Daily prediction of inpatient suicide attempts using routinely collected theory-driven data.

We lack knowledge about the short-term predictors of suicide attempts (SAs) among treatment-seeking individuals. The current study evaluated whether (a) interpersonal difficulties, hopelessness, and affective states are associated with an increased risk of SAs on the same and the next day; (b) these daily states are interconnected differently over time among inpatients who attempt suicide compared to those who do not. In total, 110 psychiatric inpatients who attempted suicide during their stay at a psychiatric hospital self-reported their suicidal ideation, negative affect, positive affect, wish to live, interpersonal needs, and hopelessness each day (3,018 daily reports). Multilevel structural equation modeling was used to examine same-day and next-day predictors of SAs. Multilevel temporal network models assessed interconnectedness between daily predictors and were compared to network models from a matched sample of 110 psychiatric inpatients who did not attempt suicide. In multivariate models, increases in perceived burdensomeness were significantly associated with same-day SAs, whereas increased hopelessness was associated with next-day SAs. Network models for patients who attempted suicide indicated that hopelessness and suicidal ideation were central to change, leading to next-day deteriorations in mental health. In subsequent models, feeling calm and relaxed, and feeling fresh and rested were centrally connected to other variables. The centrality of these metrics tended to be higher than in the network models for patients who did not attempt suicide, suggesting differences in the interplay between risk and protective factors. This study suggests routinely monitoring interpersonal factors and hopelessness may help identify increased short-term risk of SAs among psychiatric inpatients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Relative Effectiveness of Bilateral and Unilateral Electrode Placement in Electroconvulsive Therapy (ECT) in Patients With Major Depressive Disorder: A Retrospective Cohort Study.

Background This study is focused on the comparative efficacy of bilateral and unilateral electroconvulsive therapy (ECT) on depressive symptoms in patients at the Perth Clinic for the period from 2016 to 2021. Methods This was a retrospective cohort study of 485 patients who received ECT treatment. The expected improvements in depressive symptoms were evaluated by the Depression Anxiety Stress Scale (DASS) assessment tool filled out by the patients on admission and discharge from the hospital. Only the depression score of the DASS scale was utilised for this research. Results The results suggested that both electrode placements resulted in a significant improvement in depressive symptoms. The positive response rates for the bilateral and unilateral electrode placements were 78.3% and 71.6%, respectively. There was no difference between males and females in the average DASS score at discharge for bilateral and unilateral electrode placements. Conclusions This study confirmed that the results obtained at the Perth Clinic are similar to the existing international research results on the same topic. Bifrontal and unilateral ECT electrode placements are equally efficacious in improving depressive symptoms in patients suffering from major depressive disorder (MDD).

Daily prediction of nonsuicidal self-injury among inpatients: The roles of suicidal thoughts, interpersonal difficulties, hopelessness, and affect.

OBJECTIVE: Nonsuicidal self-injury (NSSI) is a major public health issue. Despite increased research efforts in clinical samples, we still have little understanding of the short-term correlates, predictors, and targets of NSSI among treatment-seeking individuals. The present study was designed to (a) evaluate how suicidal thoughts, interpersonal difficulties, hopelessness, and affective states are associated with same-day and next-day NSSI; (b) identify which factors may be effective targets in treatment through network modeling. METHOD: Data from 1,265 psychiatric inpatients who self-injured throughout their visit to a psychiatric hospital self-reported their suicidal ideation, negative affect, and positive affect on a daily basis (in total 36,345 prospective reports). An additional 632 patients were also surveyed regarding feelings of hopelessness, wish to live, and interpersonal difficulties. Using multilevel structural equation modeling, we examined contemporaneous and time-lagged associations with NSSI. Multilevel network analyses assessed interconnectedness of daily predictors and were compared with a matched sample of 1,265 patients who did not self-injure during their stay. RESULTS: Increases in suicidal ideation were associated with increased probability of same-day and next-day self-injury, and an inverse relationship was observed for wish to live. Increases in positive affect were also significantly associated with decreased probability of next-day self-injury. Perceived burdensomeness had high centrality in network models, particularly among patients who self-injured, indicating it is susceptible to activation and directly associated with all predictors. CONCLUSIONS: Routine monitoring may improve prediction of when a patient is at short-term risk to self-injure and provides person-specific data that can assist in targeting risk and protective factors during treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Illustrating routine outcomes monitoring at different points in a patient's journey: Inpatient then daypatient treatment of a patient with depressive and borderline symptoms.

