Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis

Different control conditions can produce different effect estimates in psychotherapy trials for depression

OBJECTIVES

Control conditions' influence on effect estimates of active psychotherapeutic interventions for depression has not been fully elucidated. We used network meta-analysis to estimate the differences between control conditions.

STUDY DESIGN AND SETTING

We have conducted a comprehensive literature search of randomized trials of psychotherapies for adults with depression up to January 1, 2019 in four major databases (PubMed, PsycINFO, Embase, and Cochrane). The network meta-analysis included broadly conceived cognitive behavior therapies in comparison with the following control conditions: Waiting List (WL), No Treatment (NT), Pill Placebo (PillPlacebo), Psychological Placebo (PsycholPlacebo).

RESULTS

123 studies with 12,596 participants were included. The I-squared was 55.9% (95% CI: 45.9%; to 64.0%) (moderate heterogeneity). The design-by-treatment global test of inconsistency was not significant (P = 0.44). Different control conditions led to different estimates of efficacy for the same intervention. WL appears to be the weakest control (odds ratio of response against NT = 1.93 (1.30 to 2.86), PsycholPlacebo = 2.03 (1.21 to 3.39), and PillPlacebo = 2.66 (1.45 to 4.89), respectively).

CONCLUSIONS

Different control conditions produce different effect estimates in psychotherapy randomized controlled trials for depression. WL was the weakest, followed by NT, PsycholPlacebo, and PillPlacebo in this order. When conducting meta-analyses of psychotherapy trials, different control conditions should not be lumped into a single group.

A Digital Program (Hope) for People Living With Cancer During the COVID-19 Pandemic: Protocol for a Feasibility Randomized Controlled Trial

Background

During the COVID-19 lockdown period in the United Kingdom that began on March 23, 2020, more than a quarter of a million people with cancer reported worsening mental health. Help to Overcome Problems Effectively (Hope) is a self-management program for people with cancer, designed to provide support for distress, unmet needs, and poor psychological health. In light of social distancing during the COVID-19 pandemic, digital delivery of the Hope Programme has become ever more vital for people with cancer. Previous pre-post studies of the digital Hope Programme have found reduced anxiety and depression and improved well-being for people with cancer. However, evaluation of this evidence has been limited by the lack of a control group in these previous studies.

Objective

We now present a protocol for a feasibility randomized controlled trial of the digital Hope Programme for people with cancer during the COVID-19 pandemic. Primary outcomes will be recruitment, dropout, and adherence rates, and estimations of sample and effect size. To detect signals of efficacy, secondary outcomes will be participant mental health and well-being.

Methods

Participants will be recruited by Macmillan Cancer Support (MCS) through their social media networks. The study will employ a feasibility wait-list randomized controlled trial (RCT) design, with people with cancer being randomized to join the digital Hope Programme immediately (intervention group [IG]) or join a 6-week waiting list (wait-list control group [WLCG]) with a 1:1 allocation ratio. Participants will complete digital measures of depression, anxiety, mental well-being, and confidence in managing their own health. Online questionnaires will be administered preprogram and 6 weeks postprogram.

Results

All people who had requested access to the Hope Programme from MCS (N=61) will be invited to participate in the trial. Baseline data collection commenced in April 2020, and the Hope Programme began for the IG in May 2020 and for the WLCG in June 2020. Postprogram data collection was completed by the end of August 2020.

Conclusions

This feasibility study will provide data to inform the design of a future definitive trial. Wider-scale provision of the digital Hope Programme has potential to improve the lives of thousands of people with cancer and reduce the burden on health care providers during these unprecedented times.

Trial Registration

ISRCTN Registry ISRCTN79623250; http://www.isrctn.com/ISRCTN79623250

International Registered Report Identifier (IRRID)

DERR1-10.2196/24264

Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis

Background

There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development.

Objective

This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom.

Methods

Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls.

Results

A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found.

Conclusions

Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects.

Trial Registration

International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184

PartnerCARE-a psycho-oncological online intervention for partners of patients with cancer: study protocol for a randomised controlled feasibility trial

INTRODUCTION

Cancer burdens not only the patient but also the partner to a comparable extent. Partners of patients with cancer are highly involved in the caring process and therefore often experience distress and report a low quality of life. Interventions for supporting partners are scarce. Existing ones are rarely used by partners because they are often time-consuming per se and offer only limited flexibility with regard to schedule and location. The online intervention PartnerCARE has been developed on the basis of caregiver needs and consists of six consecutive sessions and four optional sessions, which are all guided by an e-coach. The study aims to evaluate feasibility and acceptance of the online intervention PartnerCARE and the related trial process. In addition, first insights of the putative efficacy of PartnerCARE should be gained.

METHODS AND ANALYSIS

A two-arm parallel-group randomised controlled trial will be conducted to compare the PartnerCARE online intervention with a waitlist control group. The study aims to recruit in total n=60 partners of patients with any type of cancer across different access paths (eg, university medical centres, support groups, social media). Congruent with feasibility study objectives, the primary outcome comprises recruitment process, study procedure, acceptance and satisfaction with the intervention (Client Satisfaction Questionnaire adapted to Internet-based interventions), possible negative effects (Inventory of Negative Effects in Psychotherapy) and dropout rates. Secondary outcomes include quality of life, distress, depression, anxiety, caregiver burden, fear of progression, social support, self-efficacy, coping and loneliness. Online measurements will be performed by self-assessment at three time points (baseline/pre-randomisation, 2 months and 4 months after randomisation). Data analyses will be based on intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Ethics Committee of the University of Ulm (No 390/18). Results from this study will be disseminated to relevant healthcare communities, in peer-reviewed journals and at scientific and clinical conferences.

TRIAL REGISTRATION NUMBER

DRKS00017019.

Open-label placebo clinical trials: is it the rationale, the interaction or the pill?

National surveys of primary care physicians demonstrate that placebo use is prevalent. Against their widespread use, until recently, it was assumed among researchers that placebos must be deceptively prescribed for beneficial effects to be elicited. However, a new programme of research in placebo studies indicates that it may be possible to harness placebo effects in clinical practice via ethical, non-deceptively prescribed 'open label placebos' ('OLPs'). To date, there have been 14 small scale clinical and experimental trials into OLPs. Results suggest therapeutic potential of these treatments for a range of conditions and symptoms. In this evidence-based Analysis we identify conceptual issues that, if not given due consideration, risk undermining research methodologies in OLP trials. Counterintuitively, owing to the nuances posed by placebo terminology, and the difficulties of designing placebos controls in OLP trials, we suggest that experimentalists reflect more deeply when formulating adequate comparison groups. Further research is needed to disentangle which specific components of OLPs are effective, such as: the rationale provided to participants; the quality of provider interaction; and/or the action of taking the pills. We conclude with recommendations for how researchers might take up the significant challenge of devising optimal placebo controls for OLP clinical trials. Although these issues are intricate, they are not merely academic: without due diligence to conceptual, and as a consequence, methodological considerations, OLP effect sizes may be over- or underestimated. We conclude that there may yet be potential to use OLPs in medical practice but clinical translation depends on rigorously controlled research.

Cognitive rehabilitation program to improve cognition of cancer patients treated with chemotherapy: A 3-arm randomized trial

Background

There is no treatment for cancer‐related cognitive impairment, an important adverse effect that negatively impacts quality of life (QOL). We conducted a 3‐arm randomized controlled trial to evaluate the impact of computer‐assisted cognitive rehabilitation (CR) on cognition, QOL, anxiety, and depression among cancer patients treated with chemotherapy.

Methods

Patients who reported cognitive complaints during or after completing chemotherapy were randomly assigned to 1 of 3 12‐week CR programs: computer‐assisted CR with a neuropsychologist (experimental group A), home cognitive self‐exercises (active control group B), or phone follow‐up (active control group C). Subjective cognition was assessed by the Functional Assessment of Cancer Therapy–Cognitive Function (FACT‐Cog), objective cognition was assessed by neuropsychological tests, QOL was assessed by the FACT‐General, and depression and anxiety were assessed by psychological tests. The primary endpoint was the proportion of patients with a 7‐point improvement in the FACT‐Cog perceived cognitive impairment (PCI) score.

