Search tips
Search criteria

Results 1-25 (26)

Clipboard (0)

Select a Filter Below

Year of Publication
more »
1.  Anhedonia in melancholic and non-melancholic depressive disorders 
Anhedonia represents a core symptom of major depression and may be a potential marker for melancholia. However, current understanding of this construct in depressive sub-types is limited.
Participants were recruited from the Black Dog Institute (Sydney) and Massachusetts General Hospital (Boston). Diagnostic groups were derived on the basis of agreement between clinician and DSM-IV diagnosis from structured interviews. Currently depressed unipolar melancholic, non-melancholic and healthy control participants were administered a probabilistic reward task (PRT) to assess a behavioural correlate of anhedonia - blunted reward-based learning. Self-reported measures of anhedonia, approach and avoidance motivation were completed by the Sydney sample.
Relative to healthy controls and non-melancholic participants, melancholic depressed participants had reduced response bias, highlighting blunted reward learning. Moreover, although non-melancholic participants were characterized by a delayed response bias, melancholic depressed participants failed to develop a bias throughout blocks. Response bias showed no associations with self-report measures of hedonic tone in depressed participants. Positive associations were observed between response bias, approach and avoidance motivation in non-melancholic participants only.
Possible medication, fatigue and anxiety effects were not controlled; small sample sizes; inclusion criteria may have excluded those with severe melancholia and led to underestimation of group differences.
Melancholia is characterised by a reduced ability to modulate behaviour as a function of reward, and the motivational salience of rewarding stimuli may differ across depressive sub-types. Results support the view that melancholia is a distinct sub-type. Further exploration of reward system functioning in depressive sub-types is warranted.
PMCID: PMC4519400  PMID: 26074016
Melancholic; non-melancholic; depression; anhedonia; reward responsiveness; motivation
2.  Cross-Cultural Detection of Depression from Nonverbal Behaviour 
Millions of people worldwide suffer from depression. Do commonalities exist in their nonverbal behavior that would enable cross-culturally viable screening and assessment of severity? We investigated the generalisability of an approach to detect depression severity cross-culturally using video-recorded clinical interviews from Australia, the USA and Germany. The material varied in type of interview, subtypes of depression and inclusion healthy control subjects, cultural background, and recording environment. The analysis focussed on temporal features of participants‘ eye gaze and head pose. Several approaches to training and testing within and between datasets were evaluated. The strongest results were found for training across all datasets and testing across datasets using leave-one-subject-out cross-validation. In contrast, generalisability was attenuated when training on only one or two of the three datasets and testing on subjects from the dataset(s) not used in training. These findings highlight the importance of using training data exhibiting the expected range of variability.
PMCID: PMC4955623  PMID: 27453895
3.  Therapeutic Alliance With a Fully Automated Mobile Phone and Web-Based Intervention: Secondary Analysis of a Randomized Controlled Trial 
JMIR Mental Health  2016;3(1):e10.
Studies of Internet-delivered psychotherapies suggest that clients report development of a therapeutic alliance in the Internet environment. Because a majority of the interventions studied to date have been therapist-assisted to some degree, it remains unclear whether a therapeutic alliance can develop within the context of an Internet-delivered self-guided intervention with no therapist support, and whether this has consequences for program outcomes.
This study reports findings of a secondary analysis of data from 90 participants with mild-to-moderate depression, anxiety, and/or stress who used a fully automated mobile phone and Web-based cognitive behavior therapy (CBT) intervention called “myCompass” in a recent randomized controlled trial (RCT).
Symptoms, functioning, and positive well-being were assessed at baseline and post-intervention using the Depression, Anxiety and Stress Scale (DASS), the Work and Social Adjustment Scale (WSAS), and the Mental Health Continuum-Short Form (MHC-SF). Therapeutic alliance was measured at post-intervention using the Agnew Relationship Measure (ARM), and this was supplemented with qualitative data obtained from 16 participant interviews. Extent of participant engagement with the program was also assessed.
Mean ratings on the ARM subscales were above the neutral midpoints, and the interviewees provided rich detail of a meaningful and collaborative therapeutic relationship with the myCompass program. Whereas scores on the ARM subscales did not correlate with treatment outcomes, participants’ ratings of the quality of their emotional connection with the program correlated significantly and positively with program logins, frequency of self-monitoring, and number of treatment modules completed (r values between .32-.38, P≤.002). The alliance (ARM) subscales measuring perceived empowerment (r=.26, P=.02) and perceived freedom to self-disclose (r=.25, P=.04) also correlated significantly in a positive direction with self-monitoring frequency.
