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The Obsessive-Compulsive Beliefs Questionnaire-87 (OBQ-87) has been constructed by leading obsessive-compulsive disorder (OCD) experts to assess dysfunctional beliefs typical for OCD patients. The OBQ-87 has recently been revised (Obsessive-Compulsive Beliefs Questionnaire-44 [OBQ-44]) to improve its psychometric properties. The current investigation entailed two goals: (1) to assess the sensitivity of both Obsessive Beliefs Questionnaire (OBQ) versions to treatment change and other OCD measures; and (2) to assess relations between symptom subtypes, OBQ beliefs and changes in beliefs as a consequence of treatment. One hundred and four patients have completed the OBQ before and after 12 sessions of behaviour therapy. Results suggest that (1) both OBQ versions exhibit an identical medium effect size; (2) overlap between clinical and non-clinical populations limit the use of the OBQ as a primary measure of treatment change; and (3) the symptom dimension obsessions + checking was related to initial OBQ scores, but no symptom dimensions were related to OBQ pre-treatment to post-treatment changes. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: • Both versions of the OBQ demonstrate similar sensitivity to treatment change; however the clinical utility of this measure is doubtful. [ABSTRACT FROM AUTHOR]

Influence of type of comorbidity was studied over the course of 1 year in a sample of 141 outpatients with panic disorder with or without agoraphobia and generalized anxiety disorder, who were receiving different forms of cognitive behavior therapy. Influence of type of comorbidity was determined on the basis of change scores (linear regression analysis) and remission data (Kaplan–Meier survival analysis). Three categories, as assessed at baseline, were compared: no comorbidity, comorbidity among anxiety disorders, and comorbidity with mood disorders. Primary outcome variable: State-Trait Anxiety Inventory State subscale measured at four assessments (0, 12, 24, and 52 weeks). Analyses of change and remission indicated that comorbidity with mood disorders led to (i) less improvement and (ii) a lower remission rate than comorbidity among anxiety disorders and no comorbidity. Because comorbidity has a critical influence on prognosis, it seems to be important to make a reliable diagnosis of the disorders present. Depression and Anxiety 0:1–8, 2007. © 2007 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

Objetivo: Este estudio, por lo que saben los autores, es el primer ensayo aleatorizado con grupo de control que comparó la eficacia de la terapia cognitivo-conductual (TCC), la paroxetina y un placebo (administrado con enmascaramlento doble) en el tratamiento de la hipocondría. Método: Los autores asignaron al azar a 112 individuos con hipocondría según los criterios del DSM-IV a un tratamiento ambulatorio de 16 semanas con TCC, paroxetina o placebo. El criterio de valoración principal rue el Índice de Whiteley. Los a utores efectua ron eva lua ci on es pretest y p ostest y analizaron todos los criterios de valoración utilizando un análisis de varianza con medidas repetidas mediante un modelo lineal general 3 x 2 con contrastes de Helmert. Los autores consideraron respondedores a los individuos queen el Índice de Whiteley obtuvieron una puntuación por lo menos una desviación estándar por debajo de la puntuación media en el pretest. Los análisis se efectuaron basándose en la intención de tratar yen los individuos que completaron el tratamiento. Resultados: En el Índice de Whiteley, los contrastes de Helmert en las cohortes de intención detratar y de los que completaron el tratamiento revelaron que la TCC y la paroxetina agrupadas eran significativa mente superiores al placebo, pero que no diferían significativamente entre elias. El análisis de los respondedores de la cohorte de intención de tratar y de la cohorte que completó el tratamiento, respectivamente, constato los siguientes porcentajes de respondedores por grupo: grupo con TCC, 45 y 54 %; grupo con paroxetina, 30 y 38 %, y grupo con un placebo, 14 y 12 %, respectivamente. En el análisis por intención de tratar, sólo laTCCfuesignificativamentediferente del placebo. En el análisis de los que completaron el tratamiento, tanto la paroxetina como la TCC fueron significativamente diferentes del placebo. Conclusiones: La TCC o la paroxetina son opciones terapéuticas eficaces a corto plazo para individuos con hipocondria. [ABSTRACT FROM AUTHOR]

Aims: Clinical and epidemiological research has shown that comorbidity is the rule rather than exception in the case of psychiatric disorders. Cognitive behavioral therapy (CBT) has been clearly demonstrated to be effective in treating anxiety and avoidance symptoms in patient samples of social phobia and agoraphobia without comorbid alcohol use disorders. It has recently been shown that treatment of comorbid anxiety disorders in alcohol-dependent patients can also be very successful. The purpose of the present study was to find predictors of treatment success for comorbid anxiety disorders in alcohol-dependent patients. Methods: The study was conducted in a sample of 34 completers with a double diagnosis of alcohol dependence and agoraphobia or social phobia who received CBT for their comorbid anxiety disorder in a 32-week randomized controlled trial comparing alcohol and CBT anxiety disorder treatment with alcohol treatment alone. In the current report, treatment success was defined as a clinically significant change (recovery) on the anxiety discomfort scale. Results: The severity of comorbid alcohol dependence did not influence the beneficial effect of CBT on the anxiety disorder. Psychological distress (SCL-90), neuroticism (NEO N), conscientiousness (NEO C), gender, employment and age of onset of alcohol dependence showed some predictive value. Conclusions: Alcohol-dependent males with a comorbid anxiety disorder seem to benefit most from CBT if their alcohol dependence started after age 25, if they are employed and if their general psychopathology is less severe. The most important conclusion, however, is that even severely alcohol-dependent patients with an anxiety disorder can benefit from psychotherapy for their anxiety disorder. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective: This study, to the authors' knowledge, is the first randomized con- trolled trial comparing the efficacy of cognitive behavior therapy (CBT), paroxetine, and a placebo (administered in a double blind fashion) in the treatment of hypochondriasis. Method: The authors randomly assigned 112 subjects with hypochondriasis according to DSM-IV criteria to 16 weeks of outpatient treatment with CBT, paroxetine, or a placebo. The main outcome measure was the Whiteley Index. The authors made pretest and posttest assessments and analyzed all outcome measures using a General Linear Model 3×2 repeated measures analysis of variance with Helmert contrasts. The authors considered subjects who scored at least one standard deviation below the mean pretest score on the Whiteley Index as responders. All analyses were conducted on intent-to-treat and completer bases. Results: On the Whiteley Index, Helmert contrasts on the intent-to-treat and completer cohorts revealed that pooled CBT and paroxetine were significantly superior to placebo, but did not differ significantly from each other. The responder analysis on the intent-to-treat cohort and completer cohort, respectively, revealed the following percentages of responders per group: CBT group, 45% and 54%; paroxetine group, 30% and 38%; and placebo group, 14% and 12%. In the intent-to-treat analysis, only CBT differed significantly from the placebo. In the completer analysis, both paroxetine and CBT differed significantly from the placebo. Conclusions: CBT or paroxetine are effective short-term treatment options for subjects with hypochondriasis. [ABSTRACT FROM AUTHOR]

