The acceptability of a guided internet-based trauma-focused self-help programme (Spring) for post-traumatic stress disorder (PTSD)

MASS VIOLENCE—WHETHER INTENTIONAL ATtacks or the result of natural disasters— adversely affects survivors and often causes widespread disruption, displacement, and disability. Epidemiological studies have reported posttraumatic stress disorder (PTSD) or symptoms of PTSD in almost one-third of communities affected by mass violence. Evidence-based psychological therapies used to treat PTSD are available, but obstacles such as a shortage of mental health care professionals and patient stigma toward treatment often limit accessibility to these therapies. Posttraumatic stress disorder is associated with significant socio-occupational dysfunction; therefore, an imperative need exists for approaches that enhance access to treatment while preserving effectiveness of important factors such as the therapeutic relationship between patients and mental health care professionals. One approach that has been evaluated recently is use of the Internet to deliver therapist-assisted treatment to trauma survivors. Such Web-based approaches may be worth considering for the treatment of PTSD symptoms for 2 reasons. First, in contrast to other mental health disorders, a traumatic event is an identifiable etiological factor and, hence, may be more amenable to being treated via a less-intensive Internet-based mode. Second, a single traumatic event, as in the case of the recent Japanese tsunami or the September 11 terrorist attacks in the United States, can be the cause of PTSD in thousands of individuals, rendering the Internet a potentially useful mode via which treatment can be provided on a large scale. Research has shown that Internet-based interventions for trauma survivors are feasible. The course of treatment typically occurs over several weeks and includes key components of trauma-focused therapy such as exposure, cognitive reappraisal, and writing assignments. Lange et al developed a protocol-driven, therapist-assisted online treatment program in which patients work mostly independently and therapists provide regular feedback via e-mail. In a randomized controlled trial conducted in a community sample, significant improvements occurred among those who used the protocol compared with waiting-list controls. A notable limitation of that trial was the significant number of participants who dropped out of treatment. Hirai and Clum studied the efficacy of an online self-help treatment for patients with subclinical posttraumatic distress. Although the therapist role was minimal, consisting only of prompting participants to take assessments, study participants reported a significant reduction in avoidance behavior, intrusive symptoms, and anxiety compared with waitinglist controls. However, the generalizability of the study’s results is limited because of the predominantly female college student sample. Litz et al tested use of an Internet-based treatment program in a sample of US service members with clinically diagnosed PTSD related to combat or the September 11 attacks on the Pentagon. The study compared therapistassisted, Internet-based, self-management cognitive behavioral therapy (CBT) vs Internet-based supportive counseling in an 8-week module. Those in the former group made significantly more clinical gains than those receiving supportive counseling alone. Of note, this study involved an in-person initial evaluation by a therapist and planned telephone conversations through the treatment course. Klein et al assessed use of a 10-week Internet CBT intervention in a sample with clinically significant PTSD and therapist support offered via e-mail only. Although the results suggested a significant reduction in PTSD symptom severity that was maintained at 3-month follow-up, the study was limited by the absence of a control group. Current evidence for the effectiveness of Web-based interventions for PTSD treatment is limited by a lack of comparisons with the gold standard of face-to-face therapy, a predominance of small sample sizes, significant dropout rates, and lack of follow-up data to assess whether positive outcomes were sustained over time. Furthermore, issues related to Internet availability and use of smartphones, a digital divide based on socioeconomic status and age, and user privacy, confidentiality, and safety are important concerns associated with Internet-based treatment that have yet to be fully addressed. The issue of therapeutic alliance deserves special attention in the treatment of PTSD. Therapeutic alliance is the

