A network perspective on posttraumatic stress disorder and comorbid borderline personality disorder symptoms.

Background: Comorbidity between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) is surrounded by diagnostic controversy and although various effective treatments exist, dropout and nonresponse are high.Objective: By estimating the network structure of comorbid PTSD and BPD symptoms, the current study illustrates how the network perspective offers tools to tackle these challenges.Method: The sample comprised of 154 patients with a PTSD diagnosis and BPD symptoms, assessed by clinician-administered interviews. A regularised partial correlation network was estimated using the GLASSO algorithm in R. Central symptoms and bridge symptoms were identified. The reliability and accuracy of network parameters were determined through bootstrapping analyses.Results: PTSD and BPD symptoms largely clustered into separate communities. Intrusive memories, physiological cue reactivity and loss of interest were the most central symptoms, whereas amnesia and suicidal behaviour were least central.Conclusions: Present findings suggest that PTSD and BPD are two distinct, albeit weakly connected disorders. Treatment of the most central symptoms could lead to an overall deactivation of the network, while isolated symptoms would need more specific attention during therapy. Further experimental, longitudinal research is needed to confirm these hypotheses.Trial registration: ClinicalTrials.gov identifier: NCT03833453.

A network analysis of PTSD and BPD symptoms.PTSD and BPD symptoms largely clustered into separate communities.Intrusive memories, loss of interest and physiological cue reactivity seem valuable treatment targets.

Coercion During Psychiatric Ambulance Versus Police Transport in Mental Health Crises: A Pre- and Postimplementation Study.

OBJECTIVE: Police officers are often the first responders when individuals experience a mental health crisis and typically remain responsible for transport to a psychiatric emergency department. In 2014, a psychiatric ambulance (PA) was introduced in the city of Amsterdam to take over the transport of individuals in a mental health crisis. The purpose of the PA was to use fewer restrictive measures while guaranteeing safety for both patients and personnel. METHODS: A preimplementation-postimplementation design was used to assess the feasibility and utility of a single-vehicle PA service compared with police transport. Data on 498 rides were collected in the 4 months before implementation of the PA (pre-PA cohort) and on 655 rides in the 6 months after implementation (PA cohort). RESULTS: After PA implementation, most patients were transported by the PA (82%), and rides by police vehicle were very rare (1%). Individuals in the PA cohort had a greater transportation delay, compared with those in the pre-PA cohort, but the PA reduced use of coercive measures with no increase in the incidence of patient aggression. Among individuals in the PA cohort, hospitalization was more often voluntary than among those in the pre-PA cohort. CONCLUSIONS: Transporting emergency psychiatric patients by a special PA rather than by the police reduced the use of coercive measures during transport, kept the occurrence of aggressive incidents stable, and was associated with fewer coercive hospital admissions.

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

BACKGROUND: Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder. AIMS: To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy - short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy - with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941. METHOD: We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder. RESULTS: Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = -0.53, 95% CI -0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010). CONCLUSIONS: Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.

Economic evaluation of intensive home treatment in comparison to care as usual alongside a randomised controlled trial.

BACKGROUND: There is a dearth of research on the cost-effectiveness of intensive home treatment (IHT), an alternative to psychiatric hospitalisation for patients experiencing psychiatric crises. We therefore present a health economic evaluation alongside a pre-randomised controlled trial of IHT compared to care as usual (CAU). METHOD: Patients were pre-randomised to IHT or CAU using a double-consent open-label Zelen design. For the cost-utility analysis, the EuroQol 5-dimensional instrument was used. The cost-effectiveness was assessed using the Brief Psychiatric Rating Scale (BPRS). RESULTS: Data of 198 patients showed that each additional QALY gained from offering IHT instead of CAU was on average associated with an extra cost of €48,003. There is a 38% likelihood that IHT will lead to more QALYs at lower costs compared to CAU. An improvement of one additional point on the BPRS by offering IHT instead of CAU was associated with an extra cost of €19,203. There is a 38% likelihood that IHT will lead to higher BPRS score improvements at lower costs. Based on the NICE willingness-to-pay threshold of £30,000 (€35,000) per QALY, IHT could potentially be considered cost-effective with a likelihood of 55-60% when viewed from a societal perspective, and > 75% from a health care perspective. CONCLUSIONS: IHT appears slightly more attractive in terms of cost-utility and cost-effectiveness than CAU, although differences in both costs and effects are small especially when viewed from the societal costs perspective. From the health care sector costs perspective, IHT has a higher probability of being cost-effective compared to CAU. TRIALS REGISTRATION: Netherlands Trial Register: NTR6151.

