Differences in psychological treatment outcomes by ethnicity and gender: an analysis of individual patient data.

PURPOSE: There are discrepancies in mental health treatment outcomes between ethnic groups, which may differ between genders. NHS Talking Therapies for anxiety and depression provide evidence-based psychological therapies for common mental disorders. This study examines the intersection between ethnicity and gender as factors associated with psychological treatment outcomes. Aims were to explore by gender: (1) differences in psychological treatment outcomes for minoritized ethnic people compared to White-British people, (2) whether differences are observed when controlling for clinical and socio-demographic factors associated with outcomes, and (3) whether organization-level factors moderate differences in outcomes between ethnic groups. METHODS: Patient data from eight NHS Talking Therapies for anxiety and depression services (n = 98,063) was used to explore associations between ethnicity and outcomes, using logistic regression. Stratified subsamples were used to separately explore factors associated with outcomes for males and females. RESULTS: In adjusted analyses, Asian (OR = 0.82 [95% CI 0.78; 0.87], p < .001, 'Other' (OR = 0.79 [95%CI 0.72-0.87], p < .001) and White-other (0.93 [95%CI 0.89-0.97], p < .001) ethnic groups were less likely to reliably recover than White-British people. Asian (OR = 1.48 [95% CI 1.35-1.62], p < .001), Mixed (OR = 1.18 [95% CI 1.05-1.34], p = .008), 'Other' (OR = 1.60 [95% CI 1.38-1.84], p < .001) and White-other (OR = 1.18 [95% CI 1.09-1.28], p < .001) groups were more likely to experience a reliable deterioration in symptoms. Poorer outcomes for these groups were consistent across genders. There was some evidence of interactions between ethnic groups and organization-level factors impacting outcomes, but findings were limited. CONCLUSIONS: Across genders, Asian, 'Other' and White-other groups experienced worse treatment outcomes across several measures in adjusted models. Reducing waiting times or offering more treatment sessions might lead to increased engagement and reduced drop-out for some patient groups.

The association between trajectories of change in social functioning and psychological treatment outcome in university students: a growth mixture model analysis.

BACKGROUND: The transition to university and resultant social support network disruption can be detrimental to the mental health of university students. As the need for mental health support is becoming increasingly prevalent in students, identification of factors associated with poorer outcomes is a priority. Changes in social functioning have a bi-directional relationship with mental health, however it is not clear how such measures may be related to effectiveness of psychological treatments. METHODS: Growth mixture models were estimated on a sample of 5221 students treated in routine mental health services to identify different trajectories of change in self-rated impairment in social leisure activities and close relationships during the course of treatment. Multinomial regression explored associations between trajectory classes and treatment outcomes. RESULTS: Five trajectory classes were identified for social leisure activity impairment while three classes were identified for close relationship impairment. In both measures most students remained mildly impaired. Other trajectories included severe impairment with limited improvement, severe impairment with delayed improvement, and, in social leisure activities only, rapid improvement, and deterioration. Trajectories of improvement were associated with positive treatment outcomes while trajectories of worsening or stable severe impairment were associated with negative treatment outcomes. CONCLUSIONS: Changes in social functioning impairment are associated with psychological treatment outcomes in students, suggesting that these changes may be associated with treatment effectiveness as well as recovery experiences. Future research should seek to establish whether a causal link exists to understand whether integrating social support within psychological treatment may bring additional benefit for students.

Understanding the psychological therapy treatment outcomes for young adults who are not in education, employment, or training (NEET), moderators of outcomes, and what might be done to improve them.

