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1.  A five-year randomized parallel and blinded clinical trial of an extended specialized early intervention vs. regular care in the early phase of psychotic disorders: study protocol 
BMC Psychiatry  2015;15:22.
Specialized Early Intervention services (SEI) for first episode psychosis are shown to be effective for the treatment of positive and negative symptoms, medication adherence, rates of relapse, substance abuse disorders, functional outcome and quality of life at two-year treatment follow up. However, it is also reported that these benefits are not maintained when SEI is not sustained. The objective of this trial is to test the efficacy of a 3-year extension of a SEI service (following 2 years of SEI prior to randomization) for the maintenance and consolidation of therapeutic gains as compared to regular care in the community.
Following an initial 2 years of SEI, patients are randomized to receive either 3-years of continued SEI or regular care. SEI provided at three sites within the McGill network of SEI services, using a model of treatment comprised of: modified assertive case management; psycho education for families; multiple family intervention; cognitive behavioural therapy; and substance abuse treatment and monitoring. Blinded research assistants conduct ongoing evaluation of the outcome variables every three months. The primary outcome measure is remission status measured both as the proportion of patients in complete remission and the mean length of remission achieved following randomization during the additional three years of follow up. Based on preliminary data, it is determined that a total of 212 patients are needed to achieve adequate statistical power. Intent to treat with the last observation carried forward will be the primary method of statistical analysis.
The “critical period” hypothesis posits that there is a five year window during which the effects of the nascent psychotic illness can be countered and the impact of the disorder on symptomatic and functional outcomes can be offset through active and sustained treatment. Providing SEI throughout this critical period may solidify the benefits of treatment such that gains may be more sustainable over time as compared to intervention delivered for a shorter period. Findings from this study will have implications for service provision in first episode psychosis.
Trial registration
PMCID: PMC4336502
Specialized early intervention; First episode psychosis; Treatment; Critical period; Remission; Case management; Randomized controlled trial
2.  The two-year course of late-life depression; results from the Netherlands study of depression in older persons 
BMC Psychiatry  2015;15:20.
We aimed to examine the course of depression during 2-year follow-up in a group clinically depressed older persons. Subsequently, we studied which socio-demographic and clinical characteristics predict a depression diagnoses at 2-year follow-up.
Data were used from the Netherlands Study of Depression in Older persons (NESDO; N = 510). Diagnoses of depression DSM-IV-TR criteria were available from 285 patients at baseline and at 2-year follow-up. Severity of the depressive symptoms, as assessed with the Inventory of Depressive Symptoms (IDS), was obtained from 6-monthly postal questionnaires. Information about socio-demographic and clinical variables was obtained from the baseline measurement.
From the 285 older persons who were clinically depressed at baseline almost half (48.4%) also suffered from a depressive disorder two years later. Patients with more severe depressive symptoms, comorbid dysthymia, younger age of onset and more chronic diseases were more likely to be depressed at 2-year follow-up. 61% of the persons that were depressed at baseline had a chronic course of depressive symptoms during these two years.
Late-life depression often has a chronic course, even when treated conform current guidelines for older persons. Our results suggest that physical comorbidity may be candidate for adjusted and intensified treatment strategies of older depressed patients with chronic and complex pathology.
PMCID: PMC4329675
Late-life depression; Course; Determinants; Cohort study; Longitudinal
3.  The effects of the Omagh bomb on adolescent mental health: a school-based study 
BMC Psychiatry  2015;15:18.
The main objective of this study was to assess psychiatric morbidity among adolescents following the Omagh car bombing in Northern Ireland in 1998.
Data was collected within schools from adolescents aged between 14 and 18 years via a self-completion booklet comprised of established predictors of PTSD; type of exposure, initial emotional response, long-term adverse physical problems, predictors derived from Ehlers and Clark’s (2000) cognitive model, a PTSD symptoms measure (PDS) and the General Health Questionnaire (GHQ).
Those with more direct physical exposure were significantly more likely to meet caseness on the GHQ and the PDS. The combined pre and peri trauma risk factors highlighted in previous meta-analyses accounted for 20% of the variance in PDS scores but the amount of variance accounted for increased to 56% when the variables highlighted in Ehlers and Clark’s cognitive model for PTSD were added.
High rates of chronic PTSD were observed in adolescents exposed to the bombing. Whilst increased exposure was associated with increased psychiatric morbidity, the best predictors of PTSD were specific aspects of the trauma (‘seeing someone you think is dying’), what you are thinking during the event (‘think you are going to die’) and the cognitive mechanisms employed after the trauma. As these variables are in principle amenable to treatment the results have implications for teams planning treatment interventions after future traumas.
PMCID: PMC4329658
PTSD; Bombing; Cognitive models; Adolescents; School survey
4.  A community-based pilot randomised controlled study of life skills classes for individuals with low mood and depression 
BMC Psychiatry  2015;15:17.
