Reliability and validity of DSM-IV axis V

Therapist cultural humility in early psychotherapy: A catalyst for improved client functioning at treatment termination

OBJECTIVE

Several studies have identified therapist cultural humility as an important predictor of client psychotherapy outcomes, yet most have been conducted cross-sectionally, retrospectively, and/or with inconsistent assessment of other related therapy process constructs. Here, we bridge this gap by examining early treatment ratings of therapist cultural humility, multicultural competence, working alliance, and client-centered treatment approaches as prospective predictors of client functioning in an active community clinic.

METHOD

Fifty participants (56% women, 10% gender diverse; 44% ethnoracially diverse), aged 18-69, rated these factors within 12 weeks of intake in a community mental health clinic. Therapists assessed client functioning at pre-treatment screening, diagnostic feedback, and treatment termination.

RESULTS

Multilevel modeling analyses indicated clients rating higher therapist cultural humility in early treatment had the largest improvements in therapist-rated functioning from pre-treatment to termination. Notably, the association between therapist cultural humility and client functioning at termination was moderated by ethnoracial status, with higher cultural humility ratings predicting better client functioning at termination solely for ethnoracially diverse clients.

CONCLUSION

These findings underscore the importance of integrating cultural humility instruction in training programs and therapeutic standards to promote mental health equity.

Emotional intelligence as a predictor of functional outcomes in psychotic disorders

Psychotic disorders are associated with significant impairment in psychosocial functioning, yet mechanisms associated with this impairment remain poorly understood. Emotional intelligence, a component of social cognition, is associated with psychosocial functioning in this population. However, prior work has used relatively small samples, reported inconsistent relations between functioning domains and emotional intelligence, and inconsistently considered negative symptoms. To address these limitations, we examined the predictive ability of emotional intelligence on functional outcomes using a five-year longitudinal design. We used a large sample of individuals with and without psychotic disorder diagnoses (N = 324), a performance-based measure of emotional intelligence, and three measures of functioning (i.e., social performance, assessor-rated social and occupational functioning, self-rated functioning in independent living). Results revealed individuals diagnosed with a psychotic disorder have lower emotional intelligence than those without a history of psychosis. Emotional intelligence was associated with social performance and social and occupational functioning in both those with and without a history of psychosis. In those diagnosed with a psychotic disorder, emotional intelligence and negative symptoms better predict social performance (βEmotional = 0.36, R2delta = 0.09) and social and occupational functioning (βEmotional = 0.21, R2 = 0.03), but not self-rated functioning in independent living (βEmotional = -0.08, R2delta = 0.00), as compared to negative symptoms alone. Overall, findings support the use of emotional intelligence as a longitudinal predictor of social and occupational outcomes above and beyond negative symptoms alone. This work highlights potential, specific intervention targets for individuals with psychotic disorders.

Three-year course of clinical high-risk symptoms for psychosis in the community: a latent class analysis

AIMS

Clinical high-risk for psychosis (CHR-P) states exhibit diverse clinical presentations, prompting a shift towards broader outcome assessments beyond psychosis manifestation. To elucidate more uniform clinical profiles and their trajectories, we investigated CHR-P profiles in a community sample.

METHODS

Participants (N = 829; baseline age: 16-40 years) comprised individuals from a Swiss community sample who were followed up over roughly 3 years. latent class analysis was applied to CHR-P symptom data at baseline and follow-up, and classes were examined for demographic and clinical differences, as well as stability over time.

RESULTS

Similar three-class solutions were yielded for both time points. Class 1 was mainly characterized by subtle, subjectively experienced disturbances in mental processes, including thinking, speech and perception (basic symptoms [BSs]). Class 2 was characterized by subthreshold positive psychotic symptoms (i.e., mild delusions or hallucinations) indicative of an ultra-high risk for psychosis. Class 3, the largest group (comprising over 90% of participants), exhibited the lowest probability of experiencing any psychosis-related symptoms (CHR-P symptoms). Classes 1 and 2 included more participants with functional impairment and psychiatric morbidity. Class 3 participants had a low probability of having functional deficits or mental disorders at both time points, suggesting that Class 3 was the healthiest group and that their mental health and functioning remained stable throughout the study period. While 91% of Baseline Class 3 participants remained in their class over time, most Baseline Classes 1 (74%) and Class 2 (88%) participants moved to Follow-up Class 3.

CONCLUSIONS

Despite some temporal fluctuations, CHR-P symptoms within community samples cluster into distinct subgroups, reflecting varying levels of symptom severity and risk profiles. This clustering highlights the largely distinct nature of BSs and attenuated positive symptoms within the community. The association of Classes 1 and 2 with Axis-I disorders and functional deficits emphasizes the clinical significance of CHR-P symptoms. These findings highlight the need for personalized preventive measures targeting specific risk profiles in community-based populations.

Clinical and neurocognitive profiles of a combined clinical high risk for psychosis and clinical control sample: latent class analysis

BACKGROUND

The clinical high-risk (CHR) state for psychosis demonstrates considerable clinical heterogeneity, presenting challenges for clinicians and researchers alike. Basic symptoms, to date, have largely been ignored in explorations of clinical profiles.

AIMS

We examined clinical profiles by using a broader spectrum of CHR symptoms, including not only (attenuated) psychotic, but also basic symptoms.

METHOD

Patients (N = 875) of specialised early intervention centres for psychosis in Germany and Switzerland were assessed with the Schizophrenia Proneness Instruments and the Structured Interview for Psychosis-Risk Syndromes. Latent class analysis was applied to CHR symptoms to identify clinical profiles. Additionally, demographics, other symptoms, current non-psychotic DSM-IV axis I disorders and neurocognitive variables were assessed to further describe and compare the profiles.

RESULTS

A three-class model was best fitting the data, whereby basic symptoms best differentiated between the profiles (η2 = 0.08-0.52). Class 1 had a low probability of CHR symptoms, the highest functioning and lowest other psychopathology, neurocognitive deficits and transition-to-psychosis rate. Class 2 had the highest probability of basic and (attenuated) positive symptoms (excluding hallucinations), lowest functioning, highest symptom load, most neurocognitive deficits and highest transition rate (55.1%). Class 3 was mostly characterised by attenuated hallucination, and was otherwise intermediate between the other two classes. Comorbidity rates were comparable across classes, with some class differences in diagnostic categories.

CONCLUSIONS

Our profiles based on basic and (attenuated) psychotic symptoms provide clinically useful entities by parsing out heterogeneity in clinical presentation. In future, they could guide class-specific intervention.

What predicts psychosocial functioning in borderline personality disorder? Investigating the association with reflective functioning

OBJECTIVES

The aim of this study was to investigate factors associated with functioning in participants with and without borderline personality disorder (BPD). In particular, we were interested whether mentalizing and related social cognitive capacities, as factors of internal functioning, are important in predicting psychosocial functioning, in addition to other psychopathological and sociodemographic factors.

METHOD

This is a cross-sectional study with N = 53 right-handed females with and without BPD, without significant differences in age, IQ, and socioeconomic status, who completed semi-structured diagnostic and self-report measures of social cognition. Mentalizing was assessed using the Reflective Functioning Scale based on transcribed Adult Attachment Interviews. A regularized regression with the elastic net penalty was deployed to investigate whether mentalizing and social cognition predict psychosocial functioning.

RESULTS

Borderline personality disorder symptom severity, sexual abuse trauma, and social and socio-economic factors ranked as the most important variables in predicting psychosocial functioning, while reflective functioning (RF) was somewhat less important in the prediction, social cognitive functioning and sociodemographic variables were least important.

CONCLUSIONS

Borderline personality disorder symptom severity was most important in determining functional impairment, alongside trauma related to sexual abuse as well as social and socio-economic factors. These findings verify that BPD symptoms themselves most robustly predict functional impairment, followed by history of sexual abuse, then contextual factors (e.g. housing, financial, physical health), and then RF. These results lend marginal support to the conceptualization that mentalizing may enhance psychosocial functioning by facilitating social learning, but emphasize symptom reduction and stabilization of life context as key intervention targets.

Beyond Symptoms - A Cross-Sectional Study Exploring Functioning in Psychiatric Outpatients

OBJECTIVE

This study aimed to explore factors influencing functioning in psychiatric outpatients, both separately and in combination. The primary objectives were to determine predictors of functioning, assess their significance in a combined analysis, and quantify their collective predictive power.

METHOD

A sample of 137 psychiatric outpatients diagnosed with bipolar disorder, borderline personality disorder, or attention deficit hyperactivity disorder (ADHD) participated in this cross-sectional study, undergoing semi-structured diagnostic interviews for psychiatric and personality disorders. Participants also completed assessments of current functioning, personality traits (temperament and character), attachment style, and childhood trauma. Linear regression models were employed to analyse the relationships between these factors and level of functioning.

RESULTS

The majority of temperament and character traits and attachment dimensions, as well as having a personality disorder, predicted impaired functioning, but comorbidity and childhood trauma did not. When all variables were taken into account in a multiple regression analysis, only the temperament and character traits Harm Avoidance and Self-directedness remained significantly predictive (p = .006 and .003, respectively). These two factors explain about one-third of the variance.

CONCLUSIONS

Personality traits-more specifically, the temperament trait Harm Avoidance and the character trait Self-directedness-are strong predictors of functioning among psychiatric outpatients. Interestingly, when accounting for these factors, traditionally associated variables, such as attachment, comorbidity, and childhood trauma, lost their significance as predictors. These findings underscore the pivotal role of specific personality traits in understanding and predicting the functioning of psychiatric patients.

