The clinical effectiveness and cost-effectiveness of low-intensity psychological interventions for the secondary prevention of relapse after depression: a systematic review

Diagnosis

Depression is typically diagnosed according to criteria set out in either the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV),1 or the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10). 16 DSM-IV was developed by the American Psychiatric Association, whereas the ICD-10 is the comparable European guide for diagnosis of mental disorders. Although similar, the two systems are not identical, having slightly differing thresholds for the number of symptoms required for a depressive episode (as termed in ICD-10; ‘major depressive episode’ in DSM-IV).

The 2010 NICE guideline8 on depression states that a diagnosis of a depression requires assessment of three linked but separate factors: (1) severity, (2) duration and (3) course. Diagnosis requires a minimum of 2 weeks’ duration of symptoms and including at least one key symptom (low mood, loss of interest or pleasure). Individual symptoms should be assessed for severity and impact on function and be present for most of every day. The following categories adapted from DSM-IV were outlined:

• subthreshold depressive symptoms (fewer than five out of nine symptoms of depression)

• mild depression (few, if any, symptoms in excess of the five required to make the diagnosis, and the symptoms result in only minor functional impairment)

• moderate depression (symptoms or functional impairment are between ‘mild’ and ‘severe’)

• severe depression (most symptoms, and the symptoms markedly interfere with functioning).

Treatment

The objective of treatment is to achieve remission or at least adequate control of depressive symptoms. For some, depression can become a gateway to a lifetime of disability and impairment, so it is important to develop interventions and services to not only reduce depressive symptoms and restore functioning, but also to enable people to self-manage their problems and prevent relapse and recurrence of episodes of major depression. This acknowledgement of the nature of recurrent depression and the high potential of recurrence has therefore led to a greater emphasis on long-term management approaches. 17

Many people are unwilling to seek help for depression and there is a failure to recognise depression, especially in primary care; of those patients diagnosed with depression, the majority will receive psychological, pharmacological or combined treatment in primary care. 8 Pharmacological treatments typically include antidepressant agents such as tricyclic antidepressants (TCAs) or, more commonly, specific serotonin reuptake inhibitors (SSRIs). Other drugs used either alone or in combination with antidepressants include lithium salts and antipsychotics, although these are usually reserved for people with severe, psychotic or chronic depression, or as prophylactics. 8 Psychological treatments for depression reviewed in the most recent NICE depression guidelines include cognitive behavioural therapy (CBT), behaviour therapy (BT), interpersonal therapy (IPT), problem-solving therapy (PST), counselling, short-term psychodynamic psychotherapy and couple-focused therapies. Owing to the different needs of individuals with depression, the NICE clinical guidelines advocate a ‘stepped-care’ treatment model (Figure 1), which aims to provide a framework to organise the provision of services supporting patients, carers and health-care professionals in identifying and accessing the most effective interventions. 8

FIGURE 1.

The stepped-care model. 8 a, Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms and/or is associated with significant psychiatric comorbidity or psychosocial factors. b, Only for depression in someone who also has a chronic physical health problem and associated functional impairment (see ‘Depression in adults with a chronic physical health problem: treatment and management’, NICE clinical guideline 918). ECT, electroconvulsive therapy.

Reproduced with permission from the National Collaborating Centre for Mental Health. Depression. The NICE guideline on the treatment and management of depression in adults (updated edition). National clinical practice guideline 90. London: National Institute for Health and Clinical Excellence; 2010.

Reproduced with permission from the National Collaborating Centre for Mental Health. Depression. The NICE guideline on the treatment and management of depression in adults (updated edition). National clinical practice guideline 90. London: National Institute for Health and Clinical Excellence; 2010.

Low-intensity interventions for depression

In general, people with depression tend to prefer psychological and psychosocial interventions to pharmacological interventions. 21 However, high-intensity psychological and psychosocial therapies (e.g. CBT, problem-solving, counselling) that involve one-to-one therapy with a mental health professional over extended periods of time are resource intensive. Consequently, less intensive therapies and innovative delivery formats such as group-based work have been developed. Less resource-intensive therapies include a variety of psychological treatments in which there is no or only a low level of therapist involvement, including computer-delivered treatment and bibliotherapy among other intervention technologies. The 2010 NICE guideline8 on depression refers to such approaches as ‘low-intensity psychosocial interventions’ and provides clinical evidence on three main forms of low-intensity therapy:

• Computerised cognitive behavioural therapy (CCBT) provides a structured programme of care based on the principles of standard therapist-delivered CBT, but is delivered via a CD-ROM/DVD or the internet. Where CCBT is delivered as a primary intervention with minimal therapist involvement, it is considered a low-intensity intervention.

• Guided self-help involves the use of evidence-based self-help books or manuals aimed specifically at depression. Guided self-help is distinct from ‘pure’ self-help in that a health-care professional (or para-professional) facilitates the use of the material by introducing, monitoring and assessing the outcome of the intervention.

• Physical activity programmes have been defined as any structured physical activity with a recommended frequency, intensity and duration when used for depression. This could be aerobic (e.g. running/jogging, dancing) or anaerobic (e.g. resistance training), and be supervised or unsupervised, and undertaken in a group or individually.

The NICE clinical practice guidelines recommend that CCBT, individual-guided self-help and structured group physical activity programmes be considered for people with persistent subthreshold depressive symptoms or mild-to-moderate depression. The recommended duration of CCBT and guided self-help is 9–12 weeks including follow-up. Group physical activity with practitioner support is recommended for three sessions per week over 10–14 weeks. 8

Although the NICE guidance covers low-intensity psychological interventions, it does not provide a clear definition of what constitutes ‘low-intensity’ treatment more broadly. However, recent good practice guidance produced by the IAPT programme states22 that ‘A low-intensity intervention … may use simple or “single strand” approaches that are less complex to undertake than formal psychotherapy; contact with people is generally briefer than in other forms of therapy and can be delivered by para-professionals or peer supporters using non-traditional methods such as telephone or the internet’. Low intensity, therefore, is defined on the basis of four characteristics: the complexity of the intervention, the duration of contact, the level of training and the mode of delivery. In IAPT, a particular emphasis is on interventions delivered by PWPs without formal health-care professional or CBT therapist qualifications. 23 Although the IAPT guidance states that there is no arbitrary session limit, evidence from the IAPT demonstration site showed that the mean number of low-intensity CBT-based interventions was around five per person, although there was considerable variability around this figure. 22

A similar definition of low intensity is offered by Bennett-Levy et al,24 who identified the ability of an intervention to offer high-volume access to treatment as the defining feature of a low-intensity intervention, which can be achieved through strategies such as reduced practitioner–patient contact and the use of practitioners who do not have formal professional or high-intensity therapy qualifications. They also pointed out that the definition of low intensity remains contested. For example, they chose to include mindfulness-based cognitive therapy (MBCT) as a low-intensity treatment. This is a complex intervention that is typically delivered by a qualified mental health professional with specific expertise in its delivery but which limits patient contact time per therapist because it is delivered in a group format. They recognised that not everyone would agree with its inclusion.

Definitions

In an effort to standardise terms and facilitate communication, several conceptual definitions of improvement and subsequent return of depressive symptoms exist. 25–26 In terms of improvement, a distinction is made between response, remission and recovery. Response is defined as a clinically meaningful improvement in depressive symptoms that has continued for a sufficient length of time (3 consecutive weeks) to protect against misclassification owing to symptom variation or measurement error. 26 Response is typically operationalised as an improvement of ≥ 50% over pre-treatment scores. However, problems have been noted with this approach; for example, such a definition may be too stringent for patients with highly treatment-resistant depression. 26

Remission relies on a definition of an asymptomatic range, defined as the presence of no or very few symptoms. A person can be judged to be in the asymptomatic range only if neither of the two essential features of depression (sad mood and loss of interest or pleasure) is present and fewer than three of the additional core symptoms of depression are present. 26 Remission requires that the person remains in this range for at least 3 weeks, again to protect against factors such as natural symptom variation. After this point, remission status is still ascribed if the person’s symptoms fall above the asymptomatic range but fall short of meeting diagnostic criteria for a major depressive episode. Recovery is defined as an extended length of time in remission, which has been operationalised as at least 4 months. 26

The definitions of relapse and recurrence are linked to these definitions of improvement. Relapse occurs when a person in remission experiences a return to full symptoms of a major depressive episode. Relapse, therefore, occurs after achieving remission but before the recovery phase. Recurrence indicates the return to the full symptoms of depression after a person has achieved recovery status.

The definitions of relapse and recurrence are also linked to the differentiation of treatment phases. Acute-phase treatment is defined as treatment during an episode of depression, the aim of which is to achieve remission. Continuation-phase treatment occurs during the remission phase with the aim of continuing remission and ultimately achieving recovery. Maintenance treatment occurs during the recovery stage with the aim of maintaining this state.

Despite these definitions, there is still inconsistent use of the terminology within the literature, particularly in terms of the distinction made between relapse and recurrence. In the current project, ‘relapse and recurrence’ will be used as phrase throughout to refer to the return of full depressive symptoms. When the results of particular studies are described the terms used in that study are retained, even when their use is different to the definitions given above.

Interventions to reduce depressive relapse or recurrence

Search strategy

Literature searches were developed to systematically identify studies on the effectiveness of low-intensity psychological interventions to prevent relapse or recurrence after depression. The base search strategy was constructed using MEDLINE and then adapted for other resources searched. The search strategy included the following components:

1. depression terms, and

2. relapse terms, and

3. low-intensity psychological intervention-related terms.

The searches were restricted to studies published after 1950. No language restrictions or study design filters were applied.

Search terms were identified by scanning key papers identified at the beginning of the project, through discussion with the review team and clinical experts, and the use of database thesauri.

Sources of information were identified by an information specialist with input from the project team. The following databases were searched during September 2010:

• MEDLINE (via OvidSP)

• MEDLINE In-Process & Other Non-Indexed Citations (via OvidSP)

• PsycINFO (via OvidSP)

• EMBASE (via OvidSP)

• The Cochrane Library (via Wiley)

  1. – CDSR (Cochrane Database of Systematic Reviews)

  2. – DARE (Database of Abstracts of Reviews of Effects)

  3. – CENTRAL (Cochrane Central Register of Controlled Trials)

  4. – HTA (Health Technology Assessment Database)

• Science Citation Index (via ISI Web of Knowledge)

• Social Science Citation Index (via ISI Web of Knowledge)

• BIOSIS Previews (via ISI Web of Knowledge and Dialog).

In addition, a range of resources were searched or browsed to identify guidelines on the treatment of depression. The bibliographies of relevant reviews and guidelines and included studies were checked for further potentially relevant studies.

Records were managed within an EndNote library, version X3 (Thomson Reuters, CA, USA). After de-duplication, 9112 records in total were identified.

The full search strategies and results for each database can be found in Appendix 1.

Inclusion and exclusion criteria

Two reviewers independently examined titles and abstracts for relevance; all potentially relevant papers meeting the inclusion criteria were ordered. All full papers were then independently screened by two reviewers, with disagreements resolved by consensus.

