Patient motivation and adherence in metacognitive therapy for major depressive disorder: an observational study.

The aim of this observational study was to examine the predictive and discriminant validity of patient motivation and adherence in metacognitive therapy (MCT) for depression. Motivational development for recovered- and non-recovered patients was also investigated. Motivation in sessions 1, 4, and 7 was measured using the Motivational Interviewing Skill Code 2.5 (MISC) in a 10-session trial of MCT for depression (N = 37). Adherence was assessed with the CBT compliance measure in session 7. The Beck Depression Inventory measured treatment outcome at 3-year follow-up. Recovered patients developed significantly more change talk and taking steps, and less sustain talk, as therapy progressed, compared to non-recovered patients. Evidence of the predictive validity of motivation in sessions 1 and 4 was limited. Higher sustain talk and taking steps in session 7 were significant predictors of more and less depressive symptoms, respectively. There was a moderate-strong correlation between motivation and adherence. The results confirm the predictive value of MISC in sessions 7 of MCT for depression, and establish differential motivational development between recovered and non-recovered patients. Subsequent research should clarify the discriminant validity and temporal relationships between motivation, adherence, and other clinical variables.

An empirical investigation of the associations between metacognition, mindfulness experiential avoidance, depression, and anxiety.

BACKGROUND: The aims of this study were to explore the possible relation between metacognition, mindfulness, and experiential avoidance, as well as their association with symptoms of anxiety and depression. METHODS: Cross-sectional data was collected from a community sample (N = 364) who completed the Metacognitions Questionnaire-30 (MCQ-30), the Five Facet Mindfulness Questionnaire-24 (FFMQ-24), the Acceptance and Action Questionnaire-II (AAQ-II), the Generalized Anxiety Disorder 7-item (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9). RESULTS: There were moderate-strong associations between mindfulness (FFMQ-24), metacognition (MCQ-30), and experiential avoidance (AAQ-II) (0.62 - 0.67), and they showed similar relations with symptoms of depression (PHQ-9) and anxiety (GAD-7) (0.57 - 0.71). Mindfulness, experiential avoidance, and the non-judging subscale of FFMQ-24 constituted a latent factor of flexibility in cognition and emotional experience, while three FFMQ-24 subscales (describing, acting with awareness, and observing) constituted a present-centered attention and awareness factor. Regression analyses indicated that flexibility explained more of the variance in symptoms of anxiety and depression than present-centered attention and awareness. CONCLUSIONS: The results suggest that flexibility in cognitive and emotional regulation skills could be important in explaining symptoms of anxiety and depression.

Effectiveness of 'motivational interviewing' on sick leave: a randomized controlled trial in a social insurance setting.

OBJECTIVE: This study aimed to evaluate the effectiveness of motivational interviewing (MI) - a counselling approach offered by caseworkers at the Norwegian Labor and Welfare Administration (NAV) - on return to work (RTW) for individuals sick-listed for ≥8 weeks due to any diagnoses. MI was compared to usual case management and an active control during 12 months of follow-up. METHODS: In a randomized clinical trial with three parallel arms, participants were randomized to MI (N=257), usual case management (N=266), or an active control group (N=252). MI consisted of two MI sessions while the active control involved two sessions without MI, both were offered in addition to usual case management. The primary outcome was number of sickness absence days based on registry data. Secondary outcomes included time to sustainable RTW, defined as four consecutive weeks without medical benefits. RESULTS: The median number of sickness absence days for the MI group was 73 days [interquartile range (IQR) 31-147], 76 days (35-134) for usual care, and 75 days (34-155) for active control. In total 89%, 88% and 86% of the participants, respectively, achieved sustainable RTW. The adjusted hazard ratio (HR) for time to sustainable RTW was 1.12 (95% CI 0.90-1.40) for MI compared to usual case management and HR 1.16 (95% CI 0.93-1.44) compared to the active control. CONCLUSIONS: This study did not provide evidence that MI offered by NAV caseworkers to sick-listed individuals was more effective on RTW than usual case management or an active control. Providing MI in this context could be challenging as only half of the MI group received the intervention.

Measuring Resilience in Long-term Sick-listed Individuals: Validation of the Resilience Scale for Adults.

