To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Reviews of the relative efficacy of psychotherapy and combined therapy (psychotherapy with pharmacotherapy) for depression have yielded contradicting conclusions. This may be explained by the clinical heterogeneity of the studies reviewed.
To conduct a meta-analysis with an acceptable level of homogeneity in order to investigate the relative efficacy of psychotherapy and combined therapy in the acute treatment of depression.
A systematic search was performed for RCTs published between 1980 and 2005 comparing psychotherapy and combined therapy in adult psychiatric outpatients with non-psychotic unipolar major depressive disorder. The studies were classified according to the chronicity and severity of the depression. Data were pooled by means of meta-analysis and statistical tests were conducted to measure heterogeneity.
The meta-analysis included seven studies looking at a total of 903 patients. None of the heterogeneity tests established significance. This indicates a lack of evidence for the heterogeneity of the results. The dropout rates did not differ significantly between the two treatment modalities (25% in combined therapy and 24% in psychotherapy, p = 0.77). At treatment termination, the intention-to-treat remission rate for combined therapy (46%) was better than for psychotherapy (34%) (p = 0.0007); Relative Risk 1.32 (95% CI: 1.12–1.56), Odds Ratio 1.59 (95% CI: 1.22–2.09). In moderate depression, the difference between the remission rate for combined therapy and psychotherapy was statistically significant (47% compared to 34% respectively, p = 0.001). This was not the case in mild major depression (42% compared to 37% respectively, p = 0.29). The difference was also statistically significant in chronic major depression (48% compared to 32%, p < 0.001), but not in non-chronic major depression (43% compared to 37%, p = 0.22). On a more specific level, no differences were found in the remission rates for the treatment modalities in mild or moderate non-chronic depression. Combined therapy led to significantly better results than psychotherapy in moderate chronic depression only (48% compared to 32%, p < 0.001).
In the acute treatment of adult psychiatric outpatients with major depressive disorder, patient compliance with combined therapy matches compliance with psychotherapy alone. Combined therapy is more efficacious than psychotherapy alone. However, these results depend on severity and chronicity. Combined therapy outperformed psychotherapy in moderate chronic depression only. No differences were found in mild and moderate non-chronic depression. No data were found for mild chronic depression and for severe depression.
The joint development of the Dutch and English versions of the Quality of Life in Depression Scale (QLDS) is described. The QLDS is based on the needs model of quality of life developed by Hunt and McKenna. The scale has good reliability and internal consistency. Test-retest correlation coefficients were 0.94 and 0.87 in the United Kingdom and the Netherlands, respectively. Internal consistency alpha-coefficients were 0.95 and 0.92, respectively. The validity of the scale is highly acceptable. The QLDS was shown to correlate relatively highly with established measures of well-being, and scores obtained with the measure were related to severity of depression as assessed by the Hamilton Rating Scale for Depression. The QLDS was shown to be responsive to change in an open study with fluoxetine in 540 patients with major depression. The scale has wide applicability and has been shown to be user-friendly, both for respondents and administrators. It has been, or is in the process of being, tested for reliability and validity in the following additional countries: Australia, Austria, Belgium, Canada, Denmark, France, Germany, Italy, Morocco, Spain and the United States.
To study the long term effects of delirium in elderly hip-surgery patients on cognitive mortality.
This is a prospective study. Medical school-affiliated general hospital in Alkmaar, The Netherlands. Participants (n=603) from the €Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium. A Randomized Placebo-Controlled Study (Kalisvaart et al., 2005). Patients with and without post-operative delirium were followed for 2 years. Mortality risk associated with delirium was estimated using a Cox proportional hazards regression model; the outcome was time to death.
A total of 75/603 patients (12.4%) died during the study period (table 1). Incidence of delirium was higher in patients who died compared with those who survived (HR 2.16, CI 1.30-3.58). They were more often at risk for delirium as indicated by higher rates of cognitive impairment and visual impairment.
Delirium after hip-surgery and delirium risk factors are associated with long-term follow-up mortality.
To study the long term effects of delirium in elderly hip-surgery patients on cognitive outcome.
Prospective matched controlled cohort study. Medical school-affiliated general hospital in Alkmaar, The Netherlands.
