Stepped, evidence-based and integrated care service model vs. usual care for mental disorders: A randomized controlled trial (RECOVER).

Stepped, evidence-based and integrated care service models have the potential to be used as a reference for mental health services. RECOVER aimed to evaluate cost savings, effectiveness, and cost-effectiveness of such a model within a two arm, assessor- and data analysist-blinded RCT in Hamburg, Germany. Participants aged 16-79 years with mental disorders were randomly assigned either to RECOVER or treatment as usual (TAU). Primary outcomes comprised costs, effectiveness (combined symptoms, functioning, quality of life), and cost-effectiveness, hierarchically ordered. Outcomes were evaluated according to the ITT principle, group differences regarding costs with adjusted generalized linear models, effectiveness with ANCOVA models, and cost-effectiveness with the incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curves (CEACs). Between 1/1/2018 and 12/31/2020, n = 891 were finally included (n = 477 in RECOVER, n = 444 in TAU). RECOVER was associated with significantly lower annual total costs (-22 %), health and social care costs (-25 %) and hospital costs (-50 %). Effectiveness analyses showed a significantly better outcome for RECOVER with the fully imputed data . The CEACs descriptively demonstrated that RECOVER was cost-effective with a probability of >95 %. Treatment in RECOVER resulted in substantial cost reductions with better cost-effectiveness. RECOVER can be recommended as a reference model for comprehensive and integrated mental health services.

Intraoperative alignment correlates well with long standing radiographs - The X-ray grid method in complex knee surgery.

OBJECTIVE: While long standing radiographs (LSR) represent the gold standard for preoperative alignment assessment and planning of lower limb deformity corrections, there is no consensus about the intraoperative alignment assesments (IAC) due to various limitations of the common methods. The present study introduces a radiolucent X-ray grid with integrated radiopaque lines explicitly designed for fluoroscopic IAC and evaluates its reliability in comparsion to the LSR. METHODS: Patients with posttaumatic and congenital lower limb deformity surgery and preoperative LSR as well as fluoroscopic IAC utilizing the X-ray grid were retrospectively included to the study. The mechanical axis deviation (MAD) in percentage of the maximum tibial width from the medial to the lateral in comparison between the image pairs was set as primary outcome parameter. Multiple rater and measurements determined intra- and interobserver reliabilit of both imaging methods. In addition, the effects of age, gender, body mass index (BMI), etiology, joint line convergence angle (JLCA), and extent varus or valgus deformity were analysed. RESULTS: A total of 84 patients were finally included. The mean absolute difference of MAD between the two techniques was 7.2 ± 0.8%. MAD between the LSR and IAC correlated at a high level (R = 0.96, p <0.001). The agreement decreased with increasing extent of deformity (p <0.01) and with higher deviation of JLCA between LSR and IAC (p <0.01). Intra- and interobserver concordance correlation coefficient (CCC) for MAD measurements were 0.99 for both imaging techniques. CONCLUSION: Fluoroscopy combined with the X-ray grid method is a valid tool for intraoperative assessment of lower limb alignment in deformity correction surgery, and the correlation between LSR and IAC is better than in other similar techniques described in the literature. However, in case of severe coronal alignment deformity and highly divergent JLCA, the agreement between both imaging techniques decreases significantly.

New directions in the mental health care of migrants, including refugees-A randomized controlled trial investigating the efficacy of value-based counselling.

