Trauma informed interventions: A systematic review.

BACKGROUND: Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes. METHODS: We performed database searches- PubMed, Embase, CINAHL, SCOPUS and PsycINFO-to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria. RESULTS: More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5). CONCLUSIONS: There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.

Meta-Analysis of the Treatment of Posttraumatic Stress Disorder in Adults With Comorbid Severe Mental Illness.

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder).Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness.Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis.Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1-0 in R (3.6.0).Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = -1.009, P < .001, k = 34). Prolonged exposure (g = -1.464; P < .001; SE = 0.276; k = 5), eye movement desensitization and reprocessing (g = -1.351; P < .001; SE = 0.276; k = 5), and brief treatment program (g = -1.009; P < .001; SE = 0.284; k = 5) had the largest effects on PTSD symptoms.Conclusions: Although underrepresented in the PTSD literature, PTSD psychotherapies are effective for individuals with SMI. Treatments with an exposure-based component may have greater efficacy in this clinical population.

Quality of Outpatient Depression Treatment in Patients With Comorbid Substance Use Disorder.

OBJECTIVE: Clinical practice guidelines recommend concurrent treatment of co-occurring depression and substance use disorders; however, the degree to which patients with substance use disorders receive guideline-concordant treatment for depression is unknown. The authors investigated the provision of guideline-concordant depression treatment to patients with and without substance use disorders in a large integrated health care system. METHODS: In a retrospective cohort study of 53,034 patients diagnosed with a depressive disorder in fiscal year 2017 in the U.S. Veterans Health Administration, the authors assessed the association of comorbid substance use disorders with guideline-concordant depression treatment, including both medication and psychotherapy, while adjusting for patient demographic and clinical characteristics. RESULTS: Guideline-concordant depression treatment was lower across metrics for patients with co-occurring depression and substance use disorders compared to those without substance use disorders. Consistent findings emerged in covariate-adjusted models of antidepressant treatment, such that patients with substance use disorders had 21% lower odds of guideline-concordant acute treatment (adjusted odds ratio=0.79, 95% CI=0.73, 0.84) and 26% lower odds of continuation of treatment (adjusted odds ratio=0.74, 95% CI=0.69, 0.79). With regard to psychotherapy, patients with co-occurring depression and substance use disorders had 13% lower odds (adjusted odds ratio=0.87, 95% CI=0.82, 0.91) of adequate acute-phase treatment and 19% lower odds (adjusted odds ratio=0.81; 95% CI=0.73, 0.89) of psychotherapy continuation. CONCLUSIONS: Despite the availability of effective treatments for depression, patients with co-occurring substance use disorders are less likely to receive guideline-concordant depression treatment. Efforts to improve the provision of care to those with co-occurring substance use disorders should focus on clinician-based interventions and use of integrated care models to improve the quality of depression treatment.

Effects of Art and Reminiscence Therapy on Agitated Behaviors Among Older Adults With Dementia.

BACKGROUND: Cognitive degeneration and agitated behavior symptoms of dementia in older adults are the main causes of disability and inability and increase the cost of medical care. Agitated behavior symptoms of dementia are the main causes of early institutionalization and make caregivers exhausted. PURPOSE: The aim of this study was to examine the effects of art therapy and reminiscence therapy on the alleviation of agitated behaviors in older adults with dementia. METHODS: An experimental research design with two experimental groups and one comparison group was conducted to examine the effects for each group on agitated behaviors. Participants were recruited from two dementia care centers in central and northern Taiwan. The study included 54 older individuals who met the sampling criteria and completed the data collection process. The participants were randomly allocated into the art therapy group (n = 24), the reminiscence therapy group (n = 22), and the comparison group (n = 8). The intervention consisted of 50-minute sessions conducted weekly for 12 weeks. Regular activities were continued in the comparison group. The structured questionnaires were completed, and observations of agitated behaviors were collected before the intervention and at 1 and 6 weeks after the intervention. RESULTS: Significant differences were found in agitated behavior symptoms at the three time points in the art therapy group, whereas reminiscence therapy was found to have had a clear and immediate effect on decreasing agitated behavior. The generalized estimating equation exchange model test revealed a significant and sustained, postintervention effect of art therapy on agitated behavior. In contrast, no significant and sustained effect on agitated behavior was observed in the reminiscence therapy group. CONCLUSIONS: The findings of this study support that art therapy may have a positive effect on dementia-associated agitated behaviors in institutionalized older adults. Reminiscence therapy activities conducted weekly for 50 minutes each session did not reach statistically significant implications. It is suggested that future studies consider conducting art and reminiscence therapies for a 16-week duration with two weekly sessions to evaluate the effectiveness of the therapy. The duration of follow-up should be extended as well in future studies.

