The impact of comorbid personality difficulties on response to IAPT treatment for depression and anxiety

Is the Norwegian stepped care model for allocation of patients with mental health problems working as intended? A cross-sectional study

OBJECTIVE

Stepped care models are frameworks for mental health care systems in several countries. According to Norwegian guidelines, individuals with mental health problems of mild severity should be treated in community mental health services, moderate severity in specialist mental health services, while complex/severe problems are often a shared responsibility. This study investigated whether patients are allocated as intended.

METHODS

In a cross-sectional study, 4061 outpatients recruited from community- and specialist mental health services reported demographic variables, symptoms of anxiety/depression, functional impairment, health status, and sick leave status. The community sample consisted of two subsamples: mild/moderate problems and complex problems.

RESULTS

There was substantial overlap (80%-99%) of symptoms, impairment, and health between community- and specialist mental health services. More impairment, worse health, lower age, and being male were associated with treatment at specialist level compared to community mild/moderate. Better health, being in a relationship, and lower age were associated with specialized treatment compared to community complex group.

CONCLUSION

The limited association between treatment level and symptoms and functional impairment reveals inconsistencies between treatment guidelines and clinical practice. How the existing organization affects patient outcomes and satisfaction should be investigated further.

Pharmacotherapy for sleep disturbances in post-traumatic stress disorder (PTSD): A network meta-analysis

BACKGROUND

Sleep disturbances are an important symptom dimension of post-traumatic-stress-disorder (PTSD). There is no meta-analytic evidence examining the effects of all types of pharmacotherapy on sleep outcomes among patients with PTSD.

METHODS

Medline/Embase/PsychInfo/CENTRAL/clinicaltrials.gov/ICTRP, reference lists of published reviews and all included studies were searched for Randomised Controlled Trials (RCTs) examining any pharmacotherapy vs. placebo or any other drug among patients with PTSD.

PRIMARY OUTCOMES

total sleep time, nightmares, sleep quality.

SECONDARY OUTCOMES

sleep onset latency, number of nocturnal awakenings, time spent awake following sleep onset, dropouts due to sleep-related adverse-effects, insomnia/somnolence/vivid-dreams as adverse-effects. Pairwise and network meta-analyses were performed.

RESULTS

99 RCTs with 10,481 participants were included. Prazosin may be the most effective treatment for insomnia (SMD = -0.88, 95%CI = [-1.22;-0.54], nightmares (SMD = -0.44, 95%CI = [-0.84;-0.04]) and poor sleep quality (SMD = -0.55, 95%CI = [-1.01;-0.10]). Evidence is scarce and indicates lack of efficacy for SSRIs, Mirtazapine, z-drugs and benzodiazepines, which are widely used in daily practice. Risperidone and Quetiapine carry a high risk of causing somnolence without having a clear therapeutic benefit. Hydroxyzine, Trazodone, Nabilone, Paroxetine and MDMA-assisted psychotherapy may be promising options, but more research is needed.

CONCLUSIONS

Underpowered individual comparisons and very-low to moderate confidence in effect estimates hinder the generalisability of the results. More RCTs, specifically reporting on sleep-related outcomes, are urgently needed.

Psychometric properties of the Japanese version of the standardised assessment of personality abbreviated scale

This study was undertaken to translate the Standardised Assessment of Personality - Abbreviated Scale (SAPAS) into Japanese and to evaluate its validity and reliability. SAPAS is one of the most rapid tools for assessing personality disorder (PD) and has excellent sensitivity and good specificity, whereas other PD assessment tools require such a significant investment of time that they are infeasible for large surveys or routine clinical practice. Customary assessment in clinical practice ideally incorporates screening for PD, as it is associated with a substantial public health burden, including premature mortality and increased health service utilization. Furthermore, PD's status as a key prognostic variable of mental disorders also drives PD screening. While SAPAS has been translated into several languages, there has been no Japanese version. Therefore, we translated SAPAS into Japanese (SAPAS-J) and evaluated its reliability and validity. Study 1 recruited undergraduates to reveal its test-retest reliability. Although its internal consistency was not high, since the intent of the original SAPAS was to assess the broad character of personality disorder with the fewest possible items, minimal correlations between items were reasonable. We tested two factorial models, the single-factor model and the higher-order-single-factor model, and the latter offered better fitting. This higher-order model contained a three-factor structure corresponding to clusters described in DSM-5. It measures general PD traits as a common higher-order latent variable comprising those factors. Correlations of SAPAS-J with the much longer PD screening questionnaire in Study 1 and depressive and anxiety symptoms in Study 2 from the general population support its validity. Although validation for the clinical use of SAPAS-J is limited, our research with non-clinical populations demonstrated sufficient validity to justify its use in the context of psychopathological analog research. Since PD is understood as a continuum, the severity of which is distributed dimensionally, the analog study recruiting from the general population and attempting to reveal psychopathological mechanisms of PD is meaningful.

Clinical presentation of psychotic experiences in patients with common mental disorders attending the UK primary care improving access to psychological therapies (IAPT) Programme

BACKGROUND

Improving Access to Psychological Therapies (IAPT) services address anxiety and depression in primary care, with psychotic disorders typically excluded. Our previous research found 1 in 4 patients report distressing psychotic experiences (PE) alongside common mental disorders, yet little is known about their clinical presentation and impact on recovery.

METHODS

We used the Community Assessment of Psychic Experiences - Positive Scale (CAPE-P15) to assess the clinical presentation and symptomatic profile of PE within IAPT settings across three National Health Service (NHS) trusts, serving a diverse population in Southern England. We identified different classes based on the reported PE frequencies using latent class analysis.

RESULTS

A total of 2042 IAPT patients completed the CAPE-P15. The mean age was 39.8 (±15.3) years. We identified five distinct classes of symptom profiles, findings that PE were common, especially self-referential and persecutory ideas. Prevalence and intensity increased across classes, extending to bizarre experiences and perceptual abnormalities in the fifth and least common class. Perceptual abnormalities were a strong indicator of symptom severity, with patients being the least likely to achieve recovery by the end of treatment.

LIMITATIONS

Data were collected during a service evaluation. Replication of these findings across other IAPT services could prove beneficial. We did not collect information on negative PE.

CONCLUSIONS

Patients seeking treatment for anxiety and depression in primary care commonly experience a wide range of positive PE. Self-referential and persecutory ideation were prevalent; perceptual abnormalities were infrequent. Providing information about prevalence and tailoring therapy may help reduce patient distress.

Non-randomised feasibility study of training workshops for Talking Therapies service high-intensity therapists to optimise depression and anxiety outcomes for individuals with co-morbid personality difficulties: a study protocol

BACKGROUND

The NHS Talking Therapies for Anxiety and Depression programme ('TTad'; formerly Improving Access to Psychological Therapies 'IAPT') delivers high-intensity cognitive behavioural therapy (CBT) to over 200,000 individuals each year for common mental health problems like depression and anxiety. More than half of these individuals experience comorbid personality difficulties, who show poorer treatment outcomes. TTad therapists report feeling unskilled to work with clients with personality difficulties, and enhancing the training of TTad therapists may lead to improved treatment outcomes for individuals presenting with secondary personality difficulties alongside depression and anxiety.

