Can CBT-E be delivered in an online group format? A pilot study of the Body Image module in a child and adolescent eating disorder service.

The increased prevalence of eating disorders during the COVID-19 pandemic has led to long waiting lists in child and adolescent services. A pilot study was conducted to evaluate the feasibility and acceptability of providing the Body Image module, from the enhanced cognitive behavioral therapy for eating disorders (CBT-E), in a virtual group setting. Primary outcomes were acceptance rates, completion rates, qualitative feedback and quantitative data from routine questionnaires. From 22 eligible referrals, 12 participants accepted and enrolled in therapy. Eight completed all six sessions. Qualitative feedback was positive, with both the content and group nature of the intervention being described as helpful. There was an reduction in scores in the Clinical Impairment Assessment and all subscales of the Eating Disorder Examination for Adolescents, suggesting this was a feasible method of providing psychological therapy within the service. A larger trial is recommended to robustly test the effectiveness of the intervention compared to one-to-one in-person CBT-E, and whether the full CBT-E protocol can be effectively delivered in the same format.

Are people with an intellectual disability at increased risk of attachment difficulties? A critical review.

Attachment difficulties are associated with a range of adverse outcomes in mental health, and people with intellectual disabilities (IDs) may be at greater risk of experiencing difficulties in their attachment relationships. This review critically evaluated recent research measuring the prevalence of attachment difficulties in people with ID. Eight studies met the inclusion criteria, and a higher prevalence of insecure and disorganized attachment classifications, and symptoms of attachment disorder, was found across a number of subgroups of people with diagnoses of ID. However, the validity and reliability of measures of attachment have not been empirically established in this population, and control groups were not always appropriate. These findings indicate the need to (1) develop reliable and standardized assessments of attachment for people with ID and (2) evaluate the efficacy of attachment-based interventions in relation to reducing psychological distress, mental health problems and expression of behaviours experienced by others as challenging.

Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials.

OBJECTIVE: To critically appraise papers reporting on moderators and mediators of recommended psychological treatments for anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents. METHOD: A systematic search of databases was conducted including PsycINFO, Embase, MEDLINE, AMED, CINAHL, and the Cochrane Library. Studies were included where a randomized controlled trial (RCT) compared therapies for AN or BN and reported on moderators or mediators of treatment effect. Twenty-one eligible papers were included, all based on data from eight RCTs. RESULTS: Family therapies were dominant in the literature. Individual or separated treatment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a family approach than to individual therapies. There was some evidence that a family treatment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with multiple, and post-hoc, analyses being run, and a broad range of outcome measures used. DISCUSSION: This review recommends that emerging findings are explored further in adequately powered trials of the different recommended therapies, with a move toward focusing on effect sizes. A consensus on acceptable definitions of outcome, including remission and recovery, would benefit future research.

OBJETIVO: Evaluar críticamente los artículos que informan sobre moderadores y mediadores de los tratamientos psicológicos recomendados para la anorexia nervosa (AN) y la bulimia nervosa (BN) en adolescentes. MÉTODO: Una búsqueda sistemática fue realizada en bases de datos incluyendo PsycINFO, Embase, MEDLINE, AMED, CINAHL y la Bibliotrca Cochrane. Los estudios fueron incluidos cuando un ensayo controlado aleatorio (RCT) comparaba terapias para AN o BN y reportaba en efectos del tratamiento de moderadores o mediadores. Se incluyeron veintiún artículos elegibles, todos basados en datos de ocho RCTs. RESULTADOS: Las terapias familiares fueron dominantes en la literatura. El tratamiento individual o separado parecía superior para familias con relaciones más difíciles, mientras que el tratamiento familiar en conjunto parecía ser superior cuando fueron reportadas buenas relaciones familiares. Cuando hubo una mayor psicopatología de trastorno de la conducta alimentaria en AN, incluyendo obsesiones y compulsiones relacionadas al trastorno de la conducta alimentaria, la respuesta a un abordaje familiar fue mejor que a terapias individuales. Hubo alguna evidencia de que un tratamiento familiar fue superior para aquellos involucrados en conductas purgativas en BN. Las medidas de las relaciones familiares, autoeficacia de los padres y cambio temprano emergieron como posibles mediadores, sin embargo, la calidad de la evidencia fue mixta y los hallazgos, en algunos casos, posiblemente circulares. Los análisis de moderadores y mediadores tenían poca potencia en todos los estudios, con multiples análisis llevados a cabo, y post-hoc, y un amplio rango de medidas de resultados utilizadas. DISCUSIÓN: Esta revisión recomienda que los hallazgos emergentes sean explorados más a fondo en ensayos adecuadamente potenciados de las diferentes terapias recomendadas, con un movimiento hacia enfocarse en el tamaño del efecto. Un consenso sobre definiciones aceptables del resultado, incluyendo remisión y recuperación, beneficiaría la investigación futura.

Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods.

