Effects of a Contextual Adaptation of the Unified Protocol in Multiple Emotional Disorders in Individuals Exposed to Armed Conflict in Colombia: A Randomized Clinical Trial.

Importance: A transdiagnostic treatment, the Unified Protocol, is as effective as single diagnostic protocols in comorbid emotional disorders in clinical populations. However, its effects on posttraumatic stress disorder and other emotional disorders in individuals living in war and armed conflict contexts have not been studied. Objective: To evaluate the efficacy of a cultural and contextual adaptation of the Unified Protocol (CXA-UP) on posttraumatic stress disorder, anxiety, and depression compared to waitlist control in individuals exposed to armed conflict in Colombia. Design, Setting, and Participants: From April 2017 to March 2020, 200 participants 18 years and older were randomly assigned to the CXA-UP or to a waitlist condition. CXA-UP consisted of 12 to 14 twice-a-week or weekly individual 90-minute face-to-face sessions. Outcomes were assessed at baseline, posttreatment, and 3 months following treatment. Analyses were performed and compared for all randomly allocated participants (intent-to-treat [ITT]) and for participants who completed all sessions and posttreatment measures (per protocol [PP]). The study took place at an outpatient university center and included individuals who were registered in the Colombian Victims Unit meeting DSM-5 diagnostic criteria for posttraumatic stress disorder, anxiety, or depression or were severely impaired by anxiety or depression. Individuals who were receiving psychological therapy, were dependent on alcohol or drugs, were actively suicidal or had attempted suicide in the previous 2 months, had psychosis or bipolar disorder, or were cognitively impaired were excluded. Intervention: CXA-UP or waitlist. Main Outcomes and Measures: Primary outcomes were changes in anxiety, depression, and somatic scores on the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist for DSM-5. Results: Among the 200 participants (160 women [80.0%]; 40 men [20.0%]; mean [SD] age, 43.1 [11.9] years), 120 were randomized to treatment and 80 to waitlist. Results for primary outcomes in the ITT analysis showed a significant pretreatment-to-posttreatment reduction when comparing treatment and waitlist on the posttraumatic stress disorder checklist for DSM-5 scores (slope [SE], -31.12 [3.00]; P < .001; Cohen d, 0.90; 90% CI, 0.63-1.19), 9-item Patient Health Questionnaire (PHQ-9) (slope [SE],-11.94 [1.30]; P < .001; Cohen d, 0.77; 90% CI, 0.52-1.06), PHQ-anxiety (slope [SE], -6.52 [0.67]; P < .001; Cohen d, 0.82; 90% CI, 0.49-1.15), and PHQ-somatic (slope [SE], -8.31 [0.92]; P < .001; Cohen d, 0.75; 90% CI, 0.47-1.04). Conclusions and Relevance: In this study, significant reductions and large effect sizes in all measures of different emotional disorders showed efficacy of a single transdiagnostic intervention in individuals exposed to armed conflicts. Trial Registration: ClinicalTrials.gov Identifier: NCT03127982.

The effect of information seeking behaviors in fear control.

BACKGROUND AND OBJECTIVES: Individuals experiencing conditioned fear reactions often resort to avoidance and escape behaviors as attempts to decrease fear. Nevertheless, these strategies are not always available. In such cases, people seek information to mitigate aversive events. This study aimed at evaluating the effect of information seeking behaviors on self-reported fear, predictability, and physiological responses. METHODS: Participants were randomly assigned to two groups. In group one, individuals were given the choice to perform an instrumental behavior which provided information about the occurrence of either an aversive or a neutral event (100% contingency). In group two, individuals were also allowed to perform an instrumental behavior. However, such behavior provided partial information (50% contingency). RESULTS: Individuals in group one presented lower levels of fear compared to individuals assigned to group two. LIMITATIONS: The generalizability of the results may be restricted to undergraduate students. CONCLUSIONS: The results suggests that when avoidance and escape are not available, individuals seek information that provides control over fear. Clinical implications are discussed.