BACKGROUND: To determine: whether young adults (aged 18-24) not in education, employment or training (NEET) have different psychological treatment outcomes to other young adults; any socio-demographic or treatment-related moderators of differential outcomes; and whether service-level changes are associated with better outcomes for those who are NEET. METHODS: A cohort was formed of 20 293 young adults treated with psychological therapies in eight Improving Access to Psychological Therapies services. Pre-treatment characteristics, outcomes, and moderators of differential outcomes were compared for those who were and were not NEET. Associations between outcomes and the following were assessed for those that were NEET: missing fewer sessions, attending more sessions, having a recorded diagnosis, and waiting fewer days between referral and starting treatment. RESULTS: Those who were NEET had worse outcomes: odds ratio (OR) [95% confidence interval (CI)] for reliable recovery = 0.68 (0.63-0.74), for deterioration = 1.41 (1.25-1.60), and for attrition = 1.31 (1.19-1.43). Ethnic minority participants that were NEET had better outcomes than those that were White and NEET. Living in deprived areas was associated with worse outcomes. The intensity of treatment (high or low) did not moderate outcomes, but having more sessions was associated with improved outcomes for those that were NEET: odds (per one-session increase) of reliable recovery = 1.10 (1.08-1.12), deterioration = 0.94 (0.91-0.98), and attrition = 0.68 (0.66-0.71). CONCLUSIONS: Earlier treatment, supporting those that are NEET to attend sessions, and in particular, offering them more sessions before ending treatment might be effective in improving clinical outcomes. Additional support when working with White young adults that are NEET and those in more deprived areas may also be important.

Measurement invariance of the PHQ-9 and GAD-7 across males and females seeking treatment for common mental health disorders.

BACKGROUND: The nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalised Anxiety Disorder scale (GAD-7) scales are routinely used in research and clinical practice. Whilst measurement invariance of these measures across gender has been demonstrated individually in general population studies and clinical samples, less is known about invariance of the distinct but correlated latent factors ('depression' and 'anxiety'). The current study assessed measurement invariance of these constructs across males and females seeking treatment for common mental health disorders. METHODS: Data were provided from eight psychological treatment services in London, England. Data from initial assessments with the services where individual items on the PHQ-9 and GAD-7 were available were included in analyses. Measurement invariance was explored across self-identified genders, with 'male' and 'female' categories available in the dataset. Sensitivity analyses were conducted using propensity score matching on sociodemographic and clinical variables. RESULTS: Data were available for 165,872 patients (110,833 females, 55,039 males). There was evidence of measurement invariance between males and females in both the full sample and a propensity score matched sample (n = 46,249 in each group). CONCLUSIONS: Measurement invariance of the correlated depression and anxiety factors of PHQ-9 and GAD-7 were indicated in this sample of individuals seeking psychological treatment for CMHDs. These results support the use of these measures in routine clinical practice for both males and females. This is of particular importance for assessing the prevalence of clinically significant levels of symptoms as well as comparing treatment outcomes across genders.

Are students less likely to respond to routinely delivered psychological treatment? A retrospective cohort analysis.

BACKGROUND: Depression and anxiety disorders are increasingly prevalent among university students, making the provision of effective treatment in this population a priority. Whilst campus-based services provide some psychological treatments, many students are treated by routine adult psychological treatment services which have no focus or adaptations to treatment for student populations. We aimed to compare psychological treatment outcomes between university students and young adults (aged 18-25) in employment to explore whether routinely delivered psychological interventions are equally effective for these groups, or whether students report poorer outcomes. METHODS: A retrospective cohort was formed of 19,707 patients treated by eight National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) services in England. Associations between student status (compared to same-age employed adults) and psychological treatment outcomes were explored using logistic regression models. Models were adjusted for important treatment, clinical and demographic characteristics, and propensity score matching was used to explore the robustness of effects. RESULTS: Students and the employed comparison group were similar on baseline characteristics at assessment, but students were less likely to reliably recover (OR = 0.90 [95% CI = 0.83;0.96]) and reliably improve (OR = 0.91 [95% CI = 0.84;0.98]) by the end of treatment in fully adjusted models. Students and the employed group did not differ regarding the likelihood of deterioration (OR = 0.89 [95% CI = 0.78;1.02]) or treatment dropout (OR = 1.01 [95% CI = 0.93;1.11]). CONCLUSIONS: Students appear at risk of poorer outcomes compared to employed younger adults when treated in routine psychological treatment services. Students may require additional support and treatment adaptations that account for student-specific stressors as this might improve psychological treatment outcomes.

