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The database supporting Internet delivered minimal therapist contact cognitive behavioral therapy (CBT) is growing rapidly. Several randomized trials show that this novel treament approach can work for anxiety disorders and major depression of mild to moderate character. However, in clinical practice the implementation of Internet delivered CBT is not straightforward, as it can be difficult to target the right audience and client might worsen following or during the first “low cost” treatment attempt. The aim of this talk is to describe a model for the stepped care implemention of Internet CBT and data supporting the model. Results from a randomised trial on major depression will be presented as well as a summary of the available evidence regarding Internet CBT vs. regular CBT in individual or group format and the potential for stepped care. The data obtained so far raises some doubts regarding the widespread implementation of stepped care. For example, it is not clear why more intensive therapist contact should work when minimal contact therapy has not. However, at the same time stepped care approaches can help us think more clearly regarding different levels of intervention and cost effectiveness. Further research in this field is encouraged.
Panic Disorder with or without or without agoraphobia (PD/A) is common and can be treated effectively with SSRI medication or cognitive behaviour therapy (CBT). However, a great challenge is generally the lack of skilled CBT therapists. Therefore, there has been a move toward evaluating different forms of self-help approaches requiring less therapist contact than in traditional CBT. A novel treatment modality in this field, showing efficacy in several randomised trials, but until yet not evauated within regular care, is Internet-based treatment.
The aim of these two studies was to evaluate the effectiveness of Internet-based CBT for PD within regular care with patients referred for treatment.
We have conducted two trials. The first trial was a small open study including 20 patients and the second is a larger randomised trial comparing Internet-CBT with group CBT. The Internet-CBT consisted of 10 weekly modules accompanied by e-mail support. In the randomised trial, the group CBT included the same self-help material administered during 10 group sessions.
The results of these trials indicate that Internet-based CBT is both an effective and potentially cost-effective alternative for patients with PD, in both trials showing a clinically significant effect on PD-symptoms measured by the clinician rated Panic Disorder Severity Scale. Moreover, preliminary data from the randomised trial show no significant differences in effect between Internet- or group-delivered CBT.
Our work suggests the possibility of markedly increasing the access to evidence-based psychological treatment within regular psychiatric care by using the internet as treatment medium.
Cognitive-behavioural therapy (CBT) is the first-line psychological treatment for obsessive-compulsive disorder (OCD). However, most individuals suffering from OCD do not receive CBT. An innovative approach to improve access to evidence-based care is the use of the Internet to deliver effective treatments. Therapist-guided Internet-based cognitive-behavioural therapy (iCBT) involves the administration of structured online lessons that provide the same information and skills typically taught in clinician-administered CBT, often with email support from a therapist. Accumulating evidence on iCBT for OCD has been produced, but a meta-analysis has not been conducted.
Through meta-analytic methods, the present study summarized evidence on iCBT for OCD.
Efficacy on OCD symptoms and comorbid depression versus control conditions at post-treatment and follow-up was evaluated.
A PRISMA meta-analysis was performed on randomized controlled trials. Treatments were classified as iCBT if they included CBT components for OCD (eg, exposure and response prevention) delivered through the Internet with or without email/phone support from a therapist.
Four trials were included (n = 238), which were classified at low bias risk. At post-treatment iCBT outperformed control conditions with a high effect size on OCD symptoms (d = 0.85, P<.05) and a medium on comorbid depression (d = 0.52, P<.05). Treatment effects were stable at 4-month follow-up with a high effect size on OCD (d = 1.45, P<.05), but not on comorbid depression (d = 0.33, P<.05).
iCBT seems a promising treatment modality for OCD. Further trials should assess log-term outcomes and effects on quality of life.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
A superconductor of paired protons is thought to form in the core of neutron stars soon after their birth. Minimum energy conditions suggest that magnetic flux is expelled from the superconducting region due to the Meissner effect, such that the neutron star core retains or is largely devoid of magnetic fields for some nuclear equation of state and proton pairing models. We show via neutron star cooling simulations that the superconducting region expands faster than flux is expected to be expelled because cooling timescales are much shorter than timescales of magnetic field diffusion. Thus magnetic fields remain in the bulk of the neutron star core for at least 106 − 107yr. We estimate the size of flux free regions at 107yr to be ≲ 100m for a magnetic field of 1011G and possibly smaller for stronger field strengths.
