Is there a prospective association between psychological distress as measured by the CORE-OM and treatment attendance and treatment duration? A follow-up study at a Norwegian Community Mental Health Centre

BACKGROUND

Feasible and reliable methods for identifying factors associated with treatment duration and treatment attendance in mental health services are needed. This study examined to what degree the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the start of treatment is associated with treatment attendance and treatment duration.

METHODS

Outpatients (N = 124) at a community mental health centre in Norway completed the 34-item CORE-OM questionnaire addressing the domains of subjective well-being, problems and symptoms, functioning and risk at the start of treatment. The CORE-OM subscales and the 'all' items total scale were used as predictor variables in regression models, with treatment duration, number of consultations attended, treatment attendance (number of therapy sessions attended divided by number of sessions offered) and termination of treatment (planned versus unplanned) as outcome variables.

RESULTS

Higher CORE-OM subscale scores and the 'all' scale were associated with longer treatment duration. No association was found between CORE-OM scales and number of therapy sessions, treatment attendance (sessions attended/offered) or whether the patients unexpectedly ended treatment.

CONCLUSION

Higher patient-reported psychological distress as measured by the CORE-OM at the start of treatment was prospectively associated with treatment duration but not with treatment attendance or drop-out of treatment. The findings imply that patients with higher initial psychological distress need longer treatment but that treatment attendance may be related to factors other than the severity of distress.

Navigating Adherence: Unraveling Factors Shaping Opioid Substitution Therapy Compliance

Background and objective In drug-deaddiction programs, dropout is a major problem in any drug de-addiction program, as dependence is a chronic illness known to relapse frequently. Understanding factors that predict dropout can help design targeted interventions to promote follow-up. This study aimed to assess the various sociodemographic characteristics of opioid-dependent subjects on buprenorphine maintenance treatment and dropping out at or before the three-month follow-up period. Method In this study, the sociodemographic characteristics and quality of life (QOL) of 34 opioid-dependent subjects (males, 32, 94%; females, 2, 6%) on the day of their enrolment in an opioid substitution therapy (OST) center were assessed, and a comparison of sociodemographic and drug use pattern was made between those who followed up and those who dropped out by the end of three months. Results Statistical analysis of the various sociodemographic characteristics using appropriate tests yielded that predictors of good follow-up are younger age (F = 4.57907, P = 0.04008), better education (F = 5.07221, P = 0.031305), and being part of a nuclear family. Longer follow-up was associated with shorter opioid intake duration (F = 8.58908, P = 0.006195). Better social relationships, as evidenced by the social relationship domain score of QOL, predicted longer follow-up (F = 8.58908, P = 0.006195). Other characteristics analyzed did not yield significant associations. Conclusions The study unveils the complexity of opioid addiction recovery, revealing the interplay of age, education, family, addiction duration, and support, shaping one's resilience in recovery.

The characteristics of organized sport and physical activity initiatives for older adults in Sweden

There is a common understanding that sport and physical activity can be important to address healthy aging. There are individual-level recommendations about how much physical activity people of different ages should engage in to gain health benefits, but at the same time there are no recommendations for how organizations should organize physical activities to suit as many people as possible for as long as possible. The purpose of this study was to explore the characteristics of sport and physical activity initiatives that older adults participate in. Different ongoing sport and physical activity initiatives that involve older adults were investigated regarding their focus, organization, intensity and organizer, and in relation to their costs, booking opportunities and recruitment. The study was conducted with a cross-sectional design using the Salutogenic Physical Activity Health Resources Questionnaire (SPAHRQ). The study included 27 different initiatives with 372 participants (60% women) ranging from 60 to 96 years of age. A health-promoting, salutogenic settings-based approach, and specifically the concepts drop-in, drop-through and drop-over were used in discussing recommendations for the organization of sport and physical activity for older adults. The main findings were that who organizes the sport and physical activity initiative seems to affect the characteristics of how it is organized and what characterizes the participants in it. Despite the differing characters of sport and physical activity initiatives, the majority of older adults are recruited by internal contacts like friends and family. Which older adults participate in which initiatives is explained mostly by the age and gender of the participants. In conclusion, to attract as many older adults as possible, organizations should work with lowering the thresholds, as well as within and between, organizations, and raise the threshold for dropping out of sports and physical activity.

Quality of life, psychosocial characteristics, and study skills affecting recruits' intention to quit Basic Military Training

Quitting Basic Military Training (BMT) is a problem in the Dutch Armed Forces. Previous research focused on physical factors. Yet, contemporary research focuses on psychosocial characteristics, study skills, and quality of life factors associated with recruits' intention to quit BMT. We combined several factors to identify the key factors affecting recruits' intentions to quit BMT. We also studied gender and rank position differences. Three hundred fifty-five recruits enrolled in BMT participated by completing a self-report questionnaire. Multiple regression analysis showed that being highly engaged with BMT, having a high sense of belonging, and being highly proactive resulted in lower intention to quit. Having a high sense of responsibility resulted in higher intention to quit BMT. For gender, significant differences were found in study skills and self-esteem. For rank positions, significant differences were found in several psychosocial characteristics, study skills, quality of life factors, and intention to quit; with officer rank recruits showing higher intentions to quit than noncommissioned officer rank recruits. These identified factors can be used to improve conditions for BMT recruits. It is further advised to investigate the origin of gender and rank position differences that affect associations between psychosocial characteristics, study skills, quality of life factors, and recruits' intention to quit, so that these differences can be minimized in the future.

Acceptability of cognitive remediation for schizophrenia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acceptability is an important factor for predicting intervention use and potential treatment outcomes in psychosocial interventions. Cognitive remediation (CR) improves cognition and functioning in people with a diagnosis of schizophrenia, but its acceptability, and the impact of participants and treatment characteristics, remain to be investigated. Few studies provide a direct measure of acceptability, but treatment drop-out rates are often available and represent a valid surrogate.

METHOD

The systematic search conducted for the most comprehensive CR outcomes database for schizophrenia was updated in December 2020. Eligible studies were randomized clinical trials comparing CR with any other control condition in patients diagnosed with schizophrenia spectrum disorders and that also reported drop-out in treatment and control arms separately. Acceptability was measured as odd-ratios (OR) of drop-out.

RESULTS

Of 2119 identified reports, 151 studies, reporting 169 comparisons between CR and control interventions with 10 477 participants were included in the analyses. The overall rate of drop-out was 16.58% for CR programs and 15.21% for control conditions. In the meta-analysis, no difference emerged between CR interventions and controls [OR 1.10, 95% confidence interval (CI) 0.96-1.25, p = 0.177]. Factors improving acceptability were: inpatient only recruitment, participants with fewer years of education and lower premorbid IQ, the presence of all CR core elements, and the presence of techniques to transfer cognitive gains into real-world functioning.

CONCLUSIONS

CR for people diagnosed with schizophrenia is effective and has a good acceptability profile, similar to that of other evidence-based psychosocial interventions.

Some residents drop out of specialty training. How important is prior clinical experience? A survey among residents in the Netherlands

OBJECTIVES

The drop-out rate among residents across all medical specialties in the Netherlands approximates 12.7%. This implies a capacity loss in the medical workforce, a waste of educational resources and personal damage to individuals. The aim of our study was to investigate reasons for dropping out of residency and the relationship with medical work experience after medical school and prior to residency, which is common among Dutch graduates.

METHOD

A questionnaire listing 28 reasons for drop-out was developed and tested. The questionnaire was sent in a nationwide survey to all residents who drop out between 1 September 2017 and 1 September 2019. The respondents were asked to indicate on a 5-point Likert scale, how they weighed reasons for drop-out. Factor analysis was applied to identify dominant factors.

RESULTS

The response rate was 39% (N=129; 99 females) representing all medical specialties. The factor structure of our measure showed 5 factors; high emotional job demands, lack of professional satisfaction, incompatible lifestyle, tensions in working relationships and disappointing career perspectives. Of the respondents 69 (54%) had prior clinical experience as a physician-not-in-training in the same medical specialty before residency. The factor "lack of professional satisfaction" weighed heavier for respondents without prior experience as a reason for drop-out.

CONCLUSION

Of influence on dropping out of residency is the lack of a clear image of the responsibilities as a physician within the residency of choice, fuelled by limited prior experience after medical school and before residency. One third of dropouts confirmed that prior physician experience within the same specialty could have prevented dropping out or prevented choosing this specialty in the first place.

