[The working alliance in inpatient treatment for personality disorders and its connection with patient characteristics: an exploratory study]. / De werkalliantie in klinische psychotherapie voor persoonlijkheidsstoornissen en gehechtheid.

BACKGROUND: The working alliance between therapist and patient has been investigated frequently, but much less is known about the working alliance in specific patient groups in specific settings. AIM: To obtain insight into the characteristics of the working alliance in intensive inpatient psychotherapy involving patients with severe personality disorders, and to pay special attention to patient characteristics such as diagnosis and attachment. METHOD: At the end of the first phase of treatment we collected, on the basis of questionnaires, information about the working alliance and attachment of 60 patients with a severe personality disorders who had received inpatient psychotherapy. RESULTS: Working alliances with therapist and team were found to be weaker than in outpatient populations; working alliances with the therapist proved to be stronger than working alliances with the treatment team. Cluster C patients developed a better working alliance with the treatment team than did cluster B patients, particularly in the domain of treatment goals. Patients in this study turned out to be attached more anxiously and 'avoidantly' than patients in general outpatient populations; no correlation was found between patients' attachment and the strength of the working alliance. However, when a distinction was made between patients with extreme scores and patients with average scores, results showed that the more anxiously patients felt attached, the higher were their scores for their working alliance with the treatment team. CONCLUSION: It is more difficult to establish a working alliance with patients who have a severe personality disorder than with patients suffering from a less severe personality disorder. Patients with a severe personality disorder seemed to show a higher degree of anxious attachment and to have a more critical attitude to the working alliance.

Predictors of response to the 'Coping with Depression' course for older adults. A field study.

This field study explored the prognostic factors of the immediate and long-term effects of the Coping with Depression course for older adults (CWD). With the aim of both indicated as well as secondary prevention, the course is provided by the prevention departments of the community mental health care system in the Netherlands. A total of 317 course participants (age 55-85 years; 69% female) took part in this study; 41% had a major depressive disorder (MDD). A variety of demographic, clinical, psychosocial and treatment factors of possible relevance for indicated and secondary prevention were investigated. Random coefficient regression models and logistic regression models were used to examine their contribution to the immediate and maintenance effect. The course was beneficial for all participants, and the level of depression reached at the end of the course was maintained over the next 14-months. Current MDD, high levels of anxiety, less previous depressive episodes and more education predicted a larger benefit. However, the clinical significance of these predictors was too small to justify further triage. Further treatment should be considered for the participants with a post-treatment score >/=16. Group-membership was not a significant predictor of the variation in effect.

Effectiveness of the Coping With Depression (CWD) course for older adults provided by the community-based mental health care system in the Netherlands: a randomized controlled field trial.

BACKGROUND: The Dutch version of the Coping With Depression (CWD) course for older adults has been implemented in the prevention arm of the community-based mental health care system in the Netherlands. The study group included older adults with subclinical depression as well as those with a major depressive disorder; all were enrolled into the course by mental health care professionals. The effectiveness (immediate and long-term) of the course for this heterogeneous population was studied in an effectiveness trial. METHOD: Participants were self-referred, responding to media announcements. A total of 119 participants aged 55-85 years (69% female), with subclinical depression and major depression, were randomized to either the CWD course (N = 61) or the waiting list (N = 58). RESULTS: Nine participants dropped out of the course. According to a diagnostic interview based on the DSM-IV, 39% had a major depressive disorder (MDD), 69% had had a previous MDD, and 45% had an anxiety disorder. Older adults in the intervention group showed a significant decrease in depression symptoms. Gains were maintained over 14 months. In the intervention condition 83% had a pre-treatment score > or = 16 on the Center for Epidemiologic Studies Depression Scale (CES-D); at post-treatment 62% still scored > or = 16. CONCLUSIONS: The course was beneficial for participants with mild or severe depression, and treatment acceptability was high. It should be fitted into a stepped-care protocol that varies intervention intensity according to clinical needs, using the post-treatment level of functioning as an indication for the next step.

The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology.

BACKGROUND: The criterion validity of the Center for Epidemiological Studies Depression scale (CES-D) was assessed in a group of elderly Dutch community-residents who were self-referred to a prevention program for depression. METHODS: Paper-and-pencil administration of the CES-D to 318 elders (55-85 years). Criterion validity was evaluated with the Mini International Neuropsychiatric Interview (MINI), a clinical diagnostic interview based on DSM-IV. Sensitivity and specificity for various cut-off scores of CES-D were compared with the DSM-IV major depressive disorder (MDD) and with clinically relevant depression (CRD), a composite diagnosis of MDD, subthreshold depression or dysthymia. Furthermore the characteristics of true versus false positives were analyzed. RESULTS: For MDD, the optimal cut-off score was 25, (sensitivity 85%, specificity 64%, and positive predicted value of 63%). For CRD, the optimal cut-off was 22 (sensitivity 84%, specificity 60%, and positive predicted value 77%). True positives, MDD and CRD, reported significantly more anxiety symptomatology and more co-morbid anxiety disorders, false positives reported more previous depressive episodes. CONCLUSIONS: The criterion validity of the CES-D for MDD and CRD was satisfactory in this semi-clinical sample of elders. Subjects scoring >/=25 constitute a target group for further diagnostic assessment in order to determine appropriate treatment.