Patterns, predictors, and patient-reported reasons for antidepressant discontinuation in the WHO World Mental Health Surveys.

BACKGROUND: Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation. METHODS: Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months. RESULTS: 10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation. CONCLUSION: Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

The Migration Experience: A Conceptual Framework and Systematic Scoping Review of Psychological Acculturation.

ACADEMIC ABSTRACT: One of the key challenges to researching psychological acculturation is the immense heterogeneity in theories and measures. These inconsistencies make it difficult to compare past literature, hinder straightforward measurement selections, and stifle theoretical integration. To structure acculturation, we propose to utilize the four basic aspects of human experiences (wanting, feeling, thinking, and doing) as a conceptual framework. We use this framework to build a theory-driven assessment of past theoretical (final N = 92), psychometric (final N = 233), and empirical literature (final N = 530). We find that the framework allows us to examine and compare past conceptualizations. For example, empirical works have understudied the more internal aspects of acculturation (i.e., motivations and feelings) compared with theoretical works. We, then, discuss the framework's novel insights including its temporal resolution, its comprehensive and cross-cultural structure, and how the framework can aid transparent and functional theories, studies, and interventions going forward. PUBLIC ABSTRACT: This systematic scoping review indicates that the concept of psychological acculturation can be structured in terms of affect (e.g., feeling at home), behavior (e.g., language use), cognition (e.g., ethnic identification), and desire (e.g., independence wish). We find that the framework is useful in structuring past research and helps with new predictions and interventions. We, for example, find a crucial disconnect between theory and practice, which will need to be resolved in the future.

Need Fulfillment During Intergroup Contact: Three Experience Sampling Studies.

One challenge of modern intergroup contact research has been the question of when and why an interaction is perceived as positive and improves intergroup relations. We propose to consider the perceived fulfillment of the situationally most relevant need. We conducted three intensive longitudinal studies with recent migrants to capture their interactions with the majority out-group (Nmeasurements = 10,297; Nparticipants = 207). The situational need fulfillment mechanism is consistently a strong predictor of perceived interaction quality and positive out-group attitudes following intergroup interactions. The model is specific to out-group contact, robust to various need types, and works at least as well as Allport's contact conditions. As one of the first studies to test intergroup contact theory using intensive longitudinal data, we offer insight into the mechanisms of positive intergroup contact during real-life interactions and find situational motivations to be a key building block for understanding and addressing positive intergroup interactions.Public significance statement: In this article, we provide evidence that the fulfillment of situational needs during real-life intergroup contacts meaningfully predicts perceived interaction quality and positive outgroup attitudes. Methodologically, this offers a testament to the emerging practice of capturing real-life interactions using intensive longitudinal data. Theoretically, our results give weight to motivational fulfillment as a flexible and effective mechanism for understanding positive intergroup contact.

Commentary: The evidence base regarding the long-term effects of childhood mental disorder treatments needs to be strengthened - reply to Dekkers et al. (2023).

In their reply to our editorial (Journal of Child Psychology and Psychiatry, 2023, 64, 464), Dekkers et al. (Journal of Child Psychology and Psychiatry, 2023, 64, 470) argue that treatment is the best choice for children with mental disorders because there is 'sound evidence' that interventions are effective, also in the long term. We agree that there is sound evidence for treatment effectiveness in the short-term and there is some evidence for longer-term effects of certain specific treatments, such as behavioral parent training in children with behavioral disorders, as acknowledged in our editorial. However, we strongly disagree that there is sound evidence for long-term effectiveness.

Wild and Willful Kids: Can We Help Parents? The Effectiveness of a Group Parent Training Program Without a Psychiatric Label.

