Tipping the scales for global mental health: A summary of the Presidential Panel at the 39th Annual Meeting of the International Society for Traumatic Stress Studies.

In the past decade, there has been an increasing focus within scientific research on how to assist people affected by the negative consequences of trauma and crises around the globe. As many countries struggle with a lack of resources to deliver mental health interventions, scalable strategies have been developed to help more people in need. These scalable strategies were the theme of the 39th annual meeting of the International Society for Traumatic Stress Studies (ISTSS). The presidential panel, chaired by Marit Sijbrandij during her ISTSS presidency, brought together a group of experts in the field of scalable interventions: Kenneth Carswell, Syed Usman Hamdani, Judy Bass, and Eirini Karyotaki. The panel highlighted the current state of the evidence on scalable interventions for adults and children and outlined important next steps for research and implementation. These recommendations include further improving the availability of, and evidence for, scalable interventions through increased training and sustained funding; conducting more studies in underrepresented samples, such as children and adolescents; and promoting open access availability of research findings worldwide. In this paper, we provide an overview of the topics discussed in the panel as well as the key takeaways.

The effectiveness of self-guided interventions in adults with depressive symptoms: a systematic review and meta-analysis.

BACKGROUND: Despite promising scalability and accessibility, evidence on the efficacy of self-guided interventions for adult depression is inconclusive. This study investigated their effectiveness and acceptability, considering diverse delivery formats and support levels. METHODS: We systematically searched PubMed, PsycINFO, Embase, and Cochrane Library until 1st January 2024. Included were randomised controlled trials comparing self-guided interventions with a control condition for adult depression. Two independent researchers extracted data. Effect sizes were pooled using random-effects models, with post-intervention depressive severity compared with control conditions as the primary outcome. Study validity was evaluated using Cochrane Risk of Bias 2.0. This study was pre-registered with OSF (https://osf.io/rd43v). FINDINGS: We identified 92 studies (111 interventions vs. control comparisons) with 16,706 participants (mean age: 18.78-74.41 years). Compared to controls, self-guided interventions were moderately effective at post-assessment (g = 0.53, 95% CI: 0.45-0.61; I2 = 79.17%) and six to twelve months post-randomisation follow-up (g = 0.32, 95% CI: 0.16-0.48; I2 = 79.19%). Trials with initial human screening (g = 0.59) and interventions delivered in computer programs (g = 1.04) had the significantly largest effect sizes. No differences in treatment effects were observed across support levels, therapy types, commercial availability, or the presence of online discussion forums. Self-guided interventions were less acceptable than control conditions (RR = 0.92, p < 0.001). Most studies showed a moderate to high risk of bias (n = 80). INTERPRETATION: Existing trials on self-guided interventions are at high risk of bias, potentially overestimating treatment effects. Despite lower acceptability compared to controls, self-guided interventions are moderately effective in treating adult depression, regardless of support levels and online discussion features. FUNDING: None.

Web-Based, Human-Guided, or Computer-Guided Transdiagnostic Cognitive Behavioral Therapy in University Students With Anxiety and Depression: Randomized Controlled Trial.

