Introduction
Anxiety disorders are among the most prevalent mental disorders. However, only a minority of patients receives adequate psychotherapeutic treatment despite strong empirical evidence for ...the efficacy of CBT in anxiety disorders (Marcks
et al.
Psychiatr Serv 2009; 60 823-830). App-based psychotherapy can help to reduce this massive treatment gap.
Objectives
We aimed at evaluating the efficacy of an app-based treatment for anxiety disorders including exposure in virtual reality.
Methods
The randomized controlled trial was conducted in two university outpatient treatment centers in Northern Germany. Patients were diagnosed with agoraphobia (AP; with or without panic disorder; n=103), panic disorder (PD; n=84) or social anxiety disorder (SAD; n=110) and were randomly assigned to either the app-based intervention or treatment as usual (up to 6 sessions of supportive therapy). The app was developed based on evaluated CBT manuals and includes 14 hours of audio and video content and 15 disorder specific virtual reality exposure scenarios. Participants in the intervention groups also received two appointments with a therapist during the app-based treatment. Primary outcome was the change in Beck Anxiety Inventory (BAI) score pre to post (after 6 months). Mixed ANOVAs were conducted in intention to treat and completer analyses. Secondary outcomes were disorder specific questionnaires (Liebowitz Social Anxiety Scale LSAS for SAD and Panic and Agoraphobia Scale PAS for AP and PD) and health related quality of life measured with a single item (L-1).
Results
In the ITT analysis, the interaction effect between group and time was significant in patients with AP as well as in patients with PD (AP: p=.014, partial η²=.06; PD: p=.028, partial η²=.06). This indicates a stronger improvement of symptoms in the intervention group compared to the control group. In patients with SAD, there was no significant interaction effect (p=.101, partial η²=.03). The disorder specific measures LSAS and PAS showed a significantly stronger decrease in the intervention group than in the control group for each of the specific disorders. Concerning quality of life, a stronger improvement in the intervention group was only found in patients with PD.
Conclusions
A stronger symptom reduction in the app-based intervention group compared to the control group could be found in patients with AP (BAI/PAS), PD (BAI/PAS) and SAD (LSAS). This is particularly remarkable as the app was compared to an active control group with up to 6 sessions of psychotherapy. Effect sizes were comparable to those found in studies comparing face-to-face CBT to an active control group. The lack of an intervention-specific effect on BAI scores in patients with SAD might be due to the poor sensitivity of the BAI for the specific symptoms of SAD.
Disclosure of Interest
None Declared
The aetiology of suicidal behaviour is complex, and knowledge about its neurobiological mechanisms is limited. Neuroimaging methods provide a noninvasive approach to explore the neural correlates of ...suicide vulnerability in vivo. The ENIGMA-MDD Working Group is an international collaboration evaluating neuroimaging and clinical data from thousands of individuals collected by research groups from around the world. Here we present analyses in a subset sample (n=3097) for whom suicidality data were available. Prevalence of suicidal symptoms among major depressive disorder (MDD) cases ranged between 29 and 69% across cohorts. We compared mean subcortical grey matter volumes, lateral ventricle volumes and total intracranial volume (ICV) in MDD patients with suicidal symptoms (N=451) vs healthy controls (N=1996) or MDD patients with no suicidal symptoms (N=650). MDD patients reporting suicidal plans or attempts showed a smaller ICV (P=4.12 × 10
) or a 2.87% smaller volume compared with controls (Cohen's d=-0.284). In addition, we observed a nonsignificant trend in which MDD cases with suicidal symptoms had smaller subcortical volumes and larger ventricular volumes compared with controls. Finally, no significant differences (P=0.28-0.97) were found between MDD patients with and those without suicidal symptoms for any of the brain volume measures. This is by far the largest neuroimaging meta-analysis of suicidal behaviour in MDD to date. Our results did not replicate previous reports of association between subcortical brain structure and suicidality and highlight the need for collecting better-powered imaging samples and using improved suicidality assessment instruments.