Intimate Partner Violence: A New Cognitive, Interpersonal and Motivational Framework for the Rehabilitation of Perpetrators in Portugal

Intimate partner violence (IPV) has been targeted as a significant concern worldwide, but evidence for the efficacy of perpetrators' interventions is not undisputable. This article briefly summarizes the evidence about perpetrators' intervention efficacy, factors associated with recidivism, and evidence-based recommendations, before outlining the assumptions of a new community-delivered intervention aiming to rehabilitate IPV perpetrators: the CONTIGO Program. This program uses an innovative framework, focused on early maladaptive schemas, and combining cognitive, interpersonal, and motivational interview principles. The features of this intervention are discussed, and exploratory results regarding drop-out rates (8%) and recidivism (15.4%) in a sample of 162 court-mandated males are exposed. The detailed presentation of the CONTIGO Program and its intervention model represents a novel contribution that is sorely lacking in the IPV literature and could foster further research and debate about what can be done to effectively intervene with IPV perpetrators.

Place of residence and coach-athlete relationship predict drop-out from competitive cross-country skiing

The current study investigated whether factors such as living residence, the coach-athlete working alliance, goal orientation, and intrinsic motivation could explain drop-out, and whether these factors differed between athletes included in the elite- vs. general sport programs during high school years. In total 257 cross-country skiers, graduated from three different Norwegian Top Sport schools during the period from 2015 to 2019, were recruited to retrospectively investigate their experiences related to the time period when they participated in programs for cross-country skiing at high school. In total 116 of these athletes completed an online survey including validated and standardized instruments for the assessment of the coach-athlete working alliance (CAWAI), goal orientation (GO), perceived satisfaction with their performances (PAP) and intrinsic motivation (IM). The results showed that 84% of the athletes had dropped out from cross-country skiing, while 16% were still active. The highest ranked fixed statements of causes for drop-out was "a natural choice" (3.79 ± 1.11), "priority of education or work" (3.61 ± 1.30), "lack of motivation" (3.49 ± 1.28), "negative performance development" (3.46 ± 1.18), and "challenges with health" (3.25 ± 1.54). There were significant differences between active and drop-out in scores for reciprocity between the coaches' and the athletes' perceptions of goals (CAWAI-goal; 5.87 ± .98 vs. 5.07 ± 1.15; p = .004), the coach-athlete relationship bond (CAWAI-bond; 6.08 ± .91 vs. 5.07 ± 1.38; p = .001), and tasks chosen to reach the defined goals (CAWAI-task; 5.61 ± .92 vs. 4.90 ± 1.09; p = .006). Furthermore, active athletes had higher mastery orientation (22.11 ± 2.88 vs. 20.00 ± 3.74; p = .010). A hierarchical binary logistic regression analysis showed that place of residence and the coach-athlete working alliance were significant predictors of drop-out while mastery and performance goal orientation or intrinsic motivation were not significant. All five predictors explained 23% of the variability in drop out from cross-country skiing. Overall, 58% and 42% of the athletes participated in the elite and general programs for cross-country skiing during high school, respectively. The athletes that took part in the elite programs reported significantly stronger coach-athlete working alliances (CAWAI-sum; 14.46±3.10 vs. 14.28±3.37; p = .000), higher mastery orientation (21.19±3.50 vs. 19.36±3.66; p = .008), and performance satisfaction (PAP; 19.17±5.98 vs. 15.69±5.19; p = .001) compared to the athletes attending general programs. The results are discussed in terms of existing knowledge on how place of residence, the coach-athlete working alliance, goal orientation, performances, and motivation might impact drop-out in cross-country skiing.

Psychosocial Predictors of Drop-Out from Organised Sport: A Prospective Study in Adolescent Soccer

In recent years an increased drop-out rate in adolescents' soccer participation has been observed. Given the potentially adverse consequences of drop-out from soccer, more information about risk factors for drop-out is warranted. In the current study, Classification and Regression Tree (CRT) analysis was used to investigate demographic and motivational factors associated with an increased risk of drop-out from adolescent soccer. The results of this study indicate that older age, experiencing less autonomy support from the coach, less intrinsic motivation, being female, and lower socioeconomic status are factors associated with an increased risk of drop-out. An interpretation of the results of this study is that coaches play a central part in creating a sports context that facilitates motivation and continued soccer participation. Based on the findings of the current study we propose that soccer clubs implement theoretically informed coach education programs to help coaches adopt autonomy-supportive coaching strategies.

In Patients with Obesity, Are Affective Temperaments Associated with Attrition? An Evaluation during and before the SARS-CoV-2 Pandemic

Timely data on attrition from weight loss programs for patients with obesity during the SARS-CoV-2 pandemic are lacking, so we aimed to contribute to filling this gap in the literature by comparing attrition during or outside of the SARS-CoV-2 pandemic and its possible association with patients' affective temperaments, psychopathology, and clinical variables. Two-hundred and eleven outpatients with obesity were recruited and completed the Temperament Evaluation of Memphis, Pisa, and San Diego Auto-questionnaire, Binge Eating Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Those who dropped out during the pandemic period were mostly men, with younger age of weight gain, and with a larger waist circumference than completers. Patients with obesity who dropped out outside of the SARS-CoV-2 pandemic showed marked levels of depression, anxiety, binge eating episodes, and higher affective temperaments (but the hyperthymic one) when compared to their counterparts. The cyclothymic temperament slightly increased attrition (OR = 1.13, 95% CI 1.00-1.27 p = 0.05) outside the pandemic, while during the pandemic, male gender (OR = 3.50, 1.04-11.7, p = 0.04) was associated with attrition. These findings suggested that male patients with obesity are at particular risk of drop-out from weight-loss treatment during the SARS-CoV-2 pandemic; contrariwise, outside the pandemic, affective temperaments could be a useful baseline assessment for defining the attrition risk in these patients.

Day-hospital enhanced cognitive behavior therapy for adults with eating disorders: Immediate and follow-up effects

OBJECTIVE

To assess outcomes in adult patients with eating disorders administered enhanced cognitive behavioral therapy (CBT-E) in a day-hospital setting.

METHOD

Forty-three consecutive patients with eating disorders (86% females; mean age 28.8 [SD = 11.8]) were admitted to a 13-week day-hospital CBT-E program. Twenty-five (58.1%) patients were underweight (i.e., body mass index [BMI] <18.5 kg/m² ; BMI 15.4 [SD = 2.2]) and 18 not (mean BMI 23.1 [SD = 6.3]) at baseline. All patients responded poorly to prior outpatient treatment. Body mass index and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at baseline, end of treatment, and 20-week follow-up.

RESULTS

In 37 patients (86.0%) who completed the treatment, there were substantial improvements in eating-disorder features, general psychopathology, clinical impairment, and body weight (only in underweight patients), which were well maintained at follow-up.

DISCUSSION

Day-hospital CBT-E is a promising treatment for adults with eating disorders.

Assessment of the quality of randomized controlled trials in surgery using Jadad score: Where do we stand?

Introduction

Quality assessment of randomized controlled trials (RCTs) is important to prevent clinical application of erroneous results.

Materials and Methods

This was an assessment of published RCTs in surgical subspecialties during 2011-2018 based on MEDLINE and EMBASE search. The primary objective of the present study was to quantitatively and qualitatively analyze the RCTs published from India based on year of publication, geographical distribution, and subspecialty using the modified Jadad score (high quality if score is ≥3; or ≥2 if blinded design was not feasible). Its secondary objective was to identify factors affecting the quality of RCTs.

Results

Among 1304 trials identified, 162 were analyzed. Of these 96 (59%) had a score of ≥3; and 104 (64.2%) were of high quality (score ≥2). Year-wise there was no significant quantitative (P = 0.329) or qualitative (P = 0.255) variation. Geographic regions had similar quantity (P = 0.206) and quality (P = 0.068). The RCTs among subspecialties too were comparable in quantity and quality. Higher impact factor of journal (P = 0.013) and assessment by Institute Review Board (IRB) (P = 0.004) were significantly associated with a better study quality. Type of institution, number of authors, centricity, assistance by a statistician, and source of funding did not affect the quality of RCTs.

Conclusions

: The quantity and quality of surgical RCTs were stable and comparable over the years and across geographical regions and subspecialties. Higher impact factor of journal and review by IRB were significantly associated with a better study quality.

Which factors influence the frequency of participation in longitudinal cohort studies? - An analysis of demographics, social factors, and medical preconditions in participants of the health effects in high level exposure to polychlorinated biphenyls (HELPcB) cohort

The continuous drop out of participants in longitudinal studies is a trend that may be observed in nearly all fields of medical research. A reduced participation rate might compromise the power of statistical analysis as well as lead to an attrition bias of the study. The aim of this analysis was to identify influencing factors on participation frequency in the monitoring program Health Effects in High Level Exposure to polychlorinated biphenyls (HELPcB) study, a cohort investigation of occupationally polychlorinated biphenyls (PCB) exposed individuals. The HELPcB study was initiated in 2010 and consisted of 7 study visits. At the last cross-section in 2019, less than one third of the included patients still actively participated. As possible influencing factors on study participation frequency, demographic, social, and medical characteristics of the participants were examined. In addition, a logistic regression model to predict study participation behavior was calculated. An overall higher frequency of participation was observed, if participants joined the program together with relatives or friends and had a higher age. For PCB plasma levels, an exceedance of the biological reference value (BAR) and further factors, such as (1) professional qualification, (2) later inclusion, (3) type of participant and (4) occupational-related disease notification, significant differences in the participation frequency were observed in the univariate analysis. Only age and joined study participation remained significant in the multivariate logistic regression. In conclusion, it was possible to identify several social and occupational-related factors that influence the frequency of participation of study attendees.

