Prediction of treatment discontinuation and recovery from Borderline Personality Disorder: Results from an RCT comparing Schema Therapy and Transference Focused Psychotherapy.

Knowing what predicts discontinuation or success of psychotherapies for Borderline Personality Disorder (BPD) is important to improve treatments. Many variables have been reported in the literature, but replication is needed and investigating what therapy process underlies the findings is necessary to understand why variables predict outcome. Using data of an RCT comparing Schema Therapy and Transference Focused Psychotherapy as treatments for BPD, variables derived from the literature were tested as predictors of discontinuation and treatment success. Participants were 86 adult outpatients (80 women, mean age 30.5 years) with a primary diagnosis of BPD who had on average received 3 previous treatment modalities. First, single predictors were tested with logistic regression, controlling for treatment type (and medication use in case of treatment success). Next, with multivariate backward logistic regression essential predictors were detected. Baseline hostility and childhood physical abuse predicted treatment discontinuation. Baseline subjective burden of dissociation predicted a smaller chance of recovery. A second study demonstrated that in-session dissociation, assessed from session audiotapes, mediated the observed effects of baseline dissociation on recovery, indicating that dissociation during sessions interferes with treatment effectiveness. The results suggest that specifically addressing high hostility, childhood abuse, and in-session dissociation might reduce dropout and lack of effectiveness of treatment.

Salivary cortisol levels and the 2-year course of depressive and anxiety disorders.

INTRODUCTION: Depression and anxiety disorders have been associated with hyperactivity of the hypothalamic-pituitary adrenal (HPA) axis. However, lower cortisol levels have also been observed in depressed patients. Whether cortisol level predicts the course of these disorders has not been examined in detail. We examined whether salivary cortisol indicators predict the 2-year course of depression and anxiety disorders. METHODS: Longitudinal data are obtained from 837 participants of the Netherlands Study of Depression and Anxiety, with a DSM-IV based depressive and/or anxiety disorder at baseline. At baseline, seven saliva samples were obtained, including the 1-h cortisol awakening response, evening cortisol level and a 0.5mg dexamethasone suppression test. At follow-up, DSM-IV based diagnostic interviews and Life Chart Interview integrating diagnostic and symptom trajectories over 2 years were administered to determine an unfavorable course. RESULTS: 41.5% of the respondents had a 2-year unfavorable course trajectory without remission longer than 3 months. Adjusted analyses showed that a lower awakening response was associated with an unfavorable course (RR=0.83, p=0.03). No associations were found between evening cortisol or cortisol suppression after dexamethasone ingestion and an unfavorable course trajectory. CONCLUSIONS: Among patients with depressive or anxiety disorders, a lower cortisol awakening response - which may be indicative of underlying exhaustion of the HPA axis - predicted an unfavorable course trajectory.

Depressive and anxiety disorders on-the-job: the importance of job characteristics for good work functioning in persons with depressive and anxiety disorders.

This study examines the importance of job characteristics on absence and on-the-job performance in a large group of employees with diagnosed depressive and anxiety disorders. In a sample of 1522 employees (1129 persons with and 393 persons without psychopathology) participating in Netherlands Study of Depression and Anxiety (NESDA, n=2981) we examined associations between job characteristics and work functioning (absenteeism and work performance) in multinominal logistic regression models. Job characteristics were working hours, psychosocial working conditions and occupational status. As expected, depressed and anxious patients were at significantly elevated risk for absenteeism and poor work performance. In analyses adjusted for psychopathology, absenteeism and poor performance were significantly lower among persons reporting high job support, high job control, less working hours, self-employed and high skilled jobs. Associations were comparable between persons with and without psychopathology. High job support, high job control and reduced working hours were partially related to work functioning in both workers with- and without-psychopathology. Since depressed and anxious employees are at a substantially increased risk for absenteeism and poor work performance, strategies that improve job support and feelings of control at work may be especially helpful to prevent poor work functioning in this at-risk group of employees.