Introduction Deep brain stimulation (DBS) is a well-established procedure for the treatment of therapy-refractory movement disorders. Limited evidence suggests that DBS of the nucleus accumbens ...region (NACC) may be effective for the treatment of psychiatric disorders, such as obsessive compulsive disorder and major depressive disorder (MDD). Hitherto, little is known concerning behavioural responses upon acute high-frequency stimulation of the NACC region in patients suffering from MDD. Objective To further characterize behavioural responses and clinical effects elicited upon acute unilateral DBS of the NACC area. Intra- and postoperative observations (including video-sequences) as well as a two-month outcome are presented. Material and Methods We performed bilateral NACC-DBS in a female patient (age: 47) with MDD refractory to psycho-, pharmaco- and electroconvulsive (>50 sessions) therapy on a compassionate-use basis. The stereotactic procedure was performed under local anaesthesia. The NACC was targeted (x) 7 mm lateral to the midline, (y) 3 mm anterior to the anterior commissure, (z) 4 mm below the anterior commissure-posterior commissure plane. A commercially available DBS lead with 4 contacts (model 3391, Medtronic Co., MN, USA; contact length: 3 mm; interelectrode distance: 4 mm) was inserted bilaterally for permanent stimulation. Results Upon test-stimulation in the operating room, acute unilateral NACC-DBS on both hemispheres stereotypically induced a visible facial reaction with a contralateral smile (bipolar stimulation of the ventralmost contacts (0− cathodal vs. 1+ anodal); pulse width: 90 μs; frequency: 130 Hz). This smile could repeatedly be elicited either when stimulation amplitude was slowly ramped up to 7 mA, or abruptly switched on to 4–5 mA. The smile was invariably associated with a significantly improved mood (as assessed by an analog scale). This effect was documented by different examiners and clearly reproducible in the subsequent clinical course. A dramatic improvement of the depression scores, patient’s mood and social behaviour was documented at a first follow-up (6 weeks postoperatively). Conclusion Albeit preliminary, the patient’s beneficial response tentatively suggests that NACC-DBS may be a viable option for selected patients with MDD. In line with previous reports on stimulation-induced smile responses in patients with obsessive compulsive disorder, our intraoperative observations support and expand the notion of the NACC area constituting or containing an important interface between limbic and motor networks, respectively, that may be involved in the pathophysiology of MDD. It is suggested that the results of long-term NACC-DBS in patients with MDD should be evaluated by larger patient samples and randomized, controlled trials.
Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) is the psychotherapeutic treatment of choice for obsessive-compulsive disorder (OCD). However, little is known about the ...impact of CBT on frontostriatal dysfunctioning, known to be the neuronal correlate of OCD.
A probabilistic reversal learning (RL) task probing adaptive strategy switching capabilities was used in 10 unmedicated patients with OCD and 10 healthy controls during an event-related functional magnetic resonance imaging (fMRI) experiment. Patients were scanned before and after intensive CBT, controls twice at comparable intervals.
Strategy change within the RL task involved activity in a broad frontal network in patients and controls. No significant differences between the groups or in group by time interactions were detected in a whole-brain analysis corrected for multiple comparisons. However, a reanalysis with a more lenient threshold revealed decreased responsiveness of the orbitofrontal cortex and right putamen during strategy change before treatment in patients compared with healthy subjects. A group by time effect was found in the caudate nucleus, demonstrating increased activity for patients over the course of time. Patients with greater clinical improvement, reflected by greater reductions in Yale-Brown Obsessive Compulsive Scale (YBOCS) scores, showed more stable activation in the pallidum.
Although these findings are preliminary and need to be replicated in larger samples, they indicate a possible influence of psychotherapy on brain activity in core regions that have been shown to be directly involved both in acquisition of behavioral rules and stereotypes and in the pathophysiology of OCD, the caudate nucleus and the pallidum.
The study aims to investigate the recognition of patients with Obsessive-Compulsive Disorder (OCD) in psychiatric outpatients.
A total of 2282 outpatients seen at 14 different psychiatric clinics in ...South Germany were asked to participate in the study. Five hundred and eighty-nine (30%) of the original 2282 patients met screening criteria for OCD, and of those, 237 (42%) participated in the final interview including DSM-IV diagnosis, and comorbidity.
Sixty-nine of 589 participating patients who screened positively for obsessive symptoms actually had an Obsessive-Compulsive Disorder. Only 19 (28%) of the outpatients diagnosed with OCD according to DSM-IV criteria were also given this diagnosis by their consultant. The psychopathology scores indicated that the OCD patients had clinically relevant OCD with a mean Yale-Brown Obsessive Compulsive Score (Y-BOCS) of 17.5 (± 5.4), and a mean Clinical Global Impression Score (CGI) of 5.2 (± 1.2).
In outpatient clinics over 70% of OCD patients remain unrecognised and thus untreated by consultants. Screening questions provide a rapid way of identifying those who may have OCD and should be incorporated into every mental state examination by consultants.