Data extraction strategy

Data were extracted independently by one reviewer using a standardised data extraction form and checked by another. Discrepancies were resolved by discussion, with involvement of a third reviewer when necessary. Authors were contacted for any missing data or for clarification where necessary. Data from multiple publications of the same study were extracted as a single study. Extraction included data on patient characteristics, interventions, comparators, study design and outcomes.

Critical appraisal strategy

The quality appraisal checklist for quantitative intervention studies described in NICE’s guide to methods for developing guidance in public health was obtained for assessing the internal and external validity of studies included in the systematic review of low-intensity interventions (part A). 44 For the scoping review of brief therapy interventions (part B), formal critical appraisal of the included studies was not planned or conducted, with the exception of one study,45 in which the necessity of health professionals to deliver the intervention was unclear (see Assessment of effectiveness, Part B: brief therapy interventions for the prevention of relapse of depression, below).

Methods of data synthesis

Given the limited number of included studies and their clinical and methodological heterogeneity, a meta-analysis was not appropriate. Therefore, extracted data have been tabulated and discussed in a narrative synthesis.

Quantity and quality of research available

A total of 9112 unique records were identified from the searches and 129 articles were ordered for assessment. Figure 2 shows the flow of records through the review process, and the numbers included and excluded at each stage. Details of studies excluded at the full publication stage are presented in Appendix 2 (excluded studies).

FIGURE 2.

Study selection process for clinical effectiveness.

Assessment of effectiveness

Search strategy

The literature search strategy for the identification of cost-effectiveness studies was developed from the base search strategy usedfor the clinical effectiveness searches (see Chapter 3, Search strategy). Economic terms were added to the strategy to limit retrieval to economic studies. The additional economic terms were from the search strategy used for identifying studies for the NHS Economic Evaluations Database (NHS EED).

The following databases were searched in October 2011:

• MEDLINE (via OvidSP)

• EMBASE (via OvidSP)

• EconLit (via OvidSP)

• The Cochrane Library (via Wiley)

  1. – CENTRAL (Cochrane Central Register of Controlled Trials)

  2. – NHS EED

• IDEAS [via Research Papers in Economics (RePEc)].

After de-duplication in EndNote X3, 466 records were identified. The full search strategies and results for each database can be found in Appendix 1.

Inclusion and exclusion criteria

Two reviewers independently examined titles and abstracts for relevance; all potentially relevant papers meeting the inclusion criteria were ordered. All full papers were then independently screened by two reviewers, with disagreements resolved by consensus.

In addition to the criteria used to screen for the clinical papers (see Chapter 3, Data extraction strategy) a set of cost-effectiveness criteria were also applied to screen for the papers on cost-effectiveness. Only full economic evaluations that compared two or more treatment options and considered both costs and consequences (including cost-effectiveness, cost–utility and cost–benefit analyses) were included in the review of economic literature. Economic evaluations conducted alongside trials, modelling studies and analyses of administrative databases were all considered for inclusion. As with the clinical review, the review of cost-effectiveness evidence was also conducted in two parts: A and B (see Chapter 2, Overall aims and objectives).

Critical appraisal strategy

The quality of the cost-effectiveness studies was assessed according to a checklist updated from that developed by Drummond and Jefferson. 74 This information is summarised within the text of the report, alongside a detailed critique of included studies and the relevance to the NHS.

Methods of data synthesis

Drawing on the findings from the systematic reviews of both clinical effectiveness and cost-effectiveness, the intention was to develop a de novo economic model to assess the cost-effectiveness of low-intensity interventions to prevent relapse in patients with depression, and to further use this economic model to estimate the expected value of perfect information (EVPI) in order to help determine future research priorities in this area. However, given the lack of any studies meeting the main part A inclusion criteria in either the clinical effectiveness or cost-effectiveness review, the development of a de novo model was not considered feasible. Instead, through our review of the existing literature we have highlighted key issues that we think should be addressed as part of any future modelling work in this area.

Quantity and quality of research available

A total of 466 unique records were identified from the searches and 23 articles were ordered for assessment. Figure 3 shows the flow of records through the review process and the numbers included and excluded at each stage.

FIGURE 3.

Study selection process for cost-effectiveness.

Assessment of cost-effectiveness

The following sections provide a detailed critique of the cost-effectiveness evidence from the included studies and an assessment of the quality and relevance of the data from the perspective of the NHS. A quality assessment checklist is provided in Appendix 5.

Clinical effectiveness

Although there is a substantial volume of literature on the effectiveness of low-intensity,38,82,83 high-intensity84–86 and mixed-intensity31,87,88 psychological treatments for the initial treatment of depression, this review has shown that there is currently very little intervention research specifically focused on the effectiveness of low-intensity interventions for relapse prevention.

No studies met the main review inclusion criteria (part A); a total of 17 completed and ongoing studies evaluating brief (≤ 6 hours of contact per patient) high-intensity therapy interventions (e.g. therapist-delivered continuation CBT, group MBCT) were identified and described (part B). These studies were clinically and methodologically diverse, and reported differing degrees of efficacy for the evaluated interventions. Of these, one study45 was felt to be of particular potential relevance to the main focus of the project, if the intervention could be delivered by PWP or equivalent practitioners. This was a RCT that evaluated a collaborative care-type programme which was specifically aimed at prevention of depressive relapse in high-risk patients in a US primary care setting. This study, which involved providing patients with face-to-face, telephone and postal contact with trained ‘depression specialists’, reported no difference between patients receiving the intervention and those receiving usual care in terms of relapse of depression over 12 months.

Cost-effectiveness

In the review of cost-effectiveness evidence, no studies met the main review inclusion criteria (part A); two studies that met the criteria for brief interventions (part B) were identified. 63,75 One of these was an economic evaluation of the same study identified as being potentially relevant to the main focus of the project in the clinical effectiveness review. This study demonstrated that the low-intensity intervention evaluated (providing patients with face-to-face, telephone and postal contact with trained ‘depression specialists’ in addition to usual care) may be a cost-effective use of NHS resources when compared with usual care. 75 However, the reported incremental cost-effectiveness ratios (ICERs) when converted into sterling and inflated to 2010 prices of £21,511 per QALY to £43,519 per QALY ranged from borderline cost-effective to not cost-effective under accepted thresholds for cost-effectiveness. 81 It was also unclear how valid these estimates were for the NHS. The other study (regarding the use of MBCT to prevent relapse) was inconclusive; furthermore, its use of disease-specific measures in reporting cost-effectiveness made it difficult to generalise the results. 63

Clinical effectiveness

This is currently the only systematic review of the literature on the effectiveness of low-intensity interventions for the prevention of relapse or recurrence of depression. This review involved a comprehensive search for relevant evidence; over 9000 records identified from searches of electronic databases, online resources, clinical guidelines and other sources were independently screened by two or more reviewers, with primary study authors contacted where necessary.

The effectiveness of high-intensity interventions for the prevention of relapse or recurrence in depression have been reviewed elsewhere. 29,89 However, given the dearth of evidence on the effectiveness of low-intensity interventions, this review also incorporated a scoping exercise covering evaluations of brief high-intensity therapies for the prevention of relapse or recurrence typically delivered by clinical psychologists, CBT therapists, and other qualified mental health professionals. Inclusion was restricted to interventions involving limited patient contact time (delivered in a group setting or involving very brief individual encounters), as these approaches may be of interest to decision-makers who are concerned with improving access to psychological therapies and/or maximising available resources. Although any definition of ‘brief’ is likely to be somewhat arbitrary, an inclusion threshold of 6 hours of contact per patient was used to select these brief high-intensity intervention studies. The majority of studies excluded on this basis evaluated clearly resource-intensive interventions, although occasionally studies with similar treatment protocols to those included in the scoping review had to be excluded on the basis of having only slightly more than 6 hours of contact per patient (e.g. Fava et al. 90,91). A full list of excluded studies with reasons for exclusion is available in Appendix 2.

Cost-effectiveness

The review of cost-effectiveness evidence found minimal evidence supporting the use of low-intensity interventions for the prevention of relapse or recurrence in depression, with the one study that could potentially be relevant to the main focus of the project (administered by PWPs or equivalent practitioners) suggesting that the evaluated intervention may have been borderline cost-effective, although the results were highly uncertain and their validity to the NHS is questionable. 75 It should also be noted that the study compared its intervention in addition to usual care with usual care alone; other systematic reviews have considered other interventions for the prevention of relapse or recurrence. 29,89 The review has made it apparent that there are many low-intensity interventions, such as CCBT, which have not been evaluated for the prevention of relapse or recurrence in depression.

Both studies identified as relevant for part B had relatively short time horizons (12 and 15 months)63,75 and, given the chronic nature of depression, it is unclear if these time horizons would capture all the possible differences in costs and effects between the treatment arms, as would be considered good practice in economic evaluation. 77 The cost-effectiveness studies also made no attempt to explore any heterogeneity in terms of patient characteristics, with no subgroup analyses conducted in either study.

Definition of low-intensity interventions

There are likely to be a range of alternative low-intensity interventions that could be feasible in the NHS. In the 2010 NICE guideline92 on depression three forms of low-intensity intervention were distinguished: CCBT, guided self-help and physical activity programmes. However, this list is not exhaustive and other interventions could be described as low intensity; for example, the intervention described in Katon et al. 45 could conceivably be delivered by para-professionals or PWPs and therefore be classed as low intensity. The same point could be made about a number of other interventions, some of which are currently classified as high intensity. It is not clear what level of training is required to adequately deliver such interventions effectively. Similarly, group work (as found in most of the interventions identified in part B studies) is ‘high-intensity’ in the sense that it is typically delivered by a mental health professional, although delivering interventions in a group setting could potentially provide more efficient use of resources and increased throughput. The further evaluation of such group interventions may be of use. There are also likely to be pragmatic considerations that need to be taken into account when deciding on which low-intensity interventions should be evaluated; for example, some interventions may be more feasible for widespread introduction in the NHS than others.

Relevant comparators

It is important to consider carefully what the relevant comparators should be in any future evaluation. ‘Psychological placebo’ or sham psychological treatments may have limited use in the evaluation of psychological treatments. One of the factors that a placebo condition should control for is patient expectancy, which may in part be related to a practitioner’s expectancy of whether or not a treatment is likely to be effective. There are obvious difficulties in ensuring that a practitioner is unaware of whether a psychological intervention is designed to be a genuine intervention or a control condition. It is also possible that the patient will be able to discern whether or not an intervention is intended to be therapeutic. Therefore, TAU may be an appropriate comparator; however, studies must report what participants in the TAU group actually received, including medication (NICE recommends that patients receive maintenance antidepressant therapy), any additional psychosocial support and previous treatments (e.g. medication and/or IAPT interventions).

