Evaluating the Responsiveness to Therapeutic Change with Routine Outcome Monitoring: A Comparison of the Symptom Questionnaire-48 (SQ-48) with the Brief Symptom Inventory (BSI) and the Outcome Questionnaire-45 (OQ-45)

Temporal Directionality Between Symptoms During Treatment of Depressed Inpatients: A Dynamic Time Warp Network Analysis

BACKGROUND

Depression is generally perceived from the perspective of the common-cause disease model. However, the network perspective assumes mutual influence of individual symptoms and stresses the importance of investigating symptom dynamics. Gaining a better understanding of symptom dynamics within individuals might contribute to more effective treatments.

METHODS

Current exploratory longitudinal research studied the associations and directionality between 43 symptoms from the generic questionnaire Symptom Questionnaire-48 (SQ-48) using dynamic time warp (DTW) analyses, in which trajectories with similar time-dependent patterns can be identified. Data from individuals were analysed first, yielding distance matrices for all symptom trajectories, after which the data were aggregated.

RESULTS

The 148 included patients were all admitted for the treatment of their clinical depression. Undirected DTW analyses of three patients with longer time series but otherwise randomly chosen showed large variability among individuals. Group-level undirected DTW analyses showed numerous significant edges between symptoms, largely clustering symptoms according to the eight pre-existing subscales of the SQ-48. Group-level directed DTW analyses showed five symptoms with significant outstrength: 'hopeless', 'restless', 'down/depressed', 'feeling tense' and 'no enjoyment', meaning that change in these key symptoms preceded change in other symptoms.

LIMITATIONS

The 43 included symptoms of the SQ-48 primarily focus on internalizing problems in severely depressed inpatients, potentially limiting generalizability.

CONCLUSIONS

DTW networks provided us with five key symptoms based on the dynamics of symptom scores. Future studies could explore whether process-based therapy targeted at symptoms with high outstrength might result in more effectivity as part of personalized treatment.

Unravelling the Longitudinal Relations Between Developmental Milestones, General Psychopathology, and Personality Functioning in a Youth Clinical Sample

Personality functioning, general psychopathology, and developmental milestones achievement are critical domains in the field of young people's mental health; however, no prior research has considered these variables jointly or examined the temporal dynamics between them. To fill these gaps, the present study aimed to investigate the longitudinal associations between the above constructs in a clinical sample of Dutch youth. 525 outpatients (72.5% women; age range: 12-26 years, M = 18.8 ± 2.83) diagnosed with different psychological difficulties were recruited from specialized mental health care services in The Netherlands. They completed self-report measures assessing personality functioning, psychopathological symptoms, and the achievement of youth-specific developmental milestones. Data were collected on three occasions within a year and modelled using a Cross-Lagged Panel Model approach. The levels of personality dysfunction, general psychopathology, and developmental milestones achievement were found to fluctuate from one wave to the other. Personality dysfunction and general psychopathology were positively interrelated at each time point, while both constructs were negatively associated with developmental milestones achievement. Importantly, difficulties achieving developmental milestones predicted a worsening in personality functioning 6 months later. This result would suggest that the achievement of developmental milestones precedes personality functioning, supporting the importance of interventions promoting age-adequate functioning in youth.

Short-term, manualized schema-focused group therapy for patients with CBT-resistant disorders within primary care: a pilot study with a naturalistic pre-treatment and post-treatment design

The aim of this study was to explore the feasibility and preliminary effectiveness of a short-term, manualized schema therapy group for 77 patients with CBT-resistant mood and/or anxiety and/or personality disorders (PDs) in primary care. The primary focus was on the effects of this treatment on Early Maladaptive Schemas (EMS), schema modes, and psychological well-being. These aspects were assessed pre-and post-treatment treatment using the Young Schema Questionnaire (YSQ), the Schema Mode Inventory version 1.1 (SMI), and the Symptom Questionnaire-48 (SQ-48). The treatment consisted of 16 sessions, incorporating cognitive, behavioral, and experiential techniques. EMS significantly decreased from pre-treatment to post-treatment, as along with maladaptive schema modes. Adaptive modes increased, as did psychological wellbeing. There were no significant differences between the DSM-5 classifications regarding changes in the aforementioned measures, except for the maladaptive modes, where the value of the corrected within-subject effect indicated a significant interaction. Post hoc comparisons were therefore conducted which showed that patients with a mood disorder experienced more positive changes in maladaptive modes compared to patients with anxiety disorders and PDs (p < 0.001). There was no significant difference between those with PDs and those with Anxiety Disorders. Our findings provide preliminary evidence that short-term, manualized schema therapy might be an effective treatment for patients with CBT-resistant mood and/or anxiety and/or PDs in primary care.