OBJECTIVE: Specialized literature has identified a need for evidence-based, low-threshold, short-term, and intracultural psychological interventions that can be made available to migrants, including refugees, who suffer from psychological symptoms in host countries. The objective of the present study is to measure the efficacy of value-based counselling (VBC) as such an intervention. METHOD: We conducted a pragmatic, rater-blinded randomized controlled trial employing a pre-post control group design to assess the efficacy of VBC based on a study sample of 103 migrants, including refugees, who resided in Germany at the time. A set of instruments was used to evaluate primary outcome measures of depression, posttraumatic stress disorder (PTSD) symptoms, perceived stress, generalized anxiety, and somatic complaints. RESULTS: Per protocol analysis included 42 participants in the VBC group, and 43 in the waiting list. Compared with participants in the waiting-list group, the VBC group, following an average of four counselling sessions, experienced a clinically meaningful reduction of depression (adjusted difference 7.06, 95% CI [4.86, 9.26], effect size 0.68, p < .001), PTSD (adjusted difference 17.15, 95% CI [10.49, 23.81], effect size 0.76, p < .001), perceived stress (adjusted difference 9.25, 95% CI [6.23, 12.27], effect size 0.75, p < .001), anxiety (adjusted difference 5.34, 95% CI [3.47, 7.20], effect size 0.70, p < .001), and somatic complaints (adjusted difference 5.52, 95% CI [3.30, 7.74], effect size 0.72, p < .001). The positive outcomes were maintained at 3-month follow-up. Utilization of mental health services was significantly reduced at the 3-month follow-up conducted with participants of the VBC group. CONCLUSIONS: VBC, a culturally sensitive and strength-based mental health service, is an effective short-term intervention which meets the specific mental health needs of migrants, including refugees.

[Prophylactic fasciotomy in tibial osteotomies: functional results]. / Prophylaktische Fasziotomie bei Tibia-Osteotomien: funktionelle Ergebnisse.

BACKGROUND: Intramedullary nailing in tibial osteotomy (TO) can be combined with minimally invasive prophylactic fasciotomy (PF) of the anterior compartment of the lower leg to prevent postoperative acute compartment syndrome (CS). So far no studies are available on the effects of TO or PF on specific functions of the extensor muscles. OBJECTIVE: To investigate the medium-term outcome after PF in TO in patients without preoperative functional impairment. MATERIAL AND METHODS: In 41 cases (28 women, 13 men) the patients were questioned with respect to clinical function on average 6.1 years after elective TO and PF fixed with intramedullary nails. Of the cases 23 were examined measuring isometric strength and range of motion (ROM) of dorsiflexion (DF) of the foot. Strength was compared to the 10% standard percentile to test for clinical relevance and to the contralateral side if applicable. RESULTS: In an average of 86% of the cases no or minor functional impairment of the extensors was reported. The DF of the foot was rated as the leading impairment. Mean strength did not differ significantly from the gender-specific 10% standard percentiles but was significantly lower on the operated side with 16.0 ± 6.5 kgf compared to the healthy side with 17.5 ± 6.3 kgf (p < 0.01). Subjective impairments of DF of the foot correlated clearly negatively with ROM (rs = -0.46, p < 0.05) but not with strength. CONCLUSION: The results indicate a low occurrence of subjectively relevant functional impairment of the extensor muscles. The decrease of strength was not found to be clinically relevant. Subjective impairments appeared to be caused by a decrease of ROM, not strength.

Evidence of SARS-CoV2 entry protein ACE2 in the human nose and olfactory bulb

Usually, pandemic COVID-19 disease, caused by SARS-CoV2, presents with mild respiratory symptoms such as fever, cough but frequently also with anosmia and neurological symptom. Virus-cell fusion is mediated by Angiotensin-Converting Enzyme 2 (ACE2) and Transmembrane Serine Protease 2 (TMPRSS2) with their organ expression pattern determining viral tropism. Clinical presentation suggests rapid viral dissemination to central nervous system leading frequently to severe symptoms including viral meningitis. Here, we provide a comprehensive expression landscape of ACE2 and TMPRSS2 proteins across human, post-mortem nasal and olfactory tissue. Sagittal sections through the human nose complemented with immunolabelling of respective cell types represent different anatomically defined regions including olfactory epithelium, respiratory epithelium of the nasal conchae and the paranasal sinuses along with the hardly accessible human olfactory bulb. ACE2 can be detected in the olfactory epithelium, as well as in the respiratory epithelium of the nasal septum, the nasal conchae and the paranasal sinuses. ACE2 is located in the sustentacular cells and in the glandular cells in the olfactory epithelium, as well as in the basal cells, glandular cells and epithelial cells of the respiratory epithelium. Intriguingly, ACE2 is not expressed in mature or immature olfactory receptor neurons and basal cells in the olfactory epithelium. Similarly ACE2 is not localized in the olfactory receptor neurons albeit the olfactory bulb is positive. Vice versa, TMPRSS2 can also be detected in the sustentacular cells and the glandular cells of the olfactory epithelium. Our findings provide the basic anatomical evidence for the expression of ACE2 and TMPRSS2 in the human nose, olfactory epithelium and olfactory bulb. Thus, they are substantial for future studies that aim to elucidate the symptom of SARS-CoV2 induced anosmia of via the olfactory pathway.