Treatment of patients with anorexia nervosa and comorbid post-traumatic stress disorder; where do we stand? A systematic scoping review.

Objective: Comorbid post-traumatic stress disorder in patients with anorexia nervosa may negatively affect the course of anorexia nervosa treatment, which is already challenging. There are currently no guidelines or recommendations on concurrent treatment approaches for both anorexia nervosa and post-traumatic stress disorder. This systematic scoping review aims to explore the feasibility, acceptability and effectiveness of psychological trauma-focused treatment concurrently offered to underweight patients receiving anorexia nervosa treatment. Method: A multi-step literature search, according to an a priori protocol was performed. Databases PubMed, Embase, APA PsycINFO, Web of Science, Scopus and Cochrane Central were searched up to September 19th 2022, and the search was rerun June 19th 2023. For quality assessment, Risk of Bias in Non-randomised Studies-of Interventions tool was used. Results: The extensive search yielded 1769 reports, out of which only three observational pilot studies, both English and German, published between 2004 and 2022, could be included. The included studies reported on a total of 13 female participants between 16 and 58 years old, with anorexia nervosa or otherwise specified feeding or eating disorder, baseline BMI ranging between 14.6 and 16.5, who received concurrent anorexia and post-traumatic stress disorder treatment. In all participants, the emotional and cognitive functioning was sufficient to process the offered trauma-focused interventions, despite their significantly low body weight. Discussion: The findings of this review identify a dearth of treatment research on knowledge of concurrent trauma-focused treatments for patients with anorexia nervosa. Refraining patients with anorexia nervosa from trauma-focused treatment may not be warranted.

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

BACKGROUND: A strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning. METHODS: We analysed registry data for 2008-2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission. RESULTS: In 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls. CONCLUSION: There are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Impact of clinical severity on treatment response in a randomized controlled trial comparing day hospital and intensive outpatient mentalization-based treatment for borderline personality disorder.

This study examined the impact of clinical severity on treatment outcome in two programs that differ markedly in treatment intensity: day hospital mentalization-based treatment (MBT-DH) and intensive outpatient mentalization-based treatment (MBT-IOP) for borderline personality disorder (BPD). A multicenter randomized controlled trial was conducted. Participants include the full intention-to-treat sample of the original trial of N = 114 randomized BPD patients (MBT-DH n = 70, MBT-IOP n = 44), who were assessed at baseline and subsequently every 6 up to 36 months after start of treatment. Outcomes were general symptom severity, borderline features, and interpersonal functioning. Clinical severity was examined in terms of severity of BPD, general symptom severity, comorbid symptom disorders, comorbid personality disorders, and cluster C personality features. None of the severity measures was related to treatment outcome or differentially predicted treatment outcome in MBT-DH and MBT-IOP, with the exception of a single moderating effect of co morbid symptom disorders on outcome in terms of BPD features, indicating less improvement in MBT-DH for patients with more symptom disorders. Overall, patients with varying levels of clinical severity benefited equally from MBT-DH and MBT-IOP, indicating that clinical severity may not be a useful criterion to differentiate in treatment intensity.

Prescriptive factors for intensive home treatment in acute psychiatry: a secondary analysis of a randomised controlled trial.

