Is type of depressive symptoms associated with patient-perceived need for professional psychological care in depressed individuals with diabetes?

AIMS: The objective of this study is to investigate whether type of depressive symptoms (i.e. cognitive-affective or somatic) is related to a patient-perceived need for professional psychological care in individuals with diabetes. METHODS: In total 2266 participants were recruited as part of the screening procedure for a multi-center randomized controlled trial on the treatment of depressive symptoms among individuals with diabetes. Individuals were invited to complete Beck Depression Inventory-II (BDI-II). Patients with elevated depressive symptoms (BDI-II ≥14) were interviewed about their psychological care need. Based on their care needs patients were categorized into: unmet need, no need, met need and unclear need. These groups were compared on type of depressive symptoms, as categorized into cognitive-affective symptoms and somatic symptoms. RESULTS: 568 eligible individuals had elevated depressive symptoms, of whom 519 were reached. Among these depressed individuals, 19.7% (102 of 519) had an unmet need for psychological care. Participants with an unmet need were younger (p<0.001) and had higher total depression scores compared to the group with no need (p<0.001). They also scored higher on cognitive-affective symptoms (p<0.001), whereas somatic symptoms did not significantly differ (p = 0.232). Logistic regression revealed that cognitive-affective symptoms predicted an unmet need (p = 0.001). However, overall predictive capacity of type of depressive symptoms on care needs was weak. CONCLUSIONS: Cognitive-affective symptoms of depression-but not somatic symptoms-were associated with an unmet need for psychological care among depressed individuals with diabetes. Future research is needed to reveal better predictors explaining the discrepancy between distress and low care needs in order to optimize screening procedures.

WHO-5 and BDI-II are acceptable screening instruments for depression in people with diabetes.

AIMS: To investigate the acceptability of two questionnaires, the five item WHO Well-being Index (WHO-5) and the Beck Depression Inventory II (BDI-II), which differ in length and focus, by comparing three screening groups: (1) WHO-5, (2) BDI-II and (3) WHO-5 and BDI-II. METHODS: A total of 699 individuals with diabetes were approached to participate in the study, of whom 95 completed the WHO-5, 254 completed the BDI-II and 350 completed both the WHO-5 and the BDI-II questionnaires. Five facets of acceptability were compared, including objective aspects (response rate and completion level) and subjective aspects (appreciation, agreeableness and accuracy of the screening questionnaire). Data were analysed using logistic regression analysis and (multivariate) analysis of covariance. RESULTS: The overall response rate was 65% (453 out of 699). No differences between the three groups were found with respect to the response rate (WHO-5: 66%; BDI-II: 63%; WHO-5 and BDI-II: 66%; P ≥ 0.19) and completion level (WHO-5: 99.5%; BDI-II: 97.8%; WHO-5 and BDI-II: 98.7%; P=0.45). The three groups did differ significantly in their scores on two of the three subjective indicators (P<0.03), i.e. appreciation (P=0.002) and agreeableness (P=0.035), with those completing only the WHO-5 reporting greater appreciation and agreeableness. CONCLUSIONS: A brief well-being questionnaire, such as the WHO-5, results in greater appreciation of mood screening and appreciation of completing the questionnaire, but this does not result in a better response rate and higher questionnaire completion. Given these results, either or both questionnaires can be used to screen for depressive symptoms in people with diabetes in clinical practice.

Enhancement of exposure therapy in participants with specific phobia: A randomized controlled trial comparing yohimbine, propranolol and placebo.

