Longitudinal Clusters of Long-Term Trajectories in Patients with Early-Onset Chronic Depression: 2 Years of Naturalistic Follow-Up after Extensive Psychological Treatment.

INTRODUCTION: In clinical trials, mostly group-level treatment effects of repeated cross-sectional measures are analyzed. However, substantial heterogeneity regarding individual symptom profiles and the variability of treatment effects are often neglected, especially over the long-term course. To provide effective personalized treatments, investigations of these characteristics are urgently needed. METHODS: Depression severity ratings over 104 weeks of follow-up after year-long treatment with the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) or Supportive Psychotherapy (SP) were analyzed. Longitudinal cluster analysis and multinomial logistic regression analysis were conducted to investigate intraindividual trajectories from one of the largest psychotherapy trials in early-onset chronic depression. RESULTS: Two-year post-study-treatment trajectories of N = 188 patients with early-onset chronic depression were grouped into four prototypical clusters. Overall, 16.0% of patients remitted (cluster 1) and most of them did not receive any treatment during the 2-year follow-up. However, 84.0% of patients continued to experience subthreshold (37.2% cluster 2) or major depressive symptoms (46.8% clusters 3-4) and spent on average more than half of the follow-up in pharmacological and psychological treatment. Hierarchical regression analysis indicated that previous study treatment with CBASP or SP did not significantly predict cluster allocation, while baseline variables accounted for a large proportion of explained variance (R2 N = 0.64). CONCLUSION: While some patients experienced stable remission over 2 years of follow-up, the majority of patients experienced subthreshold or major depressive symptoms regardless of former study treatment with CBASP or SP. This calls for a long-term perspective implementing staging and innovative treatment approaches such as the sequential model or modular psychotherapy.

Methodological and Statistical Practices of Using Symptom Networks to Evaluate Mental Health Interventions: A Review and Reflections.

The network approach to psychopathology, which assesses associations between individual symptoms, has recently been applied to evaluate treatments for mental disorders. While various options for conducting network analyses in intervention research exist, an overview and an evaluation of the various approaches are currently missing. Therefore, we conducted a review on network analyses in intervention research. Studies were included if they constructed a symptom network, analyzed data that were collected before, during or after treatment of a mental disorder, and yielded information about the treatment effect. The 56 included studies were reviewed regarding their methodological and analytic strategies. About half of the studies based on data from randomized trials conducted a network intervention analysis, while the other half compared networks between treatment groups. The majority of studies estimated cross-sectional networks, even when repeated measures were available. All but five studies investigated networks on the group level. This review highlights that current methodological practices limit the information that can be gained through network analyses in intervention research. We discuss the strength and limitations of certain methodological and analytic strategies and propose that further work is needed to use the full potential of the network approach in intervention research.

Symptom-specific improvement across therapies and their putative mediators: A mediation network intervention analysis.

OBJECTIVE: We evaluated differential treatment effects on specific symptoms and their mediators for Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Supportive Psychotherapy (SP) in persistently depressed patients. METHOD: We conducted a Bayesian mediation network intervention analysis with data from a randomized controlled trial comparing CBASP and SP. Three networks were calculated to investigate (1) differential treatment effects on specific symptoms, (2) differential treatment effects on the potential mediators interpersonal problems and social functioning, and (3) associations between change in symptoms and change in the potential mediators. RESULTS: First, we found no evidence that CBASP more strongly improves most depressive symptoms specifically, except minimal evidence of symptom-specific effects on sleeping problems and self-esteem. Second, no and minimal evidence for differential treatment effects on interpersonal problems and social functioning was shown, respectively. Third, interpersonal problems and social functioning were strongly related to depressive symptoms. CONCLUSION: While CBASP showed superior treatment effects for overall symptom severity, this treatment might not be superior in improving specific symptoms and the potential mediators interpersonal problems and social functioning. Still, interpersonal problems and social functioning seem to play an important role for depression symptoms. Future research needs to further investigate potential working mechanisms of CBASP.Trial registration: ClinicalTrials.gov identifier: NCT00970437.

Post-traumatic stress disorder in refugee minors in an outpatient care center: prevalence and associated factors.

