Dosage effects of psychodynamic and schema therapy in people with comorbid depression and personality disorder: four-arm pragmatic randomised controlled trial

BACKGROUND

Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder.

AIMS

To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy - short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy - with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941.

METHOD

We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder.

RESULTS

Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = -0.53, 95% CI -0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010).

CONCLUSIONS

Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study

BACKGROUND

A strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning.

METHODS

We analysed registry data for 2008-2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission.

RESULTS

In 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls.

CONCLUSION

There are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Interrater Reliability of the Psychological Mindedness Assessment Procedure, Extended (Dutch) Version, in a Clinical Patient Population

The Psychological Mindedness Assessment Procedure, Extended Dutch Version (PMAP-plus), was developed to assess psychological mindedness in mental health care. Psychological Mindedness represents the ability to understand self and others through mental representations of internal psychodynamic states. In patients, deficits in psychological mindedness capacity can cause problems in self- and interpersonal functioning. This brief report describes interrater reliability of four PMAP-plus scenarios for evaluating psychological mindedness capacity among patients. Patients with personality disorders (N = 194) were asked to respond to four enacted videotaped PMAP-plus scenarios presenting a person talking about a personal experience. The videotaped scenarios varied in their emotional impact. All verbatim responses were scored by two clinically experienced raters on a hierarchical scale with gradually increasing complexity of psychodynamic understanding. Clinicians achieved acceptable interrater reliability on PMAP-plus in this patient population. Two scenarios with low emotional impact evoked significantly higher interrater agreement as compared to two scenarios with high emotional impact. Our results suggest that mental health professionals can reliably distinguish levels of psychological mindedness by assessing PMAP-plus in a patient population. Scenarios differ in potency to reveal psychological mindedness capacity. The variation in emotional impact in subsequent scenarios makes it a promising instrument measuring psychodynamic capacities for psychotherapeutic treatment.

Web-based guided self-help cognitive behavioral therapy-enhanced versus treatment as usual for binge-eating disorder: a randomized controlled trial protocol

Binge-eating disorder (BED) is a psychiatric disorder characterized by recurrent episodes of eating a large amount of food in a discrete period of time while experiencing a loss of control. Cognitive behavioral therapy-enhanced (CBT-E) is a recommended treatment for binge-eating disorder and is typically offered through 20 sessions. Although binge-eating disorder is highly responsive to CBT-E, the cost of treating these patients is high. Therefore, it is crucial to evaluate the efficacy of low-intensity and low-cost treatments for binge-eating disorder that can be offered as a first line of treatment and be widely disseminated. The proposed noninferiority randomized controlled trial aims to determine the efficacy of web-based guided self-help CBT-E compared to treatment-as-usual CBT-E. Guided self-help will be based on a self-help program to stop binge eating, will be shorter in duration and lower intensity, and will require fewer therapist hours. Patients with binge-eating disorder (N = 180) will be randomly assigned to receive guided self-help or treatment-as-usual. Assessments will take place at baseline, mid-treatment, at the end of treatment, and at 20- and 40-weeks post-treatment. Treatment efficacy will be measured by examining the reduction in binge-eating days in the previous 28 days between baseline and the end of treatment between groups, with a noninferiority margin (Δ) of 1 binge-eating day. Secondary outcomes will include full remission, body shape dissatisfaction, therapeutic alliance, clinical impairment, health-related quality of life, attrition, and an economic evaluation to assess cost-effectiveness and cost-utility. The moderators examined will be baseline scores, demographic variables, and body mass index. It is expected that guided self-help is noninferior in efficacy compared to treatment-as-usual. The proposed study will be the first to directly compare the efficacy and economically evaluate a low-intensity and low-cost binge-eating disorder treatment compared to treatment-as-usual. If guided self-help is noninferior to treatment-as-usual in efficacy, it can be widely disseminated and used as a first line of treatment for patients with binge-eating disorder. The Dutch trial register number is R21.016. The study has been approved by the Medical Research Ethics Committees United on May 25th, 2021, case number NL76368.100.21.