A representative general population sample (n = 7,076) was used to study retrospectively and prospectively the nature of the relationship between co-morbid alcohol dependence and anxiety disorders. Four different models were tested: (1) anxiety disorders increase the risk of alcohol dependence; (2) alcohol dependence increases the risk of anxiety disorders; (3) family history or childhood traumatisation increase the risk of both alcohol dependence and anxiety disorders, and (4) comorbid conditions are a separate psychopathological entity. The data show that alcohol dependence does not precede the onset of anxiety disorders, that anxiety disorders do precede the onset of alcohol dependence, that family history is not very likely to be the third factor explaining the elevated comorbidity, and that in women childhood trauma might be partially responsible for the association between both disorders. The data are inconsistent with regard to comorbidity as a distinct psychopathological entity. These findings are of great importance for treatment planning in patients with alcohol dependence and comorbid anxiety disorders. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire that has been developed in primary care to distinguish non-specific general distress from depression, anxiety and somatization. The purpose of this paper is to evaluate its criterion and construct validity. Methods: Data from 10 different primary care studies have been used. Criterion validity was assessed by comparing the 4DSQ scores with clinical diagnoses, the GPs' diagnosis of any psychosocial problem for Distress, standardised psychiatric diagnoses for Depression and Anxiety, and GPs' suspicion of somatization for Somatization. ROC analyses and logistic regression analyses were used to examine the associations. Construct validity was evaluated by investigating the inter-correlations between the scales, the factorial structure, the associations with other symptom questionnaires, and the associations with stress, personality and social functioning. The factorial structure of the 4DSQ was assessed through confirmatory factor analysis (CFA). The associations with other questionnaires were assessed with Pearson correlations and regression analyses. Results: Regarding criterion validity, the Distress scale was associated with any psychosocial diagnosis (area under the ROC curve [AUC] 0.79), the Depression scale was associated with major depression (AUC = 0.83), the Anxiety scale was associated with anxiety disorder (AUC = 0.66), and the Somatization scale was associated with the GPs' suspicion of somatization (AUC = 0.65). Regarding the construct validity, the 4DSQ scales appeared to have considerable intercorrelations (r = 0.35-0.71). However, 30-40% of the variance of each scale was unique for that scale. CFA confirmed the 4-factor structure with a comparative fit index (CFI) of 0.92. The 4DSQ scales correlated with most other questionnaires measuring corresponding constructs. However, the 4DSQ Distress scale appeared to correlate with some other depression scales more than the 4DSQ Depression scale. Measures of stress (i.e. life events, psychosocial problems, and work stress) were mainly associated with Distress, while Distress, in turn, was mainly associated with psychosocial dysfunctioning, including sick leave. Conclusion: The 4DSQ seems to be a valid self-report questionnaire to measure distress, depression, anxiety and somatization in primary care patients. The 4DSQ Distress scale appears to measure the most general, most common, expression of psychological problems. [ABSTRACT FROM AUTHOR]

Background Anxiety disorders are prevalent in primary care. Psychological treatment is effective but time-consuming, and there are waiting lists for secondary care. Interest has therefore grown in developing guidelines for treatment that would be feasible in primary care. Aim To compare the effectiveness and feasibility of guided self help, the Anxiety Disorder Guidelines of the Netherlands College of General Practitioners and cognitive behavioural therapy (CBT). Design of study Randomised controlled study lasting 12 weeks with follow-up at 3 and 9 months for primary care patients with panic disorder and/or generalised anxiety disorder. Setting The first two forms of treatment were carried out by 46 GPs who were randomly assigned to one or the other form. CBT was carried out by cognitive behaviour therapists in a psychiatric outpatient clinic. Method Participants (n = 154) were randomly assigned to one of the three forms of treatment. The main outcome measure used was the state subscale of the Spielberger Anxiety Inventory. Results All three forms of treatment gave significant improvement between pre-test and post test, and this improvement remained stable between post-test and the follow-ups. The results obtained with the three treatment forms did not differ significantly over time. The feasibility of the Anxiety Disorder Guidelines was low compared with that of guided self-help. Conclusion Our results indicate that primary care patients with prevalent anxiety disorders for whom the GP does not find referral necessary can be adequately treated by the GP Psychiatric outpatient clinic referral does not give superior results. Guided self-help is easier for the GP to carry out than a less highly-structured treatment like that laid down in the Anxiety Disorder Guidelines. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to (1) describe the characteristics of patients reporting craving for benzodiazepines (BZs) and (2) to search for associations between BZ craving and other clinical variables in a population of general practice (GP) patients who have made an attempt to discontinue their long-term BZ use. Methods: The Benzodiazepine Craving Questionnaire (BCQ) and other self-report questionnaires were administered once to a population of 113 long-term and 80 former long-term GP BZ users participating in a large BZ reduction trial in GP. Cross-sectional data were gathered on self-reported BZ craving (BCQ), self-reported BZ dependence severity (Bendep-SRQ), psychopathology (General Health Questionnaire 12-item version), mood state (Profile of Mood States), personality (Dutch shortened MMPI), and lifestyle characteristics. Differences between patients who reported craving and patients who did not were analyzed univariately. Multivariate analyses were performed on variables significantly associated with craving, controlling for current use status. Results: (1) Patients reporting craving differed significantly from patients not reporting craving on aspects of BZ dependence severity, psychopathology, negative mood state, and personality. (2) Negative mood and somatization were positively associated with BZ craving, although only the contribution of negative mood to craving was statistically significant for the total group of (former) BZ users (P = .002). Conclusions: Self-reported negative mood and somatization are positively associated with BZ craving. In future BZ craving research, personality factors should be further explored. [ABSTRACT FROM AUTHOR]

The Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ) measures the severity of benzodiazepine (BZ) dependence on four domains: awareness of problematic use, preoccupation with the availability of BZ, lack of compliance with the therapeutic regimen, and withdrawal. Although promising results of the Bendep-SRQ have been obtained in cross-sectional studies, no attention has been paid to its clinical relevance during BZ withdrawal, i.e., predictive validity and time course. We performed cross-validation and evaluated the predictive validity and time course on 180 long-term BZ users who were taking part in a general practice BZ discontinuation trial. Three of the four domains had good scalability. Some concerns arose about the preoccupation scale, which emphasizes the need for cross-validation in clinically relevant populations. All scales showed excellent reliability (subject discriminability, item discriminability), while construct and discriminant validity were adequate. All four scales contributed significantly to the prediction of whether complete abstinence would be achieved directly after taking part in the discontinuation program. This prediction was independent of the other prognostic variables, except for those in the domain problematic use. The scales problematic use and preoccupation showed good sensitivity to changes during follow-up. The insensitivity of the scale, lack of compliance can be explained by low baseline scores in our population, while the insensitivity of the withdrawal scale was probably the result of the study design. In conclusion, our study indicated the clinical relevance of the Bendep-SRQ before and during a BZ discontinuation trial. We recommend the use of the Bendep-SRQ in discontinuation therapy and research into the field of BZ addiction. [ABSTRACT FROM AUTHOR]

Eighty-two patients with social phobia were randomly assigned to cognitive therapy or double-blind drug treatment with moclobemide (300–600 mg per day) or placebo. After 15 weeks of active treatment, a 2-month treatment-free follow-up as well as a 15-month naturalistic follow-up were scheduled. At post-test, cognitive therapy was significantly superior to moclobemide, but not to placebo, on a composite social phobia measure. At 2-month follow-up, cognitive therapy was superior to both moclobemide and placebo. Treatment gains were maintained in cognitive therapy during 2-month and 15-month follow-up, however, most patients (66%) who completed the study needed additional cognitive and/or behavioural treatment. Moclobemide proved not superior to placebo at post-test as well as at 2-month follow-up. As most patients from the medication conditions were treated with cognitive and/or behavioural treatment during the naturalistic follow-up period, at the 15-month assessment no between-group differential effects were found to remain. These results indicate that cognitive therapy is an effective treatment for social phobia in both the short and long term. As the results from previous studies on the efficacy of moclobemide in social phobia were inconclusive, our data tip the scales in the direction that there is no place for moclobemide in the treatment of social phobia. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article discusses the need to understand and maintain therapeutic relationship with conversational artificial intelligence (CAI) as compared to the human therapist to mitigate the morally undesirable effects of CAI mimicking agency. Topics discussed include mediating role of CAI between the human therapist and the patient, shortcomings of CAI and the independent use of CAI.