The effects of fifteen evidence-supported therapies for adult depression: A meta-analytic review.

Objective: In the past decades, many different types of psychotherapy for adult depression have been developed. Method: In this meta-analysis we examined the effects of 15 different types of psychotherapy using 385 comparisons between a therapy and a control condition: Acceptance and commitment therapy, mindfulness-based cognitive behavior therapy (CBT), guided self-help using a self-help book from David Burns, Beck's CBT, the "Coping with Depression" course, two subtypes of behavioral activation, extended and brief problem-solving therapy, self-examination therapy, brief psychodynamic therapy, non-directive counseling, full and brief interpersonal psychotherapy, and life review therapy. Results: The effect sizes ranged from g = 0.38 for the "Coping with Depression" course to g = 1.10 for life review therapy. There was significant publication bias for most therapies. In 70% of the trials there was at least some risk of bias. After adjusting studies with low risk of bias for publication bias, only two types of therapy remained significant (the "Coping with Depression" course, and self-examination therapy). Conclusions: We conclude that the 15 types of psychotherapy may be effective in the treatment of depression. However, the evidence is not conclusive because of high levels of heterogeneity, publication bias, and the risk of bias in the majority of studies.

Defining Success in Measurement-Based Care for Depression: A Comparison of Common Metrics.

OBJECTIVE: The National Committee for Quality Assurance recommends response and remission as indicators of successful depression treatment for the Healthcare Effectiveness and Data Information Set. Effect size and severity-adjusted effect size (SAES) offer alternative metrics. This study compared measures and examined the relationship between baseline symptom severity and treatment success. METHODS: Electronic records from two large integrated health systems (Kaiser Permanente Colorado and Washington) were used to identify 5,554 new psychotherapy episodes with a baseline Patient Health Questionnaire (PHQ-9) score of ≥10 and a PHQ-9 follow-up score from 14-180 days after treatment initiation. Treatment success was defined for four measures: response (≥50% reduction in PHQ-9 score), remission (PHQ-9 score <5), effect size ≥0.8, and SAES ≥0.8. Descriptive analyses examined agreement of measures. Logistic regression estimated the association between baseline severity and success on each measure. Sensitivity analyses evaluated the impact of various outcome definitions and loss to follow-up. RESULTS: Effect size ≥0.8 was most frequently attained (72% across sites), followed by SAES ≥0.8 (66%), response (46%), and remission (22%). Response was the only measure not associated with baseline PHQ-9 score. Effect size ≥0.8 favored episodes with a higher baseline PHQ-9 score (odds ratio [OR]=2.3, p<0.001, for 10-point difference in baseline PHQ-9 score), whereas SAES ≥0.8 (OR=0.61, p<0.001) and remission (OR=0.43, p<0.001) favored episodes with lower baseline scores. CONCLUSIONS: Response is preferable for comparing treatment outcomes, because it does not favor more or less baseline symptom severity, indicates clinically meaningful improvement, and is transparent and easy to calculate.

A hermeneutic study of integrating psychotherapist competence in postnatal Child Health Care: Parents' perspectives.

A child's emotional and social development depends on the parents' provision of optimal support. Many parents with perinatal distress experience difficulties in mastering parenthood and seek help from professionals within primary healthcare. A clinical project was launched in Stockholm, where psychodynamic psychotherapists provided short-term consultations at Child Health Centers. This study qualitatively explored parents' experiences of perinatal distress and of receiving help by nurses and therapists in the project. Thirteen parents were interviewed, and their responses were analyzed with a hermeneutical method. Three main themes crystallized; accessibility of psychological help and detection of emotional problems; experiences of therapy at the Child Health Center; and the therapists' technique. Parents were also clustered into three so-called ideal types: the insecure; parents in crisis; and parents with lifelong psychological problems. Parents experienced obstacles in accessing psychological care within primary healthcare. Psychotherapists with a holistic family perspective and who managed to oscillate between insight-promoting and supportive interventions were especially appreciated. Patient categories who benefitted from insight promotion and support, respectively, were identified.

