Behavioral and psychological factors associated with suboptimal weight loss in post-bariatric surgery patients

PURPOSE

Bariatric surgery is the most effective long-term treatment for sustained weight loss in obesity. Studies have shown that not all patients lose the expected amount of weight. The aim of this study was to develop a better understanding of which behavioral and psychological factors are associated with suboptimal weight loss.

METHODS

The present paper describes a cross-sectional study that included 140 participants. The mean follow-up period after bariatric surgery was 3.16 years. Eating disorder pathology (Eating Disorder Examination-Questionnaire), impulsivity (Barratt Impulsiveness scale-II) and depressive symptoms (Beck Depression Inventory) were compared with successful and suboptimal participants. A weight loss of more than or equal to 50% of excess weight, was considered to be successful.

RESULTS

More than 81% of the participants met the criterion for successful weight loss. The suboptimal weight loss group reported more symptoms of eating disorder pathology (p = .001), more loss of control over eating (p = .001), and more avoidant behavior due to poor body image (p < .001). The suboptimal weight loss group scored higher on impulsivity (p = .007) and on depression (p < .001). More early weight loss was associated with better weight outcome later on (r = .491). Reporting more eating disorder pathology, a longer follow-up period and pre-operative super-obesity (body mass index ≥ 50 kg/m²) at the time of surgery were associated with poorer weight loss (p < .001).

CONCLUSION

Eating disorder pathology, loss of control over eating and avoidant behavior due to poor body image, as well as depressive symptoms and impulsivity, (as reported postoperatively) are associated with suboptimal weight loss. Level III: Case-control analytic study.

Exploring differences in quality of life in clinical populations of depressed outpatients with and without personality disorders

BACKGROUND

Although depression and personality disorders (PDs) often co-occur, less is known about the impact of PDs on health-related quality of life (HRQOL) in patients with depression. This study explores the differences in HRQOL of depressed patients with and without PD.

METHODS

Baseline data of 397 patients with depression from two randomised controlled trials were used for this analysis. HRQOL was measured with the EuroQol-5D (EQ-5D). Differences were examined between three groups: patients with 1) depression-only, 2) depression and comorbid PD and 3) PD and comorbid depression. The EQ-5D scores of the groups were compared with linear regression.

RESULTS

HRQOL scores were lower in the depression-only group than the depression + PD group, even though depression severity was higher in patients with PD. HRQOL in the PD ± depression group did not differ from the other groups. In addition, no associations were found between the type or severity of PD and HRQOL.

DISCUSSION

These findings could indicate that patients with PD are less affected by the impact of depression on HRQOL. In addition, the EQ-5D might not adequately capture the impact of PD on quality of life. Further research is needed to compare the EQ-5D with quality of life instruments that include more life domains.

LIMITATIONS

Two study samples are combined, and therefore not designed to compare the three groups directly. Generalisation of the results should be done with caution.

CONCLUSION

Depressed patients with PD report higher HRQOL than depression-only patients. Although higher HRQOL, patients with PD report more severe depressions than depressed-only patients.

The Temporal Associations of Therapeutic Alliance and Manual Adherence With Depressive Symptom Change in Cognitive Behavioral Therapy for Adult Outpatient Major Depression

Background: The therapeutic alliance is considered an important causal agent of psychotherapy efficacy. However, studies in cognitive behavioral therapy (CBT) for depression have suggested that alliance might be more of a consequence rather than a cause of depressive symptom change, while adherence to CBT specific techniques was found to be associated with subsequent depression change. We aimed to add to this body of literature by assessing the temporal associations of both therapeutic alliance and manual adherence with depressive symptom change in a relatively large sample of depressed adult outpatients over the full course of CBT. Methods: Adults with a major depressive episode (n = 98) participating in a randomized clinical trial were offered 22 weeks of CBT and rated the Penn Helping Alliance Questionnaire (HAq-I) at weeks 5 and 22. Therapists rated their adherence to the CBT manual after each session and observers assessed the Hamilton Depression Rating Scale scores at weeks 0, 5, 10, and 22. Linear mixed model analyses were used to assess the associations of alliance and adherence with prior and subsequent depression change. Results: HAq-I Relationship and manual adherence ratings were not significantly associated with prior nor with subsequent depression change (p > 0.14). Prior depression change was associated with the HAq-I subscale Perceived helpfulness at the end of treatment (r = 0.30, CI = 0.03-0.56, p = 0.03). Conclusion: We were not able to replicate prior depression change in CBT for depression to be associated with improved quality of the therapeutic alliance when using a more "pure" measure of the therapeutic relationship. Limitations of this study include the subjective alliance and adherence assessments. Our findings indicate the need to appropriately distinguish between the perceived helpfulness and the relationship factors when examining therapeutic alliance.

