How people with persistent pain experience in-person physiotherapy blended with biopsychosocial digital health - A qualitative study on participants' experiences with Back2Action

Background

A blended intervention consisting of in-person physiotherapy and psychologically-informed digital health, called Back2Action, was developed to optimise the management of people with persistent spinal pain who also have psychosocial risk factors associated with the development or maintenance of persistent pain. This study aimed to gain insights in how participants experienced this blended intervention.

Methods

A qualitative study using semi-structured interviews was conducted. Eleven people with persistent non-specific spinal pain who received the blended intervention within a randomised clinical trial were included. All interviews were recorded, transcribed verbatim and analysed independently by two researchers. Data were analysed using a thematic analysis.

Results

The analysis identified four themes: (1) Experiencing a better understanding of the relationship between own physical and mental health; (2) Importance of the physiotherapist's active involvement in biopsychosocial blended care, which describes the crucial role of physiotherapists in supporting participants in this; (3) Appreciation of digital health, to better understand persistent pain and make meaningful lifestyle changes; and (4) Trials and triumphs, revealing gains such as better coping, but also challenges with implementation of changes into long-term routines.

Conclusion

Participants of the blended intervention experienced positive changes in thoughts and behaviours, which highlights the feasibility and acceptability of the blended intervention as a more holistic treatment within pain management. The differences in personal preferences for receiving psychologically-informed digital health poses challenges for implementation of blended biopsychosocial care in evidence-based practice.

E-Health intervention for subthreshold depression: Reach and two-year effects of a randomized controlled trial

BACKGROUND

There is evidence for e-Health interventions for full-blown depression. Little is known regarding commonly untreated subthreshold depression in primary care. This randomized controlled multi-centre trial assessed reach and two-year-effects of a proactive e-Health intervention (ActiLife) for patients with subthreshold depression.

METHODS

Primary care and hospital patients were screened for subthreshold depression. Over 6 months, ActiLife participants received three individualized feedback letters and weekly messages promoting self-help strategies against depression, e.g., dealing with unhelpful thoughts or behavioural activation. The primary outcome depressive symptom severity (Patient Health Questionnaire;PHQ-8) and secondary outcomes were assessed 6, 12 and 24 months.

RESULTS

Of those invited, n = 618(49.2 %) agreed to participate. Of them, 456 completed the baseline interview and were randomized to ActiLife (n = 227) or assessment only (n = 226). Generalised estimation equation analyses adjusting for site, setting and baseline depression revealed that depressive symptom severity declined over time, with no significant group differences at 6 (mean difference = 0.47 points; d = 0.12) and 24 months (mean difference = -0.05 points; d = -0.01). Potential adverse effects were observed at 12 months, with higher depressive symptom severity for ActiLife than control participants (mean difference = 1.33 points; d = 0.35). No significant differences in rates of reliable deterioration or reliable improvement of depressive symptoms were observed. ActiLife increased applied self-help strategies at 6 (mean difference = 0.32; d = 0.27) and 24 months (mean difference = 0.22; d = 0.19), but not at 12 months (mean difference = 0.18; d = 0.15).

LIMITATIONS

Self-report measures and lack of information on patients' mental health treatment.

DISCUSSION

ActiLife yielded satisfactory reach and increased the use of self-help strategies. Data were inconclusive in terms of depressive symptom changes.

Remote mental health care interventions during the COVID-19 pandemic: An umbrella review

Mitigating the COVID-19 related disruptions in mental health care services is crucial in a time of increased mental health disorders. Numerous reviews have been conducted on the process of implementing technology-based mental health care during the pandemic. The research question of this umbrella review was to examine what the impact of COVID-19 was on access and delivery of mental health services and how mental health services have changed during the pandemic. A systematic search for systematic reviews and meta-analyses was conducted up to August 12, 2022, and 38 systematic reviews were identified. Main disruptions during COVID-19 were reduced access to outpatient mental health care and reduced admissions and earlier discharge from inpatient care. In response, synchronous telemental health tools such as videoconferencing were used to provide remote care similar to pre-COVID care, and to a lesser extent asynchronous virtual mental health tools such as apps. Implementation of synchronous tools were facilitated by time-efficiency and flexibility during the pandemic but there was a lack of accessibility for specific vulnerable populations. Main barriers among practitioners and patients to use digital mental health tools were poor technological literacy, particularly when preexisting inequalities existed, and beliefs about reduced therapeutic alliance particularly in case of severe mental disorders. Absence of organizational support for technological implementation of digital mental health interventions due to inadequate IT infrastructure, lack of funding, as well as lack of privacy and safety, challenged implementation during COVID-19. Reviews were of low to moderate quality, covered heterogeneously designed primary studies and lacked findings of implementation in low- and middle-income countries. These gaps in the evidence were particularly prevalent in studies conducted early in the pandemic. This umbrella review shows that during the COVID-19 pandemic, practitioners and mental health care institutions mainly used synchronous telemental health tools, and to a lesser degree asynchronous tools to enable continued access to mental health care for patients. Numerous barriers to these tools were identified, and call for further improvements. In addition, more high quality research into comparative effectiveness and working mechanisms may improve scalability of mental health care in general and in future infectious disease outbreaks.

A risk algorithm that predicts alcohol use disorders among college students

The first year of college may carry especially high risk for onset of alcohol use disorders. We assessed the one-year incidence of alcohol use disorders (AUD) among incoming first-year students, predictors of AUD-incidence, prediction accuracy and population impact. A prospective cohort study of first-year college students (baseline: N = 5843; response rate = 51.8%; 1-year follow-up: n = 1959; conditional response rate = 41.6%) at a large university in Belgium was conducted. AUD were evaluated with the AUDIT and baseline predictors with the Composite International Diagnostic Interview Screening Scales (CIDI-SC). The one-year incidence of AUD was 3.9% (SE = 0.4). The most important individual-level baseline predictors of AUD incidence were being male (OR = 1.53; 95% CI = 1.12-2.10), a break-up with a romantic partner (OR = 1.67; 95% CI = 1.08-2.59), hazardous drinking (OR = 3.36; 95% CI = 1.31-8.63), and alcohol use characteristics at baseline (ORs between 1.29 and 1.38). Multivariate cross-validated prediction (cross-validated AUC = 0.887) shows that 55.5% of incident AUD cases occurred among the 10% of students at highest predicted risk (20.1% predicted incidence in this highest-risk subgroup). Four out of five students with incident AUD would hypothetically be preventable if baseline hazardous drinking was to be eliminated along with a reduction of one standard deviation in alcohol use characteristics scores, and another 15.0% would potentially be preventable if all 12-month stressful events were eliminated. Screening at college entrance is a promising strategy to identify students at risk of transitioning to more problematic drinking and AUD, thus improving the development and deployment of targeted preventive interventions.

Scalable psychological interventions for Syrian refugees: Preliminary results of a randomized controlled trial on the peer-refugee delivered Problem Management Plus (PM+) intervention in the Netherlands

Introduction

In the past decade, millions of Syrians have sought refuge in neighboring countries and Europe. Refugees are at increased risk for the development of common mental disorders (CMD), such as depression and posttraumatic stress disorder (PTSD), but only a small percentage access mental health services. Problem Management Plus (PM+) is a brief, scalable intervention targeting symptoms of CMDs that can be delivered by non-specialist helpers in communities affected by adversity, such as refugees.

Objectives

The aim of this randomized controlled trial (RCT) is to evaluate the effectiveness of PM+ among Syrian refugees in the Netherlands.

Methods

Adult Syrian refugees and other Arabic-speaking refugees of 18 years and older with self-reported psychological distress (K10 >15) and functional impairment (WHODAS 2.0 >16) are included. Participants are randomized into PM+ or care as usual. Follow-up assessments are conducted at one-week, three-month and twelve-month follow-ups. Clinical outcomes are symptoms of depression/anxiety (HSCL-25), PTSD (PCL-5), and functional impairment (WHODAS 2.0).