Study Engagement and Burnout of the PhD Candidates in Medicine: A Person-Centered Approach

This study focused on exploring individual variations in doctoral candidates' well-being, in terms of experienced research engagement and burnout by using a person-centered approach. In addition, the associations between well-being profiles and gender, country of origin, study status (full-time or part-time), research group status and drop-out intentions were explored. The participants were 692 PhD candidates in the field of medicine. Latent profile analysis was employed to identify the well-being profiles. Four distinct profiles were identified: high engagement-low burnout, high engagement-moderate burnout, moderate engagement-moderate burnout, and moderate engagement-high burnout. Working in a clinical unit or hospital and working in a research group seemed to be related to increased engagement and reduced risk for suffering burnout, while the intentions to quit one's doctoral studies were more frequently reported in profiles with moderate levels of engagement. The findings imply that although a significant number of PhD candidates in medicine had an increased risk for developing burnout, for most of the PhD candidates research education is an engaging experience.

Is non-completion of treatment related to security need?

BACKGROUND

Treatment completion difficulties are common in forensic mental health settings and may have a profound impact on recidivism rates.

AIMS

To test for associations between measures of risk and of security needs on the one hand and treatment non-completion on the other among male offender-patients in one medium security hospital.

METHODS

We conducted a retrospective file study in a Flemish medium security hospital. A random sample of 25 treatment non-completers was compared to a random same-size sample of completers, each rated, blind to outcome, on the DUNDRUM-1 security needs scale from data recorded at the time of admission to the unit. 'Non-completion' was defined as any failure to complete treatment, whether staff-terminated or self-terminated; in Flanders, failure to comply with the judicial conditions of placement can result in re-imprisonment. We used binary logistic regression to test relationships between treatment completion/non-completion and security need, measured with the DUNDRUM-1, together with a range of possible confounding variables.

RESULTS

Most patients had psychosis and/or personality disorder and often substance use disorders also. Treatment non-completion was invariably staff ordered because of security breaches. DUNDRUM-1 and PCL-R Facet 4 scores at the time of admission and HCR-20 scores during admission were significantly higher among non-completers than completers, but after binary logistic regression, only the DUNDRUM-1 rating was independently associated with non-completion.

CONCLUSIONS

Our study showed that an admission DUNDRUM-1 rating, indicating levels of security need, co-varies only to a small extent with the historical items of the HCR-20, so may be regarded as measuring complementary domains. While conditions in Flanders at the time of the study complicated it in that medium security hospital units offered the highest level of hospital security available, the finding that non-completion of treatment was particularly likely when the DUNDRUM-1 indicated a higher security need than facilities could provide may have implications for all secure hospital services.

The European Stag Beetle (Lucanus cervus) Monitoring Network: International Citizen Science Cooperation Reveals Regional Differences in Phenology and Temperature Response

Simple Summary

International cooperation is needed to prevent the loss of threatened species. To evaluate the situation, standardised monitoring is an important tool. Involving the general public (citizen science) can play a crucial role in realising such international monitoring. Here we report on the start-up and initial findings of the European Stag Beetle Monitoring Network (ESBMN), an international network of stag beetle (Lucanus cervus) monitoring schemes using the same protocol. This network aims to regularly assess local and international changes in the population of the stag beetle. Therefore, an internationally standardised protocol was agreed and a website was created where volunteers can create a transect and submit the data of their transect walks. Currently, the number of transects and transect walks submitted is increasing annually and will soon allow trend analysis. Our initial experience with the ESBMN shows that volunteers need more guidance and encouragement to avoid them dropping out of the project. In conclusion, we believe this system of international cooperation can be used for other charismatic insects in order to evaluate their threatened status and plan conservation actions.

Abstract

To address the decline in biodiversity, international cooperation in monitoring of threatened species is needed. Citizen science can play a crucial role in achieving this challenging goal, but most citizen science projects have been established at national or regional scales. Here we report on the establishment and initial findings of the European Stag Beetle Monitoring Network (ESBMN), an international network of stag beetle (Lucanus cervus) monitoring schemes using the same protocol. The network, started in 2016, currently includes 14 countries (see results) but with a strong variation in output regarding the number of transects (148 successful transects in total) and transect walks (1735). We found differences across European regions in the number of stag beetles recorded, related to phenology and temperature, but not for time of transect start. Furthermore, the initial experiences of the ESBMN regarding international cooperation, citizen science approach, and drop-out of volunteers is discussed. An international standardised protocol that allows some local variation is essential for international collaboration and data management, and analysis is best performed at the international level, whereas recruiting, training, and maintaining volunteers is best organised locally. In conclusion, we appeal for more joint international citizen science-based monitoring initiatives assisting international red-listing and conservation actions.

Youth Perspectives on What Makes a Sports Club a Health-Promoting Setting-Viewed through a Salutogenic Settings-Based Lens

Sports participation has the potential to contribute to young people’s health. A prerequisite for young people to benefit from sports is that they stay in sports. Studies that consider both personal and contextual factors are needed to unpack the broader health-promoting potential of youth sports. The purpose of the study is to contribute to knowledge about the health-promoting potential of young people’s participation in organized sports by exploring youth perspectives on what makes a sports club health-promoting with a focus on health resources that young people consider important for sports club participation. For this cross-sectional study a brief survey was conducted with 15–16 year old students (n = 123) at two schools in Sweden, asking three open-ended questions about their participation in sports. The study used a salutogenic theory-driven analysis in combination with statistical analysis. Five health resources that young people consider important for sports club participation are revealed. On an individual, more ‘swimmer’-related level, these are personal well-being and social relations, including relationally meaningful activities, and on an organizational level, relating to the ‘river’, that sports clubs offer a supportive and well-functioning environment. For sports clubs to be health-promoting settings for young people and thus hopefully to reduce drop-out, we need a more sustainable approach emphasizing drop-in, drop-through, and drop-over as a continuous iterative process. We also need to consider the complexity of sports participation for young people, involving individual, organizational and environmental issues.

Drop-out from chronic pain treatment programmes: Is randomization justified in biopsychosocial approaches?

Objective

To identify profiles of patients who are at risk of dropping out from biopsychosocial approaches to chronic pain management.

Patients

A total of 575 patients were included in the study. Of these, 203 were randomized into 4 treatment groups: self-hypnosis/self-care; music/self-care; self-care; and psychoeducation/cognitive behavioural therapy. The remaining 372 patients were not randomized, as they presented with the demand to learn self-hypnosis/self-care, and therefore were termed a “self-hypnosis/self-care demanders” group.

Methods

Socio-demographics and behavioural data were included in the analyses. Univariates analyses, comparing early drop-outs (never attended treatment), late drop-outs (6/9 sessions’ treatment) and continuers were conducted in order to select variables to include in a multivariate logistic regression.

Results

Univariate analyses yielded 8 variables, out of 18 potential predictors for drop-out, which were eligible for inclusion in the multivariate logistic regression. The model showed that having an intermediate or high educational level protects against dropping out early or late in the pain management process. Having to wait for more than 4 months before starting the treatment increases the risk of never starting it. Being randomized increases the risk of never starting the treatment.

Conclusion

In a context in which randomization is considered a “gold standard” in evidence-based practice, these results indicate that this very principle could be deleterious to pain management in patients with chronic pain.

Antisocial Personality Disorder Among Patients in Treatment for Alcohol Use Disorder (AUD): Characteristics and Predictors of Early Relapse or Drop-Out

Background

Patients with alcohol use disorders (AUD) vary significantly in many clinically important characteristics making them a heterogenous group. AUD patients with comorbid antisocial personality disorder (ASPD) form an important sub-group, and studies indicate that these patients may have poorer treatment outcomes. Therefore, we aimed to investigate the characteristics of AUD inpatients with comorbid ASPD and identify predictors of early relapse or treatment drop-out in these patients.

Methods

In a longitudinal study of AUD patients (n = 113; 30 females; aged 27 to 72 years) in treatment at three residential rehabilitation clinics in Norway, we used interviews and self-report questionnaires to collect data on alcohol use, mental health, and trauma experience. In addition, we assessed biochemical parameters. The patients were followed up at 6 weeks to identify early relapse or drop-out.

