Publications by authors named "Jack Dekker"

180 Publications

The effectiveness of intensive home treatment as a substitute for hospital admission in acute psychiatric crisis resolution in the Netherlands: a two-centre Zelen double-consent randomised controlled trial.

Lancet Psychiatry 2022 08 30;9(8):625-635. Epub 2022 Jun 30.

Department of Research, Arkin, Amsterdam, Netherlands; Vrije Universiteit Department Clinical Psychology, Amsterdam, The Netherlands.

Background: Although de-institutionalisation has been underway for decades, admission to hospital followed by low-intensity outpatient care remains the usual treatment for patients with an acute psychiatric crisis. Intensive home treatment has been developed for patients in a severe psychiatric crisis as an alternative to inpatient care. This study aimed to evaluate the potential of intensive home treatment to reduce bed-days and its clinical effectiveness compared with treatment as usual.

Methods: We did a two-armed, two-centre, open-label, Zelen, double-consent, pragmatic randomised controlled trial. Patients aged 18-65 years were recruited at the psychiatric emergency service and psychiatric emergency wards of the two major mental health institutions (Arkin and GGZ inGeest) in Amsterdam, the Netherlands. Patients diagnosed with at least one DSM-IV-TR or DSM-5 disorder and in a psychiatric crisis and for whom psychiatrists had indicated or completed a clinical admission could be included. Trained psychiatric emergency service and hospital professionals did the automated web-based pre-randomisation procedure upon first contact with the patient. A seeded pseudo-random number generator allocated patients (2:1) to intensive home treatment or treatment as usual. Informed consent was obtained after randomisation as soon as the patient was mentally capable within 14 days. Due to the nature of this study, patients and professionals were not masked to treatment. Intensive home treatment was tailored to the nature of the crisis and goals of patients and relatives, and developed in collaboration with them and a multidisciplinary professional team. All main analyses were intention-to-treat, and the primary outcome was the total number of admission days 12 months after randomisation. To investigate the effect of treatment conditions on the outcome measures, linear mixed modelling analyses using restricted maximum likelihood estimation were done. This trial was prospectively registered with Trialregister.nl, NL-6020 (NTR-6151).

Findings: Between Nov 15, 2016, and Oct 15, 2018, 246 patients were included in the study (183 patients with intensive home treatment vs 63 patients with treatment as usual). 135 women (55%) and 111 men (45%) were included, with a mean age of 41·01 years (range 18-65; SD 12·68). 114 participants (46%) were born in the Netherlands and 85 (35%) elsewhere (missing data on 47 [19%] participants). Ethnicity data were not available. After 12 months, the mean number of admission days in the intensive home treatment condition was 42·47 (SD 53·92) versus 67·02 (SD 79·03) for treatment as usual, a reduction of 24·55 days (SD 10·73) or 36·6% (p=0·033). 26 adverse events were registered, 23 (89%) of which were suicide attempts. The number of patients with a reported adverse event did not differ significantly between the groups (15 [8%] in the intensive home treatment group vs five [8%] in the treatment as usual group; p=0·950). Five patients died by suicide (three [2%] in the intensive home treatment group vs two [3%] in the treatment as usual group; p=0·610). No treatment-related deaths occurred.

Interpretation: Intensive home treatment is a safe and effective partial substitute for conventional psychiatric crisis care that led to a reduction in admission days, causing patients to stay longer in their social environment, with similar clinical effects, patient satisfaction and adverse events.

Funding: De Stichting tot Steun Vereniging voor Christelijke Verzorging van Geestes-en Zenuwzieken.
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http://dx.doi.org/10.1016/S2215-0366(22)00187-0DOI Listing
August 2022

Economic evaluation of day hospital versus intensive outpatient mentalization-based treatment alongside a randomized controlled trial with 36-month follow-up.

Personal Disord 2022 Jun 30. Epub 2022 Jun 30.

De Viersprong, Viersprong Institute for Studies on Personality Disorders.

Mentalization-based treatment (MBT) has demonstrated robust effectiveness in the treatment of borderline personality disorder (BPD) in both day-hospital (MBT-DH) and intensive outpatient MBT (MBT-IOP) programs. Given the large differences in intensity and associated treatment costs, there is a need for studies comparing their cost-effectiveness. A health economic evaluation of MBT-DH versus MBT-IOP was performed alongside a multicenter randomized controlled trial with a 36-month follow-up. In three mental health-care institutions in the Netherlands, 114 patients were randomly allocated to MBT-DH ( = 70) or MBT-IOP ( = 44) and assessed every 6 months. Societal costs were compared with quality-adjusted life years (QALYs) gained and the number of months in remission over 36 months. The QALY gains over 36 months were 1.96 ( = .58) for MBT-DH and 1.83 ( = .56) for MBT-IOP; the respective number of months in remission were 16.0 ( = 11.5) and 11.1 ( = 10.7). Societal costs were €106,038 for MBT-DH and €91,368 for MBT-IOP. The incremental cost for one additional QALY with MBT-DH compared with MBT-IOP was €107,000. The incremental cost for 1 month in remission was almost €3000. Assuming a willingness-to-pay threshold of €50,000 for a QALY, there was a 33% likelihood that MBT-DH is more cost-effective than MBT-IOP in terms of costs per QALY. Although MBT-DH leads to slightly more QALYs and remission months, it is probably not cost-effective when compared with MBT-IOP for BPD patients, as the small additional health benefits in MBT-DH did not outweigh the substantially higher societal costs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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http://dx.doi.org/10.1037/per0000577DOI Listing
June 2022

General Demographics and Behavioral Patterns of Visitors Using a Self-help Website for Identification of and Intervention in Alcoholism and Common Mental Disorders in Suriname: Descriptive Study.

JMIR Form Res 2022 Jun 9;6(6):e33793. Epub 2022 Jun 9.

Arkin, Amsterdam, Netherlands.

Background: Digital health applications have been shown to be an accepted means to provide mental health information and advice in various high- and middle-income countries. Started in 2015, ehealth.sr was the first website to offer preventive information, self-tests, and unguided digital self-help for depression, anxiety symptoms, and problematic alcohol use in Suriname, an upper middle-income country in South America.

Objective: This study aimed to assess the general demographics and behavioral patterns of the visitors of ehealth.sr, as well as to evaluate different promotional channels to attract the target audience to the website.

Methods: Data collection for this study took place between August 2015 and December 2020. Conventional promotion channels such as newspaper and radio advertisements as well as social media advertisements were used to attract users to the website. The number of visits and activity on the website was registered using Google analytics and the website's internal activity log.

