Physical and psychosocial work-related exposures and the occurrence of disorders of the shoulder: A systematic review update

This review is an update of a previous systematic review and assesses the evidence for the association of work-related physical and psychosocial risk factors and specific disorders of the shoulders. Medline, Embase, Web of Science Core Collection, Cochrane Central and PsycINFO were searched and study eligibility and risk of bias assessment was performed by two independent reviewers. A total of 14 new articles were added with the majority focusing on rotator cuff syndrome (RCS) with seven studies. Nine articles reported psychosocial exposures in addition to physical exposures. The strongest evidence was found for the association between elevation, repetition, force and vibration and the occurrence of SIS and tendinosis/tendonitis. Evidence also suggests that psychosocial exposures are associated with the occurrence of RCS and tendinosis/tendonitis. Other findings were inconsistent which prevents drawing strong conclusions.

Clinical improvements due to specific effects and placebo effects in conservative interventions and changes observed with no treatment in randomized controlled trials of patients with chronic nonspecific low back pain: a systematic review and meta-analysis

ABSTRACT

Little is known about the contribution of placebo effects and changes observed with no treatment in interventions for nonspecific low back pain (NSLBP). This systematic review assessed the proportions of the overall treatment effect that may be attributable to specific treatment effects, placebo effects, and changes observed with no treatment in randomized controlled trials (RCTs) in patients with NSLBP. Trials published before 2019 were identified from a published systematic review, and the search was updated in MEDLINE, Embase, and Cochrane Central for trials published between January 2019 and March 2023. Three-arm RCTs comparing the effects of experimental interventions vs placebo control vs no intervention reporting pain intensity, physical function, and/or health-related quality of life (HRQoL) were included. Sixteen RCTs with 1436 adults with chronic NSLBP testing conservative and mainly passive interventions were included. For pain intensity (16 studies), 33%, 18%, and 49% of the overall short-term treatment effect was attributable to specific treatment effects, placebo effects, and changes observed with no treatment, respectively. For physical function (11 studies) and HRQoL (6 studies), these proportions were 34%, 13%, and 53%, and 11%, 41%, and 48%, respectively. These results show that approximately half of the overall treatment effect of conservative and mainly passive interventions for patients with chronic NSLBP is attributable to changes observed with no treatment, rather than specific or placebo effects of treatments. However, the certainty of evidence was very low to low, suggesting that the true effects might be markedly different from the effect sizes underlying these estimates.

Physical and psychosocial work-related exposures and the incidence of carpal tunnel syndrome: A systematic review of prospective studies

This systematic review summarizes the evidence on associations between physical and psychosocial work-related exposures and the development of carpal tunnel syndrome (CTS). Relevant databases were searched up to January 2020 for cohort studies reporting associations between work-related physical or psychosocial risk factors and the incidence of CTS. Two independent reviewers selected eligible studies, extracted relevant data, and assessed risk of bias (RoB). We identified fourteen articles for inclusion which reported data from nine cohort studies. Eight reported associations between physical exposure and the incidence of CTS and five reported associations between psychosocial exposures and the incidence of CTS. Quality items were generally rated as unclear or low RoB. Work-related physical exposure factors including high levels of repetition, velocity, and a combination of multiple physical exposures were associated with an increased risk of developing CTS. No other consistent associations were observed for physical or psychosocial exposures at work and CTS incidence.

Lay Perspectives on Empathy in Patient-Physician Communication: An Online Experimental Study

Research indicates that patients consider empathy as a key factor contributing to the quality-of-care. However, ambiguities in the definition of this multidimensional construct complicate definite conclusions to-date. Addressing the challenges in the literature, and using a hypothetical physician-patient interaction which explored patient-perceived differences between expressions of affective empathy, cognitive empathy, compassion and no empathy, this study aimed to test whether lay participants' evaluations of the quality-of-care depend on the type of empathic physician behavior, and on the physician's gender. We conducted a randomized web-based experiment using a 4 (type of empathy) by 2 (physician gender) between-subjects design. Empathy was subdivided into three concepts: first, affective empathy (i.e. feeling with someone); second, cognitive empathy (i.e. understanding); and third, compassion (i.e. feeling for someone and offering support). Perceived quality-of-care was the primary outcome. Compared with non-empathic interactions, quality-of-care was rated higher when physicians reacted cognitively empathic or compassionate (d = 0.71; 0.43 to 1.00 and d = 0.68; 0.38 to 0.98). No significant difference was found between affective empathy and no empathy (d = 0.13; -0.14 to 0.42). The physician's gender was not related with quality-of-care. Aspects of participants' personality but not their age, gender or the number of physician visits were associated with quality-of-care. No interactions were observed. In showing that patients rated quality-of-care higher when physician reactions were described as cognitively empathic and compassionate, as compared with affectively empathic or non-empathic, our findings refine views about the kinds of empathy that are important in patient care with implications for clinical practice, education and communication trainings.

Evaluation of practice nurses' management of paediatric psychosocial problems in general practice

BACKGROUND

Child mental health services are under major pressure worldwide. In the Netherlands, Youth Mental Health Practice Nurses (YMHPNs) have been introduced in general practice to improve access to care. In this study, we evaluated care delivered by YMHPNs.

METHODS

We used medical records of a population-based cohort (21 717 children, 0-17 years). Characteristics of children consulting a YMHPN, type of problem, care delivered by YMHPNs and referrals were assessed using quantitative content analysis.

RESULTS

Records of 375 children (mean age 12.9 years, 59.2% girl) were analysed. These children were often in their adolescence (57.3% was between 13 and 17 years), and more often female than male (59.2% vs 40.8%). YMHPNs had a median of four consultations (IQR 2-7) with the child. YMHPNs managed a variety of psychosocial problems. YMHPNs managed 22.4% of children without need of referral, 52.0% were eventually referred for additional care. 13.3% of children dropped out during the treatment trajectory. In the remaining 12.3% of children, the treatment trajectory was stopped because the child was already attending specialized services, the treatment trajectory was still ongoing or the medical record was inconclusive.

CONCLUSIONS

YMHPNs successfully managed one in four children with psychosocial problems without need for referral. Nevertheless, most children were eventually referred for additional care.

