Trends - Volume 42 – Issue 1 – January-March 2020 by APRS

Trends in Psychiatry and Psychotherapy Editors-in-Chief

Ives Cavalcante Passos

Universidade Federal do Rio Grande do Sul - UFRGS, Porto Alegre, RS, Brazil

Rochele Paz Fonseca

Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS, Porto Alegre, RS, Brazil

Associate Editors Adriane R. Rosa

Universidade Federal do Rio Grande do Sul - UFRGS, Porto Alegre, RS, Brazil

Benício Noronha Frey

McMaster University, Hamilton, ON, Canada

Bruno Palazzo Nazar

Universidade Federal do Rio de Janeiro - UFRJ, Rio de Janeiro, RJ, Brazil

Fabiano Gomes

Queen’s University School of Medicine, Kingston, ON, Canada

Joana Bucker

Universidade do Vale do Taquari (Univates), Lajeado, RS, Brazil

Karen Jansen

Universidade Católica de Pelotas, Pelotas, RS, Brazil

Mônica C. Miranda

Universidade Ibirapuera, São Paulo, SP, Brazil

Raffael Massuda

Universidade Federal do Paraná - UFPR, Curitiba, PR, Brazil

Taianede Azevedo Cardoso

McMaster University, Hamilton, ON, Canada

Statistical consulting Hugo Cogo

Universidade Federal de São Paulo – UNIFESP, São Paulo, SP, Brazil

International Editorial Board Andrew A. Nierenberg (Massachusetts General Hospital, Boston, MA, USA) • Antonino Ferro (Italian Psychoanalytic Society, Palermo, Italy) • Boris Birmaher (University of Pittsburgh, Pittsburgh, PA, USA) • David Tuckett (University College London, London, UK) • Eduard Vieta (University of Barcelona, Barcelona, Spain) • Gary S. Sachs (Duke University Medical Center, Durham, NC, USA) • George Woody (University of Pennsylvania, Philadelphia, PA, USA) • German E. Berrios (University of Cambridge, Cambridge, UK) • Glen O. Gabbard (Baylor College of Medicine, Houston, TX, USA) • Gustavo Turecki (McGill University, Montreal, QC, Canada) • Host Kächele (University of Ulm, Ulm, Germany) • Jorge Folino (Universidad Nacional de La Plata, La Plata, Argentina) • Joseph Biederman (Massachusetts General Hospital, Boston, MA, USA) • Júlio Licínio (Flinders University, Adelaide, South Australia, Australia) • Lakshmi N. Yatham (University of British Columbia, Vancouver, BC, Canada) • Otto Kernberg (Weill Cornell Medical College, Cornell University, New York, NY, USA) • Ricardo Bernardi (Asociación Psicoanalítica del Uruguay, Montevideo, Uruguay) • Robert Michels (Weill Cornell Medical College, Cornell University, New York, NY, USA) • Robert N. Emde (University of Colorado Denver School of Medicine, Aurora, CO, USA) • Roger K. Pitman (Massachusetts General Hospital, Boston, MA, USA) National Editorial Board Aldo Lucion (Universidade Federal do Rio Grande do Sul – UFRGS)  Antônio E. Nardi (Universida de Federal do Rio de Janeiro – UFRJ)  Beny Lafer (Universidade de São Paulo – USP)  Carlos Alexandre Netto (UFRGS)  Cláudio Laks Eizirik (UFRGS)  Eurípides Miguel Filho (USP)  Flávio Pechansky (UFRGS)  Gisele Gus Manfro (UFRGS)  Hélio Elkis (USP)  Humberto Correa (Universidade Federal de Minas Gerais - UFMG)  Ivan Figueira (UFRJ)  Ivan Izquierdo (Pontifícia Universidade Católica do Rio Grande do Sul – PUCRS)  Jair de Jesus Mari (Universidade Federal de São Paulo – UNIFESP)  Jerson Laks (UFRJ)  José Roberto Goldim (UFRGS)  Luis Alberto Hetem (USP – Faculdade de Medicina de Ribeirão Preto)  Luis Augusto Paim Rhode (UFRGS)  Marcelo Pio de Almeida Fleck (UFRGS)  Neury J. Botega (Universidade Estadual de Campinas – UNICAMP)  Paulo Mattos (UFRJ)  Ricardo Primi (Universidade São Francisco – USF)  Rodrigo Bressan (UNIFESP)  Valentim Gentil Filho (USP)

2019/2021 Board Flávio Milman Shansis / President Fernando Muhlenberg Schneider / Vice-President Andrea Poyastro Pinheiro / Scientific Director Rafael Mondrzak / Media Director Lucas Spanemberg / Executive Treasurer Mateus Reche / Adjunct Executive Treasurer Berenice Rheinheimer / Adjunct Executive Secretary of Professional Practice Andréia Sandri / Executive Secretary of Norms Audit Committee Fernando Lejderman Laís Knijnik Lizete Pessini Pezzi

Assistant Audit Committee Members Alba Tereza do Prado Veppo Prolla Ana Lucia Duarte Baron Tiago Crestana

Editorial Staff Managing editor: Denise Arend Layout: Marta Castilhos Typesetting: Isabel Kubaski

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Trends in Psychiatry and Psychotherapy Volume 42 – Issue 1 – January-March 2020

Table of contents Original Articles HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo’s “Cracolândia”........................................... 1 Ariadne Ribeiro, Alisson Trevizol, Oladunni Oluwoye, Sterling McPherson, Michael G. McDonell, Viviane Briese, André Miguel, Rosana C. Fratzinger, Ronaldo R. Laranjeira, Ana L. Alonso, Ana L. Karasin, Marcelo Ribeiro, Clarice S. Madruga

Anxiety in Malaysian children and adolescents: validation of the Screen for Child Anxiety Related Emotional Disorders (SCARED)............................................................................................ 7 Chin-Siang Ang

Strategies for eating and body change among Brazilian women and men........................................... 16 Wanderson R. da Silva, João Marôco, Juliana A. D. B. Campos

The effectiveness of acceptance and commitment therapy for social anxiety disorder: a randomized clinical trial............................................................................................................... 30 Samad Khoramnia, Amir Bavafa, Nasrin Jaberghaderi, Aliakbar Parvizifard, Aliakbar Foroughi, Mojtaba Ahmadi, Shahram Amiri

Cross-cultural adaptation of the Brazilian version of the Questionnaire on Eating and Weight Patterns-5 (QEWP-5)........................................................................................................ 39 Carlos Eduardo Ferreira de Moraes, Carla Mourilhe, Sílvia Regina de Freitas, Glória Valéria da Veiga, Marsha D. Marcus, José Carlos Appolinário

Analysis of psychiatrists’ prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States............................................................................................. 48 Kevin Pan, Shawgi Silver, Charles Davis

Effectiveness of mindfulness-integrated cognitive behavior therapy on anxiety, depression and hope in multiple sclerosis patients: a randomized clinical trial..................................................... 55 Sahar Pouyanfard, Mohsen Mohammadpour, Ali A. ParviziFard, Kheirollah Sadeghi

The association between traumatic experiences and suicide attempt in patients treated at the Hospital de Pronto Socorro in Porto Alegre, Brazil...................................................................... 64 Cleonice Zatti, Luciano Santos Pinto Guimarães, Mauro Soibelman, Márcia Rejane Semensato, Andre Goettems Bastos, Vítor Crestani Calegaro, Lúcia Helena Machado Freitas

Defense mechanisms and quality of life of medical students according to graduation phase.................. 74 Gisely Barddal Medeiros Borges, Ingrid Eidt, Louise Nassif Zilli, Ana Maria Maykot Prates Michels, Alexandre Paim Diaz

Brief Communications Construct validity of the Motor Development Scale (MDS)................................................................ 82 Paola Matiko Martins Okuda, Erika Félix, Hugo Cogo-Moreira, Ting Liu, Francisco Rosa Neto, Pamela J. Surkan, Silvia S. Martins, Sheila C. Caetano

Prevalence and trends of mental disorders requiring inpatient care in the city of Porto Alegre: a citywide study including all inpatient admissions due to mental disorders in the public system from 2013-2017..................................................................................................... 86 Giovanni A. Salum, Loiva dos S. Leite, Sara Jane E. dos Santos, Gabriel Mazzini, Fernanda L. C. Baeza, Lucas Spanemberg, Sara Evans Lacko, João Ricardo Sato, Diane P. do Nascimento, Thiago Frank, Juliana Pfeil, Natan Katz, Jorge Osório, Paulo Ricardo dos Santos, Eliana da Silva, Christiane Nunes, Kelma Nunes Soares, Ângela Maria Grando Machado, Tatiana Breyer, Márcio Rodrigues, Adriani Galão, Gledis Lisiane Motta, Silvia Schuch, Eduardo Osório, Cláudia Rodrigues, Pablo de Lannoy Sturmer, Erno Harzheim

Review Articles Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review.................................................................................................. 92 Stephanie Zakhour, Antonio E. Nardi, Michelle Levitan, José Carlos Appolinario*

Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review..................................... 102 Anthony Paulo Sunjaya, Arlends Chris, Dewi Novianti

Corrigendum Instructions for Authors

Trends in Psychiatry and Psychotherapy

Original Article

HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo’s “Cracolândia” Ariadne Ribeiro,1,2,3 Alisson Trevizol,1,3 Oladunni Oluwoye,4 Sterling McPherson,5 Michael G. McDonell,4 Viviane Briese,1,2 André C. Miguel,1,3 Rosana C. Fratzinger,1,3 Ronaldo R. Laranjeira,1,3 Ana L. Alonso,1,3 Ana L. Karasin,1,3 Marcelo Ribeiro,1,2,3 Clarice S. Madruga1,3

Abstract Introduction: This study describes the epidemiological scenario of human immunodeficiency virus (HIV) and syphilis at the biggest specialist drug addiction center in Brazil. The great challenge is to find strategies to reduce the impact of inequality and discrimination and develop policies to protect individuals living with – or at risk of – infections. Methods: During the period from January 1 to May 31, 2016, a cross-sectional study was conducted on which all patients (N = 806) seeking inpatient treatment were enrolled. A structured diagnostic interview and rapid tests were conducted initially, and diagnoses were confirmed by tests conducted at a venereal disease research laboratory (VDRL). Results: HIV and syphilis rates were 5.86% and 21.9%, respectively. Women were nearly 2.5 times more likely to have syphilis. HIV infection was associated with unprotected sex (odds ratio [OR]: 3.27, p = 0.003, 95% confidence interval [95%CI]: 1.51-7.11), and suicidal ideation (OR: 6.63, p = 0.001, 95%CI: 3.37-14.0). Although only 1.86% reported injecting drugs at any point during their lifetimes, this variable was associated with both HIV and syphilis. Elevated rates of HIV and syphilis were observed in the context of this severe social vulnerability scenario. Conclusion: The risk factors identified as associated with HIV and syphilis should be taken into consideration for implementation of specific prevention strategies including early diagnosis and treatment of sexually transmitted infections (STI) to tackle the rapid spread of STIs in this population. Keywords: Brazil, substance use disorder, addiction, HIV, syphilis, crack/cocaine, suicidal ideation.

Introduction The burden of sexually transmitted infections (STIs) and crack cocaine use is higher in low and middleincome countries than in high-income ones and the great challenge is to find strategies to reduce the impact of inequality and discrimination and to develop policies to protect individuals living with or at risk of infections.1-4

Approximately 47% of all human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) cases in Latin America5 are in Brazil, which is also the country with the highest rate of crack cocaine use, affecting 0.8% of the total population.6 Although no significant reductions in supply or demand for crack cocaine have occurred recently, HIV/AIDS prevention and treatment initiatives have reduced the incidence of

1 Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. 2 Centro de Referência em Álcool Tabaco e Outras Drogas (CRATOD), São Paulo, SP, Brazil. 3 Instituto Nacional de Ciência e Tecnologia para Polítias do Álcool e Outras Drogas (INCT-INPAD), UNIFESP, São Paulo, SP, Brazil. 4 Initiative for Research and Education to Advance Community Health, Washington State University Health Sciences, Washington State University, Spokane, WA, USA. 5 Department of Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane WA, USA.

Submitted Sep 23 2018, accepted for publication Apr 28 2019. Epub Mar 20 2020. Suggested citation: Ribeiro A, Trevizol A, Oluwoye O, McPherson S, McDonell MG, Briese V, et al. HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo’s “Cracolândia.”. Trends Psychiatry Psychother. 2020;42(1):1-6. http://dx.doi.org/10.1590/2237-6089-2018-0081 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 1-6

HIV and syphilis in “Cracolândia,” Brazil - Ribeiro et al.

new HIV/AIDS cases significantly all over the globe,5 from 3.1 million in 2000 to 2.1 million in 2015. In Brazil, however, reports showed a 53.2% increase in HIV rates amongst those aged 15 to 19 and a 10.3% increase among those aged 20 to 24 between 2004 and 2013.5,7 The increase in HIV rates was followed by a significant increase in syphilis infections.7 In Brazil, a calamitous increase in acquired syphilis infections was observed between 2011 and 2016, despite government efforts at containment. In 2015, primary syphilis accounted for 31.6% of the total number of cases, while latent, secondary and tertiary syphilis accounted for 23.6%, 10.7% and 5.8%, respectively.7,8 The scenario is of even greater concern when it comes to syphilis during pregnancy: in this population the detection rate increased from 3.7 to 11.2% over the same period.8 This increase was followed by a rise in the incidence rate of congenital syphilis (from 2.4 to 6.5%), underscoring the severity of the epidemiological situation.9 Based on previously established risk factors associated with STIs and HIV in substance use disorders (SUD), public health policies have been proposed and implemented in Brazil, usually focusing on prioritizing specific high-risk populations (i.e. sex workers, men who have sex with men, transgender people and drug users).10-12 Annually, Brazil consumes a third of all cocaine destined for the South American market and is currently the largest crack consumer on the planet.13 In 2012, the proportion of the country’s population that consumed reached 0.8%,6 while the most common route of transmission of STI and HIV is sexual.14 The greatest open-air concentration of drug users is in São Paulo, in an area known nationally as “Cracolândia,” where drugs are used and traded non-stop.13 Although data on the prevalence of STIs among crack cocaine users in the Cracolândia setting is still limited, early studies have illustrated that the problems described above constitute a synergy between social vulnerability, low education and economic inequality.15,16

Methods Sample During the study period (January 1, 2016 to May 31, 2016), a total of n = 806 individuals presented at the observation unit at the Specialist Alcohol, Tobacco, and Drugs Center in São Paulo (CRATOD – Observation Unit) and were provided with rapid testing services (blood borne viruses [BBV]/STI).

2 – Trends Psychiatry Psychother. 2020;42(1)

Measures and data The rapid STI/BBV test data used in the analysis are based on results (positive versus negative status) from the following immunochromatographic assays: (1) Alere™ anti-TP syphilis test, for qualitative detection of all Treponema pallidum antibody isotypes (IgG, IgM, IgA); (2) Bioclin™ HIV Tri Line K087, for qualitative detection of total anti-HIV 1 antibodies (IgM, IgG, IgA, IgE), the O subtype and anti-HIV 2; (3) Alere® hepatitis C virus (HCV) test, for qualitative detection of immunoreactive antigens, such as those found in NS3, NS4 and NS5 regions of the HCV genome. A variety of additional sociobehavioral, drug use and clinical data indicators were collected from a semi-structured interview protocol administered by the CRATOD staff at various stages of patient assessment and from patients’ files. Relevant data was extracted from these files without unique personal identifiers. The following variables were created, partly by combining result categories, and included as follows: sex (male versus female), age (continuous), length of education (categorical variable: No education, Up to 5 years, 6 to 9 years, 10 to 13 years, 14 years or more), housing status (stable versus transient versus homeless), primary drug problem (marijuana versus cocaine versus crack cocaine versus alcohol), suicidal ideation (thought or plan of suicide, past attempt, considered suicide as an escape, yes versus no), psychotic symptoms (at admission, yes versus no), safer sex practice (operationalized as consistent or occasional condom use, yes versus no), and rapid test results for syphilis, HIV and HCV (reactive versus non-reactive). The assessment interview defines the risk criteria and guides admission conduct. It is conducted before any rapid testing and STI diagnosis, and guides admission of patients to emergency beds or referral to outpatient services in the region, as well as reception in therapeutic communities, always in accordance with the psychiatric risk criteria assessed during the interview.17 In general, the main complications resulting from use of drugs that bring patients to the emergency department are as follows: acute intoxication by psychoactive drugs, withdrawal and instability of psychiatric comorbidities. Participants showing signs of intoxication (i.e. agitation or sedation) or displaying aggressive behavior were referred for observation and were interviewed either later the same day or early the following morning. Data were manually entered into a single electronic database (Excel), followed by a double-checking procedure conducted by two members of the research staff.17

HIV and syphilis in “Cracolândia,” Brazil - Ribeiro et al.

Statistical analyses We conducted descriptive and multivariate analyses on the retrospective cross-sectional sample data, with HIV diagnosis and syphilis test reaction status as the primary outcomes of interest. We initially described all sociobehavioral, drug use and clinical indicator values for the total study population, and then compared male and female subsets. Bivariate analyses were conducted and odds ratios (OR) and 95% confidence intervals (95%CI) were calculated, and chi-square tests were used to measure associations between covariates of interest and HIV and syphilis infection outcomes. Multiple logistic regression analysis was used to determine factors independently associated with HIV and syphilis infection and adjusted odds ratios (AOR) were calculated. All variables that were moderately associated with a significance of p ≤ 0.05 in bivariate analyses were considered for inclusion in the multivariate model. Potential confounders, such as age, were included in all regression models. Data were processed using STATA (Stata Corp, College Station, TX) version 15.

interview. Twenty-one individuals (44.6%) from a total of 47 confirmed cases of HIV were aware of their diagnosis; 17 (36.1%) of these reported suicidal ideation. Suicidal ideation rates were 40% among those with syphilis and 74.5% among those infected with HIV. Additionally, 61.4% of HIV patients reported having had unprotected sex during the preceding month. The logistic regression model revealed that women were nearly 2.5 times more likely to have syphilis (OR: 2.44, p = 0.001, 95%CI: 1.67-3.65) than men. Syphilis was also associated with drug injection (OR: 3.54, p = 0.01 95%CI: 1.23-10.1), but no associations between syphilis and sociodemographic characteristics or risk behavior were detected. HIV was robustly associated with suicidal ideation (OR: 6.63, p = 0.001 95%CI: 3.37-14.0), unprotected sex (OR: 3.27, p = 0.003 95%CI: 1.51-7.11) and history of drug injection (OR: 13.05, p = 0.01 95%CI: 4.32-39.3).

Ethics statement The study was approved by the Ethics Review Board at the Federal University of São Paulo (CAAE: 6850.8117.5.0000.5505) and is registered with the Brazilian National Ethics Committee.

The staggering rates of HIV and syphilis detected amongst individuals seeking treatment for SUD in São Paulo (5.8% and 21.9%, respectively) underscore the urgent need to develop more effective prevention and treatment strategies. Our findings indicate that current prevention and treatment strategies are either insufficient or poorly targeted at the key populations.7,15 In addition, most of the sample reported having had unprotected sex in the preceding month,18 and a third of them reported having suicidal thoughts at the time of the interview.19 Both of these aspects were robustly associated with HIV infection, as was unprotected sex with syphilis. In relation to history of drug injection amongst the population studied, it is pertinent to point out that during the past decade most injection drug users abandoned the habit and chose to begin smoking crack cocaine instead.6 Bearing in mind that most of the current crack cocaine users are not injecting cocaine anymore, safe injection sites would not be relevant in the present situation.20 Furthermore, although it was associated with HIV and syphilis, this practice is restricted to less than 2% of the sample.12 Despite their intense exposure to STI and HIV infection, the majority of the sample reported engaging in unprotected sex and the hypothesis of its association with HIV infection was confirmed. It is known that policies based exclusively on promotion of safe sex practices are insufficient as prevention strategies.18,21 Initiatives to reduce harm must go beyond such policies

Results The sample (n = 806) was composed mostly of men (77.9%, n = 628), with a mean age of 36.5 years (standard deviation [SD] = 11.5). With regards to education, most subjects had interrupted their studies before reaching high school (69.8%, n = 563). Nearly half of the entire sample was homeless, with a third living in the Cracolândia region, and approximately two thirds were unemployed. Crack cocaine use was the primary reason for seeking treatment in 92.2% of cases (n = 743). The HIV infection rate was 5.8% (n = 47; 1:1 ratio) and only just under half (48.6%) of the males and a third (30%) of the females reported already having been diagnosed (Table 1). Over a third of the women (n = 284) tested positive for syphilis, 76.7% of whom had their diagnoses confirmed by tests at the venereal disease research laboratory (VDRL). Amongst men, 18.2% tested positive, 80% of whom were confirmed as positive by the VDRL (Table 1). Over 41.0% of the women and 31.0% of the male subjects reported suicidal ideation at the time of the

Discussion

Trends Psychiatry Psychother. 2020;42(1) – 3

HIV and syphilis in “Cracolândia,” Brazil - Ribeiro et al.

and should invest in maintenance of HIV and syphilis treatment in order to reduce transmission rates,21 in addition to reinforcing strategies for reduction of unprotected sex that are already being implemented. Our findings also highlight the importance of always addressing suicidal ideation, which was reported by a third of the sample. Moreover, patients who tested positive for HIV had a more than six times greater likelihood of reporting suicidal ideation. Twenty-one (44.6%) cases out of the total of 47 confirmed cases of HIV were aware of their diagnoses and 17 (36.1%) of these cases presented suicidal ideation, probably due to the stigma related to the virus and the lack of information provided, which their drug-dependent condition tends to exacerbate.19

It is relevant to mention that suicidal ideation assessment was performed before HIV test results were disclosed, thereby reducing the possibility of an immediate impact. There is a large body of evidence to support the belief that suicidal ideation is not only associated with crack cocaine abuse, but also with the diagnosis of HIV infection. This relationship is even more apparent during the first few months following diagnosis.19 There are recently-reported findings in the medical literature in which it was noted that suicidal ideation was significantly associated with diagnosis of HIV in the preceding three years (n = 304 patients).22 This association emphasizes the importance of implementing suicide prevention measures at addiction services.

Table 1 - Sociodemographic characteristics Sociodemographic characteristics

Total

Men 77.9 (74.9-80.6)

Women 22.1 (19.3-25.1)

Age Up to 24

12.5 (10.4-15.1)

10.8 (8.0-3.5)

18.5 (13.4-25.0)

25 to 34

35.1 (31.8-38.4)

34.9 (30.7-38.2)

37.6 (30.7-45.0)

35 to 44

29.6 (26.5-32.9)

30.7 (27.2-34.4)

25.8 (19.8-32.8)

45 or older

22.7 (19.9-25.7)

24.0 (20.8-27.5)

17.9 (12.9-24.3)

Years in education None

1.4 (0.8-0.26)

1.4 (0.08-2.60)

1.7 (20.5-5.14)

Up to 5 years

18.2 (15.7-21.0)

17.2 (14.4-20.3)

21.9 (16.3-28.6)

6 to 9 years

50.2 (46.7-53.7)

49.2 (45.2-53.1)

53.9 (46.5-61.1)

10 to 13 years

27.0 (24.0-30.2)

28.8 (25.4-32.4)

20.7 (15.4-27.4)

2.9 (2.1-5.0)

3.34 (2.18-5.07)

1.7 (0.5-5.14)

14 years or more Housing Institution

6.7 (5.1-8.5)

6.84 (5.1-8.6)

6.7 (3.4-10.8)

Homeless

46.0 (42.6-49.4)

45.7 (41.8-49.6)

47.2 (39.9-54.6)

Fixed address

47.2 (43.8-50.7)

47.4 (43.5-51.3)

46.6 (39.3-54.0)

Cracolândia

31.2 (28.1-34.5)

31.5 (27.9-35.2)

30.5 (24.1-37.7)

Other

68.7 (64.4-71.8)

68.4 (64.7-72.0)

69.5 (62.2-75.8)

Employed

34.7 (31.5-38.1)

35.5 (31.8-39.3)

32.0 (25.5-39.2)

On social benefits

30.1 (26.9-33.2)

28.3 (24.9-32.0)

36.0 (29.1-43.3)

Suicidal ideation (Missing = 0)

33.6 (30.4-36.9)

31.5 (28.0-35.2)

41.0 (33.9-48.4)

Unprotected sex (Missing = 0)

61.4 (58.0-64.7)

60.8 (57.0-64.6)

63.5 (56.0-70.2)

History of drug injection (Missing = 0)

1.86 (1.12-3.06)

1.27 (0.63-2.53)

1.56 (1.8-8.0)

HIV/AIDS (Missing = 6)

5.86 (4.43-7.72)

5.92 (4.31-8.07)

5.68 (3.06-10.2)

Previously diagnosed

44.6 (30.7-59.4)

48.6 (32.5-65.0)

30.0 (7.63-68.9)

Syphilis (Missing = 5)

21.9 (19.2-25.0)

18.2 (15.4-21.4)

35.2 (28.5-42.6)

Confirmatory VDRL result

79.7 (72.9-85.2)

81.4 (72.8-87.8)

76.6 (14.1-36.0)

Active disease

16.6 (14.2-19.4)

14.0 (11.5-17.0)

25.8 (19.9-32.8)

4.2 (3.0-5.8)

3.2 (2.0-4.9)

7.8 (4.7-12.9)

Region

Risk behaviors

Sexually transmitted infections

Treated disease

95%CI = 95% confidence interval; HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; VDRL = venereal disease research laboratory.

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HIV and syphilis in “Cracolândia,” Brazil - Ribeiro et al.

Most of the patients included (73%) were crack cocaine-dependent individuals, who belong to a socially vulnerable layer of society and are highly exposed to a variety of risk behaviors. Previous studies reported higher mortality rates amongst HIV-positive patients who use crack cocaine.23 These elevated rates persisted even after adjustment for time since diagnosis, adherence to antiretroviral therapy and relevant sociodemographic variables.24-26 The harmful consequences related to crack cocaine consumption in HIV-positive patients emphasize the need for effective treatment strategies focusing on cessation of drug use. To the best of our knowledge, this is the first combination mental health and infectious care strategy covering both syphilis and HIV/AIDS in Cracolândia. Our findings corroborate those of previous studies that highlighted the importance of prioritizing STI testing on admission and initiating clinical care as soon as diagnoses are made.27

Acknowledgements

Limitations The study was performed at a single center with a convenience sample. Consequently, the risk of selection bias has to be addressed. CRATOD is located in the heart of Cracolândia, thus, it is reasonable to assume that the population treated at CRATOD is not representative of the wider substance use disorder population. These patients are probably facing more severe addiction and in a more vulnerable situation. Only six patients refused to take the rapid test, and remain in the study, with the data counted as missing. According to the database used, one of these six patients had been tested at another service and a diagnosis of syphilis was found on the system and this individual was counted as positive for VDRL. This description is included as a study limitation. It can therefore be assumed that generalizability is limited. Furthermore, there is a possibility of underreporting, since all of the information on drug intake and risk behaviors was based on self-reports.

1. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend. 2007;88:188-96. 2. Daar ES, Corado K. Condomless sex with virologically suppressed HIV-infected individuals: how safe is it? JAMA. 2016;316:14951. 3. Maartens G, Celum C, Lewin SR. HIV infection: epidemiology, pathogenesis, treatment, and prevention. The Lancet. 2014;384:258-71. 4. World Health Organization. Global Report World Health Organization. Geneva: World Health Organization; 2015. 5. UNAIDS. Global Aids Response Progress Reporting 2016, Construction of core indicators for monitoring the 2011 United Nations Political Declaration on HIV and AIDS Geneva: UNAIDS; 2016. 6. Abdalla RR, Madruga CS, Ribeiro M, Pinsky I, Caetano R, Laranjeira R. Prevalence of cocaine use in Brazil: data from the II Brazilian national alcohol and drugs survey (BNADS). Addict Behav. 2014;39:297-301. 7. Brasil, Ministério da Saúde, Departamento de Vigilância PeCdI, HIV/Aids e das Hepatites Virais. Pesquisa de conhecimentos, atitudes e práticas da população brasileira. Brasília: Ministério da Saúde; 2016. 8. Brasil, Ministério da Saúde, Vigilância Epidemiológica. Boletim Epidemiológico de Sifilis. Brasília: DIAHV; 2017. 9. Milanez H. Syphilis in pregnancy and congenital syphilis: why can we not yet face this problem? Rev Bras Ginecol Obstet. 2016;38:425-7. 10. Baptista CJ, Dourado I, de Andrade TM, Brignol S, Bertoni N, Bastos FI. HIV prevalence, knowledge, attitudes, and practices among polydrug users in Brazil: a biological survey using respondent driven sampling. AIDS Behav. 2017;22:2089-103. 11. Brasil, Ministério da Saúde. PCDT: Protocolo clínico e diretrizes terapêuticas para manejo da infecção do HIV em adultos. Brasília: Ministério da Saúde; 2017. 12. United Nations Office on Drugs and Crime. Practical guide for civil society HIV service providers among people who use drugs. Vienna: UNODC; 2013. 13. United Nations Office on Drugs and Crime. Global consulation UNODC on prevention. Vienna: UNODC; 2014. 14. Tan AX, Kapiga S, Khoshnood K, Bruce RD. Epidemiology of drug use and HIV-related risk behaviors among people who inject drugs in Mwanza, Tanzania. PLoS One. 2015;10: e0145578. 15. McPherson SM, Madruga CS, Miguel AQC, McDonell MG, Ribeiro, A. Preliminary findings: HIV/STD risk among crack cocainedependent patients in treatment in Brazil’s ‘Crackland’. Drug Alcohol Depend. 2017;171:e140-1. 16. Ribeiro M, Duailibi S, Frajzinger R, Alonso AL, Marchetti L, Williams AV, et al. The Brazilian ‘Cracolândia’ open drug scene

Conclusions Elevated rates of HIV and syphilis were ascertained in the context of an extremely severe social vulnerability scenario. The most significant risk factors identified as associated with STI, such as suicidal ideation, unprotected sex and drug injection, should be taken into consideration for implementation of specific prevention strategies based on early diagnosis and treatment of sexually transmitted infections, to tackle the rapid spread of STI in this population.

This study was partially financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; Finance Code 001). We would like to thank the professionals who contributed to this study: the nursing team at CRATOD, Relba Fritoli, Aparecida Santos, Shirley Aparecida Lima and Gabriela Asaeda, and proof reader Marjory Donda, who conducted a revision of the article.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References

Trends Psychiatry Psychother. 2020;42(1) – 5

HIV and syphilis in “Cracolândia,” Brazil - Ribeiro et al.

and the challenge of implementing a comprehensive and effective drug policy. Addiction. 2016;111:571-3. 17. Zoldan LGV, Ribeiro M, editors. CRATOD 15 Anos – Uma proposta de cuidado ao dependente químico. São Paulo; Imprensa Oficial: 2017. 18. Johnson MW, Herrmann ES, Johnson PS, Sweeney MM. Cocaine decreases preference for condom use as function of delayed condom availability and STI risk. Drug Alcohol Dep. 2017;171:e97. 19. Kang CR, Bang JH, Cho SI, Kim KN, Lee HJ, Ryu BY, et al. Suicidal ideation and suicide attempts among human immunodeficiency virus-infected adults: differences in risk factors and their implications. AIDS Care. 2016;28:306-13. 20. Dunn J, Laranjeira RR. Transitions in the route of cocaine administration--characteristics, direction and associated variables. Addiction. 1999;94:813-24. 21. Des Jarlais DC, Arasteh K, McKnight C, Feelemyer J, Campbell AN, Tross S, et al. What happened to the HIV epidemic among noninjecting drug users in New York City? Addiction. 2017;112:2908. 22. Quinlivan EB, Gaynes BN, Lee JS, Heine AD, Shirey K, Edwards M, et al. Suicidal ideation is associated with limited engagement in HIV care. AIDS Behav. 2017;21:1699-708. 23. Ribeiro M, Dunn J, Sesso R, Lima MS, Laranjeira R. Crack cocaine: a five-year follow-up study of treated patients. Eur Addict Res. 2007;13:11-9. 24. Cook JA, Burke-Miller JK, Cohen MH, Cook RL, Vlahov D, Wilson TE, et al. Crack cocaine, disease progression, and mortality in a

6 – Trends Psychiatry Psychother. 2020;42(1)

multicenter cohort of HIV-1 positive women. AIDS. 2008;22:135563. 25. Malta M, Magnanini MM, Strathdee SA, Bastos FI. Adherence to antiretroviral therapy among HIV-infected drug users: a metaanalysis. AIDS Behav. 2010;14:731-47. 26. Ti L, Dong H, Kerr T, Turje RB, Parashar S, Min JE, et al. The effect of engagement in an HIV/AIDS integrated health programme on plasma HIV-1 RNA suppression among HIV-positive people who use illicit drugs: a marginal structural modelling analysis. HIV Med. 2017;18:580-6. 27. Doshi RK, Vogenthaler NS, Lewis S, Rodriguez A, Metsch L, del Rio C. Correlates of antiretroviral utilization among hospitalized HIV-infected crack cocaine users. AIDS Res Hum Retroviruses. 2012;28:1007-14.

Correspondence: Ariadne Ribeiro Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP) Rua Borges Lagoa, 570/82, Vila Clementino 04038-000 - São Paulo, SP - Brazil Tel/Fax.: +55 (11) 55764990 E-mail: ariadnerf@gmail.com

Trends

Original Article

in Psychiatry and Psychotherapy

Anxiety in Malaysian children and adolescents: validation of the Screen for Child Anxiety Related Emotional Disorders (SCARED) Chin-Siang Ang1

Abstract Objective: Use of the Screen for Child Anxiety Related Emotional Disorders (SCARED) has increased significantly since its publication. Although the validity of the SCARED is well established, most of the samples investigated primarily comprised Caucasian children and, where available, people from Asian cultures such as China. Furthermore, the instrument’s utility for screening use in community samples has yet to be validated, although it is commonly advocated for this use. The present study addressed the psychometric properties of the SCARED in a community sample of Malaysian children and adolescents. Method: A total of 386 participants from an urban area, aged between 8 and 17, completed the 41-item SCARED. Confirmatory factor analysis and exploratory factor analysis were performed to investigate the factor structure of the SCARED. Results: Internal consistency ratings for the SCARED’s total and subscale scores were good, except for School Avoidance. The validity of the SCARED was further demonstrated through a significant correlation with the Internalizing subscale of the Strength and Difficulties Questionnaire (SDQ). In contrast with the five-factor structure proposed for primarily Caucasian samples, factor analysis revealed a four-factor structure for this Malaysian sample. Conclusions: These research findings support the validity of the SCARED and its utility as a screening tool in a community sample of Malaysian children and adolescents. Keywords: Adolescents, children; Malaysia, reliability, validity

Introduction Anxiety is an emotion characterized by a general, unpleasant feeling of apprehension.1,2 Experiencing occasional anxiety is a common human experience and everyone experiences anxiety at times. In fact, anxiety is considered a normal, beneficial emotion in response to fear-producing stimuli that activate the body’s physiological response, known as the fight-orflight response. An anxiety disorder, however, involves repeated episodes of intense and excessive anxiety, along with other debilitating symptoms such as sweating,

palpitations, heart pounding, chest tightness, lightheadedness, and upset stomach.2,3 Anxiety disorders can alter how a person processes behaviors, thinking, and emotions that disrupt day-to-day living. Anxiety disorders are among the most common types of childhood psychopathology, affecting approximately 8-12% of children and adolescents at some point in their lives.3 They may experience anxiety in a variety of ways, such as specific phobias, separation anxiety, and social anxiety disorder.4 A large majority of studies have explored sex differences in anxiety and found that, in general terms, anxiety is somewhat more prevalent

TMC Academy, Singapore.

Submitted Dec 20 2018, accepted for publication May 04 2019. Suggested citation: Ang C-S. Anxiety in Malaysian children and adolescents: validation of the Screen for Child Anxiety Related Emotional Disorders (SCARED). Trends Psychiatry Psychother. 2020;42(1):7-15. http://dx.doi.org/10.1590/2237-6089-2018-0109 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 7-15

Validation of the SCARED - Ang

among girls than boys.5-8 The most likely explanation for the sex differences observed is stereotypic sex traits. Notably, girls showed more anxiety than boys, because of their propensity for behavioral inhibition, rumination, and sensitivity to negative stimuli. Although some studies argue that anxiety fades as children grow up,2 some children may have anxiety disorders that persist into adulthood.4,9 Because anxiety disorders can cause significant impairment in social and other important areas of functioning,2,3 there is an imperative to identify children who are at-risk for anxiety. Self-reports are still the best and most direct type of measure for assessing the internal, subjective nature of anxiety. Despite some drawbacks (e.g., social desirability bias and acquiescence), self-reports remain a time-efficient, brief tool for identifying at-risk children and adolescents who require further psychiatric evaluation.10 Recent decades have seen considerable advances in terms of development of clinically useful and empirically sound tools for investigating childhood and adolescent anxiety. Common measures include the Spence Children’s Anxiety Scale,11 the Multidimensional Anxiety Scale for Children,12 and the State-Trait Anxiety Inventory for Children.13 In contrast with other self-report scales, the Screen for Child Anxiety Related Emotional Disorders (SCARED) is one of the few screening tools that closely corresponds to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The SCARED was originally developed as a screening tool for use in clinical settings, but it is now often used in community settings.5 The scale is a 41item rating scale that contains five subscales: Panic Attack, Generalized Anxiety, Separation Anxiety, Social Anxiety, and School Avoidance. Panic attack is an acute disorder involving sudden and intense feelings of terror and apprehension. It results in palpitations, breathlessness, feelings of suffocation, trembling, and nausea.1,14 Panic disorders usually occur after exposure to a frightening experience or persistent stress, but may also strike out of the blue, or without a clear warning. Nearly 16% of adolescents are affected.15 Generalized anxiety disorder is characterized by excessive, long-lasting anxiety, and worries about everyday things.14 Many people with generalized anxiety disorder find it difficult to control their anxiety even when there is no apparent reason.1 About 37% of children went to a large anxiety clinic to consult the physician because of generalized anxiety disorder.16 Separation anxiety disorders usually occur when faced with situations of separation from a person or place to which there is a strong emotional attachment.1,2 Children who suffer from separation anxiety disorder commonly worry about bad things happening to their 8 – Trends Psychiatry Psychother. 2020;42(1)

parents, and may experience repeated nightmares about being separated.16 Prolonged separation anxiety in teenagers sometimes evolves into complete panic attacks.1 Approximately 4% to 10% of young children have this disorder.17 Social anxiety describes a disorder in which an individual experiences fear of being scrutinized and judged negatively by others in social situations.4,14 Children with social anxiety disorder may often exhibit stage fright, problems with intimacy, and fear of shame and humiliation, causing them to avoid public situations to the point that ability to function in some parts of daily life is impaired. Social anxiety affects 6% to 12% of all school-age children.4 School avoidance is an anxiety disorder that manifests as an irrational and intense fear of going to school and has significant short and longterm effects on children’s educational, emotional, and social development.1,2 Children with school avoidance may express somatic complaints including migraines, abdominal pain, vomiting, nausea, or diarrhea. School avoidance can present with a vast number of reasons such as stressful life events, separation anxiety, and periods of transition. School avoidance occurs in 2 to 5% of children and adolescents.4 Since its publication, the SCARED has rapidly become a preferred instrument for assessment of anxiety in children and adolescents due to its established psychometric qualities. In the original study, the SCARED demonstrated good reliability, with values of internal consistency for the five subscales ranging from 0.74 to 0.89 and 0.93 for the total scale.5 To date, several validation studies of the SCARED have been carried out in different community samples18-20 and epidemiological samples.21,22 These studies have supported the scale’s internal consistency and testretest reliability. Moreover, convergent validity was established on the basis of patterns of correlations with other anxiety questionnaires6,19 and negative correlation with quality of life.22 Adequate discriminant validity has also been reported for this measure, differentiating between youth with and without anxiety disorders, and also between children with depressive disorders and anxiety disorders.5,21 Nevertheless, in some psychometric studies School Avoidance emerged as a weak factor and was unreliable.8,23 Unreliability of the School Avoidance factor has also been documented in a variety of non-Caucasian populations, including Chinese adolescents6 and South African youth.7 These studies generally find that a revised four-factor model that excludes School Avoidance items provides a better fit to the data. Although the psychometric characteristics of the SCARED have been well established,5,19,20,24-26 most of

Validation of the SCARED - Ang

the samples consisted primarily of Caucasian children and, where available, children from Asian cultures like China.6 More work is needed that examines the psychometric properties of the SCARED in nonCaucasian samples, given that psychometric qualities of self-report instruments vary significantly between Western and Eastern samples.27 This illustrates the relevance of presenting the psychometric properties of the SCARED in Malaysian children and adolescents. Specifically, item frequencies, descriptive statistics for the entire SCARED scale and its subscales, and itemitem reliability were computed. Convergent validity was also assessed by examining the relationship between the SCARED and a measure of internalizing symptoms. Additionally, both confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were performed to examine the factorial structure of the SCARED.