Cognitive profiles across the psychosis continuum

Cognitive impairments are core features in individuals across the psychosis continuum and predict functional outcomes. Nevertheless, substantial variability in cognitive functioning within diagnostic groups, along with considerable overlap with healthy controls, hampers the translation of research findings into personalized treatment planning. Aligned with precision medicine, we employed a data driven machine learning method, self-organizing maps, to conduct transdiagnostic clustering based on cognitive functions in a sample comprising 228 healthy controls, 200 individuals at ultra-high risk for psychosis, and 98 antipsychotic-naïve patients with first-episode psychosis. The self-organizing maps revealed six clinically distinct cognitive profiles that significantly predicted baseline functional level and changes in functional level after one year. Cognitive flexibility in particular, as well as specific executive functions emerged as cardinal in differentiating the profiles. The application of self-organizing maps appears to be a promising approach to inform clinical decision-making based on individualized cognitive profiles, including patient allocation to different interventions. Moreover, this method has the potential to enable cross-diagnostic stratification in research trials, utilizing data-driven subgrouping informed by categories from underlying dimensions of cognition rather than from clinical diagnoses. Finally, the method enables cross-diagnostic profiling across other data modalities, such as brain networks or metabolic subtypes.

The complexity of treatment-resistant depression: A data-driven approach

BACKGROUND

Recent systematic reviews highlight great variability in defining and assessing treatment-resistant depression (TRD). A key problem is that definitions are consensus rather than data-led. This study seeks to offer a comprehensive socio-demographic and clinical description of a relevant sample.

METHODS

As part of a pragmatic randomized controlled trial, patients (N = 129) were managed in primary care for persistent depression and diagnosed with TRD. Data included previous treatment attempts, characteristics of the depressive illness, functioning, quality of life, co-occurring problems including suicidality, psychiatric and personality disorders, physical health conditions, and adverse events.

RESULTS

Findings show a severe and chronic course of depression with a duration of illness of 25+ years. Overall, 82.9 % had at least one other psychiatric diagnosis and 82.2 % at least one personality disorder; 69.8 % had significant musculoskeletal, gastrointestinal, genitourinary, or cardiovascular and respiratory physical health problems. All but 14 had severe difficulties in social and occupational functioning and reported severely impaired quality of life. Suicidal ideation was high: 44.9 % had made at least one serious suicide attempt and several reported multiple attempts with 17.8 % reporting a suicide attempt during childhood or adolescence. Of the patients, 79.8 % reported at least one adverse childhood experience.

LIMITATIONS

Potential for recall bias, not examining possible interactions, and absence of a control group.

CONCLUSIONS

Our findings reveal a complex and multifaceted condition and call for an urgent reconceptualization of TRD, which encompasses many interdependent variables and experiences. Individuals with TRD may be at a serious disadvantage in terms of receiving adequate treatment.

Group schema therapy for personality disorders: Systematic review, research agenda and treatment implications

OBJECTIVE

There are significant temporal and financial barriers for individuals with personality disorders (PD) receiving evidence-based psychological treatments. Emerging research indicates Group Schema Therapy (GST) may be an accessible, efficient, and cost-effective PD intervention, however, there has been no synthesis of the available evidence to date. This review therefore aimed to investigate the efficacy of GST for PDs by systematically synthesizing available literature.

METHOD

Five electronic databases were screened with resulting studies subjected to a specific eligibility criteria, which yielded fourteen relevant studies. Characteristics were extracted and methodological quality rigorously assessed.

RESULTS

Strong support was evidenced for GST's ability to reduce Cluster B and C symptomology, particularly for Borderline and Avoidant PD. GST appeared to improve global symptom severity, quality of life and functional capacity, as well as treatment targets such as schemas and modes.

CONCLUSION

Although not without limitations and a moderate risk of bias, the current body of evidence supports GST as a potential solution to current service deficits in economical and evidence-based care for individuals with PD. Implications for treatment and future research are discussed.

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

Demographic and clinical correlates of suicidal ideation in individuals with at-risk mental state (ARMS): A study from Pakistan

BACKGROUND

Suicide is a major public health concern and one of the leading causes of mortality worldwide. People with an at-risk-mental-state (ARMS) for psychosis are more vulnerable to psychiatric co-morbidity and suicide, however, there are limited data from low-middle-income countries. The present study aimed to identify the prevalence of depressive symptoms and suicidal ideation along with sociodemographic and clinical correlates of suicidal ideation in individuals with ARMS from Pakistan.

METHOD

Participants between the age of 16 and 35 years who met the criteria for ARMS based on the Comprehensive Assessment of At-Risk Mental State (CAARMS), were recruited from the community, general practitioner clinics and psychiatric units across Pakistan (n = 326). Montgomery and Asberg Depression Rating Scale (MADRS) and Social-Occupational-Functional-Assessment-Scale (SOFAS) were administered to participants.

RESULTS

The prevalence of depressive symptoms and suicidal thoughts in the sample at baseline were 91.1% (n = 297) and 61.0% (n = 199), respectively. There were significant mean differences between groups (mean difference [95% CI]; p-value) without suicidal ideation and with suicidal ideation on measures of MADRS (-5.47 [-7.14, -3.81]; p < .001), CAARMS non-bizarre ideas (-0.29 [-0.47, -0.11]; p = .002) and perceptual abnormalities (-0.23 [-0.41, -0.04]; p = .015).

CONCLUSION

These findings indicate that suicidal ideation and depressive symptoms are highly prevalent in individuals with ARMS in Pakistan. Given the pivotal developmental stages that ARMS presents, and the poor outcomes associated with co-morbid depression, there is an urgent need to prioritize the development of low-cost and scalable evidence-based interventions to address psychiatric comorbidity and suicidality in the ARMS population in Pakistan.

Clustering of antipsychotic-naïve patients with schizophrenia based on functional connectivity from resting-state electroencephalography

Schizophrenia is associated with aberrations in the Default Mode Network (DMN), but the clinical implications remain unclear. We applied data-driven, unsupervised machine learning based on resting-state electroencephalography (rsEEG) functional connectivity within the DMN to cluster antipsychotic-naïve patients with first-episode schizophrenia. The identified clusters were investigated with respect to psychopathological profile and cognitive deficits. Thirty-seven antipsychotic-naïve, first-episode patients with schizophrenia (mean age 24.4 (5.4); 59.5% males) and 97 matched healthy controls (mean age 24.0 (5.1); 52.6% males) underwent assessments of rsEEG, psychopathology, and cognition. Source-localized, frequency-dependent functional connectivity was estimated using Phase Lag Index (PLI). The DMN-PLI was factorized for each frequency band using principal component analysis. Clusters of patients were identified using a Gaussian mixture model and neurocognitive and psychopathological profiles of identified clusters were explored. We identified two clusters of patients based on the theta band (4-8 Hz), and two clusters based on the beta band (12-30 Hz). Baseline psychopathology could predict theta clusters with an accuracy of 69.4% (p = 0.003), primarily driven by negative symptoms. Five a priori selected cognitive functions conjointly predicted the beta clusters with an accuracy of 63.6% (p = 0.034). The two beta clusters displayed higher and lower DMN connectivity, respectively, compared to healthy controls. In conclusion, the functional connectivity within the DMN provides a novel, data-driven means to stratify patients into clinically relevant clusters. The results support the notion of biological subgroups in schizophrenia and endorse the application of data-driven methods to recognize pathophysiological patterns at earliest stage of this syndrome.

A randomized controlled trial on the effectiveness of the abridged illness management and recovery program for people with schizophrenia spectrum disorders

Objective

This study aimed to investigate the effectiveness of an abridged version of the Illness Management and Recovery Programme (AIMR) that was modified and developed in Hong Kong through a mult-centre randomized controlled trial for patients with schizophrenia spectrum disorders.

Methods

This study was implemented in 10 occupational therapy departments, psychiatric day hospitals of 7 Hospital Authority clusters in Hong Kong. A total of 211 patients with schizophrenia or schizoaffective disorder was recruited and randomized into either the experimental or the control condition. In the control group, the subjects went through conventional occupational therapy programmes. In the experimental group, the subjects went through an additional 10-session programme of AIMR.

Participants

were measured at baseline, completion of the AIMR, and 3-month after the AIMR programme. Measures include the expanded version of the Brief Psychiatric Rating Scale (BPRS-E), the client version of the Illness Management and Recovery Scale (IMRS), the Snyder Hope Scale, the Social and Occupational and Occupational Functioning Assessment Scale (SOFAS), the WHO Quality of Life Scale (WHOQOL-BREF), and the Chinese Version of the Short Warwick-Edinburgh Mental Well-Being Scale (C-SWEMWBS).

Results

Both the experimental and control cohorts had comparable clinical and socio-demographic characteristics except years of education and duration of illness. These two variables were entered as covariates in the linear mixed model which showed that the experimental group had significantly higher improvement than the control group in terms of illness management (F = 4.82; p = .03; Cohen's d = .45), functional (F = 10.65; p = .001; Cohen's d = .58), and hope (F = 5.52; p = .02; Cohen's d = .08) measures after the completion of treatment.

Conclusion

The results supported the effectiveness of the AIMR programm which would be important in the recovery oriented practices in psychiatry.