Adjusting advance care planning to older people's needs: results from focus groups and interviews

BACKGROUND

Advance care planning (ACP) is becoming increasingly important in medical care. Some suggest standardized approaches to initiate ACP with all older adults. However, the idea of patient-centered care suggests more nuanced approaches tailored to individual older adults' needs. This study investigated how older adults with different views and needs about ACP can be approached in an adequate and most beneficial way by health care professionals.

METHODS

We used questionnaires, interviews, focus groups and informal conversations with older adults, living in their own homes, who volunteered to take part in our research. The research was participatory as we collaborated closely with practice partners and we used the obtained findings immediately and continuously to inform the next steps of our research throughout the process.

RESULTS

We identified three subgroups of older adults with differential needs regarding ACP-related activities: The first group avoids talking about their needs and wishes for care towards the end of life. These older people benefit from activities, which aim at motivating them to concern themselves with ACP-related topics. The second group consists of older adults who are in principle open for ACP-conversations but do not initiate these themselves. This group either trusts their next-of-kin or their healthcare professional to act in accordance with their wishes or does not bring up the topic in order to avoid confronting relevant others with possibly unpleasant topics. This group of people benefits from information about ACP and from healthcare professionals initiating the ACP process. The third group of older people initiates the ACP process themselves, gathers information, and takes the necessary steps for ACP. With this group it remains relevant to check carefully whether they have indeed taken all relevant steps and shared the information with all relevant involved care institutions and relatives.

CONCLUSIONS

We propose a model to simplify adjustments of ACP to individuals' needs. Our suggested approach might contribute to increasing the motivation of older people to engage in ACP conversations if these are more closely related to their own needs. Further, it might also contribute to simplifying the individual shaping of the ACP process for healthcare professionals as our suggested model offers clear guidance for approaching different types of older people in different ways. The suggested approach may in future be used for training health care professionals in the conduct of ACP conversations.

Exposure to hand-arm vibrations in the workplace and the occurrence of hand-arm vibration syndrome, Dupuytren's contracture, and hypothenar hammer syndrome: a systematic review and meta-analysis

This study provides an overview of the relationships between exposure to work-related hand-arm vibration and the occurrence of pre-defined disorders of the hands. We searched Medline, Embase, Web of Science, Cochrane Central, and PsycINFO for cross-sectional and longitudinal studies on the association between work-related vibration exposure and the occurrence of hand-arm vibration syndrome (including vibration-induced white finger), Dupuytren's contracture, or hypothenar hammer syndrome. We used a 16-item checklist for assessing the risk of bias. We present results narratively, and we conducted random effects meta-analyses if possible. We included 10 studies with more than 24,381 participants. Our results showed statistically significant associations between the exposure to hand-arm vibrations and the occurrence of the selected disorders, with pooled odds ratios ranging between 1.35 (95% CI: 1.28 to 2.80) and 3.43 (95% CI: 2.10 to 5.59). Considerable between-study heterogeneity was observed. Our analyses show that exposure to vibrating tools at work is associated with an increased risk for the occurrence of selected disorders of the hands. Due to the majority of studies being cross-sectional, no firm conclusion is possible regarding causal relationships between vibration exposure and disorder occurrence. Future research should specifically address whether reducing exposure to hand-held vibrating tools at work reduces the incidence of the disorders of the hands investigated in this systematic review.

Interventions for ADHD in childhood and adolescence: A systematic umbrella review and meta-meta-analysis

There are several meta-analyses of treatment effects for children and adolescents with attention deficit hyperactivity disorder (ADHD). The conclusions of these meta-analyses vary considerably. Our aim was to synthesize the latest evidence of the effectiveness of psychological, pharmacological treatment options and their combination in a systematic overview and meta-meta-analyses. A systematic literature search until July 2022 to identify meta-analyses investigating effects of treatments for children and adolescents with ADHD and ADHD symptom severity as primary outcome (parent and teacher rated) yielded 16 meta-analyses for quantitative analyses. Meta-meta-analyses of pre-post data showed significant effects for pharmacological treatment options for parent (SMD = 0.67, 95% CI 0.60 to 0.74) and teacher ADHD symptom ratings (SMD = 0.68, 95% CI 0.54 to 0.82) as well as for psychological interventions for parent (SMD = 0.42, 95% CI 0.33 to 0.51) and teacher rated symptoms (SMD = 0.25, 95% CI 0.12 to 0.38). We were unable to calculate effect sizes for combined treatments due to the lack of meta-analyses. Our analyses revealed that there is a lack of research on combined treatments and for therapy options for adolescents. Finally, future research efforts should adhere to scientific standards as this allows comparison of effects across meta-analyses.

Physical and psychosocial work-related exposures and the occurrence of disorders of the elbow: A systematic review

This systematic review updates a previous systematic review on work-related physical and psychosocial risk factors for elbow disorders. Medline, Embase, Web of Science, Cochrane Central and PsycINFO were searched for studies on associations between work-related physical or psychosocial risk factors and the occurrence of elbow disorders. Two independent reviewers selected eligible studies and assessed risk of bias (RoB). Results of studies were synthesized narratively. We identified 17 new studies and lateral epicondylitis was the most studied disorder (13 studies). Five studies had a prospective cohort design, eight were cross-sectional and four were case-control. Only one study had no items rated as high RoB. Combined physical exposure indicators (e.g. physical exertion combined with elbow movement) were associated with the occurrence of lateral epicondylitis. No other consistent associations were observed for other physical and psychosocial exposures. These results prevent strong conclusions regarding associations between work-related exposures, and the occurrence of elbow disorders.

Effectiveness of hospital clowning on pediatric anxiety and pain: Network meta-analysis

OBJECTIVE

Anxiety and pain during medical procedures may have adverse short and long-term consequences. We summarize the effectiveness of hospital clown interventions, as compared with medication, the presence of a parent, standard care, and other non-pharmacological distraction interventions on anxiety and pain in minors undergoing medical procedures.

