Transdiagnostic considerations of the relationship between reward sensitivity and psychopathological symptoms - a cross-lagged panel analysis.

BACKGROUND: Reward sensitivity constitutes a potential key mechanism regarding the etiology and maintenance of mental disorders, especially depression. However, due to a lack of longitudinal studies, the temporal dynamics are not clear yet. Although some evidence indicates that reward processing could be a transdiagnostic mechanism of disorders, these observations could be also a product of comorbidity with depression. This study aimed at investigating the temporal dynamics of reward sensitivity and the course of psychopathological symptoms in a longitudinal investigation, while taking a possible mediating role of depression into account. METHODS: We conducted a three-wave longitudinal online survey with a 4-week interval. A total of N = 453 participants filled out all three questionnaires. Reward sensitivity was assessed with the Positive Valence System Scale-21 (PVSS-21), depression with the Patient Health Questionnaire (PHQ-9), eating disorder symptoms with the Eating Disorder Examination-Questionnaire-8 (EDE-Q-8), social anxiety with the Mini-social phobia inventory (Mini-SPIN) and alcohol consumption with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Cross-lagged panels and mediation analyses were calculated using path analyses. RESULTS: Depressive and eating disorder symptoms predicted reward insensitivity at later points in time. Effects were larger from T2 to T3. A bidirectional relationship concerning social anxiety was found. Higher alcohol consumption predicted higher reward sensitivity. Depression at T2 fully mediated the association between psychopathological symptoms at T1 and reward sensitivity at T3 for social anxiety and eating disorder symptoms. CONCLUSIONS: Our findings imply that reduced reward sensitivity seems to be a consequence rather than an antecedent of psychopathological symptoms. Comorbid depression plays a crucial role in other mental disorders regarding observed hyposensitivity towards rewards. Therefore, our results do not support a transdiagnostic notion of reward sensitivity, but they indicate a potential role of reward sensitivity for symptom persistence. TRIAL REGISTRATION: The study was preregistered at the Open Science Framework (OSF) ( https://archive.org/details/osf-registrations-6n3s8-v1 ; registration DOI https://doi.org/10.17605/OSF.IO/6N3S8 ).

Let us talk about death: gender effects in cancer patients' preferences for end-of-life discussions.

PURPOSE: Patients with advanced cancer often receive suboptimal end-of-life (EOL) care. Particularly males with advanced cancer are more likely to receive EOL care that is more aggressive, even if death is imminent. Critical factors determining EOL care are EOL conversations or advance care planning. However, information about gender-related factors influencing EOL conversations is lacking. Therefore, the current study investigates gender differences concerning the content, the desired time point, and the mode of initiation of EOL conversations in cancer patients. METHODS: In a cross-sectional study, 186 female and male cancer patients were asked about their preferences for EOL discussions using a semi-structured interview, focusing on (a) the importance of six different topics (medical and nursing care, organizational, emotional, social, and spiritual/religious aspects), (b) the desired time point, and (c) the mode of discussion initiation. RESULTS: The importance of EOL topics differs significantly regarding issue (p = 0.002, η2 = 0.02) and gender (p < 0.001, η2 = 0.11). Males wish to avoid the engagement in discussions about death and dying particularly if they are anxious about their end-of-life period. They wish to be addressed regarding the "hard facts" nursing and medical care only. In contrast, females prefer to speak more about "soft facts" and to be addressed about each EOL topic. Independent of gender, the majority of patients prefer to talk rather late: when the disease is getting worse (58%), at the end of their therapy, or when loosing self-sufficiency (27.5%). CONCLUSION: The tendency of patients to talk late about EOL issues increases the risk of delayed or missed EOL conversations, which may be due to a knowledge gap regarding the possibility of disease-associated incapability. Furthermore, there are significant gender differences influencing the access to EOL conversations. Therefore, for daily clinical routine, we suggest an early two-step, gender-sensitive approach to end-of-life conversations.

Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders.