Return to work from long-term sick leave is influenced by personal and social factors, which can be measured by resilience, a construct that describe healthy adaptation against adversity. This study aimed to validate the validity and psychometric properties of the resilience scale for adults in a sample of long-term sick-listed individuals, and to investigate measurement invariance when compared with a university student sample. Confirmatory factor analysis was used on a sick-listed sample (n = 687) to identify the scale?s factor structure, and comparison with a university student sample (n = 241) was utilized to determine measurement invariance. Results show that a slightly modified factor structure, in accordance with previous research, achieved acceptable fit in the sick-listed sample, while comparisons with the student sample supported measurement invariance. This means that the study to a large degree support the factor structure of the resilience scale for adults in long-term sick-listed. Furthermore, the results indicate that the scale is similarly understood among long-term sick-listed as in a previously validated student sample. Thus, the resilience scale for adults can be a valid and reliable measure of protective factors in the long-term sickness absence and return to work context, and the subscale and total score can be interpreted similarly in long-term sick-listed as in other populations.

Nicotine use and non-pathological alcohol use and their relationship to affective symptoms and sleep disturbances in bipolar disorder.

BACKGROUND: The use of alcohol and nicotine can negatively impact the course of bipolar disorder (BD), but there is limited knowledge about how symptoms and sleep disturbances are related to concurrent nicotine use and non-pathological use of alcohol. METHODS: We investigated how nicotine use and non-pathological use of alcohol relates to affective symptoms and sleep disturbances in 453 participants with BD without substance use disorders. Manic symptoms were assessed with the Young Mania Rating Scale, and depressive symptoms with The Inventory of Depressive Symptomatology, Clinician-Rated (IDS-C). Sleep-related questions from IDS-C were used to create proxy variables for sleep disturbances, including Insomnia and Hypersomnia. Multinomial regression analysis was conducted to investigate the associations between nicotine use and sleep disturbances, controlling for possible confounders such as current use of illicit drugs and psychopharmacological treatment. RESULTS: Depressive and manic symptoms were not associated with the concurrent level of alcohol or nicotine use. Individuals with medium and high levels of daily nicotine use had higher risk of insomnia than those without. Non-pathological alcohol use was not associated with sleep disturbances. LIMITATIONS: Sleep disturbances were based on items from the IDS-C questionnaire. CONCLUSION: We found an elevated risk for insomnia in individuals with BD and medium or high levels of daily nicotine use. We found no association between the level of affective symptoms and the level of use of alcohol or nicotine. The direction of the relationship between nicotine use and insomnia needs clarification, as it is highly relevant for treatment planning.

Effectiveness of adding motivational interviewing or a stratified vocational advice intervention to usual case management on return to work for people with musculoskeletal disorders: the MI-NAV randomised controlled trial.

OBJECTIVES: To evaluate if adding motivational interviewing (MI) or a stratified vocational advice intervention (SVAI) to usual case management (UC), reduced sickness absence over 6 months for workers on sick leave due to musculoskeletal disorders. METHODS: We conducted a three-arm parallel pragmatic randomised controlled trial including 514 employed workers (57% women, median age 49 (range 24-66)), on sick leave for at least 50% of their contracted work hours for ≥7 weeks. All participants received UC. In addition, those randomised to UC+MI were offered two MI sessions from social insurance caseworkers and those randomised to UC+SVAI were offered vocational advice from physiotherapists (participants with low/medium-risk for long-term sickness absence were offered one to two sessions, and those with high-risk were offered three to four sessions). RESULTS: Median sickness absence was 62 days, (95% CI 52 to 71) in the UC arm (n=171), 56 days (95% CI 43 to 70) in the UC+MI arm (n=169) and 49 days (95% CI 38 to 60) in the UC+SVAI arm (n=169). After adjusting for predefined potential confounding factors, the results showed seven fewer days in the UC+MI arm (95% CI -15 to 2) and the UC+SVAI arm (95% CI -16 to 1), compared with the UC arm. The adjusted differences were not statistically significant. CONCLUSIONS: The MI-NAV trial did not show effect on return to work of adding MI or SVAI to UC. The reduction in sickness absence over 6 months was smaller than anticipated, and uncertain due to wide CIs. TRIAL REGISTRATION NUMBER: NCT03871712.

Depression, Anxiety, Insomnia, and Quality of Life in a Representative Community Sample of Older Adults Living at Home.

