Stimulating existential communication - first steps towards enhancing health professionals' reflective skills through blended learning.

Introduction: Talking about existential issues with patients is often experienced as challenging for healthcare professionals. This paper describes our first steps towards developing existential communication training with particular attention to reflective learning methods. Blended learning was chosen to support reflection and an easier transition to classroom conversations, and through Participatory Action Research (PAR), patients were involved in developing the curriculum. Method: To develop the most valuable and relevant communication training, patients, relatives, healthcare professionals and researchers were involved in a PAR process including 1) three theatre workshops and 2) collaborative meetings to develop the blended learning curriculum and reflection videos. The evaluation of the communication training was based on semi-structured interviews with the healthcare professionals participating in the blended learning communication training. Discussion and innovation: The results indicate that a blended learning format involving a high degree of reflection is valuable for developing skills related to existential communication. Engaging patients in the process may be essential to develop a training curriculum for healthcare professionals that accommodates the patient's needs. Conclusion: Future communication training on existential communication may benefit from adopting a blended learning format, including reflective learning methods and the involvement of patients in curriculum development.

Patients' Experiences of Using a Self-help App for Posttraumatic Stress Disorder: Qualitative Study.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a common disorder that requires more treatment options. Mobile health (mHealth) app interventions are promising for patients with PTSD, as they can provide easily accessible support, strategies, and information. However, knowledge about mHealth interventions is sparse and primarily based on quantitative studies. OBJECTIVE: The aim of this study is to qualitatively explore the experiences of patients with PTSD with regard to using an mHealth app as a stand-alone intervention before commencing psychotherapeutic treatment. METHODS: We conducted semistructured interviews with 14 participants 6 weeks after they received the app. The participants were all referred to PTSD treatment and were waiting to commence psychotherapeutic treatment. During this waiting time, the participants had no contact with the health staff. Interviews were transcribed and were analyzed using thematic analysis. RESULTS: A total of 3 themes were identified-the use of app, being a patient, and the overall evaluation of the app. The use of the app was described with the subtheme of habits, and the theme of being a patient included the subthemes of having negative experiences with the app and being a part of a research project. The use of the app encompassed how psychological factors and technical problems could interfere with the use of the app. The theme of being a patient depicted that the waiting time before starting treatment was long, and a subgroup of patients experienced feeling worse during this time, which they partly attributed to using the app. Several suggestions for change have been described in the overall evaluation of the app. CONCLUSIONS: The findings in this study revealed that emotional arousal influenced the use of the app and that it was difficult for participants to establish a habit of using the app, thus reflecting the importance of supporting habit formation when implementing an mHealth app in mental health care services. This study makes an important contribution to the field of mHealth research, as it revealed that some participants had negative experiences resulting from using the app, thus reflecting the potential harm of having an mHealth app without the support of a clinician. It is therefore recommended to use a blended care treatment or an approach in which mental health care professionals prescribe an mHealth app for relevant patients to avoid increased suicidal risk.

Improving the precision of depression diagnosis in general practice: a cluster-randomized trial.

BACKGROUND: Methods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral. METHODS: This study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups. RESULTS: Fifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78-0.88) and 0.93 (95% CI 0.89-0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs. CONCLUSIONS: In this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression. TRIAL REGISTRATION: The trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845 .

Collaborative care for depression and anxiety disorders: results and lessons learned from the Danish cluster-randomized Collabri trials.