Results

By November 2021 [recruitment ends by December 2021], 214 participants were screened for eligibility and 184 participants were included. Participants are M=36.5yrs old (range 18-69yrs), and 73 participants are female (39.7%). We will present preliminary results for the effects of PM+ on depression, anxiety, PTSD, and functional impairment at one-week follow-up, as well as barriers and facilitators for implementing PM+ in a European country.

Conclusions

After positive evaluation of peer-refugee delivered PM+, the Arabic manual and training materials will be made available through WHO to encourage scaling-up.

Disclosure

No significant relationships.

A systematic review and meta-analysis of the diagnostic accuracy of self-report screening instruments for common mental disorders in Arabic-speaking adults

Introduction

Self-report questionnaires to screen for symptoms of common mental disorders (CMDs) are commonly used as inexpensive, easy-to-administer tools in research and clinical practice. However, their validity to detect the presence of any CMD across cultures and languages is unclear. Psychometrically sound and brief case-finding instruments are vital for the identification of individuals with mental health needs. With the increasing number of Arabic-speaking refugees in Europe, we aim to evaluate the diagnostic accuracy of Arabic-language screening instruments.

Objectives

The aim of this systematic review/meta-analysis is to synthesize the diagnostic accuracy of self-report questionnaires to detect depression, anxiety and posttraumatic stress disorder (PTSD) in Arabic-speaking populations.

Methods

Five databases were searched (inception-January 2021) (PROSPERO: CRD42018070645) for studies on the diagnostic accuracy of brief questionnaires in Arabic-speaking populations, with a clinical interview as reference standard. Data on sensitivity/specificity were extracted/calculated. Multi-threshold meta-analyses were performed (R diagmeta package). Study quality was assessed using QUADAS-2.

Results

We included 32 studies (N=4042 participants) reporting on questionnaires targeting depression/anxiety (14 questionnaires), distress (2 questionnaires), and PTSD (1 questionnaire). Optimal thresholds were identified for the Edinburgh Postnatal Depression Scale (EPDS; cut-off 11, sensitivity 76.9%, specificity 85.1%), Hospital Anxiety and Depression Scale (HADS) anxiety subscale (cut-off 7, sensitivity 81.9%, specificity 87.6%), depression subscale (cut-off 6, sensitivity 73.0%, specificity 88.6%), and Self-Reporting Questionnaire (SRQ-20; cut-off 8, sensitivity 86.0%, specificity 83.9%).

Conclusions

We present optimal thresholds that can be used by clinicians and researchers for the EPDS, HADS and SRQ-20. More research on Arabic-language questionnaires, especially those targeting PTSD, is needed.

Disclosure

No significant relationships.

The prevalence of common mental disorders among Syrian refugees resettled in The Netherlands

Introduction

Refugees are at elevated risk of developing common mental disorders (CMD) as they may have been exposed to stressors and traumatic experiences before, during and after their movement. However, prevalence rates of CMDs among refugees reported across studies vary strongly.

Objectives

To examine the prevalence of CMDs (PTSD, anxiety, depression and somatic disorder) among Syrian refugees in the Netherlands, and the diagnostic accuracy of self-reporting questionnaires in Arabic.

Methods

A sample of N=1339 adult Syrian refugees was randomly selected from the Dutch national population registry. Participants were approached in December 2020-March 2021 to complete questionnaires on symptoms of PTSD (PCL-5), anxiety/depression (HSCL-25), and somatic disorder (SSS-8). After the survey, a sub-sample was invited for a clinical interview using the Structured Clinical Interview for DSM-5 (SCID-5) to enquire about the presence or absence of PTSD, anxiety, depression or somatic disorder.

Results

In total, 407 participants (53.6% female, M age=34.2yrs, SD=14.1) completed the survey. The majority (65.9%) arrived in the Netherlands in 2015-2017. Using a cut-off of PCL-5 ³33, 75 participants (18.4%) reported probable PTSD. Using a cut-off of ³1.83 on the HSCL-25 depression subscale and ³1.75 on the anxiety subscale, 153 participants (37.6%) reported depression and 135 (33.2%) reported anxiety, and using a cut-off of ³12.0 on the SSS-8, 121 (29.8%) reported somatic complaints. A sub-sample of 214 participants (52.6%) were followed-up with the SCID-5. Psychometric properties will be presented.

Conclusions

Syrian refugees in the Netherlands are at high risk for the development of a CMD. Implications, strengths and limitations of the study will be discussed.

Disclosure

No significant relationships.

45 Years of Research on Psychotherapy for Depression: Lessons for the Future

More than 800 randomised controlled trials have examined the effects of psychotherapies for depression and compared psychotherapies with control conditions, with each other, with pharmacotherapy and with combined treatments. These trials have also examined the effects of therapies in specific target groups, such as women with perinatal depression, children and adolescents, older adults, people with general medical disorders and many others. Furthermore, the effects have not just been examined on depressive symptoms, but also on other outcomes, such as quality of life, functional limitations and social support. In this presentation I will present the results of a large meta-analytic project in which new trials are continuously added. I will show that the most important therapies are effective, that most therapies have comparable effects, that these effects remain significant up to one year follow up and that the therapies are effective in most specific groups. But meta-analyses should also be considered with caution, because they overestimate the effects of therapies. The effects of therapies are comparable to those of pharmacotherapy, but at the longer term psychotherapies are more effective. Combined therapy is more effective than either one alone, at the short and longer term.

Group problem management plus (PM+) to decrease psychological distress among Syrian refugees in Turkey: a pilot randomised controlled trial

BACKGROUND

Syrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul, Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention.

METHODS

Refugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses.

RESULTS

There were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementation. The study was not powered to detect an effect. No significant difference between gPM+ and E-CAU group on primary and secondary outcome measures, or in economic impacts were found.

CONCLUSIONS

gPM+ delivered by non-specialist peer providers seemed to be an acceptable, feasible and safe intervention for Syrian refugees in Turkey with elevated levels of psychological distress. This pilot RCT sets the stage for a fully powered RCT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03567083 ; date: 25/06/2018.

Reasons for not reaching or using web-based self-management applications, and the use and evaluation of Oncokompas among cancer survivors, in the context of a randomised controlled trial

INTRODUCTION

The web-based self-management application Oncokompas was developed to support cancer survivors to monitor health-related quality of life and symptoms (Measure) and to provide tailored information (Learn) and supportive care options (Act). In a previously reported randomised controlled trial (RCT), 68% of 655 recruited survivors were eligible, and of those 45% participated in the RCT. Among participants of the RCT that were randomised to the intervention group, 52% used Oncokompas as intended. The aim of this study was to explore reasons for not participating in the RCT, and reasons for not using Oncokompas among non-users, and the use and evaluation of Oncokompas among users.

METHODS

Reasons for not participating were assessed with a study-specific questionnaire among 243 survivors who declined participation. Usage was investigated among 320 participants randomised to the intervention group of the RCT via system data and a study-specific questionnaire that was assessed during the 1 week follow-up (T1) assessment.

RESULTS

Main reasons for not participating were not interested in participation in scientific research (40%) and not interested in scientific research and Oncokompas (28%). Main reasons for not being interested in Oncokompas were wanting to leave the period of being ill behind (29%), no symptom burden (23%), or lacking internet skills (18%). Out of the 320 participants in the intervention group 167 (52%) used Oncokompas as intended. Among 72 non-users, main reasons for not using Oncokompas were no symptom burden (32%) or lack of time (26%). Among 248 survivors that activated their account, satisfaction and user-friendliness were rated with a 7 (scale 0-10). Within 3 (IQR 1-4) sessions, users selected 32 (IQR 6-37) topics. Main reasons for not using healthcare options in Act were that the information in Learn was already sufficient (44%) or no supportive care needs (32%).

