Targets and outcomes of psychotherapies for mental disorders: an overview

What works for mental health problems in youth? Survey of real-world experiences of treatments and side effects

AIM

Despite youth being the most common age group for onset of mental disorders, there is less knowledge on the benefits and harms of treatments in young people. In addition, efficacy data from randomized controlled trials may not generalize to how treatment works outside of research settings. This study aimed to investigate young people's perceived effectiveness of different treatments for mental health problems, the professionals who delivered these, and the experience of negative effects.

METHODS

We developed a consumer report website where young people who were ever diagnosed with a mental disorder provided ratings on the helpfulness or harmfulness of different types of professionals, mental health treatments (medical, psychological complementary/alternative) and self-help strategies, and whether they had experienced particular negative effects.

RESULTS

Here, 557 young people aged 12-25 years, who were recruited from English-speaking, high-income countries, provided 1258 ratings of treatments. All treatments showed varied perceptions of effectiveness. Medical and psychological treatments were rated moderately helpful on average with low rates of harmfulness. Self-help strategies were rated as being as helpful as professional treatments. Side effects related to the head or mind (e.g., concentration difficulties, inability to feel emotions, depression and irritability) were the most common across all types of medicines. For psychological treatments, treatment being too expensive and feeling worse at the end of a session were the most commonly reported negative effects.

CONCLUSIONS

Study findings may be a useful guide to clinicians, researchers, young people and their families about what is likely to work in real-world settings.

Initial treatment choices to achieve sustained response in major depression: a systematic review and network meta-analysis

Major depression is often a relapsing disorder. It is therefore important to start its treatment with therapies that maximize the chance of not only getting the patients well but also keeping them well. We examined the associations between initial treatments and sustained response by conducting a network meta-analysis of randomized controlled trials (RCTs) in which adult patients with major depression were randomized to acute treatment with a psychotherapy (PSY), a protocolized antidepressant pharmacotherapy (PHA), their combination (COM), standard treatment in primary or secondary care (STD), or pill placebo, and were then followed up through a maintenance phase. By design, acute phase treatment could be continued into the maintenance phase, switched to another treatment or followed by discretionary treatment. We included 81 RCTs, with 13,722 participants. Sustained response was defined as responding to the acute treatment and subsequently having no depressive relapse through the maintenance phase (mean duration: 42.2±16.2 weeks, range 24-104 weeks). We extracted the data reported at the time point closest to 12 months. COM resulted in more sustained response than PHA, both when these treatments were continued into the maintenance phase (OR=2.52, 95% CI: 1.66-3.85) and when they were followed by discretionary treatment (OR=1.80, 95% CI: 1.21-2.67). The same applied to COM in comparison with STD (OR=2.90, 95% CI: 1.68-5.01 when COM was continued into the maintenance phase; OR=1.97, 95% CI: 1.51-2.58 when COM was followed by discretionary treatment). PSY also kept the patients well more often than PHA, both when these treatments were continued into the maintenance phase (OR=1.53, 95% CI: 1.00-2.35) and when they were followed by discretionary treatment (OR=1.66, 95% CI: 1.13-2.44). The same applied to PSY compared with STD (OR=1.76, 95% CI: 0.97-3.21 when PSY was continued into the maintenance phase; OR=1.83, 95% CI: 1.20-2.78 when PSY was followed by discretionary treatment). Given the average sustained response rate of 29% on STD, the advantages of PSY or COM over PHA or STD translated into risk differences ranging from 12 to 16 percentage points. We conclude that PSY and COM have more enduring effects than PHA. Clinical guidelines on the initial treatment choice for depression may need to be updated accordingly.

The clinical characterization of the adult patient with an anxiety or related disorder aimed at personalization of management

The clinical construct of "anxiety neurosis" was broad and poorly defined, so that the delineation of specific anxiety disorders in the DSM-III was an important advance. However, anxiety and related disorders are not only frequently comorbid, but each is also quite heterogeneous; thus diagnostic manuals provide only a first step towards formulating a management plan, and the development of additional decision support tools for the treatment of anxiety conditions is needed. This paper aims to describe systematically important domains that are relevant to the personalization of management of anxiety and related disorders in adults. For each domain, we summarize the available research evidence and review the relevant assessment instruments, paying special attention to their suitability for use in routine clinical practice. We emphasize areas where the available evidence allows the clinician to personalize the management of anxiety conditions, and we point out key unmet needs. Overall, the evidence suggests that we are becoming able to move from simply recommending that anxiety and related disorders be treated with selective serotonin reuptake inhibitors, cognitive-behavioral therapy, or their combination, to a more complex approach which emphasizes that the clinician has a broadening array of management modalities available, and that the treatment of anxiety and related disorders can already be personalized in a number of important respects.