A Complex Presentation: Psychosis in a Patient Diagnosed With Lennox-Gastaut Syndrome.

Lennox-Gastaut syndrome (LGS) is a form of severe childhood epilepsy, with most children experiencing seizures before reaching the age of eight. Typically, patients have multiple types of seizures, making an accurate diagnosis challenging. While it can be secondary to other causes, often, it is idiopathic. Over time, children develop cognitive impairment, leading to intellectual disability. The mainstay of treatment and management is seizure control. However, management remains challenging due to the complexity of the syndrome, as it is associated with multiple seizure types, intellectual deterioration, and other psychiatric comorbidities. We present the case of a 19-year-old male diagnosed with LGS and treated with various available therapies, who demonstrated multiple breakthrough seizures, significant neurocognitive disabilities, and behavior challenges. Additionally, the patient displayed psychotic features of auditory hallucinations, aggression, and attempts at self-mutilation, a rare clinical presentation in LGS.

Bidirectional changes in depressive symptoms and social functioning in older adults attending psychological therapy services.

BACKGROUND: Impairments in the ability to carry out social activities commonly co-occur alongside depression. Improving social functioning is often overlooked in treatment. This is despite the high value placed by patients on social functioning and the potential for interventions focused on social functioning to have additional benefits in reducing depressive symptoms. In older adults the relationship between depressive symptoms and social functioning during treatment is poorly understood. METHODS: We analysed data across the first four treatment sessions of 3260 older adults receiving psychological therapy for depression at eight NHS Talking Therapies for anxiety and depression services in England. Random-intercept cross-lagged panel models were estimated, modelling bi-directional change between depressive symptoms, and impairments in (a) social leisure activities, and (b) close relationships, controlling for gender and diagnosis. RESULTS: Over treatment sessions, depressive symptoms and impairments in social functioning decreased. A bi-directional relationship was observed whereby depressive symptoms were associated with future impairments in social functioning and vice versa. Changes in depressive symptoms appeared to have a greater association with future social functioning, compared to the reverse. LIMITATIONS: Patients lived in Greater London and findings may not translate to other settings. We included older adults that attended at least four treatment sessions, and had no missing data at the first assessment, potentially biasing the sample and results. CONCLUSIONS: Older adults receiving psychological therapy experience reductions in depressive symptoms and impairment in social functioning early in treatment. Treating core depressive symptoms and impairments in social functioning may benefit one another, and improve outcomes.

Symptom-specific effects of counselling for depression compared to cognitive-behavioural therapy.

BACKGROUND: Cognitive-behavioural therapy (CBT) and counselling for depression (CfD) are recommended first-line treatments for depression. While they approach change differently, there is little understanding of the impact those approaches have on change during treatment. OBJECTIVES: This study aimed to identify whether CBT and CfD target different symptoms and explore the implications of modelling choices when quantifying change during treatment. METHODS: Symptom-specific effects of treatment were identified using moderated network modelling. This was a retrospective cohort study of 12 756 individuals who received CBT or CfD for depression in primary/community care psychological therapy services in England. Change was modelled several ways within the whole sample and a propensity score matched sample (n=3446). FINDINGS: CBT for depression directly affected excessive worry, trouble relaxing and apprehensive expectation and had a stronger influence on changes between suicidal ideation and concentration. CfD had a stronger direct influence on thoughts of being a failure and on the associated change between being an easily annoyed and apprehensive of expectation. There were inconsistencies when modelling change using the first and second appointments as the baseline. Residual score models produced more conservative findings than models using difference scores. CONCLUSIONS: CfD and CBT for depression have differential effects on symptoms demonstrating specific mechanisms of change. CLINICAL IMPLICATIONS: CBT was uniquely associated with changes in symptoms associated with anxiety and may be better suited to those with anxiety symptoms comorbid to their depression. When assessing change, the baseline should be the first therapy session, not the pretreatment assessment. Residual change scores should be preferred over difference score methods.