BACKGROUND: Meta-analyses suggest that collaborative care (CC) improves symptoms of depression and anxiety. In CC, a care manager collaborates with a general practitioner (GP) to provide evidence-based care. Most CC research is from the US, focusing on depression. As research results may not transfer to other settings, we developed and tested a Danish CC-model (the Collabri-model) for depression, panic disorder, generalized anxiety disorder, and social anxiety disorder in general practice. METHODS: Four cluster-randomized superiority trials evaluated the effects of CC. The overall aim was to explore if CC significantly improved depression and anxiety symptoms compared to treatment-as-usual at 6-months' follow-up. The Collabri-model was founded on a multi-professional collaboration between a team of mental-health specialists (psychiatrists and care managers) and GPs. In collaboration with GPs, care managers provided treatment according to a structured plan, including regular reassessments and follow-up. Treatment modalities (cognitive behavioral therapy, psychoeducation, and medication) were offered based on stepped care algorithms. Face-to-face meetings between GPs and care managers took place regularly, and a psychiatrist provided supervision. The control group received treatment-as-usual. Primary outcomes were symptoms of depression (BDI-II) and anxiety (BAI) at 6-months' follow-up. The incremental cost-effectiveness ratio (ICER) was estimated based on 6-months' follow-up. RESULTS: Despite various attempts to improve inclusion rates, the necessary number of participants was not recruited. Seven hundred thirty-one participants were included: 325 in the depression trial and 406 in the anxiety trials. The Collabri-model was implemented, demonstrating good fidelity to core model elements. In favor of CC, we found a statistically significant difference between depression scores at 6-months' follow-up in the depression trial. The difference was not significant at 15-months' follow-up. The anxiety trials were pooled for data analysis due to inadequate sample sizes. At 6- and 15-months' follow-up, there was a difference in anxiety symptoms favoring CC. These differences were not statistically significant. The ICER was 58,280 Euro per QALY. CONCLUSIONS: At 6 months, a significant difference between groups was found in the depression trial, but not in the pooled anxiety trial. However, these results should be cautiously interpreted as there is a risk of selection bias and lacking statistical power. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02678624 and NCT02678845 . Retrospectively registered on 7 February 2016.

The PTSD help app in a Danish PTSD population: research protocol of a randomized controlled feasibility trial.

BACKGROUND: Due to an increase in PTSD patients seeking help in the Danish mental health sector and the addition of Complex PTSD to the ICD-11, there is a need to increase efficiency of existing treatments for PTSD. mHealth interventions have been shown to reduce PTSD symptoms. Therefore, the implementation of a mHealth intervention designed for psychiatric PTSD patients as a therapy add-on may improve treatment outcome. No study to date has explored the effects of mHealth interventions for PTSD in the Danish mental health sector, the feasibility and effect of this type of intervention needs testing. METHODS: The study is an investigator-initiated randomized controlled feasibility trial investigating the clinical mHealth tool PTSD help combined with care as usual (CAU) compared to CAU for adults with PTSD. Seventy patients will be recruited and receive either the mHealth intervention combined with CAU or CAU alone. The primary feasibility outcome is the proportion of eligible patients that participate in the study until the end assessment. Secondary outcome data consists of the fraction of compliant patients in the experimental group and exploratory data on PTSD help on PTSD symptom severity, level of psychological distress, sleep quality, dissociation symptoms, therapy readiness, quality of life, disability levels, and recovery. DISCUSSION: This study may help increase our knowledge of possible benefits of, as well as potential barriers to, the implementation of mHealth tools in the psychiatric sector. It may also provide a cost-efficient means to increase therapy outcomes and decrease the duration of suffering for PTSD patients in the psychiatric sector. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (ID: NCT03862703) https://clinicaltrials.gov/ct2/show/NCT03862703 on the 27 of February 2019 and has been approved by the Danish Data Protection Agency (journal number: VD-2018-200 ISuite number 6443). Referring to the committee law §2, the National Committee on Health Research Ethics (DNVK) [H-18024180] decided that the study could proceed without approval as the use of PTSD help did not constitute a health science intervention according to Danish health science legislation.

Social anxiety disorder and avoidant personality disorder from an interpersonal perspective.