Procedure During data collection, children who did not have a prior diagnosis of anxiety and whose parents signed consent forms were invited to participate in the study. Children who agreed to participate were also requested to sign an assent form. The questionnaires were then presented to the participants and they were asked to complete them anonymously. Throughout administration, all items were read aloud to the participants by trained research assistants to ensure they filled in the questionnaire accurately. They were reminded several times throughout the administration to ask for help if they had any difficulties with words or phrases. Each session took around 30 minutes to complete and small tokens of appreciation were gifted to the participants as well as the centers. The Departmental Ethics Committee

Method

Statistical analyses The statistical programs Statistical Package for the Social Sciences (SPSS) 25.0 and Analysis of Moments Structure (AMOS) 22.0 were used to analyze the data. An alpha level of 0.05 was adopted for all statistical analyses.

Participants There were 386 participants, 99 of whom were boys and 287 of whom were girls. Participants were recruited from twenty teaching centers in the Federal Territory of Kuala Lumpur, Malaysia, where the principals agreed to participation in our research. Participants ranged in age from 8 to 17 years, with a mean of 13.76 years (standard deviation [SD] = 2.78). All participants reported living with both parents. Measures The SCARED5 is a 41-item questionnaire that measures five types of anxiety: 13 items for Panic, 9 items for Generalized Anxiety, 8 items for Separation Anxiety, 7 items for Social Phobia, and the remaining 4 items for School Avoidance. All items are answered on a Likert scale ranging from 0 (not true/hardly ever true) to 2 (true/often true). Scores for the five subscales are created by summing the items of each subscale, which, in turn, are summed together to form a total score. The Internalizing Problem subscale of the Strength and Difficulties Questionnaire (SDQ) was used to examine convergent validity of the SCARED. This is because anxiety symptoms are usually viewed as an auxiliary part of internalizing problems.2 This scale is a 5-item questionnaire developed to operationalize the construct of internalizing problems of children aged from 3 to 16 years.28 All items are answered on a Likertscale ranging from 0 (not true) to 2 (certainly true). This scale is used extensively in research and has good evidence of both reliability and validity.29 Its reliability coefficient is high (Îą = 0.81).

approved all procedures for the study. All participants gave consent for their data to be used in the research.

Results Item distribution The distribution of responses for the SCARED is presented in Table 1. For each item, frequencies and percentages were generated by collapsing responses for 1 (somewhat true) and 2 (true/ often true).24 The top five rated anxiety symptoms were feeling nervous wherever there will be unfamiliar people, worrying about how well things are done, heart beating fast when frightened, worrying something bad might happen to parents, and feeling nervous when being watched. The anxiety symptoms for which participants rated themselves lowest were all related to panic/somatic disorders, except for worrying about sleeping alone. Mean and standard deviation for total sample and sex subgroups Table 2 presents the SCARED results for the entire sample and sex subgroups. A total score of 25 or above (in the ranges from 0 to 82) was used as a cut-off score.21 Approximately 58% (n = 224) of the sample exceeded the cut-off score. Results of multivariate analyses of variance found that girls reported significantly higher scores than boys in Total Anxiety (F1, 384 = 6.2, p < 0.05), Separation Anxiety (F1, 384 = 9.24, p < 0.01), Social Anxiety (F1, 384 Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 9

Validation of the SCARED - Ang

= 4.29, p < 0.05), and School Avoidance (F1, 384 = 8.56, p < 0.01) and all effect sizes were considered small according to psychological standards.30 Reliability Cronbach’s alpha coefficients were calculated for each subscale and for the total scale score to assess the reliability of the scale in terms of internal consistency.

The α coefficient for the total scale was 0.88. The five subscales varied from 0.45 to 0.80, with only School Avoidance being lower than the usual cut-off point of 0.70 (see Table 3). Convergent validity Convergent validity was then computed to assess the correlation between the SCARED and the Internalizing

Table 1 - Distribution of responses for the Screen for Child Anxiety Related Emotional Disorders (SCARED) No.

I feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well. SC

323

83.6

I worry about how well I do things. GD

320

82.9

When I get frightened, my heart beats fast. PN

317

82.1

I worry that something bad might happen to my parents. SP

317

82.1

I feel nervous when I am with other children or adults and I have to do something while they watch me. SC

297

77.0

I feel shy with people I don’t know well. SC

292

75.7

I worry about what is going to happen in the future. GD

288

74.7

I don’t like to be away from my family. SP

283

73.3

I am shy. SC

281

72.8

It is hard for me to talk with people I don’t know well. SC

265

68.7

I follow my mother or father whenever they go. SP

263

68.1

I don’t like to be with people I don’t know well. SC

251

65.0

I feel nervous with people I don’t know well. SC

243

63.0

When I get frightened, I sweat a lot. PN

239

61.9

I get stomach aches at school. SH

233

60.4

I worry about things that have already happened. GD

232

60.1

I am a worrier. GD

229

59.4

I have nightmares about something bad happening to me. SP

225

58.3

I worry about being as good as other kids. GD

222

57.5

I worry about other people liking me. GD

214

55.4

I am nervous. GD

212

55.0

I get shaky. PN

204

52.9

I get headaches when I am at school. SH

200

52.0

I worry about things working out for me. GD

176

45.6

I am afraid of having anxiety (or panic) attacks. PN

171

44.3

I worry about going to school. SH

169

43.8

I get scared if I sleep away from home. SP

167

43.3

I have nightmares about something bad happening to my parents. SP

164

42.5

I am afraid to be alone in the house. SP

163

42.2

When I feel frightened, it is hard to breathe. PN

163

42.2

When I get frightened, I feel like things are not real. PN

163

42.2

I get really frightened for no reason at all. PN

160

41.5

People tell me that I worry too much. GD

155

40.2

I am scared to go to school. SH

147

38.1

People tell me that I look nervous. PN

145

37.5

When I get frightened, I feel like passing out. PN

129

33.4

I worry about sleeping alone. SP

124

32.1

When I get frightened, I feel like I am going crazy. PN

123

31.8

When I get frightened, I feel like throwing up. PN

110

28.5

When I get frightened, I feel like I am choking. PN

23.6

When I get frightened, I feel dizzy. PN

23.6

19 2

Item

% = percentage; GD = Generalized Anxiety; n = frequency; PN = Panic Disorder or significant somatic symptoms; SC = Social Anxiety; SH = School Avoidance; SP = Separation Anxiety.

10 – Trends Psychiatry Psychother. 2020;42(1)

Validation of the SCARED - Ang

Problem subscale of the SDQ. The results showed that the two scales were significantly and strongly correlated (r = 0.74, p < 0.001).

an acceptable fit.31 Table 4 indicates that neither factor model generated an acceptable fit. Results for both model specifications suggested that SCARED did not factor totally onto the five subscales or the four subscales, as specified in earlier studies. An EFA was conducted on 37 of the items of the SCARED using maximum likelihood estimation to examine its underlying dimensional structure. Analysis of the data identified six factors with eigenvalues greater than 1, whereas a scree plot indicated that up to four factors were interpretable. We then forced four-, five-, and sixfactor solutions using both an oblique and orthogonal solution, and the most interpretable factor solution was the four-factor orthogonal. The four-factor model explained 42.08% of variance. The criteria adopted for retaining items were item loadings exceeding the 0.40 cut-off and at least three conceptually related items on

Factor analyses We then performed CFAs in order to examine the stability of the two factor models. Specifically, model 1 corresponds to the theoretical model proposed by the original authors5 and is composed of 41 items and 5 factors. Model 2 corresponds to the results of our reliability analysis and previous psychometric studies,8,23 and is composed of 37 items and 4 factors, with School Avoidance excluded. Model fit was examined using the comparative fit index (CFI), the incremental fit index (IFI), in which values of 0.90 or higher indicate a good fit; and the root mean square error of approximation (RMSEA), in which values of 0.08 or lower indicate

Table 2 -Mean and standard deviation for total sample and sex subgroups Boys (n = 99)

Girls (n = 287)

Total (n =386)

Mean

6.03

3.88

6.83

4.02

6.62

3.99

2.94

Effect size ns

6.87

3.28

7.01

4.20

6.97

4.14

0.09

ns 0.34

5.17

3.67

6.31

3.04

6.02

3.25

9.24*

6.14

3.09

6.94

3.40

6.74

3.34

4.29†

0.25

1.89

1.68

2.42

1.51

2.28

1.57

8.56*

0.33

26.10

10.16

29.51

12.22

28.63

11.80

6.2†

0.30

Total score

GD = Generalized Anxiety; ns = not significant; PN = Panic Disorder or significant somatic symptoms; SD = standard deviation; SH = School Avoidance; SP = Separation Anxiety; SC = Social Anxiety. Effect sizes were computed for Cohen’s d. * p < 0.01; † p < 0.05.

Table 3 - Internal consistency of the Screen for Child Anxiety Related Emotional Disorders (SCARED) Scale

No. of items

0.75

0.72

0.70

0.80

0.45

Total score

0.88

GD = Generalized Anxiety; PN = Panic Disorder or significant somatic symptoms; SH = School Avoidance; SP = Separation Anxiety; SC = Social Anxiety.

Table 4 - Fit indices for the hypothesized model Model

CFI

IFI

RMSEA

90%CI

4273.79*

769

0.469

0.473

0.109

0.106-0.112

3506.58*

623

0.506

0.509

0.110

0.106-0.113

90%CI = 90% confidence interval; CFI = comparative fit index; df = degrees of freedom; IFI = incremental fit index; RMSEA = root mean square error of approximation. * p < 0.001.

Trends Psychiatry Psychother. 2020;42(1) – 11

Validation of the SCARED - Ang

each factor.32 One item was dropped (“I get shaky”) because it loaded onto none of the four factors. The first factor clearly tapped Generalized Anxiety. The second factor primarily consisted of Social Anxiety items. The third factor contained six (of the seven) Separation

Anxiety items. The final factor captured mostly items about Panic Disorder. The factor loadings ranged in magnitude from 0.41 to 0.77. The factors were analyzed as subscales and had the following coefficients: 0.87, 0.82, 0.70, and 0.68, respectively (see Table 5).

Table 5 - Exploratory factor analysis with Varimax rotation for the Screen for Child Anxiety Related Emotional Disorders (SCARED) Factor No.

Item

I worry about what is going to happen in the future.

0.77

I worry about how well I do things.

0.69

I am a worrier.

0.65

I worry about things that have already happened.

0.62

I have nightmares about something bad happening to my parents.

0.58

When I get frightened, I feel like I am going crazy.

0.58

I worry about things working out for me.

0.56

People tell me that I worry too much.

0.56

I have nightmares about something bad happening to me.

0.55

I am afraid of having anxiety (or panic) attacks.

0.53

I am nervous

0.51

7 6

When I get frightened, I feel like passing out.

0.50

When I get frightened, I feel like things are not real.

0.43

I feel shy with people I don’t know well.

0.76

I feel nervous when I am going to parties, dances, or any place where there will be people that I don’t know well.

0.74

I am shy.

0.74

It is hard for me to talk with people I don’t know well.

0.61

I don’t like to be with people I don’t know well.

0.59

People tell me that I look nervous.

0.51

I get really frightened for no reason at all.

0.49

I feel nervous with people I don’t know well.

0.44

I am afraid to be alone in the house.

0.65

I get scared if I sleep away from home.

0.61

4 29

I don’t like to be away from my family.

0.57

I follow my mother or father wherever they go.

0.55

I worry about sleeping alone.

0.53

I worry that something bad might happen to my parents.

0.49

I feel nervous when I am with other children or adults and I have to do something while they watch me.

0.46

When I get frightened, my heart beats fast.

0.57

When I get frightened, it is hard to breathe

0.56

I worry about other people liking me.

0.56

When I feel frightened, I sweat a lot.

0.55

I worry about being as good as other kids.

0.52

When I get frightened, I feel like I am choking.

0.50

When I get frightened, I feel like throwing up.

0.42

When I get frightened, I feel dizzy.

0.41

Eigenvalue Variance

5.29

4.14

3.09

3.04

14.29

11.20

8.36

8.23

Mean

8.66

6.62

5.76

5.14

Standard deviation

5.59

3.64

2.98

2.81

0.86*

0.77*

0.61*

0.68*

0.87

0.82

0.70

0.68

Factor-total score correlation Internal consistency

Factor loadings in the table are arranged according to their magnitude with the largest value at the top. Any loadings below 0.40 were suppressed. Kaiser-Meyer-Olkin = 0.759; χ2666 = 6279.293; p = 0.000; * p < 0.001.

12 – Trends Psychiatry Psychother. 2020;42(1)

Validation of the SCARED - Ang

Discussion The present study aimed to characterize the psychometric properties of the SCARED in a community sample of children and adolescents in Malaysia. Overall, item frequencies showed that social anxiety was the most commonly endorsed of the SCARED categories. This outcome is probably because of the collectivist orientation, or allocentric focus, in Asian societies.27 Those in collectivistic cultures tend to have lower assertive skills and more concern about how their behaviors and performance impact others, and this may evoke anxiety in social situations. On the other hand, items related to panic and somatic symptoms such as the feeling of being smothered, the feeling of going crazy, and dizziness were the least frequently endorsed items in this sample. One possible explanation is the sample. To reiterate, the present study used “pure” community samples, in which the experience of panic attack, commonly involving physical somatic symptoms, should be far less likely.10,19 Anecdotal evidence on different age groups also appears to show adults more likely to report panic disorder/somatic complaints than their child counterparts.14 Additionally, the mean scores for total anxiety obtained in this sample can also be compared with previous normative data. Our data reveal a mean score of 28.63 (SD = 11.80), which is lower than observed in Saudi Arabian children and adolescents,18 but higher than in Western samples.21 The elevated scores in non-white samples could be in part attributable to the fact that they are living in cultures which favor inhibition, compliance, and obedience. This is likely to increase their levels of anxiety.33 Nevertheless, this is an area that needs further exploration to help determine whether this potential explanation is the core cause of this discrepancy. Considering the conventional cut-offs for this scale, the results revealed that a large proportion of the sample (58%) reported anxiety symptoms that were above the threshold value (scores greater than or equal to 25), indicating a need for further clinical assessment.21 Although previous studies have proved that the SCARED is able to discriminate between children with an anxiety disorder and those with nonanxiety-related disorders,7,21,26 our prevalence rate is 2-3 times higher than the global estimates.34 While the findings may support the theory that anxiety disorders often emerge during childhood and adolescence,3 contextual factors may also help to explain high rates of anxiety among this sample. In one study,35 the risk for anxiety disorders among city dwellers was higher than among non-city dwellers. Given that the current sample was recruited from a large city, they hypothetically

may experience more anxiety symptoms. Moreover, previous studies of non-diagnosed community samples have also found that children report significantly more anxiety symptoms than their parents.6,19,20 Based on these findings, screening of both children and parents is recommended, regardless of their ages. Moreover, in another community sample study,36 the sensitivity and specificity of the SCARED was uniformly high (> 0.80%), but specificity was below the recommended minimum cut-off for adequate discrimination (> 0.70), which may lead to overestimation of the presence of diagnoses.31 Future research could revisit clinical cutoffs or consider including structured interviews during assessment to avoid false positives. There were also sex differences in Total Anxiety, Separation Anxiety, Social Anxiety, and School Avoidance. Girls rated themselves more highly in these aspects than boys, which may be seen as stereotypical of evolutionary-based sex differences.5-8 Girls are supposed to be intimate, emotional, and softer, whereas boys are supposed to be brave and strong. These findings provide evidence for the utility of the SCARED for identifying sex differences in anxiety disorders. Reliability analyses showed that both total SCARED score and subscale scores had good internal consistency. Consistent with findings from a wide array of existing studies, with Italian twins,8 Chinese children,6 AfricanAmerican adolescents,24 and Saudi Arabian children and adolescents,18 the School Avoidance subscale was not found to be reliable. One possible reason for this is that the School Avoidance subscale does not appear to be part of the same construct as other anxiety disorders, nor it is not classified under the DSM-categorization, even if its symptoms are closely associated with anxiety disorders.5,21 Additionally, a significant correlation was obtained between the SCARED and the Internalizing subscale of the SDQ, lending support to the SCARED’s convergent validity. This is consistent with the anxiety literature demonstrating a positive link between the two measurements.5,7,18,21,26 Using CFA, the original five-factor solution specified by the scale’s authors5,21 provided a poor fit to the data. The goodness of model fit was mildly improved (albeit the fit still remained poor) when the School Avoidance items were not included in the analysis. By means of EFA, a four-factor orthogonal model was found to be the most interpretable factor solution. A careful inspection of the retained items revealed that the majority of items were loaded onto their respective factors. Factor 1 comprises mostly generalized anxiety items; Factor 2 comprises mostly social anxiety items; Factor 3 comprises mostly separation anxiety items; and Factor 4 comprises mostly panic attack items. These findings may lend support Trends Psychiatry Psychother. 2020;42(1) – 13

Validation of the SCARED - Ang

to previous studies showing that comorbidity among anxiety disorders is common, since many symptoms of anxiety disorders are not exclusively specific to that disorder.1,2 The variance (42.08%) of the four factors found in this study is higher than the variance (36.3%) of the four factors reported in a previous study.7 Each of the newly defined factors proved to have good reliability to warrant further evaluation. The consistency of these findings, both in the extant literature and in the present study, leads us to conclude that the SCARED as a whole is more psychometrically robust when the School Avoidance subscale is excluded.6,8 We therefore suggest that School Avoidance be excluded from future studies using the SCARED. This study has some limitations. First, there are biases involved in the selection of the sample, because it was not randomly selected from the general population. This convenience sampling may therefore limit generalizability of the findings and it is not clear to what extent the results of this study are generalizable. Future studies might aim to replicate the present study in order to provide additional information on the psychometric qualities of this scale. Specifically, other measures of social anxiety could be included to enable a more thorough examination of the concurrent validity of the SCARED and more samples would be beneficial in assessing the degree to which the current findings are replicable.

Conclusion Although some of the instrument’s psychometric properties were different from those observed in prior studies, the SCARED nevertheless appears to be useful for screening for anxiety disorder symptoms in community samples. It is evident that the present study not only highlights some important differences in SCARED scores and factor structure in a Malaysian sample compared to prior studies, but also adds to anxiety research on the psychometric qualities of this scale. To conclude, the present study provides a “new” version of the SCARED for use in Malaysia. However, it is important to note that SCARED is a screening tool, rather than a diagnostic tool. Other forms of psychological assessment are still needed in order to make an accurate diagnosis.

Disclosure No conflicts of interest publication of this article.

declared

concerning

14 – Trends Psychiatry Psychother. 2020;42(1)

the

References 1. Rapee RM. Anxiety disorders in children and adolescents: nature, development, treatment and prevention. In: Figueroa A, Soutullo C, editors. IACAPAP textbook of child and adolescent mental health. Geneva: International Association for Child and Adolscent Psychiatry and Allied Professions; 2012. p. 1-19. 2. Mash EJ, Wolfe DA. Abnormal child psychology. 6th ed. Boston: Cengage Learning; 2016. 3. Silverman WK, Ollendick TH. Evidence based assessment of anxiety and its disorders in children and adolescents. J Clin Child Adolesc Psychol. 2005;34:380-411. 4. Knappe S, Beesdo-Baum K, Wittchen HU. Familial factors in social anxiety disorder: calling for family-oriented approach for targeted prevention and early intervention. Eur Child Adolesc Psychiatry. 2010;19:857-71. 5. Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristcis. J Am Acad Child Adolesc Psychiatry. 1997;36:545-53. 6. Su L, Wang K, Fan F, Su Y, Gao X. Reliability and validity of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Chinese children. J Anxiety Disord. 2008;22:612-21. 7. Muris P, Merckelbach H, Ollendick T, King N, Bogie N. Three traditional and three new childhood anxiety questionnaires: their reliability and validity in a normal adolescent sample. Behav Res Ther. 2002;40:753-72. 8. Ogliari A, Citterio A, Zanoni A, Fagnani C, Patriarca V, Cirrincione R, et al. Genetic and environmental infleunces on anxiety dimensions in Italian twins evaluated with the SCARED questionnaire. J Anxiety Disord. 2006;20:760-77. 9. Langley AK, Falk A, Peris T, Wiley JF, Kendall PC, Ginsburg G, et al. The child anxiety impact scale: examining parent- and child-reported impairment in child anxiety disorders. J Clin Child Adolesc Psychol. 2014;43:579-91. 10. Schniering CA, Hudson JL, Rapee RM. Issues in the diagnosis and assessment of anxiety disorders in children and adolescents. Clin Psychol Rev. 2000;20:453-78. 11. Spence SH. A measure of anxiety symptoms among children. Behav Res Ther. 1998;36:545-66. 12. March JS, Parker JDA, Sullivan K, Stallings P, Conners K. The Multidimensional Anxiety Scale for Children (MASC): factor, structure, reliability and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-65. 13. Spielberger CD, Gorsuch RL, Lushene RE. Test manual for the State Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press; 1970. 14. American Psychiatry Association. Diagnostic and statistical manual of mental disorder. 5th ed. Bangkok: iGroup Press; 2013. 15. Mattis SG, Ollendick TH. Nonclinical panic attacks in late adolescence: prevalence and associated psychopathology. J Anxiety Disord. 2002;16:321-67. 16. Leyfer O, Gallo K, Cooper-Vince C, Pincus D. Patterns and predictors of comorbidity of DSM-IV anxiety disorders in a clinical sample of children and adolescents. J Anxiety Disord. 2013;27:306-11. 17. Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results fom the national comorbidity survey replication-adolescent supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49:980-9. 18. Arab A, Keshky ME, Hadwin JA. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in a non-clinical sample of children and adolescent in Saudi Arabia. Child Psychiatry Hum Dev. 2016;47:554-62. 19. Muris P, Merckelbach H, van Brakel A, Mayer B. The Revised Version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-R): further evidence for its reliability and validity. Anxiety Stress Coping. 1999;12:411-25. 20. Wren FJ, Bridge JA, Birmaher B. Screening for childhood anxiety symptoms in promary care: integrating child and parent reports. J Am Acad Child Adolesc Psychiatry. 2004;43:1364-71. 21. Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999;38:1230-6. 22. Jastrowski Mano KE, Evans JR, Tran ST, Anderson Khan K, Weisman SJ, Hainsworth KR. The psychometric properties of the

Validation of the SCARED - Ang

Screen for Child Anxiety Related Emotional Disorders in pediatric chronic pain. J Pediatr Psychol. 2012;37:999-1011. 23. Hale W, Crocetti E, Raaijmakers QW, Meeus WJ. A meta-analysis of the cross-cultural psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED). J Child Psychol Psychiatry. 2011;52:80-90. 24. Boyd RC, Ginsburg GS, Lambert SF, Cooley MR, Campbell KDM. Screen for Child Anxiety Related Emotional Disorders (SCARED): psychometric properties in an African American Parochial high school sample. J Am Acad Child Adolesc Psychiatry. 2003;42:118896. 25. Haley T, Puskar K, Terhorst L. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders in a rurual high school population. J Child Adolesc Psychiatr Nurs, 2011;24:23-32. 26. Monga S, Birmaher B, Chiappetta L, Brent D, Kaufman J, Bridge J, et al. Screen for Child Anxiety-Related Emotional Disorders (SCARED): convergent and divergent validity. Depress Anxiety. 2000;12:85-91. 27. Ang CS, Tan JP, Fam SY. Psychometric properties of training parenting style scale in a Malaysian sample: factor analysis, internal consistency, and measurement invariance. J Child Fam Stud. 2016;25:1505-14. 28. Goodman R. The Strength and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry. 1997;38:581-6. 29. Goodman R. Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry. 2001;40:1337-45.

30. Cohen J. A power primer. Psychol Bull. 1992;112:155-9. 31. Hair JF, Black WC, Babin BJ, Anderson RE. Multivariate data analysis. 7th ed. New Jersey: Prentice Hall; 2010. 32. Tabachnick BG, Fidell LS. Using multivariate statistics. 3rd ed. New York: Harper Collins; 1996. 33. Ollendick TH, Yang B, King NJ, Dong Q, Akande A. Fears in American, Australian, Chinese, and Nigerian children and adolescents: a cross-cultural study. J Child Psychol Psychiatry. 1996;37:213-20. 34. Kashani JH, Orvaschel H. Anxiety disorders in mid-adolescence: a community sample. Am J Psychiatry. 1988;145:960-4. 35. Penn J, Schoevers RA, Beekman AT, Dekker J. The current status of urban-rural differences in psychiatric disorders. Acta Psychiatr Scand. 2010;121:84-93. 36. Desousa DA, Salum GA, Isolan LR, Manfro GG. Sensitivity and specificity of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a community-based study. Child Psychiatry Hum Dev. 2013;44:391-3.

Correspondence: Ang Chin-Siang TMC Academy 250 Middle Road 577180 - Singapore E-mail: austin_ang119@hotmail.com

Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 15

Trends

Original Article

in Psychiatry and Psychotherapy

Strategies for eating and body change among Brazilian women and men Wanderson R. da Silva,1

João Marôco,2

Juliana A. D. B. Campos1

Abstract Objectives: Our study was conducted to adapt the Body Image and Body Change Inventory (BIBCI) for Portuguese; to evaluate the BIBCI’s psychometric properties in samples of university students; to calculate the prevalence of strategies for eating and body change among students; and to evaluate the impact of demographic, social, and anthropometric characteristics on the BIBCI subscales. Methods: 798 students (women = 63%) answered the Portuguese translation of the BIBCI and answered a demographic questionnaire. All analyses were performed separately for women and men. The BIBCI’s psychometric properties were estimated using confirmatory factor analysis. Mean scores were calculated for each BIBCI subscale. A multivariate regression model was tested to evaluate the impact of demographic, social, and anthropometric characteristics on mean BIBCI subscale scores. Results: The psychometric properties of the BIBCI were adequate in the samples analyzed. The BIBCI subscales scores did not differ according to sex. According to the cut-off points adopted, most of the students were classified in the very low category of the BIBCI subscales. For women, characteristics such as self-reported eating assessment, economic class, physical activity level, and work were significant. For men, only physical activity level was significant. Conclusion: The Portuguese translation of the BIBCI was presented and its psychometric properties were found to be adequate in the samples analyzed. The models identified significant characteristics that can be used in intervention protocols for preventing inappropriate behaviors in relation to body image and eating. Keywords: Eating, body image, women, men.

Introduction Physical fitness has become one of the main reasons people effect changes in eating habits and physical activities. These changes are generally made for aesthetic reasons, without concern for physical and mental health. Researchers have sought to understand individuals’ relationships with their bodies in order to develop health promotion actions.1,2 To investigate these relationships, it is relevant to identify the mental

representation that individuals construct in relation to their bodies, which has been conceptualized by Cash and Smolak3 as body image. Body image is a multidimensional concept that has been widely investigated using different measures. Most studies investigate the perceptual and attitudinal dimensions of body image.3 Satisfaction with and the importance of body image and eating and body change strategies are inherent aspects of the attitudinal dimension of body image. These refer to individuals’

1 Departamento de Alimentos e Nutrição, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista (UNESP), Araraquara, SP, Brazil. Center for Research (WJCR), Instituto Universitário Ciências Psicológicas, Sociais e da Vida (ISPA), Lisbon, Portugal.

William James

Submitted Feb 10 2019, accepted for publication May 09 2019. Suggested citation: da Silva WR, Marôco J, Campos JADB. Strategies for eating and body change among Brazilian women and men. Trends Psychiatry Psychother. 2020;42(1):16-29. http://dx.doi.org/10.1590/2237-6089-2019-0010 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 16-29

Strategies for eating and body change - da Silva et al.

feelings and behaviors in relation to the desire to change their bodies. One of the instruments cited in the literature for evaluation of these aspects is the Body Image and Body Change Inventory (BIBCI). This instrument was developed in two parts, the first (BI) referring to body image4 and the second (BCI), to eating and body change.5 McCabe and Ricciardelli5 presented the composition of both parts (BI and BCI) with different subscales for each. The BIBCI was originally developed in the English language to evaluate satisfaction with body image, importance of body image and eating and body change strategies in adolescents. The items were developed for application in girls and boys, and the subscales have been widely used in international contexts,6-11 but not in Portuguese-speaking countries.12,13 In Brazil, Conti et al.12 has presented a Portuguese version of the BIBCI, but only the second part of the instrument (BCI) was translated. Although the BIBCI was developed using a sample of adolescents, the items do not appear to be exclusive to this population. Another point that merits highlighting is related to evaluation of the psychometric properties of BIBCI, which is rarely reported in the literature, and the related lack of consensus among researchers on the analytical strategy for estimating BIBCI subscale scores (i.e., some studies use means, and others use sums). The authors of the BIBCI did not propose cut-off points for classification of individuals, which has impeded use of the instrument in clinical settings. Therefore, the present study highlights the relevance of evaluating the validity of the BIBCI and of developing and presenting methodological strategies for its use in different contexts. Meanwhile, researches have encouraged identification of characteristics that can be included in intervention protocols, such as demographic, social, and anthropometric data. Such information can be important in preventative and follow-up protocols aimed at ensuring the best clinical management of individuals. In previous studies,11,14-17 these characteristics have been reported to impact individuals’ satisfaction with their body image and its importance to them and also their eating and body change strategies. Thus, these relationships merit investigation, especially in vulnerable populations such as adolescents and university students. It is against this background that the present study was conducted to achieve the following aims: 1. To translate and culturally adapt the BIBCI for use in Portuguese. 2. To evaluate the psychometric properties of the BIBCI when administered to a sample of university students of both sexes.

To propose an analytical strategy for calculating the scores of each BIBCI subscale and to establish cut-off points for defining the degree of satisfaction with and importance of body image and strategies for eating and body change. To calculate the prevalence of the aspects assessed by each BIBCI subscale among students. To verify the impact of demographic, social, and anthropometric characteristics on BIBCI subscales.

Method Participants This study adopted a cross-sectional design. A recommendation made by Hair Jr. et al.18 that at least five respondents should be recruited per instrument item was followed when calculating the minimum sample size. Since the BIBCI comprises 53 items, the minimum sample size was estimated at 265 participants. This estimate was respected for each sex, because analyses were performed separately for women and men. The sample was composed of university students enrolled in undergraduate courses in the pharmaceutical sciences, sciences, and languages faculties at the Universidade Estadual Paulista (UNESP, Araraquara, SP, Brazil). The inclusion criteria adopted were as follows: aged 18 years or older, not pregnant, and no visual impairment. A total of 798 students participated (women = 63.0%, men = 37.0%). The mean age was 21.2 (standard deviation [SD] = 2.8) years for women and 21.3 (SD = 3.3) years for men. The mean body mass index (BMI) was 22.9 (SD = 4.5) kg/m2 for women and 24.0 (SD = 4.4) kg/m2 for men. Information on participants was collected, such as age, sex, course title and year, work, and internships. Further, participants also answered a self-report eating assessment item (bad, regular, normal, good, or excellent) and a question on use of medication or dietary supplements to change the body (never, once in a lifetime, sometimes, or frequently) and provided selfreported body weight and height. the Brazilian Criteria for social class distribution were used to estimated participants’ economic class.19 Participants’ BMI was calculated and their anthropometric weight status was obtained.20 The short form of the International Physical Activity Questionnaire (IPAQ) was used to estimate participants’ physical activity levels. The BIBCI was used to estimate satisfaction with body image, importance of body image, and eating and body change strategies.8 Trends Psychiatry Psychother. 2020;42(1) – 17

Strategies for eating and body change - da Silva et al.

Measure The BIBCI was initially developed in an Australian context from existing scales containing items exclusively for women. For this reason, interviews were conducted with men to develop new items. The resulting BIBCI items were formulated for both women and men, considering theoretical aspects (i.e., body image, eating, and body change strategies). There are a number of different combinations of BIBCI subscales in the literature. The present study used a model composed of 53 items with a five-point Likert type response scale grouped into seven subscales (body image satisfaction, body image importance, body change strategies to decrease body size, body change strategies to increase body size, strategies to increase muscle tone, binge eating, and intake of food supplements). The material, including this model, was acquired from a commercial site (http://store.ets.org) and is described in McCabe and Ricciardelli.8 It is important to note that the authors of the BIBCI gave permission for their instrument to be used in the present study. With regard to translation of BIBCI into Portuguese, Conti et al.12 presented a version entitled Questionário de Mudança Corporal. That version does not include the subscales covering body image satisfaction or body image importance. Moreover, the theoretical content of most of the items differs from that observed in the version used in the present study. Therefore, a cross-cultural adaptation of the English version of the BIBCI (i.e., including all seven subscales) to Portuguese was performed. This study prepared a Brazilian Portuguese translation of the BIBCI, taking care to verify idiomatic, semantic, conceptual, and cultural equivalence.21,22 Idiomatic and semantic equivalence were ensured via translation and back-translation. The forward translation (from English to Portuguese) was performed by three native Brazilian Portuguese speakers proficient in English. The backtranslation (from Portuguese to English) was conducted by three native English speakers proficient in Portuguese. Next, a neutral judge (a bilingual English-Portuguese translator) evaluated the agreement of words and expressions between the back-translations and original version of BIBCI. The back-translation most faithful to the original was chosen as the BIBCI Portuguese version to be used in the subsequent stages. The conceptual and cultural equivalence of the Portuguese version was evaluated by two experts in body image and eating and one Portuguese language expert, to explore whether BIBCI items and subscales were appropriate for Brazilian settings. The experts in body image and eating suggested changes to improve comprehension of some items. In items 21 and 26, the expression “lose weight” was changed to “decrease 18 – Trends Psychiatry Psychother. 2020;42(1)

body size”, to make it fit the body change strategies to decrease body size subscale. In items 49 and 52, on the food supplement intake subscale, the word “Sustagen” was changed to “nutritional supplements” to improve cultural understanding, because Sustagen is a brand. In the satisfaction with body image and importance of body image subscales, the description “leg (between the knee and the ankle)” was added to items 9 and 19, to clearly specify the part of the body being considered. The Portuguese language expert suggested using the spelling reform rules implemented in Portuguese-speaking countries in 2009. Therefore, two synonymous words were used in items 4 and 14 (hip [quadril/anca]), 6 and 16 (breast [peitoral/seios]), and 7 and 17 (abdominal [região abdominal/estômago]) to facilitate understanding in other Portuguese-speaking countries. It should be clarified that these changes did not compromise the original content of the items. After modification, the Portuguese version of the BIBCI was pre-tested in a pilot study with 30 students. These participants requested inclusion of a reference period to guide answers to the questions. The authors of the BIBCI did not specify any such period, but we believe it is important to include this information. Thus, we investigated the literature and identified “the last 12 months” as an appropriate reference period. After this reference period had been added, participants still reported difficulty in completing items that only differed in one part of the question (e.g., How often do you CHANGE your eating to increase your body size?; How often do you THINK ABOUT CHANGING your eating to increase your body size?; and How often do you WORRY ABOUT CHANGING your eating to increase your body size?). We therefore used uppercase letters and underlining to highlight the change strategy element of interest in each item. The modified Portuguese version of the BIBCI was tested once more with 30 students, who did not report any difficulty in completing the items. Table 1 presents both the English and Portuguese versions of BIBCI. Procedures The Portuguese BIBCI and a questionnaire on participants’ characteristics were completed as paperand-pencil surveys by the participants during class hours. The instructor responsible for class at the time of data collection agreed to allocate 15 minutes for the students to participate. Students received information about the study, such as the aims and purpose of the research and those who agreed to take part signed informed consent forms. Ethics approval was granted by the Human Research Ethics Committee at the Faculdade de Ciências Farmacêuticas, São Paulo, Brazil (C.A.A.E.: 46774015.5.0000.5426).

Strategies for eating and body change - da Silva et al.

Table 1 - English and Portuguese versions of the Body Image and Body Change Inventory (BIBCI) English version

Portuguese version

Body Image and Body Change Inventory

Inventário de Imagem e Mudança Corporal

Instructions:

Instruções:

Your answers are completely anonymous. No-one will know what answers you provide. There are no right or wrong answers. We just want to know how you feel and what you do. It is important not to take too long to answer each question. Simply circle the response that best applies to you. Extremely satisfied means very happy, extremely dissatisfied means very unhappy.

Suas respostas são completamente anônimas. Ninguém saberá qual resposta você forneceu. Não existem respostas certas ou erradas. Apenas queremos saber como você se sente e o que costuma fazer. É importante não demorar muito para responder cada questão. Simplesmente circule a resposta que melhor se adequa a você. Extremamente satisfeito significa muito feliz, extremamente insatisfeito significa muito infeliz. Responda as questões/itens abaixo de acordo com os ÚLTIMOS 12 MESES.

Body image satisfaction

Satisfação com a imagem corporal

Response options: 1 = Extremely dissatisfied, 2 = Fairly dissatisfied, 3 = Neutral, 4 = Fairly satisfied, 5 = Extremely satisfied.

Opções de respostas: 1 = Extremamente insatisfeito, 2 = Razoavelmente insatisfeito, 3 = Neutro, 4 = Razoavelmente satisfeito, 5 = Extremamente satisfeito.

1. How satisfied are you with your weight?

1. Quão satisfeito você está com o seu peso?

2. How satisfied are you with your body shape?

2. Quão satisfeito você está com a forma do seu corpo?

3. How satisfied are you with your muscle?

3. Quão satisfeito você está com os seus músculos?

The remainder of the questions in this section ask about your level of satisfaction with particular body parts.

O restante das questões nesta seção são sobre quão satisfeito você está com diferentes partes do seu corpo.

4. Hips

4. Quadril/Anca

5. Thighs

5. Coxas

6. Chest

6. Peitoral/Seios

7. Abdominal region/stomach

7. Região abdominal/estômago

8. Shoulders

8. Ombros

9. Legs

9. Pernas (região entre joelho e o tornozelo)

10. Arms

10. Braços

Body image importance

Importância com a imagem corporal

Response options: 1 = Extremely important, 2 = Fairly important, 3 = Neutral, 4 = Fairly unimportant, 5 = Not important at all.

Opções de respostas: 1 = Sem importância alguma, 2 = Razoavelmente sem importância, 3 = Neutro, 4 = Razoavelmente importante, 5 = Extremamente importante.

11. How important to you is what you weigh compared to other things in your life?

11. Quão importante é para você o seu peso, comparado com outras coisas da sua vida?

12. How important is the shape of your body compared to other things in your life?

12. Quão importante é para você a forma do seu corpo, comparado com outras coisas da sua vida?

13. How important is the size and strength of your muscles compared to other things in your life?

13. Quão importante é o tamanho e a força dos seus músculos, comparado com outras coisas da sua vida?

The remainder of the questions in this section ask about the importance of the appearance of different parts of your body.

O restante das questões nesta seção são sobre quão importante é para você a aparência de diferentes partes do seu corpo.

14. Hips

14. Quadril/Anca

15. Thighs

15. Coxas

16. Chest

16. Peitoral/Seios

17. Abdominal region/stomach

17. Região abdominal/estômago

18. Shoulders

18. Ombros

19. Legs

19. Pernas (região entre joelho e o tornozelo)

20. Arms

20. Braços

Strategies to decrease body size

Estratégias para reduzir o tamanho do corpo

Response options: 1 = Never, 2 = Sometimes, 3 = Frequently, 4 = Almost always, 5=Always.

Opções de respostas: 1 = Nunca, 2 = Algumas vezes, 3 = Frequentemente, 4 = Quase sempre, 5 = Sempre.

21. How often do you feel like changing the types of foods you eat so that you can lose weight?

21. Com que frequência você TEM VONTADE DE ALTERAR os tipos de alimentos que consome para diminuir o tamanho do seu corpo?