BACKGROUND: Recent research indicates that pharmacological agents may enhance psychotherapeutic outcome. Yet, empirical results have not been conclusive with respect to two pharmacological agents, yohimbine hydrochloride (YOH) and propranolol. YOH is suggested to enhance emotional memory by elevating norepinephrine, whereas the ß-adrenergic receptor antagonist propranolol might help better cope with feared situations by reducing accompanying bodily sensations. METHODS: In this controlled trial, fifty-six participants with specific phobia were randomly assigned to either 1) virtual reality exposure therapy (VRET) plus YOH, 2) VRET plus Propranolol, or 3) VRET plus placebo. Participants in all conditions received three sessions of VRET over a period of two weeks. RESULTS: We conducted 2 × 3 repeated measures MANOVA's. Results showed a significant effect for time, with partial eta squared ranging from ηp2 = 0.647 to ηp2 = 0.692, for specific phobia, yet no significant interaction effects were found. CONCLUSION: No significant differences were found when VRET with YOH or a beta-blocker was compared to VRET with a non-active placebo. Implications for clinical practice and future research are discussed.

Virtual reality exposure therapy does not provide any additional value in agoraphobic patients: a randomized controlled trial.

BACKGROUND: A number of studies have demonstrated the efficacy of virtual reality exposure therapy (VRET) in specific phobias, but research in seriously impaired patients with agoraphobia is lacking. In this randomized controlled trial with patients with agoraphobia and panic disorder, VRET and exposure in vivo were compared in terms of outcome and processes involved. METHODS: Patients with panic disorder with agoraphobia (n = 55) were randomly assigned to receive 4 sessions of cognitive behavioral therapy (CBT) followed by either 6 sessions of VRET or 6 sessions of exposure in vivo or to a waiting list control condition. RESULTS: Analyses showed that both active treatment packages were significantly more effective than no treatment and that no differences between VRET and exposure in vivo were found in three out of four outcome measures. On the panic disorder severity scale, however, CBT plus exposure in vivo was more effective than CBT plus VRET. The results show clear synchrony of temporal processes involved in VRET and exposure in vivo on weekly avoidance measures and cognitive measures. Further, it was shown that initial changes in agoraphobic cognitions during the CBT phase predicted later changes in agoraphobic avoidance behavior. CONCLUSION: These data support the notion that therapeutic processes involved might be the same in VRET and exposure in vivo. However, given the slight superiority of exposure in vivo above VRET, the costs involved in the implementation of VRET and the lack of long-term follow-up, VRET cannot yet be recommended for patients with agoraphobia.

The adolescent outcome of children with attention deficit hyperactivity disorder treated with methylphenidate or methylphenidate combined with multimodal behaviour therapy: results of a naturalistic follow-up study.

OBJECTIVE: Children with attention deficit hyperactivity disorder (ADHD) who participated in a randomized clinical trial, which compared a brief intensive multimodal behaviour therapy combined with optimally titrated methylphenidate to optimally titrated methylphenidate alone (n = 45), were re-assessed at adolescence in a naturalistic follow-up 4.5 to 7.5 years after treatment. Also a matched normal control group was recruited (n = 23). METHODS: Assessments at follow-up included diagnostic status, ADHD symptoms, oppositional and conduct behaviour, substance abuse symptoms and parenting stress. RESULTS: Of the 24 adolescents participating in the follow-up study, 50% still met diagnostic criteria for ADHD. There were no significant differences between adolescents at follow-up and those lost for follow-up. At follow-up, adolescents in the combined treatment condition used significantly less medication than children in the methylphenidate condition; there were no other significant differences between the treatment conditions. The adolescents showed a significant decline in hyperactivity/impulsivity, oppositional and conduct disorder symptoms from post-test to follow-up. Only inattention symptoms increased from post-test to follow-up but not to pre-test levels. The adolescents originally diagnosed with ADHD fared significantly worse than the matched controls on all outcomes, except on conduct disorder and substance abuse symptoms. CONCLUSIONS: Our study shows in adolescents, diagnosed with ADHD in childhood, age-dependent decline of ADHD symptoms, although they still fared significantly worse than matched normal controls. Implications of results are restricted by small samples size, and the results may be subject to chance findings and need replication before firm conclusions can be drawn.

Prepotent response inhibition predicts treatment outcome in attention deficit/hyperactivity disorder.