How Do Critical Thinking Ability and Critical Thinking Disposition Relate to the Mental Health of University Students?

Theories of psychotherapy suggest that human mental problems associate with deficiencies in critical thinking. However, it currently remains unclear whether both critical thinking skill and critical thinking disposition relate to individual differences in mental health. This study explored whether and how the critical thinking ability and critical thinking disposition of university students associate with individual differences in mental health in considering impulsivity that has been revealed to be closely related to both critical thinking and mental health. Regression and structural equation modeling analyses based on a Chinese university student sample (N = 314, 198 females, M age = 18.65) revealed that critical thinking skill and disposition explained a unique variance of mental health after controlling for impulsivity. Furthermore, the relationship between critical thinking and mental health was mediated by motor impulsivity (acting on the spur of the moment) and non-planning impulsivity (making decisions without careful forethought). These findings provide a preliminary account of how human critical thinking associate with mental health. Practically, developing mental health promotion programs for university students is suggested to pay special attention to cultivating their critical thinking dispositions and enhancing their control over impulsive behavior.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report

BACKGROUND

Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment.

METHODS

Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment.

RESULTS

The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness.

CONCLUSIONS

The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

Service users experience of psychological interventions in primary care settings: A qualitative meta-synthesis

Primary care mental health services play a crucial role in public mental health by providing local and accessible psychological interventions that meet individuals' needs. Despite growing research investigating service users' perspectives of psychological interventions, a qualitative systematic review in this context is not available. The present meta-synthesis collates the existing articles and gives a thematic synthesis of qualitative studies on service users' experience of psychological interventions in primary care. Multiple databases (CINAHL, EMBASE, PsychINFO, MEDLINE, and Cochrane Library) were searched for published qualitative studies of service users' experiences of psychological interventions delivered in primary care. Articles were included if they met inclusion criteria. Study quality was assessed using the Critical Appraisal Skills Programme tool. All types of psychological interventions were considered across model and delivery format (e.g., face-to-face, computerised programmes, and group). NVIVO was used to code the dataset and themes were extracted following thematic synthesis. Twenty-two studies were included. Four analytical themes and 10 subthemes emerged. The identified themes were as follows: (1) 'Access and Acceptability: facilitators and barriers', (2) 'Structural aspects'; (3) 'Therapeutic process' and (4) 'Outcomes'. A model of interrelationships between themes is proposed. Findings suggest several 'essential ingredients' across psychological interventions and modalities. The crucial role of relational factors, the importance of assessing service users' perceptions of treatment features (e.g., remote delivery) and of tailoring the intervention to their needs were emphasised. Results also suggest involving service users more in discussions and decisions about psychological interventions offered might enhance access, acceptability, and engagement. Recommendations for practice and research are provided.

Perceived helpfulness of treatment for specific phobia: Findings from the World Mental Health Surveys

BACKGROUND

Although randomized trials show that specific phobia treatments can be effective, it is unclear whether patients experience treatment as helpful in clinical practice. We investigated this issue by assessing perceived treatment helpfulness for specific phobia in a cross-national epidemiological survey.

METHODS

Cross-sectional population-based WHO World Mental Health (WMH) surveys in 24 countries (n=112,507) assessed lifetime specific phobia. Respondents who met lifetime criteria were asked whether they ever received treatment they considered helpful and the number of professionals seen up to the time of receiving helpful treatment. Discrete-event survival analysis was used to calculate conditional-cumulative probabilities of obtaining helpful treatment across number of professionals seen and of persisting in help-seeking after prior unhelpful treatment.

RESULTS

23.0% of respondents reported receiving helpful treatment from the first professional seen, whereas cumulative probability of receiving helpful treatment was 85.7% after seeing up to 9 professionals. However, only 14.7% of patients persisted in seeing up to 9 professionals, resulting in the proportion of patients ever receiving helpful treatment (47.5%) being much lower than it could have been with persistence in help-seeking. Few predictors were found either of perceived helpfulness or of persistence in help-seeking after earlier unhelpful treatments.

LIMITATIONS

Retrospective recall and lack of information about either types of treatments received or objective symptomatic improvements limit results.