Cognitive behavioural therapy (CBT) is recommended for the treatment of depression and anxiety. However, access is limited. Low-intensity approaches such as guided CBT self-help (bibliotherapy) can increase access to treatment and is recommended by UK guidelines. No previous research has explored the provision of group-based guidance/support for a bibliotherapy approach for depression and anxiety in community settings. The objective was to carry out a pilot study of a group guided self-help intervention, using community based recruitment methods.
A randomised controlled trial comparing an 8 week CBT group guided self-help intervention to usual care. Recruitment and the delivery of the intervention were carried out in Glasgow and Derry/Londonderry in partnership with national depression charities. Fifty-three people were randomised, however we refer only to the forty-six participants who provided baseline data: 16 males and 30 females, aged 16 or over, with a PHQ-9 score of ≥ 5, were recruited from the community. The mean age of the sample was 43.7 (sd = 13) and 93.5% of participants had suffered from low mood for a year or more.
There was effective recruitment, randomisation, uptake and adherence with 21 Immediate Access (IA) and 25 Delayed Access Control (DAC) participants. The intervention was highly acceptable to participants attending on average 4.46 of the 8 sessions (sd 3.06), 65.2% attended more than half of all sessions. The mean satisfaction on the Client Satisfaction Questionnaire was 28 out of 32 (sd 4.8). The provisional results in the pilot suggest the intervention may improve both anxiety and depression. At three months, data collection was achieved from 74% of participants. The trial successfully provided estimates of the sample size needed for the future planned trial.
Low-intensity group-based classes may offer an alternative method of managing depression and anxiety and warrant further research.
Trial registration
Current Controlled Trials ISRCTN84893887. Registered 3 November 2011.
PMCID: PMC4331464
Depression; Guided self-help; Cognitive behavioural therapy; Low intensity; Living life to the full classes
5.  The development and psychometric properties of a measure of clinicians’ attitudes to depression: the revised Depression Attitude Questionnaire (R-DAQ) 
BMC Psychiatry  2015;15:7.
Depression is a common mental disorder associated with substantial disability. It is inadequately recognised and managed, and clinicians’ attitudes to this condition and its treatment may play a part in this. Most research in this area has used the Depression Attitude Questionnaire (DAQ), but analyses have shown this measure to exhibit problems in psychometric properties and suitability for the health professionals and settings where depression recognition may occur.
We revised the DAQ using a pooled review of findings from studies using this measure, together with a Delphi study which sought the opinions of a panel of relevant experts based in the UK, USA, Australia, and European countries (n = 24) using 3 rounds of questioning to consider attitude dimensions, content, and item wording. After item generation, revision and consensus (agreement >70%) using the Delphi panel, the revised DAQ (R-DAQ) was tested with 1193 health care providers to determine its psychometric properties. Finally the test-retest reliability of the R-DAQ was examined with 38 participants.
The 22-item R-DAQ scale showed good internal consistency: Cronbach’s alpha coefficient was 0.84; and satisfactory test-retest reliability: intraclass correlation coefficient was 0.62 (95% C.I. 0.37 to 0.78). Exploratory factor analysis favoured a three-factor structure (professional confidence, therapeutic optimism/pessimism, and a generalist perspective), which accounted for 45.3% of the variance.
The R-DAQ provides a revised tool for examining clinicians’ views and understanding of depression. It addresses important weaknesses in the original measure whilst retaining items and dimensions that appeared valid. This revised scale is likely to be useful in examining attitudes across the health professional workforce and beyond the confines of the UK, and may be valuable for the purpose of evaluating training that aims to address clinicians’ attitudes to depression. It incorporates key dimensions of attitudes with a modest number of items making it applicable to use in busy clinical settings.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0381-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4321322  PMID: 25653089
6.  Temporary loss of moral behavior in a patient undergoing chemotherapy with cisplatin - breaking bad 
BMC Psychiatry  2015;15:9.
Behavioral disturbances following chemotherapy with cisplatin are rare. Here, we report a patient with temporary loss of moral behavior in the setting of cisplatin-based chemotherapy for treatment of tonsillar cancer.
Case presentation
A 66-year-old Caucasian male with no psychiatric or violent history was started on chemotherapy with cisplatin for treatment of tonsillar cancer. During the following weeks, the patient developed profound personality changes involving volatile emotions and impulsive aggression with verbal and physical assaults on others. Admitted to the hospital, the patient lacked any awareness that his behavior was wrong. Chemotherapy was discontinued and the patient was prescribed risperidone. Aside from mild cognitive impairment, comprehensive neuropsychological, neuroradiological and lab testing were unremarkable. Three weeks following cessation of chemotherapy, the patient had recovered to his original mental state and he was completely aware of his wrongdoing and social misconduct.
Since neurotoxic effects of chemotherapeutics on the brain are not yet sufficiently elucidated, our case emphasizes that early signs of behavioral abnormalities in patients receiving chemotherapy should trigger comprehensive psychiatric evaluation and ongoing monitoring of the patients’ mental state.