Due to their likelihood for experiencing a number of traumatic events, refugee minors have an increased risk of developing post-traumatic stress disorder (PTSD). However, the prevalence of PTSD in refugee children varies widely between studies, and it remains somewhat unclear what factors increase children's risk of PTSD. This study aimed to assess the prevalence of PTSD in a clinical outpatient sample of refugee minors, and to evaluate the association of different risk factors with a PTSD diagnosis. N = 417 refugee minors were recruited from an outpatient clinical center in Hamburg, Germany. The median age was 15.4 years and 74.6% of the minors were male. As part of the standard diagnostic process, their social history and a potential PTSD diagnosis using the Module K of the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was assessed. The predictive value of age, gender, number of interpersonal traumatic events, un-/accompanied status, presence of family member in the host country, flight duration, residence status, and time since arrival in the host country were investigated using logistic regression analysis. The prevalence of PTSD among the young refugee patients was 61.6%. Significant predictors of a PTSD diagnosis were number of interpersonal traumatic life events, age, residence status, and time since arrival in the host country. The prediction model explained 33.8% of variance of the outcome with the number of interpersonal traumatic events having the largest contribution (20.8%). The high prevalence of PTSD among refugee minors in outpatient care emphasizes the need to establish appropriate care structures and train specialists in the treatment of PTSD.

Depression among refugee youth in an outpatient healthcare center-prevalence and associated factors.

Background: Due to armed conflict and other crises, many children worldwide have to flee their home country and are, consequently, at a high risk for mental health problems. Objective: As the majority of previous research on refugee minors focused on post-traumatic stress disorder (PTSD), we aimed to assess the prevalence and risk factors for depression in a clinical sample of refugee youth. Methods: Data were collected during the standard diagnostic process in an outpatient refugee clinic in Germany. We assessed the prevalence of depression based on a diagnostic interview and investigated the association between age, gender, duration of flight, accompanying status, number of interpersonal traumatic experiences, residence status, and PTSD diagnosis with a depression diagnosis. More specifically, we conducted a Bayesian logistic regression with these associated factors as predictors and the presence of depression as the outcome. Additionally, we conducted a Bayesian network analysis including all these variables. Results: The majority of the 575 included refugee children were male (n = 423, 73.6%) and, on average, 15.1 years old (SD = 2.69). Nearly half of the children (n = 243, 42.3%) met the diagnostic criteria for depression, of which most also showed a comorbid PTSD diagnosis. We found strong evidence that age, gender, number of traumatic experiences, and a diagnosis of PTSD were related to depression. The network analysis indicated that only age, gender, and PTSD were directly associated to depression. Flight-related factors were only indirectly associated with depression due to their associations with number of traumatic experiences and PTSD diagnosis. Conclusion: The high prevalence of depression and its strong associations with PTSD suggest that refugee minors are likely to experience depressive symptoms which might develop from PTSD symptoms. This implies a need for monitoring depressive symptoms in refugee minors, especially when these have a PTSD diagnosis.

Application of the skills network approach to measure physician competence in shared decision making based on self-assessment.

Several approaches to and definitions of 'shared decision making' (SDM) exist, which makes measurement challenging. Recently, a skills network approach was proposed, which conceptualizes SDM competence as an organized network of interacting SDM skills. With this approach, it was possible to accurately predict observer-rated SDM competence of physicians from the patients' assessments of the physician's SDM skills. The aim of this study was to assess whether using the skills network approach allows to predict observer-rated SDM competence of physicians from their self-reported SDM skills. We conducted a secondary data analysis of an observational study, in which outpatient care physicians rated their use of SDM skills with the physician version of the 9-item Shared Decision Making Questionnaire (SDM-Q-Doc) during consultations with chronically ill adult patients. Based on the estimated association of each skill with all other skills, an SDM skills network for each physician was constructed. Network parameters were used to predict observer-rated SDM competence, which was determined from audio-recorded consultations using three widely used measures (OPTION-12, OPTION-5, Four Habits Coding Scheme). In our study, 28 physicians rated consultations with 308 patients. The skill 'deliberating the decision' was central in the population skills network averaged across physicians. The correlation between parameters of the skills networks and observer-rated competence ranged from 0.65 to 0.82 across analyses. The use and connectedness of the skill 'eliciting treatment preference of the patient' showed the strongest unique association with observer-rated competence. Thus, we found evidence that processing SDM skill ratings from the physicians' perspective according to the skills network approach offers new theoretically and empirically grounded opportunities for the assessment of SDM competence. A feasible and robust measurement of SDM competence is essential for research on SDM and can be applied for evaluating SDM competence during medical education, for training evaluation, and for quality management purposes. [A plain language summary of the study is available at https://osf.io/3wy4v.].

Correction: Application of the skills network approach to measure physician competence in shared decision making based on self-assessment.

[This corrects the article DOI: 10.1371/journal.pone.0282283.].