Cognitive behavioral interventions delivered via the internet are demonstrably efficacious treatment options for posttraumatic stress disorder (PTSD) in underserved, Arabic-speaking populations. However, the role of specific treatment components remains unclear, particularly in conflict-affected areas of the Middle East and North Africa. This study aims to evaluate 2 brief internet-based treatments in terms of efficacy, including change in PTSD symptom severity during treatment. Both treatments were developed in line with Interapy, an internet-based, therapist-assisted cognitive behavioral therapy protocol for PTSD and adapted to the specific research question. The first treatment comprised self-confrontation and social sharing (exposure treatment; 6 sessions); the second comprised cognitive restructuring and social sharing (cognitive restructuring treatment; 6 sessions). The 2 treatments were compared with each other and with a waitlist control group. In total, 365 Arabic-speaking participants from the Middle East and North Africa (mean age 25.49, SD 6.68 y) with PTSD were allocated to cognitive restructuring treatment (n=118, 32.3%), exposure treatment (n=122, 33.4%), or a waitlist control group (n=125, 34.2%) between February 2021 and December 2022. PTSD symptom severity, posttraumatic maladaptive cognitions, anxiety, depressive and somatoform symptom severity, and quality of life were assessed via self-report at baseline and after treatment or waiting time. PTSD symptom severity was also measured throughout treatment or waiting time. Treatment satisfaction was assessed after treatment completion. Treatment use and satisfaction were compared between the 2 treatment conditions using appropriate statistical tests (eg, chi-square and Welch tests). Multiple imputation was performed to address missing data and evaluate treatment-associated changes. These changes were analyzed using multigroup change modeling in the completer and intention-to-treat samples. Overall, 200 (N=240, 83.3%) participants started any of the treatments, of whom 123 (61.5%) completed the treatment. Treatment condition was not significantly associated with the proportion of participants who started versus did not start treatment (P=.20) or with treatment completion versus treatment dropout (P=.71). High treatment satisfaction was reported, with no significant differences between the treatment conditions (P=.48). In both treatment conditions, PTSD, anxiety, depressive and somatoform symptom severity, and posttraumatic maladaptive cognitions decreased, and quality of life improved significantly from baseline to the posttreatment time point (P≤.001 in all cases). Compared with the baseline assessment, overall PTSD symptom severity decreased significantly after 4 sessions in both treatment conditions (P<.001). Moreover, both treatment conditions were significantly superior to the waitlist control group regarding overall PTSD symptom severity (P<.001) and most other comorbid mental health symptoms (P<.001 to P=.03). Differences between the 2 conditions in the magnitude of change for all outcome measures were nonsignificant. Internet-based cognitive behavioral treatments for PTSD focusing primarily on either self-confrontation or cognitive restructuring are applicable and efficacious for Arabic-speaking participants. German Clinical Trials Register DRKS00010245; https://drks.de/search/de/trial/DRKS00010245.

The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.

Purpose – The residential therapeutic community (TC) treatment modality has been shown to effectively reduce drug use and improve psychiatric/medical health among clients who are often disproportionately impacted by medical conditions and have a co-occurring psychiatric disorder such as Posttraumatic Stress Disorder (PTSD). Yet not much is known regarding how clients’ health may impact their treatment satisfaction. Using path analysis, the interrelationship between PTSD, perceived health, and treatment satisfaction was examined. The paper aims to discuss these issues. Design/methodology/approach – A survey including the Posttraumatic Stress Disorder Checklist-Specific (PCL-S), a perceived health rating, and a Treatment Satisfaction Scale was collected from 303 clients at three comparable long-term residential TC treatment programs in New York City. Findings – Findings indicated that clients with PTSD rated their health significantly worse than those without PTSD. Although no direct relationship between PTSD and treatment satisfaction was found, there was a significant positive correlation between perceived health and treatment satisfaction. Research limitations/implications – Findings likely constitute a regional sample thus generalizability is limited. Practical implications – Simultaneously addressing addiction, PTSD, and medical issues can improve clients’ treatment satisfaction, consequently increasing treatment retention and producing greater positive post-treatment outcomes. Originality/value – Few if any studies have examined the extent to which PTSD and perceived health impact treatment satisfaction within residential substance abuse treatment programs.