Results: On average, about 115 unique visitors accessed the website per month. The average number of visits to the website increased notably when social media advertisement campaigns were conducted (266 per month in 2018) compared to when traditional advertisements campaigns through papers, radio, and television were used (34 per month in 2019). Of the 1908 new visitors, 1418 (74.32%) were female. On average, visitors accessed 2 (SD 0.3) pages of the website and a session lasted 2.6 (SD 0.9) minutes. The most popular pages for intervention on the website were those for the mood or anxiety screening (731/942, 77.6%) as opposed to those for alcohol screening (211/942, 22.4%). People aged <45 years (on average, 2.2 pages per session for 3.2 minutes) made more use of the website than people aged ≥45 years (on average, 1.7 pages per session for 2 minutes).

Conclusions: Promotion via social media led to more visitors to the website than newspaper or radio advertisements. Younger age groups and females visited the website more often. The pages on preventive information and brief self-tests were visited more frequently than the self-help modules. In general, user adherence to the website in terms of the average session duration and number of viewed pages per session is low and is a key point of concern for the successful implementation of digital mental health websites.
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http://dx.doi.org/10.2196/33793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9227647PMC
June 2022

Trauma and Outcomes of Mentalization-Based Therapy for Individuals With Borderline Personality Disorder.

Am J Psychother 2022 Jan 31;75(1):12-20. Epub 2022 Jan 31.

De Viersprong, Viersprong Institute for Studies on Personality Disorders, Halsteren, the Netherlands (Smits, Luyten, Feenstra, Bales); Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium, and Research Department of Clinical, Educational and Health Psychology, University College London, London (Luyten); Department of Psychology, University of Amsterdam, Amsterdam (Kamphuis); Department of Research, Arkin Mental Health Care, and Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam (Dekker); Lentis, Groningen, the Netherlands (Verheul); Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, the Netherlands (Busschbach).

Objective: Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP).

Methods: All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment.

Results: Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP.

Conclusions: Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.
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http://dx.doi.org/10.1176/appi.psychotherapy.20210027DOI Listing
January 2022

Impact of COVID-19 social distancing measures on routine mental health care provision and treatment outcome for common mental disorders in the Netherlands.

Clin Psychol Psychother 2022 Jan 24. Epub 2022 Jan 24.

Research Department, Arkin Mental Health Care, Amsterdam, The Netherlands.

Objective: The uptake of digital interventions in mental health care (MHC) has been slow, as many therapists and patients believe that in-person contact is essential for establishing a good working relationship and good outcomes in treatment. The public health policies regarding social distancing during the coronavirus disease-2019 (COVID-19) pandemic forced an abrupt transformation of MHC provisions for outpatients: Since mid-March 2020, nearly all in-person contact was replaced with videoconferencing. The COVID-19 crisis offered a unique opportunity to investigate whether MHC with videoconferencing yields inferior results as compared to in-person interventions.

Method: In a large urban MHC facility in the Netherlands, measurement-based care is routine practice. Outcome data are regularly collected to support shared decision making and monitor patient progress. For this study, pretest and post-test data were used to compare outcomes for three cohorts: treatments performed prior to, partially during and entirely during the COVID-19 lockdown. Outcomes were compared in two large data sets: Basic MHC (N = 1392) and Specialized MHC (N = 1040).

Results: Therapeutic outcomes appeared robust for COVID-19 conditions across the three cohorts: No differences in outcomes were found between treatments that were conducted during lockdown compared to in-person treatments prior to COVID-19, or treatments which started in-person, but needed to be continued by means of videoconferencing.

Discussion: Videoconferencing care during the COVID-19 pandemic had similar outcomes compared to traditional in-person care. These real-world results corroborate findings of previous randomized controlled studies and meta-analyses in which videoconferencing and in-person care has been directly compared in terms of clinical effectiveness.
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http://dx.doi.org/10.1002/cpp.2713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9015637PMC
January 2022

A survey of depression and anxiety disorders in urban and rural Suriname.

BMC Public Health 2022 01 8;22(1):51. Epub 2022 Jan 8.

Research Department, Arkin Mental Health Institute, Amsterdam, The Netherlands.

Background: Suriname is a Low-middle income country consisting of diverse population groups. Epidemiological studies concerning mental disorders like depression and anxiety had not been conducted until 2015. The treatment gap for mental disorders in Low and middle-income countries (LMICs) may reach 76-80% as treatment is not always readily available. In this study, we estimate and compare the prevalence of potential cases of depression and anxiety, as well as the size of the treatment gap in a rural (Nickerie) and urban (Paramaribo) region of Suriname, a lower middle-income country.

Methods: Subjects were selected by a specific sampling method of the national census bureau. The Center for Epidemiological Studies-Depression (CES-D) was used to assess depression. Generalized anxiety disorder was assessed with the Generalized Anxiety Disorder 7 (GAD-7) and The Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ) were used to assess Panic disorder. The treatment gap was calculated by estimating the percentage of subjects with depression or anxiety that did not seek out professional help.

Results: About 18% of the respondents from Nickerie and 16% from Paramaribo were at risk of depression and the established cut-off values of the instruments used indicate that about 3-4% in both regions may suffer from Generalized Anxiety Disorder. Women in both samples were most at risk of high anxiety about body sensations and maladaptive thoughts about panic. The treatment gap varies between 78 and 100% for the two disorders.

Conclusions: A high depression rate has been found in both areas, especially among young females. In addition, a high treatment gap is noted which insinuates that more therapeutic strategies are required to tackle depression and anxiety in Suriname.
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http://dx.doi.org/10.1186/s12889-021-12454-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8742324PMC
January 2022

Effectiveness and cost-effectiveness of cognitive behavior therapy-enhanced compared with treatment-as-usual for anorexia nervosa in an inpatient and outpatient routine setting: a consecutive cohort study.

J Eat Disord 2022 Jan 6;10(1). Epub 2022 Jan 6.

Research Department, Arkin Mental Health Institute, Klaprozenweg 111, 1033 NN, Amsterdam, The Netherlands.

Background: For anorexia nervosa, firm evidence of the superiority of specialized psychological treatments is limited and economic evaluations of such treatments in real world settings are scarce. This consecutive cohort study examined differential (cost-)effectiveness for adult inpatients and outpatients with anorexia nervosa, after implementing cognitive behavioral therapy-enhanced (CBT-E) throughout a routine setting.

Methods: Differences in remission, weight regain and direct eating disorder treatment costs were examined between one cohort (N = 75) receiving treatment-as-usual (TAU) between 2012-2014, and the other (N = 88) CBT-E between 2015-2017. The economic evaluation was performed from a health care perspective with a one-year time horizon, using EDE global score < 2.77, the absence of eating disorder behaviors combined with a BMI ≥ 18.5, as effect measure. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that CBT-E is cost effective compared to TAU.