[Treatment effect of an urban acute psychiatric clinic: a prospective cohort study]

BACKGROUND

A clinical admission is a frightening event, especially in a crisis situation, and above all when it comes with legal measures. The effectiveness of an acute crisis admission has been demonstrated in a Cochrane review, but cohort studies of a clinic setting are not yet available.

AIM

To assess and determine the treatment effects after a crisis admission in a metropolitan acute psychiatric clinic of patients with severe mental illness (SMI patients).

METHOD

In the context of routine outcome monitoring, the 12 HoNOS scores at admission and discharge (pre- and post-measurements) were rated by clinicians. The data of 1423 patients were analyzed by a statistician.

RESULTS

The crisis admissions have a substantial positive clinical effect: 76 percent of the patients improved, 16 percent was stable and 10 percent worsened (effect size ES = 1.2). The patients improved most in regard to psychotic problems, aggressiveness and social problems. This applies equally to patients who have been admitted voluntarily, as well as to patients with a legal measure. The admission duration of patients is two months, except for patients with compulsory treatment (seclusion, sedation, forced medication). In this case the treatment duration prolongs to three months.

CONCLUSION

Acute short-term clinical admission is an effective part of the clinical and outpatient treatment chain for patients with severe mental illness (SMI). A substantial treatment effect is achieved by the crisis admission. These findings are an important addition to the Cochrane review.

[The influence of corona related factors on acute psychiatric admissions]

BACKGROUND

Since the COVID-19 outbreak there are warnings for an increase of psychological complaints in the general population and in psychiatric patients.

AIM

To gain insight in corona associated factors that can provoke psychiatric decompensation, wherefore admission in our psychiatric clinic was necessary. To investigate if the admission rate of our clinic increased since the start of the quarantine measures.

METHOD

From the 16th of March until the 1st of June 2020 we collected data in our psychiatric acute admission clinic in Amsterdam of patients with a corona associated triggering factor for the current psychiatric decompensation. Additionally, the admission rates between the 16th of March and the 1st of June 2020 were compared with the admission rates in the same period in 2019.

RESULTS

In 25 of 120 admitted patients there was a corona associated triggering factor. The disruption of daily routine and increased stress due to corona were mentioned most often. In the studied period there were significantly more admissions in 2020 compared to 2019.

CONCLUSION

The corona crisis can contribute to psychiatric decompensation. In a fifth of the admitted patients a corona associated triggering factor was mentioned. Furthermore we observed a higher demand for psychiatric admissions since the start of the quarantine measures in comparison with 2019.

Psychological symptoms, early maladaptive schemas and schema modes: predictors of the outcome of group schema therapy in patients with personality disorders

Objective: This naturalistic study examined the outcomes of group schema therapy for patients with personality disorders (PD) and the effect of psychological symptoms, early maladaptive schemas (EMS) and schema modes on outcome.Method: Assessments were made of 194 patients at baseline, during treatment, at treatment termination and at three-month follow-up. We used the Symptom Checklist-General Severity Index (SCL-GSI) to measure the remission-rate of global psychological distress and as a dependent variable in a multilevel model to conduct univariate and multiple variate analyses.Results: The research sample achieved medium symptom reduction (pre-post d = 0.65, 95% CI [0.39-0.91]) and the remission rate was about 30% after 60 sessions. These results remained stable at three-month follow-up (pre-follow-up d = 0.61, 95% CI [0.29-0.94]; 28.9%). Higher baseline scores on the SCL scale interpersonal sensitivity, the EMS defectiveness/shame and all the maladaptive schema modes together predicted improvements in global psychological distress after treatment.Conclusions: A long-term form of group schema therapy proved effective for a broad group of patients with PD. Internalizing symptoms seems predictive for improvement at outcome. Almost a third of the patients achieved remission. There is therefore room for improvement, possibly by increasing dose or intensity in combination with individual sessions.

