Large Naturalistic Study Research Articles

Bilateral rTMS Shows No Advantage in Depression nor in Comorbid Depression and Anxiety: A Naturalistic Study.

The objective was to determine if adding low-frequency right-sided rTMS treatment to the standard high-frequency left-sided treatment (LUL), referred to as sequential bilateral treatment (SBT), confers additional benefit for depression or anxiety outcomes. A retrospective chart review from January 2015 through December 2018 yielded 275 patients, all of whom were treated with a figure-8 coil for a major depressive episode. Their protocol was either LUL or SBL. Outcome measures were the Generalized Anxiety Disorder 7-item scale (GAD-7) and the Patient Health Questionnaire (PHQ-9). There was no significant difference in GAD-7 change scores between patients who had LUL or SBL (4.2 vs 4.8). This was also true when the sample was restricted to only patients who started with high GAD-7 scores. There was likewise no significant difference in PHQ-9 change scores between patients who had LUL or SBL (6.8 vs 5.1). Patients switching from LUL to SBL mid-course had poorer overall outcomes as compared to patients who stayed with the same protocol throughout treatment. This large naturalistic study shows no advantage for SBL treatment any group or condition examined. The results of this study have clinical applicability and sound a cautionary note regarding the use of combination rTMS protocols.

Cumulative Clinical Experience of the Use of Paliperidone Palmitate 3-Monthly Long-Acting Injection in the Treatment of Schizophrenia: A Critical Appraisal.

Paliperidone palmitate 3-monthly (PP3M), an approved maintenance treatment for patients with schizophrenia, was the first long-acting antipsychotic injectable (LAI) to require only four administrations per year. Here, we aimed to review the available evidence about its use in the management of schizophrenia to date and highlight key study findings in order to provide a balanced overview of current experience in clinical practice. For that purpose, an extensive search of available literature from PubMed, Embase, and Web of Science was conducted in March 2023. Emerging data from real-world studies appear to signal that the benefits of the use of PP3M may well extent beyond the obvious convenience for patients and resource efficiency for services and may be actually associated with improved effectiveness and patient satisfaction. Large naturalistic studies from Australia, Europe and the US comparing treatment continuation between newer LAIs and/or oral antipsychotics showed that patients treated with PP3M had higher compliance rates and a longer period of continuous use. The risk of relapse, re-hospitalization and number of bed days was also lower with PP3M compared to PP1M and other LAIs as demonstrated by several cohort studies. Furthermore, patients treated with PP3M were using lower doses of benzodiazepines and concomitant oral antipsychotics compared with other LAIs. What is more, PP3M appears to positively impact patients' satisfaction and quality of life, facilitating long-term goals. In fact, recent studies recorded better quality-adjusted life years and decreased stigma, with improved social acceptability and promotion of rehabilitation for patients transitioning to PP3M. The rates of general satisfaction rates with PP3M were also higher among psychiatrists and caregivers who reported overall less concerns. In conclusion, clinical exposure and a growing body of evidence thus far, reinforce the use of PP3M in an effort to enhance patient outcomes alongside individual experience and treatment persistence.

A 50-state survey study of thoughts of suicide and social isolation among older adults in the United States

