Targets and outcomes of psychotherapies for mental disorders: an overview

Effect of virtual reality self-counseling with the intimate other avatar

Virtual reality self-counseling (VR-SC) is considered an effective approach for addressing mental health problems. Previous studies have shown the effectiveness of VR-SC using Sigmund Freud's avatar as the counselor. However, considering that virtual reality (VR) enables embodied perspective-taking of another person, VR-SC using the avatar of a person who cares about the participant (an intimate person), such as a family member or friend, is considered effective because it could create warm attitudes toward the participants themselves. In this study, 60 undergraduate and graduate students were split into three conditions: VR-SC with intimate persons, VR-SC with Freud, and a control group. The intervention effects were then compared. The results showed that VR-SC with an intimate person was the most effective in improving anxiety symptoms. These results may be attributed to accepting and affirming oneself from the perspective of the intimate person's avatar and counseling oneself. This study is significant in that it is the first to conduct VR-SC with the avatar of an intimate person and compare the effects with Freud's avatar. More importantly, it showed that the same VR-SC method could have different effects depending on the avatar of the counseling partner.

Socioeconomic status, psychotherapy duration, and return to work from disability due to common mental disorders

Objective Low socioeconomic status (SES) is a risk factor for work disability due to common mental disorders (CMDs), one possible reason being inequal use of services. Psychotherapy is an evidence-based treatment for CMDs. This study examines socioeconomic and sociodemographic differences in psychotherapy attendance and an association of psychotherapy duration with return to work (RTW).Methods The study subjects (N = 12,263) were all Finnish citizens granted a disability pension (DP) due to CMDs in 2010-2012. Numbers of psychotherapy sessions (maximum 200) were collected from the nine-year interval around the DP grant. Socioeconomic and sociodemographic differences in psychotherapy duration (dependent variable) among DP recipients were studied using multinomial logistic regression models, likewise, the association between psychotherapy duration and RTW (dependent variable) among temporary DP recipients was examined.Results Higher SES, female gender, and younger age were positively associated with attending longer psychotherapies and surpassing the early treatment termination level (>10 sessions). Attending 11-60 psychotherapy sessions was positively associated with full RTW and partial RTW, whereas longer psychotherapies were not. Early termination was positively associated with partial RTW only.Conclusion This study demonstrates varying tendencies among CMD patients from different backgrounds to attend long rehabilitative psychotherapies, which may create inequalities in RTW.

A consulting room with a view: Psychotherapy and the ecological context

BACKGROUND

The field of psychotherapy is witnessing a lively debate today. The literature on the efficacy of psychological interventions has grown exponentially, but the assumptions of the prevailing research paradigms have been criticised from many points of view. One of the main concerns is that of a too often simplistic conception of psychotherapy, viewed as a set of specific methods for the treatment of point-like problems or symptoms.

LITERATURE REVIEW ON MENTAL HEALTH AND THE ECOLOGICAL CONTEXT

Instead, emerging perspectives are trying to promote a more complex view on psychotherapy, as a process based on the therapeutic potential of relationships, which takes place in relevant social and cultural contexts. Even the ecological context is taken in greater consideration, as growing evidence exists about the detrimental effects of ecological threats-such as climate change and other environmental challenges-on mental health.

CONCLUSIONS

Psychotherapists and psychotherapy associations are now paying due attention to such issues, as well as to social justice and other dimensions that no longer can be thought of as mere elements of the scenario in which psychotherapy is practiced. Rather they are dimensions that exert a strong influence on psychological well-being, and thus must be properly acknowledged and assessed to connect clinical work with the communities and ecological contexts in which people live.

Extending the PROMIS item bank "ability to participate in social roles and activities": a psychometric evaluation using IRT

OBJECTIVE

Our objective was to explore whether the extension of the PROMIS item bank Ability to Participate in Social Roles and Activities (APSRA) with new items would result in more effective targeting (i.e., selecting items that are appropriate for each individual's trait level), and more reliable measurements across all latent trait levels.

METHODS

A sample of 1,022 Dutch adults completed all 35 items of the original item bank plus 17 new items (in Dutch). The new items presented in this publication have been translated provisionally from Dutch into English for presentation purposes. We evaluated the basic IRT assumptions unidimensionality, local independence, and monotonicity. Furthermore, we examined the item parameters, and assessed differential item functioning (DIF) for sex, education, region, age, and ethnicity. In addition, we compared the test information functions, item parameters, and θ scores, for the original and extended item bank in order to assess whether the measurement range had improved.

RESULTS

We found that the extended item bank was compatible with the basic IRT assumptions and showed good reliability. Moreover, the extended item bank improved the measurement in the lower trait range, which is important for reliably assessing functioning in clinical populations (i.e., persons reporting lower levels of participation).

CONCLUSION

We extended the PROMIS-APSRA item bank and improved its psychometric quality. Our study contributes to PROMIS measurement innovation, which allows for the addition of new items to existing item banks, without changing the interpretation of the scores and while maintaining the comparability of the scores with other PROMIS instruments.

The association of sociodemographic characteristics with work disability trajectories during and following long-term psychotherapy: a longitudinal register study

PURPOSE

This register-based study examined the trajectories of depression or anxiety disorder-related work disability during and following long-term psychotherapy and identified sociodemographic factors that indicate membership in different trajectory groups.

METHODS

Data were drawn from national registers (Statistics Finland, Social Insurance Institution of Finland). Participants included a random sample of Finnish working-age individuals (18-55 years) who started psychotherapy treatment between 2011 and 2014 and were followed for 5 years: 1 year before and 4 years after the onset of psychotherapy (N = 3 605 individuals; 18 025 person-observations across five time points). Group-based trajectory modeling was applied to assign individuals to work disability trajectories by the number of annual mental health-related work disability months. Multinomial logistic regression was used to examine the associations between trajectory group membership and baseline sociodemographic factors of age, gender, occupational status, and geographical area of residence.

RESULTS

Four mental health-related work disability trajectories were identified: stable very low (72%), decrease (11%), persistent low (9%) and persistent high (7%). Those with older age, female gender, lower occupational status, and living in sparsely populated geographical areas were more likely to belong to the most unfavorable trajectory group of persistent high work disability. The presence of multiple risk characteristics substantially increased the probability of belonging to the most adverse trajectory group.

CONCLUSIONS

Sociodemographic factors were associated with the course of mental health-related work disability in association with psychotherapy. Rehabilitative psychotherapy does not function as an equal support resource for work ability in all parts of the population.

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial

PURPOSE

Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up.

MATERIALS AND METHODS

Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy.

RESULTS

Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations.

CONCLUSIONS

While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.

Defining and operationalizing personalized psychological treatment - a systematic literature review

This systematic literature review aimed to propose a definition of personalized psychological treatment and to suggest how the definition can be operationalized. PsycINFO, Cochrane Library, MEDLINE and EMBASE were searched up to 11 December 2023 for studies in which a definition of personalized psychological treatment was included or a systematic operationalization of personalized psychological treatment was described. Based on a narrative synthesis of the collected definitions, summary categories were developed that informed the proposed definition. Operationalizations were described according to what aspect of treatment, how and when treatment was personalized. The extent to which the operationalizations deviated from the proposed definition was assessed. Thirty-four studies with definitions and 200 with operationalizations were included. The following definition was proposed: personalized psychological treatment aims to optimize treatment outcome for the individual patient by tailoring treatment to unique or specific needs, preferences or other characteristics and includes a systematic adaptation of treatment or a differentiation between treatment strategies. Based on the operationalizations, timing of personalization, specification of the systematic approach and treatment elements that could be personalized were added to the proposed definition. Evidence-based personalization of psychological treatments can be enhanced by clear operationalization based on a comprehensive definition of personalization.