Percutaneous Catheter Drainage in Acute Infected Necrotizing Pancreatitis: A Real-World Experience at a Tertiary Care Hospital in North India.

Introduction Open necrosectomy in acute infected necrotizing pancreatitis is associated with very high mortality and morbidity. Moreover, if it is performed before four weeks, the benefits are limited. In this study, we evaluated the safety and efficacy of percutaneous catheter drainage (PCD) in patients with acute infected necrotizing pancreatitis. Methods It was a single-center, observational study, where all consecutive patients with proven or probable infected acute necrotizing pancreatitis in whom PCD was performed were studied. The patients who failed to respond to PCD underwent open necrosectomy. Baseline characteristics and the outcome of all included patients, including complications of PCD, were studied. Results A total of 46 patients (males=36, females=10) underwent PCD over a period of 18 months. Fifteen (32.60%) patients succumbed to their illness. PCD benefitted a total of 31 (67.39%) patients; in 17 (36.95%) patients, it worked as a standalone therapy, while in 14 (30.43%) patients, additional surgery was required where it helped to delay the surgery. Median days at which PCD and surgery were performed were 17.5 days (range: 2-28 days) and 33 days (range: 7-70 days), respectively. Lower mean arterial pressure at presentation, presence of multiorgan failure, more than 50% necrosis, higher baseline creatinine and bilirubin levels, and an early surgery were markers of increased mortality. Three (6.5%) patients had PCD-related complications, out of which only one required active intervention. Conclusion PCD in infected acute pancreatic necrosis is safe and effective. In one-third of the patients, it worked as standalone therapy, and in the rest it delayed the surgery beyond four weeks, thereby preventing the complications associated with early aggressive debridement.

Risperidone induced hypotension: A case report and literature review.

Risperidone is a second-generation antipsychotic agent used in psychiatric management, acutely and chronically. A rare adverse effect has been described with its use in the form of orthostatic hypotension especially in pharmaceutical clinical trials. However, there remains a lack of literature on the replication or prevalence of this adverse effect among patients in clinical settings. Hence, we present an incidental case of orthostatic hypotension following Risperidone therapy.

N-acetylcysteine in the Treatment of Internet Gaming Disorder.

Internet gaming disorder (IGD) is the persistent and recurrent use of the internet to engage in video gaming through a single or multiplayer interface that can lead to significant impairment or distress. With technological advancements in the last decade via portable handheld devices, along with their global availability, video games have found a new medium in which they can provide instantaneous access for casual and enthusiastic users alike. Unfortunately, this exponentially increases the possibility of addiction. IGD shares a similar pathophysiological etiology to addiction as drugs or gambling. However, it can be challenging to manage IGD due to the ease of video game access and limited understanding of the newly recognized disorder. This study aims to fill in the knowledge gap concerning the limited research on internet gaming addiction, its consequential effects on human cognitive-behavioral functioning, and pharmacotherapy management as observed in our patient, who developed IGD, starting initially as a casual recreational hobby among peers. This case also highlights the lack of social awareness and seriousness attributed to this disorder. It focuses on using N-acetylcysteine in the management as well as other psychological and psychotropic drugs.

Migratory foreign body in the neck.

Oesophageal penetration and migration of foreign bodies are fairly rare occurrences. Most reported cases in the literature involve fish bones, which are eventually found in the lateral neck soft tissue or thyroid lobule. We present a case of a migrating fish bone in an elderly female which was found embedded in her right sternocleidomastoid muscle. The fish bone was successfully removed via neck exploration. Appropriate literature is reviewed.

Experiential avoidance and emotion regulation difficulties in hoarding disorder.