El desarrollo emocional y social del niño depende de que los padres le brinden un apoyo óptimo. Muchos progenitores con aflicciones perinatales experimentan dificultades al aprender a dominar la crianza y buscan ayuda de profesionales dentro del cuidado de salud de primera instancia. En Estocolmo, se inició un proyecto clínico en el que sicoterapeutas sicodinámicos ofrecieron consultas a corto plazo en los Centros de Salud Infantil. Este estudio exploró cualitativamente las experiencias de aflicciones perinatales de los padres y las de recibir ayuda del cuerpo de enfermería y terapeutas del proyecto. Método: Se entrevistaron trece progenitores y sus respuestas se analizaron con un método hermenéutico. Resultados: Se concretaron tres temas principales: la accesibilidad a ayuda sicológica con detección de problemas emocionales, las experiencias de terapia en los Centros de Salud Infantil, así como las técnicas de los terapeutas. A los progenitores se les agrupó también en tres designados Tipos Ideales: el inseguro, el progenitor en crisis, el progenitor con problemas sicológicos a lo largo de la vida. Conclusión: los progenitores se enfrentaron con obstáculos al tratar de encontrar ayuda sicológica dentro del cuidado de salud de primera instancia; los sicoterapeutas con una perspectiva familiar integral y aquellos que podían oscilar entre fomentar la percepción y las intervenciones de apoyo fueron especialmente apreciados; se identificaron categorías de pacientes que se beneficiaron del fomento de la percepción y del apoyo, respectivamente.

Le développement émotionnel et social d'un enfant dépend du soutien optimal qu'offrent les parents. Beaucoup de parents avec une détresse périnatale font l'expérience de difficultés quant à la gestion du parentage et cherchent l'aide de professionnels au sein des soins de santé primaires. Un projet clinique a été lancé à Stockholm, en Suède, au sein duquel des psychothérapeutes psychodynamiques ont offert des consultations à court terme dans les Centres de Santé de l'Enfant. Cette étude a exploré de manière qualitative les expériences de détresse périnatale des parents et l'aide qu'ils ont reçue de la part des infirmières/infirmiers et des thérapeutes dans ce projet. Méthode: Treize parents ont passé un entretien, et leurs réponses ont été analysées au moyen d'une méthode herméneutique. Résultats : Trois thèmes principaux ont émergé, l'accès à l'aide psychologique et la détection de problèmes émotionnels, les expériences de thérapie au Centre de Santé de l'Enfant, et la technique des thérapeutes. Les parents ont aussi été regroupés en trois soi-disant Types Parfaits: les insécures, les parents en crise et les parents avec des problèmes psychologiques de longue haleine. Conclusion: Les parents ont fait l'expérience d'obstacles dans l'accès au soin psychologique au sein des soins de santé primaires. Les psychothérapeutes ayant une perspective familiale holistique et ceux qui sont arrivés à osciller entre une promotion de perspicacité et des interventions de soutien ont été généralement appréciés. Les catégories de patients qui ont respectivement bénéficié de perspicacité et de soutien ont été identifiées.

[Clinical presentation and requests for support of people with HIV/AIDS seeking counselling and psychotherapy in Greece].

Despite the large progress during the last decades in the medical treatment of HIV/AIDS infection, people living with HIV nevertheless face multiple adversities at various levels of their lives. Mental disorders, in particular, are the most common comorbidities in HIV infection with negative consequences in adherence to antiretroviral medication, disease progress and overall quality of life. HIVrelated stigma, still quite intense in Greece, is one of the most debilitating factors concerning people's living with HIV mental health. The present study looked at the clinical presentation at intake and treatment requests of 191 (83% males) people living with HIV who addressed the psychological support service of the non-governmental organization 'Centre for Life' during the years 2016- 18. Data were collected through a semi-structured clinical interview and administration of adapted questionnaires (PHQ-9, BAI, CAGE), which resulted in 7 dichotomous variables related to clinical presentation and 13 dichotomous variables related to treatment requests at intake. To analyze data, we constructed frequency tables and performed chi-square tests. In the whole sample, 42.2% presented anxiety disorders, 40.3% depression, 28.8% occasional substance use, 17.5% problematic use of alcohol and 13.6% intravenous drug use. Moreover, 14% reported at least one suicide attempt in the past and 9.2% current suicidal ideation. Apart from more frequent intravenous drug use among heterosexual males and more frequent occasional/recreational drug use among men who have sex with men, no other differences related to gender, age group, sexual orientation or ethnicity were observed in the initial clinical presentation. Similarly, the most frequent treatment requests were homogenously distributed in our sample, such as depressive symptoms (58.6%), difficulties in romantic relationships (48.7%), accepting being HIV positive (42.9%), anxiety symptoms (42.4%) and issues of negative self-esteem (40.8%). The presence of clinically significant depression was found to be related to a wider range of treatment requests compared to other mental health problems. A large group of requests focused on interpersonal relationships difficulties (e.g. disclosure anxiety, social isolation, disturbed relationships with familiar persons). This indicates an important area of psychological intervention. HIV infection may affect many levels of an individual's life, including their mental health. Respectively, HIV treatment needs to adopt a more holistic approach.

