Guided internet interventions for depression: impact of sociodemographic factors on treatment outcome in Indonesia.

Depression is the leading cause of disability worldwide, but an alarming treatment gap exists, especially in lower- and middle income countries (LMIC), where people are exposed to many societal and sociodemographic risk factors. As internet access increases in LMIC, online interventions could decrease this gap, especially when shown suitable for all demographics, including vulnerable groups with low socioeconomic status (SES). We used mixed-model analysis to explore moderating effects of sociodemographic factors (age, sex, education level, SES and urbanicity) on treatment effect in a recent trial in Indonesia, comparing guided online behavioral activation versus online psychoeducation only for depression, in 313 participants from (sub)urban areas. Outcome measures were self-reported Patient Health Questionnaire 9 (PHQ-9) and Inventory of Depressive Symptomatology (IDS-SR). Without correction for multiple testing, we found urbanicity to moderate treatment effect, with stronger treatment effect in suburban relative to urban participants (IDS-SR 24 weeks past baseline, p = 0.04) and a trend towards moderation by SES, with stronger treatment effect in low SES groups (PHQ-9 10 weeks past baseline, p = 0.07). These exploratory results suggest online treatments are a promising mental health intervention for all demographics in a (sub)urban LMIC setting, but hypothesis-testing studies including rural participants are warranted.

Personalized, Web-Based, Guided Self-Help for Patients With Medically Unexplained Symptoms in Primary Care: Protocol for a Randomized Controlled Trial.

BACKGROUND: Medically unexplained symptoms (MUS) constitute a major health problem because of their high prevalence, the suffering and disability they cause, and the associated medical costs. Web-based interventions may provide an accessible and convenient tool for managing MUS. We developed a personalized, Web-based, guided self-help intervention for MUS in primary care (Grip self-help) and would compare its effectiveness with that of usual care. OBJECTIVE: This paper aims to describe the rationale, objectives, and design of a pragmatic randomized controlled trial (RCT) assessing the effectiveness of Grip self-help. METHODS: For a pragmatic multicenter RCT, 165 adult patients with mild to moderate MUS will be recruited through general practices in the Netherlands. Randomization will be performed at general practice level. Over the course of several months, patients in the intervention group will receive a personalized set of Web-based self-help exercises, targeting the unhelpful cognitions, emotions, behaviors, and social factors that are relevant to them. The intervention is guided by a general practice mental health worker. The control group will receive care-as-usual. Primary outcome is physical health-related quality of life (RAND-36 or 36-item general health survey, physical component score). Secondary outcomes include severity of physical and psychological symptoms, mental health-related quality of life, cost-effectiveness, and acceptability. Assessments will take place at baseline, end of treatment, and at 16-, 26-, and 52-week follow-ups. RESULTS: Recruitment started in December 2018, and enrolment is ongoing. The first results are expected to be submitted for publication in December 2021. CONCLUSIONS: To our knowledge, this is the first study to combine the concepts of electronic health, self-help, and personalized medicine in the treatment of MUS. By improving the quality of life and reducing symptoms of patients with MUS, Grip self-help has the potential to reduce costs and conserve scarce health care resources. TRIAL REGISTRATION: Dutch Trial Register NTR7390; https://www.trialregister.nl/trial/7390. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/13738.

Patient satisfaction in treatment of non-complex fractures and dislocations in general practice in the Netherlands: prospective cohort study protocol.

INTRODUCTION: Diagnosis and treatment of fractures and dislocations are mostly performed in hospital settings. However, equal care for patients with non--complex fractures or dislocations ('minor trauma care') may be provided in general practice. While substitution of care from secondary to primary care settings is stimulated by governments and insurers, it is unknown what the effects are on patient satisfaction level. Therefore, our primary objective is to determine the effect of minor trauma care delivered in a general practice as compared with a hospital on patient satisfaction. Secondary objectives are to assess the effects on treatment outcomes, cost-effectiveness and time consumption. METHODS AND ANALYSIS: In a prospective cohort study, we will include 200 patients aged 12 and over with an X-ray confirmed diagnosis of a non--complex fracture or dislocation out of whom 100 treated in a general practice and 100 in a secondary care hospital, both located in the Netherlands. All treatment procedures and follow-up will be done in accordance to the hospital's standards of trauma care. Study assessments will be performed pre-treatment, and 1, 6 and 12 weeks after treatment. Data collected include demographics, patient satisfaction and patient-reported outcomes including physical functioning, complications, pain scores and treatment-related costs. The primary outcome patient satisfaction measured at 12 weeks will be compared between the settings and additionally multivariable regression will be performed to assess potential confounding effects of unbalanced prognostic factors. Treatment outcomes and time consumption will be analysed following the same approach while cost-effectiveness will be assessed using an incremental cost-effectiveness ratio. Subsequently, results will be discussed using focus groups consisting of patients (n=15) and healthcare providers. ETHICS AND DISSEMINATION: The Medical Ethics Committee from the University Medical Center Groningen reviewed this study protocol and granted exemption from ethical approval (METc UMCG 2017/277). Study results will be presented at (inter)national conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03506958; Pre-results.