Results

Among the 167 enrolled patients (median age, 51 years), group A had the highest proportion of patients with a 7‐point PCI improvement (75%), followed by groups B (59%) and C (57%), but the difference was not statistically significant (P = .13). Compared with groups B and C, the mean difference in PCI score was significantly higher in group A (P = .02), with better perceived cognitive abilities (P < .01) and a significant improvement in working memory (P = .03). Group A reported higher QOL related to cognition (FACT‐Cog QOL) (P = .01) and improvement in depression symptoms (P = .03).

Conclusions

These results suggest a benefit of a computer‐based CR program in the management of cancer‐related cognitive impairment and complaints.

In this 3‐arm randomized clinical trial of 167 patients, computer‐assisted cognitive rehabilitation improved cognitive complaints, with significant improvement in working memory, quality of life related to cognition, and depression symptoms. Computer‐assisted cognitive rehabilitation is a compelling approach toward the management of cancer‐related cognitive impairment and complaints.

Can loss of agency and oppositional perturbation associated with antidepressant monotherapy and low-fidelity psychological treatment dilute the benefits of guideline-consistent depression treatment at the population level?

Despite major expansions of evidence-based treatments of common mental disorders in recent decades, especially antidepressant medication, the point prevalence of depression has not decreased; instead it probably increased in young adults. We question whether antidepressants (AD)-monotherapy and low-fidelity-to-guideline psychological treatment (PT) might have no effect or even adverse effects in some patients and contexts that dilute the benefits of treatment at the population level, making it harder for population-based studies to detect treatment-driven prevalence reductions. Randomized Clinical Trial (RCT)s have not identified these effects because AD-monotherapy and low-fidelity PT are uncommon in RCTs where treatment protocols are specified and carefully monitored, unlike treatment in real-world settings. Second, RCTs may have missed the bigger picture of ultimate outcomes due to too short follow-ups. We elaborate two mechanisms through which AD-monotherapy and low-fidelity PT could produce adverse effects on long-term illness course. Both mechanisms are speculative and we outline how to test.

Internet-based self-help intervention aimed at increasing social self-efficacy among internal migrants in Poland: Study protocol for a randomized controlled trial

BACKGROUND

Migration is a challenging life transition that may be a source of various problems related to well-being and mental health. However, the psychological adaptation of migrants may be potentially facilitated by social self-efficacy-the beliefs in one's ability to initiate and maintain interpersonal relationships. Previous research suggests that social self-efficacy is positively related to adjustment and negatively related to loneliness, depression, and psychological distress. Research also confirms that self-efficacy beliefs can be effectively enhanced using Internet-based interventions. These results served as a background for creating the New in Town, a self-help Internet-based intervention for internal migrants in Poland that aims at increasing social self-efficacy. Exercises in the intervention are based on the principles of Cognitive Behavioral Therapy and relate to sources of self-efficacy beliefs: mastery experiences, vicarious experiences, verbal persuasions, and emotional and physiological states. Users complete increasingly challenging tasks that encourage them to interact with their environment. The aim of this trial was to investigate the efficacy of the New in Town intervention.

METHODS

The efficacy of the New in Town intervention will be tested in a two-arm randomized controlled trial with a waitlist control group. Social self-efficacy will be the primary outcome. Secondary outcomes will include loneliness, perceived social support, and satisfaction with life. Additionally, we will measure user experience among participants allocated to the experimental group. We aim to recruit a total of N = 280 participants aged at least 18 years who have changed their place of residence in the last 6 months and have an Internet connection. Participants will be assessed at baseline, 3-week post-test, and 8-week follow-up.

DISCUSSION

The trial will provide insights into the efficacy of Internet-based self-help interventions in increasing social self-efficacy. Given that the intervention works, New in Town could provide an easily accessible support option for internal migrants in Poland.

TRIAL REGISTRATION

The trial was registered with ClinicalTrials.gov (identifier: NCT04088487) on 11th September 2019.

Exercise interventions for the prevention of depression: a systematic review of meta-analyses

BACKGROUND

Exercise may be a promising target for depression interventions. However, evidence for a beneficial effect of exercise interventions on the prevention of depression differs substantially across different studies.

METHODS

A systematic search was performed up to July 2018 using PubMed, Embase, PsycINFO, and Cochrane. Articles were included if a meta-analysis of randomized controlled trials was performed that examined the effect of exercise interventions on the onset of depression or depressive symptoms in the general population. Meta-analyses focusing on treatment of diagnosed depression were excluded. Two authors independently screened the articles and graded the quality of included meta-analyses using AMSTAR 2.

RESULTS

Eight meta-analyses were included that showed little overlap in 134 included studies. All meta-analyses reported on depressive symptoms rather than onset of depression. Five of these were rated as moderate quality and three of low quality. Six meta-analyses found significant effects, and two found non-significant effects of exercise interventions in reducing depressive symptoms in children, adolescents, adults and the elderly (effect sizes ranging from - 0.10 to - 0.81). Scarce evidence did not allow to draw conclusions about the role of sex and characteristics of exercise on depression. However, some findings suggest that low intensity exercise was as effective as high intensity exercise. Heterogeneity among primary studies was high, likely caused by differences in study quality and exercise characteristics.

CONCLUSIONS

The evidence from this study suggests that exercise interventions have a beneficial effect on depressive symptoms in the general population across a wide age-range.

Mind over Matter: Testing the Efficacy of an Online Randomized Controlled Trial to Reduce Distraction from Smartphone Use

Evidence suggests a growing call for the prevention of excessive smartphone and social media use and the ensuing distraction that arises affecting academic achievement and productivity. A ten-day online randomized controlled trial with the use of smartphone apps, engaging participants in mindfulness exercises, self-monitoring and mood tracking, was implemented amongst UK university students (n = 143). Participants were asked to complete online pre- and post-intervention assessments. Results indicated high effect sizes in reduction of smartphone distraction and improvement scores on a number of self-reported secondary psychological outcomes. The intervention was not effective in reducing habitual behaviours, nomophobia, or time spent on social media. Mediation analyses demonstrated that: (i) emotional self-awareness but not mindful attention mediated the relationship between intervention effects and smartphone distraction, and (ii) online vigilance mediated the relationship between smartphone distraction and problematic social media use. The present study provides preliminary evidence of the efficacy of an intervention for decreased smartphone distraction and highlights psychological processes involved in this emergent phenomenon in the smartphone literature. Online interventions may serve as complementary strategies to reduce distraction levels and promote insight into online engagement. More research is required to elucidate the mechanisms of digital distraction and assess its implications in problematic use.

Benefits of yoga in the treatment of eating disorders: Results of a randomized controlled trial

Yoga has begun to be incorporated into the treatment of eating disorders despite limited empirical support for this practice. The purpose of this study was to investigate the efficacy of incorporating Yoga into the treatment of eating disorders. This preliminary randomized controlled trial investigated the benefits of participating in an eight-week Kripalu Yoga program for 53 women with symptoms of bulimia nervosa and binge eating disorder. Compared to waitlist controls, Yoga participants experienced decreases in binge eating frequency, emotional regulation difficulties and self-criticism, and increases in self-compassion. Yoga participants also experienced increases in state mindfulness skills across the eight weeks of the Yoga program. While these results are encouraging and suggest Yoga may have a valuable role to play in the treatment of eating disorders, it is important to stress their tentative nature. Further research, adopting a more rigorous design, is needed to address the limitations of the present study and expand on these findings.

Evaluating narrative exposure therapy for post-traumatic stress disorder and depression symptoms: A meta-analysis of the evidence base

Narrative exposure therapy (NET) is an intervention for trauma spectrum disorders. Originally developed to treat refugee populations, NET has since been tested for efficacy across different settings. In this review, the NET evidence base is examined through a retrieval, synthesis and appraisal of randomized controlled trials (RCTs) published since 2002. Two independent reviewers (S. R. and N. S.) searched online databases including EMBASE, PsycINFO and PubMed. Twenty-four RCTs were selected for a meta-analysis of three outcomes: post-traumatic stress disorder (PTSD) diagnosis and PTSD and depression symptoms. All outcomes were analysed at short-term (3-4 months), midterm (6-7 months) and long-term (≥12 months) data points. A random-effects model was applied to yield standardized mean differences (SMDs) and odds ratios (ORs) as indicators of NET treatment effect. Subgroup analyses for type of trauma and type of control groups were conducted to examine potential heterogeneity. For the NET group, moderate effect sizes for PTSD symptom severity were observed at midterm and long term and at midterm for depression symptom severity. The number of PTSD diagnoses decreased significantly in the short term for the NET condition, but this was not sustained at the long term. Caution must be exercised when interpreting these results due to high heterogeneity estimates and low quality of evidence across trials. Potential small-study effects further complicate the interpretation of the findings. Recommendations are made for augmenting statistical significance research with qualitative analyses of NET efficacy to better inform clinical practice.