22. How often do you change your eating to decrease your body size?

22. Com que frequência você ALTERA sua alimentação para diminuir o tamanho do seu corpo?

23. How often do you change your levels of exercise to decrease your body size?

23. Com que frequência você ALTERA seus níveis de exercício para diminuir o tamanho do seu corpo?

24. How often do you think about changing your levels of exercise to decrease your body size?

24. Com que frequência você PENSA EM ALTERAR seus níveis de exercício para diminuir o tamanho do seu corpo? Continued on next page

Trends Psychiatry Psychother. 2020;42(1) – 19

Strategies for eating and body change - da Silva et al.

Table 1 (cont.)

English version

Portuguese version

Body Image and Body Change Inventory

Inventário de Imagem e Mudança Corporal

25. How often do you worry about changing your eating to decrease your body size?

25. Com que frequência você SE PREOCUPA EM ALTERAR sua alimentação para diminuir o tamanho do seu corpo?

26. How often do you think about exercising to lose weight?

26. Com que frequência você PENSA EM se exercitar para diminuir o tamanho do seu corpo?

Strategies to increase body size

Estratégias para aumentar o tamanho do corpo

27. How often do you change your eating to increase your body size?

27. Com que frequência você ALTERA sua alimentação para aumentar o tamanho do seu corpo?

28. How often do you change your levels of exercise to increase your body size?

28. Com que frequência você ALTERA seus níveis de exercício para aumentar o tamanho do seu corpo?

29. How often do you think about changing your eating to increase your body size?

29. Com que frequência você PENSA EM ALTERAR sua alimentação para aumentar o tamanho do seu corpo?

30. How often do you think about changing your levels of exercise to increase your body size?

30. Com que frequência você PENSA EM ALTERAR seus níveis de exercício para aumentar o tamanho do seu corpo?

31. How often do you worry about changing your eating to increase your body size?

31. Com que frequência você SE PREOCUPA EM ALTERAR sua alimentação para aumentar o tamanho do seu corpo?

32. How often do you worry about changing your levels of exercise to increase your body size?

32. Com que frequência você SE PREOCUPA EM ALTERAR seus níveis de exercício para aumentar o tamanho do seu corpo?

Strategies to increase muscle tone

Estratégias para aumentar o tônus muscular

33. How often do you change your levels of exercise to increase the size of your muscles?

33. Com que frequência você ALTERA seus níveis de exercício para aumentar o tamanho dos seus músculos?

34. How often do you change your food supplements to increase the size of your muscles?

34. Com que frequência você ALTERA seus suplementos alimentares para aumentar o tamanho dos seus músculos?

35. How often do you think about changing your eating to increase the size of your muscles?

35. Com que frequência você PENSA EM ALTERAR sua alimentação para aumentar o tamanho dos seus músculos?

36. How often do you think about changing your levels of exercise to increase the size of your muscles?

36. Com que frequência você PENSA EM ALTERAR os níveis de exercício para aumentar o tamanho dos seus músculos?

37. How often do you worry about changing your eating to increase the size of your muscles?

37. Com que frequência você SE PREOCUPA EM ALTERAR sua alimentação para aumentar o tamanho dos seus músculos?

38. How often do you worry about changing your levels of exercise to increase the size of your muscles?

38. Com que frequência você SE PREOCUPA EM ALTERAR seus níveis de exercício para aumentar o tamanho dos seus músculos?

Binge eating

Compulsão alimentar

39. How often do you quickly eat a large amount of food?

39. Com que frequência você COME rapidamente uma grande quantidade de alimentos?

40. How often do you eat to the point of stuffing yourself?

40. Com que frequência você COME até sentir-se completamente cheio?

41. How often do you eat a lot of food when you’re not even hungry?

41. Com que frequência você COME uma grande quantidade de alimentos mesmo sem estar com fome?

42. How often do you experience urges to eat and eat?

42. Com que frequência você TEM UMA VONTADE incontrolável de comer?

43. How often do you find that all you can think about is food?

43. Com que frequência você ACHA QUE só consegue pensar em comer?

44. How often do you think about eating a large amount of food?

44. Com que frequência você PENSA EM comer uma grande quantidade de alimentos?

45. How often do you think about food when you’re not even hungry?

45. Com que frequência você PENSA EM comida quando você não está com fome?

46. How often do you feel like stuffing yourself with food?

46. Com que frequência você TEM VONTADE de comer até sentir-se completamente cheio?

47. How often do you eat a lot when feeling anxious?

47. Com que frequência você COME muito quando está ansioso?

Food supplements

Suplementos alimentares

48. How often do you take vitamins to change your body weight?

48. Com que frequência você TOMA vitaminas para alterar o seu peso?

49. How often do you take food supplements (for example, diet pills, sustagens) to change your body weight?

49. Com que frequência você TOMA suplementos alimentares (por exemplo, comprimidos para dietas, suplementos nutricionais) para alterar o seu peso. Continued on next page

20 – Trends Psychiatry Psychother. 2020;42(1)

Strategies for eating and body change - da Silva et al.

Table 1 (cont.)

English version

Portuguese version

Body Image and Body Change Inventory

Inventário de Imagem e Mudança Corporal

50. If you could take steroids without them causing any harm to you, how frequently would you think about taking them?

50. Se você pudesse TOMAR esteroides sem que estes lhe causassem danos, com que frequência você pensaria em tomá-los?

51. How often do you think about taking vitamins?

51. Com que frequência você PENSA EM TOMAR vitaminas?

52. How often do you feel like taking food supplements? (for example, diet pills, sustagen)

52. Com que frequência você SENTE VONTADE DE TOMAR suplementos alimentares (por exemplo, comprimidos para dietas, suplementos nutricionais)?

53. How often do you feel like taking steroids?

53. Com que frequência você TEM VONTADE DE TOMAR esteroides?

Data analyses The BIBCI factorial model composed of 53 items and 7 correlated subscales was evaluated. The analyses were performed separately for each sex, because the BIBCI assesses distinct aspects of body image that can be perceived differently by women and men. Construct validity was examined in terms of factorial, convergent, and discriminant validity. Factorial validity was assessed by confirmatory factor analysis using the weighted least squares estimator with mean and variance adjusted. We used the following fit indices to evaluate the model: chi-square by degrees of freedom ratio (χ2/df), root mean square error of approximation (RMSEA) with 90% confidence interval (CI), TuckerLewis index (TLI), and comparative fit index (CFI).23 Values were considered acceptable at the following cutoffs: χ2/df ≤ 3.0, RMSEA ≤ 0.08, TLI ≥ 0.90, and CFI ≥ 0.90.24 The factorial weight (λ) of each item of BIBCI was assessed; values ≥ 0.40 were considered adequate. Analyses were carried out using MPLUS (v.7.2). Average variance extracted (AVE) was calculated to evaluate convergent validity.25 The coefficient of determination (r2) was calculated to evaluate discriminant validity.25 For each pair of correlated subscales, AVE ≥ 0.50 and r2 ≤ AVE indicated adequate convergent and discriminant validity, respectively.24,25 Composite reliability (CR), the ordinal alpha coefficient (α), and the omega coefficient (ω) were calculated to evaluate the reliability of BIBCI subscales. Values were considered adequate for CR, α, and ω at ≥ 0.70.24,26,27 Previous studies were consulted with regard to estimation of the final scores of each BIBCI subscale. Most of these studies calculated scores using sums, which can be problematic (for example, if items are excluded, the classification ranges will be prejudiced). In this scenario, the mean was used to calculate BIBCI scores for women and men. The mean scores of the subscales were compared between men and women using analysis of variance (ANOVA) and a 5% level of significance. We used response scale percentiles (P25,

P50, and P75) for classification of individuals according to their scores on the BIBCI subscales. The classification used for each BIBCI subscale was as follows: 1.0├┤2.0 (P ≤ 25) = very low; 2.0┤3.0 (P25┤P50) = low; 3.0┤4.0 (P50┤75) = moderate; and 4.0┤5.0 (P > 75) = high. The prevalence of individuals classified in each of categories described above was estimated for women and men with a 95%CI for each of the BIBCI subscales. The final analytical stage consisted of evaluating the impact of characteristics of interest (work, selfreport eating assessment, BMI, physical activity level, and economic class) on the mean scores of BIBCI subscales. This was performed by constructing a multivariate multiple regression model using structural equations modeling. The model was tested for women and men separately. Recommendations published by Marôco24 were implemented to evaluate the model, using the maximum likelihood estimator. Next, the significance of hypothetical causal paths (β) was evaluated using a 5% level of significance, calculated by the z-test at the critical ratios. Models were refined using the stepwise method to identify significant characteristics. These analyses were conducted using MPLUS (v.7.2).

Results Table 2 presents the participants’ characteristics in detail. Most of the participants were in their first year of undergraduate study, were not working or in internships, had never taken medication nor used dietary supplements to achieve body change, were classified as healthy weight according to BMI, had a high level of physical activity, and belonged to category B economic class. Most of the women were on the Education course and self-reported their eating as regular or normal. Most men were on the Economics course and self-reported their eating as normal or good. Trends Psychiatry Psychother. 2020;42(1) – 21

Strategies for eating and body change - da Silva et al.

Table 2 - Characterization of the sample of Brazilian university students Sample, n (%) Characteristic Course Pharmacy Business Administration Language and Literature Education Economics Social Sciences Bioprocess Engineering

Women

Men

125 (25.1) 82 (16.5) 3 (0.6) 139 (27.9) 62 (12.4) 47 (9.4) 40 (8.1)

35 (11.9) 84 (28.5) 2 (0.7) 3 (1.0) 99 (33.6) 53 (18.0) 19 (6.3)

Course year First Second Third Fourth â&#x2030;Ľ Fifth

164 (32.8) 112 (22.4) 63 (12.6) 131 (26.2) 30 (6.0)

121 (41.0) 62 (21.0) 53 (18.0) 35 (11.9) 24 (8.1)

Work No Yes

396 (79.2) 104 (20.8)

239 (81.6) 54 (18.4)

Internship No Yes

356 (71.6) 141 (28.4)

247 (84.6) 45 (15.4)

Use of medication to achieve body change Never Once in a lifetime Sometimes Frequently

413 (83.6) 40 (8.1) 36 (7.3) 5 (1.0)

252 (86.9) 14 (4.8) 21 (7.2) 3 (1.1)

Use of dietary supplements to achieve body change Never Once in a lifetime Sometimes Frequently

383 39 47 22

(78.0) (7.9) (9.6) (4.5)

181 (62.2) 37 (12.7) 53 (18.2) 20 (6.9)

Self-report eating assessment Bad Regular Normal Good Excellent

45 168 161 102 10

(9.3) (34.6) (33.1) (21.0) (2.1)

41 (14.0) 69 (23.6) 82 (28.1) 86 (29.5) 14 (4.8)

Anthropometric weight status Underweight Healthy weight Overweight Obesity

25 (5.1) 351 (70.6) 87 (17.5) 34 (6.8)

13 (4.5) 184 (63.4) 68 (23.4) 25 (8.7)

Physical activity level Low Moderate High

56 (12.0) 158 (34.0) 251 (54.0)

20 (7.0) 72 (25.4) 192 (67.6)

Economic class (by average household income) D and E ($ 188.89) C ($ 451.15 / $ 791.02) B ($ 1,430.49 / $ 2,770.33) A ($ 6,226.69)

1 (0.2) 109 (22.5) 246 (50.7) 129 (26.6)

1 (0.4) 38 (13.5) 151 (53.7) 91 (32.4)

The economic class was obtained using Brazilian Criteria. Values in Brazilian Reais (BRL) were converted into American dollars (at the exchange rate prevailing in Nov 2018).

22 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

Strategies for eating and body change - da Silva et al.

The factorial validity of the BIBCI was adequate for both women (CFA: χ2/df = 2.71, RMSEA = 0.06 [90%CI: 0.05-0.06], CFI = 0.95, TLI = 0.95, λ = 0.430.98) and men (CFA: χ2/df = 2.29, RMSEA = 0.07 [90%CI: 0.06-0.07], CFI = 0.96, TLI = 0.95, λ = 0.600.97). Both convergent and discriminant validity were adequate for both samples (women: AVE = 0.53-0.85, r2 = 0.00-0.38; men: AVE = 0.55-0.88, r2 = 0.00-0.67). With regard to reliability, all CR and α values were adequate for both samples (women: CR = 0.92-0.97, α = 0.84-0.96; men: CR = 0.92-0.98, α = 0.91-0.96). An estimation discrepancy for the omega coefficient was only observed for women, for the body change strategies to decrease body size subscale (women: ω = 0.65-0.94, men: ω = 0.90-0.96). Table 3 shows correlations among the BIBCI subscales for each sex. Most correlations were significant except for two pairs in women (strategies to increase body size vs. binge eating, strategies to increase muscle tone vs. binge eating), one pair in men (body image satisfaction vs. body image importance), and one pair in both samples (body image satisfaction vs. strategies to increase body size). The mean scores for the following subscales did not differ between women and men: body image satisfaction (women = 2.97 [SD] = 0.84; men = 2.95 [SD] 0.85, p = 0.846), body image importance (women = 3.19 [SD] 0.77; men = 3.25 [SD] 0.74, p = 0.230), body change strategies to decrease body size (women = 2.31 [SD] 1.10; men = 2.33 [SD] 1.05, p = 0.837), body change

strategies to increase body size (women = 1.79 [SD] 0.96; men = 1.75 [SD] 0.97, p = 0.679), body change strategies to increase muscle tone (women = 1.80 [SD] 0.91; men = 1.72 [SD] 0.83, p = 0.251), binge eating (women = 2.47 [SD] 0.87, men = 2.45 [SD] 0.93, p = 0.682), and food supplements use for body change (women = 1.39 [SD] 0.66; men = 1.37 [SD] 0.60, p = 0.752). Table 4 presents the prevalence of participants classified in each category according to their mean scores on each BIBCI subscale. The majority of women and men were classified as follows: low to moderate for body image satisfaction, moderate for body image importance, very low for body change strategies to decrease body size, very low for body change strategies to increase body size, very low for body change strategies to increase muscle tone, very low to low for binge eating, and very low for use of dietary supplements for body change. The only difference identified between women and men was in the prevalence rates for the body image importance subscale. Table 5 presents the estimates of the regression models. Significant characteristics for women were selfreport eating assessment, economic class, physical activity level, and work (p < 0.05). The results showed that women with better self-report eating assessment, greater body image importance, and in a higher economic class tended to have a higher category for strategies to reduce body size and increase muscle

Table 3 - Correlation matrix for the subscales of the Body Image and Body Change Inventory (BIBCI), in Brazilian university students A

A. Body image satisfaction

1.00

-0.18†

B. Body image importance

1.00

-0.56†

0.05

-0.12†

-0.35†

-0.25†

0.33†

0.11*

0.32†

0.09*

C. Body change strategies to decrease body size

0.27†

1.00

-0.11*

0.28†

0.23†

D. Body change strategies to increase body size

0.19†

1.00

0.62†

0.01

0.45†

E. Strategies to increase muscle tone

1.00

0.02

0.51†

F. Binge eating

1.00

0.14†

G. Intake of food supplements

1.00

Women

Men A. Body image satisfaction

1.00

-0.03

-0.32†

-0.10

-0.17†

-0.26†

-0.16†

B. Body image importance

1.00

0.39†

0.43†

0.48†

0.22†

0.51†

C. Body change strategies to decrease body size

1.00

0.31†

0.37†

0.33†

0.34†

D. Body change strategies to increase body size

1.00

0.82

0.17

0.64†

E. Strategies to increase muscle tone

1.00

0.12*

0.77†

F. Binge eating

1.00

0.13*

G. Intake of food supplements

1.00

* p < 0.05;

†

p < 0.01.

Trends Psychiatry Psychother. 2020;42(1) – 23

Strategies for eating and body change - da Silva et al.

tone. Women with a higher physical activity level had higher categories for strategies to decrease body size and for binge eating behavior. Moreover, women with a lower physical activity level had higher categories for strategies for food supplements use, for increasing body size, and for increasing muscle tone. Women who did not work presented a higher category for strategies for increasing muscle tone, whereas women who did

work presented a higher category for binge eating behavior. For men, only physical activity level was significant, and male students with a higher physical activity level were more satisfied with their body image and had a higher category for strategies for decreasing body size. Men with a lower physical activity level had higher categories for strategies for increasing body size and muscle tone.

Table 4 - Classification of university students according to their mean scores on subscales of the Body Image and Body Change Inventory (BIBCI) Women Subscale/classification

Men

n (%)

95%CI

n (%)

95%CI

Body image satisfaction Very low

70 (13.9)

11.1-16.9

39 (13.2)

9.5-16.9

Low

208 (41.4)

37.0-45.3

132 (44.7)

39.0-50.5

Moderate

173 (34.4)

30.4-38.6

93 (31.5)

26.1-36.9

52 (10.3)

7.8-13.1

31 (10.5)

7.5-13.9

High Body image importance Very low

43 (8.5)

6.4-11.1

26 (8.8)

5.8-12.2

Low

159 (31.6)

27.4-35.8

68 (23.1)

18.3-27.5

Moderate

249 (49.5)

45.1-53.9

178 (60.3)

55.3-66.1

52 (10.3)

7.8-13.1

23 (7.8)

4.4-11.2

High Body change strategies to decrease body size Very low

238 (47.3)

42.7-51.5

137 (46.4)

40.7-51.9

Low

146 (29.0)

25.2-33.2

81 (27.5)

22.0-32.5

79 (15.7)

12.7-19.1

60 (20.3)

16.3-25.4

40 (8.0)

5.8-10.5

17 (5.8)

3.1-8.5

370 (73.6)

69.4-77.1

223 (75.6)

70.8-80.7

83 (16.5)

13.1-19.7

41 (13.9)

10.2-18.0

Moderate

35 (7.0)

4.8-9.1

19 (6.4)

3.7-9.2

High

15 (3.0)

1.6-4.6

12 (4.1)

2.0-6.4

378 (75.1)

71.4-78.7

227 (72.2)

72.2-81.7

76 (15.1)

12.1-18.5

50 (12.9)

12.9-21.4

Moderate

34 (6.8)

4.6-8.9

12 (2.0)

2.0-6.4

High

15 (3.0)

1.6-4.6

6 (0.7)

0.7-3.7

Moderate High Body change strategies to increase body size Very low Low

Strategies to increase muscle tone Very low Low

Binge eating Very low

186 (37.0)

32.8-41.2

126 (42.7)

37.3-48.1

Low

204 (40.6)

36.0-44.9

104 (35.3)

30.2-41.0

80 (15.9)

12.7-19.3

43 (14.6)

10.5-19.0

33 (6.6)

4.4-8.7

22 (7.5)

4.7-10.5

450 (89.5)

86.9-92.0

265 (89.8)

86.4-93.2

37 (7.4)

5.0-9.7

21 (7.1)

4.4-9.8

Moderate

9 (1.8)

0.8-3.0

8 (2.7)

1.0-4.4

High

7 (1.4)

0.4-2.4

1 (0.3)

0.0-1.0

Moderate High Intake of food supplements Very low Low

95%CI = 95% confidence interval.

24 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

Strategies for eating and body change - da Silva et al.

Table 5 - Multivariate multiple regression models tested in Brazilian university students Complete Independent/dependent variable (BIBCI subscales)

Refined p

Women Work Body image satisfaction

0.001

0.050

0.980

Body image importance

-0.022

0.049

0.651

Body change strategies to decrease body size

0.039

0.049

0.422

Body change strategies to increase body size

-0.057

0.048

0.229

Strategies to increase muscle tone

-0.133

0.047

0.005*

-0.188

0.073

0.010*

Binge eating

0.109

0.048

0.023*

0.210

0.095

0.027*

Intake of food supplements

-0.065

0.049

0.182

Self-reported eating assessment Body image satisfaction

-0.029

0.051

0.563

Body image importance

0.153

0.049

0.002*

0.133

0.035

0.001*

Body change strategies to decrease body size

0.031

0.050

0.536

Body change strategies to increase body size

-0.050

0.048

0.303

Strategies to increase muscle tone

0.016

0.048

0.737

Binge eating

0.000

0.049

0.993

Intake of food supplements

-0.024

0.050

0.624

Body mass index Body image satisfaction

0.020

0.050

0.687

Body image importance

0.042

0.049

0.390

Body change strategies to decrease body size

0.018

0.049

0.717

Body change strategies to increase body size

-0.030

0.048

0.528

Strategies to increase muscle tone

0.046

0.048

0.335

Binge eating

-0.012

0.048

0.803

Intake of food supplements

-0.016

0.049

-0.749

Physical activity level Body image satisfaction

0.034

0.050

0.501

Body image importance

-0.005

0.050

0.927

Body change strategies to decrease body size

0.144

0.049

0.003*

0.234

0.072

0.001*

Body change strategies to increase body size

-0.242

0.047

0.001*

-0.359

0.063

< 0.001*

Strategies to increase muscle tone

-0.208

0.047

< 0.001*

-0.279

0.058

0.001*

Binge eating

0.234

0.048

0.001*

0.288

0.058

0.001*

Intake of food supplements

-0.129

0.049

0.009*

-0.137

0.044

0.002*

Economic class Body image satisfaction

0.007

0.050

0.886

Body image importance

0.058

0.049

0.240

Body change strategies to decrease body size

0.157

0.048

0.001*

0.212

0.071

0.003*

Body change strategies to increase body size

0.091

0.047

0.055

Strategies to increase muscle tone

0.166

0.047

< 0.001*

0.111

0.045

0.013*

Binge eating

-0.009

0.048

0.854

Intake of food supplements

0.122

0.048

0.011*

Men Work Body image satisfaction

-0.052

0.062

0.405

Body image importance

0.022

0.062

0.724

Body change strategies to decrease body size

-0.008

0.061

0.902

Body change strategies to increase body size

-0.050

0.062

0.420

Strategies to increase muscle tone

0.048

0.061

0.435

Continued on next page

Trends Psychiatry Psychother. 2020;42(1) – 25

Strategies for eating and body change - da Silva et al.

Table 5 (cont.)

Complete Independent/dependent variable (BIBCI subscales)

Refined

Binge eating

-0.028

0.063

0.654

p -

Intake of food supplements

0.071

0.062

0.255

Self-reported eating assessment Body image satisfaction

-0.139

0.064

0.029

Body image importance

-0.015

0.065

0.820

Body change strategies to decrease body size

-0.056

0.064

0.382

Body change strategies to increase body size

0.018

0.065

0.784

Strategies to increase muscle tone

-0.091

0.064

0.151

Binge eating

-0.068

0.065

0.297

Intake of food supplements

-0.126

0.064

0.048*

Body mass index Body image satisfaction

-0.042

0.062

0.496

Body image importance

0.073

0.063

0.244

Body change strategies to decrease body size

-0.012

0.062

0.844

Body change strategies to increase body size

-0.006

0.063

0.919

Strategies to increase muscle tone

-0.018

0.062

0.772

Binge eating

0.006

0.063

0.928

Intake of food supplements

0.030

0.063

0.631

0.037*

Physical activity level Body image satisfaction

0.169

0.064

0.008*

0.128

0.061

Body image importance

0.131

0.064

0.041*

Body change strategies to decrease body size

0.217

0.062

0.001*

0.183

0.060

0.002*

Body change strategies to increase body size

-0.166

0.064

0.009*

-0.161

0.061

0.008*

Strategies to increase muscle tone

-0.126

0.063

0.048*

-0.168

0.061

0.006*

Binge eating

0.133

0.064

0.039*

Intake of food supplements

0.005

0.064

0.938

Economic class Body image satisfaction

0.014

0.062

0.229

Body image importance

0.092

0.062

0.142

Body change strategies to decrease body size

0.141

0.061

0.021*

Body change strategies to increase body size

0.005

0.063

0.934

Strategies to increase muscle tone

0.106

0.062

0.085

Binge eating

-0.009

0.063

0.880

Intake of food supplements

0.096

0.062

0.124

β = standardized estimate; BIBCI = Body Image and Body Change Inventory; SE = standard error. * p < 0.05.

Discussion The BIBCI is widely used in English-speaking countries. This study developed and presented a Portuguese version of the BIBCI to promote its use in Portuguese-speaking countries. This Portuguese version of the BIBCI will enable inter-cultural comparisons in cross-cultural studies with BIBCI. The validity and reliability of the BIBCI was confirmed in the sample of Brazilian university students. Additionally, cut-off points were proposed for classifying individuals according to 26 – Trends Psychiatry Psychother. 2020;42(1)

mean BIBCI scores, which should facilitate use of the instrument in clinical and epidemiological contexts. Furthermore, significant characteristics were identified and can be included in preventive or intervention protocols designed to reduce individuals’ inappropriate behaviors in relation to body image and eating. This study has therefore contributed to both scientific knowledge and clinical practice. The process of translation and adaptation of BIBCI to the Portuguese language included the important step of verifying the instrument’s idiomatic, semantic,

Strategies for eating and body change - da Silva et al.

conceptual, and cultural equivalence.21,22 Cultural adaptations were needed to apply the BIBCI to the Brazilian context, but these did not compromise the original concept. The Portuguese BIBCI was well understood by both females and males and can be tested in other Portuguese-speaking countries. There are sex-specific instruments in the literature for evaluating body image in women and men,28 whereas the BIBCI was developed for both sexes. In our sample, the BIBCI was adequate for both women and men and it can therefore be considered an appropriate instrument for investigation of individuals body image in epidemiological and clinical applications. The psychometric properties of an instrument for a sample are validity and reliability and so the second aim of this study was to evaluate the adequacy of the BIBCI for administration to Brazilian university students. The BIBCI factorial model (53 items and 7 subscales) was adequate for both women and men. No prior study has used CFA to evaluate the validity of this model. Some studies6,8-11,13 have presented satisfactory alpha values for the BIBCI subscales, which corroborate our results showing adequate reliability. Some studies have constructed different BIBCI subscales,6,7,9,11,2932 but we followed the original proposal, with its seven correlated subscales.4,8,33 With regard to the correlations between the BIBCI subscales, the majority were significant, corroborating results presented by McCabe and Ricciardelli.4 These results support use of the instrument in terms of the relationships between its subscales. Both samples demonstrated the adequacy of all BIBCI subscales in terms of their convergent and discriminant validities. Granero-Gallegosa et al.6 also reported adequate convergent validity of two BIBCI subscales, corroborating our results. The present study is the first in the literature to present evidence regarding the psychometric properties of BIBCI using CFA. Additionally, we highlighted the good fit of the BIBCI to young adults, specifically university students, which indicates the instrument’s suitability beyond adolescence. After showing the good psychometric properties of the BIBCI factorial model for the samples, we proposed cut-off points for the instrument’s subscales (aim 3). This aim was intended to help professionals/researchers to classify individuals within ranges defined by mean scores. By defining these rating ranges, we hope to contribute to use of the BIBCI in clinical contexts and in future studies that compare scores/prevalence rates between groups. The next step was to calculate the prevalence rates of eating and body change strategies among the students. A majority of the students presented low body image satisfaction and moderate

body image importance, corroborating recent studies34,35 and revealing that this population strongly values the body. Moreover, most of the students presented very low use of strategies for body change. This result was to be expected, since this was a normative sample, i.e., recruited from among individuals without a clinical diagnosis of a body disorder that could directly influence body change strategies. However, some students were classified in the higher ranges, which could be associated with development of body image disorders. It would therefore be interesting to develop awareness regarding body image among these individuals, aiming to promote preventative health. Regarding the multivariate models, the significant paths detected merit discussion. For women, selfreported eating assessment and body image importance were significant, corroborating previous results.36,37 This finding highlights the relevant role that eating can play in an individuals’ body appearance. The significant paths between economic class and body image have been reported in previous studies,17 illustrating how individuals with greater economic power are more dissatisfied with their body and may engage more often in strategies to seek body change.38 No prior study has reported results similar to ours in relation to the significant paths found between work and strategies for body change. However, we believe that the increased availability of spare time for students who do not work may have influenced the greater frequency of use of strategies to increase muscle tone. Meanwhile, the significant path between work and binge eating has been discussed in recent studies39 that reported work as an activity that has relevance for people’s eating patterns; students who work may have little time to prepare a more balanced diet, resulting in changes in food intake. Moreover, physical activity level was significant for BIBCI subscales in women and men, and this relationship is commonly reported in previous studies.2,40 According to those studies, individuals who practice physical activities have a different perception of body image and often change their activities according to their interpretations with relation to the body. The results highlight the importance that these characteristics can have for eating and body change strategies. There is therefore a need to develop protocols that include these characteristics for preventive, educational, and/or curative treatments. In general, we hope to have increased the possibilities for use of the BIBCI in both scientific and clinical contexts by producing the Portuguese version and defining the rating ranges. This instrument showed satisfactory psychometric properties in women and men, revealing its suitability for university students, who comprise a population considered vulnerable to issues Trends Psychiatry Psychother. 2020;42(1) – 27

Strategies for eating and body change - da Silva et al.

related to body image. The characteristics found to be significant can be used in protocols for intervention or prevention of problems related to eating disorders and body dissatisfaction. Some limitations should be mentioned. The nonprobabilistic sample selection means that the results cannot be generalized to all Brazilian university students, but may help better target future studies and clinical protocols. We also highlight as a limitation the cross-sectional design, which does not allow inference of cause-and-effect relationships between the characteristics evaluated in the regression models. However, the results found may help future studies in terms of the choice of characteristics to include in protocols. Therefore, to overcome the limitations of our study, we suggest that further studies be carried out with the BIBCI in different samples and contexts.

Acknowledgments We would like to thank the Faculdade de Ciências Farmacêuticas at the Universidade Estadual Paulista (UNESP) for institutional support (SISPROPe No. 2082). We are grateful to psychologist Fernanda Cristina Maurício and pharmacist Bianca Gonzalez Martins for their contributions to data collection. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References 1. Barnes MA, Caltabiano ML. The interrelationship between orthorexia nervosa, perfectionism, body image and attachment style. Eat Weight Disord. 2017;22:177-84. 2. Pickett AC, Cunningham GB. Physical activity for every body: a model for managing weight stigma and creating body-inclusive spaces. Quest. 2017;69:19-36. 3. Cash TF, Smolak L. Body Image: a handbook of science, pratice, and prevention. 2nd Edition. New York / London: The Guilford Press; 2011. 4. McCabe MP, Ricciardelli LA. Body image and body change techniques among young adolescent boys. Eur Eat Disord Rev. 2001;9:335-47. 5. Ricciardelli LA, McCabe MP. Sociocultural and individual influences on muscle gain and weight loss strategies among adolescent boys and girls. Psychol Sch. 2003;40:209-24. 6. Granero-Gallegosa A, Lucas JM, Sicilia A, Medina-Casaubónc J, Alcaraz-Ibáñeza M. Analysis of sociocultural stereotypes towards thin body and muscular body: differences according to gender and weight discrepancy. Rev Psicodidac. 2018;23:26-32.

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7. Lawrie Z, Sullivan EA, Davies PS, Hill RJ. Body change strategies in children: relationship to age and gender. Eat Behav. 2007;8:35763. 8. McCabe MP, Ricciardelli LA. Sociocultural influences on body image and body changes among adolescent boys ans girls. Journal Soc Psychol. 2003;143:5-26. 9. McCabe MP, Ricciardelli LA, Holt K. Are there different sociocultural influences on body image and body change strategies for overweight adolescent boys and girls? Eat Behav. 2010;11:15663. 10. Mellor D, McCabe M, Ricciardelli L, Merino ME. Body dissatisfaction and body change behaviors in Chile: the role of sociocultural factors. Body Image. 2008;5:205-15. 11. Muris P, Meesters C, van de Blom W, Mayer B. Biological, psychological, and sociocultural correlates of body change strategies and eating problems in adolescent boys and girls. Eat Behav. 2005;6:11-22. 12. Conti MA, Ferreira ME, Amaral AC, Hearst N, Cordás TA, Scagliusi FB. Semantic equivalence of the Brazilian Portuguese version of the “Body Change Inventory”. Cien Saude Colet. 2012;17:245769. 13. Meireles JFF, Amaral ACS, Neves CM, Conti MA, Ferreira MEC. Psychometric evaluation of the Body Change Questionnaire for adolescents. Cad Saude Publica. 2015;31:2291-301. 14. Maruf FA, Akinpelu AO, Udoji NV. Differential perceptions of body image and body weight among adults of different socioeconomic status in a sub-urban population. J Biosoc Sci. 2014;46:279-93. 15. McCabe MP, Ricciardelli LA, Waqa G, Goundar R, Fotu K. Body image and body change strategies among adolescent males and females from Fiji, Tonga and Australia. Body Image. 2009;6:299303. 16. Silva WR, Dias JCR, Maroco J, Campos JADB. Factors that contribute to the body image concern of female college students. Rev Bras Epidemiol. 2015;18:785-97. 17. Silva WR, Santana MS, Maroco J, Maloa BFS, Campos JADB. Body weight concerns: cross-national study and identification of factors related to eating disorders. PLoS One. 2017;12:e0180125. 18. Hair Jr JF, Black WC, Babin B, Anderson RE. Multivariate data analysis. 7th ed. Upper Saddle River: Prentice Hall; 2009. 785 p. 19. ABEP. Brazilian Economic Classification. 2018 [cited 2018]; Available from: http://www.abep.org/. 20. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO: Technical Report Series; 2000. 21. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25:3186-91. 22. Reichenheim ME, Moraes CL. Operationalizing the cross-cultural adaptation of epidemological measurement instruments. Rev Saude Publica. 2007;41:665-73. 23. Byrne BM. Structural equation modeling with Amos: basic concepts, applications and programming. Mahwah: Lawrence Erlbaum Associates; 2001. 352 p. 24. Marôco J. Análise de equações estruturais. Pêro Pinheiro: ReportNumber; 2014. 25. Fornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. J Mark Res. 1981;18:39-50. 26. Dunn TJ, Baguley T, Brunsden V. From alpha to omega: a practical solution to the pervasive problem of internal consistency estimation. Br J of Psychol. 2014;105:399-412. 27. Maroco J, Garcia-Marques T. Qual a fiabilidade do alfa de Cronbach? Questões antigas e soluções modernas? Lab Psicol. 2006;4:65-90. 28. Laus MF, Kakeshita IS, Costa TM, Ferreira ME, Fortes Lde S, Almeida SS. Body image in Brazil: recent advances in the state of knowledge and methodological issues. Rev Saude Publica. 2014;48:331-46. 29. McCabe MP, Connaughton C, Tatangelo G, Mellor D, Busija L. Healthy me: a gender-specific program to address body image concerns and risk factors among preadolescents. Body Image. 2017;20:20-30. 30. Mellor D, McCabe M, Ricciardelli L, Yeow J, Daliza N, Hapidzal NF. Sociocultural influences on body dissatisfaction and body change behaviors among Malaysian adolescents. Body Image. 2009;6:121-8.

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31. Stanford JN, McCabe M. Sociocultural influences on adolescent boys’ body image and body change strategies. Body Image. 2005;2:105-13. 32. Xu X, Mellor D, Kiehne M, Ricciardelli LA, McCabe MP, Xu Y. Body dissatisfaction, engagement in body change behaviors and sociocultural influences on body image among Chinese adolescents. Body Image. 2010;7:156-64. 33. Ricciardelli LA, McCabe MP. Psychometric evaluation of the Body Change Inventory: an assessment instrument for adolescent boys and girls. Eat Behav. 2002;3:45-59. 34. Laus MF, Costa TM, Almeida SS. Gender differences in body image and preferences for an ideal silhouette among Brazilian undergraduates. Eat Behav. 2015;19:159-62. 35. Wang K, Liang R, Ma ZL, Chen J, Cheung EFC, Roalf DR, et al. Body image attitude among Chinese college students. Psych J. 2018;7:31-40. 36. de Carvalho PHB, Alvarenga MDS, Ferreira MEC. An etiological model of disordered eating behaviors among Brazilian women. Appetite. 2017;116:164-72. 37. de Oliveira da Silva P, Miguez Nery Guimaraes J, Harter Griep R, Caetano Prates Melo E, Maria Alvim Matos S, Del Carmem Molina M, et al. Association between body image dissatisfaction and selfrated health, as mediated by physical activity and eating habits: structural equation modelling in ELSA-Brasil. Int J Environ Res Public Health. 2018;15.

38. Grogan S. Age, ethnicity, social class, and sexuality. In: Grogan S, editor. Body image: understanding body dissatisfaction in men, women and children. London and New York: Taylor & Francis; 2017. p. 135. 39. Pawaskar M, Witt EA, Supina D, Herman BK, Wadden TA. Impact of binge eating disorder on functional impairment and work productivity in an adult community sample in the United States. Int J Clin Pract. 2017;71. 40. Coelho CG, Giatti L, Molina MD, Nunes MA, Barreto SM. Body image and nutritional status are associated with physical activity in men and women: The ELSA-Brasil Study. Int J Environ Res Public Health. 2015;12:6179-96.

Correspondence: Juliana Alvares Duarte Bonini Campos Departamento de Alimentos e Nutrição, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista (UNESP) Rodovia Araraquara-Jaú, km 01 14800-903 - Araraquara, SP - Brazil Tel.: +55 (16) 33016935 E-mail: juliana.campos@unesp.br

Trends Psychiatry Psychother. 2020;42(1) – 29

Trends

Original Article

in Psychiatry and Psychotherapy

The effectiveness of acceptance and commitment therapy for social anxiety disorder: a randomized clinical trial Samad Khoramnia,1

Amir Bavafa,1 Nasrin Jaberghaderi,1 Aliakbar Parvizifard,1 Aliakbar Foroughi,1 Mojtaba Ahmadi,1 Shahram Amiri1

Abstract Objective: Acceptance and commitment therapy has been used to treat anxiety disorders recently. The purpose of this study was to investigate the effectiveness of acceptance and commitment therapy for psychological symptoms in students with social anxiety disorder, including difficulty in emotion regulation, psychological flexibility based on experiential avoidance, self-compassion, and external shame. Methods: This study was a semi-experimental clinical trial. Twenty four students with social anxiety disorder were randomly divided into two groups after initial evaluations: an experimental group (12 subjects) and a control group (12 subjects). The experimental group received 12 treatment sessions based on a protocol of acceptance and commitment therapy for anxiety disorders, and the control group was put on a waiting list. Self-Compassion (SCS), Difficulty in Emotion Regulation (DERS), External Shame (ESS), Social Anxiety (SPIN), and Acceptance and Action (AAQ-II) questionnaires were used to assess participants. Data were analyzed using SPSS. Results: Acceptance and commitment therapy was shown to be effective at the post-test and follow up stages for reducing external shame, social anxiety, and difficulty in emotion regulation and its components, and for increasing psychological flexibility and self-compassion (p < 0.05). The largest effect size of treatment was for increase of psychological flexibility and the lowest efficacy was for the components “difficulty in impulse control” and “limited access to emotional strategies” at the post-test and follow-up stages, respectively. Conclusion: Acceptance and commitment therapy may be an appropriate psychological intervention for reducing the symptoms of students with social anxiety disorder and helping them to improve psychological flexibility. Emotion and related problems can be identified as one of the main targets of this treatment. Clinical trial registration: Iranian Registry of Clinical Trials, IRCT20180421039369N1. Keywords: Acceptance and commitment therapy, difficulty in emotion regulation, external shame, psychological flexibility, self-compassion, social anxiety disorder.

Introduction Social anxiety disorder is characterized by significant fear or anxiety about one or more social situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.1 Social anxiety disorder is one

of the most common disorders among young people,2,3 affecting approximately 13% of the population.4 This disorder, in addition to isolating some patients socially5 and having a destructive effect on occupation and on educational and interpersonal performance,6 can inflict huge costs on all countries’ economies every year.7,8

Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran.

Submitted Jan 11 2019, accepted for publication Jun 04 2019. Suggested citation: Khorammia S, Bavafa A, Jaberghaderi N, Parvizifard A, Foroughi A, Ahmadi M, et al. The effectiveness of acceptance and commitment therapy for social anxiety disorder: a randomized clinical trial. Trends Psychiatry Psychother. 2020;42(1):30-38. http://dx.doi.org/10.1590/2237-6089-2019-0003 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 30-38

ACT on students with anxiety - Khorammia et al.