Attachment-Based Family Therapy for Adolescents and Young Adults With Suicide Ideation and Depression

Background: Suicide ideation among adolescents is difficult to treat. Attachment-based family therapy (ABFT) is a promising evidence-based family intervention developed to decrease depressive symptoms and suicide ideation among adolescents. Aims: This open trial assessed the feasibility of ABFT for adolescents (12-23 years) with suicide ideation and depression in an outpatient community mental health center in the Netherlands, by monitoring treatment compliance and satisfaction, treatment dose, and symptom reduction. Methods: Eligible patients were referred by the multidisciplinary treatment team at the facility. Treatment dose was monitored by the therapist. Depression (CDI-2), family functioning (SRFF), and strengths and difficulties (SDQ) were assessed online before the intervention and at 3, 6, and 9 months after baseline. Suicide ideation (SIQ-JR) was assessed at each therapy session, and a satisfaction questionnaire was administered postintervention. A total of 25 families signed informed consent, received ABFT treatment, and were included in the analyses. The therapists were at beginners' level of ABFT, working under supervision during the trial. Results: The treatment dose was acceptable, though impacted by COVID-related lockdowns, and treatment compliance was 89%. Patients received on average 22 ABFT sessions, and about half of the patients received additional psychotherapy. On average, patients were satisfied with ABFT. There was a significant decrease in suicide ideation postintervention (d = 0.69) and significant effects on the CDI-2, SRFF, and SDQ at follow-up with medium-to-large effect sizes (d = 0.53-0.94). Limitations: These results should be interpreted with considerable caution, as there was no control group to establish the effectiveness of ABFT, and the sample was small. Conclusion: ABFT appears to be a feasible therapy for youth with depression and suicide ideation in an outpatient community mental health setting.

Group schema therapy: the temporal relationship between early maladaptive schemas and global psychological distress

Schema therapy is an effective treatment for personality disorders (PDs). The theory of schema therapy assumes that the decrease of global psychological distress is mediated by change in Early Maladaptive Schemas. The few studies that have investigated a temporal relationship have produced contradictory results. This study examined the temporal relationship between changes in Early Maladaptive Schemas and global psychological distress in Group Schema Therapy (GST) for patients with personality disorders.

Assessments were made of 115 patients at baseline, after 20, 40 and after 60 sessions of treatment. We used the Young Schema Questionnaire (YSQ) to measure the severity of Early Maladaptive Schemas and the Symptom Check List-90 Revisited (SCL-90R) to measure global psychological distress. Linear mixed model analyzes were used to examine the temporal relationship between the initial phase (0-20 and 0-40 sessions) and the later phase (40-60 sessions).

Change in Early Maladaptive Schemas does not precede change in global psychological distress. Conversely, global psychological distress does not precede change in Early Maladaptive Schemas; the improvement in both indicators is concurrent.

In this study, we could not confirm that the decrease of Early Maladaptive Schemas precedes decrease of global psychological distress. We found a concurrent relationship.

Alcohol use disorder treatment via video conferencing compared with in-person therapy during COVID-19 social distancing : A non-inferiority comparison of three cohorts

BACKGROUND

Social distancing measures during the COVID-19 pandemic forced an abrupt transformation of treatment delivery for mental health care. In mid-March 2020, nearly all in-person contact was replaced with video conferencing. The pandemic thus offered a natural experiment and a unique opportunity to conduct an observational study of whether alcohol use disorder treatment through video conferencing is non-inferior to in-person treatment.

METHODS

In a large urban substance use disorder treatment center in the Netherlands, treatment evaluation is routine practice. Outcome data are regularly collected to support shared decision making and monitor patient progress. For this study, pre-test and post-test data on alcohol use (Measurements in the Addictions for Triage and Evaluation), psychopathology (Depression Anxiety Stress Scales), and quality of life (Manchester Short Assessment of Quality of Life) were used to compare outcomes of cognitive behavioral therapy treatment for three cohorts: patients who received treatment for a primary alcohol use disorder performed prior to (n = 628), partially during (n = 557), and entirely during (n = 653) the COVID-19 lockdown.

RESULTS

Outcome was similar across the three cohorts: No inferior outcomes were found for treatments that were conducted predominantly through video conferencing during lockdown or treatments that started in-person, but were continued through video conferencing, compared to in-person treatments that were conducted prior to COVID-19. The number of drop-outs were also similar between cohorts. However, there was a difference in average treatment intensity between cohorts, with treatment partially or fully conducted during the COVID-19 pandemic lasting longer.

CONCLUSIONS

Treatment for a primary alcohol use disorder, provided partially or predominantly through video conferencing during the COVID-19 pandemic resulted in abstinence rates and secondary outcomes similar to traditional in-person care, in spite of the potentially negative effects of the COVID-related lockdown measures themselves. These results from everyday clinical practice corroborate findings of randomized controlled studies and meta-analyses in which video conferencing appeared non-inferior to in-person care in clinical effectiveness.

Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data

BACKGROUND

Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression.

METHODS

For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level.

RESULTS

Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [B = -0.49, 95% confidence interval (CI) -0.61 to -0.37, p < 0.0001] and for patients with a depressive episode duration of >2 years rather than <1 year (B = -0.68, 95% CI -1.31 to -0.05, p = 0.03) and than 1-2 years (B = -0.86, 95% CI -1.66 to -0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias.

CONCLUSIONS

To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression.

Effect of coercive measures on treatment outcome in involuntarily admitted patients in Amsterdam

Objective

The prevalence of involuntary admissions rose the last forty years in European countries, including the Netherlands. Involuntary admissions result in seclusion, physical restraint and forced medication in approximately 40% of patients. We looked at whether treatment outcomes differ in patients with and without coercive measures.

Methods

Using The Health of the Nation Outcome Scales (HoNOS) to measure treatment outcomes, we studied the files of 786 patients admitted involuntarily to an Amsterdam clinic. We applied Generalised Linear Models to determine whether the use, or not, of coercive measures during treatment was associated with a difference in outcomes.

Results

19% of the cohort were secluded in a High Security Room (HSR); 24% were secluded in their own room and/or received forced medication. After adjustment for the influence of diagnosis, disorder severity (initial HoNOS score) and treatment duration, the HSR group had, on average, a HoNOS difference score that was 2.4 points lower than patients without coercive measures (CI -4.0 to -0.8.; p 0.003). In the seclusion in own room group, this score was 2.6 points lower (CI -4.0 to -1.1; p 0.001), corresponding to an effect size of 0.35 and 0.40, respectively.

Conclusion

Seclusion, whether or not in combination with forced medication, was applied to two-fifths of patients. The HoNOS scores of the group without coercion improved by nearly two and a half points more on average than those of the two groups with coercion. A causal relationship between coercion and treatment outcome could neither be confirmed nor excluded on the basis of our results.

G-FORCE: the effectiveness of group psychotherapy for Cluster-C personality disorders: protocol of a pragmatic RCT comparing psychodynamic and two forms of schema group therapy

BACKGROUND

Cluster-C personality disorders (PDs), characterized by a high level of fear and anxiety, are related to high levels of distress, societal dysfunctioning and chronicity of various mental health disorders. Evidence for the optimal treatment is extremely scarce. Nevertheless, the need to treat these patients is eminent. In clinical practice, group therapy is one of the frequently offered approaches, with two important frameworks: schema therapy and psychodynamic therapy. These two frameworks suggest different mechanisms of change, but until now, this has not yet been explored. The purpose of the present G-FORCE trial is to find evidence on the differential (cost)effectiveness of two forms of schema group therapy and psychodynamic group therapy in the routine clinical setting of an outpatient clinic and to investigate the underlying working mechanisms and predictors of outcome of these therapies.

METHODS

In this mono-centre pragmatic randomized clinical trial, 290 patients with Cluster-C PDs or other specified PD with predominantly Cluster-C traits, will be randomized to one of three treatment conditions: group schema therapy for Cluster-C (GST-C, 1 year), schema-focused group therapy (SFGT, 1.5 year) or psychodynamic group therapy (PG, 2 years). Randomization will be pre-stratified on the type of PD. Change in severity of PD (APD-IV) over 24 months will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Potential predictors and mediators are selected and measured repeatedly. Also, a cost-effectiveness study will be performed, primarily based on a societal perspective, using both clinical effects and quality-adjusted life years. The time-points of assessment are at baseline, start of treatment and after 1, 3, 6, 9, 12, 18, 24 and 36 months.

DISCUSSION

This study is designed to evaluate the effectiveness and cost-effectiveness of three formats of group psychotherapy for Cluster-C PDs. Additionally, predictors, procedure and process variables are analysed to investigate the working mechanisms of the therapies. This is the first large RCT on group therapy for Cluster-C PDs and will contribute improving the care of this neglected patient group. The absence of a control group can be considered as a limitation.

TRIAL REGISTRATION

CCMO, NL72826.029.20 . Registered on 31 August 2020, first participant included on 18 October 2020.

Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE)

BACKGROUND

Cluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients.

OBJECTIVE

In this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators.

METHODS

This is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18-65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months.

DISCUSSION

This is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons.

