Optimizing treatment expectations and decision making through informed consent for psychotherapy: A randomized controlled trial.

OBJECTIVE: The objective of this research was to determine the efficacy and safety of an optimized informed consent (OIC) consultation for psychotherapy. METHOD: We performed a randomized controlled superiority online trial involving 2 weeks of treatment and 3 months of follow-up. One hundred twenty-two adults with mental disorders confirmed by structured interview currently neither in out- nor inpatient psychotherapy (mean age: 32, gender identity: 51.6% female, 1.6% diverse), were randomized. Participants received an information brochure about psychotherapy for self-study (treatment as usual [TAU]; n = 61) or TAU plus a one-session OIC utilizing expectation management, contextualization, framing, and shared decision making (n = 61). The primary outcome was treatment expectations at 2-week follow-up. RESULTS: At 2-week follow-up, participants receiving OIC showed more positive treatment expectations compared to those receiving TAU only (mean difference: 0.70, 95% CI [0.36, 1.04]) with a medium effect size (d = 0.73). Likewise, OIC positively influenced motivation (d = 0.74) and adherence intention (d = 0.46). OIC entailed large effects on reduction of decisional conflict (d = 0.91) and increase of knowledge (d = 0.93). Participants receiving OIC showed higher capacity to consent to treatment (d = 0.63) and higher satisfaction with received information (d = 1.34) compared to TAU. No statistically significant group differences resulted for expected adverse effects of psychotherapy. Results were maintained at 3-month follow-up. Data sets for n = 10 cases (8.2%) were missing (postassessment n = 4, 2-week n = 6, 3-month follow-up n = 8). CONCLUSIONS: Explaining to patients how psychotherapy works via a short consultation was effective in strengthening treatment expectations and decision making in a nonharmful way. Further trials clarifying whether this effectively translates to better treatment outcomes are required. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Validation of the German version of the Comparative Psychotherapy Process Scale.

The Comparative Psychotherapy Process Scale (CPPS) is a 20-item scale which aims to capture technical features distinguishing cognitive behavioral (CBT) from psychodynamic (PD) psychotherapy (and vice versa) in two corresponding subscales (CBT and PD Subscale). Our objective was to validate a German self-report version of the CPPS regarding a previous psychotherapy session in a psychotherapist- and in a patient-version. Fifty-three psychotherapists and their 53 patients answered to the according German CPPS Scale as well as to specific subscales of the Multitheoretical List of Therapeutic Interventions self-report-instrument (MULTI-30 subscales) assessing CBT- and PD-specific intervention characteristics. We analyzed (a) the correlation of the CPPS with the MULTI-30 subscales, (b) the ability of the CPPS to distinguish whether therapy sessions were either CBT or PD using logistic regression, and (c) the correlation between psychotherapists' and patients' self-report regarding the preceding session (correlation). Both the psychotherapist- and the patient-version showed acceptable to good values of internal consistencies (α = .78-.84). The CBT and PD Subscales of the MULTI-30 correlated with the CPPS subscales in both versions (CBT: rs = .85 [psychotherapist-version] and .80 [patient-version], PD: rs = .79 [both versions]). Subscales correctly discriminated whether the previous session was a CBT or a PD session (correct predictions in 88.7% in the psychotherapist-version, 73.6% in the patient-version; χ² ≥ 14.03, p < .001). The German version of the CPPS is a promising instrument to facilitate research on CBT- and PD-specific psychotherapy processes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Evaluation of an online suicide prevention program to improve suicide literacy and to reduce suicide stigma: A mixed methods study.

Low-threshold e-health approaches in prevention to reduce suicide stigma are scarce. We developed an online program containing video reports on lived experience of suicide and evidence-based information on suicidality. We evaluated the program by a mixed methods design. We examined pre-post-changes of program completers (n = 268) in suicide literacy, suicide stigma (self and perceived), and self-efficacy expectation of being able to seek support in psychologically difficult situations using linear mixed models. To examine reported changes and helpful program elements 12-26 weeks after program completion, we content analyzed transcripts of telephone interviews (n = 16). Program completers showed more suicide literacy (Cohen's d = .74; p < .001), higher self-efficacy expectations to seek support (d = .09; p < .01), lower self-stigma (subscales glorification/normalization: d = -.13, p = .04; isolation/depression: d = -.14; p = .04; stigma: d = -.10; p = .07; n = 168) compared to baseline. We found no significant differences in perceived suicide stigma. We identified lived experience reports, the possibility of sharing own narrative on stigma and suicidality, and information on support as helpful elements. The current online program can increase suicide literacy and self-efficacy expectations to seek support and reduce self-stigma. We recommend a larger randomized controlled trial with longer follow-up to confirm these findings.