Quantitative and qualitative findings from this analysis showed that a positive therapeutic alliance can develop in the Internet environment in the absence of therapist support, and that components of the alliance may have implications for program usage. Further investigation of alliance features in the Internet environment and the consequences of these for treatment outcomes and user engagement is warranted.
Trial Registration
Australian New Zealand Clinical Trials Registry Number (ACTRN): 12610000625077; (Archived by WebCite at
PMCID: PMC4786687  PMID: 26917096
therapeutic alliance; e-therapy; Internet interventions; depression; computerized cognitive behavior therapy
4.  Scene unseen: Disrupted neuronal adaptation in melancholia during emotional film viewing 
NeuroImage : Clinical  2015;9:660-667.
Impairments in attention and concentration are distinctive features of melancholic depression, and may diminish the ability to shift focus away from internal dysphoric states. Disrupted brain networks may underlie the inability to effectively disengage from interoceptive signals in this disorder. This study investigates changes in effective connectivity between cortical systems supporting attention, interoception, and perception in those with melancholic depression when shifting attention from rest to viewing dynamic film stimuli. We hypothesised that those with melancholia would show impaired attentional shifting from rest to emotional film viewing, captured in neuronal states that differed little across conditions. Functional magnetic resonance imaging (fMRI) data were acquired from 48 participants (16 melancholic depressed, 16 non-melancholic depressed, and 16 healthy controls) at rest and whilst viewing emotionally salient movies. Using independent component analysis, we identified 8 cortical modes (default mode, executive control, left/right frontoparietal attention, left/right insula, visual and auditory) and studied their dynamics using dynamic causal modelling. Engagement with dynamic emotional material diminished in melancholia and was associated with network-wide increases in effective connectivity. Melancholia was also characterised by an increase in effective connectivity amongst cortical regions involved in attention and interoception when shifting from rest to negative film viewing, with the converse pattern in control participants. The observed involvement of attention- and insula-based cortical systems highlights a potential neurobiological mechanism for disrupted attentional resource allocation, particularly in switching between interoceptive and exteroceptive signals, in melancholia.
•Neurobiology of impaired attention, a key feature of melancholia, is unknown.•Effective connectivity increased in melancholia when shifting attention.•Disrupted connectivity was amongst regions supporting attention and interoception.•May reflect disrupted neuronal adaptation during processing of dynamic emotion.•Synchronisation of BOLD and neuronal states during film viewing validates approach.
PMCID: PMC4660155  PMID: 26740919
Attention; Dynamic causal modelling; Film viewing; fMRI; Interoception; Melancholic depression
5.  Out-of-sync: disrupted neural activity in emotional circuitry during film viewing in melancholic depression 
Scientific Reports  2015;5:11605.
While a rich body of research in controlled experiments has established changes in the neural circuitry of emotion in major depressive disorders, little is known as to how such alterations might translate into complex, naturalistic settings - namely involving dynamic multimodal stimuli with rich contexts, such as those provided by films. Neuroimaging paradigms employing dynamic natural stimuli alleviate the anxiety often associated with complex tasks and eschew the need for laboratory-style abstractions, hence providing an ecologically valid means of elucidating neural underpinnings of neuropsychiatric disorders. To probe the neurobiological signature of refined depression subtypes, we acquired functional neuroimaging data in patients with the melancholic subtype of major depressive disorder during free viewing of emotionally salient films. We found a marked disengagement of ventromedial prefrontal cortex during natural viewing of a film with negative emotional valence in patients with melancholia. This effect significantly correlated with depression severity. Such changes occurred on the background of diminished consistency of neural activity in visual and auditory sensory networks, as well as higher-order networks involved in emotion and attention, including bilateral intraparietal sulcus and right anterior insula. These findings may reflect a failure to re-allocate resources and diminished reactivity to external emotional stimuli in melancholia.
PMCID: PMC4481375  PMID: 26112251
6.  The validity of a food frequency questionnaire as a measure of PUFA status in pregnancy 
Nutritional studies have found conflicting evidence regarding the ability of Food Frequency Questionnaires (FFQs) to demonstrate convergent validity with tissue content of omega-3 and omega-6 polyunsaturated fatty acids (PUFAs). We therefore sought to assess the convergent validity of a FFQ strategy when compared with a blood biomarker of PUFA levels in a sample of pregnant women.
A previously validated PUFA FFQ was completed by 895 pregnant women and compared to erythrocyte membrane of six PUFA variables.
Four of the six correlations were found to be formally significant, however two of these demonstrated minimal associational strength. Moderate-high correlations between the FFQ-derived PUFA intake estimates and blood biomarker PUFA levels were shown only for eicosapentaenoic acid (EPA; 0.55) and docosahexaenoic acid (DHA; 0.61).