The efficacy of adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression: A systematic review and meta-analysis of individual participant data

PURPOSE

We examined the efficacy of adding short-term psychodynamic psychotherapy (STPP) to antidepressants in the treatment of depression by means of a systematic review and meta-analysis of individual participant data, which is currently considered the most reliable method for evidence synthesis.

RESULTS

A thorough systematic literature search resulted in 7 studies comparing combined treatment of antidepressants and STPP versus antidepressant mono-therapy (n = 3) or versus antidepressants and brief supportive psychotherapy (n = 4). Individual participant data were obtained for all these studies and totaled 482 participants. Across the total sample of studies, combined treatment of antidepressants and STPP was found significantly more efficacious in terms of depressive symptom levels at both post-treatment (Cohen's d = 0.26, SE = 0.10, p = .01) and follow-up (d = 0.50, SE = 0.10, p < .001). This effect was most apparent at follow-up and in studies examining STPP's specific treatment efficacy. Effects were still apparent in analyses that controlled for risk of bias and STPP quality in the primary studies.

CONCLUSIONS

These findings support the evidence-base of adding STPP to antidepressants in the treatment of depression. However, further studies are needed, particularly assessing outcome measures other than depression and cost-effectiveness, as well as examining the relative merits of STPP versus other psychotherapies as added to antidepressants.

Psychotherapy or medication for depression? Using individual symptom meta-analyses to derive a Symptom-Oriented Therapy (SOrT) metric for a personalised psychiatry

BACKGROUND

Antidepressant medication (ADM) and psychotherapy are effective treatments for major depressive disorder (MDD). It is unclear, however, if treatments differ in their effectiveness at the symptom level and whether symptom information can be utilised to inform treatment allocation. The present study synthesises comparative effectiveness information from randomised controlled trials (RCTs) of ADM versus psychotherapy for MDD at the symptom level and develops and tests the Symptom-Oriented Therapy (SOrT) metric for precision treatment allocation.

METHODS

First, we conducted systematic review and meta-analyses of RCTs comparing ADM and psychotherapy at the individual symptom level. We searched PubMed Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials databases, a database specific for psychotherapy RCTs, and looked for unpublished RCTs. Random-effects meta-analyses were applied on sum-scores and for individual symptoms for the Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI) measures. Second, we computed the SOrT metric, which combines meta-analytic effect sizes with patients' symptom profiles. The SOrT metric was evaluated using data from the Munich Antidepressant Response Signature (MARS) study (n = 407) and the Emory Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study (n = 234).

RESULTS

The systematic review identified 38 RCTs for qualitative inclusion, 27 and 19 for quantitative inclusion at the sum-score level, and 9 and 4 for quantitative inclusion on individual symptom level for the HAM-D and BDI, respectively. Neither meta-analytic strategy revealed significant differences in the effectiveness of ADM and psychotherapy across the two depression measures. The SOrT metric did not show meaningful associations with other clinical variables in the MARS sample, and there was no indication of utility of the metric for better treatment allocation from PReDICT data.

CONCLUSIONS

This registered report showed no differences of ADM and psychotherapy for the treatment of MDD at sum-score and symptom levels. Symptom-based metrics such as the proposed SOrT metric do not inform allocation to these treatments, but predictive value of symptom information requires further testing for other treatment comparisons.

The influence of depressive symptoms on the effectiveness of a short-term group form of Schema Cognitive Behavioural Therapy for personality disorders: a naturalistic study

BACKGROUND

This naturalistic study examined the outcomes of Short-Term Schema Cognitive Behavioural Therapy in groups with personality disorders, and with high and low severity of depressive symptoms.

METHODS

Assessments were made at baseline, at mid-treatment (week 10), at treatment termination (week 20) and at three-month follow-up (week 32) of 225 patients with personality disorders and high severity of depressive symptoms (PD-Hi) and patients with low severity of depressive symptoms (PD-Lo). The assessments focused on symptom (Symptom Checklist-90) and schema severity (Young Schema Questionnaire) and coping styles (Utrecht Coping List). We also measured the rate of symptom remission. The data obtained were subjected to multilevel analysis.