TRIAL REGISTRATION

NL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

Exploring effectiveness of CBT in obese patients with binge eating disorder: personality functioning is associated with clinically significant change

BACKGROUND

Binge eating disorder (BED), as the most prevalent eating disorder, is strongly related to obesity and other somatic and psychiatric morbidity. Despite evidence-based treatments a considerable number of BED patients fail to recover. There is preliminary evidence for the association between psychodynamic personality functioning and personality traits on treatment outcome. However, research is limited and results are still contradictory. Identifying variables associated with treatment outcome could improve treatment programs. The aim of the study was to explore whether personality functioning or personality traits are associated with Cognitive Behavioral Therapy (CBT) outcome in obese female patients with BED or subthreshold BED.

METHODS

Eating disorder symptoms and clinical variables were assessed in 168 obese female patients with DSM-5 BED or subthreshold BED, referred to a 6-month outpatient CBT program in a pre-post measurement design. Personality functioning was assessed by the Developmental Profile Inventory (DPI), personality traits by the Temperament and Character Inventory (TCI). Treatment outcome was assessed by the Eating Disorder Examination-Questionnaire (EDE-Q) global score and self-reported binge eating frequency. According to the criteria of clinical significance, 140 treatment completers were categorized in four outcome groups (recovered, improved, unchanged, deteriorated).

RESULTS

EDE-Q global scores, self-reported binge eating frequency and BMI significantly decreased during CBT, where 44.3% of patients showed clinically significant change in EDE-Q global score. Treatment outcome groups showed significant overall differences on the DPI Resistance and Dependence scales and the aggregated 'neurotic' scale. Significant overall differences were found between groups on TCI Harm avoidance, although post hoc t-tests were non-significant. Furthermore, multiple logistic regression analysis, controlling for mild to moderate depressive disorder and TCI harm avoidance showed that 'neurotic' personality functioning was a significant negative predictor of clinically significant change.

CONCLUSION

Maladaptive ('neurotic') personality functioning is significantly associated with a less favorable outcome after CBT in patients with binge eating. Moreover, 'neurotic' personality functioning is a predictor of clinically significant change. Assessment of personality functioning and personality traits could support indication for more specified or augmented care, tailored towards the patients' individual strengths and vulnerabilities.

TRIAL REGISTRATION

This study protocol was retrospectively evaluated and approved on 16-06-2022 by the Medical Ethical Review Committee (METC) of the Amsterdam Medical Centre (AMC). Reference number W22_219#22.271.

Norms and T-scores for screeners of alcohol use, depression and anxiety in the population of Suriname

Background

There is a considerable gap between care provision and the demand for care for common mental disorders in low-and-middle-income countries. Screening for these disorders, e.g., in primary care, will help to close this gap. However, appropriate norms and threshold values for screeners of common mental disorders are lacking.

Methods

In a survey study, we gathered data on frequently used screeners for alcohol use disorders, (AUDIT), depression, (CES-D), and anxiety disorders (GAD-7, ACQ, and BSQ) in a representative sample from Suriname, a non-Latin American Caribbean country. A stratified sampling method was used by random selection of 2,863 respondents from 5 rural and 12 urban resorts. We established descriptive statistics of all scale scores and investigated unidimensionality. Furthermore, we compared scores by gender, age-group, and education level with t-test and Mann-Whitney U tests, using a significance level of p < 0.05.

Results

Norms and crosswalk tables were established for the conversion of raw scores into a common metric: T-scores. Furthermore, recommended cut-off values on the T-score metric for severity levels were compared with international cut-off values for raw scores on these screeners.

Discussion

The appropriateness of these cut-offs and the value of converting raw scores into T-scores are discussed. Cut-off values help with screening and early detection of those who are likely to have a common mental health disorder and may require treatment. Conversion of raw scores to a common metric in this study facilitates the interpretation of questionnaire results for clinicians and can improve health care provision through measurement-based care.

Mapping Conscience: Network Analysis Into the Differences in Maturation of Offending and Non-Offending Adolescents

Conscience is a diagnostically relevant concept in forensic psychiatry, but often misinterpreted as an all-or-none phenomenon. We conceptualize the conscience as a psychic function in which elements like empathy, self-conscience emotions such as shame, guilt and pride, and moral orientation work together. The differences in conscience functioning can be described in terms of developmental levels of integration. We conducted network analyses on data collected via a questionnaire survey held among 52 offending and 243 non-offending juveniles. We displayed two networks: One representing the non-offenders' normative and one representing the offenders' defiantly maturing conscience. As was hypothesized, in the non-offenders network, almost all elements clustered into one clinically meaningful network, indicating integration of the different elements of the normative maturing conscience. In the offenders network, the correlations between the elements were sporadic, indicating a lack of integration of the defiantly maturing conscience. The difference between the two networks was more prominent for empathy and moral orientation than for self-conscious emotions. This research supports the theory of differences in maturation of conscience instead of being an all-or-none phenomenon and calls for further research, taking a deeper look at the significance of integration of the conscience and its implications for offending behaviour.

