Changes in suicidal ideation during treatment among patients with major depressive disorder: A 6-month naturalistic follow-up study

AIM

There is limited evidence regarding predictors of changes in suicidal ideation (SI) in patients with major depressive disorder (MDD). The objective of this study was to describe changes in SI over a 6-month period and identify their predictors from naturalistic observations of MDD patients.

METHODS

In the cross-sectional analysis, we examined 257 patients with MDD at the first-visit assessment. Among the patients, 119 who completed the 6-month assessment (completers) were included in the longitudinal analysis. For the evaluation of depressive symptoms, including SI, the Quick Inventory of Depressive Symptomatology-Japanese version was administered at both the first-visit and follow-up assessments. At baseline, we also administered the Japanese version of the Ten Item Personality Inventory to assess personality traits and the PRIME Screen-Revised to assess psychotic symptoms.

RESULTS

In the cross-sectional analysis of first-visit patients, 36.2% (93/257) exhibited SI. Among completers, 14.3% (17/119) had prolonged SI. Among the completers with SI at the first-visit assessment, 38.6% (17/44) had SI at the follow-up assessment (prolonged SI). In linear regression models including all completers, prolonged SI was positively associated with endorsement of suspiciousness/persecutory ideas and negatively associated with higher age.

CONCLUSION

More than one-third of completers who had SI at the first-visit assessment experienced prolonged SI (SI at follow-up). Our findings can help clinicians predict the course of MDD by identifying associated demographic and clinical characteristics.

Quantifying Workload and Stress in Intensive Care Unit Nurses: Preliminary Evaluation Using Continuous Eye-Tracking

OBJECTIVE

(1) To assess mental workloads of intensive care unit (ICU) nurses in 12-hour working shifts (days and nights) using eye movement data; (2) to explore the impact of stress on the ocular metrics of nurses performing patient care in the ICU.

BACKGROUND

Prior studies have employed workload scoring systems or accelerometer data to assess ICU nurses' workload. This is the first naturalistic attempt to explore nurses' mental workload using eye movement data.

METHODS

Tobii Pro Glasses 2 eye-tracking and Empatica E4 devices were used to collect eye movement and physiological data from 15 nurses during 12-hour shifts (252 observation hours). We used mixed-effect models and an ordinal regression model with a random effect to analyze the changes in eye movement metrics during high stress episodes.

RESULTS

While the cadence and characteristics of nurse workload can vary between day shift and night shift, no significant difference in eye movement values was detected. However, eye movement metrics showed that the initial handoff period of nursing shifts has a higher mental workload compared with other times. Analysis of ocular metrics showed that stress is positively associated with an increase in number of eye fixations and gaze entropy, but negatively correlated with the duration of saccades and pupil diameter.

CONCLUSION

Eye-tracking technology can be used to assess the temporal variation of stress and associated changes with mental workload in the ICU environment. A real-time system could be developed for monitoring stress and workload for intervention development.

Examining the neural mechanisms of rTMS: a naturalistic pilot study of acute and serial effects in pharmacoresistant depression

Introduction

Previous studies have demonstrated the effectiveness of therapeutic repetitive transcranial magnetic stimulation (rTMS) to treat pharmacoresistant depression. Nevertheless, these trials have primarily focused on the therapeutic and neurophysiological effects of rTMS following a long-term treatment course. Identifying brain-based biomarkers of early rTMS therapeutic response remains an important unanswered question. In this pilot study, we examined the effects of rTMS on individuals with pharmacoresistant depression using a graph-based method, called Functional Cortical Networks (FCN), and serial electroencephalography (EEG). We hypothesized that changes in brain activity would occur early in treatment course.

Methods

A total of 15 patients with pharmacoresistant depression underwent five rTMS sessions (5Hz over the left dorsolateral prefrontal cortex, 120%MT, up to 4,000 pulses/session). Five participants received additional rTMS treatment, up to 40 sessions. Resting EEG activity was measured at baseline and following every five sessions, using 64-channel EEG, for 10 minutes with eyes closed. An FCN model was constructed using time-varying graphs and motif synchronization. The primary outcome was acute changes in weighted-node degree. Secondary outcomes included serial FFT-based power spectral analysis and changes in depressive symptoms measured by the 9-Item Patient Health Questionnaire (PHQ-9) and the 30-item Inventory of Depressive Symptoms-Self Report (IDS-SR).

Results

We found a significant acute effect over the left posterior area after five sessions, as evidenced by an increase in weighted-node degree of 37,824.59 (95% CI, 468.20 to 75,180.98) and a marginal enhancement in the left frontal region (t (14) = 2.0820, p = 0.056). One-way repeated measures ANOVA indicated a significant decrease in absolute beta power over the left prefrontal cortex (F (7, 28) = 2.37, p = 0.048) following ten rTMS sessions. Furthermore, a significant clinical improvement was observed following five rTMS sessions on both PHQ-9 (t (14) = 2.7093, p = 0.017) and IDS-SR (t (14) = 2.5278, p = 0.024) and progressed along the treatment course.

Discussion

Our findings suggest that FCN models and serial EEG may contribute to a deeper understanding of mechanisms underlying rTMS treatment. Additional research is required to investigate the acute and serial effects of rTMS in pharmacoresistant depression and assess whether early EEG changes could serve as predictors of therapeutic rTMS response.

Occupational stress and burnout among intensive care unit nurses during the pandemic: A prospective longitudinal study of nurses in COVID and non-COVID units

Background

Intensive care unit (ICU) nurses are highly prone to occupational stress and burnout, affecting their physical and mental health. The occurrence of the pandemic and related events increased nurses' workload and further exacerbated their stress and burnout. This work investigates occupational stress and burnout experienced by ICU nurses working with COVID and non-COVID patients.

Method

A prospective longitudinal mixed-methods study was conducted with a cohort of ICU nurses working in medical ICU (COVID unit; n = 14) and cardiovascular ICU (non-COVID unit; n = 5). Each participant was followed for six 12-h shifts. Data on occupational stress and burnout prevalence were collected using validated questionnaires. Physiological indices of stress were collected using wrist-worn wearable technologies. Participants elaborated on the causes of stress experienced each shift by completing open-ended questions. Data were analyzed using statistical and qualitative methods.

Results

Participants caring for COVID patients at the COVID unit were 3.71 times more likely to experience stress (p < 0.001) in comparison to non-COVID unit participants. No differences in stress levels were found when the same participants worked with COVID and non-COVID patients at different shifts (p = 0.58) at the COVID unit. The cohorts expressed similar contributors to stress, based in communication tasks, patient acuity, clinical procedures, admission processes, proning, labs, and assisting coworkers.

Conclusion

Nurses in COVID units, irrespective of whether they care for a COVID patient, experience occupational stress and burnout.

