Feasibility of Present-Centered Therapy for Prolonged Grief Disorder: Results of a Pilot Study.

Present-centered therapy (PCT) was originally developed as a strong comparator for the non-specific effects of psychotherapy in the treatment of posttraumatic stress disorder. PCT qualifies as a not strictly supportive treatment as it is structured and homework is assigned between sessions. It does not focus on cognitive restructuring or exposure. A growing body of literature supports its beneficial effects. For example, it demonstrated only slightly inferior effect sizes and lower dropout rates compared to that of trauma-focused cognitive behavioral therapy in several trials with patients suffering from posttraumatic stress disorder. The current study is the first to evaluate the feasibility and the treatment effects of PCT in adults with prolonged grief disorder (PGD). Meta-analyses on psychotherapy for PGD have yielded moderate effect sizes. N = 20 individuals suffering from PGD were treated with PCT by novice therapists as part of a preparation phase for an upcoming RCT in an outpatient setting. Treatment consisted of 20-24 sessions á 50 min. All outcomes were assessed before treatment, at post-treatment, and at the 3-month follow-up. The primary outcome, PGD symptom severity, was assessed using the Interview for Prolonged Grief-13. Secondary outcomes were self-reported PGD severity, depression, general psychological distress, and somatic symptom severity. Furthermore, therapists evaluated their experiences with their first PCT patient and the treatment manual. In intent-to-treat analyses of all patients we found a significant decrease in interview-based PGD symptom severity at post-treatment (d = 1.26). Decreases were maintained up to the 3-month follow-up assessment (d = 1.25). There were also significant decreases in self-reported PGD symptoms, depression, and general psychological distress. No changes were observed for somatic symptoms. The completion rate was 85%. Therapists deemed PCT to be a learnable treatment program that can be adapted to the patient's individual needs. The preliminary results of PCT as a treatment for PGD demonstrate large effects and indicate good feasibility in outpatient settings. The treatment effects were larger than those reported in meta-analyses. Thus, PCT is a promising treatment for PGD. Possible future research directions are discussed.

The effectiveness of psychosocial interventions in war-traumatized refugee and internally displaced minors: systematic review and meta-analysis.

Background: The United Nations reported that in 2016 over 65 million people worldwide have forcibly left home. Over 50% are children and adolescents; a substantial number has been traumatized and displaced by war. Objective: To provide an overview of the effectiveness of psychosocial interventions in this group we conducted a narrative review and a meta-analysis of intervention studies providing data on posttraumatic stress symptoms (PTSS), depression, anxiety, grief, and general distress. Method: We searched PILOTS, MEDLINE, WoS, Embase, CENTRAL, LILACS, PsycINFO, ASSIA, CSA, and SA for studies on treatment outcomes for war-traumatized displaced children and adolescents. Between-group effect sizes (ES) and pre-post ES were reconstructed for each trial. Overall pre-post ES were calculated using a random effects model. Results: The narrative review covers 23 studies with a variety of treatments. Out of the 35 calculated between-group ES, only six were significant, all compared to untreated controls. Two of them indicated significant adverse effects on symptoms of general distress or depression. When calculating pre-post effect sizes, the positive between-group results of cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) were reproduced and singular other treatments showed significant positive effects. However, the mean pre-post effects for PTSS and depression could not be interpreted due to the high heterogeneity of the included studies (PTSS: ES = 0.78; I2 = 88.6%; depression: ES = 0.35; I2 = 93.1%). Only the mean pre-post effect for seven active CBT treatment groups for depression (ES = 0.30, 95% CI [0.18, 0.43]) was interpretable (Q = 3.3, df = 6, p = .77). Conclusion: Given the large number of children and adolescents displaced by war there were regrettably few treatment studies available, and many of them were of low methodological quality. The effect sizes lagged behind the effects observed in traumatized minors in general, and often were small or non-significant. However, CBT and IPT showed promising results that need further replication.