Many children with a classification of attention-deficit/hyperactivity disorder exhibit mild-to-moderate problem behavior. For these children, a stepped diagnosis and stepped care approach has been proposed. Although a psychiatric classification may bring support to families, it may also have negative consequences. Therefore, in this preliminary study, the effect of a group parent training program without child-bound classifications (named Wild & Willful, Druk & Dwars in Dutch) was investigated. In 7 sessions, groups of parents (experimental, n=63; waiting list control, n=38) learned strategies to deal with wild and willful behavior in their children. Outcome variables were assessed by questionnaires. Multilevel analyses showed that, compared with the control group, the intervention group had significantly lower scores on parental stress and communication problems (Cohen d=0.47 and 0.52, respectively), but not on attention and hyperactivity problems, oppositional defiant problems, and responsivity. Zooming in on the course of outcome variables over time in the intervention group, improvements on all variables were seen, with small to moderate effect sizes (Cohen d=0.30 to 0.52). Overall, the group parent training program without the need for a classification for children seemed beneficial. The training is low cost, brings together parents who are facing similar problems in rearing their children, and may help to reduce overdiagnosis of mild and moderate problems, without risking undertreatment of severe difficulties.

Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report.

BACKGROUND: The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. METHODS: Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. RESULTS: 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2-4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. CONCLUSION: ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

Development and evaluation of a risk algorithm predicting alcohol dependence after early onset of regular alcohol use.

AIMS: Likelihood of alcohol dependence (AD) is increased among people who transition to greater levels of alcohol involvement at a younger age. Indicated interventions delivered early may be effective in reducing risk, but could be costly. One way to increase cost-effectiveness would be to develop a prediction model that targeted interventions to the subset of youth with early alcohol use who are at highest risk of subsequent AD. DESIGN: A prediction model was developed for DSM-IV AD onset by age 25 years using an ensemble machine-learning algorithm known as 'Super Learner'. Shapley additive explanations (SHAP) assessed variable importance. SETTING AND PARTICIPANTS: Respondents reporting early onset of regular alcohol use (i.e. by 17 years of age) who were aged 25 years or older at interview from 14 representative community surveys conducted in 13 countries as part of WHO's World Mental Health Surveys. MEASUREMENTS: The primary outcome to be predicted was onset of life-time DSM-IV AD by age 25 as measured using the Composite International Diagnostic Interview, a fully structured diagnostic interview. FINDINGS: AD prevalence by age 25 was 5.1% among the 10 687 individuals who reported drinking alcohol regularly by age 17. The prediction model achieved an external area under the curve [0.78; 95% confidence interval (CI) = 0.74-0.81] higher than any individual candidate risk model (0.73-0.77) and an area under the precision-recall curve of 0.22. Overall calibration was good [integrated calibration index (ICI) = 1.05%]; however, miscalibration was observed at the extreme ends of the distribution of predicted probabilities. Interventions provided to the 20% of people with highest risk would identify 49% of AD cases and require treating four people without AD to reach one with AD. Important predictors of increased risk included younger onset of alcohol use, males, higher cohort alcohol use and more mental disorders. CONCLUSIONS: A risk algorithm can be created using data collected at the onset of regular alcohol use to target youth at highest risk of alcohol dependence by early adulthood. Important considerations remain for advancing the development and practical implementation of such models.

Distinguishing dimensions of emotion dynamics across 12 emotions in adolescents' daily lives.

Research on emotion dynamics as indices of emotion functioning has become muddled by conceptual confusion, methodological heterogeneity, and seemingly conflicting results. One way to address this chaos is the study of profiles of emotion dynamics across 12 emotions and how they differ between 246 adolescents. The interpretation of these dynamic profiles was guided by auxiliary variables including age, personality, depressive symptoms, and social experiences. During 6 days, 246 adolescents (Mage = 14.20; 65% female) rated nine times daily the intensity of 12 emotions (cheerful, happy, energetic, joyful, content, relaxed, anxious, worried, irritable, insecure, down, and guilty) and their social experiences with family, friends, and classmates. Additional baseline measures included neuroticism, extraversion (Revised Junior Eysenck Personality Questionnaire Short Form), and depressive symptoms (Center for Epidemiological Studies Depression Scale). A three-mode principal component analysis (3MPCA Tucker3-based) model was estimated on the person-specific dynamic parameters of emotional intensity (mean), variability (standard deviation), instability (mean squared successive difference), and inertia (autocorrelation). The 3MPCA identified three emotion-mode components (positive affect, negative affect, and irritability) and three dynamic-mode components (emotional intensity, lability, and inertia). Five individual-mode components captured interactions between these modes, of which positive affect explained most variation in the data. These emotion dynamic profiles correlated differently with social experiences. Additional 3MPCA model structures based on imputed data (correcting missing autocorrelations) and affect scale composites (low- and high-arousal positive and negative affect) showed strong resemblance. The identified emotion dynamic profiles capture meaningful interpersonal differences in adolescents' emotional experiences and change. Future work should focus on irritability and positive affect as these were uniquely informative in adolescents' emotional experiences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Editorial Perspective: Are treatments for childhood mental disorders helpful in the long run? An overview of systematic reviews.

