Attention training technique delivered in groups as treatment for anxiety and depression in patients with coronary heart disease: study protocol for a waiting-list randomized controlled trial

IntroductionClinically significant symptoms of depression and anxiety in coronary heart disease (CHD) patients are common and associated with adverse outcomes. Psychological treatments have shown limited effectiveness and more effective treatments have been requested. Attention training technique (ATT), a component of metacognitive therapy, can potentially be effective as a stand-alone treatment for anxiety and depression. In an open study, ATT delivered face-to-face in a group format was feasible and potentially effective for improving depression and anxiety symptoms in CHD patients. The next progressive step is to test the effectiveness of ATT in a randomized controlled trial. This paper describes the methodology of this trial.MethodsATT-CHD is a randomized wait-list (WL) controlled study. Eligible CHD patients from two hospitals with Hospital Anxiety and Depression Scale (HADS)-Anxiety and/or HADS-Depression subscales scores ≥8 will be randomized into ATT (n = 32) or WL control (n = 32). After 6–8 weeks, WL patients will be allocated to ATT. Participants will be evaluated pre-, mid- and post-treatment, and at 6-months follow-up using changes in HADS as primary outcome. Secondary outcomes will be changes in psychiatric disorders, rumination, worry, type D-personality, metacognitions, insomnia, quality of life, and C-Reactive protein (CRP).DiscussionTo our knowledge, this will be the first WL-controlled randomized study testing the effectiveness of group-based ATT as treatment of symptoms of anxiety and depression in CHD patients. It will also explore correlations between changes in psychological distress and CRP. A qualitative analysis will reveal patients’ experience with ATT including processes that may facilitate or serve as barriers to effectiveness. Recruitment into the study commenced in December 2022.Ethics and disseminationThe Regional Committees for Medical and Health Research Ethics (REK), Norway has granted approval for the study (ID 52002). The trial results will be published in peer-reviewed journals. According to Norwegian legislation, the Norwegian Data Protection Authority, and the Committee of Ethics, we are not allowed to share original study data publicly.Clinical trial registrationClinicalTrials.gov, identifier NCT05621408 pre-inclusion. There were no significant changes of methods or outcomes after study start

Patterns of childhood adverse events are associated with clinical characteristics of bipolar disorder

Background Previous studies in bipolar disorder investigating childhood trauma and clinical presentations of the illness have mainly focused on physical and sexual abuse. Our aim was to explore further the relationship between childhood trauma and disease characteristics in bipolar disorder to determine which clinical characteristics were most strongly associated with childhood trauma total score, as well as subtypes of adverse childhood events, including physical, sexual, emotional abuse and neglect. Methods 141 Patients with bipolar disorder were consecutively recruited, and disease history and clinical characteristics were assessed. History of childhood abuse was obtained using the Childhood Trauma Questionnaire (CTQ). Statistical methods used were factor analysis, Poisson and linear regression, and generalized additive modeling (GAM). Results The factor analysis of CTQ identified three factors: emotional abuse/neglect, sexual abuse and physical abuse. There were significant associations between CTQ total score and earlier onset of illness, reduced level of psychosocial functioning (GAF; Global Assessment of Functioning) and decreased number of hospitalization, which mainly were due to the factor emotional abuse/neglect. Physical abuse was significantly associated with lower GAF scores, and increased number of mood episodes, as well as self-harm. Sexual abuse was significantly associated with increased number of mood episodes. For mood episodes and self-harm the associations were characterized by great variance and fluctuations. Conclusions Our results suggest that childhood trauma is associated with a more severe course of bipolar illness. Further, childhood abuse (physical and sexual), as well as emotional abuse and neglect were significantly associated with accelerating staging process of bipolar disorder. By using specific trauma factors (physical abuse, sexual abuse and emotional abuse/neglect) the associations become both more precise, and diverse

The mental health of populations directly and indirectly exposed to violent conflict in Indonesia