Overall, the correlations were lower than those found in general population studies. Findings suggest biological estimates, such as blood samples, may be most appropriate to measure PUFA levels above indirect strategies such as an FFQ in this population. The results, if an indirect strategy is unavoidable, indicate specific PUFAs where an FFQ strategy may be most informative.
PMCID: PMC4367853  PMID: 25885465
Food frequency questionnaire; Polyunsaturated fatty acid; Biomarkers; Pregnancy
7.  Breaking Open the Black Box: Isolating the Most Potent Features of a Web and Mobile Phone-Based Intervention for Depression, Anxiety, and Stress 
JMIR Mental Health  2015;2(1):e3.
Internet-delivered mental health (eMental Health) interventions produce treatment effects similar to those observed in face-to-face treatment. However, there is a large degree of variation in treatment effects observed from program to program, and eMental Health interventions remain somewhat of a black box in terms of the mechanisms by which they exert their therapeutic benefit. Trials of eMental Health interventions typically use large sample sizes and therefore provide an ideal context within which to systematically investigate the therapeutic benefit of specific program features. Furthermore, the growth and impact of mobile phone technology within eMental Health interventions provides an opportunity to examine associations between symptom improvement and the use of program features delivered across computer and mobile phone platforms.
The objective of this study was to identify the patterns of program usage associated with treatment outcome in a randomized controlled trial (RCT) of a fully automated, mobile phone- and Web-based self-help program, “myCompass”, for individuals with mild-to-moderate symptoms of depression, anxiety, and/or stress. The core features of the program include interactive psychotherapy modules, a symptom tracking feature, short motivational messages, symptom tracking reminders, and a diary, with many of these features accessible via both computer and mobile phone.
Patterns of program usage were recorded for 231 participants with mild-to-moderate depression, anxiety, and/or stress, and who were randomly allocated to receive access to myCompass for seven weeks during the RCT. Depression, anxiety, stress, and functional impairment were examined at baseline and at eight weeks.
Log data indicated that the most commonly used components were the short motivational messages (used by 68.4%, 158/231 of participants) and the symptom tracking feature (used by 61.5%, 142/231 of participants). Further, after controlling for baseline symptom severity, increased use of these alert features was associated with significant improvements in anxiety and functional impairment. Associations between use of symptom tracking reminders and improved treatment outcome remained significant after controlling for frequency of symptom tracking. Although correlations were not statistically significant, reminders received via SMS (ie, text message) were more strongly associated with symptom reduction than were reminders received via email.
These findings indicate that alerts may be an especially potent component of eMental Health interventions, both via their association with enhanced program usage, as well as independently. Although there was evidence of a stronger association between symptom improvement and use of alerts via the mobile phone platform, the degree of overlap between use of email and SMS alerts may have precluded identification of alert delivery modalities that were most strongly associated with symptom reduction. Future research using random assignment to computer and mobile delivery is needed to fully determine the most ideal platform for delivery of this and other features of online interventions.
Trial Registration
Australian New Zealand Clinical Trials Registry (ACTRN): 12610000625077; (Archived by WebCite
PMCID: PMC4607393  PMID: 26543909
eHealth; depression; anxiety; stress; psychological stress; self-help; Web-based; mental health
8.  The Treatment of Nonmelancholic Depression: When Antidepressants Fail, Does Psychotherapy Work? 
Treatment-resistant depression (TRD) is used as a descriptive or diagnostic term and has generated many management guidelines weighting antidepressant (AD) therapy, but which may be an inappropriate paradigm for the nonmelancholic disorders where psychotherapy may be a more salient modality. This study sought to evaluate the effectiveness of psychological therapy in patients whose nonmelancholic depressive condition had been resistant to at least 2 ADs.
Principal analyses compared 32 patients, diagnosed with a nonmelancholic depression who received 12 weeks of psychological therapy, with a small control group. Comparative analyses failed to find a distinct therapeutic effect, leading to an extension study pursuing candidate explanatory factors for this lack of response, including psychosocial factors.
While our sample showed a 41% response and 22% remission rate to psychotherapy, their improvement pattern was similar to the control group, thus arguing against any specific therapeutic benefit. Explanatory factors nominated by the treating psychologist weighted personality issues for 35% of the patients, distal stressors for 22%, and comorbid anxiety conditions for 18%. When sample members were compared with an age- and sex-matched sample of patients with nonmelancholic depression who improved distinctly during a similar 12-week period, rates of such putative personality, stress, and anxiety risk factors did not differ, arguing against the likelihood of these factors compromising improvement.