The effectiveness of long-term psychoanalytic psychotherapy--a meta-analysis of randomized controlled trials.

The effectiveness of psychoanalysis and long-term psychoanalytic psychotherapy (LTPP) is debated. We evaluated the effectiveness of LTPP, compared to other treatments or no treatment, in patients with clearly defined metal disorders. We selected randomised or quasi-randomised controlled trials on LTPP. Two authors independently identified trials for inclusion. Eleven trials were eligible. The risk difference for recovery (primary outcome) at the longest available follow-up was 0.00 (95% CI: -0.17 to 0.17; p=0.96; I-squared: 58%). The combined Hedges' g, at the longest follow-up for each study, were: for target problems: -0.05 (95% CI -0.55 to 0.46; p=0.86; I-squared=88%); general psychiatric symptoms: 0.69 (95% CI -0.19 to 1.57; p=0.13; I-squared=96%); personality pathology: 0.17 (95% CI: -0.25 to 0.59; p=0.42; I-squared=41%); social functioning: 0.20 (95% CI -0.10 to 0.50; p=0.19; I-squared=53%); overall effectiveness: 0.33 (95% CI -0.31 to 0.96; p=0.32; I-squared=94%); and quality of life: -0.37 (95% CI: -0.78 to 0.04; p=0.08; I-squared=55%). A subgroup analysis of the domain target problem showed that LTPP did significantly better when compared to control treatments without a specialized psychotherapy component, but not when compared to various specialized psychotherapy control treatments. An exploratory meta-regression indicated that there might be a relation between the difference in treatment intensity between the intervention and control group (session ratio) and effect size. We came to conclude that the recovery rate of various mental disorders was equal after LTPP or various control treatments, including treatment as usual. The effect sizes of the individual trials varied substantially in direction and magnitude. In contrast to previous reviews, we found the evidence for the effectiveness of LTPP to be limited and at best conflicting.

Sociodemographic and psychiatric determinants of attrition in the Netherlands Study of Depression and Anxiety (NESDA).

BACKGROUND: Although attrition is inevitable in longitudinal epidemiological studies, psychiatric studies are thought to be especially sensitive to attrition. This study aimed to evaluate the sociodemographic and psychiatric determinants of attrition at 2-year follow-up in the Netherlands Study of Depression and Anxiety. METHODS: Logistic regression was used to examine sociodemographic and psychiatric determinants of attrition and the influence of clinical psychiatric characteristics on attrition. In addition, differences in determinants between 3 types of attrition (refusal, noncontact, and not able to participate) were evaluated. RESULTS: The attrition rate at the 2-year follow-up assessment was 12.9% (385/2981), representing 6 deceased persons, 250 refusers, 51 noncontacts, and 78 persons unable to participate because of health reasons. Determinants of attrition were younger age, less years of education, not being of North European descent, being recruited in Amsterdam, no previous participation in research, and having major depressive disorder. Only the effects of age, sampling site, and previous participation in research differed between types of attrition. Furthermore, comorbid depressive and anxiety disorders and higher symptom severity were associated with attrition. CONCLUSIONS: In contrast to the view that psychiatric epidemiological research is more prone to high attrition rates, this study revealed a relatively low attrition rate. Furthermore, both sociodemographic and psychiatric variables were independent determinants of attrition. Oversampling of subgroups that are at higher risk of dropout may be advisable for future psychiatric cohort studies.

The impact of causal attributions on diagnosis and successful referral of depressed patients in primary care.