Physical Activity Intervention for Loneliness (PAIL) in community-dwelling older adults: a randomised feasibility study

BACKGROUND

Low quality social relationships in older adults are strongly associated with feelings of loneliness. Physical activity interventions could reduce loneliness and improve psychological well-being, among other health benefits. The aim of this study was to examine the feasibility of a Physical Activity Intervention for Loneliness (PAIL) in community-dwelling older adults at risk of loneliness.

METHODS

The PAIL feasibility study was a 12-week randomized controlled feasibility trial (RCT) conducted in Birmingham, United Kingdom, from February 2018 to August 2018, and ran in two waves of data collection. Eligible participants were community-dwelling adults aged 60 years and older, sedentary (less than 20 min of moderate-to-vigorous PA (MVPA) a week), and at risk of loneliness. The intervention included once-weekly group walk and health education workshop up to 90 min per session in total, with a wait-listed (WL) control group. The primary feasibility outcomes were to estimate recruitment, retention rates and adherence to the intervention. Secondary outcome measures (not blinded assessment) were body mass index, blood pressure, physical activity and psychosocial variables. Process and outcome evaluations were conducted using focus groups interviews. The recruitment and retention progression criteria for the definitive large-scale RCT was set a-priori.

RESULTS

Forty-eight participants were recruited over 4 months with a recruitment rate of 25% (48/195); 52% (25/48) met the inclusion criteria and 100% (25/25) were randomised into the intervention (n = 12) and WL control groups (n = 13). Participants were 25 older adults (mean (SD) 68.5(8.05) years), 14 (56%) female, and 18 (72%) white. At 12 weeks, 10/12 (83.3%) intervention and 10/13 (76.9%) control participants completed the final assessments. The average attendance rate was 58.3% for the intervention group (range 33.0%-75.0%) and 42.3% (range 23.1%-69.2%) among controls. The a priori recruitment and retention criteria for progression were not met. No serious adverse events occurred. The focus group results identified three themes which showed overall positive experiences of participation in PAIL in terms of (1) study design and intervention; (2) walking sessions; and (3) health education workshops.

CONCLUSIONS

The findings suggest that community-dwelling older adults at risk of loneliness found the intervention and measures acceptable and could safely participate. However, a more extensive and robust strategy would be needed to support adequate recruitment of lonely older adults and adherence into a definitive RCT.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03458793.

A scoping review of network meta-analyses assessing the efficacy and safety of complementary and alternative medicine interventions

BACKGROUND

Network meta-analysis (NMA) has rapidly grown in use during the past decade for the comparison of healthcare interventions. While its general use in the comparison of conventional medicines has been studied previously, to our awareness, its use to assess complementary and alternative medicines (CAM) has not been studied. A scoping review of the literature was performed to identify systematic reviews incorporating NMAs involving one or more CAM interventions.

METHODS

An information specialist executed a multi-database search (e.g., MEDLINE, Embase, Cochrane), and two reviewers performed study selection and data collection. Information on publication characteristics, diseases studied, interventions compared, reporting transparency, outcomes assessed, and other parameters were extracted from each review.

RESULTS

A total of 89 SR/NMAs were included. The largest number of NMAs was conducted in China (39.3%), followed by the United Kingdom (12.4%) and the United States (9.0%). Reviews were published between 2010 and 2018, with the majority published between 2015 and 2018. More than 90 different CAM therapies appeared at least once, and the median number per NMA was 2 (IQR 1-4); 20.2% of reviews consisted of only CAM therapies. Dietary supplements (51.1%) and vitamins and minerals (42.2%) were the most commonly studied therapies, followed by electrical stimulation (31.1%), herbal medicines (24.4%), and acupuncture and related treatments (22.2%). A diverse set of conditions was identified, the most common being various forms of cancer (11.1%), osteoarthritis of the hip/knee (7.8%), and depression (5.9%). Most reviews adequately addressed a majority of the PRISMA NMA extension items; however, there were limitations in indication of an existing review protocol, exploration of network geometry, and exploration of risk of bias across studies, such as publication bias.

CONCLUSION

The use of NMA to assess the effectiveness of CAM interventions is growing rapidly. Efforts to identify priority topics for future CAM-related NMAs and to enhance methods for CAM comparisons with conventional medicine are needed. SYSTEMATIC REVIEW REGISTRATION: https://ruor.uottawa.ca/handle/10393/35658.

A Web- and Mobile-Based Intervention for Comorbid, Recurrent Depression in Patients With Chronic Back Pain on Sick Leave (Get.Back): Pilot Randomized Controlled Trial on Feasibility, User Satisfaction, and Effectiveness

BACKGROUND

Chronic back pain (CBP) is linked to a higher prevalence and higher occurrence of major depressive disorder (MDD) and can lead to reduced quality of life. Unfortunately, individuals with both CBP and recurrent MDD are underidentified. Utilizing health care insurance data may provide a possibility to better identify this complex population. In addition, internet- and mobile-based interventions might enhance the availability of existing treatments and provide help to those highly burdened individuals.

OBJECTIVE

This pilot randomized controlled trial investigated the feasibility of recruitment via the health records of a German health insurance company. The study also examined user satisfaction and effectiveness of a 9-week cognitive behavioral therapy and Web- and mobile-based guided self-help intervention Get.Back in CBP patients with recurrent MDD on sick leave compared with a waitlist control condition.

METHODS

Health records from a German health insurance company were used to identify and recruit participants (N=76) via invitation letters. Study outcomes were measured using Web-based self-report assessments at baseline, posttreatment (9 weeks), and a 6-month follow-up. The primary outcome was depressive symptom severity (Center for Epidemiological Studies-Depression); secondary outcomes included anxiety (Hamilton Anxiety and Depression Scale), quality of life (Assessment of Quality of Life), pain-related variables (Oswestry Disability Index, Pain Self-Efficacy Questionnaire, and pain intensity), and negative effects (Inventory for the Assessment of Negative Effects of Psychotherapy).

RESULTS

The total enrollment rate with the recruitment strategy used was 1.26% (76/6000). Participants completed 4.8 modules (SD 2.6, range 0-7) of Get.Back. The overall user satisfaction was favorable (mean Client Satisfaction Questionnaire score=24.5, SD 5.2). Covariance analyses showed a small but statistically significant reduction in depressive symptom severity in the intervention group (n=40) at posttreatment compared with the waitlist control group (n=36; F_1,76=3.62, P=.03; d=0.28, 95% CI -0.17 to 0.74). Similar findings were noted for the reduction of anxiety symptoms (F_1,76=10.45; P=.001; d=0.14, 95% CI -0.31 to 0.60) at posttreatment. Other secondary outcomes were nonsignificant (.06≤P≤.44). At the 6-month follow-up, the difference between the groups with regard to reduction in depressive symptom severity was no longer statistically significant (F_1,76=1.50, P=.11; d=0.10, 95% CI -0.34 to 0.46). The between-group difference in anxiety at posttreatment was maintained to follow-up (F_1,76=2.94, P=.04; d=0.38, 95% CI -0.07 to 0.83). There were no statistically significant differences across groups regarding other secondary outcomes at the 6-month follow-up (.08≤P≤.42).

CONCLUSIONS

These results suggest that participants with comorbid depression and CBP on sick leave may benefit from internet- and mobile-based interventions, as exemplified with the positive user satisfaction ratings. The recruitment strategy via health insurance letter invitations appeared feasible, but more research is needed to understand how response rates in untreated individuals with CBP and comorbid depression can be increased.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00010820; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010820.

Are Randomized Controlled Trials on Pharmacotherapy and Psychotherapy for Positive Symptoms of Schizophrenia Comparable? A Systematic Review of Patient and Study Characteristics

BACKGROUND

We examined patient and study characteristics of pharmacotherapy and psychotherapy trials to establish whether the effects of these 2 treatment strategies can be compared meaningfully.