METHOD

Randomized trials were identified in PsycINFO, MEDLINE, Embase, Scopus and CINAHL, and previous reviews. Screening of titles and abstracts and full-texts, data extraction and risk of bias assessment was done by two independent reviewers. We conducted random-effects network and pairwise meta-analyses based on a frequentist framework.

RESULTS

Our analyses with 28 studies showed significantly lower anxiety scores in clowning and other distraction interventions as compared with the presence of parents. No differences were observed between clowning, medication, and other distraction interventions. Clowning interventions were superior to standard care in our main analyses, but non-significant in some of the sensitivity analyses. Furthermore, clowning led to significantly lower pain as compared with presence of parents and standard care. No differences were observed between clowning interventions and the other comparators. For both outcomes, large between study heterogeneity was present but no significant inconsistency between designs. Risk of bias was mainly high and accordingly the certainty of evidence is considered moderate to low.

CONCLUSIONS

We found no significant difference between medication, other non-medical distraction interventions and hospital clown interventions. Hospital clowns and other distraction interventions were more effective in reducing anxiety and pain in children undergoing medical procedures than the presence of parents alone. In order to allow for better insights regarding the comparative effectiveness of clowning interventions future trials should include detailed descriptions about the clowning intervention itself and the comparator. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

GPs’ and practice nurses’ views on their management of paediatric anxiety problems: an interview study

Background

Anxiety problems are common in both children and adolescents, and many affected children do not receive appropriate treatment. Understaffing of mental healthcare services and long waiting lists form major barriers. In the Netherlands, practice nurses have been introduced into general practice to support general practitioners (GPs) in the management of psychosocial problems. In this study we investigated the views of GPs and practice nurses on their management of paediatric anxiety problems.

Methods

We performed an exploratory study using semi-structured interviews with 13 GPs and 13 practice nurses in the greater Rotterdam area in 2021. Interviews were transcribed and coded into topics, which were categorized per research question.

Results

In their management of paediatric anxiety problems, both GPs and practice nurses try to explore the case and the needs of affected children and their parents. GPs rarely follow up affected children themselves. They often refer the child, preferably to their practice nurse. Practice nurses regularly initiate follow-up consultations with affected children themselves. Practice nurses reported using a variety of therapeutic techniques, including elements of cognitive behavioural therapy. In more severe cases, practice nurses refer the child to external mental healthcare services. GPs reported being satisfied with their collaboration with practice nurses. Both GPs and practice nurses experience significant barriers in the management of paediatric anxiety problems. Most importantly, long waiting lists for external mental health care were reported to be a major difficulty. Improving cooperation with external mental healthcare providers was reported to be an important facilitator.

Conclusions

In their management of paediatric anxiety problems, GPs and practice nurses experience major challenges in the cooperation with external mental healthcare providers and in the long waiting lists for these services. GPs and practice nurses believe that thanks to their shared approach more children with anxiety problems can remain treated in general practice. Future research is needed to evaluate the treatment outcomes of the shared efforts of GPs and practice nurses in their management of paediatric anxiety problems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01802-y.

Anxiety problems in children and adolescents: a population-based cohort study on incidence and management in Dutch primary care

BACKGROUND

Due to a large strain on youth mental health care, general practice is suggested as an alternative treatment setting for children and adolescents with anxiety problems. However, research on the current management of these children and adolescents within general practice is scarce.

AIM

To investigate the incidence of coded anxiety in general practice using the International Classification of Primary Care (ICPC), and GPs' management of children and adolescents presenting with anxiety problems.

DESIGN AND SETTING

Population-based cohort study using electronic medical records of 51 212 children (aged 0-17 years) in primary care in the Rotterdam region between 1 January 2012 and 31 December 2018.

METHOD

Incidence of ICPC codes for anxiety were calculated, then the characteristics of children and adolescents consulting their GP with anxiety and the GPs' management were assessed qualitatively using quantitative content analysis.

RESULTS

Incidence of ICPC codes for anxiety in children and adolescents was 5.36 (95% confidence interval [CI] = 5.02 to 5.71) per 1000 person-years. Adolescent females had the highest incidence with 14.01 (95% CI = 12.55 to 15.58) per 1000 person-years. Of the 381 children and adolescents consulting their GP with an initial anxiety problem (median age 13.3 years, 40.4% male), GPs referred 59.3% to mental health care in the first year while 26.5% of children and adolescents were managed by a specialised practice nurse within general practice. Of the 381 children and adolescents, 10.5% received psychiatric medication during the first year, with the trend being for increased prescriptions during adolescence.

CONCLUSION

In general practice children and adolescents frequently received one of two ICPC codes for anxiety, especially adolescent females. Most presenting to their GP with anxiety problems are referred externally or seen by a specialised practice nurse within general practice.

Greater than the sum of the parts: a qualitative content analysis of what constitutes a good treatment in the inpatient setting

Background

The evaluation of psychotherapy is guided by established concepts, such as efficacy and effectiveness, and acceptability. Although these concepts serve as valid proxies, little is known about corresponding criteria for those directly involved in this treatment. This study aimed to explore inpatients’ and health professionals’ definitions of a good treatment in the inpatient setting.

Methods

Fifteen semi-structured interviews were conducted in a private psychiatric clinic in Switzerland and structured by qualitative content analysis. Different subsamples of the inpatient setting (patients N = 5; psychiatrists N = 5; other health professionals N = 5) were interviewed.

Results

In total, 546 text passages were grouped in 10 superordinate categories and identified as relevant for the concept of a good treatment. Participants stressed patient-specific (i.e., new insights; basic attitudes), treatment-specific (i.e., therapy methods and expertise; treatment success; therapy setting), and relationship-based (i.e., communication and feedback; relationships within the clinical setting; overcoming challenges and hurdles) components that are indispensable for a good therapeutic process. Components that are related to the clinical inpatient setting (i.e., setting and organization of the clinic; code of conduct) were also highlighted.

Conclusions

Patients’ and health professionals’ definitions of what constitutes a good treatment entails a wide array of aspects. The clinical setting is seen to offer unique components that are emphasized to have a healing effect.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07834-5.