[Effectiveness of psychotherapy on dissociative symptoms in adult populations: A PRISMA systematic review]

INTRODUCTION

Dissociation is a psychological process in reaction to threat which can be found in many psychiatric conditions. Dissociative symptoms can become very disabling, whether in daily life or in care. Nevertheless, few studies seem to have examined the efficacy of psychotherapy on the latter and its relevance as a therapeutic target.

METHOD

A systematic review of the literature (PRISMA) on the efficacy of psychotherapy on dissociative symptoms in adults with mental disorders was conducted. Effectiveness was considered in terms of reduction in dissociative symptomatology. The search was conducted on Scopus, PubMed and PsycInfo. Overall, 50 full-text articles were evaluated.

RESULTS

Fourteen studies were included in the review. In all, 711 adult subjects with post-traumatic stress disorder, borderline personality disorder or dissociative disorder were included. Overall, this systematic review reports a reduction in dissociative symptoms associated with a variety of psychotherapeutic interventions, without allowing any conclusions to be drawn on the superiority of one psychotherapy over another.

DISCUSSION

The conclusions of this work highlight three possible therapeutic orientations for reducing dissociative symptoms: (i) by reintegrating the dynamic subsystems, (ii) by treating the cognitive processes underlying dissociation, and (iii) by acting on the processes identified as common to the effectiveness of psychotherapy.

Factors associated with satisfaction and perceived helpfulness of mental healthcare: a World Mental Health Surveys report

BACKGROUND

Mental health service providers are increasingly interested in patient perspectives. We examined rates and predictors of patient-reported satisfaction and perceived helpfulness in a cross-national general population survey of adults with 12-month DSM-IV disorders who saw a provider for help with their mental health.

METHODS

Data were obtained from epidemiological surveys in the World Mental Health Survey Initiative. Respondents were asked about satisfaction with treatments received from up to 11 different types of providers (very satisfied, satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, very dissatisfied) and helpfulness of the provider (a lot, some, a little, not at all). We modelled predictors of satisfaction and helpfulness using a dataset of patient-provider observations (n = 5,248).

RESULTS

Most treatment was provided by general medical providers (37.4%), psychiatrists (18.4%) and psychologists (12.7%). Most patients were satisfied or very satisfied (65.9-87.5%, across provider) and helped a lot or some (64.4-90.3%). Spiritual advisors and healers were most often rated satisfactory and helpful. Social workers in human services settings were rated lowest on both dimensions. Patients also reported comparatively low satisfaction with general medical doctors and psychiatrists/psychologists and found general medical doctors less helpful than other providers. Men and students reported lower levels of satisfaction than women and nonstudents. Respondents with high education reported higher satisfaction and helpfulness than those with lower education. Type of mental disorder was unrelated to satisfaction but in some cases (depression, bipolar spectrum disorder, social phobia) was associated with low perceived helpfulness. Insurance was unrelated to either satisfaction or perceived helpfulness but in some cases was associated with elevated perceived helpfulness for a given level of satisfaction.

CONCLUSIONS

Satisfaction with and perceived helpfulness of treatment varied as a function of type of provider, service setting, mental status, and socio-demographic variables. Invariably, caution is needed in combining data from multiple countries where there are cultural and service delivery variations. Even so, our findings underscore the utility of patient perspectives in treatment evaluation and may also be relevant in efforts to match patients to treatments.

Taking stock to move forward: Where the field of developmental psychopathology might be heading

In this paper, dedicated to Dante Cicchetti's contributions and enduring influence, we explore the prospective directions of developmental psychopathology. Our focus centers on key domains where Cicchetti's significant achievements have continually shaped our evolving thinking about psychological development. These domains include (a) the concepts of equifinality and multifinality, along with the challenges in predicting developmental trajectories, (b) the imperative to integrate wider sociocultural viewpoints into developmental psychopathology frameworks, (c) the interplay of genetic and environmental influences in developmental courses, (d) the significance of mental state language, and (e) the progress, or its absence, in the development of prevention and intervention tactics for children, adolescents, and their caregivers. While many of our forecasts regarding the future of developmental psychopathology may not materialize, we maintain optimistic that the essential ideas presented will influence the research agenda in this field and contribute to its growth over the next fifty years.

Understanding change - developing a typology of therapy outcomes from the experience of adolescents with depression

Outcome measures mostly focusing on symptom reduction to measure change cannot indicate whether any personally meaningful change has occurred. There is a need to broaden the current understanding of outcomes for adolescent depression and identify whether holistic, interlinked patterns of change may be more clinically meaningful.

To create a typology of therapy outcomes based on the experiences of adolescents with depression.

Interview data from 83 participants from a clinical trial of the psychological treatment of adolescent depression was analysed using ideal type analysis.

Six ideal types were constructed, reflecting different evaluations of the holistic impact of therapy: "I've worked on my relationships", "With the insight from therapy, and feeling validated, I can cope with life challenges better", "My mood still goes up and down", "If I want things to change, I need to help myself", "Therapy might help, but it hasn't been enough", and "I don't feel therapy has helped me".

Assessing change using outcome measures may not reflect the interconnected experience for adolescents or the contextual meaning of symptom change. The typology developed offers a way of considering the impact of therapy, taking into account how symptom change is experienced within a broader perspective.

Efficacy and moderators of metacognitive training for depression in older adults (MCT-Silver): A randomized controlled trial

BACKGROUND

Up to 79 % of older adults with depression do not receive treatments commensurate with guideline recommendations. Metacognitive Training-Silver (MCT-Silver) is a low-intensity group training, which aims to reduce depressive symptoms by targeting (meta)cognitive beliefs.

METHODS

A randomized controlled trial comparing MCT-Silver (n = 41) to cognitive remediation (n = 39) was conducted with older adults with major depressive disorder and/or dysthymia. Clinician-rated depression (Hamilton Depression Rating Scale [HDRS, primary outcome]), self-reported depression (Beck Depression Inventory-II [BDI-II]), negative cognitive beliefs, positive metacognitive beliefs, rumination, health status, quality of life, and neurocognitive functioning were assessed at baseline, eight weeks (post) and three months (follow-up).

RESULTS

Both groups demonstrated moderate to large reductions in depression. No superior effects of MCT-Silver on clinician-rated depression (HDRS) were detected. MCT-Silver led to greater reductions in self-reported depression and rumination at post- and follow-up. Despite this, scores at post- and follow-up assessments were similar for both groups. MCT-Silver's effect on depressive symptoms was moderated by baseline rumination, positive metacognitive beliefs and previous treatment experience. MCT-Silver was evaluated as superior according to patient appraisals.

LIMITATIONS

Conclusions are limited by divergent findings on measures of depression and that the study was conducted during the COVID-19 pandemic.

CONCLUSIONS

Whereas no superior effect of MCT-Silver was found for the primary outcome, there was a significant effect of MCT-Silver for self-reported depression and rumination. Patients endorsing rumination and positive metacognitive beliefs as well as those without previous psychological treatment may benefit more from MCT-Silver.

Effect of a long-term art-based group therapy with eating disorders

Eating disorders (EDs) affect the physical, psychological, emotional and interpersonal areas of the individual and cause serious medical and mental consequences. Their treatment should be handled in a multidisciplinary manner.The objective of this study was to investigate potential benefits of long-term art-based group therapy (ABGT) as an adjunct to treatment for a variety of EDs. This study examined the effects of ABGT on disease symptoms, difficulty regulating emotions, depression, anxiety, targeted problems, functioning of individuals with EDs and therapeutic efficiency of the group. The study was carried out as a pre-test-post-test, quasi-experimental study with a control group, with a small sample diagnosed with an ED. In addition to their standard treatment at the outpatient centre, participants were included in a 30-week long-term semistructured ABGT focused on raising awareness of their psychological problems. Participants who received ABGT had significantly better functioning and lower severity of target problems compared with the control group. The severity of the three most important problems reported by patients post-ABGT compared with pre-ABGT and the effects of these problems on their social/private lives reduction was observed. The participants mostly benefited from catharsis, universality, self-understanding, existential factors and family re-enactment in the group process. Through the artwork, participants recognised the mental conflicts causing the symptoms of their ED. We found that art-based interventions are useful in the treatment of EDs, as they positively changed the functioning and symptoms of people with EDs. We recommend that clinicians keep these interventions in mind in formulating treatment protocols for these disorders.