METHODS

We inspected all randomized controlled trials included in 2 recent meta-analyses on antipsychotics and psychotherapy in patients with positive symptoms of schizophrenia, searching EMBASE, MEDLINE, PsycINFO, Cochrane Library, and ClinicalTrials.gov. Differences between psychotherapy and pharmacotherapy trials were analyzed with Wilcoxon-Mann-Whitney and chi-square tests.

RESULTS

Eighty studies with 18 271 participants on antipsychotic drugs and 53 studies with 4068 participants on psychotherapy were included. Psychotherapy studies included less severely ill patients (P < .0001), with a shorter duration of illness (P = .021), lasted for a longer period (P < .0001), administered the intervention as add-on to antipsychotics (P < .0001), had higher risk of bias in some domains including blinding of outcome assessment (P < .0001), and were funded publicly more frequently (P < .0001). Antipsychotic trials had larger sample sizes (P < .0001) and more study centers (P < .0001), included more males (P = .0001), inpatients (P < .0001), and slightly older patients (P = .031), more often used diagnostic operationalized criteria (P = .006), and were sponsored by pharmaceutical companies. They did not differ in conflict of interest (P = .24).

CONCLUSIONS

We found key differences between the 2 groups of studies that encompass higher risk of bias in psychotherapy studies and the inclusion of more severe patients in drug trials. These differences imply that study and patient characteristics should be carefully taken into account before considering a network meta-analysis. In the interest of patients, psychopharmacologists and psychotherapists should optimize their treatments rather than seeing them in competition.

Effectiveness of cognitive behavioral therapy (CBT) for child and adolescent anxiety disorders across different CBT modalities and comparisons: a systematic review and meta-analysis

Aim: Pediatric Anxiety Disorders (AD) are common. Cognitive behavioral therapy (CBT) is one of two first-line treatments of youth AD and it has previously been shown to be superior to wait-list but not placebo therapy. This study consists of a systematic review and meta-analysis of the literature to assess the efficacy of CBT modalities in comparison to control contingencies for pediatric anxiety disorders.Methods: Studies were included if they were randomized controlled trials, and if CBT was manualized or modular, alone or in combination with medication. CBT was required to include behavioral treatment, exposure treatment, or cognitive elements. Eligible studies included participants aged 18 years or younger.Results: Eighty-one studies were included, with 3386 CBT participants and 2527 control participants. The overall results indicated that CBT is an effective treatment for childhood AD. The results showed that individual-based CBT is superior to wait-list and attention control. Group-based CBT is superior to wait-list control and treatment as usual. Remote-based CBT was superior to attention control and wait-list control. Family-based CBT was superior to treatment as usual, wait-list control, and attention control. Selective serotonin reuptake inhibitors were no more effective than individual-based CBT. Combination treatment was, however, more effective than individual-based CBT.Conclusion: To the best of our knowledge, no meta-analysis has thus far disentangled the effects of CBT modalities across various comparisons. This meta-analysis hence provides an important update to the literature on the efficacy of CBT for treating anxiety disorders in young people.

Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial

BACKGROUND

Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated.

METHODS

147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion.

RESULTS

The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.

CONCLUSIONS

DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

Mindfulness-based cognitive therapy for children and adolescents with anxiety disorders at-risk for bipolar disorder: A psychoeducation waitlist controlled pilot trial

AIM

Previous studies suggest that Mindfulness-Based Cognitive Therapy for Children (MBCT-C) is feasible and may improve anxiety and emotion regulation in youth with anxiety disorders at-risk for bipolar disorder. However, controlled studies are warranted to replicate and extend these findings.

METHODS

In the current study, 24 youth with anxiety disorders who have at least one parent with bipolar disorder participated in a MBCT-C treatment period (n = 24; M_age = 13.6, 75% girls, 79% White) with a subset also participating in a prior psychoeducation waitlist control period (n = 19 M_age = 13.8, 68% girls, 84% White). Participants in both the waitlist and MBCT-C periods completed independently-rated symptom scales at each time point. Participants in the waitlist period received educational materials 12 weeks prior to the beginning of MBCT-C.

RESULTS

There were significantly greater improvements in overall clinical severity in the MBCT-C period compared to the waitlist period, but not in clinician- and child-rated anxiety, emotion regulation or mindfulness. However, increases in mindfulness were associated with improvements in anxiety and emotion regulation in the MBCT-C period, but not the waitlist period.

CONCLUSIONS

Findings suggest that MBCT-C may be effective for improving overall clinical severity in youth with anxiety disorders who are at-risk for bipolar disorder. However, waitlist controlled designs may inflate effect sizes so interpret with caution. Larger studies utilizing prospective randomized controlled designs are warranted.

Relative Efficacy of Different Exercises for Pain, Function, Performance and Quality of Life in Knee and Hip Osteoarthritis: Systematic Review and Network Meta-Analysis

Background

Guidelines recommend exercise as a core treatment for osteoarthritis (OA). However, it is unclear which type of exercise is most effective, leading to inconsistency between different recommendations.

Objectives

The aim of this systematic review and network meta-analysis was to investigate the relative efficacy of different exercises (aerobic, mind–body, strengthening, flexibility/skill, or mixed) for improving pain, function, performance and quality of life (QoL) for knee and hip OA at, or nearest to, 8 weeks.

Methods

We searched nine electronic databases up until December 2017 for randomised controlled trials that compared exercise with usual care or with another exercise type. Bayesian network meta-analysis was used to estimate the relative effect size (ES) and corresponding 95% credibility interval (CrI) (PROSPERO registration: CRD42016033865).

Findings

We identified and analysed 103 trials (9134 participants). Aerobic exercise was most beneficial for pain (ES 1.11; 95% CrI 0.69, 1.54) and performance (1.05; 0.63, 1.48). Mind–body exercise, which had pain benefit equivalent to that of aerobic exercise (1.11; 0.63, 1.59), was the best for function (0.81; 0.27, 1.36). Strengthening and flexibility/skill exercises improved multiple outcomes at a moderate level. Mixed exercise was the least effective for all outcomes and had significantly less pain relief than aerobic and mind–body exercises. The trend was significant for pain (p = 0.01), but not for function (p = 0.07), performance (p = 0.06) or QoL (p = 0.65).

Conclusion

The effect of exercise varies according to the type of exercise and target outcome. Aerobic or mind–body exercise may be the best for pain and function improvements. Strengthening and flexibility/skill exercises may be used for multiple outcomes. Mixed exercise is the least effective and the reason for this merits further investigation.

Electronic supplementary material

The online version of this article (10.1007/s40279-019-01082-0) contains supplementary material, which is available to authorized users.

A multi-centre, parallel-group, randomised controlled trial to assess the efficacy and safety of eurythmy therapy and tai chi in comparison with standard care in chronically ill elderly patients with increased risk of falling (ENTAiER): a trial protocol

BACKGROUND

In elderly poeple, multimorbidity and polypharmacy increase while sensory, motor and cognitive functions decrease. Falls occur in 30% of people aged 65 years and older at least once per year, with injuries at 10-20%. Reducing falls and enhancing physical, emotional and cognitive capacities are essential for healthy aging despite chronic disease. Eurythmy therapy (EYT) and Tai Chi train balance, mobility and concentrative and sensory capacities.

METHODS

In eight trial sites (academic or community hospitals), 550 outpatients aged 65 years and older with chronic disease and increased risk of falling (history of imbalance, Berg Balance Scale (BBS) score ≤ 49) will be randomly assigned (1:1:1) to receive either EYT or Tai Chi (each provided in one-hour group sessions, twice, later once per week plus practice at home, for over 24 weeks) added to standard care or standard care alone. Standard care includes a detailed written recommendation on fall prevention and the visit of a primary care doctor. Seniors living a reclusive life or economically disadvantaged elderly will be particularly addressed. A motivation and communication concept supports the trial participants' compliance with trial procedures and practicing. Public and patient representatives are involved in the planning and conduction of the trial. Falls will be documented daily in a diary by the participants. These falls as well as injuries and complications will be ascertained during monthly phone visits. The falls efficacy scale, BBS, cognition (MoCA), Mood (GDS-15), quality of life (SF12), instrumental activities of daily living (IADL), use of medical and non-medical services (FIMA) and adherence will be assessed at months 3, 6, and 12 and inner correspondence with practices (ICPH) at month 6. The trial is funded by the Federal Ministry of Education and Research (BMBF 01GL1805).