Background: The aim of the study was to explore symptoms of anxiety and depression, insomnia, and quality of life in a Norwegian community sample of older adults. Methods: A representative sample (N = 1069) was drawn from home-dwelling people of 60 years and above, living in a large municipality in Norway (Trondheim). Results: Based on established cut-off scores, 83.7% of the participants showed no symptoms of anxiety/depression, 12% had mild symptoms, 2.7% moderate symptoms, 1.5% showed severe symptoms of anxiety/depression. A total of 18.4% reported insomnia symptoms. Regarding health-related quality of life, few participants reported problems with self-care, but pain and discomfort were common (59%). Depression/anxiety, insomnia, and health-related quality of life showed moderate to strong associations. Discussion: The results suggest a close interplay between anxiety/depression, insomnia, and health-related quality of life in older adults.

Metacognitions and brooding predict depressive symptoms in a community adolescent sample.

Depressive symptoms are prevalent in adolescence, and girls have higher levels of depressive symptoms and depressive disorder than boys. Rumination and especially brooding, seem to be a central maintaining factor of depressive symptoms, where metacognitions about rumination play a prominent role in maintaining depressive rumination. There is a sex difference in adults in depressive disorder. The current investigation of a high school / community sample of adolescents aged 16-20 from Norway (N = 1198, 62.2% women) found that adolescent women had higher scores than men on all relevant measures: Depressive symptoms, negative and positive metacognitions, pondering, and brooding. A path model for predicting depressive symptoms showed that the major factors for both sexes were negative metacognitions and brooding. The predictors of depressive symptoms were invariant across sex and age groups, suggesting similar underlying mechanisms across these groups. The overall findings suggest that metacognitive therapy may be an efficient intervention for depressive symptoms among adolescents.

Fidelity of a Motivational Interviewing Intervention for Improving Return to Work for People with Musculoskeletal Disorders.

The objective of this study was to conduct a fidelity evaluation of a motivational interviewing (MI) intervention delivered by social insurance caseworkers, in a three-arm randomized controlled trial (RCT) for improving return to work for people on sick leave with musculoskeletal disorders. The caseworkers received six days of MI training, including an intervention manual prior to the trial onset, as well as supervision throughout the trial. The caseworkers recorded 21 MI sessions at regular intervals during the trial. An independent MI analysis center scored the recordings using the MI treatment integrity code (MITI 4). In addition, three experienced MI trainers assessed the adherence to the MI intervention manual on a 1-4 Likert scale and MI competence. Total MITI 4 mean scores were at beginning proficiency levels for two components (global technical, mean 3.0; SD 0.6 and the reflections/questions ratio, mean 1.1; SD 0.2) and under beginning proficiency for two components (global relational, mean 3.2; SD 0.7 and complex question, mean 34.0; SD 21.2). The MI trainers' assessment showed similar results. The mean adherence score for the MI sessions was 2.96 (SD 0.9). Despite delivering a thorough course and supervision package, most of the caseworkers did not reach proficiency levels of good MI competence during the study. The fidelity evaluation showed that a large amount of training, supervision and practice is needed for caseworkers to become competent MI providers. When planning to implement MI, it is important that thorough consideration is given regarding the resources and the time needed to train caseworkers to provide MI in a social insurance setting.

Metacognitive therapy versus cognitive-behavioral therapy in adults with generalized anxiety disorder: A 9-year follow-up study.

OBJECTIVE: Metacognitive therapy (MCT) and cognitive-behavior therapy (CBT) are effective treatments for generalized anxiety disorder. In this study, we followed-up patients who had previously participated in a randomized controlled trial of MCT compared against CBT. METHOD: We collected 9-year follow-up data on 39 out of 60 original patients (i.e., 65% response rate). RESULTS: At 9 years, the recovery rates were 57% for MCT and 38% for CBT (completer analysis). Following MCT, 43% maintained their recovery status and a further 14% achieved recovery. Following CBT, the sustained recovery rate was 13%, while a further 25% achieved recovery. Patients in the MCT condition showed significantly more improvement with respect to symptoms of worry and anxiety. In the CBT group, 23.1% were re-diagnosed with generalized anxiety disorder (GAD) compared with 9.5% in the MCT group. CONCLUSIONS: This follow-up study showed a continuation of gains in both treatments at long-term follow-up, but with outcomes continuing to favor MCT and strengthening its comparative superiority.

Health, Work, and Family Strain - Psychosocial Experiences at the Early Stages of Long-Term Sickness Absence.