Effectiveness of psychotherapy for treatment-resistant depression: a meta-analysis and meta-regression.

Despite substantial advances in treatment and management strategies for major depression, less than 50% of patients respond to first-line antidepressant treatment or psychotherapy. Given the growing number of controlled studies of psychotherapy for treatment-resistant depression (TRD) and the preference for psychotherapy of depressed subjects as a treatment option, we conducted a meta-analysis and meta-regression analysis to investigate the effectiveness of psychotherapy for TRD. Seven different psychotherapies were studied in 21 trials that included a total of 25 comparisons. In three comparisons of psychotherapy v. treatment as usual (TAU) we found no evidence to conclude that there is a significant benefit of psychotherapy as compared with TAU. In 22 comparisons of add-on psychotherapy plus TAU v. TAU only, we found a moderate general effect size of 0.42 (95% CI 0.29-0.54) in favor of psychotherapy plus TAU. The meta-regression provided evidence for a positive association between baseline severity as well as group v. individual therapy format with the treatment effect. There was no evidence for publication bias. Most frequent investigated treatments were cognitive behavior therapy, interpersonal psychotherapy, mindfulness-based cognitive therapy, and cognitive behavioral analysis system of psychotherapy. Our meta-analysis provides evidence that, in addition to pharmacological and neurostimulatory treatments, the inclusion of add-on of psychotherapy to TAU in guidelines for the treatment of TRD is justified and will provide better outcomes for this difficult-to-treat population.

Patterns of practice in community mental health treatment of adult depression.

OBJECTIVE: Community mental health therapists often endorse an eclectic orientation, but few studies reveal how therapists utilize elements of evidence-based psychotherapies. This study aimed to characterize treatment as usual patterns of practice among therapists treating depressed adults in community mental health settings. METHOD: Therapists (N = 165) from the USA's largest not-for-profit provider of community-based mental health services completed surveys assessing their demographics and practice element use with depressed adult clients. Specifically, therapists indicated whether they utilized each of 45 unique practice elements from the following evidence-based psychotherapies: Acceptance and Commitment Therapy, Behavioral Activation, Brief Psychodynamic Therapy, Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Mindfulness-Based CBT, Problem-Solving Therapy, and Self-Control Therapy. Principal component analysis was employed to identify practice patterns. RESULTS: The principal component analysis included 31 practice elements and revealed a three-factor model with distinct patterns of practice that did not align with traditional evidence-based practice approaches, including: (i) Planning, Practice, and Monitoring; (ii) Cognitive, Didactic, and Interpersonal; and (iii) Between Session Activities. CONCLUSIONS: Therapist-reported practice patterns confirmed an eclectic approach that brought together elements from theoretically distinct evidence-based psychotherapies. Future research is needed to explore how these patterns of practice relate to client outcomes to inform focused training and/or de-implementation efforts.

Treatment Initiation for New Episodes of Depression in Primary Care Settings.

BACKGROUND: Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment. OBJECTIVE: To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings. DESIGN: A retrospective observational design was used to analyze electronic health record data. PATIENTS: A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013. MAIN MEASURES: ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis. KEY RESULTS: Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication. CONCLUSIONS: Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.

Rates and predictors of psychotherapy utilization after psychosocial evaluation for stem cell transplant.