PMCID: PMC4321323  PMID: 25651838
7.  The Sleep Or Mood Novel Adjunctive therapy (SOMNA) trial: a study protocol for a randomised controlled trial evaluating an internet-delivered cognitive behavioural therapy program for insomnia on outcomes of standard treatment for depression in men 
BMC Psychiatry  2015;15:16.
Insomnia is a significant risk factor for depression onset, can result in more disabling depressive illness, and is a common residual symptom following treatment cessation that can increase the risk of relapse. Internet-based cognitive behavioural therapy for insomnia has demonstrated efficacy and acceptability to men who are less likely than women to seek help in standard care. We aim to evaluate whether internet delivered cognitive behavioural therapy for insomnia as an adjunct to a standard depression therapeutic plan can lead to improved mood outcomes.
Male participants aged 50 years or more, meeting Diagnostic and Statistical Manual of Mental Disorders criteria for current Major Depressive Episode and/or Dysthymia and self-reported insomnia symptoms, will be screened to participate in a single-centre double-blind randomised controlled trial with two parallel groups involving adjunctive internet-delivered cognitive behavioural therapy for insomnia and an internet-based control program. The trial will consist of a nine-week insomnia intervention period with a six-month follow-up period. During the insomnia intervention period participants will have their depression management coordinated by a psychiatrist using standard guideline-based depression treatments. The study will be conducted in urban New South Wales, Australia, where 80 participants from primary and secondary care and direct from the local community will be recruited. The primary outcome is change in the severity of depressive symptoms from baseline to week 12.
This study will provide evidence on whether a widely accessible, evidence-based, internet-delivered cognitive behavioural therapy for insomnia intervention can lead to greater improvements than standard treatment for depression alone, in a group who traditionally do not readily access psychotherapy. The study is designed to establish effect size, feasibility and processes associated with implementing e-health solutions alongside standard clinical care, to warrant undertaking a larger more definitive clinical trial.
Trial registration
Australian and New Zealand Clinical Trials Registry ACTRN12612000985886.
PMCID: PMC4321324  PMID: 25652579
Depression; Insomnia; Adjunctive; e-health; Cognitive behavioural therapy; Randomised controlled trial; Men
8.  Continued cannabis use at one year follow up is associated with elevated mood and lower global functioning in bipolar I disorder 
BMC Psychiatry  2015;15:11.
There is limited knowledge about how environmental factors affect the course of bipolar disorder (BD). Cannabis has been proposed as a potential risk factor for poorer course of illness, but the role of cannabis use has not been studied in a first treatment BD I sample.
The present study examines the associations between course of illness in first treatment BD I and continued cannabis use, from baseline to one year follow up. Patients (N = 62) with first treatment DSM-IV BD I were included as part of the Thematically Organized Psychosis study (TOP), and completed interviews and self-report questionnaires at both baseline and follow up. Cannabis use within the last six months at baseline and use between baseline and follow up (“continued use”) was recorded.
After controlling for confounders, continued cannabis use was significantly associated with elevated mood (YMRS) and inferior global functioning (GAF-F) at follow up. Elevated mood mediated the effect of cannabis use on global functioning.
These results suggest that cannabis use has clinical implications for the early course of BD by increasing mood level. More focus on reducing cannabis use in clinical settings seems to be useful for improving outcome in early phase of the disorder.
PMCID: PMC4323143  PMID: 25651990
Cannabis; Bipolar
9.  Yoga for prenatal depression: a systematic review and meta-analysis 
BMC Psychiatry  2015;15:14.
Prenatal depression can negatively affect the physical and mental health of both mother and fetus. The aim of this study was to determine the effectiveness of yoga as an intervention in the management of prenatal depression.
A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted by searching PubMed, Embase, the Cochrane Library and PsycINFO from all retrieved articles describing such trials up to July 2014.
Six RCTs were identified in the systematic search. The sample consisted of 375 pregnant women, most of whom were between 20 and 40 years of age. The diagnoses of depression were determined by their scores on Structured Clinical Interview for DSM-IV and the Center for Epidemiological Studies Depression Scale. When compared with comparison groups (e.g., standard prenatal care, standard antenatal exercises, social support, etc.), the level of depression statistically significantly reduced in yoga groups (standardized mean difference [SMD], −0.59; 95% confidence interval [CI], −0.94 to −0.25; p = 0.0007). One subgroup analysis revealed that both the levels of depressive symptoms in prenatally depressed women (SMD, −0.46; CI, −0.90 to −0.03; p = 0.04) and non-depressed women (SMD, −0.87; CI, −1.22 to −0.52; p < 0.00001) were statistically significantly lower in yoga group than that in control group. There were two kinds of yoga: the physical-exercise-based yoga and integrated yoga, which, besides physical exercises, included pranayama, meditation or deep relaxation. Therefore, the other subgroup analysis was conducted to estimate effects of the two kinds of yoga on prenatal depression. The results showed that the level of depression was significantly decreased in the integrated yoga group (SMD, −0.79; CI, −1.07 to −0.51; p < 0.00001) but not significantly reduced in physical-exercise-based yoga group (SMD, −0.41; CI, −1.01 to −0.18; p = 0.17).