BACKGROUND: Intensive home treatment (IHT) aims to prevent psychiatric hospitalisation. Although this intervention is well tested, it is still unknown for whom this intervention works best. Therefore, this study aims to explore prescriptive factors that moderate the effect of IHT compared to care as usual (CAU) on symptom severity. METHODS: Using data from a randomised controlled trial, 198 participants that experience an exacerbation of acute psychiatric symptoms were included in this secondary analysis. In order to maximise clinical relevance, generally available environmental and clinical baseline factors were included as tentative moderators: age, gender, employment status, domestic situation, psychiatric disorders, psychological symptoms, psychosocial functioning, alcohol and other substance use. The outcome variable symptom severity was measured using the Brief Psychiatric Rating Scale (BPRS) and collected at 26 and 52 weeks post-randomisation. Multiple regression analysis was used to examine which participants' characteristics moderate the effect of IHT on the total BPRS score. RESULTS: Our results suggest that being employed (B = 0.28, SE = 0.13, 95% CI = 0.03-0.53, p = 0.03) at baseline seems to have a moderation effect, which result in lower symptom severity scores at 26 weeks follow-up for patients who received IHT. This effect was not found at 52 weeks. CONCLUSIONS: On the basis of the number of factors tested, there is no evidence for robust outcome moderators of the effect of IHT versus CAU. Our conclusion is therefore that IHT can be offered to a diverse target population with comparable clinical results. TRIAL REGISTRATION: This trial is registered (date of registration: 2016-11-23) at the international clinical trials registry platform (NTR6151).

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

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

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

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

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

Schema therapy is an effective treatment for personality disorders (PDs). The theory of schema therapy assumes that the decrease of global psychological distress is mediated by change in Early Maladaptive Schemas. The few studies that have investigated a temporal relationship have produced contradictory results. This study examined the temporal relationship between changes in Early Maladaptive Schemas and global psychological distress in Group Schema Therapy (GST) for patients with personality disorders.Assessments were made of 115 patients at baseline, after 20, 40 and after 60 sessions of treatment. We used the Young Schema Questionnaire (YSQ) to measure the severity of Early Maladaptive Schemas and the Symptom Check List-90 Revisited (SCL-90R) to measure global psychological distress. Linear mixed model analyzes were used to examine the temporal relationship between the initial phase (0-20 and 0-40 sessions) and the later phase (40-60 sessions).Change in Early Maladaptive Schemas does not precede change in global psychological distress. Conversely, global psychological distress does not precede change in Early Maladaptive Schemas; the improvement in both indicators is concurrent.In this study, we could not confirm that the decrease of Early Maladaptive Schemas precedes decrease of global psychological distress. We found a concurrent relationship.

Self-rated personality disorder symptoms do not predict treatment outcome for posttraumatic stress disorder in routine clinical care.

OBJECTIVE: To test the hypothesis that self-rated personality disorder (PD) symptoms are a significant and clinically relevant predictor of treatment outcomes in a naturalistic treatment setting specialized in trauma-focused treatment using a single-group pretest-posttest design. METHOD: Treatment-seeking patients reporting clinical levels of posttraumatic stress disorder (PTSD) symptoms filled out questionnaires at intake and after treatment. The primary outcome was change in PTSD severity after treatment, measured by the PTSD Checklist for DSM-5 (PCL-5). PD symptoms were measured with the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ). Secondary outcomes were general mental health problems, treatment response, number of sessions and dropout. RESULTS: N = 1174 patients (59% female, baseline PCL-5 score M [SD] = 53.0 [10.8]) were included for the primary analysis. Regression analysis revealed that PD symptoms explained 0.4% of variance in PTSD symptom change (p = .066). After controlling for baseline PTSD symptoms, PD symptoms explained 0.0% of variance (p = .311). The fully adjusted model including baseline PTSD symptom severity, age, gender, cumulative exposure to potentially traumatic experiences, PD symptoms, and number of sessions together explained 5% of the observed variance in PTSD symptom change. Baseline PTSD severity was the only significant predictor and negatively predicted outcome. Sensitivity analyses with imputed data from N = 2694 cases yielded comparable results. Finally, secondary analyses showed that PD symptoms did not predict significant or clinically relevant changes in treatment response status, general mental health problems, dropout rates or number of sessions. CONCLUSION: The findings provide no evidence that self-rated PD symptoms predict treatment outcomes for patients suffering from clinical levels of PTSD symptoms in a naturalistic treatment setting specializing in trauma-focused treatment. Self-report screening for these symptoms to inform clinicians about expected effects of PTSD treatment is not supported by the evidence.