Results: Using direct eating disorder treatment costs in the cost-effectiveness analysis, the cost-effectiveness plane of the base case scenario for all patients indicated a 84% likelihood of CBT-E generating better health gain at additional costs. The median ICER is €51,081, indicating a probable preference for CBT-E (> 50% probability of cost-effectiveness) assuming a WTP of €51,081 or more for each additional remission, On remission, no difference was found with 9.3% remission during TAU and 14.6% during CBT-E (p = .304). Weight regain was higher during CBT-E (EMD = 1.33 kg/m, SE = .29, 95% CI [0.76-1.9], p < .001).

Conclusions: In this mixed inpatient and outpatient cohort study, findings indicate a probability of CBT-Ebeing more effective at higher costs. These findings may contribute to the knowledge of effectiveness and cost-effectiveness of specialized psychological treatments. In this study, the effectiveness and treatment costs of a specialized psychological treatment for adult clients with anorexia nervosa were compared with a regular, non-specialist treatment. One group of inpatients and outpatients did receive non-specialist treatment, the next group of inpatients and outpatients received CBT-E, a specialized treatment, later on. CBT-E is recommended for clients with bulimia and with binge eating disorder, for clients with anorexia nervosa it is less clear which specialized psychological treatment should be recommended. Results indicate that at end-of-treatment, CBT-E was not superior on remission. When looking at weight regain, CBT-E seemed superior than the treatment offered earlier. Economic evaluation suggests that CBT-E generates better health gain, but at additional costs. This study contributes to the knowledge on the effectiveness and treatment costs of psychological treatments, as they are offered in routine practice, to adults with anorexia nervosa.
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http://dx.doi.org/10.1186/s40337-021-00526-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8734258PMC
January 2022

The Association Between Loneliness and Psychiatric Symptomatology in Older Psychiatric Outpatients.

J Geriatr Psychiatry Neurol 2021 Dec 23:8919887211060022. Epub 2021 Dec 23.

Department of Clinical Research, Arkin Mental Health Care, Amsterdam, Netherlands.

Purpose: Loneliness in adults increases with age. Although loneliness has been found to be associated with psychiatric disorders and dementia, no information is available on prevalence of loneliness in older psychiatric patients. The aims of this study were to examine prevalence of loneliness in older psychiatric outpatients, including gender differences and associations with psychiatric disorders and social isolation.

Methods: Cross-sectional study in an outpatient clinic for geriatric psychiatry between September 2013 and February 2018. Interviews were done in 181 patients.

Results: 80% of participants were lonely. Loneliness was associated with having contacts in less social network domains, in women but not in men. There were no associations with DSM-IV-TR-classifications. However, loneliness was associated with higher scores on questionnaires for depression and cognitive function. Intensity of treatment did not differ significantly between lonely and non-lonely participants.

Conclusion: Loneliness is highly prevalent in older psychiatric outpatients, with men and women equally affected. Loneliness should be assessed in all older psychiatric patients, especially when they show high scores on symptom checklists or have a restricted social network.
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http://dx.doi.org/10.1177/08919887211060022DOI Listing
December 2021

Subjective Medication Satisfaction With Antipsychotic Polypharmacy in a Naturalistic Inpatient and Outpatient Sample.

J Clin Psychiatry 2021 12 21;83(1). Epub 2021 Dec 21.

Arkin, Mental Health Care Institute Amsterdam, Amsterdam, the Netherlands.

The aim of this study was to examine satisfaction with pharmacologic treatment in patients who received antipsychotic polypharmacy compared to antipsychotic monotherapy.

This longitudinal cohort study was conducted in two mental health care institutes in Amsterdam, the Netherlands, among a randomly selected sample of in- and outpatients with a severe mental illness. Analyses were performed on data collected in 2011 for 185 patients who were diagnosed with schizophrenia or unspecified psychosis according to criteria. The outcome measure was the Treatment Satisfaction Questionnaire for Medication, version II. One-way analyses of covariance were performed to examine differences in treatment satisfaction between patients who received antipsychotic polypharmacy compared to antipsychotic monotherapy while controlling for the effects of clozapine, antipsychotic dose, and use of long-acting injectable antipsychotics.

Twenty percent of patients in this sample received 2 antipsychotic agents; in half of those patients, this involved a combination with clozapine. Polypharmacy resulted in less satisfaction with side effects compared to monotherapy ( = .002). No difference was found in perceived effectiveness ( = .168) or overall medication satisfaction ( = .379).

These results confirm that antipsychotic polypharmacy is common in a random in- and outpatient sample. Patients who receive 2 antipsychotic agents are just as positive about the effectiveness and ease of use of and overall satisfaction with their medication compared to those who receive antipsychotic monotherapy. They are, however, less satisfied with perceived side effects of their medication, which may indicate that side effect profiles of antipsychotic combinations are less favorable.
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http://dx.doi.org/10.4088/JCP.20m13756DOI Listing
December 2021

Economic Evaluation of the SOS Training to Reduce Victimization in Dual Diagnosis Patients.

J Dual Diagn 2021 Oct-Dec;17(4):333-343. Epub 2021 Sep 26.

Department of Research, Arkin Mental Health Care, Amsterdam, the Netherlands.

Objective: Economic evaluations of interventions for dual diagnosis patients are scarce. A recent randomized controlled trial has supported the effectiveness of the Self-wise, Otherwise, Streetwise (SOS) training to reduce victimization in dual diagnosis patients. The purpose of the current study was to analyze the cost-effectiveness and cost-utility of the SOS training as an add-on to care as usual (CAU).

Methods: We performed an economic evaluation from a societal perspective alongside the SOS trial. Participants were 250 dual diagnosis patients recruited at three locations from a large urban psychiatric service in the Netherlands. The main outcomes were treatment response for victimization and quality-adjusted life years (QALYs). Both costs and effects were measured across a 14-month follow-up.

Results: There was no significant difference between CAU + SOS and CAU in total costs (mean difference €4,859; 95% CI [-€4,795 to €14,513]) and QALY gains (mean difference 0.0012; 95% CI [-0.05 to 0.05]). Significantly more participants in CAU + SOS achieved treatment response for victimization compared to CAU (68% vs. 54%; mean difference 0.14; 95% CI [0.02 to 0.26]). The cost-effectiveness analysis indicated an 83% likelihood that CAU + SOS resulted in a higher treatment response rate for victimization at higher costs compared to CAU. The cost-utility analysis indicated that adding SOS-training to CAU is probably not cost-effective at conventional willingness-to-pay levels for QALYs.

Conclusions: At a societal willingness-to-pay of €38,000 or more per extra treatment responder, adding SOS-training to usual care is probably more attractive than usual care alone with regard to cost-effectiveness. This is a considerable willingness to pay. However, the direct costs of offering the SOS training are expected to be minor. Our findings should be interpreted with caution due to the short follow-up period and absence of data on potential reductions in police and judicial costs other than prison costs.
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http://dx.doi.org/10.1080/15504263.2021.1965409DOI Listing
December 2021

Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet?

Front Psychol 2021 15;12:676733. Epub 2021 Jul 15.