[Development and Psychometric Evaluation of a Short Questionnaire on Self-Efficacy Expectations in Dealing with Psychologically Difficult Situations (SWEP)]. / Entwicklung und psychometrische Überprüfung eines Kurzfragebogens zur Selbstwirksamkeitserwartung im Umgang mit psychisch belastenden Situationen (SWEP).

OBJECTIVE: Development and psychometric evaluation of a German 6-item instrument to assess self-efficacy expectations to seek support in psychologically difficult situations (SWEP). METHODS: Development of items, determination of distribution characteristics, factor structure, and internal consistency of the scale based on a paper-pencil survey (N=269) and a survey of an online intervention on suicide prevention (N=802). RESULTS: Principal component analysis revealed the SWEP scale to be a one-dimensional construct with high internal consistency (Cronbach's α=.83 and α=.89). We found content-plausible correlations to other constructs and initial evidence of a high retest reliability. CONCLUSION: The SWEP provides a reliable, valid, brief instrument for assessing self-efficacy expectations of being able to seek support.

Effectiveness of a coordinated ambulatory care program for patients with mental disorders or multiple sclerosis: results of a prospective non-randomized controlled trial in South Germany.

Background: The Psychiatry, Neurology, Psychosomatics and Psychotherapy (PNP) program of the German statutory health insurance AOK BW promotes coordinated and evidence-based specialist care with the aim of providing individualized, guideline-based outpatient care, strengthening the collaboration between health care providers, as well as reducing care costs. The purpose of this study was to evaluate its effectiveness regarding patient-reported outcomes compared to the less specialized general practitioner program (GP) and usual care (UC). Materials and methods: AOK insured patients, who were on sick leave due to a mental disorder (affective disorder, anxiety disorder, adjustment disorder, somatoform disorder, alcohol abuse disorder, schizophrenia) or multiple sclerosis were included in the prospective non-randomized controlled study. All patients either participated in the PNP program (intervention group, IG-PNP), the general practitioner program (control group, CG-GP) or usual care (control group, CG-UC). Entropy balancing was used to adjust for baseline imbalance between groups. Primary outcome was health-related quality of life, assessed by the Short-form health survey (SF-36) 12 months after diagnosis. Secondary outcomes included symptom severity, functional health, and treatment satisfaction. Results: Of the 14,483 insured patients who were contacted, 1,104 patients participated at baseline and 725 at follow-up. The adjusted mean differences of SF-36 sum score did not significantly differ between groups: -1.89 (95%-CI = -4.60; 0.81, p = 0.170) between IG-PNP and CG-GP, and -1.42 (95%-CI = -4.05; 1.22, p = 0.293) between PNP and CG-UC. The adjusted mean differences of secondary outcomes did not differ between groups, except for a slightly higher increase of functional health in CG-UC. Conclusion: We found no evidence that the PNP program is superior to the GP program or to usual care in terms of patient-reported outcomes or treatment satisfaction. The results are limited by the low response rate. Accordingly, future studies should strive for more representative samples. To improve the program, an integration of further collaborative care elements and guideline recommendations might be useful. Clinical trial registration: DRKS (German Clinical Trials Register https://drks.de/search/en); identifier (DRKS00013114).

The RIPI-f (Reporting Integrity of Psychological Interventions delivered face-to-face) checklist was developed to guide reporting of treatment integrity in face-to-face psychological interventions.

OBJECTIVES: Intervention integrity is the degree to which the study intervention is delivered as intended. This article presents the RIPI-f checklist (Reporting Integrity of Psychological Interventions delivered face-to-face) and summarizes its development methods. RIPI-f proposes guidance for reporting intervention integrity in evaluative studies of face-to-face psychological interventions. STUDY DESIGN AND SETTING: We followed established procedures for developing reporting guidelines. We examined 56 documents (reporting guidelines, bias tools, and methodological guidance) for relevant aspects of face-to-face psychological intervention integrity. Eighty four items were identified and grouped as per the template for intervention description and replication (TIDieR) domains. Twenty nine experts from psychology and medicine and other scholars rated the relevance of each item in a single-round Delphi survey. A multidisciplinary panel of 11 experts discussed the survey results in three online consensus meetings and drafted the final version of the checklist. RESULTS: We propose RIPI-f, a checklist with 50 items. Our checklist enhances TIDieR with important extensions, such as therapeutic alliance, provider's allegiance, and the adherence of providers and participants. CONCLUSION: RIPI-f can improve the reporting of face-to-face psychological interventions. The tool can help authors, researchers, systematic reviewers, and guideline developers. We suggest using RIPI-f alongside other reporting guidelines.