The Melbourne Study of Psychoanalytic Psychotherapy low‐cost clinic I: Implementation, mental health and life functioning gains

The Melbourne Study of Psychoanalytic Psychotherapy examined the implementation, lived experience, and perceived therapeutic gains of psychoanalytic psychotherapy in a low‐cost, private‐sector community clinic. A first in Australia, this 8‐year demonstration project allowed naturalistic study of the impact and process of intensive, long‐term, time‐limited psychoanalytic psychotherapy delivered to self‐referred adults by clinicians with a common theoretical frame of practice. Presented in three papers, the research employed the RE‐AIM planning and evaluation framework, using complementary quantitative and qualitative methods, to study the psychotherapy service in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance. This first paper reports the Reach of the program to be 67% for those presenting for assessment for psychoanalytic psychotherapy, with Adoption of the full 2‐year treatment program being 60%. Improvements in mental health and life functioning provided quantitative evidence of Effectiveness for those completing the 2‐year treatment program, with Maintenance at 8‐month follow‐up. Patient age, gender and personality characteristics did not modify these improvements. In‐depth qualitative exploration of patient and psychotherapist perspectives regarding the psychotherapy is reported in the second paper highlighting expectations, experience and benefits of the psychotherapy. The third companion paper presents the qualitative findings concerning factors experienced as facilitating or challenging therapeutic progress. Each of the three related papers amplifies understandings of how low‐cost, long‐term but time‐limited psychoanalytic psychotherapy can be implemented in the community with adults otherwise unable to afford such treatment, and discusses lessons learned.

Aging and Pubertal Development Differentially Predict Symptoms of ADHD, Depression, and Impairment in Children and Adolescents: An Eight-Year Longitudinal Study

Activational effects of the reproductive neuroendocrine system may explain why some youths with ADHD are at greater risk for exacerbated ADHD symptoms (hyperactivity, inattention, impulsivity) during adolescence. For youths diagnosed with ADHD, first signs of ADHD symptoms become noticeable by multiple reporters (e.g., teachers, parents) when children enter schools, typically around kindergarten. The current study examined possible sex differences in ADHD, impairment, and comorbidity due to pubertal effects, as the role of pubertal development in ADHD is understudied. ADHD symptoms, depressive symptoms, impairment, and pubertal stage were assessed annually by multiple reporters in a well-characterized community sample of 849 children over-recruited for ADHD over eight years. Ages ranged from 7 to 13 years (38.16% female) at wave 1. Multilevel models indicated that males had higher levels of hyperactivity, impulsivity, and inattention than females, but that females had higher levels of impairment than males. Inattention symptoms did not show marked maturation changes. Hyperactivity and impulsivity declined as youth aged and impairment increased as youth aged. Lastly, depressive symptoms largely increased as youth aged and were higher amongst youth at later pubertal stages. Put together, aging and pubertal development are associated with improved ADHD symptoms but not for youth with high impairment. Findings from this study contributes to understanding the role that aging, pubertal status, and pubertal development plays in ADHD, impairment, and comorbidity in children and adolescents.

Development and preliminary validation of the treatment adherence rating scale

BACKGROUND AND OBJECTIVES

Patient adherence to treatment is an important barrier to the implementation of evidence-based psychological treatments (EBPTs). There is a need for simple and deployable measures of patient adherence to treatment for use across EBPTs. The Treatment Adherence Rating Scale (TARS) was developed and validated in two samples.

METHODS

This study includes two samples: adults with Major Depressive Disorder who received Cognitive Therapy for depression (Sample 1; N = 48, mean age = 44.27 years), and at-risk adolescents who received either the Transdiagnostic Sleep and Circadian Intervention or Psychoeducation (Sample 2; N = 176, mean age = 14.77 years). Factor structure of the TARS scores was examined via Exploratory Factor Analyses (EFA) in Sample 1 and Confirmatory Factor Analyses (CFA) in Sample 2. Internal consistency, predictive validity, and construct validity of the TARS scores were examined.

RESULTS

Results from EFA in Sample 1 supported a one-factor model. Results from CFA in Sample 2 suggested that a two-factor model (i.e., agreement and compliance) fit better than a one-factor model. TARS scores from both samples demonstrated adequate predictive validity with primary clinical outcomes and construct validity with treatment expectations.

LIMITATIONS

The sample was small with two specific populations. Future research should focus on other patient populations, a larger population, and other EBPTs. Future research examining patient ratings of these items are needed for further validation of the TARS.

CONCLUSIONS

Preliminary findings support the use of a two-factor model and highlight the potential utility of a simple measure of patient adherence to treatment across age and diagnostic groups.

Associations between specific depressive symptoms and psychosocial functioning in psychotherapy

BACKGROUND

Psychotherapy for depression aims to reduce symptoms and to improve psychosocial functioning. We examined whether some symptoms are more important than others in the association between depression and functioning over the course of psychotherapy treatment.

METHODS

We studied associations between specific symptoms of depression (PHQ-9) and change in social and occupational functioning (SOFAS), both with structural equation models (considering liabilities of depression and each specific symptom) and with logistic regression models (considering the risk for individual patients). The study sample consisted of adult patients (n = 771) from the Finnish Psychotherapy Quality Registry (FPQR) who completed psychotherapy treatment between September 2018 and September 2021.

RESULTS

Based on our results of logistic regression analyses and SEM models, the baseline measures of depression symptoms were not associated with changes in functioning. Changes in depressed mood or hopelessness, problems with sleep, feeling tired, and feeling little interest or pleasure were associated with improved functioning during psychotherapy. The strongest evidence for symptom-specific effects was found for the symptom of depressed mood or hopelessness.

LIMITATIONS

Due to our naturalistic study design containing only two measurement points, we were unable to study the causal relationship between symptoms and functioning.

CONCLUSIONS

Changes in certain symptoms during psychotherapy may affect functioning independently of underlying depression. Knowledge about the dynamics between symptoms and functioning could be used in treatment planning or implementation. Depressed mood or hopelessness appears to have a role in the dynamic relationship between depression and functioning.

The duration of untreated psychosis among U.S. Latinxs and social and clinical correlates

Purpose

This study (a) documents the duration of untreated psychosis (DUP) and (b) examines both social and clinical correlates of DUP in a sample of U.S. Latinxs with first-episode psychosis (FEP).

Methods

Data were collected for a longitudinal study evaluating a community education campaign to help primarily Spanish-speaking Latinxs recognize psychotic symptoms and reduce the DUP, or the delay to first prescribed antipsychotic medication after the onset of psychotic symptoms. Social and clinical variables were assessed at first treatment presentation. A sequential hierarchical regression was conducted using √DUP to identify independent predictors of the DUP. A structural equation model was used to explore the association between DUP predictors, DUP, and clinical and social correlates.

Results

In a sample of 122 Latinxs with FEP, the median DUP was 39 weeks (M = 137.78, SD = 220.31; IQR = 160.39-5.57). For the full sample, being an immigrant and having self-reported relatively poor English-speaking proficiency and self-reported strong Spanish-speaking proficiency were related to a longer delay to first prescribed medication after psychosis onset. For the immigrant subgroup, being older at the time of migration was related to a longer delay. Self-reported English-speaking proficiency emerged as an independent predictor of the DUP. Although the DUP was not related to symptomatology, it was associated with poorer social functioning. Low self-reported English-speaking ability is associated with poorer social functioning via the DUP.

Conclusion

Latinxs with limited English language skills are especially at high risk for experiencing prolonged delays to care and poor social functioning. Intervention efforts to reduce the delay in Latinx communities should pay particular attention to this subgroup.

The relationship between sleep disturbance and self-harming behaviours in high-risk clinical adolescents

Emerging research has identified sleep disturbance as an important risk factor for predicting self-harming behaviours. However, the temporality of this relationship, particularly in clinical adolescent samples remains poorly understood. This study examines the relationship between sleep disturbance and self-harming behaviours (namely nonsuicidal self-injury and suicide attempts) in clinical adolescents engaging in risk-taking and self-harming behaviours using secondary analyses from a clinical cohort study. Cross-lagged structural equation modelling was used to determine whether baseline sleep disturbance and self-harming behaviours were predictors of each other over a one-year follow-up period in a sample of adolescents (n = 238, 89.5% female) attending and receiving treatment from an outpatient clinic specializing in risk-taking and self-harming behaviours. When controlling for age, sex and depressive symptoms, greater sleep disturbance (p = 0.001) at baseline independently predicted higher numbers of suicide attempts at follow-up. No bidirectional relationship was found when sleep disturbance was modelled with the frequency of nonsuicidal self-injury. This study adds to the growing evidence that sleep disturbance may predict suicidal behaviours. Clinicians should thus regularly assess for sleep disturbances when evaluating suicidal behaviours in high-risk adolescents. Further research and clinical trials should investigate whether sleep-based interventions may be efficacious in reducing the prevalence of suicidal behaviours.

Psychometric properties of the Kessler psychological scales in a Swiss young-adult community sample indicate poor suitability for community screening for mental disorders

AIM

The Kessler psychological distress scales (K10 and K6) are used as screening tools to assess psychological distress related to the likely presence of a mental disorder. Thus, we studied the psychometric properties of their German versions in a Swiss community sample to evaluate their potential usefulness to screen for mental disorders or relevant mental problems in the community and, relatedly, for low threshold transdiagnostic German-speaking services.

METHODS

The sample consisted of 829 citizens of the Swiss canton Bern of age 19-43 years. K10/K6 were validated against mini-international neuropsychiatric interview (M.I.N.I.) diagnoses, questionnaires about health status and quality of life. Receiver operating characteristic (ROC) curve analyses were used to test for general discriminative ability and to select optimal cut-offs of the K10 and K6 for non-psychotic full-blown and subthreshold mental disorders.

RESULTS

Cronbach's alphas were 0.81 (K10) and 0.70 (K6). ROC analyses indicated much lower optimal thresholds than earlier suggested; 10 for K10 and 6 for K6. At these thresholds, against M.I.N.I. diagnoses, Cohen's κ (≤0.173) and correspondence rates (≤58.14%) were insufficient throughout. Values were higher at the earlier suggested threshold, yet, at the cost of sensitivity that was below 0.5 in all but three, and below 0.3 in all but six cases.