Cost-effectiveness, cost-utility and the budget impact of antidepressants versus preventive cognitive therapy with or without tapering of antidepressants.

BACKGROUND: As depression has a recurrent course, relapse and recurrence prevention is essential.AimsIn our randomised controlled trial (registered with the Nederlands trial register, identifier: NTR1907), we found that adding preventive cognitive therapy (PCT) to maintenance antidepressants (PCT+AD) yielded substantial protective effects versus antidepressants only in individuals with recurrent depression. Antidepressants were not superior to PCT while tapering antidepressants (PCT/-AD). To inform decision-makers on treatment allocation, we present the corresponding cost-effectiveness, cost-utility and budget impact. METHOD: Data were analysed (n = 289) using a societal perspective with 24-months of follow-up, with depression-free days and quality-adjusted life years (QALYs) as health outcomes. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were derived to provide information about cost-effectiveness. The budget impact was examined with a health economic simulation model. RESULTS: Mean total costs over 24 months were €6814, €10 264 and €13 282 for AD+PCT, antidepressants only and PCT/-AD, respectively. Compared with antidepressants only, PCT+AD resulted in significant improvements in depression-free days but not QALYs. Health gains did not significantly favour antidepressants only versus PCT/-AD. High probabilities were found that PCT+AD versus antidepressants only and antidepressants only versus PCT/-AD were dominant with low willingness-to-pay thresholds. The budget impact analysis showed decreased societal costs for PCT+AD versus antidepressants only and for antidepressants only versus PCT/-AD. CONCLUSIONS: Adding PCT to antidepressants is cost-effective over 24 months and PCT with guided tapering of antidepressants in long-term users might result in extra costs. Future studies examining costs and effects of antidepressants versus psychological interventions over a longer period may identify a break-even point where PCT/-AD will become cost-effective.Declaration of interestC.L.H.B. is co-editor of PLOS One and receives no honorarium for this role. She is also co-developer of the Dutch multidisciplinary clinical guideline for anxiety and depression, for which she receives no remuneration. She is a member of the scientific advisory board of the National Insure Institute, for which she receives an honorarium, although this role has no direct relation to this study. C.L.H.B. has presented keynote addresses at conferences, such as the European Psychiatry Association and the European Conference Association, for which she sometimes receives an honorarium. She has presented clinical training workshops, some including a fee. She receives royalties from her books and co-edited books and she developed preventive cognitive therapy on the basis of the cognitive model of A. T. Beck. W.A.N. has received grants from the Netherlands Organisation for Health Research and Development and the European Union and honoraria and speakers' fees from Lundbeck and Aristo Pharma, and has served as a consultant for Daleco Pharma.

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis.

PURPOSE: Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care. METHODS: We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool. RESULTS: Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness. LIMITATIONS: The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety. CONCLUSIONS: E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.

Personality Traits Predict Meeting the WHO Recommendation of 6 Months' Breastfeeding: A Prospective General Population Cohort Study.