A therapist-assisted cognitive behavior therapy internet intervention for posttraumatic stress disorder: Pre-, post- and 3-month follow-up results from an open trial

Background: Veterans who did not seek and complete treatment as intended have been shown to have an elevated risk of experiencing and being exposed to post-traumatic stress disorder (PTSD). Internet-based interventions (IBIs) provide more confidentiality and fewer treatment barriers, and they are regarded as potential treatments to reduce PTSD in veterans. However, the effects of IBI for veterans with PTSD are inconclusive.Objectives: IBI is defined as any internet-based series of psychosocial interventions, of which the internet works as a way of delivery. Psychosocial content and reduction of PTSD symptoms in veterans have been recognized as two core elements of this intervention. This study aimed to (1) examine the effects of IBI on veterans’ PTSD outcomes and (2) distinguish between the elements of IBI that play an important role for veterans with PTSD.Methods: Web of Science, PubMed, EMBASE, PsycINFO, Cochrane, Wanfang Data, CNKI, and CQVIP databases were searched for randomized controlled trials (RCT) in IBI programs for veterans with PTSD, covering all studies in English and Chinese published from January 1990 to November 2020. Also, related studies tracking citations were identified. Studies met the following inclusion criteria of (1) being RCTs; (2) containing IBI in the full text; (3) having IBI conducted on veterans as participants; and (4) being on PTSD. All processes followed PRISMA. The risk of bias of the studies was assessed by the Cochrane Systematic Review Handbook. The confidence of outcomes of this review was valued according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation). The meta-analysis was done by RevMan 5.13. Two teams of reviewers independently searched the literature, made the assessment, and extracted the data.Results: A total of 1,493 citations were identified after initial searching, of which the full texts of 66 studies were screened. Eventually, six RCT studies met the inclusion criteria. Beneficial effects of IBI were found on the overall PTSD outcome (−0.29; 95% CI–0.48 to −0.11, p<0.01). Particularly, IBI based on cognitive behavioral therapy (CBT) with peer support was found to be effective for PTSD outcomes (−0.36; 95% CI–0.61 to −0.11, p<0.01). The subgroup analysis demonstrated that scores of PTSD outcome measured by a PCL (PTSD Checklist) decreased to an average score of 0.38 (95% CI –0.60 to −0.15, p=0.001). The intervention had a positive effect on the PTSD outcome on veterans with comorbid psychological disorders (−0.30; 95% CI –0.61 to −0.11, p<0.01). Overall, the six studies included were evaluated with a low risk of bias, and the outcomes of the meta-analysis were proven with high confidence.Conclusion: On the whole, IBIs have a positive effect on the overall PTSD outcome of veterans. The results encouraged us to focus on IBI with CBT with peer support for veterans, on specific instruments for veterans with PTSD, and on veterans with comorbid psychological disorders. This study, however, has limits. Only six studies with a Western population were included, which might result in cultural bias on IBI effects. In future, more high-qualified research and diverse cultural background of RCTs is needed to prove the effectiveness of IBI on veterans with PTSD.

Therapeutic alliance is a key element of successful therapy. Despite being particularly relevant in people with posttraumatic stress disorder (PTSD), due to fear, mistrust and avoidance, there has not yet been a comprehensive systematic review of therapeutic alliance in this population. This review explored (a) variables which may predict alliance and (b) whether alliance predicts PTSD outcomes. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the review identified 34 eligible studies. Studies were subjected to a quality assessment. Predictors of alliance were considered in a narrative synthesis. Twelve studies were entered into a meta-analysis of the association between therapeutic alliance and PTSD outcomes. There was some evidence for individual variables including attachment, coping styles and psychophysiological variables predicting the alliance. Therapy variables did not predict alliance. The therapeutic alliance was found to significantly predict PTSD outcomes, with an aggregated effect size of r = -.34, across both in-person and remote therapies. Included studies were restricted to peer-reviewed, English language studies. Quality of included studies was mostly rated weak to moderate, primarily reflecting issues with selection bias in this area of research. This is the first review to demonstrate that therapeutic alliance is a consistent predictor of PTSD outcomes, in both in-person and remote therapies, and the effect appears at least as strong as in other populations. This is of relevance to clinicians working with traumatized populations. The review identified a need for further research to determine variables predicting alliance in therapy for PTSD.