Suicide literacy and suicide stigma - results of a population survey from Germany.

BACKGROUND: While a growing number of studies analyze the magnitude and predictors of mental health literacy, little is known about suicide-specific knowledge and beliefs ("suicide literacy"). AIMS: To examine suicide literacy among the German population and to investigate associations between suicide literacy and suicide stigma. METHODS: Telephone interviews were conducted in Germany (N = 2002, response rate: 47.3%). The literacy of suicide scale (LOSS-SF) was used covering the knowledge domains "signs," "risk factors," "causes/nature" and "treatment/prevention." In multiple regression analyses, associations between the LOSS-SF and the three dimensions "stigma," "normalization/glorification," and "depression/isolation" of the stigma of suicide scale (SOSS-SF) were examined controlling for several covariates. RESULTS: Respondents showed most knowledge concerning "treatment and prevention" (>80% correct answers). Lower suicide literacy was found in the domains "risk factors" (33-60% correct answers) and "signs for suicidal ideation" (45-53%). Suicide literacy was negatively associated with age, while it was positively associated with education, own affliction, and personal contact. Moreover, suicide literacy showed negative associations with all three dimensions of the SOSS-SF. CONCLUSIONS: There are deficits in suicide literacy in the German public that may increase suicide stigma. Addressing those deficits in information-campaigns and encouraging personal contact could help decrease suicide stigma.

[Technology-Based Psychological Interventions (TBIs) for Bridging Waiting Periods and Aftercare for People with Depressive Disorders: The Current State of Research]. / Technologiebasierte psychologische Interventionen (TBIs) zur Überbrückung von Wartezeiten und zur Nachsorge bei Menschen mit depressiven Erkrankungen ­ der aktuelle Forschungsstand.

Our goal was to present current research on the effectiveness, acceptance and safety of technology-based psychological interventions (TBIs) for bridging waiting periods (e. g., for outpatient psychotherapy) and aftercare of people with depressive disorders and to derive implications for future research. In this systematic review of 83 studies, the use of TBIs in people with diagnosed depression was analyzed. Among these, only a few studies were identified as those applying TBIs for bridging waiting periods (n=1) and aftercare (n=4). The narrative summary of results suggests the effectiveness of TBIs for aftercare. However, very few data are available on TBIs regarding their acceptance, safety and use for bridging waiting periods. The current evidence base is insufficient for recommending the use of TBIs for bridging waiting periods and for aftercare. Further randomized controlled trials capturing effectiveness, acceptance, safety, and the potential for implementation of TBIs under real-world care conditions are needed.

[Development of an online intervention on suicidality-providing knowledge and reducing suicide stigma]. / Entwicklung einer Onlineintervention zum Thema Suizidalität ­ Vermittlung von Wissen und Reduzierung von Suizidstigma.

Fear of being stigmatized by others, self-stigmatization, and inadequate information can limit those affected by suicidality from seeking help. E­mental-health interventions provide a low-threshold way to reach many individuals with information about the topic. This enables those affected to prepare themselves for personal offers of help. As part of the funding priority "Suicide Prevention (A: Destigmatization)" of the German Federal Ministry of Health, a complex intervention was developed at the University Medical Center Hamburg-Eppendorf. The development and content of this online intervention are described in this article.Following a representative telephone survey of the German general population, which investigated gaps in knowledge and stigmatization tendencies on the subject of suicide, the online intervention "8 lives - lived experience reports and facts on suicide" was developed on the basis of an Australian suicide prevention project and involved persons with a lived experience of suicide. The intervention highlighted both scientific and clinical facts about suicidality as well as a socio-cultural perspective and offered self-help options and professional support services. Video reports of persons with a lived experience of suicide were shown within the intervention. The project is currently being evaluated. A continuation is planned.The intervention is a multi-layered offer in which different perspectives on the topic of suicidality are presented. Participants are addressed on a cognitive and emotional level. Given the prevalence of suicidality and the fact that the subject is still taboo, serious, evidence-based, and low-threshold prevention and information offers seem particularly relevant.

