Measuring treatment outcome in patients with anxiety disorders: A comparison of the responsiveness of generic and disorder-specific instruments.

BACKGROUND: For routine outcome monitoring, generic (i.e., broad-based) and disorder-specific instruments are used to monitor patient progress. While disorder-specific instruments may be more sensitive to therapeutic change, generic measures can be applied more broadly and allow for an assessment of therapeutic change, irrespective of a specific anxiety disorder. Our goal was to investigate whether disorder-specific instruments for anxiety disorders are a valuable (or even necessary) addition to generic instruments for an appropriate assessment of treatment outcome in groups of patients. METHODS: Data were collected from 2002 to 2013 from psychiatric outpatients in treatment for Social Phobia (SP; n = 834), Generalized Anxiety Disorder (GAD; n = 661), Panic Disorder (PD; n = 944), Obsessive-Compulsive Disorder (OCD; n = 460), and Posttraumatic Stress Disorder (PTSD; n = 691). Instruments used were the generic Brief Symptom Inventory (BSI), The Mood and Anxiety Symptoms Questionnaire (MASQ), and several disorder-specific instruments (e.g., Social Interaction Anxiety Scale, Social Phobia Scale, Panic Appraisal Inventory, etc.). Responsiveness (i.e., sensitivity to therapeutic change) was examined through correlational analyses, effect sizes (ES), and analysis of variance for repeated measures. RESULTS: The MASQ appeared generally more responsive than the BSI, except for the BSI Anxiety subscale for PD. Disorder-specific measures equaled the MASQ and BSI in responsiveness. When statistically significant differences occurred, the ES was small. DISCUSSION/CONCLUSIONS: For most anxiety disorder groups (i.e., SP, PD and OCD), the MASQ or BSI was equally suited as disorder-specific instruments to detect change at group level. Exceptions are GAD and PTSD. These findings suggest limited incremental information value of disorder-specific instruments over the MASQ and BSI for measuring change.

Severity, course trajectory, and within-person variability of individual symptoms in patients with major depressive disorder.

BACKGROUND: Depression shows a large heterogeneity of symptoms between and within persons over time. However, most outcome studies have assessed depression as a single underlying latent construct, using the sum score on psychometric scales as an indicator for severity. This study assesses longitudinal symptom-specific trajectories and within-person variability of major depressive disorder over a 9-year period. METHODS: Data were derived from the Netherlands Study of Depression and Anxiety (NESDA). This study included 783 participants with a current major depressive disorder at baseline. The Inventory Depressive Symptomatology-Self-Report (IDS-SR) was used to analyze 28 depressive symptoms at up to six time points during the 9-year follow-up. RESULTS: The highest baseline severity scores were found for the items regarding energy and mood states. The core symptoms depressed mood and anhedonia had the most favorable course, whereas sleeping problems and (psycho-)somatic symptoms were more persistent over 9-year follow-up. Within-person variability was highest for symptoms related to energy and lowest for suicidal ideation. CONCLUSIONS: The severity, course, and within-person variability differed markedly between depressive symptoms. Our findings strengthen the idea that employing a symptom-focused approach in both clinical care and research is of value.

Clinical and sociodemographic associations with treatment selection in major depression.

OBJECTIVE: To investigate treatment selection in a naturalistic sample of MDD outpatients and the factors influencing treatment selection in specialized psychiatric care. METHOD: Multinomial Logistic Regression analysis investigated associations between treatment selection and patients' sociodemographic and clinical characteristics, using retrospective chart review data and Routine Outcome Monitoring (ROM) data of MDD outpatients. RESULTS: Of the patients included for analyses (N = 263), 34% received psychotherapy, 32% received an antidepressant (AD) and 35% received a combination. Men were more likely than women to receive AD with reference to psychotherapy (ORAD = 5.57, 95% CI 2.38-13.00). Patients with severe depression and patients with AD use upon referral, prescribed by their general practitioner, were more likely to receive AD (ORsevere depression = 5.34, 95% CI 1.70-16.78/ORAD GP = 9.26, 95% CI 2.53-33.90) or combined treatment (ORsevere depression = 6.32, 95% CI 1.86-21.49/ORAD GP = 22.36, 95% CI 5.89-83.59) with respect to psychotherapy. More severe patients with AD upon referral received combined treatment less often compared to psychotherapy (OR = 0.14, 95% CI 0.03-0.68). CONCLUSION: AD prescriptions in primary care, severity and gender influenced treatment selection for depressive disorders in secondary psychiatric care. Other factors such as the accessibility of treatment and patient preferences may have played a role in treatment selection in this setting and need further investigation.

