used households within neighborhood clusters as the sampling frame. We administered a questionnaire, collected blood and urine, and measured height and weight. Self-reported diabetes was used to assess previously diagnosed diabetes. Participants without a prior history of diabetes were classified as having newly diagnosed diabetes if they had HbA 1c >7.0% or random glucose ≥11.1 mmol/l during the survey. RESULTS —The prevalence of previously diagnosed diabetes among Zuni Indians aged ≥5 years ( n = 1,503) was higher among female Zuni Indians (16.7% [95% CI 14.1–19.3]) than male Zuni Indians (9.7% [7.4–12.1]) ( P < 0.001). The prevalence of newly diagnosed diabetes was similar among female Zuni Indians (2.4% [1.4–3.4]) and male Zuni Indians (2.4% [1.2–3.6]). The prevalence of previously and newly diagnosed diabetes was higher among female Zuni Indians (19.1% [16.4–21.9]) than male Zuni Indians (12.2% [9.5–14.8]) ( P < 0.001). The prevalence of obesity was higher among female Zuni Indians (34.3% [30.9–37.7]) than male Zuni Indians (21.5% [18.4–24.7]) ( P < 0.001). Obesity was associated with diabetes among female and male Zuni Indians. Physical inactivity was more common among female Zuni Indians (44.2% [40.7–47.8]) than male Zuni Indians (35.1% [31.5–38.7]) ( P < 0.001). However, physical inactivity was not associated with diabetes among either female or male Zuni Indians. Gestational diabetes was a risk factor among female Zuni Indians. CONCLUSIONS —Among the Zuni Indians, the prevalence of diabetes was 57% higher among female than male members of the population. Culture, tradition, and lifestyle differences may contribute to the higher prevalence of diabetes and obesity among female Zuni Indians. GDM, gestational diabetes mellitus IQR, interquartile range OR, odds ratio PBCSS, population-based cross-sectional survey SHS, Strong Heart Study ZTC, Zuni Tribal Census Footnotes Address correspondence and reprint requests to Philip G. Zager, MD, UNM Nephrology ACC5, Albuquerque, NM 87131-5271. E-mail: pzag{at}unm.edu . Received for publication 3 March 2002 and accepted in revised form 7 October 2002. Opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Indian Health Service. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. DIABETES CARE

Kidney disease among the Zuni Indians: The Zuni Kidney Project. There is an epidemic of kidney disease among the Zuni Indians. In collaboration with health care providers and research institutions, the Zuni Pueblo established the Zuni Kidney Project to reduce the burden of kidney disease. The Zuni Kidney Project conducted a population-based, cross-sectional survey to estimate the prevalence of albuminuria, hematuria, and related risk factors. Neighborhood household clusters served as the sampling frame. Participants completed a questionnaire, donated blood and urine samples, and had blood pressure, height, and weight measured. This survey provided the foundation for ongoing studies to identify genetic and environmental risk factors for disease susceptibility and progression. Age and gender distributions among survey participants were similar to those in the eligible Zuni population. Prevalence of incipient albuminuria (IA) (0.03≤ urine albumin:creatinine ratio, UACR <0.3) and overt albuminuria (OA) (UACR <0.3) were higher among diabetics [IA 34.3% (28.3, 40.4%); OA 18.6% (13.7, 23.6%)] than nondiabetics [IA 11.1% (9.3, 12.8%); OA 1.7% (1.0, 2.5%)]. Nondiabetics comprised 58.6% (52.2, 65.0%) and 30.9% (19.9, 41.9%) of participants with IA and OA, respectively. The prevalence of hematuria was higher among diabetics [≥ trace 47.0% (40.7, 53.4); ≥50 red blood cell/μL 25.8% (20.3, 31.4%)] than nondiabetics [≥ trace 31.1% (28.5, 33.7%); ≥50 red blood cell/μL 16.6% (14.5, 18.7%)]. Hypertension was associated with albuminuria among diabetic and nondiabetic participants. Hypercholesterolemia was associated with albuminuria among nondiabetic participants. Diabetes and alcohol use were associated with hematuria. The high prevalences of albuminuria among nondiabetics and of hematuria among diabetics and nondiabetics are consistent with high rates of nondiabetic kidney disease among Zuni Indians with and without diabetes.