Therefore, comprehensive study of this disorder and use of evidence-based interventions are important. Many studies have shown that people with social anxiety disorder have ineffective experiential avoidance.9,10 This is related to a person’s desire for change and sensitivity to internal situations and events.11 Previous studies have identified selfcompassion,12-15 difficulty in emotion regulation,16-18 and extreme feelings of shame19,20 as the most important psychological problems experienced by people with social anxiety disorder. Clinicians have used pharmacological and psychological interventions to attempt to improve the symptoms of social anxiety disorder.21-28 Although some psychological interventions, such as cognitivebehavioral therapy, have demonstrated efficacy for treatment of patients with social anxiety, some people did not respond to treatment or symptoms remained.22 One treatment that has been used recently to treat anxiety disorders and has demonstrated effectiveness for reducing anxiety symptoms is acceptance and commitment therapy (ACT).23-26 ACT is derived from the modern theory of cognition and language27 and is classified as a third-wave psychological treatment, in which some cognitivebehavioral therapy concepts have been changed.28 The main assumption underlying ACT is that humans experience disturbing thoughts, emotions, and feelings29 and that their attempts to change or to get rid of these experiences are ineffective, which sometimes exacerbates these disturbances and ultimately leads to avoidance.30 The six core psychological processes employed in this treatment are Acceptance, Defusion, Self as context, Contact with the present moment, Values, and Committed action.31 These six processes are all implemented using metaphors, empirical exercises, and logical contradictions to escape the literal content of the language and interact more with the ongoing flow of experience at the present moment.32 The purpose of this treatment is to reduce experiential avoidance and increase psychological flexibility.30 A study by Azadeh et al.2 demonstrated the efficacy of ACT for the interpersonal problems and psychological flexibility of high school girls with social anxiety disorder. In that study, only clients of one gender were selected and they were not followed-up to determine the effects of treatment over time, so the effective and lasting aspects of the intervention were not evaluated. The results of a study conducted in 2007 by Dalrymple and Herbert22 showed that from pre-test to follow-up there was a significant decrease in symptoms experienced and improvement in the quality of life of people with social anxiety after ACT. More studies are needed to determine the effectiveness of ACT, especially in terms

of cultural differences and variables related to emotion regulation. Considering the study of research literature in this field, as well as the need to study the application of psychological treatments in different cultures and their effect on various psychological symptoms, especially emotion, the importance of further exploration is evident. The aim of this study is to evaluate the effectiveness in patients with social anxiety of ACT for psychological symptoms, including difficulty in emotion regulation, poor psychological flexibility rooted in experiential avoidance, self-compassion, and external shame.

Methods This study was a semi-experimental clinical trial, with control and experimental groups, that was approved under code IRCT20180421039369N1 in the IRCT (Iranian Registry of Clinical Trials). Sampling was intentional, from among all students with social anxiety disorder in Kermanshah city. In two recent studies of the effectiveness of ACT, sample sizes were 19 and 30 individuals.2,22 A sample size of 24 was selected for the present study. In coordination with the University’s Counseling Center, posters were put up in college and dormitory environments and individuals with social anxiety symptoms were invited to attend a psychological assessment session. The diagnostic interview was based on the Anxiety Disorders Interview Schedule for DSMIV (ADIS-IV) and conducted by a clinical psychologist for all participants. After reviewing inclusion and exclusion criteria, individuals willing to participate in the research were randomly assigned to groups using a random number generator (http://stattrek.com/statistics/randomnumber-generator.aspx). Inclusion criteria were as follows: 1) diagnosis of social anxiety disorder; 2) informed consent from the patient for participation in the study; 3) not receiving psychological treatment during the previous six months; 4) no psychopharmacotherapy during the previous six months; 5) no comorbidity with other anxiety and mood disorders; 6) absence of other psychiatric disorders and severe neurological disorders; 7) no substance abuse or alcohol abuse. Exclusion criteria included unwillingness to attend continuing treatment sessions and simultaneous enrollment on another treatment program. Members of the experimental group attended twelve 90-minute sessions based on a protocol of ACT for anxiety disorders.24 Members of the control group were put on the waiting list. The control group were given treatment after the final evaluation. A total of Trends Psychiatry Psychother. 2020;42(1) – 31

ACT on students with anxiety - Khorammia et al.

24 students were enrolled on the study, 22 of whom, in the experimental and control groups, completed the treatment sessions and pre-test and two-month followup evaluations. One person in the experimental group was excluded from the study because of unwillingness to continue attending therapy sessions and one person in the control group because of non-completion of final evaluations (Figure 1). Ethical considerations In order to comply with ethical standards, participants were informed of the conditions of the research and received informed consent forms before the start of the study. After completing the follow-up evaluation, individuals in the control group also attended ACT sessions. After implementation of the protocol, all research participants were referred to a psychiatrist or psychologist as necessary for complementary therapies. This research was approved by the ethics committee at the Kermanshah University of Medical Sciences (IR. KUMS.REC.1397.085).

Statistical analysis SPSS software was used to analyze findings and statistical data. Multivariate analysis of covariance was used to analyze the effectiveness of the treatment in the experimental group on the variables evaluated, in comparison with the control group. The chi-square test was used to compare the number of participants and the independent t test was used to compare the mean age of the experimental and control groups. Measurements Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) This is a semi-structured, clinical and diagnostic interview for anxiety disorders developed in 1994 by Brown et al.33 In addition to anxiety disorders, it also measures mood disorders, somatization, psychosis, and drug abuse. The Clinical Severity Rating (CSR) is scored on a scale from zero (no sign) to eight (severely disturbed). Accordingly, a severity grading of four or more indicates that the patientâ&#x20AC;&#x2122;s symptoms are at or

Statement of willingness and informed consent to participate in the research: 45 students

Excluded subjects (21) Comorbidity with other anxiety and mood disorders (13) Substance abuse history (7)

Randomization and pre-test:

Other factors (1)

24 students

Waiting list group, after completion of pre-test:

Experimental group, after completion of pre-test:

12 students

1 person excluded for not completing assessments

1 person excluded for dropping out from treatment sessions Waiting list group, after completion of post-test:

Experimental group, after completion of post-test:

11 students

Waiting list group, completed follow-up:

Experimental group, completed follow-up:

11 students

Figure 1 - Diagram illustrating participation in pre-test, post-test, and follow-up phases. 32 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

ACT on students with anxiety - Khorammia et al.

beyond the diagnostic threshold of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR). A degree of severity of three or below is attributed to diagnoses that are at partial or full improvement levels. In post-treatment studies using the ADIS-IV, clinical grade scores are usually used as an indicator for assessing post-treatment improvement.33 The validity of the Persian version of this program has been confirmed and its retest reliability coefficient was reported as 0.83.34 In this study, this measurement will be used to screen for social anxiety disorder, to confirm clinical diagnosis, and to assess clinical severity. Self-Compassion Scale (SCS) This questionnaire consists of 26 items with a fivepoint Likert response scale measuring three bipolar components in the form of six sub-scales. These components are Self-kindness vs. Self-judgment, Common humanity vs. Isolation, and Mindfulness vs. Over-identification.35 The Cronbach’s alpha coefficient of 0.92 represents an internal consistency superior to the original version of this scale. Convergent validity, discriminant validity, and appropriate retest reliability for this scale have been reported.35 In an Iranian student sample, the six-factor structure of the validation questionnaire was confirmed and a Cronbach’s alpha coefficient of 0.86 for the whole scale was reported. Cronbach’s alpha coefficients for sub-scales were in the range of 0.79-0.85.35 Difficulty in Emotion Regulation Scale (DERS) This scale is a comprehensive measurement for assessing difficulty in emotion regulation that is based on the concept of mindfulness and acceptance and was designed in 2004.36 A self-report measure with 36 items that measure usual levels of difficulty in emotion regulation as well as its specific dimensions.37 The scale’s dimensions are Non-acceptance, Goals lack, Impulse, Awareness, Strategies, and Clarity.37 Responses are scored on a five-point Likert scale. The reliability coefficient for the total scale is 0.93 and the test-retest is 0.88, while its construct validity is desirable.37 This scale has been translated into Persian by Khanzadeh et al. in Iran.38 The subscale validity of this questionnaire was reported as Cronbach’s alphas between 0.66 and 0.88 and test-retest reliability between 0.97 and 0.91.37,38 External Shame Scale (ESS) This scale is an 18-item self-report measure, designed by Gross et al. to measure external shame.39 Each option is scored from “never” to “almost always” using Likert scales. A higher score indicates greater

external shame.39 The reliability of this measure was reported as desirable, based on its Cronbach’s alpha (0.94) and 5-week retest reliability (0.94). This measure has a moderate correlation with a negative evaluation of fear and higher correlations with other methods of measuring shame in clinical student populations.39 Also, this scale has appropriate validity and Cronbach’s alphas for the whole scale and its related components have been reported as in the range of 0.71 to 0.93.39 Acceptance and Action in Social Anxiety Questionnaire, 2nd edition (AAQ-II) This questionnaire was developed to measure the symptoms of social anxiety or the extent to which individuals are aware of their thoughts and feelings about their social anxiety without attempting to change them.40 A Cronbach’s Alpha of 0.94 has been reported by the scale’s developers.41 The questionnaire also has good validity.41 The reliability of this questionnaire in Iran was 0.84 for test-retest and 0.84 for Cronbach’s alpha and its validity was also desirable.41 The results of factor analysis by principal component analysis revealed three components: acceptance, experience without judgment, and action.40 Social Phobia Inventory (SPIN) This questionnaire is a self-report scale with 17 items that are designed to assess anxiety or social anxiety.42 This scale consists of three subscales of fear (6 items), avoidance (7 items), and physiological discomfort (4 items), and each item has a 5-degree Likert response scale, ranging from 1 to 5.42 A cut-off score of 19 is used to screen for social anxiety. The testretest reliability of this scale has been reported as 0.78 to 0.89 in groups with diagnosed social anxiety and its internal consistency has been reported as 94% in a group of healthy individuals.42 The convergent validity of this questionnaire was reported as 0.57-0.85.42 Intervention An ACT protocol for anxiety disorders developed by Eifert and Forsyth24 was used with the intervention group. This protocol consists of 12 sessions, each with specific goals. Activities were tailored to the individual needs of clients, while standard sessions were maintained. In ACT, emphasis is put on establishment of a context for acceptance, followed by commitment to values and action as the main psychological processes. The purpose of the first session was psycho-education and familiarity with treatment. In the second and third sessions, the emphasis was placed on establishing a framework for acceptance for treatment through evaluation and cost estimation of past control efforts and creating a space Trends Psychiatry Psychother. 2020;42(1) – 33

ACT on students with anxiety - Khorammia et al.

for new solutions, acceptance, or willingness to change. The fourth and fifth sessions focused on acceptance and value-based life as an alternative to managing anxiety. The purpose of the sixth session was to create a pattern of behavior through value-based exposures. The seventh to eleventh sessions dealt with commitment to values and action. In the final session, the treatment sessions were reviewed and clients were prepared for recurrence and failure. Various assignments and exercises in sessions were tailored to the needs of the patients, such as mindfulness, life-enhancing, and practicing. The sessions were approximately 90 minutes long. After the fourth session, one of the clients dropped out of the treatment sessions and was excluded from the final evaluations.

Results Based on demographic variables, the mean age of the participants was 22.12±1.08. Twenty-four subjects participated in this study, 17 of whom were women (70.8%) and 7 of whom were men (29.2%). There was no significant difference between the two groups in terms of age (p > 0.05). There was no significant difference between the two groups in terms of gender (Table 1). One member of each group was excluded from the study because of non-completion of the evaluation and drop-out from treatment sessions respectively.

Table 2 illustrates changes in the target variables in the control and experimental groups. The table shows means and standard deviations of variables in different conditions. The confidence interval diagram is shown in Figure 2. Before statistical inference, the Kolmogorov-Smirnov test was performed to verify normality of the data and the data assumption was confirmed. The results of Box’s M test showed that the matrix of covariance was equal in multivariate covariance analysis (p > 0.05). The Leven test was performed to test the equality of error variances (p > 0.05). Wilk’s Lambda test to measure the efficacy of the treatment on all target variables showed that the linear combination of “difficulty in emotion regulation” and its components was significantly different for control and experimental groups (Wilk’s Lambda = 0.003, p = 2.784, F = 0.476). Multivariate analysis of covariance was performed to determine the difference between the control and experimental groups according to each target variable. According to Table 3, the results of multivariate covariance analysis indicate that there were significant changes in all therapeutic variables among students with social anxiety in experimental and control groups (p < 0.05). In other words, ACT had a significant effect, reducing external shame, social anxiety, and difficulty in emotion regulation and its components, while increasing psychological flexibility and self-compassion in the post-test and follow-up stages. The effect of this

Table 1 - Demographic features of participants Parameters

Experimental group

Control group

p-value

Age (years)

23.11±1.01

21.13±1.09

0.12

Female, n (%)

8 (66.67)

9 (75)

0.14

Male, n (%)

4 (33.33)

3 (25)

0.17

Gender

0.07

Table 2 - Comparison of means and standard deviations of target variables in the control and experimental groups Control group Variable

Experimental group

Pre-test

Post-test

Follow-up

Pre-test

Post-test

Follow-up

ESS

13.44±65.73

66.54±11.74

58.18±12.15

63.45±11.79

58.18±19.57

55.23±6.76

AAQ-II

82.27±13.10

83.00±12.73

75.18±15.89

79.72±9.55

94.45±7.28

83.02±16.46

SPIN

63.27±9.28

61.45±10.89

62.27±9.44

59.95±15.62

46.60±59.45

49.77±13.47

SCS

84.27±14.93

81.27±10.09

83.54±16.57

78.18±12.70

94.81±6.21

96.77±16.98

DERS

117.36±9.78

117.00±10.86

120.18±10.60

115.5±13.71

101.36±9.26

98.54±15.77

Data presented as mean ± standard deviation. ESS = External Shame Scale; AAQ-II = Acceptance and Action in Social Anxiety Questionnaire, 2nd edition; SPIN = Social Phobia Inventory; SCS = SelfCompassion Scale; DERS = Difficulty in Emotion Regulation Scale.

34 – Trends Psychiatry Psychother. 2020;42(1)

ACT on students with anxiety - Khorammia et al.

Figure 2 - Confidence interval diagram for target variables. AAQ-II = Acceptance and Action Questionnaire; DERS = Difficulty in Emotion Regulation Scale; ESS = External Shame Scale; SCS = Self-Compassion Scale; SPIN = Social Phobia Inventory.

Table 3 - Descriptive statistics and the effect of acceptance and commitment therapy, based on multivariate covariance analysis of target variables in the experimental group. Group/variable Post-test ESS AAQ-II SPIN SCS DERS Non-acceptance Goals lack Impulse Awareness Strategies Clarity

Effect size

Statistical power

12.3 21.1 29.2 51.8 7.7 22.12 9.31 23 31.27 14.3 43.15

0.006 0.004 0.002 0.001 0.007 0.004 0.007 0.003 0.002 0.006 0.001

0.233 0.43 0.421 0.38 0.311 0.287 0.148 0.013 0.107 0.039 0.018

0.87 0.88 0.86 0.91 0.93 0.84 0.85 0.88 0.87 0.89 0.93

Follow-up ESS AAQ-II SPIN SCS DERS Non-acceptance Goals lack Impulse Awareness Strategies Clarity

33.21 12.7 14.5 24.25 21.2 8.8 12.13 46.4 1.23 10.1 14.13

0.001 0.009 0.005 0.003 0.004 0.008 0.006 0.000 0.65 0.007 0.005

0.253 0.627 0.228 0.435 0.301 0.199 0.099 0.016 0.066 0.014 0.057

0.88 0.86 0.85 0.84 0.94 0.91 0.93 0.79 0.89 0.88 0.83

AAQ-II = Acceptance and Action Questionnaire; DERS = Difficulty in Emotion Regulation Scale; ESS = External Shame Scale; SCS = Self-Compassion Scale; SPIN = Social Phobia Inventory.

Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 35

ACT on students with anxiety - Khorammia et al.

treatment in increasing the psychological flexibility of 43% and 67%, respectively, in post-test and follow-up, shows the highest degree of efficacy for ACT. Among the variables studied, the components of “difficulty in impulse control” and “limited access to emotional strategies” had the smallest effect sizes in the post-test and follow-up stages, respectively.

Discussion The purpose of this study was to evaluate the effectiveness of ACT for improvement of psychological symptoms in students with social anxiety disorder. The psychological symptoms examined were external shame, psychological flexibility, social anxiety severity, self-compassion, and difficulty in emotion regulation and its components. The findings of this study showed that ACT improved these symptoms in students with social anxiety disorder in the experimental group, compared to the control group. The results of a randomized clinical trial conducted with 73 students by Yadavaia and colleagues showed that ACT had a significant effect, increasing self-compassion from pre-test to follow-up.43 Vowles et al. found that selfcompassion itself could be a powerful mediator of the effectiveness of ACT, undergoing change under the influence of treatment.44 Also, the results of this study showed that the effectiveness of ACT in terms of the significant increase in students’ self-compassion from pre-test to follow-up (compared with a control group) is consistent with previous studies. Although ACT do not emphasize self-compassion as a target variable, it has been argued that increased focus on self-compassion in this treatment may result in a greater effect size for the effectiveness of ACT.45 Luoma et al.45 showed that ACT is effective for reducing shame in people with a history of substance abuse. In another study,46 it was shown that experiential avoidance can be regarded as a mediator of shame and self-harmful behaviors. On the other hand, shame can be a sign and experiential avoidance is a characteristic experienced by people with social anxiety disorder,9,1921 and experiential avoidance is one of the criteria of psychological inflexibility in ACT. Therefore, it can be expected that ACT is effective for reducing feelings of shame and experiential avoidance, and subsequently for reducing the self-harmful behaviors of people with social anxiety disorder, which has been detailed in several studies.19-21 In line with this conclusion, in the present study this treatment was effective at reducing the feelings of shame experienced by students with social anxiety disorder. 36 – Trends Psychiatry Psychother. 2020;42(1)

One of the main goals of this study was to reduce the main symptoms of social anxiety disorder in response to a psychological treatment. Because these symptoms are debilitating and can have an adverse effect on individual, social, and occupational health, it is important to attempt to reduce the symptoms experienced. This study showed that ACT was effective for reducing the social anxiety symptoms of the experimental group in comparison with the control group, as measured by the Social Phobia Inventory (SPIN). In this study, it was also shown that this treatment could be effective for increasing students’ psychological flexibility, which had the largest effect size of all target variables. In several other studies, in common with the results of the present study, ACT has been shown to be effective for reducing the symptoms of social anxiety disorder.2,47,48 Yadavaia et al. also showed that ACT is effective for improving psychological flexibility,43 which is in line with the results of this study and previous studies.2,49 The explanatory factors of these results indicate that acceptance and committed action in ACT can be considered as the main psychological processes, and it seems that this treatment, considering the history of research, is effective for improvement of psychological flexibility and reduction of symptoms experienced by people with social anxiety disorder. The main purpose of this study was to investigate the effectiveness of ACT at reducing the difficulty in emotion regulation of people with social anxiety disorder, which has been shown to be a major concern in their daily lives.50,51 Of the components of difficulty in emotion regulation, ACT had the greatest impact on “lack of acceptance of emotional responses”. In view of the main psychological processes in this treatment, this result was not expected. So far, many studies have been conducted on the effectiveness of psychological treatments on emotions and related problems.52-54 It has been argued that ACT emphasizes the experience of problematic emotions rather than trying to change knowledge or reduce emotional levels.51 It seems that ACT is also effective for emotional problems and changes in levels of emotion. The results presented in other studies are in line with this.50,51 In the present study, the results showed that the experimental group compared favorably to the control group in ability to effectively reduce the difficulty in emotion regulation and its components. Several limitations of this study should be noted. First, the sample size limits the capability for generalization, which it is recommended should be addressed in future studies to increase reliability of results. Second, the sample studied consisted entirely of students, who are not comparable with the general population in terms

ACT on students with anxiety - Khorammia et al.

of social, economic, or intellectual capabilities. Third, the use of a waiting list group as control group is a limitation. It is suggested that more dynamic control groups be used to help clients in future studies.

Conclusion Given the limitations of this study, it can be concluded that, by increasing concentration on self-compassion, ACT can be effective in reducing feelings of shame and experiential avoidance in students with social anxiety disorder. This treatment can be an appropriate psychological intervention to reduce the symptoms of people with social anxiety disorder and help them to promote psychological flexibility. According to the results of this study and the literature on the efficacy of ACT, emotion and related problems can be identified as one of the main targets of this treatment.

Acknowledgments We are grateful to all of the participants in the research and for assistance in carrying out and implementing this project.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

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8. Stuhldreher N, Leibing E, Leichsenring F, Beutel ME, Herpertz S, Hoyer J, et al. The costs of social anxiety disorder: the role of symptom severity and comorbidities. J Affect Disord 2014;165:87-94. 9. Kashdan TB, Farmer AS, Adams LM, Ferssizidis P, McKnight PE, Nezlek JB. Distinguishing healthy adults from people with social anxiety disorder: evidence for the value of experiential avoidance and positive emotions in everyday social interactions. J Abnorm Psychol. 2013;122:645. 10. Soltani E, Bahrainian SA, Arani AM, Farhoudian A, Gachkar L. Psychometric properties of the Persian version of the Social Anxiety-Acceptance and Action Questionnaire. Iran J Psychiatry Behav Sci. 2016;10:e3753. 11. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol. 1996;64:1152. 12. Gill C, Watson L, Williams C, Chan SW. Social anxiety and selfcompassion in adolescents. J Adolesc. 2018;69:163-74. 13. Arch JJ, Landy LN, Schneider RL, Koban L, Andrews-Hanna JR. Self-compassion induction enhances recovery from social stressors: comparing adults with social anxiety disorder and healthy controls. Anxiety Stress Coping. 2018;31:594-609. 14. Blackie RA, Kocovski NL. Examining the relationships among selfcompassion, social anxiety, and post-event processing. Psychol Rep. 2018;121:669-89. 15. Werner KH, Jazaieri H, Goldin PR, Ziv M, Heimberg RG, Gross JJ. Self-compassion and social anxiety disorder. Anxiety Stress Coping. 2012;25:543-58. 16. Ziv M, Goldin PR, Jazaieri H, Hahn KS, Gross JJ. Emotion regulation in social anxiety disorder: behavioral and neural responses to three socio-emotional tasks. Biol Mood Anxiety Disord. 2013;3:20. 17. Farmer AS, Kashdan TB. Social anxiety and emotion regulation in daily life: spillover effects on positive and negative social events. Cogn Behav Therapy. 2012;41:152-62. 18. Mennin DS, McLaughlin KA, Flanagan TJ. Emotion regulation deficits in generalized anxiety disorder, social anxiety disorder, and their co-occurrence. J Anxiety Disord. 2009;23:866-71. 19. Hedman E, Ström P, Stünkel A, Mörtberg E. Shame and guilt in social anxiety disorder: effects of cognitive behavior therapy and association with social anxiety and depressive symptoms. PloS One. 2013;8:e61713. 20. Matos M, Pinto Gouveia J, Gilbert P. The effect of shame and shame memories on paranoid ideation and social anxiety. Clin Psychol Psychother. 2013;20:334-49. 21. Gilbert P. The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clin Psychol Psychother: 2000;7:174-89. 22. Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. Behav Modif. 2007;31:543-68. 23. Twohig MP, Hayes SC, Masuda A. Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behav Therapy. 2006;37:3-13. 24. Eifert GH, Forsyth JP, Arch J, Espejo E, Keller M, Langer D. Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cogn Behav Pract. 2009;16:368-85. 25. Dindo L. One-day acceptance and commitment training workshops in medical populations. Curr Opin Psychol. 2015;2:38-42. 26. Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. J Consult Clin Psychol. 2008;76:1083. 27. Twohig MP, Woidneck MR, Crosby JM. Newer generations of CBT for anxiety disorders. In: Simons G, Hoffman SG, editors. CBT for anxiety disorders: a practitioner book. Wiley-Blackwell; 2013. p. 225-50. 28. Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Therapy. 2004;35:639-65. 29. Hayes SC, Villatte M, Levin M, Hildebrandt M. Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annu Rev Clin Psychol. 2011;7:141-68. 30. Hayes SA, Orsillo SM, Roemer L. Changes in proposed mechanisms of action during an acceptance-based behavior therapy for generalized anxiety disorder. Behav Res Ther. 2010;48:238-45.

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31. Luoma JB, Hayes SC, Walser RD. Learning ACT: an acceptance & commitment therapy skills-training manual for therapists. Oakland: New Harbinger Publications; 2007. 32. Twohig MP. Acceptance and commitment therapy: introduction. Cogn Behav Pract. 2012;19:499-507. 33. Brown TA, Barlow DH, Liebowitz MR. The empirical basis of generalized anxiety disorder. Am J Psychiatry. 1994;151:127280. 34. Mohammadi A, Birashk B, Gharaie B. Comparison of the effect of group transdiagnostic therapy and group cognitive therapy on anxiety and depressive symptoms. Iran J Public Health. 2013;42:48-55. 35. Azizi A, Mohammadkhani P, Lotfi S, Bahramkhani M. The validity and reliability of the Iranian version of the Self-Compassion Scale. Pract Clin Psychol. 2013;1:149-55. 36. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess. 2004;26:41-54. 37. Mazaheri M. Psychometric properties of the persian version of the Difficulties in Emotion Regulation Scale (DERS-6 & DERS5-revised) in an Iranian clinical sample. Iran J Psychiatry. 2015;10:115. 38. Khanzadeh M, Saeediyan M, Hosseinchari M, Edrissi F. Factor structure and psychometric properties of Difficulties in Emotional Regulation Scale. Int J Psychol Behav Sci. 2012;6:87-96. 39. Foroughi A, Khanjani S, Kazemini M, Tayeri F. Factor structure and psychometric properties of Iranian version of External Shame Scale. Shenakht J Psychol Psychiatry. 2015;2:49-58. 40. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Therapy. 2011;42:676-88. 41. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of Acceptance and Action Questionnaire-II. J Psychol Models Methods. 2013;3:65-80. 42. Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, Foa E. Psychometric properties of the Social Phobia Inventory (SPIN): new self-rating scale. Br J Psychiatry. 2000;176:379-86. 43. Yadavaia JE, Hayes SC, Vilardaga R. Using acceptance and commitment therapy to increase self-compassion: A randomized controlled trial. J Contextual Behav Sci. 2014;3:248-57. 44. Vowles KE, Sowden G, Ashworth J. A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain. Behav Therapy. 2014;45:390-401.

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45. Luoma JB, Platt MG. Shame, self-criticism, self-stigma, and compassion in acceptance and commitment therapy. Curr Opin Psychol. 2015;2:97-101. 46. Etzel JC. A diagnostic exemplar of experiential avoidance: examining shame and self-harm in battered women with PTSD. Dissertation Abstracts International: Section B: The Sciences and Engineering. 2006;66:4480. 47. Burklund LJ, Torre JB, Lieberman MD, Taylor SE, Craske MG. Neural responses to social threat and predictors of cognitive behavioral therapy and acceptance and commitment therapy in social anxiety disorder. Psychiatry Res Neuroimaging. 2017;261:52-64. 48. Craske MG, Niles AN, Burklund LJ, Wolitzky-Taylor KB, Vilardaga JCP, Arch JJ, et al. Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. J Consult Clin Psychol. 2014;82:1034. 49. Paliliunas D, Belisle J, Dixon MR. A randomized control trial to evaluate the use of acceptance and commitment therapy (ACT) to increase academic performance and psychological flexibility in graduate students. Behav Anal Pract. 2018:1-13. 50. Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behav Modif. 2007;31:772-99. 51. Blackledge JT, Hayes SC. Emotion regulation in acceptance and commitment therapy. J Clin Psychol. 2001;57:243-55. 52. Kring AM, Sloan DM, editors. Emotion regulation and psychopathology: a transdiagnostic approach to etiology and treatment. New York: Guilford; 2009. 53. Mennin DS, Fresco DM. Emotion regulation therapy. In: Gross JJ, editor. Handbook of emotion regulation. New York: Guilford; 2014. p. 469-90. 54. Morgan D. Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Abingdon: Taylor & Francis; 2003.

Correspondence: Nasrin Jaberghaderi Department of Clinical Psychology, School of Medicine Parastar Blvd, Daneshgah St, Tagh Bostan Blvd Postal Code 6714415153 - Kermanshah, Iran Tel.: +989188330086, Fax: +988334276493 E-mail: n_jg2004@yahoo.com

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Original Article

in Psychiatry and Psychotherapy

Cross-cultural adaptation of the Brazilian version of the Questionnaire on Eating and Weight Patterns-5 (QEWP-5) Adaptação transcultural da versão brasileira do Questionnaire on Eating and Weight Patterns-5 (QEWP-5) Carlos Eduardo Ferreira de Moraes,1,2 Carla Mourilhe,1,2 Sílvia Regina de Freitas,2,3 Glória Valéria da Veiga,1 Marsha D. Marcus,4 José Carlos Appolinário2

Abstract

Resumo

Introduction: The Questionnaire on Eating and Weight Patterns-5 (QEWP-5) is a self-report instrument developed to screen individuals for binge eating disorder (BED), as defined by the DSM-5. However, this version of the instrument had not been adapted for the Brazilian population. Objective: To describe translation and cross-cultural adaptation of the QEWP-5 into Brazilian Portuguese. Methods: Translation and cross-cultural adaptation of the QEWP5 included the following steps: forward translation, comparison of translations and a synthesis version, blind back-translations, comparison of the back translations with the original version, and a comprehensibility test. The comprehensibility test was conducted with a sample of 10 participants with BED or bulimia nervosa and 10 eating disorders experts. Additionally, a Content Validity Index (CVI-I) was calculated for each item and then averaged to produce an index for the entire scale (CVI-Ave), to assess content equivalence. Results: Some inconsistencies emerged during the process of translation and adaptation. However, the expert committee solved them by consensus. The participants of the comprehensibility test understood the Brazilian version of QEWP-5 well. Only 2 patients (20%) had doubts about items related to subjective binge eating episodes. Content equivalence analysis rated all items relevant, with CVI-I ranging from 0.8 to 1.0 and an overall CVI-Ave of 0.94. In view of the good overall assessment of the pre-final version of the instrument, additional changes were not made to the final version. Conclusion: The Brazilian version of the QEWP-5 was crossculturally adapted and was well understood by the target population. Further studies are required to assess its psychometric properties. Keywords: Binge eating disorder, cross-cultural adaptation, QEWP-5, bulimia nervosa.

Introdução: O Questionnaire on Eating and Weight Patterns-5 (QEWP-5) – Questionário sobre Padrões de Alimentação e Peso5 – é um instrumento auto preenchível utilizado para rastrear indivíduos com transtorno da compulsão alimentar (TCA) segundo os critérios do DSM-5. Entretanto, essa versão do instrumento ainda não foi adaptada para a população brasileira. Objetivo: Descrever a tradução e adaptação transcultural do QEWP-5 para a língua portuguesa. Métodos: O processo de adaptação transcultural incluiu as seguintes etapas: tradução, comparação das traduções e elaboração da versão síntese, retro-tradução com cegamento, comparação das retrotraduções com a versão original, e teste de compreensibilidade. O teste de compreensibilidade foi conduzido em uma amostra de 10 indivíduos com TCA ou bulimia nervosa e 10 especialistas em Transtornos Alimentares. Adicionalmente, foram calculados o Índice de Validade de Conteúdo para cada item (IVC-I) e para a média da escala (IVC-M), para avaliar a equivalência de conteúdo. Resultados: Durante o processo de tradução e adaptação surgiram algumas discrepâncias. No entanto, elas foram solucionadas por meio de consenso do comitê de especialistas. No teste de compreensibilidade, a versão brasileira do QEWP-5 foi bem compreendida pelos participantes. Somente 2 participantes (20%) apresentaram questionamentos sobre itens relacionados aos episódios de compulsão alimentar subjetivos. Em relação à equivalência de conteúdo, todos os itens foram avaliados como relevantes, com o IVC-I variando de 0,8 a 1,0. Ademais, o IVC-M foi 0,94. Considerando a boa avaliação geral da versão pré-final do instrumento, não foram realizadas alterações na versão final. Conclusão: A versão brasileira do QEWP-5 foi adaptada transculturalmente e bem compreendida pela população-alvo. Estudos adicionais são necessários para avaliar suas propriedades psicométricas. Descritores: TCA, adaptação transcultural, QEWP-5, bulimia nervosa.

1 Departamento de Nutrição Social e Aplicada (DNSA), Instituto de Nutrição Josué de Castro (INJC), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. 2 Grupo de Obesidade e Transtornos Alimentares (GOTA), Instituto de Psiquiatria, UFRJ, Rio de Janeiro, RJ, Brazil. 3 Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, RJ, Brazil. 4 Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.

This article is based on the first author’s dissertation titled “Questionnaire on Eating and Weight Patterns-5 – QEWP-5 (Questionário sobre Padrões de Alimentação e Peso-5): tradução, adaptação transcultural e estudo de confiabilidade,” presented at Departamento de Nutrição Social e Aplicada (DNSA), Instituto de Nutrição Josué de Castro (INJC), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil, in 2019. Submitted Apr 02 2019, accepted for publication Jun 06 2019. Epub Mar 02 2020. Suggested citation: Moraes CEF, Mourilhe C, Freitas SR, Veiga GV, Marcus MD, Appolinário JC. Cross-cultural adaptation of the Brazilian version of the Questionnaire on Eating and Weight Patterns-5 (QEWP-5). Trends Psychiatry Psychother. 2020;42(1):39-47. http://dx.doi.org/10.1590/2237-6089-2019-0029

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Trends Psychiatry Psychother. 2020;42(1) – 39-47

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

Introduction Binge-eating disorder (BED) is an eating disorder recognized in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5),1 and characterized by recurrent episodes of binge eating (eating an unusually large amount of food associated with a sense of loss of control over eating). Additionally, there is marked distress related to these episodes. In BED, binge eating occurs at least once a week over a 3-month period and is not followed by the inappropriate compensatory behaviors seen in bulimia nervosa (BN).1 Additionally, binge episodes must be associated with at least 3 of the following symptoms: eating more rapidly than normal, eating until feeling uncomfortable, eating large amounts of food when not physically hungry, eating alone because of embarrassment over the amount of food being consumed, or having feelings of disgust, guilt, or depression following these episodes. BED is the most common eating disorder2 and is associated with physical, psychological, and functional impairment.3 The definition of a binge eating episode is one of the difficulties involving diagnosis of BED. Binge eating is defined as: 1) eating in a discrete period of time (usually less than 2 hours), a quantity of food definitely larger than most people would eat under similar circumstances; and 2) a sense of lack of control (feeling that one could not stop or control what or how much one is eating). This central component of BED diagnosis, also called objective binge eating (OBE) is difficult to assess because there is no exact definition of what is considered “a quantity of food definitely larger than most people would eat,” and also because the sense of lack of control is based only on one’s own perception.1,4 Several instruments have been developed to assess symptoms of eating disorders and to assess binge eating. The most widely used measures include: 1) the Eating Disorders Examination – Questionnaire (EDE-Q),5 a self-report version of the EDE interview6 developed to assess the frequency and severity of eating disorder behaviors and psychopathology; 2) the Binge Eating Scale (BES),7 developed to assess binge eating severity in individuals with obesity (The BES has been adapted for Portuguese8 and validated in obese Brazilian women)9; and 3) the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R),10 which is designed to screen individuals for BED, as diagnosed by the DSM-IV.11 The QEWP-R has been adapted and validated for the Brazilian population.12 As a result of changes made in the DSM-5, instruments developed to assess BED according to previous criteria needed to be updated in line with the current diagnostic criteria. The QEWP-R was therefore updated as the 40 – Trends Psychiatry Psychother. 2020;42(1)

QEWP-5,13 a 26-item questionnaire that includes the following modifications: 1) revision of the frequency of binge eating and compensatory behaviors; 2) revision of the threshold for inappropriate compensatory behaviors - exclusion criteria; 3) removal of some questions that were not related to the diagnostic criteria; 4) incorporation of questions to assess subjective binge eating – SBE (loss of control eating in the absence of consuming a large quantity of food); and 5) revision of the decision rules for diagnosis.13 However, to date, the QEWP-5 has not been translated into or adapted for Portuguese. Cross-cultural adaptation of the QEWP-5, following international guidelines, is therefore essential to make available a correctly translated instrument for use in Brazilian settings. The present study aims to describe the process of cross-cultural adaptation of the QEWP-5 for Brazilian Portuguese.

Methods Permission to cross-culturally adapt the scale for Brazilian Portuguese was requested from and granted by the original authors of the QEWP-5. We began a process of symmetrical translation based on the stages proposed by Sousa & Rojjanasrirat.14 This methodology involves the following five steps: Forward translation Forward translations were conducted by two independent bilingual eating disorder specialists (T1 and T2), whose native language is Brazilian Portuguese. They produced two versions (T1 and T2) of the instrument. Comparison of the translations and synthesis version A third eating disorder specialist with experience in translation, adaptation, and validation of scales compared the two different translations (T1 and T2) with the original version of the QEWP-5 and evaluated any semantic inconsistencies (including any linguistic or conceptual issues). After these comparisons, a merged and synthesized version of the two translations was produced (SV). The three translated versions (T1, T2 and SV) were presented to an eating disorders expert committee (three psychiatrists, one dietitian and one psychologist). Ambiguities and discrepancies were discussed, and consensus was achieved, with participation of all three translators. This process generated the preliminary version (PV) of the translated instrument.

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

Blinded back-translation The PV was back translated into English by two other independent translators whose native language was English, but who had different profiles. The first was experienced in psychiatric terminology and the second translator was more familiar with colloquial phrases and emotional terms in English. They were blinded to the original version of the QEWP-5. This process resulted in two back-translated versions (BTL-1 and BTL-2) of the instrument. Comparison of the back-translations The two back-translations were compared with the original instrument. One of the developers of the original version of the QEWP-5 participated in this step, evaluating both BTL-1 and BTL-2. This step generated the pre-final version (PFV) of the QEWP-5 in Brazilian Portuguese. Comprehensibility The PFV was tested on 20 participants (10 patients and 10 experts) as proposed by Sousa and Rojjanasrirat.14 The comprehensibility of the PFV was pilot tested with 10 participants recruited from the Obesity and Eating Disorders Group (Universidade Federal do Rio de Janeiro), previously diagnosed with BED and BN according to the DSM-5 diagnostic criteria. Their native language was Brazilian Portuguese. They all read, answered and rated a form containing questions about the comprehensibility of the items using a dichotomous scale (clear or unclear). They were also asked to provide suggestions for items they rated as unclear. Items rated unclear by at least 20% of the participants were revised. Next, a group of 10 eating disorder experts (who were not on the initial expert committee) were invited to evaluate the comprehensibility and relevance of the items on the scale. First, each expert rated the items as clear or unclear, and provided suggestions to make the language clearer. They then evaluated content equivalence using the following ratings: 1) not relevant; 2) unable to assess relevance; 3) relevant but needs minor alteration; 4) very relevant and succinct.15 Items rated as unclear by at least 20% of the experts (comprehensibility evaluation) and classified as 1 or 2 on the relevance scale were revised. Finally, a Content Validity Index (CVI) was calculated for each item (CVI-I) and then averaged to produce an index for the entire scale (CVI-Ave). The minimum cutoffs for acceptability were an individual CVI-I of 0.78 or above15 and a CVIAve of 0.90 or above.16 This study was approved by the ethics committee at Instituto de Psiquiatria, Universidade Federal do Rio de

Janeiro (UFRJ), Rio de Janeiro, Brazil. Written informed consent was obtained from all study participants before any of the study procedures were performed.

Results Translation, cross-cultural adaptation Certain semantic inconsistencies emerged during the process of Portuguese translation and cultural adaptation of the QEWP-5. The three translators (T1, T2, and SV) made a special effort to use colloquial expressions/ phrases to make the scale easily understood by the target population. Although they produced quite similar translations, there were ambiguities in certain items. Table 1 shows comparisons between T1, T2, SV, and the original version of QEWP-5 for the most debated items. With relation to item 9, for example, the translators disagreed on how to translate the expression “during the times” (in Portuguese “nas ocasiões” or “nas vezes”). In the final version, the final consensus was to use “nas vezes.” In items 11 and 23, the expression “feeling disgusted with yourself” was initially translated as “sentir repugnância por si mesmo.” However, in the SV this expression was changed to “sentir repulsa por si mesmo,” because the Portuguese version of DSM-5 uses the word “repulsa” to describe one of the symptoms associated with binge eating. There was also disagreement on how to translate to the word “upset” in items 13 and 25. The Portuguese word chosen in the final version was “perturbaram,” because it was considered that this expression best describes the distress associated with binge eating. Item 26 about parents’ silhouettes was the subject of some debate. The consensus was that the Portuguese translations used in T1 and T2 versions for “If you have no knowledge of your biological father and/or mother, don’t circle anything for that” was difficult to understand (in Portuguese, “Se você não conhece seu pai e/ou sua mãe biológicos não circule aquele que não conhece”). In the SV, this sentence was therefore changed for the following Portuguese expression “se você não conhece seu pai e/ou mãe biológicos, não circule nada para esse pai e/ou mãe, isto é, circule apenas para o pai e/ou mãe biológicos que você conhece.” However, since the silhouettes were introduced in QEWP-5 for research purposes only and are not a diagnostic item, they can be omitted without prejudice. An expert committee evaluated and compared the SV with the original version of QEWP-5. This group suggested some changes to address inconsistencies. Table 2 shows a summary of the items modified after the expert panel and Trends Psychiatry Psychother. 2020;42(1) – 41

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

Table 1 - Comparison of the original version, translation 1, translation 2, and the synthesis version of the QEWP-5 (items 9, 11, 13, 23, and 26). Item

Original version

Translation 1

Translation 2

Synthesis version

During the times when you ate an unusually large amount of food, did you ever feel you could not stop eating or control what or how much you were eating?