DISCUSSION

Main reasons for not reaching or using Oncokompas were no symptom burden, no supportive care needs, or lack of time. Users selected many cancer-generic and tumour-specific topics to address, indicating added value of the wide range of available topics.

Targets and outcomes of psychotherapies for mental disorders

Because the causal pathways to mental disorders are largely unknown, it is also difficult to decide what the targets and outcomes of psychotherapies should be. In this presentation I will give an overview of the main types of targets and outcomes of therapies, as well as a brief overview of some of the main results of research on these types. The most important outcomes are symptom reduction, personal targets and outcomes from the patient’s perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes, and economic outcomes. By far the most research has focused on symptom reduction. In this presentation I will focus on psychotehrapies in general, but will illustrate the findings with research on psychotherapies for depression, because these have been examined most extensively. Furthermore, the perspective of different stakeholders will be presented: Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes. The perspective of patients should have more priority in research and standardization of measures across trials is much needed.

Disclosure

No significant relationships.

Which psychotherapy is effective in panic disorder? Findings and reflections from a systematic network meta-analysis

Introduction

Panic disorder is among the most prevalent anxiety diseases. Although psychotherapy is recommended as first-line treatment for panic disorder, little is known about the relative efficacy of different types of psychotherapies.

Objectives

To evaluate the effectiveness and acceptability of different types of psychotherapies for adults suffering from panic disorder, with or without agoraphobia.

Methods

We are conducting a systematic network meta-analysis of randomized controlled trials examining panic disorder. A comprehensive search was performed to identify relevant studies. The primary efficacy outcome is anxiety symptoms at study endpoint. The primary acceptability outcome is all-cause trial discontinuation at endpoint. Pairwise and network meta-analysis will be conducted. We are considering any kind of psychotherapy delivered by any therapist, as long as they were trained to deliver the therapy, or as self-help.

Results

To date we have identified 126 panic disorder and agoraphobia trials. The publication time span ranges from 1968 to 2020. We are now extracting data to provide an overview of the included study characteristics. The statistical analysis will be conducted between December 2020 and January 2021, and its results presented for the first time at the forthcoming 2021 EPA congress.

Conclusions

126 trials on psychotherapy for panic disorders in adults are available. Because of this huge body of knowledge, it is important that the results of these studies are summarized using network meta-analytic techniques. The findings of this study will guide future research as knowledge gaps will be easily identified. Moreover, policymakers will have the opportunity to use this summarized knowledge to inform evidence-based decision making.

Disclosure

No significant relationships.

The eHealth self-management application 'Oncokompas' that supports cancer survivors to improve health-related quality of life and reduce symptoms: which groups benefit most?

BACKGROUND

Oncokompas is a web-based self-management application that supports cancer survivors to monitor their health-related quality of life (HRQOL) and symptoms, and to obtain personalised feedback and tailored options for supportive care. In a large randomised controlled trial among survivors of head and neck cancer, colorectal cancer, and breast cancer and (non-)Hodgkin lymphoma, Oncokompas proved to improve HRQOL, and to reduce several tumour-specific symptoms. Effect sizes were however small, and no effect was observed on the primary outcome patient activation. Therefore, this study aims to explore which subgroups of cancer survivors may especially benefit from Oncokompas.

MATERIALS AND METHODS

Cancer survivors (n = 625) were randomly assigned to the intervention group (access to Oncokompas, n = 320) or control group (6 months waiting list, n = 305). Outcome measures were HRQOL, tumour-specific symptoms, and patient activation. Potential moderators included socio-demographic (sex, age, marital status, education, employment), clinical (tumour type, stage, time since diagnosis, treatment modality, comorbidities), and personal factors (self-efficacy, personal control, health literacy, Internet use), and patient activation, mental adjustment to cancer, HRQOL, symptoms, and need for supportive care, measured at baseline. Linear mixed models were performed to investigate potential moderators.

RESULTS

The intervention effect on HRQOL was the largest among cancer survivors with low to moderate self-efficacy, and among those with high personal control and those with high health literacy scores. Cancer survivors with higher baseline symptom scores benefitted more on head and neck (pain in the mouth, social eating, swallowing, coughing, trismus), and colorectal cancer (weight) specific symptoms.

DISCUSSION

Oncokompas seems most effective in reducing symptoms in head and neck cancer and colorectal cancer survivors who report a higher burden of tumour-specific symptoms. Oncokompas seems most effective in improving HRQOL in cancer survivors with lower self-efficacy, and in cancer survivors with higher personal control, and higher health literacy.

[Prevention of depression: State-of-the-art and new opportunities]

background In the past 25 years, 50 randomised controlled trials have examined the effects of preventive interventions on preventing the onset of new depressive disorders. aim To describe the state of affairs in research into the prevention of depression. method Narrative review of the field. results These trials have shown that preventive interventies can indeed prevent the onset of depression in some cases. The absolute effects of the interventions are, however, modest and most trial participants don't develop a disorder, also not when they don't get an intervention. An important challenge for the future is to strengthen the effects of the interventions and to identify high-risk groups with higher absolute risk to develop a disorder. Another challenge is to increase participation rates. conclusion Innovations, such as new methods to identify high-risk groups, better and more efficient interventions and 'indirect' prevention offer new possibilities to improve the field of prevention. Tijdschrift voor Psychiatrie 63(2021)2, 129-132.

[Major depressive episode in college freshmen: prevalence, academic functioning and receipt of treatment]

Background Little is known about the epidemiology of Major Depressive Episode (mde) in university students. Aim To investigate the prevalence of mde, psychiatric comorbidity, and the association with academic performance among first-year university students, and to investigate to what extent these students use professional mental health services. Method All first-year students at the ku Leuven (Leuven, Belgium) were invited to complete a computer-assisted survey with a weighted cross-sectional design (N=5,460; response rate corrected for drop-out=51.8%). mde was assessed using the Composite International Diagnostic Interview - Screening Scales (cidi-sc) with dsm-iv criteria. Results We found that 13.6% of first-year students met criteria for a cidi-sc mde in the past year. mde was associated with a wide range of other comorbid disorders (such as generalized anxiety disorder or hypo[mania]) and suicidal thoughts and behaviors. mde was associated with significantly lower academic year percentage (-3.6 to -6.4%) and elevated odds of academic year failure (ors=1.5-2.0). Professional service use was estimated at 21.5%. Conclusion mde is common among first-year university students and is associated with a high degree of psychiatric comorbidity and poor academic performance. It is therefore surprising that so few students actually receive treatment for their psychiatric and emotional problems. Tijdschrift voor Psychiatrie 63(2021)1, 24-31.

Body image distress in head and neck cancer patients: what are we looking at?

PURPOSE

The aim of the present study is to investigate the prevalence of body image distress among head and neck cancer (HNC) patients after treatment and to examine its association with sociodemographic and clinical factors, health-related quality of life (HRQOL), HNC symptoms, sexuality, self-compassion, and psychological distress. Second, we aim to explore daily life experiences of HNC patients regarding body image.

METHODS

A cross-sectional survey among HNC patients investigated the prevalence of body image distress based on the Body Image Scale. Multivariable logistic regression analysis was applied to study associations with sociodemographic and clinical factors, HRQOL (EORTC QLQ-C30), HNC symptoms (QLQ-HN43), sexuality (FSFI-6; IIEF-5), self-compassion (SCS-SF), and psychological distress (HADS). Qualitative data from a body image writing intervention was used to explore experiences in daily life related to body image.

RESULTS

Body image distress was prevalent in 13-20% (depending on cut-off scores) of 233 HNC patients. Symptoms of depression (p < 0.001), younger age (p < 0.001), problems with social contact (p = 0.001), problems with wound healing (p = 0.013), and larger extent of surgery (p = 0.014) were associated with having body image distress. This model explained 67% of variance. Writing interventions of 40 HNC patients showed that negative body image experiences were related to appearance and function, with social functioning problems described most often.