The clinical effectiveness of a self-management intervention for patients with persistent depressive disorder and their partners/caregivers: results from a multicenter, pragmatic randomized controlled trial

BACKGROUND

Persistent depressive disorder (PDD) is prevalent and debilitating. For patients with PDD, psychiatric rehabilitation using self-management interventions is advised as the next therapeutic step after multiple unsuccessful treatment attempts. The "Patient and Partner Education Program for All Chronic Diseases" (PPEP4All) is a brief, structured self-management program that focuses on functional recovery for patients and their partners/caregivers. In chronic somatic disorder populations, PPEP4All has already been shown to be clinically effective. We examined whether PPEP4All adapted for PDD (PPEP4All-PDD, nine weekly group or individual sessions) is also clinically effective for adults/elderly with PDD and their partners/caregivers compared to care-as-usual (CAU) in specialized mental healthcare.

METHODS

In this mixed-method multicenter pragmatic randomized controlled trial, 70 patients with PDD and 14 partners/caregivers were allocated to either PPEP4All-PDD (patients, n = 37; partners/caregivers, n = 14) or CAU (patients, n = 33; partners/caregivers, not included) and completed questionnaires at 0, 3, 6, and 12 months regarding depressive symptoms, psychopathology, psychosocial burden, mental resilience, and happiness/well-being. Qualitative data were collected regarding treatment satisfaction. Data were analyzed using mixed model analyses and an intention-to-treat (ITT) approach.

RESULTS

There was no statistically significant difference in any outcome regarding clinical effectiveness between PPEP4All-PDD and CAU. Subgroup analysis for depressive symptoms did not show any interaction effect for any subgroup. Although 78% of participants recommended PPEP4All-PDD, there was no difference in treatment satisfaction between PPEP4All-PDD (score = 6.6; SD = 1.7) and CAU (score = 7.6; SD = 1.2), p = 0.06.

CONCLUSION

Although depressive symptoms did not improve relative to CAU, this only confirmed that treatment for patients with treatment-resistant PDD should move from symptom reduction to functional recovery. Also, functional recovery may be reflected in other outcomes than psychosocial burden, such as self-empowerment, in patients with treatment-resistant PDD. Future research on PPEP4All-PDD could focus on a longer-term program and/or online program that may also be offered earlier in the treatment process as an empowerment intervention.  TRIAL REGISTRATION: Netherlands Trial Register Identifier NL5818. Registered on 20 July 2016 https://clinicaltrialregister.nl/nl/trial/20302.

Effectiveness of Day Treatment Group Schema Therapy for Personality Disorders: A Multiple Baseline Single-Case Study

BACKGROUND

Schema therapy is effective for most outpatients with personality disorders (PDs). However, a subgroup does not sufficiently benefit from outpatient programmes. Despite its common clinical use, a thorough evaluation of day treatment group schema therapy (GST) is lacking.

AIMS

This study aimed to investigate the effectiveness of day treatment GST for patients with PDs.

METHODS AND PROCEDURES

Negative core beliefs were the primary outcome in a multiple baseline single-case design, measured weekly before and during 30 weeks of day treatment GST. Secondary outcomes included severity of primary PD, early maladaptive schemas (EMS), schema modes and general psychopathology measured before and after day treatment GST. Intervention effects were evaluated through visual inspection and randomization test analysis, with a reliable change index calculated for the secondary outcome measures.

OUTCOMES AND RESULTS

A total of 79% of treatment completers showed a significant positive effect of day treatment GST with large effect sizes (Cohen's d: 0.96-10.04). Secondary outcomes supported these findings: 56% had a significant decrease in the severity of primary PD and 53% in general psychopathology. In addition, 63% of EMS and 72% of schema modes (87.5% for functional schema modes) showed significant positive reliable changes.