Study protocol for a randomised controlled trial evaluating an evidence-based, stepped and coordinated care service model for mental disorders (RECOVER).

INTRODUCTION: Healthcare systems around the world are looking for solutions to the growing problem of mental disorders. RECOVER is the synonym for an evidence-based, stepped and cross-sectoral coordinated care service model for mental disorders. RECOVER implements a cross-sectoral network with managed care, comprehensive psychological, somatic and social diagnostics, crisis resolution and a general structure of four severity levels, each with assigned evidence-based therapy models (eg, assertive community treatment) and therapies (eg, psychotherapy). The study rationale is the investigation of the effectiveness and efficiency of stepped and integrated care in comparison to standard care. METHODS AND ANALYSIS: The trial is conducted in accordance to the Standard Protocol Items: Recommendations for Interventional Trials Statement. The study aims to compare the RECOVER model with treatment as usual (TAU). The following questions are examined: Does RECOVER reduce healthcare costs compared with TAU? Does RECOVER improve patient-relevant outcomes? Is RECOVER cost-effective compared with TAU? A total sample of 890 patients with mental disorders will be assessed at baseline and individually randomised into RECOVER or TAU. Follow-up assessments are conducted after 6 and 12 months. As primary outcomes, cost reduction, improvement in symptoms, daily functioning and quality of life as well as cost-effectiveness ratios will be measured. In addition, several secondary outcomes will be assessed. Primary and secondary outcomes are evaluated according to the intention-to-treat principle. Mixed linear or logistic regression models are used with the direct maximum likelihood estimation procedure which results in unbiassed estimators under the missing-at-random assumption. Costs due to healthcare utilisation and productivity losses are evaluated using difference-in-difference regressions. ETHICS AND DISSEMINATION: Ethical approval from the ethics committee of the Hamburg Medical Association has been obtained (PV5672). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications. TRIAL REGISTRATION NUMBER AND REGISTRY NAME: ClinicalTrials.gov (NCT03459664), RECOVER PROTOCOL VERSION: 19 March 2020 (V.3.0).

Tibial and femoral osteotomies in varus deformities - radiological and clinical outcome.

BACKGROUND: Varus deformities of the knee are frequently corrected by osteotomies, which should be performed at the level of origin. But in contrast to high tibial osteotomies (HTO), little data exists for distal femoral osteotomies (DFO). This study evaluates radiological and clinical outcomes after valgisation osteotomies in the proximal tibia and distal femur. METHODS: We used an observational cohort study design and prospectively performed preoperative long standing radiographs (LSR), lateral x-rays and clinical questionnaires (SF-36, Lysholm score, VAS). Postoperative LSR and lateral x-rays were obtained on average 18 months postoperative and postoperative clinical questionnaires at final visit (mean follow up 46 months). A subgroup analysis of the different surgical techniques (oHTO vs. cDFO) was performed, with regards to radiological and clinical outcomes. RESULTS: Finally 28 osteotomies with medial tibial opening (oHTO) or lateral femoral closing (cDFO) wedge osteotomies in 25 consecutive patients (mean age 40 years) were identified. There were 17 tibal and 11 femoral procedures. All osteotomies were performed at the origin of deformity, which was of different etiology. The average deviation of the final HKA compared to the preoperative planning was 2.4° ± 0.4°. Overall, there was a significant improvement in all clinical scores (SF-36: 61.8 to 79.4, p < 0.001; Lysholm-score: 72.7 to 90.4, p < 0.001; VAS: 3 to 1, p < 0.001). There was no significant correlation between surgical accuracy and outcome scores. CONCLUSION: Valgisation osteotomies lead to a significant improvement in all clinical scores with the demonstrated treatment protocol. An appreciable proportion of varus deformities are of femoral origin. Since cDFO provides comparable radiological and clinical results as oHTO, this is an important treatment option for varus deformities of femoral origin.