METHODS

This is a pre-post non-randomised mixed-method feasibility study, exploring the feasibility and acceptability of a 1-day training workshop for high-intensity (HI) CBT therapists. The workshop is focused on understanding and assessing personality difficulties and adapting HICBT treatments for anxiety and depression to accommodate client needs. The feasibility and acceptability of the workshop and the evaluation procedures will be investigated. It will be examined to what extent the workshop provision leads to improvements in therapist skills and confidence and explored to what extent the training has the potential to enhance clinical outcomes for this client group.

DISCUSSION

This feasibility study will provide data on the acceptability and feasibility of delivering brief therapist training to adapt usual HICBT to optimise care for individuals with secondary personality difficulties seeking treatment in TTad services for a primary problem of depression and/or anxiety. The study will also evaluate proof of concept that such an approach has the potential to improve clinical outcomes for those with secondary personality difficulties and report any possible harms identified. The study will inform the design of a future randomised controlled trial designed to test the effectiveness and cost-effectiveness of the training.

TRIAL REGISTRATION

ISRCTN81104604 . Submitted on 6th June 2022. Registration date: 3rd January 2023.

Trajectories of depression and anxiety symptom severity during psychological therapy for common mental health problems

BACKGROUND

There is substantial variation in patient symptoms following psychological therapy for depression and anxiety. However, reliance on endpoint outcomes ignores additional interindividual variation during therapy. Knowing a patient's likely symptom trajectories could guide clinical decisions. We aimed to identify latent classes of patients with similar symptom trajectories over the course of psychological therapy and explore associations between baseline variables and trajectory class.

METHODS

Patients received high-intensity psychological treatment for common mental health problems at National Health Service Improving Access to Psychological Therapies services in South London (N = 16 258). To identify trajectories, we performed growth mixture modelling of depression and anxiety symptoms over 11 sessions. We then ran multinomial regressions to identify baseline variables associated with trajectory class membership.

RESULTS

Trajectories of depression and anxiety symptoms were highly similar and best modelled by four classes. Three classes started with moderate-severe symptoms and showed (1) no change, (2) gradual improvement, and (3) fast improvement. A final class (4) showed initially mild symptoms and minimal improvement. Within the moderate-severe baseline symptom classes, patients in the two showing improvement as opposed to no change tended not to be prescribed psychotropic medication or report a disability and were in employment. Patients showing fast improvement additionally reported lower baseline functional impairment on average.

CONCLUSIONS

Multiple trajectory classes of depression and anxiety symptoms were associated with baseline characteristics. Identifying the most likely trajectory for a patient at the start of treatment could inform decisions about the suitability and continuation of therapy, ultimately improving patient outcomes.

Predicting non-improvement of symptoms in daily mental healthcare practice using routinely collected patient-level data: a machine learning approach

Objectives

Anxiety and mood disorders greatly affect the quality of life for individuals worldwide. A substantial proportion of patients do not sufficiently improve during evidence-based treatments in mental healthcare. It remains challenging to predict which patients will or will not benefit. Moreover, the limited research available on predictors of treatment outcomes comes from efficacy RCTs with strict selection criteria which may limit generalizability to a real-world context. The current study evaluates the performance of different machine learning (ML) models in predicting non-improvement in an observational sample of patients treated in routine specialized mental healthcare.

Methods

In the current longitudinal exploratory prediction study diagnosis-related, sociodemographic, clinical and routinely collected patient-reported quantitative outcome measures were acquired during treatment as usual of 755 patients with a primary anxiety, depressive, obsessive compulsive or trauma-related disorder in a specialized outpatient mental healthcare center. ML algorithms were trained to predict non-response (< 0.5 standard deviation improvement) in symptomatic distress 6 months after baseline. Different models were trained, including models with and without early change scores in psychopathology and well-being and models with a trimmed set of predictor variables. Performance of trained models was evaluated in a hold-out sample (30%) as a proxy for unseen data.

Results

ML models without early change scores performed poorly in predicting six-month non-response in the hold-out sample with Area Under the Curves (AUCs) < 0.63. Including early change scores slightly improved the models' performance (AUC range: 0.68-0.73). Computationally-intensive ML models did not significantly outperform logistic regression (AUC: 0.69). Reduced prediction models performed similar to the full prediction models in both the models without (AUC: 0.58-0.62 vs. 0.58-0.63) and models with early change scores (AUC: 0.69-0.73 vs. 0.68-0.71). Across different ML algorithms, early change scores in psychopathology and well-being consistently emerged as important predictors for non-improvement.

Conclusion

Accurately predicting treatment outcomes in a mental healthcare context remains challenging. While advanced ML algorithms offer flexibility, they showed limited additional value compared to traditional logistic regression in this study. The current study confirmed the importance of taking early change scores in both psychopathology and well-being into account for predicting longer-term outcomes in symptomatic distress.

Understanding the psychological therapy treatment outcomes for young adults who are not in education, employment, or training (NEET), moderators of outcomes, and what might be done to improve them

BACKGROUND

To determine: whether young adults (aged 18-24) not in education, employment or training (NEET) have different psychological treatment outcomes to other young adults; any socio-demographic or treatment-related moderators of differential outcomes; and whether service-level changes are associated with better outcomes for those who are NEET.

METHODS

A cohort was formed of 20 293 young adults treated with psychological therapies in eight Improving Access to Psychological Therapies services. Pre-treatment characteristics, outcomes, and moderators of differential outcomes were compared for those who were and were not NEET. Associations between outcomes and the following were assessed for those that were NEET: missing fewer sessions, attending more sessions, having a recorded diagnosis, and waiting fewer days between referral and starting treatment.

RESULTS

Those who were NEET had worse outcomes: odds ratio (OR) [95% confidence interval (CI)] for reliable recovery = 0.68 (0.63-0.74), for deterioration = 1.41 (1.25-1.60), and for attrition = 1.31 (1.19-1.43). Ethnic minority participants that were NEET had better outcomes than those that were White and NEET. Living in deprived areas was associated with worse outcomes. The intensity of treatment (high or low) did not moderate outcomes, but having more sessions was associated with improved outcomes for those that were NEET: odds (per one-session increase) of reliable recovery = 1.10 (1.08-1.12), deterioration = 0.94 (0.91-0.98), and attrition = 0.68 (0.66-0.71).

CONCLUSIONS

Earlier treatment, supporting those that are NEET to attend sessions, and in particular, offering them more sessions before ending treatment might be effective in improving clinical outcomes. Additional support when working with White young adults that are NEET and those in more deprived areas may also be important.

