Internet-based emotion regulation training aimed at reducing violent revictimization and depressive symptoms in victimized depressed patients: Results of a randomized controlled trial.

BACKGROUND: Depressed patients who have become victim of violence are prone to revictimization. However, no evidence-based interventions aimed at reducing revictimization in this group exist. METHODS: This multicenter randomized controlled trial evaluated the effectiveness of an internet-based emotion regulation training (iERT) added to TAU in reducing revictimization, emotion dysregulation, and depressive symptoms in recently victimized, depressed patients compared to TAU alone. Adult outpatients (N = 153) with a depressive disorder who had experienced threat, physical assault, or sexual assault within the previous three years were randomly allocated to TAU+iERT (n = 74) or TAU (n = 79). TAU involved psychotherapy (mainly cognitive behavioral therapy [77.8 %]). iERT comprised six guided online sessions focused on the acquisition of adaptive emotion regulation skills. The primary outcome measure was the number of revictimization incidents at 12 months after baseline, measured with the Safety Monitor. Analyses were performed according to the intention-to-treat principle. RESULTS: Both groups showed a large decrease in victimization incidents. Mixed-model negative binomial regression analyses showed that TAU+iERT was not effective in reducing revictimization compared to TAU (IRR = 0.97; 95%CI = 0.64,1.46; p = .886). Linear mixed-model analyses demonstrated that TAU+iERT yielded a larger reduction of emotion dysregulation (B = -7.217; p = .046; Cohens d = 0.33), but not depressive symptoms (B = -1.041; p = .607) than TAU. LIMITATIONS: The study was underpowered to detect small treatment effects. Additionally, uptake of iERT was quite low. CONCLUSIONS: Although TAU+iERT resulted in a larger decrease of emotion dysregulation than TAU alone, it was not effective in reducing revictimization and depressive symptoms. Patients' revictimization risk substantially decreased during psychotherapy.

[Guided discontinuation of antidepressants: approach and first results of a Dutch multidisciplinary outpatient clinic]. / Werkwijze en eerste resultaten van multidisciplinaire afbouwpoli anti-depressiva.

BACKGROUND: Discontinuation of antidepressant medication can be difficult due to withdrawal symptoms and relapse risk. Scientific evidence on the questions of who, when, and how to stop antidepressants is limited. In Amsterdam a multidisciplinary outpatient clinic was started to provide advice and guidance. AIM: To substantiate the design of the clinic. Central questions relate to knowing which patients are referred, the background of their request, and their experiences with the outpatient clinic. METHOD: The first 51 patients of the clinic were described on the basis of file research, in addition a survey was conducted into patient experiences. RESULTS: Half of the patients (55%) actually started discontinuation, 39% were advised not to do so (yet). Patients at the clinic had used antidepressants for an average of 10 years, and 76% had previously attempted to stop. 21% had now successfully stopped and 25% were satisfied with a lower dose. One patient relapsed during tapering. CONCLUSION: So far, patients with long-term antidepressant use and multiple quit attempts have been referred. Our experiences are aimed at helping individual patients but can also result in more knowledge about who can stop at what moment, and how this should be done.

Violent victimization and revictimization in patients with depressive disorders: context characteristics, disclosure rates, and gender differences.

BACKGROUND: Depressed patients are prone to violent victimization, and patients who were victimized once are at increased risk to fall victim to violence again. However, knowledge on the context of victimization in depressed patients is lacking, and research identifying targets for prevention is urgently needed. METHODS: This cross-sectional study explored context characteristics, disclosure rates and gender differences regarding violent victimization in 153 recently victimized depressed patients. Additionally, 12-month prevalence rates of repeat threat, physical assault, and sexual assault were examined, and gender differences were investigated using t-tests, Chi-square tests, and Fisher's exact tests. Furthermore, logistic regression analyses were used to identify factors associated with repeat victimization. RESULTS: Overall, depressed men were most often victimized by a stranger in public, and women by their partner or ex-partner at home. Regarding sexual assault, no gender differences could be examined. Patients were sexually assaulted most often by an acquaintance (50.0%) or stranger (27.8%). In all patients, the most recent incidents of threat (67.6%) and physical assault (80.0%) were often preceded by a conflict, and only a minority had been intoxicated prior to the assault. Notably, less than half of patients had disclosed their recent experience of threat (40.6%) and physical assault (47.1%) to their mental health caregiver. For sexual assault, this was only 20%. Less than one third of patients had reported their recent experience of threat (27.9%), physical assault (30.0%) and sexual assault (11.1%) to the police. 48.4% of patients had been victimized repeatedly in the past year, with no gender differences found. Only depressive symptoms and unemployment were univariately associated with repeat victimization, but not in the multiple model. CONCLUSIONS: The high prevalence of repeat victimization in depressed patients and their low disclosure rates stress the need to implement routine enquiry of victimization in mental health care, and to develop preventive interventions accounting for specific needs of men and women.