There are many other interventions, including both high-intensity psychological interventions and pharmacological therapies, which are used to prevent relapse or recurrence of depression. 93 However, there may be constraints which limit the relevance of particular interventions as comparators; for example, there may be a limited number of qualified health-care professionals so more intensive psychological interventions are not feasible or long-term antidepressant use may not be acceptable for patients. Many studies examining the use of psychotherapy for the treatment of depression involve psychotherapy provided in addition to usual care by a GP, which will often include an antidepressant. 93 Similarly, collaborative care and case management strategies have also been used in the treatment of depression, and have been found to be cost-effective in the treatment of depressive episodes. 93 This suggests that any future evaluation should also consider relevant combinations of interventions/therapies as comparators.

Furthermore, it may be appropriate to consider evaluating the whole treatment pathway for a patient, to incorporate any possible treatment interactions. Treatment interactions may exist between combinations of interventions or between interventions received for the initial depressive episode and subsequent interventions. Such interactions may alter the patient population, which will be at risk of relapse in the future. Evaluating interventions separately without recourse to this may result in contradictory results. Adopting a more comprehensive evaluative approach to the whole-patient pathway being considered would allow the use of particular interventions to be optimised within a broader range of alternatives considering the entire treatment pathway of patients.

Outcomes

Any future evaluation also needs to consider carefully which outcomes are of importance when evaluating interventions preventing relapse or recurrence in depression. Clearly, relapse or recurrence is a key outcome; however, QoL measures, such as depression-free days, etc., are also important but were rarely measured in the identified studies. Good practice in cost-effectiveness analysis demands the use of generic (non-disease-specific) outcome measures so as to allow decisions on resource allocation across disease areas, not simply within them. 77 In the UK, the recommended outcome measure is the QALY, which takes into account both quantity of life and HRQoL. 81 Although depression has been shown to affect mortality,94 it also has a major impact on QoL; it is therefore important to consider by what process an intervention may affect QoL.

Previous economic models that have considered the treatment of depression have often modelled patients as either in a depressive episode or not, with no in-between and no consideration of severity. 82,95 However, depression is not a dichotomous disorder and instead there is a scale of severity, such that individuals considered to be in remission may at times have depressive symptoms that affect their HRQoL, and those individuals who are considered to be depressed may be so to varying severities (see Chapter 1, Diagnosis, for details on different categories of depression). The study by Simon et al. 75 identified in the review of cost-effectiveness, described itself as addressing depression relapse; however, the primary measure of effectiveness used is the number of depression-free days, not the prevention of relapse, and even depression-free days are measured as continuous rather than dichotomous, with intermediate severity scores being treated as between depression free and fully symptomatic. Although prevention of relapse is clearly an important factor in the effectiveness of treatment, and something that needs to be included in any future evaluation, there may be other effects of treatment that cannot be captured by focusing solely on relapse prevention. For example, it may be important to capture the effects of treatment on HRQoL during periods of remission or depressive episodes, as well as the impact on risk of relapse or recurrence.

Heterogeneity of patients

As we have shown, there is currently minimal evidence to support the use of low-intensity psychological interventions for the prevention of relapse or recurrence. However, this patient group is not homogeneous, and within this group there are many sources of explorable heterogeneity that could be considered. Therefore, before any future evaluation it is important to consider which subgroups should be examined.

Risk of relapse within depression is heavily dependent on the number of previous episodes; for example, it has been reported that risk of relapse is 50% among patients having experienced one episode of major depression, rising to 70% among patients who have experienced two episodes and 90% among patients who have experienced three episodes. 14 Previous models examining treatments for depression have taken account of the number of previous depressive episodes. 95 Any future evaluation needs to take account of the differing baseline risk of relapse by number of previous episodes, as this will impact on the benefits of treatment. Similarly, it may also be worth examining if treatment effects differ by number of previous episodes.

As discussed previously, depression is not a dichotomous disorder and patients experiencing depressive episodes may suffer from different severities of the condition, with the associated differences in HRQoL. If the severity of prior depressive episodes is associated with the future severity of depression following relapse, then it may also be appropriate to consider this as a source of identifiable heterogeneity.

Comorbidity is also likely to be important in considering response to treatment and risk of relapse. For example, comorbid anxiety and depression are particularly common96 and are associated with poorer compliance with, and response to, treatment. 97

Another possible source of heterogeneity is the treatment received for the previous depressive episode (or episodes). Both low- and high-intensity psychological interventions are widely used in the treatment of depressive episodes; however, not all patients receive the same intervention, or a psychological intervention at all, with many patients receiving only pharmacological therapy. 98 It could be expected that there would be treatment interactions between the therapy received for the initial depressive episode and that received to prevent relapse or recurrence; for example, psychological therapies for depressive episodes have been found to have a relapse-preventative effect beyond the end of treatment,29 and, as such, this should be considered in any future evaluation. As discussed previously, this supports focusing on the whole-patient pathway rather than a selected part of it.

Societal costs

In the UK, guidelines for the economic evaluation of health-care technologies recommend that the perspective taken on costs should be that of the NHS and PSS; in exceptional circumstances when a substantial proportion of the costs fall outside of the NHS and PSS, costs to other government bodies may be considered as well when they are not reflected in HRQoL measures. 81 However, there is a large literature showing the substantial wider societal costs of depression; for example, one study99 found the annual cost of depression to England was over £9B, of which only £370M was in direct treatment costs. Key to whether or not these costs should be considered in an economic evaluation is whether or not the estimates of HRQoL capture the financial impact on the patient (and possibly any carer). If they do then capturing this impact in costs as well as in the HRQoL measure will result in double counting. Although many have argued that the measure of HRQoL should not capture the financial impact,100 the EQ-5D, the preferred measure within the UK,81 includes in its description of health states the ability to perform a ‘usual social role’, which will include participation in the labour market and its financial implications.

Any future evaluation also needs to consider what health-care resource should be collected to enable comparison between interventions. Although the inclusion of resources related directly to the treatment of depression is evident, depression has also been shown to increase the use of other health-care resources by patients even after controlling for comorbidities. 101 Good practice in economic evaluation involves including any differences between treatments in terms of resource use; therefore, a broad view of health-care resource use should be considered. 77

MEDLINE

OvidSP http://ovidsp.ovid.com/

1950 to week 4 August 2010.

Searched on 6 September 2010.

2455 records were retrieved.

1. Beating the Blues.ti,ab. (11)

2. Depression Relief.ti,ab. (5)

3. Overcoming Depression.ti,ab. (9)

4. (BluePages or Blue Pages).ti,ab. (5)

5. (MoodGYM or Mood GYM).ti,ab. (15)

6. Keeping the Blues Away.ti,ab. (1)

7. Sadness Program.ti,ab. (0)

8. Stressbusters.ti,ab. (2)

9. Think feel do.ti,ab. (0)

10. Wellbeing Program.ti,ab. (3)

11. Living Life to the Full.ti,ab. (3)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (49)

13. exp Depressive Disorder/ (66,517)

14. Depression/ (57,156)

15. (depression or depressive or depressed).ti,ab. (224,153)

16. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (6848)

17. 13 or 14 or 15 or 16 (259,354)

18. Recurrence/ (136,231)

19. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (376,377)

20. Secondary Prevention/ (499)

21. (secondary adj3 prevent$).ti,ab. (12,026)

22. (prophylaxis or prophylactic$).ti,ab. (96,242)

23. Remission Induction/ (25,968)

24. (remission or remitted).ti,ab. (67,244)

25. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (2704)

26. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (967)

27. 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 (584,508)

28. 17 and 27 (16,144)

29. Cognitive Therapy/ (10,799)

30. exp Behavior Therapy/ (41,600)

31. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (11,263)

32. (behavio?r$ adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (31,770)

33. CBT.ti,ab. (2696)

34. cognitive restructuring.ti,ab. (404)

35. (cCBT or iCBT).ti,ab. (93)

36. Telemedicine/ (7621)

37. Therapy, Computer-Assisted/ (3887)

38. Computer-Assisted Instruction/ (7483)

39. (telepsychology or teletherapy or telemedicine or telehealth).ti,ab. (6043)

40. (Interactive Voice Response or IVR).ti,ab. (507)

41. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 (87,903)

42. 41 and 28 (998)

43. counseling/or directive counseling/ (24,264)

44. counsel$.ti,ab. (51,434)

45. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (1728)

46. (cybercounsel$ or cyber counsel$).ti,ab. (2)

47. 43 or 44 or 45 or 46 (64,489)

48. 47 and 28 (191)

49. mindfulness.ti,ab. (594)

50. 49 and 28 (41)

51. exp Self Care/ (31,830)

52. Self-Help Groups/ (6870)

53. (selfcare or self care).ti,ab. (7272)

54. (selfmanage$ or self manage$).ti,ab. (4803)

55. (selfmonitor$ or self monitor$).ti,ab. (3133)

56. (selfhelp or self help).ti,ab. (3641)

57. (selftreat$ or self treat$).ti,ab. (911)

58. (selfadminister$ or self administer$).ti,ab. (16,624)

59. Bibliotherapy/ (277)

60. Manuals as Topic/ (3199)

61. Books/ (1941)

62. bibliotherap$.ti,ab. (208)

63. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (8770)

64. 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 (75,989)

65. 64 and 28 (278)

66. exp Exercise/ (52,567)

67. exp Exercise Therapy/ (21,709)

68. exp Exercise Movement Techniques/ (3903)

69. exp Sports/ (86,678)

70. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (180,715)

71. ((resistance or strength$ or weight) adj training).ti,ab. (4258)

72. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (1120)

73. (bicycl$ or cycle$ or cycling).ti,ab. (321,463)

74. (run$ or jog$ or treadmill$).ti,ab. (105,892)

75. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (498)

76. (yoga or yogic or pilates or danc$).ti,ab. (3789)

77. 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 (642,671)

78. 77 and 28 (1028)

79. Patient Education as Topic/ (59,612)

80. (psychoeducation$ or psycho education$).ti,ab. (2157)

81. 79 or 80 (61,166)

82. 81 and 28 (254)

83. Allied Health Personnel/ (9265)

84. Case Management/ (6903)

85. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

86. (para professional$ or paraprofessional$).ti,ab. (700)

87. peer support$.ti,ab. (901)

88. ((patient$ or client$) adj2 support group$).ti,ab. (257)

89. mental health peer$.ti,ab. (4)

90. graduate mental health worker$.ti,ab. (9)

91. low intensity worker$.ti,ab. (0)

92. health care assistant$.ti,ab. (133)

93. (case adj (worker$ or management)).ti,ab. (5798)

94. stepped care.ti,ab. (515)

95. (collaborative adj (care or management)).ti,ab. (600)

96. 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 (22,348)

97. 96 and 28 (70)

98. (low intensity adj5 (psychological or psychosocial)).ti,ab. (12)

99. Increasing Access to Psychological Therap$.ti,ab. (1)

100. Improving Access to Psychological Therap$.ti,ab. (5)

101. IAPT.ti,ab. (6)

102. 98 or 99 or 100 or 101 (22)

103. 12 or 42 or 48 or 50 or 65 or 78 or 82 or 97 or 102 (2540)

104. Animals/ (4,635,961)

105. Humans/ (11,394,975)

106. 104 not (104 and 105) (3,440,150)

107. 103 not 106 (2484)

108. letter.pt. (688,191)

109. editorial.pt. (261,694)

110. comment.pt. (418,836)

111. 108 or 109 or 110 (1,019,325)

112. 107 not 111 (2455)

MEDLINE In-Process & Other Non-Indexed Citations

OvidSP http://ovidsp.ovid.com/

3 September 2010.

Searched on 6 September 2010.