BACKGROUND: DSM-5 introduced a fundamental revision of the category of somatoform disorders, which resulted in the new somatic symptom disorder (SSD) and related disorders. However, prognostic validity of SSD remains unclear, while other classification proposals, such as bodily distress disorder (BDD) or polysymptomatic distress disorder (PSDD), might be promising alternatives for the new ICD-11. Therefore, the comparison of the different approaches concerning long-term prognosis of disorder-relevant factors is of special interest. METHOD: In a longitudinal design (baseline, 1-year, and 4-year follow-up), the three proposals (SSD, BDD, PSDD) were compared in an age-representative sample of the German general population (N = 321). To this end, the baseline sample was divided into three independent pairs of groups (with/without SSD, with/without BDD, with/without PSDD). It was tested how well each approach differentiated with regard to medium- and long-term healthcare utilization, number of symptoms, and impairment. RESULTS: Criteria for BDD distinguished best with regard to future healthcare utilization resulting in a large-sized effect (f = 0.44) for the difference between persons with and without BDD, while SSD and PSDD revealed only medium-sized effects (f = 0.28 and f = 0.32) between subjects with and without diagnosis. The three proposals distinguished equally well with regard to future subjective impairment (between f = 0.39 and f = 0.41) and the number of reported symptoms (between f = 0.77 and f = 0.83). CONCLUSION: In accordance with our data regarding prognostic validity, the current draft of the WHO group is based on the BDD proposal. However, existing limitations and weaknesses of the present proposal for the ICD-11 are further discussed.

Is it best to expect the worst? Influence of patients' side-effect expectations on endocrine treatment outcome in a 2-year prospective clinical cohort study.

BACKGROUND: This study aims to determine the role of patient expectations as potentially modifiable factor of side-effects, quality of life, and adherence to endocrine treatment of breast cancer. PATIENTS AND METHODS: A 2-year prospective clinical cohort study was conducted in routine primary care with postoperative patients with hormone-receptor-positive breast cancer, scheduled to start adjuvant endocrine treatment. Structured patient-reported assessments of side-effects, side-effect expectations, quality of life, and adherence took place during the first week post-surgery and after 3 and 24 months of endocrine treatment. RESULTS: Of 111 enrolled patients, at 3 and 24 months, 107 and 88 patients, respectively, were assessed. After 2 years of endocrine treatment, patients reported high rates of side-effects (arthralgia: 71.3%, weight gain: 53.4%, hot flashes: 46.5%), including symptoms not directly attributable to the medication (breathing problems: 28.1%, dizziness: 25.6%). Pre-treatment expectations significantly predicted patient-reported long-term side-effects and quality of life in multivariate models controlling for relevant medical and psychological variables. Relative risk of side-effects after 2 years of endocrine treatment was higher in patients with high negative expectations at baseline than in those with low negative expectations (RR = 1.833, CI 95%, 1.032-3.256). A significant interaction confirmed this expectation effect to be particularly evident in patients with high side-effects at 3 months. Furthermore, baseline expectations were associated with adherence at 24 months (r = -0.25, P = 0.006). CONCLUSIONS: Expectations are a genuine factor of clinical outcome from endocrine treatment for breast cancer. Negative expectations increase the risk of treatment-specific side-effects, nocebo side-effects, and non-adherence. Yet, controlled studies are needed to analyze potential causal relationships. Optimizing individual expectations might be a promising strategy to improve side-effect burden, quality of life, and adherence during longer-term drug intake. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02088710.

Acceptance and commitment group therapy (ACT-G) for health anxiety: a randomized controlled trial.

BACKGROUND: Severe health anxiety is frequent and costly, yet rarely diagnosed or treated. Earlier treatment studies show problems with recruitment, dropout and recovery. In the current study, the authors aimed to test the effect of acceptance and commitment group therapy (ACT-G) compared to waitlist in patients with severe health anxiety. METHOD: During March 2010 to April 2012, 126 consecutively referred patients meeting research criteria for severe health anxiety were block-randomized (1:1) to ACT-G or a 10 months' waitlist (Clinicaltrials.gov, no. NCT01158430). Patients allocated to ACT-G were treated in seven groups of nine patients between December 2010 and October 2012 and received nine weekly 3-h group sessions and a booster session consisting of ACT techniques. The primary outcome was decided a priori as the mean change in self-reported illness worry on the Whiteley-7 Index (WI) from baseline to 10 months' follow-up. Secondary outcomes were improvement in emotional distress and health-related quality of life at 10 months' follow-up. RESULTS: Intention-to-treat analysis showed a statistically significant mean difference of 20.5 points [95% confidence interval (CI) 11.7-29.4, p < 0.001] on the WI between the groups at 10 months, and the between-group effect sizes were large (Cohen's d = 0.89, 95% CI 0.50-1.29). The number needed to treat was 2.4 (95% CI 1.4-3.4, p < 0.001). Diagnosis and treatment were well accepted by the patients. CONCLUSIONS: ACT-G seems feasible, acceptable and effective in treating severe health anxiety.