Background Large disasters affect people who live both near and far from the areas in which they occur. The mental health impact is expected to be similar to a ripple effect, where the risk of mental health consequences generally decreases with increasing distance from the disaster center. However, we have not been able to identify studies of the ripple effect of man-made disaster on mental health in low-income countries. Objectives The objective was to examine the hypothesis of a ripple effect on the mental health consequences in populations exposed to man-made disasters in a developing country context, through a comparison of two different populations living in different proximities from the center of disaster in Mollucas. Methods Cross-sectional longitudinal data were collected from 510 Internally Displaced Persons (IDPs) living in Ambon, who were directly exposed to the violence, and non-IDPs living in remote villages in Mollucas, Indonesia, who had never been directly exposed to violence in Mollucas. Data were collected during home visits and statistical comparisons were conducted by using chi square tests, t-test and logistic regression. Results There was significantly more psychological distress "caseness" in IDPs than non-IDPs. The mental health consequences of the violent conflict in Ambon supported the ripple effect hypothesis as displacement status appears to be a strong risk factor for distress, both as a main effect and interaction effect. Significantly higher percentages of IDPs experienced traumatic events than non-IDPs in all six event types reported. Conclusions This study indicates that the conflict had an impact on mental health and economic conditions far beyond the area where the actual violent events took place, in a diminishing pattern in line with the hypothesis of a ripple effect

Availability and access in modern obstetric care: a retrospective population-based study

Objective: To assess the availability of obstetric institutions, the risk of unplanned delivery outside an institution and maternal morbidity in a national setting in which the number of institutions declined from 95 to 51 during 30 years. Design: Retrospective population-based, three cohorts and two cross-sectional analyses. Setting: Census data, Statistics Norway. The Medical Birth Registry of Norway from 1979 to 2009. Population: Women (15–49 years), 2000 (n=1 050 269) and 2010 (n=1 127 665). Women who delivered during the period 1979–2009 (n=1 807 714). Methods: Geographic Information Systems software for travel zone calculations. Cross-table and multiple logistic regression analysis of change over time and regional differences. World Health Organization Emergency Obstetric and Newborn Care (EmOC) indicators. Main outcome measures: Proportion of women living outside the 1-hour travel zone to obstetric institutions. Risk of unplanned delivery outside obstetric institutions. Maternal morbidity. Results: The proportion of women living outside the 1-hour zone for all obstetric institutions increased from 7.9% to 8.8% from 2000 to 2010 (relative risk, 1.1; 95% confidence interval, 1.11– 1.12), and for emergency obstetric care from 11.0% to 12.1% (relative risk, 1.1; 95% confidence interval, 1.09–1.11). The risk of unplanned delivery outside institutions increased from 0.4% in 1979–83 to 0.7% in 2004–09 (adjusted odds ratio, 2.0; 95% confidence interval, 1.9–2.2). Maternal morbidity increased from 1.7% in 2000 to 2.2% in 2009 (adjusted odds ratio, 1.4; 95% confidence interval, 1.2–1.5) and the regional differences increased. Conclusions: The availability of and access to obstetric institutions was reduced and we did not observe the expected decrease in maternal morbidity following the centralisation

Contours of a causal feedback mechanism between adaptive personality and psychosocial function in patients with personality disorders: a secondary analysis from a randomized clinical trial

Background Patients with personality disorders commonly exhibit impairment in psychosocial function that persists over time even with diagnostic remission. Further causal knowledge may help to identify and assess factors with a potential to alleviate this impairment. Psychosocial function is associated with personality functioning which describes personality disorder severity in DSM-5 (section III) and which can reportedly be improved by therapy. Methods The reciprocal association between personality functioning and psychosocial function was assessed, in 113 patients with different personality disorders, in a secondary longitudinal analysis of data from a randomized clinical trial, over six years. Personality functioning was represented by three domains of the Severity Indices of Personality Problems: Relational Capacity, Identity Integration, and Self-control. Psychosocial function was measured by Global Assessment of Functioning. The marginal structural model was used for estimation of causal effects of the three personality functioning domains on psychosocial function, and vice versa. The attractiveness of this model lies in the ability to assess an effect of a time – varying exposure on an outcome, while adjusting for time – varying confounding. Results Strong causal effects were found. A hypothetical intervention to increase Relational Capacity by one standard deviation, both at one and two time-points prior to assessment of psychosocial function, would increase psychosocial function by 3.5 standard deviations (95% CI: 2.0, 4.96). Significant effects of Identity Integration and Self-control on psychosocial function, and from psychosocial function on all three domains of personality functioning, although weaker, were also found. Conclusion This study indicates that persistent impairment in psychosocial function can be addressed through a causal pathway of personality functioning, with interventions of at least 18 months duration