Nas ocasiões em que você comeu quantidades de comida que a maioria das pessoas consideraria demais, você sentiu que não conseguia parar de comer ou controlar o que ou quanto comia?

Nas vezes em que você comeu uma quantidade excepcionalmente grande de comida, você sempre sentia que não poderia parar de comer, nem controlar o que e o quanto você estava comendo?

11e 23e

Feeling disgusted with yourself, depressed, or feeling very guilty afterward?

Sentia repugnância por você mesmo, muita culpa ou depressão após o episódio de excesso alimentar?

Sentir repugnância por si mesmo, muito culpado ou deprimido logo após o episódio

Sentir-se desgostoso consigo mesmo, deprimido ou muito culpado depois do episódio?

In general, during the past three months, how upset were you by these episodes (when you ate a large amount of food and felt your eating was out of control)?

De modo geral, nos últimos três meses, quanto você se aborreceu por causa desses episódios (quando você comeu grandes quantidades de comida e sentiu que não conseguia parar de comer ou controlar o que/ quanto comia)?

De modo geral, nos últimos três meses, quanto você se aborreceu por causa destes episódios (em que comeu grandes quantidades de comida e sentiu que a sua alimentação estava fora de controle)?

Em geral, durante os últimos três meses, quanto esses episódios perturbaram você (os episódios em que você comeu uma grande quantidade de comida e sentiu que a sua alimentação estava fora do controle)?

Please take a look at these silhouettes. Put a circle around the silhouettes that most resemble the body builds of your biological father and mother at their heaviest. If you have no knowledge of your biological father and/or mother, don’t circle anything for that

Por favor, observe essas silhuetas. Circule aquela que mais se assemelha ao feitio do corpo de seu pai e/ou sua mãe

Por favor, observe essas silhuetas. Circule aquela que mais se assemelha ao feitio do corpo de seu pai e sua mãe biológicos no seu peso mais alto. Se você não conhece seu pai e/ou mãe biológicos, não circule aquele que conhece.

Table 2 - Examples of items changed after the panel of experts: Comparison of the original version, synthesis version (SV), preliminary version (PV), back-translations (BTL-1 and BTL-2) and the final version (FV) of the QEWP-5 Item

Original version

BTL-1

BTL-2

During the times when you ate an unusually large amount of food, did you ever feel you could not stop eating or control what or how much you were eating?

Nas vezes em que você comeu uma quantidade excepcionalmente grande de comida, você sempre sentia que não poderia parar de comer, nem controlar o que e o quanto você estava comendo?

Nas vezes em que você comeu uma quantidade excepcionalmente grande de comida, você alguma vez sentiu que não poderia parar de comer ou controlar o que ou o quanto você estava comendo?

The times you ate a quantity exceptionally large, did you ever feel that you could not stop eating or control what or how much you were eating?

When you have eaten an unusually large amount of food, have you ever felt that you couldn’t stop eating or control what or how much you were eating?

Nas vezes em que você comeu uma quantidade excepcionalmente grande de comida, você alguma vez sentiu que não poderia parar de comer ou controlar o que ou o quanto você estava comendo?

During the past three months, how often, on average, did you have episodes like this -- that is, eating large amounts of food plus the feeling that your eating was out of control? (There may have been some weeks when this did not happen -- just average those in.)

Durante os últimos três meses, com que frequência, em média, você teve episódios como esse – isto é, episódios em que comia grandes quantidades de comida com a sensação de que sua alimentação estava fora do controle? (Pode ter havido algumas semanas em que isto não aconteceu – calcule a média..).

Durante os últimos três meses, com que frequência, em média, você teve episódios como esse – isto é, episódios em que comeu grandes quantidades de comida acompanhado da sensação de que sua alimentação estava fora do controle? (Pode ter havido algumas semanas em que isto não aconteceu – dê uma média).

During the last three months, how often, on average, did you have episodes like this – that is, episodes when you ate large quantities of food accompanied by the sensation that your eating was out of control? (There could have been some weeks when this did not happen – give an average).

In the last three months, how often on average did you have episodes like this – in which you ate large amounts of food along with the feeling that your eating was out of control? (There may have been some weeks when this didn’t happen – give an average).

12c 24c

As best you can remember, please list everything you ate and drank during that episode. Please list the foods eaten and liquids consumed during the episode. Be specific include brand names where possible, and amounts or portion sizes as best you can estimate.

Por favor, procure se lembrar da melhor forma possível e escreva abaixo tudo o que você comeu e bebeu durante esse episódio. Por favor, faça uma lista dos alimentos ingeridos e dos líquidos consumidos durante o episódio. Seja detalhista – inclua os nomes das marcas onde for possível e estime as quantidades ou o tamanho das porções com a máxima precisão que puder

Please try to remember as best as possible and write below everything you ate and drank during this episode. Please make a list of foodstuffs ingested and liquids consumed during the episode. Be detailed – include the names of the brands when possible and estimate the quantities or portion sizes with the highest precision you can.

Please try to remember as best as you can and write below what you ate and drank during this episode. Please make a list of the foods you ate and the liquids you drank during the episode. Be detailed – include the brand names whenever possible and estimate the amounts or size of the servings as accurately as you can.

Continued on next page

42 – Trends Psychiatry Psychother. 2020;42(1)

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

the respective comparisons between the original version, SV, PV, the back-translations and the final version of the QEWP-5. Ambiguities affecting items 10, 12c, 22, and 24c were solved. For items 10 and 22 (about frequency of OBE and SBE, respectively), the expression “just average those in” was translated to “dê uma média” in the PV.

There was consensus in the committee that questions 12c and 24c (describing a typical binge eating episode) should not suggest examples of brands or quantities of foods, to avoid inducing answers. After this step, some additional suggestions made by the eating disorder experts were incorporated into

Table 2 (cont.) Item

Original version

BTL-1

BTL-2

During the past three months, did you ever exercise excessively –for example, exercised even though it interfered with important activities or despite being injured –specifically in order to avoid gaining weight after episodes of eating like you described (when you ate a large amount of food and felt your eating was out of control)?

Durante os últimos três meses, você alguma vez se exercitou excessivamente por exemplo, fez exercícios mesmo quando eles interferiam em importantes atividades ou mesmo estando machucado – especificamente para evitar ganhar peso após ter tido episódios como esses que você descreveu (em que comeu grandes quantidades de comida e sentiu que a sua alimentação estava fora de controle)?

Durante os últimos três meses, você alguma vez se exercitou excessivamente – por exemplo, fez exercícios mesmo quando eles interferiam em atividades importantes ou mesmo estando machucado – especificamente para evitar ganhar peso após ter tido episódios como esses que você descreveu (em que comeu grandes quantidades de comida e sentiu que a sua alimentação estava fora de controle)?

During the last three months, did you ever exercise excessively – for example, you exercised even when it interfered with important activities or while injured – specifically to avoid gaining weight after having had episodes like those that you described (when you ate a large quantity of food and felt that your eating was out of control)?

In the last three months, have you ever over-exercised – for example, exercised even when it interfered in important activities or even when you were hurt – specifically to avoid gaining weight after having episodes like the ones you described (in which you ate a large amount of food and felt that your eating was out of control)?

During the last three months, did you ever have episodes when you felt you could not stop eating or control what or how much you were eating, but you did not consume a quantity of food which the majority of people would consider exceptionally large?

Durante os últimos três meses, algumas vezes, você teve episódios durante os quais você sentiu que não poderia parar de comer, nem controlar o que ou quanto você estava comendo, mas nos quais você não consumiu uma quantidade de comida que a maioria das pessoas consideraria excepcionalmente grande?

Durante os últimos três meses, alguma vez você teve episódios durante os quais você sentiu que não poderia parar de comer ou controlar o que ou o quanto você estava comendo, mas nos quais você não consumiu uma quantidade de comida que a maioria das pessoas consideraria excepcionalmente grande?

In last three months, have you had episodes in which you felt you couldn’t stop eating or controlling what or how much you were eating, but you did not consume an amount of food that most people would consider unusually large?

During the past three months how often did you have episodes like this -- the feeling that your eating was out of control, but you did not consume what most people would think was an unusually large amount of food? (There may have been some weeks when this did not happen --just average those in.)

Durante os últimos três meses, com que frequência você teve episódios como esse - sentiu que a sua alimentação estava fora de controle, mas você não consumiu uma quantidade de comida que a maioria das pessoas consideraria excepcionalmente grande? (Pode ter havido algumas semanas em que isto não aconteceu – calcule a média...).

During the last three months, how often did you have episodes like this - you felt that your eating was out of control, but you did not consume a quantity of food which the majority of people would consider exceptionally large? (There could have been some weeks when this did not happen – give an average).

In the last three months, how often have you had episodes like this – when you felt your eating was out of control, but you did not consume an amount of food that most people would consider unusually large? (There may have been weeks when this did not happen– give an average).

In general, during the past three months, how upset were you by these episodes (that is, when you felt you could not stop eating or control what or how much you were eating but in which you did not consume an unusually large amount of food)?

De modo geral, nos últimos três meses, quanto você se aborreceu por causa destes episódios (em que sentiu que não poderia parar de comer ou controlar o que, ou como estava comendo, entretanto nestes episódios você não consumiu uma quantidade de comida que a maioria das pessoas consideraria excepcionalmente grande)?

Em geral, durante os últimos três meses, quanto esses episódios chatearam você (os episódios em que você sentiu que não poderia parar de comer ou controlar o que ou o quanto você estava comendo, mas no qual você não consumiu uma quantidade de comida excepcionalmente grande)?

In general, during the last three months, how much did these episodes bother you (episodes when you felt you could not stop eating or control what or how much you were eating, but you did not consume an exceptionally large quantity of food)?

In general, in the last three months, how much did these episodes bother you (the episodes in which felt you could not stop eating or control what or how much you were eating, but you did not consume an usually large amount of food)?

Trends Psychiatry Psychother. 2020;42(1) – 43

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

to the SV, resulting in the PV. This version was back translated to English. BTL-1 and BTL-2 were sent to the author of the original version of QEWP-5. Additionally, detailed explanations of each change made to the Portuguese version of the instrument were provided. All alterations were approved by the author. The PFV was then generated and the pilot test was conducted. Comprehensibility The PFV was pilot tested on ten patients (two men and eight women) diagnosed with BED (n = 7) and BN (n = 3), to evaluate the instructions and the items and to ask them questions regarding the comprehensibility of the QEWP-5. The participants had a mean age of 37.5 years (SD = 10.5) and 80% of them had a college degree. Table 3 shows percentage comprehension ratings from the patients and eating disorder experts for the PFV. The Brazilian version of the QEWP-5 was well understood by the patients. The main doubts were related to the expression defining SBE (questions 21,

23, and 24). In item 21, one participant considered the expression in Portuguese “mas nos quais” very formal and difficult to understand. In addition, in item 23, one participant questioned the consistency of sub-items b (in Portuguese, “Comer até se sentir desconfortavelmente cheio”) and c (in Portuguese, “Comer grandes quantidades de comida sem estar fisicamente com fome”). The patient pointed out that if the item were related to SBE (when there is a sense of loss of control without consuming a large amount of food), these two sub-items did not make sense because they are related to objective binge eating (consider the ingestion of a large quantity of food). Finally, in item 24 (about the characteristics of a typical SBE episode), one participant asked if the question was similar to item 12 (about the characteristics of a typical OBE episode). Also, two patients asked if they could describe more than one episode of SBE. A group of ten experts in eating disorders (five psychiatrists, two nutritionists, two psychologists, and one nurse) was invited to evaluate the instructions,

Table 3 - Comprehensibility (patients and eating disorder experts) and relevance (eating disorder experts) of items in the Brazilian version of QEWP-5 Item

Patients

Eating disorder experts

Clear

Unclear

Clear

Unclear

CVI-I

100%

0.9

100%

0.9

100%

0.9

100%

80%

20%

0.9

100%

90%

10%

0.9

100%

0.9

100%

0.9

80%

20%

90%

10%

90%

10%

100%

0,00%

100%

90%

10%

70%

30%

90%

10%

80%

20%

0.9

100%

40%

60%

100%

40%

60%

100%

70%

30%

100%

0,00%

100%

50%

90%

10%

100%

80%

20%

100%

0.9

100%

0.9

80%

20%

60%

40%

0.9

70%

30%

80%

20%

0.8

90%

10%

90%

10%

0.9

90%

10%

80%

20%

CVI-Ave 44 – Trends Psychiatry Psychother. 2020;42(1)

0.9 0.94

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

items and response options on the PFV, in terms of clarity and relevance (Table 3). They suggested some modifications to the questions about inappropriate compensatory behaviors (items 15 to 19). The group proposed removing the expression in Portuguese “dose recomendada,” because it could suggest that there is a recommended dose of medications to avoid weight gain. However, we decided to retain the expression, because it is related to measurement of quantities of medications taken. In common with the patients’ evaluation, some of the experts (40%) considered item 23 (about SBE) unclear. After discussion with the experts, we decided to maintain the items related to SBE as they were, because these items are not used to diagnose BED. They were included in the original instrument for research purposes only. It is important to take into account that only items 8 and 9 (about binge eating), 10 (binge eating frequency), 11 (associated symptoms during the episode), 13 (distress regarding binge eating), and 14 through 19 (inappropriate compensatory behaviors) are BED diagnosis items. The PFV of the Brazilian QEWP-5 was considered relevant on the basis of its content equivalence. All 26 items were rated with a CVI of 0.80 or higher. Additionally, the CVI-Ave was 0.94. Participants took a mean time of 12 minutes to answer the questionnaire. In general, the PFV was well evaluated. Therefore, we did not make changes to the final version. The layout of the original version was maintained. The instrument was given the Portuguese name “Questionário sobre Padrões de Alimentação e Peso-5 (QEWP-5)” (see online-only supplementary material).

Discussion The QEWP-513 is an updated version (based on DSM5) of a widely-used self-report instrument (QEWP-R)17 for BED screening. This article describes the translation and cross-cultural adaptation of the QEWP-5 into Brazilian Portuguese. To our knowledge, this is the first cross-cultural adaptation of this instrument. The process followed internationally accepted standards, comprising the stages forward translation, comparison of translations and synthesis version, blinded backtranslations, comparison of the back translations with the original version, and an evaluation of comprehensibility. The Brazilian Portuguese version of the QEWP-5 was successfully cross-culturally adapted for future validation and application in Brazil. The process of cross-cultural adaptation of instruments needs to follow rigorous and standardized 1

guidelines to generate a reliable translated instrument.14 This is an essential procedure that enables comparison of results obtained from samples with different cultural backgrounds.18 Although there is no consensus on the best methodological approach, international guidelines on this process do agree that symmetrical translation should be conducted, following a “road map” comprising forward translations, back translations, experts’ panel, and pre-testing.14,19,20 Unlike the QEWP-R,17 which was based on the DSMIV-TR,21 the QEWP-513 contains the current diagnostic criteria for BED. The major change made to the BED criteria in the DSM-5 was related to the minimum average frequency of binge eating required for diagnosis.1 Thus, the QEWP-5 incorporates the DSM-5 frequency threshold of “at least one binge eating episode per week over the last 3 months,”1 rather than the DSMIV-TR21 criterion of “at least two binge days a week for 6 months.”11 Another change made in the QEWP-5 was to alter the threshold for inappropriate compensatory behaviors. In the QEWP-R,17 the threshold for misuse in terms of compensatory behaviors was “taking more than twice the recommended dose of medications to avoid weight gain.” In contrast, in the QEWP-5,13 taking more than the recommended dose of diuretics, obesity drugs, or laxatives is considered misuse. Another important change in the QEWP-5 was inclusion of questions to assess SBE. SBE describes episodes in which eating is out of control, but the amount of food is not considered unusually large.6 There is evidence showing that SBE can cause marked distress and impairment to individuals who experience it, similar to OBE.22 The 11th edition of the International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11) therefore included both OBE and SBE in the diagnostic criteria for BED.23,24 Therefore, the QEWP-5 can also potentially be used to assess BED according to ICD-11 criteria. It is important to highlight that the main doubts raised in the comprehensibility test were related to items assessing SBE. One possible explanation is that the expression “an amount of food not considered unusually large” is ambiguous. We therefore consider that the problem lies in the definition of SBE itself and not specifically with the question asked in the QEWP-5. Along the same lines, Mitchell et al.25 have commented that it is difficult to distinguish OBE from SBE in individuals with BED, especially when self-report instruments (like the QEWP-5) are used. The level of agreement between self-report instruments and clinical interviews for assessment of OBE and SBE tends to be low.25 In a study that compared the EDE interview with the EDE-Q for assessment of the features of eating Trends Psychiatry Psychother. 2020;42(1) – 45

Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

disorders in patients with BED, Grilo et al.26 found that SBE frequencies assessed with the EDE and the EDE-Q were not significantly correlated and that the magnitude of the difference between them was large. These authors concluded that the EDE-Q may therefore underestimate SBE frequency.26 The present study has some limitations. First, although the sample size analyzed for the comprehensibility test was that recommended by the guideline followed when conducting the cross-cultural adaptation,14 it could nevertheless be considered too small for generalization of the findings. Second, the fact that all participants in the comprehensibility test were patients from an outpatient eating disorder service limits generalization of results to individuals with other characteristics. Diagnosing BED is challenging. Several aspects related to binge eating episodes, such as the amount of food eaten, the presence of loss of control over eating and the frequency of the episodes, among others, are sometimes difficult to capture for non-specialists in eating disorders. Unfortunately, in Brazil only the previous version of QEWP (the QEWP-R) is currently available,12 which does not include the most recent changes in the DSM-51 criteria, and also the BES,8 which is not appropriate for categorical diagnosis. This Portuguese version of the QEWP-5 will therefore be very useful, filling the gap left by lack of an instrument for screening that enables a researcher or clinician to assign a DSM-5 diagnosis of BED and BN.

Conclusion The Brazilian Portuguese version of the QEWP5 was correctly adapted. Items were well understood by the target population. This version is available for Brazilian research and clinical settings. The instrument’s psychometric properties should be assessed in clinical and non-clinical settings in the next steps of its application.

Acknowledgements José Carlos Appolinário has received research grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). The authors are grateful to João Hiluy, Bruno Palazzo Nazar, Marcelo Papelbaum, Maria Francisca Mauro, Arnaldo Cascardo, Maene Cristine, Livia Menescal, Adriana Daquer and Amanda Rodrigues for their assistance in the process of translation of the QEWP-5. 46 – Trends Psychiatry Psychother. 2020;42(1)

Disclosure Marsha D. Marcus is a member of the Scientific Advisory Board of WW International, Inc. José Carlos Appolinário has received research grants, consultancy fees, and advisory board fees from Shire Pharmaceuticals. No other conflicts of interest declared concerning the publication of this article.

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Cross-cultural adaptation of Brazilian QEWP-5 - Moraes et al.

22. Latner JD, Clyne C. The diagnostic validity of the criteria for binge eating disorder. Int J Eat Disord. 2008;41:1-14. 23. First MB, Reed GM, Hyman SE, Saxena S. The development of the ICD-11 clinical descriptions and diagnostic guidelines for mental and behavioural disorders. World Psychiatry. 2015;14:82-90. 24. Reed GM, First MB, Elena Medina-Mora M, Gureje O, Pike KM, Saxena S. Draft diagnostic guidelines for ICD-11 mental and behavioural disorders available for review and comment. World Psychiatry. 2016;15:112-3. 25. Mitchell JE, Devlin MJ, Zwaan M De, Crow SJ, Peterson CB. Diagnosis and epidemiology of binge-eating disorder. In: Mitchell JE, Devlin MJ, Zwaan M De, Crow SJ, Peterson CB, editors. Bingeeating disorder: clinical foudations and treatment. New York: Guilford; 2008. p. 3-86.

26. Grilo CM, Masheb RM, Wilson GT. Different methods for assessing the features of eating disorders in patients with binge eating disorder: a replication. Obes Res. 2001;9:418-22.

Correspondence: Carlos Eduardo Ferreira de Moraes Grupo de Obesidade e Transtornos Alimentares (GOTA) Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro Av. Venceslau BrĂĄs, 71, Campus Praia Vermelha, Botafogo 22290-140 - Rio de Janeiro, RJ - Brazil Tel: +55 (21) 995663661 E-mail: carloseduardofm09@gmail.com

Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 47

Trends

Original Article

in Psychiatry and Psychotherapy

Analysis of psychiatrists’ prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States Kevin Pan,1

Shawgi Silver,2 Charles Davis3

Abstract Introduction: The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. Objective: To describe psychiatrists’ prescription of opioid, benzodiazepine, and buprenorphine in the United States. Methods: We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists’ prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. Results: In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. Conclusions: The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription. Keywords: Psychiatry, addiction, geriatric psychiatry, opioid, addiction treatment.

Introduction The opioid abuse crisis is a dangerous and growing problem in many parts of the world.1-3 For example, in Brazil, while the drug monitoring program has been successful at keeping opioid prescriptions low,4 the sales of prescription opioids still increased by more than 450% between 2009 and 2015.5 The opioid epidemic is

especially significant in the United States, where opioid overdose deaths account for more than 60% of all drug overdose deaths.6 In addition, 40% of the opioid overdose deaths are due to prescription opioids.7 As nations around the world search for ways to curb the opioid crisis, it would be interesting to examine the role of psychiatrists in this scenario. Psychiatrists, among all specialties, should have a minimal contribution

Department of Economics, Finance, and Quantitative Analysis, Samford University, Birmingham, AL, USA. University of Washington, Seattle, WA, USA. 3 Christ Health, Birmingham, AL, USA.

Department of Child and Adolescent Psychiatry,

Submitted Mar 01 2019, accepted for publication Jun 17 2019. Suggested citation: Pan K, Silver S, Davis C. Analysis of psychiatrists’ prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States. Trends Psychiatry Psychother. 2020;42(1):48-54. http://dx.doi.org/10.1590/2237-6089-2019-0015 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 48-54

Psychiatrists’ prescription in Medicare Part D - Pan et al.

to opioid prescription. However, it would be relevant to know if psychiatrists contribute to the opioid crisis indirectly. An important factor in opioid overdose death is the concurrent prescription of benzodiazepine, one of the most frequently prescribed medications for anxiey.8 Concurrent use of benzodiazepine and opioid can exacerbate overdose death, and the overdose mortality rate has increased drastically in the last two decades, with increasing concurrent prescriptions of opioid and benzodiazepine.9,10 In the study of opioid and benzodiazepine prescriptions, one particular population of interest is the elderly population, because of the increased prescriptions of benzodiazepines in this age group.8 Additionally, with the elderly patients susceptible to suicide,11 there is a dangerous association between opioid abuse and suicidal attempts in the geriatric patient population: geriatric patients with suicidal ideation can consume more opioid and benzodiazepine, which could result in overdose death.12-14 In the United States, many of the elderly patients are covered by Medicare, an insurance plan for Americans who are 65 years or older and patients with certain disabilities. A particular part of Medicare is Medicare Part D, which is an optional coverage plan for prescription drugs. When a beneficiary becomes eligible, he or she can choose to enroll in the Medicare Part D plan.15 Once a beneficiary is enrolled, qualified prescription medications can be covered by the plan. Even though it is optional, many patients choose to enroll in it: more than 43 million beneficiaries are enrolled in the optional Medicare Part D today, accounting for more than 1 billion prescriptions and USD 80 billion in claims each year.16 Of the total prescriptions written for Medicare Part D patients, more than 78 million were written for opioids in 2016.17 Furthermore, more than 6 of every 1,000 Medicare beneficiaries have opioid use disorder, which is among the highest rates considering all patient groups.18 Meanwhile, psychiatrists could play an important role in the treatment of opioid addiction. One approach is to treat opioid addiction using buprenorphine, a partial opioid receptor agonist that has been shown to be an effective maintenance treatment for opioid dependence.19 To be able to prescribe buprenorphine in the United States, a physician has to obtain a waiver from the Drug Enforcement Administration (DEA); among all physicians that have obtained a waiver to prescribe buprenorphine, 41.6% were psychiatrists.20 Previously, the relative ratio of opioid and opioid agonist treatment has been examined for each specialty,21 but the overall contribution of psychiatrists to all buprenorphine prescriptions was not reported.

In addition to buprenorphine, another approach to combat opioid addiction is extended-release naltrexone, formulated as naltrexone microspheres, a monthly injectable opioid antagonist.22 Previous data showed that buprenorphine and extended-release naltrexone had similar safety and effectiveness, once initiated.23 In this paper, we seek to describe psychiatrists’ prescriptions of opioid, benzodiazepine, buprenorphine and naltrexone microspheres using the Medicare Part D Provider Utilization and Payment Data for year 2016. We examine the percentage of prescriptions coming from psychiatrists for each of these medications, and also analyze the geographical distribution of the percentages.

Methods Following Chen et al.,16 we used the Medicare Provider Utilization and Payment Data: Part D for our analysis.24 The study was considered by the university’s institutional review board to be exempt from approval, as it only used existing publicly available data. This study was a retrospective, cross-sectional study: we were interested in having a cross-sectional view of opioid, benzodiazepine, and buprenorphine prescriptions in the United States. For the cross-sectional analysis, we used the most recent year then available, which was year 2016. For our analysis, we adopted the same list of opioids defined by the Medicare Provider Utilization and Payment Data, which contains 93 opioids, including fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tramadol.24 The complete list of opioids is available at the Medicare Provider Utilization and Payment Data website.24 Benzodiazepines include clonazepam, lorazepam, and alprazolam. We followed the same inclusion and exclusion criteria defined by the Medicare Provider Utilization and Payment Data, i.e., prescribers with fewer than 11 claims were excluded from analysis; only prescribers with 11 or more claims were included.24 Therefore, in order to be considered an opioid prescriber, at least 11 opioid claims had to be found on the system for that presciber. These inclusion and exclusion criteria helped to protect identifiable patient information. We calculated ratios representing total drug claims per prescriber and opioid claims per prescriber, as follows: All Claims Per Prescriber =

Σ Total Claim Count Number of Prescribers

Trends Psychiatry Psychother. 2020;42(1) – 49

Psychiatrists’ prescription in Medicare Part D - Pan et al.

Opioid Claims Per Prescriber =

Σ Opioid Claim Count Number of Prescribers

For each prescriber specialty, the opioid prescription was calculated as follows24: Opioid Prescription Rate =

Opioid Claim Count Total Claim Count

All the analyses in this study refer to population statistics, as we examined the complete set of Medicare Part D data, which included all providers in Medicare Part D. As a result, all numbers reported are population statistics, not sample statistics. Therefore, sample statistics measures such as p-values are not applicable in this study. Analyses were performed using Microsoft Excel (Microsoft Inc.) and Tableau Desktop software (Tableau Inc.). Geographical distribution was analyzed using the location information available in Medicare Part D data, namely, prescriber state and city. This allowed us to find the number of claims among all prescribers in each state. Likewise, we were able to calculate the percentages of each state. Computationally, geographical analysis and charting were performed using Tableau Desktop software.

Results Opioid prescription analysis Table 1 shows the number and percentage of prescribers who were psychiatrists. There were a total of 1,131,550 prescribers of all specialties in Medicare Part D, 2016. Among them, 25,528 were psychiatrists, accounting for 2.3% of all prescribers. In terms of opioid prescription claims, there were a total of 78,145,305 claims among all prescribers. Psychiatrists accounted

for only 131,115 opioid claims, i.e., 0.2% of all opioid claims. Table 1 also shows the opioid prescription rates of psychiatrists in comparison with all prescribers. Among all prescribers, 44.2% prescribed opioids, and the overall opioid prescription rate was 5.4%. Among psychiatrists, 8.9% prescribed opioids, and the overall opioid prescription rate was 0.3%. Figure 1 shows the geographical distribution of the percentages of opioid claims accounted for by psychiatrists in the 48 states (Alaska and Hawaii are not shown in the figure but were included in the analysis) in the United States. The states with the highest percentages were West Virginia, Rhode Island, and Kansas. In these three states, psychiatrists accounted for 0.81% of all opioid prescriptions. In all other states, psychiatrists accounted for less than 0.33% of all opioid prescriptions. Benzodiazepine prescription analysis Table 1 also shows the number and percentage of benzodiazepines prescribed by psychiatrists among all prescribers in Medicare Part D in 2016. There were 33,640,456 benzodiazepine claims, of which 5,820,447 were prescribed by psychiatrists. In other words, psychiatrists accounted for 17.3% of benzodiazepine claims. Table 1 also shows the benzodiazepine prescription rates of psychiatrists in comparison with all prescribers. Among all prescribers, 26.3% prescribed benzodiazepines, and the overall benzodiazepine prescription rate was 2.6%. Among psychiatrists, 82.2% prescribed benzodiazepines, and the overall benzodiazepine prescription rate was 14.0%. Figure 2 shows the geographical distribution of the percentages of benzodiazepine claims accounted for by psychiatrists in the 48 states (Alaska and Hawaii are not shown in the figure but were included in the analysis) in the United States. The states with the highest percentages were New York, Minnesota, Massachusetts,

Table 1 - Percentage of opioid and benzodiazepine prescriptions accounted for by psychiatrists, Medicare Provider Utilization and Payment Data: Part D, 2016 All specialties Total number of prescribers Total number of all prescriptions Total number of opioid claims Percentage of prescribers who prescribe opioids Opioid prescription rate Total number of benzodiazepine claims Percentage of prescribers who prescribe benzodiazepines Benzodiazepine prescription rate 50 – Trends Psychiatry Psychother. 2020;42(1)

Psychiatrists (percentage of all specialties)

1,131,550

25,528 (2.3%)

1,480,972,766

44,684,504 (3.0%)

78,145,305

131,115 (0.2%)

44.2%

8.9%

5.3%

0.3%

33,640,456

5,820,447 (17.3%)

26.3%

82.2%

2.6%

14.0%

Psychiatristsâ&#x20AC;&#x2122; prescription in Medicare Part D - Pan et al.

Maryland, Wisconsin, and Rhode Island. Psychiatrists accounted for nearly 25% of all benzodiazepine prescriptions in these states. Buprenorphine prescription analysis Table 2 shows the number and percentage of buprenorphine prescriptions by psychiatrists among all prescribers in Medicare Part D in 2016. There were 1,007,115 buprenorphine claims, of which 164,147 were prescribed by psychiatrists. In other words, psychiatrists

accounted for 16.3% of buprenorphine claims. Table 2 also shows the buprenorphine prescription rates of psychiatrists in comparison with all prescribers. Among all prescribers, 1.4% prescribed buprenorphine, and the overall buprenorphine prescription rate was 0.1%. Among psychiatrists, 7.8% prescribed buprenorphine, and the overall buprenorphine prescription rate was 2.3%. Figure 3 shows the geographical distribution of the percentages of buprenorphine claims accounted for by

Figure 1 - Percentage of opioids prescribed by psychiatrists among all prescribers for the states in the United States (Alaska and Hawaii not shown but accounted for), Medicare Provider Utilization and Payment Data: Part D, 2016.

Figure 2 - Percentage of benzodiazepines prescribed by psychiatrists among all prescribers for the states in the United States (Alaska and Hawaii not shown but accounted for), Medicare Provider Utilization and Payment Data: Part D, 2016. Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 51

Psychiatristsâ&#x20AC;&#x2122; prescription in Medicare Part D - Pan et al.

psychiatrists in the 48 states (Alaska and Hawaii are not shown in the figure but were included in the analysis) in the United States. The states with the highest percentages were Hawaii, Connecticut, Wyoming, and West Virginia, where psychiatrists accounted for more than 30% of all buprenorphine prescriptions. Naltrexone microsphere prescription analysis Table 2 also shows the number and percentage of naltrexone microsphere prescriptions by psychiatrists among all prescribers in Medicare Part D in 2016. There were 4,357 naltrexone microsphere claims, and 1,455 of them were prescribed by psychiatrists. In other words, psychiatrists accounted for 33.4% of naltrexone microsphere claims. Due to the small size of data, geographical analysis of naltrexone microsphere prescriptions was not performed.

Discussion As countries around the world strategize to combat the opioid crisis, psychiatrists can play a pivotal role in this battle. First, psychiatrists contribute directly, even if minimally, to opioid prescriptions. As shown in the present study, psychiatrists account for 2.3% of all prescribers, and yet only 0.2% of all opioid claims. This is not surprising, as psychiatrists do not practice pain management as often as physicians from other specialties. While psychiatrists have a minimal direct contribution to opioid prescriptions, they could help reduce the number of opioid overdose deaths by monitoring benzodiazepine prescriptions. In other words, while psychiatrists do not prescribe opioids to patients directly, the same patients could be receiving opioids from other physicians.

Table 2 - Percentage of buprenorphine and naltrexone microsphere prescriptions accounted for by psychiatrists, Medicare Provider Utilization and Payment Data: Part D, 2016 All specialties Total number of prescribers Total number of all prescriptions Total number buprenorphine claims

Psychiatrists (percentage of all specialties)

1,131,550

25,528 (2.3%)

1,480,972,766

44,684,504 (3.0%)

1,007,115

164,147 (16.3%)

Percentage of prescribers who prescribe buprenorphine

1.4%

7.8%

Buprenorphine prescription rate

0.1%

2.3%

Total number of naltrexone microsphere claims

4,357

1,455 (33.4%)

Percentage of prescribers who prescribe naltrexone microsphere Naltrexone microsphere prescription rate

0.022%

0.33%

0.0003%

0.0033%

Figure 3 - Percentage of buprenorphine prescriptions by psychiatrists among all prescribers for the states in the United States (Alaska and Hawaii not shown but accounted for), Medicare Provider Utilization and Payment Data: Part D, 2016. 52 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

Psychiatristsâ&#x20AC;&#x2122; prescription in Medicare Part D - Pan et al.

Therefore, when psychiatrists prescribe benzodiazepine, it would be beneficial to ask their patients if they are receiving opioids from other physicians, concurrently with the benzodiazepine prescription. In this paper, we did not analyze whether a patient received opioids and benzodiazepines simultaneously because patientlevel data were not available (only prescriber-level data were). To protect patient confidentiality, no patient-level data or prescription-level data were available. Future studies should investigate concurrent prescription of opioids and benzodiazepines. Likewise, we were also not able to study patient demographics or clinical indications associated with the prescriptions, since such data were not available. Similarly, in the Medicare Part D data, there were no cases of duplicate claims at prescriber level, but there could be duplicate prescription claims at patient level, i.e., the same patient receiving multiple prescriptions from different prescribers. Future research could use smaller-scale studies with private data to study these factors. Further, psychiatrists can help in the fight against the opioid crisis by prescribing opioid addiction treatments, including buprenorphine and naltrexone microspheres. While psychiatrists already contribute significantly to the prescription of buprenorphine, it seems that they could contribute even more, because only about 16% of psychiatrists have a waiver from the DEA to prescribe buprenorphine,20 and only 7.8% of psychiatrists prescribe buprenorphine (Table 2). Also, it seems that naltrexone microspheres account for a small amount of prescriptions in Medicare Part D, yet this is a valid treatment option for psychiatrists and their patients to consider to help prevent relapse. A next step could be to encourage more psychiatrists to receive provider education on buprenorphine and naltrexone microspheres, and to investigate why some of those who have received the DEA waiver are not actively prescribing buprenorphine. Previous literature has suggested that psychiatrists are more concentrated in urban areas, and therefore do not contribute as much to buprenorphine prescriptions in rural areas.20 However, our results showed that this is not necessarily the case: in more rural states, such as West Virginia and Wyoming, psychiatrists contributed to more than 30% of all buprenorphine prescriptions. In rural areas, primary care physicians could prescribe opioids more frequently than their peers in urban areas.25 To combat the opioid crisis in the rural areas, psychiatrists can likely play a key role in opioid addiction treatment. Our results suggest that there is substantial geographical variation for the prescription of both

benzodiazepine (Figure 2) and buprenorphine (Figure 3) by psychiatrists. A recent paper suggested that the opioid epidemic is not limited to rural areas or the Midwestern states, as previously thought, but has migrated toward urban and eastern states.26 Our analysis of the geographical distribution suggested that there are states, such as New York, where psychiatrists could monitor benzodiazepine prescriptions, as they account for almost 25% of all benzodiazepine prescriptions, and they could also study the possibility of increasing prescription of opioid addiction treatments such as buprenorphine, as the percentages in these states are lower than in other states. This study was a retrospective, cross-sectional study. For future research, a longitudinal analysis could be performed to characterize the trend of opioid, benzodiazepine, and buprenorphine prescriptions over time. For instance, it would be of interest to know if buprenorphine prescriptions become more prevalent. Also, a future prospective study could assess the efficacy of opioid treatment and addiction prevention by psychiatrists. By combining opioid treatment medications with other modalities of addiction treatment, psychiatrists can play an important role in reducing the opioid epidemic. It was previously reported that patients with cocaine dependence can have depression and anxiety.27 It is possible that patients with opioid dependence can similarly have depression and anxiety, and therefore psychiatric treatments should be an important part of addiction treatment. For elderly patients, a holistic approach, including other activities such as physical exercise, can help patients cope with anxiety.28 Similarly, to treat anxiety, holistic quality of life assessment should be considered.29 Currently, when a psychiatrist prescribes buprenorphine or naltrexone microspheres, there is no clear financial benefit to the prescriber, as a psychiatrist likely gets paid similar amounts either prescribing buprenorphine or providing typical psychiatric services. However, for a psychiatrist to be able to prescribe buprenorphine, they have to afford additional expenses, such as obtaining the waiver from the DEA,20 training, record keeping, and overhead costs. Therefore, psychiatrists may not be incentivized to offer buprenorphine. Meanwhile, there are grants for community health centers in the United States to help support medication-assisted treatment such as with buprenorphine.30 One possible future policy change could be to offer grants for psychiatrists to provide medication-assisted treatment for opioid abuse.31 Future studies could investigate the cost-effectiveness of awarding such grants to psychiatrists to help combat the opioid crisis. Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 53

Psychiatrists’ prescription in Medicare Part D - Pan et al.