OBJECTIVE: Although standard of care prior to hematopoietic stem cell transplantation (HSCT) includes a psychosocial evaluation, little is known about the rate and predictors of psychotherapy utilization among patients presenting for pre-HSCT evaluations. This study aimed to examine the proportion of patients undergoing pre-HSCT evaluations who subsequently utilize psychotherapy services and to explore predictive factors, including distress, anxiety, depression, and quality of life (QoL). METHODS: Participants were a cross-sectional sample of 351 HSCT candidates at an NCI-designated comprehensive cancer center. Questionnaires assessing distress, anxiety, depression, and QoL were administered using validated instruments. RESULTS: A subset of patients, representing 14% of the sample, utilized psychotherapy services. Relative to patients who did not utilize psychological services, patients who followed-up with psychotherapy reported significantly more depressive and anxious symptoms (P < .001) and endorsed worse QoL on the Functional Assessment of Cancer Therapy-General. (P = .04). Of note, a subset of patients who utilized psychotherapy services reported low levels of distress (67%), depression (13%), or anxiety (13%); on the other hand, a subset of patients reported moderate-to-high levels of distress (25%), depression (71%), or anxiety (60%) but did not utilize services. CONCLUSIONS: Results indicate that only a small subset of patients presenting for pre-HSCT psychosocial evaluation subsequently utilized psychotherapy services. Most patients who reported psychosocial concerns and who could potentially benefit from intervention did not use psychotherapy services. Further research is necessary to help clarify barriers to psychotherapy service utilization among HSCT patients and to help improve uptake among high-need patients.

Integrating clients' religion/spirituality in clinical practice: A comparison among social workers, psychologists, counselors, marriage and family therapists, and nurses.

OBJECTIVE: This study was designed to describe and compare five helping professions' views and behaviors regarding the integration of clients' religion/spirituality (RS) in clinical practice. METHOD: A cross-sectional design was used to survey 3,500 licensed clinical psychologists, nurses, marriage and family therapists (LMFTs), clinical social workers, and professional counselors across Texas. A total of 550 responded to this online survey, which included the Religious/Spiritually Integrated Practice Assessment Scale and background questions. RESULTS: Attitudes concerning the integration of clients' RS did not differ by profession and were fairly positive. However, differences emerged regarding self-efficacy, perceived feasibility, and behaviors, with LMFTs reporting the highest scores for these subscales. CONCLUSION: This is the first comparison of these five professions' attitudes, behaviors, perceived feasibility, and self-efficacy regarding integrating clients' RS. These encouraging results not only indicate helping professionals' openness to integrating clients' RS, but also highlight key differences in training, self-efficacy, views of feasibility, and implementation.

Use of non-pharmacological strategies for pain relief in addiction treatment patients with chronic pain.

BACKGROUND AND OBJECTIVES: We examined use of non-pharmacological treatments for pain in addiction treatment patients. METHODS: Patients in addiction treatment with chronic pain (N = 501) were classified based on use of non-pharmacological pain treatments. Demographic and clinical correlates were compared. RESULTS: A total of 49% (N = 243) of patients used a non-pharmacological treatment in the past year versus 72% (N = 361) who used opioids. Non-pharmacological treatment users were more likely to use opioids and other pain medications. CONCLUSIONS: Non-pharmacological treatments are less commonly used than opioids by addiction treatment patients. SCIENTIFIC SIGNIFICANCE: Findings highlight the need to better understand pain treatment decision-making among addiction treatment patients. (Am J Addict 2017;26:564-567).

Primary Care-Mental Health Integration in the VA Health System: Associations Between Provider Staffing and Quality of Depression Care.

OBJECTIVES: The study examined whether staffing of Primary Care-Mental Health Integration (PCMHI) services in the Department of Veterans Affairs (VA) health system is related to quality of depression care. METHODS: Site surveys and administrative data from 349 VA facilities for fiscal year 2013 were used to calculate PCMHI staffing (full-time equivalents) per 10,000 primary care patients and discipline-specific staffing proportions for PCMHI psychologists, social workers, nurses, and psychiatric medication prescribers. Multivariable regression analyses were conducted at the facility level and assessed associations between PCMHI staffing ratios and the following indicators of depression treatment in the three months following a new episode of depression: any antidepressant receipt, adequacy of antidepressant receipt, any psychotherapy receipt, and psychotherapy engagement (three or more visits). RESULTS: Higher facility PCMHI staffing ratios were associated with a greater percentage of patients who received any psychotherapy treatment (B=1.16, p<.01) and who engaged in psychotherapy (B=.39, p<.01). When analyses controlled for total PCMHI staffing, the proportion of social workers as part of PCMHI was positively correlated with the percentage of patients with adequate antidepressant treatment continuation (B=3.16, p=.03). The proportion of nurses in PCMHI was negatively associated with the percentage of patients with engagement in psychotherapy (B=-2.83, p=.02). CONCLUSIONS: PCMHI programs with greater overall staffing ratios demonstrated better performance on indicators of psychotherapy for depression but not on indicators of antidepressant treatment. Further investigation is needed to determine whether differences in discipline-specific staffing play a causal role in driving associated differences in receipt of treatment.

