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BackgroundThe highly recurrent nature of Major Depressive Disorder is a major contributor to disability and health care costs. Several studies indicate that recurrence may be prevented with Preventive Cognitive Therapy (PCT). This study is the first to perform an economic evaluation of PCT in comparison with care as usual for recurrently depressed patients who experienced two or more depressive episodes and remitted after receiving Cognitive Behavioural Therapy.MethodsAn economic evaluation from the societal perspective was performed alongside a randomized trial (N = 214). Health-related quality of life (QALYs), depression-free days, health care utilization, and productivity losses were measured between randomization and 15 months follow-up. The costs were indexed to the reference year 2014.ResultsQALY gains did not differ significantly between the groups (p = 0.69). Depression-free days were higher after PCT (p = 0.02). Societal costs of PCT were 10,417 euro and for care as usual 9,545 euro per person. We found a 47% likelihood that PCT led to additional QALYs at higher costs, and there was a 26% likelihood that PCT led to fewer QALYs at higher costs. When depression-free days was used as an outcome, we found PCT had a 72% likelihood of leading to more depression-free days at higher costs than care as usual and a 27% likelihood of leading to more depression-free days at lower societal costs.LimitationsThe 15-month follow-up might be too short to draw long-term conclusions about the cost-effectiveness of the PCT. The data collected for this study is part of an RCT to examine the effectiveness of adding PCT to care as usual. Therefore, the study was powered primarily to detect an effect in time to relapse/recurrences.ConclusionThe economic evaluation is slightly in favour of the PCT condition when depression-free days is used as an outcome. PCT is not cost-effective given the high costs per additional QALYs from the societal perspective when QALYs are the effect measure.Clinical trial registrationhttps://www.onderzoekmetmensen.nl/en, identifier NL2482.

Psychotherapists can differ in their effectiveness. Yet, more research is needed to determine the generalizability of between-therapist effects to cultures beyond the US and UK, and whether these effects differ by treatment context. Addressing these gaps, we examined therapist effects in a randomized trial comparing cognitive behavioral therapy (CBT) versus psychodynamic therapy (PDT) for depression in the Netherlands, hypothesizing that therapists would explain significant outcome variance across both treatments. We also explored whether the size of therapist effects differed by degree of treatment standardization; in this trial, CBT was structured and manualized, whereas PDT was flexible and principle driven. Patients were 254 adults who received 16 sessions of CBT or PDT from 59 therapists nested within the condition. As predicted, multilevel models revealed significant therapist effects (explaining 3–8% of variance) on patient depression and general distress outcomes. Moreover, PDT therapists (10–16%) accounted for more outcome variance than CBT therapists (2–6%), though differences were only statistically significant for the clinician-rated depression outcome. Results extend the cultural “reach” of therapist effects. Moreover, they highlight treatment standardization as one possible determinant of effectiveness differences, which necessitates determining for which therapists such standardization is most important for optimizing their patient’s outcomes.

Abstract Background Cluster-C personality disorders (PDs), characterized by a high level of fear and anxiety, are related to high levels of distress, societal dysfunctioning and chronicity of various mental health disorders. Evidence for the optimal treatment is extremely scarce. Nevertheless, the need to treat these patients is eminent. In clinical practice, group therapy is one of the frequently offered approaches, with two important frameworks: schema therapy and psychodynamic therapy. These two frameworks suggest different mechanisms of change, but until now, this has not yet been explored. The purpose of the present G-FORCE trial is to find evidence on the differential (cost)effectiveness of two forms of schema group therapy and psychodynamic group therapy in the routine clinical setting of an outpatient clinic and to investigate the underlying working mechanisms and predictors of outcome of these therapies. Methods In this mono-centre pragmatic randomized clinical trial, 290 patients with Cluster-C PDs or other specified PD with predominantly Cluster-C traits, will be randomized to one of three treatment conditions: group schema therapy for Cluster-C (GST-C, 1 year), schema-focused group therapy (SFGT, 1.5 year) or psychodynamic group therapy (PG, 2 years). Randomization will be pre-stratified on the type of PD. Change in severity of PD (APD-IV) over 24 months will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Potential predictors and mediators are selected and measured repeatedly. Also, a cost-effectiveness study will be performed, primarily based on a societal perspective, using both clinical effects and quality-adjusted life years. The time-points of assessment are at baseline, start of treatment and after 1, 3, 6, 9, 12, 18, 24 and 36 months. Discussion This study is designed to evaluate the effectiveness and cost-effectiveness of three formats of group psychotherapy for Cluster-C PDs. Additionally, predictors, procedure and process variables are analysed to investigate the working mechanisms of the therapies. This is the first large RCT on group therapy for Cluster-C PDs and will contribute improving the care of this neglected patient group. The absence of a control group can be considered as a limitation. Trial registration CCMO, NL72826.029.20 . Registered on 31 August 2020, first participant included on 18 October 2020.