Despite growing concerns of over-treatment, the under-diagnosis and undertreatment of major depressive disorders is still prevalent. Causal attributions are thought to be involved in help seeking behavior, time to diagnosis and the chance for successful referral. Yet, little is known about the extent to which these processes are influenced by causal attributions. 120 patients, involved in the nationwide second Dutch National Survey of General Practice (Schellevis, Westert, & Bakker, 2005), with a current DSM-IV diagnosis of depression, severe depression or with a depression lasting over six months, completed a causal attributions inventory. Demographic and clinical data from the survey, and causal attribution scores were used as independent variables in association with getting a diagnosis of depression from the general practitioner, or being in treatment by a mental health care provider for more than 3 sessions. Causal attributions related to intrapsychic fears were significantly associated with getting a diagnosis of depression and successful referral. Causal attributions related to childhood were also positively associated with successful referral. In association models derived from all the demographic and clinical data available in the survey, causal attributions substantially contributed to the explained variance, 55% and 39% respectively. The findings suggest causal attributions have a statistically significant impact on time to diagnosis and the chance of successful referral. Using the Causal Attribution Inventory with high-risk patients in primary care might enhance the chance of detection and successful referral of depressed patients. Schellevis, F. G., Westert, G. P., & De Bakker, D. H. (2005). The actual role of general practice in the dutch health-care system. Results of the second dutch national survey of general practice. Medizinische Klinik (Munich), 100(10), 656-661.

Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA).

BACKGROUND: Whether course trajectories of depressive and anxiety disorders are different, remains an important question for clinical practice and informs future psychiatric nosology. This longitudinal study compares depressive and anxiety disorders in terms of diagnostic and symptom course trajectories, and examines clinical prognostic factors. METHODS: Data are from 1209 depressive and/or anxiety patients residing in primary and specialized care settings, participating in the Netherlands Study of Depression and Anxiety. Diagnostic and Life Chart Interviews provided 2-year course information. RESULTS: Course was more favorable for pure depression (n=267, median episode duration = 6 months, 24.5% chronic) than for pure anxiety (n=487, median duration = 16 months, 41.9% chronic). Worst course was observed in the comorbid depression-anxiety group (n=455, median duration > 24 months, 56.8% chronic). Independent predictors of poor diagnostic and symptom trajectory outcomes were severity and duration of index episode, comorbid depression-anxiety, earlier onset age and older age. With only these factors a reasonable discriminative ability (C-statistic 0.72-0.77) was reached in predicting 2-year prognosis. LIMITATION: Depression and anxiety cases concern prevalent - not incident - cases. This, however, reflects the actual patient population in primary and specialized care settings. CONCLUSIONS: Their differential course trajectory justifies separate consideration of pure depression, pure anxiety and comorbid anxiety-depression in clinical practice and psychiatric nosology.

Longitudinal evidence for unfavorable effects of antidepressants on heart rate variability.

BACKGROUND: It was previously shown that antidepressants are associated with diminished vagal control over the heart. Longitudinal studies are needed to test the causality of this association further. METHODS: Longitudinal data were obtained in the Netherlands Study of Depression and Anxiety. At baseline and at 2-year follow-up, heart rate and cardiac vagal control as indexed by respiratory sinus arrhythmia were measured in 2114 subjects (mean age = 42.0 years; 66.2% female), who either used antidepressants at one or two time points (n = 603) or did not use antidepressants at any time point (n = 1511). Linear mixed-model analyses were conducted to compare changes in respiratory sinus arrhythmia and heart rate over time across antidepressant-naive subjects, subjects who started using an antidepressant during follow-up, subjects who stopped using an antidepressant, and persistent antidepressant users. Analyses were adjusted for demographics, health, and lifestyle factors. RESULTS: Compared with continuous nonusers, subjects who started the use of a tricyclic antidepressant or a serotonergic and noradrenergic antidepressant showed a significantly greater increase in heart rate and a decrease of respiratory sinus arrhythmia at 2 years. Subjects who started the use of selective serotonin reuptake inhibitors also showed a decrease in respiratory sinus arrhythmia, but their heart rate did not increase. Discontinuing antidepressants systematically caused opposite effects; levels returned in the direction of those observed among nonusers. CONCLUSIONS: These 2-year longitudinal results indicate that all antidepressants cause a decrease in cardiac vagal control. After discontinuing antidepressants, autonomic function recovers, suggesting that the unfavorable effects are (partly) reversible.