OBJECTIVE: Inhibition deficits, including deficits in prepotent response inhibition and interference control, are core deficits in ADHD. The predictive value of prepotent response inhibition and interference control was assessed for outcome in a 10-week treatment trial with methylphenidate. METHODS: Thirty-four children with ADHD (ages 8-12) received 10 weeks of methylphenidate treatment. At pretest prepotent response inhibition was assessed using the Stop-Signal Task; interference control was assessed using the Stroop Color-Word task. Methylphenidate was individually titrated to an optimal dose. Treatment outcome was assessed by parent- and teacher-rated ADHD behavior. RESULTS: Only stop-signal reaction time of the Stop-Signal Task was a significant predictor of parent-rated levels of inattention and hyperactivity/impulsivity at outcome. Children with lower levels of inhibition showed worse outcome after 10 weeks of treatment, independent of medication dose. CONCLUSIONS: Low levels of prepotent response inhibition are associated with worse response to treatment with methylphenidate. Prepotent response inhibition may be an intermediate phenotypical predictor of treatment outcome.

Treatment of post-traumatic stress disorder in children using cognitive behavioural writing therapy.

OBJECTIVES: This study evaluated the effectiveness of Cognitive Behavioral Writing Therapy (CBWT) in 23 children (age 8-18 years) in the Netherlands, who experienced a range of single and recurrent traumatic experiences. CBWT uses exposure, cognitive restructuring and social sharing. METHODS: At pre-test, post-test and follow-up, post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, trauma-related cognitions and general behavioural problems were assessed. RESULTS: At post-test there was a significant reduction of all symptoms, and this effect was maintained at 6 months follow-up. The mean amount of treatment sessions needed was 5.5. CONCLUSIONS: This study shows that short-term CBWT is a potentially effective intervention for clinically referred traumatized children. There is now a clear need of establishing the effectiveness of CBWT in a randomized, controlled trial. PRACTICE IMPLICATION: This first study indicates CBWT is a promising treatment, which can easily be used in clinical practice.

Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis.

INTRODUCTION: This meta-analysis compares effect-sizes of methylphenidate and psychosocial treatments and their combination on ADHD, concurrent oppositional, conduct symptoms, social behaviors and academic functioning. METHOD: Several databases (PubMed, PsycInfo, ISI Web of Science) were searched for articles published between 1985 and September 2006. Inclusion criteria were: a diagnosis of ADHD; age from 6-12 years; a randomized controlled treatment design; efficacy established with parent and teacher rating scales; psychosocial treatments used were described as behavioral or cognitive-behavioral; the methylphenidate treatment was short-acting; and finally, treatment was conducted in a clinical setting. RESULTS: ADHD outcomes showed large mean weighted effect-sizes for both methylphenidate and combined treatments, psychosocial treatments had a moderate mean weighted effect-size; a similar pattern emerged for oppositional and conducted behavior symptoms. Social behavior outcomes showed comparable moderate mean weighted effect-sizes for all treatments, while on academic functioning, all treatments had low mean weighted effect-sizes. There was no correlation between duration of psychosocial treatment and effect-size. CONCLUSIONS: Both methylphenidate and psychosocial treatments are effective in reducing ADHD symptoms. However, psychosocial treatment yields smaller effects than both other treatment conditions. Psychosocial treatment has no additional value to methylphenidate for the reduction of ADHD and teacher rated ODD symptoms. However, for social behavior and parent rated ODD the three treatments were equally effective. For improvement of academic functioning no treatment was effective.

Treatment of attention deficit hyperactivity disorder in children. Predictors of treatment outcome.