Preferences of young adults on the development of a new digital add-on alcohol intervention for depression treatment: A qualitative study.

Aim: To explore the preferences of young adults with regard to the development of a new digital add-on alcohol intervention to complement depression treatment. Methods: This qualitative study included young adults (18-35 years) with experience of either problematic alcohol use or depression or both (n = 29). Two rounds of focus groups were conducted, with two focus groups in each round. All focus groups were recorded, transcribed and analysed deductively and inductively on the basis of qualitative content analysis of the intervention type, features and design. Results: Young adults preferred a mobile health application with a clear and simple objective and navigation which was also accessible on a computer. With regard to intervention features, participants indicated a preference for in-depth, gain-framed information on alcohol use and a main feature enabling them to record their alcohol use and mood, which would be rewarded. Other preferences included personal goal-setting and monitoring, an activity list, experience stories, peer contact, guidance from experts by experience or volunteers and receiving notifications from the application. In terms of design, participants preferred short, animated videos and animation figure illustrations to complement written text. Moreover, participants rated the design of the intervention as highly important, yet very personal. Generally, participants preferred a light pastel colour scheme. Once again, participants indicated a need for a clear dashboard using pictograms to reduce the amount of text and fast, easy-to-use navigation. Conclusion: The preferences indicated by young adults with regard to the intervention type, features and design may enhance the development of a new digital add-on alcohol intervention to complement depression treatment.

Economic evaluation of web-based guided self-help cognitive behavioral therapy-enhanced for binge-eating disorder compared to a waiting list: A randomized controlled trial.

INTRODUCTION: The aim is to perform an economic evaluation alongside a randomized controlled trial comparing guided self-help cognitive behavioral therapy-enhanced (CBT-E) for binge-eating disorder (BED) to a waiting list control condition. METHODS: BED patients (N = 212) were randomly assigned to guided self-help CBT-E or the 3-month waiting list. Measurements took place at baseline and the end-of-treatment. The cost-effectiveness analysis was performed using the number of binge-eating episodes during the last 28 days as an outcome indicator according to the eating disorder examination. A cost-utility analysis was performed using the EuroQol-5D. RESULTS: The difference in societal costs over the 3 months of the intervention between both conditions was €679 (confidence interval [CI] 50-1330). The incremental costs associated with one incremental binge eating episode prevented in the guided self-help condition was approximately €18 (CI 1-41). From a societal perspective there was a 96% likelihood that guided self-help CBT-E led to a greater number of binge-eating episodes prevented, but at higher costs. Each additional quality-adjusted life year (QALY) gained was associated with incremental costs of €34,000 (CI 2494-154,530). With a 95% likelihood guided self-help CBT-E led to greater QALY gain at higher costs compared to waiting for treatment. Based on the National Institute for Health and Clinical Excellence willingness-to-pay threshold of €35,000 per QALY, guided self-help CBT-E can be considered cost-effective with a likelihood of 95% from a societal perspective. DISCUSSION: Guided self-help CBT-E is likely a cost-effective treatment for BED in the short-term (3-month course of treatment). Comparison to treatment-as-usual is recommended for future research, as it enables an economic evaluation with a longer time horizon. PUBLIC SIGNIFICANCE: Offering treatment remotely has several benefits for patients suffering from binge-eating disorders. Guided self-help CBT-E is an efficacious and likely cost-effective treatment, reducing binge eating and improving quality-of-life, albeit at higher societal costs.