Dynamic Functional Connectivity of Emotion Processing in Beta Band with Naturalistic Emotion Stimuli

While naturalistic stimuli, such as movies, better represent the complexity of the real world and are perhaps crucial to understanding the dynamics of emotion processing, there is limited research on emotions with naturalistic stimuli. There is a need to understand the temporal dynamics of emotion processing and their relationship to different dimensions of emotion experience. In addition, there is a need to understand the dynamics of functional connectivity underlying different emotional experiences that occur during or prior to such experiences. To address these questions, we recorded the EEG of participants and asked them to mark the temporal location of their emotional experience as they watched a video. We also obtained self-assessment ratings for emotional multimedia stimuli. We calculated dynamic functional the connectivity (DFC) patterns in all the frequency bands, including information about hubs in the network. The change in functional networks was quantified in terms of temporal variability, which was then used in regression analysis to evaluate whether temporal variability in DFC (tvDFC) could predict different dimensions of emotional experience. We observed that the connectivity patterns in the upper beta band could differentiate emotion categories better during or prior to the reported emotional experience. The temporal variability in functional connectivity dynamics is primarily related to emotional arousal followed by dominance. The hubs in the functional networks were found across the right frontal and bilateral parietal lobes, which have been reported to facilitate affect, interoception, action, and memory-related processing. Since our study was performed with naturalistic real-life resembling emotional videos, the study contributes significantly to understanding the dynamics of emotion processing. The results support constructivist theories of emotional experience and show that changes in dynamic functional connectivity can predict aspects of our emotional experience.

Variation sets in the speech directed to toddlers in Argentinian households.SES and type of activity effects

The study adopts a naturalistic perspective, looking at the relationship between socio-economic status (SES), activities and variation sets in child-directed speech (CDS) to Spanish-speaking Argentinian toddlers. It aims to determine the effect of SES and type of activity on the proportion of words and utterances in variation sets and on the pragmatic function they serve in interaction. Thirty two children (mean: 14.3 months) and their families were audio-recorded for four hours and the middle two hours were analyzed using CLAN. We developed an automatic algorithm for variation sets extraction that compares noun, verb and adjective lexemes in successive utterances. Mixed-effects beta regression showed SES and activity type effects on the proportion of variation sets and on the pragmatic function served by variation sets. Findings revealed that the contextual variables considered impact on how interlocutors organize the information to young children at the local level of natural at home interactions.

Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder: The Results of a Naturalistic Outcomes Study

Cognitive−behavioral therapy is a well-established treatment for obsessive−compulsive disorder (OCD). There are a variety of cognitive and behavioral strategies, and it is necessary to analyze the outcomes of the treatments. The aim of the present study is to verify the effectiveness of a treatment that combines evidence-based procedures and specific cognitive interventions highlighting the issue of acceptance. Forty patients with OCD were recruited and underwent a specific treatment procedure. All patients had a psychodiagnostic assessment for OCD using the Y−BOCS (Yale−Brown obsessive−compulsive scale) performed twice: before treatment (t0) and after nine months (t1). Data analysis showed a decrease in the scores between t0 and t1 according to the Y−BOCS in terms of the interference, severity, and impairment of obsessive−compulsive symptoms. A repeated-measures ANOVA showed a significant reduction in symptoms after treatment, with values of F (1, 39) = 137.56, p < 0.001, and η2 = 0.78. The ANOVA results were corroborated by a Wilcoxon signed-rank test. A reliable change index analysis indicated that 33 participants reported improvements in symptoms, of which 23 were clinically significant. The results showed clinical relevance for OCD treatment and highlighted how this cognitive procedure favored positive outcomes.

Naturalistic Study on the Effects of Electroconvulsive Therapy (ECT) on Depressive Symptoms

OBJECTIVE

The effectiveness of ECT under naturalistic conditions has not been well-studied. The current study aimed to 1) characterize a naturalistic sample of ECT patients; and 2) examine the long-term outcomes of ECT on depressive symptoms (Beck Depression Inventory-II; BDI-II) and functional disability symptoms (WHO Disability Assessment Schedule 2.0) in this sample.

METHODS

Participants were adults who received ECT for a major depressive episode at an ambulatory ECT clinic between September 2010 and November 2020. Clinical and cognitive assessments were completed at baseline (n = 100), mid-ECT (n = 94), 2-4 weeks post-ECT (n = 64), 6-months post-ECT (n = 34), and 12-months post-ECT (n = 19).

RESULTS

At baseline, participants had severe levels of depressive symptoms (BDI-II: M = 41.0, SD = 9.4), and 62.9% screened positive for multiple psychiatric diagnoses on the MINI International Neuropsychiatric Interview. Depressive symptoms (F(4,49.1) = 49.92, P < 0.001) and disability symptoms (F(3,40.72) = 12.30, P < 0.001) improved significantly following ECT, and this was maintained at 12-months follow-up. Improvement in depressive symptoms trended towards significantly predicting reduction in disability symptoms from baseline to post-ECT, (F(1,56) = 3.67, P = 0.061). Although our clinical remission rate of 27% (BDI-II score ≤ 13 and ≥ 50% improvement) and overall response rate of 41.3% (≥ 50% improvement in BDI-II score) were lower than the rates reported in the extant RCT and community ECT literature, 36% of those treated with ECT were lost to follow-up and did not complete post-ECT rating scales. At baseline, remitters had significantly fewer psychiatric comorbidities, lower BDI-II scores, and lower disability symptoms than non-responders (P < 0.05).

CONCLUSIONS

Participants were severely symptomatic and clinically complex. ECT was effective at reducing depressive symptoms and functional disability in this heterogeneous sample. Although a large amount of missing data may have distorted our calculated response/remission rates, it is also likely that clinical heterogeneity and severity contribute to lower-than-expected remission and response rates to ECT.

Lower activity linkage between caregivers and persons with neurodegenerative diseases is associated with greater caregiver anxiety

Physiological linkage refers to the degree to which two individuals' central/peripheral physiological activities change in coordinated ways. Previous research has focused primarily on linkage in the autonomic nervous system in laboratory settings, particularly examining how linkage is associated with social behavior and relationship quality. In this study, we examined how linkage in couples' daily somatic activity (e.g., synchronized movement measured from wrist sensors)-another important aspect of peripheral physiology-was associated with relationship quality and mental health. We focused on persons with neurodegenerative diseases (PWNDs) and their spousal caregivers, whose linkage might have direct implications for the PWND-caregiver relationship and caregiver's health. Twenty-two PWNDs and their caregivers wore wristwatch actigraphy devices that provided continuous measurement of activity over 7 days at home. PWND-caregiver activity linkage was quantified by the degree to which activity was "in-phase" or "anti-phase" linked (i.e., coordinated changes in the same or opposite direction) during waking hours, computed by correlating minute-by-minute activity levels averaged using a 10-min rolling window. Caregivers completed well-validated surveys that assessed their mental health (including anxiety and depression) and relationship quality with the PWND. We found that lower in-phase activity linkage, but not anti-phase linkage, was associated with higher caregiver anxiety. These dyad-level effects were robust, remaining significant after adjusting for somatic activity at the individual level. No effects were found for caregiver depression or relationship quality. These findings suggest activity linkage and wearables may be useful for day-by-day monitoring of vulnerable populations such as family caregivers. We offered several possible explanations for our findings.