Dimensional models of personality disorders: Challenges and opportunities

Categorical models of personality disorders have been beneficial throughout psychiatric history, providing a mechanism for organizing and communicating research and treatment. However, the view that individuals with personality disorders are qualitatively distinct from the general population is no longer tenable. This perspective has amassed steady criticism, ranging from inconsequential to irreconcilable. In response, stronger evidence has been accumulated in support of a dimensional perspective that unifies normal and pathological personality on underlying trait continua. Contemporary nosology has largely shifted toward this dimensional perspective, yet broader adoption within public lexicon and routine clinical practice appears slow. This review focuses on challenges and the related opportunities of moving toward dimensional models in personality disorder research and practice. First, we highlight the need for ongoing development of a broader array of measurement methods, ideally facilitating multimethod assessments that reduce biases associated with any single methodology. These efforts should also include measurement across both poles of each trait, intensive longitudinal studies, and more deeply considering social desirability. Second, wider communication and training in dimensional approaches is needed for individuals working in mental health. This will require clear demonstrations of incremental treatment efficacy and structured public health rebates. Third, we should embrace cultural and geographic diversity, and investigate how unifying humanity may reduce the stigma and shame currently generated by arbitrarily labeling an individual's personality as normal or abnormal. This review aims to organize ongoing research efforts toward broader and routine usage of dimensional perspectives within research and clinical spaces.

Patient characteristics associated with retrospectively self-reported treatment outcomes following psychological therapy for anxiety or depressive disorders - a cohort of GLAD study participants

BACKGROUND

Progress towards stratified care for anxiety and depression will require the identification of new predictors. We collected data on retrospectively self-reported therapeutic outcomes in adults who received psychological therapy in the UK in the past ten years. We aimed to replicate factors associated with traditional treatment outcome measures from the literature.

METHODS

Participants were from the Genetic Links to Anxiety and Depression (GLAD) Study, a UK-based volunteer cohort study. We investigated associations between retrospectively self-reported outcomes following therapy, on a five-point scale (global rating of change; GRC) and a range of sociodemographic, clinical and therapy-related factors, using ordinal logistic regression models (n = 2890).

RESULTS

Four factors were associated with therapy outcomes (adjusted odds ratios, OR). One sociodemographic factor, having university-level education, was associated with favourable outcomes (OR = 1.37, 95%CI: 1.18, 1.59). Two clinical factors, greater number of reported episodes of illness (OR = 0.95, 95%CI: 0.92, 0.97) and higher levels of personality disorder symptoms (OR = 0.89, 95%CI: 0.87, 0.91), were associated with less favourable outcomes. Finally, reported regular use of additional therapeutic activities was associated with favourable outcomes (OR = 1.39, 95%CI: 1.19, 1.63). There were no statistically significant differences between fully adjusted multivariable and unadjusted univariable odds ratios.

CONCLUSION

Therapy outcome data can be collected quickly and inexpensively using retrospectively self-reported measures in large observational cohorts. Retrospectively self-reported therapy outcomes were associated with four factors previously reported in the literature. Similar data collected in larger observational cohorts may enable detection of novel associations with therapy outcomes, to generate new hypotheses, which can be followed up in prospective studies.

Determinants of patient-reported outcome trajectories and symptomatic recovery in Improving Access to Psychological Therapies (IAPT) services

BACKGROUND

Despite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.

METHODS

Using data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.

RESULTS

Being female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).

CONCLUSIONS

We must continue to investigate how best to tailor psychotherapeutic interventions to fit patients' needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.

Prognostic Value of Pathological Personality Traits for Treatment Outcome in Anxiety and Depressive Disorders: The Leiden Routine Outcome Monitoring Study

ABSTRACT

Previous studies have failed to take baseline severity into account when assessing the effects of pathological personality traits (PPT) on treatment outcome. This study assessed the prognostic value of PPT (Dimensional Assessment of Personality Pathology-Short Form) on treatment outcome (Brief Symptom Inventory [BSI-posttreatment]) among patients with depressive and/or anxiety disorders ( N = 5689). Baseline symptom level (BSI-pretreatment) was taken into account as a mediator or moderator variable. Results showed significant effects of PPT on outcome, of which Emotional Dysregulation demonstrated the largest association ( β = 0.43, p < 0.001). When including baseline BSI score as a mediator variable, a direct effect ( β = 0.11, p < 0.001) remained approximately one-third of the total effect. The effects of Emotional Dysregulation (interaction effect β = 0.061, p < 0.001) and Inhibition (interaction effect β = 0.062, p < 0.001), but not Compulsivity or Dissocial Behavior, were moderated by the baseline symptom level. PPT predicts higher symptom levels, both before and after treatment, but yields relatively small direct effects on symptom decline when the effect of pretreatment severity is taken into account.

Effectiveness of cognitive-behavioural therapies of varying complexity in reducing depression in adults: systematic review and network meta-analysis

BACKGROUND

Cognitive-behavioural therapy (CBT) is frequently used as an umbrella term to include a variety of psychological interventions. It remains unclear whether more complex CBT contributes to greater depression reduction.

AIMS

To (a) compare the effectiveness of core, complex and ultra-complex CBT against other psychological intervention, medication, treatment-as-usual and no treatment in reducing depression at post-treatment and in the long term and (b) explore important factors that could moderate the effectiveness of these interventions.

METHOD

MEDLINE, PsycInfo, Embase, Web of Science and the Cochrane Register of Controlled Trials were searched to November 2021. Only randomised controlled trials were eligible for the subsequent network meta-analysis.

RESULTS

We included 107 studies based on 15 248 participants. Core (s.m.d. = -1.14, 95% credible interval (CrI) -1.72 to -0.55 [m.d. = -8.44]), complex (s.m.d. = -1.24, 95% CrI -1.85 to -0.64 [m.d. = -9.18]) and ultra-complex CBT (s.m.d. = -1.45, 95% CrI -1.88 to -1.02 [m.d. = -10.73]) were all significant in reducing depression up to 6 months from treatment onset. The significant benefits of the ultra-complex (s.m.d. = -1.09, 95% CrI -1.61 to -0.56 [m.d. = -8.07]) and complex CBT (s.m.d. = -0.73, 95% CrI -1.36 to -0.11 [m.d. = -5.40]) extended beyond 6 months. Ultra-complex CBT was most effective in individuals presenting comorbid mental health problems and when delivered by non-mental health specialists. Ultra-complex and complex CBT were more effective for people younger than 59 years.

CONCLUSIONS

For people without comorbid conditions healthcare and policy organisations should invest in core CBT. For people <59 years of age with comorbid conditions investments should focus on ultra-complex and complex CBT delivered without the help of mental health professionals.

Modular-based psychotherapy (MoBa) versus cognitive-behavioural therapy (CBT) for patients with depression, comorbidities and a history of childhood maltreatment: study protocol for a randomised controlled feasibility trial

INTRODUCTION

In depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms, and a high rate of comorbid disorders. Personalised treatments targeting comorbidities as well as underlying transdiagnostic mechanisms and factors like early childhood maltreatment may lead to better outcomes. A modular-based psychotherapy (MoBa) approach provides a treatment model of independent and flexible therapy elements within a systematic treatment algorithm to combine and integrate existing evidence-based approaches. By optimally tailoring module selection and application to the specific needs of each patient, MoBa has great potential to improve the currently unsatisfying results of psychotherapy as a bridge between disorder-specific and personalised approaches.