Parental history of depression or anxiety and the cortisol awakening response.

BACKGROUND: It is unclear whether altered hypothalamic-pituitary-adrenal (HPA) axis regulation, which frequently accompanies depression and anxiety disorders, represents a trait rather than a state factor. AIMS: To examine whether HPA axis dysregulation represents a biological vulnerability for these disorders, we compared cortisol levels in unaffected people with and without a parental history of depressive or anxiety disorders. We additionally examined whether possible HPA axis dysregulations resemble those observed in participants with depression or anxiety disorders. METHOD: Data were from the Netherlands Study of Depression and Anxiety. Within the participants without a lifetime diagnoses of depression or anxiety disorders, three groups were distinguished: 180 people without parental history, 114 with self-reported parental history and 74 with CIDI-diagnosed parental history. These groups were additionally compared with people with major depressive disorder or panic disorder with agoraphobia (n = 1262). Salivary cortisol samples were obtained upon awakening, and 30, 45 and 60 min later. RESULTS: As compared with unaffected participants without parental history, unaffected individuals with diagnosed parental history of depression or anxiety showed a significantly higher cortisol awakening curve (effect size (d) = 0.50), which was similar to that observed in the participants with depression or anxiety disorders. Unaffected people with self-reported parental history did not differ in awakening cortisol levels from unaffected people without parental history. CONCLUSIONS: Unaffected individuals with parental history of depression or anxiety showed a higher cortisol awakening curve, similar to that of the participants with depression or anxiety disorders. This suggests that a higher cortisol awakening curve reflects a trait marker, indicating an underlying biological vulnerability for the development of depressive and anxiety disorders.

Do Automatic Self-Associations Relate to Suicidal Ideation?

Dysfunctional self-schemas are assumed to play an important role in suicidal ideation. According to recent information-processing models, it is important to differentiate between 'explicit' beliefs and automatic associations. Explicit beliefs stem from the weighting of propositions and their corresponding 'truth' values, while automatic associations reflect more simple associations in memory. Both types of associations are assumed to have different functional properties and both may be involved in suicidal ideation. Thus far, studies into self-schemas and suicidal ideation focused on the more explicit, consciously accessible traces of self-schemas and predominantly relied on self-report questionnaires or interviews. To complement these 'explicit' findings and more directly tap into self-schemas, this study investigated automatic self-associations in a large scale community sample that was part of the Netherlands Study of Depression and Anxiety (NESDA). The results showed that automatic self-associations of depression and anxiety were indeed significantly related to suicidal ideation and past suicide attempt. Moreover, the interactions between automatic self-depressive (anxious) associations and explicit self-depressive (anxious) beliefs explained additional variance over and above explicit self-beliefs. Together these results provide an initial insight into one explanation of why suicidal patients might report difficulties in preventing and managing suicidal thoughts.

Treatment of depression in patients from ethnic minority groups in the Netherlands.

This article presents the results of a large efficacy study comparing different forms of therapy for major depressive disorder (MDD), including interpersonal psychotherapy (IPT) and pharmacotherapy. Patients were randomized to either IPT, IPT in combination with anti-depressant medication, IPT in combination with pill-placebo or medication only. The primary outcome measure was the Hamilton Rating Scale for Depression (HAMD). Patients were treated for 12 to 16 weeks. Ratings were performed at baseline, after 6 weeks of treatment and at the end of treatment. Ethnic minority patients (EMP) had higher scores on the HAMD than non-EMP for every rating period. However, the rate of improvement was the same for EMP and non-EMP. The higher mean scores of EMP on the HAMD could not be explained as solely due to higher scores on somatic items of the rating scales. The attrition rate in EMP (45.9%) was significantly higher than in non-EMP (24.4%), even in the structured treatment format studied. The results suggest that standard antidepressant therapy, be it medication, psychotherapy or both, may be effective for depressed minority patients but therapists should focus on enhancing adherence to treatment.

[Depression and somatic comorbidity]. / Depressie en somatische comorbiditeit.