Arkin, Amsterdam, Netherlands.

Narcissistic Personality Disorder is the new borderline personality disorder of our current era. There have been recent developments on narcissism that are certainly worthwhile examining. Firstly, relational and intersubjective psychoanalysts have been rethinking the underlying concepts of narcissism, focusing on the development of self and relations to others. Secondly, in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) was presented for a dimensional evaluation of the severity of personality disorder pathology. The combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning. Finally, Pincus and Lukowitsky encourage clinicians to use a hierarchical model of pathological narcissism, as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. As for most non-psychodynamic clinicians and researchers the DSM-5 clearly bears dominant weight in their work, we will take the AMPD model for NPD as our point of reference. We will discuss the narcissist's unique pattern of self-impairments in identity and self-direction, and of interpersonal disfunctioning (evaluated by assessing empathy and intimacy). Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD. For us, one of the big advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning and the dimensional evaluation of severity. As psychodynamically oriented therapists, we are enthusiastic about the opportunities for inclusion of psychodynamic concepts, but we also discuss a number of sticking points.
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http://dx.doi.org/10.3389/fpsyg.2021.676733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8321510PMC
July 2021

Effectiveness of a digital alcohol moderation intervention as an add-on to depression treatment for young adults: study protocol of a multicentre pragmatic randomized controlled trial.

BMC Psychiatry 2021 05 22;21(1):265. Epub 2021 May 22.

Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands.

Background: Depressive disorders and problematic drinking often co-occur, also among young adults. These co-occurring conditions are associated with various negative health outcomes compared to both conditions alone. Early intervention by addressing alcohol use and depressive symptoms simultaneously in the same treatment might improve both conditions. However, evidence on the (cost-) effectiveness of digital combined depression and alcohol interventions for young adults is currently insufficient. We therefore developed an add-on digital alcohol moderation adherence-focussed guided intervention to complement treatment as usual (TAU) for depressive disorders. The digital intervention is a web-app, including 6 modules based on motivational interviewing and cognitive behavioural therapy. This study aims to evaluate the (cost-)effectiveness of a digital alcohol moderation intervention + TAU compared to TAU on alcohol and depression outcomes among young adults with co-occurring depressive disorders and problematic alcohol use.

Methods: One hundred fifty-six participants, aged 18-35 years, with problematic alcohol use and a diagnosed depressive disorder will participate in a pragmatic multicentre two-arm randomized controlled trial. Problematic alcohol use is operationalised as scoring ≥5 for women and ≥ 8 for men on the Alcohol Use Disorder Identification Test (AUDIT). Participants will be randomized to either the experimental group (digital alcohol intervention + TAU) or control group (TAU only). Participants will be recruited at three Dutch mental health care centres and through social media. Assessments take place at baseline and after 3, 6 and 12 months post-randomization. The primary outcome is treatment response at 6-month follow-up, operationalized as a composite score that combines alcohol use and depression measures and indicates whether treatment has been successful or not. Secondary outcomes are depressive symptoms and alcohol use (i.e. number of weekly standard drinks and AUDIT score). An economic evaluation will be conducted alongside the trial.

Discussion: This study evaluates the (cost-) effectiveness of an add-on digital alcohol moderation intervention for young adults who are in treatment for depressive disorders. If proven effective, the digital intervention could be implemented in mental health care and improve treatment for people with co-occurring depressive disorders and problematic alcohol use.

Trial Registration: Pre-registered on October 29, 2019 in The Netherlands Trial Register ( NL8122 ).
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http://dx.doi.org/10.1186/s12888-021-03222-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140318PMC
May 2021

Neural correlates of treatment effect and prediction of treatment outcome in patients with PTSD and comorbid personality disorder: study design.

Borderline Personal Disord Emot Dysregul 2021 May 5;8(1):13. Epub 2021 May 5.

Sinai Centrum, Amstelveen, The Netherlands.

Background: Neural alterations related to treatment outcome in patients with both post-traumatic stress disorder (PTSD) and comorbid personality disorder are unknown. Here we describe the protocol for a neuroimaging study of treatment of patients with PTSD and comorbid borderline (BPD) or cluster C (CPD) personality disorder traits. Our specific aims are to 1) investigate treatment-induced neural alterations, 2) predict treatment outcome using structural and functional magnetic resonance imaging (MRI) and 3) study neural alterations associated with BPD and CPD in PTSD patients. We hypothesize that 1) all treatment conditions are associated with normalization of limbic and prefrontal brain activity and hyperconnectivity in resting-state brain networks, with additional normalization of task-related activation in emotion regulation brain areas in the patients who receive trauma-focused therapy and personality disorder treatment; 2) Baseline task-related activation, together with structural brain measures and clinical variables predict treatment outcome; 3) dysfunction in task-related activation and resting-state connectivity of emotion regulation areas is comparable in PTSD patients with BPD or CPD, with a hypoconnected central executive network in patients with PTSD+BPD.

Methods: We aim to include pre- and post-treatment 3 T-MRI scans in 40 patients with PTSD and (sub) clinical comorbid BPD or CPD. With an expected attrition rate of 50%, at least 80 patients will be scanned before treatment. MRI scans for 30 matched healthy controls will additionally be acquired. Patients with PTSD and BPD were randomized to either EMDR-only or EMDR combined with Dialectical Behaviour Therapy. Patients with PTSD and CPD were randomized to Imaginary Rescripting (ImRs) or to ImRs combined with Schema Focused Therapy. The scan protocol consists of a T1-weighted structural scan, resting state fMRI, task-based fMRI during an emotional face task and multi-shell diffusion weighted images. For data analysis, multivariate mixed-models, regression analyses and machine learning models will be used.

Discussion: This study is one of the first to use neuroimaging measures to predict and better understand treatment response in patients with PTSD and comorbid personality disorders. A heterogeneous, naturalistic sample will be included, ensuring generalizability to a broad group of treatment seeking PTSD patients.

Trial Registration: Clinical Trials, NCT03833453 & NCT03833531 . Retrospectively registered, February 2019.
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http://dx.doi.org/10.1186/s40479-021-00156-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097786PMC
May 2021

Clinical Efficacy and Cost-Effectiveness of Imagery Rescripting Only Compared to Imagery Rescripting and Schema Therapy in Adult Patients With PTSD and Comorbid Cluster C Personality Disorder: Study Design of a Randomized Controlled Trial.

Front Psychiatry 2021 19;12:633614. Epub 2021 Mar 19.

Sinai Centrum, Amstelveen, Netherlands.