CONCLUSIONS

Despite these limitations, results suggest that helpfulness of specific phobia treatment could be increased, perhaps substantially, by increasing patient persistence in help-seeking after earlier unhelpful treatments. Improved understanding is needed of barriers to help-seeking persistence.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

Duration of untreated illness predicts 3-year outcome in patients with obsessive-compulsive disorder: A real-world, naturalistic, follow-up study

Duration of untreated illness (DUI) is a predictor of outcome in psychotic and affective disorders. The few available data on the effect of DUI in obsessive-compulsive disorder (OCD) suggest an association between longer DUI and poorer response to treatments. This is a real-world, naturalistic, follow-up study evaluating the impact of DUI on long-term clinical outcomes. The sample consists of 83 outpatients with OCD with a mean DUI of 7.3 (5.8) years. Patients with symmetry/ordering cluster symptoms were younger at onset of the disease (20.4 ± 7.9 vs. 27.8 ± 10.6; p<.05, d = 0.79), had a longer duration of the illness (10.1 ± 4.6 vs. 6.8 ± 4.6, p<.05; d = 0.53) and a longer DUI (7.9 ± 6.5 vs. 5.4 ± 3.6, p<.05, d = 0.49) compared to patients not presenting with those symptoms. Fifty-nine patients completed the follow-up, and 33.9% (N = 20) met the criteria for partial remission, scoring <15 at the Y-BOCS for at least eight weeks. Patients in partial remission for more than 40% of the follow-up were defined as "good outcome" and they had a significantly shorter DUI compared to patients with "poor outcome". Access to adequate treatments is highly delayed in patients with OCD. DUI is strongly associated with poor treatment outcomes. Therefore, strategies to ensure an early diagnosis and treatment are needed.

Higher Negative Self-Reference Level in Patients With Personality Disorders and Suicide Attempt(s) History During Biological Treatment for Major Depressive Disorder: Clinical Implications

Objective: The aim of the study was to identify clinical variables associated with changes in specific domains of self-reported depression during treatment by antidepressant and/or repetitive Transcranial Magnetic Stimulation (rTMS) in patients with Major Depressive Disorder (MDD).

Methods: Data from a trial involving 170 patients with MDD receiving either venlafaxine, rTMS or both were re-analyzed. Depressive symptoms were assessed each week during the 2 to 6 weeks of treatment with the 13-item Beck Depression Inventory (BDI₁₃). Associations between depression changes on BDI₁₃ domains (Negative Self-Reference, Sad Mood, and Performance Impairment), treatment arm, time, and clinical variables were tested in a mixed linear model.

Results: A significant decrease of self-reported depressive symptoms was observed over time. The main characteristics associated with persistent higher depressive symptomatology on Negative Self-Reference domain of the BDI₁₃ were personality disorders (+2.1 points), a past history of suicide attempt(s) (+1.7 points), age under 65 years old (+1.5 points), and female sex (+1.1 points).

Conclusions: Early cognitive intervention targeting specifically negative self-referencing process could be considered during pharmacological or rTMS treatment for patients with personality disorders and past history of suicide attempt(s).

Involving patients' perspective in the development of an internet- and mobile-based CBT intervention for adolescents with chronic medical conditions: Findings from a qualitative study

OBJECTIVE

A user-centered approach is critical for increasing the adherence to and effectiveness of an internet- and mobile-based intervention program. Therefore, potential future intervention users were involved in the development of an internet- and mobile-based cognitive behavioral therapy program (iCBT) for adolescents and young adults (AYA) with chronic medical conditions and comorbid symptoms of anxiety or depression. We aimed to identify challenges and coping strategies of the intended target group, as well as their needs and preferred intervention characteristics for an iCBT program.

METHODS

Twenty AYA (aged 14-20, 60% females) with either type 1 diabetes (55%), juvenile idiopathic arthritis (25%) or cystic fibrosis (20%) were interviewed in condition-specific focus groups (4-11 participants per group) either via videoconferencing or face-to-face. Transcript verbatim data was analyzed using content analysis.

RESULTS

Frequently reported disease-specific burdens were among others fear of disease progression, non-acceptance of disease and stressful incidents related to and aversions against medical therapy. Most frequently reported coping strategies included, seeking social support and accepting the disease. Recommendations for the content of an iCBT for comorbid symptoms of anxiety and depression comprised: dealing with disease-related fears and getting advice on health-promoting lifestyles. iCBT characteristics considered preferable by participants were: providing individual feedback by a real-person; implementation of a feature to monitor treatment progress; youthful and varied content presentation; time per session not exceeding 1 h; non-involvement of parents. A mobile-based reminder feature was considered useful, and individual tailoring and self-determination of iCBT content was considered desirable.