CONCLUSIONS

For the lack of sufficient validity and sensitivity, respectively, our findings suggest that both K10 and K6 would only be of limited use in a low-threshold transdiagnostic mental health service for young adults in Switzerland and likely other German-speaking countries.

Clinical staging and the differential risks for clinical and functional outcomes in young people presenting for youth mental health care

BACKGROUND

Clinical staging proposes that youth-onset mental disorders develop progressively, and that active treatment of earlier stages should prevent progression to more severe disorders. This retrospective cohort study examined the longitudinal relationships between clinical stages and multiple clinical and functional outcomes within the first 12 months of care.

METHODS

Demographic and clinical information of 2901 young people who accessed mental health care at age 12-25 years was collected at predetermined timepoints (baseline, 3 months, 6 months, 12 months). Initial clinical stage was used to define three fixed groups for analyses (stage 1a: 'non-specific anxious or depressive symptoms', 1b: 'attenuated mood or psychotic syndromes', 2+: 'full-threshold mood or psychotic syndromes'). Logistic regression models, which controlled for age and follow-up time, were used to compare clinical and functional outcomes (role and social function, suicidal ideation, alcohol and substance misuse, physical health comorbidity, circadian disturbances) between staging groups within the initial 12 months of care.

RESULTS

Of the entire cohort, 2093 young people aged 12-25 years were followed up at least once over the first 12 months of care, with 60.4% female and a baseline mean age of 18.16 years. Longitudinally, young people at stage 2+ were more likely to develop circadian disturbances (odds ratio [OR]=2.58; CI 1.60-4.17), compared with individuals at stage 1b. Additionally, stage 1b individuals were more likely to become disengaged from education/employment (OR=2.11, CI 1.36-3.28), develop suicidal ideations (OR=1.92; CI 1.30-2.84) and circadian disturbances (OR=1.94, CI 1.31-2.86), compared to stage 1a. By contrast, we found no relationship between clinical stage and the emergence of alcohol or substance misuse and physical comorbidity.

CONCLUSIONS

The differential rates of emergence of poor clinical and functional outcomes between early versus late clinical stages support the clinical staging model's assumptions about illness trajectories for mood and psychotic syndromes. The greater risk of progression to poor outcomes in those who present with more severe syndromes may be used to guide specific intervention packages.

A Hybrid Ecological Momentary Compassion–Focused Intervention for Enhancing Resilience in Help-Seeking Young People: Prospective Study of Baseline Characteristics in the EMIcompass Trial

Background

Young people are a target population for mental health–related early intervention and prevention. Although evidence for early intervention is promising, availability of and access to youth mental health services remain limited. Therefore, the development of an evidence-based hybrid intervention is urgently needed.

Objective

This study aimed to present a manual for a hybrid intervention, combining an ecological momentary intervention and face-to-face sessions aimed for enhancing resilience in help-seeking young people based on compassion-focused interventions, and explore whether participants’ baseline characteristics are associated with putative mechanisms and outcomes of the EMIcompass intervention. Specifically, we aimed to explore initial signals as to whether participants’ sociodemographic, clinical, and functional characteristics at baseline are associated with putative mechanisms (ie, change in self-compassion, change in emotion regulation, working alliance, training frequency); and whether participants’ sociodemographic, clinical, and functional characteristics, self-compassion, and emotion regulation at baseline are associated with clinical outcomes (ie, psychological distress and general psychopathology at postintervention and 4-week follow-ups) in the experimental condition and obtain first parameter estimates.

Methods

We recruited young people aged 14 to 25 years, with psychological distress, Clinical High At-Risk Mental State, or first episodes of severe mental disorder for an exploratory randomized controlled trial with assessments at baseline and postintervention and 4-week follow-ups. A structured manual was developed and optimized based on a pilot study’s manual, a scoping review of existing literature and manuals, exchange with experts, the team’s clinical experience of working with compassion-focused interventions, and the principles of ecological momentary interventions. This analysis focuses on the experimental condition receiving the EMIcompass intervention.

Results

A total of 46 young individuals were randomized to the experimental condition. There was evidence for initial signals of effects of age (B=0.11, 95% CI 0.00-0.22), general psychopathology (B=0.08, 95% CI −0.01 to 0.16), and clinical stage (B=1.50, 95% CI 0.06-2.93) on change in momentary self-compassion and change in emotion regulation from baseline to postintervention assessments. There was no evidence for associations of other baseline characteristics (eg, gender, minority status, and level of functioning) and putative mechanisms (eg, overall self-compassion, working alliance, and training frequency). In addition, except for an initial signal for an association of momentary self-compassion at baseline and psychological distress (B=−2.83, 95% CI −5.66 to 0.00), we found no evidence that baseline characteristics related to clinical outcomes.

Conclusions

The findings indicated the reach of participants by the intervention largely independent of sociodemographic, clinical, and functional baseline characteristics. The findings need to be confirmed in a definitive trial.

Trial Registration

German Clinical Trials Register NDRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265

International Registered Report Identifier (IRRID)

RR2-10.2196/27462

[Home-Based Treatment of Multi-Problem Families (MPF): State of Research and New Results]

This article summarizes four studies of process and outcome research on family outreach therapy (ATF) with multi-problem families (MPF). We examined the relationship between different "patterns of of collaboration" and outcome variables in the treatment of MPF. Furthermore, we examined the relationship between childhood adversity factors and protective factors for the development of child psychiatric symptoms, and evaluated catamnesis data (follow-up 3 years). The paper summarizes four naturalistic studies of pre and post values and follow-up data in children aged 4-18 years, participating in an integrative, structural family therapy with (X = 115 sessions in 28.8 months, SD = 19.2). The data n = 1,031 show large effect sizes (ES) (d) (thirteen parameters, mean = 1.04, range 0.34 - 2.18). The outcome values correlate most strongly with the pattern "Improving Alliance", i. e. the improvement of the working alliance in the pre-post comparison (d = 0.64). Empirical studies on childhood adversity and protective factors showed significantly higher stress factors and significantly fewer protective factors in children from MPF compared to the non-clinical sample (95.7 % of children from MPF had a psychopathological diagnosis). The follow-up data showed stable treatment effects (three years of follow-up).The empirical research on the treatment of MPF requires further empirical studies in the sense of the treatment aptitude research on the question "what works for whom?".

Influence of mental health literacy on help-seeking behaviour for mental health problems in the Swiss young adult community: a cohort and longitudinal case-control study

Poor knowledge about mental health disorders and their treatment likely contributes to the large treatment gap reported for mental health problems. Therefore, we studied the association between mental health literacy (MHL) and active help-seeking in a community sample. Participants were recruited from an add-on questionnaire study to the 'Bern Epidemiological At-Risk' (BEAR) study on 16-40-year-old community subjects of the Swiss canton Bern. At baseline, data of N = 1504, and at 3-year follow-up, data of N = 535 were available. Based on an unlabelled case vignette (on depression or schizophrenia), MHL was assessed by the questionnaire of Angermeyer and colleagues. Cross-sectional and longitudinal baseline predictors of help-seeking were analysed using path analyses. Additionally, sensitivity analyses of the prospective model were computed for sex, vignette, and baseline mental health problems/disorders. Cross-sectionally, help-seeking was associated with non-endorsement of biogenetic causal explanations, presence of mental health problems/disorders, help-seeking before baseline, poorer functioning, and lower health satisfaction. The prospective model was similar; yet, help-seeking at follow-up was associated with endorsements of the causal explanation 'biogenetics' and, additionally, 'childhood trauma' but not the presence of baseline mental health problems/disorders. Sensitivity analyses revealed a significant impact on sex, vignette, and mental health problems/disorders. For example, actual functional problems were predictive in males, while health satisfaction was predictive in females. Our findings indicate that future studies on drivers of help-seeking should assess very large community samples with case vignettes on different mental disorders to examine appropriate subgroups and their likely interaction to address group-specific factors in awareness campaigns.

The Impact of Electroconvulsive Therapy on Negative Symptoms in Schizophrenia and Their Association with Clinical Outcomes

OBJECTIVE

The treatment efficacy of electroconvulsive therapy (ECT) for negative symptoms amongst patients with schizophrenia remains unclear. In this study, we aim to examine the effects of ECT on negative symptoms in schizophrenia and their association with other clinical outcomes, including cognition and function.

METHODS

This is a retrospective data analysis of patients with schizophrenia/schizoaffective disorder treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and December 2019. Clinical outcomes were assessed by the Brief Psychiatric Rating Scale (BPRS), the Montreal Cognitive Assessment (MoCA), and Global Assessment of Function (GAF). Changes in scores were compared with repeated measures analysis of variance. Sequential structural modelling was utilized to examine the pathway relationships between changes in negative symptoms, global functioning, and cognition functioning after ECT.

RESULTS

A total of 340 patients were analysed. Hence, 196 (57.6%), 53 (15.5%), and 91 (26.7%) showed improvements, no change, and deterioration in negative symptoms, respectively. ECT-induced improvement of negative symptoms was significantly associated with improvement of global functioning (direct effect correlation coefficient (r): -0.496; se: 0.152; p = 0.001) and cognition function (indirect effect r: -0.077; se: 0.037; p = 0.035). Moreover, having capacity to consent, more severe baseline negative symptoms, lithium prescription, and an indirect effect of voluntary admission status via consent capacity predicted ECT associated negative symptoms improvement.

CONCLUSION

ECT is generally associated with improvements of negative symptoms in people with schizophrenia, which correlate with improvements of overall function. Possible novel clinical predictors of negative symptom improvement have been identified and will require further research and validation.

Is social functioning in older age patients with bipolar disorder associated with affective and/or non-affective cognition?