Background: Although cognitive behavioral therapy (CBT) is effective in the treatment of anxiety disorders, few evidence-based alternatives exist. Autonomy enhancing treatment (AET) aims to decrease the vulnerability for anxiety disorders by targeting underlying autonomy deficits and may therefore have similar effects on anxiety as CBT, but yield broader effects.Methods: A multicenter cluster-randomized clinical trial was conducted including 129 patients with DSM-5 anxiety disorders, on average 33.66 years of age (SD = 12.57), 91 (70.5%) female, and most (92.2%) born in the Netherlands. Participants were randomized over 15-week groupwise AET or groupwise CBT and completed questionnaires on anxiety, general psychopathology, depression, quality of life, autonomy-connectedness and self-esteem, pre-, mid-, and posttreatment, and after 3, 6, and 12 months (six measurements).Results: Contrary to the hypotheses, effects on the broader outcome measures did not differ between AET and CBT (d = .16 or smaller at post-test). Anxiety reduction was similar across conditions (d = .059 at post-test) and neither therapy was superior on long term.Conclusion: This was the first clinical randomized trial comparing AET to CBT. The added value of AET does not seem to lie in enhanced effectiveness on broader outcome measures or on long term compared to CBT. However, the study supports the effectiveness of AET and thereby contributes to extended treatment options for anxiety disorders. [ABSTRACT FROM AUTHOR]

Mental health chatbots (MHCBs) designed to support individuals in coping with mental health issues are rapidly advancing. Currently, these MHCBs are predominantly used in commercial rather than clinical contexts, but this might change soon. The question is whether this use is ethically desirable. This paper addresses a critical yet understudied concern: assuming that MHCBs cannot have genuine emotions, how this assumption may affect psychotherapy, and consequently the quality of treatment outcomes. We argue that if MHCBs lack emotions, they cannot have genuine (affective) empathy or utilise countertransference. Consequently, this gives reason to worry that MHCBs are (a) more liable to harm and (b) less likely to benefit patients than human therapists. We discuss some responses to this worry and conclude that further empirical research is necessary to determine whether these worries are valid. We conclude that, even if these worries are valid, it does not mean that we should never use MHCBs. By discussing the broader ethical debate on the clinical use of chatbots, we point towards how further research can help us establish ethical boundaries for how we should use mental health chatbots. [ABSTRACT FROM AUTHOR]

Background: Phobic anxiety disorders are among the most prevalent psychiatric disorders and are burdensome in terms of loss of quality of life and work productivity. Evidence-based treatments are relatively successful in the majority of patients, especially exposure therapy. However, a substantial subset of patients fails to achieve or stay in remission. Preclinical and genetic research have yielded evidence that the cannabinoid system is involved in the extinction of fear, presumed to underlie the beneficial effects of exposure therapy in phobic disorders. A cannabinoid constituent that may enhance endocannabinoid signaling is cannabidiol (CBD), a non-psychoactive component of cannabis. Hence, the addition of CBD to exposure therapy is expected to strengthen effects of treatment. To determine the added benefit of CBD on exposure therapy, we conduct a randomized controlled trial, in which patients in whom previous treatment as usual has not yielded sufficient response receive either CBD or placebo preceding 8 exposure sessions in a double-blind fashion. A subsidiary aim is to explore which (combination of) clinical, behavioral and genetic profiles of patients are related to treatment response. Methods/design: This is an 8-week multicenter, randomized, double-blind, placebo-controlled trial. Seventy-two patients with social phobia or panic disorder with agoraphobia with incomplete response to earlier treatment will be included from outpatient clinics in the Netherlands. Patients are randomized to augmentation of exposure therapy with 300 mg CBD or placebo. The study medication is administered orally, 2 h preceding each of the eight 90 min exposure sessions. Measurements will take place at baseline, first administration of medication, every session, mid-treatment, last administration of medication, post-treatment and at 3 and 6 months' follow-up. The primary outcome measure is the score on the Fear Questionnaire (FQ). In addition, determinants of the expected treatment enhancing effect of CBD will be explored. Discussion: This is the first trial to investigate whether the addition of CBD to exposure therapy is effective in reducing phobic symptoms in treatment refractory patients with social phobia or panic disorder with agoraphobia. Trial registration: Netherlands Trial Register NTR5100. Registered 13 March 2015. Protocol version: issue date 17 Jan 2018, protocol amendment number 7. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to explore perceptions of free will in the repetitive behaviors of patients with obsessive-compulsive disorder (OCD) and to explore their relation with core clinical characteristics. Methods: Experiences of free will were assessed with the Symptomatology And Perceived Free will rating scale (SAPF) in 295 subjects with a lifetime diagnosis of OCD. Patients' scores on the SAPF were subjected to an explorative principal axis factor analysis (PAF). Factor scores were regressed on five OCD symptom dimensions and on seven clinical variables: illness duration, severity of OCD, insight, anxiety and depression, suicidal ideation and quality of life. Results: The PAF revealed three factors: the perceived ability to control and change one's course of action when faced with an obsession or compulsion (the "alternative possibilities" factor); the experience of obsessions or compulsions as intentional (the "intentionality" factor); and the experience of being the source or owner of the obsessions or compulsions (the "ownership" factor). Lower scores on the "alternative possibilities" factor were associated with lower scores on the washing dimension (β = 0.237, p = 0.004) and higher scores on the precision dimension (β = − 0.190, p = 0.025) and independently associated with longer illness duration (β = − 0.134, p = 0.039), higher illness severity (β = − 0.298, p < 0.001) and lower quality of life (β = 0.172, p = 0.046). Lower scores on the "intentionality" factor were independently associated with lower quality of life (β = 0.233, p = 0.027). Higher scores on the "ownership" factor were associated with higher scores on the precision dimension (β = 0.207, p = 0.023) and independently associated with poorer insight (β = 0.170, p = 0.045). Conclusions: The most notable finding of this study is that a diminished experience of free will in OCD is associated with core clinical characteristics: illness duration and severity, insight and quality of life. [ABSTRACT FROM AUTHOR]

Background: Selection of the optimal initial treatment in patients with major depressive disorder (MDD) in need of highly specialized care has the potential to benefit treatment outcomes and cost-effectiveness of treatment strategies. However, to date, there is a paucity of measures that could guide the selection of the initial treatment, in particular to indicate which patients with MDD are in need of highly specialized care. Recognizing this gap, this paper reports on the development and psychometric evaluation of the Decision Tool Unipolar Depression (DTUD), aimed to facilitate the early identification of patients with MDD in need of highly specialized care. Methods: The DTUD was developed using a mixed-methods approach, consisting of a systematic review and a concept mapping study. To evaluate the psychometric features of the DTUD, a cross-sectional multicenter study was conducted. A total of 243 patients with MDD were evaluated with the DTUD. Feasibility was operationalized as the time required to complete the DTUD and the content clarity of the DTUD. Inter-rater reliability was evaluated using Krippendorf's alpha. The Maudsley Staging Method (MSM) and the Dutch Measure for quantification of Treatment Resistance in Depression (DM-TRD) were administered to assess the convergent validity. A receiver operator characteristic curve was generated to evaluate the criterion validity and establish the optimal cut-off value. Results: The mean administration time was 4.49 min (SD = 2.71), and the content of the total DTUD was judged as clear in 94.7% of the evaluations. Inter-rater reliability values ranged from 0.69 to 0.91. Higher scores on the DTUD were associated with higher scores on the MSM (rs = 0.47) and DM-TRD (rs = 0.53). Based on the maximum Youden index (0.494), maximum discrimination was reached at a cut-off score of ≥5 (sensitivity 67%, specificity 83%). Conclusion: The DTUD demonstrated to be a tool with solid psychometric properties and, therefore, is a promising measure for the early identification of patients with MDD in need of highly specialized care. Use of the DTUD has the potential to facilitate the selection and initiation of the optimal initial treatment in patients with MDD, which in turn may improve the clinical effectiveness and cost-effectiveness of treatment strategies. [ABSTRACT FROM AUTHOR]