Mental disorders and the risk of adult violent and psychological victimisation: a prospective, population-based study.

AIMS: Psychiatric patients are at increased risk to become victim of violence. It remains unknown whether subjects of the general population with mental disorders are at risk of victimisation as well. In addition, it remains unclear whether the risk of victimisation differs across specific disorders. This study aimed to determine whether a broad range of mood, anxiety and substance use disorders at baseline predict adult violent (physical and/or sexual) and psychological victimisation at 3-year follow-up, also after adjustment for childhood trauma. Furthermore, this study aimed to examine whether specific types of childhood trauma predict violent and psychological victimisation at follow-up, after adjustment for mental disorder. Finally, this study aimed to examine whether the co-occurrence of childhood trauma and any baseline mental disorder leads to an incrementally increased risk of future victimisation. METHODS: Data were derived from the first two waves of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2): a psychiatric epidemiological cohort study among a nationally representative adult population. Mental disorders were assessed using the Composite International Diagnostic Interview version 3.0. Longitudinal associations between 12 mental disorders at baseline and violent and psychological victimisation at 3-year follow-up (n = 5303) were studied using logistic regression analyses, with adjustment for sociodemographic characteristics and childhood trauma. Furthermore, the moderating effect of childhood trauma on these associations was examined. RESULTS: Associations with victimisation varied considerably across specific mental disorders. Only alcohol dependence predicted both violent and psychological victimisation after adjustment for sociodemographic characteristics and childhood trauma. Depression, panic disorder, social phobia, generalised anxiety disorder and alcohol dependence predicted subsequent psychological victimisation in the fully adjusted models. All types of childhood trauma independently predicted violent and psychological victimisation after adjustment for any mental disorder. The presence of any childhood trauma moderated the association between any anxiety disorder and psychological victimisation, whereas no interaction between mental disorder and childhood trauma on violent victimisation existed. CONCLUSIONS: The current study shows that members of the general population with mental disorders are at increased risk of future victimisation. However, the associations with violent and psychological victimisation vary considerably across specific disorders. Clinicians should be aware of the increased risk of violent and psychological victimisation in individuals with these mental disorders - especially those with alcohol dependence - and individuals with a history of childhood trauma. Violence prevention programmes should be developed for people at risk. These programmes should not only address violent victimisation, but also psychological victimisation.

[Guided web-based intervention for sleeping problems (I-Sleep) in depressed patients within outpatient specialist mental health care: a pilot study]. / Begeleide web-based interventie voor slaapproblemen (I-Sleep) bij patiënten met een depressie in de ambulante gespecialiseerde ggz: een pilotstudie.

