Does the network structure of obsessive-compulsive symptoms at treatment admission identify patients at risk for non-response?

Using network analysis to characterize clinical improvement during cognitive processing therapy

OBJECTIVE

Cross-sectional network studies find mixed results regarding changes in network structure as a response to treatment across disorders. This study characterized improvement in mental health following Cognitive Processing Therapy (CPT) for PTSD in veterans from the perspective of network psychometrics and explored how cross-sectional networks inform our understanding of PTSD recovery.

METHODS

Veterans with PTSD participated in CPT-based intensive treatment programs (ITPs), offered in two-week (N = 635) or three-week (N = 457) formats. PTSD symptoms were self-reported on the PTSD Checklist for DSM-5 (PCL-5) at pre-, mid-, and post-treatment. Cross-sectional networks for each time point were compared using network comparison tests. Linear regression tested if the relationship of initial treatment gains from admission to mid-treatment with overall outcomes was associated with the expected influence centrality of a node.

RESULTS

Substantial improvement in PTSD symptoms were found, but network structure remained largely unaffected, with global edge strength increasing from pre-to post-treatment. Initial treatment gains in nodes with high expected influence were associated with overall treatment outcomes. A post-hoc simulation based on a common-cause model produced similar regression results, indicating that while our findings align with spreading activation, they are not exclusive to this mechanism.

CONCLUSION

The indiscernibility of cross-sectional networks between pre- and post-treatment raises questions about whether cross-sectional networks can illuminate PTSD recovery beyond traditional measures of treatment response.

A network analysis of mechanisms of change during exposures over the course of intensive OCD treatment

Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). Theories for how it works vary in their emphasis on active mechanisms of change. The current study aimed to clarify mechanisms of change in ERP for OCD using network analysis, comparing ERP networks at the start and end of intensive treatment (partial hospital and residential). In our sample of 182 patients, the most central node in both networks was engagement with exposure, which was consistently related to greater understanding of ERP rationale, higher willingness, and less ritualization, accounting for all other variables in the network. There were no significant differences in networks between the start and end of treatment. These results suggest that nonspecific parameters like facilitating engagement in exposures without ritualizing and providing a clear rationale to clients may be key to effective treatment. As such, it may be useful for clinicians to spend adequate time underscoring the need to eliminate rituals to fully engage in exposure tasks and explaining the rationale for ERP prior to doing exposures, regardless of theoretical orientation. Nonetheless, findings represent group-level statistics and more fine-grained idiographic analyses may reveal individual-level differences with respect to central mechanisms of change. Other limitations include demographic homogeneity of our sample.

Associations among the workplace violence, burnout, depressive symptoms, suicidality, and turnover intention in training physicians: a network analysis of nationwide survey

Depression and anxiety are the most common mental disorders among physicians, who have a greater risk of suicide than those in other professional occupations. Relationships among a demanding workload, workplace violence, burnout, and intention to turnover have also been reported. The current study examined the principal components and propagating patterns of mental health and working environment interactions in training physicians. A total of 1981 training physicians completed online self-report questionnaires during September-October (midpoint of the training year) 2020. Regularized partial correlations in a mixed graphical model (MGM) and joint probability distributions (directed acyclic graph; DAG) were estimated for four subtypes of workplace violence (verbal abuse/physical violence perpetrated by clients/hospital staff), three burnout subdomains (Maslach Burnout Inventory), thoughts about quitting, and nine depressive symptoms, including suicidality, comprising the DSM-5 diagnostic criteria for major depressive disorder (assessed using the Patient Health Questionnaire-9). Thoughts of death/self-harm showed directional dependencies on the joint probability distributions of psychomotor agitation/retardation, concentration difficulty, self-reproach, and sadness in the DAG. In the MGM, a partial correlation with psychomotor agitation/retardation (r = 0.196) accounted for 56.5% of the variance in thoughts of death/self-harm. Partial correlations with concentration difficulties (r = 0.294), self-reproach (r = 0.257), changes in appetite (r = 0.184), and worker-on-worker physical violence (r = 0.240) in the MGM accounted for 54.4% of the variance in psychomotor agitation/retardation. Thoughts about quitting were partially correlated with and dependent upon the joint probability distributions of emotional exhaustion (r = 0.222), fatigue (r = 0.142), anhedonia (r = 0.178), and sadness (r = 0.237). In contrast, worker-on-worker (r = 0.417) and client-on-physician (r = 0.167) verbal abuse had regularized partial correlations with directional dependencies on thoughts about quitting. Organization-level interventions aiming to reduce the worker-on-worker violence and individual-level approaches of clinical screening program and psychiatric counseling clinic are required. Follow-up studies to verify the effectiveness of these interventions for training physicians are needed.