Quantifying Occupational Stress in Intensive Care Unit Nurses: An Applied Naturalistic Study of Correlations Among Stress, Heart Rate, Electrodermal Activity, and Skin Temperature

OBJECTIVE

To identify physiological correlates to stress in intensive care unit nurses.

BACKGROUND

Most research on stress correlates are done in laboratory environments; naturalistic investigation of stress remains a general gap.

METHOD

Electrodermal activity, heart rate, and skin temperatures were recorded continuously for 12-hr nursing shifts (23 participants) using a wrist-worn wearable technology (Empatica E4).

RESULTS

Positive correlations included stress and heart rate (ρ = .35, p < .001), stress and skin temperature (ρ = .49, p < .05), and heart rate and skin temperatures (ρ = .54, p = .0008).

DISCUSSION

The presence and direction of some correlations found in this study differ from those anticipated from prior literature, illustrating the importance of complementing laboratory research with naturalistic studies. Further work is warranted to recognize nursing activities associated with a high level of stress and the underlying reasons associated with changes in physiological responses.

APPLICATION

Heart rate and skin temperature may be used for real-time detection of stress, but more work is needed to validate such surrogate measures.

In Older Adults the Antidepressant Effect of Repetitive Transcranial Magnetic Stimulation Is Similar but Occurs Later Than in Younger Adults

Background

Treatment resistant depression is common in older adults and treatment is often complicated by medical comorbidities and polypharmacy. Repetitive transcranial magnetic stimulation (rTMS) is a treatment option for this group due to its favorable profile. However, early influential studies suggested that rTMS is less effective in older adults. This evidence remains controversial.

Methods

Here, we evaluated the rTMS treatment outcomes in a large international multicenter naturalistic cohort of >500 patients comparing older vs. younger adults.

Results

We show that older adults, while having similar antidepressant response to younger adults, respond more slowly, which may help to explain differences from earlier studies when the duration of a treatment course was shorter.

Conclusions

Such evidence helps to resolve a long-standing controversy in treating older depressed patients with rTMS. Moreover, these findings provide an important data point in the call to revise policy decisions from major insurance providers that have unfairly excluded older adults.

Therapeutic Alliance: A Comparison Study between Adolescent Patients and Their Therapists

The aim of this study was to examine the congruence of adolescent- and therapist-rated therapeutic alliance, and to explore which rating or combination of ratings would predict treatment outcome or premature termination. We also studied whether the alliance changes over the course of treatment and if the change is related to the outcome or dropout. This study comprised 58 adolescents clinically referred for psychotherapeutic interventions. The alliance (Working Alliance Inventory, patient/therapist ratings) and treatment outcomes (Beck Depression Inventory, Clinical Outcomes in Routine Evaluation—Outcome Measure) were measured at baseline and at 3-, 6-, and 12-month follow-ups. The alliance did not change significantly over the course of therapy, but adolescent and therapist ratings did not correlate. Low values in the early assessment of adolescent-rated alliance and discrepancy between the ratings were significant predictors of undesirable treatment outcome. Weak adolescent- or therapist-rated alliance later in treatment and change for the worse in adolescent-rated alliance was associated with treatment dropout. As adolescent-rated alliance predicts treatment outcome better than therapist-rated alliance, therapists should frequently use assessments of therapeutic relationship within the therapy and pay attention if the adolescent feels the alliance is weakening or his/her evaluation is contrary to the therapist’s.

Effectiveness and Predictors of Outcome for Psychotherapeutic Interventions in Clinical Settings Among Adolescents

Background

The aim of this study was to investigate the effectiveness of psychotherapeutic interventions for clinically referred adolescents, as well as to examine whether sociodemographic, clinical, or treatment-related variables and patients’ role expectations predict treatment outcome or are possible predictors of treatment dropout.

Method

The study comprised 58 adolescents (mean age 14.2, 65.5% female) suffering from diverse psychiatric disorders referred to psychotherapeutic interventions conducted in outpatient care. The outcome measures, The Beck Depression Inventory, and the Clinical Outcomes in Routine Evaluation – Outcome Measure were filled in at baseline and at 3-, 6-, and 12-month follow-ups. Possible predictors were assessed at baseline.

Results

The results indicate that the mean level of symptoms and psychological distress decreased during the treatment, most reduction occurring in the first 6 months. The frequency of treatment sessions was the strongest predictor of good outcome. Adolescents with a higher level of externalizing problems or lower level of expectations for their own active role in treatment seem to have a higher risk of dropping out.

Conclusion

Offering intensive treatment for a shorter period might be the most efficient way to gain symptom reduction and decrease psychological distress in psychotherapeutic interventions with adolescents. Being aware of externalizing behavior and increasing the adolescents’ own agency during the assessment could strengthen commitment and result in the adolescent benefiting more from treatment.

Psychiatric disorders in older adults: a naturalistic study from North India

The number of older adults is increasing, especially among low- and middle-income countries. This raises specific issues related to healthcare since, as people are living longer, it is much more likely they will be living with complex co-morbidities, both physical and mental. In a naturalistic study from a private healthcare clinic from an industrial town in North India, details of 52 patients (mean age 72.4 years) were collected. Two thirds were male, and a vast majority attended the clinic accompanied by a family member. Those with different types of dementias were much more likely to present with sleep disturbances. A significant number of patients were illiterate or poorly educated, and a large number dropped out of healthcare. Reasons for this are discussed and detailed presentations regarding symptoms are described. Healthcare policies must take into account rural urban factors and ensure that policies take into account healthcare needs of older adults across geographical areas and complex co-morbidities.

The influence of driving anger on truck drivers' speeding behavior in Serbia: the evidence from naturalistic global positioning system driving data

OBJECTIVE

Speeding behavior is recognized as one of the three main causes of risk on the roads and the most frequent ordinary violation among truck drivers. The study reported in this article focused on the driving anger personality trait and its role in predicting the observed speeding behavior in a sample of truck drivers.

METHODS

A longitudinal study design was implemented, where 93 Serbian truck drivers filled in an adapted form of the Driving Anger Scale designed to assess the amount of driving anger evoked by specific traffic situations. The drivers' second-by-second speeding behavior data were captured using GPS tracking and recording devices installed in the vehicles over a period of six months. Hierarchical multiple linear regression was used to examine the predictive performance of driving anger.