METHODS AND ANALYSIS

In a randomised controlled feasibility trial, N=70 outpatients with episodic or persistent major depression, comorbidity and childhood maltreatment are treated in 20 individual sessions with MoBa or standard cognitive-behavioural therapy for depression. The three modules of MoBa focus on deficits associated with early childhood maltreatment: the systems of negative valence, social processes and arousal. According to a specific questionnaire-based treatment algorithm, elements from cognitive behavioural analysis system of psychotherapy, mentalisation-based psychotherapy and/or mindfulness-based cognitive therapy are integrated for a personalised modular procedure.As a proof of concept, this trial will provide evidence for the feasibility and efficacy (post-treatment and 6-month follow-up) of a modular add-on approach for patients with depression, comorbidities and a history of childhood maltreatment. Crucial feasibility aspects include targeted psychopathological mechanisms, selection (treatment algorithm), sequence and application of modules, as well as training and supervision of the study therapists.

ETHICS AND DISSEMINATION

This study obtained approval from the independent Ethics Committees of the University of Freiburg and the University of Heidelberg. All findings will be disseminated broadly via peer-reviewed articles in scientific journals and contributions to national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00022093.

The recording of personality strengths: An analysis of the impact of positive personality features on the long-term outcome of common mental disorders

Although personality strengths are assessed frequently in occupational and managerial settings and in children, they have been less used in studies of personality disorder. The aim of this study is to examine the impact of a measure of personality strengths derived from the comprehensive version of the Personality Assessment Schedule (CPAS) (i.e., positive and reinforcing traits) on clinical symptoms and functioning. Eighty-nine patients with anxiety and depression seen at the 30-year follow-up point in a cohort study (Nottingham Study of Neurotic Disorder) were administered the Comprehensive version of the PAS (CPAS). A factor analysis of the results determined the main groupings and their impact on long-term outcomes as well as their association with change of outcomes over 30 years. Five positive factors (strengths), forceful considerateness, emotional toughness, cautiousness, independence and discernment accounted for 67.2% of the variance using both Varimax and Promax rotations. Low positive scores were strongly associated with suicide attempts, moderate/severe personality disorder, cothymia (mixed anxiety-depression), greater symptomatology and poor social function. High scores were protective of serious pathology and particularly effective in inhibiting suicidal behaviour. The promotion of personality strengths may be of value in preventing suicidal behaviour and helping pro-social change in those with personality disturbance.

The efficacy and acceptability of exposure therapy for the treatment of post-traumatic stress disorder in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is common among children and adolescents who have experienced traumatic events. Exposure therapy (ET) has been shown to be effective in treating PTSD in adults. However, its efficacy remains uncertain in children and adolescents.

AIMS

To evaluate the efficacy and acceptability of ET in children and adolescents with PTSD.

METHOD

We searched PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, ProQuest, LILACS, and international trial registries for randomized controlled trials (RCTs) assessed ET in children and adolescents (aged ≤18 years) with PTSD up to August 31, 2020. The primary outcomes were efficacy (the endpoint score from PTSD symptom severity rating scales) and acceptability (all-cause discontinuation), secondary outcomes included efficacy at follow-up (score from PTSD scales at the longest point of follow-up), depressive symptoms (end-point score on depressive symptom severity rating scales) and quality of life/social functioning (end-point score on quality of life/social functioning rating scales). This study was registered with PROSPERO (CRD42020150859).

RESULT

A total of 6 RCTs (278 patients) were included. The results showed that ET was statistically more efficacious than control groups (standardized mean differences [SMD]: - 0.47, 95% confidence interval [CI]: - 0.91 to - 0.03). In subgroup analysis, exposure therapy was more efficacious for patients with single type of trauma (SMD: - 1.04, 95%CI: - 1.43 to - 0.65). Patients with an average age of 14 years and older, ET was more effective than the control groups (SMD: - 1.04, 95%CI: - 1.43 to - 0.65), and the intervention using prolonged exposure therapy (PE) (SMD: - 1.04, 95%CI: - 1.43 to - 0.65) was superior than control groups. Results for secondary outcomes of efficacy at follow-up (SMD: - 0.64, 95%CI: - 1.17 to - 0.10) and depressive symptoms (SMD: - 0.58, 95%CI: - 0.93 to - 0.22) were similar to the previous findings for efficacy outcome. No statistically significant effects for acceptability and quality of life/social functioning were found.

CONCLUSION

ET showed superiority in efficacy at post-treatment/follow-up and depressive symptoms improvement in children and adolescents with PTSD. Patients with single type of trauma may benefit more from ET. And ET is more effective in patients 14 years or older. Moreover, PE could be a better choice.

The Relationship Between CBT-Mindedness and iCBT Outcomes Amongst a Large Adult Sample

Background

Predicting response to cognitive behavior therapy (CBT) assists efforts to enhance treatment outcome when predictive factors are modifiable prior to, or during, treatment. The extent to which clients hold beliefs and attitudes consistent with CBT (termed CBT-mindedness) is a relatively new concept with research suggesting it predicts response to CBT amongst small samples of adults with anxiety. This study aimed to investigate CBT-mindedness amongst a larger clinical population receiving internet-delivered CBT (iCBT).

Method

1132 adults with anxiety, depression or mixed anxiety and depression who accessed iCBT with or without therapist support via the THIS WAY UP clinic completed a brief self-report measure of CBT-mindedness along with measures of distress, anxiety, and depression. Measures were completed pre- and post-treatment.

Results

The 3-factor structure of the CBT Suitability Scale (CBT-SUITS) was confirmed and scores were unrelated or very weakly related to symptoms/distress. CBT-mindedness increased amongst treatment completers. CBT-mindedness predicted post-treatment distress (but not symptoms), and change in CBT-mindedness predicted lower post-treatment symptoms and distress.

Conclusions

The CBT-SUITS represents a psychometrically sound measure of CBT-mindedness. Results amongst this large sample of adults accessing iCBT in a community service indicate that CBT-mindedness (or CBT-mindedness change) is an important predictor of therapy response.

Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial

IMPORTANCE

Depression is a major cause of disability worldwide. Although empirically supported treatments are available, there is scarce evidence on how to effectively personalize psychological treatment selection.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of 2 treatment selection strategies: stepped care and stratified care.

DESIGN, SETTING, AND PARTICIPANTS

This multisite, cluster randomized clinical trial recruited participants from the English National Health Service from July 5, 2018, to February 1, 2019. Thirty clinicians working across 4 psychological therapy services were randomly assigned to provide stratified (n = 15) or stepped (n = 15) care. In stepped care, patients sequentially access low-intensity guided self-help followed by high-intensity psychotherapy. In stratified care, patients are matched with either low- or high-intensity treatments at initial assessment. Data were analyzed from May 18, 2020, to October 13, 2021, using intention-to-treat principles.

INTERVENTIONS

All clinicians used the same interview schedule to conduct initial assessments with patients seeking psychological treatment for common mental disorders, but those in the stratified care group received a personalized treatment recommendation for each patient generated by a machine learning algorithm. Eligible patients received either stratified or stepped care (ie, treatment as usual).

MAIN OUTCOMES AND MEASURES

The preregistered outcome was posttreatment reliable and clinically significant improvement (RCSI) of depression symptoms (measured using the 9-item Patient Health Questionnaire). The RCSI outcome was compared between groups using logistic regression adjusted for baseline severity. Cost-effectiveness analyses compared incremental costs and health outcomes of the 2 treatment pathways.