CONCLUSIONS AND IMPLICATIONS

This is the first empirical study that demonstrated the effectiveness of day treatment GST in patients with severe PDs. Day treatment GST can serve as a stepped care treatment option for nonresponsive patients in outpatient programmes. Further randomized controlled (cost-)effectiveness research is necessary to substantiate these findings and investigate the specific patient populations for which day treatment is essential.

Sensitivity to change in well-being and health-related quality of life in adults with eating disorder symptoms: ICECAP-A versus EQ-5D-5L

OBJECTIVE

Economic evaluations of treatments help to inform decisions on allocating health care resources. These evaluations involve comparing costs and effectiveness in terms of quality of life. To calculate quality-adjusted life years, generic health related quality of life is often used, but is criticized for not being sensitive to change in mental health populations. Another approach, using experienced well-being measured through capabilities with the ICECAP-A, has been proposed as an alternative. The aim of this study was to investigate whether changes in individuals with eating disorder (ED) symptoms can be better captured using health related quality of life (EQ-5D-5L) or well-being (ICECAP-A).

METHOD

Measurements at two time points with an interval of 1 year were used from a sample of 233 participants with self-reported ED symptoms. An analysis of variance was used to test whether the EQ-5D-5L and ICECAP-A differed in sensitivity to change over time. In order to compare the two questionnaires in terms of clinically significant outcome, the reliable change index and clinical cut-off score were calculated.

RESULTS

The two questionnaires did not differ in sensitivity to change. More individuals had recovered but also more had deteriorated according to the EQ-5D-5L compared to the ICECAP.

DISCUSSION

The present study revealed no differences in sensitivity to change in health-related quality of life or well-being in individuals with ED symptoms in the context of mild clinical change. Results corroborated the pervasiveness of low quality of life in this population, even after alleviation of ED symptoms.

PUBLIC SIGNIFICANCE STATEMENT

Measuring treatment benefits in terms of improvements in quality of life is an integral part of economic evaluations in health care. It was expected that these treatment benefits would be better captured as changes in well-being (measured with the ICECAP-A) than as changes in health-related quality of life (measured with the EQ-5D-5L) for individuals with ED symptoms. Based on the results of this study, no preference for one of the two approaches was found.

Efficacy of Hypnosis and Catalepsy Induction in Functional Neurological Disorders

BACKGROUND

Patients with Functional Neurological Disorder (FND) experience complex patterns of motor and/or sensory symptoms. Treatment studies of psychological interventions are promising but limited.

OBJECTIVES

The aim of the current pilot study is to investigate the effect of treatment consisting of a combination of hypnosis and catalepsy induction on FND symptom severity.

METHODS

A within-subject waiting list-control design was used with 46 patients diagnosed with FND. The treatment consisted of 10 sessions. The primary outcome measure was FND symptom severity (The Psychogenic Movement Disorder Rating Scale; PMDRS). The secondary outcome measures were psychological distress and quality of life.

RESULTS

The repeated measures (RM) ANOVA for the PMDRS as outcome measure revealed a significant effect for time with a large effect size (η2  = 0.679). Pairwise comparisons indicated that the effect of time in the treatment period was significant for the measure of FND symptom severity, whereas the waiting list period was not. The effect remained stable even at 8 weeks post treatment. As for the additional measurement, general psychological distress and quality of life, no statistically significant differences between individual time points were found.

CONCLUSIONS

This pilot study showed that eight sessions of treatment consisting of a combination of hypnosis and catalepsy induction was effective in reducing FND symptom severity. Some explanations and limitations are provided in the paper as well as several avenues of future research.

Perception of risk of relapse among patients with first episode and recurrent schizophrenia: a descriptive phenomenological study

BACKGROUND

Patients suffering from schizophrenia are at a higher risk of relapse. The perception of the risk of relapse in patients is critical for relapse prevention. In the field of psychiatry, the study of risk perception of relapse has been neglected.

METHODS

We carried out a qualitative study using a descriptive phenomenological approach. Data were collected at two psychiatric hospitals in China. In total, 22 patients with schizophrenia were recruited through purposive sampling. Face to face semi-structured in-depth interviews were conducted. Interview recordings were transcribed by the research team, and transcripts were analysed by two independent coders with Colaizzi's descriptive analysis framework. The consolidated criteria for reporting qualitative research checklist were used for reporting.