Routine outcomes monitoring (ROM), combined with a psychotherapeutic intervention, can improve outcomes by assisting therapists in supporting patients who are off track to achieve a better treatment endpoint. While many ROM systems are suitable for particular clinical contexts, psychotherapy delivered in a hospital setting presents unique challenges. People can be treated as inpatients and daypatients, and psychotherapy may be delivered in multiple formats (e.g., closed and open groups; group and individual). The present case study will illustrate the adaptation of ROM to this environment with an 18-year-old woman with Borderline Personality Disorder. The patient was successfully treated with Dialectical Behavior Therapy as both an inpatient and daypatient. The case demonstrates the use of ROM systems and illustrate they are sufficiently flexible to accommodate these complexities of routine care.

Distress tolerance as a moderator of the dynamic associations between interpersonal needs and suicidal thoughts.

BACKGROUND: Identifying the interaction between dispositional and dynamic risk factors is necessary in understanding, predicting, and managing suicide risk. Interpersonal factors have consistently been linked to suicidal ideation over short-term periods. Additionally, distress tolerance may be a relevant dispositional protective factor against stressful events. METHODS: Seven hundred and seventeen psychiatric inpatients (Male = 30.31%, Average Age = 40.71 years, Min = 14, Max = 82) self-reported their distress tolerance at hospital admission, and interpersonal needs and suicidal ideation on a daily basis. Dynamic structural equation modelling was used to examine whether within-level dynamics were moderated by distress tolerance. RESULTS: Both perceived burdensomeness and thwarted belongingness were significantly associated with same-day suicidal ideation. Higher distress tolerance was associated with weaker daily associations between suicidal ideation and both perceived burdensomeness and thwarted belongingness. Distress tolerance was also associated with lower variability in suicidal ideation. Moderating effects were also evident when lifetime suicide attempts were added as a covariate, which was associated with stronger associations between interpersonal dysfunction and suicidal ideation, and higher variability in ideation. CONCLUSIONS: Distress tolerance may be important to consider when examining the dynamic relationships between suicidal ideation and proximal factors. Psychotherapy that specifically targets distress tolerance may be effective in reducing reactivity to interpersonal stressors.

Outcomes of brief versions of Dialectical Behaviour Therapy for diagnostically heterogeneous groups in a routine care setting.

INTRODUCTION: Brief versions of Dialectical Behaviour Therapy (DBT) may enhance patient outcomes in diverse service settings. This study examined the effectiveness of two DBT-informed treatments for diagnostically heterogeneous groups in routine practice: 5-day group training in DBT skills (DBT-5) and a 12-week DBT program (DBT-12). METHODS: : Depression, anxiety, stress, borderline symptoms, self-esteem, and general mental wellbeing were measured at pre-and post-treatment in a sample of inpatients and outpatients (N=395). Rates of clinically significant change on these measures were calculated and effect sizes benchmarked against prior DBT outcome studies. Readmission rates were used to measure treatment response maintenance. RESULTS: : Scores on all measures improved significantly from pre- to post-treatment. DBT-5 and DBT-12 yielded similar effect sizes compared to prior DBT outcome studies. At least 43.5% of patients were classified as recovered or improved regarding borderline symptoms at the end of both DBT-5 and DBT-12. Readmission rates were also low (5%-6.8%). CONCLUSIONS: Brief DBT-informed treatments may offer a fast reduction in symptoms and quicker return to functioning.