Symptoms, functioning and coping strategies in individuals with schizophrenia spectrum disorders who do not take antipsychotic medication: a comparative interview study.

BACKGROUND: A considerable proportion of people with schizophrenia spectrum disorders do not take antipsychotic medication but seem to be functioning well. However, little is known about this group. To test the assumption that absence of medication is compensated for by more effective coping and increased social support, this study compared symptoms, functioning, coping strategies and social support in non-medicated and medicated individuals with schizophrenia spectrum disorders. METHOD: In all, 48 participants with a DSM-IV schizophrenia spectrum disorder who were taking (n = 25) or not taking antipsychotic medication (n = 23) were included. Assessment consisted of self-ratings of symptoms, symptom-related distress and social support combined with a semi-structured interview that assessed general and social functioning, subjective evaluation of symptoms and coping strategies. RESULTS: Symptom severity and distress did not differ between the groups. However, the non-medicated participants had significantly higher levels of general functioning than medicated participants and a longer duration of being non-medicated was significantly associated with a higher level of general functioning. In contrast to the hypotheses, not taking medication was not associated with more effective coping strategies or with higher levels of social support. Medicated participants more frequently reported the use of professional help as a coping strategy. CONCLUSIONS: Our results corroborate previous studies finding improved functioning in individuals with schizophrenia spectrum disorders who do not take medication compared with those who take medication, but do not support the notion that this difference is explicable by better coping or higher levels of social support. Alternative explanations and avenues for research are discussed.

[Traumatization and posttraumatic stress disorder. Effect of type and number of traumatic experiences]. / Traumatisierung und posttraumatische Belastungsstörungen. Auswirkung von Art und Anzahl traumatischer Erfahrung.

OBJECTIVE: The number and type of traumatic experiences show differential associations with posttraumatic stress disorder (PTSD). OBJECTIVE: The associations of number and type of traumatic experiences with PTSD were investigated in a representative population sample in Germany. MATERIAL AND METHODS: Traumatic experiences and PTSD were assessed with a self-rating questionnaire in a sample of 2510 participants from the general German population. RESULTS: The risk of (partial) PTSD increased with an increasing number of traumatic experiences. In contrast interpersonal and accidental traumatization showed no substantial differences with respect to the risk of PTSD. CONCLUSION: To quantify the relevance of the number and type of traumatic experiences for onset and persistence of PTSD, a multidimensional and complex assessment of those experiences is necessary. This is a great challenge in epidemiological research on this topic.

Breaking bad news-what patients want and what they get: evaluating the SPIKES protocol in Germany.

BACKGROUND: Evaluation of the SPIKES protocol, a recommended guideline for breaking bad news, is sparse, and information about patients' preferences for bad-news delivery in Germany is lacking. Being the first actual-theoretical comparison of a 'breaking bad news' guideline, the present study evaluates the recommended steps of the SPIKES protocol. Moreover, emotional consequences and quality of bad-news delivery are investigated. PATIENTS AND METHODS: A total of 350 cancer patients answered the MABBAN (Marburg Breaking Bad News Scale), a questionnaire representing the six SPIKES subscales, asking for the procedure, perception and satisfaction of the first cancer disclosure and patient's assign to these items. RESULTS: Only 46.2% of the asked cancer patients are completely satisfied with how bad news had been broken to them. The overall quality is significantly related to the emotional state after receiving bad news (r = -0.261, P < 0.001). Patients' preferences differ highly significantly from the way bad news were delivered, and the resulting rang list of patients' preferences indicates that the SPIKES protocol do not fully meet the priorities of cancer patients in Germany. CONCLUSIONS: It could be postulated that the low satisfaction of patients observed in this study reflects the highly significant difference between patients' preferences and bad-news delivery. Therefore, some adjunctions to the SPIKES protocol should be considered, including a frequent reassurance of listeners' understanding, the perpetual possibility to ask question, respect for prearrangement needs and the conception of bad-news delivery in a two-step procedure.