Mental disorders among adults formerly in out-of-home care: a systematic review and meta-analysis of longitudinal studies

While children and adolescents placed in child welfare or juvenile justice out-of-home care show higher prevalence rates of mental disorders compared to the general population, it remains unclear whether this pattern persists into adulthood. A quantitative synthesis of existing studies is lacking. The aim of this meta-analysis was to estimate the prevalence rates for mental disorders among adults with a foster or residential child welfare or juvenile justice care history, comparing them where possible to rates among the general population. PubMed, PsycInfo, EMBASE, and Web of Science were systematically searched for epidemiological studies published up to 28 October 2020. Nineteen studies, totaling 604,257 participants, met our inclusion criteria. Random-effects models were used for prevalence rates and odds ratios (OR) of mental disorders, and study quality was rated. A prevalence rate of 30% [95% CI (23.36, 37.36)] for any mental disorder in adults with a child welfare care history was found (3-17% for specific disorders). A prevalence rate of 45% [95% CI (42.38, 47.38)] for any mental disorder was found in adults with a juvenile justice care history (6-66% for specific disorders). For out-of-home placement history, adult mental disorders were significantly higher than in the general population (OR = 1.33-2.76). Studies differed in terms of methodology and the disorder groups considered, so heterogeneity between effect sizes ranged from low to high. Our findings suggest that the high risk that mental health issues will persist in adults with an out-of-home placement history needs to be taken seriously in the transition from adolescence to adulthood. The care systems involved need to collaborate and to be aware of these risks.

Does information structuring improve recall of discharge information? A cluster randomized clinical trial

OBJECTIVES

The impact of the quality of discharge communication between physicians and their patients is critical on patients' health outcomes. Nevertheless, low recall of information given to patients at discharge from emergency departments (EDs) is a well-documented problem. Therefore, we investigated the outcomes and related benefits of two different communication strategies: Physicians were instructed to either use empathy (E) or information structuring (S) skills hypothesizing superior recall by patients in the S group.

METHODS

For the direct comparison of two communication strategies at discharge, physicians were cluster-randomized to an E or a S skills training. Feasibility was measured by training completion rates. Outcomes were measured in patients immediately after discharge, after 7, and 30 days. Primary outcome was patients' immediate recall of discharge information. Secondary outcomes were feasibility of training implementation, patients' adherence to recommendations and satisfaction, as well as the patient-physician relationship.

RESULTS

Of 117 eligible physicians, 80 (68.4%) completed the training. Out of 256 patients randomized to one of the two training groups (E: 146 and S: 119) 196 completed the post-discharge assessment. Patients' immediate recall of discharge information was superior in patients in the S-group vs. E-group. Patients in the S-group adhered to more recommendations within 30 days (p = .002), and were more likely to recommend the physician to family and friends (p = .021). No differences were found on other assessed outcome domains.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Immediate recall and subsequent adherence to recommendations were higher in the S group. Feasibility was shown by a 69.6% completion rate of trainings. Thus, trainings of discharge information structuring are feasible and improve patients' recall, and may therefore improve quality of care in the ED.

Comparative efficacy and acceptability of expressive writing treatments compared with psychotherapy, other writing treatments, and waiting list control for adult trauma survivors: a systematic review and network meta-analysis

BACKGROUND

Expressive writing about a traumatic event is promising in treating posttraumatic stress disorder (PTSD) symptoms in adult trauma survivors. To date, the comparative efficacy and acceptability of this approach is uncertain. Therefore, we aimed to examine the comparative efficacy and acceptability of expressive writing treatments.

METHODS

We included 44 RCTs with 7724 participants contributing 54 direct comparisons between expressive writing (EW), enhanced writing (i.e. including additional therapist contact or individualized writing assignments; EW+), PTSD psychotherapies (PT), neutral writing (NW), and waiting-list control (WL).

RESULTS

EW, EW+, PT, and NW were statistically significantly more efficacious than WL at the longest available follow-up, with SMDs (95% CI) of -0.78 (-1.10 to -0.46) for PT, -0.81 (-1.02 to -0.61) for EW+ , -0.43 (-0.65 to -0.21) for EW, and -0.37 (-0.61 to -0.14) for NW. We found small to moderate differences between the active treatments. At baseline mean PTSD severity was significantly lower in EW+ compared with WL. We found considerable heterogeneity and inconsistency and we found elevated risk of bias in at least one of the bias dimensions in all studies. When EW+-WL comparisons were excluded from the analyses EW+ was no longer superior compared with EW.

CONCLUSIONS

The summarized evidence confirms that writing treatments may contribute to improving PTSD symptoms in medium to long-term. Methodological issues in the available evidence hamper definite conclusions regarding the comparative efficacy and acceptability of writing treatments. Adequately sized comparative randomized controlled trials preferably including all four active treatment approaches, reporting long-term data, and including researchers with balanced preferences are needed.

Effectiveness of animal-assisted interventions for children and adults with post-traumatic stress disorder symptoms: a systematic review and meta-analysis

Background: Animal-assisted interventions (AAI) are increasingly applied for people with post-traumatic stress disorder (PTSD) symptoms albeit its effectiveness is unclear.Objectives: To examine the effectiveness of AAI for treating PTSD symptoms.Method: We searched 11 major electronic databases for studies reporting quantitative data on effects of AAI for children and adults with PTSD symptoms. Of 22'211 records identified, we included 41 studies with 1111 participants in the systematic review comprising eight controlled studies with 469 participants in the meta-analysis. We conducted random-effects meta-analyses with all controlled studies based on standardized mean differences (SMD), and calculated standardized mean change (SMC) as effect sizes for studies with a pre-post one-group design. Two independent researchers assessed the quality of the included studies using the NIH Study Quality Assessment Tools. The primary outcome was PTSD or depression symptom severity measured via a standardized measurement at pre- and post-intervention assessments.Results: There was a small but not statistically significant superiority of AAI over standard PTSD psychotherapy (SMD = -0.26, 95% CI: -0.56 to 0.04) in reducing PTSD symptom severity while AAI was superior to waitlist (SMD = -0.82, 95% CI: -1.56 to 0.08). Getting a service dog was superior to waiting for a service dog (SMD = -0.58, 95% CI: -0.88 to -0.28). AAI led to comparable effects in reducing depression as standard PTSD psychotherapy (SMD = -0.03, CI: -0.88 to 0.83). Pre-post comparisons showed large variation for the reduction in PTSD symptom severity, with SMCs ranging from -0.38 to -1.64, and for depression symptom severity, ranging from 0.01 to -2.76. Getting a service dog lowered PTSD symptoms between -0.43 and -1.10 and depression with medium effect size of -0.74.Conclusions: The results indicate that AAI are efficacious in reducing PTSD symptomatology and depression. Future studies with robust study designs and large samples are needed for valid conclusions.