Results

Prevalence of ASPD among AUD patients was 15%. AUD patients with comorbid ASPD were exclusively male, of younger age, and reported more childhood trauma, and adult attention-deficit-hyperactivity-disorder symptoms. They reported more hazardous drinking behavior and more often had dependence on substances in addition to alcohol. The presence of ASPD did not predict early relapse or drop-out. However, early relapse or drop-out in ASPD patients was associated with childhood and adult trauma, younger age of drinking debut, and higher baseline prolactin levels.

Conclusion

AUD patients with ASPD had different clinical characteristics to other AUD patients and they had specific predictors of early relapse or drop-out. Our findings indicate that the early relapse or drop-out among AUD patients with ASPD may be attributed to environmental and possibly biological vulnerability. However, further studies with larger sample size are warranted to confirm these preliminary associations.

[Associations between psychological attitudes toward exercise and fitness club membership resignation among new members: A cohort study]

Objectives　Approximately 40% of new fitness club (FC) members drop out within the first six months; however, the factors associated with FC membership resignation are largely unknown. This study aimed to identify the association between psychological attitudes toward exercise and FC membership resignation.Methods　We conducted a cohort study enrolling participants from 17 FCs. All individuals who became members at FCs between April 1st, 2015 and March 31st, 2016 (n=5,421) were invited to participate in the study, and those who agreed to participate completed a self-administered baseline questionnaire (n=2,934). We excluded participants aged <20 years (n=167) and those with missing values (n=702). Psychological factors were evaluated using the short version of the perceived benefit and barriers to exercise scale. Participants were followed until September 30th, 2016, at which time we assessed the FC membership drop-out rate. Cox proportional-hazards models were used to evaluate the association between perceived benefits/barriers of exercise and FC membership resignation. Sub-analyses were then conducted, stratifying by gender and age group.Results　A total of 2,065 participants were included in the analyses. The mean (standard deviation) age was 39.0 (15.0) years and 28.8% were male. Over 10.1 (4.4) months of newly-joined member follow-up, the FC membership drop-out rate was 24.6 instances per 1000 person-months. Multivariable analyses revealed no significant factors associated with FC membership drop-out. However, men aged 40-59 years who had a high physical benefit score and who perceived improving physical fitness as a benefit, were less likely to resign their memberships (hazard ratio [HR], 95% confidence interval [CI], 0.72 [0.52-1.00]). However, women aged <40 years with a high discomfort score and who saw discomfort as a barrier were more likely to resign membership (HR, 1.10 [1.01-1.19]). Women aged 40-59 years with high social benefit scores and who perceived social interaction as a benefit were less likely to resign their memberships, as were women with higher lack of motivation to exercise scores and who perceived lack of motivation as a barrier to exercise (HR for social benefit, 0.84 [0.74-0.97]; HR for lack of motivation, 0.85 [0.73-0.99]). Among both male and female participants aged ≥60 years, higher self-improvement scores, indicating that peer recognition was perceived as a benefit of exercise, was associated with higher HR for drop-out (men, 2.52 [1.10-5.81]; women, 1.31 [1.00-1.72]).Conclusions　The results revealed gender and age differences in the association between the perceived benefits/barriers of exercise and FC membership dropout. Implementing programs based on enrollees' characteristics and psychological factors may contribute to preventing FC dropout in the future.

The impact of duration of illness on treatment nonresponse and drop-out: Exploring the relevance of enduring eating disorder concept

OBJECTIVE

There are no generally accepted definitions or markers of treatment nonresponse in eating disorders (EDs). The aim of this paper was to examine how the duration of illness and other potential prognostic markers impacted on nonresponse and drop-out from treatment across different EDs subtypes.

METHODS

A total sample of 1199 consecutively treated patients with EDs, according to Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria, participated in this study. Kaplan-Meier curves were calculated for each ED diagnosis in which the probability of recovery was plotted against the duration of illness.

RESULTS

Full remission was more likely for people with binge eating disorder (BED; 47.4%) and anorexia nervosa (AN; 43.9%) compared to bulimia nervosa (BN; 25.2%) and other specified feeding and EDs (OSFED; 23.2%). The cut-off points for the duration of the illness related with high likelihoods of poor response was 6-8 years among OSFED, 12-14 years among AN and BN and 20-21 years among BED. Other variables predicting nonresponse included dysfunctional personality traits.

CONCLUSIONS

Nonresponse to treatment is associated with duration of illness which is in turn associated with poor response to previous treatment. However, there was no evidence for staging the illness using specific duration of illness criteria. Nevertheless, the shorter temporal trajectory for OSFED suggests that early interventions may be of importance for this group.

Overcoming Expressional Drop-outs in Lineage Reconstruction from Single-Cell RNA-Sequencing Data

Single-cell lineage tracing provides crucial insights into the fates of individual cells. Single-cell RNA sequencing (scRNA-seq) is commonly applied in modern biomedical research, but genetics-based lineage tracing for scRNA-seq data is still unexplored. Variant calling from scRNA-seq data uniquely suffers from "expressional drop-outs," including low expression and allelic bias in gene expression, which presents significant obstacles for lineage reconstruction. We introduce SClineager, which infers accurate evolutionary lineages from scRNA-seq data by borrowing information from related cells to overcome expressional drop-outs. We systematically validate SClineager and show that genetics-based lineage tracing is applicable for single-cell-sequencing studies of both tumor and non-tumor tissues using SClineager. Overall, our work provides a powerful tool that can be applied to scRNA-seq data to decipher the lineage histories of cells and that could address a missing opportunity to reveal valuable information from the large amounts of existing scRNA-seq data.

Analysis of the Emails From the Dutch Web-Based Intervention "Alcohol de Baas": Assessment of Early Indications of Drop-Out in an Online Alcohol Abuse Intervention

Nowadays, traditional forms of psychotherapy are increasingly complemented by online interactions between client and counselor. In (some) web-based psychotherapeutic interventions, meetings are exclusively online through asynchronous messages. As the active ingredients of therapy are included in the exchange of several emails, this verbal exchange contains a wealth of information about the psychotherapeutic change process. Unfortunately, drop-out-related issues are exacerbated online. We employed several machine learning models to find (early) signs of drop-out in the email data from the "Alcohol de Baas" intervention by Tactus. Our analyses indicate that the email texts contain information about drop-out, but as drop-out is a multidimensional construct, it remains a complex task to accurately predict who will drop out. Nevertheless, by taking this approach, we present insight into the possibilities of working with email data and present some preliminary findings (which stress the importance of a good working alliance between client and counselor, distinguish between formal and informal language, and highlight the importance of Tactus' internet forum).

Examining the Relationship of Personality Functioning and Treatment Completion in Substance Misuse Treatment

Background:

Treatment retention is a major factor contributing to favourable outcome in the treatment of substance misuse, but the literature remains very limited. Despite evidence of the association of personality with drug use experimentation and relapse, surprisingly little is known about its role in the treatment process. Clients’ personality functioning as measured by malleable and context sensitive characteristic adaptations in treatment are of concern.

Aims:

This study examines whether, and to what extent, personality functioning contributes to or hinders treatment completion. This paper examined the extent to which service users’ characteristic adaptations may be potential determinants of treatment completion.

Methodology:

A longitudinal multi-site design was utilised, examining the therapy process in a naturalistic setting in five inpatient treatment units. The study examined whether service users’ characteristic adaptations (SIPP-118) predict completion, while controlling psychosocial, motivational and treatment engagement indicators involving n = 340 participants from 5 inpatient centres. Multivariate regression analyses were applied to examine the predictive role of characteristic adaptations on treatment completion.

Results:

Findings indicated that certain dysfunctional characteristic adaptations emerged as strong predictors of treatment completion. Dysfunctional levels on Self-control and Social concordance were significant predictors of drop out from treatment. Individuals with low capacity to tolerate, use and control one’s own emotions and impulses were almost three times more likely to drop-out compared to those without [OR] = 2.73, Wald = 6.09, P = .014, 95% CI [1.2, 6.0]. Individuals with dysfunctional levels on the ability to value someone’s identity, withhold aggressive impulses towards others and work together with others were 2.21 more times more likely to complete treatment [OR] = 2.21, Wald = 4.12, P = .042, 95% CI [1.0, 4.7]. The analysis at the facet level provided additional insight. Individuals with higher adaptive levels on Effortful Control were 46% more times likely to complete treatment than the group [OR] = 4.67, Wald = 10.231, P = .001, 95% CI [1.81, 12.04], 47% more likely on Aggression regulation [OR] = 4.76, Wald = 16.68, P < .001, 95% CI [2.1, 10.3], and 26% more likely on Stable self-image [OR] = 2.62, Wald = 6.75, P < .009, 95% CI [0.9, 3.0].