BackgroundWe aimed to characterize the prevalence of social disconnection and thoughts of suicide among older adults in the United States, and examine the association between them in a large naturalistic study. MethodsWe analyzed data from 6 waves of a fifty-state non-probability survey among US adults conducted between February and December 2021. The internet-based survey collected the PHQ-9, as well as multiple measures of social connectedness. We applied multiple logistic regression to analyze the association between presence of thoughts of suicide and social disconnection. Exploratory analysis, using generalized random forests, examined heterogeneity of effects across sociodemographic groups. ResultsOf 16,164 survey respondents age 65 and older, mean age was 70.9 (SD 5.0); the cohort was 61.4 % female and 29.6 % male; 2.0 % Asian, 6.7 % Black, 2.2 % Hispanic, and 86.8 % White. A total of 1144 (7.1 %) reported thoughts of suicide at least several days in the prior 2 week period. In models adjusted for sociodemographic features, households with 3 or more additional members (adjusted OR 1.73, 95 % CI 1.28–2.33) and lack of social supports, particularly emotional supports (adjusted OR 2.60, 95 % CI 2.09–3.23), were independently associated with greater likelihood of reporting such thoughts, as was greater reported loneliness (adjusted OR 1.75, 95 % CI 1.64–1.87). The effects of emotional support varied significantly across sociodemographic groups. ConclusionsThoughts of suicide are common among older adults in the US, and associated with lack of social support, but not with living alone. Trial registrationNA.

2.3 A Large Naturalistic Study on the Brief Rating of Aggression by Children and Adolescents (BRACHA): Confirmation of the Predictive Validity

2.3 A Large Naturalistic Study on the Brief Rating of Aggression by Children and Adolescents (BRACHA): Confirmation of the Predictive Validity

A Large Naturalistic Study on the BRACHA: Confirmation of the Predictive Validity.

Aggression is a major challenge on child/adolescent inpatient psychiatric units. A screening instrument to accurately identify risk is urgently needed. To determine the predictive validity of the Brief Rating of Aggression by Children and Adolescents (BRACHA). Prospective cohort study.BRACHA is administered by clinical staff in the emergency department (ED) prior to inpatient psychiatric admission.A consecutive sample of 10,054 admitted patients from 2010-2021. No patients refused screening nor were excluded.BRACHA administered to patients in the ED prior to admission at Cincinnati Children's Hospital Medical Center (CCHMC).Patient behavioral outcomes measured by Overt Aggression Scale (OAS), categorizing aggression as verbal or physical, then as towards self, others, or objects.Female patients comprised 53.6% (n = 5,386) of the sample. Most patients were white (n = 6,556, 65.2%). Patients ranged in age from 4 to 18years, with a mean age of 13.6 ± 3.1years. A single biological parent (n = 5,317, 52.9%) was the predominant living arrangement among patients. The Area Under the Curve (AUC), as an assessment of predictive validity across all possible cut-offs of BRACHA scores ranged from 0.640 (aggression to self) to 0.758 (physical aggression towards others).Our findings support the BRACHA as a useful predictive instrument for aggression in inpatient psychiatric admissions from ED regardless of length of stay. Treating staff are then able to immediately classify risk level and inform care plans for all lengths of hospitalization. Applies to potential risk for aggression, except for self-aggression. Future data analyses will evaluate demographic factors to determine which improve predictive power of the BRACHA and can be used to create a BRACHA calculator. To our knowledge, this naturalistic outcomes study is one of the largest in psychiatry. The BRACHA will continue to be studied to evaluate risk for aggression on inpatient units and aim to assist in keeping unit staff and patients safe.

The risk-benefit ratio of Covid-19 vaccines: Publication policy by retraction does nothing to improve it.