RESULTS

The results showed that more than three fourths of the exceeded speed ranged from 1 to 9 km/h and the highest percentage of speed events occurred in urban areas. The findings suggest that truck drivers experienced the highest level of anger in driving because of the discourteous and illegal behavior of other drivers. Younger truck drivers are more likely to drive fast compared to older drivers. Truck drivers who perform driving tasks more often and spend less time driving are more likely to participate in speed events. The results revealed that the subscales of anger, hostile gestures and traffic obstructions have a positive effect, while slow driving has a negative effect on the observed speeding behavior of truck drivers.

CONCLUSIONS

This study confirms the predictive performance of driving anger facets. The results of the research can help us improve our understanding of the mechanisms of speeding behavior of truck drivers.

In-home conversations of couples with advanced cancer: Support has its costs

OBJECTIVE

The goal of this study was to describe the quality of naturalistic communication between patients with advanced cancer and their spouse caregivers using observational methods. We also assessed the association between patient and caregiver communication behaviors and psychological and physical health using the actor-partner interdependence model.

METHODS

Data on 81 dyads were gathered as part of a prospective observational study. Patients with advanced cancer and their spouse caregivers completed demographic, physical health, and emotional well-being questionnaires. Cancer and relationship communication captured in "day-in-the-life" audio recordings were coded using Gottman's Turning System to assess the quality of bids for attention and responses.

RESULTS

Bids for attention were most often informational (Low Bids) and responses were mostly positive and effortful (Turn Towards); patients and caregivers did not significantly differ in communication behavior. More effortful bids for attention (High Bids) were associated with more positive and effortful responses. Patient communication behaviors were significantly associated with caregiver emotional well-being, whereas caregiver communication behaviors were significantly associated with their own emotional well-being and patient physical health.

CONCLUSIONS

While patients may benefit from caregivers' more positive and engaged communication at home, the emotional labor of focusing on and engaging the patient may take a toll on caregivers' own well-being. This work contributes to the understanding of what everyday communication looks like for patients with advanced cancer and their spouse caregivers and how this communication may impact physical and psychological health. Our findings provide a foundation to develop guidelines for psychosocial couple-based interventions.

Advantages and Limitations of Naturalistic Study Designs and their Implementation in Alcohol Hangover Research

In alcohol hangover research, both naturalistic designs and randomized controlled trials (RCTs) are successfully employed to study the causes, consequences, and treatments of hangovers. Although increasingly applied in both social sciences and medical research, the suitability of naturalistic study designs remains a topic of debate. In both types of study design, screening participants and conducting assessments on-site (e.g., psychometric tests, questionnaires, and biomarker assessments) are usually equally rigorous and follow the same standard operating procedures. However, they differ in the levels of monitoring and restrictions imposed on behaviors of participants before the assessments are conducted (e.g., drinking behaviors resulting in the next day hangover). These behaviors are highly controlled in RCTs and uncontrolled in naturalistic studies. As a result, the largest difference between naturalistic studies and RCTs is their ecological validity, which is usually significantly lower for RCTs and (related to that) the degree of standardization of experimental intervention, which is usually significantly higher for RCTs. In this paper, we specifically discuss the application of naturalistic study designs and RCTs in hangover research. It is debated whether it is necessary to control certain behaviors that precede the hangover state when the aim of a study is to examine the effects of the hangover state itself. If the preceding factors and behaviors are not in the focus of the research question, a naturalistic study design should be preferred whenever one aims to better mimic or understand real-life situations in experimental/intervention studies. Furthermore, to improve the level of control in naturalistic studies, mobile technology can be applied to provide more continuous and objective real-time data, without investigators interfering with participant behaviors or the lab environment impacting on the subjective state. However, for other studies, it may be essential that certain behaviors are strictly controlled. It is, for example, vital that both test days are comparable in terms of consumed alcohol and achieved hangover severity levels when comparing the efficacy and safety of a hangover treatment with a placebo treatment day. This is best accomplished with the help of a highly controlled RCT design.

[Effectiveness of Psychoanalytic Psychotherapy for Children and Adolescents with Severe Anxiety Psychopathology in a Naturalistic Treatment Setting]

Effectiveness of Psychoanalytic Psychotherapy for Children and Adolescents with Severe Anxiety Psychopathology in a Naturalistic Treatment Setting The aim of the study was to evaluate naturalistic out-patient psychoanalytic youth psychotherapy in Germany. The study was a partly controlled effectiveness trial. While the first treatment interval (25 sessions, 6.13 months) was compared with a wait-list control group (5 supportive sessions, 2.94 months), the effects of long-term psychoanalytical treatment were analyzed using a time-series design. 86 children and adolescents (aged 4 to 21 years) and their parents who entered psychoanalytic therapy in private practices participated in this study. The wait-list control group comprised 35 patients. Questionnaires were administered at the beginning and the end of treatment, as well as 6 and 12 month follow-up (FU). Patients received on average 94.04 therapy sessions (range 8 to 300) over 25.70 months. Data analyses were carried out with multilevel mixed linear models on the intention-to-treat (ITT) sample. The patients in the intervention group reported moderate symptom improvements at the end of therapy (d = .57), these effects are stable at the 1-year follow-up and increase from the patient perspective (d = .80). When comparing the first therapy interval with the (minimal treatment) wait-list control group, both groups improved significantly with small effect sizes and no significant group differences. The results suggest that long-term psychoanalytic therapy is successful in alleviating anxiety pathology and improving quality of life for youth with anxiety disorders, and that improvements remain stable across a 1-year follow-up period.

Measuring Psychological Change and Predicting Recidivism Following the Swedish One-to-One Program

The One-to-One program aims to reduce criminal recidivism among prisoners shortly awaiting release, and among probationers. Of 1,484 program participants in Sweden, 776 contained adequate data for analysis. Pre- and post-program scores were available for the Alternative Thinking Test, Levenson's Locus of Control Scale, Skill Survey, Citizen Scale, and Problem Checklist, all areas addressed in the program. This study examined predictive properties of test scores and background characteristics regarding recidivism, as well as differences between sub-groups. All post-tests indicated pro-social changes. Older participants were more likely to complete the program. The most potent predictor for non-recidivism was program completion, with non-completers 64% more likely to re-offend. Significant associations occurred between recidivism and the tests measuring skill improvement over time, chance locus of control pre- and post-program, and attitudes and values (Citizen Scale), partly supporting the theory behind the program.