DISCUSSION

This study will determine whether EYT and Tai Chi reduce falls, injurious falls, fear of falling and healthcare utilisation and improve mobility, cognition, mood, quality of life and functional independence. A reduction of fall risk and fear of falling and an improvement of mobility, autonomy, quality of life, mood, and cognition are highly relevant for older people to cope with aging and diseases and to reduce healthcare costs. TRAIL REGISTRATION: www.drks.de. DRKS00016609. Registered 30th July 2019.

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.

Let’s Distinguish Relative and Absolute Efficacy to Move Psychotherapy Research Forward

Objective: Background regarding a recent debate between Cuijpers et al. (2019a, b) and the authors (Munder et al. 2019) about the efficacy of psychotherapy for depression is given. Method: A main reason for the discrepancy in Cuijpers et al.'s and our conclusions is discussed. Results: In our view the discrepancy is due, among other things, to a blurred distinction between questions of relative and absolute efficacy of psychotherapy. Although the efficacy of psychotherapy vis-à-vis alternative treatments may be ambiguous, there can be little doubt about the benefits of psychotherapy relative to no treatment. Conclusion: We do not think that raising fundamental concerns about the value of psychotherapy is a service to the field. We argue that moving the field forward requires a focus on how psychotherapy works and how the access to psychotherapy can be increased.

Psychological and Psychosocial Interventions for PTSD, Depression and Anxiety Among Children and Adolescents in Low- and Middle-Income Countries: A Meta-Analysis

BACKGROUND

In low- and middle-income countries, rates of common mental health disorders are found to be very high among children and adolescents while individuals, particularly in these countries, face barriers to mental health care. In the recent years, randomized controlled trials (RCTs) have been conducted that implemented and tested different psychological and psychosocial treatment approaches to treat common mental disorders. This review aims to analyze psychological interventions among children and adolescents in low- and middle-income countries.

METHODS

RCTs carried out in low- and middle-income countries on psychological and psychosocial interventions for children and adolescents with symptoms of trauma- and stressor related disorders, depression or anxiety were identified in bibliographic databases. Databases were systematically searched until December 14, 2018. Effect sizes indicating differences between treatment and control groups at post-test were computed using a random-effects model. Outcomes were symptoms of depression, anxiety and posttraumatic stress disorder (PTSD).

RESULTS

Thirteen studies with a total of 2,626 participants aged between 5 and 18 years were included. Treatments varied between studies and number of treatment sessions ranged from 1 to 16. The pooled effect size, combining outcomes of depression, anxiety and PTSD of psychological or psychosocial intervention versus care-as-usual or a control conditions yielded a medium effect (g = 0.62; 95% CI: 0.27-0.98). Heterogeneity was very high (I2 = 94.41; 95% CI = 80-91). The beneficial effect of interventions increased after excluding outliers (g = 0.72; 95% CI: 0.37-1.07), while heterogeneity remained high (I2 = 86.12; 95% CI = 87-94).

CONCLUSION

High quality RCTs investigating the effect of psychological and psychosocial interventions on PTSD, depression and anxiety among children and adolescents in low- and middle-income countries are scarce. Results of the available studies may suggest that psychological and psychosocial interventions might be more effective in reducing symptoms of anxiety, depression and PTSD compared to control conditions. Due to very high heterogeneity, this evidence must be considered with caution.

Effectiveness of a tailored, integrative Internet intervention (deprexis) for depression: Updated meta-analysis

Digitally delivered interventions for depression vary in many aspects, including their therapeutic orientation, depth of content, interactivity, individual tailoring, inclusion of multimedia, cost, and effectiveness. However, their effectiveness is rarely examined in intervention-specific meta-analyses. An earlier meta-analysis of eight randomized controlled trials (RCT) demonstrated the effectiveness of a tailored, integrative digital intervention (deprexis), which is delivered via the Internet. This updated meta-analysis of twelve deprexis-specific RCT with a total of N = 2901 participants confirmed the effectiveness of deprexis for depression reduction at post-intervention (g = 0.51, 95% CI: 0.40-0.62, I2 = 26%). Results were analogous when study quality, screening and randomization procedure were taken into account. Clinician guidance, developer-involvement, setting (community vs. clinical), and initial symptom severity did not have statistically significant effects on the effect size, and there was no evidence of publication bias. Thus, these findings demonstrate that deprexis can facilitate clinically relevant reduction of depressive symptoms over 8-12 weeks across a broad range of initial symptom severity, and that the intervention can be combined with other forms of depression treatment. There is now a need to study the intervention's implementation in routine care settings as well as its long-term effectiveness and cost-effectiveness in diverse cultural and linguistic settings.

Metta-based group meditation and individual cognitive behavioral therapy (MeCBT) for chronic depression: study protocol for a randomized controlled trial

BACKGROUND

Depression is a widespread disorder with severe impacts for individuals and society, especially in its chronic form. Current treatment approaches for persistent depression have focused primarily on reducing negative affect and have paid little attention to promoting positive affect. Previous studies have shown that metta meditation increases positive affect in chronically depressed patients. Results from previous trials provide evidence for the efficacy of a stand-alone metta meditation group treatment in combination with mindfulness-based approaches. Further research is needed to better understand the implementation of meditation practice into everyday life. Therefore, mindfulness and metta meditation in a group setting are combined with individual cognitive behavioral therapy (CBT) into a new, low-intensity, cost-effective treatment ("MeCBT") for chronic depression.

METHODS/DESIGN

In this single-center, randomized, observer-blinded, parallel-group clinical trial we will test the efficacy of MeCBT in reducing depression compared to a wait-list control condition. Forty-eight participants in a balanced design will be allocated randomly to a treatment group or a wait-list control group. Metta-based group meditation will be offered in eight weekly sessions and one additional half-day retreat. Subsequent individual CBT will be conducted in eight fortnightly sessions. Outcome measures will be assessed at four time points: before intervention (T0); after group meditation (T1); after individual CBT (T2); and, in the treated group only, at 6-month follow-up (T3). Changes in depressive symptoms (clinician rating), assessed with the Quick Inventory of Depressive Symptoms (QIDS-C) are the primary outcome. We expect a significant decline of depressive symptoms at T2 compared to the wait-list control group. Secondary outcome measures include self-rated depression, mindfulness, benevolence, rumination, emotion regulation, social connectedness, social functioning, as well as behavioral and cognitive avoidance. We will explore changes at T1 and T2 in all these secondary outcome variables.

DISCUSSION

To our knowledge this is the first study to combine a group program focusing on Metta meditation with state-of-the art individual CBT specifically tailored to chronic depression. Implications for further refinement and examination of the treatment program are discussed.

TRIAL REGISTRATION

ISRCTN, ISRCTN97264476. Registered 29 March 2018 (applied on 14 December 2017)-retrospectively registered.

Research Review: Psychological and psychosocial treatments for children and young people with post-traumatic stress disorder: a network meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder that affects a significant minority of youth exposed to trauma. Previous studies have concluded that trauma-focused cognitive behavioural therapy (TF-CBT) is an effective treatment for PTSD in youth, but the relative strengths of different psychological therapies are poorly understood.

METHODS

We undertook a systematic review and network meta-analyses of psychological and psychosocial interventions for children and young people with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1-4-month follow-up, and remission post-treatment.

RESULTS

We included 32 trials of 17 interventions and 2,260 participants. Overall, the evidence was of moderate-to-low quality. No inconsistency was detected between direct and indirect evidence. Individual forms of TF-CBT showed consistently large effects in reducing PTSD symptoms post-treatment compared with waitlist. The order of interventions by descending magnitude of effect versus waitlist was as follows: cognitive therapy for PTSD (SMD -2.94, 95%CrI -3.94 to -1.95), combined somatic/cognitive therapies, child-parent psychotherapy, combined TF-CBT/parent training, meditation, narrative exposure, exposure/prolonged exposure, play therapy, Cohen TF-CBT/cognitive processing therapy (CPT), eye movement desensitisation and reprocessing (EMDR), parent training, group TF-CBT, supportive counselling and family therapy (SMD -0.37, 95%CrI -1.60 to 0.84). Results for parent training, supportive counselling and family therapy were inconclusive. Cohen TF-CBT/CPT, group TF-CBT and supportive counselling had the largest evidence base. Results regarding changes in PTSD symptoms at follow-up and remission post-treatment were uncertain due to limited evidence.