Loneliness, social network size and mortality in older adults: a meta-analysis

Loneliness and social network size have been found to be predictors of mortality in older adults. The objective of this study was to investigate whether loneliness and small social network size are associated with an increased mortality risk and to review the evidence for either network size, or loneliness that constitutes the higher mortality risk. A systematic literature search was performed in PubMed, EMBASE and PsychInfo in January/February 2018 and March/April 2021. Studies that mentioned outcome data were included in the meta-analysis and coded using the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. The meta-analysis showed that both loneliness and small social network size are associated with mortality risk in older adults (Hazard Ratio 1.10 (95% Confidence Interval 1.06-1.14) for loneliness and 0.96 (95% Confidence Interval 0.93-0.99) for larger network size). Sensitivity analyses according to the Newcastle-Ottawa Quality Assessment Scale yielded varying results. Heterogeneity was large. In conclusion, both loneliness and small social network size in older adults are associated with increased mortality, although the effect size is small. Targeting subjective and objective aspects of older adults' social contacts should be on the agenda of preventive as well as personalized medicine. In order to be able to compare the association between loneliness and network size and mortality, more studies are needed that include both these risk factors.

The Association Between Loneliness and Psychiatric Symptomatology in Older Psychiatric Outpatients

PURPOSE

Loneliness in adults increases with age. Although loneliness has been found to be associated with psychiatric disorders and dementia, no information is available on prevalence of loneliness in older psychiatric patients. The aims of this study were to examine prevalence of loneliness in older psychiatric outpatients, including gender differences and associations with psychiatric disorders and social isolation.

METHODS

Cross-sectional study in an outpatient clinic for geriatric psychiatry between September 2013 and February 2018. Interviews were done in 181 patients.

RESULTS

80% of participants were lonely. Loneliness was associated with having contacts in less social network domains, in women but not in men. There were no associations with DSM-IV-TR-classifications. However, loneliness was associated with higher scores on questionnaires for depression and cognitive function. Intensity of treatment did not differ significantly between lonely and non-lonely participants.

CONCLUSION

Loneliness is highly prevalent in older psychiatric outpatients, with men and women equally affected. Loneliness should be assessed in all older psychiatric patients, especially when they show high scores on symptom checklists or have a restricted social network.

The effectiveness of intensive home treatment as a substitute for hospital admission in acute psychiatric crisis resolution in the Netherlands: a two-centre Zelen double-consent randomised controlled trial

BACKGROUND

Although de-institutionalisation has been underway for decades, admission to hospital followed by low-intensity outpatient care remains the usual treatment for patients with an acute psychiatric crisis. Intensive home treatment has been developed for patients in a severe psychiatric crisis as an alternative to inpatient care. This study aimed to evaluate the potential of intensive home treatment to reduce bed-days and its clinical effectiveness compared with treatment as usual.

METHODS

We did a two-armed, two-centre, open-label, Zelen, double-consent, pragmatic randomised controlled trial. Patients aged 18-65 years were recruited at the psychiatric emergency service and psychiatric emergency wards of the two major mental health institutions (Arkin and GGZ inGeest) in Amsterdam, the Netherlands. Patients diagnosed with at least one DSM-IV-TR or DSM-5 disorder and in a psychiatric crisis and for whom psychiatrists had indicated or completed a clinical admission could be included. Trained psychiatric emergency service and hospital professionals did the automated web-based pre-randomisation procedure upon first contact with the patient. A seeded pseudo-random number generator allocated patients (2:1) to intensive home treatment or treatment as usual. Informed consent was obtained after randomisation as soon as the patient was mentally capable within 14 days. Due to the nature of this study, patients and professionals were not masked to treatment. Intensive home treatment was tailored to the nature of the crisis and goals of patients and relatives, and developed in collaboration with them and a multidisciplinary professional team. All main analyses were intention-to-treat, and the primary outcome was the total number of admission days 12 months after randomisation. To investigate the effect of treatment conditions on the outcome measures, linear mixed modelling analyses using restricted maximum likelihood estimation were done. This trial was prospectively registered with Trialregister.nl, NL-6020 (NTR-6151).