Posttraumatic stress disorder (PTSD) is a serious and relatively common mental disorder causing a high burden of suffering. Whereas evidence-based treatments are available, dropout and non-response rates remain high. PTSD and Cluster C personality disorders (avoidant, dependent or obsessive-compulsive personality disorder; CPD) are highly comorbid and there is evidence for suboptimal treatment effects in this subgroup of patients. An integrated PTSD and CPD treatment may be needed to increase treatment efficacy. However, no studies directly comparing the efficacy of regular PTSD treatment and treatment tailored to PTSD and comorbid CPD are available. Whether integrated treatment is more effective than treatment focused on PTSD alone is important, since (1) no evidence-based guideline for PTSD and comorbid CPD treatment exists, and (2) treatment approaches to CPD are costly and time consuming. Present study design describes a randomized controlled trial (RCT) directly comparing trauma focused treatment with integrated trauma focused and personality focused treatment. An RCT with two parallel groups design will be used to compare the clinical efficacy and cost-effectiveness of "standalone" imagery rescripting ( = 63) with integrated imagery rescripting and schema therapy ( = 63). This trial is part of a larger research project on PTSD and personality disorders. Predictors, mediators and outcome variables are measured at regular intervals over the course of 18 months. The main outcome is PTSD severity at 12 months. Additionally, machine-learning techniques will be used to predict treatment outcome using biopsychosocial variables. This study protocol outlines the first RCT aimed at directly comparing the clinical efficacy and cost-effectiveness of imagery rescripting and integrated imagery rescripting and schema therapy for treatment seeking adult patients with PTSD and comorbid cluster C personality pathology. Additionally, biopsychosocial variables will be used to predict treatment outcome. As such, the trial adds to the development of an empirically informed and individualized treatment indication process. ClinicalTrials.gov, NCT03833531.
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http://dx.doi.org/10.3389/fpsyt.2021.633614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044980PMC
March 2021

Police Encounters, Agitation, Diagnosis, and Employment Predict Psychiatric Hospitalisation of Intensive Home Treatment Patients During a Psychiatric Crisis.

Front Psychiatry 2021 5;12:602912. Epub 2021 Feb 5.

Department of Research, Arkin Institute for Mental Health Care, Amsterdam, Netherlands.

This study aims to determine factors associated with psychiatric hospitalisation of patients treated for an acute psychiatric crisis who had access to intensive home treatment (IHT). This study was performed using data from a randomised controlled trial. Interviews, digital health records and eight internationally validated questionnaires were used to collect data from patients on the verge of an acute psychiatric crisis enrolled from two mental health organisations. Thirty-eight factors were assigned to seven risk domains. The seven domains are "sociodemographic", "social engagement", "diagnosis and psychopathology", "aggression", "substance use", "mental health services" and "quality of life". Multiple logistic regression analysis (MLRA) was conducted to assess how much pseudo variance in hospitalisation these seven domains explained. Forward MLRA was used to identify individual risk factors associated with hospitalisation. Risks were expressed in terms of relative risk (RR) and absolute risk difference (ARD). Data from 183 participants were used. The mean age of the participants was 40.03 (SD 12.71), 57.4% was female, 78.9% was born in the Netherlands and 51.4% was employed. The range of explained variance for the domains related to "psychopathology and care" was between 0.34 and 0.08. The "aggression" domain explained the highest proportion ( = 0.34) of the variance in hospitalisation. "Quality of life" had the lowest explained proportion of variance ( = 0.05). The forward MLRA identified four predictive factors for hospitalisation: previous contact with the police or judiciary (OR = 7.55, 95% CI = 1.10-51.63; ARD = 0.24; RR = 1.47), agitation (OR = 2.80, 95% CI = 1.02-7.72; ARD = 0.22; RR = 1.36), schizophrenia spectrum and other psychotic disorders (OR = 22.22, 95% CI = 1.74-284.54; ARD = 0.31; RR = 1.50) and employment status (OR = 0.10, 95% CI = 0.01-0.63; ARD = -0.28; RR = 0.66). IHT teams should be aware of patients who have histories of encounters with the police/judiciary or were agitated at outset of treatment. As those patients benefit less from IHT due to the higher risk of hospitalisation. Moreover, type of diagnoses and employment status play an important role in predicting hospitalisation.
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http://dx.doi.org/10.3389/fpsyt.2021.602912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901988PMC
February 2021

Exploring differences in quality of life in clinical populations of depressed outpatients with and without personality disorders.

J Affect Disord 2021 03 7;282:1125-1131. Epub 2021 Jan 7.

Department of Research, Arkin Mental Health Care, Department of Clinical Psychology, Vrije Universiteit Amsterdam, The Netherlands. Electronic address:

Background: Although depression and personality disorders (PDs) often co-occur, less is known about the impact of PDs on health-related quality of life (HRQOL) in patients with depression. This study explores the differences in HRQOL of depressed patients with and without PD.

Methods: Baseline data of 397 patients with depression from two randomised controlled trials were used for this analysis. HRQOL was measured with the EuroQol-5D (EQ-5D). Differences were examined between three groups: patients with 1) depression-only, 2) depression and comorbid PD and 3) PD and comorbid depression. The EQ-5D scores of the groups were compared with linear regression.

Results: HRQOL scores were lower in the depression-only group than the depression + PD group, even though depression severity was higher in patients with PD. HRQOL in the PD ± depression group did not differ from the other groups. In addition, no associations were found between the type or severity of PD and HRQOL.

Discussion: These findings could indicate that patients with PD are less affected by the impact of depression on HRQOL. In addition, the EQ-5D might not adequately capture the impact of PD on quality of life. Further research is needed to compare the EQ-5D with quality of life instruments that include more life domains.

Limitations: Two study samples are combined, and therefore not designed to compare the three groups directly. Generalisation of the results should be done with caution.

Conclusion: Depressed patients with PD report higher HRQOL than depression-only patients. Although higher HRQOL, patients with PD report more severe depressions than depressed-only patients.
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http://dx.doi.org/10.1016/j.jad.2020.12.122DOI Listing
March 2021

Digital Interventions for People With Co-Occurring Depression and Problematic Alcohol Use: A Systematic Review and Meta-Analysis.

Alcohol Alcohol 2022 Jan;57(1):113-124

Department of Research, Arkin Mental Health Care, 1033 NN Amsterdam, The Netherlands.

Aims: This systematic review and meta-analysis assessed the effectiveness of digital interventions addressing depressive symptoms and alcohol use simultaneously among people with co-occurring depression and problematic alcohol use.

Methods: Seven databases were searched for trials evaluating digital interventions aimed at depression and alcohol use. Random-effects meta-analyses were conducted to pool effects on depressive symptoms and alcohol use up to 3-month and 6-month follow-up. Overall quality for every outcome was assessed with GRADE (Grading of Recommendations Assessment, Development and Evaluation).