CONCLUSIONS

Trauma-focused cognitive behavioural therapy, in particular individual forms, appears to be most effective in the management of PTSD in youth. EMDR is effective but to a lesser extent. Supportive counselling does not appear to be effective. Results suggest a large positive effect for emotional freedom technique, child-parent psychotherapy, combined TF-CBT/parent training, and meditation, but further research is needed to confirm these findings as they were based on very limited evidence.

Biofeedback and Neurofeedback for Anxiety Disorders: A Quantitative and Qualitative Systematic Review

Biofeedback refers to the operant training of physiological responding. Variants include electromyography (EMG), electrodermal activity (EDA), skin temperature, heart rate (HR) and heart rate variability (HRV), respiratory biofeedback of end-tidal CO₂ (ETCO₂), electroencephalography (EEG) signal, and blood oxygen-level dependent signal using functional magnetic resonance imaging (fMRI). This chapter presents a qualitative and quantitative systematic review of randomized controlled trials of biofeedback for anxiety disorders as defined by the 3rd through 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Meta-analytic results indicated that biofeedback (broadly defined) is superior to wait list, but has not been shown to be superior to active treatment conditions or to conditions in which patients are trained to change their physiological responding in a countertherapeutic direction. Thus, although biofeedback appears generally efficacious for anxiety disorders, the specific effects of biofeedback cannot be distinguished from nonspecific effects of treatment. Further, significant limitations were identified in the existing literature, with the majority receiving a "weak" rating according to Effective Public Health Practice Project (EPHPP) rating system guidelines. Future directions for research are discussed.

Tasuki for neck pain: An individually-randomized, open-label, waiting-list-controlled trial

OBJECTIVES

Neck pain ranks 4th highest in terms of disability as measured by years lived with disabilities. This study was conducted to determine whether Tasuki-style posture supporter improves neck pain compared to waiting-list.

METHODS

This trial was an individually-randomized, open-label, waiting-list-controlled study. Adults (20 years or older) with non-specific chronic neck pain who reported 10 points or more on modified Neck Disability Index (mNDI: range, 0-50; higher points indicate worse condition) were enrolled. Participants were randomly assigned 1:1 to the intervention group or waiting-list. Prespecified primary outcome was the change in mNDI at 1 week. The principle of intention-to-treat analyses (as randomized) was applied. This trial was prospectively registered with UMIN (UMIN000034825).

RESULTS

In total, 50 participants (mean age, 40.9 [standard deviation (SD) = 9.6]; 32 participants [64%] were female, mean mNDI, 14.3 [SD = 2.9]) were enrolled. Of these participants, 26 (52%) were randomly assigned to the intervention group and 24 (48%) to the waiting-list. Attrition rate was low in both groups (1/50). The mean mNDI change score at 1 week was more favorable for Tasuki than waiting-list (between-group difference, -3.5 points (95% confidence interval (CI), -5.3 to -1.8); P = .0002). More participants (58%) had moderate benefit (at least 30% improvement) with Tasuki than waiting-list (13%) (relative risk 4.6 (95% CI 1.5 to 14); risk difference 0.45 (0.22 to 0.68)).

CONCLUSION

This trial suggests that wearing Tasuki might moderately improve neck pain. With its low-cost, low-risk, and easy-to-use nature, Tasuki could be an option for those who suffer from neck pain.

Electroacupuncture plus on-demand gastrocaine for refractory functional dyspepsia: Pragmatic randomized trial

BACKGROUND AND AIM

Treatment options for functional dyspepsia (FD) refractory to pharmacological treatments are limited but the effectiveness of electroacupuncture (EA) is uncertain. We assessed the effectiveness of EA combined with on-demand gastrocaine.

METHODS

We conducted a single-center, assessor-blind, randomized parallel-group 2-arm trial on Helicobacter pylori negative FD patients of the postprandial distress syndrome subtype refractory to proton pump inhibitor, prokinetics, or H₂ antagonists. Enrolled participants were block randomized in a 1:1 ratio, with concealed random sequence. The treatment and control groups both received on-demand gastrocaine for 12 weeks, but only those in treatment group were offered 20 sessions of EA over 10 weeks. The primary endpoint was the between-group difference in proportion of patients achieving adequate relief of symptoms at week 12.

RESULTS

Of 132 participants randomly assigned to EA plus on-demand gastrocaine (n = 66) or on-demand gastrocaine alone (n = 66), 125 (94.7%) completed all follow-up at 12 weeks. The EA group had a compliance rate 97.7%. They had a significantly higher likelihood in achieving adequate symptom relief at 12 weeks, with a clinically relevant number needed to treat (NNT) value of 2.36 (95% CI: 1.74, 3.64). Among secondary outcomes, statistically and clinically significant improvements were observed among global symptom (NNT = 3.85 [95% CI: 2.63, 7.69]); postprandial fullness and early satiation (NNT = 5.00 [95% CI: 2.86, 25.00]); as well as epigastric pain, epigastric burning, and postprandial nausea (NNT = 4.17 [95% CI: 2.56, 11.11]). Adverse events were minimal and nonsignificant.

CONCLUSION

For refractory FD, EA provides significant, clinically relevant symptom relief when added to on-demand gastrocaine (ChiCTR-IPC-15007109).

School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis

BACKGROUND

Rates of anxiety and depression are increasing among children and young people. Recent policies have focused on primary prevention of mental disorders in children and young people, with schools at the forefront of implementation. There is limited information for the comparative effectiveness of the multiple interventions available.

METHODS

We did a systematic review and network meta-analysis, searching MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled trials for published and unpublished, passive and active-controlled randomised and quasi-randomised trials. We included educational setting-based, universal, or targeted interventions in which the primary aim was the prevention of anxiety and depression in children and young people aged 4-18 years. Primary outcomes were post-intervention self-report anxiety and depression, wellbeing, suicidal ideation, or self-harm. We assessed risk of bias following the Cochrane Handbook for Systematic Reviews of Interventions. We estimated standardised mean differences (SMD) using random effects network meta-analysis in a Bayesian framework. The study is registered with PROPSERO, number CRD42016048184.

FINDINGS

1512 full-text articles were independently screened for inclusion by two reviewers, from which 137 studies of 56 620 participants were included. 20 studies were assessed as being at low risk of bias for both random sequence generation and allocation concealment. There was weak evidence to suggest that cognitive behavioural interventions might reduce anxiety in primary and secondary settings. In universal secondary settings, mindfulness and relaxation-based interventions showed a reduction in anxiety symptoms relative to usual curriculum (SMD -0·65, 95% credible interval -1·14 to -0·19). There was a lack of evidence to support any one type of intervention being effective to prevent depression in universal or targeted primary or secondary settings. Comparison-adjusted funnel plots suggest the presence of small-study effects for the universal secondary anxiety analysis. Network meta-analysis was not feasible for wellbeing or suicidal ideation or self-harm outcomes, and results are reported narratively.

INTERPRETATION

Considering unclear risk of bias and probable small study effects for anxiety, we conclude there is little evidence that educational setting-based interventions focused solely on the prevention of depression or anxiety are effective. Future research could consider multilevel, systems-based interventions as an alternative to the downstream interventions considered here.

FUNDING

UK National Institute for Health Research.

Short group psychoeducation followed by daily electronic self-monitoring in the long-term treatment of bipolar disorders: a multicenter, rater-blind, randomized controlled trial

Background

Despite various pharmacological and psychological treatment interventions, bipolar disorders rank among the leading causes of global disease burden. Group psychoeducation has been demonstrated an effective add-on to pharmacotherapy, but it may be difficult to implement in practice depending on the clinical setting and available human resources.

Methods

Multicenter, rater-blind, randomized controlled trial to investigate the efficacy of a new intervention program consisting of an initial 6-week psychoeducation protocol plus a subsequent structured daily computer-based self-charting program (ChronoRecord) over 54 weeks in remitted patients with bipolar disorders. The control condition included non-structured group sessions followed by daily computer-based self-reports (unstructured like a diary). Both groups received treatment-as-usual.

Results

Over 2 years, 41 mood episodes occurred in the experimental group (n = 39) compared to 27 in the control group (n = 34), without reaching statistical significance. Time to recurrence did not significantly differ between the experimental and control group (25% relapsed after 112 and 273 days, respectively). There were no significant group-by-time interactions in mood symptoms, quality of life, self-efficacy expectations or perceived involvement in care.