107 records were retrieved.

1. Beating the Blues.ti,ab. (1)

2. Depression Relief.ti,ab. (0)

3. Overcoming Depression.ti,ab. (0)

4. (BluePages or Blue Pages).ti,ab. (0)

5. (MoodGYM or Mood GYM).ti,ab. (2)

6. Keeping the Blues Away.ti,ab. (0)

7. Sadness Program.ti,ab. (0)

8. Stressbusters.ti,ab. (0)

9. Think feel do.ti,ab. (0)

10. Wellbeing Program.ti,ab. (0)

11. Living Life to the Full.ti,ab. (0)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (2)

13. exp Depressive Disorder/ (0)

14. Depression/ (0)

15. (depression or depressive or depressed).ti,ab. (7827)

16. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (204)

17. 13 or 14 or 15 or 16 (7908)

18. Recurrence/ (3)

19. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (13,341)

20. Secondary Prevention/ (1)

21. (secondary adj3 prevent$).ti,ab. (495)

22. (prophylaxis or prophylactic$).ti,ab. (2953)

23. Remission Induction/ (0)

24. (remission or remitted).ti,ab. (1770)

25. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (148)

26. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (49)

27. 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 (17,891)

28. 17 and 27 (572)

29. Cognitive Therapy/ (0)

30. exp Behavior Therapy/ (0)

31. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (729)

32. (behavio?r$ adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (1558)

33. CBT.ti,ab. (228)

34. cognitive restructuring.ti,ab. (25)

35. (cCBT or iCBT).ti,ab. (11)

36. Telemedicine/ (1)

37. Therapy, Computer-Assisted/ (0)

38. Computer-Assisted Instruction/ (0)

39. (telepsychology or teletherapy or telemedicine or telehealth).ti,ab. (274)

40. (Interactive Voice Response or IVR).ti,ab. (115)

41. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 (2291)

42. 41 and 28 (51)

43. counseling/or directive counseling/ (0)

44. counsel$.ti,ab. (1889)

45. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (133)

46. (cybercounsel$ or cyber counsel$).ti,ab. (0)

47. 43 or 44 or 45 or 46 (2003)

48. 47 and 28 (9)

49. mindfulness.ti,ab. (59)

50. 49 and 28 (9)

51. exp Self Care/ (0)

52. Self-Help Groups/ (0)

53. (selfcare or self care).ti,ab. (278)

54. (selfmanage$ or self manage$).ti,ab. (351)

55. (selfmonitor$ or self monitor$).ti,ab. (176)

56. (selfhelp or self help).ti,ab. (124)

57. (selftreat$ or self treat$).ti,ab. (35)

58. (selfadminister$ or self administer$).ti,ab. (648)

59. Bibliotherapy/ (0)

60. Manuals as Topic/ (0)

61. Books/ (0)

62. bibliotherap$.ti,ab. (9)

63. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (471)

64. 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 (1996)

65. 64 and 28 (13)

66. exp Exercise/ (2)

67. exp Exercise Therapy/ (0)

68. exp Exercise Movement Techniques/ (0)

69. exp Sports/ (0)

70. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (7289)

71. ((resistance or strength$ or weight) adj training).ti,ab. (314)

72. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (72)

73. (bicycl$ or cycle$ or cycling).ti,ab. (15,967)

74. (run$ or jog$ or treadmill$).ti,ab. (5926)

75. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (36)

76. (yoga or yogic or pilates or danc$).ti,ab. (286)

77. 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 (28,416)

78. 77 and 28 (34)

79. Patient Education as Topic/ (1)

80. (psychoeducation$ or psycho education$).ti,ab. (113)

81. 79 or 80 (114)

82. 81 and 28 (6)

83. Allied Health Personnel/ (0)

84. Case Management/ (0)

85. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

86. (para professional$ or paraprofessional$).ti,ab. (8)

87. peer support$.ti,ab. (64)

88. ((patient$ or client$) adj2 support group$).ti,ab. (15)

89. mental health peer$.ti,ab. (0)

90. graduate mental health worker$.ti,ab. (1)

91. low intensity worker$.ti,ab. (0)

92. health care assistant$.ti,ab. (5)

93. (case adj (worker$ or management)).ti,ab. (198)

94. stepped care.ti,ab. (18)

95. (collaborative adj (care or management)).ti,ab. (67)

96. 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 (373)

97. 96 and 28 (4)

98. (low intensity adj5 (psychological or psychosocial)).ti,ab. (1)

99. Increasing Access to Psychological Therap$.ti,ab. (1)

100. Improving Access to Psychological Therap$.ti,ab. (1)

101. IAPT.ti,ab. (3)

102. 98 or 99 or 100 or 101 (4)

103. 12 or 42 or 48 or 50 or 65 or 78 or 82 or 97 or 102 (110)

104. Animals/ (27)

105. Humans/ (134)

106. 104 not (104 and 105) (13)

107. 103 not 106 (110)

108. letter.pt. (15,007)

109. editorial.pt. (9160)

110. comment.pt. (23,331)

111. 108 or 109 or 110 (40,683)

112. 107 not 111 (107)

PsycINFO

OvidSP http://ovidsp.ovid.com/

1806 to week 5 August 2010.

Searched on 6 September 2010.

1891 records were retrieved.

1. Beating the Blues.ti,ab. (10)

2. Depression Relief.ti,ab. (8)

3. Overcoming Depression.ti,ab. (32)

4. (BluePages or Blue Pages).ti,ab. (2)

5. (MoodGYM or Mood GYM).ti,ab. (10)

6. Keeping the Blues Away.ti,ab. (0)

7. Sadness Program.ti,ab. (1)

8. Stressbusters.ti,ab. (1)

9. Think feel do.ti,ab. (3)

10. Wellbeing Program.ti,ab. (0)

11. Living Life to the Full.ti,ab. (2)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (67)

13. exp major depression/ (70,891)

14. “depression (emotion)”/ (19,720)

15. atypical depression/ (129)

16. seasonal affective disorder/ (810)

17. (depression or depressive or depressed).ti,ab. (160,866)

18. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (9393)

19. 13 or 14 or 15 or 16 or 17 or 18 (168,930)

20. “relapse (disorders)”/ (4222)

21. relapse prevention/ (1519)

22. exp “remission (disorders)”/ (1959)

23. maintenance therapy/ (675)

24. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (32,060)

25. (secondary adj3 prevent$).ti,ab. (1795)

26. (prophylaxis or prophylactic$).ti,ab. (3829)

27. (remission or remitted).ti,ab. (7924)

28. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (1054)

29. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (1115)

30. 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 (46,330)

31. 19 and 30 (12,129)

32. exp cognitive techniques/ (12,609)

33. exp cognitive behavior therapy/ (6703)

34. exp behavior modification/ (34,126)

35. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (21,958)

36. (behavio?r$ adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (49,995)

37. CBT.ti,ab. (4577)

38. cognitive restructuring.ti,ab. (1576)

39. computer assisted therapy/ (234)

40. computer assisted instruction/ (10,048)

41. online therapy/ (623)

42. telemedicine/ (1260)

43. (telehealth or telemedicine or teletherapy or telepsychology).ti,ab. (840)

44. Interactive Voice Response.ti,ab. (139)

45. IVR.ti,ab. (115)

46. (cCBT or iCBT).ti,ab. (59)

47. 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 (96,113)

48. 47 and 31 (1082)

49. exp counseling/ (57,787)

50. counsel$.ti,ab. (70,051)

51. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (2543)

52. (cybercounsel$ or cyber counsel$).ti,ab. (24)

53. 49 or 50 or 51 or 52 (100,086)

54. 53 and 31 (183)

55. mindfulness/ (1174)

56. mindfulness$.ti,ab. (1901)

57. 55 or 56 (1959)

58. 57 and 31 (101)

59. self care skills/ (2754)

60. exp self help techniques/ (6420)

61. (selfcare or self care).ti,ab. (3985)

62. (selfmanage$ or self manage$).ti,ab. (3625)

63. (selfmonitor$ or self monitor$).ti,ab. (3801)

64. (selfhelp or self help).ti,ab. (5425)

65. (selftreat$ or self treat$).ti,ab. (236)

66. (selfadminister$ or self administer$).ti,ab. (6963)

67. bibliotherapy/ (507)

68. exp books/ (3974)

69. reading materials/ (1454)

70. bibliotherap$.ti,ab. (714)

71. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (1782)

72. 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 or 71 (34,914)

73. 72 and 31 (145)

74. exp exercise/ (11,910)

75. movement therapy/ (505)

76. exp sports/ (11,533)

77. dance therapy/ (570)

78. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (42,784)

79. ((resistance or strength$ or weight) adj training).ti,ab. (528)

80. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (353)

81. (bicycl$ or cycle$ or cycling).ti,ab. (27,764)

82. (run$ or jog$ or treadmill$).ti,ab. (26,735)

83. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (205)

84. (yoga or yogic or pilates or danc$).ti,ab. (5067)

85. 74 or 75 or 76 or 77 or 78 or 79 or 80 or 81 or 82 or 83 or 84 (109,028)

86. 85 and 31 (521)

87. psychoeducation/ (2414)

88. client education/ (2519)

89. (psychoeducation$ or psycho education$).ti,ab. (5693)

90. 87 or 88 or 89 (8441)

91. 90 and 31 (147)

92. allied health personnel/ (498)

93. paraprofessional personnel/ (1297)

94. case management/ (2140)

95. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

96. (para professional$ or paraprofessional$).ti,ab. (1648)

97. peer support$.ti,ab. (1461)

98. ((patient$ or client$) adj2 support group$).ti,ab. (70)

99. mental health peer$.ti,ab. (9)

100. graduate mental health worker$.ti,ab. (6)

101. health care assistant$.ti,ab. (25)

102. low intensity worker$.ti,ab. (3)

103. (case adj (worker$ or management)).ti,ab. (3379)

104. stepped care.ti,ab. (248)

105. (collaborative adj (care or management)).ti,ab. (393)

106. 92 or 93 or 94 or 95 or 96 or 97 or 98 or 99 or 100 or 101 or 102 or 103 or 104 or 105 (9135)

107. 106 and 31 (49)

108. (low intensity adj5 (psychological or psychosocial)).ti,ab. (13)

109. Increasing Access to Psychological Therap$.ti,ab. (3)

110. Improving Access to Psychological Therap$.ti,ab. (15)

111. IAPT.ti,ab. (20)

112. 108 or 109 or 110 or 111 (38)

113. 12 or 48 or 54 or 58 or 73 or 86 or 91 or 107 or 112 (1955)

114. (rat or rats or mouse or mice or hamster or hamsters or animal or animals or dog or dogs or cat or cats or bovine or sheep).ti,ab,sh. (202,139)

115. 113 not 114 (1934)

116. (editorial or letter).dt. (27,226)

117. 115 not 116 (1901)

118. limit 117 to yr = “1950 -Current” (1891)

EMBASE

OvidSP http://ovidsp.ovid.com/

1980 to week 38 2010.