A compassion-based treatment for couples with the female partner suffering from current depressive disorder: A randomized-controlled trial

BACKGROUND

Studies have shown that depression and interpersonal relationships are interdependently connected and that including the intimate partner in treatment for depression has beneficial effects. Given evidence that compassion is both an interpersonal quality and a promising treatment target, the goal of this study was to examine the effects of a compassion-based, contemplative treatment for couples employing a multi-method approach for evaluation.

METHODS

In a pre-post-follow-up design, n = 53 different-sex couples including women with current depression were randomly assigned to a 10-week-long CBCT®-fC (Cognitively-Based Compassion Training/intervention for couples) or treatment-as-usual (TAU) condition. Multi-level linear regression models and post-hoc contrasts were calculated to determine changes in depressive symptoms, mindfulness and self-compassion, interpersonal functioning and neuroendocrine markers collected during a partnership appreciation task (PAT) in the laboratory before and after CBCT-fC treatment.

RESULTS

While CBCT-fC led to a comparable decrease of depressive symptoms as TAU, the training specifically increased self-compassion and mindfulness versus TAU. Interestingly, interpersonal functioning did not improve, which was also reflected in participants' preferred self-focus in-between-session practices, instead of practices with interpersonal focus. There were no group-specific changes in psychobiological stress-marker reactivity.

CONCLUSIONS

CBCT-fC was effective in decreasing current depressive symptomatology and increasing mindfulness, and self-compassion. Especially the motivation to participate, such as improving interpersonal functioning, should be addressed and intrinsic motives of the partners to be involved. In highly burdened individuals, self-regulation may need to be improved before co-regulation can be addressed, which would requiring longer treatments. Facilitating factors for engaging in the practice between-sessions seem meaningful.

Comparing self-reported quality of life in youth with bipolar versus other disorders

OBJECTIVES

This study benchmarks quality of life (QoL) of youth with bipolar disorder (BD) against healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders. The relative impacts of depressive, (hypo)manic, mixed, and externalizing symptoms on QoL are tested for youth with BD.

METHOD

In total, 657 youth completed the Schedule for Affective Disorders and Schizophrenia for Children (KSADS), the KSADS depression and mania scales, the Parent General Behavior Inventory (PGBI), and the Child Behavior Checklist (CBCL). Youth-reported QoL was determined by the Revised Children Quality of Life Questionnaire (KINDL) and was compared to healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders.

RESULTS

Youth with BD reported poorer QoL overall and on most subscales compared to healthy youth, youth with chronic medical conditions, youth with behavior disorders, and youth with other non-behavior/non-mood disorders. QoL in youth with BD did not differ significantly from QoL in youth with unipolar depression. Parent-report and interview-rated depressive symptoms were associated with decreases in Total QoL and all QoL subscales except Family. Externalizing symptoms were associated with decreases in Family QoL and increases in Friend QoL, and (hypo)manic symptoms were associated with increases in Emotional Well-Being QoL.

CONCLUSIONS

Depressive symptoms may drive the decline in QoL causing youth with BD to rate their QoL worse than healthy youth, youth with chronic medical conditions, and youth with behavior disorders, but not worse than youth with unipolar depression.

Predicting acupuncture efficacy for major depressive disorder using baseline clinical variables: A machine learning study

Acupuncture is a viable treatment option for major depressive disorder (MDD). However, its effectiveness varies among patients. This study aimed to develop a model to predict the efficacy of acupuncture therapy for MDD using machine learning and baseline clinical variables. A total of 124 patients with MDD from five research centers were included in our machine learning study. All patients underwent acupuncture treatment for 6 weeks and the efficacy of the treatment was evaluated using the Hamilton Depression Scale-17 (HAMD-17). The max-relevance and min-redundancy (mRMR) algorithm and Pearson correlation analysis were used for selecting 11 significant features from 26 baseline clinical variables for model training. We compared the performance of five machine learning models, including logistic regression, support vector machine, K-nearest neighbor, random forest, and XgBoost, in predicting the effect of acupuncture in relieving major depression. Among the five models, XgBoost performed the best with an area under the receiver operating characteristic curve (AUC) of 0.835, an accuracy of 0.730, a sensitivity of 0.670, a specificity of 0.774, and an F1 score of 0.751. The key predictive variables identified were anxiety score in the self-rating depression scale (SDS), the traditional Chinese medicine syndrome of deficiency in both heart and spleen, and body mass index (BMI). The study demonstrates that the developed model can help physicians predict the patients who will benefit from acupuncture treatment, which is of positive significance for improving the clinical efficacy of acupuncture on MDD.

Protocol Development for a Qualitative Methodological Study Within a Trial (Qual-SWAT): The KARMA-Dep-2 Trial

Background

Despite methodological improvements in clinical trial design and conduct more generally, methodological limitations persist in trials concerning mental health care. A qualitative Study Within A Trial (Qual-SWAT), embedded in the KARMA-Dep-2 host trial, will be undertaken to explore and gain an understanding of two methodological questions in randomised trials specific to mental health care: (1) what are the key barriers and enablers of participation in randomised trials in mental health; and (2) how can randomised trials become part of routine mental health care. These issues will be examined from patient-participant and clinician- / researcher-participant perspectives, in alignment with PRioRiTy research themes.

Methods

A descriptive qualitative study design will be used. Data will be collected via one-to-one semi-structured interviews, conducted via Microsoft Teams. The interview data will be analysed using Braun and Clarke's Thematic Analysis approach. One-to-one interviews will be conducted with three participant groups ( N = 30): 1) host trial patient-participants ( n = 10); 2) potentially eligible host trial patient-participants who refused enrolment in the host trial ( n = 10); and 3) clinician- / researcher-participants who are associated with work on the host trial ( n = 10).

Ethics and dissemination

Ethical approval has been granted by St. Patrick's Mental Health Services Research Ethics Committee, Ireland (Ref: Protocol 09/20). When the study is completed, a report will be prepared and submitted to the Health Research Board (HRB). Findings will be shared with the host trial team and study participants, and submitted for publication.

Host trial registration

ClinicalTrials.gov ( NCT04939649); EudraCT ( 2019-003109-92). Official title: Ketamine as an Adjunctive Therapy for Major Depression - A Randomised Controlled Trial: [KARMA-Dep (2)].

A blended module (STAIRS) to promote functional and personal recovery in patients with a major depressive disorder in remission: study protocol of a concurrent mixed methods randomized controlled trial

BACKGROUND

Despite the availability of a wide variety of evidence-based treatments for major depressive disorder (MDD), many patients still experience impairments in their lives after remission. Programs are needed that effectively support patients in coping with these impairments. The program Storytelling and Training to Advance Individual Recovery Skills (STAIRS) was developed to address this need and combines the use of peer contact, expert-by-experience guidance, family support and professional blended care. The aim of the planned study is (1) to assess the efficacy of the STAIRS program in patients with remitted MDD, (2) to investigate patients' subjective experiences with STAIRS, and (3) to evaluate the program's cost-effectiveness.

METHODS

A concurrent mixed-methods randomized controlled trial design will be used. Patients aged between 18 and 65 years with remitted MDD (N = 140) will be randomized to either a group receiving care as usual (CAU) + the STAIRS-program or a control group receiving CAU + some basic psychoeducation. Quantitative efficacy data on functional and personal recovery and associated aspects will be collected using self-report questionnaires at the start of the intervention, immediately following the intervention, and at the six-month follow-up. Insights into patients' experiences on perceived effects and the way in which different program elements contribute to this effect, as well as the usability and acceptability of the program, will be gained by conducting qualitative interviews with patients from the experimental group, who are selected using maximum variation sampling. Finally, data on healthcare resource use, productivity loss and quality of life will be collected and analysed to assess the cost-effectiveness and cost-utility of the STAIRS-program.