The influence of baseline severity has been examined for antidepressant
medications but has not been studied properly for cognitive–behavioural
therapy (CBT) in comparison with pill placebo.
To synthesise evidence regarding the influence of initial severity on
efficacy of CBT from all randomised controlled trials (RCTs) in which
CBT, in face-to-face individual or group format, was compared with
pill-placebo control in adults with major depression.
A systematic review and an individual-participant data meta-analysis
using mixed models that included trial effects as random effects. We used
multiple imputation to handle missing data.
We identified five RCTs, and we were given access to individual-level
data (n = 509) for all five. The analyses revealed that
the difference in changes in Hamilton Rating Scale for Depression between
CBT and pill placebo was not influenced by baseline severity (interaction
P = 0.43). Removing the non-significant interaction
term from the model, the difference between CBT and pill placebo was a
standardised mean difference of –0.22 (95% CI –0.42 to –0.02,
P = 0.03, I2 = 0%).
Patients suffering from major depression can expect as much benefit from
CBT across the wide range of baseline severity. This finding can help
inform individualised treatment decisions by patients and their
Visual processing problems may be one underlying factor for cognitive impairments related to autism spectrum disorders (ASDs). We examined associations between ASD-traits (Autism-Spectrum Quotient) and visual processing performance (Rey–Osterrieth Complex Figure Test; Block Design task of the Wechsler Adult Intelligence Scale-III) in young adults (mean age=25.0, s.d.=2.1 years) born preterm at very low birth weight (VLBW; <1500 g) (n=101) or at term (n=104). A higher level of ASD-traits was associated with slower global visual processing speed among the preterm VLBW, but not among the term-born group (P<0.04 for interaction). Our findings suggest that the associations between ASD-traits and visual processing may be restricted to individuals born preterm, and related specifically to global, not local visual processing. Our findings point to cumulative social and neurocognitive problems in those born preterm at VLBW.
West Nile virus (WNV) is a growing public health concern in Europe and there is a need to develop more efficient early detection systems. Nervous signs in horses are considered to be an early indicator of WNV and, using them in a syndromic surveillance system, might be relevant. In our study, we assessed whether or not data collected by the passive French surveillance system for the surveillance of equine diseases can be used routinely for the detection of WNV. We tested several pre-processing methods and detection algorithms based on regression. We evaluated system performances using simulated and authentic data and compared them to those of the surveillance system currently in place. Our results show that the current detection algorithm provided similar performances to those tested using simulated and real data. However, regression models can be easily and better adapted to surveillance objectives. The detection performances obtained were compatible with the early detection of WNV outbreaks in France (i.e. sensitivity 98%, specificity >94%, timeliness 2·5 weeks and around four false alarms per year) but further work is needed to determine the most suitable alarm threshold for WNV surveillance in France using cost-efficiency analysis.
Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach.
Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data.
A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29–0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit–risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.
Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.
Results of adulthood mental health of those born late-preterm (34 + 0–36 + 6 weeks + days of gestation) are mixed and based on national registers. We examined if late-preterm birth was associated with a higher risk for common mental disorders in young adulthood when using a diagnostic interview, and if this risk decreased as gestational age increased.
A total of 800 young adults (mean = 25.3, s.d. = 0.62 years), born 1985–1986, participated in a follow-up of the Arvo Ylppö Longitudinal Study. Common mental disorders (mood, anxiety and substance use disorders) during the past 12 months were defined using the Composite International Diagnostic Interview (Munich version). Gestational age was extracted from hospital birth records and categorized into early-preterm (<34 + 0, n = 37), late-preterm (34 + 0–36 + 6, n = 106), term (37 + 0–41 + 6, n = 617) and post-term (⩾42 + 0, n = 40).