Is age of self-harm onset associated with increased frequency of non-suicidal self-injury and suicide attempts in adolescent outpatients?

Background Self-harm in adolescents is an increasing public health concern and an important risk factor for suicide. We aimed to examine how age of self-harm onset in adolescents was associated with frequency of subsequent suicidal and non-suicidal self-harm (NSSI) episodes, and how age of onset and duration of self-harm may influence the frequency of self-harm. Methods Data from 103 adolescents with recurrent self-harm recruited from child and adolescent psychiatric outpatient clinics were collected through clinical interviews and self-reports, and analysed with negative binomial and hurdle models. Results A lower age of self-harm onset and a longer duration of self-harm were both significantly associated with increased frequency of subsequent episodes of NSSI and risk of a first suicide attempt. There was an increase in repeated suicide attempts when the age of onset of self-harm decreased and the duration increased, and dramatically more for long duration of NSSI before first suicide attempt. Conclusion Initiating self-harm behaviour at the youngest age had the highest risk of increased frequency of NSSI and suicide attempts. Longer duration of self-harm behaviour increased this risk. This underlines the importance of early identification of self-harm behaviour in adolescents, and the use of effective interventions

Adult ADHD and Comorbid Somatic Disease: A Systematic Literature Review

Objective: To systematically review, synthesize, and appraise available evidence, connecting adult ADHD (aADHD) with somatic disease. Method: Embase, Psychinfo, and Medline databases were searched for studies published from 1994 to 2015 addressing aADHD and somatic comorbidity. Somatic conditions were classified according to International Classification of Diseases (ICD-10) codes. Levels of evidence were graded as inconclusive, tentative, or well documented. Results: Most of the 126 studies included in the qualitative synthesis were small and of modest quality. Obesity, sleep disorders, and asthma were well-documented comorbidities in aADHD. Tentative evidence was found for an association between aADHD and migraine and celiac disease. In a large health registry study, cardiovascular disease was not associated with aADHD. Conclusion: There are few large systematic studies using standardized diagnostic criteria evaluating aADHD and somatic comorbidities. Significant associations are found between aADHD and several somatic diseases, and these are important to consider when assessing and treating either aADHD or the somatic diseases

G-estimation of causal pathways in vocational rehabilitation for adults with psychotic disorders – a secondary analysis of a randomized trial

Background Vocational rehabilitation (VR) has increasingly become an important intervention targeting poor occupational functioning in schizophrenia. The Norwegian Job Management Program (JUMP), sought to enhance occupational outcomes by augmenting VR with either cognitive behavioral therapy (CBT) techniques aiming to improve psychotic symptoms or cognitive remediation (CR) aiming to improve cognition. CBT is standard treatment in schizophrenia, but recent meta-analyses question the effect of CBT on negative psychotic symptoms. It is of interest to study the causal role of psychotic symptoms and cognitive functioning on occupational functioning. Methods Data from the JUMP VR – program, was reanalyzed with a causal inference method to assess the causal effects of reduced symptoms / improved neurocognitive functioning on occupational functioning measured by number of working hours per week. Participants (N = 131) had been randomized to either VR + CBT (N = 68) or VR + CR (N = 63). Large improvements in number of working hours were demonstrated in both intervention groups (nonsignificant group difference). G-estimation was used to assess the strength and nature of the causal effects, adjusted for time-varying confounding and selection – bias from loss to follow-up. Results Significant causal effects of reduction in each of four dimensions of symptoms and improved neurocognition respectively, on number of working hours were found (separate models). The effect of negative symptoms was the strongest and increased in magnitude during the whole observation period, while the effect of two other symptoms and neurocognition was constant. Adjusted for confounding (including potential feedback), the causal effect of a hypothetical change in negative symptoms equal to the average improvement in the CBT group corresponded to an increase in working hours of 3.2 h per week (95% CI: 1.11, 5.35). Conclusion High performance of g-estimation in a small psychiatric data set with few repeated measures and time-varying confounding and effects, was demonstrated. Augmented vocational rehabilitation showed causal effects of intervention targets with the strongest and increasing effect from negative symptoms on number of working hours. Combination of therapy and activation (indirect and direct approach) might explain improvement in both cognition and negative symptoms, and shed some light on effective ingredients for improved treatment of negative symptoms