OBJECTIVES: The general objective of this article is to study the unclear and overlapping relationship between social anxiety disorder (SAD) and avoidant personality disorder (AvPD) from an interpersonal perspective. The first specific objective is to compare the disorders with regard to interpersonal problems and general symptom distress. The second specific objective is to examine interpersonal subgroups and pathoplasticity. DESIGN: In a cross-sectional design, patients from an outpatient psychotherapy clinic diagnosed with social anxiety disorder (SAD, n = 299), avoidant personality disorder (AvPD, n = 180), or the comorbid condition of both disorders (AvPD + SAD, n = 29) were assessed before treatment. METHODS: Patients filled out the Inventory of Interpersonal Problems (IIP-64) and the Symptom Checklist-Revised (SCL-R-90) before treatment. RESULTS AND CONCLUSIONS: From an interpersonal perspective, the relationship between the diagnostic groups is well described by the severity continuum hypothesis, with similar interpersonal problems related to Nonassertiveness and lower levels of general interpersonal stress in the SAD group compared to the two AvPD groups. However, other differences in severity do not fit the severity continuum hypothesis, as there are no differences in severity on the global severity index, and, moreover, the SAD group has the most severe problems on the SCL-90 phobic anxiety scale. Interpersonal pathoplasticity is not found in the diagnostic groups or in the full sample. However, three interpersonal subgroups are identified in the full sample, designated as Nonassertive, Friendly-submissive, and Cold-submissive. Implications for treatment are discussed. PRACTITIONER POINTS: SAD is characterized by a lower level of interpersonal distress compared to AvPD, but the two disorders are similar in having Nonassertiveness as their general interpersonal problem. Contrary to expectation, SAD and AvPD did not differ in general level of symptom severity, and patients with SAD reported more problems with phobic anxiety than AvPD patients did. When understanding SAD and AvPD as different conceptualizations of the same disorder and analysing all patients together, three distinct interpersonal subgroups emerge, which can be identified as Nonassertive, Friendly-submissive, and Cold-submissive.

(Dis-)solving the Weight Problem in Binge-Eating Disorder: Systemic Insights From Three Treatment Contexts With Weight Stability, Weight Loss, and Weight Acceptance.

Binge-eating disorder (BED) is a severe eating disorder strongly associated with obesity. Treatments struggle to provide safe and effective ways of addressing weight in a BED context. This study explored a two-phased treatment for BED developed at a major out-patient eating disorder service in Denmark. The study used interviews and participant observations to gain insight into experiences and processes related to weight and body issues in three treatment contexts that addressed weight stability, weight acceptance, and weight loss. Using systems theory, the study proposed a relational weight problem that embeds feelings of non-acceptance due to weight, a merge of weight and identity, and an internalized body- and weight-critical gaze of others. Contrary to critical claims that weight acceptance discourages people with obesity from engaging in weight loss efforts, this study suggests that acceptance and a disentanglement of weight and identity are prerequisites for weight loss for this group.

Patient reported outcome measures (PROMs): examination of the psychometric properties of two measures for burden of symptoms and quality of life in patients with depression or anxiety.

INTRODUCTION: Patient-reported outcome measures (PROMs) for anxiety and depressive disorders are an important aspect of measurement-based care. AIM: The aim of the study was to perform a clinimetric analysis of two PROMs scales in patents with depression and anxiety. METHODS: Patients completed a 10-item version (SCL-10) of the Symptom Checklist to measure burden of symptoms and a brief 5-item version of World Health Organization Well-being scale (WHO-5) to measure quality of life. T-scores were used to standardize the SCL-10 and WHO-5 in terms of being in need of treatment. The coefficient of alpha and the coefficient of homogeneity were used to evaluate the internal consistency or scalability respectively of SCL-10 and WHO-5. Effect size statistics and Spearman correlation coefficients were used to measure the effect of gender and age, respectively. RESULTS: A total of 801 patients were recruited from two Danish mental health centers with anxiety or depression. The standardization of the SCL-10 and WHO-5 by T-scores indicated that a T-score of 65 corresponding to being moderately in need of treatment and a T-score of 75 to be severely in need of treatment. The coefficient of alpha and the coefficient of homogeneity were both found acceptable for SCL-10 and WHO-5. No gender or age factors were found being in operation. CONCLUSION: The results from the current study supported the use of the SCL-10 and WHO-5 as potential PROMs to capture symptom burden and quality of life within groups of people with anxiety or depression undergoing psychotherapy treatment.

The association between interpersonal problems and treatment outcome in patients with eating disorders.