RESULTS

A total of 951 patients were included (618 women among 950 with data available [65.1%]; mean [SD] age, 38.27 [14.53] years). The proportion of cases of RCSI was significantly higher in the stratified care arm compared with the stepped care arm (264 of 505 [52.3%] vs 134 of 297 [45.1%]; odds ratio, 1.40 [95% CI, 1.04-1.87]; P = .03). Stratified care was associated with a higher mean additional cost per patient (£104.5 [95% CI, £67.5-£141.6] [$139.83 (95% CI, $90.32-$189.48)]; P < .001) because more patients accessed high-intensity treatments (332 of 583 [56.9%] vs 107 of 368 [29.1%]; χ2 = 70.51; P < .001), but this additional cost resulted in an approximately 7% increase in the probability of RCSI.

CONCLUSIONS AND RELEVANCE

In this cluster randomized clinical trial of adults with common mental disorders, stratified care was efficacious and cost-effective for the treatment of depression symptoms compared with stepped care. Stratified care can improve depression treatment outcomes at a modest additional cost.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN11106183.

Investigating Effectiveness and Predicting Outcome and Dropout From Systems Training for Emotional Predictability and Problem Solving for Emotional Intensity Difficulties (STEPPS EI) in UK Primary Care

Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder (BPD) has been adapted for a primary care setting into a 13-week group treatment for emotional intensity difficulties (STEPPS EI). This is the first study to examine the effectiveness and potential outcome and dropout predictors of STEPPS EI in a primary care setting. Severity of BPD, depression, and anxiety symptoms were measured pre- and postintervention for 148 participants. Treatment completers showed improvements in depression, anxiety, and BPD symptoms with medium to large effect sizes. A predictor of symptom improvement was higher baseline severity for each of the symptom measures. Attending a psychoeducational group prior to STEPPS EI was associated with lower odds of dropout. The findings support the use of STEPPS EI in a primary care setting, with the potential to alleviate the burden from other local services.

Risk of First General Hospital Admissions for Self-Harm Among People With Personality Disorder: A Retrospective Cohort Study

For individuals with a personality disorder (PD), it is unknown whether additional psychiatric conditions increase their risk of self-harm. The authors therefore conducted a retrospective cohort study, using data from secondary mental health care, to identify self-harm admissions. Adults with diagnosed PD, followed up over a 6-year period, were involved (N = 7,475). Cox regression was used to model the risk of self-harm admissions, with comorbid depression, substance use disorders (SUD), severe mental illness (SMI), anorexia nervosa (AN), and bulimia nervosa (BN) as primary exposures; sociodemographics were considered as confounders. In multivariable analyses, comorbid SUD (adjusted HR = 1.66; 95% CI [1.45, 1.90]), depressive disorder (1.25; [1.09, 1.44]), AN (1.63; [1.10, 2.39]), and BN (1.65; [1.09, 2.51]) were positively associated with increased risks of hospitalization due to self-harm. However, a negative association was found for comorbid SMI. The findings highlight the importance of assessing and treating comorbid psychiatric disorders in PD.

Comorbid personality difficulties are not associated with poorer outcomes for online cognitive behaviour therapy for symptoms of anxiety and depression

Little is known about the prevalence and impact on treatment of comorbid personality disorders for adults undertaking online cognitive behaviour therapy (internet-delivered or internet-based cognitive behaviour therapy (iCBT)) for anxiety and depressive disorders. This study explored how common comorbid personality difficulties were in a large sample of consecutive patients (N = 1 132) seeking iCBT for their symptoms of anxiety and depression in routine care settings. Patients completed the Standardized Assessment of Personality-abbreviated Scale Self-Report prior to commencing an iCBT programme, as well as completing assessments of anxiety and depression symptom severity and psychological distress pre-iCBT and post-iCBT. Consistent with previous studies, a high proportion of the sample (62.6%) reported experiencing comorbid personality difficulties. However, comorbid personality difficulties were not significantly associated with poorer treatment adherence or higher post-treatment symptom severity or psychological distress (controlling for baseline symptom severity, demographic characteristics and treatment variables). Current findings support an inclusive approach to iCBT provision where comorbid personality difficulties do not appear to be a contraindication for treatment. © 2021 John Wiley & Sons, Ltd.

Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?

BACKGROUND

The Improving Access to Psychological Therapies (IAPT) programme has been impactful in increasing access to psychological therapies at primary care level. However, it remains unclear whether IAPT's widely disseminated achievements include the reduction in service users' transition to secondary care services and whether IAPT services are providing interventions that match the level of complexity of presenting problems of those who are referred.

AIMS

This review sets out to clarify the clinical characteristics of IAPT cohorts, whether the interventions provided target these characteristics, and whether outcomes are related to the use of the stepped-care model advocated in the operationalization of IAPT services.

METHOD

A systematic literature search was undertaken on PsycINFO, MEDLINE, and Embase using the terms: IAPT, anxiety, and depression.

RESULTS

Of 472 paper identified, 24 articles were deemed pertinent. It appears that IAPT cohorts are complex and current service delivery frameworks may not meet their needs. IAPT developments and research for long-term physical health conditions and serious mental illness have been recently advocated, though whether these are sufficient and viable when set in IAPT's prescriptive backdrop remains unclear.

CONCLUSIONS

Improving Access to Psychological Therapies provision and research at present does not adequately consider the complexity of its clientele in the context of treatment outcomes and service delivery. Recommendations are provided for future research and practice to tackle these deficiencies.

PRACTITIONER POINTS

Improving Access to Psychological Therapies (IAPT) has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged. Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model's original objectives is required, as a precursor to its expansion into other clinical areas. The review indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands. Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

Circulating cytokine levels in the treatment of comorbid anxiety disorders

Psychotherapy research aims to investigate predictors and moderators of treatment outcome, but there are few consistent findings. This study aimed to investigate cytokines in patients undergoing treatment for anxiety disorders and whether the level of cytokines moderated the treatment outcome. Thirty-seven patients with comorbid and treatment-resistant anxiety disorders were investigated using multilevel modelling. Serum cytokine levels were measured three times: pretreatment, in the middle of treatment, and at the end of treatment. Anxiety and metacognitions were measured weekly throughout treatment by self-report. The levels of monocyte chemoattractant protein-1, tumour necrosis factor-alpha, and interleukin-1 receptor antagonist did not change during therapy or were not related to the level of anxiety. Metacognitive beliefs predicted anxiety, but the relationship between metacognitions and anxiety was not moderated by cytokines. Limitations of the study include that the patients were not fasting at blood sampling, and we did not assess body mass index, which may affect cytokine levels. The lack of significance for cytokines as a predictor or moderator may be due to a lack of power for testing moderation hypotheses, a problem associated with many psychotherapy studies. Cytokines did not predict the outcome in the treatment of comorbid anxiety disorders in our sample. Furthermore, cytokines did not moderate the relationship between metacognitions and anxiety.

Subthreshold personality disorder: how feasible is treatment in primary care?