Conclusions:

These findings extend our knowledge of the predictive role of characteristic adaptations in treatment completion and highlight the clinical utility of capturing these individual differences early on. Delineating the role of characteristic adaptations in treatment may provide the basis for enhancing treatment effectiveness through individualized interventions that are scientifically driven and may open new avenues for the scientific enquiry of personality and treatment.

IVF, from the past to the future: the inheritance of the Capri Workshop Group

Today IVF use is booming all over the world and has even started to play a role in demographic analyses. Prognosis-adjusted estimates suggest that up to two-thirds of couples could achieve a live birth. However, the scenario is less exciting in reality. Discontinuation during the cycles is common, and age and ovarian response continue to be crucial in modulating this rate of success. A growing interest is now given to the risk of abuses and in particular to overtreatment and to prescriptions of useless, if not harmful, expensive additional treatments (‘add-ons’). A more rational, evidence-based and wise approach is needed. From a scientific perspective, several obscure aspects remain and warrant future investigations. Of particular interest are the neglected role of sperm selection, the potential adult implications of early embryo life in vitro and the issue of sustainability.

Clinical Utility of Assessing Changes of Personality Functioning During Substance Misuse Treatment

Dimensional models for classifying personality have received extensive empirical support in the treatment of substance misuse. However, we do not currently understand whether and which dimensions of personality functioning are amenable to change. The aim was to examine whether there are clinically significant changes between pre- and during-treatment and assess whether these differ between those completing or dropping out of treatment. From the 200 participants from the outpatient and 340 from the inpatient treatment, a purposeful selection was utilised of 75 cases that participated in both phases and had complete datasets of the assessment battery. A quantitative multi-site individual follow-up design allowed the examination of the potential effects of treatment in personality functioning as well as the degree of clinical significant change of personality functioning. We use Jacob and Truax's formula of reliable and clinically significant change. Five independent mixed between-within subject analyses of variance were performed. All personality adaptations changed towards higher-functioning levels, except Social Concordance, which remained stable. Compared to those dropping out, completers had significantly more changes towards functional characteristic adaptations and higher clinical improvement. The persistence of maladaptive characteristic adaptations may be an important risk marker for poor treatment outcomes, requiring therapeutic attention.

Chest pain in an elite master ultra-marathon runner: a case report with a follow-up on his subsequent athletic activity

Ultra-marathon running has enjoyed increasing popularity, with the number of master ultra-marathon runners growing annually. This study presents a case of a 51-year-old highly experienced long-distance runner (body mass: 65.1 kg, body height: 168 cm), who took part in a 48-h ultra-marathon race held in 2010, but dropped out of the competition due to acute cardiac problems manifested after 16 h of running and having completed a distance of 129 km. Two weeks following the race, intense cardiac examination was performed to explain the drop-out due to chest pain. A 12‑lead electrocardiogram, a 2D transthoracic echocardiography in 3 apical projections of the left ventricle, a computed tomography of the chest, an invasive coronary angiography and a maximal oxygen uptake (VO_2max) test were performed. The 12-lead ECG revealed a negative T wave in III and aVF without morphological abnormalities. The echocardiographic examinations presented a normal size and function of the heart chambers, and a normal valvar structure and function (only trivial mitral and tricuspid regurgitation was observed). The invasive coronary arteriography - due to an increased calcium score in the CT scan - showed only a non-significant systolic dynamic narrowing in the eighth segment of the left anterior descending artery due to a muscle bridge. The physical performance characteristics of the athlete and a follow-up history of his athletic activity showed that the cardiac problems he had experienced during the ultra-marathon race did not prevent him from being active in sport. Int J Occup Med Environ Health. 2020;33(4):523-34.

Longitudinal Trends in Sport Participation and Retention of Women and Girls

Measurement and analysis of sport participation data is vital to understand trends, and therefore to make informed decisions relating to sport policy and strategies to get more people active through sport. This study identified patterns of club sport participation, retention and drop-out of women and girls over a 7 year period in a popular team sport in Australia. The study included registered women and girls of all ages (4–96 years at baseline) in an almost exclusively female sport, with a particular focus on the ages 4–14 years where most participation occurs. All commencing participants in the base year (2010) were tracked over the 7 year period. Participants were classified in two ways: the total number of years they played and their overall pattern of participation. Differences between age groups were analyzed using Kruskall Wallis and Mann Whitney tests. Registration records of 29,225 participants were analyzed in the study. Overall, there were considerable differences in the years participating in the sport. Almost one third (30%) of commencing 4–9 year olds played continuously for the 7 years. This proportion diminished through ages at commencement from 10 to 19, reaching a low point of 4% for ages 15–19, then rebounded slightly, reaching 7% for ages 30+. The proportion who dropped out during the 7 year period and did not return varied with age in the converse manner, as did the proportion of single-year players. The optimal age of entry to sport for retention in participation was 6–9 years. Consideration needs to be given to the age appropriateness of sports programs for very young participants. Strategies specifically relating to retention of girls and young women during adolescence should be developed.

The Feasibility of Using Guided Self-Help in Anorexia Nervosa: An Analysis of Drop-Out From the Study Protocol and Intervention Adherence

The implementation of online technologies to promote wellbeing is increasingly becoming a worldwide priority. This study includes secondary analyses of data and examined drop-out rates in an online guided self-help intervention for patients with anorexia nervosa. Specifically, rates of drop-out at end of treatment (i.e., 6 weeks assessment), as well as intervention adherence (minimum of four of six online guided sessions) and differences between completers and drop-outs were examined. Motivation to change and associated patient variables were assessed as predictors of drop-out using structural equation modeling. Ninety-nine patients were randomized to the intervention arm of the trial. Data were available for 82 individuals, 67 of whom completed the 6 weeks assessment and attended a minimum of four online sessions. No significant differences were found between completers and drop-outs at baseline. At the end of the first week of participation, drop-outs from the 6 weeks assessment or the intervention reported less satisfaction with their work with the mentor delivering online guidance. Greater confidence in own ability to change and higher controlled motivation (willingness to change due to pressure from others) predicted lower drop-out rates from the 6 weeks assessment. Stronger alliance with the therapist at the treatment center and lower psychological distress were associated with greater autonomous motivation (self-directed motivation) and importance and ability to change. Data demonstrate that a novel online guided self-help intervention for patients with anorexia nervosa is feasible. Early satisfaction with the program and external pressure to change have a protective role against drop-out rates.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02336841.

Predictors of treatment outcomes and adherence in internet-based cognitive behavioral therapy for social anxiety in China

BACKGROUND

Although internet-based cognitive behaviour therapy (ICBT) is an effective treatment for social anxiety disorder (SAD), a substantial proportion of patients do not achieve clinically significant improvement. More research is needed to identify which factors predict treatment adherence and outcomes.

AIMS

The aims of this study were to (1) identify demographic and clinical factors associated with treatment adherence and outcomes in ICBT for social anxiety in China, and (2) explore whether low-intensity therapist support results in improved treatment adherence or outcomes.

METHOD

Participants were assigned to either therapist-guided (N = 183) or self-guided ICBT (N = 72). Level of social anxiety was measured at both pre- and post-treatment. Treatment adherence and outcomes were analysed using a two-step linear and logistic regression approach. Clinical and demographic characteristics were examined.

RESULTS

No significant group differences were found for treatment adherence or outcomes between the therapist-guided and self-guided conditions. Participants diagnosed with SAD were significantly less likely to drop out (OR 0.531, p = .03) compared with subclinical participants with social anxiety symptoms. Older participants (B = 0.17, SE = 0.04, p = .008) and participants with a diagnosis of SAD (B = 0.16, SE = 0.44, p = .01) tended to complete more modules. Participants who completed more modules (B = 0.24, SE = 0.03, p = .01) and participants who identified as female (B = -0.20, SE = 0.18, p = .04) reported greater reductions in SAD symptoms.

CONCLUSIONS

Understanding of factors related to adherence and outcome is necessary to prevent drop-out and optimize outcome.

Predictors of Dropout From Residential Treatment for Posttraumatic Stress Disorder Among Military Veterans

Background: Successful psychotherapy for posttraumatic stress disorder (PTSD) necessitates initial and sustained engagement. However, treatment dropout is common, with rates of 50-70% depending on the setting, type of treatment and how dropout is calculated. Dropout from residential treatment is less understood and could be impacted by participation of more symptomatic patient populations and reduced day-to-day barriers to engagement. Gaining insight into predictors of treatment dropout is critical given that individuals with greater symptoms are the most in need of successful treatments but also at higher risk of unsuccessful psychotherapy episodes. Aim: The aim of the current study was to examine predictors of treatment dropout among veterans receiving residential treatment for PTSD. Methods: The study included 3,965 veterans who initiated residential PTSD treatment within a Department of Veterans Affairs program during Fiscal Year 2015 and completed self-report measures of demographics and psychiatric symptoms at admission. Results: In our sample (N = 3,965, 86.5% male, mean age = 45.5), 27.5% did not complete the residential program (n = 1,091). Controlling for age, marital status, combat/non-combat trauma, and facility, generalized estimating equation modeling analysis indicated greater PTSD symptoms and physical functioning at admission were associated with reduced likelihood of completing the residential program. There were significant differences in trauma-focused psychotherapy received by individuals who dropped out of residential treatment and those who did not. Among veterans who dropped out, 43.6% did not get any trauma-focused psychotherapy; 22.3% got some, but less than 8 sessions; and 34.1% got at least 8 sessions; compared to 37.3%, 4.8%, and 57.9%, respectively, among program completers. Conclusion: Dropout rates from residential PTSD programs indicate that at least one in four veterans do not complete residential treatment, with more symptomatic individuals and those who do not receive trauma-focused therapy being less likely to complete.