Prediction and network modelling of self-harm through daily self-report and history of self-injury.

BACKGROUND: Self-harm is a significant public health issue, and both our understanding and ability to predict adverse outcomes are currently inadequate. The current study explores how preventative efforts could be aided through short-term prediction and modelling of risk factors for self-harm. METHODS: Patients (72% female, Mage = 40.3 years) within an inpatient psychiatric facility self-reported their psychological distress, interpersonal circumstances, and wish to live and die on a daily basis during 3690 unique admissions. Hierarchical logistic regressions assessed whether daily changes in self-report and history of self-harm could predict self-harm, with machine learning used to train and test the model. To assess interrelationships between predictors, network and cross-lagged panel models were performed. RESULTS: Increases in a wish to die (ß = 1.34) and psychological distress (ß = 1.07) on a daily basis were associated with increased rates of self-harm, while a wish to die on the day prior [odds ratio (OR) 3.02] and a history of self-harm (OR 3.02) was also associated with self-harm. The model detected 77.7% of self-harm incidents (positive predictive value = 26.6%, specificity = 79.1%). Psychological distress, wish to live and die, and interpersonal factors were reciprocally related over the prior day. CONCLUSIONS: Short-term fluctuations in self-reported mental health may provide an indication of when an individual is at-risk of self-harm. Routine monitoring may provide useful feedback to clinical staff to reduce risk of self-harm. Modifiable risk factors identified in the current study may be targeted during interventions to minimise risk of self-harm.

An exploration of the relationships between patient application of CBT skills and therapeutic outcomes during a two-week CBT treatment.

The application of Cognitive Behavioural Therapy (CBT) skills are believed to be a mechanism of therapeutic change in treatment. Research has shown that the application of CBT skills affects outcomes, however, the way these relationships may change during treatment has not been explored. In this study, a naturalistic observational approach is used to examine the relationships between patients' wellbeing, symptoms, and the application of CBT skills throughout treatment. It is hypothesized that the application of CBT skills would lead to an increase in patients reported wellbeing, and a decrease in symptoms. Additionally, it was hypothesized that the application of CBT skills affects wellbeing and symptoms at different points in therapy. A sample of 584 patients in a two-week CBT treatment completed session-to-session measures of wellbeing, symptoms, and their application of CBT skills. Results of an autoregressive cross-lagged path analysis indicated that in the early stages of treatment the application of CBT skills predicted patient wellbeing but not symptoms. At the later stages of therapy, the application of CBT skills predicted both patient wellbeing and symptoms. At no point in treatment did patient wellbeing or symptoms predict the later application of CBT skills. Implications and future directions for research are discussed.

Severity of borderline personality disorder symptoms as a moderator of the association between the use of dialectical behaviour therapy skills and treatment outcomes.

A core aspect of Dialectical Behaviour Therapy (DBT) is the acquisition and use of DBT skills to replace maladaptive behaviours. However, it is unclear whether DBT skill use is associated with differential reductions in psychological distress across individuals with varying severities of borderline personality disorder (BPD) symptoms. In the current study, moderated mediation analyses were conducted to examine the relationships among DBT skill use and attitudes towards skill use, pre-treatment BPD symptom severity and changes in psychological distress over the course of a 12-week DBT-informed program in a sample of outpatients with mixed psychopathology (N = 102), including a minority with BPD (N = 16). It was predicted that (i) self-reported use of the four types of DBT skills (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) and (ii) patient attitudes towards these skills (confidence and perceived effectiveness) would be associated with greater improvements in psychological distress in individuals with higher levels of BPD symptoms compared to individuals with lower levels of BPD symptoms. Results supported this hypothesis, indicating that self-reported DBT skill use and attitudes towards DBT skills are associated with differential patterns of reductions in psychological distress.

Progress monitoring and feedback delivered in routine psychiatric care: Beneficial but not reaching those thought to need it most.

