The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders.

BACKGROUND: The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression. METHODS: A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires. RESULTS: Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression. CONCLUSIONS: These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors.

BACKGROUND: Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes. METHODS: Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model. RESULTS: The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change. CONCLUSIONS: Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Culture and psychopathology: An attempt at reconsidering the role of social learning.

This paper proposes a model for developmental psychopathology that is informed by recent research suggestive of a single model of mental health disorder (the p factor) and seeks to integrate the role of the wider social and cultural environment into our model, which has previously been more narrowly focused on the role of the immediate caregiving context. Informed by recently emerging thinking on the social and culturally driven nature of human cognitive development, the ways in which humans are primed to learn and communicate culture, and a mentalizing perspective on the highly intersubjective nature of our capacity for affect regulation and social functioning, we set out a cultural-developmental approach to psychopathology.

A comparison of completion and recovery rates between first-line protocol-based cognitive behavioural therapy and non-manualized relational therapies within a UK psychological service.

This study compares completion and recovery rates between protocol-based cognitive behavioural therapy (CBT), offered as a first-line therapy for common mental health problems as per national guidelines, and relational therapies (RTs), scarcely provided in the English Improving Access to Psychological Therapies (IAPT) programme. This is a non-randomized, naturalistic study in a treatment-seeking community sample (n = 708). RTs consist of brief psychodynamic and relational integrative therapy. Completion rates relied on clinicians' coding and recovery rates were calculated based on the Patient Health Questionnaires-9 and the Generalized Anxiety Disorder-7. Doubly robust regression analysis was used to control both the treatment allocation and outcome variables for pretreatment differences between the intervention groups. Significantly more RT clients completed treatment compared with CBT clients. No significant differences in recovery rates between CBT and RTs were found using traditional null hypothesis significance tests; the groups were found to be equivalent using equivalence tests. Only when the analysis was repeated in treatment completers did CBT clients achieve around one-quarter higher recovery rates. Both CBT and RTs appeared to be equally effective and showed recovery and completion rates equivalent to or above the national average. These findings demonstrate the advantages of therapies other than CBT. Future research is needed to replicate the equivalence between these two treatments and to explore specific patient characteristics that make one treatment more suitable and acceptable than the other.

Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial.

BACKGROUND: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. METHODS: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. RESULTS: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes. CONCLUSIONS: DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

Study protocol for a pragmatic randomised multiple baseline trial evaluating Knowledge Insight Tools (KIT), a cognitive behavioural therapy-informed school-based counselling intervention for children and young people in UK secondary schools with low mood and anxiety.

BACKGROUND: There is a pressing need to offer more accessible, evidence-based psychological interventions to secondary school students who are increasingly reporting difficulties with anxiety and low mood. The aim of this pragmatic randomised multiple baseline trial is to evaluate the efficacy of a school-based counselling intervention called Knowledge Insight Tools (KIT) for reducing anxiety and low mood in UK secondary school students. KIT is a flexible intervention delivered individually and informed by cognitive behavioural therapy (CBT). METHODS: We will use a randomised multiple baseline design whereby young people will be randomly allocated to a baseline wait period of 3, 4, 5, 6, 7, or 8 weekly measurements, followed by receiving up to 10 weekly sessions of KIT delivered by trained, school-based practitioners. We aim to recruit 60 young people aged 11-18 who are primarily experiencing problems with low mood and/or anxiety from secondary schools across England and Scotland. We will assess child-reported anxiety, mood, and general psychological distress/coping with the Young Person's Clinical Outcomes in Routine Evaluation (YP-CORE), recorded at each session during the baseline and intervention phases. We will also assess child-reported anxiety and low mood with the Revised Children's Anxiety and Depression Scale (RCADS) at the beginning and end of treatment; practitioner-reported treatment fidelity with the KIT Fidelity Checklist; and practitioner-reported feasibility with an end-of-treatment Implementation Survey. We will analyse within-person and between-person change in YP-CORE scores across the baseline and intervention phases using visual analysis and piecewise multilevel growth curve models. We will also analyse pre-post changes in YP-CORE scores using randomisation tests, and reliable and clinically significant change using the RCADS scores. DISCUSSION: The KIT trial is a pragmatic, randomised multiple baseline trial aimed at evaluating a school-based, individual CBT counselling intervention for reducing anxiety and low mood in UK secondary school students. Results will directly inform the provision of KIT in school-based counselling services, as well as the growing evidence-base for school-based CBT interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT06188962. Retrospectively registered on 02/01/24.

Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data.

BACKGROUND: Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions. METHODS: PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models. RESULTS: IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations. CONCLUSIONS: These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

Eight-year prospective follow-up of mentalization-based treatment versus structured clinical management for people with borderline personality disorder.

Participants (n = 134) treated in a randomized controlled trial with mentalization-based treatment (MBT) compared with structured clinical management were followed up for 8 years after starting treatment in terms of the initial primary outcome of the trial-namely, suicide attempts, self-harm, and hospitalization-as well as service use and functional outcomes. Patients in the study group were interviewed by research assistants who remained masked to the original group allocation. Interviews were scheduled annually. Of the original participants, 98 (73%) agreed to participate. Overall, the beneficial outcomes at the end of treatment were maintained in both groups. Over the follow-up period, the number of patients who continued to meet the primary recovery criteria was significantly higher in the MBT group (74% vs. 51%). Use of most other services was comparable. Participants treated with MBT showed better functional outcomes in terms of being more likely to be engaged in purposeful activity and reporting less use of professional support services and social care interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Interpersonal Problems in Borderline Personality Disorder: Associations With Mentalizing, Emotion Regulation, and Impulsiveness.

Interpersonal problems are a core symptom of borderline personality disorder (BPD). This study investigated the relationship between emotion dysregulation, impulsiveness, and impaired mentalizing in the context of predicting interpersonal problems in BPD. A total of 210 patients with BPD completed the Difficulties in Emotion Regulation Scale (DERS), Barratt Impulsiveness Scale (BIS-11), Reflective Functioning Questionnaire (RFQ), and Inventory of Interpersonal Problems (IIP-32). The authors conducted three path models, with either mentalizing, emotion regulation, or impulsiveness as the exogenous variable. Emotion dysregulation and attentional impulsiveness predicted interpersonal problems directly, whereas hypomentalizing predicted interpersonal problems only indirectly throughout emotion dysregulation and attentional impulsiveness. The results suggest that these domains contribute significantly to interpersonal problems in BPD. Moreover, hypomentalizing might affect on interpersonal problems via its effect on impulsiveness and emotion regulation. The authors argue that focusing on emotion regulation and mentalizing in BPD treatments might have interlinked beneficial effects on interpersonal problems.

Drs. Constantinou and Fonagy Reply.

We thank Aristodemou and Fried1 for their thoughtful comments on our article about changes in the psychopathology bifactor dimensions over a psychosocial intervention.2 Aristodemou and Fried expressed concerns over our interpretation of the p factor and our selection of the bifactor model over alternative models. We will address each concern and highlight the issues they raise for the field more broadly.

Long-term outcomes of psychological interventions on children and young people's mental health: A systematic review and meta-analysis.

BACKGROUND: Over 600 RCTs have demonstrated the effectiveness of psychosocial interventions for children and young people's mental health, but little is known about the long-term outcomes. This systematic review sought to establish whether the effects of selective and indicated interventions were sustained at 12 months. METHOD: We conducted a systematic review and meta-analysis focusing on studies reporting medium term outcomes (12 months after end of intervention). FINDINGS: We identified 138 trials with 12-month follow-up data, yielding 165 comparisons, 99 of which also reported outcomes at end of intervention, yielding 117 comparisons. We found evidence of effect relative to control at end of intervention (K = 115, g = 0.39; 95% CI: 0.30-0.47 I2 = 84.19%, N = 13,982) which was maintained at 12 months (K = 165, g = 0.31, CI: 0.25-0.37, I2 = 77.35%, N = 25,652) across a range of diagnostic groups. We explored the impact of potential moderators on outcome, including modality, format and intensity of intervention, selective or indicated intervention, site of delivery, professional/para-professional and fidelity of delivery. We assessed both risk of study bias and publication bias. CONCLUSIONS: Psychosocial interventions provided in a range of settings by professionals and paraprofessionals can deliver lasting benefits. High levels of heterogeneity, moderate to high risk of bias for most studies and evidence of publication bias require caution in interpreting the results. Lack of studies in diagnostic groups such as ADHD and self-harm limit the conclusions that can be drawn. Programmes that increase such interventions' availability are justified by the benefits to children and young people and the decreased likelihood of disorder in adulthood.