Conclusions

Six weekly psychoeducational group sessions followed by daily self-monitoring via ChronoRecord for 54 weeks may not be superior to non-structured group meetings followed by unstructured self-reporting. Other psychotherapeutic interventions may be needed to optimize the treatment of patients with bipolar disorders, especially for those at later disease stages.

Trial registration Retrospectively registered at German Clinical Trials Register on May 24, 2019; DRKS00017319

Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis

Generalized anxiety disorder (GAD) is a significant and common mental illness with a lifetime prevalence of 3.7%. Regardless of the complexity of treatment decisions for GAD, few studies have conducted systematic comparisons of the efficacies of varying interventions. Thus, this study performed a valid network meta-analysis (NMA) of randomized controlled trials (RCTs) to synthesize direct and indirect evidence for alternative interventions for GAD. We searched four major bibliographic databases, the Cochrane Central Register of Controlled Trials, Embase, PsycINFO, and PubMed, for published RCTs of adult patients with a diagnosis of GAD and allowed for all comorbidities. A total of 91 articles (14,812 participants) were identified in the final NMA. The results showed that all pharmacological treatments except for serotonin modulators and second-generation antipsychotics had greater effects than placebo: norepinephrine-dopamine reuptake inhibitors (standardized mean difference (SMD) -1.84, 95% credible interval -3.05 to -0.62), noradrenergic and specific serotonergic antidepressants (-0.91, -1.62 to -0.20), melatonergic receptor agonists (-0.68, -1.15 to -0.21), selective serotonin reuptake inhibitors (SSRIs; -0.67, -0.90 to -0.43), azapirones (-0.58, -1.00 to -0.17), anticonvulsants (-0.56, -0.85 to -0.28), serotonin-norepinephrine reuptake inhibitors (SNRIs; -0.54, -0.79 to -0.30), and benzodiazepines (BZDs; -0.40, -0.65 to -0.15). Most psychological and self-help interventions exerted greater effects than the waitlist group. However, no psychological interventions had greater effects compared with the psychological placebo. Overall, most pharmacological interventions had larger effect sizes than psychological interventions, and most psychological interventions showed larger effect sizes than self-help interventions.

Longitudinal Analysis of Mortality for Older Adults Receiving or Waiting for Aging Network Services

OBJECTIVES

For older adults screened by an Area Agency on Aging (AAA) in the National Aging Network, we aimed to examine the 12-month mortality rate for wait-listed callers compared with those who received services within 12 months, and to assess whether the mortality rate differed according to how quickly they received services.

DESIGN

The design was a longitudinal analysis of 3 years of AAA administrative data, using survival analysis.

SETTING

The data source was administrative data from an AAA spanning a five-county region in west central Florida.

PARTICIPANTS

All older adults (age 60 y and older) screened for service eligibility from July 15, 2013, to August 15, 2015, who completed initial screening during the study period were included (N = 6288).

MEASUREMENTS

The outcome was mortality within 12 months of the initial screening. Covariates included demographics, caregiver status, health status, access to healthcare, and AAA service status.

RESULTS

In the first survival analysis, the strongest predictor was waiting for services compared with receiving services; waiting increased the odds to die vs not to die by 141%, after controlling for health status and other covariates. In the second survival analysis, those who received services within 0 to 3 months had a higher mortality risk compared with those who received services within 6 to 9 months or 9 to 12 months.

CONCLUSION

Older adults placed on aging service waiting lists may be at a greater risk of mortality within 12 months than those receiving services. Given that rapid receipt of services was less protective than receiving services later, those prioritized to receive services quickly may be at very high risk of adverse outcomes. Findings raise the possibility that aging services may lower mortality, although additional services may benefit those waiting long periods for services, as well as those eligible for services rapidly. Research is needed to replicate and extend these findings. J Am Geriatr Soc 68:519-525, 2020.

Targets and outcomes of psychotherapies for mental disorders: an overview

It is not yet clear what mental disorders are and what are the causal pathways that lead to them. That makes it difficult to decide what the targets and outcomes of psychotherapies should be. In this paper, the main types of targets and outcomes of psychotherapies are described, and a brief overview is provided of some of the main results of research on these types. These include symptom reduction, personal targets and outcomes from the patient's perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes to be avoided, and economic outcomes. In line with the dominance of the DSM and ICD systems for diagnoses, most research has been focused on symptom reduction. This considerable body of research, with hundreds of randomized trials, has shown that for most mental disorders effective psychotherapies are available. There is also research showing that psychotherapies can result in improvement of quality of life in most mental disorders. However, relatively little research is available on patient-defined outcomes, intermediate outcomes, negative outcomes and economic outcomes. Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes of psychotherapies. The perspective of patients should have more priority in research, and a standardization of outcome measures across trials is much needed.

Web-Based Intervention and Email-Counseling for Problem Gamblers: Results of a Randomized Controlled Trial

Web-based interventions have the potential to reduce the treatment gap for problem gambling. In the past years, several web-based help options were made available to the public. However, only few studies were conducted to test their effects. This study investigated the efficacy of two interventions for problem gamblers provided online by the German Federal Center for Health Education (BZgA). The first intervention is the guided program “Check Out” (CO), the second is email counselling (EC). A web-based randomized controlled trial with follow-up surveys after 3, 6 and 12 months was conducted. Participants were allocated to CO, to EC or to a waitlist (WL). Outcomes were the degree of problem gambling according to the Problem Gambling Severity Index, the number of days gambled in past 30 days, the highest stake during the past 30 days and the subjective well-being (WHO-5). 167 individuals were included in the trial. In comparison to the WL at the 3 months follow-up, participants of CO showed significant improvements with moderate to strong effect sizes in all outcomes. Strongest effects were found in the problem gambling severity (d = 0.91; p = 0.023), followed by the well-being (d = 0.70; p = 0.011), the gambling days (d = 0.59; p = 0.001) and the highest stake (d = 0.55; p = 0.012). Improvements were sustained until last follow-up. Compared to the WL, users of EC had beneficiary results in the problem gambling severity (d = 0.74; p = 0.022). No significant effect differences were found between CO and EC. However, according to process evaluation, users of CO reported a significantly stronger working alliance than users of EC (d = 0.70; p = 0.019) and used the intervention considerably longer (d = 0.84; p = 0.004). CO helps treatment-seeking individuals to sustainably reduce their gambling behavior and to increase their general well-being. Compared to EC, CO seems a better support option, since its effects include a wider range of outcomes. Possible reasons are the more engaging program structure and elements of CO, as well as the closer interaction between client and counselor.

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.

Effectiveness of an internet-based intervention for procrastination in college students (StudiCare Procrastination): Study protocol of a randomized controlled trial

BACKGROUND

Procrastination, defined as irrational and voluntary delaying of necessary tasks, is widespread and clinically relevant. Its high prevalence among college students comes with serious consequences for mental health and well-being of those affected. Research for proper treatment is still relatively scarce and treatment of choice seems to be cognitive behavior therapy (CBT). The aim of this study is to evaluate the effectiveness and acceptability of an internet- and mobile-based intervention (IMI) for procrastination based on CBT for college students.

METHODS

A two-armed randomized controlled trial with a calculated sample size of N = 120 participants with problematic procrastination behavior will be conducted. Students will be recruited in Germany, Austria and Switzerland via circular emails at 15+ cooperating universities in the framework of StudiCare, a well-established project that provides IMIs to college students for different health related issues. The intervention group will receive the e-coach guided 5-week IMI StudiCare Procrastination. A waitlist-control group will get access to the unguided IMI 12 weeks after randomization. Assessments will take place before as well as 6 and 12 weeks after randomization. Primary outcome is procrastination, measured by the Irrational Procrastination Scale (IPS). Secondary outcomes include susceptibility to temptation, depression, anxiety, wellbeing and self-efficacy as well as acceptability aspects such as intervention satisfaction, adherence and potential side effects. Additionally, several potential moderators as well as the potential mediators self-efficacy and susceptibility to temptation will be examined exploratorily. Data-analysis will be performed on intention-to-treat basis.