Depressed persons have a higher risk of developing somatic conditions such as cardiovascular disease, diabetes and obesity. Somatic comorbidity in depressed persons may be explained by mediating mechanisms such as unhealthy lifestyle and unfavorable pathophysiological disturbances. There are alternative explanations for somatic comorbidity in depressed persons: genetic pleiotropy, iatrogenic effects, and the phenomenon 'somatic depression'. In the latter, the symptoms of depression are a consequence of clinical or subclinical somatic conditions. When treating a depressed patient, their somatic health should also be monitored. Further research is needed to examine whether specific interventions may prevent somatic comorbidity in depression.

Stimulated gene expression profiles as a blood marker of major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) is a moderately heritable disorder with a high lifetime prevalence. At present, laboratory blood tests to support MDD diagnosis are not available. METHODS: We used a classifier approach on blood gene expression profiles of a unique set of unmedicated subjects (MDD patients and control subjects) to select genes with expression predictive for disease status. To reveal blood gene expression changes related to major depressive disorder-disease, we applied a powerful ex vivo stimulus to the blood: incubation with lipopolysaccharide (LPS; 10 ng/mL blood). RESULTS: Based on LPS-stimulated blood gene expression using whole-genome microarrays (primary cohort; 21 MDD patients, 21 healthy control subjects), we identified a set of genes (CAPRIN1, CLEC4A, KRT23, MLC1, PLSCR1, PROK2, ZBTB16) that serves as a molecular signature of MDD. These findings were validated using an independent quantitative polymerase chain reaction method (primary cohort, p = .007). The difference between depressive patients and control subjects was confirmed (p = .019) in a replication cohort of 13 MDD patients and 14 control subjects. The MDD signature score comprised expression levels of seven genes could discriminate depressive patients from control subjects with sensitivity of 76.9% and specificity of 71.8%. CONCLUSIONS: We have shown for the first time that molecular analysis of stimulated blood cells can be used as an endophenotype for MDD diagnosis, which is a milestone in establishing biomarkers for neuropsychiatric disorders with moderate heritability in general. Our results may provide a new entry point for following and predicting treatment outcome, as well as prediction of severity and recurrence of major depressive disorder.

A randomized trial of cognitive-behavioral therapy or selective serotonin reuptake inhibitor or both combined for panic disorder with or without agoraphobia: treatment results through 1-year follow-up.

OBJECTIVE: To establish the long-term effectiveness of 3 treatments for DSM-IV panic disorder with or without agoraphobia: cognitive-behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT + SSRI). As a secondary objective, the relationship between treatment outcome and 7 predictor variables was investigated. METHOD: Patients were enrolled between April 2001 and September 2003 and were randomly assigned to treatment. Academic and nonacademic clinical sites participated. Each treatment modality lasted 1 year. Pharmacotherapists were free to choose between 5 SSRIs currently marketed in The Netherlands. Outcome was assessed after 9 months of treatment (posttest 1), after discontinuation of treatment (posttest 2), and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2). RESULTS: In the sample (N = 150), 48% did not suffer from agoraphobia or suffered from only mild agoraphobia, while 52% suffered from moderate or severe agoraphobia. Patients in each treatment group improved significantly from pretest to posttest 1 on the primary outcome measures of level of anxiety (P < .001), degree of coping (P < .001), and remitter status (P < .001), as well as on the secondary outcome measures of depressive symptomatology (P < .001), and from pretest to posttest 2 for health-related quality of life (P < .001). Gains were preserved from posttest 2 throughout the follow-up period. Some superiority of CBT + SSRI and SSRI as compared with CBT was observed at posttest 1. However, at both follow-ups, differences between treatment modalities proved nonsignificant. Client satisfaction appeared to be high at treatment endpoint, while patients receiving CBT + SSRI appeared slightly (P < .05) more satisfied than those receiving CBT only. CONCLUSIONS: No fall-off in gains was observed for either treatment modality after treatment discontinuation. SSRIs were associated with adverse events. Gains produced by CBT were slower to emerge than those produced by CBT + SSRI and SSRI, but CBT ended sooner. TRIAL REGISTRATION: Netherlands Trial Register (www.trialregister.nl) Identifier: ISRCTN8156869.