Abstract Background: Improving supportive social networks in forensic psychiatric patients is deemed important due to the protective effects of such networks on both mental health problems and criminal recidivism. Informal interventions targeted at social network enhancement by community volunteers showed positive effects in various patient and offender populations. However, these interventions have not specifically been studied in forensic psychiatric populations. Therefore, forensic psychiatric outpatients’ and volunteer coaches’ experiences with an informal social network intervention were explored in this study. Methods: This qualitative study was based on semi-structured interviews conducted alongside an RCT. Forensic outpatients allocated to the additive informal social network intervention, and volunteer coaches, were interviewed 12 months after baseline assessment. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to identify and report patterns in the data. Results: We included 22 patients and 14 coaches in the study. The analysis of interviews revealed five main themes reflecting patients’ and coaches’ experiences: (1) dealing with patient receptivity, (2) developing social bonds, (3) receiving social support, (4) achieving meaningful change, and (5) using a personalized approach. Patient receptivity, including willingness, attitudes, and timing, was a common reported barrier affecting patients’ engagement in the intervention. Both patients’ and coaches’ experiences confirmed that the intervention can be meaningful in developing new social bonds between them, in which patients received social support. Despite, experiences of meaningful and sustainable changes in patients’ social situations were not clearly demonstrated. Coaches’ experiences revealed broadened worldviews and an enhanced sense of fulfillment and purpose. Finally, a personalized, relationship-oriented rather than goal-oriented approach was feasible and preferable. Conclusion: This qualitative study showed positive experiences of both forensic psychiatric outpatients and volunteer coaches with an informal social network intervention in addition to forensic psychiatric care. Notwithstanding the limitations, the study suggests that these additive interventions provide an opportunity for forensic outpatients to experience new positive social interactions with individuals in the community, which can initiate personal development. Barriers and facilitators to engagement are discussed to improve further development and implementation of the intervention. Trial registration: This study is registered at the Netherlands Trial Register (NTR7163, registration date: 16/04/2018).

Abstract Background Cluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients. Objective In this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators. Methods This is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18–65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months. Discussion This is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons. Trial registration NL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

ObjectivesA supportive social network is associated with better mental health and wellbeing, and less criminal behavior. Therefore, this study examined the effectiveness of an additive informal social network intervention to treatment as usual (TAU) among forensic psychiatric outpatients.Materials and methodsAn randomized controlled trial (RCT) was conducted in forensic psychiatric care, allocating eligible outpatients (N = 102) to TAU with an additive informal social network intervention or TAU alone. Participants receiving the additive intervention were matched to a trained community volunteer over 12 months. TAU consisted of forensic care (e.g., cognitive behavioral therapy and/or forensic flexible assertive community treatment). Follow-up assessments were conducted at 3, 6, 9, 12, and 18 months after baseline. The primary outcome was the between-group effect on mental wellbeing at 12 months. Between-group effects on secondary outcomes (e.g., general psychiatric functioning, hospitalization, criminal behavior) were explored.ResultsIntention-to-treat analyses showed non-significant between-group effects on mental wellbeing on average over time and at 12 months. However, significant between-group effects were found on hospitalization duration and criminal behavior. Specifically, TAU participants were hospitalized 2.1 times more days within 12 months and 4.1 more days within 18 months than participants in the additive intervention. Furthermore, TAU participants reported 2.9 times more criminal behaviors on average over time. There were no significant effects on other outcomes. Exploratory analyses revealed that sex, comorbidity, and substance use disorders moderated effects.ConclusionThis is the first RCT examining the effectiveness of an additive informal social network intervention in forensic psychiatric outpatients. Although no improvements were found on mental wellbeing, the additive intervention was effective in reducing hospitalization and criminal behavior. The findings suggest that forensic outpatient treatment can be optimized by collaborating with informal care initiatives aimed at improving social networks within the community. Future research is warranted to determine which specific patients might benefit from the intervention and if effects can be improved by extending the intervention duration and enhancing patient compliance.Clinical Trial Registration: [https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7163], identifier [NTR7163].