Results: The pooled effect of digital interventions compared to their comparators was in favour of digital interventions. Small but significant effects on depressive symptoms at 3-month follow-up were found (g = 0.34, 95% confidence interval (CI): 0.06-0.62, P = 0.02, k = 6) and non-significant effects at 6-month follow-up (g = 0.29, 95% CI: -0.16 to 0.73, P = 0.15, k = 5). For alcohol use, the pooled effect of digital interventions was small and non-significant at 3-month follow-up (g = 0.14, 95% CI: -0.02 to 0.30, P = 0.07, k = 6) and significant at 6-month follow-up (g = 0.14, 95% CI: 0.07-0.20, P = 0.005, k = 5). Sensitivity analysis indicated the latter finding to be sensitive to statistical estimator choice. Quality of evidence was moderate, except for depressive symptoms at 6-month follow-up for which it was low.

Conclusion: Based on the literature, digital interventions are effective in reducing depressive symptoms at 3-month follow-up and alcohol use at 6-month follow-up among people with comorbid depression and problematic alcohol use. More high-quality trials are needed to confirm the current findings.
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http://dx.doi.org/10.1093/alcalc/agaa147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753780PMC
January 2022

Prevalence of substance use disorders in an urban and a rural area in Suriname.

Trop Med Health 2021 Feb 2;49(1):12. Epub 2021 Feb 2.

Department of Physiology, Faculty of Medical Science, Anton de Kom University of Suriname, Paramaribo, Suriname.

Background: Alcohol use disorders (AUD) have the worst impact in low-middle-income countries (LMICs), where the disease burden per liter of alcohol consumed is higher than in wealthy populations. Furthermore, the median treatment gap for AUDs in LMICs is 78.1%. The highest prevalence of AUDs worldwide in 2004 was found in the western Pacific region, Southeast Asia, and the Americas. The main aim of this study was to estimate and compare the prevalence of risky alcohol use and the extent of the treatment gap in a rural (Nickerie) and in an urban (Paramaribo) area in Suriname, a LMICs country with a wide variety of ethnic groups.

Methods: The respondents were randomly recruited using a specific sampling method of the National Census Bureau. The final samples were 1837 households for Paramaribo and 1026 for Nickerie, reflecting the populations in both regions. The Alcohol Use Disorder Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were used to assess the likelihood of the presence of alcohol use disorder. A score of > 7 for the AUDIT implies risky alcohol use.

Results: The results indicated that 2% of the women and 15% of the men in the rural area scored 8 or higher on the AUDIT. In the urban area, these numbers were 3% and 17%, respectively. In both samples, the men had the highest addiction risk at about 16% compared with 2% for females. Married persons are significantly less likely to become alcoholic than singles and other groups in Paramaribo. In both areas, higher education was associated with a lower probability of alcohol abuse and dependence, while handymen showed a higher odd. A treatment gap of 50% was found for alcohol use disorders in the rural area. The corresponding gap in the urban area was 64%.

Conclusions: Surinamese men show a high prevalence of the likelihood of AUD. In addition, the treatment gap for these possible patients is large. It is therefore of paramount importance to develop therapeutic strategies with the aim of tackling this physically and mentally disabling disorder. Tailored E-health programs may be of benefit.
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http://dx.doi.org/10.1186/s41182-021-00301-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7852200PMC
February 2021

The Temporal Associations of Therapeutic Alliance and Manual Adherence With Depressive Symptom Change in Cognitive Behavioral Therapy for Adult Outpatient Major Depression.

Front Psychiatry 2020 13;11:602294. Epub 2021 Jan 13.

Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands.

The therapeutic alliance is considered an important causal agent of psychotherapy efficacy. However, studies in cognitive behavioral therapy (CBT) for depression have suggested that alliance might be more of a consequence rather than a cause of depressive symptom change, while adherence to CBT specific techniques was found to be associated with subsequent depression change. We aimed to add to this body of literature by assessing the temporal associations of both therapeutic alliance and manual adherence with depressive symptom change in a relatively large sample of depressed adult outpatients over the full course of CBT. Adults with a major depressive episode ( = 98) participating in a randomized clinical trial were offered 22 weeks of CBT and rated the Penn Helping Alliance Questionnaire (HAq-I) at weeks 5 and 22. Therapists rated their adherence to the CBT manual after each session and observers assessed the Hamilton Depression Rating Scale scores at weeks 0, 5, 10, and 22. Linear mixed model analyses were used to assess the associations of alliance and adherence with prior and subsequent depression change. HAq-I Relationship and manual adherence ratings were not significantly associated with prior nor with subsequent depression change ( > 0.14). Prior depression change was associated with the HAq-I subscale Perceived helpfulness at the end of treatment ( = 0.30, CI = 0.03-0.56, = 0.03). We were not able to replicate prior depression change in CBT for depression to be associated with improved quality of the therapeutic alliance when using a more "pure" measure of the therapeutic relationship. Limitations of this study include the subjective alliance and adherence assessments. Our findings indicate the need to appropriately distinguish between the perceived helpfulness and the relationship factors when examining therapeutic alliance.
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http://dx.doi.org/10.3389/fpsyt.2020.602294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838346PMC
January 2021

The effects of intensive home treatment on self-efficacy in patients recovering from a psychiatric crisis.

Int J Ment Health Syst 2021 Jan 6;15(1). Epub 2021 Jan 6.

Department of Research, Arkin Mental Health Care, Klaprozenweg 111, 1033 NN, Amsterdam, The Netherlands.

Background: This study evaluated whether providing intensive home treatment (IHT) to patients experiencing a psychiatric crisis has more effect on self-efficacy when compared to care as usual (CAU). Self-efficacy is a psychological concept closely related to one of the aims of IHT. Additionally, differential effects on self-efficacy among patients with different mental disorders and associations between self-efficacy and symptomatic recovery or quality of life were examined.

Methods: Data stem from a Zelen double consent randomised controlled trial (RCT), which assesses the effects of IHT compared to CAU on patients who experienced a psychiatric crisis. Data were collected at baseline, 6 and 26 weeks follow-up. Self-efficacy was measured using the Mental Health Confidence Scale. The 5-dimensional EuroQol instrument and the Brief Psychiatric Rating Scale (BPRS) were used to measure quality of life and symptomatic recovery, respectively. We used linear mixed modelling to estimate the associations with self-efficacy.

Results: Data of 142 participants were used. Overall, no difference between IHT and CAU was found with respect to self-efficacy (B = - 0.08, SE = 0.15, p = 0.57), and self-efficacy did not change over the period of 26 weeks (B = - 0.01, SE = 0.12, t (103.95) = - 0.06, p = 0.95). However, differential effects on self-efficacy over time were found for patients with different mental disorders (F(8, 219.33) = 3.75, p < 0.001). Additionally, self-efficacy was strongly associated with symptomatic recovery (total BPRS B = - 0.10, SE = 0.02, p < 0.00) and quality of life (B = 0.14, SE = 0.01, p < 0.001).