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness. [ABSTRACT FROM AUTHOR]

Background: Panic disorder (PD) and generalized anxiety disorder (GAD) are two of the most disabling and costly anxiety disorders seen in primary care. However, treatment quality of these disorders in primary care generally falls beneath the standard of international guidelines. Collaborative stepped care is recommended for improving treatment of anxiety disorders, but cost-effectiveness of such an intervention has not yet been assessed in primary care. This article describes the aims and design of a study that is currently underway. The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual.Methods/design: The study is a two armed, cluster randomized controlled trial. Care managers and their primary care practices will be randomized to deliver either collaborative stepped care (CSC) or care as usual (CAU). In the CSC group a general practitioner, care manager and psychiatrist work together in a collaborative care framework. Stepped care is provided in three steps: 1) guided self-help, 2) cognitive behavioral therapy and 3) antidepressant medication. Primary care patients with a DSM-IV diagnosis of PD and/or GAD will be included. 134 completers are needed to attain sufficient power to show a clinically significant effect of 1/2 SD on the primary outcome measure, the Beck Anxiety Inventory (BAI). Data on anxiety symptoms, mental and physical health, quality of life, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months.Discussion: It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual. The pragmatic design of this study will enable the researchers to evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options for GAD and PD in the primary care setting. Results will become available in 2011.Trial Registration: NTR1071. [ABSTRACT FROM AUTHOR]

Background: Previous research on barriers and facilitators regarding treatment-seeking of adults with depressive and anxiety disorders has been primarily conducted in the Anglosphere. This study aims to gain insight into treatment-seeking behaviour of adults with depressive and anxiety disorders in a European healthcare system. Methods: In-depth semi-structured interviews were conducted with 24 participants, aged ≥18 years and diagnosed with an anxiety disorder and/or depressive disorder according to DSM-IV. Participants were purposively sampled from an outpatient department for mental health care in the Netherlands. The seven steps of framework analysis were used to identify relevant themes emerging from the interviews. Results: Data analysis suggested an interplay between individual aspects, personal social system, healthcare system and sociocultural context influences. Amongst the most relevant themes were mental health illiteracy, stigma, a negative attitude toward professional help, the influence of significant others and general practitioner, and waiting time. Financial barriers were not of relevance. Conclusions: Even in a country with a well-developed mental health care system and in absence of financial barriers, there are many barriers to treatment-seeking in adult patients with depressive and anxiety disorders. National campaigns to increase awareness and decrease stigma in the general population, and to empower the social environment might reduce the treatment gap. [ABSTRACT FROM AUTHOR]

To examine the prevalence rate, impairment, comorbidity, course of illness and determinants of eight specific phobia variants: animals (animal subtype); heights, water, storms (natural environment subtype); flying, enclosed spaces, being alone (situational subtype); and blood/injury (blood/injury subtype). Data were obtained from the Netherlands Mental Health Survey and Incidence Study, a prospective study in the Dutch general population aged 18–65 ( N = 7,076). The most prevalent condition was specific phobia with a fear of heights (4.9%). On all parameters except duration, specific phobia with a fear of being alone emerged as the most severe condition. Phobias with fear of enclosed spaces and phobias with fear of blood showed a slightly greater likelihood of impairment, comorbidity and personality problems than phobias with fear of animals, heights, water or storms. The situational and blood/injury phobia subtypes appear to be a more significant index for impairments and for comorbid psychiatric disorders than the animal and natural environment phobia subtypes. [ABSTRACT FROM AUTHOR]

Aims: Despite claims that comorbid anxiety disorders tend to lead to a poor outcome in the treatment of alcohol dependence, the few studies on this topic show conflicting results. Objective: To test whether the outcome of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder is worse than that of similar patients without a comorbid phobic disorder. Methods: The probabilities of starting to drink again and of relapsing into regular heavy drinking in (i) a group of 81 alcohol-dependent patients with comorbid social phobia or agoraphobia were compared with those in (ii) a group of 88 alcohol-dependent patients without anxiety disorders in a naturalistic follow-up using Cox regression analysis. Results: Adjusted for initial group differences, the hazard ratio for the association of phobic disorders with resumption of drinking was 1.05 (95% CI, 0.85-1.30, P = 0.66) and the adjusted hazard ratio for the association of phobic disorders with a relapse into regular heavy drinking was 1.02 (95% CI, 0.78-1.33, P = -0.89). Conclusion: The findings of this study do not confirm the idea that alcohol-dependent patients who have undergone alcohol-dependence treatment are at greater risk of a relapse if they have a comorbid anxiety disorder. No differences were found in abstinence duration or time to relapse into regular heavy drinking between patients with and without comorbid phobic disorders. [ABSTRACT FROM AUTHOR]

Objective: The uptake of evidence‐based guideline recommendations appears to be challenging. In the midst of the discussion on how to overcome these barriers, the question of whether the use of guidelines leads to improved patient outcomes threatens to be overlooked. This study examined the effectiveness of evidence‐based guidelines for all psychiatric disorders on patient health outcomes in specialist mental health care. All types of evidence‐based guidelines, such as psychological and medication‐focused guidelines, were eligible for inclusion. Provider performance was measured as a secondary outcome. Time to remission when treated with the guidelines was also examined. Method: Six databases were searched until 10 August 2020. Studies were selected, and data were extracted independently according to the PRISMA guidelines. Random effects meta‐analyses were used to pool estimates across studies. Risk of bias was assessed according to the Cochrane Effective Practice and Organization of Care Review Group criteria. PROSPERO:CRD42020171311. Results: The meta‐analysis included 18 studies (N = 5380). Guidelines showed a positive significant effect size on the severity of psychopathological symptoms at the patient level when compared to treatment‐as‐usual (TAU) (d = 0.29, 95%‐CI = (0.19, 0.40), p < 0.001). Removal of a potential outlier gave globally the same results with Cohen's d = 0.26. Time to remission was shorter in the guideline treatment compared with TAU (HR = 1.54, 95%‐CI = (1.29, 1.84), p = 0.001, n = 3). Conclusions: Patients cared for with guideline‐adherent treatments improve to a greater degree and more quickly than patients treated with TAU. Knowledge on the mechanisms of change during guideline‐adherent treatment needs to be developed further such that we can provide the best possible treatment to patients in routine care. [ABSTRACT FROM AUTHOR]