OBJECTIVES

Previous research showed impairments in non-affective cognition, affective cognition, and social functioning in adult patients with bipolar disorder (BD). Only 37% of adult BD patients recovers in social functioning, and both aspects of cognition are important constructs of influence. The role of affective cognition in older age bipolar disorder (OABD) patients is still unclear. Therefore, the aim of our study was to examine the separate and combined effects of affective cognition and non-affective cognition on social functioning.

METHODS

The current study included 60 euthymic patients (aged >60) of the Dutch Older Bipolar Study. Affective cognition was measured by Theory of Mind and Emotion Recognition. Non-affective cognition was assessed through the measurements of attention, learning and memory, and executive functioning. Social functioning was examined through global social functioning, social participation, and meaningful contacts. The research questions were tested with linear and ordinal regression analyses.

RESULTS

Results showed a positive association of all non-affective cognitive domains with global social functioning. Associations between affective cognition and social functioning were non-significant. Results did show an interaction between non-affective and affective cognition.

CONCLUSIONS

Associations between non-affective cognition and social functioning were confirmed, associations between affective cognition and social function were not found. For generalizability, studies with a greater sample size are needed. Conducting additional research about OABD patients and affective cognition is important. It may lead to more insight in impairment and guide tailored treatment that focusses more on all aspects of recovery and the needs of OABD patients.

Symptom changes in patients with pre-existing psychiatric disorders in the initial phase of the COVID-19 pandemic: Vulnerability of female patients and patients with mood disorders

How patients with pre-existing psychiatric disorders are responding to the COVID-19 pandemic remains unclear, and no comprehensive studies have yet been performed. To elucidate (1) which psychiatric disorders were exacerbated during the initial phase of the COVID-19 pandemic and (2) the contributing factors, we prospectively assessed psychiatric symptoms of 1592 psychiatric outpatients in a single-center study using the Global Assessment of Functioning (GAF) before the state of emergency was declared in Japan and during two months under the state of emergency (study period: April 8 to June 7, 2020). We conducted a chi-squared test for the relationship between psychiatric diagnostic category (ICD-10) and exacerbation. To control for confounders, we conducted a logistic regression analysis using sex, age, diagnostic category, and pre-pandemic GAF score as independent variables. Exacerbation rates of patients with mood disorders (F3) and neurotic disorders (F4) were 4.32% and 5.37%, respectively, and were significantly higher than those for patients with organic disorders (F0) and schizophrenic disorders (F2) (X² (9, N = 1592) = 27.8, p < .01). Logistic regression analysis revealed that patients with F3 and female patients were significantly more affected than patients with other disorders or male patients, respectively (odds ratio (95% confidence interval) = 2.4 (1.2-4.6), p < .01 for F3; 3.1 (1.5-6.6), p < .01 for females). These findings suggest a need for careful management of patients with mood disorders and female psychiatric patients during a pandemic.

Payment schemes and treatment responses after a demand shock in mental health care

We study whether two groups of mental health care providers-each paid according to a different payment scheme-adjusted the duration of their patients' treatments after they faced an exogenous 20% drop in the number of patients. For the first group of providers, self-employed providers, we find that they did not increase treatment duration to recoup their income loss. Treatment duration thresholds in the stepwise fee-for-service payment function seem to have prevented these providers to treat patients longer. For the second group of providers, large mental health care institutions who were subject to a budget constraint, we find an average increase in treatment duration of 8%. Prior rationing combined with professional uncertainty can explain this increase. We find suggestive evidence for overtreatment of patients as the longer treatments did not result in better patient outcomes, i.e. better General Assessment of Functioning scores.

Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial

Importance

Although the importance of recovery-oriented care for people with severe mental illness (SMI) is widely acknowledged, essential elements such as personalization and involvement of significant others are not adequately implemented in practice.

Objective

To determine whether using resource groups (RGs) within flexible assertive community treatment (FACT) has favorable effects on empowerment and recovery-related outcomes in people with SMI.

Design, Setting, and Participants

This assessor-blind, multisite randomized clinical trial was conducted from September 1, 2017, to September 30, 2020, with follow-up at 9 and 18 months. A total of 158 participants aged 18 to 65 years meeting the criteria for SMI were randomly allocated to FACT plus RG vs FACT as usual (1:1) in 20 FACT teams throughout the Netherlands. Data were analyzed from September 1, 2020, to January 31, 2021. The study was prespecified in the trial protocol and data from the intent-to-treat population were analyzed.

Interventions

In the FACT plus RG condition, patients chose members from their informal and formal networks to form an RG that meets quarterly to discuss self-formulated recovery goals. The RG was integrated into the multidisciplinary support provided by the FACT team. In the FACT as-usual condition, empowerment (defined as overcoming powerlessness and gaining control of one's life) and involvement of significant others was also part of the provided care, but without the structure of the RG.

Main Outcomes and Measures

The primary outcome was self-reported empowerment, measured with the Netherlands Empowerment List.

Results

A total of 158 participants with SMI (median age, 38 [median absolute deviation, 13] years; 93 men [58.9%]) were randomized to FACT plus RG (n = 80) or FACT as usual (n = 78) care. Intention-to-treat analyses showed that randomization to the RG condition was associated with a clinically significant increase in empowerment (Cohen d, 0.54; 95% CI, 0.21-0.86) and improved outcomes with small to medium effect sizes in terms of quality of life (Cohen d, 0.25; 95% CI, -0.07 to 0.56), personal recovery (Cohen d, 0.38; 95% CI, 0.06-0.69), quality of social contact (Cohen d, 0.24; 95% CI, -0.07 to 0.56), disability (Cohen d, 0.29; 95% CI, -0.03 to 0.60), general functioning (Cohen d, 0.30; 95% CI, -0.01 to 0.62), and social functioning (Cohen d, 0.28; 95% CI, -0.04 to 0.59). No differences between conditions were found regarding psychopathological symptoms, attachment, frequency of social contact, and employment. Compared with FACT as usual, participants who stayed with the assigned treatment in the RG condition were more satisfied with treatment at 9 (Cohen d = 0.45; t135 = -2.62; P = .009) and 18 (Cohen d = 0.41; t116 = -2.22; P = .02) months.

Conclusions and Relevance

These findings show that working with RGs improves empowerment and other mental health outcomes in people with SMI who receive community-based mental health services. This method of network-oriented care empowers people with SMI within their own environment.

Trial Registration

Netherlands Trial Register Identifier: NL6548.

Effectiveness of therapeutic milieu intervention on inpatients with depressive disorder: A feasibility study from North India

PURPOSE

This study examined therapeutic milieu interventions on self-esteem, socio-occupational functioning, and depressive symptoms among inpatients with depressive disorders.

METHODS

A pretest-posttest nonequivalent control group quasi-experimental design was adopted. Sixty participants with depression who got admitted to the general hospital psychiatric ward were assigned to a control (Treatment as Usual) group and an experimental (therapeutic milieu intervention) group nonrandomly using a convenience sampling technique. We evaluated the following outcome measures: self-esteem, socio-occupational functioning, and depressive symptoms for both groups at baseline, 4th, 8th, and 12th weeks.

RESULTS

Therapeutic milieu interventions improved self-esteem, socio-occupational functioning, and reduced depressive symptoms. The findings provided initial evidence for practice.

IMPLICATIONS

Psychiatric nurses can implement simple, milieu therapy interventions in any setting, which will enhance the clinical outcomes and socio-occupational functioning of depressive patients.

Deep Brain Stimulation of the Nucleus Accumbens, Ventral Striatum, or Internal Capsule Targets for Medication-Resistant Obsessive-Compulsive Disorder: A Multicenter Study

BACKGROUND

Deep brain stimulation of the nucleus accumbens, ventral striatum, or internal capsule region has shown a 45%-60% response rate in adults with severe treatment-refractory obsessive-compulsive disorder, regardless of which target is used. We sought to improve the effectiveness of deep brain stimulation by placing the electrode along a trajectory including these 3 targets, enabling a change of stimulation site depending on the patient's response.

METHODS

This study used the medical records of 14 patients from 4 different Spanish institutions: 7 from the Hospital Universitario La Princesa, 3 from the Hospital Universitario Central de Asturias, 2 from Hospital Universitario Fundación Jiménez Díaz, and 2 from Hospital Universitari Son Espases. All patients were operated on under the same protocol. Qualitative and quantitative data were collected.

RESULTS

Of 14 patients, 11 showed significant improvement in obsessive-compulsive disorder symptoms, as evident in a reduction ≥35% in Yale-Brown Obsessive Compulsive Scale scores following stimulation relative to preoperative scores. Seven patients responded to stimulation at the nucleus accumbens (the first area we set for stimulation), whereas 4 patients needed to have the active contact switched to the internal capsule to benefit from stimulation.

CONCLUSIONS

Deep brain stimulation of the nucleus accumbens, internal capsule, and ventral striatum significantly benefited our cohort of patients with medication-resistant obsessive-compulsive disorder. Electrode insertion through the 3 main targets might confer additional therapeutic efficacy.

Off-label use of antipsychotic medications in psychiatric inpatients in China: a national real-world survey

BACKGROUND

The off-label use of antipsychotic medications is common in many countries, and the extent of such use in psychiatric inpatients in China has not been sufficiently studied. The purpose of this study was to survey the incidence and examine the correlates of off-label antipsychotic use in a large, nationally-representative sample in China.

METHODS

This study included discharged psychiatric patients between March 19 and 31, 2019 from 41 tertiary psychiatric hospitals across 29 provinces in China. Their socio-demographic and clinical data were collected and analyzed.