CONCLUSIONS

The findings highlight important patient perspectives and age-specific recommendations which can help design more optimal iCBT interventions for AYA with chronic medical conditions.

Effectiveness of Specific Techniques in Behavioral Teacher Training for Childhood ADHD: A Randomized Controlled Microtrial

Objective: Behavioral teacher training is the most effective classroom-based intervention for children with attention-deficit/hyperactivity disorder (ADHD). However, it is currently unknown which components of this intervention add to its effectiveness and for whom these are effective.

Method: In this microtrial, teachers of 90 children with impairing levels of ADHD symptoms (6–12 years) were randomly assigned to one of three conditions: a short (2 sessions), individualized intervention consisting of either (A) antecedent-based techniques (stimulus control), (B) consequent-based techniques (contingency management) or (C) waitlist. Primary outcome was the average of five daily assessments of four individualized problem behaviors, assessed pre and post intervention and three months later. Moderation analyses were conducted to generate hypotheses on child, teacher and classroom factors that may contribute to technique effectiveness.

Results: Multilevel analyses showed that both antecedent- and consequent-based techniques were equally and highly effective in reducing problem behaviors compared to the control condition (Cohen’s d =.9); effects remained stable up to three months later. Child’s age and class size were moderators of technique effectiveness. For younger children, consequent-based techniques were more effective than antecedent-based techniques, whereas for older children the effect was in the opposite direction. Further, beneficial effects of antecedent-based techniques increased when the number of students per class decreased, whilst effectiveness of consequent-based techniques did not depend on class size.

Conclusions: This study shows that both antecedent- and consequent-based techniques are highly effective in reducing problem behavior of children with ADHD. Interventions may be adapted to the child’s age and class size.

Predictors and moderators of treatment outcome for single incident paediatric PTSD: a multi-centre randomized clinical trial

BACKGROUND

With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments.

OBJECTIVE

To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT).

METHOD

Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8-18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child's baseline sociodemographic and clinical characteristics, and parent's psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups.

RESULTS

At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile.

CONCLUSIONS

The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (<4 hours) of both treatments, the present findings suggest a focus on implementation and dissemination, rather than tailoring, of evidence-based trauma-focused treatments for paediatric PTSD tied to a single event.

A Naturalistic Study of Time to Recovery in Adults with Treatment-refractory Disorders

Objectives: Individuals with treatment-refractory disorders have high comorbidity. There is little information on whether recovery is possible and how long it might require. We focused on the individual's recovery using a broad measure of psychopathology, regardless of the variety of disorders present.Methods: We recruited 226 adults [mean age 31.0, SD = 10.3; 75.2% female] entering residential treatment for treatment-refractory disorders to delineate their course and outcome. Individuals received periodic Longitudinal Interval Follow-along Evaluation interviews for symptoms and functioning variables for up to 14 years. Periodic psychodynamic and relationship vignette interviews were rated with the Psychodynamic Conflict Rating Scales (PCRS) for a subgroup of 54 subjects. Outcome variables included modeled rates of change, final scores, time to recovery, and time to attaining healthy adaptive functioning, using Kaplan-Meier estimates from time-to-event analyses.Results: Recovery of PCRS Pathological Functioning occurred in 12 (22%) of 54 subjects rated: median time-to-recovery = 11.63 years (CI: 9.64- upper number not calculable). Eight (14.81%) subjects also developed healthy adaptive functioning, with the time-to-attainment for the first quartile at 10.95 years (CI: 7.87 - upper bound not calculable). Recovery from psychopathology was significantly associated with a median percentage recovered in the domains of symptoms (64.29%), functioning (87.50%), and psychodynamic functioning (50%). Although attaining healthy adaptive functioning was less common, it was highly associated with already achieving recovery from dynamic psychopathology, [OR = 57.40, CI 5.80 - 567.83, p = .0001].Conclusions: These results provided convergent validation of recovery in psychodynamic psychopathology. Some recovered individuals also attained healthy adaptive functioning, which took somewhat longer.

Support for the higher-order factor structure of the WHODAS 2.0 self-report version in a Dutch outpatient psychiatric setting

PURPOSE

Previous studies of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) interview version suggested a second-order model, with a general disability factor and six factors on a lower level. The goal of this study is to investigate if we can find support for a similar higher-order factor structure of the 36-item self-report version of the WHODAS 2.0 in a Dutch psychiatric outpatient sample. We aim to give special attention to the differences between the non-working group sample and the working group sample. Additionally, we intend to provide preliminary norms for clinical interpretation of the WHODAS 2.0 scores in psychiatric settings.