Development of an online suicide prevention program involving people with lived experience: ideas and challenges.

BACKGROUND: Fear of stigmatization, self-stigmatization, and insufficient information can lead to secrecy, reduced help-seeking, lower self-esteem, and lower self-efficacy among people affected by suicidality or suicide. Therefore, we developed an online suicide prevention program aiming to improve knowledge about suicidality and suicide stigma. METHODS: Inspired by the Australian program The Ripple Effect, a German team comprising people with lived experience of suicide, researchers, and clinicians was established for developing an online suicide prevention program. Therefore, we oriented on guidelines for evidence-based health information, for reporting on suicide, and on dealing with suicidality. The lived experience team discussed and developed concept, structure, and content of the program. This manuscript presents summaries of protocols from 16 team meetings and 3 written text reviews to outline the program development process. A summative evaluation 3 years after program development began was qualitatively analyzed based on thematic analysis. RESULTS: Between 2018 und 2021, the lived experience team (n = 10) discussed possibilities of support in suicidal crises, attitudes towards suicide, content, and design of the online program. In a structured process, six members of the lived experience team reviewed the content. Eight persons shared their lived experience of suicide in video reports by focusing on constructive ways of dealing with suicidality or a loss by suicide, conveying hope and encouraging people to continue living. Team members recommended greater public and patient involvement from the application stage, as well as more financial and personnel resources. CONCLUSIONS: Through contributions to discussions and text reviews, the lived experience team shaped decisions in the program development process. While involving persons with lived experiences of suicide, it is important to consider that suicidality is 1. emotionally challenging, 2. a stigmatized issue, and 3. that the aspect of safety must be a priority. A distinction must be made between the duty of care based on actual risk and inappropriate overprotection. Hereby, transparency, autonomy, and a clear structure appeared to be helpful. For further research, we recommend a structured formative review process of the development of the program. Additionally, we recommend discussing the purpose and the specific design of the evaluation with a lived experience team in advance. Trial registration German Clinical Trial RegisterDRKS00015071 on August 6, 2018.

A team of persons with a lived experience of suicide and researchers jointly developed an online suicide prevention program. This online program addresses the taboo and stigmatized topic of suicidality from the perspective of people with lived experience. In our team are people who tried to take their own lives, thought about suicide, and people who lost a close person by suicide. For the program we wrote texts on suicidality and suicide on a scientific basis. In videos the team shared their experiences with suicide. The team told what helped them to continue living and gave them hope. Online program participants can read these texts and watch these videos. Participants can learn about suicidality and are encouraged to seek help if needed.During the development of the program, the researchers created a working atmosphere characterized by respect, empathy, transparency, and openness. Dealing with suicidality can be emotionally stressful. The team felt comfortable and safe. The team was proud of the developed online program.We describe strengths and weaknesses of the program development. We did not evaluate the involvement during the program development. If one wants to do this, the purpose should be explained to the team. The team should have a say in the design, such as what questions are asked.Our program gained enormously from involvement of people with a lived experience of suicide. Involvement is possible and necessary even with complex and sensitive topics such as suicidality. Antistigma work should involve those affected. Involvement is important to create a credible program.

Evidence on Technology-Based Psychological Interventions in Diagnosed Depression: Systematic Review.