What are the Key Characteristics of a 'Good' Psychotherapy? Calling for Ethical Patient Involvement

OBJECTIVE

The evidence-based practice movement clearly defines the relevant components of a good treatment. In the present article, we elaborate on how the active involvement of patients within psychotherapy can and should be increased in order to respect ethical considerations. Our arguments complement the requirements of evidence-based practice, and are independent of the actual psychotherapeutic treatment approach being used.

METHOD

Theoretical and ethical analysis.

RESULTS

In order to respect patient autonomy, psychotherapy needs to be transparent and honest when it comes to disclosing the relevant factors for promoting therapeutic change. It has been argued that ethical informed consent needs to include empirically supported patient information. In this paper we go one step further: we outline that fully respecting ethical considerations in psychotherapeutic treatment necessarily calls for acknowledging and strengthening the active role of patients in the course of psychotherapy. Accordingly, patients need not only to be informed openly and transparently about the planned treatment, the treatment rationale, and the expected prognosis of improvement in the course of psychotherapy, but they also need to be actively involved in the decision-making process and during the entire process of psychotherapeutic treatment.

CONCLUSIONS

Our arguments support the tendency that can be observed in health care in recent years towards more active patient involvement across different health-care domains, but also in clinical research. This article offers an ethical perspective on the question what defines a 'good psychotherapy', which, hopefully, will help to leave behind some of the ongoing psychotherapy debates and move the field forward.

Comparative Efficacy and Acceptability of Pharmacological, Psychotherapeutic, and Combination Treatments in Adults With Posttraumatic Stress Disorder: A Network Meta-analysis

IMPORTANCE

Posttraumatic stress disorder (PTSD) is a prevalent mental disorder, with a high risk of chronicity, comorbidity, and functional impairment; PTSD is complicated to treat, and the debate on the best treatment approach is ongoing.

OBJECTIVE

To examine comparative outcomes and acceptability of psychotherapeutic and pharmacological treatments and their combinations in adults with PTSD.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Cochrane Controlled Trials Register, and PSYNDEX were searched for studies published from January 1, 1980, to February 28, 2018. Reference lists of included studies and of previously published guidelines and systematic reviews were also searched.

STUDY SELECTION

Of 11 417 records identified, 12 published randomized clinical trials (RCTs) comprising 922 participants, contributing 23 direct comparisons between psychotherapeutic and pharmacological treatments or their combinations were included.

DATA EXTRACTION AND SYNTHESIS

Standardized mean differences (SMDs) and odds ratios were aggregated using random-effects network and pairwise meta-analyses. Risk of bias and indirectness was rated for each study, and network confidence was rated using the Confidence in Network Meta-Analysis framework.

MAIN OUTCOMES AND MEASURES

The primary outcome was the comparative benefit between 2 treatment approaches to PTSD symptom improvement, and secondary outcome was the comparative acceptability of the treatment approaches, as indicated by patient dropout rates before treatment termination.

RESULTS

No treatment approach was found to be superior at the end of treatment (for all, 95% CI included 0). At the last follow-up, psychotherapeutic treatments showed greater benefit than pharmacological treatments in both network (SMD, -0.83; 95% CI, -1.59 to -0.07) and pairwise (SMD, -0.63; 95% CI, -1.18 to -0.09, 3 RCTs) meta-analyses. No difference was found between combined treatments and psychotherapeutic treatments at long-term follow-up, and combined treatments were associated with better outcomes than pharmacological treatments in the network meta-analysis (SMD, -0.96; 95% CI, -1.87 to -0.04), but not in the pairwise meta-analysis, which included 2 RCTs (SMD, -1.02; 95% CI, -2.77 to 0.72). No evidence was found for differential acceptability of the 3 treatment approaches.

CONCLUSIONS AND RELEVANCE

These results suggest superiority of psychotherapeutic treatments over pharmacological treatments; network, but not pairwise, meta-analyses suggest superiority of combined treatments over pharmacological treatments in improving PTSD symptom severity in the long term. The scarcity of reported long-term findings hampers definite conclusions and demonstrates the need for robust evidence from large-scaled comparative trials providing long-term follow-up data.

The Other Side of the Coin: Nocebo Effects and Psychotherapy

Psychotherapy and placebo have a long history, and both have been shown to have significant and clinically meaningful effects. In the last 100 years and up to today, psychotherapy has been subject to an enduring and often heated debate about its mechanisms and its possible relationship to placebos and their effects. However, there is little awareness of the placebo effects' counterpart-nocebo effects (from Latin "I will harm")-in the context of psychotherapy. Embedded in the controversy of whether psychotherapy and placebo share some unwanted proximity in terms of effects and mechanisms, the question arises which role nocebo effects may play in relation to psychotherapy. By using two examples, this article analyzes and discusses two different kinds of possible associations between psychotherapy and nocebo effects. We close with possibilities of how to prevent the occurrence of nocebo effects in psychotherapy, including some specific recommendations for clinical practice.

The effects of aerobic, resistance, and meditative movement exercise on sleep in individuals with depression: protocol for a systematic review and network meta-analysis

BACKGROUND

The main objective of this review is to assess the effects of aerobic, resistance, and meditative movement exercise on sleep quality in patients with unipolar depression. A secondary goal is to ascertain the effects on sleep duration, sleepiness, daytime functioning, use of hypnotics, and adverse events.