COMPliance and Arthralgia in Clinical Therapy: the COMPACT trial, assessing the incidence of arthralgia, and compliance within the first year of adjuvant anastrozole therapy.

BACKGROUND: This prospective study evaluated the relationship between arthralgia and compliance during the first year of adjuvant anastrozole therapy in postmenopausal women with hormone receptor-positive early breast cancer. PATIENTS AND METHODS: COMPliance and Arthralgia in Clinical Therapy (COMPACT) was an open-label, multicenter, noninterventional study conducted in Germany. Patients had started adjuvant anastrozole 3-6 months before the study start. The primary end points were arthralgia, compliance, and the relationship between compliance and arthralgia, assessed at specific time points. RESULTS: Overall, 1916 patients received upfront anastrozole. Mean arthralgia scores were increased from baseline at each visit up to 9 months. Compliance with anastrozole therapy gradually decreased over time from baseline to 9 months (P<0.001). At 9 months, investigators estimated that >95% of patients were compliant versus patient reports of <70%. There was a significant association between arthralgia mean scores and noncompliance at 6 months (P<0.0001), 9 months (P<0.0001), and overall (P<0.0001). Over time, new events or impairment of existing arthralgias were reported in 14% (3 months), 11% (6 months), and 9% (9 months) of patients. CONCLUSION: Arthralgia is important in the clinical management of women with early breast cancer and may contribute to noncompliance and clinical outcomes. CLINICALTRIALSGOV IDENTIFIER: NCT00857012.

Effectiveness of behavioral activation and mindfulness in increasing reward sensitivity and reducing depressive symptoms - A randomized controlled trial.

Reward insensitivity is a potential key mechanism regarding the maintenance of depression. However, there is a lack of research examining and comparing the effectiveness of different psychological interventions in modifying reward insensitivity. This four-arm randomized controlled trial (RCT) investigated a two-week online intervention. After screening for eligibility, a total of 336 participants were randomized, and 224 participated per-protocol. Participants were assigned to either a) behavioral activation, b) mindfulness and gratitude, c) a combination of both, or d) a waitlist control condition. They received videos and implemented daily exercises. Reward sensitivity and depressive symptoms served as primary outcomes. Behavioral activation and mindfulness significantly improved depressive symptoms and reward sensitivity. However, the effects of behavioral activation were not superior. The combination treatment versus the waiting group was insignificant regarding reward insensitivity. Explorative analyses revealed that all intervention groups reduced anhedonia substantially. Our findings imply that brief online interventions with behavioral activation and mindfulness-based approaches can impact reward insensitivity, while effects for a combination were less clear. Nonetheless, our results do not allow us to infer the differential effectiveness of the interventions. There is a clear need for treatments better targeting maintaining factors of depression, such as reward insensitivity. Clinical trial registration number: NCT05402150.

Really just a little prick? A meta-analysis on adverse events in placebo control groups of seasonal influenza vaccination RCTs.

BACKGROUND: The Corona pandemic and ongoing mass vaccinations raise the question of the nocebo mechanisms involved. Since immunization is usually administered to healthy people as a preventive health measure, adverse events (AE) following immunization are less accepted and could contribute to vaccine hesitancy. Assuming that vaccinees experience nocebo responses, the aim of this meta-analysis was to investigate the effect sizes of solicited adverse events (or assumed reactogenicity) reported in placebo groups in RCTs on seasonal influenza vaccination. METHODS: Literature search via PubMed, Web of Science, and CENTRAL was conducted considering gray literature. Only RCTs with placebo groups using pharmacologically inert substances (like saline) were included. Quality was assessed using Cochrane Collaboration's Risk of Bias Tool. Effect sizes were estimated using a random mixed effects model based on k = 31 studies covering 14,326 participants in placebo groups. RESULTS: Reported solicited AEs in placebo groups showed significant effect sizes of proportions (ESp). In k = 13 analyzed placebo groups, 35 % of the participants reported at least one solicited systemic AE (p = 0.007). The most common particular solicited systemic AEs were headache (k = 27; 17 %; p = 0.001), malaise (k = 13; 12 %; p = 0.004), and hyperhidrosis (k = 4; 12 %; p < 0.001) within one week after vaccination. CONCLUSION: The results show significant solicited AEs in placebo groups, indicating substantial nocebo responses after vaccination. Based on the fact that most vaccination programs include similar groups of healthy people, we expect that comparable nocebo effects occur during other campaigns. Health care professionals should be aware of the nocebo response and take action to prevent or decrease the burden of adverse events following immunization. Fear of side effects must be addressed early in order to diminish vaccine hesitancy. Prospero identifier: CRD42020156287, October 2019.