CONCLUSION

Prevalence of body image distress in HNC patients, using different cut-off scores, is 13-20%. Younger patients, patients after extensive surgery, and patients who had wound healing problems are most at risk. There is a significant association between body image distress and depressive symptoms and social functioning.

Adaptation of the Problem Management Plus programme for Syrian, Eritrean and Afghan refugee youth

Background

Common mental health problems are prevalent among refugee minors and impair their daily functioning. Due to various barriers such as lack of culturally appropriate treatments, waiting lists, and stigma they have limited access to care. Problem Management Plus (PM+) was developed by the World Health Organization to address these barriers. PM+ is transdiagnostic, delivered by non-professional helpers, and consists of 5 sessions of problem-solving skills, behavioural activation and stress management. PM+ is effective in reducing adults' distress and improve functioning. We aimed to adapt PM+ for refugee minors and add an emotional processing module to target symptoms of posttraumatic stress disorder.

Methods

We culturally and contextually adapted PM+ for use in Syrian, Eritrean and Afghan refugee minors (age 16-18 years). Data were collected through: 1) free list interviews with Syrian, Eritrean and Afghan refugee minors (n = 30), 2) key informant interviews with knowledgeable refugees (n = 6), professionals (n = 6), policy makers (n = 6) and 3) focus group discussions (n = 24). Data were analysed in ATLAS.ti through inductive and deductive framework analysis.

Results

The interviews with youth revealed daily life problems around the following themes: language, family and peers, and substance use. The overall results suggested the need for culture- and age-specific adaptations of 1) the PM+ manual content (language, metaphors, illustrations) and 2) intervention delivery (modality, content and presentation of the trauma processing module, and duration).

Conclusions

This study led to specific adaptations of PM+ for refugee adolescents to be used in two randomized controlled trials in the Netherlands and Sweden.

Key message

Refugee minors face numerous barriers reaching mental health care. Scalable, culturally adapted psychological interventions should be developed and evaluated to address common mental disorders in refugee youth.

Problem Management Plus (PM+) for Syrian refugees in the Netherlands

Background

Refugees are at considerable risk to develop common mental disorders and related somatic health symptoms. In order to meet the mental health needs of individuals affected by crisis worldwide, the World Health Organization has developed a set of transdiagnostic low-intensity psychological interventions. These interventions, including Problem Management Plus (PM+) and its variants, are delivered by trained non-professional counsellors under supervision of local clinicians. The EU H2020 STRENGTHS project evaluates the effectiveness of these interventions across refugee settings in Europe and the Middle East. This presentation will present the results of a pilot randomized controlled trial (RCT) on individual PM+ in the Netherlands.

Methods

Syrian refugees (N = 60) with elevated levels of psychological distress (10 item-Kessler Psychological Distress Scale &gt;15) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 &gt;16) were randomized into PM + (N=30)) or care-as-usual control (CAU; N = 30). The main outcomes were symptoms of depression and anxiety at 3 months. Secondary outcomes were functioning, symptoms of posttraumatic stress disorder, service utilisation and health costs.

Results

At 3 months follow-up, the PM+ group had significantly lower scores than control for depression (d=.52?) and anxiety (d=.48), symptoms of posttraumatic stress disorder (d=.66, p = .006?), functional impairment (d=.73, p = .009) and self-identified problems (d=.81, p = .005). PM+ potentially may be cost effective with an ICER of €5,047, (95% CI €0, €19773) per additional recovery achieved.

Conclusions

PM+ delivered by non-specialist peer-refugee helpers has the potential be effective in reducing depression, anxiety, improving functioning, and reducing health costs. Larger RCTs on the effects of PM+ are currently conducted within the EU STRENGTHS project.

Cost-utility of an eHealth application 'Oncokompas' that supports cancer survivors in self-management: results of a randomised controlled trial

Purpose

The eHealth self-management application ‘Oncokompas’ was developed to support cancer survivors in monitoring health-related quality of life (HRQOL) and symptoms, and obtaining personalized feedback and options for supportive care. The aim of this study was to assess the cost-utility of Oncokompas compared with care as usual (CAU) among cancer survivors.

Methods

Survivors were randomly allocated to the intervention or control group. Direct (non-)medical, indirect non-medical costs, and HRQOL were measured at 3- and 6-month follow-up, using iMTA Medical Consumption and Productivity Costs and the EuroQol-5D questionnaires. Mean cumulative costs and quality-adjusted life-years (QALYs) were compared between both groups.

Results

In total, 625 survivors were randomized into intervention (n = 320) or control group (n = 305). Base case analysis showed that incremental costs from a societal perspective were − €163 (95% CI, − 665 to 326), and incremental QALYs were 0.0017 (95% CI, − 0.0121 to 0.0155) in the intervention group compared with those in the control group. The probability that, compared with CAU, Oncokompas is more effective was 60%, less costly 73%, and both more effective and less costly 47%. Sensitivity analyses showed that incremental costs vary between − €40 and €69, and incremental QALYs vary between − 0.0023 and − 0.0057.

Conclusion

Oncokompas is likely to be equally effective on utilities, and not more expensive than CAU, and will therefore contribute to sustainable cancer survivorship care in a (cost-)effective manner.

Implications for Cancer Survivors

Oncokompas seems to improve HRQOL and reduces the burden of several tumour-specific symptoms, while costs from a societal perspective are similar to CAU.

Electronic supplementary material

The online version of this article (10.1007/s11764-020-00912-9) contains supplementary material, which is available to authorized users.

The effect of e-mental health interventions on academic performance in university and college students: A meta-analysis of randomized controlled trials

BACKGROUND

Mental health symptoms are common among college and university students and these can affect their academic performance. E-mental health interventions have proven effective in addressing mental health complaints but their effect on academic performance has not been synthesized yet.

OBJECTIVES

To synthesize the evidence from randomized controlled trials for the effectiveness of e-mental health interventions on academic performance in college and university students compared to inactive controls.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched six databases (PubMed, Cochrane library, CINAHL, ERIC, PsycINFO, Web of Science) during the period January 2000 until September 2019 for randomized controlled trials that reported on e-mental health interventions (guided or unguided) for college and university students and measured academic performance (e.g. grade point average).

STUDY APPRAISAL AND SYNTHESIS METHODS

Study and participant characteristics and the academic performance measures at post-intervention were extracted. The latter were pooled and Hedges' g was calculated as the effect size. Heterogeneity and publication bias were investigated.

RESULTS

Six studies containing 2428 participants were included in the meta-analysis. These focussed on either mood and anxiety or alcohol and tobacco use. The pooling of data resulted in a small but non-significant effect of g = 0.26 (95% CI, -0.00, 0.52; p = .05) on academic performance, favouring e-mental health interventions over inactive controls. Interventions had positive effects on depression (g = -0.24) and anxiety (g = -0.2). Heterogeneity was high.

DISCUSSION

Despite the small and non-significant effect, our meta-analysis points to a promising direction for the effectiveness of e-mental health interventions on academic performance. Yet, these results must be interpreted with caution, as heterogeneity was high and few studies on the effectiveness of e-mental health interventions for students reported academic performance measures.

Clinical relevance of findings in trials of CBT for depression

Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression – Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant clinical response. The non-specific or placebo effect of being in a psychotherapy trial was a 29% reduction of HAMD.

Predicting the incidence of non-suicidal self-injury in college students

Background:

Despite increased awareness that non-suicidal self-injury (NSSI) poses a significant public health concern on college campuses worldwide, few studies have prospectively investigated the incidence of NSSI in college and considered targeting college entrants at high risk for onset of NSSI.

Methods:

Using data from the Leuven College Surveys (n = 4,565; 56.8%female, Mage = 18.3, SD = 1.1), students provided data on NSSI, sociodemographics, traumatic experiences, stressful events, perceived social support, and mental disorders. A total of 2,163 baseline responders provided data at a two-year annual follow-up assessment (63.2% conditional response rate).