METHODS

A systematic computerized search will be performed in the following online databases: PubMed, EMBASE (on Ovid), Cochrane Library, PsycINFO (on Ovid), SPORTDiscus (on EBSCOhost), CINHAL (on EBSCOhost), Clinicaltrials.gov , WHO International Clinical Trials Registry, OpenGrey, and ProQuest Dissertations and Theses. Bibliographies of all included studies as well as any other relevant reviews identified via the search will be screened. Randomized trials using aerobic, resistance, or meditative movement exercise interventions which target sleep as a primary or secondary outcome will be included. The primary outcome will be differences in sleep quality at post-intervention. Secondary outcomes will be adverse events, differences in sleep duration, daytime sleepiness and functioning, and the use of hypnotics at post-intervention. Two authors will independently screen the identified records. Disagreement will be resolved by consensus or if no consensus can be reached by adjudication of a designated third reviewer. Data extraction will be done independently by two authors using a standardized and piloted data extraction sheet. Bias in individual studies will be assessed using the revised Cochrane risk of bias tool. The certainty of evidence across all outcomes will be evaluated using the CINeMA (Confidence in Network Meta-Analysis) framework. A frequentist network meta-analysis will be conducted. The systematic review and network meta-analysis will be presented according to the PRISMA for Network Meta-Analyses (PRISMA-NMA) guideline.

DISCUSSION

This systematic review and network meta-analysis will provide a synthesis of the currently available evidence concerning the effects of aerobic, resistance, and meditative movement exercises on sleep in patients with unipolar depression. Thereby, we hope to accelerate the consolidation of evidence and inform decision-makers on potential benefits and harms.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019115705).

Long-Term Effects of Psychological Interventions to Improve Adherence to Antiretroviral Treatment in HIV-Infected Persons: A Systematic Review and Meta-Analysis

We examined the efficacy of psychological adherence-enhancing interventions (AEIs) compared with usual care in HIV-infected adults under antiretroviral treatment (ART) by focusing on adherence and clinical HIV markers as outcomes in the short term and long term. We searched relevant databases for controlled studies that compared psychological AEIs with usual care. We included 31 comparisons from 27 individual studies in our meta-analyses. Psychological AEIs were significantly superior to usual care in improving adherence [standardized mean difference (SMD) 0.30, 95% CI 0.20-0.40] and reducing HIV viral load (SMD 0.15, 0.07-0.23) at the end of treatment. At the last follow-up, we found no difference between psychological AEIs and usual care, neither on adherence (SMD 0.07, -0.11-0.24) nor on clinical markers (SMD 0.06, -0.03-0.15). After excluding outliers from the analyses, between-study heterogeneity was small, and we did not identify any relevant moderators of intervention effects. In summary, psychological AEIs may significantly improve ART adherence and HIV viral load compared with usual care in the short term, but fail to be superior in achieving long-lasting improvements on ART adherence and clinical HIV markers as compared with usual care. Owing to limited quality and the majority of studies being conducted in the United States or Europe, our results have to be interpreted with caution, and are most relevant to the United States and Europe. The consistently reported difficulties to achieve sustained ART adherence improvements in previous and the present meta-analyses highlight the need to focus on maintaining ART adherence improvements in future research.

The Healing Encounters and Attitudes Lists (HEAL): Psychometric Properties of a German Version (HEAL-D) in Comparison With the Original HEAL

Introduction: Over the last years, the interest in understanding health improvements that occur due to non-specific treatment effects, rather than in response to the specific active treatment ingredients, increased. Nevertheless, investigations on patients' idiosyncratic perspectives on the non-specific aspects of the healing encounter or of the treatment itself that contribute to placebo effects are still rare. The Healing Encounters and Attitudes Lists (HEAL) offer a unique and parsimonious set of instruments to measure patients' views on a variety of non-specific aspects of the caring encounter. The HEAL items can be administered as computerized adaptive tests or short forms that assess the patient-provider connection, the healthcare environment, treatment expectancy, positive outlook, spirituality, as well as attitudes towards complementary and alternative medicine. So far, no German version of the HEAL exists. Methods: The original 168 HEAL items were translated into German (HEAL-D) applying a translation-back-translation procedure. We examined the psychometric properties of HEAL-D in a sample of 165 participants who reported at least one healthcare visit during the last year. Results: The German short forms of HEAL (HEAL-D-SF) showed good internal consistency and test-retest reliability. The factor structure observed in the English original items showed low to moderate model fit in our sample. Discussion: The development of a German version of HEAL in addition to the original English items offers new possibilities for investigating patients' idiosyncratic perspectives on the non-specific aspects of treatments across language borders. We will close with presenting possible clinical application as well as promising and relevant future research directions using HEAL-D-SF, including for instance large-scale, cross-national investigations.

Trust in the health care professional and health outcome: A meta-analysis

Objective

To examine whether patients’ trust in the health care professional is associated with health outcomes.

Study selection

We searched 4 major electronic databases for studies that reported quantitative data on the association between trust in the health care professional and health outcome. We screened the full-texts of 400 publications and included 47 studies in our meta-analysis.

Data extraction and data synthesis

We conducted random effects meta-analyses and meta-regressions and calculated correlation coefficients with corresponding 95% confidence intervals. Two interdependent researchers assessed the quality of the included studies using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

Results

Overall, we found a small to moderate correlation between trust and health outcomes (r = 0.24, 95% CI: 0.19–0.29). Subgroup analyses revealed a moderate correlation between trust and self-rated subjective health outcomes (r = 0.30, 0.24–0.35). Correlations between trust and objective (r = -0.02, -0.08–0.03) as well as observer-rated outcomes (r = 0.10, -0.16–0.36) were non-significant. Exploratory analyses showed a large correlation between trust and patient satisfaction and somewhat smaller correlations with health behaviours, quality of life and symptom severity. Heterogeneity was small to moderate across the analyses.

Conclusions

From a clinical perspective, patients reported more beneficial health behaviours, less symptoms and higher quality of life and to be more satisfied with treatment when they had higher trust in their health care professional. There was evidence for upward bias in the summarized results. Prospective studies are required to deepen our understanding of the complex interplay between trust and health outcomes.