RESULTS

After excluding patients with schizophrenia spectrum disorder or bipolar disorder, 981 patients were included in the analysis. Overall, antipsychotics were prescribed to 63.2% (95%CI 60.2-66.2%) of the sample. Antipsychotics were used in a wide spectrum of psychiatric disorders, with the rate being the highest among patients with dissociative (conversion) disorders (89.9, 95%CI 83.0-94.8%), organic mental disorders (81.7, 95%CI 73.1-88.7%), dementia (79.0,95%CI 67.8-87.9%), obsessive-compulsive disorder (77.8, 95%CI 55.7-92.5%), mental disorders due to psychoactive substances (75.3,95%CI 64.7-84.2%), behavioural and emotional disorders with onset usually occurring in childhood and adolescence (71.4, 95%CI 45.5-90.1%), somatoform disorders (63.2, 95%CI 40.8%-82..2%), major depression disorder (53.7,95%CI 48.8-58.6%), anxiety disorder (38.8,95%CI 30.5-47.7%), and insomnia (25.0, 95%CI 8.5-28.9%). The top three most commonly used antipsychotics were olanzapine (29.1%), quetiapine (20.3%) and risperidone (6.8%), and their corresponding average doses were 9.04 ± 5.80 mg/day, 185.13 ± 174.72 mg/day, and 2.98 ± 1.71 mg/day, respectively. A binary logistic regression showed that younger age, having the Employee Health Insurance or Residents Health Insurance, having psychotic symptoms and requiring restraint during hospitalization were significantly associated with off-label use of antipsychotics.

CONCLUSION

Off-label use of antipsychotics is very common in psychiatric inpatients in China, mainly with moderate-dose use of single agents. However, the efficacy and safety of this practice is uncertain for many diagnoses and for the elderly. Clinicians should be cautious about this practice while waiting for more research data.

The effect of N-acetylcysteine on bipolar depression: a systematic review and meta-analysis of randomized controlled trials

RATIONALE

The current pharmacotherapy of bipolar depression often presents limited efficacy and increased risk for adverse events. N-acetylcysteine (NAC) has been suggested as potentially effective and well-tolerated adjunctive treatment for bipolar disorder (BD).

OBJECTIVES

This systematic review and meta-analysis aimed to examine the efficacy of N-acetylcysteine, as an adjunctive therapy, for treating bipolar depression.

METHODS

PubMed, Cochrane Library, Scopus databases, and grey literature were searched for studies retrieval. Randomized controlled trials including patients with a diagnosed bipolar disorder and a current depressive episode were included in the analysis. The measured variables included symptoms, functioning, and quality of life scales. The mean change in Montgomery-Åsberg Depression Rating Scale (MADRS) was set as the primary outcome.

RESULTS

A total of five studies were included in the analysis. A significant improvement was not observed from the addition of NAC to standard therapy in symptomatology [MADRS (MD = -3.32; 95% CI = -12.79 to 6.16), Young Mania Rating Scale (MD = -0.7; 95% CI = -2.15 to 0.75), Bipolar Depression Rating Scale (MD = -3.19; 95% CI = -15.48 to 9.1), and Clinical Global Impression for severity (MD = -0.13; 95% CI = -0.33 to 0.08)], functioning, [Global Assessment of Functioning Scale (MD = 3.21; 95% CI = -12.55 to 18.97), Social and Occupational Functioning Assessment Scale (MD = 0.47; 95% CI = -4.60 to 5.53), or quality of life [Quality of Life Enjoyment and Satisfaction Questionnaire (MD = 2.27; 95% CI = -9.13 to 13.67)].

CONCLUSIONS

There is no evidence indicating that NAC has beneficial effects as an adjunctive treatment for bipolar depression. Future trials with improved methodological design and efficient sample sizes are required to draw safer conclusions.

Effect of an online healthy lifestyle psychoeducation programme to improve cardiometabolic outcomes and affective symptoms in youth receiving mental health care: study protocol for a pilot clinical trial

INTRODUCTION

Worsened cardiometabolic profiles in youth with mental ill health have been associated with a number of modifiable lifestyle risk factors. It is becoming increasingly evident that clinical interventions need to be multimodal in focus to improve mental health symptoms and the physical health symptoms in this already at-risk cohort.

METHODS AND ANALYSIS

This 12-week pilot clinical trial examines the efficacy, feasibility and acceptability of an adjunctive online psychoeducation programme for improving cardiometabolic risk parameters and affective symptoms in a transdiagnostic sample of at least 44 young people aged 16-25 years presenting for mental healthcare for mood and/or psychotic syndromes (including anxiety, depression, bipolar disorder and psychosis). Individuals will be invited to participate in a pilot clinical trial for a structured online psychoeducation programme incorporating nutritional, physical activity, sleep-wake and healthy lifestyle information, delivered fortnightly over six online modules. Participants will undergo a series of assessments including: (1) self-report and clinician administered assessments determining mental health symptomatology; (2) fasting blood tests to assess cardiometabolic markers (fasting insulin, fasting glucose and blood lipids); (3) anthropometric assessments (height, weight, waist circumference and blood pressure); and (4) sleep-wake behaviours and circadian rhythm assessments. Changes in scores for all cardiometabolic and affective measures will be assessed via paired samples t-tests, and correlations between change scores will be assessed via Pearson's or Spearman's correlations. Feasibility will be assessed via completion rates, and the acceptability of the programme will be assessed via programme satisfaction measures.

ETHICS AND DISSEMINATION

This pilot clinical trial has been approved by the Sydney Local Health District Research Ethics and Governance Office (X20-0228 & 2020/ETH01201). The results of this pilot clinical trial will be disseminated into the scientific and broader community through peer-reviewed journals, conference presentations, social media and university websites.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12620000772943, Date 28 August 2020.

Neurobiology Youth Follow-up Study: protocol to establish a longitudinal and prospective research database using multimodal assessments for current and past mental health treatment-seeking young people within an early intervention service

INTRODUCTION

Approximately 75% of major mental illness occurs before the age of 25 years. Despite this, our capacity to provide effective, early and personalised interventions is limited by insufficient evidence for characterising early-stage, and less specific, presentations of major mental disorders in youth populations. This article describes the protocol for setting up a large-scale database that will collect longitudinal, prospective data that incorporate clinical, social and occupational function, neuropsychological, circadian, metabolic, family history and genetic metrics. By collecting data in a research-purposed, standardised manner, the 'Neurobiology Youth Follow-up Study' should improve identification, characterisation and profiling of youth attending mental healthcare, to better inform diagnosis and treatment at critical time points. The overall goal is enhanced long-term clinical and functional outcomes.

METHODS AND ANALYSIS

This longitudinal clinical cohort study will invite participation from youth (12-30 years) who seek help for mental health-related issues at an early intervention service (headspace Camperdown) and linked services. Participants will be prospectively tracked over 3 years with a series of standardised multimodal assessments at baseline, 6, 12, 24 and 36 months. Evaluations will include: (1) clinician-administered and self-report assessments determining clinical stage, pathophysiological pathways to illness, diagnosis, symptomatology, social and occupational function; (2) neuropsychological profile; (3) sleep-wake patterns and circadian rhythms; (4) metabolic markers and (5) genetics. These data will be used to: (1) model the impact of demographic, phenomenological and treatment variables, on clinical and functional outcomes; (2) map neurobiological profiles and changes onto a transdiagnostic clinical stage and pathophysiological mechanisms framework.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Human Research Ethics Committee of the Sydney Local Health District (2020/ETH01272, protocol V.1.3, 14 October 2020). Research findings will be disseminated through peer-reviewed journals and presentations at scientific conferences and to user and advocacy groups. Participant data will be de-identified.

Double blind randomized controlled trial of deep brain stimulation for obsessive-compulsive disorder: Clinical trial design

Obsessive-compulsive disorder (OCD), a leading cause of disability, affects ~1–2% of the population, and can be distressing and disabling. About 1/3 of individuals demonstrate poor responsiveness to conventional treatments. A small proportion of these individuals may be deep brain stimulation (DBS) candidates. Candidacy is assessed through a multidisciplinary process including assessment of illness severity, chronicity, and functional impact. Optimization failure, despite multiple treatments, is critical during screening. Few patients nationwide are eligible for OCD DBS and thus a multi-center approach was necessary to obtain adequate sample size. The study was conducted over a six-year period and was a NIH-funded, eight-center sham-controlled trial of DBS targeting the ventral capsule/ventral striatum (VC/VS) region. There were 269 individuals who initially contacted the sites, in order to achieve 27 participants enrolled. Study enrollment required extensive review for eligibility, which was overseen by an independent advisory board. Disabling OCD had to be persistent for ≥5 years despite exhaustive medication and behavioral treatment. The final cohort was derived from a detailed consent process that included consent monitoring. Mean illness duration was 27.2 years. OCD symptom subtypes and psychiatric comorbidities varied, but all had severe disability with impaired quality of life and functioning. Participants were randomized to receive sham or active DBS for three months. Following this period, all participants received active DBS. Treatment assignment was masked to participants and raters and assessments were blinded. The final sample was consistent in demographic characteristics and clinical features when compared to other contemporary published prospective studies of OCD DBS. We report the clinical trial design, methods, and general demographics of this OCD DBS sample.

Premorbid adjustment amongst outpatients with schizophrenia in a Nigerian psychiatric facility

BACKGROUND

Studies from developed countries have shown that poor premorbid adjustment in patients with schizophrenia is associated with poor outcome. However, similar studies in developing countries like Nigeria are few despite the stability of schizophrenia prevalence across cultures.

AIM

The aim of this study was to assess the prevalence and correlates of poor premorbid adjustment amongst outpatients with schizophrenia.

SETTING

The Neuropsychiatric Hospital, Abeokuta in Ogun State, Nigeria.