Prenatal yoga intervention in pregnant women may be effective in partly reducing depressive symptoms.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-015-0393-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4323231  PMID: 25652267
Yoga; Prenatal depression; Systematic review; Meta-analysis
10.  Roles of attachment and self-esteem: impact of early life stress on depressive symptoms among Japanese institutionalized children 
BMC Psychiatry  2015;15:8.
Although exposure to early life stress is known to affect mental health, the underlying mechanisms of its impacts on depressive symptoms among institutionalized children and adolescents have been little studied.
To investigate the role of attachment and self-esteem in association with adverse childhood experiences (ACEs) and depressive symptoms, 342 children (149 boys, 193 girls; age range 9-18 years old, mean age = 13.5 ± 2.4) living in residential foster care facilities in Japan completed questionnaires related to internal working models, self-esteem, and depressive symptoms. Their care workers completed questionnaires on ACEs.
Structural equation modeling (SEM) was created and the goodness of fit was examined (CMIN = 129.223, df = 1.360, GFI = .959, AGFI = .936, CFI = .939, RMSEA = .033). Maltreatment negatively predicted scores on secure attachment, but positively predicted scores on avoidant and ambivalent attachment. The secure attachment score negatively predicted depressive symptoms. The ambivalent attachment score positively predicted depressive symptoms both directly and through self-esteem, whereas the avoidant attachment score positively predicted depressive symptoms only directly. Maltreatment neither directly predicts self-esteem nor depressive symptoms, and parental illness/death and parental sociopathic behaviors did not predict any variables.
Results show that the adversity of child maltreatment affects depression through attachment styles and low self-esteem among institutionalized children. Implications of child maltreatment and recommendations for child welfare services and clinical interventions for institutionalized children are discussed.
PMCID: PMC4324421  PMID: 25651759
Adverse childhood experiences (ACEs); Attachment; Depressive symptoms; Institutionalized children; Maltreatment; Self-esteem
11.  Suicide attempts and emergency room psychiatric consultation 
BMC Psychiatry  2015;15:13.
Suicidal behaviours are major public health concerns worldwide. They are associated with risk factors that vary with age and gender, occur in combination, and may change over time. The aim of our study was to investigate how frequently patients visiting a hospital emergency room (ER) require a psychiatric consultation for attempted suicide, and to outline the characteristics of this population.
Determinants of emergency room visits for psychiatric reasons were studied prospectively from 2008 to 2011 at the “Maggiore” Hospital in Novara.
280 out of 1888 patients requiring psychiatric consultation were referred to the ER because of suicide attempt. Suicide attempters were more often female. The rate of suicide attempters among Italian people was 14.2%, compared to 19.5% in foreigners. Subjects living with parents or own family and those having a permanent job had a higher frequency of suicide attempt. Suicide attempts were more frequent among patients with a history of psychiatric disorders; nonetheless, suicide attempts were more common among those who had not previously been hospitalized in a psychiatric ward or were not under the care of a psychiatrist. The multivariate analysis found that female gender was a risk factor for suicide attempt, while being in the colder months of the year and, surprisingly, unemployment were protective factors.
A better understanding of patients referring to the ER due to attempted suicide may allow the identification of at-risk subjects and the implementation of targeted treatment approaches.
PMCID: PMC4327969  PMID: 25652192
Emergency room; Suicide attempt; Psychiatric symptoms; Referral
12.  The impact of age differences in couples on depressive symptoms: evidence from the Korean longitudinal study of aging (2006–2012) 
BMC Psychiatry  2015;15:10.
Depression represents one of the most common psychiatric disorders among older adults. Married couples are affected frequently, and psychiatric problems usually affect marital satisfaction. Despite the frequency of such relationships, it appears that very few studies have examined the issues that arise in couples of this type of marriage. Therefore, we investigate whether age differences between couples affect extent of depressive symptoms among older adults.
Our analysis included 2,881 couples (i.e., 2,881 households) at least 45 years of age at baseline (2006), in addition to 3,033 couples in 2008, 2,772 couples in 2010, and 2,711 couples in 2012. A generalized linear mixed model was used for the data analysis.
When the age difference between husbands and wives was 3 years or less, the estimated severity of depressive symptoms was 0.309 higher (SE = 0.084, p = 0.000) than that of same-aged couples. When the age gap was 3 years or more, the estimated severity of depressive symptoms was 0.645 higher (SE = 0.109, p < .0001) than that of same-aged couples. For every 1–2 years extra in age difference between wives and husbands, the estimated severity of depressive symptoms increased by 0.194 (SE = 0.082, p = 0.018), compared with same-aged couples.
Age differences between husbands and wives impact their relationship, including any particular marital issues encountered.
PMCID: PMC4330941  PMID: 25651908
Age differences; Couples; Depressive symptoms
13.  Psychometric properties of EURO-D, a geriatric depression scale: a cross-cultural validation study 
BMC Psychiatry  2015;15:12.