BACKGROUND: Evidence on technology-based psychological interventions (TBIs) for the treatment of depression is rapidly growing and covers a broad scope of research. Despite extensive research in this field, guideline recommendations are still limited to the general effectiveness of TBIs. OBJECTIVE: This study aims to structure evidence on TBIs by considering different application areas (eg, TBIs for acute treatment and their implementation in health care, such as stand-alone interventions) and treatment characteristics (eg, therapeutic rationale of TBIs) to provide a comprehensive evidence base and to identify research gaps in TBIs for diagnosed depression. Moreover, the reporting of negative events in the included studies is investigated in this review to enable subsequent safety assessment of the TBIs. METHODS: Randomized controlled trials on adults diagnosed with unipolar depression receiving any kind of psychotherapeutic treatment, which was at least partly delivered by a technical medium, were eligible for inclusion in our preregistered systematic review. We searched for trials in CENTRAL (Cochrane Central Register of Controlled Trials; until August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL; until the end of January 2018), clinical trial registers, and sources of gray literature (until the end of January 2019). Study selection and data extraction were conducted by 2 review authors independently. RESULTS: Database searches resulted in 15,546 records, of which 241 publications were included, representing 83 completed studies and 60 studies awaiting classification (ie, preregistered studies, study protocols). Almost all completed studies (78/83, 94%) addressed the acute treatment phase, being largely either implemented as stand-alone interventions (66/83, 80%) or blended treatment approaches (12/83, 14%). Studies on TBIs for aftercare (4/83, 5%) and for bridging waiting periods (1/83, 1%) were scarce. Most TBI study arms (n=107) were guided (59/107, 55.1%), delivered via the internet (80/107, 74.8%), and based on cognitive behavioral treatment approaches (88/107, 79.4%). Almost all studies (77/83, 93%) reported information on negative events, considering dropouts from treatment as a negative event. However, reports on negative events were heterogeneous and largely unsystematic. CONCLUSIONS: Research has given little attention to studies evaluating TBIs for aftercare and for bridging waiting periods in people with depression, even though TBIs are seen as highly promising in these application areas; thus, high quality studies are urgently needed. In addition, the variety of therapeutic rationales on TBIs has barely been represented by identified studies hindering the consideration of patient preferences when planning treatment. Finally, future studies should use specific guidelines to systematically assess and report negative events. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-028042.

Effectiveness and Acceptance of Technology-Based Psychological Interventions for the Acute Treatment of Unipolar Depression: Systematic Review and Meta-analysis.

BACKGROUND: Evidence on technology-based psychological interventions (TBIs) for the acute treatment of depression is rapidly growing. Despite extensive research in this field, there is a lack of research determining effectiveness and acceptance of TBIs considering different application formats in people with a formally diagnosed depressive disorder. OBJECTIVE: The goal of the review was to investigate the effectiveness and acceptance of TBIs in people with diagnosed depression with particular focus on application formats (stand-alone interventions, blended treatments, collaborative and/or stepped care interventions). METHODS: Studies investigating adults with diagnosed unipolar depressive disorders receiving any kind of psychotherapeutic treatment delivered (at least partly) by a technical medium and conducted as randomized controlled trials (RCTs) were eligible for inclusion. We searched CENTRAL (Cochrane Central Register of Controlled Trials; August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL (January 2018), clinical trial registers, and sources of grey literature (January 2019). Two independent authors decided about study inclusion and extracted data. We performed random effects meta-analyses to synthesize the data. RESULTS: Database searches resulted in 15,546 records of which 78 completed studies were included. TBIs delivered as stand-alone interventions showed positive effects on posttreatment depression severity when compared to treatment as usual (SMD -0.44, 95% CI -0.73 to -0.15, k=10; I²=86%), attention placebo (SMD -0.51, 95% CI -0.73 to -0.30; k=12; I²=66%), and waitlist controls (SMD -1.01, 95% CI -1.23 to -0.79; k=19; I²=73%). Superior long-term effects on depression severity were shown when TBIs were compared to treatment as usual (SMD -0.24, 95% CI -0.41 to -0.07; k=6; I²=48%) attention placebo (SMD -0.23, 95% CI -0.40 to -0.07; k=7; I²=21%) and waitlist controls (SMD -0.74, 95% CI -1.31 to -0.18; k=3; I²=79%). TBIs delivered as blended treatments (providing a TBI as an add-on to face-to-face treatment) yielded beneficial effects on posttreatment depression severity (SMD -0.27, 95% CI -0.48 to -0.05; k=8; I²=53%) compared to face-to-face treatments only. Additionally, TBIs delivered within collaborative care trials were more effective in reducing posttreatment (SMD -0.20, 95% CI -0.36 to -0.04; k=2; I²=0%) and long-term (SMD -0.23, 95% CI -0.39 to -0.07; k=2; I²=0%) depression severity than usual care. Dropout rates did not differ between the intervention and control groups in any comparison (all P≥.09). CONCLUSIONS: We found that TBIs are effective not only when delivered as stand-alone interventions but also when they are delivered as blended treatments or in collaborative care trials for people with diagnosed depression. Our results may be useful to inform routine care, since we focused specifically on different application formats, formally diagnosed patients, and the long-term effectiveness of TBIs. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-028042.

[The Stigma of Suicide Scale: Psychometric Validation of the German Short Version (SOSS-SF-D)]. / Die Stigma of Suicide Scale: psychometrische Überprüfung der deutschen Kurzversion (SOSS-SF-D).