Patients with nonmelancholic TRD also failed to demonstrate a clear response to a psychotherapeutic approach, while our pursuit of clinically explanatory variables was not supported empirically.
PMCID: PMC4086318  PMID: 25004496
9.  Construct validity of the Experiences of Therapy Questionnaire (ETQ) 
BMC Psychiatry  2014;14:369.
The Experiences of Therapy Questionnaire (ETQ) is a reliable measure of adverse effects associated with psychotherapy. The measure has not been subject to validity analyses. This study sought to examine the validity of the ETQ by comparison against a measure of therapist satisfaction.
Participants were recruited from the Black Dog Institute’s website and completed all measures online, at two time points (two weeks apart). Correlational analyses compared scale scores on the ETQ with related constructs of the Therapist Satisfaction Scale (TSS). To exclude any impact of current depression on ratings, we examined correlations between salient ETQ and TSS scales after controlling for depression severity.
Forty-six participants completed all the measures at both time points. Hypothesised associations between the ETQ and TSS scales were supported, irrespective of current depression severity.
The validity of the ETQ is supported; however limitations of the study are noted, including generalizability due to sample characteristics.
PMCID: PMC4299478  PMID: 25551579
Therapy; Psychotherapy; Measure; Validity; Side-effects; Psychology; Questionnaire
10.  The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders 
The American journal of psychiatry  2013;170(11):1249-1262.
The risk-benefit profile of antidepressant medications in bipolar disorder is controversial. When conclusive evidence is lacking, expert consensus can guide treatment decisions. The International Society for Bipolar Disorders (ISBD) convened a task force to seek consensus recommendations on the use of antidepressants in bipolar disorders.
An expert task force iteratively developed consensus through serial consensus-based revisions using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new or reworded items and items that needed to be rerated. This process resulted in the final ISBD Task Force clinical recommendations on antidepressant use in bipolar disorder.
There is striking incongruity between the wide use of and the weak evidence base for the efficacy and safety of antidepressant drugs in bipolar disorder. Few well-designed, long-term trials of prophylactic benefits have been conducted, and there is insufficient evidence for treatment benefits with antidepressants combined with mood stabilizers. A major concern is the risk for mood switch to hypomania, mania, and mixed states. Integrating the evidence and the experience of the task force members, a consensus was reached on 12 statements on the use of antidepressants in bipolar disorder.
Because of limited data, the task force could not make broad statements endorsing antidepressant use but acknowledged that individual bipolar patients may benefit from antidepressants. Regarding safety, serotonin reuptake inhibitors and bupropion may have lower rates of manic switch than tricyclic and tetracyclic antidepressants and norepinephrine-serotonin reuptake inhibitors. The frequency and severity of antidepressant-associated mood elevations appear to be greater in bipolar I than bipolar II disorder. Hence, in bipolar I patients antidepressants should be prescribed only as an adjunct to mood-stabilizing medications.
PMCID: PMC4091043  PMID: 24030475
11.  Effects of mental health self-efficacy on outcomes of a mobile phone and web intervention for mild-to-moderate depression, anxiety and stress: secondary analysis of a randomised controlled trial 
BMC Psychiatry  2014;14:272.
Online psychotherapy is clinically effective yet why, how, and for whom the effects are greatest remain largely unknown. In the present study, we examined whether mental health self-efficacy (MHSE), a construct derived from Bandura’s Social Learning Theory (SLT), influenced symptom and functional outcomes of a new mobile phone and web-based psychotherapy intervention for people with mild-to-moderate depression, anxiety and stress.
STUDY I: Data from 49 people with symptoms of depression, anxiety and/or stress in the mild-to-moderate range were used to examine the reliability and construct validity of a new measure of MHSE, the Mental Health Self-efficacy Scale (MHSES). STUDY II: We conducted a secondary analysis of data from a recently completed randomised controlled trial (N = 720) to evaluate whether MHSE effected post-intervention outcomes, as measured by the Depression, Anxiety and Stress Scales (DASS) and Work and Social Adjustment Scale (WSAS), for people with symptoms in the mild-to-moderate range.
STUDY I: The data established that the MHSES comprised a unitary factor, with acceptable internal reliability (Cronbach’s alpha = .89) and construct validity. STUDY II: The intervention group showed significantly greater improvement in MHSE at post-intervention relative to the control conditions (p’s < = .000). MHSE mediated the effects of the intervention on anxiety and stress symptoms. Furthermore, people with low pre-treatment MHSE reported the greatest post-intervention gains in depression, anxiety and overall distress. No effects were found for MHSE on work and social functioning.