Many of the assessment tools used to study depression among older people are adaptations of instruments developed in other cultural setting. There is a need to validate those instruments in low and middle income countries (LMIC).
A one-phase cross-sectional survey of people aged [greater than or equal to] 65 years from LMIC. EURO-D was checked for psychometric properties. Calibration with clinical diagnosis was made using ICD-10. Optimal cutpoint was determined. Concurrent validity was assessed measuring correlations with WHODAS 2.0.
17,852 interviews were completed in 13 sites from nine countries. EURO-D constituted a hierarchical scale in most sites. The most commonly endorsed symptom in Latin American sites was depression; in China was sleep disturbance and tearfulness; in India, irritability and fatigue and in Nigeria loss of enjoyment. Two factor structure (affective and motivation) were demonstrated. Measurement invariance was demonstrated among Latin American and Indian sites being less evident in China and Nigeria. At the 4/5 cutpoint, sensitivity for ICD-10 depressive episode was 86% or higher in all sites and specificity exceeded 84% in all Latin America and Chinese sites. Concurrent validity was supported, at least for Latin American and Indian sites.
There is evidence for the cross-cultural validity of the EURO-D scale at Latin American and Indian settings and its potential applicability in comparative epidemiological studies.
PMCID: PMC4332422  PMID: 25652111
Depression; EURO-D scale; Psychometric properties; Old age; Validation
14.  Decision making, central coherence and set-shifting: a comparison between Binge Eating Disorder, Anorexia Nervosa and Healthy Controls 
BMC Psychiatry  2015;15:6.
Several studies have investigated the cognitive profile in patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN); on the contrary few studies have evaluated it in patients with Binge Eating Disorder (BED). The purpose of this study was to compare decision making, central coherence and set-shifting between BED and AN patients.
A battery of neuropsychological tests including the Iowa Gambling Task (IGT), the Rey-Osterrieth Complex Figure Test (RCFT), the Wisconsin Card Sorting Test (WCST), the Trial Making Task (TMT) and the Hayling Sentence Completion Task (HSCT) were administered in a sample of 135 women (45 AN, 45 BED, 45 Healthy Controls [HC]). Furthermore, Beck Depression Inventory (BDI) was administered to evaluate depressive symptoms. Years of education, age, Body Mass Index (BMI) and depression severity were considered as covariates in statistical analyses.
BED and AN patients showed high rates of cognitive impairment compared to HC on the domains investigated; furthermore, the cognitive profile of BED patients was characterised by poorer decision making and cognitive flexibility compared to patients with AN. Cognitive performance was strongly associated with depressive symptoms.
In the present sample, two different neurocognitive profiles emerged: a strong cognitive rigidity and a central coherence based on the details was predominant in patients with AN, while a lack of attention and difficulty in adapting to changes in a new situation seemed to better describe patients with BED. The knowledge of the different cognitive profiles of EDs patients may be important for the planning their psychotherapeutic intervention.
PMCID: PMC4308856  PMID: 25616812
Anorexia Nervosa; Binge Eating Disorder; Cognitive flexibility; Central coherence; Set-shifting; Decision making; Neuropsychology; Depression
15.  Did female prisoners with mental disorders receive psychiatric treatment before imprisonment? 
BMC Psychiatry  2015;15:5.
Throughout the world, high prevalence rates of mental disorders have been found in prison populations, especially in females. It has been suggested that these populations do not access psychiatric treatment. The aim of this study was to establish rates of psychiatric in- and outpatient treatments prior to imprisonment in female prisoners and to explore reasons for discontinuation of such treatments.
150 consecutively admitted female prisoners were interviewed in Berlin, Germany. Socio-demographic characteristics, mental disorders, and previous psychiatric in- and outpatient treatments were assessed by trained researchers. Open questions were used to explore reasons for ending previous psychiatric treatment.
A vast majority of 99 prisoners (66%; 95% CI: 58–73) of the total sample reported that they had previously been in psychiatric treatment, 80 (53%; 95 CI: 45–61) in inpatient treatment, 62 (41%; 95 CI: 34–49) in outpatient treatment and 42 (29%; 21–39) in both in- and outpatient treatments. All prisoners with psychosis and 72% of the ones with any lifetime mental health disorder had been in previous treatment. The number of inpatient treatments and imprisonments were positively correlated (rho = 0.27; p < 0.01). Inpatient treatment was described as successfully completed by 56% (N = 41) of those having given reasons for ending such treatment, whilst various reasons were reported for prematurely ending outpatient treatments.
The data do not support the notion of a general ‘mental health treatment gap’ in female prisoners. Although inpatient care is often successfully completed, repeated inpatient treatments are not linked with fewer imprisonments. Improved transition from inpatient to outpatient treatment and services that engage female prisoners to sustained outpatient treatments are needed.
PMCID: PMC4307137  PMID: 25608668
Prisoners; Mental health; Psychiatric hospitalized care; Outpatient mental health treatment
16.  The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder 
BMC Psychiatry  2015;15:2.