Bowlegs and Intensive Football Training in Children and Adolescents.

BACKGROUND: In many countries around the world, football (association football, or "soccer" predominantly in North America) is the sport most commonly played by children and adolescents. It is widely thought that football players are more likely to develop genu varum (bowlegs); an association with knee arthritis also seems likely. The goals of this systematic review and meta-analysis are to provide an overview of the available evidence on genu varum after intensive soccer training in childhood and adolescence, and to discuss the possible pathogenetic mechanisms. METHODS: We systematically searched the PubMed, Medline, Embase, and Coch- rane Library databases for studies of the relation between leg axis development and intensive football playing during the growing years. RESULTS: Controlled studies employing the intercondylar distance (ICD) as the target variable were evaluated in a meta-analysis, with the mean difference as a measure of effect strength. This meta-analysis included 3 studies with a total of 1344 football players and 1277 control individuals. All three studies individually showed a signifi- cant difference in the mean ICD values of the two groups. The pooled effect esti- mator for the mean difference was 1.50 cm (95% confidence interval [0.53; 2.46]). Two further studies that could not be included in the meta-analysis had similar con- clusions. Asymmetrical, varus muscle forces and predominantly varus stress on the osseous growth plates neighboring the knee joint, especially during the prepubertal growth spurt, seem to be the cause of this phenomenon. CONCLUSION: Intensive soccer playing during the growing years can promote the devel- opment of bowlegs (genu varum) and, in turn, increase the risk of knee arthritis. Phy- sicians should inform young athletes and their parents of this if asked to advise about the choice of soccer as a sport for intensive training. It cannot be concluded, however, that football predisposes to bowlegs when played merely as a leisure activity.

We cannot change the past, but we can change its meaning. A randomized controlled trial on the effects of self-help imagery rescripting on depression.

BACKGROUND: Imagery rescripting is a psychotherapeutic technique that aims to ameliorate negative emotions by altering (i.e., rescripting) inner representations of negative memories and images. Although the treatment was initially developed for traumatized individuals, face-to-face interventions have yielded promising results for patients with other diagnoses as well. The present study explored the feasibility and efficacy of the approach when used as a self-help intervention for depression. METHOD: A total of 127 individuals with diagnosed depression were randomly allocated to either a wait-list control condition or received a brief or long version of a manual teaching imagery rescripting. Six weeks after inclusion, patients were invited to participate in the post assessment. The Beck Depression Inventory (BDI-II) served as the primary outcome (registered at ClinicalTrials.gov (NCT03299127). RESULTS: The long version was superior to the wait-list control condition on the BDI-II, self-esteem, and quality of life at a medium effect size. No effects emerged for anxiety. No significant between-group differences were found for the brief version. Moderation analyses indicated that the self-help approach seems particularly beneficial for those scoring high on symptoms, willingness to change, and expectancy (baseline). Most patients indicated they would use the technique in the future. DISCUSSION: The efficacy of imagery rescripting was confirmed when applied via self-help. Use of the long form of the manual is recommended. Future studies are needed to ascertain whether treatment effects are sustained over time.

Comparative Microarray Analysis of Proliferating and Differentiating Murine ENS Progenitor Cells.