Treatment course and its predictors in patients with somatoform disorders: A routine outcome monitoring study in secondary psychiatric care.

AIM: Somatoform disorders are common and often chronic. It would be helpful to distinguish those patients who are likely to have a positive treatment course from those who are likely to follow a negative course. Such studies of different somatoform disorders are scarce, especially in secondary psychiatric care. This study examined the 6-month treatment course of psychological, physical symptoms, and functioning, and its predictors in a naturalistic sample of secondary psychiatric care outpatients with somatoform disorders. METHOD: The present study used routine outcome monitoring data of patients with somatoform disorders regarding their 6-month treatment course of psychological and physical symptoms as well as functioning. The following patient groups were included: total group of somatoform disorders (N = 435), and undifferentiated somatoform disorder (N = 242), pain disorder (N = 102), body dysmorphic disorder (N = 51), and hypochondriasis (N = 40). Measures were Mini-International Neuropsychiatric Interview plus, Brief Symptom Inventory, Montgomery-Ǻsberg Depression Rating Scale, Brief Anxiety Scale, Short Form Health Survey 36, and Physical Symptom Checklist (PSC). RESULTS: The study population generally showed high co-morbidity, especially with anxiety and mood disorders. The PSC total score, body dysmorphic disorder, and hypochondriasis were significant predictors for the treatment course of symptoms (Brief Symptom Inventory), whereas the PSC total score was the only significant predictor for the course of functioning (Short Form Health Survey 36). CONCLUSION: Secondary psychiatric care outpatients with somatoform disorders showed high co-morbidity with anxiety and mood disorders, and an unfavourable 6-month course of both symptoms and functioning. Clinical implications are discussed, such as additional treatment of co-morbidity in somatoform disorders.

Agreement between clinical and MINI diagnoses in outpatients with mood and anxiety disorders.

BACKGROUND: Standardized Diagnostic Interviews (SDIs) such as the Mini International Neuropsychiatric Interview (MINI) are widely used to systematically screen for psychiatric disorders in research. To support generalizability of results to clinical practice, we assessed agreement between the MINI and clinical diagnoses. METHODS: Agreement was assessed in a large, real life dataset (n = 7016) using concordance statistics such as sensitivity, specificity, efficiency and area under the curve (AUC). RESULTS: 41.5% of clinical diagnoses were mood disorders, 26.5% were anxiety disorders. Overall, we found moderate agreement between MINI and clinical diagnoses (median efficiency: 0.92, median AUC: 0.79). For mood disorders, the AUC for all participants showed a range between 0.55 and 0.81 (median: 0.73), and for anxiety disorders the AUC ranged from 0.78 to 0.88 (median: 0.83). The AUC showed better agreement for mood disorders in the single diagnosis group than in the total group (median 0.77 vs. 0.71). For anxiety disorders, the AUC for the single diagnosis group was comparable to the AUC of the total group (median: 0.81 vs. 0.83 respectively). Numbers of false positives were high for both mood and anxiety diagnoses, but less so in the single diagnosis group. LIMITATIONS: Time lag between MINI and clinical diagnosis, the availability of only the primary clinical diagnosis, and relatively high severity of the current sample are limitations of the current study. CONCLUSIONS: Agreement between MINI and clinical diagnoses was moderate at best, which partly reflects the difference between the different measures used in the current study.

[Comorbidity on axis I and treatment outcome]. / Comorbiditeit op as I en de uitkomst van de behandeling.