RESULTS

The data of first-episode patients yielded three themes: (i) lack of knowledge about disease recognition and medical treatment; (ii) overoptimistic estimation of the risk of relapse; (iii) perceived importance of treatment. For first-relapse patients : (i) initial awareness of relapse warning signs; (ii) lack of systematic and accurate assessment of disease information; (iii) the perception that drug withdrawal is related to relapse. Patients with multiple relapses: (i) susceptibility to relapse: confusion and powerlessness; (ii) the severity of relapse: suicidal thoughts and behavior; (iii) effects of perceived benefits and barriers of medication behaviour.

CONCLUSIONS

In schizophrenic patients with first-episode, first-relapse, and multiple relapses, there were dynamic changes in the perception of disease relapse risk and medication behaviour. Medical workers must improve risk awareness education. They should provide patients with scientific, accurate, and timely communication channels, and dynamically assess and manage the risk of relapse in various patients.

Symptoms of maternal psychological distress during pregnancy: sex-specific effects for neonatal morbidity

OBJECTIVES

Maternal psychological distress during pregnancy has been associated with preterm birth. However, little is known about the relationship of a woman's psychological symptoms during pregnancy to the infant's morbidity at birth or any differential effects of these symptoms on female vs. male fetuses. Our research aims addressed these gaps.

METHODS

A total of 186 women were enrolled between 24 and 34 weeks gestation when demographic information was acquired and they completed the Brief Symptom Inventory to measure psychological distress. Data on gestational age at birth, fetal sex, and neonatal morbidity was extracted from the medical record. To control for their effects, obstetric complications were also identified. Multiple linear regressions were computed to examine the aims, including interaction terms to measure moderating effects of fetal sex.

RESULTS

Symptoms of maternal psychological distress were a significant predictor of neonatal morbidity but were not associated with gestational age. The interaction between symptom distress and fetal/infant sex was also significant for neonatal morbidity but not for gestational age. For boys, high levels of maternal symptom distress during pregnancy were associated with neonatal resuscitation, ventilatory assistance, and infection. Maternal distress was not associated with neonatal morbidity for girls.

CONCLUSIONS

The male fetus may be more sensitive to effects of mothers' psychological symptoms than the female fetus. Further research is needed to confirm our findings and identify potential biological mechanisms that may be responsible for these sex differences. Findings suggest the importance of symptom screening and early intervention to reduce maternal distress and risk of neonatal morbidity.

Peer Academic Supports for Success (PASS) for College Students with Mental Illness: Open Trial

Increasing numbers of college students have serious mental health conditions, but their dropout rates are high and debt accrual is common. A well-specified intervention that colleges can directly offer their undergraduates with serious mental health conditions that sustains their academic persistence is greatly needed. The Peer Academic Supports for Success (PASS) coaching model was developed to address this need. This study’s goal was to conduct an open trial of the initial PASS model to test the feasibility of the model and research methods in preparation for more rigorous testing. Ten college juniors and seniors, with and without lived mental health experience, were hired, trained, and supervised to be PASS peer coaches. Twelve undergraduate students with academically impairing mental health conditions served as study participants and received PASS. Student data were collected at baseline and two semesters post baseline. Intervention feasibility data were assessed through coach report. Results indicate PASS can be delivered with fidelity by peer coaches, can attract and retain students, and is safe. Results also suggest that PASS has significant effects on most of the targeted proximal outcomes. The PASS findings are promising as a college-based intervention to support young adult students with mental health conditions.

Understanding personality pathology in a clinical sample of youth: study protocol for the longitudinal research project 'APOLO'

INTRODUCTION

We propose that a dimensional, multilayered perspective is well suited to study maladaptive personality development in youth. Such a perspective can help understand pathways to personality pathology and contribute to its early detection. The research project 'APOLO' (a Dutch language acronym for Adolescents and their Personality Development: a Longitudinal Study) is designed based on McAdams' integrative three-layered model of personality development and assesses the interaction between dispositional traits, characteristic adaptations, the narrative identity and functioning.