A Culturally Adapted Cognitive Behavioral Internet-Delivered Intervention for Depressive Symptoms: Randomized Controlled Trial.

BACKGROUND: Internet-delivered treatments for depressive symptoms have proved to be successful in high-income Western countries. There may be potential for implementing such treatments in low- and middle-income countries such as Colombia, where access to mental health services is limited. OBJECTIVE: The objective of this study was to assess the efficacy of a culturally adapted cognitive behavioral internet-delivered treatment for college students with depressive symptoms in Colombia. METHODS: This was a randomized controlled trial with a 3-month follow-up. The program comprised seven modules. A total of 214 Colombian college students were recruited. They were assessed and randomly assigned to either the treatment group (n=107) or a waiting list (WL) control group (n=107). Participants received weekly support from a trained supporter. The primary outcome was symptoms of depression, as measured by the Patient Health Questionnaire - 9, and the secondary outcomes were anxiety symptoms assessed by the Generalized Anxiety Disorder questionnaire - 7. Other measures, including satisfaction with treatment, were evaluated after 7 weeks. RESULTS: Research attrition and treatment dropouts were high in this study. On average, 7.6 sessions were completed per user. The mean time spent on the program was 3 hours and 18 min. The linear mixed model (LMM) showed significant effects after treatment (t197.54=-5.189; P<.001) for the treatment group, and these effects were maintained at the 3-month follow-up (t39.62=4.668; P<.001). Within-group results for the treatment group yielded a large effect size post treatment (d=1.44; P<.001), and this was maintained at the 3-month follow-up (d=1.81; P<.001). In addition, the LMM showed significant differences between the groups (t197.54=-5.189; P<.001). The results showed a large effect size between the groups (d=0.91; P<.001). In the treatment group, 76.0% (16/107) achieved a reliable change, compared with 32.0% (17/107) in the WL control group. The difference between groups was statistically significant (X22=10.5; P=.001). CONCLUSIONS: This study was the first contribution to investigating the potential impact of a culturally adapted internet-delivered treatment on depressive symptoms for college students as compared with a WL control group in South America. Future research should focus on identifying variables associated both with premature dropout and treatment withdrawal at follow-up. TRIAL REGISTRATION: ClinicalTrials.gov NCT03062215; https://clinicaltrials.gov/ct2/show/NCT03062215.

Assessing the efficacy of a culturally adapted cognitive behavioural internet-delivered treatment for depression: protocol for a randomised controlled trial.

BACKGROUND: Depression is the principal cause of disability in the world. High prevalence rates of depression in general populations and college students have been found worldwide and in various cultural groups. Low-intensity cognitive behavioural internet-delivered treatment has demonstrated efficacy in high-income-countries (HICs). However little is known of their potential for adaptation and efficacy in low and middle-income countries. METHODS: Study (1) involves the cultural adaptation of the Space from Depression cognitive-behaviour internet-delivered programme with an asynchronous support for depressive symptoms. This includes initial researcher/clinician adaptation and the integration of cultural assessment feedback of the programme by a panel of experts and users through the theoretically-based Cultural Relevance Questionnaire (CRQ). Study (2) describes the implementation of the culturally adapted intervention using a randomised controlled trial methodology. The efficacy trial will include an active treatment group and a waiting-list control group of participants meeting eligibility criteria (mild to moderate depression symptoms). The active condition will consist of 7 weekly modules of internet-delivered cognitive behavioural therapy (iCBT) Space from Depression, with post-session feedback support. The primary outcome will be the Patient Health Questionnaire (PHQ-9). The study also involves collection of client reported significant events and client satisfaction with the internet-delivered treatment. Data will be collected at baseline and at post-treatment (week 7), and at follow-up (week 20/3 months). Analysis will be conducted on the intention-to-treat basis. DISCUSSION: The study seeks to establish a theoretically robust methodology for culturally adapting internet-delivered interventions for mental health disorders and to evaluate the efficacy of a culturally adapted internet-delivered treatment for depression in Colombia, with support. The study will be a first contribution to a method for culturally adapting internet-delivered interventions and also a first to examine the efficacy of such an adapted intervention in Latin America. TRIAL REGISTRATION: Clinical trials NCT03062215. Retrospectively registered 14th February 2017.