Searched on 29 September 2010.

2905 records were retrieved.

1. Beating the Blues.ti,ab. (16)

2. Depression Relief.ti,ab. (8)

3. Overcoming Depression.ti,ab. (14)

4. (BluePages or Blue Pages).ti,ab. (7)

5. (MoodGYM or Mood GYM).ti,ab. (19)

6. Keeping the Blues Away.ti,ab. (1)

7. Sadness Program.ti,ab. (0)

8. Stressbusters.ti,ab. (2)

9. Think feel do.ti,ab. (1)

10. Wellbeing Program.ti,ab. (4)

11. Living Life to the Full.ti,ab. (3)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (67)

13. exp *depression/ (125,235)

14. (depression or depressive or depressed).ti,ab. (264,422)

15. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (8650)

16. 13 or 14 or 15 (299,144)

17. *recurrent disease/ (5836)

18. *relapse/ (2425)

19. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (450,289)

20. *secondary prevention/ (1035)

21. (secondary adj3 prevent$).ti,ab. (16,107)

22. *prophylaxis/ (4975)

23. (prophylaxis or prophylactic$).ti,ab. (117,902)

24. *remission/ (1457)

25. (remission or remitted).ti,ab. (79,158)

26. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (3160)

27. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (1183)

28. 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 (628,701)

29. 16 and 28 (19,094)

30. *cognitive therapy/ (7474)

31. *behavior therapy/ (13,293)

32. *behavior modification/ (1031)

33. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (18,961)

34. (behavio?r$ adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (48,358)

35. CBT.ti,ab. (4164)

36. cognitive restructuring.ti,ab. (677)

37. (cCBT or iCBT).ti,ab. (129)

38. exp *telehealth/ (7617)

39. *computer assisted therapy/ (1548)

40. (telepsychology or teletherapy or telemedicine or telehealth).ti,ab. (6906)

41. *interactive voice response system/ (39)

42. (Interactive Voice Response or IVR).ti,ab. (676)

43. 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 (77,933)

44. 43 and 29 (1110)

45. exp *counseling/ (22,273)

46. counsel$.ti,ab. (61,285)

47. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (2415)

48. (cybercounsel$ or cyber counsel$).ti,ab. (2)

49. 45 or 46 or 47 or 48 (73,648)

50. 49 and 29 (236)

51. mindfulness.ti,ab. (924)

52. 51 and 29 (68)

53. exp *self care/ (14,330)

54. (selfcare or self care).ti,ab. (8667)

55. (selfmanage$ or self manage$).ti,ab. (6339)

56. (selfmonitor$ or self monitor$).ti,ab. (4162)

57. (selfhelp or self help).ti,ab. (4653)

58. (selftreat$ or self treat$).ti,ab. (1176)

59. (selfadminister$ or self administer$).ti,ab. (19,015)

60. *book/ (3872)

61. bibliotherap$.ti,ab. (299)

62. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (11,170)

63. 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 (66,094)

64. 63 and 29 (268)

65. exp *exercise/ (71,270)

66. exp *sport/ (37,531)

67. exp *physical activity/ (53,097)

68. exp *kinesiotherapy/ (16,054)

69. *music therapy/ (2050)

70. *treadmill/or *treadmill exercise/ (2173)

71. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (215,071)

72. ((resistance or strength$ or weight) adj training).ti,ab. (5135)

73. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (1384)

74. (bicycl$ or cycle$ or cycling).ti,ab. (365,808)

75. (run$ or jog$ or treadmill$).ti,ab. (126,820)

76. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (681)

77. (yoga or yogic or pilates or danc$).ti,ab. (5196)

78. 65 or 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 or 77 (739,132)

79. 78 and 29 (1264)

80. *psychoeducation/ (333)

81. *patient education/ (20,510)

82. (psychoeducation$ or psycho education$).ti,ab. (3197)

83. 80 or 81 or 82 (23,553)

84. 83 and 29 (255)

85. *paramedical personnel/ (5290)

86. *case management/or *case manager/ (3110)

87. *support group/ (508)

88. *peer group/ (2658)

89. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

90. (para professional$ or paraprofessional$).ti,ab. (677)

91. peer support$.ti,ab. (1155)

92. ((patient$ or client$) adj2 support group$).ti,ab. (345)

93. mental health peer$.ti,ab. (6)

94. graduate mental health worker$.ti,ab. (14)

95. low intensity worker$.ti,ab. (1)

96. health care assistant$.ti,ab. (151)

97. (case adj (worker$ or management)).ti,ab. (6627)

98. stepped care.ti,ab. (631)

99. (collaborative adj (care or management)).ti,ab. (770)

100. 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 or 96 or 97 or 98 or 99 (20,104)

101. 100 and 29 (80)

102. (low intensity adj5 (psychological or psychosocial)).ti,ab. (12)

103. Increasing Access to Psychological Therap$.ti,ab. (3)

104. Improving Access to Psychological Therap$.ti,ab. (21)

105. IAPT.ti,ab. (21)

106. 102 or 103 or 104 or 105 (46)

107. 12 or 44 or 50 or 52 or 64 or 79 or 84 or 101 or 106 (2972)

108. editorial.pt. (355,119)

109. letter.pt. (702,108)

110. 108 or 109 (1,057,227)

111. 107 not 110 (2962)

112. exp animal/ (1,629,045)

113. exp nonhuman/ (3,502,467)

114. exp animal experiment/ (1,392,148)

115. (rat or rats or mouse or mice or hamster or hamsters or animal or animals or dog or dogs or cat or cats or bovine or sheep).ti,ab,sh. (3,938,570)

116. 112 or 113 or 114 or 115 (5,657,477)

117. exp human/ (11,999,569)

118. exp human experiment/ (282,161)

119. 117 or 118 (12,000,950)

120. 116 not (116 and 119) (4,482,506)

121. 111 not 120 (2905)

The Cochrane Library

Wiley http://onlinelibrary.wiley.com/

Cochrane Database of Systematic Reviews (CDSR), Issue 9, September 2010.

Database of Abstracts of Reviews of Effects (DARE), Issue 3, 2010.

Cochrane Central Register of Controlled Trials (CENTRAL), Issue 3, 2010.

Health Technology Assessment database (HTA), Issue 3, 2010.

Searched on 17 September 2010.

702 records were retrieved – 20 from CDSR, six from DARE, 674 from CENTRAL, two from HTA database.

#1 “Beating the Blues”:ti,ab (4)

#2 “Depression Relief”:ti,ab (2)

#3 “Overcoming Depression”:ti,ab (6)

#4 (“BluePages” or “Blue Pages”):ti,ab (3)

#5 (“MoodGYM” or “Mood GYM”):ti,ab (9)

#6 “Keeping the Blues Away”:ti,ab (1)

#7 “Sadness Program”:ti,ab (0)

#8 “Stressbusters”:ti,ab (0)

#9 “Think feel do”:ti,ab (0)

#10 “Wellbeing Program”:ti,ab (0)

#11 “Living Life to the Full”:ti,ab (0)

#12 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11) (23)

#13 MeSH descriptor Depressive Disorder explode all trees (6039)

#14 MeSH descriptor Depression, this term only (3924)

#15 (depression or depressive or depressed):ti,ab (24,924)

#16 (melancholi* or dysphori* or dysthymi*):ti,ab (1130)

#17 (#13 OR #14 OR #15 OR #16) (26,859)

#18 MeSH descriptor Recurrence, this term only (10,144)

#19 (recur* or reoccur* or (re NEXT occur*) or relaps*):ti,ab (26,763)

#20 MeSH descriptor Secondary Prevention, this term only (39)

#21 (secondary NEAR/3 prevent*):ti,ab (1375)

#22 (prophylaxis or prophylactic*):ti,ab (16,307)

#23 MeSH descriptor Remission Induction, this term only (2326)

#24 (remission or remitted):ti,ab (7994)

#25 (maintain* NEAR/3 (health or wellbeing or (well NEXT being))):ti,ab (134)

#26 ((another or further or second or repeat* or previous or initial or subsequent) NEAR/4 (episode* or bout* or instance* or symptom* or occurrence*) NEAR/4 depress*):ti,ab (137)

#27 (#18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26) (52,009)

#28 (#17 AND #27) (2833)

#29 MeSH descriptor Cognitive Therapy, this term only (3139)

#30 MeSH descriptor Behavior Therapy explode all trees (7327)

#31 (cognitive NEAR/3 (therap* or treatment* or intervention* or program* or package* or training or group*)):ti,ab (5233)

#32 ((behavior* or behaviour*) NEAR/3 (therap* or treatment* or intervention* or program* or package* or training or activat* or modif* or group*)):ti,ab (7966)

#33 CBT:ti,ab (1147)

#34 (cognitive NEXT restructuring):ti,ab (208)

#35 (cCBT or iCBT):ti,ab (27)

#36 MeSH descriptor Telemedicine, this term only (595)

#37 MeSH descriptor Therapy, Computer-Assisted, this term only (418)

#38 MeSH descriptor Computer-Assisted Instruction, this term only (598)

#39 (telepsychology or teletherapy or telemedicine or telehealth):ti,ab (456)

#40 (“Interactive Voice Response” or IVR):ti,ab (104)

#41 (#29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40) (15,592)

#42 (#28 AND #41) (417)

#43 MeSH descriptor Counseling, this term only (2088)

#44 MeSH descriptor Directive Counseling, this term only (121)

#45 counsel*:ti,ab (4665)

#46 (motivation* NEAR/2 (interview* or enhance* or intervention* or therap*)):ti,ab (707)

#47 (cybercounsel* or (cyber NEXT counsel*)):ti,ab (0)

#48 (#43 OR #44 OR #45 OR #46 OR #47) (5885)

#49 (#28 AND #48) (51)

#50 mindfulness:ti,ab (178)

#51 (#28 AND #50) (26)

#52 MeSH descriptor Self Care explode all trees (2741)

#53 MeSH descriptor Self-Help Groups, this term only (458)

#54 (selfcare or (self NEXT care)):ti,ab (733)

#55 (selfmanage* or (self NEXT manage*) or selfmonitor* or (self NEXT monitor*)):ti,ab (1728)

#56 (selfhelp or (self NEXT help)):ti,ab (768)

#57 (selftreat* or (self NEXT treat*)):ti,ab (96)

#58 (selfadminister* or (self NEXT administer*)):ti,ab (1631)

#59 MeSH descriptor Bibliotherapy, this term only (66)

#60 MeSH descriptor Manuals as Topic, this term only (107)

#61 MeSH descriptor Books, this term only (25)

#62 bibliotherap*:ti,ab (103)

#63 ((patient* or client* or user*) NEAR/3 (manual* or handbook* or workbook* or guide*)):ti,ab (773)

#64 (#52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63) (7409)

#65 (#64 AND #28) (71)