BACKGROUND: Clinical practice shows that patients with complicated psychopathology are more difficult to treat than those with simple psychopathology. Comorbidity may be the complicating factor involved here. The prognostic value that comorbidity on axis I has on treatment outcome may be relevant for establishing the treatment plan for a patient and may also be relevant for the evaluation of aggregated treatment outcomes achieved by clinicians, treatment teams or institutes.
AIM: To investigate whether comorbidity on axis I can explain disappointing results and whether we should correct for comorbidity when comparing the aggregated treatment results achieved by clinicians, treatment teams or institutes.
METHOD: Our observational study involved a large group of patients (n = 25,651). Outcome data for a subgroup of patients (n = 7754) were available. Comorbidity in this subgroup was established by means of a structured diagnostic interview (MINI-Plus) performed by trained research nurses.
RESULTS: Comorbidity appeared to have some association with the treatment outcome, but the severity of symptoms seemed to be a much more powerful predictor of treatment outcome.
CONCLUSION: After correcting for baseline severity, we found that comorbidity had very little prognostic value as far as the treatment outcome was concerned.

The clinical effectiveness of concise cognitive behavioral therapy with or without pharmacotherapy for depressive and anxiety disorders; a pragmatic randomized controlled equivalence trial in clinical practice.

BACKGROUND: Depressive and anxiety disorders contribute to a high disease burden. This paper investigates whether concise formats of cognitive behavioral- and/or pharmacotherapy are equivalent with longer standard care in the treatment of depressive and/or anxiety disorders in secondary mental health care. METHODS: A pragmatic randomized controlled equivalence trial was conducted at five Dutch outpatient Mental Healthcare Centers (MHCs) of the Regional Mental Health Provider (RMHP) 'Rivierduinen'. Patients (aged 18-65 years) with a mild to moderate anxiety and/or depressive disorder, were randomly allocated to concise or standard care. Data were collected at baseline, 3, 6 and 12 months by Routine Outcome Monitoring (ROM). Primary outcomes were the Brief Symptom Inventory (BSI) and the Web Screening Questionnaire (WSQ). We used Generalized Estimating Equations (GEE) to assess outcomes. RESULTS: Between March 2010 and December 2012, 182 patients, were enrolled (n=89 standard care; n=93 concise care). Both intention-to-treat and per-protocol analyses demonstrated equivalence of concise care and standard care at all time points. Severity of illness reduced, and both treatments improved patient's general health status and subdomains of quality of life. Moreover, in concise care, the beneficial effects started earlier. DISCUSSION: Concise care has the potential to be a feasible and promising alternative to longer standard secondary mental health care in the treatment of outpatients with a mild to moderate depressive and/or anxiety disorder. For future research, we recommend adhering more strictly to the concise treatment protocols to further explore the beneficial effects of the concise treatment. The study is registered in the Netherlands Trial Register, number NTR2590. Clinicaltrials.gov identifier: NCT01643642.

Gender differences in outpatients with anxiety disorders: the Leiden Routine Outcome Monitoring Study.