BACKGROUND: Internet-based cognitive behavioral interventions (iCBTs) are efficacious treatments for depression and anxiety. However, it is unknown whether adding human guidance is feasible and beneficial within a large educational setting. OBJECTIVE: This study aims to potentially demonstrate the superiority of 2 variants of a transdiagnostic iCBT program (human-guided and computer-guided iCBT) over care as usual (CAU) in a large sample of university students and the superiority of human-guided iCBT over computer-guided iCBT. METHODS: A total of 801 students with elevated levels of anxiety, depression, or both from a large university in the Netherlands were recruited as participants and randomized to 1 of 3 conditions: human-guided iCBT, computer-guided iCBT, and CAU. The primary outcome measures were depression (Patient Health Questionnaire) and anxiety (Generalized Anxiety Disorder scale). Secondary outcomes included substance use-related problems (Alcohol Use Disorder Identification Test and Drug Abuse Screening Test-10 items). Linear mixed models were used to estimate the effects of time, treatment group, and their interactions (slopes). The primary research question was whether the 3 conditions differed in improvement over 3 time points (baseline, midtreatment, and after treatment) in terms of depression and anxiety symptoms. Results were analyzed according to the intention-to-treat principle using multiple imputation. Patients were followed exploratively from baseline to 6 and 12 months. RESULTS: In both short-term and long-term analyses, the slopes for the 3 conditions did not differ significantly in terms of depression and anxiety, although both web-based interventions were marginally more efficacious than CAU over 6 months (P values between .02 and .03). All groups showed significant improvement over time (P<.001). For the secondary outcomes, only significant improvements over time (across and not between groups) were found for drug use (P<.001). Significant differences were found in terms of adherence, indicating that participants in the human-guided condition did more sessions than those in the computer-guided condition (P=.002). CONCLUSIONS: The transdiagnostic iCBT program offers a practical, feasible, and efficacious alternative to usual care to tackle mental health problems in a large university setting. There is no indication that human guidance should be preferred over technological guidance. The potential preference of human support also depends on the scale of implementation and cost-effectiveness, which need to be addressed in future trials. TRIAL REGISTRATION: International Clinical Trials Registry Platform NL7328/NTR7544; https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON26795.

Effect of trauma on asylum seekers and refugees receiving a WHO psychological intervention: a mediation model.

Background: Scalable psychological interventions such as the WHO's Self-Help Plus (SH+) have been developed for clinical and non-clinical populations in need of psychological support. SH+ has been successfully implemented to prevent common mental disorders among asylum seekers and refugees who are growing in number due to increasing levels of forced migration. These populations are often exposed to multiple, severe sources of traumatisation, and evidence of the effect of such events on treatment is insufficient, especially for non-clinical populations.Objective: We aim to study the effect of potentially traumatic experiences (PTEs) and the mediating role of symptoms of posttraumatic stress disorder (PTSD) on the improvement following SH+.Method: Participants allocated to SH+ who received at least three sessions (N = 345) were extracted from two large, randomised, European prevention trials involving asylum seekers and refugees. Measures of distress, depression, functional impairment, and post-traumatic stress symptoms were administered at baseline and 6 months post-intervention, together with measures of well-being and quality of life. Adjusted models were constructed to examine the effect of PTEs on post-intervention improvement. The possible mediating role of PTSD symptoms in this relationship was then tested.Results: Increasing numbers of PTEs decreased the beneficial effect of SH+ for all measures. This relationship was mediated by symptoms of PTSD when analysing measures of well-being and quality of life. However, this did not apply for measures of mental health problems.Conclusions: Exposure to PTEs may largely reduce benefits from SH+. PTSD symptomatology plays a specific, mediating role on psychological well-being and quality of life of participants who experienced PTE. Healthcare professionals and researchers should consider the role of PTEs and PTSD symptoms in the treatment of migrants and refugees and explore possible feasible add-on solutions for cases exposed to multiple PTEs.

Increasing numbers of potentially traumatic experiences can decrease the beneficial effect of a manualized group psychotherapeutic intervention in migrants and refugees across multiple countries.In absence of a full threshold diagnosis of post-traumatic stress disorder, post-traumatic stress symptoms still mediate the relation between potentially traumatic experiences and some outcome improvements at follow-up.While the moderating role of number of potentially traumatic experiences applies to all outcomes (depression symptoms, psychological distress, functional impairment, well-being, and quality of life), the mediating role of post-traumatic stress symptoms in this relation only applies to well-being and quality of life.

Use of Machine Learning Algorithms Based on Text, Audio, and Video Data in the Prediction of Anxiety and Posttraumatic Stress in General and Clinical Populations: A Systematic Review.