Mental disorders may have severe consequences for individuals across their entire lifespan, especially when they start in childhood. Effective treatments (both psychosocial and pharmacological) exist for the short-term treatment of common mental disorders in young people. These could, at least theoretically, prevent future problems, including recurrence of the disorder, development of comorbidity, or problems in functioning. However, little is known about the actual effects of these treatments in the long run. In the current editorial perspective, we consider the available evidence for the long-term (i.e., ≥2 years) effectiveness and safety of treatments for attention deficit hyperactivity disorder, behavior disorders, and anxiety and depressive disorders for children between 6 and 12 years old. After providing an overview of the literature, we reflect on two key issues, namely, methodological difficulties in establishing long-term treatment effects, and the risk-benefit ratio of treatments for common childhood mental disorders. In addition, we discuss future research possibilities, clinical implications, and other approaches, specifically whole-of-society-actions that could potentially reduce the burden of common childhood mental disorders.

Age differences in hedonic adaptation to societal restrictions? Positive and negative affect trajectories during the first wave of the COVID-19 pandemic in 33 nations.

We examined age group differences in hedonic adaptation trajectories of positive and negative affect (PA/NA) at different arousal levels during the severe societal restrictions that governments implemented to contain the first wave of the COVID-19 pandemic (March to June 2020). Data from 10,509 participants from 33 countries and 12 weekly assessments were used (67% women, aged 18 to 85 +, on average 318 participants per country (SD = 434) and 5.6 assessments (SD = 2.5) per participant). Multilevel models (level 1: assessments, level 2: participants, level 3: countries) were fit to examine trajectories of low to high arousal PA and NA during the phase of tightening societal restrictions, the phase of stable peak restrictions, and the phase of easing restrictions separately. During the entire study period mean levels of PA were lower in emerging and young adults (aged 18-44) than older adults, whereas mean NA levels were higher. During peak societal restrictions, participants reported increasingly more PA, especially high-arousal emotions (d = .36 per month vs. .19 unaroused). NA levels decreased over time, especially high-arousal emotions (d = .35 vs. .14 p/month). These hedonic adaptation trajectories were largely similar across age groups. Nevertheless, up to 30% of the participants increased in NA and up to 6% decreased in PA, against the general trend, demonstrating substantial individual differences in emotional adaptation. Finally, heterogeneity in the effects of time on affect was larger on the individual level than the country level. Emotional recovery trajectories during the first lockdown in the COVID-19 pandemic were virtually similar across age groups in 33 countries, across valence and arousal levels, suggesting age advantages in emotional well-being remain restricted to mean-level differences rather than emotion dynamics. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The associations between traumatic experiences and subsequent onset of a substance use disorder: Findings from the World Health Organization World Mental Health surveys.