Results:

One-year incidence of first onset NSSI was 10.3% in year 1 and 6.0% in year 2, with a total of 8.6% reporting sporadic NSSI (1–4 times per year) and 7.0% reporting repetitive NSSI (≥ 5 times per year) during the first two years of college. Many hypothesized proximal and distal risk factors were associated with the subsequent onset of NSSI (ORs = 1.5–18.2). Dating violence prior to age 17 and severe role impairment in daily life were the strongest predictors. Multivariate prediction suggests that an intervention focused on the 10% at highest risk would reach 23.9% of students who report sporadic, and 36.1% of students who report repetitive NSSI during college (cross-validated AUCs =.70–.75).

Discussion:

The college period carries high risk for the onset of NSSI. Individualized web-based screening may be a promising approach for detecting young adults at high risk for self-injury and offering timely intervention.

Priorities and preferences for school-based mental health services in India: a multi-stakeholder study with adolescents, parents, school staff, and mental health providers

BACKGROUND

Schools are important settings for increasing reach and uptake of adolescent mental health interventions. There is limited consensus on the focus and content of school-based mental health services (SBMHSs), particularly in low-resource settings. This study elicited the views of diverse stakeholders in two urban settings in India about their priorities and preferences for SBMHSs.

METHODS

We completed semi-structured interviews and focus group discussions with adolescents (n  =  191), parents (n  =  9), teachers (n  =  78), school counsellors (n  =  15), clinical psychologists/psychiatrists (n  =  7) in two urban sites in India (Delhi and Goa). Qualitative data were obtained on prioritized outcomes, preferred content and delivery methods, and indicated barriers.

RESULTS

All stakeholders indicated the need for and acceptability of SBMHSs. Adolescents prioritized resolution of life problems and exhibited a preference for practical guidance. Parents and teachers emphasized functional outcomes and preferred to be involved in interventions. In contrast, adolescents' favored limited involvement from parents and teachers, was related to widespread concerns about confidentiality. Face-to-face counselling was deemed to be the most acceptable delivery format; self-help was less frequently endorsed but was relatively more acceptable if blended with guidance or delivered using digital technology. Structured sensitization was recommended to promote adolescent's engagement. Providers endorsed a stepped care approach to address different levels of mental health need among adolescents.

CONCLUSION

SBMHSs are desired by adolescents and adult stakeholders in this setting where few such services exist. Sensitization activities are required to support implementation. School counsellors have an important role in identifying and treating adolescents with different levels of mental health needs, and a suite of interventions is needed to target these needs effectively and efficiently.

The associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors

BACKGROUND

Theoretical and empirical literature suggests that non-suicidal self-injury (NSSI) is an important correlate of suicide risk. The present study was designed to evaluate: (a) whether NSSI is associated with increased odds of subsequent onsets of suicidal thoughts and behaviors (STB) independent of common mental disorders, (b) whether NSSI is associated with increased risk of transitioning from suicide ideation to attempt, and (c) which NSSI characteristics are associated with STB after NSSI.

METHOD

Using discrete-time survival models, based on retrospective age of onset reports from college students (n = 6,393, 56.8% female), we examined associations of temporally prior NSSI with subsequent STB (i.e., suicide ideation, plan, and attempt) controlling mental disorders (i.e., MDD, Broad Mania, GAD, Panic Disorder, and risk for Alcohol Dependence). NSSI characteristics associated with subsequent STB were examined using logistic regressions.

RESULTS

NSSI was associated with increased odds of subsequent suicide ideation (OR = 2.8), plan (OR = 3.0), and attempt (OR = 5.5) in models that controlled for the distribution of mental disorders. Further analyses revealed that NSSI was associated with increased risk of transitioning to a plan among those with ideation, as well as attempt among those with a plan (ORs = 1.7-2.1). Several NSSI characteristics (e.g., automatic positive reinforcement, earlier onset NSSI) were associated with increased odds of experiencing STB.

LIMITATIONS

Surveys relied on self-report, and thus, there is the potential for recall bias.

CONCLUSIONS

This study provides support for the conceptualization of NSSI as a risk factor for STB. Investigation of the underlying pathways accounting for these time-ordered associations is an important avenue for future research.

What are the effects of preventative interventions on major depressive disorder (MDD) in young adults? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Depression is a prevalent disorder with a peak rate of onset in young adulthood from 18 to 25 years. To date, no review has systematically assessed the effectiveness of programs that aim to reduce depressive symptoms or diagnosis of depression in young adults.

METHOD

A systematic search was performed in Cochrane, PubMed, PsycINFO and EMBASE. We performed a random-effects meta-analysis of the randomized controlled studies that compared an intervention for young adults (aged 18-25) without a diagnosis or history of depression and a control condition. Comparisons between intervention and control group outcomes were carried out at the post-intervention time point. We also compared intervention and control group outcomes at later follow-up time points where data were available.

RESULTS

Twenty-six randomized controlled trials among 2865 young adults were included in the analysis. The pooled effect size of the interventions versus control at post-intervention was g = 0.37 (95% CI: 0.28-0.47, NNT = 9) and heterogeneity was moderate I²= 36 (95% CI: 11-64). There were no significant effects in terms of the type of delivery, focus of study, type of control, or type of support within the interventions.

LIMITATIONS

The authors were unable to assess the effects of interventions on the onset of depression as none of the included studies measured incidence. The risk of bias was high in most studies (81%). Only one study included a follow-up of more than a year. Demographic factors were inconsistently reported in the included articles.

CONCLUSION

While it was not possible to investigate the effects of interventions on depression incidence, some evidence was found for the effectiveness of preventative interventions in reducing depressive symptoms in young adults. Future research should address limitations of the current evidence base to allow stronger conclusions to be drawn.

Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis

BACKGROUND

A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice.

METHODS

Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted.

RESULTS

64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.

LIMITATIONS

Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field.

CONCLUSIONS

The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

The prevalence of suicidal thoughts and behaviours among college students: a meta-analysis

BACKGROUND

Adolescence and young adulthood carry risk for suicidal thoughts and behaviours (STB). An increasing subpopulation of young people consists of college students. STB prevalence estimates among college students vary widely, precluding a validated point of reference. In addition, little is known on predictors for between-study heterogeneity in STB prevalence.

METHODS

A systematic literature search identified 36 college student samples that were assessed for STB outcomes, representing a total of 634 662 students [median sample size = 2082 (IQR 353-5200); median response rate = 74% (IQR 37-89%)]. We used random-effects meta-analyses to obtain pooled STB prevalence estimates, and multivariate meta-regression models to identify predictors of between-study heterogeneity.

RESULTS

Pooled prevalence estimates of lifetime suicidal ideation, plans, and attempts were 22.3% [95% confidence interval (CI) 19.5-25.3%], 6.1% (95% CI 4.8-7.7%), and 3.2% (95% CI 2.2-4.5%), respectively. For 12-month prevalence, this was 10.6% (95% CI 9.1-12.3%), 3.0% (95% CI 2.1-4.0%), and 1.2% (95% CI 0.8-1.6%), respectively. Measures of heterogeneity were high for all outcomes (I 2 = 93.2-99.9%), indicating substantial between-study heterogeneity not due to sampling error. Pooled estimates were generally higher for females, as compared with males (risk ratios in the range 1.12-1.67). Higher STB estimates were also found in samples with lower response rates, when using broad definitions of suicidality, and in samples from Asia.

CONCLUSIONS

Based on the currently available evidence, STB seem to be common among college students. Future studies should: (1) incorporate refusal conversion strategies to obtain adequate response rates, and (2) use more fine-grained measures to assess suicidal ideation.

Demographic and need factors of early, delayed and no mental health care use in major depression: a prospective study

BACKGROUND

Despite the availability of evidence based treatments, many people with major depression receive no or delayed professional treatment, which may put them at risk for adverse outcomes. The aim of this study was to examine which demographic and need factors distinguish early, delayed and no treatment use.