Motivation as an important criterion for graduation among medical students admitted from the waiting list

Aim: Graduation rates among medical students who have been admitted to medical school from the waiting list quota are significantly lower than those for medical students who are directly admitted on the basis of their competitive secondary school academic record or through the universities' selection process. The aim of this study was to identify risk factors that can predict a longer length of study or dropping out and potential resilience factors predictive of timely and successful graduation. Method: First, students admitted from the waiting list were asked in qualitative interviews at the beginning of their studies about risk factors connected with dropping out. These students were then followed until completion of the first state medical exam, or at least until the end of their fourth semester. In parallel, personality traits were measured using the NEO Five-Factor Inventory according to Costa and McCrae (NEO-FFI). Successful study was defined as a length of study time lasting four semesters before taking the first section of the state medical exam (Physikum). Serving as indicators for students at risk were a prolonged period of study and dropping out before taking the first state medical examination. Finally, the factors associated with successful study were identified. Results: Students from the waiting list who displayed a stronger than average conscientiousness in their personality and stated being underchallenged in their prior (medicine-related) occupation as the motivation for studying medicine were significantly more often successful than students from the waiting list who displayed a less pronounced conscientious personality and named dissatisfaction with their previous occupation as their motivation to pursue medical study. In addition, successful students were often distinguished by ambition and reported placing high academic demands on themselves. Early failures on exams were found to be predictive of an uncertain course of study at Rostock Medical School. Conclusions: The reason for studying medicine and an ambitious personality appear to be basic predictors of study success and could therefore be considered not only as a selection criterion for admission, but also monitored during the course of study as a predictive marker for prolonged study or drop-out. Regardless how students are selected for admission, medical schools should take a closer look at the academic performance of the enrolled students to identify at-risk students who are failing exams early in the course of study and to adequately advise them on course scheduling, motivation and exam preparation.

Young adults' reasons for dropout from residential substance use disorder treatment

Dropout from substance use disorder treatment is usually investigated and understood from a perspective of quantitative patient-related factors. Patients' own perspectives (user perspective) are rarely reported. This study, therefore, aimed to explore patients' own understanding of their dropout from residential substance use disorder treatment. The participants were 15 males and females, aged 19-29 years, who had dropped out of residential substance use disorder treatment at the Department of Addiction Treatment, Oslo University Hospital, Norway. Qualitative methodology with semistructured interviews was used to explore how the participants described their dropout and their reasons for doing so. Thematic analysis was used as the framework for analyzing the data derived from the interviews. Dropout had different meanings for different participants. It was understood as a break from treatment, as an end to treatment, or as a means of reduced treatment intensity. Against that background, four main themes for dropout were found: drug craving, negative emotions, personal contact, and activity. Patient and treatment factors seem to interact when participants explore reasons for their dropout. A complex pattern of variables is involved. As remedies, participants suggested that substance use disorder treatment should provide more focus on drug craving and training to understand and tolerate emotional discomfort. They also wanted closer contact with the staff during treatment, more activities, and rigorous posttreatment follow-up. These findings from the user perspective have important implications for substance use disorder treatment, clinical and social work practice, management, and research.

The Effects of Psychotherapist's and Clients' Interpersonal Behaviors during a First Simulated Session: A Lab Study Investigating Client Satisfaction

The purpose of this study was to examine the effects of psychotherapists' behaviors during a first simulated therapy session on clients' satisfaction, including their intention to pursue or drop out from therapy. The importance of psychotherapists' warmth on clients' satisfaction was examined to check previous findings stressing this determining factor. Examining the role of warm behaviors is however insufficient according to the interpersonal perspective. We therefore tested the role of the psychotherapist's agentic behaviors since only a few studies provide contradictory results about the role of this interpersonal dimension on clients' satisfaction and how it is influenced by matching up client and therapist's profiles. To test our hypotheses and control for alternative therapy-related explanatory variables, we used different videos as experimental conditions manipulating the therapist's behaviors. Seventy-five participants had to imagine themselves as potential clients arriving for a first therapy session. They successively watched a role-playing therapist behaving according to five randomized interpersonal profiles. Results confirmed that warmth was a major dimension predicting client satisfaction. They revealed that agency was also a determinant of client satisfaction and that its effects depended on the client's own interpersonal agentic profile. Dominant clients were found to be more satisfied with the dominant psychotherapist than the submissive one while submissive clients preferred only the warm psychotherapist. These findings are discussed and suggest that therapists may need to be flexible and adapt their behaviors according to their client's interpersonal profile to increase their client satisfaction and decrease drop outs.

The impact of drop-out in cardiac rehabilitation on outcome among coronary artery disease patients

Background The effect of adherence to cardiac rehabilitation (CR) on outcome is not clear. Therefore, we aimed to assess the impact of drop-out for non-medical reasons of CR on event-free survival in coronary artery disease (CAD). Methods A total of 876 patients who attended CR after acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were included. Drop-out was defined as attending ≤50% of the training sessions. A combined endpoint of all-cause mortality and rehospitalization for a cardiovascular event was used to specify event-free survival. Differences in clinical characteristics were assessed and parameters with p < 0.10 were entered in a multiple Cox regression analysis. Results A total of 15% died or had a cardiovascular event during a median follow-up period of 33 months (interquartile range 24, 51). Overall, 17% dropped out before finishing half of the program. Patients who withdrew prematurely had a risk twice as high for a cardiovascular event or death (hazard ratio 1.92, 95% confidence interval 1.28-2.90) than those who attended more than half of the sessions. Both ACS (2.36, 1.47-3.58) and PCI (2.20, 1.22-3.96), as primary indicators for CR, were associated with an adverse outcome and also a prior history of chronic heart failure (CHF) remained negatively associated with event-free survival (3.67, 1.24-10.91). Finally, the presence of hyperlipidemia was independently related to a worse outcome (1.48, 1.02-2.16). Conclusions Drop-out for non-medical reasons was independently associated with a negative outcome in CAD. Therefore, underlying factors for drop-out should gain more attention in future research and should be taken into account when organizing CR.

The efficacy of psychoeducation on recurrent depression: a randomized trial with a 2-year follow-up

BACKGROUND

The efficacy of psychoeducation is well documented in the treatment of relapse prevention of schizophrenia, and recently also in bipolar disorder; however, for recurrent depression only few controlled studies focusing on the efficacy of psychoeducation have been conducted.

AIMS

This randomized study tests the efficacy of treatment-as-usual supplemented with a psychoeducative programme for patients with recurrent depression, treated at Community Mental Health Centres (CMHC) in Denmark. The primary outcome measurements concern was decline in consumption of psychiatric inpatient services and decline in Beck's Depression Inventory (BDI).

METHODS

Eighty patients were randomized, either to the psychoeducative programme (consisting of eight sessions, each of 2 hours duration) and 2-year outpatient follow-up (42 cases), or only to 2-year outpatient follow-up (38 controls). The patients were monitored during 2 years after randomization. Data were collected from interviews including BDI, drug treatment and social measurements, and register data concerning use of psychiatric services.

RESULTS

At 2-year follow-up, a significant reduction in the consumption of psychiatric inpatient services and in BDI was found; however, it was uniform for case and control patients. Drop-out/non-compliance was significantly more frequent among patients randomized to the control group. Furthermore, during follow-up the case group got a significant stronger attachment to the Labour market than the control group.

CONCLUSIONS

The primary hypothesis could not be confirmed. Secondary outcome measurements concerning drop-out/non-compliance and attachment to the Labour market were significantly in favour of cases.