This study examined the impact of clinical severity on treatment outcome in two programs that differ markedly in treatment intensity: day hospital mentalization‐based treatment (MBT‐DH) and intensive outpatient mentalization‐based treatment (MBT‐IOP) for borderline personality disorder (BPD). A multicenter randomized controlled trial was conducted. Participants include the full intention‐to‐treat sample of the original trial of N = 114 randomized BPD patients (MBT‐DH n = 70, MBT‐IOP n = 44), who were assessed at baseline and subsequently every 6 up to 36 months after start of treatment. Outcomes were general symptom severity, borderline features, and interpersonal functioning. Clinical severity was examined in terms of severity of BPD, general symptom severity, comorbid symptom disorders, comorbid personality disorders, and cluster C personality features. None of the severity measures was related to treatment outcome or differentially predicted treatment outcome in MBT‐DH and MBT‐IOP, with the exception of a single moderating effect of co morbid symptom disorders on outcome in terms of BPD features, indicating less improvement in MBT‐DH for patients with more symptom disorders. Overall, patients with varying levels of clinical severity benefited equally from MBT‐DH and MBT‐IOP, indicating that clinical severity may not be a useful criterion to differentiate in treatment intensity. [ABSTRACT FROM AUTHOR]

Abstract 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 ).

Abstract 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

Abstract 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.

Objective: 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).Methods: 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).Results: 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 (R2 = 0.34) of the variance in hospitalisation. “Quality of life” had the lowest explained proportion of variance (R2 = 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).Conclusion: 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.

Abstract Background Pain management in the Emergency Department has often been described as inadequate, despite proven benefits of pain treatment protocols. The aim of this study was to investigate the effectiveness of our current pain protocol on pain score and patient satisfaction whilst taking the patients’ wishes for analgesia into account. Methods We conducted a 10-day prospective observational study in the Emergency Department. Demographics, pain characteristics, Numeric Rating Scale pain scores and the desire for analgesics were noted upon arrival at the Emergency Department. A second Numeric Rating Scale pain score and the level of patient satisfaction were noted 75–90 min after receiving analgesics. Student T-tests, Mann-Whitney U tests and Kruskall-Wallis tests were used to compare outcomes between patients desiring vs. not desiring analgesics or patients receiving vs. not receiving analgesics. Univariate and multivariate logistic regression models were used to investigate associations between potential predictors and outcomes. Results In this study 334 patients in pain were enrolled, of which 43.7% desired analgesics. Initial pain score was the only significant predictive factor for desiring analgesia, and differed between patients desiring (7.01) and not desiring analgesics (5.14). Patients receiving analgesics (52.1%) had a greater decrease in pain score than patients who did not receive analgesics (2.41 vs. 0.94). Within the group that did not receive analgesics there was no difference in satisfaction score between patients desiring and not desiring analgesics (7.48 vs. 7.54). Patients receiving analgesics expressed a higher satisfaction score than patients not receiving analgesics (8.10 vs. 7.53). Conclusions This study pointed out that more than half of the patients in pain entering the Emergency Department did not desire analgesics. In patients receiving analgesics, our pain protocol has shown to adequately treat pain, leading to a higher satisfaction for emergency health-care at discharge. This study emphasizes the importance of questioning pain score and desire for analgesics to prevent incorrect conclusions of inadequate pain management, as described in previous studies.

Abstract Background Patients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change. Methods In a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9–12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective. Discussion This trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom. Trial registration This trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre (NTR5941).

Background: 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.Methods: Adults with a major depressive episode (n = 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.Results: HAq-I Relationship and manual adherence ratings were not significantly associated with prior nor with subsequent depression change (p > 0.14). Prior depression change was associated with the HAq-I subscale Perceived helpfulness at the end of treatment (r = 0.30, CI = 0.03–0.56, p = 0.03).Conclusion: 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.