OBJECTIVE: The present study investigated the predictive power of anxiety, IQ, severity of ADHD and parental depression on the outcome of treatment in children with ADHD. METHOD: Fifty children with ADHD (ages 8-12) were randomized to a 10-week treatment of methylphenidate or to a treatment of methylphenidate combined with multimodal behavior therapy. Prior to treatment predictors were assessed. Outcome was assessed separately for parents and teachers on a composite measure of inattentive, hyperactive, oppositional- and conduct disorder symptoms. RESULTS: There was neither a significant difference between the two treatments at baseline nor did treatment condition predict outcome. Therefore the data were collapsed across the two treatments. A combination of anxiety and IQ predicted teacher-rated outcome, explaining 18% of the variance. Higher anxiety and higher IQ's indicated better treatment outcome. There were no significant predictors of the parent-rated outcome. CONCLUSION: This study showed a small but significant predictive effect of IQ and anxiety on treatment outcome in children with ADHD. CLINICAL IMPLICATIONS: This study supports the idea that for the treatment of ADHD children with comorbid anxiety and higher IQ respond better to the two most used treatments for ADHD.

Do self-statements enhance the effectiveness of virtual reality exposure therapy? A comparative evaluation in acrophobia.

There is a clear need for more detailed analysis of the role of cognitive self-statements in virtual reality exposure therapy (VRET). To date, no research on this topic has been done. The primary aim of this study was to investigate whether coping self-statements would enhance the effectiveness of VRET. In a randomized crossover design, 26 patients with acrophobia (DSM-IV diagnosis of specific phobia) were randomly assigned to two sessions of VRET followed by two sessions of VRET plus coping self-statements, or the other way around: first two sessions of VRET plus coping self-statements followed by two sessions of VRET. Results showed that VRET, regardless of addition of coping self-statements, decreased anxiety of heights, decreased avoidance of height situations, and improved attitudes towards heights. However, at 6-month follow-up, most gains during treatment were not fully retained.

Alexithymia, risk factor or consequence of work-related stress?

BACKGROUND: Primary alexithymia has been proposed as a trait-like risk factor for various psychiatric disorders. Alternatively, secondary alexithymia has been conceptualized as an inadequate coping reaction to a stressful situation. This study investigated the level and the type of alexithymia associated with occupational stress. METHOD: On 2 occasions, 69 patients with work-related stress and 62 healthy participants completed self-report instruments to measure alexithymia (20-item Toronto Alexithymia Scale), burnout complaints (Maslach Burnout Inventory) and general distress complaints (Depression Anxiety Stress Scales, Checklist Individual Strength). Group differences in alexithymia were analyzed using ANOVAs. The type of alexithymia was investigated by (a) determining absolute and relative stability, (b) exploring state dependence by adjusting alexithymia for burnout and distress complaints and (c) associating recovery of complaints with change in alexithymia. RESULTS: Alexithymia was significantly elevated among patients. In the patient group, absolute stability of two alexithymia dimensions (identifying feelings, describing feelings) and relative stability of one alexithymia dimension (identifying feelings) was lower than in the healthy group. Cross-sectional group differences became small and nonsignificant after adjustment for distress complaints. Among patients, change in alexithymia was moderately associated with symptom recovery. CONCLUSION: Elevated alexithymia among patients with occupational stress is highly state dependent, which indicates the presence of secondary alexithymia.

The association between parenting stress, depressed mood and informant agreement in ADHD and ODD.

OBJECTIVE: In Attention Deficit Hyperactivity Disorder (ADHD) agreement between parents and teachers is often low. Parental depressed mood and parenting stress are considered to decrease informant agreement. This study examined informant agreement in children with ADHD and the association between parental depressed mood, parenting stress and agreement in the ratings of ADHD, ODD and CD symptoms. METHOD: 65 parents completed questionnaires on ADHD behavior of their child, parenting stress and depressed mood, teachers reported on ADHD behavior. RESULTS: Low agreement was found for hyperactive and moderate agreement for inattentive, ODD and CD symptoms. Stepwise regression analyses showed that parenting stress, and not parental depressed mood accounted for 12% of the variance in inattention symptoms disagreement, 14% of the variance in hyperactive symptoms disagreement and 9% in oppositional behavior disagreement. No significant predictors were found for CD disagreement. The found effect was independent of stimulant medication use. CONCLUSION: Parenting stress, but not parental depressed mood, was associated with the disagreement between parents and teachers on both ADHD and ODD symptoms. These results emphasize the importance of considering parenting stress in diagnosing ADHD and comorbid ODD.