#66 MeSH descriptor Exercise explode all trees (7313)

#67 MeSH descriptor Exercise Therapy explode all trees (4063)

#68 MeSH descriptor Exercise Movement Techniques explode all trees (725)

#69 MeSH descriptor Sports explode all trees (6128)

#70 (exercise* or workout* or (work NEXT out*) or (physical* NEXT activ*)):ti,ab (26,568)

#71 ((resistance or strength* or weight) NEAR training):ti,ab (2529)

#72 (walk* NEAR/3 (fitness or aerobic or program* or intervention* or session* or regime*)):ti,ab (445)

#73 (bicycl* or cycle* or cycling):ti,ab (15,471)

#74 (run* or jog* or treadmill*):ti,ab (9264)

#75 ((tai NEXT ji) or taiji or taijiquan or (tai NEXT chi) or (t NEXT ai NEXT chi) or taichi or (shadow NEXT boxing)):ti,ab (194)

#76 (yoga or yogic or pilates or danc*):ti,ab (444)

#77 (#66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76) (48,050)

#78 (#77 AND #28) (177)

#79 MeSH descriptor Patient Education as Topic, this term only (4958)

#80 (psychoeducation* or (psycho NEXT education*)):ti,ab (758)

#81 (#79 OR #80) (5513)

#82 (#81 AND #28) (78)

#83 MeSH descriptor Allied Health Personnel, this term only (131)

#84 MeSH descriptor Case Management, this term only (606)

#85 (psychological NEXT wellbeing NEXT practitioner*):ti,ab (0)

#86 (psychological NEXT (well NEXT being) NEXT practitioner*):ti,ab (0)

#87 (personal NEXT wellbeing NEXT practitioner*):ti,ab (0)

#88 (personal NEXT (well NEXT being) NEXT practitioner*):ti,ab (0)

#89 ((para NEXT professional*) or paraprofessional*):ti,ab (89)

#90 (peer NEXT support*):ti,ab (122)

#91 ((patient* or client*) NEAR/2 (support NEXT group*)):ti,ab (10)

#92 (mental NEXT health NEXT peer*):ti,ab (1)

#93 (graduate NEXT mental NEXT health NEXT worker*):ti,ab (1)

#94 (low NEXT intensity NEXT worker*):ti,ab (0)

#95 (health NEXT care NEXT assistant*):ti,ab (5)

#96 (case NEXT (worker* or management)):ti,ab (771)

#97 (stepped NEXT care):ti,ab (168)

#98 (collaborative NEXT (care or management)):ti,ab (153)

#99 (#83 OR #84 OR #85 OR #86 OR #87 OR #88 OR #89 OR #90 OR #91 OR #92 OR #93 OR #94 OR #95 OR #96 OR #97 OR #98) (1682)

#100 (#99 AND #28) (29)

#101 ((low NEXT intensity) NEAR/5 (psychological or psychosocial)):ti,ab (2)

#102 “Increasing Access to Psychological Therapy”:ti,ab (0)

#103 “Increasing Access to Psychological Therapies”:ti,ab (0)

#104 “Improving Access to Psychological Therapy”:ti,ab (0)

#105 “Improving Access to Psychological Therapies”:ti,ab (0)

#106 IAPT:ti,ab (0)

#107 (#101 OR #102 OR #103 OR #104 OR #105 OR #106) (2)

#108 (#12 OR #42 OR #49 OR #51 OR #65 OR #78 OR #82 OR #100 OR #107), from 1950 to 2010 (707)

Science Citation Index (SCI), Social Science Citation Index (SSCI)

ISI Web of Knowledge www.isinet.com/

SSCI 1956–present, SCI 1899–present.

Searched on 16 September 2010.

3656 records were retrieved.

BIOSIS Previews

ISI Web of Knowledge www.isinet.com/

1969–2008.

Searched on 17 September 2010.

3121 records were retrieved.

BIOSIS Previews

Dialog www.dialog.com/

1993 to week 2 September 2010.

Searched on 20 September 2010.

777 records were retrieved.

Guideline searches

A range of resources were searched or browsed for guidelines on the treatment of depression.

The Cochrane Library

http://onlinelibrary.wiley.com/

NHS Economic Evaluation Database (NHS EED), Issue 4, 2010.

Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2010.

Searched 22 October 2010.

62 records were retrieved – three from NHS EED and 43 from CENTRAL.

#1 “Beating the Blues”:ti,ab (4)

#2 “Depression Relief”:ti,ab (2)

#3 “Overcoming Depression”:ti,ab (6)

#4 (“BluePages” or “Blue Pages”):ti,ab (3)

#5 (“MoodGYM” or “Mood GYM”):ti,ab (10)

#6 “Keeping the Blues Away”:ti,ab (1)

#7 “Sadness Program”:ti,ab (0)

#8 “Stressbusters”:ti,ab (0)

#9 “Think feel do”:ti,ab (0)

#10 “Wellbeing Program”:ti,ab (0)

#11 “Living Life to the Full”:ti,ab (0)

#12 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11) (24)

#13 MeSH descriptor Depressive Disorder explode all trees (6154)

#14 MeSH descriptor Depression, this term only (4010)

#15 (depression or depressive or depressed):ti,ab (25,249)

#16 (melancholi* or dysphori* or dysthymi*):ti,ab (1136)

#17 (#13 OR #14 OR #15 OR #16) (27,205)

#18 MeSH descriptor Recurrence, this term only (10,301)

#19 (recur* or reoccur* or (re NEXT occur*) or relaps*):ti,ab (27,197)

#20 MeSH descriptor Secondary Prevention, this term only (47)

#21 (secondary NEAR/3 prevent*):ti,ab (1404)

#22 (prophylaxis or prophylactic*):ti,ab (16,468)

#23 MeSH descriptor Remission Induction, this term only (2357)

#24 (remission or remitted):ti,ab (8105)

#25 (maintain* NEAR/3 (health or wellbeing or (well NEXT being))):ti,ab (135)

#26 ((another or further or second or repeat* or previous or initial or subsequent) NEAR/4 (episode* or bout* or instance* or symptom* or occurrence*) NEAR/4 depress*):ti,ab (141)

#27 (#18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26) (52,739)

#28 (#17 AND #27) (2884)

#29 MeSH descriptor Cognitive Therapy, this term only (3258)

#30 MeSH descriptor Behavior Therapy explode all trees (7539)

#31 (cognitive NEAR/3 (therap* or treatment* or intervention* or program* or package* or training or group*)):ti,ab (5313)

#32 ((behavior* or behaviour*) NEAR/3 (therap* or treatment* or intervention* or program* or package* or training or activat* or modif* or group*)):ti,ab (8142)

#33 CBT:ti,ab (1196)

#34 (cognitive NEXT restructuring):ti,ab (213)

#35 (cCBT or iCBT):ti,ab (30)

#36 MeSH descriptor Telemedicine, this term only (616)

#37 MeSH descriptor Therapy, Computer-Assisted, this term only (433)

#38 MeSH descriptor Computer-Assisted Instruction, this term only (621)

#39 (telepsychology or teletherapy or telemedicine or telehealth):ti,ab (476)

#40 (“Interactive Voice Response” or IVR):ti,ab (110)

#41 (#29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40) (15,916)

#42 (#28 AND #41) (427)

#43 MeSH descriptor Counseling, this term only (2146)

#44 MeSH descriptor Directive Counseling, this term only (133)

#45 counsel*:ti,ab (4780)

#46 (motivation* NEAR/2 (interview* or enhance* or intervention* or therap*)):ti,ab (747)

#47 (cybercounsel* or (cyber NEXT counsel*)):ti,ab (0)

#48 (#43 OR #44 OR #45 OR #46 OR #47) (6054)

#49 (#28 AND #48) (53)

#50 mindfulness:ti,ab (191)

#51 (#28 AND #50) (28)

#52 MeSH descriptor Self Care explode all trees (2817)

#53 MeSH descriptor Self-Help Groups, this term only (465)

#54 (selfcare or (self NEXT care)):ti,ab (741)

#55 (selfmanage* or (self NEXT manage*) or selfmonitor* or (self NEXT monitor*)):ti,ab (1788)

#56 (selfhelp or (self NEXT help)):ti,ab (780)

#57 (selftreat* or (self NEXT treat*)):ti,ab (98)

#58 (selfadminister* or (self NEXT administer*)):ti,ab (1652)

#59 MeSH descriptor Bibliotherapy, this term only (67)

#60 MeSH descriptor Manuals as Topic, this term only (112)

#61 MeSH descriptor Books, this term only (27)

#62 bibliotherap*:ti,ab (104)

#63 ((patient* or client* or user*) NEAR/3 (manual* or handbook* or workbook* or guide*)):ti,ab (793)

#64 (#52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63) (7557)

#65 (#64 AND #28) (73)

#66 MeSH descriptor Exercise explode all trees (7550)

#67 MeSH descriptor Exercise Therapy explode all trees (4256)

#68 MeSH descriptor Exercise Movement Techniques explode all trees (746)

#69 MeSH descriptor Sports explode all trees (6317)

#70 (exercise* or workout* or (work NEXT out*) or (physical* NEXT activ*)):ti,ab (27,147)

#71 ((resistance or strength* or weight) NEAR training):ti,ab (2601)

#72 (walk* NEAR/3 (fitness or aerobic or program* or intervention* or session* or regime*)):ti,ab (460)

#73 (bicycl* or cycle* or cycling):ti,ab (15,694)

#74 (run* or jog* or treadmill*):ti,ab (9350)

#75 ((tai NEXT ji) or taiji or taijiquan or (tai NEXT chi) or (t NEXT ai NEXT chi) or taichi or (shadow NEXT boxing)):ti,ab (202)

#76 (yoga or yogic or pilates or danc*):ti,ab (458)

#77 (#66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76) (48,971)

#78 (#77 AND #28) (179)

#79 MeSH descriptor Patient Education as Topic, this term only (5087)

#80 (psychoeducation* or (psycho NEXT education*)):ti,ab (776)

#81 (#79 OR #80) (5656)

#82 (#81 AND #28) (79)

#83 MeSH descriptor Allied Health Personnel, this term only (134)

#84 MeSH descriptor Case Management, this term only (612)

#85 (psychological NEXT wellbeing NEXT practitioner*):ti,ab (0)

#86 (psychological NEXT (well NEXT being) NEXT practitioner*):ti,ab (0)

#87 (personal NEXT wellbeing NEXT practitioner*):ti,ab (0)

#88 (personal NEXT (well NEXT being) NEXT practitioner*):ti,ab (0)

#89 ((para NEXT professional*) or paraprofessional*):ti,ab (93)

#90 (peer NEXT support*):ti,ab (128)

#91 ((patient* or client*) NEAR/2 (support NEXT group*)):ti,ab (10)

#92 (mental NEXT health NEXT peer*):ti,ab (2)

#93 (graduate NEXT mental NEXT health NEXT worker*):ti,ab (1)

#94 (low NEXT intensity NEXT worker*):ti,ab (0)

#95 (health NEXT care NEXT assistant*):ti,ab (5)