[Psychotherapeutic approaches for patients with somatoform disorders]. / Psychotherapeutische Ansätze für Patienten mit somatoformen Störungen.

Patients with somatoform symptoms are considered to be difficult to treat. Clinical studies on treatment of this condition are underrepresented compared to other mental and psychosomatic disorders. Cognitive-behavioral treatment for patients with somatoform symptoms was found to have a significant effect; additionally, some evidence of recently published findings supports psychodynamic therapy. This report provides information on how to effectively deal with those patients. Furthermore it describes transtherapeutic targets and explains three therapeutic phases: establishing a therapeutic relationship, developing a model of the disorder and establishing coping strategies. As a last point a cognitive-behavioral treatment study, a psychodynamically-oriented study, a group intervention study and a new approach, a combination of cognitive-behavioral therapy and emotion regulation training, are presented.

[COPD-specific anxiety and depressive symptoms in COPD patients]. / Krankheitsbezogene Ängste und Depressivität bei COPD-Patienten.

The aim of the present study was to analyze the associations between COPD-specific anxiety and depressive symptoms in COPD patients. Anxiety, as well as depression, is a prevalent comorbid complication in COPD. Either can have a negative impact on patients' experience and the course of disease. So far, assessment in studies has exclusively focused on anxiety in general and not on disease-related fears. The present study comprised a sample of ninety-six patients suffering from COPD (GOLD III/IV). Results of the MANOVA showed higher COPD-specific anxiety in patients with depressive symptoms than in patients without depressive symptoms. Depressive patients showed a higher fear of social isolation, dyspnea related fear, fear of movement and fear of progression of disease. There were no differences between the two groups with regard to functional parameters (FEV 1 % pred.; 6-minute-walk-test). Overall, our study shows the necessity of the assessment of COPD-specific fears related to depression to guarantee an adequate treatment.

[Fear of progression and end-of-life fear in COPD patients]. / Progredienzangst und End-of-Life-Ängste bei COPD-Patienten.

Anxiety and depression are prevalent comorbid conditions in COPD. Furthermore, diseases related anxieties (fear of progression, end-of-life fear) occur very often. Anxiety can have a negative impact on patients' quality of life and is sometimes even considered as a risk factor for re-hospitalisation. There are only a few studies that focus on disease related anxieties in COPD. The aim of our study was to investigate the associations between disease related anxieties (fear of progression, end-of-life fear), psychological health status and quality of life in COPD patients. 132 patients with COPD (GOLD II-IV) participated in the study. Results of a MANOVA showed no differences between diseases related anxieties among patients with different disease severity (GOLD II-IV). Furthermore, the results showed significant associations between end-of-life fear, fear of progression, depression and quality of life. Further analyses showed that there is a need for managing end-of-life fears and improving end-of-life care. Overall, our study showed, that health disease related anxieties play an important role in COPD and still do not receive enough attention.

[Personal responsibility for health. An interdisciplinary discussion on obesity as an example]. / Verantwortung für die eigene Gesundheit. Eine interdisziplinäre Diskussion am Beispiel der Adipositas.

Considering obesity as an example, the present study has developed an ethical, legal and psychological understanding of personal responsibility, which aims at enabling and activating health promoting behaviour. Enhancing individual capabilities and modifying social and political factors that have an effect on individual behaviour are highlighted as a promising, appropriate and ethically sound strategy of prevention.

[F45.41: chronic pain disorder with somatic and psychological factors : a coding aid]. / F45.41 Chronische Schmerzstörung mit somatischen und psychischen Faktoren : Eine Kodierhilfe.