METHODS

Data were obtained from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). People with a diagnosis of major depression in the past 12 months were included (N = 434). Mental health care use was assessed during this same period and at follow up (three years later). Multinomial regression analysis was used to distinguish early, delayed and no mental health care users with respect to demographic and need factors.

RESULTS

The majority of participants accessed treatment early (62%). Early treatment users were characterized by more severe and persistent symptoms and were more likely not to have a partner compared to no treatment users. The majority of those without treatment reached remission in three years (85%). Delayed treatment users were, compared to early users, characterized by relatively mild symptoms and a persistent or new major depressive disorder at follow up.

CONCLUSIONS

Early access to treatment and the finding that need factors determine mental health care use among people with depression show that the filters along the pathway to treatment are not influenced by unfavorable determinants like education or age.

Differences in executive functioning between violent and non-violent offenders

BACKGROUND

A growing body of neuropsychological and neurobiological research shows a relationship between functioning of the prefrontal cortex and criminal and violent behaviour. The prefrontal cortex is crucial for executive functions such as inhibition, attention, working memory, set-shifting and planning. A deficit in these functions - a prefrontal deficit - may result in antisocial, impulsive or even aggressive behaviour. While several meta-analyses show large effect sizes for the relationship between a prefrontal deficit, executive dysfunction and criminality, there are few studies investigating differences in executive functions between violent and non-violent offenders. Considering the relevance of identifying risk factors for violent offending, the current study explores whether a distinction between violent and non-violent offenders can be made using an extensive neuropsychological test battery.

METHOD

Male remand prisoners (N = 130) in Penitentiary Institution Amsterdam Over-Amstel were administered an extensive neuropsychological test battery (Cambridge Automated Neuropsychological Test Battery; CANTAB) measuring response inhibition, planning, attention, set-shifting, working memory and impulsivity/reward sensitivity.

RESULTS

Violent offenders performed significantly worse on the stop-signal task (partial correlation r = 0.205, p = 0.024), a task measuring response inhibition. No further differences were found between violent and non-violent offenders. Explorative analyses revealed a significant relationship between recidivism and planning (partial correlation r = -0.209, p = 0.016).

CONCLUSION

Violent offenders show worse response inhibition compared to non-violent offenders, suggesting a more pronounced prefrontal deficit in violent offenders than in non-violent offenders.

The 6-month effectiveness of Internet-based guided self-help for depression in adults with Type 1 and 2 diabetes mellitus

AIM

The aim of this research is to examine the 6-month effects of an Internet-based guided self-help intervention for comorbid depressive symptoms in people with diabetes.

METHODS

Participants (n = 260) with Type 1 or 2 diabetes and elevated depressive symptoms [Center for Epidemiological Studies Depression Scale (CES-D) ≥ 23] were randomly assigned to a guided Internet-based self-help intervention or a control condition (treatment as usual + online psychoeducation about depression). The primary outcome was a change in depressive symptom severity (CES-D) from baseline to 6-month follow-up. The secondary outcomes included numbers of people achieving treatment response (reliable change of depressive symptoms) and remission (CES-D ≤ 16), as well as the effects on glycaemic control, diabetes-related emotional distress and diabetes acceptance. Repeated measures analysis of variance examined between-group differences using intent-to-treat principles.

RESULTS

Both conditions showed improvements in depression severity: intervention condition, d = 1.48 [95% confidence interval (95% CI): 1.21 to 1.76]; control condition d = 0.55 (95% CI: 0.30 to 0.80). Changes were significantly greater in the intervention condition with a large between-group effect size (d = 0.83, 95% CI: 0.57 to 1.08). Accordingly, effects on response [relative risk (RR) = 2.60 (95% CI: 2.01 to 3.36), P < 0.001] and remission [RR = 3.36 (95% CI: 2.98 to 5.44), P < 0.001] were in favour of the intervention group, as were differences in change in diabetes emotional distress (d = 0.50, 95% CI: 0.04 to 0.54), and physical and mental functioning [Short Form Health Survey (SF-12) Physical d = 0.27 (95% CI: 0.01 to 0.51) and SF-12 Mental d = 0.68 (95% CI: 0.11 to 0.40)]. The intervention group was not superior with regard to glycaemic control, diabetes self-management and diabetes acceptance.

CONCLUSIONS

The trial indicates that Internet-based guided self-help treatments for depression in people with diabetes can have sustained effects on depressive symptoms, well-being and emotional distress associated with diabetes.

First onset of suicidal thoughts and behaviours in college

BACKGROUND

College students are a worldwide increasing group of young people at risk for suicidal thoughts and behaviours (STB). However, no previous studies have prospectively investigated the first onset of STB during the college period.

METHODS

Using longitudinal data from the Leuven College Surveys, 2337 (response rate [RR]=66.6%) incoming freshmen provided baseline data on STB, parental psychopathology, childhood-adolescent traumatic experiences, 12-month risk for mental disorders, and 12-month stressful experiences. A total of 1253 baseline respondents provided data on 12-month STB in a two-year annual follow-up survey (conditional RR=53.6%; college dropout adjusted conditional RR=70.2%).

RESULTS

One-year incidence of first-onset STB was 4.8-6.4%. Effect sizes of the included risk factors varied considerably whether viewed from individual-level (ORs=1.91-17.58) or population-level perspective (PARPs=3.4-34.3%). Dating violence prior to the age of 17, physical abuse prior to the age of 17, and 12-month betrayal by someone else than the partner were most strong predictors for first-onset suicidal ideation (ORs=4.23-12.25; PARPs=8.7-27.1%) and plans (ORs=6.57-17.58; PARPs=15.2-34.3%). Multivariate prediction (AUC=0.84-0.91) revealed that 50.7-65.7% of first-onset STB cases were concentrated in the 10% at highest predicted risk.

LIMITATIONS

As this is a first investigation of STB onset in college, future studies should use validation samples to test the accuracy of our multivariate prediction model.

CONCLUSIONS

The first onset of STB in college appears to be higher than in the general population. Screening at college entrance is a promising strategy to identify those students at highest prospective risk, enabling the cost-efficient clinical assessment of young adults in college.

The effects of cognitive and behavioural therapies for anxiety disorders on depression: a meta-analysis

BACKGROUND

The effects of cognitive behavioural therapy of anxiety disorders on depression has been examined in previous meta-analyses, suggesting that these treatments have considerable effects on depression. In the current meta-analysis we examined whether the effects of treatments of anxiety disorders on depression differ across generalized anxiety disorder (GAD), social anxiety disorder (SAD) and panic disorder (PD). We also compared the effects of these treatments with the effects of cognitive and behavioural therapies of major depression (MDD).

METHOD

We searched PubMed, PsycINFO, EMBASE and the Cochrane database, and included 47 trials on anxiety disorders and 34 trials on MDD.

RESULTS

Baseline depression severity was somewhat lower in anxiety disorders than in MDD, but still mild to moderate in most studies. Baseline severity differed across the three anxiety disorders. The effect sizes found for treatment of the anxiety disorders ranged from g = 0.47 for PD, g = 0.68 for GAD and g = 0.69 for SAD. Differences between these effect sizes and those found in the treatment of MDD (g = 0.81) were not significant in most analyses and we found few indications that the effects differed across anxiety disorders. We did find that within-group effect sizes resulted in significantly (p < 0.001) larger effect sizes for depression (g = 1.50) than anxiety disorders (g = 0.73-0.91). Risk of bias was considerable in the majority of studies.

CONCLUSIONS

Patients participating in trials of cognitive behavioural therapy for anxiety disorders have high levels of depression. These treatments have considerable effects on depression, and these effects are comparable to those of treatment of primary MDD.

Does Internet-based guided-self-help for depression cause harm? An individual participant data meta-analysis on deterioration rates and its moderators in randomized controlled trials

BACKGROUND

Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach.

METHOD

Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data.

RESULTS

A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29-0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit-risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.

CONCLUSIONS

Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.