METHODS

The premorbid adjustment of 300 outpatients with schizophrenia was assessed using the premorbid adjustment scale. Pattern and severity of psychosis, overall illness severity, global assessment of functioning and socio-demographic factors were investigated as correlates of premorbid functioning.

RESULTS

About half (53.3%) of the respondents had poor premorbid adjustment and most of them were males (56.9%). Poor premorbid adjustment was associated with male gender (χ 2 = 7.81, p = 0.005) whilst good premorbid adjustment was associated with no or borderline illness severity (χ 2 = 8.26, p = 0.016) as well as no or mild impairment in functioning (χ 2 = 7.01, p = 0.029) amongst the respondents. Positive, negative and general symptomatology were predicted by premorbid adjustment at different developmental stages.

CONCLUSION

Consistent with existing literature, poor premorbid adjustment was prevalent amongst patients with schizophrenia in this study and was associated with male gender, poorer clinical outcomes and greater illness severity. Mental health promotion and other preventative approaches are recommended as possible early intervention strategies in dealing with schizophrenia.

Patient crying during psychotherapy intake sessions: Relationship to patient characteristics and early treatment process

The aim of the present study is to further the understanding of who cries at the beginning of psychotherapy and patients' experience of crying in that process. Intake sessions for 53 patients beginning psychotherapy at a university-based clinic were coded for discrete crying segments. Data about patient characteristics were also collected at intake. Results indicate that crying during intake sessions was related to lower global functioning and higher severity of childhood sexual abuse. Furthermore, patients who cried at intake were over four times more likely to also cry at feedback, and those who cried at feedback were almost 12 times more likely to have cried at intake. Finally, crying in the intake session did not appear to be related to patient- or therapist-rated working alliance. Overall, the present study provides valuable information about characteristics of patients who cry at the outset of the therapy process and patients' experience of crying over time in therapy. Findings suggest the need for further research on patient characteristics and aspects of the therapy process that may predict patient crying over the course of treatment, as well as how these early crying experiences may be related to eventual patient outcomes.

Development of a patient rated scale for mental health global state for use during humanitarian interventions

OBJECTIVE

We present the results of a cross-cultural validation of the Mental Health Global State (MHGS) scale for adults and adolescents (<14 years old).

METHODS

We performed two independent studies using mixed methods among 103 patients in Hebron, Occupied Palestinian Territories and 106 in Cauca, Colombia. The MHGS was analyzed psychometrically, sensitivity and specificity, ability to detect clinically meaningful change, compared to the Clinical Global Impression-Severity scale (CGI-S). Principal component analysis was used to reduce the number of questions after data collection.

RESULTS

The scale demonstrated good internal consistency, with a Cronbach alpha score of 0.80 in both settings. Test retest reliability was high, ICC 0.70 (95% CI [0.41-0.85]) in Hebron and 0.87 (95% CI [0.76-0.93]) in Cauca; inter-rater reliability was 0.70 (95% CI [0.42-0.85]) in Hebron and 0.76 (95% CI [0.57-0.88]) in Cauca. Psychometric properties were also good, and the tool demonstrated a sensitivity of 85% in Hebron and 100% in Cauca, with corresponding specificity of 80% and 79%, when compared to CGI-S.

CONCLUSIONS

The MHGS showed promising results to assess global mental health thereby providing an additional easy to use tool in humanitarian interventions. Additional work should focus on validation in at least one more context, to adhere to best practices in transcultural validation.

Multimodal versus unimodal auditory hallucinations in clinical practice: Clinical characteristics and treatment outcomes

Psychological treatments for hallucinations typically target auditory verbal hallucinations (AVH) but neglect the influence of hallucinations in other sensory modalities. This study compared the baseline clinical characteristics and therapeutic outcomes (following brief Coping Strategy Enhancement) of adult clients (N = 100) with multimodal or unimodal (auditory) hallucinations attending an outpatient service for distressing AVH. The results showed that 72.1% of clients reported multimodal hallucinations in the past month. Group comparisons of most baseline clinical characteristics (AVH features, beliefs about AVH, number of traumatic events, personal and social functioning, negative affect) were non-significant. However, in the subgroup (N = 65) reporting ongoing effects of traumatic events, those with multimodal hallucinations reported significantly higher posttraumatic stress symptoms (d = 0.62). Notably, both multimodal and unimodal hallucination groups showed improvement in AVH distress and frequency post-treatment, but group differences in treatment outcomes were not significant. These findings, in a naturalistic service setting, confirm that multimodal hallucinations are common in people seeking help for distressing AVH and may be associated with higher levels of posttraumatic stress symptoms. Importantly, they also suggest that psychological therapy may be suitable and effective for clients experiencing AVH - irrespective of the presence of hallucinations in other sensory modalities.

Neurocognitive functioning predicts suicidal behaviour in young people with affective disorders

BACKGROUND

Neurocognitive impairment is recognised as a risk factor for suicidal behaviour in adults. The current study aims to determine whether neurocognitive deficits also predict ongoing or emergent suicidal behaviour in young people with affective disorders.

METHODS

Participants were aged 12-30 years and presented to early intervention youth mental health clinics between 2008 and 2018. In addition to clinical assessment a standardised neurocognitive assessment was conducted at baseline. Clinical data was extracted from subsequent visits using a standardised proforma.

RESULTS

Of the 635 participants who met inclusion criteria (mean age 19.6 years, 59% female, average follow up 476 days) 104 (16%) reported suicidal behaviour during care. In 5 of the 10 neurocognitive domains tested (cognitive flexibility, processing speed, working memory, verbal memory and visuospatial memory) those with suicidal behaviour during care were superior to clinical controls. Better general neurocognitive function remained a significant predictor (OR=1.94, 95% CI 1.29- 2.94) of suicidal behaviour in care after controlling for other risk factors.

LIMITATIONS

The neurocognitive battery used was designed for use with affective and psychotic disorders and may not have detected some deficits more specific to suicidal behaviour.

CONCLUSION

Contrary to expectations, better neurocognitive functioning predicts suicidal behaviour during care in young people with affective disorders. While other populations with suicidal behaviour, such as adults with affective disorders or young people with psychotic disorders, tend to experience neurocognitive deficits which may limit their capacity to engage in some interventions, this does not appear to be the case for young people with affective disorders.

Piloting the 'Youth Early-intervention Study' ('YES'): Preliminary functional outcomes of a randomized controlled trial targeting social participation and physical well-being in young people with emerging mental disorders

INTRODUCTION

Young people with mental disorders present with diverse social, vocational, physical, and developmental needs. However, multifaceted interventions are rare. We examine the effectiveness of a clinical trial targeting social participation and physical well-being in young people accessing clinical services.

METHODS

The 'Youth Early-intervention Study' ('YES') was an unblinded, two-phase, pilot randomized controlled trial offered as an adjunct to standard clinical care, consisting of group activities. Mixed effects models were used to examine functional outcomes over time measured by the 'Social and Occupational Functioning Assessment Scale', 'Functioning Assessment Short Test', and 'Brief Disability Questionnaire' (items 7 and 8).

RESULTS

133 participants aged 14-25 were recruited. 87 participants completed both arms and 83 participants completed a 12-month post-trial assessment. Functioning improved across all outcomes. While diagnoses differed in functioning at baseline (lower functioning in psychotic and bipolar disorders compared to depression), they did not differ in the rate of improvement across any measure. Randomization groups did not differ in baseline functioning or the rate of improvement, suggesting a non-specific impact of the intervention. Engagement with education increased from 11% at baseline to 51% at 12-months post-trial and full-time employment increased from 8% at baseline to 20% at 12-months post-trial.

LIMITATIONS

Small sample, no control group, and unmeasured potential moderators (e.g. neurocognitive impairment).

CONCLUSIONS

'YES' was effective and preliminary positive outcomes were observed across all functional outcomes. Future studies should compare the 'YES' intervention to a treatment-as-usual control condition and conduct a multi-centre trial across early intervention service sites.

A prospective international multi-center study on safety and efficacy of deep brain stimulation for resistant obsessive-compulsive disorder

Deep brain stimulation (DBS) has been proposed for severe, chronic, treatment-refractory obsessive-compulsive disorder (OCD) patients. Although serious adverse events can occur, only a few studies report on the safety profile of DBS for psychiatric disorders. In a prospective, open-label, interventional multi-center study, we examined the safety and efficacy of electrical stimulation in 30 patients with DBS electrodes bilaterally implanted in the anterior limb of the internal capsule. Safety, efficacy, and functionality assessments were performed at 3, 6, and 12 months post implant. An independent Clinical Events Committee classified and coded all adverse events (AEs) according to EN ISO14155:2011. All patients experienced AEs (195 in total), with the majority of these being mild (52% of all AEs) or moderate (37%). Median time to resolution was 22 days for all AEs and the etiology with the highest AE incidence was 'programming/stimulation' (in 26 patients), followed by 'New illness, injury, condition' (13 patients) and 'pre-existing condition, worsening or exacerbation' (11 patients). Sixteen patients reported a total of 36 serious AEs (eight of them in one single patient), mainly transient anxiety and affective symptoms worsening (20 SAEs). Regarding efficacy measures, Y-BOCS reduction was 42% at 12 months and the responder rate was 60%. Improvements in GAF, CGI, and EuroQol-5D index scores were also observed. In sum, although some severe AEs occurred, most AEs were mild or moderate, transient and related to programming/stimulation and tended to resolve by adjustment of stimulation. In a severely treatment-resistant population, this open-label study supports that the potential benefits outweigh the potential risks of DBS.

