Prevalence of suicidal ideation in German psychotherapy outpatients: A large multicenter assessment.

BACKGROUND: Suicidal ideation is a major concern in clinical practice. Yet, little is known about prevalence rates of suicidal ideation in patients undergoing outpatient psychotherapeutic treatment. Therefore, the aim of the current study is to assess the prevalence of suicidal ideation in a large sample of psychotherapy outpatients in Germany. The data analyzed in this study is taken from the KODAP-project on the coordination of data collection and analysis at German university-based research and training outpatient clinics for psychotherapy. METHODS: A total of N = 10,357 adult outpatients (64.4 % female; age: M(SD) = 35.94 (13.54), range: 18-92 years of age) starting cognitive-behavioral therapy at one of 27 outpatient clinics in Germany were included in the current study. Prevalence of suicidal ideation was assessed with the Suicide Item (Item 9) of the Beck-Depression Inventory II. RESULTS: Suicidal ideation was reported by 36.7 % (n = 3795) of the participants. Borderline Personality Disorder, Posttraumatic Stress Disorder, and recurrent Major Depression were the diagnoses most strongly associated with the presence and severity of suicidal ideation. LIMITATION: Suicide ideation was assessed only with the respective item of the Beck Depression Inventory II. CONCLUSION: Suicidal ideation is very common among adult patients who start psychotherapy in Germany. A well-founded knowledge of risk assessment in suicidal patients and suicide-specific treatment options is therefore highly relevant.

Investigating the feasibility and effectiveness of a modular treatment program for children and adolescents with depression and interpersonal problems: study protocol of a quasi-experimental pilot feasibility trial (CBASP@YoungAge).

BACKGROUND: Depression is a serious disorder in childhood and adolescence. Affected children and adolescents show significant impairments in various aspects of life. Studies on the effectiveness or efficacy of psychotherapy in depressed children and adolescents are qualitatively very heterogeneous and reveal small effect sizes. There is thus a need to better tailor psychotherapy approaches to these age groups to improve outcomes like parent-child relationship, symptomatology, or quality of life. To address this gap, we designed a modular, individualized treatment program for children and adolescents based on the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) including caregiver involvement. METHOD: This quasi-experimental pilot feasibility trial is a phase 1 to phase 2 study investigating the feasibility and effectiveness of CBASP@YoungAge by including an intervention group (CBASP@YoungAge) and a treatment-as-usual control group. The treatment of depressive symptoms as well as interpersonal problems with primary caregivers are the main targets of CBASP@YoungAge. Personalization is ensured concerning the treatment course, caregivers' involvement, and the patient's age. The primary outcome relates to two areas: the feasibility of the CBASP@YoungAge treatment program in an outpatient context and a change in patients' depressive symptomatology from before to after treatment. We conduct a brief process evaluation after each session in the intervention group to closely monitor the treatment process and examine feasibility from the therapists' and patients' perspectives and mechanisms of symptom change. In addition, we consider interpersonal behavior between children and caregivers, parenting behavior, and monitor the global-health-index in children and parents as secondary outcomes. Pre-, post-, and follow-up data are evaluated. DISCUSSION: This is the first study of a modular-based intervention program for children and adolescents with depression and a clear focus on the interpersonal problems between the depressed young patient and her/his caregiver. It will provide important knowledge on the feasibility and effectiveness of the program and potential benefits of including caregivers in psychotherapy. Based on this study's results, we plan a multicenter, randomized, controlled trial whose long-term aim is to improve the psychotherapeutic care of young patients with depression while preventing persistent courses of depressive disorders. TRIAL REGISTRATION: German Clinical Trials Register, DRKS (identifier DRKS00023281 ). Registered 17 November 2020-Retrospectively registered.

[Innovative psychotherapy research: towards an evidence-based and process-based individualized and modular psychotherapy]. / Innovative Psychotherapieforschung: auf dem Weg zu einer evidenz- und prozessbasierten individualisierten und modularen Psychotherapie.

Psychotherapy has been proven to be effective; however, this statement applies in particular to the "average patient" in randomized controlled trials. As a considerable proportion of patients do not show any benefits despite the constant development of new therapy methods and the mechanisms of action are still too little understood, innovative psychotherapy research has to address both problems. In addition, the idea of personalization that originated in somatic medicine or - from our point of view more appropriately - individualization or person-centering should be taken up. After providing an overview of further developments in psychotherapy beyond disorder-specific methods, this article presents an evidence- and process-based individualized and modular psychotherapy as a visionary goal of psychotherapeutic research: Beyond syndromes and disorders, as many biopsychosocial characteristics as possible and the processes and mechanisms underlying the mental problems should be analyzed and bundled in an individual comprehensive functional analysis. Based on this functional analysis, evidence-based techniques and modules should be selected. The individual response during the course of therapy should be continuously documented, so that feedback helps to determine the further therapeutic procedure. In order to pursue this vision, studies are needed that are oriented towards the individual patient, investigate the central mechanisms of action and generate large translational datasets. These should be analyzed by ideographic analyses and reduce the gap between research and practice, thus contributing to the paradigm of a practice research network, which is now consistently moving to the centre of research.