Individuals with subthreshold borderline personality disorder (BPD) are commonly encountered in primary care settings, yet the psychological treatments they receive are rarely tailored to their needs. In an effort to capture and treat this group of individuals in a targeted and meaningful way, some primary care settings offer Systems Training for Emotional Predictability and Problem Solving – Emotional Intensity (STEPPS-EI). This evaluation sought to assess the feasibility of STEPPS-EI within NHS primary care services. Employing an uncontrolled design, the evaluation examined recruitment, retention, effectiveness and group appraisal. Findings supported three out of four evaluation objectives for feasibility: uptake of the group was high at 74%, the group was well received by the group and significantly effective at reducing symptoms of BPD, depression and anxiety. However, retention rates were low, with only 43% classed as ‘completers’ of the programme. The results indicate preliminary evidence for STEPPS-EI as a potentially feasible intervention with possible modification to enhance retention and avenues for further study.

Key learning aims

After reading this paper, the reader will be aware of: (1)

The effectiveness of brief cognitive analytic therapy for anxiety and depression: A quasi-experimental case-control study

OBJECTIVES

To investigate the effectiveness of an 8-session cognitive analytic therapy (CAT) protocol for patients with anxiety and depression in the context of relational problems, personality disorder traits, or histories of adverse childhood experiences and then to compare outcomes with cognitive behavioural therapy (CBT).

METHODS

The study was conducted in a single Improving Access to Psychological Therapies (IAPT) service and used sessional outcome monitoring. Propensity score matching was used to derive equivalent CAT (N = 76) and CBT (N = 73) samples through matching intake characteristics. Longitudinal multilevel modelling (LMLM) compared patterns of symptomatic change over time between the two therapies.

RESULTS

LMLM found no significant differences between CAT and CBT in depression, anxiety, and functional impairment outcomes and showed similar symptom change trajectories. Small between-therapy post-treatment effects and medium-to-large within-therapy effects were found. CAT patients attended significantly more sessions, and the CAT dropout rate was significantly lower.

CONCLUSIONS

Brief CAT appears acceptable and effective for patients with anxiety and depression in the context of complex relational problems when delivered within the high intensity tier of an IAPT service. The potential added value of CAT in IAPT services is discussed.

PRACTITIONER POINTS

Practitioners (under appropriate supervision) could use 8-session CAT when treating patients with anxiety and depression in the context of clinical complexity. The 8-session CAT model holds organizational promise in IAPT services. Brief CAT interventions should retain theoretical integrity.

Personality difficulties and response to community-based psychological treatment for anxiety and depression

BACKGROUND

Previous research suggests that comorbid personality disorder may be associated with a less favourable treatment outcome for individuals with depression and anxiety disorder. However, little is known about whether personality difficulties are associated with treatment outcomes within Improving Access to Psychological Therapies (IAPT) services-the largest platform for treating depression and anxiety in England, UK. Secondary aims were to investigate i) whether individual personality difficulties are associated with treatment outcome and ii) whether findings are moderated by treatment type.

METHODS

The sample included 3,689 adults who accessed community-based psychological treatment (cognitive behavioural therapy, emotional skills training, or other psychological therapy) for depression and/or anxiety disorder. Associations between personality difficulties (assessed with the Standardised Assessment of Personality-Abbreviated Scale (SAPAS)) and treatment outcomes (recovery and reliable improvement in depression/anxiety symptom scores, assessed using questionnaire-based measures) were investigated using logistic/linear regression.

RESULTS

Personality difficulties were associated with a reduced likelihood of recovery (adjusted OR per unit increase on SAPAS: depression=0.87, 95%CI 0.84, 0.91; anxiety=0.86, 95%CI 0.82, 0.90) and reliable improvement (adjusted OR per unit increase on SAPAS: depression=0.88, 95%CI 0.84, 0.92; anxiety=0.85, 95%CI 0.82, 0.89). Those with three or more difficulties were over 30% less likely to recover/reliably improve.

LIMITATIONS

Personality difficulties data were collected via self-report and were not available for all participants.

CONCLUSION

Patients with personality difficulties have a less favourable response to psychological treatment for depression/anxiety disorder. If replicated, the findings highlight a major challenge to the way community-based psychological therapy services in England (IAPT services) are presently constituted.

Development and validation of the Readiness for Therapy Questionnaire (RTQ)

BACKGROUND

Motivational factors are generally regarded as an important ingredient for change in therapy. However, there is currently a lack of available instruments that can measure clients' readiness for change in therapy.

AIM

The objective of this paper was to create an instrument, the Readiness for Therapy Questionnaire (RTQ), which could measure clients' readiness for change.

METHOD

The RTQ was created by researchers following analysis of themes drawn from a review of the literature and interviews with patients at the end of therapy. This included both people who completed therapy and those who dropped out. As part of the standard assessment process, the RTQ was administered to 349 participants (69.6% female and 30.4% male; mean age 37.1 years; 90.5% Caucasian) who were patients at a psychological therapy service for common mental health difficulties.

RESULT

An initial 12-item scale was reduced to 6 items. This scale significantly correlated with post-therapy PHQ-9 and GAD-7 scores and changes in these scores across therapy. After controlling for baseline scores and demographic variables, a logistic regression showed that scores on this 6-item measure pre-therapy significantly predicted three outcome variables: completing therapy, being recovered on both PHQ-9 and GAD-7 post-therapy, and having a reliable change in both the PHQ-9 and GAD-7 post-therapy. However, receiver operating characteristic (ROC) curve analysis showed the measure had poor sensitivity and specificity. Symptom severity did not have a significant impact on motivation to change.

CONCLUSION

The RTQ is potentially a valid measure with useful clinical applications in treatment of common mental health difficulties.

More sensitive identification of psychotic experiences in common mental disorder by primary mental healthcare services - effect on prevalence and recovery: casting the net wider

BACKGROUND

Psychotic experiences may emerge in more severe cases of common mental disorders (CMD). Previous work identified that 30% of patients treated by mental health services in primary healthcare, specifically the Improving Access to Psychological Therapies (IAPT) programme in England, reported psychotic experiences, began treatment with more severe CMD and were less likely to reach recovery.

AIMS

To replicate our previous assessment of psychotic experiences in the IAPT programme using a more sensitive threshold and determine its impact on the prevalence of psychotic experience and likelihood of recovery. Additionally, to compare recovery rates between patients with and without psychotic experiences at the end of therapy.

METHOD

The Community Assessment of Psychic Experiences (CAPE-P15) with a cut-off of 1.30 was used to determine the prevalence of psychotic experiences. Recovery rates were determined using measures collected in the IAPT programme for depression (PHQ-9) and anxiety (GAD-7). Multi-group growth models estimated improvement trajectories.

RESULTS

In total, 2042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The prevalence of psychotic experiences was 18% higher when using a lower threshold. The recovery rate for patients with psychotic experiences was lower (36%) than for those without (64%). Despite sharing similar improvement trajectories, the higher initial severity of CMD among patients with psychotic experiences impeded likelihood of recovery.