The effectiveness of an additive informal social network intervention for forensic psychiatric outpatients: results of a randomized controlled trial.

Objectives: A supportive social network is associated with better mental health and wellbeing, and less criminal behavior. Therefore, this study examined the effectiveness of an additive informal social network intervention to treatment as usual (TAU) among forensic psychiatric outpatients. Materials and methods: An randomized controlled trial (RCT) was conducted in forensic psychiatric care, allocating eligible outpatients (N = 102) to TAU with an additive informal social network intervention or TAU alone. Participants receiving the additive intervention were matched to a trained community volunteer over 12 months. TAU consisted of forensic care (e.g., cognitive behavioral therapy and/or forensic flexible assertive community treatment). Follow-up assessments were conducted at 3, 6, 9, 12, and 18 months after baseline. The primary outcome was the between-group effect on mental wellbeing at 12 months. Between-group effects on secondary outcomes (e.g., general psychiatric functioning, hospitalization, criminal behavior) were explored. Results: Intention-to-treat analyses showed non-significant between-group effects on mental wellbeing on average over time and at 12 months. However, significant between-group effects were found on hospitalization duration and criminal behavior. Specifically, TAU participants were hospitalized 2.1 times more days within 12 months and 4.1 more days within 18 months than participants in the additive intervention. Furthermore, TAU participants reported 2.9 times more criminal behaviors on average over time. There were no significant effects on other outcomes. Exploratory analyses revealed that sex, comorbidity, and substance use disorders moderated effects. Conclusion: This is the first RCT examining the effectiveness of an additive informal social network intervention in forensic psychiatric outpatients. Although no improvements were found on mental wellbeing, the additive intervention was effective in reducing hospitalization and criminal behavior. The findings suggest that forensic outpatient treatment can be optimized by collaborating with informal care initiatives aimed at improving social networks within the community. Future research is warranted to determine which specific patients might benefit from the intervention and if effects can be improved by extending the intervention duration and enhancing patient compliance.Clinical Trial Registration: [https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7163], identifier [NTR7163].

Efficacy of Web-Based, Guided Self-help Cognitive Behavioral Therapy-Enhanced for Binge Eating Disorder: Randomized Controlled Trial.

BACKGROUND: Owing to the gap between treatment supply and demand, there are long waiting periods for patients with binge eating disorder, and there is an urgent need to increase their access to specialized treatment. Guided self-help cognitive behavioral therapy-enhanced (CBT-E) may have great advantages for patients if its efficacy can be established. OBJECTIVE: The aim of this study was to examine the efficacy of guided self-help CBT-E compared with that of a delayed-treatment control condition. METHODS: A single-blind 2-arm randomized controlled trial was designed to evaluate guided self-help CBT-E according to an intention-to-treat analysis. A total of 180 patients were randomly assigned to guided self-help CBT-E (n=90, 50%) or the delayed-treatment control condition (n=90, 50%) for which guided self-help CBT-E was provided after the initial 12-week delay. The primary outcome was reduction in binges. The secondary outcome was full recovery at the end of treatment, as measured using the Eating Disorder Examination during the last 4 weeks of treatment. A linear mixed model analysis was performed to compare treatment outcomes at the end of treatment. A second linear mixed model analysis was performed to measure between- and within-group effects for up to 24 weeks of follow-up. The Eating Disorder Examination-Questionnaire and clinical impairment assessment were conducted before and after treatment and during follow-up. In addition, dropout rates were assessed in both conditions. RESULTS: During the last 4 weeks of treatment, objective binges reduced from an average of 19 (SD 16) to 3 (SD 5) binges, and 40% (36/90) showed full recovery in the guided self-help CBT-E group. Between-group effect size (Cohen d) was 1.0 for objective binges. At follow-up, after both groups received treatment, there was no longer a difference between the groups. Of the 180 participants, 142 (78.9%) completed treatment. The overall treatment dropout appeared to be associated with gender, level of education, and number of objective binges at baseline but not with treatment condition. CONCLUSIONS: This is the first study to investigate the efficacy of guided self-help CBT-E. Guided self-help CBT-E appeared to be an efficacious treatment. This study's findings underscore the international guidelines recommending this type of treatment for binge eating disorder. TRIAL REGISTRATION: Netherlands Trial Registry (NTR) NL7994; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7994. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12888-020-02604-1.