Negative attitudes towards patients with borderline personality disorder (BPD) may affect their treatment. We aimed to identify attitudes toward patients with BPD.
Clinicians in four psychiatric hospitals in Israel (n = 710; psychiatrists, psychologists, social workers and nurses) were approached and completed questionnaires on attitudes toward these patients.
Nurses and psychiatrists reported encountering a higher number of patients with BPD during the last month, and exhibited more negative attitudes and less empathy toward these patients than the other two professions. The whole sample evaluated the decision to hospitalize such a patient as less justified than the decision to hospitalize a patient with Major Depressive Disorder. Negative attitudes were positively correlated with caring for greater numbers of patients with BPD in the past month and in the past 12 months. Nurses expressed the highest interest in studying short-term methods for treating patients with BPD and a lower percentage of psychiatrists expressed an interest in improving their professional skills in treating these patients.
The findings show that nurses and psychiatrists differ from the other professions in their experience and attitudes toward patients with BPD. We conclude that nurses and psychiatrists may be the target of future studies on their attitudes toward provocative behavioral patterns (e.g., suicide attempts) characterizing these patients. We also recommend implementing workshops for improving staff attitudes toward patients with BPD.
PMCID: PMC4307152  PMID: 25609479
Attitudes; Borderline personality disorder; Hospitalization; Mental health; Staff; Suicide
17.  Employment and financial burden of families with preschool children diagnosed with autism spectrum disorders in urban China: results from a descriptive study 
BMC Psychiatry  2015;15:3.
Autism spectrum disorder (ASD) affects many aspects of family life, such as social and economic burden. Little investigation of this phenomenon has been carried out in China. We designed this study to evaluate the employment and financial burdens of families with ASD-diagnosed preschoolers.
Four hundred and fifty-nine nuclear families of children with ASD, 418 with some other disability (OD) and 424 with typically developing (TD) children were recruited for this study. Employment and financial burdens of families were evaluated using a structured questionnaire; logistic regression was used to examine differences in job change measures by group, and ordinal logistic regression was used to investigate the association between household income and group.
Fifty-eight percent of families with ASD children and 19% of families with OD children reported that childcare problems had greatly affected their employment decisions, compared with 9% of families with TD children (p < 0.001). Age of child, parental education and parental age notwithstanding, having a child with ASD and having a child with OD were both associated with increased odds of reporting that childcare greatly interfered with employment (ASD, OR: 15.936; OD, OR: 2.502; all p < 0.001) and decreased the odds of living in a higher-income household (ASD, estimate = -1.271; OD, estimate = -0.569; all p < 0.001). The average loss of annual income associated with having a child with ASD was Chinese RenMinBi (RMB) 44,077 ($7,226), compared with RMB 20,788 ($3,408) for families of OD children.
ASD is associated with severe employment and financial burdens, much more than for OD, in families with preschool children.
PMCID: PMC4307683  PMID: 25608486
Employment burden; Financial burden; Autism spectrum disorder; Chinese
18.  The efficacy and safety of once-daily quetiapine extended release in patients with schizophrenia switched from other antipsychotics: an open-label study in Chinese population 
BMC Psychiatry  2015;15:1.
Non-adherence to antipsychotic medication in schizophrenic patients is common and associated with symptom relapse and poorer long-term outcomes. The risk factors for treatment non-adherence include dosing frequency and complexity. Besides, slower dose titration in an acute schizophrenic episode may lead to attenuated efficacy. Therefore, the convenient dosage regimen and rapid initiation scheme of quetiapine extended release (XR) were expected to provide better effectiveness and promote adherence in patients with schizophrenia. This study was implemented to assess the efficacy and safety of once-daily quetiapine XR in schizophrenic patients with switched from other antipsychotics which were suboptimal due to insufficient efficacy or tolerability.
This was a 12-week, open-label study conducted in the Chinese population in Taiwan.
Patients who had a score of 4 (moderate) or greater on any of the 7 items of the Positive and Negative Syndrome Scale (PANSS) Positive Symptom Subscale and needed to switch from previous antipsychotics were recruited. Quetiapine XR was administered at 300 mg on day 1, 600 mg on day 2 and up to 800 mg after day 2. From day 8 until the end of the study, the dose of quetiapine XR was adjusted within 400-800 mg per day, depending on the clinical response and tolerance of the patients. The variable of the primary outcome was the change from baseline to Week 12 in PANSS total and subscale scores. Secondary outcome was the baseline-to-endpoint difference in the Clinical Global Impression-Severity (CGI-S) scores of the participants.
Sixty-one patients were recruited and 55.7% of them completed the study. The mean changes in the PANSS total score and CGI-S score showed significant improvement (−18.4, p < .001 and −1.0, p < .001, respectively). Four patients (6.7%) experienced adverse events including headache, exacerbation of psychosis and dysuria. The use of concomitant anticholinergics decreased from 15.0% to 8.3%.