The Effects of Two Self-Regulation Interventions to Increase Self-Efficacy and Group Exercise Behavior in Fitness Clubs

Studies on the adoption and maintenance of group exercise behavior are scarce. The objective of this study is to test two self-efficacy based interventions to increase barrier self-efficacy and group exercise behavior. In total 122 participants (Mage 42.02 yr.; SD 12.29; 67% females) were recruited and randomly assigned to one control and two experimental groups. The control group was limited to participate in one virtual group exercise program only (group 1). The first experimental group was able to self-set their activities and participate in multiple group exercise programs (group 2). The second experimental group received an additional monthly coaching protocol to manage self-set goals (group 3). A validated scale for barrier self-efficacy was used, group exercise sessions were measured and drop-out rates were registered. An ANOVA indicated that mean amount of sessions of group 1 and 3, and 2 and 3 differed significantly (p < 0.05) in 12 weeks. Descriptive statistics demonstrate mean group exercise sessions over the total of 12 weeks of 2.74 (SD 4.65) in the control group; 4.75 (SD 6.08) in the first experimental group, and 12.25 (SD 9.07) for the second experimental group. Regression analysis indicated that self-efficacy at 8-weeks explained the highest variance in overall group exercise sessions (R(2) = 0.18; p < 0.05). Overall drop-out rates were 88% in group 1, 78% in group 2 and 48% in group 3. The results showed that group exercise behavior can significantly be improved by a coaching protocol on self-set goals. Future research should address the effectiveness of self-set activities and self-set goals for a longer period of time and in other types of exercise programs. Key pointsApproximately 144 million individuals exercise in fitness clubs worldwide.About 50% participate in at least one group exercise program and 23% participate only in group exercise classes with instructor.Research on attendance and exercise behavior in fitness clubs is limited but there are strong indications that the frequencies are low.This study demonstrates that group exercise behavior in fitness clubs can be improved significantly by a coaching protocol on self-set goals based on tenets of self-efficacy theory.

Mind the gap between high school and university! A field qualitative survey at the National University of Caaguazú (Paraguay)

Paraguay has eight public universities and 45 private universities. The National University of Caaguazú (Universidad Nacional de Caaguazú or UNCA), with its main campus located in Coronel Oviedo, is one of the most recently founded public universities, being established in 2007. The UNCA has launched a project aiming at exploring the potentiality of its educational system, as well as its gaps. In particular, the UNCA wants to assess the effectiveness of preparatory courses for preparing students for admission to the degree course in medicine (Cursos Probatorios de Ingreso or CPI), in order to identify the main strong and weak points of the system, the popularity and usefulness of CPI as perceived by the students, the students' and teachers' opinions regarding the limits of school, and their suggestions. This paper is based on a field survey and highlights the care that must be taken in order to develop conditions respectful of the wellbeing of those participating in the educational context.

Association of Inhaled Corticosteroids with Incident Pneumonia and Mortality in COPD Patients; Systematic Review and Meta-Analysis

BACKGROUND

Inhaled corticosteroids are commonly prescribed for patients with severe COPD. They have been associated with increased risk of pneumonia but not with increased pneumonia-associated or overall mortality.

METHODS

To further examine the effects of inhaled corticosteroids on pneumonia incidence, and mortality in COPD patients, we searched for potentially relevant articles in PubMed, Medline, CENTRAL, EMBASE, Scopus, Web of Science and manufacturers' web clinical trial registries from 1994 to February 4, 2014. Additionally, we checked the included and excluded studies' bibliographies. We subsequently performed systematic review and meta-analysis of included randomized controlled trials and observational studies on the topic.

RESULTS

We identified 38 studies: 29 randomized controlled trials and nine observational studies. The estimated unadjusted risk of pneumonia was increased in randomized trials: RR 1.61; 95% CI 1.35-1.93, p < 0.001; as well as in observational studies: OR 1.89; 95% CI 1.39-2.58, p < 0·001. Six randomized trials and seven observational studies were useful in estimating unadjusted risk of pneumonia -case-fatality: RR 0.91; 95% CI 0.52-1.59, p = 0.74; and OR 0.72; 95% CI 0.59-0.88, p = 0.001, respectively. Twenty-nine randomized trials and six observational studies allowed estimation of unadjusted risk of overall mortality: RR 0.95; 95% CI 0.85-1.05, p = 0.31; and OR 0.79; 95% CI 0.65-0.97, p = 0.02, respectively.

CONCLUSIONS

Despite a substantial and significant increase in unadjusted risk of pneumonia associated with inhaled corticosteroid use, pneumonia fatality and overall mortality were found not to be increased in randomized controlled trials and were decreased in observational studies.

Pseudo-empirical Likelihood-Based Method Using Calibration for Longitudinal Data with Drop-Out

In observational studies, interest mainly lies in estimation of the population-level relationship between the explanatory variables and dependent variables, and the estimation is often undertaken using a sample of longitudinal data. In some situations, the longitudinal data sample features biases and loss of estimation efficiency due to non-random drop-out. However, inclusion of population-level information can increase estimation efficiency. In this paper we propose an empirical likelihood-based method to incorporate population-level information in a longitudinal study with drop-out. The population-level information is incorporated via constraints on functions of the parameters, and non-random drop-out bias is corrected by using a weighted generalized estimating equations method. We provide a three-step estimation procedure that makes computation easier. Some commonly used methods are compared in simulation studies, which demonstrate that our proposed method can correct the non-random drop-out bias and increase the estimation efficiency, especially for small sample size or when the missing proportion is high. In some situations, the efficiency improvement is substantial. Finally, we apply this method to an Alzheimer's disease study.

Treatment engagement in eating disorders: who exits before treatment?

OBJECTIVE

Traditionally, drop-out has been investigated subsequent to treatment entry; yet some individuals "exit early," attending assessment but failing to commence the treatment offered. Early exit burdens administrative and clinical resources and means that individuals may not receive the care needed for recovery. This study aimed to describe the prevalence and characteristics associated with early exit at a statewide, outpatient eating disorder service.

METHOD

From a pool of 972 consecutive referrals of adults and youth (16+ years), two groups were formed; an "early exit" group of individuals who attended assessment but chose to exit the service prior to treatment entry and a "non-early exit" group that attended assessment and entered treatment. The groups were compared on sociodemographic, clinical, and administrative features.

RESULTS

The prevalence of early exit was 18.7%. The early exit group exhibited less pathology compared with the non-early exit group; specifically, a lower presence of Axis I comorbidity (p = .04) and self-induced vomiting (p = .04).

DISCUSSION

The findings, considered in the context of previous research, suggest that there are no measured features to date that are robustly associated with early exit from outpatient eating disorder services. Future research should investigate decision-making processes at assessment, to inform patient-centered approaches that optimize transition to treatment.

Effectiveness of a project to prevent HIV vertical transmission in the Republic of Congo

OBJECTIVES

To evaluate the effectiveness of a prevention programme against the vertical transmission of HIV in a resource-limited setting and to investigate variables associated with compliance.

PATIENTS AND METHODS

The Kento-Mwana project (2005-2008) provided counselling, serological and biomolecular testing and prophylaxis/therapy to HIV-positive pregnant women and their children attending four antenatal clinics in Pointe Noire, Republic of Congo. Expected and actual rates of vertical transmission of HIV were compared. Univariate and multivariate analyses were performed in order to identify variables associated with non-compliance.

RESULTS

The observed transmission rate in the group who completed follow-up was 5/290 (1.7%, 95% CI 0.6%-4.1%). The overall estimated transmission rate in the target population, computed taking into account the expected vertical transmission of HIV among drop-outs, was 67-115/638 (10.5%-18.0%). A comparison between this rate and the expected transmission rate in the absence of intervention (25%-40%) showed that the programme was able to prevent approximately 50% of vertical transmissions. Older age (OR 0.33, 95% CI 0.16-0.66, P = 0.002), telephone availability (OR 0.42, 95% CI 0.24-0.72, P = 0.002) and occupation (OR 0.57, 95% CI 0.29-1.10, P = 0.092) were associated with better compliance.

CONCLUSIONS

Despite the vast majority of women accepting counselling and testing, many of them refused prophylaxis or dropped out, thus reducing the effectiveness of the intervention from an ideal 2% to a still important but less impressive median transmission rate of 15% (range 10.5%-18%). Promoting participation and compliance, rather than increasing the potency of antiretroviral regimens, is crucial for preventing the vertical transmission of HIV in Africa.

Group counseling for medical students with drop-out experiences

PURPOSE

The purpose of this research was to describe our group counseling methods for medical students with drop-out experiences.

METHODS

Group counseling was offered to 11 medical students with drop-out experiences in their previous second semester. All subjects provided written informed consent before participating and completed a 2-day group counseling program using the Gestalt approach. The self-assertiveness training group counseling program consisted of 6 sessions, each of which lasted 90 minutes. Experience reports by participants after the program and data from semi-structured qualitative interviews were qualitatively analyzed.

RESULTS

Program participants reported that they were moderately satisfied with the program regarding its usefulness and helpfulness on self-awareness, understanding, and reminding them of attempts to change behavior. Most students showed heightened levels of sincerity perceptions and positive attitudes in every session. The results demonstrated significant changes in experience in self-esteem, self-recognition, and interpersonal relationships.