RESULTS

Psychiatric symptoms and maladaptive schemas improved in both patient groups. Effect sizes were moderate, and even small for the coping styles. Symptom remission was achieved in the minority of the total sample. Remission in psychiatric symptomatology was seen in more PD-Lo patients at treatment termination. However, the difference in levels of remission between the two patient groups was no longer apparent at follow-up.

CONCLUSION

A short-term form of schema therapy in groups proved to be an effective approach for a broad group of patients with personality disorders. However, the majority of patients did not achieve symptom remission.

TRIAL REGISTRATION

Not applicable.

Staging and profiling for schizophrenia spectrum disorders: Inter-rater reliability after a short training course

OBJECTIVE

Clinical staging and profiling have been proposed as a new approach in order to refine the diagnostic assessment of schizophrenia spectrum disorders. However, only limited evidence is available for the inter-rater reliability of the clinical staging and profiling model. The aim of the present study was therefore to determine the inter-rater reliability of the clinical staging and profiling model for schizophrenia spectrum disorders, and to investigate whether a short course can improve inter-rater reliability.

METHODS

Consecutively recruited inpatients with schizophrenia spectrum disorders were included between January 2015 and January 2016 (study 1), and between March 2018 and October 2018 (study 2). By contrast with the assessors in study 1, all the assessors in study 2 were trained in clinical staging and profiling. We used the clinical staging model proposed by McGorry and identified profile characteristics. Inter-rater reliability was measured using the Intraclass Correlation Coefficient (ICC).

RESULTS

The ICC score for clinical staging in study 1 was moderate (0.578). It improved considerably in study 2 (0.757). In general, the ICC scores for the profile characteristics in studies 1 and 2 ranged from poor to sufficient (0.123-0.781).

CONCLUSION

This study demonstrated that inter-rater reliability in clinical staging was sufficient after training. However, inter-rater reliability for clinical profile characteristics was highly variable. The general implementation of the clinical staging model for schizophrenia spectrum disorders is therefore feasible but clinical profile characteristics should be used with caution.

Implementing cognitive behavioral therapy-enhanced in a routine inpatient and outpatient setting: Comparing effectiveness and treatment costs in two consecutive cohorts

BACKGROUND

Even though evidence-based interventions can enhance clinical outcomes and cost effectiveness, in the field of eating disorders, implementation of empirically supported treatments (ESTs) in routine inpatient and outpatient settings is slow.

OBJECTIVE

This study examined differential (cost-) effectiveness, after implementing evidence-based cognitive behavioral therapy-enhanced (CBT-E) throughout a Dutch treatment center.

METHOD

Two consecutive cohorts of adult patients, BMI between 17.5 and 40, were compared, with one cohort (N = 239) receiving treatment-as-usual (TAU) between 2012 and 2014 and the other (N = 320) receiving CBT-E between 2015 and 2017.

RESULTS

Eating disorder pathology, measured with self-reports, decreased significantly in both cohorts; overall, no differences in clinical outcomes between both cohorts were found. Treatment costs and treatment duration were considerably lower in 2015-2017. When limiting the cost analysis to direct costs, there is a 71% likelihood that CBT-E is more cost-effective and a 29% likelihood that CBT-E leads to fewer remissions at lower costs, based on the distribution of the cost-effectiveness plane. The likelihood that TAU leads to lower costs is 0%.

DISCUSSION

Findings show that implementing an EST throughout inpatient and outpatient settings leads to lower costs with similar treatment effect and has the advantage of shorter treatment duration and a shorter inpatient stay.

[Trends in emergency admissions in Amsterdam. Fifteen years of emergency psychiatry in an increasingly crowded city]