Efficacy of inpatient psychotherapy for major depressive disorder: a meta-analysis of controlled trials.

OBJECTIVE: This meta-analysis investigates the efficacy of inpatient psychotherapy in major depressive disorders compared to control conditions. METHODS: In total, 14 studies were entered into the meta-analysis with a total of 1.080 patients. Primary outcome was the standardized mean differences in self-rated depression outcomes. A priori planned subgroup analyses included the influence of different control conditions: (a) no psychiatric inpatient treatment (e.g., waitlist control), (b) treatment as usual (TAU; e.g., non-manualized clinical management), (c) TAU determined by study design (manualized/'placebo' control condition), as well as number of sessions and influence of self- vs. clinician ratings. RESULTS: The meta-analysis of 19 available comparisons resulted in a moderate pooled effect size showing a small and statistically significant benefit of the psychotherapeutic intervention over control conditions (g = 0.24, P < 0.001, I2  = 0%). This corresponds to a number needed to treat of 7.4. The effects of the interventions were stable over 12-month follow-up (g = 0.21, P < 0.01, I2  = 30%). Comparisons with waitlist or non-standardized control treatments tended to be associated with larger effect sizes than standardized control treatments. CONCLUSIONS: Despite some limitations (small number of studies), this meta-analysis provides evidence for a small but sustained effect of inpatient psychotherapy in patients with major depressive disorders.

Oxytocin plasma levels predict the outcome of psychotherapy: A pilot study in chronic depression.

BACKGROUND: Oxytocin is associated with bonding and social deficits in psychiatric disorders and has also been discussed as a potential therapeutic intervention to augment psychotherapy. The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a specific form of psychotherapy for chronic depression, an illness in which interpersonal deficits play a major role. In this pilot study, we investigated whether Oxytocin plasma levels predict the clinical outcome of chronic depressive patients after CBASP. METHODS: Sixteen patients with chronic depression participated in a 10-week CBASP inpatient program. Oxytocin plasma levels were measured before and after participants played a virtual ball-tossing game (Cyberball) that mimics social exclusion. Clinical outcome after CBASP was evaluated with the Beck Depression Inventory-II (BDI-II) and the 24-item Hamilton Depression Rating Scale (HAMD-24). RESULTS: After CBASP, depressive symptoms decreased significantly: the response rates were 44% (BDI-II) and 50% (HAMD-24); and the remission rates, 38% (BDI-II) and 44% (HAMD-24). Lower oxytocin plasma levels at baseline correlated with smaller changes in BDI-II scores, but not with the change in HAMD-24 scores. LIMITATIONS: The limitations of our study were the small sample size, concomitant and non-standardized pharmacotherapy, and lack of a controlled design and a follow-up period. CONCLUSIONS: Our study provides first evidence that oxytocin plasma levels may predict the outcome of psychotherapy in chronic depression. These findings need to be replicated in larger randomized, controlled trials.

Adverse events of group psychotherapy in the in-patient setting - results of a naturalistic trial.

OBJECTIVE: Adverse events of psychotherapy have often been neglected in research. In this study, potential adverse events of group psychotherapies in a psychiatric hospital were systematically assessed, explored for predictors and linked to treatment outcome. METHOD: A naturalistic trial was conducted in 180 in-patients attending different group psychotherapies. Adverse events were assessed using three different measures: (i) weekly reporting of unwanted treatment reactions, (ii) mood changes in response to every single group session and (iii) premature group termination. RESULTS: Different measures of adverse events were weakly associated. Deterioration of mood state and/or unwanted treatment reactions were experienced by 60-65% of all patients. Reports of unwanted treatment reactions decreased over time and were negatively associated with symptom improvement. However, mood state deterioration was constant and unrelated to treatment outcome. The rate of premature group termination was 34%. Significant predictors of adverse events included patient characteristics as well as disadvantageous group conditions. CONCLUSIONS: For the majority of patients, group psychotherapy in the in-patient setting is associated with adverse events. Changes over time and a strong correlation with general symptom severity must be considered in the assessment and interpretation of adverse events. Predictors should be considered as potential risk factors in future research.