Hip-surgery patients (n=112) aged 70 and older who participated in a controlled clinical trial of haloperidol prophylaxis for delirium, were followed for an average of 30 months after discharge. Patients with a diagnosis of dementia or mild cognitive impairment (MCI) were identified based on psychiatric interviews. Proportions of patients with dementia or MCI were compared across patients who had postoperative delirium and selected control patients matched for preoperatively assessed risk factors who had not developed delirium during hospitalization. Other outcomes were mortality rate and rate of institutionalization.
During follow-up 54.9% of delirium patients had died compared to 34.1% controls (relative risk = 1.5, 95% CI = 1.04-2.1). Dementia or MCI was diagnosed in 77.8% of the surviving patients with postoperative delirium and in 40.1% of control patients (relative risk = 2.7, 95% CI = 1.2-5.8). Group differences for rate of institutionalization were not significant.
The risk of dementia or MCI at follow-up is more than doubled in elderly hip-surgery patients with postoperative delirium compared with patients without delirium.
Delirium is a common neuropsychiatric syndrome with considerable heterogeneity that includes a variety of clinical (motor) subtypes. Because delirium is typically highly fluctuating, understanding the longitudinal stability of subtypes is crucial to evaluating their relevance to treatment and outcome.
to examine the changes (variability) in motor subtype profile in patients with delirium over serial assessment using the Delirium Motor Subtype Scale, and to investigate predictors of variability.
We studied motor subtype profile of patients with delirium assessed daily over a week in elderly patients undergoing hip fracture surgery. A Generalized Estimating Equations Model examined possible predictors of change in motor subtype status, including baseline variables and delirium course.
We included 118 patients developing DSM-IV delirium after hip-surgery [mean age 87.0±6.5 years; range 65–102; 66% females]. At first assessment, hyperactive subtype was most common (49%), followed by hypoactive (31%) and mixed subtype (14%), with 6% of delirious patients not fulfilling criteria of any DMSS-defined motor subtype. Almost two-thirds (n=69) of these patients underwent at least one more assessment, and for these 45 (57%) remained stable in motor subtype over time, while the rest 34 (43%) underwent change. A range of baseline characteristics were not significant predictors of variability in subtype profile.
Motor subtype profile is typically stable for orthopaedic patients with delirium. Thus evidence from cross-sectional studies of motor subtypes can be applied to many patients with delirium. Further longitudinal studies can clarify the stability of motor subtypes across different clinical populations.
Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Rapid reliable identification of clinical subtypes can allow for more targeted and research efforts.
The aims of this study are to evaluate the concurrent validity (agreement) and reliability (internal consistency) of DMSS-4 in a new cohort of delirious hospitalised patients.
We explored the concordance in attribution of motor subtypes between the DMSS-4 and the original DMSS (assessed cross-sectionally) and subtypes defined longitudinally using the Delirium Symptom Interview (DSI) method.
We included 118 elderly patients developing DSM-IV delirium after hip-surgery [mean age 87.0±6.5 years; range 65–102; 66% females; 28 (23.7%) had no previous history of cognitive impairment]. Concordance was high for both the DMSS-4 and original DMSS (k=0.80), and for the DMSS-4 and DSI methods (k=0.82). The DMSS-4 also demonstrated high internal consistency (McDonald's omega = 0.78). The DMSS-11 and DMSS-4 had higher inclusion for motor subtypes than the DSI method.
The DMSS-4 provides an ultra-rapid means of identifying motor-defined clinical subtypes of delirium and is a reliable alternative to the more detailed and time-consuming original DMSS and DSI methods of subtype attribution. The DMSS-4 can be readily applied to further studies of causation, treatment and outcome in delirium.
Over 50% of adult disability claimants fail some form of SVT. While some over report psychological, affective symptoms, others may report incredible cognitive symptoms. We examined effects of different types of response bias on free recall and self-reported depression.
Participants and methods This is a single site cross-sectional study using a convenience sample (n = 224) of disability claimants in the Netherlands. The Green Word Memory Test (GWMT) was administered to all subjects. The Amsterdam Short Term Memory Test (AKTG), the Structured Inventory of Malingered. Symptomatology (SIMS), and the beck depression inventory (BDI-II) were administered in subsamples. Participant classification according to GWMT and SIMS outcomes resulted in four groups, G+/S+, G+/S−, G−/S+ and G−/S−.