The Temporary Holding Department (toa) is a link between the 7/24 service and the admissions departments. We examined the make-up of the admission cohorts and the use of isolation between 2001 and 2017 in the context of demographic developments and changes in the mental healthcare sector.<br/> METHOD: Comparison of patient data in four cohorts who came in during four consecutive periods.<br/> RESULTS: The number of admissions rose from 408 a year in the period 2001-2003 to 728 in the period 2013-2016. The proportion of voluntary admissions increased from 4 to 33%, while emergency compulsory admissions (ibs) fell from 83 to 54%. The proportion of admissions of Dutch people from outside Amsterdam and of people from other countries rose from 11 to 23%. The percentage of patients with schizophrenic disorder rose from 25 to 32%, the percentage with mood disorder from 14 to 20% and the percentage with drug-related disorders from 3 to 7%. Assessment at a police station and the classification psychotic disorder were predictors of compulsory admissions (under the terms of the Dutch bopz act). Men under the age of 45 who were admitted compulsorily were more likely to be isolated. The percentage of patients isolated during admission fell from 37% to 20%, and the length of the periods of isolation also declined. CONCLUSIONS The increase in the annual number of admissions to the toa indicates, in the context of population growth and the rise in tourism, that there is a shortage of available beds in regular admissions departments in Amsterdam. Over the course of fifteen years, the number of Dutch nationals from outside Amsterdam and foreigners doubled. Due to policy and/or as a result of the increased proportion of patients admitted voluntarily, the use of isolation decreased.

The effect of comorbid personality disorder on depression outcome after short-term psychotherapy in a randomised clinical trial

BACKGROUND

Time-limited psychotherapy for depression is effective. However, comorbid personality disorders affect therapy outcomes negatively. Studies of follow-up effects and results relating to the influence of comorbid personality disorder and treatment modality are scarce.

AIMS

To determine the influence of comorbid personality disorder and treatment modality on outcomes after cognitive-behavioural therapy (CBT) or short-term psychodynamic supportive psychotherapy (SPSP) for depression.

METHOD

This study draws on data from a previously published randomised clinical trial contrasting SPSP and CBT for depression (both 16 sessions). We compared the effectiveness of these psychotherapies for patients with and without personality disorder (n = 196). The primary measure was depression outcome; the secondary measurements were interpersonal functioning and quality of life. Collected data were analysed using multilevel analysis. Trial registration: ISRCTN31263312 (http://www.controlled-trials.com).

RESULTS

Although participants with and without comorbid personality disorder improved at treatment termination (d = 1.04, 95% CI 0.77-1.31 and d = 1.36, 95% CI 0.97-1.76, respectively) and at follow-up (d = 1.15, 95% CI 0.87-1.43 and d = 2.12, 95% CI 1.65-2.59 respectively), personality disorder had a negative effect on depression outcome at both measurement points (P < 0.05). A similar negative effect on interpersonal functioning was no longer apparent at follow-up. Comorbid personality disorder had no influence on social functioning or quality of life outcomes, irrespective of treatment modality.

CONCLUSIONS

CBT and SPSP contribute to the improvement of depressive symptoms and interpersonal problems in depressed patients with and without comorbid personality disorder. Both treatments are an effective first step in a stepped care approach, but - given remaining levels of depression in patients with personality disorder - they are probably inadequate for large numbers of patients with this comorbidity.

DECLARATION OF INTEREST

None.

Preventive cognitive therapy versus care as usual in cognitive behavioral therapy responders: A randomized controlled trial

OBJECTIVE

The optimization of long-term outcomes is an important goal in the treatment of major depressive disorder. Offering subsequent preventive cognitive therapy (PCT) to patients who responded to acute cognitive behavioral therapy (CBT) may reduce the risk of relapse/recurrence.

METHOD

Therefore, a multicenter randomized controlled trial was conducted comparing the addition of eight weekly sessions of PCT to care as usual (CAU) versus CAU alone in patients with a history of depression in remission following treatment with CBT. A total of 214 recurrently depressed patients who remitted following treatment with CBT were randomized to PCT (n = 107) or CAU (n = 107). Primary outcome was time to relapse/recurrence over 15 months and was assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Secondary outcomes were depressive symptoms measured by the Inventory of Depressive Symptomatology-Self Report and number and severity of relapses/recurrences measured by the SCID-I.

RESULTS

Over the 15-month follow-up, the addition of PCT significantly delayed time to relapse/recurrence relative to CAU alone, hazard ratio = 1.807 (number needed to treat = 8.1), p = .02, 95% CI [1.029, 3.174]. No significant differences were found between the conditions on number or severity of relapses/recurrences and residual symptoms.