METHODS

Patients seeking specialized ambulatory treatment, primarily for depressive or anxiety symptoms, completed the WHODAS 2.0 as part of the initial interview. The total sample consisted of 770 patients with a mean age of 37.5 years (SD = 13.3) of whom 280 were males and 490 were females. Several factorial compositions (i.e., one unidimensional model and two second-order models) were modeled using confirmatory factor analysis (CFA). Descriptive statistics, model-fit statistics, reliability of the (sub)scales, and preliminary norms for interpreting test scores are reported.

RESULTS

For the non-working group, the second-order model with a general disability factor and six factors on a lower level, provided an adequate fit. Whereas, for the working group, the second-order model with a general disability factor and seven factors on a lower level seemed more appropriate. The WHODAS 2.0 36-item self-report form showed adequate levels of reliability. Percentile ranks and normalized T-scores are provided to aid clinical evaluations.

CONCLUSION

Our results lend support for a factorial structure of the WHODAS 2.0 36-item self-report version that is comparable to the interview version. While we conjecture that a seven-factor solution might give a better reflection of item content and item variance, further research is needed to assess the clinical relevance of such a model. At this point, we recommend using the second-order structure with six factors that matches past findings of the interview form.

Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity.

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.

The clinical characterization of the adult patient with depression aimed at personalization of management

Depression is widely acknowledged to be a heterogeneous entity, and the need to further characterize the individual patient who has received this diagnosis in order to personalize the management plan has been repeatedly emphasized. However, the research evidence that should guide this personalization is at present fragmentary, and the selection of treatment is usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the particular features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission with the first treatment they receive. The predominant pessimism about the actual feasibility of the personalization of treatment of depression in routine clinical practice has recently been tempered by some secondary analyses of databases from clinical trials, using approaches such as individual patient data meta-analysis and machine learning, which indicate that some variables may indeed contribute to the identification of patients who are likely to respond differently to various antidepressant drugs or to antidepressant medication vs. specific psychotherapies. The need to develop decision support tools guiding the personalization of treatment of depression has been recently reaffirmed, and the point made that these tools should be developed through large observational studies using a comprehensive battery of self-report and clinical measures. The present paper aims to describe systematically the salient domains that should be considered in this effort to personalize depression treatment. For each domain, the available research evidence is summarized, and the relevant assessment instruments are reviewed, with special attention to their suitability for use in routine clinical practice, also in view of their possible inclusion in the above-mentioned comprehensive battery of measures. The main unmet needs that research should address in this area are emphasized. Where the available evidence allows providing the clinician with specific advice that can already be used today to make the management of depression more personalized, this advice is highlighted. Indeed, some sections of the paper, such as those on neurocognition and on physical comorbidities, indicate that the modern management of depression is becoming increasingly complex, with several components other than simply the choice of an antidepressant and/or a psychotherapy, some of which can already be reliably personalized.

Findings From World Mental Health Surveys of the Perceived Helpfulness of Treatment for Patients With Major Depressive Disorder

IMPORTANCE

The perceived helpfulness of treatment is an important patient-centered measure that is a joint function of whether treatment professionals are perceived as helpful and whether patients persist in help-seeking after previous unhelpful treatments.

OBJECTIVE

To examine the prevalence and factors associated with the 2 main components of perceived helpfulness of treatment in a representative sample of individuals with a lifetime history of DSM-IV major depressive disorder (MDD).

DESIGN, SETTING, AND PARTICIPANTS

This study examined the results of a coordinated series of community epidemiologic surveys of noninstitutionalized adults using the World Health Organization World Mental Health surveys. Seventeen surveys were conducted in 16 countries (8 surveys in high-income countries and 9 in low- and middle-income countries). The dates of data collection ranged from 2002 to 2003 (Lebanon) to 2016 to 2017 (Bulgaria). Participants included those with a lifetime history of treated MDD. Data analyses were conducted from April 2019 to January 2020. Data on socioeconomic characteristics, lifetime comorbid conditions (eg, anxiety and substance use disorders), treatment type, treatment timing, and country income level were collected.

MAIN OUTCOMES AND MEASURES

Conditional probabilities of helpful treatment after seeing between 1 and 5 professionals; persistence in help-seeking after between 1 and 4 unhelpful treatments; and ever obtaining helpful treatment regardless of number of professionals seen.