[Psychotherapy and Religion: A Representative Survey Among Psychotherapists in Southern Germany]. / Psychotherapie und Religion: Eine repräsentative Umfrage unter Psychotherapeuten in Süddeutschland.

Objective: Religion and spirituality play an appreciable role as a problem area or as a resource for patients with mental disorders. It is therefore of interest what attitudes psychotherapists assume towards this complex range of issues in their work, but also in their personal lives. The majority of empirical studies on this subject originate from the USA, with little data being available from Europe and Germany. Our own survey among practising psychotherapists was designed to elucidate these questions. Method and Study Population: A cross-sectional study was conducted in the form of a written survey of all accessible practising psychotherapists in the area of Northern Bavaria (Franconian administrative districts; n=1 081, return rate 65%). Results: Around two-thirds of the therapists consider religion to be an important subject in psychotherapy, but only one-fifth of them routinely take a history of the patients' religious beliefs. The therapists' own closeness to religion correlates positively with the tendency to incorporate religion in their therapy. In around one-third of the therapists, religion holds an important place within their own world view, although significantly fewer psychotherapists than the general population of Franconia are bound to a specific confession. Around one-quarter had at least once consulted a pastor due to a patient, while each seventh therapist had at least once actively mediated contact to a pastor. Conclusions: Religion is a subject that is relevant for therapeutic practice, but a history of religious beliefs is rarely taken on a routine basis. The incorporation of religion into psychotherapy correlates with religious characteristics of the therapists ("personal bias"). There appears to be a "religiosity gap" between psychotherapists and the general population. Advanced training on the subject of "religion/spirituality" and increased consideration in supervision may counteract the danger of religious needs and religion-related resources of patients being neglected.

[Utilization of outpatient psychotherapeutic treatment : A secondary data analysis]. / Inanspruchnahme ambulanter psychotherapeutischer Versorgung : Eine Analyse von Sekundärdaten.

BACKGROUND: In spite of a well-developed and complex mental healthcare system in Germany, problems remain in the capacity of psychotherapeutic care with an undersupply and long waiting times for provision of outpatient psychotherapeutic care. OBJECTIVES: The analyses address the current level of psychotherapeutic care and the role of individual medical specialties in outpatient psychotherapeutic care in Germany. MATERIAL AND METHODS: The analyses are based on secondary data from three statutory health insurance companies and the German pension funds for the years 2005-2007. Anonymized treatment data from 3.3 million insured persons with a diagnosis of a mental disorder (ICD-10 groups F0-F5) were analyzed. RESULTS: In outpatient treatment 9,670,588 psychotherapeutic accounting codes were analyzed of which 33 % were psychiatric, psychosomatic or psychotherapeutic consultations that are not covered by the scope of psychotherapy according to the standard regulations (psychotherapy guidelines). The most frequently used psychotherapeutic services were verbal interventions (accounting codes 35.100 and 31.110) and psychiatric consultations (accounting codes 14.220, 21.220 and 21.221), independent of the mental disorder. Of the patients 5.9 % received directive psychotherapy. The provider-specific analysis showed a great variation in the kind of accounting codes, which were brought into account by the different providers. CONCLUSION: With regard to the reform efforts in psychotherapeutic care, longitudinal trends in the utilization and quality of psychotherapeutic care in the individual fields of treatment should be analyzed in follow-up studies.

[Guideline-adherent inpatient psychiatric psychotherapeutic treatment of obsessive-compulsive disorder : Normative definition of personnel requirements]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische Behandlung der Zwangsstörung : Normative Personalbedarfsermittlung.