METHODS AND ANALYSIS

APOLO is a longitudinal research project that takes place in two outpatient mental healthcare centres. Participants are youth between 12 years and 23 years and their parents. Data collection is set up to build a data set for scientific research, as well as to use the data for diagnostic assessment and systematic treatment evaluation of individual patients. Measurements are conducted half-yearly for a period of 3 years and consist of self-report and informant-report questionnaires and a semistructured interview. The included constructs fit the dimensional model of personality development: maladaptive personality traits (dispositional traits), social relations, stressful life events (characteristic adaptations), a turning point (narrative identity) and functioning (eg, achievement of youth specific milestones). Primary research questions will be analysed using structural equation modelling.

ETHICS AND DISSEMINATION

The results will contribute to our understanding of (the development of) personality pathology as a complex phenomenon in which both structural personality characteristics as well as unique individual adaptations and experiences play a role. Furthermore, results will give directions for early detection and timely interventions. This study has been approved by the ethical review committee of the Utrecht University Faculty for Social and Behavioural Sciences (FETC17-092). Data distribution will be anonymous and results will be disseminated via communication canals appropriate for diverse audiences. This includes both clinical and scientific conferences, papers published in national and international peer-reviewed journals and (social) media platforms.

Development and validation of 21-item outcome inventory (OI-21)

Background

Outcome measurement is important for monitoring patients' progress. The study aimed to develop an outcome inventory (OI) for clinical use in routine practice in psychiatric services and to examine the psychometric properties of the newly developed OI.

Methods

48 items measuring anxiety, depression, interpersonal difficulties, and somatization were collected. Factor analysis was used to reduce the number of items. The final OI consisting of 21 items was then examined for psychometric properties among 1302 participants, 880 were nonclinical and 422 clinical patients. Tests included confirmatory factor analysis, internal consistency, test-retest reliability, convergent and discriminant validity, and diagnostic ability for major depression. Responsiveness was compared between baseline and 3-month follow-up.

Results

Confirmatory factor analysis revealed the OI-21 demonstrated the designated four components. Cronbach's alpha was good to excellent for all subjects with good test-retest reliability, concurrent validity, convergent and discriminant validity. It demonstrated area under the ROC curve of 0.89 indicating good diagnostic performance. Sensitivity to change after 3 months was observed in both types of treatment. However, interpersonal difficulties were sensitive to change in those receiving additional psychotherapy.

Conclusion

OI-21 demonstrated its validity, reliability, and sensitivity to change. It constitutes a promising tool for outcome assessment in nonclinical populations and among psychiatric patients.

The clinical and cost-effectiveness of a self-management intervention for patients with persistent depressive disorder and their partners/caregivers: study protocol of a multicenter pragmatic randomized controlled trial

BACKGROUND

After regular treatment, patients with persistent depressive disorder (PDD) may remain in specialized psychiatric outpatient care without achieving remission. Lacking other options, these patients often receive long-term, non-protocolized care as usual (CAU) that does not involve the partner/caregiver of the patient. Although the revised depression treatment guidelines suggest focusing on psychiatric rehabilitation and self-management as the next treatment step for PDD, an evidence-based cost-effective self-management protocol for PDD is lacking. This study investigates the "Patient and Partner Education Program for All Chronic Illnesses" (PPEP4All) as a brief self-management protocol that could lead to lower costs, higher quality of life, and less disease burden in PDD patients and their partners/caregivers.

METHODS

Presented is the rationale and methods of a multicenter pragmatic randomized controlled trial to evaluate the clinical efficacy and cost-effectiveness of PPEP4All for patients with PDD and their partners/caregivers. In accordance with current recommendations, a mixed methods research approach is used with both quantitative and qualitative data. A total of 178 eligible outpatients with PDD and their partners/caregivers are recruited and randomized to either PPEP4All or CAU. Those assigned to PPEP4All receive nine weekly self-management sessions with a trained PPEP4All therapist. Primary and secondary outcome measurements are at 0, 3, 6, and 12 months.

DISCUSSION

This project will result in the implementation of a self-management intervention for patients with PDD, meeting an urgent need in mental healthcare. Using PPEP4All can optimize the quality and efficiency of care for both patients with PDD and their partners/caregivers.

TRIAL REGISTRATION

Netherlands Trial Register Identifier NTR5973 . Registered on 20 July 2016.