Postnatal neural progenitor cells of the enteric nervous system are a potential source for future cell replacement therapies of developmental dysplasia like Hirschsprung's disease. However, little is known about the molecular mechanisms driving the homeostasis and differentiation of this cell pool. In this work, we conducted Affymetrix GeneChip experiments to identify differences in gene regulation between proliferation and early differentiation of enteric neural progenitors from neonatal mice. We detected a total of 1333 regulated genes that were linked to different groups of cellular mechanisms involved in cell cycle, apoptosis, neural proliferation, and differentiation. As expected, we found an augmented inhibition in the gene expression of cell cycle progression as well as an enhanced mRNA expression of neuronal and glial differentiation markers. We further found a marked inactivation of the canonical Wnt pathway after the induction of cellular differentiation. Taken together, these data demonstrate the various molecular mechanisms taking place during the proliferation and early differentiation of enteric neural progenitor cells.

Isolation, expansion and transplantation of postnatal murine progenitor cells of the enteric nervous system.

Neural stem or progenitor cells have been proposed to restore gastrointestinal function in patients suffering from congenital or acquired defects of the enteric nervous system. Various, mainly embryonic cell sources have been identified for this purpose. However, immunological and ethical issues make a postnatal cell based therapy desirable. We therefore evaluated and quantified the potential of progenitor cells of the postnatal murine enteric nervous system to give rise to neurons and glial cells in vitro. Electrophysiological analysis and BrdU uptake studies provided direct evidence that generated neurons derive from expanded cells in vitro. Transplantation of isolated and expanded postnatal progenitor cells into the distal colon of adult mice demonstrated cell survival for 12 weeks (end of study). Implanted cells migrated within the gut wall and differentiated into neurons and glial cells, both of which were shown to derive from proliferated cells by BrdU uptake. This study indicates that progenitor cells isolated from the postnatal enteric nervous system might have the potential to serve as a source for a cell based therapy for neurogastrointestinal motility disorders. However, further studies are necessary to provide evidence that the generated cells are capable to positively influence the motility of the diseased gastrointestinal tract.

Limb lengthening with fully implantable magnetically actuated mechanical nails (PHENIX(®))-preliminary results.

Limb lengthening and deformity correction with fully implantable systems is becoming more and more widespread. Different actuation techniques are known and every system has its specific limitations in distraction control and/or stability. A new system with magnetic actuation offers outstanding options. The mechanism of the Phenix M2(®) bone lengthening nail (Phenix Medical, France) is driven by a strong external magnet. The device can provide lengthening, shortening and bone transport. Between December 2011 and November 2012 we applied the nail in 10 patients with an average age of 25 years (range 15-40 years). There were 6 femoral and 4 tibial procedures. The intended distraction goal was achieved in 8 of 10 patients. In three cases we simultaneously corrected malalignment. Average lengthening was 4.6 cm (range 1.3-7.6 cm). Average distraction index was 0.85 mm/day (range 0.6-1.3mm/day). Average weight bearing index was 27 days/cm (range 16-37 days/cm). Three patients had revisions due to early distraction arrest. The early results are comparable to those of other intramedullary systems in the literature like the ISKD(®), the Albizzia(®) or the Fitbone(®) system. All intramedullary procedures require accurate analysis and planning, advanced operative technique and close follow-up. The custom made design of the Phenix nail with unique options for size, stroke and locking provides new options for small bones and improved stability. The shortening option may be helpful for soft tissue problems, joint subluxation and additional stimulation of bone formation. Magnetic forces have to be considered and too much soft tissue around the nail might be a limiting factor. The magnetically actuated Phenix nail offers new therapeutic options in limb lengthening.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with depressive disorder and healthy controls.