Those born late-preterm and at term were at a similar risk for any common mental disorder [odds ratio (OR) 1.11, 95% confidence interval (CI) 0.67–1.84], for mood (OR 1.11, 95% CI 0.54–2.25), anxiety (OR 1.00, 95% CI 0.40–2.50) and substance use (OR 1.31, 95% CI 0.74–2.32) disorders, and co-morbidity of these disorders (p = 0.38). While the mental disorder risk decreased significantly as gestational age increased, the trend was driven by a higher risk in those born early-preterm.
Using a cohort born during the advanced neonatal and early childhood care, we found that not all individuals born preterm are at risk for common mental disorders in young adulthood – those born late-preterm are not, while those born early-preterm are at a higher risk. Available resources for prevention and intervention should be targeted towards the preterm group born the earliest.
Boar taint is a quality defect in meat, related to accumulation of skatole and androstenone in male pigs. The levels of skatole and its main metabolites in plasma and urine samples were measured with a validated liquid chromatography-MS method and related to activity of hepatic cytochrome P450 (CYP450) in order to identify ‘fast metabolizing’ pigs. Urine (n=46), blood (n=12), liver (n=25) and adipose tissue (n=46) were sampled from a total of 46 entire male pigs. Skatole levels in fat were negatively correlated to CYP2E1 activity and positively to 3-hydroxy-3-methyloxindole (HMOI), indole-3-carboxylic acid (ICA) and 2-aminoacetophenone in urine. HMOI and ICA levels in urine were the best predictors of high skatole levels in fat. In summary, the present study provided further evidence for the key role of CYP2E1 in skatole metabolism and suggested that measurement of HMOI and/or ICA in urine might provide information about skatole levels in live pigs.
Symptoms of sleep-disordered breathing in children, such as frequent snoring, apnoea and choking, may lead to health problems if untreated. The caregiver's level of awareness of these symptoms has been poorly studied. This study aimed to study healthcare provider contact related to sleep-disordered breathing symptoms in a population of children aged 0–11 years.
A total of 1320 children were randomly selected from a national database that included all children living in Sweden. Caregivers answered a questionnaire about sleep-disordered breathing symptoms during the last month and healthcare provider contact related to these symptoms.
A total of 754 answers were received. The prevalence of sleep-disordered breathing symptoms was 4.8 per cent. Of this subgroup, 69 per cent had not been in contact with a healthcare provider regarding their symptoms.
This study shows that sleep-disordered breathing in children is underestimated and that there is a need to increase caregiver and healthcare provider awareness of sleep-disordered breathing in children.
Randomized trials with antidepressants are often run under double blind placebo-controlled conditions, whereas those with psychotherapies are mostly unblinded. This can introduce bias in favor of psychotherapy when the treatments are directly compared. In this meta-analysis, we examine this potential source of bias.
We searched Pubmed, PsycInfo, Embase and the Cochrane database (1966 to January 2014) by combining terms indicative of psychological treatment and depression, and limited to randomized trials. We included 35 trials (with 3721 patients) in which psychotherapy and pharmacotherapy for adult depression were directly compared with each other. We calculated effect sizes for each study indicating the difference between psychotherapy and pharmacotherapy at post-test. Then, we examined the difference between studies with a placebo condition and those without in moderator analyses.
We did not find a significant difference between the studies with and those without a placebo condition. The studies in which a placebo condition was included indicated no significant difference between psychotherapy and pharmacotherapy (g = −0.07; NNT = 25). Studies in which no placebo condition was included (and patients and clinicians in both conditions were not blinded), resulted in a small, but significant difference between psychotherapy and pharmacotherapy in favor of pharmacotherapy (g = −0.13; NNT = 14).
Studies comparing psychotherapy and pharmacotherapy in which both groups of patients (and therapists) are not blinded (no placebo condition is included) result in a very small, but significantly higher effect for pharmacotherapy.