OBJECTIVE: The Australian Stigma of Suicide Scale (SOSS-SF) was translated and tested for applicability and psychometric properties in Germany. Further, it was investigated whether the observed factors from the Australian original could be replicated in a German sample. METHODS: Based on a nation-wide, representative telephone survey (N = 2,002), the 16 items of the SOSS-SF-D were examined with a principal component analysis (varimax rotation). Mean values, standard deviations and medians as well as the z-standardized values for skewness and kurtosis were determined. RESULTS: The principal component analysis revealed 3 subscales (stigma, normalization/glorification, depression/isolation), just as in the Australian sample. Internal consistency of the subscales was acceptable (Cronbachs α: 0.64-0.78). CONCLUSION: The SOSS-SF-D is a valid and short instrument for measuring the multidimensionality of attitudes towards suicidal persons.

Therapeutic Alliance in Technology-Based Interventions for the Treatment of Depression: Systematic Review.

BACKGROUND: There is growing evidence that technology-based interventions (TBIs) are effective for the treatment of depression. As TBIs are gaining acceptance, a question arises whether good therapeutic alliance, considered a key aspect of psychotherapy, can be established without or with minimal face-to-face contact or rather changes if blended concepts are applied. While therapeutic alliance has been studied extensively in the context of face-to-face therapy, only few studies have reviewed evidence on alliance ratings in TBIs. OBJECTIVE: The purpose of this study was to examine therapeutic alliance in technology-based psychological interventions for the treatment of depression. METHODS: We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PSYNDEX, CINAHL, clinical trial registers, and sources of grey literature for randomized controlled trials on TBIs in the treatment of adults with unipolar depression. All publications were selected according to prespecified criteria. Data were extracted by two independent reviewers. RESULTS: A total of eight out of 98 studies (9.5%) included in the review on TBIs for depression considered therapeutic alliance as part of their evaluation. The available data covered eight different treatment conditions, including four stand-alone treatments (face-to-face psychotherapy, email, telephone, and internet program) and four combined treatments (face-to-face psychotherapy plus a smartphone app and an internet program combined with face-to-face psychotherapy, treatment as usual, or email/telephone). On average, patients rated the alliance positively across all groups. Importantly, no relevant group differences regarding therapeutic alliance sum scores were found in any of the studies. Five studies investigated the relationship between patients' alliance ratings and treatment outcome, revealing mixed results. CONCLUSIONS: Our results suggest that it is possible to establish a positive therapeutic alliance across a variety of different TBIs for depression, but this is based on a small number of studies. Future research needs to determine on what basis therapeutic alliance is formed in settings that do not allow for additional nonverbal cues, perhaps with adapted instruments to measure therapeutic alliance. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-028042.

Public Stigma Toward Persons with Suicidal Thoughts-Do Age, Sex, and Medical Condition of Affected Persons Matter?

OBJECTIVE: Suicidal persons often face public stigmatization which affects help-seeking behavior and may lead to an additional suicide risk. There is not much known about differences in stigmatizing attitudes concerning characteristics of affected persons. The present study investigates public stigma toward suicidal persons in Germany by focussing on differences concerning sex, age, and medical condition of the affected person. METHOD: A national telephone survey (N = 2,002) was conducted using case vignettes presenting a person with suicidal thoughts. Vignettes systematically varied in sex, age, and medical condition (depressive symptoms vs. cancer). Several components of stigma were assessed ("weakness of will" as a cause, separation, negative emotional reactions, and desire for social distance). RESULTS: About 44% of the respondents agreed that a cause of suicidal thoughts is "weakness of will," and two thirds disagreed that they would feel and think the same as the described person. In terms of emotional reactions, fear was more pronounced than anger. Stigmatizing attitudes were particularly pronounced when the described person was female and depressive symptoms were presented. CONCLUSIONS: Magnitude of public suicide stigma varies depending on the characteristics of the described person. Groups that are at special risk of being stigmatized should be considered in antistigma programs.

[PNP Program - Collaborative Mental and Neurological Health Care Program in Baden-Württemberg: Evaluation from the Perspective of Health Care Providers Enrolled in the Program]. / PNP-Vertrag ­ Facharztvertrag Psychotherapie, Neurologie, Psychiatrie in Baden-Württemberg: Evaluation aus der Sicht der teilnehmenden Behandlerinnen und Behandler.