FINDINGS

Between Nov 15, 2016, and Oct 15, 2018, 246 patients were included in the study (183 patients with intensive home treatment vs 63 patients with treatment as usual). 135 women (55%) and 111 men (45%) were included, with a mean age of 41·01 years (range 18-65; SD 12·68). 114 participants (46%) were born in the Netherlands and 85 (35%) elsewhere (missing data on 47 [19%] participants). Ethnicity data were not available. After 12 months, the mean number of admission days in the intensive home treatment condition was 42·47 (SD 53·92) versus 67·02 (SD 79·03) for treatment as usual, a reduction of 24·55 days (SD 10·73) or 36·6% (p=0·033). 26 adverse events were registered, 23 (89%) of which were suicide attempts. The number of patients with a reported adverse event did not differ significantly between the groups (15 [8%] in the intensive home treatment group vs five [8%] in the treatment as usual group; p=0·950). Five patients died by suicide (three [2%] in the intensive home treatment group vs two [3%] in the treatment as usual group; p=0·610). No treatment-related deaths occurred.

INTERPRETATION

Intensive home treatment is a safe and effective partial substitute for conventional psychiatric crisis care that led to a reduction in admission days, causing patients to stay longer in their social environment, with similar clinical effects, patient satisfaction and adverse events.

FUNDING

De Stichting tot Steun Vereniging voor Christelijke Verzorging van Geestes-en Zenuwzieken.

Impact of COVID‐19 social distancing measures on routine mental health care provision and treatment outcome for common mental disorders in the Netherlands

Objective

The uptake of digital interventions in mental health care (MHC) has been slow, as many therapists and patients believe that in‐person contact is essential for establishing a good working relationship and good outcomes in treatment. The public health policies regarding social distancing during the coronavirus disease‐2019 (COVID‐19) pandemic forced an abrupt transformation of MHC provisions for outpatients: Since mid‐March 2020, nearly all in‐person contact was replaced with videoconferencing. The COVID‐19 crisis offered a unique opportunity to investigate whether MHC with videoconferencing yields inferior results as compared to in‐person interventions.

Method

In a large urban MHC facility in the Netherlands, measurement‐based care is routine practice. Outcome data are regularly collected to support shared decision making and monitor patient progress. For this study, pretest and post‐test data were used to compare outcomes for three cohorts: treatments performed prior to, partially during and entirely during the COVID‐19 lockdown. Outcomes were compared in two large data sets: Basic MHC (N = 1392) and Specialized MHC (N = 1040).

Results

Therapeutic outcomes appeared robust for COVID‐19 conditions across the three cohorts: No differences in outcomes were found between treatments that were conducted during lockdown compared to in‐person treatments prior to COVID‐19, or treatments which started in‐person, but needed to be continued by means of videoconferencing.

Discussion

Videoconferencing care during the COVID‐19 pandemic had similar outcomes compared to traditional in‐person care. These real‐world results corroborate findings of previous randomized controlled studies and meta‐analyses in which videoconferencing and in‐person care has been directly compared in terms of clinical effectiveness.

A survey of depression and anxiety disorders in urban and rural Suriname

BACKGROUND

Suriname is a Low-middle income country consisting of diverse population groups. Epidemiological studies concerning mental disorders like depression and anxiety had not been conducted until 2015. The treatment gap for mental disorders in Low and middle-income countries (LMICs) may reach 76-80% as treatment is not always readily available. In this study, we estimate and compare the prevalence of potential cases of depression and anxiety, as well as the size of the treatment gap in a rural (Nickerie) and urban (Paramaribo) region of Suriname, a lower middle-income country.

METHODS

Subjects were selected by a specific sampling method of the national census bureau. The Center for Epidemiological Studies-Depression (CES-D) was used to assess depression. Generalized anxiety disorder was assessed with the Generalized Anxiety Disorder 7 (GAD-7) and The Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ) were used to assess Panic disorder. The treatment gap was calculated by estimating the percentage of subjects with depression or anxiety that did not seek out professional help.

RESULTS

About 18% of the respondents from Nickerie and 16% from Paramaribo were at risk of depression and the established cut-off values of the instruments used indicate that about 3-4% in both regions may suffer from Generalized Anxiety Disorder. Women in both samples were most at risk of high anxiety about body sensations and maladaptive thoughts about panic. The treatment gap varies between 78 and 100% for the two disorders.