CONCLUSION

Adding PCT was significantly more effective than CAU alone in delaying time to relapse/recurrence of depression over a period of 15 months among CBT responders. After response on CBT, therapists should consider providing PCT to recurrently depressed patients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patterns of obsessive-compulsive symptoms and social functioning in schizophrenia; a replication study

Research has found that Obsessive Compulsive Symptoms (OCS) in schizophrenia are associated with either more or less negative symptoms and either better or poorer cognitive functioning. In order to explain these contradictory results, (Lysaker et al., 2004), performed a cluster analysis resulting in 2 OCS positive (OCSpos) clusters, one with higher functioning (HF) and one with poorer functioning (PF) compared to 2 OCS negative (OCSneg) clusters. The OCSpos/HF cluster had less negative symptoms compared to all other clusters, while the OCSpos/PF cluster showed poorer executive functioning. We performed a replication study, in an almost 10 times larger, representative sample, using both a longitudinal and cross-sectional design. Similar to Lysaker et al., we found a group with mild OCS and HF (OCSmild/HF) showing less negative symptoms compared to the PF groups. We also found an OCSmild/PF group, which did not significantly differ in executive functioning from the other groups. Moreover, we did not find evidence for a better prognosis in the OCSmild/HF group, and thus found no support for the assumption that for some patients OCS might be an effective coping mechanism.

Day hospital mentalization-based treatment v. specialist treatment as usual in patients with borderline personality disorder: randomized controlled trial

BACKGROUND

Day hospital mentalization-based treatment (MBT-DH) is a promising treatment for borderline personality disorder (BPD) but its evidence base is still limited. This multi-site randomized trial compared the efficacy of MBT-DH delivered by a newly set-up service v. specialist treatment as usual (S-TAU) tailored to the individual needs of patients, and offered by a well-established treatment service.

METHODS

Two mental healthcare institutes in The Netherlands participated in the study. Patients who met DSM-IV criteria for BPD and had a score of ⩾20 on the borderline personality disorder severity index (BPDSI) were randomly allocated to MBT-DH (N = 54) or S-TAU (N = 41). The primary outcome variable was the total score on the BPDSI. Secondary outcome variables included symptom severity, quality of life, and interpersonal functioning. Data were collected at baseline and every 6 months until 18-month follow-up, and were analyzed using multilevel analyses based on intention-to-treat principles.

RESULTS

Both treatments were associated with significant improvements in all outcome variables. MBT-DH was not superior to S-TAU on any outcome variable. MBT-DH was associated with higher acceptability in BPD patients compared v. S-TAU, reflected in significantly higher early drop-out rates in S-TAU (34%) v. MBT-DH (9%).

CONCLUSIONS

MBT-DH delivered by a newly set-up service is as effective as specialist TAU in The Netherlands in the treatment of BPD at 18-month follow-up. Further research is needed to investigate treatment outcomes in the longer term and the cost-effectiveness of these treatments.

Effectiveness of Integrated Dual Diagnosis Treatment (IDDT) in severe mental illness outpatients with a co-occurring substance use disorder

Integrating substance use disorder treatment with psychiatric treatment is considered more favourable then treating these disorders parallel or sequential, but the evidence base is inconclusive. We examined the effectiveness of Integrated Dual Diagnosis Treatment (IDDT) on substance use in severe mental illness outpatients with substance use disorders. IDDT is a collaborative, multidisciplinary team approach in which motivational interviewing is a key element. In addition, we also examined the effects of IDDT implementation on skills and knowledge of mental health care professionals. A randomized controlled stepped-wedge cluster trial was performed in 6 functional assertive cummunity treatment teams. We included 37 clinicians who were given a three-day IDDT training. Our primary outcome was days of substance use at follow up, 12 months after IDDT implementation. This was assessed in 154 included patients and was measured with the Measurement in the Addiction for Triage and Evaluation. After implementation of IDDT we found a reduction in the number of days patients used alcohol or drugs, but no improvements on other secondary outcomes such as psychopathology, functioning, therapeutic alliance or motivation to change. Also, IDDT training did not seem to improve clinicians' knowledge, attitudes and motivational interviewing skills. Effects on our secondary outcomes may have been limited by the absence of a training effect in our clinicians. Our study clearly underlines the complexity of disseminating IDDT and in particular motivational interviewing.

Optimizing psychotherapy dosage for comorbid depression and personality disorders (PsyDos): a pragmatic randomized factorial trial using schema therapy and short-term psychodynamic psychotherapy

BACKGROUND

Patients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change.