On June 24, 2021 we published a risk-benefit analysis of COVID-19 vaccines, admittedly based on a shaky database. This analysis resulted in the insight, that very likely for three deaths prevented by vaccination we will have to accept that about two people die as a consequence of these vaccinations.1 This analysis led to editors’ threatening to withdraw, and the journal indeed retracted the publication. After a thorough re-review, it was republished.2, 3 The database we based our analysis on was a large naturalistic study of the BioNTech vaccine in Israel.4 This was the only study at the time that allowed for a direct estimation of an absolute risk reduction (ARR) in mortality. Admittedly, the ARR estimate was only available for a short observation period of 4 weeks after the first vaccine dose, a point raised by critics. One might have wanted a longer observation period to bring out the benefit of vaccinations more clearly, and our estimate of a number needed to vaccinate (NNV) of 16 000 to prevent one death might have been overly conservative. The recently published 6-month interim report of the BioNTech-regulatory clinical trial now covers a period long enough to let us look at this risk benefit ratio once again.5 In Table S4 of this publication,5 14 deaths are reported in the placebo group (n = 21 921) and 15 in the vaccination group (n = 21 926). Among them, two deaths in the placebo-group were attributed to COVID-19, and one in the vaccination group was attributed to COVID-19 pneumonia. This leads to an ARR = 4.56 × 10–5, and conversely to an NNV = 1/ARR = 21 916 to prevent one death by COVID-19. This shows that our original estimate was not so far off the mark. These passive pharmacovigilance data, different from the active reporting system of trials and observations, are notorious for underestimating casualties and side effects.6 Other severe side effects occur, such as myocarditis in young males who according to a recent study suffer a 13.6 fold risk of myocarditis.7 Thus, we have novel and worrying data that confirm the analysis we published in summer 2021, urging us to repeat our call for an installment of a European-wide active monitoring system that documents the safety and efficacy of COVID-19 vaccines long-term and for a rational public debate about the risk-benefit ratio of these novel vaccines. The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

The Neglected Role of Psychotherapy for Treatment-Resistant Depression.

The Neglected Role of Psychotherapy for Treatment-Resistant Depression.

Chronotype changes with age; seven-year follow-up from the Netherlands study of depression and anxiety cohort

BackgroundChronotype reflects an individual's optimal daily timing of sleep, activity, and cognitive performance. Previous, cross-sectional, studies have suggested an age effect on chronotype with later chronotypes in adolescents and earlier chronotypes in children and elderly. Additionally, later chronotypes have been associated with more depressive symptoms. Few studies have been able to study longitudinal associations between chronotype and age, while adjusting for depressive symptoms. MethodsChronotype was assessed twice with the Munich Chronotype Questionnaire 7 years apart in the Netherlands Study of Depression and Anxiety (T1: N = 1842, mean age (SD): 42.63 years (12.66)) and T2: N = 1829, mean age (SD) 50.67 (13.11)). The longitudinal association between change in age and change in chronotype was tested using a generalized estimated equation analysis adjusted for covariates (including level of depressive symptoms). Using age-bins of 5 years (age at T2), change in chronotype between T1 and T2 was analyzed with Linear Mixed Models. ResultsWe found a change towards an earlier chronotype with higher age (B (95% CI): -0.011 (-0.014–0.008), p < 0.001). For the age-bins, the difference in chronotype was significant for the 25–29 years age-bin. LimitationsThe sample did not include individuals younger than 19 years or older than 68 years. ConclusionsIn the whole sample chronotype changed towards becoming more morning-type over a period of 7 years, but this change was only significant for those aged 25–29 years. The study was performed in a large naturalistic cohort study with a wide age-range, including patients with a diagnosis of depressive and anxiety disorder and healthy controls.

Bilateral rTMS Shows No Advantage in Depression nor in Comorbid Depression and Anxiety: A Large Naturalistic Study

Background: The objective was to determine if adding low-frequency (LF) right-sided rTMS treatment to the standard high-frequency (HF) left-sided treatment, together referred to as bilateral treatment, confers any additional benefit for depressive or anxiety outcomes. Design/Methods: A retrospective chart review of patients treated with rTMS was conducted, from January 2015 through December 2018, yielding 361 patients. All patients were treated with a figure-of-8 coil for a major depressive episode, and their protocol was either HF left-sided treatment or bilateral treatment. The Generalized Anxiety Disorder 7-item scale (GAD-7) was the anxiety outcome measure, and the Patient Health Questionnaire (PHQ-9) was the depression outcome measure. Results: There was no significant difference in GAD-7 change scores between patients who had unilateral (GAD change=4.2) versus bilateral rTMS (GAD change=4.5). Unilateral rTMS patients had greater improvement in PHQ-9 than bilateral (7.2 vs. 5.0; P=.011). Patients switching from unilateral to bilateral treatment mid-course had overall poorer outcomes than patients who did not. Conclusions: This large, naturalistic study shows no advantage for bilateral treatment in any group or condition examined, and for depression outcomes, there may be a deficit with bilateral versus unilateral treatment. The results of this study have clinical applicability and sound a cautionary note regarding the use of combination protocols in rTMS treatment, given the greater time and expense of bilateral treatments.