Acknowledgements This study received financial support from the Hull Fund Christian Scholarship Grant at Samford University, Birmingham, AL, USA.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References 1. Scherrer JF, David Schneider F, Lustman PJ. Opioid analgesics and chronic non-cancer pain: a prescription for research in primary care. Fam Pract. 2016;33:569-71. 2. Dyer O. Canada’s prescription opioid epidemic grows despite tamperproof pills. BMJ. 2015;351:h4725. 3. Mordecai L, Reynolds C, Donaldson LK, Williams AC. Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study. Br J Gen Pract. 2018;68:e225-33. 4. Pacurucu-Castillo SF, Ordóñez-Mancheno JM, Hernández-Cruz A, Alarcón RD. World opioid and substance use epidemic: a Latin American perspective. Psychiatr Res Clin Pract. 2019;1:32-8. 5. Krawczyk N, Greene MC, Zorzanelli R, Bastos FI. Rising trends of prescription opioid sales in contemporary Brazil, 2009-2015. Am J Public Health. 2018;108:666-8. 6. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioidinvolved overdose deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65:1445-52. 7. Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulants - United States, 20152016. MMWR Morb Mortal Wkly Rep. 2018;67:349-58. 8. Schallemberger JB, Colet Cde F. Assessment of dependence and anxiety among benzodiazepine users in a provincial municipality in Rio Grande do Sul, Brazil. Trends Psychiatry Psychother. 2016;38:63-70. 9. Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996-2013. Am J Public Health. 2016;106:686-8. 10. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017;356:j760. 11. Santos ADD, Guimarães LML, Carvalho YF, Viana LDC, Alves GL, Lima ACR, et al. Spatial analysis and temporal trends of suicide mortality in Sergipe, Brazil, 2000-2015. Trends Psychiatry Psychother. 2018;40:269-76. 12. West NA, Severtson SG, Green JL, Dart RC. Trends in abuse and misuse of prescription opioids among older adults. Drug Alcohol Depend. 2015;149:117-21. 13. Maree RD, Marcum ZA, Saghafi E, Weiner DK, Karp JF. A systematic review of opioid and benzodiazepine misuse in older adults. Am J Geriatr Psychiatry. 2016;24:949-63. 14. Schepis TS, Simoni-Wastila L, McCabe SE. Prescription opioid and benzodiazepine misuse is associated with suicidal ideation in older adults. Int J Geriatr Psychiatry. 2019;34:122-9. 15. U.S. Department of Health & Human Services. Drug coverage (Part D). [cited 2018 Dec 15]. https://www.medicare.gov/drugcoverage-part-d

54 – Trends Psychiatry Psychother. 2020;42(1)

16. Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of opioids by different types of Medicare prescribers. JAMA Intern Med. 2016;176:259-61. 17. U.S. Department of Health & Human Services, Office of Inspector General. Opioids in Medicare Part D: concerns about extreme use and questionable prescribing. HHS OIG Data Brief. 2017;1-16. 18. Dufour R, Joshi AV, Pasquale MK, Schaaf D, Mardekian J, Andrews GA, et al. The prevalence of diagnosed opioid abuse in commercial and Medicare managed care populations. Pain Pract. 2014;14:E106-15. 19. Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2004:CD002207. 20. Rosenblatt RA, Andrilla CHA, Catlin M, Larson EH. Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med. 2015;13:23-6. 21. Lembke A, Chen JH. Use of opioid agonist therapy for Medicare patients in 2013. JAMA Psychiatry. 2016;73:990-2. 22. Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson RA Jr, et al. Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. N Engl J Med. 2016;374:1232-42. 23. Lee JD, Nunes EV, Novo P, Bachrach K, Bailey GL, Bhatt S, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): A multicentre, open-label, randomized controlled trial. Lancet. 2018;391:309-18. 24. Centers for Medicare and Medicaid Services. Medicare provider utilization and payment data: Part D prescriber. [cited 2018 Dec 15]. https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Medicare-ProviderCharge-Data/Part-D-Prescriber.html 25. Pan K, Blankley AI, Hughes PJ. An examination of opioid prescription for Medicare Part D patients among family practice prescribers. Fam Pract. 2019;36:467-72. 26. Kiang MV, Basu S, Chen J, Alexander MJ. Assessment of changes in the geographical distribution of opioid-related mortality across the United States by opioid type, 1999-2016. JAMA Netw Open. 2019;2:e190040. 27. de Oliveira LDSSCB, Souza EC, Rodrigues RAS, Fett CA, Piva AB. The effects of physical activity on anxiety, depression, and quality of life in elderly people living in the community. Trends Psychiatry Psychother. 2019;41:36-42. 28. Schallemberger JB, Colet Cde F. Assessment of dependence and anxiety among benzodiazepine users in a provincial municipality in Rio Grande do Sul, Brazil. Trends Psychiatry Psychother. 2016;38:63-70. 29. Schwab B, Daniel HS, Lutkemeyer C, Neves JA, Zilli LN, Guarnieri R, et al. Variables associated with health-related quality of life in a Brazilian sample of patients from a tertiary outpatient clinic for depression and anxiety disorders. Trends Psychiatry Psychother. 2015;37:202-8. 30. The United States Department of Health and Human Services. HHS awards over $1 billion to combat the opioid crisis. [Cited 2019 Jun 3]. https://www.hhs.gov/about/news/2018/09/19/hhsawards-over-1-billion-combat-opioid-crisis.html 31. Joshi P, Shah NK, Kirane HD. Medication-assisted treatment for opioid use disorder in older adults: an emerging role for the geriatric psychiatrist. Am J Geriatr Psychiatry. 2019;27:455-7.

Correspondence: Kevin Pan Department of Economics, Finance, and Quantitative Analysis Brock School of Business, Samford University 800 Lakeshore Dr. 35229 - Birmingham, AL - USA Tel.: +1 (205) 7264640 E-mail: kpan@samford.edu

Trends

Original article

in Psychiatry and Psychotherapy

Effectiveness of mindfulness-integrated cognitive behavior therapy on anxiety, depression and hope in multiple sclerosis patients: a randomized clinical trial Sahar Pouyanfard,1

Ali A. ParviziFard,1 Mohsen Mohammadpour,1

Kheirollah Sadeghi1

Abstract Introduction: Multiple sclerosis (MS) is a chronic medical condition that attracts particular attention because of the high risks associated with it. MS patients suffer from medical problems, depression, anxiety, and reduced hopefulness. These issues can increase the severity of the disease and treatment resistance and reduce patients’ individual and social efficacy. Mindfulness-integrated cognitive behavior therapy (MICBT) is a new approach that is being applied in chronic diseases and can be used in combination with existing treatments. Therefore, the present study investigated the efficacy of MICBT in terms of anxiety, depression, and hope in MS patients. Methods: A sample of 20 patients with MS was randomly selected at Shafa Hospital in Kerman City, Iran. Patients were then assigned to one of two groups of 10 people using a random number table. The experimental group received MICBT. The control group also received the same therapy after study completion. The assessment tools used in this study included the Beck Depression Inventory-Second Edition (BDI-II), Beck Anxiety Inventory (BAI), and Miller Hope Scale (MHS). Measurements were conducted at three stages: pre-test, post-test, and follow-up. For data analysis, means and standard deviations were calculated and one-way analysis of covariance was conducted using SPSS 24. Results: Compared with controls, MICBT was effective for reducing depression (P < 0.001, F = 72.55), anxiety (P < 0.001, F = 100.75). Additionally, MICBT was effective in improving hope (P < 0.001, F = 45.36). Changes were maintained in the follow-up phase. Conclusion: The MICBT affects depression, anxiety and hope of MS patients. Therefore, mental health professionals can benefit from the results obtained in the present study to reduce depression and anxiety and increase hope in this group of patients. Clinical trial registration: Iranian Registry of Clinical Trials, IRCT201601030258N4. Keywords: Group therapy, mindfulness-integrated cognitive-behavioral treatment, multiple sclerosis.

Introduction Multiple sclerosis (MS) is a complicated, disabling, and immune-related disease, involving the central nervous system (CNS), including the brain and the spinal cord. The etiology of MS remains unidentified; the consensus is that MS is probably caused by either an abnormality

of the immune system, or contact with environmental factors (infectious agents), or a combination of both.1 Experts recognize MS as an autoimmune disease; indicating that the immune system mistakenly attacks the body’s healthy organs as though they were foreign invaders. MS is among the most prevalent chronic diseases of the CNS and it is a demyelinating disease,

Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran.

Submitted Jan 06 2019, accepted for publication Jun 26 2019. Suggested citation: Pouyanfard S, Mohammadpour M, ParviziFard AA, Sadeghi K. Effectiveness of mindfulness-integrated cognitive behavior therapy on anxiety, depression and hope in multiple sclerosis patients: a randomized clinical trial. Trends Psychiatry Psychother. 2020;42(1):55-63. http://dx.doi.org/10.1590/22376089-2018-0105 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 55-63

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

affecting motor-sensory functions.2 It is estimated that approximately 2-3 million people suffer from MS globally; According to Iranâ&#x20AC;&#x2122;s MS Association, there are 40,000 MS patients in Iran, 9,000 of whom are registered cases.3 MS frequently occurs in the 20-40 years age group4; i.e. the age associated with greatest family and social responsibilities and with reproduction.5 Due to its nature, numerous mental symptoms are correlated with MS. Depression and anxiety are the most prevalent mental symptoms associated with MS and are observed in 48% of MS sufferers during the year following diagnosis of their disease.6 Depression symptoms are the most common mental symptoms in this group. MS can lead to depression in 3 different ways, as follows: 1) various behavioral changes can occur if MS affects the areas of the brain involved in emotional expression and emotion control. 2) Endocrine or immune system changes caused by MS can lead to depression. 3) The adverse effects of some medications can cause depression in this population. Regardless of how depression is triggered, it is inevitably associated with reduced hope in relation to life.7 Untreated depression in patients diagnosed with a physical illness can lead to symptoms such as magnifying and exacerbating physical symptoms, excessive referral to medical settings and use of healthcare, increased treatment costs, involvement in high-risk behaviors, and even suicide.8 Anxiety is another mental problem in this group. Anxiety has been overlooked in MS patients, despite its disabling consequences.6 Moreover, persistent anxiety may exacerbate the disease and lead to cardiovascular disorders.9 Awareness of the degenerative nature of the disease causes anxiety in patients.10 Recent studies indicate that the prevalence rate of anxiety in MS patients is 37%.11 Additionally, MS patients recognize anxiety as the most disabling sign of their disease.12 Hopefulness is impacted negatively in MS, like any other chronic diseases.13 Tennen and Affleck (quoted by Bijari et al.) argued that hope plays an essential role in improvement of illness, since it creates positive thoughts about life and an increased tendency to identify the positive aspects of harmful conditions.14 MS reduces hopefulness in sufferers, to a level equivalent to 10 years older than their actual age.15 In response to the abovementioned issues, different treatment methods, including pharmacotherapy and cognitive behavioral therapy (CBT) have been used to attempt to improve the mental symptoms of MS. However, due to various reasons, such as the adverse effects of medications, the probability of recurrence of symptoms, the ineffectiveness of CBT, and the nonimprovement of emotion regulation skills in these patients, the present study considers a more effective 56 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

treatment approach that minimizes such problems.15 Effective individual and group-based treatments are available for these conditions. It is believed that group treatment is more effective for most mental illnesses. This is because people review how they respond to the community. Furthermore, group therapy is a process leading to improvements in cognitive, emotional and behavioral aspects. Patients feel empowered in the group, which elevates their self-confidence.16 Prior research suggests that a new generation of cognitive-behavioral therapies, known as mindfulness and acceptance-based interventions, are more effective for patients with chronic physical illnesses. Mindfulnessintegrated cognitive behavior therapy (MICBT) is a structured approach, integrating mindfulness meditation with the main principals of CBT. This integration is intended to train clients to regulate their emotions and attention, to use these skills when the pathology is triggered, and to understand in which of the mental pathologies they are involved.17 MICBT consists of a set of evidence-based techniques to enhance self-awareness, self-control, and self-efficacy in different areas of life. During this course, a person learns how to identify and modify destructive or disturbing intellectual patterns that have a negative impact on his/her behavior. The weekly schedule of MICBT is flexible and compatible with individual and group conditions. A literature review reveals that group MICBT increases clientsâ&#x20AC;&#x2122; commitment to treatment.16,17 Several studies have also reported that MICBT is an effective and appropriate intervention for MS patients and is effective for improving psychological well-being, quality of life,18 and depression and alcohol abuse,19 and for increasing hope. However, further studies are required to introduce this treatment as an effective therapy for MS. Therefore, the present study aimed to answer the following questions: Does MICBT cause a significant reduction in depression in people with MS? Does MICBT cause a significant reduction in anxiety in MS patients? Does MICBT significantly increase hope in patients with MS?

Materials and methods Study design This was a repeated measure clinical trial study with a control group. The study consisted of one experimental group (that received MICBT), and one control group. Statistical population and sampling method The statistical population of the current study included all MS patients who were referred to Shafa

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

Hospital in Kerman City, Iran, from February 21 to April 20, 2018, and diagnosed with MS by a neurologist. Sample size The sample size was calculated on the basis of prior research, using the formula shown below.20 The sample size needed in each group was estimated as about 8 people, for a 95% confidence interval (CI) and a 20% type II error. However, considering probable losses from samples, this number was increased to 10, for a total sample size of 20 patients. A total of 41 patients were initially invited to participate in the study; but some of them were excluded because they did not meeting the inclusion criteria for the study. There were no losses from the sample at the post-test or follow-up stages of the present study.

n

( Z1 / 2  Z1  ) 2 ( SD1  SD2 ) 2 d2

Inclusion and exclusion criteria The inclusion criteria for the study were a diagnosis of relapsing-remitting MS by a neurologist; confirmation of MS diagnosis by diagnostic procedures (e.g. magnetic

resonance imaging, etc.); patient aware of MS disease for 1 year prior to enrollment; age in the range of 18-50 years; signature of written informed consent form for participation in the study; and education to at least the 9th grade (to be able to complete the questionnaires). Exclusion criteria comprised comorbid physical illnesses; psychosis and/or delirium during the course of treatment; severe arousals (e.g. extreme anger, uncontrolled restlessness, or impulsiveness); and receiving other psychological treatments during the course of the study. Interventions and randomization Each study participant was coded with a number after enrolment. The sample was divided into two groups (10 patients per group) with a computerized random number generator, using the permuted block randomization method. Control group members also received MICBT after study completion. Study tools The demographic data questionnaire This was a questionnaire constructed by the researchers, covering age, gender, and educational level.

Clinical interview, screening by therapist (41)

21 individuals excluded

Informed consent for study enrollment (20)

No interest in participation (10) History of drug abuse (2) Session times incompatible (5)

Randomized and completed pre-test (20)

Medicine type and dose incompatible (3)

Intervention (10)

No intervention (10)

Completed post-test (10)

Completed follow-up (10)

Other reasons (1)

Figure 1 - Flowchart illustrating the study. Trends Psychiatry Psychother. 2020;42(1) – 57

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

Beck Depression Inventory-Second Edition (BDI-II) This questionnaire was developed by Beck to measure the severity of depression (1963) and was revised in 1994. This inventory includes 21 items, each scored from 0 to 3. The highest score achievable on this questionnaire is 63. Each item on the questionnaire measures one symptom of depression. Its retest reliability is reported as 0.48 to 0.86, with a mean score of 0.86.21 Ghassemzadeh et al. reported an alpha coefficient of 0.87 and a test-retest coefficient of 0.74 for this tool and found a correlation with the first edition of BDI of 93.0.22 Beck Anxiety Inventory (BAI) This is a 21-item self-report scale for measuring anxiety. The questionnaire was developed to cover 21 anxiety symptoms and each question is scored from 0 to 3 on a Likert-type scale. Higher scores indicate more severe anxiety. BAI generally targets the physiological aspects of anxiety. Three items address anxious mood, three items address specific phobias, and the rest of the questions evaluate the autonomous symptoms of hyperactivity and motion tension of anxiety. Beck and Clark (1988) reported the internal consistency of the scale as 0.93 and retest reliability of 0.75. Previous studies demonstrated the high reliability and internal consistency of this tool (0.92; data correlation: between 0.3 and 0.76).23 A survey of 1,513 men and women from various demographic groups (age, gender) in Tehran approved the reliability and validity of the BAI for the Iranian population (reliability:0.72, validity: 0.83, internal consistency: 0.92).24 Miller Hope Scale (MHS) The Miller Hope Scale (MHS) is a 40-item 5-point Likert-type scale developed to measure hope in adults. The scale was pretested on 75 subjects, then refined and evaluated using 522 healthy students. The score range is 40-200 with a higher score indicating a higher level of hope. Twelve of the items on this scale are formed with negative clauses, which are reverse-scored in the assessment. The MHS showed relatively high construct and concurrent validity compared to other wellestablished tools. In factor analysis, Miller found that the items could be grouped in three components: Satisfaction with self, others, and life; Avoidance of hope threats; and Anticipation of a future.25 The internal consistency alpha was reported as 0.81. Construct validity was established by calculating the correlations of the Herth Hope Index with the MHS (r = 0.43), and the MHS with the Herth Hope Index (r=0.62) at <0.001 significance level.26

58 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

Intervention procedure The authorities of Shafa Hospital in Kerman were initially requested to explain the purpose of the research to MS patients and introduce them to the researchers. Then, an independent evaluator conducted initial assessments of patients to determine whether they met the inclusion and exclusion criteria of the study. Individuals who met the inclusion criteria for the study and provided an informed consent form were enrolled on the project. The size of the sample analyzed in the present study was 20 people, who were randomly divided into two groups, an experimental group and a control group. The control group received their usual treatment, while the intervention group participated in MICBT sessions as well as drug therapy. A treatment program of 8 two-hour sessions was provided to the experimental group. Post-test measurements were conducted after the intervention and the follow-up stage was conducted two months after completion of treatment. The intervention provided in this study was extracted from a current book on practicing MICBT (covering the principles and method of implementation), written by Bruno Cayoun.15 The intervention was conducted by an MSc in clinical psychology (first author) who had undertaken specialized training in this area under supervision of a PhD in Clinical Psychology. Mindfulness-integrated cognitive behavior therapy includes internalization and externalization skills, and consists of 4 steps, as follows: 1) the individual stage 2) the exposure stage 3) the interpersonal stage, and 4) the stage of creating love and kindness for oneâ&#x20AC;&#x2122;s self and others; it comprises 8 treatment sessions. At the first meeting, MICBT was introduced to the participants, explaining that it aims to create a commitment to daily practices. The principles of mindfulness were explained to the patients and the treatment was clearly explained to them. In the second session, the most important mechanisms were introduced. The third session provided study participants with visceral insight and intellectual equilibrium. The second phase was introduced in the fourth session. In the fifth session, the second stage was continued at a more challenging level and the third stage was introduced. The sixth session consisted of introduction of assertiveness skills and role-playing as a means of encounter. In the seventh session, the fourth stage was introduced and at the eighth session, the fourth phase was consolidated and the entire intervention program was reviewed.15 Table 1 provides further details of the contents of the treatment sessions.

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

Data analysis The data obtained were analyzed using SPSS 24. Mean scores and standard deviations were calculated and one-way analysis of covariance (ANCOVA) was conducted. Ethical considerations Prior to initiating the study, a meeting was held to explain the project to patients. At this meeting, ethical issues were presented and the research was explained to the patients. Then, everyone completed informed consent forms and the study participants were assured that their results and identity would be kept confidential, and that under no circumstances would their health information be provided to any person except the medical staff. The study was approved by the Research Ethics Committee at Kermanshah University of Medical Sciences (ethics code: kums.rec.1396.616). This study was also registered on the Iranian Registry of Clinical Trials (code: IRCT201601030258N4).

Results Descriptive findings of research: Table 2 lists the demographic variables for the sample participants. As per Table 2, the number of participants in the study sample was 20. There were 8 male participants (4 in the experimental group and 4 in the control group), and 12 female participants (6 in the experimental group and 6 in the control group). The educational level of the samples was as follows: Experimental group: elementary school (1), high school (2), associate degree (1), bachelor degree (4), and master degree (2). Control group: elementary school (1), high school (2), associate degree (0), bachelor degree (5) and master degree (2). Table 3 lists the means and standard deviations for study variables in the experimental and control groups at the pre-intervention, post-intervention, and follow-up stages. As the results show, the intensity of depression and anxiety significantly decreased in the intervention

Table 1 - The curriculum for MICBT sessions Session

Content

Introductory presentation covering the sessions and rules, an overview of MICBT, the concept and principles of mindfulness, and mindful breathing

Mindful breathing (continued), an overview of a few MICBT concepts (such as situation, sensory perception, evaluation, body sensations, and reaction), the internal causes of intrusive thoughts and their modification, part-by-part body scanning

Part-by-part body scanning (continued), explaining about body sensations, informal practice

Body scanning exercises (continued), introducing some of the CBT components of MICBT (like exposure methods), encountering unpleasant sensations using SUDS (a scale used for exposure to target events) through bipolar exposure (imaginary exposure to unpleasant situations)

Body scanning exercises (continued), review of SUDS

Body scanning exercises (continued), interpersonal skills, assertiveness and role-playing

Introducing the concepts of compassion and empathy, loving-kindness meditation

Review and evaluation

CBT = cognitive behavioral therapy; MICBT = mindfulness-integrated cognitive behavior therapy; SUDS = Subjective Units of Distress Scale.

Table 2 - Demographic properties of sample group Gender

Educational level

Male

Female

Elementary school

Experimental

Control

Group

High school

Associate degree

Bachelor degree

Master degree

Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 59

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

group, more than in the control group. Additionally, hope increased in the intervention group.

the results obtained. Table 4 lists the ANCOVA results for the post-test data and Table 5 shows results for the follow-up phase. Observing the results from Table 3 and examining the mean values for experimental and control groups in post-experimental data from Table 2, it can be concluded that post-intervention, MICBT group therapy was successful for reducing depression and anxiety scores and improving hope scores. The results in Table 4 show that the difference between the two groups in depression (P < 0.001, F= 72.55), anxiety (P < 0.000, F = 100.75), and hope (P < 0.001, F = 45.36) were significant at the post-test stage. This can be interpreted as showing that MICBT group therapy is effective at reducing mean scores for depression and anxiety at the post-intervention stage and for improving hope at the same stage. The results in Table 5 show that the differences between the two groups in depression (P < 0/001, P = 85.87), anxiety (P < 0/001, F = 89.19), and hope (P < 0/001, F = 88.35) were still significant at the follow-up stage.

Data on the research hypotheses To determine whether the data obtained fulfilled the underlying assumptions for use of ANCOVA, they were tested prior to analyzing the hypothesis data. The test results showed that ANCOVA could be conducted. The assumptions examined included the following: normal distribution of data (Kolmogorov-Smirnov and Shapiro Wilk’s tests), homogeneity of the variables (Levene’s test), lack of irrelative data (box plots), homogeneity of covariance matrices (Box M test), and a linear relationship between the dependent variable and the covariate (linear regression). We examined the following research hypotheses: MICBT significantly decreases depression in the experimental group, compared to the control group; MICBT significantly reduces anxiety in the experimental group, compared to the controls; MICBT significantly increases hope in participants in the experimental group compared to the control group. One-way ANCOVA was used to analyze

Table 3 - Mean and standard deviation for anxiety, depression and hope Experimental group

Control group

Pre-test

Post-test

Follow-up

Pre-test

Post-test

Follow-up

BDI-II

43/25 (3/73)

24 (6/86)

25/12 (5/87)

45/12 (1/8)

47/37 (1/5)

46/5 (1/6)

BAI

51/37 (4/59)

26/75 (5/03)

28/12 (4/25)

50/37 (4/06)

49/75 (4/62)

48/75 (5)

MHS

107/37 (3/66)

168/37 (21)

166 (21/58)

108 (6/62)

112/12 (7/75)

114/5 (9/62)

Data presented as mean (standard deviation). BAI = Beck Anxiety Inventory; BDI-II = Beck Depression Inventory-Second Edition; MHS = Miller Hope Scale; SD = standard deviation.

Table 4 - Analysis of covariance results for depression, anxiety, and hope scores from the post-intervention stage (between groups) SS

Sig.

BDI-II

9,121/57

72/55

0/001

0/58

BAI

2,162/41

100/75

0/001

0/62

MHS

1,245/19

45/36

0/001

0/61

BAI = Beck Anxiety Inventory; BDI-II = Beck Depression Inventory-Second Edition; MHS = Miller Hope Scale; df = degrees of freedom; ES = Eta squared; MS = mean square; SS = sum of squares.

Table 5 - Analysis of covariance results for depression, anxiety and hope scores in follow-up phase BDI-II

Sig.

1,671/76

85/87

0/001

0/57

BAI

1,746/1

89/19

0/001

0/60

MHS

10,787/97

88/35

0/001

0/59

BAI = Beck Anxiety Inventory; BDI-II = Beck Depression Inventory-Second Edition; MHS = Miller Hope Scale; df = degrees of freedom; ES = Eta squared; MS = mean square; SS = sum of squares.

60 – Trends Psychiatry Psychother. 2020;42(1)

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

Discussion The data obtained suggest that MICBT significantly decreased depression in the experimental group, compared to controls, and that its impact was sustained to the follow-up stage. These findings are consistent with other studies of the effectiveness of MICBT.20,27-30 This could be because mindfulness-based exercises assist MS patients to consider their thoughts as mental events. In other words, mindfulness helped the subjects to acquire the ability to observe their disturbing thoughts and be aware of them, rather than being influenced by them and considering them to be real and definitive, and therefore the mindfulness practices reduced the effect of depressive thoughts on the subjects studied. Moreover, MICBT uses mindfulness exercises to focus on breathing as a means of living in the present moment, which can reduce concerns related to the past and disturbing worries and thoughts related to the future. According to Teasdale, Segal, and Didona,31 mindfulness improves depression by reducing and stopping the negative loops of thought and rumination, teaching people to maintain a distance from thoughts, teaching flexibility of attention, and mental empowerment. Furthermore, along with mindfulness practices, assertiveness training, and role-playing skills as a means of confrontation increased the abilities of the people in the experimental group to be prepared for taking actions and increased their willingness and capability to act, resulting in reductions in the reluctance and lack of desire for taking action that are signs of depression. Additionally, assertiveness training can reduce depression by improving decision-making ability,32 experiencing positive emotions, and increasing self-esteem.33 The present study also revealed that MICBT significantly reduced anxiety in the experimental group, compared with controls, and that this effect was sustained until the follow-up stage. These findings are consistent with other studies. 18,20,29 In explaining this finding, it can be argued that MS with its debilitating, chronic, and unpredictable characteristics imposes many challenges on patientsâ&#x20AC;&#x2122; lives. Mindfulness and its training modify feelings without judgments, increase awareness of bio-psychological feelings, and help subjects to clearly experience and accept emotions and physical phenomena, as they occur.15,27 In other words, in the experimental group, by providing the ability to clearly recognize emotions, thoughts, and physical conditions without subjective judgments about them, mindfulness reduced disturbing and distracting thoughts that envisage excessively undesirable and

disturbing conditions and cause anxiety. Additionally, as confronting measures, assertiveness training and role-playing could have improved preparedness for copying with disease-related changes and life, and reduced feelings of incapability and also could have improved the self-confidence of experimental group members for coping with undesirable conditions. Moreover, cognitive errors (catastrophizing, labeling, negative predicting, etc.) were reduced in the experimental group, which in turn improved the symptoms of anxiety.15 The data obtained also demonstrated that MICBT significantly increased hope among the participants in the experimental group, compared with the controls, and that this effect was also sustained to the follow-up stage. These findings are in agreement with previous work.19,34 In explaining this finding, it can be argued that MICBT teachings help patients to reduce their stress, change their conditions, strengthen their life tendency, cope with depression, frustration, and despair, and, ultimately, to gain optimism and trust. Mindfulness also helps individuals identify situations that cause anxiety and stress, develop a better knowledge of themselves and their thoughts, recognize their strengths and flaws, and achieve better and higher awareness regarding their emotions, thoughts, physical states, and illness. They may then be able to find coping strategies to manage these situations, thereby creating hope in their lives. Furthermore, assertiveness training and role-play also help to build confidence and better readiness to act in the future, which also increases hope in this group. Overall, the results obtained in this intervention suggest that the MICBT was effective for MS patients. MS causes fatigue and illness, and the number of research questions was high; thus, the pre-test-post-test results may have been influenced by these issues. Moreover, the same tool was applied for pre-test, post-test, and followup stages; therefore, familiarity with the test in the pre-test step may have affected the post-test and follow-up results. It is suggested that psychologists and counselors use MICBT as a therapeutic strategy to reduce anxiety and depression and increase hope among MS patients. Several limitations of this investigation need to be mentioned. One of the study limitations was the lack of theoretical background for the study, because of the novelty of the intervention. The present studyâ&#x20AC;&#x2122;s 2-month follow-up period may not be sufficient to assess longterm maintenance of treatment gains. Future studies are recommended to perform long-term follow-up assessments in order to evaluate the effects of MICBT on MS patients. Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 61

Mindfulness-integrated CBT in MS patients - Pouyanfard S et al.

Conclusion This study provided further evidence for the effectiveness of MICBT. MS patients face a variety of stresses in everyday life, in addition to the stress related to their disease. One of the most stressful aspects of this disease is uncertainty with relation to the future. Coping with MS can be very challenging and the consequences of diagnosing the disease in people can lead to various emotions such as sorrow, hopelessness, anger, anxiety, depression or distrust. Hence, mindfulness therapy can be mastered through techniques such as experiencing the present, deep breathing, relaxation, and better understanding of thoughts, better understanding of emotions, and physical states, which, in turn, will help the affected person to achieve acceptance of the illness and enact behavioral changes for better selfcare. The patient can thus become better prepared to identify appropriate coping strategies to manage challenging situations using techniques such as roleplaying and assertiveness to reduce anxiety and depression and increase hope. Therefore, with regards to the effectiveness of MICBT for reducing anxiety and depression and increasing hope, and in view of the increasing incidence of MS in the country, the results of this study may be beneficial to treatment programs and services for MS patients aiming to increase hope and reduce anxiety and depression among them.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References 1. Goetz CG. Textbook of Clinical Neurology. Amsterdam: Elsevier Health Sciences; 2007. 2. MCcabe MP. Mood and self-esteem of persons with multiple sclerosis following an exacerbation. J Psychosom Res. 2005; 59:161-6. 3. Taghizadeh ME, Miralaei MS. The study of the effectiveness of group spirituality therapy on resilience of women with multiple sclerosis, city of Isfahan. Health Psychol. 2013;2:82-102. [Persian] 4. Aghabagheri H, Mirzaeian B, Mohammad Khani P, Omrani S. The effectiveness of the mentally cognitive therapy group (MBCT) on depression in multiple sclerosis patients. Thought Behav Clin Psychol. 2012;6:75-82. [Persian] 5. Kinney MR. Quality of life research: rigor or rigor mortis. Cardiovasc Nurs. 1995;31:25-8. 6. Mitchell AJ, Benito-León J, González JM, Rivera-Navarro J. Quality of life and its assessment in multiple sclerosis: integrating physical and psychological components of wellbeing. Lancet Neurol. 2005;4:556-66. 7. Ghara ZF, Aliakbari DM, Alipour A, Mohtashami T. Efficacy of group logo therapy in the perceived stress and life expectancy in MS patients. Res Psychol Health. 2013;6:12-20. [Persian]

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8. Mohr DC, Boudewyn AC, Goodkin DE, Bostrom A, Epstein L. Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. J Consult Clin Psychol. 2001;69:942-9. 9. Potagas C, Mitsonis C, Watier L, Dellatolas G, Retziou A, Mitropoulos P, et al. Influence of anxiety and reported stressful life events on relapses in multiple sclerosis: a prospective study. Mult Scler. 2008;14:1262-8. 10. Feinstein A, O’Connor P, Gray T, Feinstein K. The effects of anxiety on psychiatric morbidity in patients with multiple sclerosis. Mult Scler. 1999;5:323-6. 11. Korostil M, Feinstein A. Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler. 2007;13:6772. 12. Stenager E, Knudsen L, Jensen K. Multiple sclerosis: correlation of anxiety, physical impairment and cognitive dysfunction. Ital J Neurol Sci. 1994;15:97-101. 13. Dennison L, Moss-Morris R, Chalder T. A review of psychological correlates of adjustment in patients with multiple sclerosis. Clin Psychol Rev. 2009;29:141-53. 14. Longi D, Kasper D, Jameson L, Faucl A, Hauser A, Loscalzo J, eds. Harrison’s principles of Internal Medicine. 20th ed. New York: McGraw Hill; 2018. p. 3198-205. 15. Cayoun B. Mindfulness-integrated CBT principles and practice. 2nd ed. Tehran: University of Tehran Press; 2011. 173-4. Translated from Persian by Khodayarifard M, Mohammadi Hasel K, Didehdar M. 16. Ezhumalai S, Muralidhar D, Dhanasekarapandian R, Nikketha BS. Group interventions. Indian J Psychiatry. 2018;60:514-21. 17. Cayoun BA. Mindfulness-integrated CBT for well-being and personal growth: four steps to enhance inner calm, selfconfidence and relationships. Hoboken: John Wiley & Sons; 2014. p. 269-71. 18. Fiest KM, Bernstein CN, Walker JR, Graff LA, Hitchon CA, Peschken CA, et al. Systematic review of interventions for depression and anxiety in persons with inflammatory bowel disease. BMC Res Notes. 2016;9:404. 19. Baker AL, Kavanagh DJ, Kay-Lambkin FJ, Hunt SA, Lewin TJ, Carr VJ, et al. Randomized controlled trial of MICBT for co-existing alcohol misuse and depression: outcomes to 36-months. J Subst Abuse Treat. 2014;46:281-90. 20. Bahrani S, Zargar F, Yousefipour G, Akbari H. The effectiveness of mindfulness-integrated cognitive behavior therapy on depression, anxiety, and stress in females with multiple sclerosis: a single blind randomized controlled trial. Iran Red Crescent Med J. 2017;19:e44566. 21. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation; 1996. 22. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric properties of a Persian‐language version of the Beck Depression Inventory--Second Edition: BDI‐II‐PERSIAN. Depress Anxiety. 2005;21:185-92. 23. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893-7. 24. Kaviani HH, Mousavi AS. Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI). Tehran Univ Med J. 2008;66:136-40. 25. Miller JF, Powers MJ. Development of an instrument to measure hope. Nurs Res. 1988;37:6-10. 26. Abdi N, Asadi Lari M. Standardization of three hope scales, as possible measures at the end of life, in Iranian population. Intern J Cancer Prev. 2011;4:71-7. 27. Simpson R, Booth J, Lawrence M, Byrne S, Mair F, Mercer S. Mindfulness based interventions in multiple sclerosis--a systematic review. BMC Neurol. 2014;14:15. 28. Hoseyni S. The effect of group cognitive therapy in reducing depression and increasing mental health of patients with multiple sclerosis. Tehran: Alzahra University; 2005. 29. Muñoz San Jose A, Oreja-Guevara C, Cebolla Lorenzo SC, Carrillo Notario L, Rodríguez Vega B, Bayón Pérez CB. Psychotherapeutic and psychosocial interventions for managing stress in multiple sclerosis: the contribution of mindfulness-based interventions. Neurologia. 2016;31:113-20. 30. Yazdanimehr R, Omidi A, Sadat Z, Akbari H. The effect of mindfulness-integrated cognitive behavior therapy on depression and anxiety among pregnant women: a randomized clinical trial. J Caring Sci. 2016;5:195.

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31. Didonna F. Clinical handbook of mindfulness. New York: Springer; 2009. 32. Tomaka J, Palacios R, Schneider KT, Colotla M, Concha JB, Herrald MM. Assertiveness predicts threat and challenge reactions to potential stress among women. J Pers Soc Psychol. 1999;76:100821. 33. Landoni MG, Giordano MT, Guidetti GP. Group psychotherapy experiences for people with multiple sclerosis and psychological support for families. J Neurovirol. 2000;6 Suppl 2:S168-71. 34. Bagheri H, Mirzaeayan B, MohammadGhani P, Omrani S. The efficacy of mindfulness-based cognitive therapy (MBCT) on the

reduction of depression in patients with multiple sclerosis (MS). Thought Behav. 2012;6:75-82.

Correspondence: Ali A. ParviziFard Department of Clinical Psychology Kermanshah University of Medical Sciences, 7617196171 - Kermanshah - Iran Tel: +98918 3308692 E-mail: parvizia@yahoo.com

Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 63

Trends in Psychiatry and Psychotherapy

Original Article

The association between traumatic experiences and suicide attempt in patients treated at the Hospital de Pronto Socorro in Porto Alegre, Brazil Cleonice Zatti,1 Luciano Santos Pinto Guimarães,2 Mauro Soibelman,3 Márcia Rejane Semensato,1 Andre Goettems Bastos,4 Vítor Crestani Calegaro,5 Lúcia Helena Machado Freitas1

Abstract Objective: To analyze associations between attempted suicide and childhood trauma. Methods: A seven month comparative case-control study (28 subjects – patients with suicide attempt; 56 controls – patients without suicide attempt). The following instruments were used: Childhood Trauma Questionnaire (CTQ), Mini International Neuropsychiatric Interview (MINI), and Medical Outcomes Study (MOS). Results: The group with suicide attempt had significantly higher scores for some variables: emotional abuse (p < 0.001), physical abuse (p < 0.001), emotional neglect (p < 0.001), and physical neglect (p < 0.001). Conclusions: The results suggest that variables related to previous trauma may influence future suicide attempts. The adoption of preventive and therapeutic actions related to mistreatments during child development is a crucial factor in reduction of suicide risk. Keywords: Childhood trauma, suicide attempt, psychological suffering, abuse, neglect.

Introduction Suicide is a multi-causal problem for which, to date, no unified reference theory has been identified. It may be the result of a multifaceted interaction between biological, genetic, psychological, social, and cultural factors. Suicide behavior must be confronted as a public health problem. This is a broad task, because it involves training healthcare professionals for suicide risk (SR) detection as well as prevention and immediate treatment at the different levels of care.1,2 Suicide is an ancient and cross-cultural theme and remains a public health problem worldwide.3

One recent meta-analysis by Zatti et al.4 identified childhood trauma as a modifiable risk factor for lifetime suicide attempts. In that study, sexual and emotional abuse and physical neglect (considered psychological traumas) were associated with suicide attempt (SA). Other studies have reported findings pointing in the same direction.4 For example, Araújo5 studied suicidal behavior and childhood trauma in a database of 71,429 volunteers. The results illustrated an association between childhood emotional abuse and suicidal behavior and the author concluded that the most serious suicide attempts were associated with severe emotional abuse.

Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. 2 Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil. 3 Hospital de Pronto Socorro, Porto Alegre, RS, Brazil. 4 Contemporâneo: Instituto de Psicanálise e Transdisciplinaridade, Porto Alegre, RS, Brazil. 5 Hospital Universitário de Santa Maria, Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brazil.

Submitted Dec 12 2018, accepted for publication Jun 27 2019. Epub Mar 20 2020. Suggested citation: Zatti C, Guimarães LSP, Soibelman M, Semensato MR, Bastos AG, Calegaro VC, et al. The association between traumatic experiences and suicide attempt in patients treated at the Hospital de Pronto Socorro in Porto Alegre, Brazil. Trends Psychiatry Psychother. 2020;42(1):64-73. http://dx.doi.org/10.1590/2237-6089-2018-0112 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 64-73

Traumatic experiences and suicide attempt - Zatti et al.

The results of a study conducted in Rio de Janeiro with patients who attempted suicide showed a significant difference between cases and controls, with less social support among the suicide attempt cases analyzed.6 The present study is justified by the importance of investigating factors that can foment SR, such as traumatic experiences, mental illnesses, and loss of a significant relative. No data were found in the suicide attempt literature that directly relate recent losses with suicide attempt. Considering the relevance of what has been outlined above, this study’s main objective was to analyze the association between childhood trauma and suicide attempt in patients who needed hospital admission due to suicide attempts at the Hospital de Pronto Socorro (HPS) in Porto Alegre, Brazil. Secondary objectives were to assess the quality of the support networks of patients with and without SA; to analyze the distribution of current suicide attempts over the days of the week; and to investigate associations between SA and significant dates. The study’s main contribution is confirmation of the hypothesis that people with childhood traumas are at higher risk of attempted suicide.