PurposeTreatment adherence is a prerequisite for treatment success and therefore an important consideration to assure that therapeutic goals are achieved both from a patient point of view and for optimal health care resource utilization. Published data on treatment adherence with fingolimod (Gilenya®) are limited. Therefore, this study investigated treatment adherence in patients with relapsing-remitting multiple sclerosis (RRMS) treated with fingolimod in Denmark.Patients and methodsThis was a 24-month, multicenter, open-label study, investigating treatment adherence, satisfaction, motivation, and health-related quality of life (QoL) in RRMS patients treated with fingolimod. In addition, the effect of a motivational interview support program on these measures was evaluated. Treatment adherence was assessed by pill count. Treatment satisfaction, motivation, and QoL were assessed by patient-reported outcomes (PROs).ResultsA total of 195 patients were enrolled in the study. A very high treatment adherence was observed during the entire study with no statistically significant difference between study visits before (99%) and after (97%) the motivational interview. In accordance, a high level of treatment satisfaction was found in the Treatment Satisfaction Questionnaire for Medication 9, which was scored high throughout the study with the highest scores seen for the convenience domain (ranging from 94.51 to 95.78). Furthermore, additional PROs demonstrated a high health-related QoL, a self-determined form of motivation for taking medication, and a patient perception of an autonomy supportive approach provided by the health care provider, at all study visits.ConclusionHigh levels of treatment adherence, satisfaction, motivation, and QoL were observed in Danish RRMS patients treated with fingolimod. As these positive measures were observed at all study visits and throughout the study, no effect of the motivational interview support program was found.

The global refugee population has significantly increased, with Syrian refugees being one of the largest displaced groups. Bereavement represents a major challenge. However, access to mental health care is limited by structural and cultural barriers. Internet-based interventions (IBIs) offer a promising solution, but most are developed in Western contexts, limiting their cultural relevance. This study aimed to evaluate the acceptability, feasibility, and preliminary efficacy of a culturally adapted self-help IBI for bereaved Syrian refugees in Switzerland. In a mixed-methods pilot randomized controlled trial (RCT), 30 bereaved Syrian refugees were randomly assigned to a 5-week app-based intervention or a waitlist control group. Semi-structured interviews with the intervention group provided qualitative insights on feasibility and acceptability and were analyzed with framework analysis. Quantitative data assessed treatment satisfaction, adherence, and preliminary efficacy on grief, depression, posttraumatic stress disorder (PTSD), anxiety, well-being, disability, post-migration difficulties, and social support. Descriptive statistics were used for feasibility and acceptability, while linear mixed-effects models assessed efficacy. High treatment satisfaction, a low dropout rate and adherence of 40% were found. Qualitative interviews indicated the intervention was relevant and beneficial, further adaptations were suggested. No significant group differences were found on bereavement or secondary outcomes. However, trends indicated reduced grief, anxiety, PTSD, and depression, with improved well-being and social support in the intervention group. The results suggest that this culturally adapted IBI is both feasible and acceptable for Syrian refugees. While trends are promising, a larger RCT is needed to investigate efficacy. This intervention shows potential as meaningful support for bereaved Syrian refugees.

GENERAL COMMENTARY article Front. Hum. Neurosci., 07 November 2013Sec. Brain Health and Clinical Neuroscience Volume 7 - 2013 | https://doi.org/10.3389/fnhum.2013.00747