Mental disorders among college students in the World Health Organization World Mental Health Surveys

BACKGROUND

Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.

METHOD

The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18-22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).

RESULTS

One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.

CONCLUSIONS

Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.

The efficacy of eye movement desensitization and reprocessing for post-traumatic stress disorder and depression among Syrian refugees: results of a randomized controlled trial

BACKGROUND

Previous research indicates a high prevalence of post-traumatic stress disorder (PTSD) and depression among refugees. Eye movement desensitization and reprocessing (EMDR) is an effective treatment for PTSD for victims of natural disasters, car accidents or other traumatic events. The current study examined the effect of EMDR on symptoms of PTSD and depression by comparing the treatment with a wait-list control condition in Syrian refugees.

METHOD

Adult refugees located in Kilis Refugee Camp at the Turkish-Syrian border with a PTSD diagnosis were randomly allocated to either EMDR (n = 37) or wait-list control (n = 33) conditions. All participants were assessed with the Mini-International Neuropsychiatric Interview Plus at pre-intervention, at 1 week after finishing the intervention and at 5 weeks after finishing the intervention. The main outcome measures were the Harvard Trauma Questionnaire (HTQ) and the Impact of Event Scale-Revised. The Beck Depression Inventory and the Hopkins Symptoms Checklist-25 were included as secondary outcome measures. The Trial Registration no. is NCT01847742.

RESULTS

Mixed-model analyses adjusted for the baseline scores indicated a significant effect of group at post-treatment indicating that the EMDR therapy group showed a significantly larger reduction of PTSD symptoms as assessed with the HTQ. Similar findings were found on the other outcome measures. There was no effect of time or group × time interaction on any measure, showing that the difference between the groups at the post-treatment was maintained to the 5-week follow-up.

CONCLUSIONS

EMDR may be effective in reducing PTSD and depression symptoms among Syrian refugees with PTSD located in a refugee camp.

Psychometric Properties of the Dutch Depression Stigma Scale (DSS) and Associations with Personal and Perceived Stigma in a Depressed and Community Sample

BACKGROUND

Research on depression stigma is needed to gain more insight into the underlying construct and to reduce the level of stigma in the community. However, few validated measurements of depression stigma are available in the Netherlands. Therefore, this study first sought to examine the psychometric properties of the Dutch translation of the Depression Stigma Scale (DSS). Second, we examined which demographic (gender, age, education, partner status) and other variables (anxiety and knowledge of depression) are associated with personal and perceived stigma within these samples.

METHODS

The study population consisted of an adult convenience sample (n = 253) (study 1) and a community adult sample with elevated depressive symptoms (n = 264) (study 2). Factor structure, internal consistency, and validity were assessed. The associations between stigma, demographic variables and anxiety level were examined with regression analyses.

RESULTS

Confirmatory factor analysis supported the validity and internal consistency of the DSS personal stigma scale. Internal consistency was sufficient (Cronbach's alpha = .70 (study 1) and .77 (study 2)). The results regarding the perceived stigma scale revealed no clear factor structure. Regression analyses showed that personal stigma was higher in younger people, those with no experience with depression, and those with lower education.

CONCLUSIONS

This study established the validity and internal consistency of the DSS personal scale in the Netherlands, in a community sample and in people with elevated depressive symptoms. However, additional research is needed to examine the factor structure of the DSS perceived scale and its use in other samples.

Stepped care targeting psychological distress in head and neck cancer and lung cancer patients: a randomized, controlled trial

BACKGROUND

This study aimed to evaluate the efficacy of stepped care (SC) targeting psychological distress in head and neck cancer (HNC) and lung cancer (LC) patients.

PATIENTS AND METHODS

Patients with untreated distress [Hospital Anxiety and Depression Scale (HADS; HADS-D > 7, HADS-A > 7, or HADS-total > 14)] were randomized to SC (n = 75) or care-as-usual (CAU) (n = 81). SC consisted of watchful waiting, guided self-help, problem-solving therapy, and psychotherapy and/or psychotropic medication. The primary outcome measure was the HADS; secondary outcome measures were recovery rate, EORTC QLQ-C30, QLQ-HN35/QLQ-LC13, and IN-PATSAT32. Measures were assessed at baseline, after completion of care, and at 3, 6, 9, and 12 months follow-up. Linear mixed models, t-tests, and effect sizes (ES) were used to assess group differences.

RESULTS

Patients with untreated distress were randomized to SC (n = 75) or care-as-usual (CAU) (n = 81). The course of psychological distress was better after SC compared with CAU (HADS-total, P = 0.005; HADS-A, P = 0.046; HADS-D, P = 0.007). The SC group scored better post-treatment (HADS-total, ES = 0.56; HADS-A, ES = 0.38; HADS-D, ES = 0.64) and at 9 months follow-up (HADS-total, ES = 0.42 and HADS-A, ES = 0.40). The recovery rate post-treatment was 55% after SC compared with 29% after CAU (P = 0.002), and 46% and 37% at 12 months follow-up (P = 0.35). Within SC, 28% recovered after watchful waiting, 34% after guided self-help, 9% after problem-solving therapy, and 17% after psychotherapy and/or psychotropic medication. The effect of SC was stronger for patients with a depressive or anxiety disorder compared with patients without such a disorder (HADS-total, P = 0.001; HADS-A, P = 0.003; HADS-D, P = 0.041).

CONCLUSIONS

SC is effective and speeds up recovery among HNC and LC patients with untreated psychological distress.

TRIAL REGISTRATION

Netherlands Trial Register (NTR1868).

E-care 4 caregivers - an online intervention for nonprofessional caregivers of patients with depression: study protocol for a pilot randomized controlled trial

Background

Nonprofessional caregivers are highly important in the everyday life of patients with depression. Yet, they may experience increased levels of burden, stress, depression, and anxiety. Therefore, there is a need for interventions that relieve symptoms and are accessible and time-efficient. This paper describes the protocol of a pilot study to evaluate (1) the feasibility of an online self-management intervention, E-care 4 caregivers, for the nonprofessional caregiver of patients with depression, and (2) the initial effects of E-care 4 caregivers on psychological distress, subjective burden, symptoms of anxiety and depression, and quality of life.

Methods/design

The study is a randomized controlled trial in which we are comparing the E-care 4 caregivers online intervention with a wait list control group. Eighty-four nonprofessional caregivers of patients with depression aged 18 years or older are being recruited from among the general population. Feasibility is determined by semistructured telephone interviews evaluating the subjects’ satisfaction with the intervention and by using a questionnaire on the user-friendliness of the system. The primary outcome measure used to examine the initial effects of the intervention is psychological distress. Secondary outcome measures are subjective burden, symptoms of anxiety and depression, level of mastery, and quality of life. Assessments will be done at baseline and 6 weeks later. Statistical analysis of the effects of the intervention will be carried out on the basis of the intention-to-treat principle.

Discussion

E-care 4 caregivers could potentially benefit nonprofessional caregivers, as well as patients and professionals indirectly.

Trial registration

Netherlands Trial Register identifier: NTR5268. Registered on 30 June 2015.

Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects

BACKGROUND

The present meta-analysis aimed to examine to what extent combined pharmacotherapy with psychotherapy results in a different response to treatment compared to psychotherapy or pharmacotherapy alone in adults with major depression at six months or longer postrandomization.

METHODS

A systematic literature search resulted in 23 randomized controlled trials with 2184 participants. Combined treatment was compared to either psychotherapy or anti-depressant medication alone in both the acute phase and the maintenance phase. Odds ratios of a positive outcome were calculated for all comparisons.

RESULTS

In acute phase treatment, combined psychotherapy with antidepressants outperformed antidepressants alone at six months or longer postrandomization in patients with major depressive disorder (OR=2.93, 95%CI 2.15-3.99, p<0.001). Heterogeneity was zero (95%CI 0-57%, p>0.05). However, combined therapy resulted in equal response to treatment compared to psychotherapy alone at six months or longer postrandomization. As for the maintenance treatment, combined maintenance psychotherapy with antidepressants resulted in better-sustained treatment response compared to antidepressants at six months or longer postrandomization (OR=1.61, 95%CI 1.14-2.27, p<0.05). Heterogeneity was zero (95%CI 0-68%, p>0.05).