Use of long acting antipsychotics and relationship to newly diagnosed bipolar disorder: a pragmatic longitudinal study based on a Canadian health registry.

Background:There is limited data from large naturalistic studies to inform prescribing of long-acting injectable medication (LAIs). Guidance is particularly rare in the case of primary mood disorders.Methods:This study describes prescribing trends of LAIs in 3879 patients in Quebec, Canada, over a period of 4 years. Health register data from the Quebec provincial health plan were reviewed.Results:In this specific registry, 32% of patients who received LAIs drugs for schizophrenia had a confirmed diagnosis of bipolar disorder and 17% had a diagnosis of major depressive disorder. Non-schizophrenia syndromes were preferentially prescribed risperidone long-acting antipsychotic, whereas patients with schizophrenia were prescribed an excess of haloperidol decanoate. Patients with non-schizophrenia disorders prescribed long-acting antipsychotics were more frequently treated in primary care compared with patients with schizophrenia.Conclusion:Data from a large number of patients treated naturalistically in Quebec with long-acting antipsychotics suggests that these compounds, prescribed to treat symptoms of schizophrenia and schizoaffective disorders, were maintained when mood symptoms emerged, even in cases when the diagnosis changed to bipolar disorder. This pragmatic study supports the need to explore this intervention as potential treatment for affective disorders.

Complementary methodologies to identify weather conditions in naturalistic driving study trips: Lessons learned from the SHRP2 naturalistic driving study & roadway information database

Adverse weather conditions play a considerable role in the safety and efficiency of the transportation network. Many studies have aimed to quantify the impact that different weather conditions have on transportation safety and mobility; however, most studies have evaluated the network capacity, average speed, and other macroscopic measures without capturing specific driving characteristics. In order to understand specific driving behavior and performance characteristics that exist during different environmental conditions, high resolution vehicle data and video footage are required. The SHRP2 sponsored the generation of a large Naturalistic Driving Study (NDS) database – which provides vehicle time series data, front and rear video, driver video, external sensor readings, and driver surveys – and the Roadway Information Database (RID) – which is a complementary database with geospatial data for commonly driven roads in the NDS and other ancillary data sources, including annual traffic, roadway geometry, accident reports, weather conditions, and 511 alerts. The purpose of this study is to leverage these SHRP2 databases and weather data from the National Climatic Data Center (NCDC) to extract trips that occur during adverse weather conditions. The extraction of weather-related trips from a NDS is unprecedented, and this study presents three complementary methodologies used in parallel to acquire relevant trips from the SHRP2 NDS database. A semi-automated data reduction procedure was developed to process the raw trip files into a format that further analysis and modeling could be completed. This novel approach to NDS trip acquisition and reduction could be extended to other naturalistic driving studies worldwide.

Patterns of symptom change in major depression: Classification and clustering of long term courses

To evaluate treatment effects in depression, it is important to monitor change during treatment and also to follow up for a reasonably long time. Describing the variability of symptom change trajectories is useful to better predict long-term status and to improve interventions.Outcome data (N_complete = 518, 4 time points, 1 year of observation time) from a large naturalistic multi-center study on the effects of inpatient and day hospital treatment of unipolar depression were used to identify clusters of symptom trajectories. Common outcome classifications and statistical methods of longitudinal cluster analysis were applied. However, common outcome classifications (in terms of e.g. remission, relapse or recurrence) were not exhaustive, as 49.3% of the trajectories could not be allocated to its classes. Longitudinal cluster analysis reveals 7 clusters (fast response, slow response, retarded response, temporary or persistent relapse, recurrence, and nonresponse). Nonresponse at the end of treatment was a predictor of poor outcome at long term follow up. The classification of patterns of symptom change in depression should be extended. Longitudinal cluster analysis seems a valid option to analyze outcome trajectories over time if a limited number of time points of measurement are available.