AIM: Exposure to traumatic events (TEs) is associated with substance use disorders (SUDs). However, most studies focus on a single TE, and are limited to single countries, rather than across countries with variation in economic, social and cultural characteristics. We used cross-national data to examine associations of diverse TEs with SUD onset, and variation in associations over time. METHODS: Data come from World Mental Health surveys across 22 countries. Adults (n = 65,165) retrospectively reported exposure to 29 TEs in six categories: "exposure to organised violence"; "participation in organised violence"; "interpersonal violence"; "sexual-relationship violence"; "other life-threatening events"; and those involving loved ones ("network traumas"). Discrete-time survival analyses were used to examine associations with subsequent first SUD onset. RESULTS: Most (71.0%) reported experiencing at least one TE, with network traumas (38.8%) most common and exposure to organised violence (9.5%) least. One in five (20.3%) had been exposed to sexual-relationship violence and 26.6% to interpersonal violence. Among the TE exposed, lifetime SUD prevalence was 14.5% compared to 5.1% with no trauma exposure. Most TE categories (except organised violence) were associated with increased odds of SUD. Increased odds of SUD were also found following interpersonal violence exposure across all age ranges (ORs from 1.56 to 1.78), and sexual-relationship violence exposure during adulthood (ORs from 1.33 to 1.44), with associations persisting even after >11 years. CONCLUSION: Sexual and interpersonal violence have the most consistent associations with progression to SUD; increased risk remains for many years post-exposure. These need to be considered when working with people exposed to such traumas.

Increased risks for mental disorders among LGB individuals: cross-national evidence from the World Mental Health Surveys.

PURPOSE: Lesbian, gay, and bisexual (LGB) individuals, and LB women specifically, have an increased risk for psychiatric morbidity, theorized to result from stigma-based discrimination. To date, no study has investigated the mental health disparities between LGB and heterosexual AQ1individuals in a large cross-national population-based comparison. The current study addresses this gap by examining differences between LGB and heterosexual participants in 13 cross-national surveys, and by exploring whether these disparities were associated with country-level LGBT acceptance. Since lower social support has been suggested as a mediator of sexual orientation-based differences in psychiatric morbidity, our secondary aim was to examine whether mental health disparities were partially explained by general social support from family and friends. METHODS: Twelve-month prevalence of DSM-IV anxiety, mood, eating, disruptive behavior, and substance disorders was assessed with the WHO Composite International Diagnostic Interview in a general population sample across 13 countries as part of the World Mental Health Surveys. Participants were 46,889 adults (19,887 males; 807 LGB-identified). RESULTS: Male and female LGB participants were more likely to report any 12-month disorder (OR 2.2, p < 0.001 and OR 2.7, p < 0.001, respectively) and most individual disorders than heterosexual participants. We found no evidence for an association between country-level LGBT acceptance and rates of psychiatric morbidity between LGB and heterosexualAQ2 participants. However, among LB women, the increased risk for mental disorders was partially explained by lower general openness with family, although most of the increased risk remained unexplained. CONCLUSION: These results provide cross-national evidence for an association between sexual minority status and psychiatric morbidity, and highlight that for women, but not men, this association was partially mediated by perceived openness with family. Future research into individual-level and cross-national sexual minority stressors is needed.

Patterns and correlates of patient-reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys.

Patient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys - 17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) - carried out as part of the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful.

ConNEcT: A Novel Network Approach for Investigating the Co-occurrence of Binary Psychopathological Symptoms Over Time.

Network analysis is an increasingly popular approach to study mental disorders in all their complexity. Multiple methods have been developed to extract networks from cross-sectional data, with these data being either continuous or binary. However, when it comes to time series data, most efforts have focused on continuous data. We therefore propose ConNEcT, a network approach for binary symptom data across time. ConNEcT allows to visualize and study the prevalence of different symptoms as well as their co-occurrence, measured by means of a contingency measure in one single network picture. ConNEcT can be complemented with a significance test that accounts for the serial dependence in the data. To illustrate the usefulness of ConNEcT, we re-analyze data from a study in which patients diagnosed with major depressive disorder weekly reported the absence or presence of eight depression symptoms. We first extract ConNEcTs for all patients that provided data during at least 104 weeks, revealing strong inter-individual differences in which symptom pairs co-occur significantly. Second, to gain insight into these differences, we apply Hierarchical Classes Analysis on the co-occurrence patterns of all patients, showing that they can be grouped into meaningful clusters. Core depression symptoms (i.e., depressed mood and/or diminished interest), cognitive problems and loss of energy seem to co-occur universally, but preoccupation with death, psychomotor problems or eating problems only co-occur with other symptoms for specific patient subgroups.