CONCLUSION

A group counseling program using the Gestalt approach could help medical students with drop-out experiences to adjust with 1 year their juniors, enhance their self-esteem, contribute to their psychological well-being, and prevent student re-failure through effective stress management and improved interpersonal relationships.

Disadvantageous Decision-Making as a Predictor of Drop-Out among Cocaine-Dependent Individuals in Long-Term Residential Treatment

BACKGROUND

The treatment of cocaine-dependent individuals (CDI) is substantially challenged by high drop-out rates, raising questions regarding contributing factors. Recently, a number of studies have highlighted the potential of greater focus on the clinical significance of neurocognitive impairments in treatment-seeking cocaine users. In the present study, we hypothesized that disadvantageous decision-making would be one such factor placing CDI at greater risk for treatment drop-out.

METHODS

In order to explore this hypothesis, the present study contrasted baseline performance (at treatment onset) on two validated tasks of decision-making, the Iowa Gambling Task (IGT) and the Cambridge Gamble Task (CGT) in CDI who completed treatment in a residential Therapeutic Community (TC) (N = 66) and those who dropped out of TC prematurely (N = 84).

RESULTS

Compared to treatment completers, CDI who dropped out of TC prematurely did not establish a consistent and advantageous response pattern as the IGT progressed and exhibited a poorer ability to choose the most likely outcome on the CGT. There were no group differences in betting behavior.

CONCLUSION

Our findings suggest that neurocognitive rehabilitation of disadvantageous decision-making may have clinical benefits in CDI admitted to long-term residential treatment programs.

Treatment Process Predictors of Program Completion or Dropout among Minority Adolescents Enrolled in a Brief Motivational Substance Abuse Intervention

This study documented significant differences in alliance in a predominantly Latino sample of adolescents who either completed or dropped out of a Guided Self-Change treatment program. Therapeutic alliance, working alliance and patient involvement were assessed via ratings of audio-recorded segments of participants' counseling sessions. Descriptive discriminant function analysis identified working alliance goals, patient participation and therapist warmth and friendliness variables as significantly predictive of completion status. These results were confirmed via follow-up logistic regression analyses. The use of brief clinical tools to monitor and manage alliance among adolescents receiving treatment who are at risk for drop-out is discussed.

Time to All-cause Treatment Discontinuation as the Primary Outcome in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Study

Time until all-cause treatment discontinuation was the primary outcome of the CATIE trial. We discuss the advantages and disadvantages of this outcome, and evaluate its association with clinical correlates through graphical response profiles. We investigate the characteristics of patients who discontinued for patient decision, including a reclassification of patient decision into other reasons. All-cause discontinuation is compared to a related outcome, time until treatment failure. Patients who discontinued had lower quality of life scores than other patients. Patients discontinuing for lack of efficacy had worsened efficacy scores compared with an improvement for other patients. Those who discontinued for patient decision had lower compliance. Blinded reclassification of discontinuation for patient decision identified 5% of cases as lack of efficacy and 21% as intolerable side effects. Reclassified patients participated in the next study phase at a higher rate than those remaining as patient decision (67% vs. 10%). Treatment group differences for time to discontinuation due to patient decision were attenuated after censoring the reclassified patients, but were still suggestive. Treatment comparisons for time to treatment failure were consistent with all cause discontinuation, although somewhat smaller. All-cause discontinuation is recommended as a simple and comprehensive outcome for pharmaceutical Phase II-IV clinical trials.

Predictors of participation in community outpatient psychosocial rehabilitation in schizophrenia

This study investigated demographic, clinical and neurocognitive factors predicting drop-out from an intensive, community outpatient psychosocial rehabilitation program for people with schizophrenia or schizoaffective disorder. One-hundred and twenty-seven outpatients with DSM-IV schizophrenia or schizoaffective disorder participated. Demographic variables of age, sex, education and race/ethnicity were recorded and formal symptom measures and a neurocognitive assessment consisting of measures of crystallized verbal ability, sustained visual vigilance, verbal learning, verbal fluency and problem-solving were administered at study entry. Thirty-seven percent of the sample dropped-out of the program. In a final multivariate model, younger age, and lower verbal fluency scores in clients with a history of a high number of hospitalizations predicted a greater likelihood of drop-out. The implications of these findings are discussed.

Development and validation of the Alcoholics Anonymous Intention Measure (AAIM)

BACKGROUND

Drop-out from 12-step groups is notoriously high, yet the field lacks strong models and scales for addressing this problem. We aim to determine whether the theory of planned behavior (TPB) can be applied to 12-step involvement, and to develop and validate a scale of 12-step readiness based on that theory: the Alcoholics Anonymous Intention Measure (AAIM).

METHOD

Data were from a longitudinal trial of a manual-guided 12-step facilitation intervention called Making AA Easier (MAAEZ) involving two treatment programs in California (N=508). Participants completed surveys at baseline, 7 weeks, 6 months, and 12 months. Surveys included the preliminary AAIM, a 12-step involvement measure, other readiness measures, and substance use outcomes.

RESULTS

The final, 17-item AAIM measured Attitude (5-item alpha's=.75-.83), Subjective Norm (4-item alpha's=.56-.81), Perceived Control (5-item alpha's=.78-.85), and Intention (3-item alpha's=.80-.95) regarding attendance at 12-step groups. Components were correlated with each other and other readiness measures as expected, supporting the AAIM's validity. Scale components predicted 31% of the variance in Intention to attend 12-step groups at 6 months and 41% of the variance in 12-step involvement at 12 months. Social factors were among the strongest predictors of 12-step involvement. Results did not support the expectancy-value formulation of the TPB, as unweighted (vs. weighted) belief items performed optimally.

CONCLUSIONS

Results generally support the TPB as a model of 12-step involvement and suggest specific targets for 12-step facilitation interventions within attitude, norm, and control components. Findings also support the AAIM as a tool for identifying drop-out risks and tailoring individual interventions.

Substance user treatment dropout from client and clinician perspectives: a pilot study

Reasons for premature termination of outpatient substance user treatment were evaluated from client and clinician perspectives using qualitative (focus groups) and quantitative (survey) methods in a pilot study (N = 44). The sample consisted of clients (n = 22), the majority of whom were male (73%) and African American (50%) or Caucasian (41%). The sample of clinicians (n = 22) were predominantly female (64%), and Caucasian (52%) or African American (24%). The most frequently endorsed reasons for leaving treatment were related to individual rather than program characteristics with heavy drug or alcohol use, transportation or financial problems, and ambivalence about abstinence being highly rated by both clinicians and clients. Survey results indicated that clinicians more frequently attributed treatment dropout to individual- or client-level factors than did clients. Focus group ratings indicated that clinicians felt client motivation and staff connection issues were primary reasons for dropout, whereas clients indicated social support and staff connection issues. The findings suggest that the development of early therapeutic alliance and active problem solving of potential barriers to treatment attendance may influence treatment retention.

Loss of health insurance among non-elderly adults in Medicaid

BACKGROUND

Major policy efforts to expand health coverage to the uninsured are under consideration. Drop-out among children in Medicaid--due to annual renewal requirements--is well-documented, but the recent extent of this problem among non-elderly adults is unknown.

OBJECTIVE

To estimate the loss of health insurance over time among adults in Medicaid and identify risk factors for drop-out.

DESIGN

Survival analysis of Medicaid enrollment, using Kaplan-Meier curves and Cox proportional-hazards regression. Data are from the nationally representative Medical Expenditure Panel Survey, 2000-2004. The sample consists of non-elderly adults (n = 4,992) and children (n = 8,559) in Medicaid. Insurance status after 12 months was measured for all individuals enrolled in Medicaid at the survey's outset. A survival analysis of disenrollment was then conducted for newly enrolled individuals.

RESULTS

Nationwide, 2 million adults leave Medicaid and become uninsured annually. Disenrollment was significantly higher among adults than children (hazard ratio 1.75, 95% CI 1.65-1.86). Respectively, 20%, 43%, and 55% of adults disenrolled within 6, 12, and 23 months of initial enrollment. Lost eligibility explained a small portion of disenrollment. Six months after disenrolling, 17% had reenrolled in Medicaid, 34% had other insurance, and 49% were uninsured. Men, younger adults, and Hispanics were more likely to drop out; those in Medicaid managed care or with disabilities were less likely. Overall health status and diseases, such as diabetes, heart disease, and depression, had no effect on drop-out.

CONCLUSIONS

Drop-out from Medicaid is a major problem among adults--even among those with chronic diseases--and contributes to the presence of millions of uninsured Americans. Policy efforts to expand health coverage must address poor Medicaid retention. Clinicians should be aware of this issue when caring for non-elderly adults in Medicaid.