Mixed findings have been obtained in prior research with respect to the presence and severity of memory and metamemory deficits in obsessive–compulsive disorder (OCD). We tested the hypothesis that ...experimentally induced increments of subjective responsibility would lead to a disproportionately strong decline of memory confidence and enhanced response latencies in OCD while leaving memory accuracy unaffected. Twenty-eight OCD patients and 28 healthy controls were presented a computerized memory test framed with two different scenarios. In the neutral scenario, the participant was requested to imagine purchasing 15 items from a do-it-yourself store. In the recognition phase, the 15 needed items were presented along with 15 distractor items. The participant was asked to decide whether items were on his or her shopping list or not, graded by subjective confidence. In the responsibility scenario, the general experimental setup was analogous except that the participant now had to envision that he or she was a helper in a region recently struck by an earthquake, dispatched to provide 15 urgently needed goods from a nearby town. In line with prior work by our group, samples did not differ in either condition on memory accuracy in a subsequent recognition task. As hypothesized, OCD participants were less certain in their responses for the high responsibility condition than controls. Whereas patients and controls did not differ in their subjective estimates for memorized items, patients expressed stronger doubt that their earthquake mission was successful. The findings indicate that low memory confidence in OCD may only be elicited in situations where perceived responsibility is high and that patients may share higher performance standards (“good is not good enough”) than controls when perceived responsibility is inflated.
Guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with obsessive-compulsive disorder (OCD) is an important part of the care available for these patients. It may not ...be adequately reflected in the current personnel resources available according to the German psychiatry personnel regulation (Psych-PV).
The goal of this work was to assess the personnel resources necessary for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD and compare the necessary resources with the resources available according to Psych-PV.
Based on the German national guidelines for OCD and a meta-analysis on treatment intensity, we formulated a normative weekly treatment plan. Based on this plan we calculated the necessary personnel resources and compared these with the resources available according to Psych-PV category A1 (standard care).
The weekly treatment time for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is 23.5 h per week. This corresponds to a weekly personnel requirement of 20.9 h. This requirement is only partly reflected in the Psych-PV (17.3 h, 82.8 %). The coverage of personnel resources by Psych-PV is even lower for psychotherapy provided by psychiatrist and psychologists (38.3 %, i. e. 183 min in the normative plan versus 70 min in Psych-PV).
The current paper shows that the personal resources required for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is not adequately reflected in the German psychiatry personnel regulation (Psych-PV). The actual shortage may be underestimated in our paper.
Deep brain stimulation (DBS) has been proposed for severe, chronic, treatment-refractory obsessive-compulsive disorder (OCD) patients. Although serious adverse events can occur, only a few studies ...report on the safety profile of DBS for psychiatric disorders. In a prospective, open-label, interventional multi-center study, we examined the safety and efficacy of electrical stimulation in 30 patients with DBS electrodes bilaterally implanted in the anterior limb of the internal capsule. Safety, efficacy, and functionality assessments were performed at 3, 6, and 12 months post implant. An independent Clinical Events Committee classified and coded all adverse events (AEs) according to EN ISO14155:2011. All patients experienced AEs (195 in total), with the majority of these being mild (52% of all AEs) or moderate (37%). Median time to resolution was 22 days for all AEs and the etiology with the highest AE incidence was 'programming/stimulation' (in 26 patients), followed by 'New illness, injury, condition' (13 patients) and 'pre-existing condition, worsening or exacerbation' (11 patients). Sixteen patients reported a total of 36 serious AEs (eight of them in one single patient), mainly transient anxiety and affective symptoms worsening (20 SAEs). Regarding efficacy measures, Y-BOCS reduction was 42% at 12 months and the responder rate was 60%. Improvements in GAF, CGI, and EuroQol-5D index scores were also observed. In sum, although some severe AEs occurred, most AEs were mild or moderate, transient and related to programming/stimulation and tended to resolve by adjustment of stimulation. In a severely treatment-resistant population, this open-label study supports that the potential benefits outweigh the potential risks of DBS.
The neuro-anatomical substrates of major depressive disorder (MDD) are still not well understood, despite many neuroimaging studies over the past few decades. Here we present the largest ever ...worldwide study by the ENIGMA (Enhancing Neuro Imaging Genetics through Meta-Analysis) Major Depressive Disorder Working Group on cortical structural alterations in MDD. Structural T1-weighted brain magnetic resonance imaging (MRI) scans from 2148 MDD patients and 7957 healthy controls were analysed with harmonized protocols at 20 sites around the world. To detect consistent effects of MDD and its modulators on cortical thickness and surface area estimates derived from MRI, statistical effects from sites were meta-analysed separately for adults and adolescents. Adults with MDD had thinner cortical gray matter than controls in the orbitofrontal cortex (OFC), anterior and posterior cingulate, insula and temporal lobes (Cohen's d effect sizes: -0.10 to -0.14). These effects were most pronounced in first episode and adult-onset patients (>21 years). Compared to matched controls, adolescents with MDD had lower total surface area (but no differences in cortical thickness) and regional reductions in frontal regions (medial OFC and superior frontal gyrus) and primary and higher-order visual, somatosensory and motor areas (d: -0.26 to -0.57). The strongest effects were found in recurrent adolescent patients. This highly powered global effort to identify consistent brain abnormalities showed widespread cortical alterations in MDD patients as compared to controls and suggests that MDD may impact brain structure in a highly dynamic way, with different patterns of alterations at different stages of life.
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