&lt;p dir="ltr"&gt;Background&lt;/p&gt;&lt;p dir="ltr"&gt;Quality of care is essential in disseminating cognitive-behavioural therapy (CBT). Yet, little is known about how therapists acquire CBT competence, to what extent CBT is delivered as intended and with skill in routine psychiatric care, and if delivered CBT improve the health of patients with common psychiatric disorders, including depression, anxiety disorders, posttraumatic stress disorder, and obsessive-compulsive disorder.&lt;/p&gt;&lt;p dir="ltr"&gt;Research aims&lt;/p&gt;&lt;p dir="ltr"&gt;The aim was to examine the quality of CBT in practice. We formulated four main hypotheses: 1) therapists are competent in delivering CBT, both following training and in clinical practice, 2) therapists adhere to CBT procedures and techniques in routine psychiatric care, 3) CBT is delivered with desired clinical outcomes in terms of symptom reduction, functional ability, and global health, and 4) therapist competence and adherence is associated with clinical outcomes.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods&lt;/p&gt;&lt;p dir="ltr"&gt;We conducted three observational studies, with longitudinal and cross-sectional designs. Competence was assessed by observers, based on sessions with standardised patients (Studies I and II). Adherence was assessed by observers, therapists, and patients (Study II), or patients only (Study III). Outcomes were based on patient reports of symptoms, function, and global health (Study II) or of perceived improvement and treatment satisfaction (Study III). Statistical analysis included non-parametric tests (Kruskal-Wallis, Mann-Whitney U, Spearman and Kendall's rank correlations), parametric tests (Pearson correlation, one-way ANOVA), reliable change index, and linear mixed models.&lt;/p&gt;&lt;p dir="ltr"&gt;Results&lt;/p&gt;&lt;p dir="ltr"&gt;First, we found that therapist competence improved after CBT training (Cohen's d effect size = 1.94). A competence threshold was passed by 72% (n = 46/64) after training and 76% (n = 22/29) in routine practice. More competent therapists tended to underestimate their performance, while less competent therapists made more accurate self-assessments.&lt;/p&gt;&lt;p dir="ltr"&gt;Second, therapist adherence was moderate to high in routine psychiatric care, across perspectives (patients, therapists, and observers), subscales, and diagnoses. Adherence ratings were higher from patients than therapists and for structure/conceptualisation than behavioural/cognitive techniques. Moreover, therapist adherence ratings were higher among patients treated for panic disorder compared to those treated for depression, generalised anxiety disorder, or obsessive-compulsive disorder.&lt;/p&gt;&lt;p dir="ltr"&gt;Third, patients improved significantly across outcomes (ds = 0.80 - 1.36) and 67% (n = 57/85) demonstrated reliable clinical improvement, while 5% reliably deteriorated (n = 5/85). Moreover, patients reported high degrees of perceived symptom improvement and treatment satisfaction.&lt;/p&gt;&lt;p dir="ltr"&gt;Finally, there was a moderate correlation between therapist adherence and patient-rated improvement (Kendall's ts rank correlation coefficient = . 37 -. 38, ps &lt; . 001). Still, neither adherence nor competence was related to clinical outcomes based on validated outcome measures.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusion&lt;/p&gt;&lt;p dir="ltr"&gt;In conclusion, CBT was delivered with high quality. Overall, therapists demonstrated competence and adherence, and patients showed clinical improvements. However, there were exceptions, including instances of below- threshold competence, non-adherence, and nearly a third of patients who did not appear to benefit from treatment. The potential association between competence/adherence and patient improvement remains unclear, possibly due to methodological limitations including limited statistical power.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Bergvall, H.&lt;/b&gt;, Ghaderi, A., Andersson, J., Lundgren, T., Andersson, G., &amp; Bohman, B. (2023). Development of competence in cognitive behavioural therapy and the role of metacognition among clinical psychology and psychotherapy students. Behavioural and Cognitive Psychotherapy. &lt;a href="https://doi.org/10.1017/S1352465822000686"&gt;https://doi.org/10.1017/S1352465822000686&lt;br&gt;&lt;/a&gt;&lt;br&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Bergvall, H.&lt;/b&gt;, Linde, J., Alfonsson, S., Sunnhed, R., Barber, J. P., Lundgren, T., Andersson, G., &amp; Bohman, B. (2024). Quality of cognitive-behavioural therapy in routine psychiatric care: therapist adherence and competence, and patient outcomes for depression and anxiety disorders. BMC Psychiatry, 24:887. &lt;a href="https://doi.org/10.1186/s12888-024-06328-4" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1186/s12888-024-06328-4&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Bergvall, H.&lt;/b&gt;, Andersson, G., Lundgren, T., &amp; Bohman, B. Therapist adherence to cognitive-behavioural therapy and quality of care from a patient perspective. [Submitted]&lt;/p&gt;