Influence of childhood trauma on depression in the INDDEP study

Traumatic experiences during childhood have been shown to be associated with a higher risk for depressive disorders, more severe symptoms, higher rates of comorbidity, and poorer response to therapy. This study aims to further investigate these links in a clinical sample, focusing especially on therapeutic outcome. Data were collected in a large naturalistic study on inpatient and day hospital treatment of depression at the beginning, the end and after treatment, with this article being a secondary data analysis. Occurrence of childhood trauma, depressive and other symptoms and therapeutic results were compared using robust MANOVA, multiple regression, mixed ANOVA, and Spearman’s correlation. Results provide support for a relationship between childhood trauma and depressive and general symptom severity, the age of onset of depression and the occurrence of personality disorders and somatic diagnoses. There was a significant reduction of depressive symptomatology after therapy. Patients with childhood trauma did not differ significantly from controls in their response to treatment. Clinicians should take the high probability of childhood trauma in depressive patients and the consequent risk of more severe symptoms into account when taking a history and consider adjusting treatment, even if the present data showed that patients generally benefitted from therapy.

Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study

BackgroundRepetitive transcranial magnetic stimulation (rTMS) is considered an efficacious non-invasive neuromodulation treatment for major depressive disorder (MDD). However, little is known about the clinical outcome of combined rTMS and psychotherapy (rTMS + PT). Through common neurobiological brain mechanisms, rTMS + PT may exert enhanced antidepressant effects compared to the respective monotherapies. ObjectiveThe current naturalistic study aimed to evaluate feasibility and clinical outcome of rTMS + PT in a large group of MDD patients. The second aim was to identify clinical predictors of response and remission. MethodsA total of 196 patients with MDD were treated with at least 10 sessions of simultaneous rTMS and PT. rTMS was applied over the DLPFC, either 10 Hz left or 1 Hz right. Psychotherapy was based on principles of cognitive behavioral therapy (CBT). Symptoms were measured using the BDI each fifth session until end of treatment and at 6-month follow-up. Comparisons were made between responders and non-responders, as well as between the 10 Hz and 1 Hz protocol. Additionally, baseline variables and early BDI change were evaluated as predictors of response/remission. Major findings and conclusions1) Combining rTMS and PT resulted in a 66% response and a 56% remission rate at the end of treatment with 60% sustained remission at follow-up. Compared to previous findings in RCTs, these rates are relatively high; 2) No differences were found between the 10 Hz and 1 Hz TMS regarding clinical outcome; 3) Clinical baseline variables were not predictive of treatment outcomes; 4) Early symptom improvement (at session 10) was highly predictive of response, and may therefore be used to guide rTMS + PT continuation; 5) Based on the current findings in a large naturalistic study, future studies employing a more standardized method are warranted to draw solid conclusions on the unique effect of rTMS + PT.

Prescribed Benzodiazepines and Suicide Risk: A Review of the Literature.

To evaluate whether prescribed benzodiazepines affect one's risk of suicide. A PubMed search of English-language publications from database inception until October 11, 2016, was conducted using the terms benzodiazepine and suicide. References and related articles were also searched to yield additional publications. Studies were included if they addressed the relationship between suicidal behavior and the prescribed use of either specific benzodiazepines or benzodiazepines as a class. A total of 17 studies were included in this review. The majority of studies found that benzodiazepines were associated with increased suicide risk. This finding was consistent across various populations and different types of research, including a placebo-controlled crossover trial, a laboratory model of suicidal behavior, case-control studies regarding completed suicides on inpatient units, and large naturalistic studies. Benzodiazepines appear to cause an overall increase in the risk of attempting or completing suicide. Possible mechanisms of prosuicidal effects may include increases in impulsivity or aggression, rebound or withdrawal symptoms, and toxicity in overdose.

