Innovative moments in low-intensity, telephone-based cognitive-behavioral therapy for depression.

Background: Innovative moments (IMs), defined as moments in psychotherapy when patients' problematic patterns change toward more elaborated and adaptive patterns, have been shown to be associated with a clinical change in patients with depression. Thus, far IMs have been studied in face-to-face settings but not in telephone-based cognitive-behavioral therapy (t-CBT). This study investigates whether IMs occur in t-CBT and examines the association between IMs and symptom improvement, and reconceptualization and symptom improvement. Methods: The therapy transcripts of n = 10 patients with mild to moderate depression (range: 7-11 sessions, in total 94 sessions) undergoing t-CBT were qualitatively and quantitatively analyzed. Symptom severity (Patient Health Questionnaire-9) and IMs (levels and proportions) were assessed for each therapy session. Hierarchical linear models were used to test the prediction models. Results: The rating of IMs was shown to be feasible and reliable using the Innovative Moments Coding System (IMCS) (84.04% agreement in words coded), which is indicative of the applicability of the concept of IMs in t-CBT. Only reconceptualization IMs were shown to have a predictive value for treatment success (R2 = 0.05, p = 0.01). Discussion: The results should be interpreted with caution due to the exploratory nature of this study. Due to the telephone setting, it was necessary to adapt the IMCS. Nonetheless, the extent of IMs identified in the low-intensity t-CBT investigated was comparable to IMs in face-to-face therapy. Further studies are needed to clarify the association between IMs and treatment success as a change process, especially for low-intensity treatments.

How mood is affected by environment and upsetting events: The moderating role of psychological flexibility.

OBJECTIVE: Patients suffering from psychological disorders report decreased quality of life and low mood. The relationship of these symptoms to daily upsetting events or environments, and in the context of active coping mechanisms is poorly understood. The present study thus investigates the association between mood, psychological flexibility, upsetting events, and environment in the daily life of outpatients. METHOD: We investigated 80 outpatients at the beginning of treatment, using event sampling methodology (ESM). Patients' mood, occurrence of upsetting events, current environment, and psychological flexibility were sampled six times per day during a one-week intensive longitudinal examination. Data were analyzed using linear mixed models (LMMs). RESULTS: Participants reported worse mood the more upsetting events they experienced. Further, participants reported better mood when in private environments (e.g., with friends), and worse mood when at the hospital, compared to being at home. Higher levels of psychological flexibility, however, were associated with better mood, irrespective of the occurrence of upsetting events or current environment. CONCLUSION: Results suggest that mood is positively associated with psychological flexibility, not despite, but especially during the dynamic and context-specific challenges of daily life. Psychological flexibility may thus potentially act as a buffer against distress-provoking situations as patients go about their daily lives. TRIAL REGISTRATION: ISRCTN.org identifier: ISRCTN11209732.

Psychotherapy for Chronic In- and Outpatients with Common Mental Disorders: The "Choose Change" Effectiveness Trial.

INTRODUCTION: Treatment non-response occurs regularly, but psychotherapy is seldom examined for such patients. Existing studies targeted single diagnoses, were relatively small, and paid little attention to treatment under real-world conditions. OBJECTIVE: The Choose Change trial tested whether psychotherapy was effective in treating chronic patients with treatment non-response in a transdiagnostic sample of common mental disorders across two variants of treatment delivery (inpatient and outpatient). METHODS: The controlled nonrandomized effectiveness trial was conducted between May 2016 and May 2021. The study took place in two psychiatric clinics with N = 200 patients (n = 108 inpatients and n = 92 outpatients). Treatment variants were integrated inpatient care versus outpatient care based on acceptance and commitment therapy (ACT) for approximately 12 weeks. Therapists delivered individualized and non-manualized ACT. Main outcome measures were symptoms (Brief Symptom Checklist [BSCL]); well-being (Mental Health Continuum-Short Form [MHC-SF]), and functioning (WHO Disability Assessment Schedule [WHO-DAS]). RESULTS: Both inpatients and outpatients showed decreases in symptomatology (i.e., BSCL: d = 0.68) and increases in well-being and functioning (MHC-SF: d = 0.60 and WHO-DAS: d = 0.70), with more improvement in the inpatients during treatment. Both groups maintained gains 1 year following treatment, and the groups did not significantly differ from each other at this timepoint. Psychological flexibility moderated impact of stress on outcomes. CONCLUSIONS: Psychotherapy as practiced under routine conditions is effective for a sample of patients with common mental disorders, a long history of treatment experience and burden of disease, in both inpatient and outpatient settings. TRIAL REGISTRATION: This study was registered in the ISRCTN registry on May 20, 2016, with the registration number ISRCTN11209732.