Testing for response shift in treatment evaluation of change in self-reported psychopathology amongst secondary psychiatric care outpatients

OBJECTIVES

If patients change their perspective due to treatment, this may alter the way they conceptualize, prioritize, or calibrate questionnaire items. These psychological changes, also called "response shifts," may pose a threat to the measurement of therapeutic change in patients. Therefore, it is important to test the occurrence of response shift in patients across their treatment.

METHODS

This study focused on self-reported psychological distress/psychopathology in a naturalistic sample of 206 psychiatric outpatients. Longitudinal measurement invariance tests were computed across treatment in order to detect response shifts.

RESULTS

Compared with before treatment, post-treatment psychopathology scores showed an increase in model fit and factor loading, suggesting that symptoms became more coherently interrelated within their psychopathology domains. Reconceptualization (depression/mood) and reprioritization (somatic and cognitive problems) response shift types were found in several items. We found no recalibration response shift.

CONCLUSION

This study provides further evidence that response shift can occur in adult psychiatric patients across their mental health treatment. Future research is needed to determine whether response shift implies an unwanted potential bias in treatment evaluation or a desired cognitive change intended by treatment.

Measuring treatment outcome in patients with anxiety disorders: A comparison of the responsiveness of generic and disorder-specific instruments

BACKGROUND

For routine outcome monitoring, generic (i.e., broad-based) and disorder-specific instruments are used to monitor patient progress. While disorder-specific instruments may be more sensitive to therapeutic change, generic measures can be applied more broadly and allow for an assessment of therapeutic change, irrespective of a specific anxiety disorder. Our goal was to investigate whether disorder-specific instruments for anxiety disorders are a valuable (or even necessary) addition to generic instruments for an appropriate assessment of treatment outcome in groups of patients.

METHODS

Data were collected from 2002 to 2013 from psychiatric outpatients in treatment for Social Phobia (SP; n = 834), Generalized Anxiety Disorder (GAD; n = 661), Panic Disorder (PD; n = 944), Obsessive-Compulsive Disorder (OCD; n = 460), and Posttraumatic Stress Disorder (PTSD; n = 691). Instruments used were the generic Brief Symptom Inventory (BSI), The Mood and Anxiety Symptoms Questionnaire (MASQ), and several disorder-specific instruments (e.g., Social Interaction Anxiety Scale, Social Phobia Scale, Panic Appraisal Inventory, etc.). Responsiveness (i.e., sensitivity to therapeutic change) was examined through correlational analyses, effect sizes (ES), and analysis of variance for repeated measures.

RESULTS

The MASQ appeared generally more responsive than the BSI, except for the BSI Anxiety subscale for PD. Disorder-specific measures equaled the MASQ and BSI in responsiveness. When statistically significant differences occurred, the ES was small.

DISCUSSION/CONCLUSIONS

For most anxiety disorder groups (i.e., SP, PD and OCD), the MASQ or BSI was equally suited as disorder-specific instruments to detect change at group level. Exceptions are GAD and PTSD. These findings suggest limited incremental information value of disorder-specific instruments over the MASQ and BSI for measuring change.

Comparative responsiveness of generic versus disorder-specific instruments for depression: An assessment in three longitudinal datasets

BACKGROUND

Routine outcome monitoring (ROM) may enhance individual treatment and is also advocated as a means to compare the outcome of different treatment programs or providers. There is debate on the optimal instruments to be used for these separate tasks.

METHODS

Three sets with longitudinal data from ROM were analyzed with correlational analysis and repeated measures ANOVAs, allowing for a head-to-head comparison of measures regarding their sensitivity to detect change. The responsiveness of three disorder-specific instruments, the Beck Depression Inventory, the Inventory of Depressive Symptoms, and the Mood and Anxiety Symptoms Questionnaire, was compared to three generic instruments, the Symptom Checklist (SCL-90), the Outcome Questionnaire (OQ-45), and the Brief Symptom Inventory, respectively.

RESULTS

In two of the three datasets, disorder-specific measures were more responsive compared to the total score on generic instruments. Subscale scores for depression embedded within generic instruments are second best and almost match disorder-specific scales in responsiveness. No evidence of a desynchronous response on outcome measures was found.