Transdiagnostic development of internalizing psychopathology throughout the life course up to age 45: a World Mental Health Surveys report.

BACKGROUND: Depressive and anxiety disorders are highly comorbid, which has been theorized to be due to an underlying internalizing vulnerability. We aimed to identify groups of participants with differing vulnerabilities by examining the course of internalizing psychopathology up to age 45. METHODS: We used data from 24158 participants (aged 45+) in 23 population-based cross-sectional World Mental Health Surveys. Internalizing disorders were assessed with the Composite International Diagnostic Interview (CIDI). We applied latent class growth analysis (LCGA) and investigated the characteristics of identified classes using logistic or linear regression. RESULTS: The best-fitting LCGA solution identified eight classes: a healthy class (81.9%), three childhood-onset classes with mild (3.7%), moderate (2.0%), or severe (1.1%) internalizing comorbidity, two puberty-onset classes with mild (4.0%) or moderate (1.4%) comorbidity, and two adult-onset classes with mild comorbidity (2.7% and 3.2%). The childhood-onset severe class had particularly unfavorable sociodemographic outcomes compared to the healthy class, with increased risks of being never or previously married (OR = 2.2 and 2.0, p < 0.001), not being employed (OR = 3.5, p < 0.001), and having a low/low-average income (OR = 2.2, p < 0.001). Moderate or severe (v. mild) comorbidity was associated with 12-month internalizing disorders (OR = 1.9 and 4.8, p < 0.001), disability (B = 1.1-2.3, p < 0.001), and suicidal ideation (OR = 4.2, p < 0.001 for severe comorbidity only). Adult (v. childhood) onset was associated with lower rates of 12-month internalizing disorders (OR = 0.2, p < 0.001). CONCLUSIONS: We identified eight transdiagnostic trajectories of internalizing psychopathology. Unfavorable outcomes were concentrated in the 1% of participants with childhood onset and severe comorbidity. Early identification of this group may offer opportunities for preventive interventions.

Emotion dynamics in children and adolescents: A meta-analytic and descriptive review.

Theories on children and adolescent emotion dynamics were reviewed using data from 102 ecological momentary assessment studies with 19,928 participants and 689 estimates. We examined age-graded differences in emotional intensity, variability, instability, inertia, differentiation, and augmentation/blunting. Outcomes included positive versus negative affect scales, discrete emotions (anger, sadness, anxiety, and happiness), and we compared samples of youth with or without mental or physiological problems. Multilevel models showed more variable positive affect and sadness in adolescents compared with children, and more intense negative affect. Our additional descriptive review suggests a decrease in instability of positive and negative emotions from early to late adolescence. Mental health problems were associated with more variable and less intense positive affect, and more intense anxiety and heightened sadness variability. These results suggest systematic changes in emotion dynamics throughout childhood and adolescence, but the supporting literature proved to be limited, fragmented, and based on heterogeneous concepts and methodology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Previous disorders and depression outcomes in individuals with 12-month major depressive disorder in the World Mental Health surveys.