Average age of the participants was 46.3 years (SD 9.9), 41.5% were female, and 43% were higher educated. GWMT was positive in 48.2% of all subjects, and 27.6% scored positive on both GWMT and SIMS. Analysis of variance of GWMT Free recall and Beck depression scores showed significant group differences [F(3, 123) = 33.21, P = .000] and [F(3, 106) = 25.17, P = .000] respectively.
Non credible test performance was prevalent in this Dutch study of disability claimants. Insufficient effort and over reporting of psychological symptoms are associated with different score profiles on regular tests and self-rating scales.
Disclosure of interest
The author receives funding for his work as a neuropsychologist in an expertise setting.
Valid assessments require sufficient effort from the part of the testee. Motivation may be compromised, particularly in psychiatric conditions. We examined associations between response bias on free recall and self-reported symptoms in depressed and PTSD patients.
Participants and methods
This is a cross-sectional study. Patients had depression (n = 48), or PTSD or other anxiety disorders (n = 37). A control group (n = 47%) had chronic pain disorder, fibromyalgia or chronic fatigue. The Green Word Memory Test (GWMT) was administered to all subjects. The Structured Inventory of Malingered. Symptomatology (SIMS), and the Beck Depression Inventory (BDI-II) were administered in subsamples. Study outcome was self-reported depressive symptoms in Symptom Validity Test (SVT) negative cases.
Average age of the participants was 45.1 years (SD 9.5), 48.5% were female. GWMT was positive in 52.3% of all cases, GWMT and SIMS were positive in 33.8%, and GWMT and SIMS were negative in 37.7%. No significant group effects on GWMT were found. Average BDI-II scores were 32.8 (SD 13.9) for depressed patients, 28.3 (15.5) for those with anxiety disorders, and 27.6 (14.1) for controls (P = 0.43). Seventy-eight percent of depressed GWMT negative cases reported at least moderate depressive symptoms (BDI-II > 18), and 44.4% severe symptoms (BDI-II > 29). Approximately half of the GWMT negative cases with anxiety disorders and controls scored BDI-II > 18.
Non credible test performance is prevalent in disability claimants with affective, mood disorders. However, depressive symptoms per se do not explain poor effort on cognitive tasks.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
In Ireland, traditionally, most public Adult Mental Health Services (AMHSs) had a small cohort of service users with eating disorders (EDs) in their service. However, over the last 5 years, the National Clinical Programmes have been encouraging Mental Health Services to develop ED programmes in each catchment area. This has culminated in a model of care for EDs for children and adults. It appears that in relation to AMHSs, meaningful inclusion of families/significant other(s) in ED programmes is somewhat inconsistent. This paper will discuss the possible impact of excluding or minimising family/significant other(s)’ inclusion. It will also outline a suggested approach of including families/significant other(s) in a meaningful way in an out-patient ED programme.
Objectives: To adequately monitor the course of cognitive functioning in persons with moderate to severe dementia, relevant cognitive tests for the advanced dementia stages are needed. We examined the ability of a test developed for the advanced dementia stages, the Severe Impairment Battery Short version (SIB-S), to measure cognitive change over time. Second, we examined type of memory impairment measured with the SIB-S in different dementia stages. Methods: Participants were institutionalized persons with moderate to severe dementia (N = 217). The SIB-S was administered at 6-month intervals during a 2-year period. Dementia severity at baseline was classified according to Global Deterioration Scale criteria. We used mixed models to evaluate the course of SIB-S total and domain scores, and whether dementia stage at baseline affected these courses. Results: SIB-S total scores declined significantly over time, and the course of decline differed significantly between dementia stages at baseline. Persons with moderately severe dementia declined faster in mean SIB-S total scores than persons with moderate or severe dementia. Between persons with moderate and moderately severe dementia, there was only a difference in the rate of decline of semantic items, but not episodic and non-semantic items. Conclusions: Although modest floor and slight ceiling effects were noted in severe and milder cases, respectively, the SIB-S proved to be one of few available adequate measures of cognitive change in institutionalized persons with moderate to severe dementia. (JINS, 2019, 25, 204–214)
We present 12-month follow-up results for a randomised controlled trial of prolonged exposure and eye movement desensitisation and reprocessing (EMDR) therapy in 85 (78.8%) participants with psychotic disorder and comorbid post-traumatic stress disorder (PTSD). Positive effects on clinician-rated PTSD, self-rated PTSD, depression, paranoid-referential thinking and remission from schizophrenia were maintained up to 12-month follow-up. Negative post-traumatic cognitions declined in prolonged exposure and were stable in EMDR. A significant decline in social functioning was found, whereas reductions in interference of PTSD symptoms with social functioning were maintained. These results support that current PTSD guidelines apply to individuals with psychosis.