OBJECTIVE: To evaluate structure and process quality from the perspective of health care providers enrolled in the PNP program. This collaborative care program developed by a German statutory health insurance provides specific rules on psychiatric, neurological, psychosomatic, and psychotherapeutic treatment. It aims to improve the quality of health care by strengthening evidence-based outpatient care and collaboration between health care providers. METHODS: Based on qualitative interviews with n = 9 enrolled health care providers a questionnaire was developed and sent to all N = 720 enrolled health care providers. RESULTS: N = 430 health care providers (81 % psychotherapists, 2 % psychiatrists, 2 % neurologists, 15 % ≥ one profession) participated (60 %). 94 % were satisfied with the program. Problems with access, treatment and cooperation were reported. CONCLUSION: The positive evaluation and the potential for improvements of the PNP program can support its advancement (e. g. enrolment, billing).

Effectiveness of Telephone-Administered Cognitive-Behavioral Psychotherapy for Depression With Versus Without Additional Letters: A Randomized Controlled Trial.

Background: Telephone-administered cognitive-behavioral psychotherapy (T-CBT) can effectively treat patients with depressive symptoms. Introduction: We investigated whether adding letters (via postal mail) to T-CBT reduces depressive symptoms and increases response and remission. Additionally, we assessed whether T-CBT reduced all patients' symptoms in the first depression-specific T-CBT sample in German healthcare. Materials and Methods: Primary care patients were randomized to T-CBT with versus without letters. All received 1 face-to-face and 8-12 telephone-administered sessions. An intention-to-treat sample was analyzed. Between-groups differences in symptom change and the total sample's symptom change were computed using linear mixed models with group as fixed effect, referring general practice as random effect and several covariates. Differences in response and remission were assessed using logistic regressions. Results: Fifty-nine patients were referred to T-CBT and randomized. Twenty-six patients actually participated in T-CBT with letters and 21 without letters. The groups did not differ significantly regarding symptom change (Patient Health Questionnaire [PHQ-9]) from baseline to end: T-CBT without letters showed 1.05 points greater reduction (95% confidence interval: -4.72 to 2.62; p = 0.56; Cohen's d = -0.12) (adjusted mean change). The groups did not differ significantly regarding symptom change from baseline to 6-month follow-up nor odds of response or remission. The total sample's PHQ-9 showed significant adjusted mean reduction from baseline to end of T-CBT and to 6-month follow-up. Discussion: Additional letters did not lead to greater symptom reduction. Overall results for the first German T-CBT intervention for depression appear promising but require further assessment using a control condition. Conclusions: Additional letters do not appear to enhance the effectiveness of T-CBT.

Development and evaluation of e-mental health interventions to reduce stigmatization of suicidality - a study protocol.

BACKGROUND: Worldwide, approximately 800,000 persons die by suicide every year; with rates of suicide attempts estimated to be much higher. Suicidal persons often suffer from a mental disorder but stigma, lack of available and suitable support, and insufficient information on mental health limit help seeking. The use of internet-based applications can help individuals inform themselves about mental disorders, assess the extent of their own concerns, find local treatment options, and prepare for contact with health care professionals. This project aims to develop and evaluate e-mental health interventions to improve knowledge about suicidality and to reduce stigmatization of those affected. In developing these interventions, a representative telephone survey was conducted to detect knowledge gaps and stigmatizing attitudes in the general population. METHODS: First, a national representative telephone survey with N = 2000 participants in Germany was conducted. Second, e-mental health interventions are developed to address knowledge gaps and public stigma detected in the survey. These comprise an evidence-based health information package about suicidality, information on regional support services, a self-administered depression test-including suicidality-and an interactive online intervention including personal stories. The development is based on a trialogical exchange of experience between persons affected by suicidality, relatives of affected persons, and clinical experts. Australian researchers who developed an e-mental health intervention for individuals affected by rural suicide were invited to a workshop in order to contribute their knowledge and expertise. Third, the online intervention will be evaluated by a mixed methods design. DISCUSSION: From representative telephone survey data, content can be developed to address specific attitudes and knowledge via the e-mental health interventions. These interventions will be easily accessed and provide an opportunity to reach people who tend not to seek professional services, prefer to inform themselves in advance and/or wish to remain anonymous. Evaluation of the online intervention will provide information on any changes in participants' self-stigma and perceived-stigma of suicidality, and any increase in participants' knowledge on suicidality or self-efficacy expectations. TRIAL REGISTRATION: German Clinical Trial Register DRKS00015071 on August 6, 2018.

Comparative effectiveness of continuation and maintenance treatments for persistent depressive disorder in adults.