CONCLUSIONS

Combined therapy results in a superior enduring effect compared to antidepressants alone in patients with major depression. Psychotherapy is an adequate alternative for combined treatment in the acute phase as it is as effective as combined treatment in the long-term.

Differential efficacy of cognitive behavioral therapy and psychodynamic therapy for major depression: a study of prescriptive factors

BACKGROUND

Minimal efficacy differences have been found between cognitive behavioral therapy (CBT) and psychodynamic therapies for depression, but little is known about patient characteristics that might moderate differential treatment effects. We aimed to generate hypotheses regarding such potential prescriptive factors.

METHOD

We conducted post-hoc model-based recursive partitioning analyses alongside a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy (SPSP). Severely depressed patients received additional antidepressant medication. We included 233 adults seeking treatment for a major depressive episode in psychiatric outpatient clinics, who completed post-treatment assessment. Post-treatment mean Hamilton Depression Rating Scale scores constituted the main outcome measure.

RESULTS

While treatment differences (CBT v. SPSP) were minimal in the total sample of patients (d = 0.04), model-based recursive partitioning indicated differential treatment efficacy in certain subgroups of patients. SPSP was found more efficacious among moderately depressed patients receiving psychotherapy only who showed low baseline co-morbid anxiety levels (d = -0.40) and among severely depressed patients receiving psychotherapy and antidepressant medication who reported a duration of the depressive episode of ⩾1 year (d = -0.31), while CBT was found more efficacious for such patients reporting a duration <1 year (d = 0.83).

CONCLUSIONS

Our findings are observational and need validation before they can be used to guide treatment selection, but suggest that knowledge of prescriptive factors can help improve the efficacy of psychotherapy for depression. Depressive episode duration and co-morbid anxiety level should be included as stratification variables in future randomized clinical trials comparing CBT and psychodynamic therapy.

Posttraumatic growth among head and neck cancer survivors with psychological distress

BACKGROUND

Information on posttraumatic growth (PTG) among head and neck cancer (HNC) survivors with a high level of distress is limited. The aim of this cross-sectional study was to investigate the occurrence of PTG among distressed HNC survivors and its association with anxiety, depressive, nicotine, and alcohol use disorders and health-related quality of life.

METHODS

Seventy-four HNC survivors with psychological distress (Hospital Anxiety and Depression Scale (HADS) anxiety > 7 and/or HADS depression > 7) completed the Posttraumatic Growth Inventory, which comprises five subscales: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. Anxiety, depressive, nicotine, and alcohol use disorders were measured using the Composite International Diagnostic Interview.

RESULTS

Moderate to high Posttraumatic Growth Inventory (PTGI) scores occurred in 10% of the HNC survivors with distress. The mean total PTGI score was 30.8 (SD = 19.7), with the highest mean score on the subscale relating to others. A multivariate regression model consisting of tumor stage, anxiety disorder, alcohol use disorder, and social functioning predicted total PTGI score best (F(4, 64) = 7.565, p < .000, R²  = .321).

CONCLUSIONS

The presence of PTG in this population of distressed HNC survivors was low. PTG occurred most in the domain of relating to others. Among distressed HNC survivors, higher PTG was associated with lower tumor stage, absence of an anxiety disorder, absence of an alcohol use disorder, and better social functioning. Copyright © 2016 John Wiley & Sons, Ltd.

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe

PURPOSE

Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given.

METHODS

We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders.

RESULTS

We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences.

DISCUSSION

The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD.

CONCLUSION

Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.

Is duration of psychological treatment for depression related to return into treatment?

PURPOSE

There is increasing pressure on mental health providers to reduce the duration of treatments, while retaining level of quality and effectiveness. The risk is that the population is underserved and therefore needs new treatment episodes. The primary aim of this study was to investigate whether duration of treatment and return into mental health care were related.

METHODS

This study examined Dutch patients with an initial treatment episode in 2009 or 2010 in specialized mental health settings for depressive disorder (N = 85,754). Follow-up data about treatment episodes were available up until 2013. The data set included demographic (age, gender), and clinical factors (comorbidity with other DSM-IV Axis; scores on the 'Global Assessment of Functioning'). Cox regression analyses were used to assess whether duration of treatment and relapse into mental health care were related.

RESULTS

The majority of patients did not return into mental health care (86 %). Patients with a shorter duration of treatment (5-250 min; 251-500 min and 751-1000 min) were slightly more likely to return (reference group: >1000 min) (HR 1.19 95 % CI 1.13-1.26; HR 1.11 95 % CI 1.06-1.17; HR 1.18 95 % CI 1.11-1.25), adjusted for demographic and clinical variables.

CONCLUSIONS

The results suggest that a longer duration of treatment may prevent return into mental health care in some groups. However, because of the design of the study, no causal inference can be drawn. Further research, preferably in a RCT, is needed to determine whether the trend towards lower intensity treatments is associated with repeated mental health care use.

A randomized clinical trial on the effectiveness of an intervention to treat psychological distress and improve quality of life after autologous stem cell transplantation

Psychological distress contributes to impaired quality of life in hematological cancer patients. Stepped care treatment, in which patients start with the least intensive treatment most likely to work and only receive more intensive interventions if needed, could improve distress. We aimed to evaluate the outcome of stepped care treatment on psychological distress and physical functioning in patients treated with autologous stem cell transplantation for hematological malignancies. In the present study, we performed a randomized clinical trial with two treatment arms: stepped care and care as usual. Baseline assessment and randomization occurred during pre-transplant hospitalization. Stepped care was initiated after 6 weeks, consisting of (1) watchful waiting, (2) Internet-based self-help intervention, and (3) face-to-face counseling/ psychopharmacological treatment/ referral. Follow-up measurements were conducted at 13, 30, and 42 weeks after transplantation. Stepped care (n = 47) and care as usual (n = 48) were comparable on baseline characteristics. The uptake of the intervention was low: 24 patients started with step 1, 23 with step 2, and none with step 3. Percentages of distressed patients ranged from 4.1 to 9.7 %. Ten percent of patients received external psychological or psychiatric care. No statistically significant differences were found between stepped care and care as usual on psychological distress or physical functioning in intention to treat analyses, nor in per protocol analyses. The stepped care program was not effective in decreasing psychological distress. The low intervention uptake, probably related to the low levels of psychological distress, offers an explanation for this outcome. Future research should take into account patients' specific care needs. Netherlands Trial Registry identifier: NTR1770.

[Comparison of efficacy of psychiatric treatment versus treatment in general medicine]

There is increasing attention to the costs and efficacy of health care and in particular to psychiatry. To weigh the costs and benefits appropriately, it is important to be able to compare effects.<br/> AIM: To describe the efficacy of psychiatric treatment compared to treatment in general medicine.<br/> METHOD: Narrative review.<br/> RESULTS: The average effect size of psychiatric treatment was 0.49 and that of general medicine treatment 0.45. The effect size of psychotherapy varied from 0.3 - 0.84, but in a meta-analysis, corrected for publication bias, the effect size average amounted to only 0.39.<br/> CONCLUSION: The average efficacy of psychiatric treatments is similar to the efficacy of treatments in general medicine. However, there is a large variation in efficacy within the two treatment areas. The variation is even larger in the treatment results for individual patients. The main objective of 'personalised medicine' is to tailor the type of treatment to the particular symptoms of the individual patient so that he or she will not be exposed to types of treatment that are not strictly relevant to the patient's symptoms or illness. In view of the limited and less-than-perfect results of treatment and medication in the entire medical field, 'personalised medicine' seems to be a goal worth striving for in order to improve treatment outcomes.