Research in machine learning (ML) algorithms using natural behavior (i.e., text, audio, and video data) suggests that these techniques could contribute to personalization in psychology and psychiatry. However, a systematic review of the current state of the art is missing. Moreover, individual studies often target ML experts who may overlook potential clinical implications of their findings. In a narrative accessible to mental health professionals, we present a systematic review conducted in 5 psychology and 2 computer science databases. We included 128 studies that assessed the predictive power of ML algorithms using text, audio, and/or video data in the prediction of anxiety and posttraumatic stress disorder. Most studies (n = 87) were aimed at predicting anxiety, while the remainder (n = 41) focused on posttraumatic stress disorder. They were mostly published since 2019 in computer science journals and tested algorithms using text (n = 72) as opposed to audio or video. Studies focused mainly on general populations (n = 92) and less on laboratory experiments (n = 23) or clinical populations (n = 13). Methodological quality varied, as did reported metrics of the predictive power, hampering comparison across studies. Two-thirds of studies, which focused on both disorders, reported acceptable to very good predictive power (including high-quality studies only). The results of 33 studies were uninterpretable, mainly due to missing information. Research into ML algorithms using natural behavior is in its infancy but shows potential to contribute to diagnostics of mental disorders, such as anxiety and posttraumatic stress disorder, in the future if standardization of methods, reporting of results, and research in clinical populations are improved.

The efficacy of psychotherapy for social anxiety disorder, a systematic review and meta-analysis.

BACKGROUND: Given the growth in research examining the effects of psychotherapy on social anxiety disorder (SAD), an up-to-date comprehensive meta-analysis in this field is needed. METHODS: We selected studies from a database of randomized trials (RCTs) on psychotherapies for anxiety disorders (last updated search of PubMed, PsycINFO, Embase, and Cochrane (CENTRAL): 1 January 2024) We included RCTs comparing psychotherapy to a control condition for adults with SAD and conducted random effects meta-analyses to examine the efficacy of psychotherapy compared to control conditions at post-treatment. RESULTS: Sixty-six RCTs were included with 5560 participants and 98 comparisons between psychotherapy and control groups. Psychotherapy was effective in reducing SAD symptoms, with a large effect size (g = 0.88; 95 % CI: 0.76 to 1.0; I2 = 74 %; 95 % CI: 69 to 79, NNT = 3.8). Effects remained robust across sensitivity analyses. However, there was evidence for significant risk of bias in the included trials. The multivariable meta-regression indicated significant differences in treatment delivery formats, type of recruitment strategy, target group, and number of sessions. CONCLUSION: Psychotherapy is an effective treatment for SAD, with moderate to large effect sizes across all treatment types and formats. Future research is needed to determine the long-term effects.

Amount and frequency of psychotherapy as predictors of treatment outcome for adult depression: A meta-regression analysis.

BACKGROUND: It is not clear whether the amount and frequency of psychotherapy is associated with treatment effects for adult depression. We investigated whether a number of indicators of the amount and frequency of psychotherapy were related to the treatment effects in randomized controlled trials (RCTs) comparing individual, face-to-face psychotherapy to a control group (e.g., care-as-usual [CAU] or waitlist condition [WL]). METHODS: Four databases were systematically searched, and meta-regression analyses conducted to assess the relationship between the effect size (Hedges' g) of the treatment and number of sessions, duration of psychotherapy, total contact time with the therapist, and number of sessions per week. RESULTS: We included 176 studies (210 comparisons) with 15,158 participants. We did not find a relationship between the effect size, and number of sessions, or total contact time. There was a small negative association between duration of treatment and the effect size, an additional week of treatment was related to a 0.014 decrease in the effect size. In addition, there was a strong association between number of sessions per week and the effect size, an increase from one to two sessions per week was related to an effect size higher by 0.596. Both associations were no longer significant when controlling for characteristics of studies. LIMITATIONS: The current findings are correlational, future research should thus address this question in an RCT. CONCLUSIONS: We should deliver brief therapies, and thus shorten waiting lists. More sessions, if necessary, should be delivered with higher frequency and over a shorter period of time.

Combining endpoint and change data did not affect the summary standardised mean difference in pairwise and network meta-analyses: An empirical study in depression.