Conclusions: Although self-efficacy was associated with symptomatic recovery and quality of life, IHT does not have a supplementary effect on self-efficacy when compared to CAU. This result raises the question whether, and how, crisis care could be adapted to enhance self-efficacy, keeping in mind the development of self-efficacy in depressive, bipolar, personality, and schizophrenia spectrum and other psychotic disorders. The findings should be considered with some caution. This study lacked sufficient power to test small changes in self-efficacy and some mental disorders had a small sample size. Trial registration This trial is registered at Trialregister.nl, number NL6020.
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http://dx.doi.org/10.1186/s13033-020-00426-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789166PMC
January 2021

Predicting hospitalization following psychiatric crisis care using machine learning.

BMC Med Inform Decis Mak 2020 12 10;20(1):332. Epub 2020 Dec 10.

Department of Research, Arkin Mental Health Care, Klaprozenweg 111, 1033NN, Amsterdam, The Netherlands.

Background: Accurate prediction models for whether patients on the verge of a psychiatric criseis need hospitalization are lacking and machine learning methods may help improve the accuracy of psychiatric hospitalization prediction models. In this paper we evaluate the accuracy of ten machine learning algorithms, including the generalized linear model (GLM/logistic regression) to predict psychiatric hospitalization in the first 12 months after a psychiatric crisis care contact. We also evaluate an ensemble model to optimize the accuracy and we explore individual predictors of hospitalization.

Methods: Data from 2084 patients included in the longitudinal Amsterdam Study of Acute Psychiatry with at least one reported psychiatric crisis care contact were included. Target variable for the prediction models was whether the patient was hospitalized in the 12 months following inclusion. The predictive power of 39 variables related to patients' socio-demographics, clinical characteristics and previous mental health care contacts was evaluated. The accuracy and area under the receiver operating characteristic curve (AUC) of the machine learning algorithms were compared and we also estimated the relative importance of each predictor variable. The best and least performing algorithms were compared with GLM/logistic regression using net reclassification improvement analysis and the five best performing algorithms were combined in an ensemble model using stacking.

Results: All models performed above chance level. We found Gradient Boosting to be the best performing algorithm (AUC = 0.774) and K-Nearest Neighbors to be the least performing (AUC = 0.702). The performance of GLM/logistic regression (AUC = 0.76) was slightly above average among the tested algorithms. In a Net Reclassification Improvement analysis Gradient Boosting outperformed GLM/logistic regression by 2.9% and K-Nearest Neighbors by 11.3%. GLM/logistic regression outperformed K-Nearest Neighbors by 8.7%. Nine of the top-10 most important predictor variables were related to previous mental health care use.

Conclusions: Gradient Boosting led to the highest predictive accuracy and AUC while GLM/logistic regression performed average among the tested algorithms. Although statistically significant, the magnitude of the differences between the machine learning algorithms was in most cases modest. The results show that a predictive accuracy similar to the best performing model can be achieved when combining multiple algorithms in an ensemble model.
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http://dx.doi.org/10.1186/s12911-020-01361-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731561PMC
December 2020

Personality Functioning in Obesity and Binge Eating Disorder: Combining a Psychodynamic and Trait Perspective.

J Psychiatr Pract 2020 11;26(6):472-484

Objective: There is preliminary evidence for an association between personality traits and binge eating disorder (BED) in obese patients. In addition, recent studies have shown impaired psychodynamic personality functioning in BED. However, these results are partly inconsistent. The goal of this study was to explore and evaluate personality traits and personality functioning in obese patients with BED or subthreshold BED. Moreover, we aimed to explore the additional value of combined assessment of personality traits and personality functioning.

Methods: Treatment-seeking obese female patients with BED (n=129) or subthreshold BED (n=91) were compared with obese (n=107) and nonobese (n=90) female community controls in terms of personality traits (using the Temperament and Character Inventory) and personality functioning (using the Developmental Profile Inventory) in univariate and multivariate analyses.

Results: Harm Avoidance was higher and Self-Directedness was lower in obese patients with BED or subthreshold BED compared with obese and nonobese community controls. In addition, obese patients with BED or subthreshold BED presented more maladaptive and less adaptive personality functioning than controls. Although univariate analyses did not find significant differences in personality traits or personality functioning between obese patients with BED and those with subthreshold BED, when both personality traits and personality functioning were combined in multivariate analysis (data from both the Temperament and Character Inventory and Developmental Profile Inventory), obese patients with BED showed greater vulnerabilities in personality traits and functioning than obese patients with subthreshold BED.

Conclusions: Obese patients with BED or subthreshold BED had specific impairments in personality traits and personality functioning. Combined assessment indicated that patients with BED had the most vulnerable personality profile of the 4 groups. The results support the added value of assessment of both personality traits and psychodynamic personality functioning, in line with the alternative Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) model for personality disorders.
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http://dx.doi.org/10.1097/PRA.0000000000000513DOI Listing
November 2020

Psychological symptoms, early maladaptive schemas and schema modes: predictors of the outcome of group schema therapy in patients with personality disorders.

Psychother Res 2021 09 3;31(7):831-842. Epub 2020 Dec 3.

Research Department, Arkin Mental Health Care Institute, Amsterdam, Netherlands.

: This naturalistic study examined the outcomes of group schema therapy for patients with personality disorders (PD) and the effect of psychological symptoms, early maladaptive schemas (EMS) and schema modes on outcome. Assessments were made of 194 patients at baseline, during treatment, at treatment termination and at three-month follow-up. We used the Symptom Checklist-General Severity Index (SCL-GSI) to measure the remission-rate of global psychological distress and as a dependent variable in a multilevel model to conduct univariate and multiple variate analyses.: The research sample achieved medium symptom reduction (pre-post  = 0.65, 95% CI [0.39-0.91]) and the remission rate was about 30% after 60 sessions. These results remained stable at three-month follow-up (pre-follow-up  = 0.61, 95% CI [0.29-0.94]; 28.9%). Higher baseline scores on the SCL scale interpersonal sensitivity, the EMS defectiveness/shame and all the maladaptive schema modes together predicted improvements in global psychological distress after treatment.: A long-term form of group schema therapy proved effective for a broad group of patients with PD. Internalizing symptoms seems predictive for improvement at outcome. Almost a third of the patients achieved remission. There is therefore room for improvement, possibly by increasing dose or intensity in combination with individual sessions.
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http://dx.doi.org/10.1080/10503307.2020.1852482DOI Listing
September 2021

Loneliness, social network size, and mortality in older adults and the role of cortisol.

Aging Ment Health 2021 12 5;25(12):2246-2254. Epub 2020 Nov 5.

GGZ InGeest, Amsterdam, the Netherlands.

Background: Loneliness and social isolation have both been found to be associated with increased mortality in previous studies. One potential underlying mechanism is via the hypothalamic-pituitary-adrenal axis.