BACKGROUND: Interpersonal problems are thought to play an essential role in the development and maintenance of eating disorders. The aim of the current study was to investigate whether a specific interpersonal profile could be identified in a group of patients diagnosed with Bulimia Nervosa, Binge Eating Disorder, or Eating Disorders Not Otherwise Specified, and to explore if specific types of interpersonal problems were systematically related to treatment outcome in this group of patients. METHODS: The participants were 159 patients who received systemic/narrative outpatient group psychotherapy. Interpersonal problems were measured at baseline, and eating disorder symptoms were measured pre- and post treatment. Data were analysed with the Structural Summary Method, a particular method for the analysis of the Inventory of Interpersonal Problems, and hierarchical regression analysis was conducted. RESULTS: The patients demonstrated a generally Non-assertive and Friendly-submissive interpersonal style. No significant association between the overall level of interpersonal problems and treatment outcome was identified. However, the results showed a correlation between being cold and hostile and poor treatment outcome, while being domineering showed a trend approaching significance in predicting better treatment outcome. CONCLUSION: The results indicate that patients with eating disorders show a specific interpersonal profile, and suggest that particular types of interpersonal problems are associated with treatment outcome.

Collaborative care for panic disorder, generalised anxiety disorder and social phobia in general practice: study protocol for three cluster-randomised, superiority trials.

BACKGROUND: People with anxiety disorders represent a significant part of a general practitioner's patient population. However, there are organisational obstacles for optimal treatment, such as a lack of coordination of illness management and limited access to evidence-based treatment such as cognitive behavioral therapy. A limited number of studies suggest that collaborative care has a positive effect on symptoms for people with anxiety disorders. However, most studies are carried out in the USA and none have reported results for social phobia or generalised anxiety disorder separately. Thus, there is a need for studies carried out in different settings for specific anxiety populations. A Danish model for collaborative care (the Collabri model) has been developed for people diagnosed with depression or anxiety disorders. The model is evaluated through four trials, of which three will be outlined in this protocol and focus on panic disorder, generalised anxiety disorder and social phobia. The aim is to investigate whether treatment according to the Collabri model has a better effect than usual treatment on symptoms when provided to people with anxiety disorders. METHODS: Three cluster-randomised, clinical superiority trials are set up to investigate treatment according to the Collabri model for collaborative care compared to treatment-as-usual for 364 patients diagnosed with panic disorder, generalised anxiety disorder and social phobia, respectively (total n = 1092). Patients are recruited from general practices located in the Capital Region of Denmark. For all trials, the primary outcome is anxiety symptoms (Beck Anxiety Inventory (BAI)) 6 months after baseline. Secondary outcomes include BAI after 15 months, depression symptoms (Beck Depression Inventory) after 6 months, level of psychosocial functioning (Global Assessment of Functioning) and general psychological symptoms (Symptom Checklist-90-R) after 6 and 15 months. DISCUSSION: Results will add to the limited pool of information about collaborative care for patients with anxiety disorders. To our knowledge, these will be the first carried out in a Danish context and the first to report results for generalised anxiety and social phobia separately. If the trials show positive results, they could contribute to the improvement of future treatment of anxiety disorders. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02678624 . Retrospectively registered 7 February 2016; last updated 15 August 2016.

Collaborative care for depression in general practice: study protocol for a randomised controlled trial.

BACKGROUND: Depression is a common illness with great human costs and a significant burden on the public economy. Previous studies have indicated that collaborative care (CC) has a positive effect on symptoms when provided to people with depression, but CC has not yet been applied in a Danish context. We therefore developed a model for CC (the Collabri model) to treat people with depression in general practice in Denmark. Since systematic identification of patients is an "active ingredient" in CC and some literature suggests case finding as the best alternative to standard detection, the two detection methods are examined as part of the study. The aim is to investigate if treatment according to the Collabri model has an effect on depression symptoms when provided to people with depression in general practice in Denmark, and to examine if case finding is a better method to detect depression in general practice than standard detection. METHODS/DESIGN: The trial is a cluster-randomised, clinical superiority trial investigating the effect of treatment according to the Collabri model for CC, compared to treatment as usual for 480 participants diagnosed with depression in general practice in the Capital Region of Denmark. The primary outcome is depression symptoms (Beck's Depression Inventory (BDI-II)) after 6 months. Secondary outcomes include depression symptoms (BDI-II) after 15 months, anxiety symptoms (Beck's Anxiety Inventory (BAI)), level of functioning (Global Assessment of Function (GAF)) and psychological stress (Symptom Checklist-90-Revised (SCL-90-R)). In addition, case finding (with the recommended screening tool Major Depression Inventory (MDI)) and standard detection of depression is examined in a cluster-randomized controlled design. Here, the primary outcome is the positive predictive value of referral diagnosis. DISCUSSION: If the Collabri model is shown to be superior to treatment as usual, the study will contribute with important knowledge on how to improve treatment of depression in general practice, with major benefit to patients and society. If case finding is shown to be superior to standard detection, it will be recommended as the detection method in future treatment according to the Collabri model. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02678845 . Retrospectively registered on 7 February 2016.