The Relationship Between Dropout and Outcome in Naturalistic Cognitive Behavior Therapy

Dropout from psychotherapy is frequent and limits the benefits patients can receive from treatment. The study of factors associated with dropout has the potential to yield strategies to reduce it. This study analyzed data from a large sample of adults (N = 1,092) receiving naturalistic cognitive behavioral therapy (CBT) to test the hypotheses that dropouts, as compared to completers, had (1) higher symptom severity at treatment termination, (2) a slower rate of symptom change during treatment, and (3) a higher odds that the therapist rated treatment as ending for reasons related to poor outcome. Results showed that although dropouts ended treatment with higher symptom severity than completers, dropouts and completers did not differ in their rate of symptom change during treatment, suggesting that dropouts had higher symptom severity at termination because they received fewer sessions of treatment, not because their symptoms changed at a slower rate. Dropout was also associated with a higher odds of having a therapist-rated termination reason indicating a poor outcome, suggesting that dropout is more likely if patients are dissatisfied with some aspect of the therapy outcome or process. These findings suggest that strategies for monitoring and enhancing patient satisfaction with the process and outcome of treatment may help patients stay in treatment longer and end treatment with fewer symptoms than if they had dropped out.

Lithium, valproate, and carbamazepine prescribing patterns for long-term treatment of bipolar I and II disorders: A prospective study

OBJECTIVE

This study aims to describe the prescription patterns of the mood stabilizers most commonly used for the treatment of bipolar I and II disorders (lithium, valproate, and carbamazepine) and to analyze the treatment outcomes.

METHODS

Two hundred and thirty-four outpatients with bipolar disorders receiving prophylactic treatment with lithium, valproate, carbamazepine, or their combination were followed up for at least 18 months in two Italian psychiatric centers specialized in mood disorders.

RESULTS

The combination of lithium and valproate or carbamazepine was the most common prophylactic treatment (54.3%), followed by valproate or carbamazepine (24%) and lithium monotherapy (22%). Polytherapy was prescribed mainly to patients with bipolar I disorder, a high number of previous episodes and lifetime psychotic symptoms, whereas valproate or carbamazepine monotherapy was prescribed to patients with anxiety comorbidity. The annual frequency of recurrences decreased significantly after entering the study in the overall sample, and the reduction was significantly higher in patients on lithium plus valproate or carbamazepine compared with the valproate or carbamazepine group, but not with the lithium monotherapy group. The number of mixed recurrences during the follow-up was significantly higher in patients on lithium plus valproate or carbamazepine.

CONCLUSIONS

Our findings may help clinicians to personalize long-term treatment to prevent relapses of bipolar disorder according to clinical presentation.

Routine treatment duration for clients attending a community based anxiety disorders clinic

OBJECTIVE

To determine the average duration of treatment at a community-based anxiety disorders clinic.

METHOD

Data were collected on primary disorder, the presence of co-occurring disorders and treatment length (both in terms of number of sessions and weeks of therapy) for 248 consecutive clients.

RESULTS

The mean number of sessions was 13, and average treatment length was 29 weeks. There was substantial variation in treatment duration (range for number of sessions = 1-128, range for treatment duration = 0-186 weeks).

CONCLUSION

Clients with anxiety disorders were often treated in relatively few sessions, in line with randomised controlled trials (RCTs). However, a number of clients required many more sessions and were treated for a longer period of time than clients in RCTs. Health services should be cautious in mandating limits to therapy duration for anxiety disorders given the wide range in the duration of treatment for clients in our sample.

Effectiveness of paliperidone long-acting injection in clinical practice

BACKGROUND

The efficacy of the long-acting injectable formulation of the antipsychotic paliperidone (paliperidone palmitate) has been investigated in randomized controlled trials. Due to the nature of study designs, these may not be representative of usual clinical practice. The aim of this study was to assess the clinical effectiveness of the long-acting injectable antipsychotic paliperidone palmitate using treatment continuation at 1 year as an outcome.

METHODS

Patients were initiated on paliperidone palmitate prior to December 2014 in a single health board in Wales (UK). Demographic factors that may have influenced outcome, including diagnosis, age at initiation, sex, inpatient or outpatient status on initiation, were analysed to assess whether they influenced patient outcome. For patients completing 1 year of treatment, inpatient stay in the 12 months prior to and following paliperidone palmitate initiation was compared.

RESULTS

Data were available for 64 patients; 41 had a diagnosis of schizophrenia and 7 had previously received clozapine. Continuation rates at 6 and 12 months were 69% and 63% respectively. Treatment continuation was not associated with demographic factors. For continuers, mean inpatient stay pre- and post-initiation was 83.2 ± 105.3 and 73.5 ± 103.3 days respectively (p = 0.61). The most common reason for discontinuation was lack of effect (n = 9).

CONCLUSIONS

The proportion of patients remaining on treatment was comparable to that reported in other naturalistic studies. Prescribing for indications outside the product licence was relatively common, but did not appear to influence outcome, although the number of patients in each group was small. Treatment continuation at 6 months appeared to be a predictor of longer-term outcome.

Effects of aripiprazole once-monthly on symptoms of schizophrenia in patients switched from oral antipsychotics

OBJECTIVE

To assess the effects of aripiprazole once-monthly 400 mg (AOM 400) on clinical symptoms and global improvement in schizophrenia after switching from an oral antipsychotic.

METHODS

In a multicenter, open-label, mirror-image, naturalistic study in patients with schizophrenia (>1 year, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR] criteria), changes in efficacy measures were assessed during prospective treatment (6 months) with AOM 400 after switching from standard-of-care oral antipsychotics. During prospective treatment, patients were cross-titrated to oral aripiprazole monotherapy (1-4) weeks followed by open-label AOM 400 (24 weeks). Mean change from baseline of the open-label AOM 400 phase in Positive and Negative Syndrome Scale (PANSS) scores (total, positive and negative subscales) and Clinical Global Impression-Severity (CGI-S) scores; mean CGI-Improvement (CGI-I) score; and proportion of responders (≥30% decrease from baseline in PANSS total score or CGI-I score of 1 [very much improved] or 2 [much improved]) were assessed.

RESULTS

PANSS and CGI-S scores improved from baseline (P<0.0001) and CGI-I demonstrated improvement at all time points. By the end of the study, 49.0% of patients were PANSS or CGI-I responders.

CONCLUSIONS

In a community setting, patients with schizophrenia who were stabilized at baseline and switched to AOM 400 from oral antipsychotics showed clear improvements in clinical symptoms.