The role of safety signals in fear extinction: An analogue study.

BACKGROUND AND OBJECTIVES: Safety signals are conditioned inhibitory stimuli that indicate the absence of unconditioned stimuli. It is not clear whether the presence of safety signals is detrimental or beneficial in extinction-based interventions. The purpose of this study was to evaluate the effect of safety signals on autonomic and expectancy fear-related responses. METHODS: Following the conditional discrimination paradigm (AX +, BX-), undergraduate students (N = 48) underwent an aversive conditioning procedure, while safety signals were experimentally created. Participants were randomly assigned to one of two conditions during extinction: presence or absence of safety signals. RESULTS: Significant reductions of fear-related responses were found in both groups. Expectancy measures showed that the presence of safety signals did not interfere with reduction of fear related responses at follow-up. LIMITATIONS: The analogue nature of the study affects its ecological validity. There are some methodological issues. CONCLUSIONS: Safety signals did not interfere with extinction learning. Attention may be a mechanism associated with the maintenance of fear responses.

Salud mental en el hospital general: resultados del Cuestionario de Salud del Paciente (PHQ) en cuatro servicios de atención / Mental health in the general hospital: results of the patient health questionnaire (PHQ) in four hospital services

Introducción: Pocas personas tienen acceso a tratamientos de trastornos mentales, en parte porque no son adecuadamente detectados. Como es más frecuente consultar servicios de salud por condiciones médicas, la atención primaria en salud constituye una puerta de entrada útil de detección de problemas de salud mental. Objetivo: Detectar la frecuencia de problemasde salud mental en cuatro servicios de la Fundación Santa Fe de Bogotá: consulta externa, hospitalización, urgencias y atención primaria, mediante un cuestionario breve, el Cuestionario de Salud del Paciente (PHQ), así como los índices de comorbilidad. Método: Estudio de corte transversal de pacientes que asistieron a los cuatro servicios, a quienes se les aplicó un Cuestionario de Datos Demográficos y el PHQ. Resultados: De los pacientes que asistieron a los servicios entre septiembre del 2010 y mayo del 2011, un total de 1094 seleccionados aleatoriamente participaron en el estudio. Los problemas de salud mental más frecuentes fueron trastorno depresivo mayor (7,3%), abuso de alcohol (14,4%) y algún trastorno de ansiedad (7,7%) y se observaron con una mayor frecuencia en urgencias. Conclusiones: Se reafirma la utilidad de un cuestionario breve (PHQ) para detectar problemas de salud mental en el medio hospitalario y se analiza la necesidad de diseñar programas de atención en salud mental en el hospital general. Se recomienda repetir este estudio en otros centros y realizar más investigación…

Introduction: Few individuals have access to mental health services due in part to underdetection. As it is more likely to consult for medical conditions, primary care may be a useful gateway for early detection of mental health problems. Objective: Detection of the frequency of mental health problems in four hospital services at the Fundación Santa Fe de Bogotá: Outpatient unit, hospitalization, emergency department, and primary care through a brief detection questionnaire, the Patient Health Questionnaire (PHQ). Method: Cross-sectional study of patients seen at the four services who answered a Demographic Data Questionnaire and the PHQ together with information gathered about current medical diagnosis, history of visits, and hospitalizations during the last year. Results: 1094 patients seen at the four hospital services between September 2010 and May 2011 were selected at random. A mental health problem was detected in 36.7% of the total sample. Major depressive disorder (7.3%), alcohol abuse (14.4%), and any anxiety disorder (7.7%) showed the highest prevalence with the emergency department showing the highest frequency of detection. Conclusions: The usefulness of a brief detection questionnaire such as the PHQ in hospital settings is demonstrated and implications in the design of mental health programs in the general hospital are discussed. The need to replicate this study in other settings and to undertake further research is outlined…

[Mental Health in the General Hospital: Results of the Patient Health Questionnaire (PHQ) in Four Hospital Services]. / Salud mental en el hospital general: resultados del Cuestionario de Salud del Paciente (PHQ) en cuatro servicios de atención.