BACKGROUND: Guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with obsessive-compulsive disorder (OCD) is an important part of the care available for these patients. It may not be adequately reflected in the current personnel resources available according to the German psychiatry personnel regulation (Psych-PV). OBJECTIVES: The goal of this work was to assess the personnel resources necessary for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD and compare the necessary resources with the resources available according to Psych-PV. METHODS: Based on the German national guidelines for OCD and a meta-analysis on treatment intensity, we formulated a normative weekly treatment plan. Based on this plan we calculated the necessary personnel resources and compared these with the resources available according to Psych-PV category A1 (standard care). RESULTS: The weekly treatment time for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is 23.5 h per week. This corresponds to a weekly personnel requirement of 20.9 h. This requirement is only partly reflected in the Psych-PV (17.3 h, 82.8 %). The coverage of personnel resources by Psych-PV is even lower for psychotherapy provided by psychiatrist and psychologists (38.3 %, i. e. 183 min in the normative plan versus 70 min in Psych-PV). CONCLUSIONS: The current paper shows that the personal resources required for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is not adequately reflected in the German psychiatry personnel regulation (Psych-PV). The actual shortage may be underestimated in our paper.

An integrated workplace mental health intervention in a policing context: Protocol for a cluster randomised control trial.

BACKGROUND: In this paper, we present the protocol for a cluster-randomised trial to evaluate the implementation and effectiveness of a workplace mental health intervention in the state-wide police department of the south-eastern Australian state of Victoria. n. The primary aims of the intervention are to improve psychosocial working conditions and mental health literacy, and secondarily to improve mental health and organisational outcomes. METHODS/DESIGN: The intervention was designed collaboratively with Victoria Police based on a mixed methods pilot study, and combines multi-session leadership coaching for the senior officers within stations (e.g., Sergeants, Senior Sergeants) with tailored mental health literacy training for lower and upper ranks. Intervention effectiveness will be evaluated using a two-arm cluster-randomised trial design, with 12 police stations randomly assigned to the intervention and 12 to the non-intervention/usual care control condition. Data will be collected from all police members in each station (estimated at >20 per station). Psychosocial working conditions (e.g., supervisory support, job control, job demands), mental health literacy (e.g., knowledge, confidence in assisting someone who may have a mental health problem), and mental health will be assessed using validated measures. Organisational outcomes will include organisational depression disclosure norms, organisational cynicism, and station-level sickness absence rates. The trial will be conducted following CONSORT guidelines. Identifying data will not be collected in order to protect participant privacy and to optimise participation, hence changes in primary and secondary outcomes will be assessed using a two-sample t-test comparing summary measures by arm, with weighting by cluster size. DISCUSSION: This intervention is novel in its integration of stressor-reduction and mental health literacy-enhancing strategies. Effectiveness will be rigorously evaluated, and if positive results are observed, the intervention will be adapted across Victoria Police (total employees ~16,500) as well as possibly in other policing contexts, both nationally and internationally. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN82041334. Registered 24th July, 2014.

Non-pharmacological interventions to reduce ICU-related psychological distress: a systematic review.

INTRODUCTION: Patients frequently suffer stress in intensive care units (ICUs) and many develop serious psychological morbidity after discharge. Little is known about the nature and efficacy of interventions to reduce ICU-related distress. There is growing evidence that administering sedative drugs can be harmful. Therefore we carried out a systematic review of non-pharmacological interventions to reduce ICU-related distress. EVIDENCE ACQUISITION: A systematic search was conducted using Medline, Embase, Psychinfo, Cinahl and the Web of Science. Included studies evaluated the effect of non-pharmacological interventions to reduce ICU stress. Study populations were adults in mixed or general ICUs. Outcomes were stress or psychological distress in or after the ICU, using self-report or physiological measures. No meta-analysis was possible due to heterogeneity, therefore studies were arranged according to intervention type, and outcomes examined together with risk of bias criteria. EVIDENCE SYNTHESIS: Twenty-three studies were eligible, including 15 randomized controlled trials. Non-pharmacological interventions included music therapy (11 studies), mind-body practices (5) and psychological interventions (7). 12 studies showed a beneficial effect. However only three of the 12 had a low risk of bias, and many studies in the review were under-powered to detect an effect. Only 5 studies measured a medium/long term psychological outcome such as PTSD or depression at 2-12 months. CONCLUSIONS: Evidence indicates that non-pharmacological approaches to reducing ICU distress, in particular psychological interventions, may be beneficial. The evidence base would be strengthened by the implementation of fully-powered studies using robust designs, that measure longer-term outcomes.