Personality disorders: patient characteristics and level of outpatient treatment service.

BACKGROUND: In this naturalistic study, patients with personality disorders (N = 388) treated at Stolpegaard Psychotherapy Center, Mental Health Services, Capital Region of Denmark were allocated to two different kinds of treatment: a standardized treatment package with a preset number of treatment hours (basic hospital service) and 2: a specialized treatment program for the most severely affected patients without a predetermined restricted number of treatment hours and significantly more individual psychotherapy (regional specialized hospital services). AIMS: To investigate patient characteristics associated with clinicians' allocation of patients to the two different personality disorder services. METHODS: Patient characteristics across eight domains were collected in order to study whether there were systematic differences between patients allocated to the two different treatments. Patient characteristics included measures of symptom severity, personality pathology, trauma and socio-demographic characteristics. Significance testing and binary regression analysis were applied to identify important predictors. RESULTS: Patient characteristics on fifteen variables differed significantly, all in the expected direction, with patients in regional specialized hospital services showing more pathology and psychosocial problems. In the regression model, only age and two variables capturing psychosocial functioning remained significant predictors of allocation. DISCUSSION: The finding that younger age was the most significant predictor of longer treatment replicates an earlier finding of allocation to treatment for personality disorder. Overall, this study therefore lends further support to the importance of demographic and social contextual factors in clinicians' allocation of patients to different treatment services for personality disorder.

Mandatory communication training of all employees with patient contact.

UNLABELLED: In 2010 a communication program that included mandatory communication skills training for all employees with patient contact was developed and launched at a large regional hospital in Denmark. OBJECTIVE: We describe the communication program, the implementation process, and the initial assessment of the process to date. METHOD: The cornerstone of the program is a communication course based on the Calgary Cambridge Guide and on the experiences of several efficacy and effectiveness studies conducted at the same hospital. The specific elements of the program are described in steps and a preliminary assessment based on feedback from the departments will be presented. RESULTS: The elements of the communication program are as follows: (1) education of trainers; (2) courses for health professionals employed in clinical departments; (3) education of new staff; (4) courses for health professionals in service departments; and (5) maintenance of communication skills. Thus far, 70 of 86 staff have become certified trainers and 17 of 18 departments have been included in the program. CONCLUSION AND PRACTICE IMPLICATIONS: Even though the communication program is resource-intensive and competes with several other development projects in the clinical departments, the experiences of the staff and the managers are positive and the program continues as planned.

[Short-term treatment of depression. Implementation of group-based cognitive behavioral therapy]. / Korttidsbehandling af depressioner. Implementering af gruppebaseret kognitiv adfaerdsterapi.

INTRODUCTION: Psychotherapy of depressive conditions is more and more in demand by patients. The effect of individual cognitive behavioral therapy (CBT) on depression is well-documented, and foreign studies indicate that group CBT also works well. There was no Danish manual on group CBT for the purpose of clinical implementation. The aim of the present project was to develop such a manual and complete a preliminary evaluation of the outcome. MATERIALS AND METHODS: A therapy manual consisting of 12 group sessions of 2 hours duration was developed. A constituent part of the evaluation of the clinical effect was 10 group courses with a total of 51 consecutively referred patients with a non-psychotic depression requiring treatment. RESULTS: On the basis of clinical experience, the manual has been revised and is now ready for publication. 80% of the patients completed the therapy course with a large Effect Size (ES) on psychiatric/depression symptoms (SCL-90R) and function level (GAF), as well as moderate ES on the degree of hopelessness (BHS). CONCLUSION: The development and clinical implementation of a manual in cognitive behavioral group therapy has resulted in this treatment now being offered as permanent treatment for depressive patients throughout the cooperating centers. The existing manual can relatively easily be implemented in other treatment centers and clinics. The preliminary results are positive, but the design does not permit further conclusions.