DISCUSSION

Well-designed recovery-oriented programs for patients suffering from MDD are scarce. If efficacy and cost-effectiveness are demonstrated with this study and patients experience the STAIRS program as usable and acceptable, this program can be a valuable addition to CAU. The qualitative interviews may give insights into what works for whom, which can be used to promote implementation.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov on 1 July 2021, registration number NCT05440812.

Improving behavioral test data collection and analysis in animal models with an image processing program

Behavioral studies are commonly used as a standard procedure to evaluate anxiety and depression in animal models. Recently, different methods have been developed to improve data collection and analysis of the behavioral tests. Currently available methods, including manual analysis and commercially available products, are either time-consuming or costly. The objective of this study was to improve the collection and analysis of behavioral test data in animal models by developing an image processing program. Eleven behavioral parameters were evaluated by three different methods, including (i) manual detection, (ii) commercially available TopScan software (CleverSys Inc, USA), and (iii) In-housed-developed Advanced Move Tracker (AMT) software. Results obtained from different methods were compared to validate the accuracy and efficiency of AMT. Results showed that AMT software provides highly accurate and reliable data analysis compared to other methods. Less than 5% tolerance was reported between results obtained from AMT compared to TopScan. In addition, the analysis processing time was remarkably reduced (68.3%) by using AMT compared to manual detection. Overall, the findings confirmed that AMT is an efficient program for automated data analysis, significantly enhancing research outcomes through accurate analysis of behavioral test data in animal models.

The Therapeutic Aspects of Embroidery in Art Therapy from the Perspective of Adolescent Girls in a Post-Hospitalization Boarding School

This phenomenological qualitative study explored the experiences of adolescent girls with emotional disorders from post-hospitalization boarding schools who embroidered in an art therapy open studio group. A Youth Participatory Action Research approach and the bioecological model were used to shed light on the therapeutic process of embroidery. Through a thematic analysis of the focus groups and interviews with 13 participants, we identified five themes specifically related to embroidery: (a) control versus release/freedom; (b) calmness that comes from the repetitive action and focus; (c) the experience of being exceptional versus conventional; (d) the "stitch through time" experience, which involves a dialogue with the past, present, and future through embroidery; and (e) the overt-latent layers of consciousness. The findings suggest that embroidery has therapeutic benefits for this population and supports psychological development. This study reveals that embroidery, whose threads are intricately embedded in society and culture, and may provide a unique and meaningful activity for young people in post-hospitalization boarding schools and enables a social and cultural exploration of self and community. Limitations of this study and recommendations for further research are also discussed.

Income gradient in psychotherapy use and psychotropic drug purchases: A longitudinal register study in Finnish employed population

OBJECTIVE

We examined the income gradient changes in the use of long-term rehabilitative psychotherapy and psychotropic drug purchases in men and women during a 9-year follow-up.

METHODS

We used register data from a random sample of the working-age population (18-64 years) with information on annual income, psychotherapy use and psychotropic drug purchases from 2011 to 2019 (N = 736 613, 49.7% women). Sex-stratified generalized estimating equations logistic regression models with predicted marginal probabilities were used to examine change in the treatment use rates over time for income quartiles.

RESULTS

Treatment rates increased during the follow-up, with men having lower rates than women. There were no significant differences in psychotherapy use rates between the income quartiles during the follow-up in men. A small income gradient in women (the wealthiest group with the highest use rate) remained stable throughout the follow-up. As for psychotropic drug purchases, the rates increased more among the poorest income quartile compared to the wealthiest quartile in both men and women. In the last year of the follow-up, the initial income gradient (wealthiest group having the highest psychotropic drug purchase rate) had become reversed, and the poorest group had the highest psychotropic drug purchase rate.

CONCLUSION

In psychotherapy use, no income gradient was found in men, while a stable income gradient was found in women. Psychotropic drug purchases have previously been more common in the wealthiest groups, but more recently among the poorest. The findings indicate that gender and income have distinct relationships with the treatment modality over time.

Responsiveness to change in health status of the EQ-5D in patients treated for depression and anxiety

BACKGROUND

The EQ-5D is a commonly used generic measure of health but evidence on its responsiveness to change in mental health is limited. This study aimed to explore the responsiveness of the five-level version of the instrument, the EQ-5D-5 L, in patients receiving treatment for depression and anxiety.

METHODS

Patient data (N = 416) were collected at baseline and at end of treatment in an observational study in a Norwegian outpatient clinic. Patients were adults of working age (18-69 years) and received protocol-based metacognitive or cognitive therapy for depression or anxiety according to diagnosis. Responsiveness in the EQ-5D was compared to change in the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). Effect sizes (Cohen's d), Standardised response mean (SRM), and Pearson's correlation were calculated. Patients were classified as "Recovered", "Improved", or "Unchanged" during treatment using the BDI-II and the BAI. ROC analyses determined whether the EQ-5D could correctly classify patient outcomes.

RESULTS

Effect sizes were large for the BAI, the BDI-II, the EQ-5D value and the EQ VAS, ranging from d = 1.07 to d = 1.84. SRM were also large (0.93-1.67). Pearson's correlation showed strong agreement between change scores of the EQ-5D value and the BDI-II (r_s -0.54) and moderate between the EQ-5D value and the BAI (r_s -0.43). The EQ-5D consistently identified "Recovered" patients versus "Improved" or "Unchanged" in the ROC analyses with AUROC ranging from 0.72 to 0.84.

CONCLUSION

The EQ-5D showed good agreement with self-reported symptom change in depression and anxiety, and correctly identified recovered patients. These findings indicate that the EQ-5D may be appropriately responsive to change in patients with depression and anxiety disorders, although replication in other clinical samples is needed.

Notes from the youth mental health field: Using movement towards goals as a potential indicator of service change and quality improvement

The aim of this paper is to report our notes from the field on using movement toward goals at an aggregate level as an inference of service effectiveness. Analysis of routinely collected data from UK youth mental health services was conducted (N = 8,172, age M = 13.8, 67% female, 32% male) to explore the impact of including goal-based outcome data in combined calculations of standardized measures based on the principles of reliable change ("measurable change"). Due to the broad nature of standardized measures, inferred validity becomes diluted in any team or service level aggregate analysis. To make inferences that are closer to the person's interpretation of their difficulties, we argue that Idiographic Patient Reported Outcome Measures (I-PROMs) counterbalance these limitations. This is supported by our findings. The measurable change metric is the first step towards enabling national analysis of aggregated I-PROMs. I-PROMs, supplemented by standardized measures should be used to consider service evaluation.

Baseline executive functioning moderates treatment-related changes in quality of life in veterans with posttraumatic stress disorder and comorbid traumatic brain injury

Posttraumatic stress disorder (PTSD) treatment has been associated with improvement in quality of life (QOL); however, little is known about factors that moderate treatment-related changes in QOL, particularly cognitive factors. Executive functioning (EF) is important for success across all aspects of everyday life and predicts better psychological and physical health. EF is important to QOL, but more work is needed to better understand the association between EF and QOL improvements following interventions. We hypothesized that poorer baseline EF would be associated with less improvement in overall life satisfaction and satisfaction with health following PTSD treatment. U.S. veterans who served after the September 11, 2001 terrorist attacks (post 9-11; N = 80) with PTSD and a history of mild-to-moderate traumatic brain injury were randomized to standard cognitive processing therapy (CPT) or CPT combined with cognitive rehabilitation (SMART-CPT). Multilevel modeling was used to examine whether baseline EF performance was associated with changes in QOL scores from pretreatment to follow-up across both groups. Results indicated that poorer baseline performance on EF tests of working memory and inhibition were associated with less treatment-related improvements in general life satisfaction and satisfaction with health, rs = .26-.36. Treatment condition did not moderate any results. Future research should examine whether implementing EF-focused techniques before and/or concurrently with CPT for individuals with poorer baseline working memory and inhibition enhances QOL treatment gains, particularly in terms of general life and health-related satisfaction.