BACKGROUND: Although personality as well as anxiety and depression are recognized as predictors for breastfeeding initiation, evidence of an association of these factors with 6 months' exclusive breastfeeding as recommended by the World Health Organization (WHO) is sparse. PURPOSE: The purpose of this study was to investigate the associations of personality and symptoms of anxiety and depression during and after pregnancy with meeting the WHO recommendation of 6 months' exclusive breastfeeding. METHODS: In their first trimester of pregnancy, 5784 pregnant women were enrolled in Dutch primary obstetric care centers and hospitals, of which 2927 completed the breastfeeding assessments 6 months postpartum. We performed logistic regression analyses to test the associations of "big five" personality traits (NEO Five Factor Inventory), anxiety (State-Trait Anxiety Inventory), and depression (Edinburgh Postnatal Depression Scale) symptom levels during pregnancy and postpartum with meeting the WHO recommendation of 6 months' exclusive breastfeeding. RESULTS: Agreeableness (odds ratio [OR] = 1.18, P = .006) and openness (OR = 1.31, P < .001) were positively associated with meeting the WHO recommendation, whereas extraversion (OR = 0.83, P = .005) and neuroticism (OR = 1.18, P = .006) were negatively associated. After adjustment for both antenatal and postpartum symptom levels of anxiety and depression, the associations of the agreeableness, extraversion, and openness personality traits remained strong and statistically significant (P < .05). IMPLICATIONS FOR PRACTICE: Patient-centered care should take personality into account in an effort to tailor interventions to optimize breastfeeding behavior. IMPLICATIONS FOR RESEARCH: In contrast to earlier findings, personality traits may be of greater importance than symptoms of anxiety and depression for meeting the WHO recommendation of 6 months' exclusive breastfeeding.

Economic Evaluation of an Internet-Based Preventive Cognitive Therapy With Minimal Therapist Support for Recurrent Depression: Randomized Controlled Trial.

BACKGROUND: Major depressive disorder (MDD) is highly recurrent and has a significant disease burden. Although the effectiveness of internet-based interventions has been established for the treatment of acute MDD, little is known about their cost effectiveness, especially in recurrent MDD. OBJECTIVES: Our aim was to evaluate the cost effectiveness and cost utility of an internet-based relapse prevention program (mobile cognitive therapy, M-CT). METHODS: The economic evaluation was performed alongside a single-blind parallel group randomized controlled trial. Participants were recruited via media, general practitioners, and mental health care institutions. In total, 288 remitted individuals with a history of recurrent depression were eligible, of whom 264 were randomly allocated to M-CT with minimal therapist support added to treatment as usual (TAU) or TAU alone. M-CT comprised 8 online lessons, and participants were advised to complete 1 lesson per week. The economic evaluation was performed from a societal perspective with a 24-month time horizon. The health outcomes were number of depression-free days according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) criteria assessed with the Structured Clinical Interview for DSM-IV axis I disorders by blinded interviewers after 3, 12, and 24 months. Quality-adjusted life years (QALYs) were self-assessed with the three level version of the EuroQol Five Dimensional Questionnaire (EQ-5D-3L). Costs were assessed with the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness (TiC-P). Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that M-CT is cost effective compared to TAU. RESULTS: Mean total costs over 24 months were €8298 (US $9415) for M-CT and €7296 (US $8278) for TAU. No statistically significant differences were found between M-CT and TAU regarding depression-free days and QALYs (P=.37 and P=.92, respectively). The incremental costs were €179 (US $203) per depression-free day and €230,816 (US $261,875) per QALY. The cost-effectiveness acceptability curves suggested that for depression-free days, high investments have to be made to reach an acceptable probability that M-CT is cost effective compared to TAU. Regarding QALYs, considerable investments have to be made but the probability that M-CT is cost effective compared to TAU does not rise above 40%. CONCLUSIONS: The results suggest that adding M-CT to TAU is not effective and cost effective compared to TAU alone. Adherence rates were similar to other studies and therefore do not explain this finding. The participants scarcely booked additional therapist support, resulting in 17.3 minutes of mean total therapist support. More studies are needed to examine the cost effectiveness of internet-based interventions with respect to long-term outcomes and the role and optimal dosage of therapist support. Overall, more research is needed on scalable and cost-effective interventions that can reduce the burden of recurrent MDD. TRIAL REGISTRATION: Netherlands Trial Register NTR2503; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2503 (Archived by WebCite at http://www.webcitation.org/73aBn41r3).

Age-related reference values for the pediatric Scale for Assessment and Rating of Ataxia: a multicentre study.