Objectives: Obsessive‐compulsive disorder (OCD) is a debilitating psychiatric disorder, often complicated with comorbidities. Social phobia (SP) is the most frequent co‐occurring anxiety disorder in OCD, associated with increased clinical severity. However, no study had examined the relevance of interpersonal processes in this comorbidity, which are at the core of SP. This study characterized the clinical (i.e., symptom profile, age of onset, chronicity, and comorbidity), vulnerability (i.e., childhood trauma, negative life events), and interpersonal (attachment style, expressed emotion, and social support) correlates of comorbid SP in a large sample of OCD patients. Methods: We analysed the data of 382 OCD patients participating in the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. We examined the correlates of SP in OCD using self‐report questionnaires and structured clinical interviews. In addition, data of 312 non‐OCD SP patients were drawn from the Netherlands Study of Depression and Anxiety (NESDA), to compare the age of onset of SP between groups. Descriptive univariate analyses were followed by backward stepwise logistic regression analyses. Results: Social phobia was present among approximately 20% of OCD patients. Social phobia in OCD was associated with increased depression severity and decreased ratings of secure attachment style. Among OCD patients, SP had a significantly earlier age onset as compared to SP in non‐OCD patients. Conclusion: Social phobia in OCD might render a vulnerable clinical picture, characterized with early onset of SP symptoms, insecure attachment style, and increased depressive symptoms. Future studies should use prospective designs to better understand the nature of comorbid SP in OCD. Practitioner points: Approximately one fifth of OCD patients were diagnosed with comorbid social phobia in a large representative clinical sample.OCD patients with comorbid social phobia presented with a vulnerable clinical picture, characterized with increased depression severity and decreased ratings of secure attachment style.Social phobia in OCD was associated with an earlier AOO as compared to the AOO of social phobia without OCD.The findings are limited by a cross‐sectional design; thus, causality could not be assessed.Research is needed to further examine the mechanisms of comorbid social phobia in OCD. [ABSTRACT FROM AUTHOR]

Background: Early identification of patients with an anxiety disorder, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD) in need of highly specialized care could facilitate the selection of the optimal initial treatment in these patients. This paper describes the development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP), which aims to aid clinicians in the early identification of patients with an anxiety disorder, OCD, or PTSD in need of highly specialized mental healthcare. Methods: A systematic literature review and a concept mapping procedure were carried out to inform the development of the DTAOP. To evaluate the psychometric properties of the DTAOP, a cross-sectional study in 454 patients with a DSM-IV-TR anxiety disorder was carried out. Feasibility was evaluated by the completion time and the content clarity of the DTAOP. Inter-rater reliability was assessed in a subsample of 87 patients. Spearman's rank correlation coefficients between the DTAOP and EuroQol five-dimensional questionnaire (EQ-5D-5L) scores were computed to examine the convergent validity. Criterion validity was assessed against independent clinical judgments made by clinicians. Results: The average time required to complete the eight-item DTAOP was 4.6 min and the total DTAOP was evaluated as clear in the majority (93%) of the evaluations. Krippendorff's alpha estimates ranged from 0.427 to 0.839. Based on the qualitative feedback, item wording and instructions were improved. As hypothesized, the DTAOP correlated negatively with EQ-5D-5L scores. The area under the curve was 0.826 and the cut-off score of ≥4 optimized sensitivity (70%) and specificity (71%). Conclusions: The DTAOP demonstrated excellent feasibility and good validity, but weak inter-rater reliability. Based on the qualitative feedback and reliability estimates, revisions and refinements of the wording and instructions were made, resulting in the final version of the DTAOP. [ABSTRACT FROM AUTHOR]

Abstract: Predicting the onset and persistence of psychopathology and limited functioning might enable personalized care. Specific phobia (SP) might serve as a predictor, but this needs further evaluation. Participants of the Netherlands Mental Health Survey and Incidence Study-2 were divided into three groups: no-SP (n = 6094), history of SP (n = 204), and current SP (n = 348). Results showed that current SP was associated with a higher prevalence of other anxiety disorders, mood and substance use disorders, and lower levels of functioning. The 6-year onset of other anxiety disorders was associated with history and current SP. Current-SP was also associated with the onset of mood disorders. Neuroticism and childhood trauma only partly accounted for these associations. To conclude, SP was independently associated with presence and onset of other disorders and with limited functioning over time. The presence of SP may serve as an identifier of persons vulnerable to the development of other psychopathologies. [ABSTRACT FROM AUTHOR]

Objective: Despite the availability of mental health care, only a minority of depressed adolescents and young adults receive treatment. This study aimed to investigate facilitating factors and barriers in help-seeking behaviour of adolescents and young adults with depressive symptoms, using qualitative research methods. Methods: In-depth, semi-structured interviews with 32 participants with current or previous depressive symptoms aged 16 to 24 years using thematic content analysis. Findings: Our sample consisted mainly of adolescents who eventually found their way to professional help. Five main themes in help-seeking by adolescents and young adults were identified: (I) Individual functioning and well-being, (II) Health literacy, (III) Attitudinal aspects, (IV) Surroundings, and (V) Accessibility. Prompts to seek treatment were disease burden and poor academic performance. Health illiteracy negatively influenced treatment-seeking behaviour. Attitudinal aspects either hampered (shame, wanting to handle the problem oneself, negative attitudes towards treatment) or facilitated (positive attitudes towards treatment) help-seeking. Furthermore, adolescents' surroundings (school, family, and peers) appeared to play a critical role in the recognition of depressive symptoms and encouragement to seek help. Barriers regarding accessibility of mental health care were found, whereas direct and easy access to treatment greatly improved mental health care use. Conclusion: Facilitating factors can play a critical role in the help-seeking process of depressed adolescents and young adults, and may guide efforts to increase access to mental health care of this vulnerable age group. In particular, recognition and encouragement from school personnel and peers and easy access to care providers positively influenced help-seeking in our sample. Health illiteracy and attitudinal aspects appeared to be important barriers to seeking treatment and public/school campaigns aimed at reducing health illiteracy and stigma might be necessary to improve treatment-seeking and health care utilization in this age group. [ABSTRACT FROM AUTHOR]

Objective: Patients with obsessive compulsive disorder (OCD) have high disease burden. It is important to restore quality of life (QoL) in treatment, so that patients become able to live a fulfilling life. Little is known about the longitudinal course of QoL in patients with OCD, its association with remission from OCD, and about factors that contribute to an unfavourable course of QoL in remitting patients.Methods: Study on the 4-year course of QoL of patients with chronic (n = 144), intermittent (n = 22), and remitting OCD (n = 73) using longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA; complete data: n = 239; imputed data n = 382). The EuroQol five-dimensional questionnaire (EQ-5D) utility score was used to assess QoL. In patients with remitting OCD, we examined patient characteristics that contributed to an unfavourable course of QoL, including sociodemographics, OCD characteristics, psychiatric comorbidity, and personality traits.Results: Course of QoL was associated with course of OCD. QoL improved in those who remitted from OCD; however, even in these patients, QoL remained significantly below the population norms. The correlation between QoL and severity of OCD was only moderate: r = - 0.40 indicating that other factors besides OCD severity contribute to QoL. In remitters, more severe anxiety and depression symptoms were related to a lower QoL. Results were similar in complete and imputed data sets.Conclusions: Remission from OCD is associated with improvement of QoL, but comorbid anxiety and depression symptoms hamper the improvement of QoL. QoL could be improved by reducing OCD symptoms in patients with OCD and by treating comorbid anxiety and depression symptoms in remitting patients. [ABSTRACT FROM AUTHOR]