BACKGROUND: One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise. OBJECTIVE: The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects. METHODS: Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training. RESULTS: A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being -0.06 (95% Cl -1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl -1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference -0.70, 95% CI -1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92). CONCLUSIONS: Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

Ketamine and other glutamate receptor modulators for depression in bipolar disorder in adults.

BACKGROUND: There is emerging evidence that glutamatergic system dysfunction might play an important role in the pathophysiology of bipolar depression. This review focuses on the use of glutamate receptor modulators for depression in bipolar disorder. OBJECTIVES: 1. To assess the effects of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with bipolar disorder.2. To review the acceptability of ketamine and other glutamate receptor modulators in people with bipolar disorder who are experiencing acute depression symptoms. SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR, to 9 January 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We cross-checked reference lists of relevant papers and systematic reviews. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing ketamine, memantine, or other glutamate receptor modulators with other active psychotropic drugs or saline placebo in adults with bipolar depression. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected studies for inclusion, assessed trial quality and extracted data. Primary outcomes for this review were response rate and adverse events. Secondary outcomes included remission rate, depression severity change scores, suicidality, cognition, quality of life, and dropout rate. We contacted study authors for additional information. MAIN RESULTS: Five studies (329 participants) were included in this review. All included studies were placebo-controlled and two-armed, and the glutamate receptor modulators - ketamine (two trials), memantine (two trials), and cytidine (one trial) - were used as add-on drugs to mood stabilisers. The treatment period ranged from a single intravenous administration (all ketamine studies), to repeated administration for memantine and cytidine (8 to 12 weeks, and 12 weeks, respectively). Three of the studies took place in the USA, one in Taiwan, and in one, the location was unclear. The majority (70.5%) of participants were from Taiwan. All participants had a primary diagnosis of bipolar disorder, according to the DSM-IV or DSM-IV-TR, and were in a current depressive phase. The severity of depression was at least moderate in all but one study.Among all glutamate receptor modulators included in this review, only ketamine appeared to be more efficacious than placebo 24 hours after the infusion for the primary outcome, response rate (odds ratio (OR) 11.61, 95% confidence interval (CI) 1.25 to 107.74; P = 0.03; I² = 0%, 2 studies, 33 participants). This evidence was rated as low quality. The statistically significant difference disappeared at three days, but the mean estimate still favoured ketamine (OR 8.24, 95% CI 0.84 to 80.61; 2 studies, 33 participants; very low quality evidence). We found no difference in response between ketamine and placebo at one week (OR 4.00, 95% CI 0.33 to 48.66; P = 0.28, 1 study; 18 participants; very low quality evidence).There was no significant difference between memantine and placebo in response rate one week after treatment (OR 1.08, 95% CI 0.06 to 19.05; P = 0.96, 1 study, 29 participants), two weeks (OR 4.88, 95% CI 0.78 to 30.29; P = 0.09, 1 study, 29 participants), four weeks (OR 5.33, 95% CI 1.02 to 27.76; P = 0.05, 1 study, 29 participants), or at three months (OR, 1.66, 95% CI 0.69 to 4.03; P = 0.26, I² = 36%, 2 studies, 261 participants). These findings were based on very low quality evidence.There was no significant difference between cytidine and placebo in response rate at three months (OR, 1.13, 95% CI 0.30 to 4.24; P = 0.86, 1 study, 35 participants; very low quality evidence).For the secondary outcome of remission, no significant differences were found between ketamine and placebo, nor between memantine and placebo. For the secondary outcome of change scores from baseline on depression scales, ketamine was more effective than placebo at 24 hours (MD -11.81, 95% CI -20.01 to -3.61; P = 0.005, 2 studies, 32 participants) but not at one or two weeks after treatment. There was no difference between memantine and placebo for this outcome.We found no significant differences in terms of adverse events between placebo and ketamine, memantine, or cytidine. There were no differences between ketamine and placebo, memantine and placebo, or cytidine and placebo in total dropouts. No data were available on dropouts due to adverse effects for ketamine or cytidine; but no difference was found between memantine and placebo. AUTHORS' CONCLUSIONS: Reliable conclusions from this review are severely limited by the small amount of data usable for analysis. The body of evidence about glutamate receptor modulators in bipolar disorder is even smaller than that which is available for unipolar depression. Overall, we found limited evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours; ketamine did not show any better efficacy in terms of remission in bipolar depression. Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. Ketamine's psychotomimetic effects could compromise study blinding; this is a particular issue for this review as no included study used an active comparator, and so we cannot rule out the potential bias introduced by inadequate blinding procedures.We did not find conclusive evidence on adverse events with ketamine. To draw more robust conclusions, further RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine and to study different methods of sustaining antidepressant response, such as repeated administrations. There was not enough evidence to draw meaningful conclusions for the remaining two glutamate receptor modulators (memantine and cytidine). This review is limited not only by completeness of evidence, but also by the low to very low quality of the available evidence.