RESULTS

Survey response rates ranged from 50.4% (Poland) to 97.2% (Medellín, Columbia), with a pooled response rate of 68.3% (n = 117 616) across surveys. Mean (SE) age at first depression treatment was 34.8 (0.3) years, and 69.4% were female. Of 2726 people with a lifetime history of treatment of MDD, the cumulative probability (SE) of all respondents pooled across countries of helpful treatment after seeing up to 10 professionals was 93.9% (1.2%), but only 21.5% (3.2%) of patients persisted that long (ie, beyond 9 unhelpful treatments), resulting in 68.2% (1.1%) of patients ever receiving treatment that they perceived as helpful. The probability of perceiving treatment as helpful increased in association with 4 factors: older age at initiating treatment (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01-1.03), higher educational level (low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level), shorter delay in initiating treatment after first onset (AOR, 0.98; 95% CI, 0.97-0.99), and medication received from a mental health specialist (AOR, 2.91; 95% CI, 2.04-4.15). Decomposition analysis showed that the first 2 of these 4 factors were associated with only the conditional probability of an individual treatment professional being perceived as helpful (age at first depression treatment: AOR, 1.02; 95% CI, 1.01-1.02; educational level: low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high-average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level), whereas the latter 2 factors were associated with only persistence (treatment delay: AOR, 0.98; 95% CI, 0.97-0.99; treatment type: AOR, 3.43; 95% CI, 2.51-4.70).

CONCLUSIONS AND RELEVANCE

The probability that patients with MDD obtain treatment that they consider helpful might increase, perhaps markedly, if they persisted in help-seeking after unhelpful treatments with up to 9 prior professionals.

Identifying outcomes for depression that matter to patients, informal caregivers, and health-care professionals: qualitative content analysis of a large international online survey

BACKGROUND

Many clinical trials have assessed treatments for depressive disorders and bipolar depression. However, whether, and which, assessed outcome domains really matter to patients, informal caregivers, and health-care professionals remains unclear.

METHODS

We did an international online survey in French, German, and English. Participants were adult patients with a history of depression, informal caregivers, and health-care professionals, recruited by purposeful sampling. To identify outcome domains, participants answered four open-ended questions about their expectations for depression treatment. We disseminated the survey without restriction via social media, patient and professional associations, and a media campaign. Four researchers independently did qualitative content analyses. We assessed data saturation using mathematical models to ensure the comprehensive identification of outcome domains.

FINDINGS

Between April 5, 2018, and Dec 10, 2018, 1912 patients, 464 informal caregivers, and 627 health-care professionals from 52 countries provided 8183 open-ended answers. We identified 80 outcome domains related to symptoms (64 domains), such as mental pain (or psychological or psychic pain, 523 [17%] of 3003 participants) and motivation (384 [13%]), and functioning (16 domains), such as social isolation (541 [18%]). We identified 57 other outcome domains regarding safety of treatment, health care organisation, and social representation, such as stigmatisation (408 [14%]).

INTERPRETATION

This study provides a list of outcome domains important to patients, informal caregivers, and health-care professionals. Unfortunately, many of these domains are rarely measured in clinical trials. Results from this study should set the foundation for a core outcome set for depression.

FUNDING

Fondation pour la Recherche Medicale and NIHR Oxford Health Biomedical Research Centre.

Patient experiences of psychological therapy for depression: a qualitative metasynthesis

BACKGROUND

Globally, national guidelines for depression have prioritised evidence from randomised controlled trials and quantitative meta-analyses, omitting qualitative research concerning patient experience of treatments. A review of patient experience research can provide a comprehensive overview of this important form of evidence and thus enable the voices and subjectivities of those affected by depression to have an impact on the treatments and services they are offered. This review aims to seek a comprehensive understanding of patient experiences of psychological therapies for depression using a systematic and rigorous approach to review and synthesis of qualitative research.

METHOD

PsychINFO, PsychARTICLES, MEDLINE, and CINAHL were searched for published articles using a qualitative approach to examine experiences of psychological therapies for depression. All types of psychological therapy were included irrespective of model or modes of delivery (e.g. remote or in person; group or individual). Each article was assessed following guidance provided by the Critical Appraisal Skill Programme tool. Articles were entered in full into NVIVO and themes were extracted and synthesized following inductive thematic analysis.

RESULTS

Thirty-seven studies, representing 671 patients were included. Three main themes are described; the role of therapy features and setting; therapy processes and how they impact on outcomes; and therapy outcomes (benefits and limitations). Subthemes are described within these themes and include discussion of what works and what's unhelpful; issues integrating therapy with real life; patient preferences and individual difference; challenges of undertaking therapy; influence of the therapist; benefits of therapy; limits of therapy and what happens when therapy ends.