When studies use different scales to measure continuous outcomes, standardised mean differences (SMD) are required to meta-analyse the data. However, outcomes are often reported as endpoint or change from baseline scores. Combining corresponding SMDs can be problematic and available guidance advises against this practice. We aimed to examine the impact of combining the two types of SMD in meta-analyses of depression severity. We used individual participant data on pharmacological interventions (89 studies, 27,409 participants) and internet-delivered cognitive behavioural therapy (iCBT; 61 studies, 13,687 participants) for depression to compare endpoint and change from baseline SMDs at the study level. Next, we performed pairwise (PWMA) and network meta-analyses (NMA) using endpoint SMDs, change from baseline SMDs, or a mixture of the two. Study-specific SMDs calculated from endpoint and change from baseline data were largely similar, although for iCBT interventions 25% of the studies at 3 months were associated with important differences between study-specific SMDs (median 0.01, IQR -0.10, 0.13) especially in smaller trials with baseline imbalances. However, when pooled, the differences between endpoint and change SMDs were negligible. Pooling only the more favourable of the two SMDs did not materially affect meta-analyses, resulting in differences of pooled SMDs up to 0.05 and 0.13 in the pharmacological and iCBT datasets, respectively. Our findings have implications for meta-analyses in depression, where we showed that the choice between endpoint and change scores for estimating SMDs had immaterial impact on summary meta-analytic estimates. Future studies should replicate and extend our analyses to fields other than depression.

Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis.

Psychotherapies are first-line treatments for most mental disorders, but their absolute outcomes (i.e., response and remission rates) are not well studied, despite the relevance of such information for health care users, providers and policy makers. We aimed to examine absolute and relative outcomes of psychotherapies across eight mental disorders: major depressive disorder (MDD), social anxiety disorder, panic disorder, generalized anxiety disorder (GAD), specific phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and borderline personality disorder (BPD). We used a series of living systematic reviews included in the Metapsy initiative (www.metapsy.org), with a common strategy for literature search, inclusion of studies and extraction of data, and a common format for the analyses. Literature search was conducted in major bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane Register of Controlled Trials) up to January 1, 2023. We included randomized controlled trials comparing psychotherapies for any of the eight mental disorders, established by a diagnostic interview, with a control group (waitlist, care-as-usual, or pill placebo). We conducted random-effects model pairwise meta-analyses. The main outcome was the absolute rate of response (at least 50% symptom reduction between baseline and post-test) in the treatment and control conditions. Secondary outcomes included the relative risk (RR) of response, and the number needed to treat (NNT). Random-effects meta-analyses of the included 441 trials (33,881 patients) indicated modest response rates for psychotherapies: 0.42 (95% CI: 0.39-0.45) for MDD; 0.38 (95% CI: 0.33-0.43) for PTSD; 0.38 (95% CI: 0.30-0.47) for OCD; 0.38 (95% CI: 0.33-0.43) for panic disorder; 0.36 (95% CI: 0.30-0.42) for GAD; 0.32 (95% CI: 0.29-0.37) for social anxiety disorder; 0.32 (95% CI: 0.23-0.42) for specific phobia; and 0.24 (95% CI: 0.15-0.36) for BPD. Most sensitivity analyses broadly supported these findings. The RRs were significant for all disorders, except BPD. Our conclusion is that most psychotherapies for the eight mental disorders are effective compared with control conditions, but absolute response rates are modest. More effective treatments and interventions for those not responding to a first-line treatment are needed.

The outcomes of mental health care for depression over time: A meta-regression analysis of response rates in usual care.