BACKGROUND: Knowledge about the psychosocial experiences of sick-listed workers in the first months of sick leave is sparse even though early interventions are recommended. The aim of this study was to explore psychosocial experiences of being on sick leave and thoughts about returning to work after 8-12 weeks of sickness absence. METHODS: Sixteen individuals at 9-13 weeks of sick leave participated in semi-structured individual interviews. Data was analyzed through Giorgi's descriptive phenomenological method. RESULTS: Three themes emerged: (1) energy depleted, (2) losing normal life, (3) searching for a solution. A combination of health, work, and family challenges contributed to being drained of energy, which affected both work- and non-work roles. Being on sick leave led to a loss of social arenas and their identity as a contributing member of society. Participants required assistance to find solutions toward returning to work. CONCLUSION: Even in this early stage of long-term sick leave, sick listed workers faced complex challenges in multiple domains. Continuing sick leave was experienced as necessary but may challenge personal identity and social life. Those not finding solutions may benefit from additional early follow-up that examine work-related, social and personal factors that influence return to work.

Workplace flexibility important for part-time sick leave selection-an exploratory cross-sectional study of long-term sick listed in Norway.

BACKGROUND: Part-time sick leave (PTSL) where sick-listed individuals work a percentage corresponding to their remaining work capabilities is often used to promote return to work. The effects of PTSL are uncertain due to participant selection on personal and social factors, which are not easily captured by evaluations that primarily rely on register-data. More knowledge of health-related, workplace and personal characteristics that influence the propensity to utilize PTSL is needed. The objective of the present study was to explore whether individuals on PTSL and full-time sick leave (FTSL) differ in terms of self-reported health, workplace resources and psychological resilience while also considering known sociodemographic factors that influence PTSL selection. METHODS: The study utilized a cross-sectional sample of 661 workers sick listed for 8 weeks with a 50-100% sick-listing degree. Differences between those on PTSL and FTSL with regard to current self-reported health, previous long-term sick leave, workplace adjustment latitude, psychosocial work environment, work autonomy, coping with work demands, and psychological resilience were examined and adjusted for known selection factors (age, education, gender, sector, diagnosis, and physical work) using logistic regression. RESULTS: An inverse U-shaped curvilinear association between self-reported health and PTSL was identified. Those on PTSL also reported greater workplace adjustment latitude and better psychosocial work environment than those on FTSL. These differences persisted after adjusting for previously known selection factors. Furthermore, the PTSL group reported more work autonomy and poorer coping with work demands, but these differences were more uncertain after adjustment. The groups did not differ in terms of previous long-term sick leave or psychological resilience. CONCLUSION: The present study found differences between those on PTSL and FTSL with regards to self-reported health, workplace adjustment latitude and psychosocial work environment that were independent of differences identified in previous research. These results are important for future evaluations of the effect of PTSL on RTW, suggesting more attention should be paid to self-reported health status and workplace characteristics that are not captured using register data.

Barriers and Facilitators for Implementing Motivational Interviewing as a Return to Work Intervention in a Norwegian Social Insurance Setting: A Mixed Methods Process Evaluation.

Purpose The aim of this study was to evaluate potential barriers and facilitators for implementing motivational interviewing (MI) as a return to work (RTW) intervention in a Norwegian social insurance setting. Methods A mixed-methods process evaluation was conducted alongside a randomized controlled trial involving MI sessions delivered by social insurance caseworkers. The study was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework using focus groups with the caseworkers. MI fidelity was evaluated through audio-recordings of MI sessions and questionnaires to sick-listed participants. Results Lack of co-worker and managerial support, time and place for practicing to further develop MI skills, and a high workload made the MI intervention challenging for the caseworkers. The MI method was experienced as useful, but difficult to master. MI fidelity results showed technical global scores over the threshold for "beginning proficiency" whereas the relational global score was under the threshold. The sick-listed workers reported being satisfied with the MI sessions. Conclusions Despite caseworker motivation for learning and using MI in early follow-up sessions, MI was hard to master and use in practice. Several barriers and facilitators were identified; these should be addressed before implementing MI in a social insurance setting.Trial registration ClinicalTrials.gov: NCT03212118 (registered July 11, 2017).

Subgroups of Long-Term Sick-Listed Based on Prognostic Return to Work Factors Across Diagnoses: A Cross-Sectional Latent Class Analysis.