Naturalistic study of the risky situations faced by novice riders

This article sets out to identify the typical risky situations experienced by novice motorcyclists in the real world just after licensing. The procedure consists of a follow-up of six novices during their first two months of riding with their own motorbike instrumented with cameras. The novices completed logbooks on a daily basis in order to identify the risky situations they encountered, and were given face-to-face interviews to identify the context and their shortcomings during the reported events. Data show a large number of road configurations considered as risky by the riders (248 occurrences), especially during the first two weeks. The results revealed that a lack of hazard perception skills contributed to the majority of these incidents. These situations were grouped together to form clusters of typical incident scenarios on the basis of their similarities. The most frequent scenario corresponds to a lane change in dense traffic (15% of all incidents). The discussion shows how this has enhanced our understanding of novice riders' behaviour and how the findings can improve training and licensing. Lastly, the main methodological limitations of the study and some guidelines for improving future naturalistic riding studies are presented. Practitioner Summary: This article aims to identify the risky situations of novice motorcyclists in real roads. Two hundred forty-eight events were recorded and 13 incident scenarios identified. Results revealed that a lack of hazard perception contributed to the majority of these events. The most frequent scenario corresponds to a lane change in dense traffic.

Cognitive functioning throughout the treatment history of clinical late-life depression

OBJECTIVE

Previous investigations into the relationship between late-life depressive symptoms and cognitive functioning have resulted in mixed findings concerning whether or not depressive symptoms and cognitive functioning are related. The mixed reports may be due in part to differences in clinical and nonclinical samples and to inadequate consideration of the dynamic nature (i.e., fluctuating course) of depressive symptoms and cognitive functioning in older adults. The current study examined the chronic, acute, and longitudinal relationships between depressive symptoms and cognitive functioning in older adults in an ongoing treatment study of major depressive disorder (MDD).

METHODS

The neurocognitive outcomes of depression in the elderly study operates in a naturalistic treatment milieu using a pharmacological treatment algorithm and regular psychiatric assessment. Four hundred and fifty-three older adults [mean age 70 years, standard deviation (SD) = 7.2] meeting criteria for MDD at study enrollment received annual neuropsychological testing and depressive symptom monitoring for an average of 8.5 years (SD = 4.5).

RESULTS

Hierarchical linear modeling revealed that higher age, lower education, and higher average/chronic levels of depressive symptoms were related to lower cognitive functioning. Additionally, results revealed that when an individual's depressive symptoms are higher than is typical for a specific individual, general cognitive function was worse than average. There was no evidence of lagged/longitudinal relationships between depressive symptoms and cognitive functioning in older adults in treatment for MDD.

CONCLUSIONS

Cognitive functioning and depressive symptoms are concurrently associated in older adults with MDD, highlighting the potential importance for stabilizing mood symptoms as a means to manage cognitive deficits in late-life depression.

Five-year patient outcomes with risperidone long-acting injection or oral aripiprazole

BACKGROUND

This study examined 5-year outcomes of patients prescribed risperidone long-acting injection (RLAI) or aripiprazole in a clinical setting, using treatment discontinuation as a measure of effectiveness.

METHOD

Patients who received RLAI or aripiprazole in the 18 months following their respective UK launches were included. Two-year outcome data were previously reported for these cohorts; this study reported an additional 3 years of follow up for each group. Data were collected from pharmacy records and by retrospective case note review. Patients were classified as continuers or discontinuers at 5 years and reasons for treatment discontinuation noted.

RESULTS

The number of patients remaining on treatment at 2 years (and included in this study) was 28/84 and 27/92 for RLAI and aripiprazole respectively. Two patients treated with RLAI and three treated with aripiprazole were lost to follow up. Therefore, 5-year outcome data were available for 50 patients. Fifteen patients from each group were continuers at 5 years. Of these, four receiving RLAI and three receiving aripiprazole were coprescribed other antipsychotics at study endpoint. Reasons for discontinuation of RLAI and aripiprazole respectively were lack of effect (n = 4; n = 4), adverse effects (n = 3; n = 1), noncompliance or patient choice (n = 2; n = 4) and patient death (n = 2; n = 0).

CONCLUSION

There was no significant difference between the proportions of patients continuing RLAI or aripiprazole for 5 years. Continuation rates were relatively low (18% and 16% of the original RLAI and aripiprazole cohorts respectively), whilst coprescription of other antipsychotics at endpoint was relatively common. Lack of effectiveness was the most common reason for discontinuation of both compounds. These findings suggested that clinical effectiveness was somewhat disappointing, although the long period of follow up and number of patients previously treated with clozapine in the original cohorts were confounding factors.

Reduction in inpatient resource utilization and costs associated with long-acting injectable antipsychotics across different age groups of Medicaid-insured schizophrenia patients

OBJECTIVE

Evaluate utilization of inpatient healthcare resources and associated costs after 12 months of treatment using long-acting injectable (LAI) antipsychotic medications among a large sample of Medicaid-insured patients categorized by different age groups.

METHOD

Adult patients with schizophrenia were identified from the Thomson Reuters MarketScan Research database (1/1/2006-12/31/2010) before initiation of treatment using LAI antipsychotic agents. Utilization of inpatient healthcare resources and associated direct medical costs were compared for 12-month baseline and 12-month follow-up periods.

RESULTS

Among 3,094 Medicaid-insured patients with schizophrenia initiating treatment with LAIs, the mean number of all-cause hospitalizations and hospitalization days were reduced by 24% and 31% (p<0.0001) compared with baseline, respectively, with similar significant reductions among all age groups (18-30, 31-40, 41-50, and 51-60 years). During 12-month follow-up with LAIs, mean reductions in all-cause costs were $4,369 (18-30 years, p<0.0001), $3,681 (31-40 years, p<0.0001), $2,051 (41-50 years, p=0.1332), and $4,492 (51-60 years, p=0.0107). Subanalyses separating first-generation and second-generation medication groups resulted in mean reduction in all-cause costs of $3,561 and $3,645, respectively.

CONCLUSIONS

Results from this large cohort study provide naturalistic real-world evidence of the utility of LAIs in patients with schizophrenia and suggest that these agents may help to reduce the risk of relapse across all age groups (especially among younger patients). Given that relapse prevention is the ultimate goal of antipsychotic treatment, results from this large Medicaid patient population establish the value of LAIs for the management of schizophrenia.

The relation between prototypical processes and psychological distress in psychodynamic therapy of five inpatients with borderline personality disorder

Five inpatients with borderline personality disorder (BPD) participated in 6 months of three times per week psychodynamic therapy (PDT). Patients completed a measure of psychological distress every week. A total of 127 sessions were audiotaped and coded using the psychotherapy process Q-set (PQS) and correlated with PQS prototypes of five treatment models-PDT, cognitive-behaviour therapy (CBT), interpersonal therapy, transference focused psychotherapy and dialectical behaviour therapy. Prototypical CBT process was most prevalent in three of the five PDT-labelled treatments. Prototypical PDT process significantly decreased over time in three of the five treatments. Prototypical process correlations with time were inversely proportional to prototypical process correlations with distress levels. In a multiple regression model that included all five prototypical process correlations across these three treatments, CBT and transference focused psychotherapy predicted distress reduction, whereas PDT predicted increases in distress. PQS items most negatively correlated with distress included the therapist's emphasis on feelings, empathic attunement and control over the interaction. Discussion of dreams or fantasies and therapist aloofness were most positively correlated with distress. An effective PDT treatment model for severely disturbed BPD inpatients requires technical flexibility to supplement CBT processes such as control over the interaction that can structure intense interpersonal dysregulation and stabilize distress.