#96 (case NEXT (worker* or management)):ti,ab (781)

#97 (stepped NEXT care):ti,ab (178)

#98 (collaborative NEXT (care or management)):ti,ab (160)

#99 (#83 OR #84 OR #85 OR #86 OR #87 OR #88 OR #89 OR #90 OR #91 OR #92 OR #93 OR #94 OR #95 OR #96 OR #97 OR #98) (1720)

#100 (#99 AND #28) (31)

#101 ((low NEXT intensity) NEAR/5 (psychological or psychosocial)):ti,ab (2)

#102 “Increasing Access to Psychological Therapy”:ti,ab (0)

#103 “Increasing Access to Psychological Therapies”:ti,ab (0)

#104 “Improving Access to Psychological Therapy”:ti,ab (0)

#105 “Improving Access to Psychological Therapies”:ti,ab (0)

#106 IAPT:ti,ab (0)

#107 (#101 OR #102 OR #103 OR #104 OR #105 OR #106) (2)

#108 (#12 OR #42 OR #49 OR #51 OR #65 OR #78 OR #82 OR #100 OR #107) (723)

#109 MeSH descriptor Economics, this term only (76)

#110 MeSH descriptor Costs and Cost Analysis explode all trees (30,817)

#111 MeSH descriptor Economics, Dental, this term only (7)

#112 MeSH descriptor Economics, Hospital explode all trees (3247)

#113 MeSH descriptor Economics, Medical, this term only (143)

#114 MeSH descriptor Economics, Nursing, this term only (29)

#115 MeSH descriptor Economics, Pharmaceutical, this term only (690)

#116 (econom* or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic*) (58,512)

#117 (expenditure* not energy) (2134)

#118 (value NEAR/1 money) (4)

#119 budget* (835)

#120 (#109 OR #110 OR #111 OR #112 OR #113 OR #114 OR #115 OR #116 OR #117 OR #118 OR #119) (58,779)

#121 ((energy or oxygen) NEAR/1 cost) (242)

#122 (metabolic NEAR/1 cost) (51)

#123 ((energy or oxygen) NEAR/1 expenditure) (1485)

#124 (#121 OR #112 OR #123) (4906)

#125 (#120 AND NOT #124) (55,202)

#126 (#108 AND #125) (62)

MEDLINE

OvidSP http://ovidSP.ovid.com

1950 to week 2 October 2010.

Searched on 22 October 2010.

158 records were retrieved.

1. Beating the Blues.ti,ab. (11)

2. Depression Relief.ti,ab. (5)

3. Overcoming Depression.ti,ab. (9)

4. (BluePages or Blue Pages).ti,ab. (5)

5. (MoodGYM or Mood GYM).ti,ab. (16)

6. Keeping the Blues Away.ti,ab. (1)

7. Sadness Program.ti,ab. (0)

8. Stressbusters.ti,ab. (2)

9. Think feel do.ti,ab. (0)

10. Wellbeing Program.ti,ab. (3)

11. Living Life to the Full.ti,ab. (3)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (50)

13. exp Depressive Disorder/ (67,684)

14. Depression/ (58,231)

15. (depression or depressive or depressed).ti,ab. (228,568)

16. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (6964)

17. 13 or 14 or 15 or 16 (264,178)

18. Recurrence/ (137,770)

19. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (381,860)

20. Secondary Prevention/ (556)

21. (secondary adj3 prevent$).ti,ab. (12,217)

22. (prophylaxis or prophylactic$).ti,ab. (97,325)

23. Remission Induction/ (26,272)

24. (remission or remitted).ti,ab. (68,089)

25. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (2761)

26. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (1009)

27. 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 (592,441)

28. 17 and 27 (16,518)

29. Cognitive Therapy/ (11,080)

30. exp Behavior Therapy/ (42,681)

31. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (11,630)

32. (behavio?r$ adj3 (therap$ or treatment$ or intervention$program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (32,564)

33. CBT.ti,ab. (2786)

34. cognitive restructuring.ti,ab. (411)

35. (cCBT or iCBT).ti,ab. (97)

36. Telemedicine/ (7759)

37. Therapy, Computer-Assisted/ (3969)

38. Computer-Assisted Instruction/ (7640)

39. (telepsychology or teletherapy or telemedicine or telehealth).ti,ab. (6110)

40. (Interactive Voice Response or IVR).ti,ab. (531)

41. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 (90,094)

42. 41 and 28 (1033)

43. counseling/or directive counseling/ (24,542)

44. counsel$.ti,ab. (52,258)

45. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (1813)

46. (cybercounsel$ or cyber counsel$).ti,ab. (2)

47. 43 or 44 or 45 or 46 (65,484)

48. 47 and 28 (199)

49. mindfulness.ti,ab. (621)

50. 49 and 28 (44)

51. exp Self Care/ (32,543)

52. Self-Help Groups/ (6922)

53. (selfcare or self care).ti,ab. (7406)

54. (selfmanage$ or self manage$).ti,ab. (4946)

55. (selfmonitor$ or self monitor$).ti,ab. (3226)

56. (selfhelp or self help).ti,ab. (3684)

57. (selftreat$ or self treat$).ti,ab. (925)

58. (selfadminister$ or self administer$).ti,ab. (17,074)

59. Bibliotherapy/ (283)

60. Manuals as Topic/ (3229)

61. Books/ (1970)

62. bibliotherap$.ti,ab. (213)

63. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (8973)

64. 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 (77,546)

65. 64 and 28 (291)

66. exp Exercise/ (53,519)

67. exp Exercise Therapy/ (22,146)

68. exp Exercise Movement Techniques/ (3963)

69. exp Sports/ (88,172)

70. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (183,654)

71. ((resistance or strength$ or weight) adj training).ti,ab. (4351)

72. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (1150)

73. (bicycl$ or cycle$ or cycling).ti,ab. (330,414)

74. (run$ or jog$ or treadmill$).ti,ab. (108,076)

75. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (509)

76. (yoga or yogic or pilates or danc$).ti,ab. (3884)

77. 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 (657,412)

78. 77 and 28 (1052)

79. Patient Education as Topic/ (60,271)

80. (psychoeducation$ or psycho education$).ti,ab. (2208)

81. 79 or 80 (61,864)

82. 81 and 28 (260)

83. Allied Health Personnel/ (9346)

84. Case Management/ (7023)

85. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

86. (para professional$ or paraprofessional$).ti,ab. (704)

87. peer support$.ti,ab. (923)

88. ((patient$ or client$) adj2 support group$).ti,ab. (263)

89. mental health peer$.ti,ab. (5)

90. graduate mental health worker$.ti,ab. (10)

91. low intensity worker$.ti,ab. (0)

92. health care assistant$.ti,ab. (134)

93. (case adj (worker$ or management)).ti,ab. (5885)

94. stepped care.ti,ab. (520)

95. (collaborative adj (care or management)).ti,ab. (624)

96. 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 (22,658)

97. 96 and 28 (72)

98. (low intensity adj5 (psychological or psychosocial)).ti,ab. (12)

99. Increasing Access to Psychological Therap$.ti,ab. (1)

100. Improving Access to Psychological Therap$.ti,ab. (6)

101. IAPT.ti,ab. (7)

102. 98 or 99 or 100 or 101 (24)

103. 12 or 42 or 48 or 50 or 65 or 78 or 82 or 97 or 102 (2617)

104. Animals/ (4,722,671)

105. Humans/ (11,541,120)

106. 104 not (104 and 105) (3,501,448)

107. 103 not 106 (2559)

108. letter.pt. (696,237)

109. editorial.pt. (265,801)

110. comment.pt. (425,820)

111. 108 or 109 or 110 (1,033,359)

112. 107 not 111 (2529)

113. economics/ (25,987)

114. exp “costs and cost analysis”/ (153,908)

115. economics, dental/ (1835)

116. exp “economics, hospital”/ (16,898)

117. economics, medical/ (8323)

118. economics, nursing/ (3826)

119. economics, pharmaceutical/ (2155)

120. (econom$ or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic$).ti,ab. (334,038)

121. (expenditure$ not energy).ti,ab. (13,844)

122. (value adj1 money).ti,ab. (18)

123. budget$.ti,ab. (14,021)

124. or/113–123 (443,197)

125. ((energy or oxygen) adj cost).ti,ab. (2244)

126. (metabolic adj cost).ti,ab. (583)

127. ((energy or oxygen) adj expenditure).ti,ab. (12,761)

128. or/125–127 (14,993)

129. 124 not 128 (439,696)

130. letter.pt. (696,237)

131. editorial.pt. (265,801)

132. historical-article.pt. (270,029)

133. or/130–132 (1,219,838)

134. 129 not 133 (415,600)

135. animals/ (4,722,671)

136. human/ (11,541,120)

137. 135 not (135 and 136) (3,501,448)

138. 134 not 137 (391,795)

139. 112 and 138 (158)

EMBASE

OvidSP http://ovidSP.ovid.com/

1980 to week 41 2010.

Searched on 22 October 2010.

423 records were retrieved.

1. Beating the Blues.ti,ab. (16)

2. Depression Relief.ti,ab. (8)

3. Overcoming Depression.ti,ab. (14)

4. (BluePages or Blue Pages).ti,ab. (7)

5. (MoodGYM or Mood GYM).ti,ab. (19)

6. Keeping the Blues Away.ti,ab. (1)

7. Sadness Program.ti,ab. (0)

8. Stressbusters.ti,ab. (2)

9. Think feel do.ti,ab. (1)

10. 10 Wellbeing Program.ti,ab. (4)

11. Living Life to the Full.ti,ab. (3)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (67)

13. exp depression/ (230,624)

14. (depression or depressive or depressed).ti,ab. (265,744)

15. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (8685)

16. 13 or 14 or 15 (356,576)

17. recurrent disease/ (104,082)

18. relapse/ (33,031)

19. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (452,614)

20. Secondary Prevention/ (9386)

21. (secondary adj3 prevent$).ti,ab. (16,204)

22. prophylaxis/ (44,266)

23. (prophylaxis or prophylactic$).ti,ab. (118,378)

24. remission/ (48,652)

25. (remission or remitted).ti,ab. (79,463)

26. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (3185)

27. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (1187)

28. 17 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 (705,789)

29. 16 and 28 (24,581)

30. Cognitive Therapy/ (22,766)

31. behavior therapy/ (32,526)

32. behavior modification/ (5677)

33. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (17,204)

34. (behavio?r$ adj3 (therap$ or treatment$ or intervention$program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (41,007)

35. CBT.ti,ab. (4196)

36. cognitive restructuring.ti,ab. (679)

37. (cCBT or iCBT).ti,ab. (130)

38. exp telehealth/ (10,779)

39. computer assisted therapy/ (2607)

40. (telepsychology or teletherapy or telemedicine or telehealth).ti,ab. (6927)

41. interactive voice response system/ (131)

42. (Interactive Voice Response or IVR).ti,ab. (682)

43. 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 (96,338)

44. 43 and 29 (1917)

45. exp counseling/ (77,508)

46. counsel$.ti,ab. (61,636)

47. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (2440)

48. (cybercounsel$ or cyber counsel$).ti,ab. (2)

49. 45 or 46 or 47 or 48 (106,226)

50. 49 and 29 (466)

51. mindfulness.ti,ab. (937)

52. 51 and 29 (75)

53. exp Self Care/ (35,497)

54. (selfcare or self care).ti,ab. (8715)

55. (selfmanage$ or self manage$).ti,ab. (6402)

56. (selfmonitor$ or self monitor$).ti,ab. (4188)

57. (selfhelp or self help).ti,ab. (4669)

58. (selftreat$ or self treat$).ti,ab. (1180)

59. (selfadminister$ or self administer$).ti,ab. (19,130)

60. book/ (12,945)

61. bibliotherap$.ti,ab. (300)

62. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (11,266)

63. 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 (89,419)

64. 63 and 29 (405)

65. exp Exercise/ (146,682)

66. exp sport/ (70,614)

67. exp physical activity/ (153,076)

68. exp kinesiotherapy/ (34,433)

69. music therapy/ (3057)

70. treadmill/or treadmill exercise/ (12,465)

71. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (216,208)

72. ((resistance or strength$ or weight) adj training).ti,ab. (5173)

73. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (1400)

74. (bicycl$ or cycle$ or cycling).ti,ab. (368,044)

75. (run$ or jog$ or treadmill$).ti,ab. (127,399)

76. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (689)

77. (yoga or yogic or pilates or danc$).ti,ab. (5228)

78. 65 or 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 or 77 (855,163)

79. 78 and 29 (1796)

80. psychoeducation/ (1832)

81. patient education/ (70,747)

82. (psychoeducation$ or psycho education$).ti,ab. (3207)

83. 80 or 81 or 82 (74,268)

84. 83 and 29 (628)

85. paramedical personnel/ (9745)

86. case management/or case manager/ (5489)

87. support group/ (4954)

88. peer group/ (8195)

89. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

90. (para professional$ or paraprofessional$).ti,ab. (677)

91. peer support$.ti,ab. (1165)

92. ((patient$ or client$) adj2 support group$).ti,ab. (348)

93. mental health peer$.ti,ab. (7)

94. graduate mental health worker$.ti,ab. (15)

95. low intensity worker$.ti,ab. (1)

96. health care assistant$.ti,ab. (151)

97. (case adj (worker$ or management)).ti,ab. (6668)

98. stepped care.ti,ab. (632)

99. (collaborative adj (care or management)).ti,ab. (779)

100. 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 or 96 or 97 or 98 or 99 (35,819)

101. 100 and 29 (156)

102. (low intensity adj5 (psychological or psychosocial)).ti,ab. (12)

103. Increasing Access to Psychological Therap$.ti,ab. (3)

104. Improving Access to Psychological Therap$.ti,ab. (21)

105. IAPT.ti,ab. (21)

106. 102 or 103 or 104 or 105 (46)

107. 12 or 44 or 50 or 52 or 64 or 79 or 84 or 101 or 106 (4592)

108. editorial.pt. (356,865)

109. letter.pt. (704,364)

110. 108 or 109 (1,061,229)

111. 107 not 110 (4485)

112. exp animal/ (1,632,799)

113. exp nonhuman/ (3,514,218)

114. exp animal experiment/ (1,396,171)

115. (rat or rats or mouse or mice or hamster or hamsters or animal or animals or dog or dogs or cat or cats or bovine or sheep).ti,ab,sh. (3,950,443)

116. 112 or 113 or 114 or 115 (5,675,551)

117. exp human/ (12,039,117)

118. exp human experiment/ (282,706)

119. 117 or 118 (12,040,498)

120. 116 not (116 and 119) (4,494,950)

121. 111 not 120 (4418)

122. health-economics/ (29,603)

123. exp economic-evaluation/ (160,071)

124. exp health-care-cost/ (153,513)

125. exp pharmacoeconomics/ (132,321)

126. 122 or 123 or 124 or 125 (369,725)

127. (econom$ or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic$).ti,ab. (407,190)

128. (expenditure$ not energy).ti,ab. (16,385)

129. (value adj2 money).ti,ab. (854)

130. budget$.ti,ab. (17,453)

131. 127 or 128 or 129 or 130 (424,985)

132. 126 or 131 (645,743)

133. letter.pt. (704,364)

134. editorial.pt. (356,865)

135. note.pt. (424,000)

136. 133 or 134 or 135 (1,485,229)

137. 132 not 136 (578,462)

138. (metabolic adj cost).ti,ab. (622)

139. ((energy or oxygen) adj cost).ti,ab. (2457)

140. ((energy or oxygen) adj expenditure).ti,ab. (14,419)

141. 138 or 139 or 140 (16,852)

142. 137 not 141 (574,620)

143. exp animal/ (1,632,799)

144. exp animal-experiment/ (1,396,171)

145. nonhuman/ (3,514,218)

146. (rat or rats or mouse or mice or hamster or hamsters or animal or animals or dog or dogs or cat or cats or bovine or sheep).ti,ab,sh. (3,950,443)

147. 143 or 144 or 145 or 146 (5,675,551)

148. exp human/ (12,039,117)

149. exp human-experiment/ (282,706)

150. 148 or 149 (12,040,498)

151. 147 not (147 and 150) (4,494,950)

152. 142 not 151 (534,924)

153. 121 and 152 (423)

EconLit

OvidSP http://ovidSP.ovid.com/

1969 to September 2010.

Searched on 22 October 2010.

12 records were retrieved.

1. Beating the Blues.ti,ab. (0)

2. Depression Relief.ti,ab. (1)

3. Overcoming Depression.ti,ab. (0)

4. (BluePages or Blue Pages).ti,ab. (0)

5. (MoodGYM or Mood GYM).ti,ab. (0)

6. Keeping the Blues Away.ti,ab. (0)

7. Sadness Program.ti,ab. (0)

8. Stressbusters.ti,ab. (0)

9. Think feel do.ti,ab. (0)

10. 10 Wellbeing Program.ti,ab. (0)

11. Living Life to the Full.ti,ab. (0)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (1)

13. (depression or depressive or depressed).ti,ab. (2745)

14. (melancholi$ or dysphori$ or dysthymi$).ti,ab. (4)

15. 13 or 14 (2746)

16. (recur$ or reoccur$ or re occur$ or relaps$).ti,ab. (3173)

17. (secondary adj3 prevent$).ti,ab. (15)

18. (prophylaxis or prophylactic$).ti,ab. (51)

19. (remission or remitted).ti,ab. (40)

20. (maintain$ adj3 (health or wellbeing or well being)).ti,ab. (46)

21. ((another or further or second or repeat$ or previous or initial or subsequent) adj4 (episode$ or bout$ or instance$ or symptom$ or occurrence$) adj4 depress$).ti,ab. (1)

22. 16 or 17 or 18 or 19 or 20 or 21 (3321)

23. 15 and 22 (27)

24. (cognitive adj3 (therap$ or treatment$ or intervention$ or program$ or package$ or training or group$)).ti,ab. (21)

25. (behavio?r$ adj3 (therap$ or treatment$ or intervention$program$ or package$ or training or activat$ or modif$ or group$)).ti,ab. (525)

26. CBT.ti,ab. (18)

27. cognitive restructuring.ti,ab. (0)

28. (cCBT or iCBT).ti,ab. (1)

29. (telepsychology or teletherapy or telemedicine or telehealth).ti,ab. (16)

30. (Interactive Voice Response or IVR).ti,ab. (5)

31. 24 or 25 or 26 or 27 or 28 or 29 or 30 (579)

32. 31 and 23 (1)

33. counsel$.ti,ab. (483)

34. (motivation$ adj2 (interview$ or enhance$ or intervention$ or therap$)).ti,ab. (18)

35. (cybercounsel$ or cyber counsel$).ti,ab. (0)

36. 33 or 34 or 35 (501)

37. 36 and 23 (0)

38. mindfulness.ti,ab. (6)

39. 38 and 23 (0)

40. (selfcare or self care).ti,ab. (21)

41. (selfmanage$ or self manage$).ti,ab. (332)

42. (selfmonitor$ or self monitor$).ti,ab. (24)

43. (selfhelp or self help).ti,ab. (241)

44. (selftreat$ or self treat$).ti,ab. (4)

45. (selfadminister$ or self administer$).ti,ab. (62)

46. bibliotherap$.ti,ab. (0)

47. ((patient$ or client$ or user$) adj3 (manual$ or handbook$ or workbook$ or guide$)).ti,ab. (151)

48. 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 (832)

49. 48 and 23 (0)

50. (exercise$ or workout$ or work out$ or physical$activ$).ti,ab. (6161)

51. ((resistance or strength$ or weight) adj training).ti,ab. (2)

52. (walk$ adj3 (fitness or aerobic or program$ or intervention$ or session$ or regime$)).ti,ab. (8)

53. (bicycl$ or cycle$ or cycling).ti,ab. (18,680)

54. (run$ or jog$ or treadmill$).ti,ab. (26,985)

55. (tai ji or taiji or taijiquan or tai chi or t ai chi or taichi or shadow boxing).ti,ab. (4)

56. (yoga or yogic or pilates or danc$).ti,ab. (156)

57. 50 or 51 or 52 or 53 or 54 or 55 or 56 (50,234)

58. 57 and 23 (4)

59. (psychoeducation$ or psycho education$).ti,ab. (3)

60. 59 and 23 (1)

61. ((psychological or personal) adj (wellbeing practitioner$ or well being practitioner$)).ti,ab. (0)

62. (para professional$ or paraprofessional$).ti,ab. (10)

63. peer support$.ti,ab. (12)

64. ((patient$ or client$) adj2 support group$).ti,ab. (0)

65. mental health peer$.ti,ab. (0)

66. graduate mental health worker$.ti,ab. (0)

67. low intensity worker$.ti,ab. (0)

68. health care assistant$.ti,ab. (0)

69. (case adj (worker$ or management)).ti,ab. (80)

70. stepped care.ti,ab. (0)

71. (collaborative adj (care or management)).ti,ab. (17)

72. 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 or 71 (119)

73. 72 and 23 (1)

74. (low intensity adj5 (psychological or psychosocial)).ti,ab. (0)

75. Increasing Access to Psychological Therap$.ti,ab. (0)

76. Improving Access to Psychological Therap$.ti,ab. (1)

77. IAPT.ti,ab. (5)

78. 74 or 75 or 76 or 77 (5)

79. 12 or 32 or 37 or 39 or 49 or 58 or 60 or 73 or 78 (12).

IDEAS database

http://ideas.repec.org/search.html

Searched on 3 November 2010.

114 records retrieved.

((recur|recurs|recurrence|recurred|relapse|relapses|relapsed|reoccur|reoccurs|reoccurrence|reoccurred|repeat|subsequent)+(depression|depressive|depressed|melancholia|melancholic|melancholy|dysphoria|dysphoric|dysthymia|dysthymic))

Match: Change to Boolean

Word forms:Change to Exact

Use Synonyms: Change to No

Background