Modelling change in neurocognition, symptoms and functioning in young people with emerging mental disorders

Mental disorders and their functional impacts evolve dynamically over time. Neurocognition and clinical symptoms are commonly modelled as predictors of functioning, however, studies tend to rely on static variables and adult samples with chronic disorders, with limited research investigating change in these variables in young people with emerging mental disorders. These relationships were explored in a longitudinal clinical cohort of young people accessing early intervention mental health services in Australia, around three-quarters of whom presented with a mood disorder (N = 176, aged 12-30 at baseline). Bivariate latent change score models quantified associations between neurocognition (a latent variable of working memory, verbal memory, visuospatial memory, and cognitive flexibility), global clinical symptoms, and functioning (self- and clinician-rated) and their relative change over follow-up (median = 20 months). We found that longitudinal changes in functioning were coupled with changes in global clinical symptoms (β = -0.43, P < 0.001), such that improvement in functioning was related to improvement in clinical symptoms. Changes in neurocognition were not significantly associated with changes in functioning or clinical symptoms. Main findings were upheld in three sensitivity analyses restricting the sample to: (a) adults aged 18-30; (b) participants with 12-24 months of follow-up; and (c) participants without a psychotic disorder. Our findings show that global symptom reduction and functional improvement are related in young people with emerging mental disorders. More work is needed to determine the temporal precedence of change in these variables. Future studies should apply this methodology to intervention studies to untangle the causal dynamics between neurocognition, symptoms, and functioning.

Cognitive remediation plus standard treatment versus standard treatment alone for individuals at ultra-high risk of developing psychosis: Results of the FOCUS randomised clinical trial

BACKGROUND

Individuals at ultra-high risk (UHR) for psychosis have significant cognitive deficits that can impede functional recovery. Applying cognitive remediation (CR) before the onset of frank psychosis may improve the cognitive and functional prognosis of UHR individuals, however, little is known about the feasibility and efficacy of CR for this population.

METHODS

In this randomised, clinical trial 146 individuals at UHR for psychosis aged 18-40 years were randomly assigned to treatment as usual (TAU) or TAU plus cognitive remediation. The CR targeted neurocognitive and social cognitive remediation. Assessments were carried out at 6- and 12-months post baseline.

RESULTS

A total of 73 UHR individuals were assigned to TAU and 73 assigned to TAU + cognitive remediation. Compared to the control group, cognitive remediation did not result in significant improvement on the primary outcome; the Brief Assessment of Cognition in Schizophrenia composite score at 6-month follow-up (b = -0.125, 95%CI: -0.23 to 0.172, p = 0.41). Nor did the intervention improve secondary outcomes in clinical symptoms or functioning. Exploratory analyses found emotion recognition latencies to be significantly more reduced in the intervention group at 6-months. At 12-months, the intervention group exhibited significantly better performance on two measures of executive function and visual memory.

CONCLUSION

The 20-session treatment protocol was not well received in the UHR group, and unsurprisingly global measures did not improve. The benefit found in isolated neuro- and social cognitive measures after even a few sessions points to a potential for cognitive malleability if people can be engaged sufficiently to practice the skills. Trial registration ClinicalTrial.gov identifier: NCT02098408.

Facilitating Recovery of Daily Functioning in People With a Severe Mental Illness Who Need Longer-Term Intensive Psychiatric Services: Results From a Cluster Randomized Controlled Trial on Cognitive Adaptation Training Delivered by Nurses

BACKGROUND

Feasible and effective interventions to improve daily functioning in people with a severe mental illness (SMI), such as schizophrenia, in need of longer-term rehabilitation are scarce.

AIMS

We assessed the effectiveness of Cognitive Adaptation Training (CAT), a compensatory intervention to improve daily functioning, modified into a nursing intervention.

METHOD

In this cluster randomized controlled trial, 12 nursing teams were randomized to CAT in addition to treatment as usual (CAT; n = 42) or TAU (n = 47). Daily functioning (primary outcome) was assessed every 3 months for 1 year. Additional follow-up assessments were performed for the CAT group in the second year. Secondary outcomes were assessed every 6 months. Data were analyzed using multilevel modeling.

RESULTS

CAT participants improved significantly on daily functioning, executive functioning, and visual attention after 12 months compared to TAU. Improvements were maintained after 24 months. Improved executive functioning was related to improved daily functioning. Other secondary outcomes (quality of life, empowerment, negative symptoms) showed no significant effects.

CONCLUSIONS

As a nursing intervention, CAT leads to maintained improvements in daily functioning, and may improve executive functioning and visual attention in people with SMI in need of longer-term intensive psychiatric care. Given the paucity of evidence-based interventions in this population, CAT can become a valuable addition to recovery-oriented care.

Establishing the dose of memory support to improve patient memory for treatment and treatment outcome

BACKGROUND AND OBJECTIVES

Patient memory for the contents of treatment sessions is poor and this is associated with worse treatment outcome. Preliminary findings indicate that treatment provider use of memory support can be helpful in enhancing patient memory for treatment and improving outcome. The development of a novel Memory Support Intervention is currently underway. A key step in this process is to establish the dose of memory support that treatment providers deliver in treatment-as-usual, as well as the optimal dose of memory support needed to maximize patient memory for treatment points and outcomes.

METHODS

Forty-two adults with major depressive disorder (MDD) were randomized to receive either cognitive therapy plus memory support (CS + Memory Support; n = 22) or cognitive therapy as-usual (CT-as-usual; n = 20). Patients completed a free recall of treatment points task at post-treatment. Outcome measures were administered at baseline and post-treatment.

RESULTS

Treatment providers delivering CT-as-usual used, on average, 8.39 instances of memory support and 3.40 different types of memory support per session. Receiver Operating Characteristics (ROC) analyses using the combined sample indicate that 12.45 instances of memory support and 3.88 to 4.13 different types of memory support are needed to maximize patient recall and functional outcome.

LIMITATIONS

Dosing recommendations were established using a limited sample of participants receiving cognitive therapy for MDD.

CONCLUSIONS

Treatment providers appear to deliver a suboptimal amount of memory support. Delivering the optimal dose of memory support could improve treatment outcome.

Can broad-spectrum multinutrients treat symptoms of antenatal depression and anxiety and improve infant development? Study protocol of a double blind, randomized, controlled trial (the 'NUTRIMUM' trial)

BACKGROUND

Untreated antenatal depression and anxiety can be associated with short and long term health impacts on the pregnant woman, her infant and the rest of the family. Alternative interventions to those currently available are needed. This clinical trial aims to investigate the efficacy and safety of a broad-spectrum multinutrient formula as a treatment for symptoms of depression and anxiety in pregnant women and to determine the impact supplementation has on the general health and development of the infant.

METHODS

This randomised, controlled trial will be conducted in Canterbury, New Zealand between April 2017 and June 2022. One hundred and twenty women aged over 16 years, between 12 and 24 weeks gestation and who score ≥ 13 on the Edinburgh Postnatal Depression Scale (EPDS) will be randomly assigned to take the intervention (n = 60) or an active control formula containing iodine and riboflavin (n = 60) for 12 weeks. After 12 weeks, participants can enter an open-label phase until the birth of their infant and naturalistically followed for the first 12 months postpartum. Infants will be followed until 12 months of age. Randomisation will be computer-generated, with allocation concealment by opaque sequentially numbered envelopes. Participants and the research team including data analysts will be blinded to group assignment. The EPDS and the Clinical Global Impressions Scale of Improvement (CGI-I) will be the maternal primary outcome measures of this study and will assess the incidence of depression and anxiety and the improvement of symptomatology respectively. Generalized linear mixed effects regression models will analyse statistical differences between the multinutrient and active control group on an intent-to-treat basis. A minimum of a three-point difference in EPDS scores between the groups will identify clinical significance. Pregnancy outcomes, adverse events and side effects will also be monitored and reported.

DISCUSSION

Should the multinutrient formula be shown to be beneficial for both the mother and the infant, then an alternative treatment option that may also improve the biopsychosocial development of their infants can be provided for pregnant women experiencing symptoms of depression and anxiety.

TRIAL REGISTRATION

Trial ID: ACTRN12617000354381 ; prospectively registered at Australian New Zealand Clinical Trials Registry on 08/03/2017.

Baseline measures of cerebral glutamate and GABA levels in individuals at ultrahigh risk for psychosis: Implications for clinical outcome after 12 months

Background.

Cerebral glutamate and gamma-aminobutyric acid (GABA) levels might predict clinical outcome in individuals at ultrahigh risk (UHR) for psychosis but have previously primarily been investigated in smaller cohorts. We aimed to study whether baseline levels of glutamate and GABA in anterior cingulate cortex (ACC) and glutamate in thalamus could predict remission status and whether baseline metabolites differed in the remission versus the nonremission group. We also investigated the relationship between baseline metabolite levels and severity of clinical symptoms, functional outcome, and cognitive deficits at follow-up.

Methods.

About 124 UHR individuals were recruited at baseline. In this, 74 UHR individuals were clinically and cognitively assessed after 12 months, while remission status was available for 81 (25 remission/56 nonremission). Glutamate and GABA levels were assessed at baseline using 3 T proton magnetic resonance spectroscopy. Psychopathology, symptom severity, and remission were assessed with the Comprehensive Assessment of At-Risk Mental States and Clinical Global Impression and functional outcome with the Social and Occupational Functioning Assessment Scale. Cognitive function was estimated with the Cambridge Neuropsychological Test Automated Battery.

Results.

There were no differences between baseline glutamate and GABA levels in subjects in the nonremission group compared with the remission group, and baseline metabolites could not predict remission status. However, higher baseline levels of GABA in ACC were associated with clinical global improvement (r = −0.34, N = 51, p = 0.01) in an explorative analysis.

Conclusions.

The variety in findings across studies suggests a probable multifactorial influence on clinical outcome in UHR individuals. Future studies should combine multimodal approaches to attempt prediction of long-term outcome.