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe.

PURPOSE: Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. METHODS: We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. RESULTS: We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. DISCUSSION: The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. CONCLUSION: Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.

[Affective disorders. The significance of psychotherapeutic approaches]. / Depressive Störungen. Stellenwert psychotherapeutischer Verfahren.

The use of psychotherapeutic strategies is essential in the treatment of affective disorders. Psychotherapy proved to be at least equivalent to antidepressant medication in the treatment of mild to moderate depression. In severe cases, the combination of both treatments is considered by guidelines to be the standard treatment. Psychotherapeutic approaches show a longer latency than antidepressants; however, the effects are longer lasting. Regarding the effectiveness of pharmacotherapy sobering results have been published recently. Therefore, the further development of psychotherapy deserves special attention. Cognitive behavioral therapy and interpersonal therapy provide the highest evidence. The empirical basis for psychodynamic psychotherapies is still limited. In the treatment of chronic depression a new approach--cognitive behavioral analysis system of psychotherapy--is gaining importance. There is a trend towards an increasing specification of psychotherapy for distinct subgroups of depressed patients. Challenges for the future include increasing treatment efficacy, investigating mechanisms of efficacy and predictors for a differential indication, and making effective approaches generally available to all patients.

[The etiopathogenesis of unipolar depression. Neurobiological and psychosocial factors]. / Atiopathogenese der unipolaren Depression. Neurobiologische und psychosoziale Faktoren.

Despite its clinical and socio-economic relevance, surprisingly little is known on the etiology of depression. A multitude of neurobiological and psychosocial hypotheses have been postulated but most lack empirical validity or cannot be integrated into comprehensive pathophysiological models. In neurobiological research, most evidence supports a contribution of genetic factors in the causation of depression. However, it seems that only the susceptibility for the disorder is inherited which ultimately causes the onset of depressive symptoms by interacting with psychosocial adversity. More recent research suggests an important role for altered stress responses and disturbed neuroplasticity in the etiopathogenesis of depression. From a psychosocial point of view, the different approaches prioritize different aspects. Psychoanalytical approaches assume a fragile self-worth system developed in early childhood as a decisive vulnerability factor for later depression. Behavioral-cognitive theories focus on dysfunctional cognitions coupled with learned helplessness and behavioural deficits as well as a failing in positive reinforced activities as predisposing factors for affective disorders. Interpersonal theories, however, postulate that the psychosocial and interpersonal context is most important for the development and course of depression. With regard to the etiopathogenesis of the so called difficult-to-treat chronic depression, especially early traumata as well as preoperational patterns of thinking seem to play a decisive role. In conclusion, only bio-psycho-social models which integrate neurobiological and psychosocial vulnerabilities and stressors have the potential to contribute to a better understanding of the etiology of depression.

P300 is enhanced in responders to vagus nerve stimulation for treatment of major depressive disorder.

BACKGROUND: Vagus nerve stimulation (VNS) is a new therapy option for treatment of otherwise therapy-refractory major depressive disorder. However, the mechanism of central nervous action is poorly understood. Electroencephalographic (EEG) studies may be of interest since chronic peripheral current application to the vagus nerve may exert lasting neurophysiologically detectable effects on central electrical activity. In an exploratory study, we investigated the effects of VNS on auditory event-related potentials (ERP). METHODS: Thirteen depressive patients (mean Hamilton depression score (HAMD) at baseline=24.2) receiving VNS were investigated prior to implantation and 10 weeks after standard cycling VNS. Stimulation intensity was 0.94+/-0.46 mA, pulse width 0.250 mus, and frequency 20 Hz. 1 h prior to follow-up investigation, VNS was turned off. Auditory ERP were elicited using a standard auditory oddball paradigm and were recorded with 29-channel EEG. RESULTS: Post VNS, grand averages of the auditory ERP did not show significant differences as compared to baseline recording. However, differential effects were found when separating ERP of responders (N=5, mean HAMD post VNS=8.8) and non-responders (N=8, mean HAMD post VNS=22.4). In VNS responders only, P300 at midline electrodes Fz and Cz was significantly increased and correlated with HAMD scores. CONCLUSION: Auditory ERP seem to provide a useful tool for investigating VNS-induced changes concerning information processing in major depressive disorder. In our sample, enhancement of P300 distinguished VNS responders from non-responders 10 weeks after therapy onset. Our findings may be relevant for the understanding of both neurophysiological mechanism of action of VNS and pathophysiology of depression.