METHODS

In a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9-12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective.

DISCUSSION

This trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom.

TRIAL REGISTRATION

This trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR5941 ).

Exploring construct validity of clinical staging in schizophrenia spectrum disorders in an acute psychiatric ward

OBJECTIVE

clinical staging and profiling of schizophrenia spectrum disorders has been proposed to describe and define the heterogenous course of disease. We examined the construct validity of clinical staging in schizophrenia spectrum disorders by measuring differences in distribution and severity of relevant clinical profilers and therapeutic improvement (HoNOS) across clinical stages.

METHODS

we performed a prospective cross-sectional study with 258 inpatiënts who met DSM-IV criteria for schizophrenia spectrum disorders, recruited in an acute ward of a psychiatric hospital from 1-1-2015 until 31-12-2016. All patients (N=258) were assigned to a clinical stage, according to the criteria described by McGorry and clinical profilers were determined. Therapeutic improvement was assessed by measuring change in differences in HoNOS score during admission.

RESULTS

significant higher severity scores of clinical profilers were found in more advanced stages compared to earlier stages. This pattern was apparent in the clinical profilers negative symptoms (F=4.56, P<0.01), number of psychotic episodes last year (F=13.65, P<0.01), compliance (F=2.76, P<0.05), work and daily activities (F=9.85, P<0.001), living situation (F=3.71, P<0.05), support of close relatives (F=9.38, P<0.001) and pre-morbid functioning (F=7.33, P<0.001). Judicial background was less prevalent in earlier stages compared to more advanced disease stages. No differences in therapeutic improvement (HoNOS) were found between clinical stages.

CONCLUSION

this study demonstrates that clinical staging in schizophrenia spectrum disorders has an acceptable construct validity between earlier and more chronic stages of disease. Several clinical profilers increase in more advanced stages compared to earlier clinical stages, which supports construct validity.

Cognitive-behavioral versus psychodynamic therapy for major depression: Secondary outcomes of a randomized clinical trial

OBJECTIVE

In a randomized clinical trial, we compared the efficacy of cognitive-behavioral therapy (CBT) and psychodynamic therapy for adult outpatient depression on measures of psychopathology, interpersonal functioning, pain, and quality of life.

METHOD

There were 341 Dutch adults (70.1% female, mean age = 38.9, SD = 10.3) meeting Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) criteria for a major depressive episode and with a Hamilton Depression Rating Scale (HAM-D) score ≥14, who were randomized to 16 sessions of individual manualized CBT or short-term psychodynamic supportive psychotherapy. Severely depressed patients (HAM-D >24) received additional antidepressant medication according to a protocol. Outcome measures included the Brief Symptom Inventory, Beck Anxiety Inventory, Outcome Questionnaire, a visual analogue scale for pain, and EuroQol. Data were analyzed with mixed model analyses using intention-to-treat samples. Noninferiority margins were prespecified as Cohen's d = -0.30.

RESULTS

Across treatment conditions, 45-60% of the patients who completed posttreatment assessment showed clinically meaningful change for most outcome measures. We found no significant differences between the treatment conditions on any of the outcome measures at both posttreatment and follow-up. Noninferiority of psychodynamic therapy to CBT was shown for posttreatment and follow-up anxiety measures as well as for posttreatment pain and quality of life measures, but could not be consistently demonstrated for the other outcomes.

CONCLUSIONS

This is the first study that shows that psychodynamic therapy can be at least as efficacious as CBT for depression on important aspects of patient functioning other than depressive symptom reduction. These findings extend the evidence-base of psychodynamic therapy for depression, but replication is needed by means of rigorously designed noninferiority trials. (PsycINFO Database Record

[Discrepancies in reported medication use in elderly psychiatric outpatients]

Different fields of study have revealed discrepancies between the reported medication use presented by patients and medical records held by their doctor or apothecary. These also appear to have clinically relevant consequences. At present only two studies have explored medication discrepancies in psychiatry.<br/> AIM: To investigate the occurrence of discrepancies in the reported medication use of a psychiatric elderly out-patient population.<br/> METHOD: Comparing 40 medication records of patients to their respective general practitioner and pharmacy records. Information on their social situation, Mini-Mental State Examination score and diagnosis was collected.<br/> RESULTS: One or more discrepancies were present in 80 percent of cases. Patients living alone had a higher percentage of discrepancies. Patients with cognitive problems or a low score on the Mini-Mental State Examination had less discrepancies.<br/> CONCLUSION: Medication discrepancies are also common in a psychiatric elderly outpatient population.