Does the therapy manual or the therapist matter most in treatment of obsessive-compulsive disorder? A randomized controlled trial of exposure with response or ritual prevention in 118 patients.

BACKGROUND: The importance of the therapist's education and experience for the successful behavior treatment of obsessive-compulsive disorder (OCD) has not been investigated. Data on the relative effectiveness of self-controlled versus therapist-controlled in vivo exposure with response or ritual prevention (ERP) have yielded conflicting results. The present study compared the effectiveness of 4 different modes of delivery of ERP in a referred sample of OCD patients. METHOD: Of the 146 eligible OCD outpatients, 118 patients enrolled in this randomized controlled trial and were randomly assigned to (1) therapist-controlled ERP performed by experienced behavior therapists; (2) therapist-controlled ERP performed by master's students of clinical psychology; (3) self-controlled ERP performed by experienced behavior therapists; and (4) self-controlled ERP performed by master's students of clinical psychology. This trial was performed from January 1999 to January 2005. RESULTS: Our analyses revealed no significant differences in clinical outcome between any of the different modes of delivery of ERP at posttreatment. The different ERP modes of delivery were associated with significant pretreatment to posttreatment improvement on all measurements, with large effect sizes on the primary outcome measure, the Yale-Brown Obsessive Compulsive Scale. CONCLUSIONS: Our results indicate that clinically inexperienced master's students with no postgraduate training can be as capable as experienced and certified behavior therapists in treating OCD patients, as long as therapists adhere to a standardized treatment manual and adequate training and supervision is provided. In contrast to other studies, we did not find a supposed benefit of therapist-controlled ERP versus self-controlled ERP in patients with OCD. TRIAL REGISTRATION: www.trialregister.nl Identifier: NTR1444.

Stabilizing group treatment for Complex Posttraumatic Stress Disorder related to childhood abuse based on psycho-education and cognitive behavioral therapy: a pilot study.

OBJECTIVE: This study tests a Stabilizing Group Treatment protocol, designed for the management of the long-term sequelae of child abuse, that is, Complex Posttraumatic Stress Disorder (Complex PTSD). Evidence-based treatment for this subgroup of PTSD patients is largely lacking. This stabilizing treatment aims at improving Complex PTSD using psycho-education and cognitive behavioral interventions. METHOD: Thirty-six patients with a history of childhood abuse, Complex PTSD and severe co-morbidity entered a 20-week treatment with pre-, post-, and follow-up-assessments. RESULTS: Improvement was found for PTSD and borderline symptoms. Post-treatment 64% and after 6 months 78% of patients no longer met criteria for Complex PTSD. CONCLUSIONS: This open study indicates both the feasibility of investigating treatment outcome and the initial efficacy of stabilizing group treatment in severely ill patients with Complex PTSD related to childhood abuse.

Salivary cortisol levels in persons with and without different anxiety disorders.

OBJECTIVE: To examine the association between several subtypes of anxiety disorders and various cortisol indicators in a large cohort study. Anxiety disorders have been suggested to be linked to hypothalamic-pituitary-adrenal (HPA) axis activity, although results are scarce and inconsistent. No earlier studies have examined consistency of HPA axis findings across several anxiety subtypes and whether associations are state or trait dependent. METHODS: Data are derived from 1427 participants of the Netherlands Study of Depression and Anxiety. Three groups were compared: 342 control participants without psychiatric disorders; 311 persons with a remitted (no current) anxiety disorder (social phobia, generalized anxiety disorder, panic disorder); and 774 persons with a current anxiety disorder, as diagnosed using the Composite International Diagnostic Interview psychiatric interview. Cortisol levels were measured in seven saliva samples, determining the 1-hour cortisol awakening response, evening cortisol, and cortisol response after 0.5 mg of dexamethasone ingestion. RESULTS: Current anxiety disorder was associated with higher awakening cortisol levels (p = .002). These findings were mainly present for patients with panic disorder with agoraphobia and anxious patients with comorbid depressive disorder. Remitted anxiety only showed a trend toward higher morning cortisol (p = .08). No associations were observed for anxiety status and evening cortisol level or cortisol suppression after dexamethasone. CONCLUSIONS: This study showed a modest but significantly higher 1-hour cortisol awakening response among anxiety patients, which was driven by those with panic disorder with agoraphobia and those with comorbid depression.