CONCLUSIONS

Findings point to the importance of common factors in psychotherapies; highlight the need to assess negative outcomes; and indicate the need for patients to be more involved in discussions and decisions about therapy, including tailoring therapy to individual needs and taking social and cultural contexts into account.

Primary outcome reporting in adolescent depression clinical trials needs standardization

BACKGROUND

Evidence-based health care is informed by results of randomized clinical trials (RCTs) and their syntheses in meta-analyses. When the trial outcomes measured are not clearly described in trial publications, knowledge synthesis, translation, and decision-making may be impeded. While heterogeneity in outcomes measured in adolescent major depressive disorder (MDD) RCTs has been described, the comprehensiveness of outcome reporting is unknown. This study aimed to assess the reporting of primary outcomes in RCTs evaluating treatments for adolescent MDD.

METHODS

RCTs evaluating treatment interventions in adolescents with a diagnosis of MDD published between 2008 and 2017 specifying a single primary outcome were eligible for outcome reporting assessment. Outcome reporting assessment was done independently in duplicate using a comprehensive checklist of 58 reporting items. Primary outcome information provided in each RCT publication was scored as "fully reported", "partially reported", or "not reported" for each checklist item, as applicable.

RESULTS

Eighteen of 42 identified articles were found to have a discernable single primary outcome and were included for outcome reporting assessment. Most trials (72%) did not fully report on over half of the 58 checklist items. Items describing masking of outcome assessors, timing and frequency of outcome assessment, and outcome analyses were fully reported in over 70% of trials. Items less frequently reported included outcome measurement instrument properties (ranging from 6 to 17%), justification of timing and frequency of outcome assessment (6%), and justification of criteria used for clinically significant differences (17%). The overall comprehensiveness of reporting appeared stable over time.

CONCLUSIONS

Heterogeneous reporting exists in published adolescent MDD RCTs, with frequent omissions of key details about their primary outcomes. These omissions may impair interpretability, replicability, and synthesis of RCTs that inform clinical guidelines and decision-making in this field. Consensus on the minimal criteria for outcome reporting in adolescent MDD RCTs is needed.

Future Directions in Single-Session Youth Mental Health Interventions

The United States spends more money on mental health services than any other country, yet access to effective psychological services remains strikingly low. The need-to-access gap is especially wide among children and adolescents, with up to 80% of youths with mental health needs going without services, and the remainder often receiving insufficient or untested care. Single-session interventions (SSIs) may offer a promising path toward improving accessibility, cost-effectiveness, and completion rates for youth mental health services. SSIs are structured programs that intentionally involve only one visit or encounter with a clinic, provider, or program; they may serve as stand-alone or adjunctive clinical services. A growing body of evidence supports the capacity of SSIs to reduce and prevent youth psychopathology of multiple types. Here, we provide a working definition of SSIs for use in future research and practice; summarize the literature to date on SSIs for child and adolescent mental health; and propose recommendations for the future design, evaluation, and implementation of SSIs across a variety of settings and contexts. We hope that this paper will serve as an actionable research agenda for gauging the full potential of SSIs as a force for youth mental health.

A Meta-Analysis of Dropout and Metabolic Effects of Antipsychotics in Anorexia Nervosa

BACKGROUND

Second-generation antipsychotics are often used off-label in the treatment of anorexia nervosa (AN) across the clinical spectrum. Patients with anorexia nervosa often cite concerns about metabolic effects, such as weight gain, as reasons for their reluctance to start or continue second-generation antipsychotics. Improving our understanding of the metabolic effect patients experience and reasons underlying their disinclination will enable us to build rapport and guide our clinical decisions. We therefore aimed to conduct a comprehensive review of dropouts, metabolic effects, and patient-reported outcomes associated with second-generation antipsychotic in people with AN.

METHOD

EMBASE, Medline, and PsycINFO were searched for all relevant studies published until 2019, and retrieved studies were assessed for eligibility as per predefined inclusion criteria. A random-effects meta-analysis was conducted to assess overall dropout rates.

RESULTS

Of 983 citations retrieved, 21 studies met the inclusion criteria for the systematic review and 10 studies had appropriate data for meta-analysis. Using the random effects model, the pooled dropout rate in the intervention arm (95% confidence interval) from psychopharmacological trials was 28% (19 to 38%) in people with AN. Personal reasons or factors associated with study were commonest reason for dropout, not adverse events or metabolic effects as hypothesized.

CONCLUSION

Compared to personal reasons, drug-related factors such as side effects seem to play a lesser role for the discontinuation of antipsychotic treatment under trial conditions. This suggests an urgent need to consider and fully examine potential individual and patient-related factors that influence dropout rates in psychopharmacological trials and treatment compliance in clinical settings.