Background: Depressive and anxiety disorders have shown to be associated to premature or advanced biological aging and consequently to adversely impact somatic health. Treatments with antidepressant medication or running therapy are both found to be effective for many but not all patients with mood and anxiety disorders. These interventions may, however, work through different pathophysiological mechanisms and could differ in their impact on biological aging and somatic health. This study protocol describes the design of an unique intervention study that examines whether both treatments are similarly effective in reducing or reversing biological aging (primary outcome), psychiatric status, metabolic stress and neurobiological indicators (secondary outcomes). Methods: The MOod Treatment with Antidepressants or Running (MOTAR) study will recruit a total of 160 patients with a current major depressive and/or anxiety disorder in a mental health care setting. Patients will receive a 16-week treatment with either antidepressant medication or running therapy (3 times/week). Patients will undergo the treatment of their preference and a subsample will be randomized (1:1) to overcome preference bias. An additional no-disease-no-treatment group of 60 healthy controls without lifetime psychopathology, will be included as comparison group for primary and secondary outcomes at baseline. Assessments are done at week 0 for patients and controls, and at week 16 and week 52 for patients only, including written questionnaires, a psychiatric and medical examination, blood, urine and saliva collection and a cycle ergometer test, to gather information about biological aging (telomere length and telomerase activity), mental health (depression and anxiety disorder characteristics), general fitness, metabolic stress-related biomarkers (inflammation, metabolic syndrome, cortisol) and genetic determinants. In addition, neurobiological alterations in brain processes will be assessed using structural and functional Magnetic Resonance Imaging (MRI) in a subsample of at least 25 patients per treatment arm and in all controls. Discussion: This intervention study aims to provide a better understanding of the impact of antidepressant medication and running therapy on biological aging, metabolic stress and neurobiological indicators in patients with depressive and anxiety disorders in order to guide a more personalized medicine treatment. Trial registration: Trialregister.nl Number of identification: NTR3460, May 2012. [ABSTRACT FROM AUTHOR]

Background: Anxiety and depressive disorders are common mental disorders. A substantial part of patients does not achieve symptomatic remission after treatment in specialized services. Current care as usual (CAU) for these patients consists of long-term supportive contacts. Termination of CAU is often not considered to be an option due to persistent symptoms, a low level of functioning, and the absence of further treatment options. A new intervention, ZemCAD, offers a program focused on rehabilitation and self-management, followed by referral back to primary care. Methods: This multicenter randomized controlled trial was carried out in twelve specialized outpatient mental health care services in the Netherlands. Consenting and eligible patients were invited for the MINI interview and the baseline questionnaire. Assessments were done at 6 (T1), 12 (T2) and 18 (T3) months post baseline. We used linear mixed model analysis (LMM) to ascertain the effectiveness of the ZemCAD group relative to the CAU group on quality of life, symptom severity and empowerment. Results: In total 141 patients were included. The results at 18-month follow-up regarding to quality of life and symptom severity, showed no significant differences between the ZemCAD group and the CAU group, except on the 'social relationships'-domain (d = 0.37). With regard to empowerment a significant difference between both groups was observed in the total empowerment score and one empowerment dimension (d = 0.45 and d = 0.39, respectively). After the ZemCAD intervention, more patients went from specialized outpatient mental health services back to a less specialized health care setting with less intensive treatment, such as primary care. Conclusion: The findings in this study suggest that patients with chronic and treatment-resistant anxiety and depression using the ZemCAD intervention improve on empowerment but not on symptom severity or quality of life. Since little is known about the effects of rehabilitation and self-management in patients with chronic and treatment resistant anxiety and depressive disorders, this is a first attempt to provide a proof-of-concept study in this under-researched but important field. Trial registration: Netherlands Trial Register: NTR3335, registered 7 March 2012. [ABSTRACT FROM AUTHOR]

Background: Despite increasing evidence for the diagnostic instability between and within depressive and anxiety disorders, most studies report solely on the recurrence rates of the specific index disorders. Neglecting this evidence has an inherent risk of underestimating recurrence rates of depressive and anxiety disorders. This study investigates the impact of diagnostic instability of recurrence rates in depression and anxiety.Methods: Data were derived from the Netherlands Study of Depression and Anxiety (NESDA). The sample of 656 participants had a panic disorder with or without agoraphobia, agoraphobia, social phobia, generalized anxiety disorder, major depressive disorder or dysthymia, and a subsequent remission. Recurrence rates of index disorders (diagnostically stable recurrence) and newly arisen anxiety or depressive disorders (diagnostically unstable recurrence), were calculated over a 4-year follow-up period.Results: In anxiety disorders (n=281), the recurrence rate is more than doubled, from 23.8% with a stable recurrence, to 54.8%, when diagnostically unstable recurrences are included. In depressive disorders (N=173) the recurrence rate increases from 37.6% to 49.7%, and in comorbid anxiety and depressive disorders (N=202) the diagnostically unstable recurrences increase from 54.0% to 66.3%.Limitations: Attrition during follow up may have biased the results; remission was defined as absence of symptoms for 1 month; very short-term remission and recurrence patterns were not assessed.Conclusions: Diagnostically unstable recurrences have a significant impact on recurrence rates, with the greatest instability for anxiety disorders. When only diagnostically stable recurrences are assessed, recurrence rates are highly underrated and provide biased estimates of the true course of these disorders. [ABSTRACT FROM AUTHOR]

Background While studies into the implementation of clinical practice guidelines for mental health care are scarce, studies on the effectiveness of implementing practice guidelines for anxiety disorders appear to be entirely non-existent. Objective To examine whether adherence to anxiety disorder clinical practice guidelines in secondary mental health care yields superior treatment results than non-adherence. Method A closed-cohort study of 181 outpatients with an anxiety disorder or hypochondriasis who were treated in a routine mental health setting. Preceding the inclusion of these 181 patients, a start was made on the implementation of the Dutch national multidisciplinary practice guidelines for anxiety disorders. Patients were asked to complete several questionnaires before the start of treatment and again 1 year later. The medical records of these patients were reviewed to assess guideline adherence. Ultimately, adherence or non-adherence to the different treatment algorithms described in the guidelines was related to changes in the severity of psychiatric symptomatology, psychiatric functioning, general well-being and satisfaction with treatment. Results Compared with patients whose treatment did not adhere to the guidelines, those whose treatment adhered to the guidelines were found to have greater symptom reduction after 1 year ( P < 0.01). The latter group of patients also rated their satisfaction with their treatment significantly higher ( P = 0.01). No significant differences were found after 1 year with respect to changes in impairment of functioning and quality of life in the two groups of patients. Conclusions Adherence to anxiety disorder guidelines yields superior treatment results and increased patient satisfaction with treatment when compared with patients whose treatment did not adhere to the clinical guidelines. These results should encourage a more widespread implementation of such guidelines in mental health care facilities. [ABSTRACT FROM AUTHOR]

Background: Obsessive-compulsive disorder (OCD) and symptoms (OC symptoms) are associated with tic disorders and share an aetiological relationship. The extent to which OCD/OC symptoms are correlated with other hyperkinetic movement disorders is unclear. The aim of this review was to investigate this co-occurrence and the extent to which OCD/OC symptoms and hyperkinetic movement disorders share a neurobiological basis.Methods: A systematic review was performed, specifically searching for OCD/OC symptom comorbidity in hyperkinetic movement disorders using case control studies, longitudinal studies and family based studies. The literature search was conducted using PubMed and PsycINFO databases.Results: Heterogeneity of measurement instruments to detect OCD diagnosis and OC symptoms decreased comparability between studies. The most convincing evidence for a relationship was found between the choreas (Huntington's disease and Sydenham's chorea) and OCD/OC symptoms. Furthermore, elevated frequencies of OC symptoms were found in small case control series of dystonias. Small family based studies in dystonia subtypes modestly suggest shared familial/genetic relationships between OC symptoms and dystonia.Conclusion: Current data indicate a relationship between OCD/OC symptoms and the choreas. As OCD and the choreas have been associated with dysfunctional frontal-striatal circuits, the observed relationships might converge at the level of dysfunctions of these circuits. However, paucity of longitudinal and family studies hampers strong conclusions on the nature of the relationship.Implications: The relationship between OCD and movement disorders needs further elaboration using larger family based longitudinal studies and sound instruments to characterise OC symptomatology. This could lead to better understanding of the shared pathology between OCD and hyperkinetic movement disorders. [ABSTRACT FROM AUTHOR]