CONCLUSIONS

A high depression rate has been found in both areas, especially among young females. In addition, a high treatment gap is noted which insinuates that more therapeutic strategies are required to tackle depression and anxiety in Suriname.

Effectiveness and cost-effectiveness of cognitive behavior therapy-enhanced compared with treatment-as-usual for anorexia nervosa in an inpatient and outpatient routine setting: a consecutive cohort study

BACKGROUND

For anorexia nervosa, firm evidence of the superiority of specialized psychological treatments is limited and economic evaluations of such treatments in real world settings are scarce. This consecutive cohort study examined differential (cost-)effectiveness for adult inpatients and outpatients with anorexia nervosa, after implementing cognitive behavioral therapy-enhanced (CBT-E) throughout a routine setting.

METHODS

Differences in remission, weight regain and direct eating disorder treatment costs were examined between one cohort (N = 75) receiving treatment-as-usual (TAU) between 2012-2014, and the other (N = 88) CBT-E between 2015-2017. The economic evaluation was performed from a health care perspective with a one-year time horizon, using EDE global score < 2.77, the absence of eating disorder behaviors combined with a BMI ≥ 18.5, as effect measure. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that CBT-E is cost effective compared to TAU.

RESULTS

Using direct eating disorder treatment costs in the cost-effectiveness analysis, the cost-effectiveness plane of the base case scenario for all patients indicated a 84% likelihood of CBT-E generating better health gain at additional costs. The median ICER is €51,081, indicating a probable preference for CBT-E (> 50% probability of cost-effectiveness) assuming a WTP of €51,081 or more for each additional remission, On remission, no difference was found with 9.3% remission during TAU and 14.6% during CBT-E (p = .304). Weight regain was higher during CBT-E (EMD = 1.33 kg/m², SE = .29, 95% CI [0.76-1.9], p < .001).

CONCLUSIONS

In this mixed inpatient and outpatient cohort study, findings indicate a probability of CBT-Ebeing more effective at higher costs. These findings may contribute to the knowledge of effectiveness and cost-effectiveness of specialized psychological treatments. In this study, the effectiveness and treatment costs of a specialized psychological treatment for adult clients with anorexia nervosa were compared with a regular, non-specialist treatment. One group of inpatients and outpatients did receive non-specialist treatment, the next group of inpatients and outpatients received CBT-E, a specialized treatment, later on. CBT-E is recommended for clients with bulimia and with binge eating disorder, for clients with anorexia nervosa it is less clear which specialized psychological treatment should be recommended. Results indicate that at end-of-treatment, CBT-E was not superior on remission. When looking at weight regain, CBT-E seemed superior than the treatment offered earlier. Economic evaluation suggests that CBT-E generates better health gain, but at additional costs. This study contributes to the knowledge on the effectiveness and treatment costs of psychological treatments, as they are offered in routine practice, to adults with anorexia nervosa.

[Differences in the prevalence of acute involuntary admissions between Apeldoorn, Rotterdam and Amsterdam]

BACKGROUND

There are regional differences in the Netherlands in the numbers of emergency compulsory admissions (Inbewaringstelling: IBS). We looked at three 24/7 facilities to investigate the relationships between patient and consultation characteristics on the one hand, and numbers of emergency compulsory admissions on the other, against the background of the level of urbanisation.

METHOD

We compared emergency consultations in 18-64 year olds in Apeldoorn, Amsterdam and Rotterdam between 2012 and 2016 in terms of socio-demographic, procedural and clinical characteristics, and in terms of outcome. We used the Severity of Psychiatric Illness Scale (SPI) to determine disorder severity.

RESULTS

Apeldoorn had as many consultations per 100,000 inhabitants as the highly urbanised city of Rotterdam. GPs there referred 68% of patients, compared with 25% in Amsterdam and 50% in Rotterdam. In Apeldoorn, 17% of the patients were psychotic, compared with 35% in the other regions. In addition, 66% of the patients there had a low SPI score, compared with 40% in the large cities. Amsterdam and Rotterdam had 3.5 times higher risk of emergency compulsory admissions as Apeldoorn. After adjustment for socio-demographic, procedural and clinical characteristics, this difference with Apeldoorn was 1.5 for Amsterdam and 2.6 for Rotterdam. SPI score and psychotic disorder were found to be the most important predictors of IBS admission.