Patient-reported outcomes of the nurse-patient relationship in psychiatric inpatient hospitals: A multicentred descriptive cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric and/or mental health nurses are struggling to measure the outcomes of the nurse-patient relationship. Collecting nurse-sensitive patient outcomes is a strategy to provide outcomes of a nurse-patient relationship from patients' perspectives. Because there was no validated scale, the Mental Health Nurse-Sensitive Patient Outcome-Scale (six-point Likert-scale) was recently developed and psychometrically evaluated. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study using the Mental Health Nurse-Sensitive Patient Outcome-scale to measure nurse-sensitive patient outcomes of the nurse-patient relationship in psychiatric hospitals. Moderate to good average scores for the MH-NURSE-POS total (4.42) and domains scores (≥4.09). are observed. Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60). Our results are consistent with the patient-reported effect(s) of relation-based nursing in qualitative research. The scores generate evidence to support the outcomes of the nurse-patient relationship and implicates that further investment in (re)defining and elaborating nurse-patient relationships in mental healthcare is meaningful and justified. More comparative patient-reported data can determine how nurse-sensitive patient outcomes are affected by the patient, nurse, and context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Demonstrating patient-reported outcomes of the nurse-patient relationship can be important to enhance the therapeutic alliance between nurses and patients, organize responsive nursing care, and create nursing visibility in mental healthcare. Further nursing staff training on interpersonal competencies, such as self-awareness and cultural sensitivity, can be pivotal to achieving the patient-reported outcomes for inpatients with mental health problems.

ABSTRACT

INTRODUCTION: Identifying patient-reported outcomes of the nurse-patient relationship is a priority in inpatient mental healthcare to guide clinical decision-making and quality improvement initiatives. Moreover, demonstrating nurse-sensitive patient outcomes can be a strategy to avoid further erosion of the specialism of psychiatric and/or mental health nursing.

AIM/QUESTION

To measure nurse-sensitive patient outcomes of the nurse-patient relationship.

METHOD

In a multicentred cross-sectional study, 296 inpatients admitted to five psychiatric hospitals completed the recently developed and validated Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS). The MH-NURSE-POS consists of 21 items (six-point Likert-scale) in four domains: 'growth', 'expression', 'control', and 'motivation'.

RESULTS

Participants displayed moderate to good average scores for the MH-NURSE-POS total (4.42) and domain scores (≥4.09). Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60).

DISCUSSION

The results demonstrate that patients perceive the nurse-patient relationship and the care given by psychiatric and/or mental health nurses as contributing to their treatment.

IMPLICATIONS FOR PRACTICES

Patient-reported outcomes can guide nurses and managers to provide and organize nursing care and to build a nurse-patient relationship that has a positive impact on these outcomes. Additionally, outcomes can create nursing visibility as a profession in- and outside mental healthcare.

Benchmarking quality of life to posttraumatic stress disorder symptom changes in cognitive processing therapy

Although there is ample evidence that PTSD is effectively treated by first-line therapies such as Cognitive Processing Therapy (CPT), it is less clear to what degree these treatments improve quality of life (QOL), a common presenting concern of treatment-seeking individuals (Rosen et al., 2013). Only two studies, both conducted in military veteran samples, have examined the magnitude of PTSD symptom change needed in order to achieve corresponding changes in QOL during treatment. The current study aimed to replicate and extend these two previous studies by benchmarking multi-faceted QOL in a civilian sample of primarily female interpersonal violence survivors (N = 115) treated with CPT. We grouped participants into categories of increasingly greater PTSD symptom change: no response, response, loss of diagnosis, and remission. Outcomes were clinically meaningful change and good endpoint across five measures of QOL. Some QOL measures showed clinically meaningful change and/or good endpoint after a response to treatment or loss of diagnosis, but only remission from PTSD was associated with both clinically meaningful change and a good endpoint across all QOL indicators. These findings add to the emerging literature showing that treating PTSD to remission may maximize the likelihood of improvements in quality of life.

Negative cognitive beliefs, positive metacognitive beliefs, and rumination as mediators of metacognitive training for depression in older adults (MCT-Silver)

Background

Metacognitive Training for Depression in older adults (MCT-Silver; www.uke.de/mct-silver) is a cognitive-behavioral based group intervention that aims at reducing depression by targeting (meta)cognitive beliefs and rumination. In the present study, it was examined whether negative cognitive beliefs, positive metacognitive beliefs and/or rumination may be implicated as mediators of MCT-Silver's effects on depression.

Materials and methods

We conducted a secondary analysis of a randomized controlled trial comparing MCT-Silver to an active control intervention (cognitive remediation) including 66 older adults (60 years and older) with complete baseline data. Clinician-rated (Hamilton Depression Rating Scale) and self-reported (Beck Depression Inventory-II) depression, negative cognitive beliefs (Dysfunctional Attitudes Scale-18B), positive metacognitive beliefs (positive beliefs subscale; Metacognition Questionnaire-30) and rumination (10-item Ruminative Response Scale) were assessed before (pre) and after 8 weeks of treatment (post), as well as 3 months later (follow-up). It was examined whether change in depression (pre- to follow-up) was mediated by change in negative cognitive beliefs, positive metacognitive beliefs and/or rumination (pre- to post-assessment).

Results

Mediation results differed for self-reported vs. clinician-rated depression. The effect of MCT-Silver on reduction in clinician-rated depression was mediated by a reduction in self-reported rumination, whereas reduction in self-reported depression was mediated by a reduction in negative cognitive beliefs. Positive metacognitive beliefs were not a significant mediator for either outcome.

Conclusion

The current study provides initial evidence for the roles of negative cognitive beliefs and rumination in the treatment of depression in later life with MCT-Silver. Given the divergence of findings and lack of causal precedence, mechanisms of change for MCT-Silver cannot yet be equivocally identified.

Psychological interventions for symptoms of depression among informal caregivers of older adult populations: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Symptoms of depression are commonly experienced by informal caregivers of older adults, however there is uncertainty concerning effectiveness of psychological interventions targeting symptoms of depression in this population. Further, there is uncertainty concerning important clinical moderators, including intervention type and care recipient health condition. This review examined the effectiveness of psychological interventions targeting symptoms of depression in informal caregivers of older adults.

METHODS

PubMed, CINAHL, Embase, PsycINFO, Cochrane Library and Web of Science were searched. Risk of bias was assessed using the Cochrane Risk of Bias tool version 2.

RESULTS

Fifteen studies were identified and twelve (1270 participants) provided data for the meta-analysis. Interventions included cognitive behavioral therapy (4 studies), problem-solving therapy (4 studies); non-directive supportive therapy (4 studies) and behavioral activation (3 studies). A small effect size favouring the intervention was found for symptoms of depression (g = -0.49, CI = -0.79, -0.19, I² = 83.42 %) and interventions were effective in reducing incidence of major depression (OR = 0.177, CI = 0.08, 0.38), caregiver burden (g = -0.35, CI = -0.55, -0.15) and psychological distress (g = -0.49, CI = -0.70, -0.28). Given high heterogeneity, findings should be interpreted with caution. Overall risk of bias was high.

LIMITATIONS

Studies were limited to those in English or Swedish.

CONCLUSION

Psychological interventions may be effective in reducing symptoms of depression among informal caregivers of older adults. However, evidence is inconclusive due to heterogeneity, high risk of bias, and indirectness of evidence.