The results of our investigation implicated that quetiapine XR was an effective and well tolerated alternative for Chinese schizophrenic patients with previous suboptimal treatment. Future large-scale studies are warranted to validate our results.
Trial registration ID NCT02142556. Registered 15 May 2014.
PMCID: PMC4308905  PMID: 25609320
Schizophrenia; Quetiapine XR; Antipsychotic agents; Drug switching; Chinese population
19.  Natural course of behavioral addictions: a 5-year longitudinal study 
BMC Psychiatry  2015;15:4.
Resolving the theoretical controversy on the labeling of an increasing number of excessive behaviors as behavioral addictions may also be facilitated by more empirical data on these behavioral problems. For instance, an essential issue to the classification of psychiatric disorders is information on their natural course. However, longitudinal research on the chronic vs. episodic nature of behavioral addictions is scarce. The aim of the present study, therefore, was to provide data on prevalence, substance use comorbidity, and five-year trajectories of six excessive behaviors—namely exercising, sexual behavior, shopping, online chatting, video gaming, and eating.
Analyses were based on the data of the Quinte Longitudinal Study, where a cohort of 4,121 adults from Ontario, Canada was followed for 5 years (2006 to 2011). The response rate was 21.3%, while retention rate was 93.9%. To assess the occurrence of each problem behavior, a single self-diagnostic question asked people whether their over-involvement in the behavior had caused significant problems for them in the past 12 months. To assess the severity of each problem behavior reported, the Behavioral Addiction Measure was administered. A mixed design ANOVA was used to investigate symptom trajectories over time for each problem behavior and whether these symptom trajectories varied as a function of sex.
The large majority of people reported having problematic over-involvement for just one of these behaviors and just in a single time period. A main effect of time was found for each problem behavior, indicating a moderately strong decrease in symptom severity across time. The time x sex interaction was insignificant in each model indicating that the decreasing trend is similar for males and females. The data also showed that help seeking was very low in the case of excessive sexual behavior, shopping, online chatting, and video gaming but substantially more prevalent in the case of excessive eating and exercising.
The present results indicate that self-identified excessive exercising, sexual behavior, shopping, online chatting, video gaming, and/or eating tend to be fairly transient for most people. This aspect of the results is inconsistent with conceptualizations of addictions as progressive in nature, unless treated.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-015-0383-3) contains supplementary material, which is available to authorized users.
PMCID: PMC4320621  PMID: 25608605
Behavioral addiction; Natural course; Spontaneous recovery; Prevalence; Prospective design; Sex differences; Help-seeking; Substance abuse comorbidity
20.  Construct validity of the Experiences of Therapy Questionnaire (ETQ) 
BMC Psychiatry  2014;14(1):369.
The Experiences of Therapy Questionnaire (ETQ) is a reliable measure of adverse effects associated with psychotherapy. The measure has not been subject to validity analyses. This study sought to examine the validity of the ETQ by comparison against a measure of therapist satisfaction.
Participants were recruited from the Black Dog Institute’s website and completed all measures online, at two time points (two weeks apart). Correlational analyses compared scale scores on the ETQ with related constructs of the Therapist Satisfaction Scale (TSS). To exclude any impact of current depression on ratings, we examined correlations between salient ETQ and TSS scales after controlling for depression severity.
Forty-six participants completed all the measures at both time points. Hypothesised associations between the ETQ and TSS scales were supported, irrespective of current depression severity.
The validity of the ETQ is supported; however limitations of the study are noted, including generalizability due to sample characteristics.
PMCID: PMC4299478  PMID: 25551579
Therapy; Psychotherapy; Measure; Validity; Side-effects; Psychology; Questionnaire
21.  Sustained improvements in students’ mental health literacy with use of a mental health curriculum in Canadian schools 
BMC Psychiatry  2014;14(1):379.
Enhancement of mental health literacy for youth is a focus of increasing interest for mental health professionals and educators alike. Schools are an ideal site for addressing mental health literacy in young people. Currently, there is limited evidence regarding the impact of curriculum-based interventions within high school settings. We examined the effect of a high-school mental health curriculum (The Guide) in enhancing mental health literacy in Canadian schools.
We conducted a secondary analysis on surveys of students who participated in a classroom mental health course taught by their usual teachers. Evaluation of students’ mental health literacy (knowledge/attitudes) was completed before and after classroom implementation and at 2-month follow-up. We used paired-samples t-tests and Cohen’s d value to determine the significance and impact of change.
There were 265 students who completed all surveys. Students’ knowledge significantly improved between pre- and post-tests (p < 0.001; d = 0.90) and was maintained at follow-up (p < 0.001; d = 0.73). Similarly, attitude significantly improved between pre- and post-tests (p < 0.001; d = 0.25) and was significantly higher at follow-up than base-line (p < 0.007; d = 0.18)
The Guide, applied by usual teachers in usual classroom curriculum, may help improve student knowledge and attitudes regarding mental health. This is the first study to demonstrate the positive impact of a curriculum-based mental health literacy program in a Canadian high school population.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0379-4) contains supplementary material, which is available to authorized users.