CONCLUSION

Differences in consultation numbers, referral patterns and the location of consultations indicate that there are regional differences in the position of the 24/7 facility in the mental health care system. The numbers of emergency compulsory emissions were related in part to the level of urbanisation and the associated epidemiological differences but probably also to differences in the position of the crisis facility in the mental health care system. Differences in admission numbers were primarily linked to differences in diagnostic characteristics and disorder severity and, to a lesser extent, to referral patterns and socio-demographic characteristics. However, these variables did not explain all the observed inter-regional differences.

Exploration of symptom dimensions and duration of untreated psychosis within a staging model of schizophrenia spectrum disorders

AIM

Clinical staging of schizophrenia entails a new method that identifies clusters of symptoms and variation in level of remission, with the goal to create a framework for early intervention. Additionally, duration of untreated psychosis (DUP) may influence symptom severity in the first episode of psychosis (FEP) and could necessitate refining of the staging model. However, consistent evidence concerning variation in symptom severity and DUP between stages is missing. Therefore, we evaluated the clinical validity of the staging model by investigating differences in symptom severity across stages in schizophrenia spectrum disorders. Second, we assessed if a prolonged DUP is associated with higher symptom severity in FEP.

METHODS

We performed a cross-sectional study of 291 acutely admitted patients with a schizophrenia spectrum disorder. Patients were assigned to clinical stages following the definition of McGorry. Symptom severity was evaluated with the new DSM-5 Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS). In FEP, we determined the DUP.

RESULTS

Significantly higher severity scores of CRDPSS items hallucinations (H = 14.34, df = 4, P-value = .006), negative symptoms (H = 19.678, df = 4, P-value = .001) and impaired cognition (H = 26.294, df = 4, P-value = <.001) were found in more advanced stages of disease. Moreover, patients with FEP and a DUP longer than 1 year showed significantly more severe negative symptoms (U = 314 000, P = .015) compared to patients with a DUP shorter than 1 year.

CONCLUSIONS

The present study found supporting evidence for the clinical validity of the staging model in schizophrenia spectrum disorders. In addition, we found support for refining the stage "first episode" with information concerning the DUP.

Mentalization-Based Treatment Versus Specialist Treatment as Usual for Borderline Personality Disorder: Economic Evaluation Alongside a Randomized Controlled Trial With 36-Month Follow-Up

The authors present an economic evaluation performed alongside a randomized controlled trial of mentalization-based treatment in a day hospital setting (MBT-DH) versus specialist treatment as usual (S-TAU) for borderline personality disorder (BPD) with a 36-month follow-up period. Ninety-five patients from two Dutch treatment institutes were randomly assigned. Societal costs were compared with the proportion of BPD remissions and quality-adjusted life years (QALYs) measured using the five-dimensional EuroQol instrument. The incremental societal costs for one additional QALY could not be calculated. The costs for one additional BPD remission with MBT-DH are approximately €29,000. There was a 58% likelihood that MBT-DH leads to more remitted patients at additional costs compared with S-TAU, and a 35% likelihood that MBT-DH leads to more remissions at lower costs. MBT-DH is not cost-effective compared with S-TAU with QALYs as the outcome, and slightly more cost-effective than S-TAU at 36 months with BPD symptoms as the outcome.

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.

The association between ethnic background and characteristics of first mental health treatment for psychotic disorders in the Netherlands between 2001 and 2005

PURPOSE

To test the hypothesis that ethnic minority status of patients is associated with specific psychotic disorder treatment characteristics.

METHODS

Longitudinal data (2001-2005) were extracted from a nationwide psychiatric case register in the Netherlands. The sample consisted of 30,655 episodes of mental health treatment for 23,122 patients with psychotic disorders. Information was available about waiting time and treatment duration, source of referral, occurrence of crisis contacts, admittance to clinical care and compulsory admissions. In addition, information was available about ethnicity (based on country of birth), gender, age and marital status. Results were calculated for ethnic and gender groups separately. In addition, a number of multivariate regression analyses were conducted to correct for differences in age and marital status.

RESULTS

There was substantial variation between ethnic minority and gender groups in relation to the treatment characteristics. Compared with a Dutch ethnic background, ethnic minority background was generally associated with less waiting time, and more police referrals, crisis contacts, admittance to clinical care and compulsory admission, but shorter treatment duration. Characteristics appeared to be least favorable in episodes that involved male patients with Antillean and Surinamese backgrounds, whereas episodes were quite similar for ethnic Dutch and Turkish patients.

CONCLUSIONS

Characteristics of mental health treatment for psychosis in the Netherlands are different for ethnic minority patient groups than for patients with an ethnic Dutch background. However, there were substantial differences between ethnic minority groups.