Abstract Background More than one in five patients presenting to the emergency department (ED) with (suspected) infection or sepsis deteriorate within 72 h from admission. Surprisingly little is known about vital signs in relation to deterioration, especially in the ED. The aim of our study was to determine whether repeated vital sign measurements in the ED can differentiate between patients who will deteriorate within 72 h and patients who will not deteriorate. Methods We performed a prospective observational study in patients presenting with (suspected) infection or sepsis to the ED of our tertiary care teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), respiratory rate and body temperature) were measured in 30-min intervals during the first 3 h in the ED. Primary outcome was patient deterioration within 72 h from admission, defined as the development of acute kidney injury, liver failure, respiratory failure, intensive care unit admission or in-hospital mortality. We performed a logistic regression analysis using a base model including age, gender and comorbidities. Thereafter, we performed separate logistic regression analyses for each vital sign using the value at admission, the change over time and its variability. For each analysis, the odds ratios (OR) and area under the receiver operator curve (AUC) were calculated. Results In total 106 (29.5%) of the 359 patients deteriorated within 72 h from admission. Within this timeframe, 18.3% of the patients with infection and 32.9% of the patients with sepsis at ED presentation deteriorated. Associated with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well as the variability of the MAP (OR: 1.06). Repeated measurements of heart rate and body temperature were not associated with deterioration. Conclusions Repeated vital sign measurements in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single vital sign measurements at ED admission.

Abstract Background Liberal use of oxygen in an emergency situation is common. Today, most health care professionals do not adjust the amount of oxygen given when a saturation of 100% or a PaO2 which exceeds the normal range is reached- which may result in hyperoxia. There is increasing evidence for the toxic effects of hyperoxia. Therefore, it seems justified to aim for normoxia when giving oxygen. This study evaluates whether it is feasible to aim for normoxia when giving oxygen therapy to patients at the emergency department (ED). Methods A prospective cohort study was performed at the ED of the University Medical Center Groningen (UMCG). A protocol was developed, aiming for normoxia. During a 14 week period all patients > 18 years arriving at the ED between 8 a.m. and 23 p.m. requiring oxygen therapy registered for cardiology, internal medicine, emergency medicine and pulmonology were included. Statistical analysis was performed using student independent t-test, Mann–Whitney U-test, Fisher’s exact test or a Pearson’s chi-squared test. Results During the study period the study protocol was followed and normoxia was obtained after 1 h at the ED in 86,4% of the patients. Patients with COPD were more at risk for not being titrated to normal oxygen levels. Conclusions We showed that it is feasible to titrate oxygen therapy to normoxia at the ED. The study results will be used for further research assessing the potential beneficial effects of normoxia compared to hyper- or hypoxia in ED patients and for the development of guidelines.

Abstract Background Psychiatric patients are at high risk of becoming victim of a violent crime compared to the general population. Although most research has focused on patients with severe mental illness, depressed patients have been demonstrated to be prone to victimization as well. Victimization is associated with more severe symptomatology, decreased quality of life, and high risk of revictimization. Hence, there is a strong need for interventions that focus on preventing violent revictimization. Since emotion dysregulation is associated with both victimization and depression, we developed an internet-based Emotion Regulation Training (iERT) to reduce revictimization in depressed patients. This study aims to evaluate the clinical and cost-effectiveness of iERT added to Treatment As Usual (TAU) in reducing incidents of violent revictimization among depressed patients with a recent history of victimization. Furthermore, this study aims to examine secondary clinical outcomes, and moderators and mediators that may be associated with treatment outcomes. Methods In a multicenter randomized controlled trial with parallel group design, patients with a major depressive disorder and a history of violent victimization over the past three years (N = 200) will be allocated to either TAU + iERT (N = 100) or TAU only (N = 100), based on computer-generated stratified block randomization. Assessments will take place at baseline, 8 weeks, 14 weeks, and 6 months after start of treatment, and 12, 24, and 36 months after baseline. The primary outcome measure is the total number of violent victimization incidents at 12 months after baseline, measured with the Safety Monitor: an adequate self-report questionnaire that assesses victimization over the preceding 12 months. Secondary outcome measures and mediators include emotion dysregulation and depressive symptomatology. An economic evaluation with the societal perspective will be performed alongside the trial. Discussion This study is the first to examine the effectiveness of an intervention aimed at reducing violent revictimization in depressed patients. If effective, iERT can be implemented in mental health care, and contribute to the well-being of depressed patients. Furthermore, the results will provide insight into underlying mechanisms of revictimization. Trial registration The study is registered at the Netherlands Trial Register (NTR5822). Date of registration: 4 April 2016.