BACKGROUND: Data from the general population show higher prevalence of different anxiety disorders in women as compared with men. We analysed gender differences in a naturalistic sample of outpatients with anxiety disorders in a mental healthcare setting. METHOD: Routine outcome monitoring data were collected from 1333 patients (age: 18-65; 63.3% women) fulfilling Diagnostic and Statistical Manual of Mental Disorders IV criteria of current anxiety disorder according to the Mini-International Neuropsychiatric Interview between 2004 through 2006. Data included Comprehensive Psychopathological Rating Scale, Brief Symptom Inventory (BSI), Short Form Health Survey (SF-36), Mood and Anxiety Symptom Questionnaire (MASQ). Chi-squared test and t-test were used to compare women with men for variables with parametric distributions, and Mann-Whitney test for non-parametric distribution. Adjustments for potential confounders (age, level of education, ethnicity and comorbidites) were made by logistic regression models (for discrete variables) or analysis of covariance. RESULTS: The female-to-male ratio (i.e., 844 women, 489 men) for any anxiety disorder was 1.73 : 1 (95% confidence interval [CI]: 1.63-1.83), with the strongest skewness for post-traumatic stress disorder (2.80 : 1) and the smallest one for social phobia (1.18 : 1). Compared with men, women reported more severe self-rating scores on the BSI (on average, the scores were 12.3% higher on 3 of 9 subscales: somatisation, interpersonal sensitivity and anxiety), SF-36 (self-reported generic health status was lower on 5 of 8 subscales: physical functioning, social functioning, physical problems, vitality and bodily pain) and MASQ (on average, the scores were 6.6% higher on 4 of 5 subscales: anxious arousal, general distress, general distress depression, general distress anxiety). On the contrary, no gender difference was found in the severity of anxiety symptoms measured by the Brief Anxiety Scale. Women were more likely to suffer from comorbid depression and bulimia nervosa, and less likely from substance abuse. CONCLUSIONS: In a treatment-seeking population the prevalence rate of anxiety disorders was 1.7 times higher in female compared with men. Female outpatients were more severely affected on self-rated but not on observer-rated scales.

Are childhood and adult life adversities differentially associated with specific symptom dimensions of depression and anxiety? Testing the tripartite model.

BACKGROUND: Different types of adverse events may have general or specific effects on depression and anxiety symptomatology. We examined the effects of adversities on the dimensions of the tripartite model: general distress, anhedonic depression and anxious arousal. METHODS: Data were from 2615 individuals from the Netherlands Study for Depression and Anxiety (NESDA), with or without depressive or anxiety disorders. We analysed associations of childhood trauma, childhood life events (childhood trauma interview), and recent life events (List of Threatening Events Questionnaire, LTE-Q) with anhedonic depression, anxious arousal, and general distress (assessed by the adapted Mood and Anxiety Symptoms Questionnaire, MASQ-D30). RESULTS: We controlled for co-occurrence of adversities. Regarding childhood trauma, only emotional neglect was associated with all three symptom dimensions. Psychological and sexual abuse were associated with general distress and anxious arousal, whereas physical abuse was associated only with anxious arousal. Particularly strong associations were seen for emotional neglect with anhedonic depression and for sexual abuse with anxious arousal. Childhood life events showed no associations with symptom dimensions. The recent life events 'Serious problems with friend', 'Serious financial problems', and 'Becoming unemployed' were associated with all three dimensions. The recent life event 'death of parent/child/sibling' was associated with anxious arousal. Several associations remained significant when controlled for current diagnosis of depression or anxiety. LIMITATIONS: Our cross-sectional analyses do not allow for causal interpretation. CONCLUSIONS: Distinct childhood traumas had different effects on the symptom dimensions, whereas most recent adult life events were associated with all three symptom dimensions. Our observations help to understand the often reported associations of these adversities with depressive and anxiety symptomatology. In addition, symptom dimensions of the tripartite model were shown to capture effects of adverse events on top of those captured by diagnostic categories.

[Empirical evidence for the effectiveness of Routine Outcome Monitoring. A study of the literature]. / Empirische evidence voor de effectiviteit van routine outcome monitoring; een literatuuronderzoek.

BACKGROUND: Routine Outcome Monitoring ROM is an important instrument for measuring the effectiveness of treatment and has been implemented in the Dutch mental health care system. AIM: To review the effectiveness of ROM with regard to diagnosis, treatment, and other outcomes. METHOD: The literature study focused on randomised controlled trials RCT's of ROM performed on patients of all age groups, some being general patients, others being psychiatric patients. The main search words were 'routine outcome monitoring' or 'routine outcome measurement'. RESULTS: 52 RCTs on adult patients were included in the study; 45 of these trials were performed on patients with mental health problems, but not always in a psychiatric setting or as primary outcome measure. rom appears to have positive effects on diagnosis and treatment and on the communication between patient and therapist. Other results were less clear. CONCLUSION: ROM seems to be particularly effective for the monitoring of treatments which have not been entirely successful. Further research needs to be done into the clinical and cost-effectiveness of ROM when used with adults and children who have mental health problems.