BACKGROUND: Over the past decades dozens of randomized trials have shown that psychological treatments are more effective than care-as-usual (CAU). It could be expected that these treatments are implemented in routine care and that the response rates in usual care improve over time. The aim of the current meta-analysis is to examine if response and remission rates in usual care have improved over time. METHODS: We used an existing meta-analytic database of randomized controlled trials examining the effects of psychological treatments of depression and selected CAU control groups from these trials. We only included CAU conditions in primary care, specialized mental health care, perinatal care and general medical care. The response rate (50 % symptom reduction) was the primary outcome. RESULTS: We included 125 CAU control groups (8542 participants). The response rate for all CAU control groups was 0.22 (95 % CI: 0.19; 0.24) with high heterogeneity (I2 = 83; 95 % CI: 80; 85), with somewhat higher rates in primary care (0.27; 95 % CI: 0.23; 0.31). We found hardly any indications that the outcomes have improved over the years. The meta-regression analysis with publication year as predictor in the full dataset resulted in a coefficient of 0.1 (SE = 0.01; p = 0.0.35). A series of sensitivity analyses supported the main findings. Remission rates and pre-post effect sizes also did not significantly improve over time. CONCLUSIONS: Response and remission rates in usual care are low, with the large majority of patients not responding or remitting, and the outcomes have probably not improved over time.

Understanding priorities and needs for child and adolescent mental health in Greece from multiple informants: an open resource dataset.

The Child and Adolescent Mental Health Initiative (CAMHI) aims to enhance mental health care capacity for children and adolescents across Greece. Considering the need for evidence-based policy, the program developed an open-resource dataset for researching the field within the country. A comprehensive, mixed-method, community-based research was conducted in 2022/2023 assessing the current state, needs, barriers, and opportunities according to multiple viewpoints. We surveyed geographically distributed samples of 1,756 caregivers, 1,201 children/adolescents, 404 schoolteachers, and 475 health professionals using validated instruments to assess mental health symptoms, mental health needs, literacy and stigma, service use and access, professional practices, training background, and training needs and preferences. Fourteen focus groups were conducted with informants from diverse populations (including underrepresented minorities) to reach an in-depth understanding of those topics. A dataset with quantitative and qualitative findings is now available for researchers, policymakers, and society [ https://osf.io/crz6h/ and https://rpubs.com/camhi/sdashboard ]. This resource offers valuable data for assessing the needs and priorities for child and adolescent mental health care in Greece. It is now freely available to consult, and is expected to inform upcoming research and evidence-based professional training. This initiative may inspire similar ones in other countries, informing methodological strategies for researching mental health needs.

Assessment of suicidality in trials of psychological interventions for depression: a meta-analysis.

BACKGROUND: Psychological interventions that are efficacious as treatments for depression could indirectly affect suicide-related outcomes. We examined suicidal thoughts and behaviours as eligibility criteria, outcomes, and adverse events across trials of psychotherapy for depression. METHODS: We used a publicly available meta-analytic database developed through systematic searches (updated as of May 1, 2023) to identify randomised controlled trials in which a psychological intervention for depression was compared with an inactive or non-specific control condition in adults with depression and in which any suicide-related outcomes were reported. We also identified studies in which suicide risk was an exclusion criterion. We excluded inpatient studies and trials of unguided digital interventions or collaborative care that included a psychological component. Pairs of reviewers worked independently to select studies and extract data. In a random-effects meta-analysis with robust variance estimation, we assessed the effect of the psychological intervention on suicide outcomes in trials in which suicide was explicitly assessed as an outcome with clinical scales with established psychometric properties. Risk of bias was assessed with the Cochrane risk-of-bias tool (version 2). FINDINGS: Of the 469 randomised trials we identified in which a psychological intervention was compared with an inactive control in people with depression, 251 excluded people judged at risk of suicide. Any assessment of suicide was included in only 45 trials, 12 of which assessed suicidal ideation or risk as an outcome. These 12 trials included 3930 participants, 2795 (71%) of whom were female and 1135 (29%) of whom were male; data for age and ethnicity were not consistently reported. Psychological interventions for depression were associated with a small reduction in suicidal ideation and risk in 11 trials (one trial reported only follow-up data) after the intervention (standardised mean difference -0·31 [95% CI -0·60 to -0·03]) but not at follow-up (-0·49 [-1·31 to 0·32]). Suicide-related adverse events were reported in 25 trials, and suicide-related serious adverse events (eg, suicide attempts, deaths by suicide) were reported in 13 trials. Heterogeneity was substantial across all analyses, and prediction intervals crossed zero. INTERPRETATION: Trials of psychological interventions for depression rarely report assessments of suicide. Psychological interventions might reduce suicidal ideation in patients with depression, but more randomised controlled trials are required to clarify this effect. Monitoring and reporting of suicide-related adverse events should be improved in trials of psychological interventions for depression, and future trials should incorporate outcomes related to suicidal thoughts or behaviours. FUNDING: None. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

What works for whom and why? Treatment effects and their moderators among forcibly displaced people receiving psychological and psychosocial interventions: study protocol for an individual patient data meta-analysis.