Oxytocin and Autism Spectrum Disorders: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aim: Oxytocin presents an exciting potential to target the core symptoms of autism spectrum disorder (ASD) pharmacologically in an easily administered, cost-effective form with possibly minimal adverse effects. But, there are still major gaps in this area of research. This paper reviewed randomized controlled trials (RCTs) examining the effects of oxytocin administration on social cognition and restricted, repetitive behaviors in individuals with an ASD. Method: Electronic literature searches were conducted from PsycINFO, PubMed, Web of Knowledge, and EMBASE for RCTs published through June 2015. Results: 12 RCTs were included in this review. 7 out of the 11 studies that examined social cognition reported improvements. Additionally, one out of the 4 studies on restricted, repetitive behaviors, reported improvements following oxytocin administration. However, results from our meta-analyses suggest that oxytocin has no significant effect on these 2 domains. Conclusion: Previous evidence revealed mixed findings about the effects of oxytocin on ASD. Given the limited number of RCTs, our summary of findings on the effectiveness of oxytocin on ASD should still be considered tentative.

Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis

(Reprinted with permission from PLoS Med 2013; 10(5):e1001454).

Does It Matter Who Provides Psychological Interventions for Medically Unexplained Symptoms? A Meta-Analysis

BACKGROUND

Patients with medically unexplained symptoms (MUS) are difficult to treat and cause high health-care costs. Psychological interventions might be a beneficial option for treating patients with MUS, but evidence is inconsistent. This meta-analysis compares the effectiveness of psychological interventions for MUS - delivered either by psychotherapists (PTs) or by general practitioners (GPs) - with that of usual care.

METHOD

We conducted a systematic review and meta-analysis on randomised controlled trials of psychological interventions for MUS. Physical symptoms were the primary outcome, and physical functioning and psychological symptoms were the secondary outcomes. We pooled between-group effect sizes (ESs) after the treatment and at the follow-up in random-effects meta-regressions and stratified meta-analyses. We repeated these analyses with the intervention provider, intervention dose, MUS severity and methodological quality as predictors of relative intervention effects.

RESULTS

A total of 3,225 patients in 20 studies were analysed. After the treatment, small and significant ESs were found for all 3 outcome domains (ES range: 0.13-0.19, all p < 0.05). Psychological interventions were more beneficial for physical symptoms when delivered by PTs than by GPs (p = 0.02). There was no difference between PTs and GPs in terms of physical functioning and psychological symptoms.

CONCLUSION

Psychological interventions are effective for patients with MUS, but the effects are small and most likely of short duration. Interventions that are delivered by PTs appear to have larger effects on unexplained physical symptoms than those delivered by GPs. Whether this superiority is due to a larger number of sessions of PT interventions remains unclear from our findings.

Integrating fragmented evidence by network meta-analysis: relative effectiveness of psychological interventions for adults with post-traumatic stress disorder

BACKGROUND

To summarize the available evidence on the effectiveness of psychological interventions for patients with post-traumatic stress disorder (PTSD).

METHOD

We searched bibliographic databases and reference lists of relevant systematic reviews and meta-analyses for randomized controlled trials that compared specific psychological interventions for adults with PTSD symptoms either head-to-head or against control interventions using non-specific intervention components, or against wait-list control. Two investigators independently extracted the data and assessed trial characteristics.

RESULTS

The analyses included 4190 patients in 66 trials. An initial network meta-analysis showed large effect sizes (ESs) for all specific psychological interventions (ESs between -1.10 and -1.37) and moderate effects of psychological interventions that were used to control for non-specific intervention effects (ESs -0.58 and -0.62). ES differences between various types of specific psychological interventions were absent to small (ES differences between 0.00 and 0.27). Considerable between-trial heterogeneity occurred (τ²= 0.30). Stratified analyses revealed that trials that adhered to DSM-III/IV criteria for PTSD were associated with larger ESs. However, considerable heterogeneity remained. Heterogeneity was reduced in trials with adequate concealment of allocation and in large-sized trials. We found evidence for small-study bias.

CONCLUSIONS

Our findings show that patients with a formal diagnosis of PTSD and those with subclinical PTSD symptoms benefit from different psychological interventions. We did not identify any intervention that was consistently superior to other specific psychological interventions. However, the robustness of evidence varies considerably between different psychological interventions for PTSD, with most robust evidence for cognitive behavioral and exposure therapies.

Combination of psychological intervention and phosphodiesterase-5 inhibitors for erectile dysfunction: a narrative review and meta-analysis

INTRODUCTION

Erectile dysfunction (ED) is an increasing health problem that demands effective treatment. There is evidence that phosphodiesterase-5 inhibitors (PDE5-Is) and psychological intervention (PI) are effective treatment options; however, little is known about their comparative efficacy and the efficacy of combined treatments.

AIM

The aim of this systematic review and meta-analysis is to evaluate the comparative efficacy of PI, PDE5-Is, and their combination in the treatment of ED.

MAIN OUTCOME MEASURES

Primary outcome was ED symptoms, and secondary outcome was sexual satisfaction of the patient.

METHODS

A systematic literature search was conducted in order to identify relevant articles published between 1998 and 2012. We included randomized controlled trials and controlled trials comparing PI with PDE5-I treatment or one of them against a combination of both.

RESULTS

Eight studies with a total number of 562 patients were included in the meta-analysis. The results of the included studies are inconclusive, though they show a trend towards a larger effect of combined treatment compared with PI or PDE5-I treatment alone. The meta-analysis found that, overall, combined treatment was more efficacious for ED symptoms than PDE5-I treatment or PI alone. Combined treatment was more efficacious than PDE5-I use alone on sexual satisfaction. No differences were found between PDE5-Is and PI as stand-alone treatments. None of the moderators (treatment duration, methodological quality, or researcher allegiance) altered the effects.

CONCLUSIONS

The combination of PI and PDE5-Is is a promising strategy for a favorable outcome in ED and can be considered as a first-choice option for ED patients. Stronger RCTs are required to confirm this initial finding.

Specific and nonspecific psychological interventions for PTSD symptoms: a meta-analysis with problem complexity as a moderator

CONTEXT

The necessity of specific intervention components for the successful treatment of patients with posttraumatic stress disorder is the subject of controversy.

OBJECTIVE

To investigate the complexity of clinical problems as a moderator of relative effects between specific and nonspecific psychological interventions.