AIM: For reliable assessment of ataxia severity in children, the Childhood Ataxia and Cerebellar Group of the European Pediatric Neurology Society aimed to validate the Scale for Assessment and Rating of Ataxia (SARA) according to age. METHOD: Twenty-two pediatric ataxia experts from 15 international institutions scored videotaped SARA performances in 156 typically developing children (4-16y: m/f=1; 12 children per year of age; including nine different nationalities). We determined age-dependency and reliability of pediatric SARA scores by a mixed model. RESULTS: In typically developing children, age was the only variable that revealed a relationship with SARA scores (p<0.001). The youngest children revealed the highest scores and the highest variation in scores (<8y; p<0.001). After 11 years of age, pediatric scores approached adult outcomes. The interobserver agreement of total SARA scores was substantial with an intraclass correlation coefficient of 0.63 (95% confidence interval 0.56-0.69; p<0.001). INTERPRETATION: In typically developing European children, both SARA scores and interobserver agreement are age-dependent. For reliable interpretation of pediatric SARA scores, consideration of the underlying test construct appears prudent. These data will hopefully contribute to a correct and uniform interpretation of longitudinal SARA scores from childhood to adulthood.

Blended care vs. usual care in the treatment of depressive symptoms and disorders in general practice [BLENDING]: study protocol of a non-inferiority randomized trial.

BACKGROUND: The majority of patients with depressive disorders are treated by general practitioners (GPs) and are prescribed antidepressant medication. Patients prefer psychological treatments but they are under-used, mainly due to time constraints and limited accessibility. A promising approach to deliver psychological treatment is blended care, i.e. guided online treatment. However, the cost-effectiveness of blended care formatted as an online psychological treatment supported by the patients' own GP or general practice mental health worker (MHW) in routine primary care is unknown. We aim to demonstrate non-inferiority of blended care compared with usual care in patients with depressive symptoms or a depressive disorder in general practice. Additionally, we will explore the real-time course over the day of emotions and affect, and events within individuals during treatment. METHODS: This is a pragmatic non-inferiority trial including 300 patients with depressive symptoms, recruited by collaborating GPs and MHWs. After inclusion, participants are randomized to either blended care or usual care in routine general practice. Blended care consists of the 'Act and Feel' treatment: an eight-week web-based program based on behavioral activation with integrated monitoring of depressive symptomatology and automatized feedback. GPs or their MHWs coach the participants through regular face-to-face or telephonic consultations with at least three sessions. Depressive symptomatology, health status, functional impairment, treatment satisfaction, daily activities and resource use are assessed during a follow-up period of 12 months. During treatment, real-time fluctuations in emotions and affect, and daily events will be rated using ecological momentary assessment. The primary outcome is the reduction of depressive symptoms from baseline to three months follow-up. We will conduct intention-to-treat analyses and supplementary per-protocol analyses. DISCUSSION: This trial will show whether blended care might be an appropriate treatment strategy for patients with depressive symptoms and depressive disorder in general practice. TRIAL REGISTRATION: Netherlands Trial Register: NTR4757; 25 August 2014. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4757 . (Archived by WebCite® at http://www.webcitation.org/6mnXNMGef ).

Reliability of phenotypic early-onset ataxia assessment: a pilot study.

AIM: To investigate the interobserver agreement on phenotypic early-onset ataxia (EOA) assessment and to explore whether the Scale for Assessment and Rating of Ataxia (SARA) could provide a supportive marker. METHOD: Seven movement disorder specialists provided independent phenotypic assessments of potentially ataxic motor behaviour in 40 patients (mean age 15y [range 5-34]; data derived from University Medical Center Groningen medical records 1998-2012). We determined interobserver agreement by Fleiss' kappa. Furthermore, we compared percentage SARA subscores ([subscore/total score]×100%) between 'indisputable' (primary ataxia recognition by at least six observers) and 'mixed' (ataxia recognition, unfulfilling 'indisputable' criteria) EOA phenotypes. RESULTS: Agreement on phenotypic EOA assessment was statistically significant (p<0.001), but of moderate strength (Fleiss' kappa=0.45; 95% CI 0.38-0.51). During mild disease progression, percentage SARA gait subscores discriminated between 'indisputable' and 'mixed' EOA phenotypes. In patients with percentage SARA gait subscores >30%, primary ataxia was more frequently present than in those with subscores <30% (p=0.001). INTERPRETATION: Among movement-disorder professionals from different disciplines, interobserver agreement on phenotypic EOA recognition is of limited strength. SARA gait subscores can provide a supportive discriminative marker between EOA phenotypes. Hopefully, future phenotypic insight will contribute to the inclusion of uniform, high-quality data in international EOA databases.

Pregnancy Outcomes After a Maternity Intervention for Stressful Emotions (PROMISES): A Randomised Controlled Trial.