Implications of the Network Theory for the Treatment of Mental Disorders: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Conceptualizing mental disorders as latent entities has been challenged by the network theory of mental disorders, which states that psychological problems are constituted by a network of mutually interacting symptoms. While the implications of the network approach for planning and evaluating treatments have been intensively discussed, empirical support for the claims of the network theory regarding treatment effects is lacking. Objective: To assess the extent to which specific hypotheses derived from the network theory regarding the (interindividual) changeability of symptom dynamics in response to treatment align with empirical data. Design, Setting, and Participants: This secondary analysis entails data from a multisite randomized clinical trial, in which 254 patients with chronic depression reported on their depressive symptoms at every treatment session. Data collection was conducted between March 5, 2010, and October 14, 2013, and this analysis was conducted between November 1, 2021, and May 31, 2022. Intervention: Thirty-two sessions of either disorder-specific or nonspecific psychotherapy for chronic depression. Main Outcomes and Measures: Longitudinal associations of depressive symptoms with each other and change of these associations through treatment estimated by a time-varying longitudinal network model. Results: In a sample of 254 participants (166 [65.4%] women; mean [SD] age, 44.9 [11.9] years), symptom interactions changed through treatment, and this change varied across treatments and individuals. The mean absolute (ie, valence-ignorant) strength of symptom interactions (logarithmic odds ratio scale) increased from 0.40 (95% CI, 0.36-0.44) to 0.60 (95% CI, 0.52-0.70) during nonspecific psychotherapy and to 0.56 (95% CI, 0.48-0.64) during disorder-specific psychotherapy. In contrast, the mean raw (ie, valence-sensitive) strength of symptom interactions decreased from 0.32 (95% CI, 0.28-0.36) to 0.26 (95% CI, 0.20-0.32) and to 0.09 (95% CI, 0.02-0.16), respectively. Changing symptom severity could be explained to a large extent by symptom interactions. Conclusions and Relevance: These findings suggest that specific treatment-related hypotheses of the network theory align well with empirical data. Conceptualizing mental disorders as symptom networks and treatments as measures that aim to change these networks is expected to give further insights into the working mechanisms of mental health treatments, leading to the improvement of current and the development of new treatments. Trial Registration: ClinicalTrials.gov Identifier: NCT00970437.

A Multilevel Meta-analysis of Single-Case Research on Interventions for Internalizing Disorders in Children and Adolescents.

The effectiveness of interventions for internalizing disorders in children and adolescents was studied using a review and meta-analysis of published single-case research. Databases and other resources were searched for quantitative single-case studies in youth with anxiety, depressive, and posttraumatic stress disorders. Raw data from individual cases were aggregated and analyzed by means of multilevel meta-analytic models. Outcome variables were symptom severity assessed across baseline and treatment phases of the studies, and diagnostic status at post- and follow-up treatment. Single-case studies were rated for quality. We identified 71 studies including 321 cases (Mage = 10.66 years; 55% female). The mean quality of the studies was rated as below average, although there were considerable differences between the studies. Overall, positive within-person changes during the treatment phase in comparison to the baseline phase were found. In addition, positive changes in the diagnostic status were observed at post- and follow-up treatment. Yet high variability in treatment effects was found between cases and studies. This meta-analysis harvests the knowledge from published single-case research in youth-internalizing disorders and illustrates how within-person information from single-case studies can be summarized to explore the generalizability of the results from this type of research. The results emphasize the importance of keeping account of individual variability in providing and investigating youth interventions.

Using clinical expertise and empirical data in constructing networks of trauma symptoms in refugee youth.

Background: In recent years, many adolescents have fled their home countries due to war and human rights violations, consequently experiencing various traumatic events and putting them at risk of developing mental health problems. The symptomatology of refugee youth was shown to be multifaceted and often falling outside of traditional diagnoses. Objective: The present study aimed to investigate the symptomatology of this patient group by assessing the network structure of a wide range of symptoms. Further, we assessed clinicians' perceptions of symptoms relations in order to evaluate the clinical validity of the empirical network. Methods: Empirical data on Post-Traumatic Stress Disorder (PTSD), depression and other trauma symptoms from N = 366 refugee youth were collected during the routine diagnostic process of an outpatient centre for refugee youth in Germany. Additionally, four clinicians of this outpatient centre were asked how they perceive symptom relations in their patients using a newly developed tool. Separate networks were constructed based on 1) empirical symptom data and 2) clinicians' perceived symptom relations (PSR). Results: Both the network based on empirical data and the network based on clinicians' PSR showed that symptoms of PTSD and depression related most strongly within each respective cluster (connected mainly via sleeping problems), externalizing symptoms were somewhat related to PTSD symptoms and intrusions were central. Some differences were found within the clinicians' PSR as well as between the PSR and the empirical network. Still, the general PSR-network structure showed a moderate to good fit to the empirical data. Conclusion: Our results suggest that sleeping problems and intrusions play a central role in the symptomatology of refugee children, which has tentative implications for diagnostics and treatment. Further, externalizing symptoms might be an indicator for PTSD-symptoms. Finally, using clinicians' PSR for network construction offered a promising possibility to gain information on symptom networks and their clinical validity.