Mental health self-efficacy influences symptom outcomes of a self-guided mobile phone and web-based psychotherapeutic intervention and may itself be a worthwhile target to increase the effectiveness and efficiency of online treatment programs.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12610000625077.
PMCID: PMC4189737  PMID: 25252853
eHealth; Depression; Anxiety; Psychological stress; Self-efficacy; Mobile health; Intervention studies; Work functioning
12.  Biological differences between melancholic and nonmelancholic depression subtyped by the CORE measure 
The purpose of this study was to compare melancholic patients rated by the CORE measure of observable psychomotor disturbance with nonmelancholic and control subjects across a set of biomarkers.
Depressed patients were classified as melancholic or nonmelancholic by using the CORE measure. Both groups of patients, as well as control subjects, were compared for a set of clinical and laboratory measures. Serum levels of brain-derived neurotrophic factor, of two markers of oxidative stress (protein carbonyl content [PCC] and thiobarbituric acid reactive substances [TBARS]), and of several immunity markers (interleukin [IL]-2, IL-4, IL-6, IL-10, IL-17, tumor necrosis factor-alpha, and interferon-gamma) were analyzed.
Thirty-three depressed patients and 54 healthy controls were studied. Depressive patients showed higher IL-4, IL-6, and PCC values than healthy controls. Thirteen (39%) of the depressed patients were assigned as melancholic by the CORE measure. They generated lower interferon-gamma (compared with nonmelancholic depressed patients) and TBARS (compared with both the nonmelancholic subset and controls) and returned higher IL-6 levels than controls. Both depressive groups generated higher PCC scores than controls, with no difference between melancholic and nonmelancholic subsets.
A sign-based measure to rate melancholia was able to replicate and extend biological findings discriminating melancholic depression. Signs of psychomotor disturbance may be a useful diagnostic measure of melancholia.
PMCID: PMC4149384  PMID: 25187716
melancholic depression; oxidative stress; inflammatory cytokines; brain-derived neurotrophic factor
13.  Feasibility and Effectiveness of a Web-Based Positive Psychology Program for Youth Mental Health: Randomized Controlled Trial 
Youth mental health is a significant public health concern due to the high prevalence of mental health problems in this population and the low rate of those affected seeking help. While it is increasingly recognized that prevention is better than cure, most youth prevention programs have utilized interventions based on clinical treatments (eg, cognitive behavioral therapy) with inconsistent results.
This study explores the feasibility of the online delivery of a youth positive psychology program, Bite Back, to improve the well-being and mental health outcomes of Australian youth. Further aims were to examine rates of adherence and attrition, and to investigate the program’s acceptability.
Participants (N=235) aged 12-18 years were randomly assigned to either of two conditions: Bite Back (n=120) or control websites (n=115). The Bite Back website comprised interactive exercises and information across a variety of positive psychology domains; the control condition was assigned to neutral entertainment-based websites that contained no psychology information. Participants in both groups were instructed to use their allocated website for 6 consecutive weeks. Participants were assessed pre- and postintervention on the Depression Anxiety Stress Scale-Short form (DASS-21) and the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS).
Of the 235 randomized participants, 154 (65.5%) completed baseline and post measures after 6 weeks. Completers and dropouts were equivalent in demographics, the SWEMWBS, and the depression and anxiety subscales of the DASS-21, but dropouts reported significantly higher levels of stress than completers. There were no differences between the Bite Back and control conditions at baseline on demographic variables, DASS-21, or SWEMWBS scores. Qualitative data indicated that 49 of 61 Bite Back users (79%) reported positive experiences using the website and 55 (89%) agreed they would continue to use it after study completion. Compared to the control condition, participants in the Bite Back condition with high levels of adherence (usage of the website for 30 minutes or more per week) reported significant decreases in depression and stress and improvements in well-being. Bite Back users who visited the site more frequently (≥3 times per week) reported significant decreases in depression and anxiety and improvements in well-being. No significant improvements were found among Bite Back users who demonstrated low levels of adherence or who used the website less frequently.
Results suggest that using an online positive psychology program can decrease symptoms of psychopathology and increase well-being in young people, especially for those who use the website for 30 minutes or longer per week or more frequently (≥3 times per week). Acceptability of the Bite Back website was high. These findings are encouraging and suggest that the online delivery of positive psychology programs may be an alternate way to address mental health issues and improve youth well-being nationally.
Trial Registration
Australian New Zealand Clinical Trials Registry: ACTRN1261200057831; (Archived by Webcite at
PMCID: PMC4071231  PMID: 24901900
adolescent; resilience; psychological; mental health; Internet; early medical intervention
14.  Bias and discriminability during emotional signal detection in melancholic depression 
BMC Psychiatry  2014;14:122.