AIMS: Major depressive disorder (MDD) is characterised by a recurrent course and high comorbidity rates. A lifespan perspective may therefore provide important information regarding health outcomes. The aim of the present study is to examine mental disorders that preceded 12-month MDD diagnosis and the impact of these disorders on depression outcomes. METHODS: Data came from 29 cross-sectional community epidemiological surveys of adults in 27 countries (n = 80 190). The Composite International Diagnostic Interview (CIDI) was used to assess 12-month MDD and lifetime DSM-IV disorders with onset prior to the respondent's age at interview. Disorders were grouped into depressive distress disorders, non-depressive distress disorders, fear disorders and externalising disorders. Depression outcomes included 12-month suicidality, days out of role and impairment in role functioning. RESULTS: Among respondents with 12-month MDD, 94.9% (s.e. = 0.4) had at least one prior disorder (including previous MDD), and 64.6% (s.e. = 0.9) had at least one prior, non-MDD disorder. Previous non-depressive distress, fear and externalising disorders, but not depressive distress disorders, predicted higher impairment (OR = 1.4-1.6) and suicidality (OR = 1.5-2.5), after adjustment for sociodemographic variables. Further adjustment for MDD characteristics weakened, but did not eliminate, these associations. Associations were largely driven by current comorbidities, but both remitted and current externalising disorders predicted suicidality among respondents with 12-month MDD. CONCLUSIONS: These results illustrate the importance of careful psychiatric history taking regarding current anxiety disorders and lifetime externalising disorders in individuals with MDD.

The clinical characterization of the adult patient with an anxiety or related disorder aimed at personalization of management.

The clinical construct of "anxiety neurosis" was broad and poorly defined, so that the delineation of specific anxiety disorders in the DSM-III was an important advance. However, anxiety and related disorders are not only frequently comorbid, but each is also quite heterogeneous; thus diagnostic manuals provide only a first step towards formulating a management plan, and the development of additional decision support tools for the treatment of anxiety conditions is needed. This paper aims to describe systematically important domains that are relevant to the personalization of management of anxiety and related disorders in adults. For each domain, we summarize the available research evidence and review the relevant assessment instruments, paying special attention to their suitability for use in routine clinical practice. We emphasize areas where the available evidence allows the clinician to personalize the management of anxiety conditions, and we point out key unmet needs. Overall, the evidence suggests that we are becoming able to move from simply recommending that anxiety and related disorders be treated with selective serotonin reuptake inhibitors, cognitive-behavioral therapy, or their combination, to a more complex approach which emphasizes that the clinician has a broadening array of management modalities available, and that the treatment of anxiety and related disorders can already be personalized in a number of important respects.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

Hybrid Systematic Review and Network Meta-Analysis of Randomized Controlled Trials of Interventions for Depressive Symptoms in Patients With Coronary Artery Disease.

OBJECTIVE: Depression is common in patients with coronary artery disease (CAD) and is associated with poor outcomes. Although different treatments are available, it is unclear which are best or most acceptable to patients, so we conducted a network meta-analysis of evidence from randomized controlled trials (RCTs) of different depression treatments to ascertain relative efficacy. METHODS: We searched for systematic reviews of RCTs of depression treatments in CAD and updated these with a comprehensive search for recent individual RCTs. RCTs comparing depression treatments (pharmacological, psychotherapeutic, combined pharmacological/psychotherapeutic, exercise, collaborative care) were included. Primary outcomes were acceptability (dropout rate) and change in depressive symptoms 8 week after treatment commencement. Change in 26-week depression and mortality were secondary outcomes. Frequentist, random-effects network meta-analysis was used to synthesize the evidence, and evidence quality was evaluated following Grading of Recommendations, Assessment, Development and Evaluations recommendations. RESULTS: Thirty-three RCTs (7240 participants) provided analyzable data. All treatments were equally acceptable. At 8 weeks, combination therapy (1 study), exercise (1 study), and antidepressants (10 studies) yielded the strongest effects versus comparators. At 26 weeks, antidepressants were consistently effective, but psychotherapy was only effective versus usual care. There were no differences in treatment groups for mortality. Grading of Recommendations, Assessment, Development and Evaluations ratings ranged from very low to low. CONCLUSIONS: Overall, the evidence was limited and biased. Although all treatments for post-CAD depression were equally acceptable, antidepressants have the most robust evidence base and should be the first-line treatment. Combinations of antidepressants and psychotherapy, along with exercise, could be more effective than antidepressants alone but require further rigorous, multiarm intervention trials.Systematic Review Registration: CRD42018108293 (International Prospective Register of Systematic Reviews).