Exploring service users experiences of remotely delivered CBT interventions in primary care during COVID-19: An interpretative phenomenological analysis

Primary Care Mental Health Services (PMHCS) aim to provide accessible and effective psychological interventions. However, there is a scarcity of qualitative research focused on patients' experiences. Service users' experience can inform development of accessible, high-quality mental health services. Nine semi-structured interviews were analysed from Primary Care Mental Health users in Northern Scotland using Interpretative Phenomenological Analysis (IPA). Four superordinate themes were generated: Orientating to treatment, Intervention features, Change enablers, and Impact. The results identified both facilitators and barriers associated with access and psychological change; and narratives around CBT acceptability, outcomes and remote delivery. The role of GPs emerged as a key determinant of access to PMHCS. The therapeutic relationship contributed to person-centred care provision, idiosyncratic change processes and self-empowerment. A personal commitment to engage with homework was described as a crucial change enabler. Findings are discussed in relation to existing literature, practical implications and suggestions for future research.

Implementation of a task-shared psychosocial intervention for perinatal depression in South Africa: A grounded theory process evaluation

Perinatal depression carries significant levels of disability for both women and their infants, but there is a large treatment gap for this condition in low and middle-income countries (LMICs). To address this gap, task-sharing using community health workers (CHWs) to provide psychosocial interventions for perinatal depression is increasingly common. Many of these interventions have shown significant positive effects on maternal mood, however not all have done so. This study used data from a task-shared psychosocial intervention for perinatal depression in Cape Town, South Africa, the 'Africa Focus on Intervention Research for Mental Health' (AFFIRM-SA) randomised controlled trial (RCT). It aimed to examine the processes that occurred within the delivery of the counselling intervention, and to use these findings to provide recommendations for psychosocial task sharing in LMICs. A grounded theory analysis was conducted of 234 counselling session transcripts from 39 randomly selected participants from the RCT. This revealed that the effectiveness of the intervention was compromised by the negative influence of participants' socio-economic context, and by counselling strategies that did not align with what was intended in the counselling manual. Despite this, participants provided spontaneous accounts of improvement in mood and cognition, and reasons for these improvements, interpreted as elements that were therapeutically effective for them. Most of these elements aligned with previously identified 'common elements' of therapy. Recommendations for future research and practice include conducting participatory formative research, using an iterative and responsive research design informed by implementation science, incorporating contextually appropriate strategies in interventions such as addressing social determinants of mental health, conducting intensive training and supervision, adopting a staged approach to managing depression, and using common elements of therapy as the basis for psychosocial interventions.

The relative importance of diagnostic specific and transdiagnostic factors in evaluating treatment outcome of depressed patients

Determinations of the efficacy of treatments for depression most commonly are based on changes in scores on symptom severity scales. This narrow symptom-focused approach towards evaluating outcome is at variance with patients' broader conceptualization of the factors deemed important in evaluating the outcome of depression treatment. In the present report we examine the factors associated with depressed patients' global ratings of improvement after a treatment intervention. Five hundred and three patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. The patients completed the RDQ at admission and discharge from the treatment program. At discharge, the patients made a global rating of the effectiveness of treatment. The patients significantly improved from admission to discharge on each RDQ subscale. Changes in the well-being/life satisfaction and coping subscales were the only 2 subscales that were independently associated with the patients' ratings of improvement. These results suggest that when evaluating outcome in the treatment of depression a focus on symptom improvement is too narrow. Consideration of a broader perspective in measuring outcome in treatment studies of depression is more consistent with a biopsychosocial conceptualization.

Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence.

AIMS

To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis.

METHOD

We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258).

RESULTS

We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive-behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = -0.67, 95% CI -0.95 to -0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI -0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = -0.61, 95% CI -1.15 to -0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54-1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU.

CONCLUSIONS

CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.

Measuring the longitudinal course of voice hearing under psychological interventions: A systematic review

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course and impact of voice hearing under these interventions and to evaluate how these variables change over time. Inclusion and exclusion criteria were applied, resulting in a total of 66 articles. Of these, 60 studies (28 RCTs, 23 uncontrolled, 9 non-randomised) were published in peer-reviewed journals, whilst 6 were recently completed or currently ongoing. The findings of this review suggest that a range of variables that are not directly relevant to psychological interventions have been used (e.g., depression, characteristics of voice hearing experience), whilst those directly impacted by psychological interventions (e.g., voice-related distress), broader concepts of outcome (e.g., functioning) and specific associated processes (e.g., self-schema) have received less attention. Findings also showed that the majority of variables demonstrated improvements, but effect sizes varied considerably across trials. This may be attributed to methodological differences such as statistical power, blinding, control groups and different methods of measurement. Our review highlights the importance of determining a set of outcomes that are directly targeted and should change under psychological interventions. Recommendations include the use of voice-related distress as a primary outcome. This can ultimately facilitate comparisons across studies and inform the development of psychological interventions.

The unified protocol as an internet-based intervention for emotional disorders: Randomized controlled trial

The Unified Protocol (UP) as a transdiagnostic intervention has primarily been applied in the treatment of anxiety disorders and in face-to-face-settings. The current study investigated the efficacy of a 10-week Internet-based adaptation of the UP for anxiety, depressive, and somatic symptom disorders. The trial was registered under DRKS00014820 at the German Clinical Trial Registry, DRKS. Participants (n = 129) were randomized to treatment or waitlist control. Significant treatment effects were found for symptom distress, satisfaction with life, positive/negative affect and markers of anxiety, depression, and somatic symptom burden (within-group Hedges’ g = 0.32–1.38 and between-group g = 0.20–1.11). Treatment gains were maintained at 1- and 6-month-follow-up. Subgroup analyses showed comparable effects in participants with anxiety and depressive disorders. 26.6% dropped out of treatment and 35.38% did not provide post-treatment assessments. The results strengthen the application of the UP as an Internet-based treatment for alleviating symptom distress across emotional disorders. More research on the applicability for single disorders is needed and avenues to improve adherence and attrition rates should be explored.

Psychopathology and health-related quality of life as patient-reported treatment outcomes: evaluation of concordance between the Brief Symptom Inventory (BSI) and the Short Form-36 (SF-36) in psychiatric outpatients

PURPOSE

Treatment outcome for common psychiatric disorders, such as mood and anxiety disorders, is usually assessed by self-report measures regarding psychopathology [e.g., via Brief Symptom Inventory (BSI)]. However, health-related quality of life [as measured by the 36-item Short-Form Health Survey (SF-36)] may be a useful supplementary outcome domain for routine outcome monitoring (ROM). To date, the assessment of both outcomes has become fairly commonplace with severe mental illness, but this is not yet the case for common psychiatric disorders. The present study examined among outpatients with common psychiatric disorders whether aggregate assessments of change across treatment regarding psychopathology and health-related quality of life yield similar results and effect sizes.

METHODS

We compared treatment outcome on the BSI and the SF-36 in a sample of 13,423 outpatients. The concordance of both instruments was assessed at various time points during treatment.

RESULTS

Scores on both instruments were associated, but not so strongly to suggest they measure the same underlying construct. The SF-36 scales presented a varied picture of treatment outcome: understandably, patients changed more on the mental component scales than on physical component scales. Outcome according to the BSI was quite similar to outcome according to scales of the SF-36 that showed the largest change.

CONCLUSIONS

Although (mental health) scores on both instruments are associated, adding the SF-36 in addition to the BSI in treatment evaluation research produces valuable information as the SF-36 measures a broader concept and contains physical/functional component scales, resulting in a more complete clinical picture of individual patients.

Treatment of difficult-to-treat depression - clinical guideline for selected interventions

BACKGROUND

Difficult-to-treat-depression (DTD) is a clinical challenge. The interventions that are well-established for DTD are not suitable or effective for all the patients. Therefore, more treatment options are highly warranted. We formulated an evidence-based guideline concerning six interventions not well-established for DTD in Denmark.