&lt;p dir="ltr"&gt;Background&lt;/p&gt;&lt;p dir="ltr"&gt;Quality of care is essential in disseminating cognitive-behavioural therapy (CBT). Yet, little is known about how therapists acquire CBT competence, to what extent CBT is delivered as intended and with skill in routine psychiatric care, and if delivered CBT improve the health of patients with common psychiatric disorders, including depression, anxiety disorders, posttraumatic stress disorder, and obsessive-compulsive disorder.&lt;/p&gt;&lt;p dir="ltr"&gt;Research aims&lt;/p&gt;&lt;p dir="ltr"&gt;The aim was to examine the quality of CBT in practice. We formulated four main hypotheses: 1) therapists are competent in delivering CBT, both following training and in clinical practice, 2) therapists adhere to CBT procedures and techniques in routine psychiatric care, 3) CBT is delivered with desired clinical outcomes in terms of symptom reduction, functional ability, and global health, and 4) therapist competence and adherence is associated with clinical outcomes.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods&lt;/p&gt;&lt;p dir="ltr"&gt;We conducted three observational studies, with longitudinal and cross-sectional designs. Competence was assessed by observers, based on sessions with standardised patients (Studies I and II). Adherence was assessed by observers, therapists, and patients (Study II), or patients only (Study III). Outcomes were based on patient reports of symptoms, function, and global health (Study II) or of perceived improvement and treatment satisfaction (Study III). Statistical analysis included non-parametric tests (Kruskal-Wallis, Mann-Whitney U, Spearman and Kendall's rank correlations), parametric tests (Pearson correlation, one-way ANOVA), reliable change index, and linear mixed models.&lt;/p&gt;&lt;p dir="ltr"&gt;Results&lt;/p&gt;&lt;p dir="ltr"&gt;First, we found that therapist competence improved after CBT training (Cohen's d effect size = 1.94). A competence threshold was passed by 72% (n = 46/64) after training and 76% (n = 22/29) in routine practice. More competent therapists tended to underestimate their performance, while less competent therapists made more accurate self-assessments.&lt;/p&gt;&lt;p dir="ltr"&gt;Second, therapist adherence was moderate to high in routine psychiatric care, across perspectives (patients, therapists, and observers), subscales, and diagnoses. Adherence ratings were higher from patients than therapists and for structure/conceptualisation than behavioural/cognitive techniques. Moreover, therapist adherence ratings were higher among patients treated for panic disorder compared to those treated for depression, generalised anxiety disorder, or obsessive-compulsive disorder.&lt;/p&gt;&lt;p dir="ltr"&gt;Third, patients improved significantly across outcomes (ds = 0.80 - 1.36) and 67% (n = 57/85) demonstrated reliable clinical improvement, while 5% reliably deteriorated (n = 5/85). Moreover, patients reported high degrees of perceived symptom improvement and treatment satisfaction.&lt;/p&gt;&lt;p dir="ltr"&gt;Finally, there was a moderate correlation between therapist adherence and patient-rated improvement (Kendall's ts rank correlation coefficient = . 37 -. 38, ps &lt; . 001). Still, neither adherence nor competence was related to clinical outcomes based on validated outcome measures.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusion&lt;/p&gt;&lt;p dir="ltr"&gt;In conclusion, CBT was delivered with high quality. Overall, therapists demonstrated competence and adherence, and patients showed clinical improvements. However, there were exceptions, including instances of below- threshold competence, non-adherence, and nearly a third of patients who did not appear to benefit from treatment. The potential association between competence/adherence and patient improvement remains unclear, possibly due to methodological limitations including limited statistical power.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Bergvall, H.&lt;/b&gt;, Ghaderi, A., Andersson, J., Lundgren, T., Andersson, G., &amp; Bohman, B. (2023). Development of competence in cognitive behavioural therapy and the role of metacognition among clinical psychology and psychotherapy students. Behavioural and Cognitive Psychotherapy. &lt;a href="https://doi.org/10.1017/S1352465822000686"&gt;https://doi.org/10.1017/S1352465822000686&lt;br&gt;&lt;/a&gt;&lt;br&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Bergvall, H.&lt;/b&gt;, Linde, J., Alfonsson, S., Sunnhed, R., Barber, J. P., Lundgren, T., Andersson, G., &amp; Bohman, B. (2024). Quality of cognitive-behavioural therapy in routine psychiatric care: therapist adherence and competence, and patient outcomes for depression and anxiety disorders. BMC Psychiatry, 24:887. &lt;a href="https://doi.org/10.1186/s12888-024-06328-4" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1186/s12888-024-06328-4&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Bergvall, H.&lt;/b&gt;, Andersson, G., Lundgren, T., &amp; Bohman, B. Therapist adherence to cognitive-behavioural therapy and quality of care from a patient perspective. [Submitted]&lt;/p&gt;