Method A case-control design was used in the study. Data were collected at the HPS in Porto Alegre, Brazil. The hospital is open 24 hours a day, offering urgent and emergency care for the entire population of Porto Alegre. Suicide attempt is one of several different urgent and emergency situations seen by the healthcare teams working at the HPS. The hospital is run according to SUS regulations (the SUS is Brazil’s universal access public healthcare service) and it is the primary emergency service in the state of Rio Grande do Sul. The number of participants was calculated using data published by Roy,7 who compared childhood trauma in groups of patients with and without suicide attempt. According to Roy’s study, standard deviations (SD) for the variable “childhood trauma” were ±3.24 and ±5.07 in groups with and without SA respectively. To achieve 80% power and a significance level of 5%, using a proportion of two controls per case, and with the goal of detecting a 3-point difference in total CTQ scores, we selected 84 participants (56 controls and 28 cases). The calculation was performed using WINPEPI Version 11.43. Participants were patients admitted via or seen in the HPS emergency room because of SA between August 20, 2015 and March 21, 2016. The total number of suicide attempt cases seen during the study period was 37. Nine cases were excluded from this study because of refusal to participate

(n = 4) or because the patient was unresponsive to verbal interaction (n = 5). The participants were 28 cases and 56 controls. Controls were paired for gender and age and were recruited from patients seen on the same day as the cases for any reason other than suicide attempt and with no previous record of suicide attempt. The inclusion criteria stipulated that patients should be at least 18 years old, be able to reply to the questionnaires verbally, and be free from psychotic symptoms. They should also have agreed to participate in the study and provided signed informed consent to be included in the study. Patients were approached and data were collected at the bedside during the patients’ time in hospital. Data were collected by a researcher with experience in suicidal behavior. Instruments Childhood Trauma Questionnaire (CTQ) The CTQ is an adapted and validated tool that has been widely used to investigate the occurrence of abusive situations during childhood.8 The CTQ was developed by Bernstein et al.,9 and translated and validated for Portuguese by Grassi-Oliveira et al.10 It is used to assess childhood trauma and abuse. This instrument can be administered to adolescents (12+ years of age) and adults. There are two versions of the CTQ: the first has 70 items and the second is a brief version with 28 items, with five-point Likert response scales.9 The CTQ investigates five dimensions of trauma in childhood: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Scores range from 25 (absence of any trauma) to 125 (the maximum score when all traumas are present).8 Medical Outcomes Study (MOS) This is a social support survey that evaluates the following dimensions: tangible support (provision of practical resources and material aid), affectionate support (physical demonstrations of love and affection), emotional support (capacity of the social network to satisfy individual needs related to emotional problems), informational support (counting on people who can offer guidance, information, and counsel), and positive social interaction (having people to relax and have fun with). The MOS was developed by Sherbourne & Stewart,11 and translated and validated for Portuguese by Griep et al.12-14 Answers to items “a” to “t” are distributed along a five-point Likert scale.15 Mini International Neuropsychiatric Interview (MINI) A short, standardized diagnostic interview (15-30 minutes). The Brazilian translation of version 5.0 for the DSM IV was used.16 Trends Psychiatry Psychother. 2020;42(1) – 65

Traumatic experiences and suicide attempt - Zatti et al.

Sociodemographic questionnaire Used to collect general information such as gender, age, education, income, marital status, and occupation. As an additional item, the researcher also surveyed the medical team’s clinical impression of the severity and lethality of each suicide attempt, case by case. The lethality of each attempt was scaled by the doctors as: 1, mild (no clinical complications, no admission required); 2, moderate (with clinical complications, requiring hospital admission); or 3, serious (with critical complications, requiring Intensive Care Unit admission or special medical care). Ethical aspects All subjects were given the necessary clarifications. Procedures followed ethical standards, such as confidentiality of personal identity. Data collection tools were not administered to patients who refused to participate and their medical care at the hospital was unaffected. The protocol for this study was approved by the research ethics committees at the Hospital de Clínicas de Porto Alegre (HCPA; protocol 150267; CAAE 44823315.1.0000.5327, opinion 1.111.108/2015) and the Porto Alegre Municipal Health Department (opinion 1.180.317/2015). The committees were informed of the data collected in the project. All participants were cared for by the HPS Psychology Service while in hospital, which also dealt with referrals for subsequent treatment as needed. Statistical analysis Attribute variables were expressed as absolute and relative frequencies. Quantitative variables were expressed as means and SD or medians and interquartile ranges, depending on the results of the Shapiro-Wilk test. Groups were compared in terms of sociodemographic variables using the Chi-square test, the t test for independent samples, or the Mann-Whitney test, depending on the types of variables and their distribution. A generalized estimating equation (GEE) was used to compare means or proportions between groups. A correct analysis should consider paired subjects a single unit (1 case for 2 controls of the same gender and age). A covariance matrix with robust estimator was used with an exchangeable working correlation matrix for the GEE model. For the MOS questionnaire variables, a normal distribution and link identity function was used for the variable number of friends and relatives. Binomial distributions with logit link function were used for the variables recent loss of someone and childhood loss. The means of each variable on the CTQ questionnaire were compared for the factors ‘group’ and ‘gender’ and 66 – Trends Psychiatry Psychother. 2020;42(1)

the interaction ‘group × gender’. A gamma distribution with log link was used. The Bonferroni post-hoc test was conducted for analyses that exhibited statistical significance.17 For the MOS questionnaire, odds ratios were calculated using conditional logistic regression. Some variables consisted of one item with multiple answers. These variables were analyzed in descriptive form. Analyses were performed using SPSS v.18 software. The level of significance adopted was 0.05.

Results Participants (n = 84) had similar distribution with regards to gender (M/F = 46.4%/53.6%) and mean age was 35.6 years (SD = 12.8). The mean number of years in education was 9.9 (SD = 4.6). Almost half of the participants were in a stable relationship (48.8%). During the interviews, 61.9% said they were employed, 27.4% were unemployed, and 10.7% were retired or students (Table 1). 26.2% of the subjects had a history of mental disorder; 56.3% reported at least one close family member with a history of mental disorder; 54.8% reported the loss of a significant other by death during their childhood; and 47% reported recent loss of a significant other by death. In 46.4%, hospital admission coincided with a significant date, regardless of the reason for admission or emergency room visit. There were no statistically significant differences in sociodemographic characteristics. When evaluated separately, the control group had only a 7.3% prevalence of previous mental disorder, while the case group had a 64.3% prevalence (p < 0.001). In the control group, 64.3% reported loss of a significant other during childhood, in contrast with 35.7% in the case group (p = 0.025). Sixteen of the case group subjects had a history of previous mental disorder; 62.5% (n = 10) were on psychiatric treatment; 12.5% (n = 2) were being seen by a psychologist, and 25% (n = 4) were receiving both psychiatric and psychological treatment. Fourteen (50%) of the subjects who attempted suicide (n = 28) had a record of previous suicide attempt and eight of these attempts were made in 2015-16. The SA methods used were: ingestion of medication (53%), cutting weapon/firearm (3.1%), hanging (6.3%), overdose (6.3%), burning (9.4%), jumping out of a moving car or from a great height (9.4%), cuts to wrist and neck (9.4%), and poisoning (lye, naphthalene, rat poison) (9.4%). The total number of answers was 32, because four SAs used more than one method.

Traumatic experiences and suicide attempt - Zatti et al.

Seven people (28%) wrote a suicide letter or left a message on smartphone apps and 13 people (46%) tried to commit suicide in the presence of someone else. Four patients (14%) reported that their chosen suicide method was not easy to acquire (for instance, buying rat poison or lye in agriculture/animal supply stores), while 24 subjects (85%) described using means available in their own homes. Half of the participants (14 people, 50%) reported that the index attempt was not their first suicide attempt and one subject reported eight suicide attempts over the course of his life. The most frequent days of the week for SA were: Mondays and Tuesdays (43%) and the most frequent time of day was in the morning, between 7:00 am and 10:00 am. There were no statistically significance differences in CTQ results between men and women (p ≥ 0.05). Case and control groups had different means for the following variables: emotional abuse, physical abuse, emotional neglect, and physical neglect (p < 0.001 for all variables), with case means always higher than control means (Table 2). Emotional abuse was the variable with the highest difference between means

for cases and controls, followed by emotional neglect (5.3 and 5.1, respectively). Regarding gender, women presented significantly higher means than men for the variables: emotional abuse (p < 0.001), physical abuse (p = 0.020), sexual abuse (p = 0.037), and emotional neglect (p < 0.001) (Table 2). In the case group, 23 participants (82.1%) were classified as being at high risk for suicide, half of whom (n = 14; 50%) presented suicidal ideation at the time of the interview, while 18 (64.3%) cases had a history of psychiatric disease in the family. Fifty-five people (98.2%) in the control group had neither suicide risk nor suicidal ideation. With regard to social support, for the whole sample, the mean number of family supporters was 3.4 (SD = 3.3) and mean number of close friends was 1.90 (SD = 2.8). The control group had a mean of 6.6 support people, including both family and close friends, in contrast with 2.5 in the case group (p < 0.001). Still with relation to the MOS results, Table 3 shows the results for the dimensions: The control group presented means equal to or above 4.4 in all dimensions. In contrast, all means were below 3.4

Table 1 - Sociodemographic characteristics by group Variable

Controls (n = 56)

Cases (n = 28)

Male

26 (46.4)

13 (46.4)

> 0.999

Female

30 (53.6)

15 (53.6)

35.6 (12.9) [19-66]

35.4 (12.8) [20-71]

0.933

10.1 (4.9) [1-25]

9.7 (4.0) [2-18]

0.707

2.000 (1.250-3.650) [233-33.000]

2.000 (1.360-3.500) [0-5.000]

0.611

Single

20 (35.7)

10 (35.7)

0.177

Long-term relationship

30 (53.6)

11 (39.3)

Gender

Age, mean (SD) [min-max]* Years in education, mean (SD) [min-max]* Income, Q2 (Q1-Q3) [min-max]† Marital status

Widowed

1 (1.8)

0 (0)

Separated

5 (8.9)

7 (25)

Occupation Unemployed

14 (25.0)

9 (32.1)

Employed

37 (66.1)

15 (53.6)

5 (8.9)

4 (14.3)

Retired or student Prior psychiatric history

0.522

< 0.001

4 (7.1)

18 (64.3)

Family psychiatric history

27 (48.2)

18 (64.3)

0.246

History of significant loss in childhood

36 (64.3)

10 (35.7)

0.025

Commemorative date near hospitalization

29 (51.8)

10 (37)

0.305

Recent loss (death) of someone

24 (42.9)

15 (53.6)

0.486

Suicide attempt (in last 3 months), Q2 (Q1-Q3) [min-max]

1 (0-1) [0-3]

Data presented as n (%), unless otherwise specified. Min-max = minimum-maximum; Q = quartile; SD = standard deviation. * t test for independent samples. † Brazilian reais (BRL) per month; Mann-Whitney U test.

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Traumatic experiences and suicide attempt - Zatti et al.

Table 2 - Inter-group comparison of mean Childhood Trauma Questionnaire (CTQ) scores, using generalized estimating equation model analysis with gamma distribution Control n = 56

Type of trauma

Case n = 28

Total n = 84

pgroup

Pgender

pinteraçtion

< 0.001

0.020

0.672

0.067

0.037

0.927

Emotional abuse 6.4 (5.7-7.1)

10.6 (7.9-13.4)

8.2 (7.1-9.3)

Female

9.0 (7.1-10.9)

15.6 (12.5-18.7)

11.8 (10.1-13.6)

Total

7.6 (6.7-8.5)

12.9 (10.8-15.0)

Male

5.9 (5.4-6.4)

10.2 (7.2-13.3)

7.8 (6.6-9.0)

Female

7.9 (6.5-9.4)

12.5 (9.6-15.3)

9.9 (8.6-11.3)

6.9 (6.2-7.5)

11.3 (9.2-13.4)

Male

Physical abuse

Total Sexual abuse Male

5.3 (4.8-5.9)

7.0 (4.8-9.2)

6.1 (5.1-7.1)

Female

7.0 (5.7-8.3)

8.9 (5.8-12.1)

7.9 (6.5-9.3)

Total

6.1 (5.5-6.8)

7.9 (6.0-9.8)

Emotional neglect 7.0 (5.8-8.1)

10.8 (9.0-12.5)

8.7 (7.5-9.8)

10.1 (8.1-12.2)

17.0 (13.7-20.3)

13.1 (11.6-14.6)

8.4 (7.3-9.5)

13.5 (11.8-15.3)

Male Female Total

< 0.001 < 0.001

0.676

< 0.001

0.162

Physical neglect Male

7.1 (6.7-7.5)

8.3 (6.6-10.0)

7.7 (6.9-8.5)

Female

7.5 (6.5-8.6)

10.8 (8.9-12.7)

9.0 (7.8-10.2)

7.3 (6.8-7.9)

9.5 (8.2-10.8)

Male

31.7 (29.9-33.7)

46.9 (39.7-55.4)

38.6 (35.2-42.3)

Female

41.6 (35.6-48.6)

64.8 (54.8-76.7)

51.9 (46.6-57.8)

36.3 (33.4-39.5)

55.1 (49.0-62.1)

Total

0.064

Total Score

Total

< 0.001 < 0.001

0.731

Results expressed as mean (95% confidence interval). pgroup = p value for the effect of the group; pgender = p value for the effect of gender; pinteraction = p value for the effect of the group × gender interaction.

Table 3 - Previous/recent losses by death and Medical Outcomes Study (MOS) results: evaluation of dimensions

Conditional logistic regression

Control Mean (95%CI)

Case Mean (95%CI)

95%CI

Family+Close friends

6.6 (5.2-8.0)

2.5 (1.4-3.7)

< 0.001

0.76

(0.64-0.91)

0.003

MOS_Tangible

4.6 (4.4-4.8)

3.4 (2.9-3.8)

< 0.001

0.20

(0.08-0.51)

< 0.001

MOS_Affection

4.6 (4.4-4.8)

3.4 (2.9-3.9)

< 0.001

0.31

(0.15-0.63)

< 0.001

MOS_Emotional

4.4 (4.2-4.6)

3.0 (2.4-3.5)

< 0.001

0.45

(0.29-0.69)

< 0.001

MOS_Informational

4.5 (4.3-4.7)

3.1 (2.6-3.5)

< 0.001

0.29

(0.15-0.57)

< 0.001

MOS_PositiveSocialInteraction

4.5 (4.3-4.7)

2.9 (2.4-3.4)

< 0.001

0.35

(0.20-0.62)

< 0.001

MOS_f1_Aff_PosSoc

4.5 (4.3-4.7)

3.1 (2.6-3.6)

< 0.001

0.30

(0.15-0.59)

< 0.001

MOS_f2_Em_Inf

4.5 (4.2-4.7)

3.0 (2.5-3.5)

< 0.001

0.37

(0.22-0.62)

< 0.001

MOS_f3_Tangible

4.6 (4.4-4.8)

3.4 (2.9-3.8)

< 0.001

0.20

(0.08-0.51)

< 0.001

Recent loss of someone

57.1 (45.3-69.0)

46.4 (28.0-64.9)

0.382

1.46

(0.62-3.45)

0.388

History of childhood loss

35.7 (23.7-47.7)

64.3 (46.5-82.0)

0.013

0.32

(0.12-0.84)

0.021

Childhood + Recent loss*

67.9 (57.7-78.0)

78.6 (63.4-93.8)

0.312

0.75

(0.42-1.34)

0.334

95%CI = 95% confidence interval. All variables with normal distribution in the generalized estimating equation (GEE); * binomial distribution in the GEE.

68 – Trends Psychiatry Psychother. 2020;42(1)

Traumatic experiences and suicide attempt - Zatti et al.

in the case group, presenting significant values in all dimensions (p < 0.001). As can be observed from the table, having an extra family member and/or friend to count on offers 24% protection against suicide risk and one additional point of tangible support is associated with 80% protection. One additional point of affectionate support offers 69% protection against risk of suicide attempt; emotional support provides 55% (p < 0.001); informational support provides 71% (p < 0.001); and positive social interaction offers 65% protection. When combined, affectionate support and social interaction offer 70% protection (p < 0.001) with one additional point. Combining emotional support with informational support gives 63% (p < 0.001). Family history data is shown in Table 4. Forty-three subjects responded to a parallel investigation about

adverse events, memories, or significant dates and 65% (n = 28) exhibited proximity between the date of admission and anniversaries of these items, whether related to the patients themselves or to a close family member. Table 5 shows that 10 people admitted due to SA reported 11 events: 54.5% (6 events) related to anniversaries and 45.5% (5 events) related to holidays. In the control group, 29 people reported 32 events: 68.8% (22 events) were anniversaries and 15.6% (5 events) were holidays. An additional investigation asked the medical team to give their impression of the seriousness and lethality of the SA. They classified 32% (n = 9) of the SA as ‘Mild’, 18% (n = 5) as ‘Moderate’, and 50% (n = 18) as ‘Serious’. Most of the cases (93%, n = 26) believed that their self-destructive act had caused some kind of emotional impact on a family member or friend.

Table 4 - Family psychiatric disorders Control

Case

Mother

11 (29.7)

8 (28.6)

Father

10 (27.0)

8 (28.6)

4 (10.8)

3 (10.7)

Relationship

Child Sibling

12 (32.4)

9 (32.1)

Total responses

37 (100)

28 (100)

Total subjects Type of disorder*

16 (8.7)

11 (10.8)

Suicide attempt

Depression

4 (2.2)

8 (7.8)

Suicide

2 (1.1)

Bipolar disorder

1 (0.5)

2 (2)

14 (7.6)

12 (11.8)

Drug problems

Alcohol problems

9 (4.9)

7 (6.9)

Psychiatric hospitalization

2 (1.1)

Psychiatric treatment

5 (2.7)

6 (5.9)

184 (100)

102 (100)

Total responses Total subjects * Collected using the sociodemographic questionnaire.

Table 5 - Analysis of Reasons for Hospitization, by Adverse Events Birthdays

Traumatic memory/fight

Stressful event

Holidays*

Total†

6 (60)

0 (0)

5 (50)

Accident (traffic/work/domestic)

12 (75)

0 (0)

1 (6.3)

5 (31.3)

Illness

6 (66.7)

2 (22.2)

0 (0)

Assault

4 (100)

0 (0)

Hospitalization reason SA

Total‡ * Easter, Christmas, New Year, Carnival. † Total number of people ‡ Total number of responses.

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Traumatic experiences and suicide attempt - Zatti et al.

Discussion This study evaluated situations of childhood trauma, social support, sociodemographic aspects, and loss of parents during childhood or recent losses. Suicide attempt, as a bid to end one’s life, is considered a matter of public health.3 With that in mind, this research was conducted to evaluate suicide attempt in patients who were seen in the emergency room or needed admission or medical care at the Hospital de Pronto Socorro, in Porto Alegre, Brazil. In the course of normal human development, all people may face traumatic events inherent to life. However, traumatic events can occur that exceed children’s capacity to understand and then become etched on their minds. Occasions that trigger trauma leave painful marks in the psychic apparatus. Such traumatic experiences are continually relived through memories and, depending on the intensity, they can become overpowering in a person’s life, causing mental disorder, suicide attempt, and completed suicide. Psychic pain can seriously damage human development, impairing cognitive and emotional development, and leading people to commit violent acts of self-harm.18 In the suicide attempt sample collected at the HPS, 28% of the participants wrote some kind of suicide letter or sent messages through smartphone apps, i.e., they sought to express their unbearable psychic pain. In many cases, suicide attempt is founded on an absence of psychic resources capable of containing the psychic pain.18 The results of the instrument for measuring social support for the sample as a whole showed that the mean number of relatives considered socially supportive was 3.4 (SD = 3.3), while the mean number of close friends was 1.9 (SD = 2.8). The sum of the mean numbers of relatives and close friends was higher for the control group (6.6) than for the case group (2.5) (p < 0.001). In other words, patients in the control group had more social support and were more likely to be active and interactive in their social environments. We sought to understand whether support from family or close friends would protect against suicide risk. As mentioned above, having one additional relative and/or close friend lowered suicide risk by 24% and one extra point of instrumental support reduced risk by 80%. One extra point of affectionate support gave 69% protection against risk of suicide attempt, one point of emotional support gave 55% (p < 0.001), and one point of informational support gave 71% protection (p < 0.001). Combining affectionate support and informational support resulted in 63% protection (p < 0.001). 70 – Trends Psychiatry Psychother. 2020;42(1)

The authors of a study conducted to test the construct validity of the MOS stated that there was a positive association between relatives and close friends and emotional support/social companionship. Compared to those who reported having no close friends or relatives, the likelihood of perceiving strong support was around three times higher (OR = 3.3; 95%CI: 2.2-4.9) for those who had one to two friends and about 10 times higher (OR = 10.3; 95%CI: 6.9-15.4) for those who reported eight or more friends.10 However, a recent study by Zatti et al.19 with patients who attempted suicide found that the sample had severe symptoms of depressive disorder and social support rejection. The researchers calculated Pearson coefficients for correlations between the variable depressive disorder and the MOS dimensions and found significant and inverse relationships with tangible support, emotional support, social interaction, and emotional support; in other words, the higher the score for depressive disorder, the lower the scores for the MOS dimensions.19 Certain crises, such as vital (aging) and circumstantial (unexpected events), for example, may lead to what Botega20 calls existential collapse. This collapse generates anguish, helplessness, incapacity, burnout, and lack of prospects for solutions and may increase vulnerability to suicide, which begins to seem like a solution for the unbearable pain.20 We investigated whether such existential collapse can be triggered by anniversaries or special dates that bring back memories or whether such dates can become overwhelming due to the individual having suffered intensely, such as feeling abandoned, helpless, and lacking prospects. We analyzed the suicide attempt cases and obtained 11 positive answers for 11 anniversaries (including birthdays) and/or special dates: 54.5% (6 events) related to anniversaries and 45.5% (5 events) related to holidays. The feeling of abandonment or loneliness is often experienced in early childhood. In the analysis of loss of a significant other during childhood among subjects who had attempted suicide, 68% (p < 0.001) indicated that they had lost a significant other during childhood. This figure serves as an alert for existential crises. Based on the above, some factors are associated with increased suicide risk: suicidal thoughts, mental disorder, physical diseases, childhood trauma, psychosocial issues, and psychological and demographic aspects.21 Our research findings are in line with these factors, since the prevalence of a previous psychiatric medical record was lower in the control group (7%) than in the case group (63.4%) (p < 0.001). Concerning clinical implications, patients with these disorders and a record of childhood trauma must be

Traumatic experiences and suicide attempt - Zatti et al.

carefully evaluated for suicide risk as well as for impulsive and aggressive tendencies, which must be treated during mental health care follow-up with the aim of preventing suicidal behavior.22 This study also investigated whether the patients had a history of disorders within their immediate families, and the most prevalent conditions reported were depressive disorder and alcoholism. During data collection, some histories appeared to show symptoms of trauma and suffering dating back to childhood that had been caused by witnessing constant fights/arguments within the immediate family, because of constant use of alcohol by caregivers. Adverse situations experienced during childhood, such as sexual, physical, and psychological abuse, as well as physical and emotional neglect, are strong risk factors for many of the main causes of psychic suffering, death, diseases, and incapacitation in all phases of development.23,24 Effective interventions are needed to prevent mistreatment in childhood and it is important that such services are available for young people who may be at increased risk for suicide, given their prior history.25 Studies state that the CTQ is an appropriate tool for retrospective measurement and evaluation of previous trauma in adolescents and adults.10 The estimates observed in our study showed that means for the case group were always higher than those for the control group. Emotional abuse and emotional neglect, in that order, were the variables with the highest differences between the two groups (differences of 5.3 and 5.1 respectively). Studies that evaluated CTQ comparing cases with suicide attempt and controls without suicide attempt have shown that CTQ mean scores are higher in suicide attempt cases than in controls.25 Analysis of childhood abuse results in our sample showed that women had higher means than men for the following variables: emotional abuse (p < 0.001), physical abuse (p = 0.020), sexual abuse (p = 0.037), and emotional neglect (p < 0.001). Results from several small studies across the world reveal alarming data concerning the level of abuse against women, beginning in childhood, as we can confirm.8,24 The ARYS (At Risk Youth Study) collected data in Canada from 2005 to 2013. The street youths from this prospective cohort study were aged between 14 and 26 years and were involved with drugs and street life. Participants responded to the CTQ and, using the Cox regression model, the study examined associations between five types of mistreatment and suicide attempt, concluding that childhood mistreatment is associated with higher risk of suicidal behavior among youths.26 Our study also corroborates these results,

since childhood traumas were statistically significant in our case group. The presence of childhood mistreatment was strongly associated with risk of suicide attempt. Subjects who had a history of previous physical abuse, emotional abuse, or emotional neglect were 3 to 5 times more likely to report a suicide attempt. When examined in a combined statistical model, only physical abuse maintained an independent effect on risk of suicide attempt. Sexual abuse was the least common childhood trauma among those reported in this study. However, the authors did not rule out the possibility that the participants felt uneasy about communicating such experiences.26 This corroborates our findings, since sexual abuse was the least common childhood trauma reported: only one person replied “always” to all of the assertions related to sexual abuse in the CTQ. In a longitudinal study that followed 183 youths who had suffered sexual abuse for 9 years, analysis showed that the risk of suicide was 13 times higher than that observed in the general population.27 Studies of childhood abuse and suicidal behavior state that the risk of suicidal behavior increases according to the intensity of the abuse during childhood.28,29 Forty-three participants answered a parallel investigation about events, memories, or birthdays/ anniversaries/important dates and 65% of them (n = 28) had an admission date near a birthday (the patient’s own or that of a significant family member). These data expose unconscious aspects involved in traffic accidents and bias in suicide attempts concealed in traffic accidents, and thus not considered suicide attempts, since the majority of people in the group were admitted due to the former.30 Traffic accidents concern authorities throughout the world, given the number of people involved in fatal events of this kind. The victims might be indulging a desire for competition, speed, and living dangerously, poised between life and death.31,32 The relationship between admission and commemorative dates suggests unconscious aspects to be analyzed. In short, we could suppose that presenting suicidal behavior or suicide risk represents sadistic fury against oneself. One of the limitations of this study is the number of participants, which prevents us from proposing generalizations. Pompili conducted a bibliographic search on PubMed and PsycInfo for publications from 1955 to 2011 that reported evidence of a connection between drivers involved in traffic accidents and suicidal behavior.33,34 Some scientists emphasize that the suicidal motivations or self-destructive impulses in traffic accidents are unconscious.30,35 According to one estimate, by the year 2030, injuries caused by traffic accidents will be the Trends Psychiatry Psychother. 2020;42(1) – 71

Traumatic experiences and suicide attempt - Zatti et al.

fifth largest cause of death in the world. However, the phenomenon is most often reported as an accidental act in national statistics.33 In the conclusions to a meta-analysis of longitudinal studies from the last decade, Zatti et al.4 compared people who were exposed to traumatic events in childhood with the general population, showing that they are at increased risk of SA. Since the various forms of childhood trauma are preventable, there are strong reasons for governments to invest in programs, policies, and interventions to minimize childhood exposure to sources of severe adversity.4

Conclusion The results of this study show that situations of abuse or neglect provoke unbearable psychic pain, many times impairing reality test performance. Such ‘echoes’ inside the individual may provoke a desire to interrupt life by ending it. The results of this study suggest that a combination of factors, such as childhood trauma, lack of social support, and history of psychiatric diseases in the immediate family, are involved in risk of suicidal behavior. The profile of the patients who attempted suicide was associated with a history of psychiatric problems and physical/emotional abuse and neglect in childhood. Additionally, SA was associated with lower means in all domains of social support and with history of childhood loss. It is on these elements that we must focus attention, prevention, and intervention. Finally, both the literature reviewed and the results of this study indicate that preventive and therapeutic measures act as key factors in reducing risk of suicide when administered to people who have suffered mistreatment during childhood development. The same preventive care is applicable when increased transgenerational selfdestructive tendencies are observed.

Acknowledgements This study was part financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; Finance Code 001), the Fundação Instituto de Pesquisas Econômicas (grant 150267), and the Fundo de Incentivo a Pesquisa – Hospital de Clínicas de Porto Alegre (FIPEHCPA), Porto Alegre, RS, Brazil. We are grateful to the patients who were willing to participate in our research, to the Hospital de Pronto Socorro, and to the Hospital de Clínicas of Porto Alegre for their support in making this study possible. 72 – Trends Psychiatry Psychother. 2020;42(1)

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References 1. World Health Organization. Child maltreatment [Internet]. 2014 [cited 2018 Jan 5]. http://www.who.int/mediacentre/factsheets/ fs150/en/ 2. Souza F. Suicídio - dimensão do problema e o que fazer? Rev Debates Psiquiatr. 2010;5:6-8. 3. Wilcox HC, Wyman PA. Suicide prevention strategies for improving population health. Child Adolesc Psychiatr Clin N Am. 2016;25:219-33. 4. Zatti C, Rosa V, Barros A, Valdivia L, Calegaro VC, Freitas LH, et al. Childhood trauma and suicide attempt: A meta-analysis of longitudinal studies from the last decade. Psychiatry Res. 2017;256:353-8. 5. Araújo RMF. Mais do que palavras: a associação do abuso emocional na infância com o comportamento suicida [dissertation]. Porto Alegre: Pontífícia Universidade Católica do Rio Grande do Sul; 2015. 6. Fonseca DL. Apoio social e eventos estressantes em pacientes atendidos por tentativas de suicídio em uma grande emergência do Rio de Janeiro [dissertation]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2009. 7. Roy A. Combination of family history of suicidal behavior and childhood trauma may represent correlate of increased suicide risk. J Affect Disord. 2011;130:205-8. 8. Grassi-Oliveira R, Stein LM, Pezzi JC. Tradução e validação de conteúdo da versão em português do Childhood Trauma Questionnaire. Rev Saude Publica. 2006;40:249-55. 9. Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al.. Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl. 2003;27:169-90. 10. Grassi-Oliveira R, Cogo-Moreira H, Salum JA, Brietzke E, Viola TW, Manfro GG, et al. Childhood Trauma Questionnaire (CTQ) in Brazilian samples of different age groups: Findings from confirmatory factor analysis. PLoS One. 2014;9:e87118. 11. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;38:705-14. 12. Griep Rh, Chor D, Faerstein E, Lopes C. Apoio social: confiabilidade teste-reteste de escala no Estudo Pró-Saúde. Cad Saude Publica. 2003;19:625-34. 13. Griep RH, Chor D, Faerstein E, Lopes C. Confiabilidade testereteste de aspectos da rede social no Estudo Pró-Saúde. Rev Saude Publica. 2003;37:379-85. 14. Griep RH. Confiabilidade e validade de instrumentos de medida de rede social e de apoio social utilizados no Estudo Pró-Saúde [doctoral thesis]. Rio de Janeiro: Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz; 2003. 15. Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study: adaptada para o português no Estudo Pró-Saúde. Cad Saude Publica. 2005;21:703-14. 16. Amorim P. Mini International Neuropsychiatric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Braz J Psychiatry. 2000;22:106-15. 17. Hair JR, Black WC, Babin BJ, Anderson REE, Tatham RL. Análise multivariada de dados. 6ª ed. Porto Alegre: Bookman; 2009. 18. Macedo MMK, Werlang BSG. Tentativa de suicídio: o traumático via ato-dor. Psicol Teor Pesq. 2007;23:185-94. 19. Zatti C, Guimarães LSP, Soares MA, Neves J, Santana MRM, Calegaro V, et al. Relación entre apoyo social y trastornos mentales en pacientes ingresados por intento de suicidio en un hospital de emergencia. Acta Psiquiatr Psicol Am Lat. 2018;64:261-72. 20. Botega NJ. Crise suicida: avaliação e manejo. Porto Alegre: Artmed; 2015. 21. Neves F, Corrêa H, Nicolato R. Suicídio: propostas de serviços e ações a serem executadas. Rev Psiquiatr Hoje. 2010;5:36-40 22. Park S, Hong JP, Jeon HJ, Seong S, Cho MG. Childhood exposure to psychological trauma and the risk of suicide attempts: the

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modulating effect of psychiatric disorders. Psychiatry Investig. 2015;12:171-6. 23. Spinhoven P, Elzinga BM, Van-Hemert AM, Rooij M, Penninx PW. Childhood maltreatment, maladaptive personality types and level and course psychological distress: a six-year longitudinal study. J Affect Disord. 2016;191:100-8. 24. Viola TW, Salumb GA, Kluwe-Schiavona B, Sanvicente-Vieira B, Levandowskia ML, Grassi-Oliveira R. The influence of geographical and economic factors in estimates of childhood abuse and neglect using the Childhood Trauma Questionnaire: a worldwide metaregression analysis. Child Abuse Negl. 2016;51:1-11. 25. Hadland SE, Marshall BDL, Kerr T, Qi J, Montaner JS, Wood E. Suicide and history of childhood trauma among street youth. J Affect Disord. 2012;136:377-80. 26. Hadland SE, Wood E, Dong H, Marshall BDL, Kerr T, Montaner JS, et al. Suicide attempts and childhood maltreatment among street youth: a prospective cohort study. Pediatrics. 2015;136:440-9. 27. Plunkett A, O’toole B, Swanston H, Oates RK, Shrimpton S, Parkinson P. Suicide risk following child sexual abuse. Ambul Pediatr. 2001;1:262-6. 28. Lopez-Castroman J, Jaussent I, Beziat S, Guillaume S, BacaGarcia E, Olié E, et al. Posttraumatic stress disorder following childhood abuse increases the severity of suicide attempts. J Affect Disord. 2015;170:7-14.

29. Devries KM, Mak JYT, Child JC, Falder G, Bacchus LJ, Astbury J, et al. Childhood sexual abuse and suicidal behavior: a metaanalysis. Pediatrics. 2014;133:e1331-44. 30. Lima KC, Pinho MX. Suicídio e ato falho: considerações psicanalíticas acerca de suicídios acidentais. Rev ConScientiae Saude. 2010;9:139-45. 31. Botega NJ. Comportamento suicida: epidemiologia. Psicologia USP. 2014;25:231-6. 32. Menninger KA. Purposive accidents an expression of selfdestructive tendencies. Int J Psychoanal. 1936;18:6-16. 33. Pompili M, Serafini G, Innamorati M, Montebovi F, Palermo M, Campi S, et al. Car accidents as a method of suicide: a comprehensive overview. Forensic Sci Int. 2012;223:1-9. 34. Pompili M, Girardi P, Tatarelli G, Tatarelli R. Suicidal intent in single-car accident drivers: review and new preliminary findings. Crisis. 2006;27:92-9. 35. Selzer L, Payne CE. Automobile accidents, suicide and unconscious motivation. Am J Psychiatry. 1962;119:237-40.

Correspondence: Cleonice Zatti Rua Ramiro Barcelos, 2400, 2º andar, Bairro Santana 90035-003 - Porto Alegre, RS - Brazil E-mail: cleonice.zatti@outlook.com

Trends Psychiatry Psychother. 2020;42(1) – 73

Trends in Psychiatry and Psychotherapy

Original Article

Defense mechanisms and quality of life of medical students according to graduation phase Gisely Barddal Medeiros Borges,1 Ingrid Eidt,1 Louise Nassif Zilli,2 Ana Maria Maykot Prates Michels,2,3 Alexandre Paim Diaz4

Abstract Objectives: To compare health-related quality of life (QoL) of medical students in initial and final phases of the program, and to evaluate the association between ego defense mechanisms and specific healthrelated QoL domains within each group. Methods: This was an observational, cross-sectional study. Quality of life was assessed according to the World Health Organization Quality of Life instrument - Abbreviated Version (WHOQOL-Bref); anxiety and depression symptoms were evaluated using the Hospital Anxiety and Depression Scale (HADS); defense mechanisms were assessed using the Defense Style Questionnaire (DSQ-40). Results: A total of 139 medical students were evaluated. Students in the initial semesters of the program (1st and 3rd) presented more depressive symptoms and worse quality of life in the psychological domain of WHOQOL-Bref when compared to those in the final semesters (8th and 12th). In a later analysis, conducted to identify the variables associated with the psychological domain of the WHOQOL-Bref for each group, both depressive symptoms and defense mechanisms were independently associated with the outcome for medical students in the beginning and in the end of the graduation program. Conclusions: Students in the initial phases of medical school may need more specific attention from educational managers. Understanding the role of ego defense mechanisms in the quality of life of medical students may help identify effective psychopedagogical interventions for this population. In addition, the results reinforce the impact of depressive symptoms on quality of life, an association already well evidenced in the literature. Keywords: Medical academics, quality of life, defense mechanisms, depressive symptoms.

Introduction Quality of life (QoL) is an important outcome in health. It is defined as the “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”1 QoL incorporates, in a complex way, the subject’s physical and psychological state, their level of independence, social relations, personal beliefs and their relations with the environment.1,2 Among the several factors

associated with QoL, depression is one of the most frequently found in the literature.3 Anxiety symptoms, depression and suicidal ideation are not uncommon in medical students and resident physicians. A systematic review on the prevalence of depressive symptoms and suicidal ideation in medical students observed that the prevalence of depressive symptoms in this population was higher than that reported for the general population.4 Medical school is described as a stressor that can negatively affect the academic performance, health, and psychological

Faculdade de Medicina, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil. 2 Programa de Residência Médica em Psiquiatria, Instituto de Psiquiatria de Santa Catarina, São José, SC, Brazil. 3 Departamento de Clínica Médica, UFSC, Florianópolis, SC, Brazil. 4 Núcleo de Psiquiatria, UFSC, Florianópolis, SC, Brazil. 1

Submitted Mar 09 2019, accepted for publication Jun 27 2019. Suggested citation: Borges GBM, Eidt I, Zilli LN, Michels AM, Diaz AP. Defense mechanisms and quality of life of medical students according to graduation phase. Trends Psychiatry Psychother. 2020;42(1):74-81. http://dx.doi.org/10.1590/2237-6089-2019-0022 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 74-81

Defense mechanisms and quality of life - Borges et al.

well-being of these students.5 The highly competitive selection before even entering the medical school and later the competitive university environment, not to mention the intense hours and the conviviality with people in situation of illness, can all influence the QoL of the students and medical professionals. In addition to the evaluation of QoL in the different phases of the medical training program, in order to identify phases of greater vulnerability, it is indispensable to study which variables would be associated with the students’ QoL – this could help identify interventions that could have an impact on their future professional performance.6 Most Brazilian medical students are in their adolescence, a period of learning and social development, when they are susceptible to peer influence and the sense of self is in development.7 The cognitive development of adolescents includes the development of more advanced reasoning skills, the ability to think abstractly and the capacity of more accurately perceiving their own feelings and how others perceive them.8 Psychosocial and emotional development is characterized by increased autonomy, the establishment of identity and better selfregulation of emotions.8 In addition, as they mature, stronger regulatory control is achieved, allowing delay in gratification and improved long-term planning.7 The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines a defense mechanism as “mechanisms that mediate the individual’s reaction to emotional conflicts and external stressors. Some defense mechanisms are almost invariably maladaptive. Others may be maladaptive or adaptive, depending on their severity, inflexibility and the context in which they occur.”9 This is a concept derived from psychoanalysis and represents unconscious resources used by the ego to reduce the conflict between the id and the superego.10 In a prospective study, George Vaillant accompanied 30 physically healthy men selected from a sample of 268 male university students with the goal of ranking ego defense mechanisms. From this study, which made it possible to map the defense styles of the participants, Vaillant classified the defenses as “immature,” “neurotic,” and “mature.” For the author, the ego’s primitive mechanisms evolve into more mature mechanisms. In addition, individuals with mature defenses would exhibit optimal adaptation to life, while those with immature defenses, only a regular adaptation.11 In the research literature, we observed that only a small number of studies evaluated the association between defense mechanisms and QoL, and few have adjusted the findings for psychiatric symptoms – a relevant confounder in QoL research. In a crosssectional study, Vojvodić et al. found that military personnel that use mature defense mechanisms

have a better perception of QoL.12 Talepasand & Mahfar evaluated the relationship between defense mechanisms and QoL among women with breast cancer in a correlational study. The authors found and inverse association between displacement and regression defense mechanisms and physical, cognitive and role aspects of QoL.13 Only one study has investigated this association in medical students.14 Thus, the objectives of this study were to compare the medical students’ QoL in different phases of the medical program, and to identify the sociodemographic, clinical and defense mechanisms associated with QoL in a Brazilian sample of medical students. Considering that the impact of the imminent beginning of professional life and the greater responsibility with patients grows in importance towards the end of the program, our hypothesis was that students attending the final semesters would present worse QoL when compared to students in the initial semesters.