Cognitive disturbances in depression are pernicious and so contribute strongly to the burden of the disorder. Cognitive function has been traditionally studied by challenging subjects with modality-specific psychometric tasks and analysing performance using standard analysis of variance. Whilst informative, such an approach may miss deeper perceptual and inferential mechanisms that potentially unify apparently divergent emotional and cognitive deficits. Here, we sought to elucidate basic psychophysical processes underlying the detection of emotionally salient signals across individuals with melancholic and non-melancholic depression.
Sixty participants completed an Affective Go/No-Go (AGN) task across negative, positive and neutral target stimuli blocks. We employed hierarchical Bayesian signal detection theory (SDT) to model psychometric performance across three equal groups of those with melancholic depression, those with a non-melancholic depression and healthy controls. This approach estimated likely response profiles (bias) and perceptual sensitivity (discriminability). Differences in the means of these measures speak to differences in the emotional signal detection between individuals across the groups, while differences in the variance reflect the heterogeneity of the groups themselves.
Melancholic participants showed significantly decreased sensitivity to positive emotional stimuli compared to those in the non-melancholic group, and also had a significantly lower discriminability than healthy controls during the detection of neutral signals. The melancholic group also showed significantly higher variability in bias to both positive and negative emotionally salient material.
Disturbances of emotional signal detection in melancholic depression appear dependent on emotional context, being biased during the detection of positive stimuli, consistent with a noisier representation of neutral stimuli. The greater heterogeneity of the bias across the melancholic group is consistent with a more labile disorder (i.e. variable across the day). Future work will aim to understand how these findings reflect specific individual differences (e.g. prior cognitive biases) and clarify whether such biases change dynamically during cognitive tasks as internal models of the sensorium are refined and updated in response to experience.
PMCID: PMC4022535  PMID: 24766992
Bayesian analysis; Decision-making; Depression; Melancholia; Signal detection
15.  Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial 
BMC Psychiatry  2013;13:312.
Mobile phone-based psychological interventions enable real time self-monitoring and self-management, and large-scale dissemination. However, few studies have focussed on mild-to-moderate symptoms where public health need is greatest, and none have targeted work and social functioning. This study reports outcomes of a CONSORT-compliant randomised controlled trial (RCT) to evaluate the efficacy of myCompass, a self-guided psychological treatment delivered via mobile phone and computer, designed to reduce mild-to-moderate depression, anxiety and stress, and improve work and social functioning.
Community-based volunteers with mild-to-moderate depression, anxiety and/or stress (N = 720) were randomly assigned to the myCompass program, an attention control intervention, or to a waitlist condition for seven weeks. The interventions were fully automated, without any human input or guidance. Participants’ symptoms and functioning were assessed at baseline, post-intervention and 3-month follow-up, using the Depression, Anxiety and Stress Scale and the Work and Social Adjustment Scale.
Retention rates at post-intervention and follow-up for the study sample were 72.1% (n = 449) and 48.6% (n = 350) respectively. The myCompass group showed significantly greater improvement in symptoms of depression, anxiety and stress and in work and social functioning relative to both control conditions at the end of the 7-week intervention phase (between-group effect sizes ranged from d = .22 to d = .55 based on the observed means). Symptom scores remained at near normal levels at 3-month follow-up. Participants in the attention control condition showed gradual symptom improvement during the post-intervention phase and their scores did not differ from the myCompass group at 3-month follow-up.
The myCompass program is an effective public health program, facilitating rapid improvements in symptoms and in work and social functioning for individuals with mild-to-moderate mental health problems.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN 12610000625077
PMCID: PMC4225666  PMID: 24237617
eHealth; Public health; Depression; Anxiety; Psychological stress; Mobile health; Intervention studies; Work functioning
17.  Melancholia: restoration in psychiatric classification recommended 
Acta psychiatrica Scandinavica  2007;115(2):89-92.
PMCID: PMC3712974  PMID: 17244171 CAMSID: cams3199
18.  Mechanisms underpinning effective peer support: a qualitative analysis of interactions between expert peers and patients newly-diagnosed with bipolar disorder 
BMC Psychiatry  2012;12:196.
The increasing burden on mental health services has led to the growing use of peer support in psychological interventions. Four theoretical mechanisms have been proposed to underpin effective peer support: advice grounded in experiential knowledge, social support, social comparison and the helper therapy principle. However, there has been a lack of studies examining whether these mechanisms are also evident in clinical populations in which interpersonal dysfunction is common, such as bipolar disorder.