Increased risk of peripartum perinatal mortality in unplanned births outside an institution: a retrospective population-based study

Background: Births in midwife-led institutions may reduce the frequency of medical interventions and provide cost-effective care, while larger institutions offer medically and technically advanced obstetric care. Unplanned births outside an institution and intrapartum stillbirths have frequently been excluded in previous studies on adverse outcomes by place of birth. Objective: The objective of the study was to assess peripartum mortality by place of birth and travel time to obstetric institutions, with the hypothesis that centralization reduces institution availability but improves mortality. Study Design: This was a national population-based retrospective cohort study of all births in Norway from 1999 to 2009 (n = 648,555) using data from the Medical Birth Registry of Norway and Statistics Norway and including births from 22 gestational weeks or birthweight ≥500 g. Main exposures were travel time to the nearest obstetric institution and place of birth. The main clinical outcome was peripartum mortality, defined as death during birth or within 24 hours. Intrauterine fetal deaths prior to start of labor were excluded from the primary outcome. Results: A total of 1586 peripartum deaths were identified (2.5 per 1000 births). Unplanned birth outside an institution had a 3 times higher mortality (8.4 per 1000) than institutional births (2.4 per 1000), relative risk, 3.5 (95% confidence interval, 2.5–4.9) and contributed 2% (95% confidence interval, 1.2–3.0%) of the peripartum mortality at the population level. The risk of unplanned birth outside an institution increased from 0.5% to 3.3% and 4.5% with travel time 2 hours, respectively. In obstetric institutions the mortality rate at term ranged from 0.7 per 1000 to 0.9 per 1000. Comparable mortality rates in different obstetric institutions indicated well-functioning routines for referral. Conclusion: Unplanned birth outside an institution was associated with increased peripartum mortality and with long travel time to obstetric institutions. Structural determinants have an important impact on perinatal health in high-income countries and also for low-risk births. The results show the importance of skilled birth attendance and warrant attention from clinicians and policy makers to negative consequences of reduced access to institutions

Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ullevål personality project

Background Although psychotherapy is considered the treatment of choice for patients with personality disorders (PDs), there is no consensus about the optimal level of care for this group of patients. This study reports the results from the 6-year follow-up of the Ullevål Personality Project (UPP), a randomized clinical trial comparing outpatient individual psychotherapy with a long-term step-down treatment program that included a short-term day hospital treatment followed by combined group and individual psychotherapy. Methods The UPP included 113 patients with PDs. Outcome was evaluated after 8 months, 18 months, 3 years and 6 years and was based on a wide range of clinical measures, such as psychosocial functioning, interpersonal problems, symptom severity, and axis I and II diagnoses. Results At the 6-year follow-up, there were no statistically significant differences in outcome between the treatment groups. Effect sizes ranged from medium to large for all outcome variables in both treatment arms. However, patients in the outpatient group had a marked decline in psychosocial functioning during the period between the 3- and 6-year follow-ups; while psychosocial functioning continued to improve in the step-down group during the same period. This difference between groups was statistically significant. Conclusions The findings suggest that both hospital-based long-term step-down treatment and long-term outpatient individual psychotherapy may improve symptoms and psychosocial functioning in poorly functioning PD patients. Social and interpersonal functioning continued to improve in the step-down group during the post-treatment phase, indicating that longer-term changes were stimulated during treatment. Trial registration NCT00378248