Background: Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression. Methods: For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level. Results: Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [ B = −0.49, 95% confidence interval (CI) −0.61 to −0.37, p < 0.0001] and for patients with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) and than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias. Conclusions: To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression. [ABSTRACT FROM AUTHOR]

Abstract Background Patients with substance use disorders and co-occurring mental health disorders are vulnerable to violent victimization. However, no evidence-based interventions are available to reduce patients’ vulnerability. An exploration of the characteristics of physical and sexual violence can provide valuable information to support the development of interventions for these patients. This study aimed to examine gender differences in characteristics of violent victimization in patients with dual diagnosis. Methods In this cross-sectional survey study recent incidents of physical and sexual assault were examined with the Safety Monitor in 243 patients with dual diagnosis. Chi-square tests were used to examine gender differences in the prevalence of physical and sexual victimization. Fisher’s exact tests and Fisher-Freeman-Halton exact tests were used to determine whether there were significant differences between victimized men and women with regard to perpetrators, locations, reporting to the police and speaking about the assault with others. Results There was no significant difference in the prevalence of physical violence in men (35%) and women (47%) with dual diagnosis. There was a significant association between gender of the victim and type of perpetrator (P

Childhood abuse is a major public health problem that has been linked to depression in adulthood. Although different types of childhood abuse often co-occur, few studies have examined their unique impact on negative mental health outcomes. Most studies have focused solely on the consequences of childhood physical or sexual abuse; however, it has been suggested that childhood emotional abuse is more strongly related to depression. It remains unclear which underlying psychological processes mediate the effect of childhood emotional abuse on depressive symptoms. In a cross-sectional study in 276 female college students, multiple linear regression analyses were used to determine whether childhood emotional abuse, physical abuse, and sexual abuse were independently associated with depressive symptoms, emotion dysregulation, and interpersonal problems. Subsequently, OLS regression analyses were used to determine whether emotion dysregulation and interpersonal problems mediate the relationship between childhood emotional abuse and depressive symptoms. Of all types of abuse, only emotional abuse was independently associated with depressive symptoms, emotion dysregulation, and interpersonal problems. The effect of childhood emotional abuse on depressive symptoms was mediated by emotion dysregulation and the following domains of interpersonal problems: cold/distant and domineering/controlling. The results of the current study indicate that detection and prevention of childhood emotional abuse deserves attention from Child Protective Services. Finally, interventions that target emotion regulation skills and interpersonal skills may be beneficial in prevention of depression.

OBJECTIVE:Remitted patients with a history of several previous major depressive episodes have a higher risk of relapse/recurrence than patients with fewer previous episodes, and the probability of another episode increases progressively with each successive episode. This study examines the association between the number of previous episodes and modifiable vulnerability factors in remitted patients with recurrent depression. METHODS:Patients with recurrent depression (DSM-IV-diagnosed) who were in remission (N = 214) were recruited between September 2011 and July 2016. The association was examined between the number of previous episodes and the following factors: i.e. interpersonal functioning, daily stress, sense of mastery, coping and dysfunctional beliefs. RESULTS:A history of more previous episodes was associated with higher levels of interpersonal problems (P < .001), daily stress (P = .04) and a lower sense of mastery (P = .05). Interpersonal problems were most strongly associated with more previous episodes in a Generalized Linear Regression model. In the domain of interpersonal problems, the subscales that showed the strongest relationship were domineering/controlling, vindictive/self-centred, socially inhibited and self-sacrificing. CONCLUSIONS:Patients with a history of more depressive episodes reported higher levels of interpersonal problems, daily stress and a lower sense of mastery. Future studies should examine these factors in a longitudinal cohort and look at whether the effect of interventions to prevent relapse can be explained by targeting these psychological factors. TRIAL REGISTRATION:Netherlands Trial Register: 2599.