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BackgroundTelephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist. The study describes patient homework engagement (HE) and homework-related therapist behaviors (TBH) over the course of treatment and explores their relation to depressive symptoms during tel-CBT for patients with depression.MethodsAudiotaped sessions (N = 197) from complete therapies of 22 patients (77% female, age: M = 54.1, SD = 18.8) were rated by five trained raters using two self-constructed rating scales measuring the extent of HE and TBH (scored: 0–4).ResultsAverage scores across sessions were moderate to high in both HE (M = 2.71, SD = 0.74) and TBH (M = 2.1, SD = 0.73). Multilevel mixed models showed a slight decrease in HE and no significant decrease in TBH over the course of treatment. Higher TBH was related to higher HE and higher HE was related to lower symptom severity.ConclusionsResults suggest that HE is a relevant therapeutic process element related to reduced depressive symptoms in tel-CBT and that TBH is positively associated with HE. Future research is needed to determine the causal direction of the association between HE and depressive symptoms and to investigate whether TBH moderates the relationship between HE and depressive symptoms.Trial RegistrationClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Background Low-intensity treatments imply reduced therapist contact due to an emphasis on self-help and the use of technologies to deliver treatment. The role of the remoteness, the reduced therapist contact, and the interplay of these components has not been differentiated from a patients’ perspective so far. This study’s purpose is to capture patients’ experiences with telephone-based self-help cognitive behavioural therapy (tel-CBT). Methods A subsample of mildly to moderately depressed patients ( N = 13) who finished tel-CBT as part of a larger randomised controlled trial (RCT) in routine care were interviewed using a semi-structured questionnaire. Interviews were audiotaped, transcribed verbatim, and independently coded by two coders blind to treatment outcome. Using qualitative content analysis with deductive and inductive procedures, a two-level category system was established. Results The category system contains four category clusters regarding expectations, self-help related aspects, telephone-related aspects, and implications for patients’ treatment pathway, and subsumes a total of 15 categories. Self-help related aspects circulate around the interplay between written materials and professional input, trust and support in the therapeutic relationship and its relation to the initial personal contact, as well as CBT principles. Telephone-related aspects entail perceived advantages and disadvantages of the telephone on an organisational and content level as well as a discourse around distance and closeness in the interaction. Although patients raised doubts regarding the long-term effect of the intervention on symptomatology, patients expressed satisfaction with the treatment and reported an immediate as well as a longer lasting personal impact of the treatment. These results indicate user acceptance with tel-CBT. Conclusions This qualitative analysis captures patients’ experiences with tel-CBT and the perceived helpfulness of the diverse treatment components. This can facilitate refining aspects of low-intensity treatments and might improve dissemination. Trial registration ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Background More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care. Methods An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10–15 min to complete. Spearman’s correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data. Results Eight hundred and sixty-seven ( N  = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers. Conclusions Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.

Background The aim of the study was to examine the prevalence of and factors associated with antidepressant (AD) prescriptions in order to draw a comprehensive picture of prescribing practices in Switzerland. Method We conducted a population-based, cross-sectional descriptive study using a large Swiss healthcare claims database, covering approximately 13% of the Swiss population. AD prescription was determined by identifying patients ( N  = 105,663) with health claims data of at least 1 AD prescription in the year 2016. AD medication was identified using ATC-codes classified by the World Health Organisation. Univariate, bivariate and multivariate analyses using logistic regression were performed. Results The extrapolated 1-year prevalence of AD prescription was 8.7% (95% CI, 8.7–8.8) with two thirds of AD recipients being female and the average age being 59 years (SD = 19.1). The regional distribution of prescription rates varied between cantons and ranged from 6.5 to 11.7%. Logistic regression revealed higher prescription rates among females compared to males (OR: 1.52) and an increased probability of AD prescription by age up until 54 years (OR: 2.25) and ≥ 85 years (OR: 2.32). Comorbidity is associated with higher odds (OR: 3.26 with 1–2 comorbidities) and enrollment in a managed care plan (compared to standard care) with lower odds for an AD prescription (OR: 0.85). Conclusion This study is the first in Switzerland to describe the prevalence of and factors associated with AD prescription based on a large health claims database reflecting routine care. The results provide important information about regional variation, prescription source, and potential over-prescription in the treatment of depressive disorders.