INTRODUCTION: Forcibly displaced people (FDP) have a high risk of developing mental disorders such as post-traumatic stress (PTS) disorder. Providing adequate mental healthcare for FDP is crucial but despite overall efficacy of many existing interventions, a large proportion of FDP does not benefit from treatment, highlighting the necessity of further investigating factors contributing to individual differences in treatment outcome. Yet, the few studies that have explored moderators of treatment effects are often insufficiently powered. Therefore, the present Individual Patient Data meta-analysis (IPD-MA) will investigate treatment effects and their moderators-variables related to beneficiaries, providers, intervention and study characteristics in relation to PTS outcomes. METHODS AND ANALYSIS: A systematic literature search will be conducted from database inception in the databases PsycINFO, Cochrane, Embase, PTSDpubs and Web of Science. Only studies published in English, German, French, Spanish, Portuguese, and Dutch will be considered. Retrieved records will be screened for eligibility. Randomised controlled trials on adult FDP receiving psychological and psychosocial interventions aimed at alleviating symptoms such as PTS compared with a control condition without intervention will be included in this IPD-MA. Subsequently, authors of eligible studies will be contacted to request individual patient data (IPD). All datasets obtained will be synthesised into one large dataset which will be analysed using a one-stage approach by conducting mixed-effects linear regression models (ie, primary analysis). Additionally, aggregate data meta-analyes will be run using a two-stage approach by conducting multivariate regression models including all IPD (transformed) and available meta-data from study reports (ie, secondary analysis). PTS will serve as primary outcome measure, while mental health outcomes other than PTS, attendance, attrition, treatment non-response and adverse outcomes will be examined as secondary outcomes. ETHICS AND DISSEMINATION: This IPD-MA does not require ethical approval. The results will be published in international peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42022299510.

Non-directive supportive therapy for depression: A meta-analytic review.

BACKGROUND: Non-directive supportive therapy (NDST) is an important treatment of adult depression, but no recent meta-analysis has integrated the randomized trials examining its effects. METHODS: We conducted a meta-analysis comparing NDST to control conditions and to other therapies, by using an existing database of randomized trials of psychological treatments of depression in adults. This database was built through searches in PubMed, PsycINFO, Embase and the Cochrane Library. RESULTS: 48 randomized controlled trials (5075 participants), with 20 comparisons between NDST and a control group and 49 comparisons between NDST and another psychotherapy were included. Random effects meta-analyses found an effect size of NDST compared with control conditions of g = 0.53 (95 % CI, 0.34; 0.72) with moderate heterogeneity (I2 = 51; 95 % CI: 18; 71; PI = -0.02 to 1.09). NDST was less effective than other therapies (g = -0.21; 95 % CI: -0.31; -0.11). The difference with other therapies was significantly larger in studies in which NDST was used as a control group (p = .003). There was no significant difference between NDST and other therapies in which NDST was not used as a control group (k = 14; g = -0.05; 95 % CI: -0.17; 0.07). CONCLUSIONS: NDST probably is an effective treatment of depression. The effects may be somewhat smaller than those of other therapies, but that may also be an artefact, because NDST is often used as a control group and may be designed as an "intent-to-fail" intervention in some studies.

EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis.