OBJECTIVE: Only few studies have compared the frequency of traumatic life events during childhood in inpatients with depression with a healthy control group. METHODS: Consecutively admitted inpatients with depression (n = 79), most of whom belonged to the melancholic subtype (n = 73; 92.4%), and healthy controls (n = 110) were investigated using a comprehensive retrospective interview with 203 questions regarding childhood traumatic life events, parental attitudes, family history of psychiatric disorders and birth risk factors. RESULTS: Depressed patients had significantly more severe traumatic events (mean score 1.33; SD 1.4) than control subjects (0.85; SD 1.2) on a 0-10 point "severe trauma scale". 70.9% (n = 56) of the depressed patients, but only 48.2% (n = 53) of the controls reported at least one severe traumatic event. When looking at single events, only few differences were found between patients and controls. Compared to controls, patients described significantly higher rates of psychiatric disorders in their families, in particular depression. Parental rearing styles were rated as more unfavorable in the patient group. In a logistic regression model, of all possible etiological factors examined, only a family history of psychiatric disorders showed a significant influence (OR = 3.6). CONCLUSIONS: Melancholic depression seems to be less associated with traumatic events than other psychiatric disorders.

Radiation-free drill guidance in interlocking of intramedullary nails.

Intramedullary nailing is a technically demanding procedure which involves an excessive amount of x-ray acquisitions; one study lists as many as 48 to successfully complete the procedure. In this work, a novel low cost radiation-free drilling guide is designed to assist surgeons in completing the distal locking procedure without any x-ray acquisitions. Using an augmented reality fluoroscope that coregisters optical and x-ray images, we exploit solely the optical images to detect the drilling guide in order to estimate the tip position in real-time in x-ray. We tested over 200 random drill guide poses showing a mean tip-estimation error of 1.72 +/- 0.7mm which is significantly robust and accurate for the interlocking. In a preclinical study on dry bone phantom, three expert surgeons successfully completed the interlocking 56 out of 60 trials with no x-ray acquisition for guidance and an average time of 2 min.

Intra-op measurement of the mechanical axis deviation: an evaluation study on 19 human cadaver legs.

The alignment of the lower limb in high tibial osteotomy (HTO) or total knee arthroplasty (TKA) must be determined intraoperatively. One way to do so is to deform the mechanical axis deviation (MAD), for which a tolerance measurement of 10 mm is widely accepted. Many techniques are proposed in clinical practice such as visual inspection, cable method, grid with lead impregnated reference lines, or more recently, navigation systems. Each has their disadvantages including reliability of the MAD measurement, excess radiation, prolonged operation time, complicated setup and high cost. To alleviate such shortcomings, we propose a novel clinical protocol that allows quick and accurate intraoperative calculation of MAD. This is achieved by an X-ray stitching method requiring only three X-ray images placed into a panoramic image frame during the entire procedure. The method has been systematically analyzed in a simulation framework in order to investigate its accuracy and robustness. Furthermore, we validated our protocol via a preclinical study comprising 19 human cadaver legs. Four surgeons determined MAD measurements using our X-ray panorama and compared these values to a gold-standard CT-based technique. The maximum average MAD error was 3.5mm which shows great potential for the technique.

Treatment outcome of female agoraphobics 3-9 years after exposure in vivo: a comparison with healthy controls.

It is well documented that most agoraphobics, with or without panic disorder, respond to exposure in vivo. But only little data compared their anxiety levels at follow-up (FU) with those of healthy controls. Forty-two female agoraphobics with or without panic disorder participated in FUs 3-9 years after exposure in vivo. Agoraphobic symptoms were compared to data of 42 healthy controls, who were matched according to gender, age, marital and occupational status. Remission criteria were defined from agoraphobia scores of the controls. A total of 17 (40%) of the patients had no further agoraphobic symptoms at all. A total of 15 (36%) patients still had mild-to-moderate agoraphobic symptoms at FU. A total of 10 (24%) were non-responders and suffered from severe agoraphobia at FU. The percentage of treated patients with complete remission is much higher than previously reported. However, the majority still suffer from mild or severe agoraphobic symptoms and could possibly benefit from additional interventions.

A prospective long-term follow-up study of alexithymia in obsessive-compulsive disorder.