This qualitative study, conducted alongside a randomized controlled trial, examined whether the four mechanisms proposed to underpin effective peer support were expressed in the email exchange between 44 individuals newly-diagnosed with bipolar disorder and their Informed Supporters (n = 4), over the course of a supported online psychoeducation program for bipolar disorder. A total of 104 text segments were extracted and coded. The data were complemented by face-to-face interviews with three of the four Informed Supporters who participated in the study.
Qualitative analyses of the email interchange and interview transcripts revealed rich examples of all four mechanisms. The data illustrated how the involvement of Informed Supporters resulted in numerous benefits for the newly-diagnosed individuals, including the provision of practical strategies for illness management as well as emotional support throughout the intervention. The Informed Supporters encouraged the development of positive relationships with mental health services, and acted as role models for treatment adherence. The Informed Supporters themselves reported gaining a number of benefits from helping, including a greater sense of connectedness with the mental health system, as well as a broader knowledge of illness management strategies.
Examples of the mechanisms underpinning effective peer support were found in the sample of emails from individuals with newly-diagnosed bipolar disorder and their Informed Supporters. Experiential knowledge, social support, social comparison and helper therapy were apparent, even within a clinical population for whom relationship difficulties are common. Trial registration number ACTRN12608000411347.
PMCID: PMC3549948  PMID: 23140497
Bipolar disorder; Peer support; Experiential knowledge; Social support; Social comparison; Helper therapy
19.  Clinical Patterns and Treatment Outcome in Patients with Melancholic, Atypical and Non-Melancholic Depressions 
PLoS ONE  2012;7(10):e48200.
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.
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.
Our study supports a different clinical pattern and treatment outcome for melancholic and atypical depression subtypes.
PMCID: PMC3482206  PMID: 23110213
20.  A consensus statement for safety monitoring guidelines of treatments for major depressive disorder 
This paper aims to present an overview of screening and safety considerations for the treatment of clinical depressive disorders and make recommendations for safety monitoring.
Data were sourced by a literature search using MEDLINE and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content.
Screening and monitoring can detect medical causes of depression. Specific adverse effects associated with antidepressant treatments may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment.
The adoption of safety monitoring guidelines when treating clinical depression is likely to improve overall physical health status and treatment outcome. It is important to implement these guidelines in the routine management of clinical depression.
PMCID: PMC3190838  PMID: 21888608
21.  The Ins and Outs of an Online Bipolar Education Program: A Study of Program Attrition 
The science of eHealth interventions is rapidly evolving. However, despite positive outcomes, evaluations of eHealth applications have thus far failed to explain the high attrition rates that are associated with some eHealth programs. Patient adherence remains an issue, and the science of attrition is still in its infancy. To our knowledge, there has been no in-depth qualitative study aimed at identifying the reasons for nonadherence to—and attrition from— online interventions.
This paper explores the predictors of attrition and participant-reported reasons for nonadherence to an online psycho-education program for people newly diagnosed with a bipolar disorder.
As part of an ongoing randomized controlled trial (RCT) evaluating an online psycho-education program for people newly diagnosed with a bipolar disorder, we undertook an in-depth qualitative study to identify participants’ reasons for nonadherence to, and attrition from, the online intervention as well as a quantitative study investigating predictors of attrition. Within the RCT, 370 participants were randomly allocated to 1 of 2 active interventions or an attention control condition. Descriptive analyses and chi-square tests were used to explore the completion rates of 358 participants, and standard regression analysis was used to identify predictors of attrition. The data from interviews with a subsample of 39 participants who did not complete the online program were analyzed using “thematic analysis” to identify patterns in reported reasons for attrition.
Overall, 26.5% of the sample did not complete their assigned intervention. Standard multiple regression analysis revealed that young age (P= .004), male gender (P= .001), and clinical recruitment setting (P= .001) were significant predictors of attrition (F7,330= 8.08, P< .001). Thematic analysis of interview data from the noncompleter subsample revealed that difficulties associated with the acute phases of bipolar disorder, not wanting to think about one’s illness, and program factors such as the information being too general and not personally tailored were the major reasons for nonadherence.
The dropout rate was equivalent to other Internet interventions and to face-to-face therapy. Findings from our qualitative study provide participant-reported reasons for discontinuing the online intervention, which, in conjunction with the quantitative investigations about predictors, add to understanding about Internet interventions. However, further research is needed to determine whether there are systematic differences between those who complete and those who do not complete eHealth interventions. Ultimately, this may lead to the identification of population subgroups that most benefit from eHealth interventions and to informing the development of strategies to improve adherence.