BACKGROUND: This systematic review and individual participant data meta-analysis (IPDMA) examined the overall effectiveness of eye movement desensitization and reprocessing (EMDR) in reducing posttraumatic stress disorder (PTSD) symptoms, achieving response and remission, and reducing treatment dropout among adults with PTSD compared to other psychological treatments. Additionally, we examined available participant-level moderators of the efficacy of EMDR. METHODS: This study included randomized controlled trials. Eligible studies were identified by a systematic search in PubMed, Embase, PsyclNFO, PTSDpubs, and CENTRAL. The target population was adults with above-threshold baseline PTSD symptoms. Trials were eligible if at least 70% of study participants had been diagnosed with PTSD using a structured clinical interview. Primary outcomes included PTSD symptom severity, treatment response, and PTSD remission. Treatment dropout was a secondary outcome. The systematic search retrieved 15 eligible randomized controlled trials (RCTs); 8 of these 15 were able to be included in this IPDMA (346 patients). Comparator treatments included relaxation therapy, emotional freedom technique, trauma-focused cognitive behavioral psychotherapies, and REM-desensitization. RESULTS: One-stage IPDMA found no significant difference between EMDR and other psychological treatments in reducing PTSD symptom severity (ß = -0.24), achieving response (ß = 0.86), attaining remission (ß = 1.05), or reducing treatment dropout rates (ß = -0.25). Moderator analyses found unemployed participants receiving EMDR had higher PTSD symptom severity at the post-test, and males were more likely to drop out of EMDR treatment than females. CONCLUSION: The current study found no significant difference between EMDR and other psychological treatments. We found some indication of the moderating effects of gender and employment status.

Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials.

Importance: Generalized anxiety disorder (GAD) is one of the most common mental disorders in adults. Psychotherapies are among the most recommended treatments for GAD, but which should be considered as first-line treatment needs to be clarified. Objective: To use a network meta-analysis to examine the short- and long-term associations of different psychotherapies with outcomes of effectiveness and acceptability in adults with GAD. Data Sources: MEDLINE, Embase, PsycINFO, and the Cochrane Register of Controlled Trials were searched from database inception to January 1, 2023, to identify randomized clinical trials (RCTs) of psychotherapies for adults with GAD. Study Selection: RCTs comparing any type of psychotherapy against another or with a control condition for the treatment of adults (≥18 years, both sexes) with a primary diagnosis of GAD were eligible for inclusion. Data Extraction and Synthesis: This study followed Cochrane standards for extracting data and assessing data quality and used the PRISMA guideline for reporting. Risk of bias of individual studies was assessed using the second version of the Cochrane risk of bias tool, and the Confidence in Network Meta-Analysis was used to rate the certainty of evidence for meta-analytical results. Main Outcomes and Measures: Eight psychotherapies were compared against one another and with 2 control conditions. Primary outcomes were severity of GAD symptoms and acceptability of the psychotherapies. Random-effects model pairwise and network meta-analyses were conducted. For effectiveness, standardized mean differences (SMDs) were pooled, and for acceptability, relative risks with 95% CIs were calculated. Results: Data from 65 RCTs were included. Effect size estimates on data from 5048 participants (mean [SD], 70.9% [11.9%] women; mean [SD] age, 42.2 [12.5] years) suggested that third-wave cognitive behavior therapies (CBTs) (SMD, -0.76 [95% CI, -1.15 to -0.36]; certainty, moderate), CBT (SMD, -0.74 [95% CI, -1.09 to -0.38]; certainty, moderate), and relaxation therapy (SMD, -0.59 [95% CI, -1.07 to -0.11]; certainty, low) were associated with reduced GAD symptoms vs treatment as usual. Relative risks for all-cause discontinuation (indication of acceptability) signaled no differences compared with treatment as usual for all psychotherapies (eg, relative risk, 1.04 [95% CI, 0.64-1.67] for CBT vs treatment as usual). When excluding studies at high risk of bias, relaxation therapy lost its superiority over treatment as usual (SMD, -0.47; 95% CI, -1.18 to 0.23). When considering anxiety severity at 3 to 12 months after completion of the intervention, only CBT remained significantly associated with greater effectiveness than treatment as usual (SMD, -0.60; 95% CI, -0.99 to -0.21). Conclusions and Relevance: Given the evidence in this systematic review and network meta-analysis for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

The efficacy of cognitive behavioral therapies for depression in China in comparison with the rest of the world: A systematic review and meta-analysis.