Objective: The study evaluated the use and effectiveness of a progress monitoring system routinely operational in a private mental health care setting. Method: In a nonrandomized trial in which 778 consecutively admitted patients underwent a 2-week cognitive behavioral therapy intervention, the effectiveness of therapists choosing to use progress monitoring feedback to frame therapist-patient discussions about individuals' progress was evaluated. Results: Patients engaged in discussions involving progress monitoring feedback during the intervention achieved a more consistent recovery rate. Furthermore, individuals that were not-on-track to achieve a positive outcome experienced a boost to recovery immediately after receiving feedback. However, evidence suggested that therapists were not using progress monitoring to primarily focus additional resources on not-on-track patients. Conclusion: Progress monitoring feedback benefited patient recovery. However, guidelines could improve the system by directing therapists to use feedback primarily with patients not on course for a positive therapeutic outcome.

Assessing interpersonal and mood factors to predict trajectories of suicidal ideation within an inpatient setting.

BACKGROUND: A limited amount of research has assessed how suicide risk changes over time, and how changes can be predicted. The current study assessed suicidal ideation and risk factors throughout inpatient visits to a psychiatric facility to refine prediction of suicide risk. METHOD: In total, 491 patients (73% Female; mean age = 39.21) at a psychiatric inpatient facility self-reported the frequency of their suicidal thoughts, perceived burdensomeness, thwarted belongingness, hopelessness, depression, and anxiety in the prior 24 h on a daily basis. Levels of suicidal ideation and risk factors at each quarter of an inpatient's stay were identified, and latent class growth analysis used to identify common patterns of change over time. RESULTS: Changes in mood and interpersonal factors were associated with changes in suicidal ideation over days and weeks. Further, they contributed to the prediction of future levels of suicidal ideation. Thwarted belongingness at admission predicted whether patients had pervasively high suicidal thoughts over the course of inpatient visits or showed marked improvements, while perceived burdensomeness predicted which patients would develop suicidal thoughts during their visit. LIMITATIONS: The use of single item measures may limit specificity of measurement of suicide risk factors. Hourly, rather than daily measurement used in the current study, may more accurately identify suicide risk. CONCLUSIONS: Change in suicidal ideation is associated with changes in a number of psychological risk factors. Regular assessment of interpersonal risk factors may identify warning signs and aid clinical interventions in reducing suicidal thoughts and associated self-injurious behaviours.

A comparison between the clinical significance and growth mixture modelling early change methods at predicting negative outcomes.

Objective: Routine outcome monitoring benefits treatment by identifying potential no change and deterioration. The present study compared two methods of identifying early change and their ability to predict negative outcomes on self-report symptom and wellbeing measures. Method: 1467 voluntary day patients participated in a 10-day group Cognitive Behaviour Therapy (CBT) program and completed the symptom and wellbeing measures daily. Early change, as defined by (a) the clinical significance method and (b) longitudinal modelling, was compared on each measure. Results: Early change, as defined by the simpler clinical significance method, was superior at predicting negative outcomes than longitudinal modelling. The longitudinal modelling method failed to detect a group of deteriorated patients, and agreement between the early change methods and the final unchanged outcome was higher for the clinical significance method. Conclusions: Therapists could use the clinical significance early change method during treatment to alert them of patients at risk for negative outcomes, which in turn could allow therapists to prevent those negative outcomes from occurring.

Daily assessment of interpersonal factors to predict suicidal ideation and non-suicidal self-injury in psychiatric inpatients.