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

Background: There is a considerable gap between care provision and the demand for care for common mental disorders in low-and-middle-income countries. Screening for these disorders, e.g., in primary care, will help to close this gap. However, appropriate norms and threshold values for screeners of common mental disorders are lacking. Methods: In a survey study, we gathered data on frequently used screeners for alcohol use disorders, (AUDIT), depression, (CES-D), and anxiety disorders (GAD-7, ACQ, and BSQ) in a representative sample from Suriname, a non-Latin American Caribbean country. A stratified sampling method was used by random selection of 2,863 respondents from 5 rural and 12 urban resorts. We established descriptive statistics of all scale scores and investigated unidimensionality. Furthermore, we compared scores by gender, age-group, and education level with t-test and Mann-Whitney U tests, using a significance level of p < 0.05. Results: Norms and crosswalk tables were established for the conversion of raw scores into a common metric: T-scores. Furthermore, recommended cut-off values on the T-score metric for severity levels were compared with international cut-off values for raw scores on these screeners. Discussion: The appropriateness of these cut-offs and the value of converting raw scores into T-scores are discussed. Cut-off values help with screening and early detection of those who are likely to have a common mental health disorder and may require treatment. Conversion of raw scores to a common metric in this study facilitates the interpretation of questionnaire results for clinicians and can improve health care provision through measurement-based care.

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

BACKGROUND: Cluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients. OBJECTIVE: In this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators. METHODS: This is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18-65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months. DISCUSSION: This is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons. TRIAL REGISTRATION: NL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

Patients' and volunteer coaches' experiences with an informal social network intervention in forensic psychiatric care: a qualitative analysis.

BACKGROUND: Improving supportive social networks in forensic psychiatric patients is deemed important due to the protective effects of such networks on both mental health problems and criminal recidivism. Informal interventions targeted at social network enhancement by community volunteers showed positive effects in various patient and offender populations. However, these interventions have not specifically been studied in forensic psychiatric populations. Therefore, forensic psychiatric outpatients' and volunteer coaches' experiences with an informal social network intervention were explored in this study. METHODS: This qualitative study was based on semi-structured interviews conducted alongside an RCT. Forensic outpatients allocated to the additive informal social network intervention, and volunteer coaches, were interviewed 12 months after baseline assessment. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to identify and report patterns in the data. RESULTS: We included 22 patients and 14 coaches in the study. The analysis of interviews revealed five main themes reflecting patients' and coaches' experiences: (1) dealing with patient receptivity, (2) developing social bonds, (3) receiving social support, (4) achieving meaningful change, and (5) using a personalized approach. Patient receptivity, including willingness, attitudes, and timing, was a common reported barrier affecting patients' engagement in the intervention. Both patients' and coaches' experiences confirmed that the intervention can be meaningful in developing new social bonds between them, in which patients received social support. Despite, experiences of meaningful and sustainable changes in patients' social situations were not clearly demonstrated. Coaches' experiences revealed broadened worldviews and an enhanced sense of fulfillment and purpose. Finally, a personalized, relationship-oriented rather than goal-oriented approach was feasible and preferable. CONCLUSION: This qualitative study showed positive experiences of both forensic psychiatric outpatients and volunteer coaches with an informal social network intervention in addition to forensic psychiatric care. Notwithstanding the limitations, the study suggests that these additive interventions provide an opportunity for forensic outpatients to experience new positive social interactions with individuals in the community, which can initiate personal development. Barriers and facilitators to engagement are discussed to improve further development and implementation of the intervention. TRIAL REGISTRATION: This study is registered at the Netherlands Trial Register (NTR7163, registration date: 16/04/2018).