CONCLUSIONS

As psychotic experiences may be a marker of severity in CMD, the benefits of identifying these in IAPT populations may also apply to patients with milder experiences. Further investigation of the consequential demands on service provision and how this would affect clinical practice is recommended.

Personality disorder co-morbidity in primary care ‘Improving Access to Psychological Therapy’ (IAPT) services: a qualitative study exploring patient perspectives on treatment experience

Background:

High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care ‘Improving Access to Psychological Therapies’ (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England.

Aims:

This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the ‘Standardised Assessment of Personality – Abbreviated Scale’ (SAPAS) in receipt of primary care-based IAPT treatment.

Method:

A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach.

Results:

Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important.

Conclusions:

For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach.

Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis

BACKGROUND

Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events.

METHODS AND FINDINGS

We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis.

CONCLUSIONS

In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.

Prevalence of and recovery from common mental disorder including psychotic experiences in the UK Primary Care Improving Access to Psychological Therapies (IAPT) Programme

BACKGROUND

Psychotic experiences (PE) may co-occur with common mental disorders (CMD), such as depression and anxiety. However, we know very little about the prevalence of and recovery from PE in primary mental health care settings, such as the Improving Access to Psychological Therapies (IAPT) services in the UK National Health Service (NHS), where most CMD are treated.

METHODS

We used the Community Assessment of Psychic Experiences - Positive 15-item Scale (CAPE-P15) to determine the prevalence of PE in patients receiving treatment from IAPT services. Patient-reported measures of depression (PHQ-9) and anxiety (GAD-7) are routinely collected and establish recovery in IAPT services. We studied recovery rates according to the absence and presence of PE. Multi-group growth models estimated improvement trajectories for each group.

RESULTS

A total of 2,042 patients with CMD completed the CAPE-P15. The mean age was 39.8. The overall prevalence of PE was 29.68%. The recovery rate was 27.43% compared to 62.08% for those without PE. Although patients with or without PE shared similar improvement trajectories, the initial severity of patients with PE impeded their likelihood of recovery.

LIMITATIONS

We mirrored routine data collection in IAPT services, including self-report questionnaires that may affect valid reporting of symptoms. Missing data in the calculation of improvement trajectories may reduce generalisability.

CONCLUSIONS

At least one in four patients receiving treatment from IAPT services in primary care experience CMD and PE. This significant group of people experience a lower recovery rate, with adverse implications not only for them but also for efficiency of services.

Do people living in disadvantaged circumstances receive different mental health treatments than those from less disadvantaged backgrounds?

BACKGROUND

Socio-economic status (SES) has been linked to treatment outcomes for mental health problems, whilst little to no literature has explored the effects of SES on access to both medication and psychological therapy. The aim of this study was to explore whether access to mental health treatments differed by SES.

METHODS

The North West Coast Household Health Survey (HHS) collected data from residents aged 18+ from across 20 disadvantaged and 8 less disadvantaged neighbourhoods in 2015, and from 20 disadvantaged neighbourhoods in 2018. Logistic regression was used to explore the effects of SES on access to treatment (medication, psychological therapy) for people who had experienced mental health problems in the past 12 months.

RESULTS

Of 6860 participants, 2932 reported experiencing mental health problems in the past 12 months. People from more disadvantaged backgrounds experienced greater rates of anxiety and depression. Anti-depressant and anti-psychotic medication treatment was significantly more common in residents with lower SES, as well as counselling. Regression analysis showed that residents from more disadvantaged neighbourhoods who reported mental distress were more likely to receive medication.

CONCLUSIONS

This appears to be the first study showing higher levels of treatment with medication and psychological therapy in people from disadvantaged backgrounds. Future research needs to address the underlying factors associated with increased mental health treatment uptake in people from lower socio-economic backgrounds.

Do people living in disadvantaged circumstances receive different mental health treatments than those from less disadvantaged backgrounds?

BACKGROUND

Socio-economic status (SES) has been linked to treatment outcomes for mental health problems, whilst little to no literature has explored the effects of SES on access to both medication and psychological therapy. The aim of this study was to explore whether access to mental health treatments differed by SES.

METHODS

The North West Coast Household Health Survey (HHS) collected data from residents aged 18+ from across 20 disadvantaged and 8 less disadvantaged neighbourhoods in 2015, and from 20 disadvantaged neighbourhoods in 2018. Logistic regression was used to explore the effects of SES on access to treatment (medication, psychological therapy) for people who had experienced mental health problems in the past 12 months.

RESULTS

Of 6860 participants, 2932 reported experiencing mental health problems in the past 12 months. People from more disadvantaged backgrounds experienced greater rates of anxiety and depression. Anti-depressant and anti-psychotic medication treatment was significantly more common in residents with lower SES, as well as counselling. Regression analysis showed that residents from more disadvantaged neighbourhoods who reported mental distress were more likely to receive medication.

CONCLUSIONS

This appears to be the first study showing higher levels of treatment with medication and psychological therapy in people from disadvantaged backgrounds. Future research needs to address the underlying factors associated with increased mental health treatment uptake in people from lower socio-economic backgrounds.

Disordered personality traits and psychiatric morbidity in pregnancy: a population-based study

This study aims to investigate the characteristics and mental health status of pregnant women with disordered personality traits. A cross-sectional study of a stratified sample of 545 women attending antenatal booking at a South London maternity service was conducted. Disordered personality traits were assessed using the Standardised Assessment of Personality-Abbreviated Scale (SAPAS). Mental disorders were assessed using the Structured Clinical Interview DSM-IV (SCID). Logistic regression was used to model associations, adjusting for confounders. Complete SAPAS data were collected for over 99% of women (n = 541). The weighted prevalence of elevated disordered personality traits (SAPAS ≥ 3) was 16.2% (95% CI 12.6-20.5). Women with elevated disordered personality traits were younger, less likely to live alone and more likely to report living in insecure accommodation. Among women with elevated disordered personality traits, the most common mental disorders were anxiety disorders (31.4%) and depressive disorders (17.6%). Each extra item endorsed on the SAPAS was associated with an 82% higher odds of meeting criteria for an Axis I mental disorder (adjusted OR 1.82 (1.42-2.33); p < 0.001). Women with elevated disordered personality traits were at significantly increased risk of experiencing thoughts of self-harm (adjusted OR 2.12 (1.33-3.40); p = 0.002). Pregnant women with disordered personality traits are a particularly vulnerable population, with multiple psychosocial problems that are likely to require tailored support to ameliorate future health risks for mother and baby.

Integrated treatment for patients with comorbid depression and personality disorders

PURPOSE OF REVIEW

To provide an update on the epidemiology and the clinical consequences of depression complicated by comorbid personality disorders, and to discuss optimal treatment options.

RECENT FINDINGS

Studies have confirmed the frequent co-occurrence of depression and personality disorders. These comorbid states are consistently associated with unfavourable clinical indicators such as duration of episode, symptom severity and recurrence of depression, as well as a negative effect on treatment outcome. Nevertheless, this is a neglected theme and there are hardly any well designed treatment studies available.