METHODS

Selected review questions were formulated according to the PICO principle with specific definitions of the patient population (P), the intervention (I), the comparison (C), and the outcomes of interest (O), and systematic literature searches were performed stepwise for each review question to identify relevant systematic reviews/meta-analyses, and randomized controlled trials. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the methodological quality of the included studies. Clinical recommendations were formulated based on the evidence, the risk-benefit ratio, and perceived patient preferences.

RESULTS

We found sufficient evidence for a weak recommendation of repetitive transcranial magnetic stimulation (rTMS) and cognitive behavioural analysis system of psychotherapy (CBASP). The use of bright light therapy in DTD was not sufficiently supported by the evidence, but should be considered as good clinical practice. The interventions should be considered in addition to ongoing antidepressant treatment. We did not find sufficient evidence to recommend intravenous ketamine/esketamine, rumination-focused psychotherapy, or cognitive remediation to patients with DTD.

CONCLUSION

The evidence supported two of the six reviewed interventions, however it was generally weak which emphasizes the need for more good quality studies. This guideline does not cover all treatment options and should be regarded as a supplement to relevant DTD-guidelines.

Efficacy of metacognitive training for depression as add-on intervention for patients with depression in acute intensive psychiatric inpatient care: A randomized controlled trial

BACKGROUND

Metacognitive training for depression (D-MCT) is a novel low-intensity group training for economic treatment of depression. Previous studies demonstrate its efficacy in moderately depressed outpatients. The present study evaluated efficacy and patients' perspective of the D-MCT in severely depressed psychiatric inpatients.

METHODS

In a randomized-controlled trial, 75 individuals with a major depressive disorder (MDD) were allocated to D-MCT versus euthymic therapy as add-on (twice a week) to cognitive-behavioural-based (CBT) inpatient-care. Depressive symptoms (HDRS, BDI), dysfunctional (meta)cognition (DAS, MCQ-30) and subjective appraisal were assessed at baseline, 4 weeks (post) and 3 months (follow-up).

RESULTS

Participants in both conditions showed a large decline in depression at post and follow-up-assessment. No superior add-effect of D-MCT versus active control emerged for depression severity on top of the inpatient care. However, among patients with a diagnosis of MDD with no (vs. at least one) comorbidity, D-MCT participants showed a larger decline in depressive (meta-)cognition at follow-up with medium-to-large effect sizes. D-MCT was evaluated as superior in overall appraisal, treatment preference, motivation and satisfaction.

LIMITATIONS

The follow-up time interval of 3 months may have been too short to detect long-term effects. There is emerging evidence that modification of (meta)cognition unfolds its full effects only with time. Effects of CBT inpatient-care on outcome parameters cannot be differentiated.

CONCLUSIONS

Although D-MCT as an add-on was not superior in complete case analyses, results suggest greater benefit for patients with MDD and no comorbidity. D-MCT proved feasible in acute-psychiatric inpatient-care and was highly accepted by patients. Future studies should investigate the role of modified (meta)cognition on long-term treatment outcome, including dropout and relapse rates.

Clinical- and Cost Effectiveness of a Guided Internet-Based Intervention for Children (12–18 Years) of Parents With Mental Disorders (iCHIMPS): Study Protocol of a Multicentered Cluster-Randomized Controlled Trial

Introduction

Children of parents with mental disorders have a high chance of developing a mental disorder themselves. However, this at-risk group is regularly overlooked and typically not seen by any mental health professionals. Internet- and mobile-based interventions (IMIs) can provide a means of promoting mental health for children of parents with mental disorders.

Objective

The introduced study will evaluate the clinical- and cost-effectiveness of the iCHIMPS IMI in promoting mental health for children of parents with mental disorders.

Methods

A two-armed multicentered cluster-randomized controlled trial (cRCT) comparing the clinical- and cost-effectiveness of the iCHIMPS IMI in the intervention group (IG) to a treatment-as-usual (TAU) control group will be conducted. Recruitment will be handled at currently 21 adult mental health clinics throughout Germany. Participating families will be randomly divided into the two groups until the final sample size of 306 participating adolescents (age 12–18) has been reached. The adolescents in the intervention group will receive access to the IMI and can take part in up to eight intervention modules. Assessment will be conducted during the recruitment (baseline), 1-month, 2-months, and 6-month post-inclusion. Primary outcome is the mental health of the participating adolescents at 6-months post-inclusion as measured by the Youth Self Report score. Secondary self-report outcomes are mental wellbeing, self-efficacy, coping strategies and negative effects as well as mental health of the adolescents as reported by their parent(s). Included moderators are sociodemographic characteristics, working alliance, social support and the mental health diagnoses of the parents. Statistical analyses will be conducted on the intention-to-treat principle as well as with additional per-protocol analyses. Additionally, the cost-effectiveness as well as qualitative data concerning the adherence, acceptance, and feasibility of the IMI will be analyzed.

Discussion

The iCHIMPS cRCT examines the clinical- as well as cost-effectiveness of the iCHIMPS mental health promotion IMI for children of parents with mental disorders. This provides the opportunity to gain insights into an innovative as well as time- and location-independent form of support for this often-overlooked at-risk group. Additionally, the larger CHIMPS-NET project allows comparisons between internet-based and face-to-face interventions for a similar target group.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: DRKS00025158.

The Common-Sense Model and Mental Illness Outcomes: A Meta-Analysis

Psychotherapists can improve their patients' outcomes during and after therapy by improving patients' self-management. Patients who do not effectively manage their mental illness generally have worse outcomes. Leventhal's Common-Sense Model of Self-Regulation theorizes that patients' perceptions of their illness (illness representations) guide their self-management, influencing health outcomes. The present study quantified the relations between illness representations, self-management, and outcomes for mental illnesses. We conducted a meta-analysis and included articles if they reported: 1) on adults with mental illnesses; and 2) the correlation between mental illness representations and mental illness outcomes. 25 articles were included which represented 28 independent samples. The pattern of correlations among illness representations (identity, consequences, timeline, control, coherence, and emotional representations), self-management strategies (attendance, engagement, and adherence to treatment) and mental illness outcomes (symptom severity and quality of life) was consistent with analyses from previous studies of mental and physical illnesses. The results found threat-related illness representations mostly had a large relationship with worse mental illness outcomes and self-management. Protective illness representations had a small-to-large relationship with better mental illness outcomes and self-management. The results suggest patients' perceptions of their mental illness may be a critical indicator of their mental illness outcomes, including symptom severity and quality of life. This theory-driven meta-analysis supports calls for the inclusion of illness representations in psychotherapy for mental illness.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited.

METHOD

We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood.

RESULTS

For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children.

CONCLUSION

Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: -0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

Perceived helpfulness of service sectors used for mental and substance use disorders: Findings from the WHO World Mental Health Surveys

BACKGROUND

Mental healthcare is delivered across service sectors that differ in level of specialization and intervention modalities typically offered. Little is known about the perceived helpfulness of the combinations of service sectors that patients use.

METHODS

Respondents 18 + years with 12-month DSM-IV mental or substance use disorders who saw a provider for mental health problems in the year before interview were identified from WHO World Mental Health surveys in 17 countries. Based upon the types of providers seen, patients were grouped into nine mutually exclusive single-sector or multi-sector 'treatment profiles'. Perceived helpfulness was defined as the patient's maximum rating of being helped ('a lot', 'some', 'a little' or 'not at all') of any type of provider seen in the profile. Logistic regression analysis was used to examine the joint associations of sociodemographics, disorder types, and treatment profiles with being helped 'a lot'.

RESULTS

Across all surveys combined, 29.4% (S.E. 0.6) of respondents with a 12-month disorder saw a provider in the past year (N = 3221). Of these patients, 58.2% (S.E. 1.0) reported being helped 'a lot'. Odds of being helped 'a lot' were significantly higher (odds ratios [ORs] = 1.50-1.89) among the 12.9% of patients who used specialized multi-sector profiles involving both psychiatrists and other mental health specialists, compared to other patients, despite their high comorbidities. Lower odds of being helped 'a lot' were found among patients who were seen only in the general medical, psychiatrist, or other mental health specialty sectors (ORs = 0.46-0.71). Female gender and older age were associated with increased odds of being helped 'a lot'. In models stratified by country income group, having 3 or more disorders (high-income countries only) and state-funded health insurance (low/middle-income countries only) were associated with increased odds of being helped 'a lot'.