This review summarizes six decades of clinical outcome research relevant to evidence-based practices for depression and anxiety delivered via clinical videoconferencing. The authors conducted a literature search of previous systematic reviews and an updated search of publications specific to anxiety and depression. Overall, strong evidence supports the safety and clinical effectiveness of administering evidence-based psychotherapy for anxiety and depression via clinical videoconferencing among heterogeneous populations and age ranges, and in multiple care settings, with similar outcomes to in-person care. Despite the overall clinical effectiveness of the modality, the authors discuss common logistical and institutional barriers to long-term effective implementation. Future systems-level research is required to investigate replicable and sustainable models for implementing and expanding access to evidence-based psychotherapies via clinical videoconferencing.

Accidental awareness under general anaesthesia: Incidence, risk factors, and psychological management

This study was undertaken to evaluate (i) factors associated with patient-reported hypoglycaemia; (ii) association of patient-reported hypoglycaemic symptoms with treatment satisfaction and barriers to adherence and (iii) association between treatment satisfaction, adherence and glycaemic control among patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin. This observational, cross-sectional, multicentre study was conducted in seven countries (Finland, France, Germany, Norway, Poland, Spain and UK) from June 2006 to February 2007. Patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin therapy on a date (index date) from January 2001 through January 2006 and who had at least one haemoglobin A1C (HbA1C) measurement in the 12-month period before the visit date were eligible. Questionnaires were used to ascertain patients' reports of hypoglycaemic symptoms, treatment satisfaction, and treatment adherence. The Treatment Satisfaction Questionnaire for Medication was used to measure patients' treatment satisfaction. An adherence and barriers questionnaire was used to measure patients' adherence to treatment. Glycaemic control was based on documented HbA1C measurements within the prior 12 months. The mean +/- s.d. age was 62.9 +/- 10.6 years, and the mean +/- s.d. duration of diabetes was 7.8 +/- 5.1 years. HbA1C in this population of patients who had failed metformin monotherapy and were treated with oral antihyperglycaemic agents was below the International Diabetes Federation goal of 6.5% in only 477 (27.9%) patients. Approximately 38% of patients reported hypoglycaemic symptoms during the past year. Hypoglycaemia was significantly more likely in patients with a history of macrovascular complications of diabetes (OR = 1.346; 95% CI = 1.050-1.725) and with no regular physical activity (OR = 1.295; 95% CI = 1.037-1.618). Patients reporting hypoglycaemia had significantly lower treatment satisfaction scores (71.6 +/- 17.6 vs. 76.3 +/- 16.8; p < 0.0001 for global satisfaction). Compared with their counterparts reporting no hypoglycaemic symptoms, patients with such symptoms were also significantly more likely to report barriers to adherence, including being unsure about instructions (37.0 vs. 30.5%; p = 0.0057). Patients at HbA1C goal had significantly higher treatment satisfaction and adherence compared with those who were not. Patients' reports of hypoglycaemic symptoms are common in European outpatients with type 2 diabetes and are associated with significantly lower treatment satisfaction and with barriers to adherence. In addition, being at HbA1C goal is associated with treatment satisfaction and adherence.