Cognitive-motivational, interpersonal, and behavioral functioning in relationship to treatment and research engagement in forensic patients with ADHD.

OBJECTIVES: To provide more insight into treatment and research responsivity in offenders with attention-deficit hyperactivity disorder (ADHD). METHOD: Via self-reports and patients' scores on cognitive computer tasks, it was examined whether poorer cognitive-motivational, interpersonal, and behavioral functioning were related to treatment no-shows, longer treatment time duration intervals, and no-show at the research appointment in 52 forensic outpatients with ADHD (Mage = 35.3, SD = 9.38). Treatment adherence was tracked for 10 appointments after research participation. RESULTS: Regression analyses showed that higher self-reported impulsivity was associated with research no-show, and more alcohol use with longer treatment time intervals. Yet, self-reported delay aversion was associated with fewer treatment no-shows, and, uncontrolled for alcohol use, impulsivity was associated with shorter treatment time intervals in a subsample of patients. CONCLUSIONS: These preliminary results indicate that externalizing behaviors increase the risk for nonadherence in forensic ADHD patients, but that cognitive-motivational problems also motivate patients to be more engaged.

Treatment no-show in forensic outpatients with ADHD.

BACKGROUND: 'No-show' is important in today's mental healthcare services, yet in forensic psychiatry, little is known about its relationship to general and disorder-specific patient characteristics. AIMS: The aim of this article is to determine the prevalence of no-show and any general and disorder-specific features associated with no-show in a cohort of offenders with attention deficit hyperactivity disorder registered at a specialist forensic mental health clinic. METHODS: Participants were 118 adult men with a mean age just over 32 years (SD 8.75) attending forensic mental health outpatient clinics in the Netherlands who had a primary diagnosis of attention deficit hyperactivity disorder and who had been aggressive and/or delinquent. RESULTS: Over a 1-year period, most patients (101, 86%) missed at least one appointment. The average number of appointments offered was 37.88 (SD = 27.27), and the average number of no-shows was 6.53 (SD = 5.99) per patient. Multivariate linear regressions showed a 10-fold likelihood of later no-shows if the first appointment was missed; not showing up after the intake procedure was also associated with higher rates of later no-show. None of the disorder-specific characteristics contributed to the problem. CONCLUSIONS: No-show is of particular concern in forensic mental health settings. In the current study, no-show was primarily associated with features related to the time of initial consultation. More attention should thus be paid at this stage to using a standard method of assessing a wider range of variables likely to affect attendance. Copyright © 2016 John Wiley & Sons, Ltd.

Efficacy versus effectiveness: a direct comparison of the outcome of treatment for mild to moderate depression in randomized controlled trials and daily practice.

BACKGROUND: Results from randomized controlled trials (RCTs) are considered to give the most reliable information on treatment outcome (efficacy). Yet, the generalizability of efficacy results to daily practice (effectiveness) might be diminished by the design of RCTs. The STAR*D trial approached daily practice as much as possible, but still has some properties of an RCT. In this study, we compare results from treatment of major depressive disorder (MDD) in routine clinical practice to those of RCTs and STAR*D. METHODS: Effectiveness in routine clinical practice was compared with efficacy results from 15 meta-analyses on antidepressant, psychotherapeutic and combination treatment and results from STAR*D. Data on daily practice patients and treatments were derived from a routine outcome monitoring (ROM) system. Treatment outcome was defined as proportion of remitters (MADRS ≤10) and within-group effect size. RESULTS: From ROM, 598 patients suffering from a MDD episode according to the MINI-plus were included. Remission percentages were lower in routine practice than in meta-analyses for all treatment modalities (32 vs.40-74%). Differences were less explicit for antidepressants (21 vs. 34-47%) than for individual psychotherapy (27 vs. 34-58%; effect size 0.85 vs. 1.71) and combination therapy (21 vs. 45-63%), since only 60% of the meta-analyses for antidepressants showed significant differences with ROM, while for psychotherapy and combination treatment almost all meta-analyses showed significant differences. No differences in effectiveness were found between routine practice and STAR*D (antidepressants 27 vs. 28%; individual psychotherapy 27 vs. 25%; combination treatment 21 vs. 23%, respectively). CONCLUSIONS: Effectiveness of treatment for mild-to-moderate MDD in daily practice is similar to STAR*D and significantly lower than efficacy results from RCTs.

The generalizability of psychotherapy efficacy trials in major depressive disorder: an analysis of the influence of patient selection in efficacy trials on symptom outcome in daily practice.

BACKGROUND: Treatment guidelines for major depressive disorder (MDD) are based on results from randomized clinical trials, among others in psychotherapy efficacy trials. However, patients in these trials differ from routine practice patients since trials use stringent criteria for patient selection. It is unknown whether the exclusion criteria used in psychotherapy efficacy trials (PETs) influence symptom outcome in clinical practice. We first explored which exclusion criteria are used in PETs. Second, we investigated the influence of commonly used exclusion criteria on symptom outcome in routine clinical practice. METHODS: We performed an extensive literature search in PubMed, PsycInfo and additional databases for PETs for MDD. From these, we identified commonly used exclusion criteria. We investigated the influence of exclusion criteria on symptom outcome by multivariate regression models in a sample of patients suffering from MDD according to the MINIplus from a routine clinical practice setting (n=598). Data on routine clinical practice patients were gathered through Routine Outcome Monitoring. RESULTS: We selected 20 PETs and identified the following commonly used exclusion criteria: 'a baseline severity threshold of HAM-D≤14', 'current or past abuse or dependence of alcohol and/or drugs' and 'previous use of medication or ECT'. In our routine clinical practice sample of patients suffering from MDD (n=598), presence of 'current or past abuse of or dependence on alcohol and/or drugs' had no significant influence on outcome.'Meeting a baseline severity threshold of HAM-D≤14' and 'previous use of medication or ECT' were associated with better outcome, but the explained variance of the models was very small (R2=2-11%). CONCLUSIONS: The most consistently used exclusion criteria are not a major threat to the generalizability of results found in PETs. However, PETs do somewhat improve their results by exclusion of patients with minor depression and patients who used antidepressants prior to psychotherapy.

Reliability and validity of the Global Assessment of Functioning Scale in clinical outpatients with depressive disorders.

RATIONALE, AIMS AND OBJECTIVES: The Global Assessment of Functioning Scale (GAF) is widely used to assess psychological, social and occupational functioning. The validity and reliability of the GAF in clinical practice have only scarcely been studied in naturalistic samples. METHODS: A total of 432 outpatients with a current major depressive disorder (MDD) were evaluated with routine outcome monitoring (ROM). At baseline the GAF score was assessed by the treating clinician and at ROM baseline and follow-up sessions also by a trained test nurse. Sociodemographic data, the Mini International Neuropsychiatric Interview Plus and scores on the Montgomery-Äsberg Depression Rating Scale, Beck Depression Inventory-revised, Brief Symptom Inventory and Short Form-36 were assessed. RESULTS: At baseline, the mean GAF score by the clinician was 54.8 (range 35-85), and this was systematically lower than the mean GAF score by the test nurse of 57.5 (range 31-88). GAF scores by the clinician and test nurse correlated weakly (r = 0.26). The GAF scores of the clinicians correlated strongly with disease severity, and social and physical functioning. CONCLUSION: The GAF showed rather poor inter-rater reliability as well as poor discriminant validity with disease severity and physical limitations in a large naturalistic sample of outpatients with MDD.