Comorbidity is common among long-term sick-listed and many prognostic factors for return to work (RTW) are shared across diagnoses. RTW interventions have small effects, possibly due to being averaged across heterogeneous samples. Identifying subgroups based on prognostic RTW factors independent of diagnoses might help stratify interventions. The aim of this study was to identify and describe subgroups of long-term sick-listed workers, independent of diagnoses, based on prognostic factors for RTW. Latent class analysis of 532 workers sick-listed for eight weeks was used to identify subgroups based on seven prognostic RTW factors (self-reported health, anxiety and depressive symptoms, pain, self-efficacy, work ability, RTW expectations) and four covariates (age, gender, education, physical work). Four classes were identified: Class 1 (45% of participants) was characterized by favorable scores on the prognostic factors; Class 2 (22%) by high anxiety and depressive symptoms, younger age and higher education; Class 3 (16%) by overall poor scores including high pain levels; Class 4 (17%) by physical work and lack of workplace adjustments. Class 2 included more individuals with a psychological diagnosis, while diagnoses were distributed more proportionate to the sample in the other classes. The identified classes illustrate common subgroups of RTW prognosis among long-term sick-listed individuals largely independent of diagnosis. These classes could in the future assist RTW services to provide appropriate type and extent of follow-up, however more research is needed to validate the class structure and examine how these classes predict outcomes and respond to interventions.

Validity of a Norwegian version of the Desire Thinking Questionnaire (DTQ): Associations with problem drinking, nicotine dependence and problematic social media use.

The aim of the current study was to test the validity of the Norwegian version of the Desire Thinking Questionnaire (DTQ). Three cross-sectional surveys were conducted investigating the psychometric properties of the DTQ in alcohol use (N = 588), nicotine use (N = 446) and social media use (N = 359). Principal components and confirmatory factor analyses supported the original two-factor solution consisting of verbal perseveration (VP) and imaginal prefiguration (IP); however, one item was removed to obtain good fit. Internal consistency was acceptable. Both IP and VP showed significant correlations with problem drinking, nicotine dependence and problematic social media use. Regression analyses, controlling for demographics and negative affect, found IP and VP to be significantly associated with all dependent variables. The results confirm that desire thinking is an important construct across different addictive behaviours.

Change in personality traits and facets (Revised NEO Personality Inventory) following metacognitive therapy or cognitive behaviour therapy for generalized anxiety disorder: Results from a randomized controlled trial.

OBJECTIVE: We aimed to discover whether psychological treatment for generalized anxiety disorder (GAD) was associated with changes in the big five personality traits and their facets. METHOD: Patients with GAD were randomized either to receive cognitive behaviour therapy (CBT, n = 28) or metacognitive therapy (MCT, n = 32). Before and after 12 sessions of treatment, 55 of the patients completed the full Revised NEO Personality Inventory (NEO-PI-R) (240 items). RESULTS: Patients with GAD showed a personality profile with high Neuroticism and lower Extraversion and Openness. Treatment across conditions was associated with significant reduction in Neuroticism and increased Extraversion and Openness. There were no significant changes in Agreeableness and Conscientiousness. However, their facets of Actions and Trust increased. Post-treatment levels of neuroticism were associated with symptoms of worry before and after therapy, whereas post-treatment extraversion was related to depressive symptoms after treatment. MCT was associated with greater reduction of Neuroticism than CBT. CONCLUSIONS: This is the first study to show that efficient treatment for a specific disorder resulted in changes across NEO-PI-R factors and facets and that more efficient treatment results in greater change. If this reflects a reduced trait vulnerability for mental disorder, this might provide evidence of relapse prevention.

Protective and Vulnerability Factors in Self-Esteem: The Role of Metacognitions, Brooding, and Resilience.

The aim of the current study was to explore protective (resilience) and vulnerability factors (dysfunctional metacognitions and brooding) for self-esteem. A total of 725 participants were included in a cross-sectional study. A path analysis revealed five paths to self-esteem. The three main paths were as follows: (1) symptoms -> metacognitions -> brooding -> self-esteem, (2) symptoms -> resilience -> self-esteem, and (3) a direct path from symptoms. The first path corresponds with the metacognitive model of psychopathology and suggests that triggers in the form of anxiety and depression symptoms lead to the activation of metacognitive beliefs, which in turn activates brooding in response to these triggers. When a person engages in brooding, this makes the person vulnerable to experiencing low self-esteem. The second path suggests a protective role of resilience factors. The overall model explained 55% of the variance in self-esteem. Regression analysis found that unique predictors of self-esteem were female sex, symptoms of anxiety and depression, brooding, and resilience. These findings have possible clinical implications, as treatment may benefit from addressing both protective and vulnerability factors in individuals suffering from low self-esteem.