Experiential avoidance can be defined as the tendency to avoid contact with unwanted internal experiences. Current conceptualizations of pathological hoarding appear broadly consistent with an experiential avoidant model. Eighty participants in four groups, namely hoarding disorder (HD) without comorbid obsessive-compulsive disorder (OCD), HD with comorbid OCD, non-hoarding OCD, and healthy controls, were administered measures of experiential avoidance and emotion regulation difficulties. Hoarding individuals reported higher levels of experiential avoidance and difficulties in emotion regulation compared to healthy but not to OCD participants. Both experiential avoidance and emotion regulation difficulties were significantly more prominent when HD was comorbid with OCD than when HD occurred without comorbid OCD. Correlation analyses further showed that both experiential avoidance and emotion regulation were moderately but significantly associated with obsessive-compulsive but not hoarding symptoms. Thus, experiential avoidance and emotion regulation difficulties are not specifically relevant to HD but to a broad range of psychopathologies. However, despite the lack of specificity, the findings raise some potentially useful clinical implications for the treatment of HD.

Stressful life events and material deprivation in hoarding disorder.

Traumatic life events and early material deprivation have been identified as potential environmental risk factors for the development of pathological hoarding behavior, but the evidence so far is preliminary and confounded by the presence of comorbid obsessive-compulsive disorder (OCD). This study retrospectively examined the occurrence of traumatic/stressful life events and material deprivation in four well-characterized groups: hoarding disorder without comorbid OCD (HD; n=24), hoarding disorder with comorbid OCD (HD+OCD; n=20), OCD without hoarding symptoms (OCD; n=17), and non-clinical controls (Control; n=20). Participants completed clinician and self-administered measures of hoarding, OCD, depression, psychological adjustment, and traumatic experience. Semi-structured interviews were undertaken to assess the temporal relation between traumatic/stressful life events and the onset and worsening of hoarding symptoms, and to determine the level of material deprivation. Although rates of post-traumatic stress disorder were comparable across all three clinical groups, hoarders (regardless of the presence of comorbid OCD) reported greater exposure to a range of traumatic and stressful life events compared to the two non-hoarding groups. Results remained unchanged after controlling for age, gender, education level, depression, and obsessive-compulsive symptoms. The total number of traumatic life events correlated significantly with the severity of hoarding but not of obsessive-compulsive symptoms. About half (52%) of hoarding individuals linked the onset of hoarding difficulties to stressful life circumstances, although this was significantly less common among those reporting early childhood onset of hoarding behavior. There was no link between levels of material deprivation and hoarding. Results support a link between trauma, life stress and hoarding, which may help to inform the conceptualization and treatment of hoarding disorder, but await confirmation in a representative epidemiological sample and using a longitudinal design.

Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both?

OBJECTIVE: Compulsive hoarding is a debilitating problem that is often associated with obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder. However, the precise nosology of compulsive hoarding has yet to be determined. METHOD: Participants were 25 patients with severe compulsive hoarding with OCD and 27 patients with severe compulsive hoarding without OCD. Both groups were carefully characterized and compared on the following sociodemographic and clinical variables: precise phenomenology of hoarding behavior, severity of other OCD symptoms, axis I and axis II psychopathology, and adaptive functioning. For comparison purposes, the following individuals were also recruited: 71 patients with OCD without hoarding, 19 patients with anxiety disorder, and 21 community participants. RESULTS: Overall, the phenomenology of hoarding behavior was similar in the two hoarding groups. The majority of participants in both groups reported hoarding common items as a result of their emotional and/or intrinsic value. However, approximately one-fourth of participants in the compulsive hoarding with OCD group showed a different psychopathological profile, which was characterized by the hoarding of bizarre items and the presence of other obsessions and compulsions related to their hoarding, such as fear of catastrophic consequences, the need to perform checking rituals, and the need to perform mental compulsions before discarding any item. These patients had a more severe and disabling form of the disorder. The strong relationship between compulsive hoarding and obsessive-compulsive personality disorder was explained entirely by the overlapping item content. CONCLUSIONS: In most individuals, compulsive hoarding appears to be a syndrome separate from OCD, which is associated with substantial levels of disability and social isolation. However, in other individuals, compulsive hoarding may be considered a symptom of OCD and has unique clinical features. These findings have implications for the classification of OCD and compulsive hoarding in the next edition of DSM.