Is helping you helping me? The assessment of helping others using event sampling methodology in a clinical and a non-clinical sample.

Individuals diagnosed with major depressive disorder (MDD) and social phobia (SP) have difficulties in social interactions. It is unknown, however, whether such difficulties prevent them from helping others, thereby depriving them of the natural benefits of helping, such as receiving gratitude. Using event sampling methodology (ESM), individuals (MDD, n = 118; SP, n = 47; and control group, n = 119) responded to questions about the frequency of helping, in total at 5333 time points, and their well-being. Contrary to our hypothesis, individuals in the MDD, SP and control group did not differ in their helping frequency. Results did show an association between helping and well-being, such that helping is related to well-being and well-being to helping. Understanding the complex relation of helping others and well-being and how this might be used during therapy and prevention programmes are discussed.

Meaningful and Lasting Change - Psychotherapy in the Light of Evolutionary Processes.

Psychotherapies can lead to meaningful and lasting change.Evolutionary theory is relevant for understanding psychotherapy.Process-based approaches to conceptualizing psychotherapy can help organize clinical knowledge.Process-based approaches may be more useful than competitions between psychotherapy schools.

Meaningful Relationships in Community and Clinical Samples: Their Importance for Mental Health.

Meaningful relationships are centrally important for human functioning. It remains unclear, however, which aspects of meaningful relationships impact wellbeing the most and whether these differ between psychiatric patients and members of the community. Information about relationship attributes and functions were collected in community members (N = 297) and psychiatric patients (N = 177). Relationship attributes and functions were examined for differences between groups (community vs. patients), their impact on wellbeing and symptoms, and the size of network (one vs. many relationships). Community members reported fewer relationships, higher frequency of contact and less desire for change when compared to the psychiatric patients. Nevertheless, both groups reported relatively high levels of fulfilled functions. Quality of the relationship and investment into the relationship was associated with both wellbeing and symptoms for both the community and the patient group. Almost all functions were associated with wellbeing and symptoms for the community group. However, for the patient group, only few functions (sexual partner, go-to person for compassion, go-to person when happy) were associated with wellbeing and no functions were associated with symptoms. Contrary to our hypotheses, the results show that psychiatric patients do not have a deficit in fulfilling relationships. Most people report a well-functioning network of meaningful, high-quality relationships. Patients benefit from meaningful, function-fulfilling relationships just as much as community members. Results are discussed with respect to how targeting relationships can be used clinically.

To Help or Not to Help? Prosocial Behavior, Its Association With Well-Being, and Predictors of Prosocial Behavior During the Coronavirus Disease Pandemic.

The coronavirus disease (COVID-19) pandemic fundamentally disrupted humans' social life and behavior. Public health measures may have inadvertently impacted how people care for each other. This study investigated prosocial behavior, its association well-being, and predictors of prosocial behavior during the first COVID-19 pandemic lockdown and sought to understand whether region-specific differences exist. Participants (N = 9,496) from eight regions clustering multiple countries around the world responded to a cross-sectional online-survey investigating the psychological consequences of the first upsurge of lockdowns in spring 2020. Prosocial behavior was reported to occur frequently. Multiple regression analyses showed that prosocial behavior was associated with better well-being consistently across regions. With regard to predictors of prosocial behavior, high levels of perceived social support were most strongly associated with prosocial behavior, followed by high levels of perceived stress, positive affect and psychological flexibility. Sociodemographic and psychosocial predictors of prosocial behavior were similar across regions.

"Unrigging the support wheels" - A qualitative study on patients' experiences with and perspectives on low-intensity CBT.