SUMMARY

We advocate considering depression and personality as being more closely related and argue in favour of the development of integrated treatment options tailored to understanding symptoms as being interwoven with a variety of long-standing disturbing personality patterns. Both clinically and conceptually, psychodynamic and schema-focused approaches provide good opportunities to adjust available therapies and they could optimize outcomes in this complex patient group. Given the risk of treatment resistance and chronicity, a combination of psychotherapy and medication should always be considered.

Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing

The primary focus of classic cognitive behavioural therapy (CBT) for depression and anxiety is on decreasing symptoms of psychopathology. However, there is increasing recognition that it is also important to enhance wellbeing during therapy. This study investigates the extent to which classic CBT for anxiety and depression leads to symptom relief versus wellbeing enhancement, analysing routine outcomes in patients receiving CBT in high intensity Improving Access to Psychological Therapy (IAPT) Services in the UK. At intake, there were marked symptoms of anxiety and depression (a majority of participants scoring in the severe range) and deficits in wellbeing (a majority of participants classified as languishing, relative to general population normative data). CBT was more effective at reducing symptoms of anxiety and depression than repairing wellbeing. As a result, at the end of treatment, a greater proportion of participants met recovery criteria for anxiety and depression than had moved from languishing into average or flourishing levels of wellbeing. Given the importance of wellbeing to client definitions of recovery, the present results suggest a greater emphasis should be placed on enhancing wellbeing in classic CBT.

Personality disorder co-morbidity in primary care 'Improving Access to Psychological Therapy' services: A qualitative study exploring professionals' perspectives of working with this patient group

A high prevalence of people present to 'Improving Access to Psychological Therapies' (IAPT) in England with common mental health disorders and co-morbid personality disorder. This group have suboptimal treatment outcomes in IAPT. Whilst new short-term treatment approaches are advocated, no solutions or guidance have been provided. This qualitative study explored IAPT health-care professional (N = 28) perspectives of working with people who present to IAPT with co-morbid personality disorder. Individual semi-structured interviews were digitally recorded, transcribed verbatim and analysed using a framework analysis approach. Results identified a lack of skills and confidence in working with this patient group, restrictive service constraints and a treatment gap between the interface of primary and secondary services. Insight into acceptable adaptions to practice are identified that have transferable utility to a wider international audience who can identify people outside of specialist mental health services with common mental health disorders and co-morbid personality disorder traits. © 2019 John Wiley & Sons, Ltd.

GPs' views and experiences of managing patients with personality disorder: a qualitative interview study

OBJECTIVE

The aim of this study was to explore GPs' views and experiences of managing patients with personality disorder (PD), and their views on the role of the Improving Access to Psychological Therapies (IAPT) programme as a support service.

DESIGN

In-depth interviews, analysed thematically.

PARTICIPANTS

Fifteen GPs (7 women and 8 men) of varying age and clinical experience, working in practices that differed in terms of the socio-demographic characteristics of their patient populations.

SETTING

Twelve general practices based in the West of England, UK.

RESULTS

GPs described patients with PD as being challenging to work with and that this work required dedicated time and care. They described experiencing particular difficulty with monitoring their patient's mental health, as well as having little knowledge about the efficacy or availability of treatments for their attenders with PD. They were aware that this patient population often experienced poor mental health and reported a propensity for them to fall into the gap between primary and secondary mental health services, leaving GPs with little choice but to improvise their own management plans, which occasionally involved funding third-sector treatment options. In terms of IAPT services' role in managing these patients, GPs wanted shorter waiting times, better inter-agency communication, more highly trained therapists and more treatment options for patients with PD. They also wanted the service to be able to 'hold' patients with PD in treatment over a longer period than currently offered.

CONCLUSIONS

Findings suggest that, overall, GPs did not consider National Health Service mental health services to offer an effective treatment for patients with PD. While they considered the IAPT programme to be a valuable service for patients with less complex mental health needs, such as depression and anxiety; they felt that the current service provision struggled to meet the needs of patients with more complex mental health needs, as exemplified by people with PD.

Management of perinatal depression with non-drug interventions

Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.

Predicting treatment outcome for anxiety disorders with or without comorbid depression using clinical, imaging and (epi)genetic data

PURPOSE OF REVIEW

The present review complements previous reviews on prediction research in anxiety disorders with a focus on clinical, imaging and genetic as well as epigenetic factors and aims to provide recommendations for the design of future integrative studies in adults as well as children.

RECENT FINDINGS

Clinical factors predicting worse outcome such as a diagnosis of social anxiety disorder, comorbid depression and certain cognitive, behavioral and personality traits as well as low socioeconomic status were confirmed in large clinical studies. Imaging factors focusing on the fear and anxiety network were repeatedly described as predicting therapy response in small exploratory studies. The plethora of candidate gene studies has now been complemented by large genome-wide association studies and small epigenetic investigations with the need for replication in larger samples.

SUMMARY

The present status of research on predictors for therapy response in anxiety disorders, in particular on imaging and genetic factors, is still fragmentary. Some clinical factors for poorer outcome, though, have been consistently replicated and should be considered in the revision of therapy guidelines. There is a definite need for large integrative studies at the national and international level integrating multiple levels of biomarkers at different stages of development.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Efficacy of narrative reformulation during cognitive analytic therapy for depression: Randomized dismantling trial

BACKGROUND

Narrative reformulation (NR) is a component of cognitive analytic therapy (CAT) that is assumed to increase client engagement and improve clinical outcomes. This study set out to test these claims.

METHODS

A single-blind randomized and controlled dismantling trial investigated treatment outcomes for moderate to severely depressed patients receiving CAT in Primary Care. Ninety-five participants were randomized to either full-CAT (n = 52) or CAT minus narrative reformulation (CAT-NR, n = 43). Treatment duration in both arms was 8-sessions and was matched apart from the omission of the NR in the CAT-NR arm. The primary outcome measure was the Patient Health Questionnaire (PHQ-9), with secondary outcome measures of anxiety, functioning, helpfulness and the therapeutic alliance. Outcomes were assessed at screening, every treatment session and at 8-weeks follow-up.

RESULTS

Growth curve modelling found that NR did not enhance the efficacy of CAT for depression. There were no significant differences between groups in terms of attendance, adverse events, anxiety, functioning, helpfulness or therapeutic alliance. There were large within-group effect sizes (d₊ > 1.5), as CAT with or without NR produced significant reductions in depression (p < .01).

LIMITATIONS

The primary outcome were assessed via self-report and the follow-up period was brief.

CONCLUSIONS

These results suggest that NR may be redundant when treating depression with CAT. Whilst a brief 8-session version of the CAT model appears suitable for treating depression in Primary Care, further research regarding the need for NR is indicated.

A cost-benefit analysis of the Improving Access to Psychological Therapies programme using its key defining outcomes

The economic argument underpinning the Improving Access to Psychological Therapy programme has been a central component in its initial and continued investment. Using open-access data, this article undertook a cost-benefit analysis using the programme's key defining outcomes to determine its return-on-investment. It was found that in terms of investment and efficiency gains, the programme was in the higher ends of the cost spectrum for delivering psychological therapies. Although cost-estimates appear promising at first, when set in the context of a lower number of treatment contacts and a high proportion of early disengagement, estimates increased sharply.