Web-Based Self-Help for Problematic Alcohol Use: a Large Naturalistic Study

PurposeThis observational study examined user characteristics, intervention use patterns, and variables associated with reductions in alcohol consumption for anonymous Internet help-seekers using a Web-based self-help program.MethodA Web-based cognitive behavioral therapy (CBT) program with eight modules delivered over 10 weeks was offered to participants with at least hazardous use of alcohol according to the Alcohol Use Disorders Identification Test (AUDIT) (n = 4165). At baseline and 10-week follow-up, participants completed the Timeline-followback (TLFB), AUDIT, Drug Use Disorders Identification Test (DUDIT), Hospital Anxiety and Depression Scale (HADS), EuroQol-5 dimension (EQ-5D), World Health Organization Quality of Life Scale-abbreviated version (WHOQOL-BREF), Readiness to Change Questionnaire (RCQ), and Readiness Ruler. Follow-up completers and non-completers were compared at baseline, and follow-up completer outcomes were reported. Predictors of change in drinking behavior were evaluated at follow-up.ResultsRegistered users were 41.88 years old on average (SD = 12.36), and 52 % were women; the mean baseline number of drinks during the past week was 27.27 (SD = 17.92) with 62 % in the AUDIT category of probable dependence and only 7 % having low-risk consumption according to public health guidelines. At follow-up (n = 1043), 53 % showed a clinically significant change to a lower level of alcohol use (χ2 = 254.403, p < 0.001); the mean alcohol consumption fell (t = 22.841, p < 0.001) and the proportion with low-risk consumption rose to 40 %. Being male, scoring higher on baseline readiness, completing the program, and accessing other support predicted low-risk drinking and clinically significant change to a lower level of alcohol use at follow-up.ConclusionA publicly available Web-based program for managing problematic alcohol use attracted users with considerable alcohol- and health-related problems, which were changed to lower severity for follow-up completers.

Bipolar affective disorder, pregnancy and childbirth: clinical characteristics and heredity

ABSTRACTBipolar affective disorder has higher frequency among women of reproductive age and can relapse both during pregnancy and immediately after childbirth. The presence of family history is one of the leading risk factors for bipolar affective disorder. A cross-sectional study was performed as part of a large naturalistic study. It included 81 women with pronounced symptoms of bipolar disorder who required hospitalization. The clinical method included comprehensive assessment of patients in the cohort, assessment of the severity of symptoms and the family history. The results showed that more than 50% of the women were at an average age of 25 years and experienced bipolar affective disorder mostly in the first and third trimester, whereas, in the puerperal period, the risk was highest in the first two weeks after childbirth. There was previous history of bipolar affective disorder in about 50% of the women. In 55.6% of the women, there was family history of bipolar affective disorder. The presence of previous history of bipolar affective disorder, first-degree family history and pregnancy at later age were shown to be risk factors for a new relapse during pregnancy and after childbirth. Clinical expression of manic–psychotic symptoms was more typical of the period of lactation than manic symptoms, which were associated rather with younger age and the period of pregnancy. In the studied cohort of patients, the risk of repeatability of affective episodes was significantly higher with each subsequent pregnancy.