Objective: This study aimed to examine the association between social network size and cortisol, to analyze the associations between both loneliness and social network size and mortality, and to examine to what extent the association between network size and/or loneliness and mortality is mediated by cortisol.

Design: The study group consisted of 443 depressed and non-depressed participants of the Netherlands Study of Depression in the Elderly (NESDO). Cross-sectional analysis of the association between social network size and cortisol measures was followed by a survival analysis of the associations between both social network size and loneliness and mortality.

Results: There were no significant associations between social network size and cortisol measures. Loneliness and small social network size were not associated with mortality. Age and partner status were more important predictors of mortality.

Conclusion: As people grow older the variety of factors that influence mortality risk increases, diminishing the effect of a single factor. Prevention of early morbidity and mortality in older adults should be tailored to specific needs and risks, instead of aiming at one specific factor.
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http://dx.doi.org/10.1080/13607863.2020.1843001DOI Listing
December 2021

A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of eye movement desensitization and reprocessing (EMDR) and integrated EMDR-Dialectical Behavioural Therapy (DBT) in the treatment of patients with post-traumatic stress disorder and comorbid (Sub)clinical borderline personality disorder: study design.

BMC Psychiatry 2020 08 6;20(1):396. Epub 2020 Aug 6.

Arkin Sinai Centrum, Amstelveen, The Netherlands.

Background: Comorbidity between Posttraumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD) is high. There is growing motivation among clinicians to offer PTSD treatments - such as Eye Movement Desensitization and Reprocessing (EMDR) - to patients with PTSD and comorbid BPD. However, a large subgroup with comorbid BPD does not sufficiently respond to PTSD treatment and is more likely to be excluded or to dropout from treatment. Dialectical Behaviour Therapy (DBT) for BPD is well established and although there is some evidence that DBT combined with DBT Prolonged Exposure (DBT + DBT PE) is twice as effective in reducing PTSD symptoms than DBT alone, the comparative efficacy of integrated PTSD-DBT and PTSD-only treatment has not been investigated yet. The current study will therefore evaluate the comparative clinical efficacy and cost-effectiveness of EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD. Moreover, it is not clear yet what treatment works best for which individual patient. The current study will therefore evaluate neurobiological predictors and mediators of the individual response to treatment.

Method: A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of integrated EMDR-DBT (n = 63) and EMDR-only (n = 63) in treatment-seeking adult patients with PTSD and comorbid (sub)clinical BPD. In addition, neurobiological predictors and mediators of treatment outcome, such as hair cortisol, FKBP5 and BDNF protein levels and FKBP5 and BDNF methylation status, are measured through hair and blood samples.

Discussion: This is the first study to compare the clinical efficacy and cost-effectiveness of integrated EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD, while simultaneously identifying individual predictors and mediators of treatment response. Results will reveal which treatment works best for which individual patient, thereby guiding individual treatment choices and personalizing psychiatry.

Trial Registration: Clinical Trials, NCT03833453 . Retrospectively registered, 15 March 2019.
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http://dx.doi.org/10.1186/s12888-020-02713-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409691PMC
August 2020

Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis.

J Med Internet Res 2020 09 25;22(9):e17831. Epub 2020 Sep 25.

Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands.

Background: Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited.

Objective: The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects.

Methods: We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome.

Results: The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI -0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=-0.70, 95% CI -1.51 to 0.11, P=.09), but heterogeneity was very high (I=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies.

Conclusions: cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population.

Trial Registration: PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9.
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http://dx.doi.org/10.2196/17831DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547394PMC
September 2020

The efficacy of adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression: A systematic review and meta-analysis of individual participant data.

Clin Psychol Rev 2020 08 26;80:101886. Epub 2020 Jun 26.

Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.

Purpose: We examined the efficacy of adding short-term psychodynamic psychotherapy (STPP) to antidepressants in the treatment of depression by means of a systematic review and meta-analysis of individual participant data, which is currently considered the most reliable method for evidence synthesis.

Results: A thorough systematic literature search resulted in 7 studies comparing combined treatment of antidepressants and STPP versus antidepressant mono-therapy (n = 3) or versus antidepressants and brief supportive psychotherapy (n = 4). Individual participant data were obtained for all these studies and totaled 482 participants. Across the total sample of studies, combined treatment of antidepressants and STPP was found significantly more efficacious in terms of depressive symptom levels at both post-treatment (Cohen's d = 0.26, SE = 0.10, p = .01) and follow-up (d = 0.50, SE = 0.10, p < .001). This effect was most apparent at follow-up and in studies examining STPP's specific treatment efficacy. Effects were still apparent in analyses that controlled for risk of bias and STPP quality in the primary studies.

Conclusions: These findings support the evidence-base of adding STPP to antidepressants in the treatment of depression. However, further studies are needed, particularly assessing outcome measures other than depression and cost-effectiveness, as well as examining the relative merits of STPP versus other psychotherapies as added to antidepressants.
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http://dx.doi.org/10.1016/j.cpr.2020.101886DOI Listing
August 2020

Day hospital versus intensive outpatient mentalization-based treatment: 3-year follow-up of patients treated for borderline personality disorder in a multicentre randomized clinical trial.

Psychol Med 2022 02 30;52(3):485-495. Epub 2020 Jun 30.

Viersprong Institute for Studies on Personality Disorders, Halsteren, The Netherlands.

Background: Two types of mentalization-based treatment (MBT), day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP), have been shown to be effective in treating patients with borderline personality disorder (BPD). This study evaluated trajectories of change in a multi-site trial of MBT-DH and MBT-IOP at 36 months after the start of treatment.

Methods: All 114 patients (MBT-DH n = 70, MBT-IOP n = 44) from the original multicentre trial were assessed at 24, 30 and 36 months after the start of treatment. The primary outcome was symptom severity measured with the Brief Symptom Inventory. Secondary outcome measures included borderline symptomatology, personality and interpersonal functioning, quality of life and self-harm. Data were analysed using multilevel modelling and the intention-to-treat principle.

Results: Patients in both MBT-DH and MBT-IOP maintained the substantial improvements made during the intensive treatment phase and showed further gains during follow-up. Across both conditions, 83% of patients improved in terms of symptom severity, and 97% improved on borderline symptomatology. No significant differences were found between MBT-DH and MBT-IOP at 36 months after the start of treatment. However, trajectories of change were different. Whereas patients in MBT-DH showed greater improvement during the intensive treatment phase, patients in MBT-IOP showed greater continuing improvement during follow-up.

Conclusions: Patients in both conditions showed similar large improvements over the course of 36 months, despite large differences in treatment intensity. MBT-DH and MBT-IOP were associated with different trajectories of change. Cost-effectiveness considerations and predictors of differential treatment outcome may further inform optimal treatment selection.
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http://dx.doi.org/10.1017/S0033291720002123DOI Listing
February 2022
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