LIMITATIONS

The present study compares measures head-to-had, and responsiveness is not assessed against an external criterion, such as clinical recovery.

DISCUSSION

Disorder-specific measures yield the most precise assessment for individual treatment and are recommended for clinical use. Generic measures may allow for comparisons across diagnostic groups and their embedded subscales approach the responsiveness of disorder-specific measures.

Effectiveness of a multi-facetted blended eHealth intervention during intake supporting patients and clinicians in Shared Decision Making: A cluster randomised controlled trial in a specialist mental health outpatient setting

OBJECTIVE

To investigate the effectiveness of a multi-facetted blended eHealth intervention, called SDM-Digital Intake (SDM-DI), in which patients and clinicians are supported in Shared Decision Making during the intake process.

METHODS

The study is a two-arm matched-paired cluster Randomised Controlled Trial in a specialist mental health outpatient setting with two conditions: SDM-DI and Intake As Usual (IAU). Four intake teams were allocated to each arm. All patients who followed an intake, were asked to participate if they were capable to complete questionnaires. Decisional Conflict (DC), referring to patients' engagement and satisfaction with clinical decisions, was the primary outcome. Secondary outcomes were patient participation, applying Shared Decision Making (SDM), working alliance, treatment adherence and symptom severity. Effects were measured at two weeks (T1) and two months (T2) after intake. Multilevel regression and intention-to-treat analyses were used. Additionally, the influence of subgroups and intervention adherence on DC were explored.

RESULTS

At T1, 200 patients participated (47% intervention, 53% control), and at T2 175 patients (47% intervention, 53% control). At T1 and T2, no differences were found between conditions on DC. Subgroup analyses showed that effects of SDM-DI on DC were not modified by primary diagnoses mood, anxiety and personality disorders. Compared to IAU, at T2, patients reported positive effects of SDM-DI on SDM (β 7.553, p = 0.038, 95%CI:0.403-14.703, d = 0.32) and reduction of symptoms (β -7.276, p = 0.0497, 95%CI:-14.544--0.008, d = -0.43). No effects were found on patient participation, working alliance and treatment adherence. Exploratory analyses demonstrated that if SDM was applied well, patients reported less DC (β = -0.457, p = 0.000, 95%CI:-0.518--0.396, d = -1.31), which was associated with better treatment outcomes.

CONCLUSION

Although, this trial fails to demonstrate that SDM-DI by itself is sufficient to reduce DC, the results are encouraging for further efforts in improving and implementing the SDM intervention.

Treatment course and its predictors in patients with somatoform disorders: A routine outcome monitoring study in secondary psychiatric care

AIM

Somatoform disorders are common and often chronic. It would be helpful to distinguish those patients who are likely to have a positive treatment course from those who are likely to follow a negative course. Such studies of different somatoform disorders are scarce, especially in secondary psychiatric care. This study examined the 6-month treatment course of psychological, physical symptoms, and functioning, and its predictors in a naturalistic sample of secondary psychiatric care outpatients with somatoform disorders.

METHOD

The present study used routine outcome monitoring data of patients with somatoform disorders regarding their 6-month treatment course of psychological and physical symptoms as well as functioning. The following patient groups were included: total group of somatoform disorders (N = 435), and undifferentiated somatoform disorder (N = 242), pain disorder (N = 102), body dysmorphic disorder (N = 51), and hypochondriasis (N = 40). Measures were Mini-International Neuropsychiatric Interview plus, Brief Symptom Inventory, Montgomery-Ǻsberg Depression Rating Scale, Brief Anxiety Scale, Short Form Health Survey 36, and Physical Symptom Checklist (PSC).

RESULTS

The study population generally showed high co-morbidity, especially with anxiety and mood disorders. The PSC total score, body dysmorphic disorder, and hypochondriasis were significant predictors for the treatment course of symptoms (Brief Symptom Inventory), whereas the PSC total score was the only significant predictor for the course of functioning (Short Form Health Survey 36).

CONCLUSION

Secondary psychiatric care outpatients with somatoform disorders showed high co-morbidity with anxiety and mood disorders, and an unfavourable 6-month course of both symptoms and functioning. Clinical implications are discussed, such as additional treatment of co-morbidity in somatoform disorders.