Planteamiento: Las Naciones Unidas informaron de que en 2016 más de 65 millones de personas en todo el mundo han tenido que abandonar a la fuerza sus hogares. Más del 50% son niños y adolescentes. Muchos de ellos han sido traumatizados y desplazados por la guerra. Objetivo: Con el fin de proporcionar una visión general de la eficacia de las intervenciones psicosociales en este grupo, se realizó una revisión narrativa y un metanálisis de los estudios de intervención que proporcionaban datos sobre síntomas de estrés postraumático (SEPT), depresión, ansiedad, duelo y malestar general. Método: Buscamos en PILOTS, MEDLINE, WoS, Embase, CENTRAL, LILACS, PsycINFO, ASSIA, CSA y SA estudios sobre resultados de tratamiento para niños y adolescentes traumatizados y desplazados por la guerra. Se reconstruyeron los tamaños del efecto (TE) entre los grupos y los TE pre-post para cada ensayo. Los TE generales pre-post fueron calculados usando un modelo de efectos aleatorios. Resultados: La revisión narrativa consta de 23 estudios con una amplia variedad de tratamientos. De los 35 TE entre grupos calculados, sólo 6 fueron significativos, todos en comparación con controles no tratados. Dos de ellos indicaban efectos adversos significativos en los síntomas de malestar general o en los síntomas de depresión. Al calcular los TE pre-post, se reprodujeron los TE entre grupos positivos de la terapia cognitivo-conductual (TCC) y la terapia interpersonal (TIP) y otros tratamientos singulares mostraron efectos positivos significativos. Sin embargo, los efectos promedio pre-post para SEPT y depresión no pudieron interpretarse debido a la alta heterogeneidad de los estudios incluidos (SEPT: TE = 0.78, I2 = 88.6%, depresión: TE = 0.35; I2 = 93.1%). Sólo se pudo interpretar el efecto promedio pre-post para 7 grupos activos de tratamiento con TCC para la depresión, TE = 0.30, IC del 95% [0.18, 0.43] (Q = 3.3, df = 6, p = 0.77). Conclusión: Dado el gran número de niños y adolescentes desplazados por la guerra, lamentablemente existen pocos estudios de tratamiento disponibles y muchos de ellos de baja calidad metodológica. Los tamaños del efecto se quedaron a la zaga de los efectos observados en los menores traumatizados en general, y a menudo eran pequeños o no significativos. Sin embargo, la TCC y la TIP mostraron resultados prometedores que necesitan replicarse más.

Is traumatic stress research global? A bibliometric analysis.

BACKGROUND: The representation of low- and middle-income countries (LMIC) in traumatic stress research is important to establish a global evidence base, build research capacity, and reduce the burden of unmet mental health needs around the world. Reviews of the traumatic stress literature up to 2002 showed trends toward globalization although LMIC were only marginally represented compared to high-income countries (HIC). OBJECTIVE: To examine the global nature of current traumatic stress research. In particular, we were interested in the extent to which traumatic stress research is: (1) conducted in LMIC, (2) conducted by LMIC researchers, and (3) accessible to them. METHOD: Using the databases PubMed, PsychInfo, and PILOTS, we systematically searched for peer-reviewed articles on traumatic stress published in any language in the year 2012. Out of the 3,123 unique papers identified, we coded a random sample (N=1,000) for study, author, article, and journal characteristics. RESULTS: Although our sample involved research in 56 different countries, most papers (87%) involved research in HIC, with 51% of all papers describing studies in the United States. In 88% of the papers, the author team was affiliated with HIC only. Less than 5% of all author teams involved collaborations between HIC and LMIC researchers. Moreover, 45% of the articles on LMIC studies published by a HIC corresponding author did not involve any LMIC co-authors. LMIC researchers appeared to publish empirical studies in lower impact journals. Of the 1,000 articles in our sample, 32% were open access and 10% were made available via different means; over half of the papers were not accessible without subscription. CONCLUSIONS: Traumatic stress research is increasingly global but still strongly dominated by HIC. Important opportunities to build capacity in LMIC appear to be missed. Implications toward more international traumatic stress research are discussed.

Re-examining the differential familial liability of agoraphobia and panic disorder.