PMCID: PMC4300054  PMID: 25551789
Mental health literacy; Curriculum-based intervention; Youth mental health; Stigma reduction
22.  A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq 
BMC Psychiatry  2014;14(1):360.
Experiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms.
Twenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later.
Adult survivors of systematic violence were screened (N = 732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p = .003) and dysfunction (p = .007), while CPT had a significant effect on dysfunction only (p = .004).
Both interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience.
Trial Registration
ClinicalTrials.Gov NCT00925262. Registered June 3, 2009.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0360-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4301059  PMID: 25551436
Trauma treatment; Iraq; Task sharing; Evidence-based treatments
23.  Differentiating ADHD from oral language difficulties in children: role of movements and effects of stimulant medication 
BMC Psychiatry  2014;14(1):370.
The current study was designed to test if an objective measure of both attention and movement would differentiate children with Oral Language Disorders (OLD) from those with comorbid Attention Deficit/Hyperactivity Disorder (ADHD) and if stimulant medication improved performance when both disorders were present.
The sample consisted of thirty-three children with an identified oral language disorder (of which 22 had comorbid ADHD) ages 6 to 13 who were enrolled in a yearlong intensive learning intervention program. Those on a stimulant medication were tested at baseline and again a year later on and off medication.
Objective measures that included an infrared motion analysis system which tracked and recorded subtle movements discriminated children with OLD from those with a comorbid ADHD disorder whereas classic attention measures did not. There were better attention scores and fewer movements in children while on-medication.
Use of an objective measurement that includes movement detection improves objective diagnostic differential for OLD and ADHD and provides quantifiable changes in performance related to medication for both OLD and ADHD.
PMCID: PMC4302719  PMID: 25551691
Oral language disorders; ADHD; Inattention; Hyperactivity/Impulsivity; Language; Cognitive processing; Continuous performance testing; Movement detection
24.  The feasibility of a randomised controlled trial of Dyadic Developmental Psychotherapy 
BMC Psychiatry  2014;14(1):347.
Maltreated children have significant and complex problems which clinicians find difficult to diagnose and treat. Previous US pilot work suggests that Dyadic Developmental Psychotherapy (DDP) may be effective; however, rigorous evidence from a randomised controlled trial (RCT) is lacking. The purpose of this study is to establish the feasibility of an RCT of DDP by exploring the ways that DDP is operating across different UK sites and the impacts of current practice on the potential set-up of an RCT.
Qualitative methods (interviews, focus groups and teleconferences) were used to explore trial feasibility with therapists and service managers from teams implementing both DDP and possible control interventions. Data were analysed thematically and related to various aspects of trial design.
DDP was commonly regarded as having a particular congruence with the complexity of maltreatment-associated problems and a common operating model of DDP was evident across sites. A single control therapy was harder to establish, however, and it is likely to be a non-specific and context-dependent intervention/s offered within mainstream Child and Adolescent Mental Health Services (CAMHS). Because a ‘gold standard’ Treatment as Usual (TAU) does not currently exist, randomisation between DDP and TAU (CAMHS) therefore looks feasible and ethical.
The nature of family change during DDP was regarded as multi-faceted, non-linear and relationship-based. Assessment tools need to be carefully considered in terms of their ability to capture change that covers both individual child and family-based functioning.
An RCT of DDP is feasible and timely. This study has demonstrated widespread interest, support and engagement regarding an RCT and permissions have been gained from sites that have shown readiness to participate. As maltreated children are among the most vulnerable in society, and as there are currently no treatments with RCT evidence, such a trial would be a major advance in the field.
PMCID: PMC4302079  PMID: 25551365
Dyadic Developmental Psychotherapy; Feasibility; Evidence; RCT; Qualitative; Measurement
25.  The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder 
BMC Psychiatry  2014;14:362.
Higher levels of early maladaptive schemas (EMS) and schema modes according to schematherapy by Jeffrey Young are present in obsessive-compulsive disorder (OCD) compared to healthy controls. This study examines the relationship of EMS and schema modes to OC symptom severity and the predictive value of EMS and schema modes on treatment outcome in inpatients receiving Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). The main assumption was a negative association between the EMS of the domain ‘disconnection’ and dysfunctional coping and parent schema modes and the treatment outcome.
EMS, schema modes, depression and traumatic childhood experiences were measured in 70 patients with OCD. To analyze the predictors, two regression analyses were conducted considering multiple variables, such as depression, as covariates.
Regression analyses demonstrated that higher scores on the EMS named failure and emotional inhibition and depressive symptom severity at pretreatment were significantly related to poor outcome and explained a high percentage of the variance in OC symptoms at posttreatment. No influence on the treatment outcome was observed for schema modes, other EMS or other covariates.
The results support the approach to extend the CBT with ERP treatment with therapeutic elements focusing on maladaptive schemas, particularly in non-responders.
PMCID: PMC4324412  PMID: 25540106

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