BACKGROUND: Insomnia in depressed patients is usually targeted by medication, while cognitive behavioural treatment for insomnia (CBT-I) is the treatment of first choice. Effective online CBT-I is available but is not frequently offered in regular care.
AIM: To determine the feasibility and indications for effectiveness of I-Sleep, an online CBT-I module, for uni- and bipolar depressed patients in specialised mental health care settings.
METHOD: In a pilot study I-Sleep (5 sessions) was offered to all 31 patients. Patients who did not (yet) want to participate in the online intervention, and patients who were included after the intended sample size was reached, participated in the control-group. Feasibility was assessed by compliance rates and satisfaction of patients and therapists (CSQ). Effectiveness was assessed within and between groups by the Insomnia Severity Index (ISI) and the Patient Health Questionnaire (PHQ-9) at baseline and after 6 and 12 weeks.
RESULTS: In the intervention group 41% completed all treatment sessions and 77% completed 3 or more sessions. Patients rated the intervention positively (CSQ 23.6, range 4-32). Sleep improved in the intervention group (Cohen's d = 1.93), as well as depression (Cohen's d=1.05). In the control group there was no significant improvement. The difference between the two groups was high and significant for sleep problems (Cohen's d = 0.99) but not for depressive symptoms.
CONCLUSION: Online CBT-I is a feasible treatment option for depressed patients in mental health care settings. There are indications that CBT-I is also effective in reducing sleep problems in more severely depressed patients.

Prevalence and predictors of violent victimization in remitted patients with recurrent depression.

BACKGROUND: Depressed patients are at increased risk to fall victim to a violent crime compared to the general population. It remains unknown whether their increased risk persists after remission. This study compared victimization rates of remitted patients with both a random general population sample and a group of currently depressed patients. Furthermore, this study aimed to identify predictors of future violent victimization. METHODS: In this longitudinal study conducted in the Netherlands, 12-month prevalence rates of sexual assaults, physical assaults, and threats were assessed with the Safety Monitor in 140 currently remitted patients with recurrent depression, and compared to those of a weighted general population sample (N = 9.175) and a weighted sample of currently depressed outpatients (N = 102) using Chi-square tests. Logistic regression analyses were performed to identify baseline predictors of future victimization. RESULTS: The prevalence of violent victimization did not differ between remitted patients and the general population (12.1 vs. 11.7%). Remitted patients were significantly less likely to have been victimized over the past 12 months than currently depressed patients (12.1 vs. 35.5%). In remitted patients, living alone and low sense of mastery at baseline predicted future violent victimization. However, when combined in a multiple model, only living alone was independently associated with violent victimization (χ2 = 16.725, df = 2, p < .001, R2 = 0.221). LIMITATIONS: Our comparison of victimization rates across samples was cross-sectional. CONCLUSIONS: Since the increased risk of victimization appears to be specific for the acute depressive state, preventive interventions should target victimization in currently depressed patients. TRIAL REGISTRATION: Netherlands Trial Register (NTR): 2599.

Effectiveness of blended depression treatment for adults in specialised mental healthcare: study protocol for a randomised controlled trial.

BACKGROUND: Internet-based interventions are seen as an important potential strategy to improve accessibility and affordability of high quality treatments in mental healthcare. A growing number of studies have demonstrated the clinical efficacy of internet-based treatment for mood disorders, but scientific evidence for the application in routine specialised mental healthcare settings is limited. Also, little is known about the clinical and health-economic benefits of blended treatment, where online interventions are integrated with face-to-face treatment of depression in one treatment protocol. The primary aim of this study is to investigate the clinical and cost-effectiveness of blended Cognitive Behavioural Therapy (bCBT) for depression, as compared to treatment as usual (TAU) in specialised routine mental healthcare in the Netherlands. This trial is part of the E-COMPARED project which has a broader perspective, focussing on primary and specialised care in eight European countries. METHODS/DESIGN: The study is a randomised controlled non-inferiority trial with two parallel conditions: bCBT and TAU. The blended treatment combines individual face-to-face CBT with CBT delivered through an Internet-based treatment platform (Moodbuster). This platform includes a mobile phone application, used for ecological momentary assessments, automated feedback and motivational messages. Weekly alternating face-to-face (10) and online (9) sessions will be delivered over a period of 19-20 weeks. TAU is defined as the routine care that subjects receive when they are diagnosed with depression in specialised mental healthcare. Adult patients ≥ 18 years old meeting DSM-IV diagnostic criteria for major depressive disorder will be recruited within participating outpatient specialised mental healthcare clinics in the Netherlands. Measurements will be taken at baseline and at 3, 6 and 12 months follow-up. The primary outcome will be depressive symptoms, measured with the PHQ-9 and QIDS. Secondary outcomes include health-related quality of life, mastery, treatment preference, working alliance, system usability, treatment satisfaction and possible negative side-effects. Moreover, a cost-effectiveness analysis will be conducted from a societal perspective and will include both direct and indirect healthcare costs. DISCUSSION: The results of this study will provide insight into the health and economical outcomes of blended treatment for depression and give an indication of the value of implementing blended treatment in specialised clinical settings. TRIAL REGISTRATION: Netherlands Trial Register NTR4962 . Registered 05-01-2015.