In 2009, the German version of ICD-10 (ICD-10 GM version 2009) introduced the diagnosis of "chronic pain disorder with somatic and psychological factors", because current ICD-10 diagnoses did not address the biopsychosocial character of chronic pain adequately. For most patients, a dichotomous classification into psychologically versus biomedically caused pain is inappropriate and does not reflect current knowledge on pain. The new code F45.41 addresses the relevance of psychological factors for chronic pain persistence and chronic pain treatment, even in those conditions with a clear biomedical cause at the beginning. This guideline describes how to use this new diagnosis, which boundaries have to be considered, and how comorbid and associated conditions can be classified. The distinction of this new diagnosis from other pain-associated diagnoses and recommendations for the coding of comorbid conditions are presented. The differentiation of everyday pain symptoms from pain disorders is outlined. Finally, contextual factors of the classification process, as well as problems in integrating this new diagnosis into diagnosis-related group (DRG) systems of financial reimbursement are discussed.

[Desire for early retirement and therapy of chronic back pain: relevance of social medical variables for outpatient psychotherapeutic treatment]. / Rentenbegehren und Therapie chronischer Rückenschmerzen: Die Relevanz sozialmedizinischer Variablen bei ambulanter psychotherapeutischer Behandlung.

BACKGROUND: This study investigated the influence of patients' desire for early retirement on the success of an outpatient cognitive behavioural treatment (CBT) in patients with chronic back pain. Previous studies have shown that the desire for early retirement and social compensation had a negative influence on therapy outcome, e.g. pain intensity and pain disability. This study was conducted to reassess whether these results can be replicated in an outpatient CBT setting. METHOD: Questionnaires assessing pain-related variables were issued to a total of 116 patients at the beginning, at the end of treatment and 6 months after termination of therapy. RESULTS: Overall, the treatment showed significant positive results in the variables assessed. In contrast to other studies, patients with a desire for early retirement also showed improvement during treatment. The success of treatment proved to be stable after termination of therapy. CONCLUSION: CBT in an outpatient setting seems to be an effective treatment for patients with chronic back pain and even patients with a desire for early retirement benefit from treatment.

[Conclusion: How should a meaningful meta-analysis of long-term psychodynamic psychotherapy be designed?]. / Schlusswort: Wie müsste eine aussagekräftige Metaanalyse zur psychodynamischen Langzeittherapie gestaltet sein?

In their answer to our critical evaluation of their meta-analysis about long-term psychodynamic psychotherapy (LTPP), Leichsenring and Rabung claim that all our critical points could be rejected. This is surprising, as the authors already confirmed different shortcomings of their analysis. Our major criticism is that the meta-analysis is based on very few high-quality studies (including follow-up assessments), but on many studies with poor quality and/or observational studies resulting in serious publication bias. Neither the treatment of interest (LTPP) nor the target group is sufficiently circumscribed, but the very few studies are misinterpreted as if confirming efficacy of all psychodynamic interventions for nearly all psychiatric groups. Superior efficacy over other effective psychological interventions is mentioned, although not justified by data. Patient selection bias which is a major issue in long-term treatments is not addressed adequately and led to erroneous conclusions that the more treatment people receive, the higher the benefit. To conclude, the authors try to suggest far-reaching conclusions which are only based on a few studies with poor data quality.

[Saving psychoanalysis. At any cost?]. / Die Psychoanalyse soll gerettet werden. Mit allen Mitteln?

Although long-term psychoanalysis has been criticized due to lacking scientific efficacy, a meta-analysis by Leichsenring and Rabung concludes it is even more effective than other psychological interventions and follows a dose:response relationship (i.e. the longer the better). We reassessed this meta-analysis and find that its conclusions are not warranted. First, major parts of them are not based on the included randomised clinical trials (11) but on observational studies (12), which are known to be subject to investigator bias. The definition of long-term psychoanalysis included mainly randomised clinical trials with fewer than 50 treatment sessions, which is untypically short for this kind of intervention. Comparison groups were misclassified (especially the classification "cognitive interventions"). Important disorders were not clearly defined, hindering any interpretation of which treatment is to be indicated. Moreover the authors did not consider the lack of acceptance and attrition rates, nor did they include intention-to-treat data sets. For some of the studies only 45% of samples were included in the meta-analysis. We conclude that a few of the included randomised clinical trials using psychodynamic short-term interventions truly are promising and of high quality; however these do not justify generalizations on long-term psychoanalysis, and the presented meta-analysis is clearly biased.