Psychometric evaluation of the Dutch version of the posttraumatic cognitions inventory (PTCI).

Trauma-related cognitions play an increasingly prominent role in research on trauma and in clinical practice. The present study investigated the psychometric characteristics of the Dutch version of the posttraumatic cognitions inventory (PTCI) and evaluated its potential as an outcome measure. Data were collected from a treatment-seeking sample of trauma victims (n=158) and a college sample (n=178). The PTCI's three-factor structure was retained in both samples. The PTCI demonstrated high internal consistency and two-week test-retest reliability. Convergent validity was evidenced by a pattern of correlations with instruments for trauma-related cognitions, posttraumatic stress disorder, and depressive symptoms that largely met a priori expectations. Reductions in self-reported and clinician-assessed posttraumatic stress disorder symptoms were positively associated with decreased PTCI scores, indicating that the PTCI could assist treatment evaluation. It is concluded that the Dutch version of the PTCI exhibits good psychometric characteristics and has the potential to contribute to trauma-related research.

A psychometric evaluation of the social skills rating system in children with attention deficit hyperactivity disorder.

The social skills rating system (SSRS) was developed to assess social skills of children, as observed by multiple raters (teacher, parent, child). Studies of the SSRS have been conducted with handicapped, mentally retarded and learning disabled children. No studies have reported the psychometric properties of the SSRS in a clinical ADHD sample. This is important, because deficient social functioning is associated with ADHD. The present study assesses the psychometric properties of the teacher, parent and child versions of the SSRS in children with ADHD (n = 123), and normal controls (n = 239). Also, the social skills of children with ADHD, as rated on the SSRS were examined. Results support the factor structure and internal consistency of the original SSRS-teacher version. Moreover, support was found for 3 out of 4 scales of the SSRS-parent version. The factor structure of the SSRS-child version could not be replicated. An explanatory factor analysis on the SSRS-child version yielded two factors. Evidence was found for discriminative ability of the SSRS between normal controls and children with ADHD. Finally, informant agreement between raters was found to be poor.

The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam.

OBJECTIVE: To examine long-term outcome of late-life anxiety disorders and utilization of mental health care services. METHOD: A cohort of subjects (aged > or = 55 years) with an anxiety disorder (n = 112) was identified in the Longitudinal Aging Study Amsterdam (n = 3107). At 6 year follow-up, the rate of persistence and prognostic factors for persistence of anxiety were established. RESULTS: Six years after baseline 23% of our sample met the criteria for an anxiety disorder. Another 47% suffered from subclinical anxiety symptoms. Persistence of anxiety was associated with a high score on neuroticism at baseline. Use of benzodiazepines was high (43%), while use of mental health care facilities (14%) and anti-depressants (7%) remained low in those with persistent anxiety. CONCLUSION: Results indicate that those high in neuroticism are at greater risk for persistence of anxiety. Efforts to enhance appropriate referral of anxious older adults do not seem to have had the desired effect.

Virtual reality exposure therapy of anxiety disorders: a review.

Virtual reality exposure therapy (VRET) is an altered form of behavioral therapy and may be a possible alternative to standard in vivo exposure. Virtual reality integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse patients in a computer-generated virtual environment. Research on this type of treatment for anxiety disorders is discussed in this article, and the mediating and moderating variables that influence VR treatment effectiveness as well. Evidence is found that VRET is effective for participants with fear of heights and of flying. For other phobias, research to date is not conclusive. More randomized clinical trials in which VRET is compared with standard exposure are required. Furthermore, studies are needed in which VRET is not just a component of the treatment package evaluated, but in which VRET should be assessed as a stand-alone treatment.