OBJECTIVE: The study assessed suicidal ideation and interpersonal variables to explore the extent to which (a) changes in interpersonal factors predicted future suicidal ideation and (b) changes in either predicted nonsuicidal self-injury. METHOD: In total, 1,044 patients (72.3% Female; mean age = 41.95) at a psychiatric inpatient facility were assessed daily for suicidal thoughts. If patients indicated suicidal thinking (n = 417), their feelings of perceived burdensomeness and thwarted belongingness were assessed. RESULTS: There was a reciprocal relationship between suicidal ideation and interpersonal factors, with both predicting each other on the next day. Changes in suicidal ideation, but not interpersonal factors, over two days were a significant predictor of 22.6% of nonsuicidal self-injury cases (n = 67). CONCLUSIONS: The findings reinforce the need for more intensive assessment of suicidal ideation (i.e., days, hours) to determine complex relationships with risk factors. This acts to enhance prediction and prevention of suicidal ideation and nonsuicidal self-injury. (PsycINFO Database Record

Health Related Quality of Life after ECT for depression: A study exploring the role of different electrode-placements and pulse-widths.

INTRODUCTION: Prior research has shown large improvements in HRQOL after a course of ECT for depression. However, the effect of different types of ECT on HRQOL outcomes has not been explored. This is important due to the considerable range of ECT treatment modalities that currently exist in clinical practice. METHODS: HRQOL data from 355 depressed patients in three Australian clinical hospitals, who received ECT given with a range of treatment modalities (combinations of pulse-width and electrode-placement), were analysed. HRQOL was measured at baseline and after ECT, using the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). The association between type of ECT and HRQOL after ECT was examined by regression analysis, controlling for variables that may affect HRQOL outcomes. RESULTS: There was a significant increase in HRQOL scores after ECT (p<0.0001; t=-23.4). The magnitude of change was large (54% increase, Cohen's d=1.43). Multiple regression analysis yielded a significant model (P<0.001, R2=0.18). Baseline HRQOL score (t=4.83; p<0.0001), age (t=2.75, p<0.01) and type of ECT received [Right Unilateral brief vs Bitemporal Ultrabrief (t=-2.99; p<0.01) and Right Unilateral brief vs Bifrontal Ultrabrief (t=-2.70; p<0.01)] were significant predictors of HRQOL after the ECT course. LIMITATIONS: Data was collected naturalistically from clinical services, thus ECT modality was not randomly assigned. Site could have confounded results. CONCLUSIONS: An acute course of ECT for depression produced statistically and clinically significant improvements in HRQOL. ECT treatment modality can substantially impact HRQOL outcomes, with the possibility of bilateral ultrabrief forms of ECT being less beneficial.

Effects of providing domain specific progress monitoring and feedback to therapists and patients on outcome.

OBJECTIVE: Progress monitoring and feedback reduces the number of patients deteriorating in psychotherapy. The current study examined the effects of providing treatment progress information to therapists and patients using individual feedback of both wellbeing and affective psychological distress compared to feedback of wellbeing alone. METHOD: The sample comprised 845 consecutive psychiatric day-hospital admissions using a historical cohort design. The effects of monitoring and feedback of wellbeing in Cohort 1 were compared against the effects of monitoring and feedback of both wellbeing and affective psychological distress in Cohort 2. RESULTS: Patients who were "not-on-track" in Cohort 2 demonstrated significantly greater improvement for affective psychological distress than those from Cohort 1. CONCLUSIONS: These findings suggest that providing feedback from multiple sources enhances patient outcomes in comparison to single source feedback.

Daily monitoring of temporal trajectories of suicidal ideation predict self-injury: A novel application of patient progress monitoring.

OBJECTIVE: The interpersonal theory of suicide argues that suicidal ideation predicts self-injury. We hypothesized that distinct patterns of suicidal ideation could be identified and these ratings could allow early identification of self-injury. METHOD: The sample consisted of 562 psychiatric inpatients who reported suicidal ideation. RESULTS: Latent growth class analysis identified five classes of change in suicidal ideation. Patients who displayed prolonged suicidal ideation could be identified with improved sensitivity (89.66%) and negative predictive power (94%), compared to a model based on routine ratings of suicidality at admission (sensitivity = 50%; negative predictive power = 74%). These patients had a fourfold increased risk of self-injury. CONCLUSIONS: Daily measurement of suicidal ideation may identify inpatients at risk and inform clinical decision-making.

Development and psychometrics of the five item daily index in a psychiatric sample.