OBJECTIVE: There is consistent evidence that cognitive behavioral therapies (CBTs) are effective interventions for adult depression. While some evidence has compared these effects in different countries, no prior systematic review and meta-analysis has compared the efficacy of CBTs between Chinese and people from the rest of the world. The current meta-analysis addressed this gap by a systematic review of eligible studies from Chinese and worldwide databases. METHOD: Hedges' g was calculated using a random-effects model. Subgroup analyses and multilevel meta-analytic models were conducted to examine the relationship among effect sizes and the characteristics in Chinese studies. Metaregression analyses were conducted to explore the difference of the efficacy of CBTs between Chinese studies and non-Chinese studies after controlling for the moderators. RESULTS: A total of 34 (n = 3,710) studies in China and 307 (n = 30,333) studies from the rest of the world were included. The effect size of CBTs on depression for Chinese participants was 1.19 (95% CI [0.86, 1.52]), which was higher (Q = 4.63, p = .03) than the effect size of the rest of the world (0.82, 95% CI [0.74, 0.90]). After controlling for moderators, the effect size of Chinese studies was still higher than non-Chinese studies (ß = 0.351, p = .011). CONCLUSIONS: CBTs are effective interventions for adult depression and deserve more attention in China for depression management. Moderators related to study design, clinical features, and cultural factors need to be considered in the interpretation of the results. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Baseline depression severity as moderator on depression outcomes in psychotherapy and pharmacotherapy.

BACKGROUND: Evidence-based treatments for adult depression include psychotherapy and pharmacotherapy, yet little is known about how baseline depression severity moderates treatment outcome. OBJECTIVES: We aimed to compare the effects of psychotherapy and pharmacotherapy for adult depression and to examine the association between baseline depression severity and treatment outcome, converting multiple baseline depression measures into the scores of the Beck Depression Inventory, second edition (BDI-II). METHODS: We conducted systematic searches in bibliographical databases up to September 2022 to identify randomized controlled trials (RCTs) in which psychotherapy was compared with pharmacotherapy in the treatment of adult depression. Various meta-regressions using the baseline depression severity as predictor of the relative effects of psychotherapy and pharmacotherapy were performed. RESULTS: We identified 65 RCTs including 7250 participants for the meta-analyses and 56 RCTs including 5548 participants for the meta-regression. We found no significant difference between psychotherapy and pharmacotherapy (g = -0.08, 95 % CI: -0.2 to 0.04, p = 0.193) and baseline depression severity was not significantly associated with the relative effects of psychotherapy and pharmacotherapy (B = 0.0032, SE = 0.0096, p = 0.74). Results were similar in several sensitivity analyses. LIMITATIONS: Limitations included the low quality of the included studies, and the omission of long-term effects and within-study variability. CONCLUSIONS: We found no indication for a moderation effect of baseline depression severity on the relative effects of psychotherapy and pharmacotherapy. Thus, other factors such as availability and patients' preference must be considered when deciding for treatment options.

Sources of stress among domestic and international students: a cross-sectional study of university students in Amsterdam, The Netherlands.

High perceived stress is associated with psychological and academic difficulties among college students. In this study, we aimed to investigate associations of student status (international vs domestic student in the Netherlands) with eight common sources of stress (i.e., financial, health, love life, relationship with family, relationship with people at work/ school, the health of loved ones, other problems of loved ones, and life in general). Participants were 2,196 college students (domestic: n = 1,642, international: n = 554) from two universities in Amsterdam, the Netherlands. Hierarchical linear regression analyses were used to estimate associations of student status with all eight sources of stress. Student status was significantly associated with higher levels of perceived stress in almost all life domains. International student status was significantly associated with higher perceived stress in the domains of financial situation and health of loved ones after adjusting for sociodemographic characteristics, depressive and anxiety symptoms, and other sources of stress. Findings highlight that several differences exist in the magnitude of perceived stress in certain areas between international and domestic students in the Netherlands. Consequently, it is essential to uncover the different needs of college students and develop specific strategies to deliver the most suitable services.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students.

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.