Declaration of interest
M.v.d.G. and D.v.d.B. receive income for published books on psychotic disorders and for the training of postdoctoral professionals in the treatment of psychotic disorders. A.d.J. receives income for published books on EMDR therapy and for the training of postdoctoral professionals in this method. A.v.M. receives income for published book chapters on PTSD and for the training of postdoctoral professionals in prolonged exposure. C.d.R. receives income for the training of postdoctoral professionals in EMDR therapy.
Background: Virtual reality exposure therapy (VRET) has been used to treat a variety of fears and phobias. Aim: To determine the feasibility (i.e. safety and efficacy) of using VRET to treat dental phobia. Method: Safety was evaluated by determining any adverse events or symptom exacerbation. Efficacy of VRET was evaluated by comparing the reduction in dental anxiety scores (measured 16 times within a 14-week study period, and at 6-month follow-up), and its behavioural effects with that of an informational pamphlet (IP) on ten randomized patients with dental phobia using a controlled multiple baseline design. Participants’ heart rate response during VRET, and their experience post-VRET, were indexed. Results: No personal adverse events or symptom exacerbation occurred. Visual analysis and post-hoc intention-to-treat analysis showed a significantly greater decrease in dental anxiety scores [higher PND (percentage of non-overlap data) scores of 100% and lower POD (percentage of overlap data) of 0%, Modified Dental Anxiety Scale, F (1,8) = 8.61, p = 0.019, and Dental Fear Scale, F (1,8) = 10.53, p = 0.012], and behavioural avoidance in the VRET compared with the IP group [d = 4.2 and –1.4, respectively). There was no increase in average heart rate during VRET. Of the nine treatment completers, six (four from the VRET group and two from the IP group) no longer had dental phobia at 6-month follow-up. Four of the five VRET participants, but none of the IP participants, scheduled a dental treatment appointment following the intervention. Conclusion: VRET is a feasible alternative for patients with dental phobia.
To identify causes of stress at work as well as individual, organisational and personal interventions used by employees to manage stress in public, private and non-governmental organizations (NGOs). Qualitative interviews were conducted with 51 employees from a range of organisations.
Participants reported adverse working conditions and management practices as common causes of work stress. Stress-inducing management practices included unrealistic demands, lack of support, unfair treatment, low decision latitude, lack of appreciation, effort–reward imbalance, conflicting roles, lack of transparency and poor communication. Organisational interventions were perceived as effective if they improved management styles, and included physical exercise, taking breaks and ensuring adequate time for planning work tasks. Personal interventions used outside of work were important to prevent and remedy stress.
Interventions should improve management practices as well as promoting personal interventions outside of the work setting.
Eye movement desensitisation and reprocessing (EMDR) therapy is a first-line treatment for adults with post-traumatic stress disorder (PTSD). Some clinicians argue that with refugees, directly targeting traumatic memories through EMDR may be harmful or ineffective.
To determine the safety and efficacy of EMDR in adult refugees with PTSD (trial registration: ISRCTN20310201).
In total, 72 refugees referred for specialised treatment were randomly assigned to 12 h of EMDR (3×60 min planning/preparation followed by 6×90 min desensitisation/reprocessing) or 12 h (12×60 min) of stabilisation. The Clinician-Administered PTSD Scale (CAPS) and Harvard Trauma Questionnaire (HTQ) were primary outcome measures.
Intention-to-treat analyses found no differences in safety (one severe adverse event in the stabilisation condition only) or efficacy (effect sizes: CAPS –0.04 and HTQ 0.20) between the two conditions.
Directly targeting traumatic memories through 12 h of EMDR in refugee patients needing specialised treatment is safe, but is only of limited efficacy.
This study presents secondary analyses of a recently published trial in which post-traumatic stress disorder (PTSD) patients with psychosis (n = 108) underwent 8 sessions of trauma-focused treatment, either prolonged exposure (PE) or eye movement desensitisation and reprocessing (EMDR) therapy. 24.1% fulfilled the criteria for the dissociative subtype, a newly introduced PTSD subtype in DSM-5. Treatment outcome was compared for patients with and without the dissociative subtype of PTSD. Patients with the dissociative subtype of PTSD showed large reductions in clinician-administered PTSD scale (CAPS) score, comparable with patients without the dissociative subtype of PTSD. It is concluded that even in a population with severe mental illness, patients with the dissociative subtype of PTSD do benefit from trauma-focused treatments without a pre-phase of emotion regulation skill training and should not be excluded from these treatments.