METHODS

We included 18 randomized controlled trials, directly comparing specific and nonspecific psychological interventions. We conducted moderator analyses, including the complexity of clinical problems as predictor.

RESULTS

Our results have confirmed the moderate superiority of specific over nonspecific psychological interventions; however, the superiority was small in studies with complex clinical problems and large in studies with noncomplex clinical problems.

CONCLUSIONS

For patients with complex clinical problems, our results suggest that particular nonspecific psychological interventions may be offered as an alternative to specific psychological interventions. In contrast, for patients with noncomplex clinical problems, specific psychological interventions are the best treatment option.

Efficacy of psychological interventions for sexual dysfunction: a systematic review and meta-analysis

Sexual dysfunction is highly prevalent in the general population and associated with psychological distress and impaired sexual satisfaction. Psychological interventions are promising treatment options, as sexual dysfunction is frequently caused by and deteriorates because of psychological factors. However, research into the efficacy of psychological interventions is rather scarce and an up-to-date review of outcome studies is currently lacking. Therefore, we conducted a systematic review and meta-analysis of all available studies from 1980 to 2009 to examine the efficacy of psychological interventions for patients with sexual dysfunction. A total of 20 randomized controlled studies comparing a psychological intervention with a wait-list were included in the meta-analysis. The overall post-treatment effect size for symptom severity was d = 0.58 (95% CI: 0.40 to 0.77) and for sexual satisfaction d = 0.47 (95% CI: 0.27 to 0.70). Psychological interventions were shown to especially improve symptom severity for women with Hypoactive Sexual Desire Disorder and orgasmic disorder. Our systematic review of 14 studies comparing at least two active interventions head-to-head revealed that very few comparative studies are available with large variability in effect sizes across studies (d between -0.69 and 2.29 for symptom severity and -0.56 and 14.02 for sexual satisfaction). In conclusion, psychological interventions are effective treatment options for sexual dysfunction. However, evidence varies considerably across single disorders. Good evidence exists to date for female hypoactive sexual desire disorder and female orgasmic disorder. Further research is needed on psychological interventions for other sexual dysfunctions, their long-term and comparative effects.

Researcher allegiance in psychotherapy outcome research: an overview of reviews

Researcher allegiance (RA) is widely discussed as a risk of bias in psychotherapy outcome research. The relevance attached to RA bias is related to meta-analyses demonstrating an association of RA with treatment effects. However, recent meta-analyses have yielded mixed results. To provide more clarity on the magnitude and robustness of the RA-outcome association this article reports on a meta-meta-analysis summarizing all available meta-analytic estimates of the RA-outcome association. Random-effects methods were used. Primary study overlap was controlled. Thirty meta-analyses were included. The mean RA-outcome association was r=.262 (p=.002, I(2)=28.98%), corresponding to a moderate effect size. The RA-outcome association was robust across several moderating variables including characteristics of treatment, population, and the type of RA assessment. Allegiance towards the RA bias hypothesis moderated the RA-outcome association. The findings of this meta-meta-analysis suggest that the RA-outcome association is substantial and robust. Implications for psychotherapy outcome research are discussed.

Is the allegiance effect an epiphenomenon of true efficacy differences between treatments? a meta-analysis

Many meta-analyses of comparative outcome studies found a substantial association of researcher allegiance (RA) and relative treatment effects. Therefore, RA is regarded as a biasing factor in comparative outcome research (RA bias hypothesis). However, the RA bias hypothesis has been criticized as causality might be reversed. That is, RA might be a reflection of true efficacy differences between treatments (true efficacy hypothesis). Consequently, the RA-outcome association would not be indicative of bias but an epiphenomenon of true efficacy differences. This meta-analysis tested the validity of the true efficacy hypothesis. This was done by controlling the RA-outcome association for true efficacy differences by restricting analysis to direct comparisons of treatments with equivalent efficacy. We included direct comparisons of different versions of trauma-focused therapy (TFT) in the treatment of posttraumatic stress disorder (PTSD). RA was measured from the research reports. Relative effect sizes for symptoms of PTSD were calculated. Random effects meta-regression was conducted. Twenty-nine comparisons of TFTs from 20 studies were identified. Initial heterogeneity among relative effect sizes was low. RA was a significant predictor of outcome and explained 12% of the variance in outcomes. The true efficacy hypothesis predicted the RA-outcome association to be zero; however, a substantial association was found. Thus, this study does not support the true efficacy hypothesis. Given findings from psychotherapy research and other fields that support a biasing influence of researcher preferences, RA should be regarded as a causal factor and conceptualized as a threat to the validity of conclusions from comparative outcome studies.

Testing the allegiance bias hypothesis: a meta-analysis

This meta-analysis investigated whether the association between researcher allegiance (RA) and the relative effect of two psychotherapies can be explained through the methodological weaknesses of the treatment comparisons. Seventy-nine comparisons of psychotherapies for depression or posttraumatic stress disorder (PTSD) were included. Methodological quality (MQ) was investigated as both a moderator and a mediator of the RA-outcome association. MQ included balanced nonspecific factors, balanced specific factors, conceptual quality, patients-per-therapist ratio, randomization to conditions and outcome assessment. The RA-outcome association was stronger when the MQ was low, suggesting a buffering effect of MQ. In addition, differences in the conceptual quality of treatments mediated the effect of RA on outcome. The results support the view that RA acts as a bias in treatment comparisons.

The acceptance of modern myths about sexual aggression scale: development and validation in German and English

Scales of rape myth acceptance (RMA) often yield low means and skewed distributions. This is proposed to be because of a change in rape-related beliefs toward more subtle content. Incorporating insights from racism and sexism research, a 30-item self-report scale measuring the acceptance of modern myths about sexual aggression (AMMSA) is presented. Across four studies (total N=1,279), the reliability and validity of parallel German and English versions of the AMMSA scale were examined. The results show that both language versions are highly reliable; compared with a traditional RMA scale, means of AMMSA scores are higher and their distributions more closely approximate normality. Cross-sectional and longitudinal analyses provide evidence for the AMMSA scale's concurrent and predictive construct validity.