Antecedentes: En los últimos años, muchos adolescentes han huido de sus países de origen debido a la guerra y a violaciones contra los derechos humanos experimentando, como consecuencia, diversos eventos traumáticos y situándose en riesgo de desarrollar problemas de salud mental. La sintomatología de los refugiados jóvenes mostró ser multifacética y, por lo general, quedando fuera de los diagnósticos tradicionales.Objetivos: Este estudio tiene por objetivo investigar la sintomatología de este grupo de pacientes evaluando la estructura de redes de un amplio rango de síntomas. Además, evaluamos la percepción de los clínicos respecto a la relación de los síntomas para evaluar la validez clínica del trabajo de redes empírico.Métodos: Se recolectaron datos empíricos sobre el trastorno de estrés postraumático (TEPT), la depresión y otros síntomas de trauma de N = 366 jóvenes refugiados durante los procesos diagnósticos de rutina de un centro ambulatorio para refugiados jóvenes en Alemania. Además, a cuatro clínicos de este centro ambulatorio se les preguntó sobre cómo percibían las relaciones de los síntomas de sus pacientes empleando una herramienta recientemente desarrollada. Se construyeron redes separadas sobre la base de 1) datos empíricos de síntomas y 2) la percepción de la relación de los síntomas (PRS) de los clínicos.Resultados: Tanto las redes basadas en datos empíricos como las redes basadas en la PRS de los clínicos mostraron que los síntomas del TEPT y de la depresión se relacionaban con más fuerza con cada racimo respectivo de síntomas (conectados principalmente a través de los problemas de sueño). Los síntomas externalizantes estaban algo relacionados con los síntomas asociados al TEPT mientras que las intrusiones se constituyeron en algo central. Se encontraron algunas diferencias entre las propias PRS's de los clínicos, así como entre la PRS y las redes empíricas. Aun así, la restructura general de redes basadas en la PRS mostró una correspondencia moderada a buena con los datos empíricos.Conclusión: Nuestros resultados sugieren que los problemas de sueño y las intrusiones tienen un papel central en la sintomatología de los niños refugiados, lo que tiene implicancias tentativas para el diagnóstico y el tratamiento. Además, los síntomas externalizantes podrían ser un indicador de síntomas asociados al TEPT. Finalmente, empleando la PRS de los clínicos para la construcción de redes brindó una posibilidad prometedora para obtener información sobre las redes de síntomas y su validez clínica.

A Meta-Analysis of Maternal Prenatal Depression and Anxiety on Child Socioemotional Development.

OBJECTIVE: Observed associations between maternal prenatal stress and children's socioemotional development have varied widely in the literature. The objective of the current study was to provide a synthesis of studies examining maternal prenatal anxiety and depression and the socioemotional development of their children. METHOD: Eligible studies through to February 2018 were identified using a comprehensive search strategy. Included studies examined the association between maternal prenatal depression or anxiety and the future development of their children's socioemotional development (eg, difficult temperament, behavioral dysregulation) up to 18 years later. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean effect sizes and test for potential moderators. RESULTS: A total of 71 studies met full inclusion criteria for data analysis. The weighted average effect size for the association between prenatal stress and child socioemotional problems was as follows: odds ratio (OR) = 1.66 (95% CI = 1.54-1.79). Effect sizes were stronger for depression (OR = 1.79; 95% CI = 1.61-1.99) compared to anxiety (OR = 1.50; 95% CI = 1.36-1.64). Moderator analyses indicated that effect sizes were stronger when depression was more severe and when socio-demographic risk was heightened. CONCLUSION: Findings suggest that maternal prenatal stress is associated with offspring socioemotional development, with the effect size for prenatal depression being more robust than for anxiety. Mitigating stress and mental health difficulties in mothers during pregnancy may be an effective strategy for reducing offspring behavioral difficulties, especially in groups with social disadvantage and greater severity of mental health difficulties.