UNLABELLED: There is ample evidence from observational prospective studies that maternal depression or anxiety during pregnancy is a risk factor for adverse psychosocial outcomes in the offspring. However, to date no previous study has demonstrated that treatment of depressive or anxious symptoms in pregnancy actually could prevent psychosocial problems in children. Preventing psychosocial problems in children will eventually bring down the huge public health burden of mental disease. The main objective of this study is to assess the effects of cognitive behavioural therapy in pregnant women with symptoms of anxiety or depression on the child's development as well as behavioural and emotional problems. In addition, we aim to study its effects on the child's development, maternal mental health, and neonatal outcomes, as well as the cost-effectiveness of cognitive behavioural therapy relative to usual care.We will include 300 women with at least moderate levels of anxiety or depression at the end of the first trimester of pregnancy. By including 300 women, we will be able to demonstrate effect sizes of 0.35 or more on the total problems scale of the Child Behaviour Checklist 1.5-5 with alpha 5 % and power (1-beta) 80 %.Women in the intervention arm are offered 10-14 individual cognitive behavioural therapy sessions, 6-10 sessions during pregnancy and 4-8 sessions after delivery (once a week). Women in the control group receive care as usual.Primary outcome is behavioural/emotional problems at 1.5 years of age as assessed by the total problems scale of the Child Behaviour Checklist 1.5-5 years.Secondary outcomes are mental, psychomotor and behavioural development of the child at age 18 months according to the Bayley scales; maternal anxiety and depression during pregnancy and postpartum; and neonatal outcomes such as birth weight, gestational age and Apgar score, health-care consumption and general health status (economic evaluation). TRIAL REGISTRATION: NTR2242.

Assessment of speech in early-onset ataxia: a pilot study.

AIM: The aim of the study was to determine whether paediatric ataxia speech subscores are reliably applicable for international early-onset ataxia (EOA) databases. If so, we reasoned that ataxia speech subscores should be associated with ataxia scores and involve high interobserver agreement, including those for internationally applicable Scale for Assessment and Rating of Ataxia (SARA) syllable repetition tasks (SARASRT). METHOD: Three independent paediatric neurologists and a speech therapist scored speech in 52 healthy children (mean age 10y, range 4-16y) and 40 individuals with EOA (mean age 15y, range 5-34y). We compared ataxia speech subscores for the association with age and ataxia scores as well as interobserver reliability. RESULTS: In healthy children, ataxia speech subscores were moderately associated with age (International Cooperative Ataxia Rating Scale [ICARS]: r=-0.515; SARA: r=-0.321; p<0.05) and with ataxia scores (ICARS: r=0.552; SARA: r=0.336; p<0.05), and revealed slight to moderate interobserver agreement (ICARS-intraclass correlation coefficient [ICC]: 0.380; SARA-ICC: 0.185; SARASRT-ICC: 0.509). In EOA, speech subscores have a strong association with ataxia scores (ICARS: r=0.735; SARA: r=0.730; p<0.001) and revealed substantial to nearly perfect interobserver agreement (ICARS-ICC: 0.812; SARA-ICC: 0.854; SARASRT-ICC: 0.724). INTERPRETATION: Early-onset ataxia speech subscores are associated with ataxia and also reveal high interobserver agreement, including those internationally applicable to SARASRT. We conclude that SARASRT appears to be applicable for EOA databases. However, before syllable repetition tasks are included, we would advise to wait for the results published by the international Childhood Ataxia and Cerebellar Group.

Visual assessment of segmental muscle ultrasound images in spina bifida aperta.

In spina bifida aperta (SBA), spinal MRI provides a surrogate marker to estimate muscle damage caudal to the myelomeningocele (MMC). This muscle damage by the MMC can be quantified by intra-individual comparison of muscle ultrasound density (MUD) caudal versus cranial to the MMC (dMUD = [MUD(caudal-to-the-MMC)] - [MUD(cranial-to-the-MMC)]). Quantitative dMUD assessment requires time, equipment and expertise, whereas it could also be visually determined by differences in muscle echodensity caudal vs. cranial to the MMC (visual-dMUD). If visual and quantitative dMUD correspond, visual dMUD assessment could provide a clinical screening parameter. In 100 SBA muscle ultrasound recordings of patients with various MMC levels, we aimed to compare quantitative dMUD (dMUD = [MUD(calf-muscle/S1)] - [MUD(quadriceps-muscle/L2-L4)]) with visual dMUD assessments by 20 different observers. Results indicate that quantitative dMUD can be visually detected (sensitivity 86%; specificity 57%), implicating that visual dMUD screening could provide a quick, clinical screening tool for muscle impairment by the MMC.