INTRODUCTION: Few individuals have access to mental health services due in part to underdetection. As it is more likely to consult for medical conditions, primary care may be a useful gateway for early detection of mental health problems. OBJECTIVE: Detection of the frequency of mental health problems in four hospital services at the Fundación Santa Fe de Bogotá: Outpatient unit, hospitalization, emergency department, and primary care through a brief detection questionnaire, the Patient Health Questionnaire (PHQ). METHOD: Cross-sectional study of patients seen at the four services who answered a Demographic Data Questionnaire and the PHQ together with information gathered about current medical diagnosis, history of visits, and hospitalizations during the last year. RESULTS: 1094 patients seen at the four hospital services between September 2010 and May 2011 were selected at random. A mental health problem was detected in 36.7% of the total sample. Major depressive disorder (7.3%), alcohol abuse (14.4%), and any anxiety disorder (7.7%) showed the highest prevalence with the emergency department showing the highest frequency of detection. CONCLUSIONS: The usefulness of a brief detection questionnaire such as the PHQ in hospital settings is demonstrated and implications in the design of mental health programs in the general hospital are discussed. The need to replicate this study in other settings and to undertake further research is outlined.

Propiedades psicométricas de las escalas BAS-DEP y EBAS-DEP en español para el tamizaje de depresión en una muestra geriátrica multisitio en Colombia: un estudio exploratorio / Psychometric properties of the Spanish versions of the BAS-DEP and EBAS-DEP scales as screening instruments for depression in a multi-site geriatric Colombian sample: an exploratory study / Propriedades psicrométricas das escalas BAS-DEP e EBAS-DEP em espanhol para a triagem de depressão em uma mostra geriátrica na Colômbia: um estudo exploratório

En este estudio se exploraron las propiedades psicométricas de la escala breve para la evaluación de la depresión (BAS-DEP Brief Assessment Scale for Depression) y la escala ultra-breve para la evaluación de la depresión (EBAS-DEP Even Briefer Assessment Scale for Depression) en una muestra de 104 adultos mayores, 41 hombres y 63 mujeres, residentes en dos ciudades Colombianas. La BAS-DEP contenía 21 preguntas dicotómicas sobre ánimo depresivo, preocupaciones, ideación suicida y quejas somáticas, mientras que la EBAS-DEP se obtuvo extrayendo 8 ítems de la BAS-DEP y cuyo desempeño psicométrico ha sido descrito como equivalente por los autores del estudio original (Allen, et al., 1994). Se evaluó la confiabilidad y validez, sensibilidad y especificidad, y se obtuvieron curvas de características operativas del receptor (ROC). Se realizaron análisis Rasch de ajuste, dificultad, habilidad y mapeo de ítems. La BAS-DEP mostró un nivel apropiado de confiabilidad (.82) mientras que dicho valor fuebajo para la EBAS-DEP (.56). La baja confiabilidad de la EBAS-DEP podría ser explicada por su brevedad aunque su sensibilidad y especificidad fueron apropiadas. Las soluciones factoriales demostraron que la mayoría de ítems de la BAS-DEP y EBAS-DEP aportaban en la explicación de la varianza total.Al usar la escala de depresión geriátrica (GDS) de Yesavage como criterio externo de validez, se obtuvieron coeficientes de sensibilidad y especificidad superiores a 0,70 con puntajes de corte 5/6 para la BAS-DEP y 2/3 para la EBAS-DEP. Los estadísticos ROC mostraron que las escalas son similares en su eficiencia para detectar depresión en la muestra. Estos hallazgos se asemejan a los reportados por estudios efectuados en Australia, Inglaterra, Alemania y China. Éste ha sido el primer estudio de las propiedades psicométricas de las versiones en español de estas escalas.La realización de nuevas investigaciones independientes permitirá enriquecer la base de evidencia a favor de la utilidad y validez de estos instrumentos.