Insomnia and sleep duration in a large cohort of patients with major depressive disorder and anxiety disorders.

OBJECTIVE: Disturbed sleep has a high impact on daily functioning and has been correlated with psychopathology. We investigated the extent to which insomnia and sleep duration were associated with both current and remitted depressive and anxiety disorders in a large-scale epidemiologic study, taking sociodemographics, health factors, and medication use into account. METHOD: Data of 2,619 individuals from the Netherlands Study of Depression and Anxiety (NESDA) were analyzed. Psychopathology was classified as no, current, or remitted DSM-IV-based diagnosis of major depressive or anxiety disorder. Outcome measures were insomnia (Women's Health Initiative Insomnia Rating Scale score >or= 9) and sleep duration (or= 10 hours). Baseline measurement was conducted between September 2004 and February 2007. RESULTS: Both current and remitted depressive disorder and current anxiety disorder were associated with insomnia and short sleep duration with odds ratios (ORs) for insomnia ranging from 1.42 to 3.23 and for short sleep duration ranging from 1.41 to 2.53. Associations were stronger for current than for remitted diagnoses and stronger for depressive than for anxiety disorders. Also long sleep duration was associated with current depressive disorder and anxiety disorders (OR range, 1.53-2.66). Sociodemographic factors, health indicators, and psychotropic medication use did contribute to sleep outcomes but could not explain much of the psychopathology and sleep associations. CONCLUSION: Depressive disorder-but also anxiety disorder-is strongly associated with sleep disturbances. Insomnia and short sleep duration persist after remittance of these disorders, suggesting that these are residual symptoms or possibly trait markers. Also, long sleep duration is associated with current depressive or anxiety disorders.

Long-term effectiveness and prediction of treatment outcome in cognitive behavioral therapy and sertraline for late-life anxiety disorders.

BACKGROUND: Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders. METHODS: Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established. RESULTS: Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants. CONCLUSIONS: Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Implementation of outpatient schema therapy for borderline personality disorder: study design.

BACKGROUND: Schema Therapy (ST) is an integrative psychotherapy based upon a cognitive schema model which aims at identifying and changing dysfunctional schemas and modes through cognitive, experiential and behavioral pathways. It is specifically developed for patients with personality disorders. Its effectiveness and efficiency have been demonstrated in a few randomized controlled trials, but ST has not been evaluated in regular mental healthcare settings. This paper describes the study protocol of a multisite randomized 2-group design, aimed at evaluating the implementation of outpatient schema therapy for patients with borderline personality disorder (BPD) in regular mental healthcare and at determining the added value of therapist telephone availability outside office hours in case of crisis. METHODS/DESIGN: Patient outcome measures will be assessed with a semi-structured interview and self-report measures on BPD, therapeutic alliance, quality of life, costs and general psychopathology at baseline, 6, 12, 18 and 36 months. Intention-to-treat analyses will be executed with survival analysis for dichotomous variables, and one-sample t-tests and ANCOVAs for continuous variables with baseline as covariate and condition as between group factor. All tests will be two-tailed with a significance level of 5%. DISCUSSION: The study will provide an answer to the question whether ST can be effectively implemented and whether phone support by the therapist has an additional value. TRIAL REGISTRATION: The Dutch Cochrane Center, NTR (TC = 1781).