KEY PRACTITIONER MESSAGE

Practitioners and their patients sense which prototypical processes to increase or decrease over time to reduce patients' distress. An effective PDT treatment model for severely disturbed BPD patients needs to integrate and encourage the emergence of empathically attuned interactions in the context of a highly structured therapy experience. Practitioners need to be flexible enough to change intervention strategies when they seem to be increasing distress in severely disturbed BPD patients.

The social functional outcome of being naturalistically treated with paliperidone extended-release in patients with schizophrenia

BACKGROUND

Social functioning is an important outcome for patients with schizophrenia. To evaluate the effects of paliperidone extended-release (PAL-ER) on social function, symptomatology, and safety in the routine clinical practice, we conducted a 1-year post-marketing surveillance study of PAL-ER. We also explored relationships between symptomatic improvement and socially functional outcome in patients with schizophrenia.

PATIENTS AND METHODS

Patients with an established diagnosis of schizophrenia were allowed flexible 3-12 mg/day dosing during the surveillance. Patients were assessed on social functioning using the Social and Occupational Functioning Assessment Scale (SOFAS) and on symptomatology using the Clinical Global Impression-Schizophrenia scale. All adverse events (AEs) were also collected.

RESULTS

A total of 1,429 patients were enrolled in the surveillance study, of whom 1,405 were evaluable for safety and 1,142 were evaluable for efficacy. The treatment discontinuation rate for any reason during the observation period was 34.66%. Significant improvements were observed on both Social and Occupational Functioning Assessment Scale and Clinical Global Impression-Schizophrenia scale during the observation period. The percentage of patients with socially functional remission (SOFAS ≥61) also increased significantly. A significant association between early improvements in positive symptoms, sex, severity of negative symptoms at baseline, and socially functional remission was observed. A total of 33.52% of patients had AEs and 8.75% of patients had serious AEs. Despite the recommendation of monotherapy with PAL-ER, 65.84% of patients were given additional antipsychotics (polypharmacy). Post hoc comparisons of monotherapy versus polypharmacy revealed that the monotherapy group had better outcomes and fewer AEs than the polypharmacy treated group. The improvement in social functioning and the rate of socially functional remission did not differ between groups.

CONCLUSION

PAL-ER treatment showed effective symptom control and improvement in social functioning. The data suggest that early response to antipsychotic treatment should be important for functional outcomes.

Randomized Trial of Family Therapy Versus Nonfamily Treatment for Adolescent Behavior Problems in Usual Care

A major focus of implementation science is discovering whether evidence-based approaches can be delivered with fidelity and potency in routine practice. This randomized trial compared usual care family therapy (UC-FT), implemented without a treatment manual or extramural support as the standard-of-care approach in a community clinic, to nonfamily treatment (UC-Other) for adolescent conduct and substance use disorders. The study recruited 205 adolescents (M age = 15.7 years; 52% male; 59% Hispanic American, 21% African American) from a community referral network, enrolling 63% for primary mental health problems and 37% for primary substance use problems. Clients were randomly assigned to either the UC-FT site or one of five UC-Other sites. Implementation data confirmed that UC-FT showed adherence to the family therapy approach and differentiation from UC-Other. Follow-ups were completed at 3, 6, and 12 months postbaseline. There was no between-group difference in treatment attendance. Both conditions demonstrated improvements in externalizing, internalizing, and delinquency symptoms. However, UC-FT produced greater reductions in youth-reported externalizing and internalizing among the whole sample, in delinquency among substance-using youth, and in alcohol and drug use among substance-using youth. The degree to which UC-FT outperformed UC-Other was consistent with effect sizes from controlled trials of manualized family therapy models. Nonmanualized family therapy can be effective for adolescent behavior problems within diverse populations in usual care, and it may be superior to nonfamily alternatives.

Clinical implications of predominant polarity and the polarity index in bipolar disorder: a naturalistic study

OBJECTIVE

Predominant polarity (PP) is an important variable in maintenance treatment of bipolar disorder (BD). This study aimed at determining the role of polarity index (PI), a metric indicating antimanic versus antidepressive prophylactic potential of drugs, in clinical decision-making.

METHOD

Two hundred and fifty-seven of 604 (43%) of patients with BD-I or II fulfilled criteria for manic (MPP) or depressive PP (DPP). The PI, representing the ratio of number needed to treat (NNT) for depression prevention to NNT for mania prevention, was calculated for patients' current treatment. MPP and DPP groups were compared regarding sociodemographic, clinical and therapeutic characteristics.

RESULTS

One hundred and forty-three patients (55.6%) fulfilled criteria for DPP and 114 (44.4%) for MPP. Total PI, Antipsychotics' PI, and mood stabilizers PI were higher, indicating a stronger antimanic action, in MPP. MPP presented higher prevalence of BD-I, male gender, younger age, age at onset and at first hospitalization, more hospitalizations, primary substance misuse, and psychotic symptoms. DP correlated with BD-II, depressive onset, primary life events, melancholia, and suicide attempts.

CONCLUSION

The results confirm the usefulness of the PI. In this large sample, clinical differences among these groups justify differential treatment approach. The PI appears to be a useful operationalization of what clinicians do for maintenance therapy in BD.

Implication of the nutritional and nonnutritional factors in the context of preservation of cognitive performance in patients with dementia/depression and Alzheimer disease

It has been postulated that Alzheimer disease (AD) is a systemic process, which involves multiple pathophysiological factors. A combination of pharmacotherapy and nonpharmacological interventions has been proposed to treat AD and other dementia. The nonpharmacological interventions include but are not limited to increasing sensory input through physical and mental activities, in order to modify cerebral blood flow and implementing nutritional interventions such as diet modification and vitamins and nutraceuticals therapy to vitalize brain functioning. This article highlights the recent research findings regarding novel treatment strategies aimed at modifying natural course of the disease and delaying cognitive decline through simultaneous implementation of pharmacological and nonpharmacological modulators as standardized treatment protocols.

The INDDEP study: inpatient and day hospital treatment for depression - symptom course and predictors of change

BACKGROUND

Depression can be treated in an outpatient, inpatient or day hospital setting. In the German health care system, episodes of inpatient or day hospital treatment are common, but there is a lack of studies evaluating effectiveness in routine care and subgroups of patients with a good or insufficient treatment response. Our study aims at identifying prognostic and prescriptive outcome predictors as well as comparative effectiveness in psychosomatic inpatient and day hospital treatment in depression.

