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BACKGROUND: Internet-cognitive behavioural therapy (iCBT) for depression can include multiple components. This study explored depressive symptom improvement prognostic factors (PFs) and effect modifiers (EMs) for five common iCBT components including behavioural activation, cognitive restructuring, problem solving, self-monitoring, and assertion training. METHODS: We used data from a factorial trial of iCBT for subthreshold depression among Japanese university students (N=1093). The primary outcome was the change in PHQ-9 scores at 8weeks from baseline. Interactions between each component and various baseline characteristics were estimated using a mixed-effects model for repeated measures. We calculated multiplicity-adjusted p-values at 5% false discovery rate using the Benjamini-Hochberg procedure. RESULTS: After multiplicity adjustment, the baseline PHQ-9 total score emerged as a PF and exercise habits as an EM for self-monitoring (adjusted p-values

BackgroundInternet-based cognitive-behavioural therapy (iCBT) is effective for subthreshold depression. However, which skills provided in iCBT packages are more effective than others is unclear. Such knowledge can inform construction of more effective and efficient iCBT programmes.ObjectiveTo examine the efficacy of five components of iCBT for subthreshold depression.MethodsWe conducted an factorial trial using a smartphone app, randomly allocating presence or absence of five iCBT skills including self-monitoring, behavioural activation (BA), cognitive restructuring (CR), assertiveness training (AT) and problem-solving. Participants were university students with subthreshold depression. The primary outcome was the change on the Patient Health Questionnaire-9 (PHQ-9) from baseline to week 8. Secondary outcomes included changes in CBT skills.FindingsWe randomised a total of 1093 participants. In all groups, participants had a significant PHQ-9 reduction from baseline to week 8. Depression reduction was not significantly different between presence or absence of any component, with corresponding standardised mean differences (negative values indicate specific efficacy in favour of the component) ranging between −0.04 (95% CI −0.16 to 0.08) for BA and 0.06 (95% CI −0.06 to 0.18) for AT. Specific CBT skill improvements were noted for CR and AT but not for the others.ConclusionsThere was significant reduction in depression for all participants regardless of the presence and absence of the examined iCBT components.Clinical implicationWe cannot yet make evidence-based recommendations for specific iCBT components. We suggest that future iCBT optimisation research should scrutinise the amount and structure of components to examine.Trial registration numberUMINCTR-000031307.

BackgroundThere are many different skill components used in cognitive behavioural therapy (CBT). However, there is currently no comprehensive way of measuring these skills in patients.ObjectiveTo develop a comprehensive and brief measure of five main CBT skills: self-monitoring, behavioural activation, cognitive restructuring, assertiveness training and problem-solving.MethodsUniversity students (N=847) who participated in a fully factorial randomised controlled trial of smartphone CBT were assessed with the CBT Skills Scale, the Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 (GAD-7) and the short form of the Japanese Big Five Scale. Structural validity was estimated with exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and internal consistency evaluated with Cronbach’s α coefficients. Construct validity was evaluated with the correlations between each factor of the CBT Skills Scale, the PHQ-9, the GAD-7 and the Big Five Scale.FindingsThe EFA supported a five-factor solution based on the original instruments assessing each CBT skill component. The CFA showed sufficient goodness-of-fit indices for the five-factor structure. The Cronbach’s α of each factor was 0.75–0.81. Each CBT skills factor was specifically correlated to the PHQ-9, GAD-7, and the Big Five Scale.ConclusionsThe CBT Skills Scale has a stable structural validity and internal consistency with a five-factor solution and appropriate content validity concerning the relationship with depression, anxiety and personality.Clinical implicationsThe CBT Skills Scale will be potential predictor and effect modifier in studying the optimisation of CBT interventions.Trial registrationCTR-000031307.

Background Although the clinical efficacy of electroconvulsive therapy (ECT) has been well established in patients with pharmacotherapy-resistant depression, the physiological mechanism and changes in regional cerebral function after ECT are unclear. Methods We recruited 16 depressed patients who underwent ECT, and 11 healthy controls. The change in cerebral glucose metabolism was evaluated before and after a series of ECT using [ 18 F]-fluorodeoxyglucose positron emission tomography (FDG-PET). Results Before ECT, the patient group showed significant hypometabolism in the superior frontal gyrus, and hypermetabolism in the inferior temporal gyri compared with healthy controls, and these abnormalities remained after ECT. Comparisons between pre- and post-ECT metabolic activity revealed decreased regional metabolism in the frontotemporal neocortical areas after ECT, while increased metabolism was found in the right medial temporal structures including amygdala and pons. In addition, a decrease in glucose metabolism in the fronto-temporo-parietal regions correlated with an increase in glucose metabolism in the right medial temporal regions across subjects. Limitations There was considerable variability in the interval between the last ECT and FDG-PET scan. Depressed subjects were maintained on medication. The subjects included both major depressive disorder and bipolar disorder patients, as well as both ECT responders and non-responders. Conclusion Depression refractory to pharmacotherapy might have functional deficits in specific circumscribed frontal and temporal structures. ECT resolves the clinical symptoms without largely affecting these brain metabolic abnormalities. In contrast, ECT shifts the balance of corticolimbic function, which might explain how ECT ameliorates symptoms of depression in patients.

Treatment of acute psychosis should involve a multi-dimensional approach that includes factors such as administration of justice and education, societal factors, and other similar aspects, apart from the actual medical treatment. Medical treatment in turn has various aspects such as diagnosis, treatment, prevention, and clinical research. In a multi-dimensional setting, each specialist recognizes the specialty of their peers and the importance of evaluation in each field, following which the integrated concept is pursued. The contemporary society demands a multi-dimensional approach towards acute psychosis. There are three different aspects in the diagnosis of this disorder. The first is a social-behavioral aspect, which includes the elements of justice and administration. This is useful for interventions such as involuntary hospitalization and protection hospitalization, along with medical treatment. The second is the actual treatment aspect for improving the psychotic episodes. Evidence obtained on using DSM or ICD for diagnostic purposes is useful for effective treatment and prevention of side effects of drug therapy. The third is the patients' quality of life aspect, which leads to relapse prevention and psychoeducation, and facilitates patients' acceptance of their condition by using longitudinal assessments such as those used in atypical psychosis. In this article, I aim to investigate the various recent topics of discussion regarding psychiatric illnesses, including their categories and dimensions. I described the flexibility of the psychiatric diagnosis from the standpoint of the multi-dimensional directivity requested in "acute psychosis".