To reduce the phenotypic heterogeneity of obsessive-compulsive disorder (OCD) for genetic, clinical and translational studies, numerous factor analyses of the Yale-Brown Obsessive Compulsive Scale checklist (YBOCS-CL) have been conducted. Results of these analyses have been inconsistent, likely as a consequence of small sample sizes and variable methodologies. Furthermore, data concerning the heritability of the factors are limited. Item and category-level factor analyses of YBOCS-CL items from 1224 OCD subjects were followed by heritability analyses in 52 OCD-affected multigenerational families. Item-level analyses indicated that a five factor model: (1) taboo, (2) contamination/cleaning, (3) doubts, (4) superstitions/rituals, and (5) symmetry/hoarding provided the best fit, followed by a one-factor solution. All 5 factors as well as the one-factor solution were found to be heritable. Bivariate analyses indicated that the taboo and doubts factor, and the contamination and symmetry/hoarding factor share genetic influences. Contamination and symmetry/hoarding show shared genetic variance with symptom severity. Nearly all factors showed shared environmental variance with each other and with symptom severity. These results support the utility of both OCD diagnosis and symptom dimensions in genetic research and clinical contexts. Both shared and unique genetic influences underlie susceptibility to OCD and its symptom dimensions. [ABSTRACT FROM AUTHOR]

In obsessive-compulsive disorder (OCD), the relationship between autism spectrum disorders (ASD), attention-deficit/hyperactivity disorder (ADHD) symptom, and obsessive-compulsive (OC) symptom dimensions and severity has scarcely been studied. Therefore, 109 adult outpatients with primary OCD were compared to 87 healthy controls on OC, ADHD and ASD symptoms. OCD patients showed increased ADHD and autism symptom frequencies, OCD + ADHD patients reporting more autism symptoms (particularly attention switching and social skills problems) than OCD − ADHD patients. Attention switching problems were most significant predictors of OC symptom dimensions (except hoarding) and of symptom severity. Hoarding was not associated with elevated autism scale scores, but with inattention. In conclusion, attention switching problems may reflect both symptom overlap and a common etiological factor underlying ASD, ADHD and OCD. [ABSTRACT FROM AUTHOR]

BACKGROUND: Discontinuation of benzodiazepine usage has never been evaluated in economic terms. This study aimed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy (TO+CBT), tapering off alone (TOA) and usual care.The cost of intervention treatment, prescribed drugs, healthcare services, productivity loss, and patients’ costs were measured using drug prescription data and cost diaries. Costs were indexed at 2001 prices. The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up. A secondary outcome measure was quality of life (Health Utility Index Mark III [HUI-3] and the Medical Outcomes Study 36-item Short-Form Health Survey [SF-36]). METHOD: A randomised controlled trial was conducted, incorporating a cost-effectiveness analysis from a societal as well as a pharmaceutical perspective.The cost of intervention treatment, prescribed drugs, healthcare services, productivity loss, and patients’ costs were measured using drug prescription data and cost diaries. Costs were indexed at 2001 prices. The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up. A secondary outcome measure was quality of life (Health Utility Index Mark III [HUI-3] and the Medical Outcomes Study 36-item Short-Form Health Survey [SF-36]). RESULTS: A total of 180 patients were randomised to one of TO+CBT (n = 73), TOA (n = 73) or usual care (n = 34). Intervention treatment costs were an average of €172.99 per patient for TO+CBT and €69.50 per patient for TOA. Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care. The incremental cost-effectiveness ratios (ICERs) showed that, for each incremental 1% successful benzodiazepine discontinuation, TO+CBT cost €10.30–62.53 versus usual care, depending on the study perspective. However, TO+CBT was extendedly dominated or was dominated by TOA. This resulted in ICERs of €0.57, €10.21 and €48.92 for TOA versus usual care from the limited pharmaceutical, comprehensive pharmaceutical and societal perspective, respectively. CONCLUSIONS: TO+CBT and TOA both led to a reduction in benzodiazepine costs. However, it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment. Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT, the differences were relatively small. The addition of group CBT to tapering off had no clinical or economic advantages. Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care. [ABSTRACT FROM AUTHOR]