Physiological differences between burnout patients and healthy controls: blood pressure, heart rate, and cortisol responses.

OBJECTIVES: To investigate differences between burnout patients and healthy controls regarding basal physiological values and physiological stress responses. Measures of the sympathetic-adrenergic-medullary (SAM) axis and the hypothalamic-pituitary-adrenal (HPA) axis were examined. METHODS: SAM axis and HPA axis activity was compared between 22 burnout patients and 23 healthy controls. SAM axis activity was measured by means of heart rate (HR) and blood pressure (BP). HPA axis activity was investigated by means of salivary cortisol levels. Resting levels of HR, BP, and cortisol were determined as well as reactivity and recovery of these measures during a laboratory session involving mental arithmetic and speech tasks. In addition, morning levels of cortisol were determined. RESULTS: Burnout patients showed higher resting HR than healthy controls. BP resting values did not differ between burnout patients and healthy controls, nor did cardiovascular reactivity and recovery measurements during the laboratory session. Basal cortisol levels and cortisol reactivity and recovery measures were similar for burnout patients and healthy controls. However, burnout patients showed elevated cortisol levels during the first hour after awakening in comparison to healthy controls. CONCLUSIONS: The findings provided limited proof that SAM axis and HPA axis are disturbed among burnout patients. Elevated HR and elevated early morning cortisol levels may be indicative of sustained activation.

What patient characteristics make clinicians recommend brief treatment?

OBJECTIVE: Assessing self-rated items that might have an impact on clinicians recommending brief treatment (BT) over unlimited or long-term treatment (ULT). METHOD: On the basis of patient self-report data we compared patients referred by clinicians to BT (n=71) with those referred to ULT (n=145). RESULTS: The final multiple logistic regression model indicates that the chance of being allocated to BT increases with: more satisfaction with support, higher self-esteem, primary education or less, and high desire for support as an intervention. With regard to desire to confess in treatment, low and high scores make the chance of being allocated to BT lower. This is also the case for daily hassles. Finally, some specific target complaints, in particular anxiety, lower the chance of being allocated to BT. CONCLUSION: Using data about patient's complaints and symptoms, stress and support, personality and coping, and request for type of intervention, we built a regression-model that classified 80% of the patients correctly with regard to allocation to BT or ULT.

Virtual reality treatment versus exposure in vivo: a comparative evaluation in acrophobia.

The aim of the present study was to evaluate the effectiveness of low-budget virtual reality (VR) exposure versus exposure in vivo in a between-group design in 33 patients suffering from acrophobia. The virtual environments used in treatment were exactly copied from the real environments used in the exposure in vivo program. VR exposure was found to be as effective as exposure in vivo on anxiety and avoidance as measured with the Acrophobia Questionnaire (AQ), the Attitude Towards Heights Questionnaire (ATHQ) and the Behavioral Avoidance Test (BAT). Results were maintained up to six months follow-up. The present study shows that VR exposure can be effective with relatively cheap hardware and software on stand-alone computers currently on the market. Further studies into the effectiveness of VR exposure are recommended in other clinical groups as agoraphobics and social phobics and studies in which VR exposure is compared with more emerging virtual worlds as presented in CAVE-type systems.

Virtual reality treatment in acrophobia: a comparison with exposure in vivo.

The aim of the present study was to evaluate the effectiveness of low-budget virtual reality exposure versus exposure in vivo in a within-group design in 10 individuals suffering from acrophobia. Virtual reality exposure was found to be at least as effective as exposure in vivo on anxiety and avoidance as measured with the Acrophobia Questionnaire (AQ), and even more effective on the Attitude towards Heights Questionnaire (AHQ). The present study shows that virtual reality exposure can be effective with relatively cheap hardware and software on stand-alone computers currently on the market. Further studies are recommended, in which virtual reality exposure is compared with in vivo exposure in a between-group design, thus enabling investigation of the long-term effects of virtual reality treatment.