METHODS/DESIGN

In a naturalistic study, 300 consecutive inpatient and 300 day hospital treatment episodes in seven psychosomatic hospitals in Germany will be included. Patients are assessed at four time points of measurement (admission, discharge, 3-months follow-up, 12-months follow-up) including a broad range of variables (self-report and expert ratings). First, the whole sample will be analysed to identify prognostic and prescriptive predictors of outcome (primary outcome criterion: Quick Inventory of Depressive Symptoms QIDS-total score, expert rating). Secondly, for a comparison of inpatient and day hospital treatment, samples will be matched according to known predictors of outcome.

DISCUSSION

Naturalistic studies with good external validity are needed to assess treatment outcome in depression in routine care and to identify subgroups of patients with different therapeutic needs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20317064.

Use of quetiapine XR and quetiapine IR in clinical practice for hospitalized patients with schizophrenia: a retrospective study

Quetiapine fumarate, a first-line treatment for schizophrenia, exists in two formulations: extended release (XR) and immediate release (IR). This naturalistic, noninterventional study evaluated use of quetiapine XR/IR among in-patients with schizophrenia [ClinicalTrials.gov identifier: NCT01214135]. Data were collected from medical records. Categorical and numerical outcomes were compared using χ(2) and t tests. Of 178 enrolled patients, 66% and 34% used quetiapine XR and IR respectively. Based on mean daily dose, XR was used as antipsychotic medication in 64% of patients compared with 40% of patients on IR (dose ≥ 400 mg/day; p = 0.002) and in higher doses than IR (494 versus 345 mg/day; p = 0.001; calculated averages). Schizophrenia was more commonly reported as reason for use of XR than IR (20% versus 0%; p = 0.0003). Patients with comorbid substance abuse or somatic disease were more likely to receive XR (p = 0.003; p = 0.03). Treatment cessation due to nonadherence was less common in patients on XR (3.4% versus 12%; p = 0.03). Polypharmacy was seen in 98% of patients. Quetiapine XR/IR usage varies in hospitalized patients with schizophrenia. XR is more often used in antipsychotic dosage; IR is more commonly used at lower doses as add-on therapy. Both quetiapine XR and IR have their place in clinical practice and provide treatment choice in schizophrenia.

A retrospective study of clinical usage of quetiapine XR and quetiapine IR in outpatients with schizophrenia in Denmark

OBJECTIVES

The atypical antipsychotic quetiapine is a first-line treatment for schizophrenia. This non-interventional study (NCT01212575) evaluated the clinical use of its two formulations, extended release (XR) and immediate release (IR), in outpatients with schizophrenia spectrum disorder.

METHODS

Patients who had received at least one dose of quetiapine XR and/or IR were included. A dosage ≥400 mg/day was defined as antipsychotic. Medical records data were collected retrospectively.

RESULTS

Of 186 enrolled patients, 99 (53%) and 87 (47%) received quetiapine XR and IR, respectively. Use in antipsychotic dosage was seen for 89% XR versus 63% IR patients (mean daily dose ≥400 mg/day; p < 0.0001). 75% XR and 53% IR patients used dosages ≥600 mg/day (p = 0.0019). Quetiapine XR was used at higher mean daily dosages than IR (748 vs 566 mg/day; p = 0.006). Forty-three patients (23%) used both formulations concomitantly; 55 patients (30%) used either XR or IR. Quetiapine IR was used as-needed in 44 patients (23%); one patient used XR as-needed.

CONCLUSIONS

Quetiapine XR was used more often in higher (antipsychotic) dosages; quetiapine IR more frequently on an as-needed administration basis. Concomitant use was seen. These findings probably reflect the different profiles of XR/IR and advocate the need for both formulations to offer treatment choice.

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD

BACKGROUND

Although exposure and response prevention (ERP) is an effective treatment for youth with obsessive-compulsive disorder (OCD), the majority of studies, randomized clinical trials of individual therapy, find variability in treatment response. We evaluated the potential role of individual differences in OCD presentation, comorbid disorders, age, and gender on treatment effects. Moreover, we examined these potential effects in a group format in a naturalistic, clinic-based sample of patients.

METHODS

Pediatric patients with a DSM-IV diagnosis of OCD (n=41) were treated with ERP in an intensive outpatient community-based program. OCD, mood, and anxiety symptom severity was measured at baseline, during treatment, and at discharge. Trajectories and predictors of treatment outcome were measured using linear growth models.

RESULTS

We found that group-based ERP was effective in reducing pediatric OCD symptom severity in a naturalistic treatment setting irrespective of age or gender. Furthermore, ERP was found to be effective at reducing depressive symptoms but not other anxiety symptoms. We also found inter-individual variability in the discharge levels of contamination, symmetry, and intrusive sexual thoughts and in the rate of severity reduction of intrusive sexual thoughts.

CONCLUSION

Group-based ERP is an effective treatment for children and adolescents with OCD. Several factors, including symptom dimensions and comorbid psychopathology, are associated with treatment response and outcome in this pediatric population.

Comparison of escitalopram and citalopram in outpatients with severe major depressive disorder: a prospective, naturalistic, 8-week study

Objective. Escitalopram is a new selective serotonin reuptake inhibitor indicated for the treatment of major depressive disorder (MDD). The objective of this study is to examine its efficacy in the treatment of severe MDD compared with that of citalopram in daily practice. Method. A prospective, naturalistic, 8-week study was conducted involving 127 patients fulfilling DSM-IV criteria for severe MDD and having a baseline Montgomery-Åsberg Depression Rating Scale (MADRS) score of at least 30. A full non-parsimonious logistic model, called the propensity score, was first defined to reduce bias associated with non-randomization. The primary efficacy analysis was the mean change from baseline to week 8 in MADRS score between the escitalopram and citalopram groups, after stratification on the propensity score. Other efficacy measurements consisted of the Clinical Global Impression of Severity and Improvement scales (CGI-S and CGI-I, respectively), response (defined as a reduction of at least 50% on MADRS from baseline to week 8) and remission rates (defined as MADRS ≤ 12 at week 8), after adjustment on propensity score for escitalopram use. Results. A total of 67 escitalopram-treated patients and 60 citalopram-treated patients were enrolled in this study. Escitalopram reduced mean MADRS total score at week 8 compared with citalopram (-23.5 vs. -17.5; P<0.001). The effect of escitalopram was consistently greater than that of citalopram on the CGI scales. Escitalopram-treated patients were also more likely to respond to treatment (79.4 vs. 44.0%; P<0.001), and remission rates were also in favour of escitalopram (56.9 vs. 11.2%, P<0.001). Analysis of safety data showed better tolerability of escitalopram than that of citalopram. Conclusion. Using adequate methodology to reduce biases due to non-randomization, this study indicates better efficacy and tolerability of escitalopram versus citalopram in severe MDD outpatients.