Obsessive-compulsive disorder (OCD) is linked with dysfunction in frontal-striatal, fronto-limbic, and visual brain regions. Research using proton magnetic resonance spectroscopy ( 1 H-MRS) suggests that altered neurometabolite levels, like glutamate, may contribute to this dysfunction. However, static neurometabolite levels in OCD patients have shown inconsistent results, likely due to previous studies' limited focus on neurometabolite dynamics. We employ functional MRS (fMRS) and functional magnetic resonance imaging (fMRI) to explore these dynamics and brain activation during OCD symptom provocation. We utilized a combined 7-tesla fMRI-fMRS setup to examine task-related BOLD response and glutamate changes in the lateral occipital cortex (LOC) of 30 OCD participants and 34 matched controls during an OCD-specific symptom provocation task. The study examined main effects and between-group differences in brain activation and glutamate levels during the task. A whole sample task-effects analysis on data meeting predefined quality criteria showed significant glutamate increases (n = 41 (22 OCD, 19 controls), mean change: 3.2 %, z = 3.75, p < .001) and task activation (n = 54 (26 OCD, 28 controls), p < .001) in the LOC during OCD blocks compared to neutral blocks. However, no differences in task-induced glutamate dynamics or activation between groups were found, nor a correlation between glutamate levels and task activation. We were able to measure task-induced increases in glutamate and BOLD levels, emphasizing its feasibility for OCD research. The absence of group differences highlights the need for further exploration to discern to what extent neurometabolite dynamics differ between OCD patients and controls. Once established, future studies can use pre-post intervention fMRS-fMRI to probe the effects of therapies modulating glutamate pathways in OCD., Competing Interests: Declaration of competing interest The other authors report no biomedical financial interests or potential conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Obsessive-compulsive disorder (OCD) is a condition with high patient morbidity and mortality. Research shows that eliciting patient explanations about illness causes and treatment preferences promotes cross-cultural work and engagement in health services. These topics are in the Cultural Formulation Interview (CFI), a semi-structured interview first published in DSM-5 that applies anthropological approaches within mental health services to promote person-centered care. This study focuses on the New York City site of an international multi-site study that used qualitative-quantitative mixed methods to: (1) analyze CFI transcripts with 55 adults with OCD to explore perceived illness causes and treatment preferences, and (2) explore whether past treatment experiences are related to perceptions about causes of current symptoms. The most commonly named causes were circumstantial stressors (n = 16), genetics (n = 12), personal psychological traits (n = 9), an interaction between circumstantial stressors and participants' brains (n = 6), and a non-specific brain problem (n = 6). The most common treatment preferences were psychotherapy (n = 42), anything (n = 4), nothing (n = 4), and medications (n = 2). Those with a prior medication history had twice the odds of reporting a biological cause, though this was not a statistically significant difference. Our findings suggest that providers should ask patients about illness causes and treatment preferences to guide treatment choice., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Risk factors of a chronic course of anxiety and depressive disorders were previously studied using a limited definition of recovery, i.e. remission of the index disorder. However, frequently, other mental disorders are present at follow-up. Thus, the course of anxiety and depressive disorders was represented too rosy and the identified determinants may not apply when using a broader, more realistic definition. Additionally, physical health risk factors have often been ignored., Methods: Data were used from two waves of the Netherlands Mental Health Survey and Incidence Study-2 including 509 respondents with 12-month anxiety disorder (panic disorder, social phobia, agoraphobia or generalized anxiety disorder) or/and major depressive disorder at baseline. Chronic course was defined as (1) presence of index disorder; and (2) presence of any anxiety, mood or substance use disorder (overall course) during the subsequent three years. Regression models were built with sociodemographic, clinical, and lifestyle/physical health indicators. Predictive accuracy was evaluated with area under the curve (AUC)., Results: Chronic course of the index disorder was present among 24.8% of cases, whereas 38.7% had a chronic overall course. The accuracy of prediction of chronic course of the index disorder was suboptimal (AUC = 0.68) compared to prediction of overall course (AUC = 0.75). The main risk factors were baseline number of mental disorders, neuroticism, childhood abuse, parental psychopathology and alcohol use. Lifestyle and physical health indicators were marginally relevant., Conclusion: Transdiagnostic risk factors are important in predicting overall course of anxiety and depressive disorders but cannot accurately predict chronic course of the index disorder., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objective: To test a multifaceted treatment program for patients with obsessive-compulsive disorder (OCD) who did not respond to regular cognitive behavior therapy (CBT). The treatment addresses several factors that may play a role in maintaining OCD., Methods: We designed a treatment consisting of a 6-day intensive, individual exposure in vivo with response prevention (ERP) format, with 24 therapist-assisted treatment hours at the patient's home and 12 self-controlled ERP hours, including behavioral activation and family interventions. Next, we investigated the effect (obsessive-compulsive symptoms, comorbidity, functioning, quality of life, OCD-related interaction patterns) and feasibility (dropout, treatment satisfaction, and organization) of this program using pre-post-tests, pre-follow-up tests, and qualitative data from patients, family members, and therapists., Results: In a sample of 22 participants, obsessive-compulsive symptoms (Y-BOCS pre: 28.7, post: 15.9; Wilcoxon S-R tests P<0.01) improved significantly, as did most other effect measures. Results were largely, but not completely, preserved at 3-month follow-up. There was only 1 dropout. Patients, family members, and therapists were satisfied with the treatment. Implementation of the treatment did not pose difficulties., Conclusions: In nonresponders with OCD, a multifaceted, brief, intensive home-based ERP program targeting factors maintaining OCD is promising and feasible. Extra care is needed to maintain improvement., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Depression in adolescents and young adults is common and causes considerable disease burden while hampering their development, leading to adverse consequences in later life. Although treatment is available, young people are a vulnerable group regarding uptake and completion of treatment. To improve this, insight into youth's preferences for treatment is essential., Objective: The aim of this study was to investigate patient preferences for depression treatment in a Dutch sample aged 16-24 years using a discrete choice experiment (DCE)., Methods: The study was conducted in The Netherlands between October 2018 and June 2019, and included 236 adolescents and young adults with current depressive symptoms or previous treatment. The DCE included five attributes (treatment type, frequency of appointment, waiting time, effectiveness, evaluation of therapeutic alliance) with corresponding levels. Results were analysed using latent class analysis., Results: Results show a general preference for individual psychotherapy, treatment with high frequency, high effectiveness, short waiting time and a standard evaluation of the therapeutic alliance ('click' with the therapist) early in treatment. Latent class analysis revealed three different patterns of preferences regarding treatment type and willingness to engage in therapy. The first class showed a strong preference for individual therapy. The second class, including relatively older, higher educated and treatment-experienced participants, preferred high frequency treatment and was more open to different forms of therapy. The third class, including lower educated, younger and treatment-naïve adolescents showed reluctance to engage in therapy overall and in group therapy specifically., Conclusion: In this DCE, three classes could be identified that share similar preferences regarding treatment effectiveness, waiting time and evaluation of the therapeutic alliance, but varied considerably in their preference for treatment type (individual, group, or combined psychotherapy) and their willingness to engage. The results from this study may inform mental health care providers and institutions and help optimize professional care for adolescents and young adults with depressive symptoms, improving engagement in this vulnerable group., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: In 2016, the SUicide PRevention Action NETwork (SUPRANET) was launched. The SUPRANET intervention aims at better implementing the suicide prevention guideline. An implementation study was developed to evaluate the impact of SUPRANET over time on three outcomes: 1) suicides, 2) registration of suicide attempts, and 3) professionals' knowledge and adherence to the guideline., Methods: This study included 13 institutions, and used an uncontrolled longitudinal prospective design, collecting biannual data on a 2-level structure (institutional and team level). Suicides and suicide attempts were extracted from data systems. Professionals' knowledge and adherence were measured using a self-report questionnaire. A three-step interrupted time series analysis (ITSA) was performed for the first two outcomes. Step 1 assessed whether institutions executed the SUPRANET intervention as intended. Step 2 examined if institutions complied with the four guideline recommendations. Based on steps 1 and 2, institutions were classified as below or above average and after that, included as moderators in step 3 to examine the effect of SUPRANET over time compared to the baseline. The third outcome was analyzed with a longitudinal multilevel regression analysis, and tested for moderation., Results: After institutions were labeled based on their efforts and investments made (below average vs above average), we found no statistically significant difference in suicides (standardized mortality ratio) between the two groups relative to the baseline. Institutions labeled as above average did register significantly more suicide attempts directly after the start of the intervention (78.8 per 100,000 patients, p <0.001, 95%CI=(51.3 per 100,000, 106.4 per 100,000)), and as the study progressed, they continued to report a significantly greater improvement in the number of registered attempts compared with institutions assigned as below average (8.7 per 100,000 patients per half year, p =0.004, 95%CI=(3.3 per 100,000, 14.1 per 100,000)). Professionals working at institutions that invested more in the SUPRANET activities adhered significantly better to the guideline over time (b=1.39, 95%CI=(0.12,2.65), p =0.032)., Conclusion: Institutions labeled as above average registered significantly more suicide attempts and also better adhered to the guideline compared with institutions that had performed less well. Although no convincing intervention effect on suicides was found within the study period, we do think that this network is potentially able to reduce suicides. Continuous investments and fully implementing as many guideline recommendations as possible are essential to achieve the biggest drop in suicides., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Setkowski, van Balkom, Hoogendoorn, Franx, Veerbeek, de Winter and Gilissen.)

In this article, we will address 10 questions about anxiety that are relevant to doctors who encounter this in their practice. This often occurs in the primary care setting, where individuals with anxiety frequently present with somatic complaints. A focused medical history, including questions about the use and withdrawal of psychoactive substances, can assist in the diagnostic process. Psychoeducation may be sufficient, otherwise cognitive-behavioral therapy can be conducted. In cases of non-response, serotonergic antidepressants represent a treatment option. Half of the individuals with anxiety symptoms experience remission, while the other half have a recurrent or chronic course, which may be accompanied by comorbid depression.

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders., (© 2024 World Psychiatric Association.)