BACKGROUND: Low-intensity treatments imply reduced therapist contact due to an emphasis on self-help and the use of technologies to deliver treatment. The role of the remoteness, the reduced therapist contact, and the interplay of these components has not been differentiated from a patients' perspective so far. This study's purpose is to capture patients' experiences with telephone-based self-help cognitive behavioural therapy (tel-CBT). METHODS: A subsample of mildly to moderately depressed patients (N = 13) who finished tel-CBT as part of a larger randomised controlled trial (RCT) in routine care were interviewed using a semi-structured questionnaire. Interviews were audiotaped, transcribed verbatim, and independently coded by two coders blind to treatment outcome. Using qualitative content analysis with deductive and inductive procedures, a two-level category system was established. RESULTS: The category system contains four category clusters regarding expectations, self-help related aspects, telephone-related aspects, and implications for patients' treatment pathway, and subsumes a total of 15 categories. Self-help related aspects circulate around the interplay between written materials and professional input, trust and support in the therapeutic relationship and its relation to the initial personal contact, as well as CBT principles. Telephone-related aspects entail perceived advantages and disadvantages of the telephone on an organisational and content level as well as a discourse around distance and closeness in the interaction. Although patients raised doubts regarding the long-term effect of the intervention on symptomatology, patients expressed satisfaction with the treatment and reported an immediate as well as a longer lasting personal impact of the treatment. These results indicate user acceptance with tel-CBT. CONCLUSIONS: This qualitative analysis captures patients' experiences with tel-CBT and the perceived helpfulness of the diverse treatment components. This can facilitate refining aspects of low-intensity treatments and might improve dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Antidepressant prescription practice and related factors in Switzerland: a cross-sectional analysis of health claims data.

BACKGROUND: The aim of the study was to examine the prevalence of and factors associated with antidepressant (AD) prescriptions in order to draw a comprehensive picture of prescribing practices in Switzerland. METHOD: We conducted a population-based, cross-sectional descriptive study using a large Swiss healthcare claims database, covering approximately 13% of the Swiss population. AD prescription was determined by identifying patients (N = 105,663) with health claims data of at least 1 AD prescription in the year 2016. AD medication was identified using ATC-codes classified by the World Health Organisation. Univariate, bivariate and multivariate analyses using logistic regression were performed. RESULTS: The extrapolated 1-year prevalence of AD prescription was 8.7% (95% CI, 8.7-8.8) with two thirds of AD recipients being female and the average age being 59 years (SD = 19.1). The regional distribution of prescription rates varied between cantons and ranged from 6.5 to 11.7%. Logistic regression revealed higher prescription rates among females compared to males (OR: 1.52) and an increased probability of AD prescription by age up until 54 years (OR: 2.25) and ≥ 85 years (OR: 2.32). Comorbidity is associated with higher odds (OR: 3.26 with 1-2 comorbidities) and enrollment in a managed care plan (compared to standard care) with lower odds for an AD prescription (OR: 0.85). CONCLUSION: This study is the first in Switzerland to describe the prevalence of and factors associated with AD prescription based on a large health claims database reflecting routine care. The results provide important information about regional variation, prescription source, and potential over-prescription in the treatment of depressive disorders.

The use of single armed observational data to closing the gap in otherwise disconnected evidence networks: a network meta-analysis in multiple myeloma.

BACKGROUND: Network meta-analysis (NMA) allows for the estimation of comparative effectiveness of treatments that have not been studied in head-to-head trials; however, relative treatment effects for all interventions can only be derived where available evidence forms a connected network. Head-to-head evidence is limited in many disease areas, regularly resulting in disconnected evidence structures where a large number of treatments are available. This is also the case in the evidence of treatments for relapsed or refractory multiple myeloma. METHODS: Randomised controlled trials (RCTs) identified in a systematic literature review form two disconnected evidence networks. Standard Bayesian NMA models are fitted to obtain estimates of relative effects within each network. Observational evidence was identified to fill the evidence gap. Single armed trials are matched to act as each other's control group based on a distance metric derived from covariate information. Uncertainty resulting from including this evidence is incorporated by analysing the space of possible matches. RESULTS: Twenty five randomised controlled trials form two disconnected evidence networks; 12 single armed observational studies are considered for bridging between the networks. Five matches are selected to bridge between the networks. While significant variation in the ranking is observed, daratumumab in combination with dexamethasone and either lenalidomide or bortezomib, as well as triple therapy of carfilzomib, ixazomib and elozumatab, in combination with lenalidomide and dexamethasone, show the highest effects on progression free survival, on average. CONCLUSIONS: The analysis shows how observational data can be used to fill gaps in the existing networks of RCT evidence; allowing for the indirect comparison of a large number of treatments, which could not be compared otherwise. Additional uncertainty is accounted for by scenario analyses reducing the risk of over confidence in interpretation of results.

Effectiveness and cost-effectiveness of telephone-based cognitive-behavioural therapy in primary care: study protocol of TIDe - telephone intervention for depression.