Efficacy of the interpersonal and social rhythm therapy (IPSRT) in patients with bipolar disorder: results from a real-world, controlled trial

BACKGROUND

Bipolar disorder (BD) is one of the most burdensome mental disorders, with a lifetime prevalence of 2.4%, with a prevalence of 0.6% for bipolar type I and 0.4% for bipolar type II. Several interventions have been developed to implement the treatment strategy of bipolar disorder, including the Interpersonal and Social Rhythm Therapy (IPSRT). This intervention has been specifically developed to manage patients' stressful life events, improve the disruptions of social and circadian rhythms and increase adherence to medications. The aim of the present study is to assess the efficacy of IPSRT on affective and anxiety psychopathology, social functioning, response to pharmacological treatment and affective morbidity index (AMI) in BD patients.

METHODS

BD patients were consecutively recruited at the Mood Disorder Unit of the University of Campania "Luigi Vanvitelli" and randomly assigned to the experimental group receiving the IPSRT or to the Treatment as Usual (TAU) group. Patients were assessed at baseline, after 3 and 6 months with several validated assessment tools and with the affective morbidity index.

RESULTS

At the end of the intervention, compared to controls, patients from the experimental group reported a significant improvement in anxious depressive and manic symptomatology, global functioning; and response to mood stabilizers. Patients in the IPSRT group reported a reduction at the AMI score.

CONCLUSIONS

IPSRT has been confirmed to be effective in improving the clinical symptomology of BD patients and in improving the affective morbidity index. Further studies with longer follow-up are needed in order to assess the stability of the results.Trial registration The study was approved by the local ethical review board (N001567/28.01.2018).

The mechanisms and processes of connection: developing a causal chain model capturing impacts of receiving recorded mental health recovery narratives

BACKGROUND

Mental health recovery narratives are a core component of recovery-oriented interventions such as peer support and anti-stigma campaigns. A substantial number of recorded recovery narratives are now publicly available online in different modalities and in published books. Whilst the benefits of telling one's story have been investigated, much less is known about how recorded narratives of differing modalities impact on recipients. A previous qualitative study identified connection to the narrator and/or to events in the narrative to be a core mechanism of change. The factors that influence how individuals connect with a recorded narrative are unknown. The aim of the current study was to characterise the immediate effects of receiving recovery narratives presented in a range of modalities (text, video and audio), by establishing the mechanisms of connection and the processes by which connection leads to outcomes.

METHOD

A study involving 40 mental health service users in England was conducted. Participants were presented with up to 10 randomly-selected recovery narratives and were interviewed on the immediate impact of each narrative. Thematic analysis was used to identify the mechanisms of connection and how connection leads to outcome.

RESULTS

Receiving a recovery narrative led participants to reflect upon their own experiences or those of others, which then led to connection through three mechanisms: comparing oneself with the narrative and narrator; learning about other's experiences; and experiencing empathy. These mechanisms led to outcomes through three processes: the identification of change (through attending to narrative structure); the interpretation of change (through attending to narrative content); and the internalisation of interpretations.

CONCLUSIONS

This is the first study to identify mechanisms and processes of connection with recorded recovery narratives. The empirically-based causal chain model developed in this study describes the immediate effects on recipients. This model can inform selection of narratives for use in interventions, and be used to support peer support workers in recounting their own recovery narratives in ways which are maximally beneficial to others.

Increase value and reduce waste in research on psychological therapies

A seminal Lancet series focused on increasing value and reducing waste in biomedical research, providing a transferrable template to diagnose problems in research. Our goal was to document how some of these sources of waste apply to mental health and particularly psychological treatments research. We synthesize and critically evaluate empirical findings in relation to four major sources: i) defining research priorities; ii) research design, methods and analysis; iii) accessibility of research information; iv) accuracy and usability of research reports. We demonstrate that each source of waste considered is well-represented and amply documented within this field. We describe hype and insufficient consideration of what is known in defining research priorities, persistent risk of bias, particularly due to selective outcome reporting, for psychotherapy trials across mental disorders, intellectual and financial biases, direct and indirect evidence of publication bias, largely inexistent adoption of data sharing, issues of multiplicity and fragmentation of data and findings, and insufficient adoption of reporting guidelines. We expand on a few general solutions, including supporting meta-research, properly testing interventions to increase research quality, placing open science at the center of psychological treatment research and remaining vigilant particularly regarding the strains of research currently prioritized, such as experimental psychopathology.