PRegnancy Outcomes after a Maternity Intervention for Stressful EmotionS (PROMISES): study protocol for a randomised controlled trial.

BACKGROUND: There is ample evidence from observational prospective studies that maternal depression or anxiety during pregnancy is a risk factor for adverse psychosocial outcomes in the offspring. However, to date no previous study has demonstrated that treatment of depressive or anxious symptoms in pregnancy actually could prevent psychosocial problems in children. Preventing psychosocial problems in children will eventually bring down the huge public health burden of mental disease. The main objective of this study is to assess the effects of cognitive behavioural therapy in pregnant women with symptoms of anxiety or depression on the child's development as well as behavioural and emotional problems. In addition, we aim to study its effects on the child's development, maternal mental health, and neonatal outcomes, as well as the cost-effectiveness of cognitive behavioural therapy relative to usual care. METHODS/DESIGN: We will include 300 women with at least moderate levels of anxiety or depression at the end of the first trimester of pregnancy. By including 300 women we will be able to demonstrate effect sizes of 0.35 or over on the total problems scale of the child behavioural checklist 1.5-5 with alpha 5% and power (1-beta) 80%.Women in the intervention arm are offered 10-14 individual cognitive behavioural therapy sessions, 6-10 sessions during pregnancy and 4-8 sessions after delivery (once a week). Women in the control group receive care as usual.Primary outcome is behavioural/emotional problems at 1.5 years of age as assessed by the total problems scale of the child behaviour checklist 1.5-5 years.Secondary outcomes will be mental, psychomotor and behavioural development of the child at age 18 months according to the Bayley scales, maternal anxiety and depression during pregnancy and postpartum, and neonatal outcomes such as birth weight, gestational age and Apgar score, health care consumption and general health status (economic evaluation). TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2242.

The effectiveness of family-based cognitive-behavior grief therapy to prevent complicated grief in relatives of suicide victims: the mediating role of suicide ideation.

Grief interventions are more effective for high risk individuals. The presence of suicide ideation following suicide bereavement was examined to determine whether it indicates a high risk status. Using data from a randomized controlled trial (n = 122) on the effectiveness of cognitive-behavior therapy, the effect of suicide ideation on the effectiveness of grief therapy on the bereavement outcome at 13 months post loss was examined. Results show that suicide ideators more often have a history of mental disorder and suicidal behavior than non-ideators, and suicide ideation indicates a high risk for adverse bereavement outcome. Grief therapy likely reduces the risk of maladaptive grief reactions among suicide ideators. Therefore, suicide ideators may benefit from grief therapy following a loss through suicide.

Socioeconomic position predicts specialty mental health service use independent of clinical severity: the TRAILS study.

OBJECTIVE: To investigate associations between different indices of family socioeconomic position (SEP) and the use of specialty mental health services (SMHS) and whether the associations exist after adjusting for severity of mental problems. METHOD: Using data from a large longitudinal study of adolescents (N = 2,149; mean age = 13.6 years [SD = 0.53, range = 12 to 15 years]; 51% girls), we assessed the relations of family SEP indices with SMHS use while accounting for severity of mental problems in logistic regression models. Multiple informants (parent, self, and teachers) assessed severity of mental health problems using the Achenbach scales. A parent questionnaire was used to assess family SEP (parents' education, parents' occupation, and family income) and SMHS use. Baseline response rate was 76%, and 96.4% of responders were reassessed at a 2.5-year follow-up visit. Baseline assessments ran from March 2001 through July 2002 and follow-up from September 2003 to December 2004. RESULTS: Overall, 6.7% of the total sample and 42.9% of those with mental problems accessed SMHS. Univariable analyses yielded no significant associations between SMHS and all the indices of SEP. Adjustment for the severity of mental problems resulted in substantial and statistically significant associations of indices of SEP with SMHS use. Adolescents were particularly more likely to use SMHS with increasing levels of maternal education. Compared to mothers with elementary education, those with university education were three times more likely to consult SMHS independent of severity of their offspring's mental health problems (odds ratio [OR] = 3.18, confidence interval [CI] = 1.22, 8.30). For the aggregate measure of SEP, high SEP was associated with increased use of SMHS compared with low SEP (OR = 1.63, CI = 1.04, 2.55). CONCLUSIONS: Higher levels of maternal education and overall SEP predict more SMHS use when the severity of mental problems was accounted for. Without correcting for the severity of mental problems, the true association between SEP and SMHS use is obscured in early adolescents.