PurposeThis work focuses on the experiences and practices of obstetrician–gynecologists (ob–gyns) with patients suffering from body dysmorphic disorder (BDD) and issues with their aesthetics, specifically focusing on female genitalia. Ob–gyns are likely to play an important role in the recognition and treatment of women facing such issues.MethodsThis study took a qualitative, explorative approach. Semi-structured interviews were conducted with 11 ob–gyns about their experiences with patients who presented symptoms of BDD of female genitalia, their treatments, and interest in further education and supportive material. Interviews were analyzed through qualitative content analysis.ResultsA categorization system was created. The results showed that the participating ob–gyns are often confronted with genital dissatisfaction of patients. The study sample demonstrated a lack of mental health literacy concerning BDD. The treatments that the ob–gyns of this sample suggested for BDD of female genitalia were not in line with what evidence suggests. Finally, interest in further education and supportive material for consultation was evidenced in this sample.ConclusionsThe findings encourage further studies to identify the recognition of BDD concerning genitalia or etiological factors. Furthermore, practical implications (e.g., need of supportive material) can be derived from the results.

Background Body dysmorphic disorder (BDD), defined as the obsessive idea that some aspect of one’s own body or appearance is severely flawed/deformed, is relatively common in the general population and has been shown to have strong associations with mood and anxiety disorders and substance abuse disorders. Furthermore, a previous study on symptoms of BDD among people in the military showed that muscles are an important area of preoccupation. Hence, this study aimed to 1. assess the prevalence of BDD symptoms in Swiss military recruits, 2. specify the areas of preoccupation, and 3. analyze associated features (depression and alcohol/drug abuse). Method A total of 126 Swiss male military recruits (age: M = 20.12, SD = 1.09, range: 18–24) were examined using self-report measurements to assess symptoms of BDD, depression, alcohol/drug abuse. Results The results showed that symptoms of BDD were relatively common (9.5% reached the cutoff value for probable BDD, 84% reported some symptoms), with the muscles as the most common area of preoccupation. A positive correlation (r = .38, p  < .001) between depressive symptoms and symptoms of BDD was found, thus no correlation between alcohol/drug abuse and symptoms of BDD. Conclusion The results indicate a need to develop and implement measures for prevention (e.g. raising awareness among the military) and intervention in this specific population.

In order to optimize patient allocation, guidelines recommend stepped and collaborative care models (SCM) including low-intensity treatments. The aim of this study is to investigate the implementation of guideline-adherent treatments in a SCM for depression in routine care. We analyzed care provider documentation data of n = 569 patients treated within a SCM. Rates of guideline-adherent treatment selections and initializations as well as accordance between selected and initialized treatment were evaluated for patients with mild, moderate and severe depression. Guideline-adherent treatment selection and initialization was highest for mild depression (91% resp. 85%). For moderate depression, guideline-adherent treatments were selected in 68% and applied in 54% of cases. Guideline adherence was lowest for severe depression (59% resp. 19%). In a multiple mixed logistic regression model a significant interaction between guideline adherence in treatment selection/initialization and severity degree was found. The differences between treatment selection and initialization were significant for moderate (OR: 1.8 [95% CI: 1.30 to 2.59; p = 0.0006]) and severe depression (OR: 6.9; [95% CI: 4.24 to 11.25; p < .0001] but not for mild depression (OR = 1.8, [95%-CI: 0.68 to 4.56; p = 0.2426]). Accordance between selected and initialized treatment was highest for mild and lowest for severe depression. We conclude that SCMs potentially improve care for mild depression and guideline adherence of treatment selections. Guideline adherence of treatment initialization and accordance between treatment selection and initialization varies with depression severity. Deficits in treating severe depression adequately may be more a problem of failed treatment initializations than of inadequate treatment selections.

The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders. This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy. Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference. Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model. Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care. To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care. A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP). In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562. Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Patients with depression often have limited access to outpatient psychotherapy following inpatient treatment. The objective of the study was to evaluate the long-term effectiveness of a telephone-based aftercare case management (ACM) intervention for patients with depression. We performed a prospective randomized controlled trial in four psychotherapeutic inpatient care units with N = 199 patients with major depression or dysthymia (F32.x, F33.x, F34.1, according to the ICD-10). The ACM consisted of six phone contacts at two-week intervals performed by trained and certified psychotherapists. The control group received usual care (UC). The primary outcome was depressive symptom severity (BDI-II) at 9-month follow-up, and secondary outcomes were health-related quality of life (SF-8, EQ-5D), self-efficacy (SWE), and the proportion of patients initiating outpatient psychotherapy. Mixed model analyses were conducted to compare improvements between treatment groups. Regarding the primary outcome of symptom severity, the groups did not significantly differ after 3 months (p = .132; ES = -0.23) or at the 9-month follow-up (p = .284; ES = -0.20). No significant differences in health-related quality of life or self-efficacy were found between groups. Patients receiving ACM were more likely to be in outpatient psychotherapy after 3 months (OR: 3.00[1.12-8.07]; p = .029) and 9 months (OR: 4.78 [1.55-14.74]; p = .006) than those receiving UC. Although telephone-based ACM did not significantly improve symptom severity, it seems to be a valuable approach for overcoming treatment barriers to the clinical pathways of patients with depression regarding their access to outpatient psychotherapy.