Effectiveness of an Internet-based preparation for psychosomatic treatment: Results of a controlled observational study

ObjectivePatients often have to sustain long waiting periods between the time they first apply for psychotherapy and the actual uptake of the treatment. To support patients who are on a wait-list for inpatient psychosomatic treatment an Internet-based preparatory treatment (VORSTAT) was developed. In a randomized controlled trial, VORSTAT proved to increase treatment motivation prior to intake and to accelerate the accommodation phase at the beginning of inpatient treatment. No impact of VORSTAT on inpatient treatment outcome was found. The aim of the present study was to investigate the effectiveness of VORSTAT after implementing the service into routine care. MethodsA large naturalistic observational study comparing VORSTAT participants (N=911) against non-participants (N=1721) was conducted. Propensity scores were used to control for potential confounding variables due to the non-randomized group allocation. Reliable improvement of self-reported impairment achieved during inpatient treatment was used as outcome measure. ResultsVORSTAT participants showed higher rates of reliable improvement in physical impairment (50.8% vs. 44.9%), psychological impairment (41.2% vs. 29.9%), and social problems (22.3% vs. 15.2%). ConclusionAn Internet-based preparation for psychotherapy is an effective approach to improve outcome of inpatient psychosomatic treatment.

Agomelatine in the treatment of depressive disorders in clinical practice: multicenter observational CHRONOS study.

BackgroundCHRONOS was a large naturalistic study designed to evaluate the effectiveness and safety of agomelatine in the management of patients with major depression in routine clinical practice.MethodsPatients (n=6,276) with a moderate or severe major depressive episode without psychotic symptoms were treated initially as outpatients (80.2%) or in psychiatric facilities (19.8%) in 54 regions of the Russian Federation. Patients received a flexible-dosing regimen of agomelatine 25 mg or 50 mg once daily for 8 weeks, with frequent study visits (weeks 1, 2, 3, 4, 6, and 8).ResultsPatients (mean age 44 years, 72.6% female) showed progressive improvement on the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score from 22±6.9 at baseline to 4.7±4.7 at week 8 (P<0.0001). The proportion of responders (HAMD-17 decrease of ≥50%) was 90.1% and the proportion of remitters (HAMD-17 <7) was 79.1% at week 8. All individual HAMD-17 item scores improved rapidly, and the change relative to baseline was significant (P<0.0001) at week 1 and at each subsequent visit in all cases. There were corresponding rapid improvements in Clinical Global Impression Severity and Improvement scores. In the subgroup of patients with more severe illness (HAMD-17 ≥21 at baseline; n=3,478), the proportions of responders and remitters were 92.4% and 72.8%, respectively, at week 8.ConclusionAgomelatine was effective and well tolerated in a large sample of depressed patients in an observational treatment setting, and showed a rapid onset of benefit across all HAMD-17 items.

The contribution of the quality of therapists’ personal lives to the development of the working alliance.

Research suggests that the person of the psychotherapist is important for the process and outcome of psychotherapy, but little is known about the relationship between therapists' personal experiences and the quality of their therapeutic work. This study investigates 2 factors (Personal Satisfactions and Personal Burdens) reflecting therapists' quality of life that emerged from the self-reports of a large international sample of psychotherapists (N = 4,828) (Orlinsky & Rønnestad, 2004, 2005) using the Quality of Personal Life scales of the Development of Psychotherapists Common Core Questionnaire (Orlinsky et al., 1999). These factors were investigated as predictors of alliance levels and growth (using the Working Alliance Inventory) rated by both patients and therapists in a large (227 patients and 70 therapists) naturalistic outpatient psychotherapy study (Havik et al., 1995). The Personal Burdens scale was strongly and inversely related to the growth of the alliance as rated by the patients, but was unrelated to therapist-rated alliance. Conversely, the factor scale of therapists' Personal Satisfactions was clearly and positively associated with therapist-rated alliance growth, but was unrelated to the patients' ratings of the alliance. The findings suggest that the working alliance is influenced by therapists' quality of life, but in divergent ways when rated by patients or by therapists. It seems that patients are particularly sensitive to their therapists' private life experience of distress, which presumably is communicated through the therapists' in-session behaviors, whereas the therapists' judgments of alliance quality were positively biased by their own sense of personal well-being.