BACKGROUND: Controversy surrounds the question of whether agoraphobia (AG) exists as an independent diagnostic entity apart from panic. In favor of this position, AG without panic disorder (PD) in parents was found being unrelated to offsprings' risk for AG or PD, albeit it may enhance the familial transmission of PD (Nocon et al., Depress Anxiety 2008;25:422-434). However, a recent behavioral genetic analysis (Mosing et al., Depress Anxiety 2009;26:1004-1011) found an increased risk for both PD and AG in siblings of those with AG without PD, casting doubt on whether AG exists independently of PD. Convincing evidence for either position notably requires considering also other anxiety disorders to establish the position of AG relative to the panic/anxiety spectrum. METHODS: Familial transmission of panic attacks (PAs), PD, and AG was examined in a 10-year prospective-longitudinal community study of 3,021 adolescents and young adults including completed direct and indirect information on parental psychopathology. Standardized diagnostic assessments using the Munich-Composite International Diagnostic Interview allowed generating exclusive diagnostic groups independent from diagnostic hierarchy rules. RESULTS: Parental PD without AG was associated with an increased risk for PA and PD+AG, but not for PD without AG or AG without PD in offspring. Parental AG without PD was unrelated to the offsprings' risk for PA, exclusive PD or AG, or PD+AG. Findings were largely unaffected by adjustment for other offspring or parental anxiety disorders. CONCLUSIONS: Findings provide further evidence for the independence of AG apart from the PD spectrum.

Interaction of FKBP5 gene variants and adverse life events in predicting depression onset: results from a 10-year prospective community study.

OBJECTIVE: The binding protein FKBP5 is an important modulator of the function of the glucocorticoid receptor, the main receptor of the stress hormone system. This turns the FKBP5 gene into a key candidate for gene-environment interactions, which are considered critical for pathogenesis of stress-related disorders. The authors explored gene-environment interactions between FKBP5 gene variants and adverse life events in predicting the first occurrence of a major depressive episode. METHOD: The analyses were based on 884 Caucasians in a 10-year prospective community study. At baseline, they were 14-24 years old and did not fulfill criteria for a major depressive episode. The DSM-IV-based Munich Composite International Diagnostic Interview was used to assess adverse life events preceding baseline and major depressive episodes during follow-up. On the basis of previous findings, five single-nucleotide polymorphisms (SNPs) within the FKBP5 gene were selected for genotyping. RESULTS: While the authors did not observe genetic main effects, they found interactions between the five SNPs and traumatic (but not separation) events, with the strongest effect for severe trauma. The effect of trauma on incident major depressive episodes was evident among subjects homozygous for the minor alleles but not subjects with other genotypes. The findings were replicated in the U.K. Environmental Risk Longitudinal Twin Study. CONCLUSIONS: These hypothesis-driven results suggest that an interaction between FKBP5 genotype and trauma is involved in the onset of depression. Subjects homozygous for the minor alleles of the investigated FKBP5 SNPs seem to be particularly sensitive to effects of trauma exposure in terms of triggering depression onset.

Heterogeneity of DSM-IV major depressive disorder as a consequence of subthreshold bipolarity.

CONTEXT: There is growing evidence that major depressive disorder (MDD) might be overdiagnosed at the expense of bipolar disorder (BPD). OBJECTIVES: To identify a subgroup of subthreshold BPD among DSM-IV MDD, which is distinct from pure MDD regarding a range of validators of bipolarity, and to examine the pattern of these validators among different groups with affective disorders. DESIGN: Ten-year prospective longitudinal and family study including 3 follow-up waves. Data were assessed with the DSM-IV Munich Composite International Diagnostic Interview. SETTING: Community sample in Munich, Germany. PARTICIPANTS: A total of 2210 subjects (aged 14-24 years at baseline) who completed the third follow-up. MAIN OUTCOME MEASURES: Cumulative incidence of pure MDD, BPD, and subthreshold BPD (defined as fulfilling criteria for MDD plus having manic symptoms but never having met criteria for [hypo]mania). RESULTS: Among 488 respondents with MDD, 286 (58.6%) had pure MDD and 202 (41.4%) had subthreshold BPD (cumulative incidence, 9.3%). Compared with respondents who had pure MDD, respondents with subthreshold BPD were found to have a significantly increased family history of mania, considerably higher rates of nicotine dependence and alcohol use disorders, rates of panic disorder that were twice as high, and a tendency toward higher rates of criminal acts. Prospective analyses showed that subthreshold BPD converted more often into BPD during follow-up, with DSM-IV criterion D (symptoms observable by others) being of critical predictive relevance. With increasing severity of the manic component, rates for diverse validators accordingly increased (eg, alcohol use disorders, parental mania) or decreased (harm avoidance). CONCLUSIONS: Data suggest that MDD is a heterogeneous concept including a large group with subthreshold BPD, which is clinically significant and shares similarities with BPD. Findings might support the need for a broader concept and a more comprehensive screening of bipolarity, which could be substantial for future research and adequate treatment of patients with bipolarity.