CONCLUSIONS

Patients who received specialized, multi-sector care were more likely than other patients to report being helped 'a lot'. This result is consistent with previous research suggesting that persistence in help-seeking is associated with receiving helpful treatment. Given the nonrandom sorting of patients by types of providers seen and persistence in help-seeking, we cannot discount that selection bias may play some role in this pattern.

Feasibility of an Exercise and CBT Intervention for Treatment of Depression: A Pilot Randomized Controlled Trial

Depression (DEP) is prevalent and current treatments are ineffective for many people. This pilot study's purpose was to assess the feasibility, acceptability, and plausible efficacy of an 8-week intervention employing 30 min of prescribed moderate intensity exercise ("ActiveCBT") compared to 30 min of usual activities ("CalmCBT") immediately prior to weekly online CBT sessions. Ten adults with DSM-5-diagnosed current DEP were randomized to groups and completed: an intake assessment, eight weekly CBT sessions, final assessment, and 3-month follow-up. ActiveCBT participants were prescribed 30-min of moderate exercise immediately prior to each standardized 50-min CBT session. CalmCBT participants continued with normal activities for 30 min before therapy. Questionnaires regarding DEP symptom severity (Patient Health Questionnaire-9 [PHQ-9]), between-session effectiveness (Behavioral Activation for Depression Survey [BADS], Automatic Thoughts Questionnaire [ATQ]), in-session effectiveness (Working Alliance Inventory-Short Revised [WAI]), and state anhedonia (Dimension Analog Rating Scale [DARS], Visual Analog Scale [VAS]; assessed 3 times: before Active/Calm condition, after, and after therapy) were completed each week. Therapy fidelity ratings were independently coded via a standardized codebook. The Structured Clinical Interview for DSM-5 (SCID) and Hamilton Rating Scale for Depression (HAMD) were used to assess DEP at intake, final, and 3-month follow-up. We found strong feasibility and acceptability (100% adherence, 100% retention at final visit, 74.6% therapy fidelity, and high patient satisfaction ratings). Differences between groups favoring ActiveCBT in anhedonia (DARS, Hedges' g = 0.92; VAS, g = 3.16), within- (WAI, g = 0.1.10), and between-session effectiveness (ATQ g = -0.65; BADS g = -1.40), suggest plausible efficacy of ActiveCBT for enhancing CBT. DEP rates were reduced in both groups from baseline to final (60% MDD SCID remission) and at follow up (Active: 40%; Calm: 25%). Larger and potentially quicker symptom improvement was found favoring the Active condition to the final visit (HAMD, between-group changes g = -1.33; PHQ-9, g = -0.62), with small differences remaining at follow-up (HAMD, g = -0.45; PHQ-9, g = -0.19). Exercise priming appears acceptable and plausibly efficacious for enhancing mechanisms of CBT and overall outcomes, though the present small sample precludes efficacy determinations. It appears feasible to conduct a randomized controlled trial comparing ActiveCBT to CalmCBT. Future trials evaluating this potentially promising treatment approach and mediating mechanisms are warranted.

Australian Community and Health Professionals Perceptions of Equine-Assisted Psychotherapy

Mental health conditions are increasingly prevalent in the Australian population, and despite the large evidence-based support for contemporary treatments, there are barriers which inhibit their efficacy. Thus, there is a perceived need for therapists to consider other therapeutic options which have potential to enhance treatment outcomes. There is increasing acceptance for complementary and alternative medicines (CAM) among general practitioners and clients/general community. Specifically, more than 70% of Australians utilize CAM. Equine-assisted psychotherapy (EAP) is an underutilized, culturally sensitive, complementary therapy, which has the potential to mitigate barriers of conventional therapy. The present study aimed to determine the level of knowledge about and general acceptance of EAP as a treatment for general psychopathology symptomology within community members and health professionals. The current sample included 144 community members and 55 health professionals, all with Australian citizenship. Data analysis comprised the independent t-test and two hierarchical multiple regressions. Results indicated that community members are significantly more accepting of EAP as a treatment compared to health professionals. Of the predictors tested, higher social support and openness within community members were significant predictors of accepting perceptions, and rural location was the only significant predictor for health professional's accepting perceptions of EAP. This is one of the first studies to investigate perceptions of EAP outside the EAP field and through comparison between community members and health professionals. The current study identifies the need for future research to further investigate perceptions of EAP among Australian health professionals.

How Is the History of Early Traumatic Exposure Associated With the Psychopathological Outcomes of COVID-19 Related Lockdown and Subsequent Re-opening in People With Eating Disorders?

The negative impact of COVID-19 pandemic on people with Eating Disorders (EDs) has been documented. The aim of this study was to evaluate whether a history of traumatic experiences during childhood or adolescence was associated with a higher degree of psychopathological worsening during COVID-19 related lockdown and in the following re-opening period in this group of people. People with EDs undergoing a specialist ED treatment in different Italian services before the spreading of COVID-19 pandemic (n = 312) filled in an online survey to retrospectively evaluate ED specific and general psychopathology changes after COVID-19 quarantine. Based on the presence of self-reported traumatic experiences, the participants were split into three groups: patients with EDs and no traumatic experiences, patients with EDs and childhood traumatic experiences, patients with EDs and adolescent traumatic experiences. Both people with or without early traumatic experiences reported retrospectively a worsening of general and ED-specific psychopathology during the COVID 19-induced lockdown and in the following re-opening period. Compared to ED participants without early traumatic experiences, those with a self-reported history of early traumatic experiences reported heightened anxious and post-traumatic stress symptoms, ineffectiveness, body dissatisfaction, and purging behaviors. These differences were seen before COVID-19 related restrictions as well as during the lockdown period and after the easing of COVID-19 related restrictions. In line with the "maltreated ecophenotype" theory, these results may suggest a clinical vulnerability of maltreated people with EDs leading to a greater severity in both general and ED-specific symptomatology experienced during the exposure to the COVID-19 pandemic.

A global field study of the international classification of diseases (ICD-11) mood disorders clinical descriptions and diagnostic guidelines

BACKGROUND

We report results of an internet-based field study evaluating the diagnostic guidelines for ICD-11 mood disorders. Accuracy of clinicians' diagnostic judgments applying draft ICD-11 as compared to the ICD-10 guidelines to standardized case vignettes was assessed as well as perceived clinical utility.

METHODS

1357 clinician members of the World Health Organization's Global Clinical Practice Network completed the study in English, Spanish, Japanese or Russian. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of eleven pairs of case vignettes.

RESULTS

Clinicians using the ICD-11 and ICD-10 guidelines achieved similar levels of accuracy in diagnosing mood disorders depicted in vignettes. Those using the ICD-11 were more accurate in identifying depressive episode in recurrent depressive disorder. There were no statistically significant differences detected across classifications in the accuracy of identifying dysthymic or cyclothymic disorder. Circumscribed problems with the proposed ICD-11 guidelines were identified including difficulties differentiating bipolar type I from bipolar type II disorder and applying revised severity ratings to depressive episodes. Clinical utility of ICD-11 bipolar disorders was found to be significantly lower than for ICD-10 equivalent categories.

LIMITATIONS

Standardized case vignettes were manipulated to evaluate specific changes. The degree of accuracy of clinicians' diagnostic judgments may not reflect clinical decision-making with patients.

CONCLUSIONS

Alignment of the ICD-11 with current research appears to have been achieved without sacrificing diagnostic accuracy or clinical utility though specific training may be necessary as ICD-11 is implemented worldwide. Areas in which the ICD-11 guidelines did not perform as intended resulted in further revisions.