BACKGROUND: Persistent depressive disorder (PDD) is defined as a depressive disorder with a minimum illness duration of two years, including four diagnostic subgroups (dysthymia, chronic major depression, recurrent major depression with incomplete remission between episodes, and double depression). Persistent forms of depression represent a substantial proportion of depressive disorders, with a lifetime prevalence ranging from 3% to 6% in the Western world. Growing evidence indicates that PDD responds well to several acute interventions, such as combined psychological and pharmacological treatments. Yet, given the high rates of relapse and recurrences of depression following response to acute treatment, long-term continuation and maintenance therapy are of great importance. To date, there has been no evidence synthesis available on continuation and maintenance treatments of PDDs. OBJECTIVES: To assess the effects of pharmacological and psychological (either alone or combined) continuation and maintenance treatments for persistent depressive disorder, in comparison with each other, placebo (drug/attention placebo/non-specific treatment control), and treatment as usual (TAU). Continuation treatments are defined as treatments given to currently remitted people (remission is defined as depressive symptoms dropping below case level) or to people who previously responded to an antidepressant treatment. Maintenance therapy is given during recovery (which is defined as remission lasting longer than six months). SEARCH METHODS: We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 28 September 2018. An earlier search of these databases was also conducted for RCTs via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 Dec 2015). In addition we searched grey literature resources as well as the international trial registers ClinicalTrials.gov and ICTRP to 28 September 2018. We screened reference lists of included studies and contacted the first author of all included studies. SELECTION CRITERIA: We included randomized (RCTs) and non-randomized controlled trials (NRCTs) in adults with formally diagnosed PDD, receiving pharmacological, psychological, or combined continuation and maintenance interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and extracted and analyzed data. The primary efficacy outcome was relapse/recurrence rate of depression. The primary acceptance outcome was dropout due to any reason other than relapse/recurrence. We performed random-effects meta-analyses using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS: We included 10 studies (seven RCTs, three NRCTs) involving 840 participants in this review, from which five studies investigated continuation treatments and five studies investigated maintenance treatments. Overall, the included studies were at low-to-moderate risk of bias. For the three NRCTs, the most common source of risk of bias was selection of reported results. For the seven RCTs, the most common sources of risk of bias was non-blinding of outcome assessment and other bias (especially conflict of interest due to pharmaceutical sponsoring).Pharmacological continuation and maintenance therapiesThe most common comparison was antidepressant medication versus tablet placebo (five studies). Participants taking antidepressant medication were probably less likely to relapse or to experience a recurrent episode compared to participants in the placebo group at the end of the intervention (13.9% versus 33.8%, RR 0.41, 95% CI 0.21 to 0.79; participants = 383; studies = 4; I² = 54%, moderate quality evidence). Overall dropout rates may be similar between participants in the medication and placebo group (23.0% versus 25.5%, RR 0.90, 95% CI 0.39 to 2.11; RCTs = 4; participants = 386; I² = 64%, low quality evidence). However, sensitivity analyses showed that the primary outcome (rate of relapse/recurrence) showed no evidence of a difference between groups when only including studies with low risk of bias.None of the studies compared pharmacological or psychological treatments versus TAU.Psychological continuation and maintenance therapiesOne study compared psychological therapies versus attention placebo/non-specific control. One study compared psychotherapy with medication. The results of the studies including psychotherapy might indicate that continued or maintained psychotherapy could be a useful intervention compared to no treatment or antidepressant medication. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusions.Combined psychological and pharmacological continuation and maintenance therapiesThree studies compared combined psychological and pharmacological therapies with pharmacological therapies alone. One study compared combined psychological and pharmacological therapies with psychotherapeutic therapies alone. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusionsComparison of different antidepressant medications Two studies reported data on the direct comparison of two antidepressants. However, the body of evidence for this comparison was too small and uncertain to draw any high quality conclusions. AUTHORS' CONCLUSIONS: Currently, it is uncertain whether continued or maintained pharmacotherapy (or both) with the reviewed antidepressant agents is a robust treatment for preventing relapse and recurrence in people with PDD, due to moderate or high risk of bias as well as clinical heterogeneity in the analyzed studies.For all other comparisons, the body of evidence was too small to draw any final conclusions, although continued or maintained psychotherapy might be effective compared to no treatment. There is need for more high quality trials of psychological interventions. Further studies should address health-related quality of life and adverse events more precisely, as well as assessing follow-up data.