BACKGROUND: Despite the availability of evidence-based treatments for depression, a large proportion of patients remains untreated or adequate treatment is initiated with delay. This situation is particularly critical in primary care, where not only most individuals first seek help for their mental health problems, but also depressive disorders - particularly mild to moderate levels of severity - are highly prevalent given the high comorbidity of chronic somatic conditions and depression. Improving the access for evidence-based treatment, especially in primary care, is hence a priority challenge in the mental health care agenda. Telephone usage is widespread and has the potential of overcoming many barriers that individuals suffering from mental health problems are facing: Its implementation for treatment delivery presents an option for optimisation of treatment pathways and outcomes. METHODS/DESIGN: This paper details the study protocol for a randomised controlled trial (RCT) evaluating the effectiveness of a telephone-administered short-term cognitive-behavioural therapy (T-CBT) for depression as compared to treatment as usual (TAU) in the Swiss primary care setting. The study aims at randomising a total of 216 mildly to moderately depressed patients, which are either identified by their General Practitioners (GPs) or who self-refer to the study programme in consultation with their GP. The trial will examine whether telephone-delivered, manualised treatment leads to clinically significant reduction in depression at follow-up. It will further investigate the cost-effectiveness and acceptability of the intervention in the primary care setting. DISCUSSION: Conducting a low-intensity treatment on the telephone allows for greater flexibility for both patient and therapist, can grant more anonymity and can thus lead to less hesitation in the patient about whether to attempt treatment or not. In order to benefit from this approach, large-scale studies need to prove superior effectiveness and cost-effectiveness of telephone-delivered therapy over routine care for patients with mild to moderate depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT02667366 . Registered on 3 December 2015.

Multilevel Modeling and Policy Development: Guidelines and Applications to Medical Travel.

Medical travel has expanded rapidly in recent years, resulting in new markets and increased access to medical care. Whereas several studies investigated the motives of individuals seeking healthcare abroad, the conventional analytical approach is limited by substantial caveats. Classical techniques as found in the literature cannot provide sufficient insight due to the nested nature of data generated. The application of adequate analytical techniques, specifically multilevel modeling, is scarce to non-existent in the context of medical travel. This study introduces the guidelines for application of multilevel techniques in public health research by presenting an application of multilevel modeling in analyzing the decision-making patterns of potential medical travelers. Benefits and potential limitations are discussed.

An Approach to Establishing International Quality Standards for Medical Travel.

The number of individuals traveling abroad is increasing annually. The rising popularity of medical travel and the absence of clear minimum quality requirements in this area urgently call for the development of international standards to ensure good practice and patient safety. The aim of this study is to identify the key domains in medical travel where quality standards should be established. Drawing from the evidence-based OECD framework and an extensive literature review, this study proposes three critical areas for consideration: minimum standards of health-care facilities and third-party agencies, financial responsibility, and patient centeredness. Several cultural challenges have been introduced that may pose a barrier to development of the guidelines and should be taken into consideration. Establishing international quality standards in medical travel enhances benefits to patients and providers, which is an urgent necessity given the rapid growth in this industry.

Global Health Policy and Access to Care: Investigating Patient Choice on an International Level Using Social Media.

BACKGROUND: Increased access to transportation and information has led to the emergence of more diverse patient choice and new forms of health care consumption, such as medical travel. In order for health care providers to effectively attract patients, more knowledge is needed on the mechanisms underlying decision-making of potential travelers from different countries. A particularly promising method of studying the travelers' motives is collecting data on social media. OBJECTIVES: The aim of this study was to test what factors influence decision-making of potential medical travelers and how these factors interact. Based on existing literature, the factors analyzed included quality, cost, and waiting time for 2 procedures varying in invasiveness across 12 different destination countries. METHODS: Decision-making patterns were examined using a pilot questionnaire that generated a large amount of data from over 800 participants in 40 countries. Participants indicated their willingness to travel given different scenarios. Each scenario consisted of a combination of several factors. Additionally, participants were asked to indicate the reasons for their choice. RESULTS: Individuals display high willingness to travel for medical care when combining all participants and scenarios, travel for care was chosen 66.9% of the time. Among the factors influencing their decisions, quality of the medical procedure abroad was considered most important, and cost was least important as shown by chi-square tests and corresponding odds ratios. Log-linear analyses revealed an interaction between time waiting in the local health care system and type of procedure, whereby time pressure increased the odds of agreeing to travel for the more invasive procedure. The odds of traveling to Europe and the USA were by far the highest, although participants indicated that under certain conditions they might be willing to travel to other medical destinations, such as Asia. CONCLUSION: Our measurements yielded several reliable insights into the factors driving medical decision-making. An essential next step would be to expand these findings with a more encompassing sample and more elaborate statistical modeling.