Agoraphobia and panic. Prospective-longitudinal relations suggest a rethinking of diagnostic concepts.

BACKGROUND: The relationship of panic attacks (PA), panic disorder (PD) and agoraphobia (AG) is controversial. The aim of the current study is to prospectively examine the 10-year natural course of PA, PD and AG in the first three decades of life, their stability and their reciprocal transitions. METHODS: DSM-IV syndromes were assessed via Composite International Diagnostic Interview - Munich version in a 10-year prospective-longitudinal community study of 3,021 subjects aged 14-24 years at baseline. RESULTS: (1) Incidence patterns for PA (9.4%), PD (with and without AG: 3.4%) and AG (5.3%) revealed differences in age of onset, incidence risk and gender differentiation. (2) Temporally primary PA and PD revealed only a moderately increased risk for subsequent onset of AG, and primary AG had an even lower risk for subsequent PA and PD. (3) In strictly prospective analyses, all baseline groups (PA, PD, AG) had low remission rates (0-23%). Baseline PD with AG or AG with PA were more likely to have follow-up AG, PA and other anxiety disorders and more frequent complications (impairment, disability, help-seeking, comorbidity) as compared to PD without AG and AG without PA. CONCLUSIONS: Differences in incidence patterns, syndrome progression and outcome, and syndrome stability over time indicate that AG exists as a clinically significant phobic condition independent of PD. The majority of agoraphobic subjects in this community sample never experienced PA, calling into question the current pathogenic assumptions underlying the classification of AG as merely a consequence of panic. The findings point to the necessity of rethinking diagnostic concepts and DSM diagnostic hierarchies.

The interplay of familial depression liability and adverse events in predicting the first onset of depression during a 10-year follow-up.

BACKGROUND: The aim of the present article is to explore interaction and correlation effects between familial depression liability and selected adverse (separation and traumatic) events in predicting the first onset of a major depressive episode (MDE) in a 10-year prospective longitudinal community survey. METHODS: Analyses are based on 1982 subjects (14 to 24 years at baseline) without baseline MDE who participated during the whole study period and for whom diagnostic information about psychopathology in both parents was available. The offspring's familial depression liability was determined by aggregating information on parental depressive symptoms obtained from family history data and direct interviews with parents. Data were assessed with the Munich-Composite International Diagnostic Interview according to its DSM-IV algorithms. RESULTS: Adverse events predicted a substantially increased incidence of MDE among respondents with familial liability but not in those without familial liability. There was a significant interaction between familial liability and traumatic events with the strongest effect for the number of severe traumatic events (risk difference = 11.3%; 95% confidence interval = 3.55-19.15). Associations with familial liability were most pronounced for separation events. CONCLUSIONS: Adverse events are particularly pathogenic in individuals with familial liability. The involvement of interactions and correlations between familial liability and adversity might depend on type, severity, and number of events. Both processes are suggested to be concomitant rather than exclusive.

Dual diagnosis in an inpatient drug-abuse detoxification unit.

In Spain, detoxification in general hospitals plays an important role in the medical care of patients. We aim to provide clinicians with information on the prevalence and correlates of psychiatric co-morbidity in drug abusers in detoxification. A sample of 115 substance-abuse inpatients (mean age 31.9 +/- 6.4 years) in a Detoxification Unit of a general university hospital was studied using the Spanish version of the PRISM. Most of the patients had multiple dependence diagnoses and co-morbid axis I or axis II psychiatric disorders. Patients with dual diagnosis showed lower psychosocial functioning than patients without co-morbidity and more dependence diagnoses due to cannabis and sedatives. A total of 80% of the patients successfully completed the detoxification process. The present results enhance the value of detoxification in a general hospital as a first step of the overall treatment strategy.

Dependence symptoms in young cannabis users? A prospective epidemiological study.