Effects of psychotherapy on regional cerebral blood flow during trauma imagery in patients with post-traumatic stress disorder: a randomized clinical trial.

BACKGROUND: Functional brain-imaging studies in post-traumatic stress disorder (PTSD) have suggested functional alterations in temporal and prefrontal cortical regions. Effects of psychotherapy on these brain regions have not yet been examined. METHOD: Twenty civilian PTSD out-patients and 15 traumatized control subjects were assessed at baseline using psychometric ratings. Cerebral blood flow was measured using trauma script-driven imagery during 99mtechnetium hexamethyl-propylene-amine-oxime single-photon emission computed tomography scanning. All 20 out-patients were randomly assigned to treatment or wait-list conditions. Treatment was brief eclectic psychotherapy (BEP) in 16 weekly individual sessions. RESULTS: At baseline, greater activation was found in the right insula and right superior/middle frontal gyrus in the PTSD group than in the control group. PTSD patients treated with BEP significantly improved on all PTSD symptom clusters compared to those on the waiting list. After effective psychotherapy, lower activation was measured in the right middle frontal gyrus, compared to the PTSD patients on the waiting list. Treatment effects on PTSD symptoms correlated positively with activation in the left superior temporal gyrus, and superior/middle frontal gyrus. CONCLUSIONS: BEP induced clinical recovery in PTSD patients, and appeared to modulate the functioning of specific PTSD-related sites in the prefrontal cortical regions.

The dimensionality of trauma: a multidimensional scaling comparison of police officers with and without posttraumatic stress disorder.

This study assesses the multidimensional structure of traumatic events as perceived by police officers and investigates individual differences in the scaling of such perceptions. Forty-two police officers with posttraumatic stress disorder (PTSD) and 40 officers without PTSD were given descriptions of critical incidents they were likely to encounter at work. They sorted these on the basis of similarity and rated them on 15 descriptive scales. The two groups were comparable in terms of relevant background characteristics. PTSD was diagnosed with the Structured Interview (SI-PTSD). The similarity data were subjected to individual differences multidimensional scaling analysis [Carroll and Chang, Psychometrika 35 (1970) 283]. The objective was, first, to identify the basic cognitive dimensions of psychological trauma that police officers use in discriminating between common critical incidents and, second, to test whether officers with and without PTSD apply such dimensions differently when interpreting critical incidents. The same three-dimensional solution was obtained for both groups: (1) emotional reactivity; (2) vulnerability and physical integrity; and (3) moral responsibility. Significant differences were found between the PTSD and non-PTSD groups in the salience of Dimension 2. Results are discussed with reference to other studies that address the meaning and interpretation of traumatic events. Implications for the conceptualization and assessment of trauma and PTSD are outlined.

Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder.

The authors report on a randomized, controlled clinical trial on the treatment of posttraumatic stress disorder (PTSD), comparing manualized psychotherapy to wait-list control. This is the first study to evaluate Brief Eclectic Psychotherapy (BEP), which combines cognitive-behavioral and psychodynamic approaches within one treatment method. Forty-two police officers with the diagnosis of PTSD participated in the study; 22 were randomly assigned to the treatment group and 20 to the wait-list control group. Assessments of PTSD and comorbid conditions were made 1 week before treatment, after treatment session 4, upon termination of treatment (16 sessions), and at follow-up 3 months later. As expected, no significant differences between groups were observed at pretest or at session 4. At posttest and at follow-up, BEP had produced significant improvement in PTSD, in work resumption, and in some comorbid conditions.

The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers.