The role of affect in predicting depressive symptomatology in remitted recurrently depressed patients

BACKGROUND

Major depressive disorder is an emotional disorder. It is important to improve our understanding of the role of affect in relapse/recurrence of depression. Therefore, this study examines whether affect plays a role in prospectively predicting depressive symptomatology and if there are indications for emotional scarring as a consequence of undergoing depressive episodes.

METHODS

In 107 patients remitted from recurrent depression affect was examined in predicting depressive symptomatology as measured with the Inventory of Depressive Symptomatology - Self Report. Affect was measured with the Positive and Negative Affect Schedule and with a one item Visual Analogue Mood Scale. Indication of emotional scarring was examined by comparing number of previous depressive episodes to levels of affect.

RESULTS

Less positive affect as assessed after remission predicted increased depressive symptomatology six months later, even after we controlled for baseline symptomatology. Negative affect also predicted depressive symptomatology six months later, but not after controlling for baseline depressive symptomatology. No relationship was found between affect and number of previous episodes.

LIMITATIONS

All participants in this study had two or more previous depressive episodes and received CBT during the acute phase of their depression. The instruments that measured mood and affect were administered within 4 weeks of each other.

CONCLUSIONS

Positive affect and negative affect as assessed after remission in recurrent depression can predict depressive symptomatology. Especially positive affect seems to play an independent role in predicting depressive symptomatology. Directly targeting positive affect in relapse prevention during remission might be a way to enhance treatment effects.

[Intensive follow-on care does not prevent a repeat compulsory admission; a prospective cohort study with a 5-year follow-up]

OBJECTIVE

To explore the relationship between psychiatric care consumption after a compulsory admission and the probability of a repeat compulsory admission.

DESIGN

Prospective cohort study with a 5-year follow-up.

METHOD

Mental health care consumption was registered for 460 patients admitted compulsorily under the Dutch Psychiatric Care (Compulsory Admissions) Act by the Amsterdam Emergency Psychiatry service between 15 September 2004 and 14 September 2006, with socio-demographic and clinical data as independent variables.

RESULTS

There was no repeat compulsory admission in 63% of the cohort. The odds ratio for repeat compulsory admission only decreased in the fourth year (odds ratio (OR) 0.64; 95% CI 0.45-0.92). Repeat compulsory admission was associated with high treatment continuity (χ2 p ≤ 0.001) and a high level of care consumption during the follow-up period (χ2 p ≤ 0.001). Compulsory admission was predicted on the basis of: high care consumption in the five years prior to inclusion (OR 2.61; 1.44-4.73), aged younger than 35 years at outset (OR 1.65; 1.08-2.52), living alone at the time of inclusion (OR 1.68; 1.22-2.33), and a history of compulsory admission (OR 1.56; 1.03-2.35).

CONCLUSION

Two-thirds of the patients were not re-admitted compulsorily. The probability of a repeat admission of this kind fell only after four years. Patients who underwent a repeat compulsory admission proved to be the ones who had been treated most intensively, yet this intense treatment did not prevent a higher probability of readmission. When not taking the quality and nature of care and social integration of patients into account, attempts to reduce treatment dropout on the one hand and more intense treatments on the other may not have an effect on reducing the probability of a repeat compulsory admission.

Measuring shame regulation: Validation of the Compass of Shame Scale

Shame is a powerful self-conscious emotion that can interfere with healthy psychological functioning. We examined the validity of the Compass of Shame Scale (CoSS), a self-report measure designed to assess shame regulation styles. In this paper, the construct validity of the Dutch version and two newly developed subscales of the CoSS were investigated in a survey of 324 adolescents. The results confirmed that the Dutch version and the two new subscales have satisfactory psychometric qualities. We also studied the higher level factor structure of the CoSS for measuring shame by introducing the concepts of internalizing and externalizing shame-coping styles and the results support the observation that the CoSS measures maladaptive neurotic internalizing shame regulation, as well as externalizing shame regulation.