AIM: To examine prospectively over a period of 4 years the profile of cannabis dependence and the risk of specific dependence criteria in a community sample of adolescents. METHODS: A representative community sample of 2446 young adults aged 14-24 years at baseline was followed up over a period of 4 years. Frequency of use measures and of criteria for DSM-IV dependence were assessed by standardized diagnostic interview measures (CIDI). To explore the nature of this association, frequency of use and concomitant use of other psychoactive substances was considered. RESULTS: 30% of the sample were cannabis users. Among all users 35% met at least one dependence criterion. Most frequently reported dependence criteria among all users were withdrawal (17%), tolerance (15%), loss of control (14%) and continued use despite a health problem (13%). Even without concomitant use of other illicit drugs, 22% of low frequency users and 81% of high frequency users met at least one dependence criterion. Symptom patterns were similar in high and low frequency users. The occurrence of a dependence syndrome or of specific dependence criteria could not be attributed to the use of other illicit drugs or to comorbid nicotine and alcohol dependence. CONCLUSIONS: Regular cannabis use in adolescence is associated with the development of a dependence syndrome. This association cannot be explained by the concomitant use of other illicit substances or by comorbid nicotine and alcohol dependence.

Edad de inicio en el consumo de sustancias y gravedad clínica de la drogodependencia / Age of onset of substance use and clinical severity

El objetivo de este estudio es confirmar la hipótesis demayor comorbilidad psiquiátrica, somática (HIV, VHC),gravedad psico-social y pero funcionamiento global enpacientes con inicio antes de los 18 años en el consumode sustancias ilegales en una Unidad Hospitalaria deDesintoxicación (UHD). Se estudian de forma prospectivatodos los pacientes ingresados (n=2883) en una UHDdurante un período de 20 años, comparando aquellospacientes con inicio en el consumo de sustancias ilegalesantes de los 18 años (Inicio precoz) con el resto de pacientesen función de variables: socio-demográficas,toxicológicas, comorbilidad psiquiátrica, complicacionesorgánicas (VHC,VIH), gravedad psico-social, funcionalidadglobal y variables de evolución del ingreso. Los pacientesdel grupo IP presentaron más diagnósticos TUS,siendo más frecuentes los trastornos por uso de opiáceos,cannabis e hipnosedantes, y mayor comorbilidad en ejeII, siendo más frecuentes los diagnósticos de TP Antisocialy TP Límite. También presentaban más infección porel VIH y VHC, mayor número de sobredosis referidas,más detenciones e ingresos penitenciarios, mayor tasade desocupación y menor puntuación en el GAF en relaciónal grupo de inicio tardío en el consumo de sustancias

The aim of this study is to confirm the hypothesis of morepsychiatric and somatic (HIV, HCV) comorbidity, morepsycho-social severity and worst global functioning inpatients with early-onset of illicit substance use (before18 years old), in an inpatient detoxification unit. All casesadmitted to a detoxification unit during a 20 yearsstudy period (n=2883) were studied prospectively,comparing those patients with an onset of substance usebefore 18 years old (early-onset) with the rest of thepatients, considering socio-demographic and substanceuse characteristics, psychiatric comorbidity, somaticcomplications (HCV, HIV), psycho-social severity and globalfunctioning and outcome characteristics. Early-onsetsubstance users (EOSU) had more number of substanceuse disorders, more frequently presented opioids,cannabis and sedatives related disorders and presentedmore Axis II comorbidity, concretely antisocial andborderline PD diagnostics. EOSU had also more HIV andHCV infection, more previous overdoses, more arrestsand imprisonments, a lower score in GAF Scale, andwere more frequently unemployed in comparison to lateonsetsubstance users

Pathways into ecstasy use: the role of prior cannabis use and ecstasy availability.

AIM: To explore the role of cannabis use for the availability of ecstasy as a potential pathway to subsequent first ecstasy use. METHODS: Baseline and 4-year follow-up data from a prospective-longitudinal community study of originally 3021 adolescents and young adults aged 14-24 years at baseline were assessed using the standardized M-CIDI and DSM-IV criteria. RESULTS: Baseline cannabis users reported at follow-up more frequent access to ecstasy than cannabis non-users. Higher cannabis use frequencies were associated with increased ecstasy availability reports. Logistic regression analyses revealed that cannabis use and availability of ecstasy at baseline are predictors for incident ecstasy use during the follow-up period. Testing simultaneously the impact of prior cannabis use and ecstasy availability including potential confounders, the association with cannabis use and later ecstasy use was confirmed (OR=6.3; 95%CI=3.6-10.9). However, the association with ecstasy availability was no longer significant (OR=1.2; 95%CI=0.3-3.9). CONCLUSIONS: Results suggest that cannabis use is a powerful risk factor for subsequent first onset of ecstasy use and this relation cannot be sufficiently explained by availability of ecstasy in the observation period.