Certain individuals, such as police officers, are exposed to traumatic events as part of their occupational roles. In an effort to prevent psychological illnesses, notably the post-traumatic stress disorder, from arising out of work-related traumatic incidents, psychological interventions have been developed such as Critical Incident Stress Debriefing (Mitchell, 1983; Mitchell & Everly, 1996). The present study tests the hypothesis that debriefing reduces the psychological morbidity caused by work-related incidents. Because debriefing techniques were not designed for application on a 'one-off' basis (Robinson & Mitchell, 1993), the procedure studied here consisted of three successive debriefing sessions (at 24 hours, 1 month and 3 months post-trauma), which included traumatic stress education. In a sample of 243 traumatized police officers, a subgroup of debriefed officers (N = 86) was compared with non-debriefed internal (N = 82) and external (N = 75) control groups. No differences in psychological morbidity were found between the groups at pre-test, at 24 hours or at 6 months post-trauma. One week post-trauma, debriefed subjects exhibited significantly more post-traumatic stress disorder symptomatology than non-debriefed subjects. High levels of satisfaction with debriefing were not reflected in positive outcomes. The findings are translated into recommendations for the future use of debriefing in police practice.

Intrusive traumatic recollections and comorbid posttraumatic stress disorder in depressed patients.

OBJECTIVE: Recent studies have found evidence of the presence and role of intrusive traumatic memories in depressed patients. In this study, we attempted to replicate these findings, examining the full range of early and later traumatic events, as well as comorbid posttraumatic stress disorder, in male and female depressed patients. METHODS: Sixty-nine outpatients meeting criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, for major depressive episode were recruited from the outpatient department of an academic hospital. RESULTS: Seventy-five percent of the depressed patients were found to have had one or more early and/or more recent traumatic experiences. The symptom category of reexperiencing was diagnosed in 48% of these trauma-exposed respondents. Comorbid posttraumatic stress disorder was diagnosed in 13% of the total sample. CONCLUSIONS: The findings show that depressed patients are highly likely to have experienced traumatic events and intrusive traumatic recollections. Future research should focus on the direction of any causal relationship between trauma, reexperiencing, posttraumatic stress disorder, and depression.

Clinical utility of a brief diagnostic test for posttraumatic stress disorder.

OBJECTIVE: This study examines the psychometric properties and clinical utility of a brief diagnostic instrument known as the Self-Rating Scale for PTSD (SRS-PTSD). METHOD: The scale was applied to a sample of 136 survivors of a plane crash. We designed SRS-PTSD as an abridged version of the Structured Interview for PTSD (SI-PTSD), which measures the presence and severity of PTSD symptoms from both a current and a lifetime perspective. RESULTS: The results indicate that SRS-PTSD and SI-PTSD both show satisfactory internal consistency and interjudge reliability. Furthermore, SRS-PTSD was shown to have sufficient sensitivity and specificity and an adequate likelihood ratio. CONCLUSIONS: SRS-PTSD constitutes a good alternative for SI-PTSD, especially for sites with limited clinical resources.

Risk factors for posttraumatic stress symptomatology in police officers: a prospective analysis.

This study examines internal and external risk factors for posttraumatic stress symptoms in 262 traumatized police officers. Results show that 7% of the entire sample had PTSD, as established by means of a structured interview; 34% had posttraumatic stress symptoms or subthreshold PTSD. Trauma severity was the only predictor of posttraumatic stress symptoms identified at both 3 and 12 months posttrauma. At 3 months posttrauma, symptomatology was further predicted by introversion, difficulty in expressing feelings, emotional exhaustion at time of trauma, insufficient time allowed by employer for coming to terms with the trauma, dissatisfaction with organizational support, and insecure job future. At 12 months posttrauma, posttraumatic stress symptoms were further predicted by lack of hobbies, acute hyperarousal, subsequent traumatic events, job dissatisfaction, brooding over work, and lack of social interaction support in the private sphere. Implications of the findings regarding organizational risk factors are discussed in the light of possible occupational health interventions.

[Debriefing of psychically traumatized persons]. / 'Debriefing' van psychisch getraumatiseerden.

Debriefing involves the expert psychological care of victims directly following a calamity. It includes seven items: introduction, facts, thoughts, emotions, symptoms, education, and conclusion. It was thought that early debriefing after a calamity would reduce posttraumatic stress disorder later on, but controlled trials have yielded equivocal results; in some the stress disorder was even more severe in debriefed persons. People with an adequate social network may not need debriefing.