This study aimed atexploring the psychometric properties of the Brief Assessment Scale for Depression (BAS-DEP) and the Even Briefer Assessment Scale for Depression (EBAS-DEP) scales as screening instruments in a sample of 104 elderly participants, 41 men and 63 women, residing in two Colombian cities. The BAS-DEP included 21 items assessing depressive mood, worry, suicidal ideation and somatic complaints. Meanwhile, the EBAS-DEP was derived by means of extracting 8 ítems of the BAS-DEP, and its performance was regarded as equivalent by the authors of the original study (Allen, et al., 1994).Reliability, validity,sensitivity and specificity were assessedand a receiver operating characteristics curve (ROC) was obtained. Rasch analyses of adjustment, difficulty, and performance were executed and an item map was obtained.The BAS-DEP showed an appropriate level of reliability (.82).Nonetheless, such value was low for the EBAS-DEP (.56).Low reliability of the EBAS-DEP could be explained in terms of its briefness.Nevertheless, its performance in terms of sensitivity and specificity was appropriate. Factor solutions derived from the analyses revealed that most of the items in the BAS-DEP and EBAS-DEP scales contributed in explaining the total variance.When the Yesavage GDS scale was used as an external criterion of validity, coefficients of sensitivity and specificity above .70 were obtained in addition to cut-off scores of 5/6 for the BAS-DEP and 2/3 for the EBAS-DEP.ROC statistics showed that both scales are similarly efficient to detect depression in the sample.These findings are similar to those reported in studies conducted in Australia, England, Germany, and China. This study has been the first to assess the psychometric properties of the Spanish versions of these scales.Further independent studies will enrich the evidence base in favor of the usefulness and validity of these instruments.

Neste estudo foram exploradas as propriedades psicométricas da escala breve para a avaliação da depressão (BAS-DEP Brief Assessment Scale for Depression) e a escala ultrabreve para a avaliação da depressão (EBAS-DEP Even Briefer Assessment Scale for Depression) em uma mostra de 104 idosos, sendo 41 homens e 63 mulheres, residentes em duas cidades colombianas. A BASDEP continha 21 perguntas dicotômicas sobre ânimo depressivo, preocupações, ideias suicidas e queixas somáticas, enquanto que a EBAS-DEP foi obtida extraindo 8 itens da BAS-DEP e cujo desempenho psicométrico foi descrito como equivalente pelos autores do estudo original (Allen, et al., 1994). Avaliou-se a confiabilidade e validade, sensibilidade e especificidade, obtiveramse curvas de características operativas do receptor (ROC). Realizaram-se análises Rasch de ajuste, dificuldade, habilidade e mapeamento de itens. A BAS-DEP mostrou um nível apropriado de confiabilidade (.82) enquanto que esse valor foi baixo para a EBAS-DEP (.56). A baixa confiabilidade da EBAS-DEP poderia ser explicada por sua concisão ainda que sua sensibilidade e especificidade foram apropriadas. As soluções fatoriais demonstraram que a maioria dos itens da BAS-DEP e EBAS-DEP contribuía na explicação da variância total. Ao usar a escala de depressão geriátrica (GDS) de Yesavage como critério externo de validade, obtiveram-se coeficientes de sensibilidade e especificidade superiores a .70 com notas de corte 5/6 para a BAS-DEP e 2/3 para a EBAS-DEP. Os estatísticos ROC mostraram que as escalas são similares em sua eficiência para detectar depressão na mostra. Estes descobrimentos se assemelham aos relatados por estudos efetuados na Austrália, Inglaterra, Alemanha e China. Este foi o primeiro estudo das propriedades psicométricas das versões em espanhol destas escalas. A realização de novas pesquisas independentes permitirá enriquecer a base de evidência a favor da utilidade e validade destes instrumentos.