Changes in General and Specific Psychopathology Factors Over a Psychosocial Intervention.

OBJECTIVE: Recent research suggests that comorbidity in child and adolescent psychiatric symptoms can be summarized by a single latent dimension known as the p factor and more specific factors summarizing clusters of symptoms. This study investigated within- and between-person changes in general and specific psychopathology factors over a psychosocial intervention. METHOD: A secondary analysis was conducted of the Systemic Therapy for At-Risk Teens study, a pragmatic randomized controlled trial that compared the effects of multisystemic therapy with those of management as usual for decreasing antisocial behavior in 684 adolescents (82% boys; 11-18 years old at baseline) over an 18-month period. The general p factor and specific antisocial, attention, anxiety, and mood factors were estimated from a symptom-level analysis of a set of narrowband symptom scales measured repeatedly during the study. General and specific psychopathology factors were assessed for reliability, validity, and within- and between-person change using a parallel process multilevel growth model. RESULTS: A revised bi-factor model that included a general p factor and specific anxiety, mood, antisocial, and attention factors with cross-loadings fit the data best. Although the factor structure was multidimensional, the p factor accounted for most of the variance in total scores. The p factor, anxiety, and antisocial factors predicted within-person variation in external outcomes. Furthermore, the p factor and antisocial factors showed within-person declines, whereas anxiety showed within-person increases, over time. Despite individual variation in baseline factor scores, adolescents showed similar rates of change. CONCLUSION: The bi-factor model is useful for teasing apart general and specific therapeutic changes that are conflated in standard analyses of symptom scores. CLINICAL TRIAL REGISTRATION INFORMATION: START (Systemic Therapy for At Risk Teens): A National Randomised Controlled Trial to Evaluate Multisystemic Therapy in the UK Context; http://www.isrctn.com; ISRCTN77132214.

The Effectiveness of Psychosocial Interventions for Psychological Outcomes in Pediatric Oncology: A Systematic Review.

CONTEXT: This review summarizes the current randomized controlled trials literature on psychological and physical outcomes of psychosocial interventions in pediatric oncology. OBJECTIVES: The objective of this study was to evaluate the effectiveness and impact of psychosocial interventions in children with cancer. METHODS: A search of the literature resulted in a total of 12 randomized clinical trials and these have evaluated psychosocial interventions in children younger than 18 years with current and previous diagnoses of cancer. Outcome measures were both psychological (e.g., symptoms of anxiety, depression, quality of life, and self-esteem) and physical (e.g., cancer symptoms, treatment adherence, and pain). Interventions identified included cognitive behavioral therapy (CBT; n = 4), joint CBT and physical exercise therapy (n = 1), family therapy (n = 2), therapeutic music video (n = 2), self-coping strategies (n = 1), a wish fulfillment intervention (n = 1), and joint family therapy and CBT (n = 1). RESULTS: Nine studies reported statistically significant improvements on psychological outcomes. These findings suggest that psychosocial interventions are effective at reducing anxiety and depressive symptoms as well as improving quality of life. Additionally, six studies found psychosocial interventions to have a positive impact on physical symptoms and well-being, including a reduction in procedural pain and symptom distress. CONCLUSION: These findings suggest that mental health needs in pediatric oncology patients can and should be addressed, potentially which will lead to better mental and physical health outcomes.