BACKGROUND: Studies evaluating the stability of alexithymia over long follow-up periods are rare. We examined the temporal stability of alexithymia in patients with obsessive-compulsive disorder (OCD) over 6 years and the association of alexithymia with the long-term outcome of OCD. SAMPLING AND METHODS: Of 42 patients with OCD, 34 (81%) could be reassessed 6 years after inpatient treatment. The 20-item Toronto Alexithymia Scale, Yale-Brown Obsessive-Compulsive Scale, and Hamilton Depression Rating Scale were used at pretreatment, posttreatment, and follow-up. RESULTS: The 20-item Toronto Alexithymia Scale total scores and its factors 1 and 2 decreased significantly during follow-up, whereas factor 3 remained stable. High correlations of the 20-item Toronto Alexithymia Scale total scores (r = 0.84, P < .001) and its 3 factors emerged between posttreatment and follow-up, suggesting relative stability over several years. Regression analyses (with and without controlling for depressive symptoms) showed that higher alexithymia scores did not predict a worse long-term outcome of OCD. CONCLUSIONS: Relative stability over such a very long follow-up period strongly supports the view that alexithymia is a stable psychologic characteristic in patients with OCD. The result that higher alexithymia scores were not associated with poorer long-term outcome of OCD might be explained with the decrease of alexithymia during treatment and follow-up. However, our sample size was small, and further research is clearly required to evaluate the impact of changes in alexithymia and its association with the course of OCD.

Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder.

BACKGROUND: Previous studies have found a strong association between dissociation and obsessive-compulsive disorder (OCD). The purpose of the present study was to evaluate whether dissociation is a predictor of cognitive behavior therapy (CBT) outcome in patients with OCD. METHODS: Fifty-two patients with OCD were assessed using the Dissociative Experience Scale (DES), the Yale-Brown Obsessive-Compulsive Scale and the Beck Depression Inventory. CBT lasted on average 9.5 weeks and included exposure therapy. RESULTS: Patients who dropped out due to noncompliance had higher baseline DES scores and depression scores compared to the 43 patients (83%) who completed the study. Significant OCD symptom reduction at posttreatment was observed in study completers with a large effect size (d = 1.7). More severe OCD symptoms at posttreatment were associated with higher DES scores at baseline, and treatment nonresponders had significantly higher baseline DES scores compared to responders. These associations with outcome were mainly due to the DES subfactor absorption-imaginative involvement. In regression analyses, higher absorption-imaginative involvement scores at baseline predicted poorer CBT outcome, even after controlling for depressive symptoms, comorbid axis I disorders and concomitant psychotropic drugs. CONCLUSIONS: Results from this preliminary study suggest that higher levels of dissociation (particularly absorption-imaginative involvement) in patients with OCD might predict poorer CBT outcome. If our results can be replicated, treatment outcome might be improved by additional interventions for those patients with OCD who indicate high levels of dissociation, for example by using interventions aimed at improving coping with emotionally stressful situations.

Temporal stability of symptom dimensions in adult patients with obsessive-compulsive disorder.

BACKGROUND: Although symptoms of obsessive-compulsive disorder (OCD) are heterogeneous, considerable advances have been made in subtyping OCD based on factor-analysed symptom dimensions. However, there is very little empirical data on the longitudinal course of symptom dimensions in adult OCD. METHODS: We examined prospectively the temporal symptom stability in adult OCD patients. Of 54 baseline OCD inpatients, 43 (80%) were re-assessed with the Yale-Brown Obsessive-Compulsive Scale symptom checklist after 6 years on average. RESULTS: Significant changes occurred within the symptom dimensions aggressive/checking, symmetry/ordering, and contamination/cleaning, whereas the others (hoarding, sexual/religious) remained unchanged from baseline to follow-up. Shifts between different dimensions from baseline to follow-up were rare, the score of each dimension at follow-up was most strongly predicted from the score of the same dimension at baseline. LIMITATIONS: The main limitation of the present study is the relatively small sample size. Furthermore, not the same raters conducted the baseline and follow-up assessments. CONCLUSIONS: Symptom dimensions seem to be remarkably stable over several years in adult OCD, despite various treatments and significant improvements in symptom severity. This underlines the usefulness of these symptom dimensions for studies of biological and genetic markers, comorbidity and treatment response predictors.