BACKGROUND: Effective treatment of affective disorders requires the ability to reliably monitor patient progress and outcome. The current study aimed to establish the Daily Index-5 (DI-5) as a psychometrically sound and clinically valid measure of treatment response in psychiatric care for use as a companion measure with the WHO Wellbeing Index (WHO-5; Bech et al., 1996. Psychother. Psychosom. 65, 183-190.). METHOD: Eight hundred and ninety four consecutive inpatients and day-patients at a psychiatric facility completed the DI-5, WHO-5, SF-36 (Ware et al., 1993. SF-36 Health Survey: Manual and Interpretation Guide. The Health Institute, New England Medical Centre, Boston, MA.) and DASS-21 (Lovibond and Lovibond, 1995b. Manual for the Depression Anxiety Stress Scales. Psychology Foundation, Sydney, Australia.; Ware et al., 1993. SF-36 Health Survey: Manual and Interpretation Guide. The Health Institute, New England Medical Centre, Boston, MA.) routinely during treatment. RESULTS: The DI-5 was shown to be a measure with high reliability and validity. In addition criteria for clinically significant recovery are presented with an example implementation of a Clinical Significance Monitoring system. Finally, the latent structure of the DI-5 is established as a uni-dimensional index of affective disorder. LIMITATIONS: The results may be generalized to samples with primary diagnoses of depressive and/or anxiety disorders though assessment of the DI-5 as a measure of treatment response is warranted in patients with other primary diagnoses. CONCLUSIONS: The current study indicates that the DI-5 is a quick to administer and interpret, reliable and valid measure for assessing patient outcome that is appropriate for use in monitoring patient change.

The influence of individual, group, and relative self-esteem on outcome for patients undergoing group cognitive-behavioural therapy treatment.

OBJECTIVES: Despite a strong association between individual self-esteem and treatment outcome in group cognitive-behavioural therapy (GCBT), no study has investigated how patient outcomes might be influenced by an individual's self-esteem relative to other group members. DESIGN: The study comprised a retrospective examination of patients' data and used a multiple regression analysis to identify predictors of treatment outcome. Patients' pre-treatment self-esteem scores were assessed on a continuum and assigned to be low, medium, or high. Therapy groups were assigned to be either low, balanced or high self-esteem groups based on averaged self-esteem scores of participants. METHODS: In this study, 3,878 patients who had completed a 10-day intensive cognitive behavioural group therapy programme at a private psychiatric facility were included in the study. The Rosenberg Self-Esteem measure was chosen to assess self-esteem. The three subscales of the Depression Anxiety Stress Scales were used as the outcome measures. RESULTS: Patient outcomes were influenced by pre-treatment self-esteem scores, such that higher initial self-esteem was associated with better treatment outcomes. Low group self-esteem was predictive of significantly better outcomes for depression, relative to higher self-esteem groups. Additionally, the combined influence of high individual self-esteem and low group self-esteem was associated with significantly enhanced depression improvement. CONCLUSIONS: High self-esteem patients perform better on outcome measures following completion of GCBT. Low self-esteem groups show greater improvement in depression symptoms. Similar results for depression are achieved when patients with high self-esteem complete treatment in low self-esteem groups.

Effectiveness of cognitive-behavioral therapy modified for inpatients with depression.

The effectiveness among inpatients with depression of a modified cognitive behavior therapy (CBT) program was examined. A group of 300 inpatient admissions with a primary diagnosis of depression attending a private psychiatric clinic were assessed at the beginning and end of a two-week CBT program. The effectiveness of the treatment was demonstrated by improvements on the Beck depression inventory (BDI), the health of the nation outcome scales, locus of control of behaviour scale, and the global assessment of function. The changes on the BDI for patients with depression were benchmarked against estimates generated from published studies. The degree of change in a two-week period for inpatients with depression was similar to that observed in efficacy studies of CBT that typically run over a more extended time. Implications for integrating CBT with inpatient services are discussed.