Life stressors as mediators of the relation between socioeconomic position and mental health problems in early adolescence: the TRAILS study.

OBJECTIVE: Life stressors and family socioeconomic position have often been associated with mental health status. The aim of the present study is to contribute to the understanding of the pathways from low socioeconomic position and life stressors to mental problems. METHOD: In a cross-sectional analysis using data from a longitudinal study of early adolescents (N = 2,149, 51% girls; mean age 13.6 years, SD 0.53, range 12-15), we assessed the extent of mediation of the association between family socioeconomic position and mental health problems by different types of life stressors in multiple regression models. Stressors were rated as environment related or person related. Information on socioeconomic position was obtained directly from parents, and internalizing and externalizing problem behaviors were assessed by reports from multiple informants (parents, self, and teachers). RESULTS: Low socioeconomic position was associated with more mental health problems and more life stressors. Both environment-related and person-related stressors predicted mental health problems independently of socioeconomic position. The associations between socioeconomic position and all mental health outcomes were partly mediated by environment-related life stressors. Mediation by environment-related and person-related stressors as assessed by linear regression amounted to 56% (95% confidence interval [CI] 35%-78%) and 7% (95% CI -25% to 38%) for internalizing problems and 13% (95% CI 7%-19%) and 5% (95% CI -2% to 13%) for externalizing problems, respectively. CONCLUSIONS: Environment-related, but not person-related, stressors partly mediated the association between socio economic position and adolescent mental problems. The extent of mediation was larger for internalizing than for externalizing problems. Because the effect sizes of the associations were relatively small, targeted interventions to prevent impaired mental health may have only modest benefits to adolescents from low socioeconomic background.

Socioeconomic position and mental health problems in pre- and early-adolescents: the TRAILS study.

BACKGROUND: Family socioeconomic position (SEP) is known to be associated with adolescent mental health. Whether the relationship is different for different mental health dimensions is unknown. METHODS: Using a cross-sectional design, we investigated the differential effects of family SEP on multiple mental health dimensions in preadolescents (N = 2230, baseline age 10-12, 49% boys) using reports from multiple informants (parent, self, and teachers). A score equal to or higher than the 85th percentile (averaged across informants) defined mental health problems. RESULTS: SEP was inversely associated with all dimensions. Compared to high SEP, the odds ratios (OR) for externalizing problems were 3.88 (95% confidence interval (CI): 2.56, 5.90) and 2.05 (CI: 1.34, 3.14) for low and intermediate SEP, respectively. For internalizing problems, they were 1.86 (CI: 1.28, 2.70) and 1.37 (CI: 0.94, 2.00), respectively. When adjusted for externalizing problems, SEP effects on internalizing problems materially attenuated (OR: 1.47, CI: 0.78, 1.68 and OR: 1.34, CI: 0.91, 1.96) while the converse was less pronounced (OR: 3.39, CI: 2.24, 5.15) and (OR: 1.91, CI: 1.25, 2.94). CONCLUSION: In early adolescence, the risk of mental health problems increases with decreasing SEP, particularly for externalizing problems. Further, the SEP-internalizing problems relationship is partly explained by shared aspects with externalizing problems.

Disability and treatment of specific mental and physical disorders across the world.

BACKGROUND: Advocates of expanded mental health treatment assert that mental disorders are as disabling as physical disorders, but little evidence supports this assertion. AIMS: To establish the disability and treatment of specific mental and physical disorders in high-income and low- and middle-income countries. METHOD: Community epidemiological surveys were administered in 15 countries through the World Health Organization World Mental Health (WMH) Survey Initiative. RESULTS: Respondents in both high-income and low- and middle-income countries attributed higher disability to mental disorders than to the commonly occurring physical disorders included in the surveys. This pattern held for all disorders and also for treated disorders. Disaggregation showed that the higher disability of mental than physical disorders was limited to disability in social and personal role functioning, whereas disability in productive role functioning was generally comparable for mental and physical disorders. CONCLUSIONS: Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and in low- and middle-income countries.