In patients with psychotic disorders, the effects of psychological post-traumatic stress disorder (PTSD) treatment on symptoms of psychosis, depression and social functioning are largely unknown
In a single-blind randomized controlled trial (RCT) 155 outpatients in treatment for psychosis (61.3% schizophrenic disorder, 29% schizoaffective disorder) were randomized to eight sessions prolonged exposure (PE; n = 53) or eye movement desensitization and reprocessing (EMDR) (n = 55), or a waiting-list condition (WL, n = 47) for treatment of their co-morbid PTSD. Measures were performed on (1) psychosis: severity of delusions (PSYRATS-DRS), paranoid thoughts (GPTS), auditory verbal hallucinations (PSYRATS-AHRS), and remission from psychotic disorder (SCI-SR-PANSS); (2) depression (BDI-II); (3) social functioning (PSP). Outcomes were compared at baseline, post-treatment, 6-month follow-up and over all data points.
Both PE and EMDR were significantly associated with less severe paranoid thoughts post-treatment and at 6-month follow-up, and with more patients remitting from schizophrenia, at post-treatment (PE and EMDR) and over time (PE). Moreover, PE was significantly associated with a greater reduction of depression at post-treatment and at 6-month follow-up. Auditory verbal hallucinations and social functioning remained unchanged.
In patients with chronic psychotic disorders PE and EMDR not only reduced PTSD symptoms, but also paranoid thoughts. Importantly, in PE and EMDR more patients accomplished the status of their psychotic disorder in remission. Clinically, these effects are highly relevant and provide empirical support to the notion that delivering PTSD treatment to patients with psychotic disorders and PTSD deserves increasing recognition and acceptance among clinicians.
Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Rapid reliable identification of clinical subtypes can allow for more targeted research efforts.
We explored the concordance in attribution of motor subtypes between the Delirium Motor Subtyping Scale 4 (DMSS-4) and the original Delirium Motor Subtyping Scale (DMSS) (assessed cross-sectionally) and subtypes defined longitudinally using the Delirium Symptom Interview (DSI).
We included 113 elderly patients developing DSM-IV delirium after hip-surgery [mean age 86.9 ± 6.6 years; range 65–102; 68.1% females; 25 (22.1%) had no previous history of cognitive impairment]. Concordance for the first measurement was high for both the DMSS-4 and original DMSS (k = 0.82), and overall for the DMSS-4 and DSI (k = 0.84). The DMSS-4 also demonstrated high internal consistency (McDonald's omega = 0.90). The DSI more often allocated an assessment to “no subtype” compared to the DMSS-4 and DMSS-11, which showed higher inclusion rates for motor subtypes.
The DMSS-4 provides a rapid method of identifying motor-defined clinical subtypes of delirium and appears to be a reliable alternative to the more detailed and time-consuming original DMSS and DSI methods of subtype attribution. The DMSS-4, so far translated into three languages, can be readily applied to further studies of causation, treatment and outcome in delirium.
Post-traumatic stress disorder (PTSD) is highly prevalent in patients with a psychotic disorder. Because a PTSD diagnosis is often missed in patients with psychosis in routine care, a valid screening instrument could be helpful.
To determine the validity of the Trauma Screening Questionnaire (TSQ) as a screening tool for PTSD among individuals with psychotic disorders.
Among 2608 patients with a psychotic disorder, the rate of trauma exposure was determined and the TSQ was administered to screen for PTSD. PTSD status was verified in 455 patients using the Clinician-Administered PTSD Scale (trial registration: ISRCTN 79584912).
Trauma exposure was reported by 78.2% of the 2608 patients. PTSD prevalence was estimated at 16% (95% CI 14.6–17.4%) compared with 0.5% reported in the patients' clinical charts. A TSQ cut-off score of six predicted PTSD with 78.8% sensitivity, 75.6% specificity, 44.5% correct positives and 93.6% correct negatives.
The TSQ seems to be a valid screening tool for PTSD in patients with a psychotic disorder.