Trial Registration
ACTRN12608000411347; (Archived by WebCite at
PMCID: PMC3057316  PMID: 21169169
Non-adherence; Nonadherence; attrition; eHealth; online psycho-education program; bipolar disorder; Internet intervention
22.  Community Attitudes to the Appropriation of Mobile Phones for Monitoring and Managing Depression, Anxiety, and Stress 
The benefits of self-monitoring on symptom severity, coping, and quality of life have been amply demonstrated. However, paper and pencil self-monitoring can be cumbersome and subject to biases associated with retrospective recall, while computer-based monitoring can be inconvenient in that it relies on users being at their computer at scheduled monitoring times. As a result, nonadherence in self-monitoring is common. Mobile phones offer an alternative. Their take-up has reached saturation point in most developed countries and is increasing in developing countries; they are carried on the person, they are usually turned on, and functionality is continually improving. Currently, however, public conceptions of mobile phones focus on their use as tools for communication and social identity. Community attitudes toward using mobile phones for mental health monitoring and self-management are not known.
The objective was to explore community attitudes toward the appropriation of mobile phones for mental health monitoring and management.
We held community consultations in Australia consisting of an online survey (n = 525), focus group discussions (n = 47), and interviews (n = 20).
Respondents used their mobile phones daily and predominantly for communication purposes. Of those who completed the online survey, the majority (399/525 or 76%) reported that they would be interested in using their mobile phone for mental health monitoring and self-management if the service were free. Of the 455 participants who owned a mobile phone or PDA, there were no significant differences between those who expressed interest in the use of mobile phones for this purpose and those who did not by gender (χ21, = 0.98, P = .32, phi = .05), age group (χ24, = 1.95, P = .75, phi = .06), employment status (χ22, = 2.74, P = .25, phi = .08) or marital status (χ24, = 4.62, P = .33, phi = .10). However, the presence of current symptoms of depression, anxiety, or stress affected interest in such a program in that those with symptoms were more interested (χ2 1, = 16.67, P < .001, phi = .19). Reasons given for interest in using a mobile phone program were that it would be convenient, counteract isolation, and help identify triggers to mood states. Reasons given for lack of interest included not liking to use a mobile phone or technology, concerns that it would be too intrusive or that privacy would be lacking, and not seeing the need. Design features considered to be key by participants were enhanced privacy and security functions including user name and password, ease of use, the provision of reminders, and the availability of clear feedback.
Community attitudes toward the appropriation of mobile phones for the monitoring and self-management of depression, anxiety, and stress appear to be positive as long as privacy and security provisions are assured, the program is intuitive and easy to use, and the feedback is clear.
PMCID: PMC3057321  PMID: 21169174
Mobile phones; monitoring; self-help; depression; anxiety; stress; Internet intervention
23.  Is depression overdiagnosed? Yes 
BMJ : British Medical Journal  2007;335(7615):328.
Rates of diagnosis of depression have risen steeply in recent years. Gordon Parker believes this is because current criteria are medicalising sadness, but Ian Hickie argues that many people are still missing out on lifesaving treatment
PMCID: PMC1949440  PMID: 17703040
24.  What happens after diagnosis? Understanding the experiences of patients with newly‐diagnosed bipolar disorder 
Bipolar disorder is chronic condition involving episodes of both depression and elevated mood, associated with significant disability and high relapse rates. Recent estimates suggest a lifetime prevalence of 5%. Little is known about the subjective experiences of patients after receiving a diagnosis of bipolar disorder, and the impact of these experiences on patients' willingness and ability to work with their health professionals to find the most effective combination of treatments and to set up self‐management plans.
Objective  This paper describes a qualitative study exploring the experiences and difficulties faced by patients after they have received a diagnosis of bipolar disorder, as expressed online to expert patients trained to provide informed support.
Design  Qualitative study.
Setting  Online communication within a public health service setting.
Participants  Twenty‐six participants with recently‐diagnosed bipolar disorder communicated online with ‘Informed Supporters’, people who had been managing their bipolar disorder effectively for 2 years or more, as part of an online psycho‐education programme.
Results  Participants cited unwanted side‐effects of medication, coping with unpleasant symptoms, positive and negative reactions to the diagnosis, identifying early warning signs and triggers of the illness, the loss of a sense of self, uncertainty about their future and stigma as issues of major importance after diagnosis.
Conclusions  Personal concerns and difficulties following diagnosis can undermine effective treatment, thwart self‐management efforts and interfere with effective functioning. Such data are important for clinicians to take into account when they work in partnership with their patients to fine‐tune treatments and help them set up self‐management plans.
PMCID: PMC5060482  PMID: 19538647
bipolar disorder; expert patients; online support; self‐management plans

Results 1-25 (26)