[Medical students and their attitude to psychiatry]. / Medisch studenten en hun houding ten opzichte van het vak psychiatrie.

BACKGROUND: The attitudes of medical students to psychiatry are important for the future care of patients with psychiatric (co)morbidity. Up till now the attitude of medical students to psychiatry has not been investigated in the Netherlands and the Dutch-speaking part of Belgium. AIM: To measure the attitude of third year medical students towards psychiatry by means of the ATP-30. This is a validated instrument, used internationally. To determine the extent to which medical students' attitudes were influenced by the psychiatry curriculum and by some sociodemographic determinants and which aspects of a career ­ according to earlier Dutch research ­ made students decide to opt for a particular specialism. METHOD: Our research was of the prospective cohort type; without controls. The design was a pre- and post design. RESULTS: Attitudes to psychiatry were generally positive (n = 262, ATP score: 106.1, sd 10.9, ATP score ≤ 90 was regarded as negative) and improved after students received instruction in psychiatry. Men were less positive than women. Students who previously had positive experiences with the psychiatric services had higher scores. Foreign students, mainly from non-Western countries, had lower scores. After these foreign students had completed their studies in the Netherlands, there was no longer any significant difference between the scores of the two groups. CONCLUSION: Attitudes to psychiatry are positive within our cohort. Tuition has a positive effect on students' attitudes. The less positive score of the foreign students at the start of their course is probably due to the fact that they were not familiar with psychiatry and psychiatric services.

[Treatment for chronic depression: cognitive behavioral analysis system of psychotherapy (CBASP)]. / Behandeling voor chronische depressie: 'cognitive behavioral analysis system of psychotherapy' (CBASP).

BACKGROUND: Chronic depression is a common disorder in secondary care. Treatment results for this group of depressed patients are often disappointing and the existing treatment protocols are insufficiently tailored to chronic MDD. For this reason, an effective psychotherapeutic treatment will constitute a welcome addition to the range of treatments currently available for chronically depressed patients. AIM: To describe 'cognitive behavioral analysis system of psychotherapy' (CBASP), the first form of psychotherapy specifically designed for the treatment of chronic depression. METHOD: This article describes the evidence, rational and the most important techniques of CBASP. RESULTS: In the United States CBASP has proven to be effective in one trial. As a result of these findings, CBASP is recommended in the Dutch treatment guidelines as an evidence-based treatment option for chronic depression. However, the findings have not yet been replicated and little is known about possible ways of implementing CBASP in the Netherlands. For this reason a randomised controlled trial on the effectiveness of CBASP has started in three psychiatric hospitals in the Netherlands. CONCLUSION: CBASP is recommended as a treatment option for chronic depression in the Dutch treatment guidelines, but evidence should be further supported by additional research.

[Screening for depression and anxiety in residential homes for the elderly]. / Problemen bij het opsporen van depressieve- en angststoornissen bij bewoners van verzorgingshuizen.

Elderly persons in residential homes in the Netherlands are at high risk for developing major depressive and anxiety disorders. A stepped-care protocol being used in a study for vulnerable elderly in the community may also be feasible and effective for this group. A pilot study in a residential home in Amsterdam showed more problems than expected in screening and motivating the inhabitants for this intervention protocol. This article describes the problems in our screening procedure. A personal approach, performed by familiar persons, directed at the more independent inhabitants is most likely to succeed. The need for research on effectiveness and feasibility of evidence based methods in residential care remains evident. However, the more vulnerable inhabitants need something else. For this group of inhabitants we need to look more closely to the needs and possibilities by conducting research using a qualitative design.