DISCUSSION

This study will contribute to the evidence concerning effectiveness and acceptability of an intervention for procrastination delivered via the internet. If it shows to be effective, StudiCare Procrastination could provide a low-threshold, cost-efficient way to help the multitude of students suffering from problems caused by procrastination.Trial registration: The trial is registered at the WHO International Clinical Trials Registry Platform via the German Clinical Studies Trial Register (DRKS): DRKS00014321 (date of registration: 06.04.2018). In case of important protocol modifications, trial registration will be updated.Trial status: This is protocol version number 1, 11th December 2019. Recruitment started 9th of April 2018 and was completed 30th of November 2018. Assessment and intervention are still ongoing and will be completed by April 2019.

Cognitive behavior therapy for menopausal symptoms (CBT-Meno): a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of cognitive behavioral therapy for menopausal symptoms (CBT-Meno) compared with a waitlist condition (no active intervention). A randomized controlled trial was conducted with 71 perimenopausal or postmenopausal women who were seeking treatment for menopausal symptoms.

METHODS

Blind assessments were conducted at baseline, 12 weeks postbaseline, and 3 months post-treatment. An intention-to-treat analysis was conducted. CBT-Meno sessions included psychoeducation, and cognitive and behavioral strategies for vasomotor and depressive symptoms, anxiety, sleep difficulties, and sexual concerns. Primary outcomes were scores on the Hot Flash Related Daily Interference Scale (HFRDIS) and Beck Depression Inventory (BDI-II). Secondary outcomes were scores assessing vasomotor and sexual concerns on the Greene Climacteric Scale (GCS-vm, GCS-sex), the Montgomery-Åsberg Depression Rating Scale (MADRS), Hamilton Anxiety Rating Scale (HAM-A), Pittsburgh Sleep Quality Index (PSQI), and the Female Sexual Function Index (FSFI).

RESULTS

There were significantly greater improvements in CBT-Meno compared with waitlist in vasomotor symptom interference (HFRDIS; P < 0.001, ηP = 0.21) and "bothersomeness" (GCS-vm; P = 0.04, ηP = 0.06), depressive symptoms (BDI-II; P = 0.001, ηP = 0.15), sleep difficulties (PSQI; P = 0.001, ηP = 0.17), and sexual concerns (GCS-sex; P = 0.03, ηP = 0.07). These results were found even when controlling for menopausal staging and medication use. Gains were maintained at 3 months post-treatment.

CONCLUSIONS

CBT-Meno was particularly effective in improving self-reported vasomotor symptoms, depressive symptoms, sleep difficulties, and sexual concerns. Although future studies will be needed to confirm the impact of CBT-Meno on anxiety symptoms, these results suggest that this protocol is effective in targeting commonly reported menopausal symptoms. : Video Summary: Supplemental Digiatl Content 1, http://links.lww.com/MENO/A416.

Comparative Efficacy and Acceptability of Pharmacological, Psychotherapeutic, and Combination Treatments in Adults With Posttraumatic Stress Disorder: A Network Meta-analysis

IMPORTANCE

Posttraumatic stress disorder (PTSD) is a prevalent mental disorder, with a high risk of chronicity, comorbidity, and functional impairment; PTSD is complicated to treat, and the debate on the best treatment approach is ongoing.

OBJECTIVE

To examine comparative outcomes and acceptability of psychotherapeutic and pharmacological treatments and their combinations in adults with PTSD.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Cochrane Controlled Trials Register, and PSYNDEX were searched for studies published from January 1, 1980, to February 28, 2018. Reference lists of included studies and of previously published guidelines and systematic reviews were also searched.

STUDY SELECTION

Of 11 417 records identified, 12 published randomized clinical trials (RCTs) comprising 922 participants, contributing 23 direct comparisons between psychotherapeutic and pharmacological treatments or their combinations were included.

DATA EXTRACTION AND SYNTHESIS

Standardized mean differences (SMDs) and odds ratios were aggregated using random-effects network and pairwise meta-analyses. Risk of bias and indirectness was rated for each study, and network confidence was rated using the Confidence in Network Meta-Analysis framework.

MAIN OUTCOMES AND MEASURES

The primary outcome was the comparative benefit between 2 treatment approaches to PTSD symptom improvement, and secondary outcome was the comparative acceptability of the treatment approaches, as indicated by patient dropout rates before treatment termination.

RESULTS

No treatment approach was found to be superior at the end of treatment (for all, 95% CI included 0). At the last follow-up, psychotherapeutic treatments showed greater benefit than pharmacological treatments in both network (SMD, -0.83; 95% CI, -1.59 to -0.07) and pairwise (SMD, -0.63; 95% CI, -1.18 to -0.09, 3 RCTs) meta-analyses. No difference was found between combined treatments and psychotherapeutic treatments at long-term follow-up, and combined treatments were associated with better outcomes than pharmacological treatments in the network meta-analysis (SMD, -0.96; 95% CI, -1.87 to -0.04), but not in the pairwise meta-analysis, which included 2 RCTs (SMD, -1.02; 95% CI, -2.77 to 0.72). No evidence was found for differential acceptability of the 3 treatment approaches.

CONCLUSIONS AND RELEVANCE

These results suggest superiority of psychotherapeutic treatments over pharmacological treatments; network, but not pairwise, meta-analyses suggest superiority of combined treatments over pharmacological treatments in improving PTSD symptom severity in the long term. The scarcity of reported long-term findings hampers definite conclusions and demonstrates the need for robust evidence from large-scaled comparative trials providing long-term follow-up data.

Implementing interventions to reduce work-related stress among health-care workers: an investment appraisal from the employer's perspective

Purpose

The Stress-Prevention@Work implementation strategy has been demonstrated to be successful in reducing stress in employees. Now, we assess the economic return-on-investment to see if it would make for a favourable business case for employers.

Methods

Data were collected from 303 health-care workers assigned to either a waitlisted control condition (142 employees in 15 teams) or to Stress-Prevention@Work (161 employees in 15 teams). Main outcome was productivity losses measured using the Trimbos and iMTA Cost questionnaire in Psychiatry. Measurements were taken at baseline, 6, and 12 months post-baseline.

Results

The per-employee costs of the strategy were €50. Net monetary benefits were the benefits (i.e., improved productivity) minus the costs (i.e., intervention costs) and were the main outcome of this investment appraisal. Per-employee net benefits amounted to €2981 on average, which was an almost 60-fold payout of the initial investment of €50. There was a 96.7% likelihood for the modest investment of €50 to be offset by cost savings within 1 year. Moreover, a net benefit of at least €1000 still has a likelihood of 88.2%.

Conclusions

In general, there was a high likelihood that Stress-Prevention@Work offers an appealing business case from the perspective of employers, but the employer should factor in the additional per-employee costs of the stress-reducing interventions. Still, if these additional costs were as high as €2981, then costs and benefits would break even.

This study was registered in the Netherlands National Trial Register, trial code: NTR5527.

The Other Side of the Coin: Nocebo Effects and Psychotherapy

Psychotherapy and placebo have a long history, and both have been shown to have significant and clinically meaningful effects. In the last 100 years and up to today, psychotherapy has been subject to an enduring and often heated debate about its mechanisms and its possible relationship to placebos and their effects. However, there is little awareness of the placebo effects' counterpart-nocebo effects (from Latin "I will harm")-in the context of psychotherapy. Embedded in the controversy of whether psychotherapy and placebo share some unwanted proximity in terms of effects and mechanisms, the question arises which role nocebo effects may play in relation to psychotherapy. By using two examples, this article analyzes and discusses two different kinds of possible associations between psychotherapy and nocebo effects. We close with possibilities of how to prevent the occurrence of nocebo effects in psychotherapy, including some specific recommendations for clinical practice.

The placebo and its effects: A psychoneuroendocrinological perspective

Placebos are usually employed deceptively in clinical trials in order to control for non-specific effects. However, since placebos themselves have been found to cause clinically relevant changes and in some cases are indistinguishable from the verum they are tested against, this theoretically inert, but practically effective intervention has become a scientific discipline in its own right. In this review, it is argued that placebos are generic and genuine biopsychosocial interventions and as such are highly interesting candidates for a psychoneuroendocrinological perspective. Yet, despite a considerable conceptual proximity between explanatory models of placebos and their effects with psychoneuroendocrine models and findings, placebos have thus far not been subject to systematic psychoneuroendocrine examination. Consequently, it would be highly interesting and informative to make placebos the target of psychoneuroendocrine scrutiny.