Methods Study design This was a cross-sectional, observational study. Participants The medical program at Universidade Federal de Santa Catarina (UFSC) is structured in 12 semesters, with activities being held in the community since the early semesters. The two first semesters are dedicated to basic theorical disciplines; from the 3rd semester onwards, focus is on the study of health conditions. The 8th semester is the last one predominantly theorical before the internship (9th to 12th semester). The use of active learning methodologies, in which students are more involved in the teaching process, despite being increasingly stimulated in the pedagogical process, is not mandatory. Our sample comprised students attending the 1st, 3rd, 8th and 12th semesters of the medical program at UFSC, Florianópolis, state of Santa Catarina, Brazil. These semesters were chosen after discussion among the researchers about which would be critical moments during medical school: 1st semester - beginning of the program; 3rd - beginning of the student’s contact with clinical examination of patients; 8th - last theoretical period of the program before the internship; and 12th - last period before graduation. Students were contacted and invited to participate in the study, and received explanations about the study objectives and characteristics. Those who agreed to participate signed an informed consent form. In the second half Trends Psychiatry Psychother. 2020;42(1) – 75

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of 2015, 196 students were enrolled in the 1st, 3rd, 8th and 12th semesters of the program (52, 50, 44 and 50, respectively). Inclusion criteria were students enrolled in the 1st, 3rd, 8th and 12th semesters of the medical program in the second half of 2015 (period of data collection). The only exclusion criterion was being younger than 18 years old. Research instruments This study consisted of a self-applied protocol, which included a sociodemographic questionnaire, The World Health Organization Quality of Life instrument - Abbreviated Version (WHOQOL-Bref),15 the Hospital Anxiety and Depression Scale (HADS),16 and the Defense Style Questionnaire (DSQ-40) for the evaluation of defense mechanisms.17 Data on religious practice, sports and leisure activities were investigated using yes/no questions, as was information on alcohol use. World Health Organization Quality of Life instrument Abbreviated Version (WHOQOL-Bref) The instrument chosen to assess QoL was the WHOQOL-Bref, prepared by the World Health Organization Quality of Life Group. The WHOQOL-Bref is composed of 26 questions, two of which relate to general QoL and health, and the other 24 questions form four specific domains: psychological, physical, social relations and environment. Higher scores on the WHOQOL-Bref or its domains correspond to better QoL. This instrument has been validated for application in the Brazilian population.15 The WHOQOL-Bref is one of the most widely used research tools for assessing QoL in mental health. It accesses the individuals’ perception within their cultural context and value systems, taking into account their goals and concerns. Hospital Anxiety and Depression Scale (HADS) The HADS scale was developed to assess anxiety and depression symptoms in patients hospitalized for non-psychiatric illnesses and it was subsequently validated for outpatients and non-diagnosed patients. HADS is a self-administered scale that can also be applied by an interviewer and is valid for measuring symptoms of anxiety and depression in individuals with non-psychiatric and psychiatric disorders. This instrument comprises 14 questions, of which seven investigate anxiety (HADS-A) and the other seven investigate depression (HADS-D).16 This instrument has been validated for use in the Brazilian population.18 Defense Style Questionnaire (DSQ-40) Ego defense mechanisms correspond to a psychoanalytic concept and have served as indicative 76 – Trends Psychiatry Psychother. 2020;42(1)

of the typical way an individual handles their conflicts. The DSQ-40 is a scale developed to identify how people perceive the derivatives of these defense mechanisms; to do so, it relies on questions that assess their behavior against specific situations. The DSQ-40 is composed of 40 questions, which are related to the 20 defense mechanisms described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition Revised (DSM-III-R). Each defense is evaluated by two questions. Four defenses are related to the mature factor (sublimation, humor, anticipation and suppression), 12 to the immature factor (projection, passive aggression, actuation, isolation, devaluation, “autistic fantasy,” negation, dislocation, dissociation, cleavage, rationalization and somatization), and four to the neurotic factor (nullification, pseudo-altruism, idealization and reactive formation).19 This instrument has been validated in Portuguese.17 Data analysis Continuous variables were described as mean and standard deviation or median and interquartile range, depending on the distribution of the data, analyzed according to the Kolmogorov-Smirnov test. The groups (represented by initial and final phases of the medical program) were compared according to QoL scores, as well as sociodemographic and clinical variables. For categorical variables, the chi-square test or Fisher’s exact test were used; parametric continuous data were analyzed using the Student t test. Continuous non-parametric data were analyzed using the Mann-Whitney test. Simple linear regression analysis was used to evaluate which variables were associated with QoL domain scores for each group separately. Associations whose p-value resulted < 0.20 were included in a multiple linear regression model. After these last analyses, p-values < 0.05 were considered significant. Ethical aspects The research project was approved by the research ethics committee of UFSC. All participants signed an informed consent form prior to data collection.

Results Among the 196 students enrolled in the 1st, 3rd, 8th and 12th periods of the medical program in the second semester of 2015, 139 (71.3%) agreed to participate in this study. In the second half of 2015, 52, 50, 44 and 50 students were enrolled in the 1st, 3rd, 8th and 12th semesters of the program, respectively. Of these,

Defense mechanisms and quality of life - Borges et al.

41 (78.8%), 43 (86%), 33 (75%) and 22 (44%), respectively, were evaluated. We believe that the lower rates of evaluation in the 8th and 12th semesters are due to an increased number of extra-class activities towards the end of the medical program. The protocol was presented to students in one opportunity at the end of theorical classes taught by authors GBMB and IE; fewer students were reached among those with more in-hospital activities. Unfortunately, we do not have information about how many participants have refused to answer the study protocol. All evaluations were conducted in the second half of 2015. The majority of the participants were female (53.2%), with a mean age ± standard deviation (SD) of 21.1±2.6, 22±2.8, 24.7±3, and 25.1±2 years old for the 1st, 3rd, 8th and 12th semester, respectively. Less than 30% came from the metropolitan region were the medical school is located; a minority, 26.7%, lived alone. Of the students evaluated, 59% reported having a habit of practicing sports weekly, and most of the students, 74.1%, reported consuming alcoholic beverages weekly. Students attending the 1st and 3rd semesters were grouped and referred to as “initial phases,” whereas students attending the 8th and 12th semesters

were grouped and referred to as “final phases.” The comparison between these two groups showed that students in the initial phases presented significantly more depressive symptoms – median of 5 points on HADS-D (interquartile range [IQR] = 3-7) – when compared to students in the final phases – median HADS-D score of 3 (IQR = 2-6) (p = 0.01). In relation to defense mechanisms, students in the initial phases also had significantly higher neurotic (p = 0.004) and immature (p = 0.006) scores; in the assessment of QoL, students in the initial phases presented worse QoL in the psychological domain (p = 0.008) (Table 1). Linear regression analysis was applied to identify which variables would be associated with psychological QoL scores for each group separately. It was found that, for the initial phases, depressive symptoms (coefficient B -2.82, 95% confidence interval [95%CI] -3.67 to -1.97) and the immature factor (coefficient B -12.82, 95%CI -19.30 to -5.11) were independently associated with poorer psychological QoL after multiple linear regression analysis (Tables 2 and 3). For the final phases, in addition to depressive symptoms (coefficient B -3.04, 95%CI -3.96 to -2.11), the neurotic factor (coefficient B -6.92, 95%CI -12.19 to -1.65) was associated with worse psychological QoL (Tables 4 and 5).

Table 1 - Sociodemographic characteristics, psychiatric and psychological symptoms and quality of life according to medical graduation phase (initial vs. final) Initial phases (1st and 3rd semesters) n = 84

Final phases (8th and 12th semesters) n = 55

0.42

Sociodemographic characteristics Sex Male

37 (44)

28 (50.9)

Female

47 (56)

27 (49.1)

21 (19-23)

24 (24-26)

< 0.001*†

0.07

Age in years, median (IQR) Stable relationship Yes

27 (32.1)

26 (47.3)

57 (67.9)

29 (52.7)

Metropolitan region

23 (29.9)

16 (29.6)

Other city

54 (70.1)

38 (70.4)

Yes

23 (27.4)

14 (25.5)

61 (72.6)

41 (74.5)

Yes

27 (32.1)

13 (23.6)

57 (67.9)

42 (76.4)

Dwelling‡ 0.97

Living alone 0.80

Religion practice 0.27 Continued on next page

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Defense mechanisms and quality of life - Borges et al.

Table 1 (cont.)

Initial phases (1st and 3rd semesters) n = 84

Final phases (8th and 12th semesters) n = 55

p 0.36

Sport activity weekly Yes

47 (56)

35 (63.6)

37 (44)

20 (36.4)

Yes

44 (52.4)

29 (54.7)

40 (47.6)

24 (45.3)

Yes

60 (71.4)

43 (78.2)

24 (28.6)

12 (21.8)

8.3 (4.0)

7.3 (4.0)

0.15

5 (3-7)

3 (2-6)

0.01*||

Mature factor

2.7 (0.5)

2.6 (0.5)

0.23

Neurotic factor

2.4 (0.5)

2.1 (0.7)

0.004¶

Immature factor

1.9 (0.4)

1.7 (0.5)

0.006¶

Physical domain

61.6 (15.3)

65.9 (16.3)

0.12

Psychological domain

56.9 (16.9)

64.4 (14.6)

0.008¶

Social domain

63.5 (18.6)

68.0 (20.3)

0.18

Environmental domain

63.5 (16.0)

67.4 (13.4)

0.13

Leisure activity weekly§ 0.79

Alcohol use 0.37

Psychiatric symptoms, mean (SD) HADS-A HADS-D, median (IQR) Psychological symptoms, mean (SD)

Quality of life, mean (SD)

Data presented as n (%), unless otherwise specified. HADS = Hospital Anxiety and Depression Scale; IQR = interquartile range; SD = standard deviation. * Mann-Whitney test; † p < 0.001; ‡ 8 missing; § 2 missing; || p < 0.05; ¶ p < 0.01.

Table 2 - Simple linear regression analysis between independent variables and quality of life psychological domain scores in the initial phases (1st and 3rd semesters) of medical school Variable

B coefficient

95%CI

Age

-1.36

-2.70 to -0.02

0.22

0.05

0.047*

HADS-D

-3.38

-4.26 to -2.50

0.64

0.41

< 0.001†

Neurotic factor

-7.35

-14.30 to -0.40

0.23

0.05

0.04*

-20.47

-28.20 to -12.74

0.50

0.25

< 0.001†

Immature factor

95%CI = 95% confidence interval; HADS-D = Hospital Anxiety and Depression Scale – Depression subscale. * p < 0.05; † p < 0.001.

Table 3 - Multiple linear regression analysis to evaluate the independent associations with quality of life psychological domain scores in the initial phases (1st and 3rd semesters) of medical school Variable

95%CI

R2 0.56

Age

-1.13

-2.10 to -0.17

0.02*

HADS-D

-2.82

-3.67 to -1.97

< 0.001†

Neurotic factor Immature factor

-2.98

-8.36 to 2.40

0.27

-12.82

-19.30 to -5.11

0.001‡

95%CI = 95% confidence interval; HADS-D = Hospital Anxiety and Depression Scale – Depression subscale. * p < 0.05; † p < 0.001; ‡ p < 0.01.

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Defense mechanisms and quality of life - Borges et al.

Table 4 - Simple linear regression analysis between independent variables and quality of life psychological domain scores in the final phases (8th and 12th semester) of medical school Variable Age HADS-D

B coefficient

95%CI

0.41

-1.13 to 1.94

0.07

0.005

0.59

-3.52

-4.42 to -2.62

0.73

0.54

< 0.001*

Neurotic factor

-12.06

-17.52 to -6.61

0.54

0.29

< 0.001*

Immature factor

-13.00

-21.21 to -4.79

0.41

0.17

0.003†

95%CI = 95% confidence interval; HADS-D = Hospital Anxiety and Depression Scale – Depression subscale. * p < 0.001; † p < 0.01.

Table 5 - Multiple linear regression analysis to evaluate the independent associations with quality of life psychological domain scores in the final phases (8th and 12th semesters) of medical school Variable

B coefficient

95%CI

Age

0.11

-0.88 to 1.11

0.82

HADS-D

-3.04

-3.96 to -2.11

< 0.001*

Neurotic factor

-6.92

-12.19 to -1.65

0.01†

Immature factor

-0.19

-7.57 to 7.18

0.96

R2 0.64

95%CI = 95% confidence interval; HADS-D = Hospital Anxiety and Depression Scale – Depression subscale. * p < 0.001; † p < 0.05.

The standardized residuals from both multiple linear regression analyses followed a normal distribution, according to the Kolmogorov-Smirnov normality test (p = 0.98 and p = 0.85 for the 1st/3rd and the 8th/12th semester regression models, respectively).

Discussion In this study, medical students in the initial phases (1st and 3rd phases) of the medical program, when compared to those in the final phases (8th and 12th phases), presented significantly more depressive symptoms, worse QoL in the psychological domain and higher scores on the neurotic and immature factors of the DSQ-40. When analyzing the variables associated with the QoL psychological domain for each group separately, depressive symptoms and defense mechanisms were associated with worse QoL in the psychological domain for both groups. However, whereas for the initial phases the immature factor had an independent association with a poorer QoL in this domain, for the final phases the neurotic factor of the DSQ-40 was the variable associated with the same outcome after the multiple linear regression. In our study, the mean score of depressive symptoms, according to HADS-D, was 5.3±3.2 and 4.1±3.0 for students in the initial and final phases, respectively. In the study of Vasconcelos et al., which aimed to assess the prevalence of anxiety and depression symptoms in medical students, the mean

HADS-D score was 4.4±3.1,20 similar to the one found in the present investigation. De Paula et al. found that the prevalence of depressive symptoms decreased as the student progressed during the period of medical school.21 Conversely, Nava et al. observed that the prevalence of depression was significantly higher among undergraduate students in the last two years of medical school than among first-year students.22 Rotenstein et al., in a systematic review of the prevalence of depressive symptoms in medical students, observed its increase by 13.5% along the course of the graduation program.4 Taking into account the information obtained by the WHOQOL-Bref questionnaire (QoL) and by the DSQ-40 (ego defense mechanisms), we observed a negative association between psychological domain scores and the immature factor for students in the initial phases, suggesting a worse quality of psychological life associated with increased immaturity. For students in the final phases, the results were similar, however for the neurotic factor of DSQ-40. The association of the psychological domain with different types of defense mechanisms in the initial and final phases of medical school reinforces the idea that ego defense mechanisms, which can influence psychological well-being, may exert different influences along the course of medical graduation. In a study conducted by physicians in the municipality of Botucatu, state of São Paulo, Brazil, with the objective of evaluating factors associated with QoL, Miranda et al. found a positive association between the psychological domain and the mature factor of DSQ-40, Trends Psychiatry Psychother. 2020;42(1) – 79

Defense mechanisms and quality of life - Borges et al.

i.e., better psychological QoL was associated with higher scores on the mature factor.23 Thus, it is possible that the defenses predominantly required at the beginning, at the end of graduation and in the medical practice are distinct, transitioning between the immature factor at the beginning of graduation, through the neurotic factor at the end of graduation, and finally the mature factor when the profession is at more advanced stage of consolidation, which could be a consequence of both age and professional experience. We observed that the students in the initial phases of the program presented lower scores in the psychological domain of the QoL when compared to those in the final phases, reflecting a worse psychological QoL of students in the 1st and 3rd periods when compared to students in the 8th and 12th ones. These findings may be related to the students’ mental exhaustion resulting from the quest to ensure a place in medical school, the prospect of starting the desired program, the transition from school life to university life, and the adaptation to this new reality, both geographically and socially, since many students come from other cities and states and are distant from their family members, who are an important support network. In a study investigating the mental health of students starting medical school in Germany, Wege et al. inferred that both the vulnerability due to the transition period into adulthood and the highly competitive environment influenced by stress could explain the poorer mental health of newcomers to medical school.24 However, contrary to our results, Alves et al.25 and Chazan et al.26 found a greater impairment of the psychological QoL in medical students in the final phases of the program. In order to evaluate the relationship between curricular structure and well-being in medical students in the period of preclinical activity (1st and 2nd year), Reed et al. measured the structure of the curriculum through the hours dedicated to didactic experiments, clinics and exams. The results showed that students whose curricular structure presented a greater percentage of hours with clinical activities reported less wear and stress and a lower tendency to drop out of the program.27 In other words, the absence of contact with medical practice in the early phases of graduation may also be a factor that contributes to increased stress and, consequently, a worsening in psychological QoL. This study has several limitations that should be addressed. First, the 12th semester is probably an atypical period of medical school, since several – if not all – medical students are also preparing themselves for the medical residency exam, which could increase their stress. In addition, the 8th semester may be more 80 – Trends Psychiatry Psychother. 2020;42(1)

similar in scope to the first half of medical school than the second one. In this sense, perhaps a comparison between the first four semesters vs. the four last ones could be more appropriate for the aims stated in this study. Second, clinical information about alcohol use lacks validity, as we have not used a validated tool for this evaluation. Third, it is not possible to discard a type II error, as we have not calculated the minimum sample size necessary for finding a specific effect size established a priori.

Conclusions Different defense mechanisms seem to be related to psychological QoL at different moments of the medical graduation program, which may reflect not only the age and experience acquired during training, but also aspects related to the transition phase (high school to college) and curricular structure (greater volume of theoretical than practical activities). Thus, this study draws attention to an aspect often neglected in studies related to QoL, namely, the potential role of defense mechanisms for the planning of psychopedagogical strategies. In addition, the results reinforce the impact of depressive symptoms on QoL, an association already well evidenced in the literature.

Acknowledgements We would like to thank all participants for their time and effort invested.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References 1. WHOQOL Group. The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41:7. 2. Fleck MP. O instrumento de avaliação de qualidade de vida da Organização Mundial de Saúde (WHOQOL-100): características e perspectivas. Cien Saude Colet. 2000;5:6. 3. Schwab B, Daniel HS, Lutkemeyer C, Neves JA, Zilli LN, Guarnieri R, et al. Variables associated with health-related quality of life in a Brazilian sample of patients from a tertiary outpatient clinic for depression and anxiety disorders. Trends Psychiatry Psychother. 2015;37:202-8. 4. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316:2214-36.

Defense mechanisms and quality of life - Borges et al.

5. Baldassin S, Andrade AG. Anxiety traits among medical students. Arq Med ABC. 2006;31:5. 6. Gonçalves SS, Silvany Neto AM. Dimensão psicológica da qualidade de vida de estudantes de Medicina. Rev Bras Educ Med. 2013;37:11. 7. Court JM. Immature brain in adolescence. J Paediatr Child Health. 2013;49:883-6. 8. Sanders RA. Adolescent psychosocial, social, and cognitive development. Pediatr Rev. 2013;34:354-8; quiz 8-9. 9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th edition (DSM-5). Washington: American Psychiatric Association; 2013. 10. Freud A. The ego and the mechanisms of defense. London: Hogarth Press and Institute of Psycho-Analysis; 1937. 11. Vaillant GE. Theoretical hierarchy of adaptive ego mechanisms: a 30-year follow-up of 30 men selected for psychological health. Arch Gen Psychiatry. 1971;24:107-18. 12. Vojvodić AR, Dedić G, Dejanović SD. Defense mechanisms and quality of life in military personnel with burnout syndrome. Vojnosanit Pregl. 2019;76:9. 13. Talepasand S, Mahfar F. Relationship between defense mechanisms and the quality of life in women with breast cancer. Int J Cancer Manag. 2018;11:8. 14. Waqas A, Rehman A, Malik A, Muhammad U, Khan S, Mahmood N. Association of ego defense mechanisms with academic performance, anxiety and depression in medical students: a mixed methods study. Cureus. 2015;7:e337. 15. Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34:178-83. 16. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361-70. 17. Blaya C, Kipper L, Heldt E, Isolan L, Ceitlin LH, Bond M, et al. [Brazilian-Portuguese version of the Defense Style Questionnaire (DSQ-40) for defense mechanisms measure: a preliminary study]. Braz J Psychiatry. 2004;26:255-8.

18. Botega N, Ponde M, Medeiros P, Lima M, Guerreiro C. Validação da Escala Hospitalar de Ansiedade e Depressão (HAD) em pacientes epiléticos ambulatoriais. J Bras Psiquiatr. 1998;47:285-9. 19. Andrews G, Singh M, Bond M. The Defense Style Questionnaire. J Nerv Ment Dis. 1993;181:246-56. 20. Vasconcelos TC, Dias BRT, Andrade LR, Melo GF, Barbosa L, Souza E. Prevalência de sintomas de ansiedade e depressão em estudantes de medicina. Rev Bras Educ Med. 2015;39:8. 21. de Paula JDA, Borges AMFS, Bezerra LRA, Parente HV, de Paula RC, Wajnsztejn R. Prevalence and factores associated with depression in medical students. J Hum Growth Dev. 2014;24:8. 22. Nava FR, Tafoya SA, Heinze G. Estudio comparativo sobre depresión y los factores asociados en alumnos del primer año de la Facultad de Medicina y del Internado. Salud Ment. 2013;36:5. 23. Miranda B, Louza MR. The physician’s quality of life: relationship with ego defense mechanisms and object relations. Compr Psychiatry. 2015;63:22-9. 24. Wege N, Muth T, Li J, Angerer P. Mental health among currently enrolled medical students in Germany. Public Health. 2016;132:92-100. 25. Alves J, Tenório M, Anjos A, Figueroa J. Qualidade de vida em estudantes de Medicina no início e final do curso: avaliação pelo WHOQOL-Bref. Rev Bras Educ Med. 2010;34:6. 26. Chazan ACS, Campos MR, Portugal FB. Qualidade de vida em estudantes de medicina da UERJ por meio do WHOQOL-Bref: uma abordagem multivariada. Cien Saude Colet. 2015;20:9. 27. Reed DA, Shanafelt TD, Satele DW, Power DV, Eacker A, Harper W, et al. Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multiinstitutional study. Acad Med. 2011;86:1367-73.

Correspondence: Alexandre Paim Diaz Universidade Federal de Santa Catarina, Campus Universitário 88040-900 - Florianópolis, SC - Brazil Tel.: +55 (48) 37218293 E-mail: alexandrepaimdiaz@gmail.com

Trends Psychiatry Psychother. 2020;42(1) – 81

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Construct validity of the Motor Development Scale (MDS) Paola Matiko Martins Okuda,1

Erika Félix,1 Hugo Cogo-Moreira,1,2 Ting Liu,3 Pamela J. Surkan,4 Silvia S. Martins,5 Sheila C. Caetano1

Abstract Objective: Construct validity for the Motor Development Scale (MDS) has not been established. The aim of this study was to examine whether the unidimensional model of MDS would be appropriate for children aged 4 to 6 years-old and provide construct validity for the items concerning this age group in Brazil. Methods: A total of 938 children participated in the study (214 4-year-olds, 643 5-year-olds, and 81 6-year-olds). Confirmatory factor analysis (CFA) was used to evaluate construct validity of the MDS using a unidimensional model. Results: The CFA for the unidimensional model showed excellent adequacy indices for age 4: χ2(2) = 0.581, p = 0.748, comparative fit index (CFI) = 1.000, Tucker-Lewis index (TLI) = 1.090, root mean square error of approximation (RMSEA) = 0.000 (90% confidence interval [90%CI] = 0.000 to 0.093, close fit [Cfit] = 0.841); age 5: χ2(2) = 2.669, p = 0.263, CFI = 0.993, TLI = 0.980, RMSEA = 0.023 (90%CI = 0.000 to 0.085, Cfit = 0.682), weighted root mean square residual (WRMR) = 0.407; and age 6: χ2(9) = 8.275, p = 0.506, CFI = 1.000, TLI = 1.010, RMSEA = 0.000 (90%CI = 0.000 to 0.118, Cfit = 0.653), WRMR = 0.495. Reliability was good: ω = 0.87 (95%CI = 0.81 to 0.92). Conclusion: The proposed unidimensional solution for the MDS provides a concise, parsimonious and reliable way to assess motor development in children aged 4 to 6 years. Keywords: Motor skills, assessment, psychometrics, construct validity, children.

Introduction A variety of standardized assessment instruments have been used to examine children’s motor skill development because they can objectively identify children with motor delays. One of the most common assessments used by Brazilian professionals is the Motor Development Scale (MDS; in Portuguese Escala de Desenvolvimento Motor [EDM]).1 This Brazilian instrument assesses children motricity based on three important concepts, namely, coordination, proprioception and perception, divided into six domains:

fine motricity, global motricity, balance, body schema, spatial organization, and temporal organization, with 10 items per domain. The instrument was translated into English and Spanish in 2018. The MDS was developed to offer a multidimensional model (six domains). Even though content and criterion validity have been established for the whole instrument,1 it has not been evaluated for construct validity based on latent trait. There is concern that some assessments used for children may not measure the intended construct due to the nature of the skills. It is necessary to confirm that the MDS instrument can accurately

1 Departamento de Psiquiatria e Psicologia Médica, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. 2 Department of Educational and Psychology, Division of Methods and Evaluation, Freie Universität Berlin, Berlin, Germany. 3 Department of Health and Human Performance, Texas State University, San Marcos, TX, USA. 4 Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. 5 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.

Submitted Dec 18 2018, accepted for publication Jun 04 2019. Suggested citation: Okuda PMM, Félix E, Cogo-Moreira H, Liu T, Surkan PJ, Martins SS, et al. Construct validity of the Motor Development Scale (MDS). Trends Psychiatry Psychother. 2020;42(1):82-85. http://dx.doi.org/10.1590/2237-6089-2018-0114 APRS | CC-BY

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measure motor skill development2 through other kinds of validity, such as construct validity (validity based on internal structure) using structural equation modeling. In order to make a succinct instrument, it is ideal to have the minimum number of dimensions and items that represent the most parsimonious solution corresponding to the underlying factor structure.3 The aim of this study was to examine whether the unidimensional model of the MDS would fit for children aged 4 to 6-years-old and provide construct validity for the items concerning this age group in Brazil.

Methods This research was approved by the ethics committee of research at Universidade Federal de São Paulo (UNIFESP). Parents provided informed consent and all children assented to participate in the study. Participants The study used previously collected data from a randomized, stratified, representative sample of 938 children of both sexes, collected at 29 public preschools from a metropolitan city of São Paulo (Embu). The sample included 214 students aged 4 (mean age = 56.28 months, standard deviation [SD] = 1.98, 50% male); 643 aged 5 (mean age = 66.19 months of age, SD = 3.38, 53% male); and 81 aged 6 (mean age = 72.56 months, SD = 1.05, 54.3% male). Because we collected data from 29 schools, in the analysis we considered at least 10 participants per observed indicator variable (item of the test) as a rule-of-thumb for a lower bound adequate sample size,4 totaling at least 80 children for each age. Instrument and procedure The Motor Development Scale is an assessment tool used to evaluate children with an ordinal scoring system. It has six dimensions (fine motricity, global motricity, balance, body schema, spatial organization and temporal organization). Each dimension has 10 unique items. The items are related to a particular age level. In our study, children were assessed at the level matching their chronological age. For example, if the participant was 5 years old, the task was initially selected at level 5. Children who successfully completed the task were scored 1; those who could not perform the task were scored 0. For the tasks requiring skills on left and right side of the body, a score of 0.5 was recorded for each side. If the child could successfully perform the task at the level for his/her age, he/she was assessed at the

next higher level; if the child could not perform the task, he/she was assessed at the previous lower level, until the child reached the limits of his/her skill level. That is, the test was stopped when the participant received a 0 score, either at the same level, above or below their chronological age. However, for this study, as we planned to test construct validity for the items by age in a unidimensional model, only the scores given for levels corresponding to the chronological ages of the participants were considered. Data analysis Confirmatory factor analysis (CFA) with clustering by school was used to evaluate: a) the goodness of fit of the measurement model; and b) the strength of the correlation between the items and overall motricity.3 As such, the factor loading was a correlation between the observed categorical item and the latent measure of motricity. The higher this correlation, the lower the residual variance, which indicates a higher reliability index for each motricity indicator. Several fit indices were used to evaluate the model solution, including chi-square (χ2), comparative fit indices (CFI), the Tucker-Lewis index (TLI), and root mean square error of approximation (RMSEA). The following cutoff criteria were used to determine good model fit: a non-statistically significant chi-square p-value (> 0.05); an RMSEA near or below 0.06; CFI and TLI near or greater than 0.95.5 The weighted root mean square residual (WRMR) estimator was also used6 because the observed indicators (i.e., motricity items) were ordinal (i.e., Likert scale). We adopted < 0.05 as statistically significant. All analyses were run using Mplus 8.0.7 To evaluate the reliability of the MDS, we used the omega total (ω).8,9 Reliability measures are commonly reported as point estimates, and there is no clear cutoff point. Therefore, we followed the guidelines of Rodriguez et al.,10 which state that ω > 0.8 indicates a sufficient relationship between the latent variable and item scores.

Results Figure 1 shows a unidimensional model for MDS (motricity) items by age, with the factor loading and standard errors. For age 4 (Figure 1A), the global motricity item was excluded because it had only one response category (all participants performed the task) and consequently did not present any variance. Temporal organization was also excluded from the model for this age because it made the model unidentifiable (bivariate empty cells = correlation Trends Psychiatry Psychother. 2020;42(1) – 83

Construct validity for MDS - Okuda PMM et al.

of 1). Finally, the CFA with clustering by school for the unidimensional model with four items presented excellent indices of adequacy for age 4: χ2(2) = 0.581, p = 0.748, CFI = 1.000, TLI = 1.090, RMSEA = 0.000 (90% confidence interval [90%CI] = 0.000 to 0.093, close fit [Cfit] = 0.841), WRMR = 0.012. All the four items presented good reliability (factor loadings). The reliability of MDS item scores in the age 4 sample, computed as omega, was ω = 0.95 (95%CI = 0.81 to 0.99). For age 5 (Figure 1B), body scheme was excluded from the model because it made the model unidentifiable (resulting in empty bivariate cells), and temporal organization was excluded because it presented a very low factor loading, suggesting that the item was not capturing the latent trait. After excluding those items, adequacy indices were excellent for the model with four items: χ2(2) = 2.669, p = 0.263, CFI = 0.993, TLI = 0.980, RMSEA = 0.023 (90%CI = 0.000 to 0.085, Cfit = 0.682), WRMR = 0.407. The reliability of MDS item scores in the age 5 sample was ω = 0.65 (95%CI = 0.58 to 0.72). For age 6 (Figure 1C), the original model with six items presented excellent indices of adequacy: χ2(9) = 8.275, p = 0.506, CFI = 1.000, TLI = 1.010, RMSEA = 0.000 (90%CI = 0.000 to 0.118, Cfit = 0.653), WRMR = 0.495. The reliability of MDS item scores in the age 6 sample was ω = 0.87 (95%CI = 0.81 to 0.92).

Discussion Using CFA, we evaluated the internal structure of MDS items for samples aged 4, 5 and 6 years. Specifically, the model for age 6 maintained the original six items, with good reliability. The models for ages 4

and 5 showed good reliability with four items. However, at age 4, global motricity was excluded because all participants had the same score, indicating that this item did not discriminate the participants’ performance. Also, temporal organization presented a correlation of 1 with the other items, indicating measurement redundancy (measuring the same aspect as other items), and therefore had to be excluded from the model. For age 5, body schema presented a correlation of 1 with the other items and needed to be excluded. In addition, temporal organization was excluded because for an item to remain in the model to capture the latent trait, the factor loading should be more than 0.3.11 This is important from a clinical perspective because it can shorten the testing time without compromising the identification of possible delays in motor performance. Thus, this study showed good internal consistency and reliability for the unidimensional model while taking into account the large number of schools sampled. We evaluated children aged 4 to 6 from only one municipality in the metropolitan area of São Paulo. Therefore, these results do not necessarily apply to other age groups or to the whole Brazilian population. In addition, because no previous study has examined the construct validity of the MDS, our results could not be compared. Further tests of the psychometric properties of the MDS are needed, such as multimensional solution, bifactor model, measure invariance and others. In summary, this is the first manuscript providing construct validity based on internal consistency for MDS items. The proposed unidimensional solution provides a concise, parsimonious, reliable way to assess motor development skills in children aged 4, 5 and 6 years, and could therefore be used in research and clinical settings.

GM 0.880 (0.118)

0.839 (0.225) 1.000 (0.000)

0.857 (0.103)

0.490 (0.082)

0.805 (0.100)

0.503 (0.087) 1.000 (0.000)

motricity 0.671 (0.206)

1.000 (0.000)

motricity

0.930 (0.117)

B 0.672 (0.072)

spa

0.711 (0.104) 0.470 (0.161)

spa

0.532 (0.127) 0.927 (0.086)

0.599 (0.074)

motricity

spa

temp

Figure 1 - Unidimensional model for the Motor Development Scale by age: A) age 4; B) age 5; C) age 6. B = balance; BS = body schema; FM = fine motricity; GM = global motricity; spa = spatial organization; temp = temporal organization. 84 – Trends Psychiatry Psychother. 2020;42(1)

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Acknowledgments This work was financed in part by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq; grant 466688/2014-8), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; Finance Code 001), and Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP; grant 2016/10120-1). We thank Dr. Francisco Rosa Neto for contributing by answering our questions regarding the EDM.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

References 1. Rosa Neto F. Manual de avaliação motora - EDM. 2nd ed. Florianópolis: Governo do Estado de Santa Catarina; 2014. 2. Pasquali L. Psychometrics. Rev Esc Enferm USP. 2009;43:992-9.

3. Brown TA. Confirmatory factor analysis for applied research. New York: Guilford Publications; 2015. 4. Nunnally JC, Bernstein IH, Berge JMT. Psychometric theory. New York: McGraw-Hill; 1967. 5. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6:1-55. 6. Muthén B, Du Toit SH, Spisic D. Robust inference using weighted least squares and quadratic estimating equations in latent variable modeling with categorical and continuous outcomes. Psychometrika. 1997;75:1-45. 7. Muthén LK, Muthén BO. Mplus user’s guide. 8th ed. Los Angeles: Muthén and Muthén; 2018. 8. McDonald RP. Test theory: a unified treatment. Mahwah: Lawrence Erlbaum; 2013. 9. McDonald RP. The theoretical foundations of principal factor analysis, canonical factor analysis, and alpha factor analysis. Br J Math Stat Psychol. 1970;23:1-21. 10. Rodriguez A, Reise SP, Haviland MG. Applying bifactor statistical indices in the evaluation of psychological measures. J Pers Assess. 2016;98:223-37. 11. Raykov T, Marcoulides GA. A first course in structural equation modeling. London: Routledge; 2012.

Correspondence: Paola Matiko Martins Okuda Rua Napoleão de Barros, 865 04024-002 - São Paulo, SP - Brazil Tel.: +55 (14) 981674959 E-mail: paolaokuda@yahoo.com.br

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Brief Communication

in Psychiatry and Psychotherapy

Prevalence and trends of mental disorders requiring inpatient care in the city of Porto Alegre: a citywide study including all inpatient admissions due to mental disorders in the public system from 2013-2017 Prevalência e tendências temporais de transtornos mentais necessitando de tratamento de internação na cidade de Porto Alegre: um estudo de toda a cidade incluindo todas as internações por motivo de saúde mental no sistema público de 2013-2017 Giovanni A. Salum,1,2,3 Loiva dos S. Leite,3 Sara Jane E. dos Santos,3 Gabriel Mazzini,3 Fernanda L. C. Baeza,1,2 Lucas Spanemberg,1,2,4 Sara Evans-Lacko,5 João Ricardo Sato,6 Diane M. do Nascimento,3 Thiago Frank,3 Juliana Pfeil,3 Natan Katz,3 Jorge Osório,3 Paulo Ricardo dos Santos,3 Eliana da Silva,3 Christiane Nunes,2 Kelma Nunes Soares,3 Ângela Maria Grando Machado,3 Tatiana Breyer,3 Márcio Rodrigues,3 Adriani Galão,3 Gledis Lisiane Motta,3 Silvia Schuch,3 Eduardo Osório,3 Cláudia Rodrigues,3 Pablo de Lannoy Sturmer,3 Erno Harzheim3,7

Abstract

Resumo

Objectives: To investigate the 5-year prevalence of patients admitted to public inpatient care units due to a mental disorder, stratifying them by age group and diagnosis, and to assess trends of admissions over this time period in Porto Alegre. Methods: All admissions to the public mental health care system regulated by the city-owned electronic system Administração Geral dos Hospitais (AGHOS) were included in the analysis. The total population size was obtained by estimations of Fundação de Economia e Estatística (FEE). General information about 5-year prevalence of inpatient admissions, time-series trends e prevalence by age groups and diagnosis were presented. Results: There were 32,608 admissions over the 5-year period analyzed. The overall prevalence of patients was 1.62% among the total population, 0.01% among children, 1.12% among adolescents, 2.28% among adults and 0.93% among the elderly. The most common diagnosis was drug-related, followed by mood, alcohol-related and psychotic disorders. There was a linear trend showing an increase in the number of admissions from 2013 to the midst of 2014, which dropped in 2015. Conclusions: Admissions due to mental disorders are relatively common, mainly among adults and related to drug use and mood disorders. Time trends varied slightly over the 5 years. Prevalence rates in real-world settings might be useful for policymakers interested in planning the public mental health system in large Brazilian cities. Keywords: Mental disorders, prevalence, inpatient care, admissions, public health.

Objetivos: Investigar a prevalência de 5 anos de pacientes internados no sistema público de saúde por motivo de saúde mental, estratificando-os por grupo etário e diagnóstico, e avaliar tendências temporais nas admissões nesse período em Porto Alegre. Métodos: Todas as admissões no sistema público de saúde mental reguladas pelo sistema eletrônico da cidade, denominado Administração Geral dos Hospitais (AGHOS), foram incluídos na análise. A população total foi obtida a partir de estimativas da Fundação de Economia e Estatística (FEE). Informações gerais sobre a prevalência de 5 anos de admissões, tendências das séries temporais e prevalência por grupo etário e por diagnóstico foram apresentadas. Resultados: Ocorreram 32.608 admissões no período de 5 anos analisado. A prevalência global de pacientes foi de 1,62% na população total, 0,01% em crianças, 1,12% em adolescentes, 2,28% em adultos e 0,93% em idosos. Os diagnósticos mais comuns foram relacionados ao uso de drogas, seguidos de transtornos de humor, relacionados ao álcool e transtornos psicóticos. Houve uma tendência linear mostrando um aumento no número de admissões de 2013 a meados de 2014, que caíram em 2015. Conclusões: Admissões por transtornos mentais são relativamente comuns, principalmente entre adultos e relacionados ao uso de drogas e transtornos de humor. Tendências lineares variaram levemente nos últimos 5 anos. Estimativas de prevalência no mundo real podem ser úteis para formuladores de políticas interessados em planejar o sistema público de saúde mental em grandes cidades brasileiras. Descritores: Transtornos mentais, prevalência, cuidados hospitalares, internações, saúde pública.

Departamento de Psiquiatria e Medicina Legal, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. 2 Seção de Afetos Negativos e Processos Sociais, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil. 3 Secretaria Municipal da Saúde, Prefeitura Municipal de Porto Alegre, Porto Alegre, RS, Brazil. 4 Núcleo de Formação em Neurociências, Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. 5 London School of Economics and Political Science, London, United Kingdon. 6 Universidade Federal do ABC, São Paulo, SP, Brazil. 7 Departamento de Medicina Social, UFRGS, Porto Alegre, RS, Brazil. Submitted Dec 21 2018, accepted for publication Jul 04 2019. Epub Jan 10 2020. Suggested citation: Salum GA, Leite LS, dos Santos SJE, Mazzini G, Baeza FLC, Spanemberg L, et al. Prevalence and trends of mental disorders requiring inpatient care in the city of Porto Alegre: a citywide study including all inpatient admissions due to mental disorders in the public system from 2013-2017. Trends Psychiatry Psychother. 2020;42(1):86-91. http://dx.doi.org/10.1590/2237-6089-2018-0115 1

APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 86-91

Mental disorders requiring inpatient care - Salum et al.

Introduction Only a minority of individuals affected by mental disorders around the world have access to treatment.1 This important treatment gap is even more profound in low- and middle-income countries (LMICs).2-4 To address this gap, it is essential to incorporate a public health approach in health systems. In LMICs, one of the barriers to building effective mental health systems is the scarcity of credible data that reflect population needs, including of those individuals who would benefit most from specialized mental health care. From a clinical perspective, the need for psychiatric admission reflects to a great extent the severity of a mental health disorder and also limited functionality. After the first psychiatric admission there is a significant increase in the risk of premature all-cause mortality and a strong increase in the number of deaths, especially by suicide.5 These findings reinforce the importance of focusing on patients requiring psychiatric inpatient care as a key population that needs attention from a public health perspective. Understanding the demands of the population with the greatest need for care can reveal important information toward preventive efforts. Data on existing patterns of inpatient service utilization represent a fundamental piece of information to understand current resource utilization at its highest level and can guide public health management towards the best application of resources, planning of services and establishment of attainable goals in mental health,6 particularly in countries with integrated public health systems, like Brazil. The Brazilian Unified Health System (Sistema Único de Saúde [SUS]) is one of the largest public health programs in the world, and covers about 70% of the population. It complies with the principles of universality, integrality, equity and decentralization, from the primary level of health care to the secondary and tertiary levels. Despite that, no citywide perspectives are available to provide such prevalence rates in Brazilian cities. The aim of this study was twofold: 1) to investigate the 5-year prevalence of patients admitted to public inpatient health care units in the municipality of Porto Alegre due to a mental disorder, stratified by age group and diagnosis; and 2) to investigate time trends of inpatient admissions over this time period.

Methods Data about all mental health admissions to any inpatient unit that receives mental disorders (a total of 17 units) through SUS between 2013 to 2017 in the

municipality of Porto Alegre were extracted from the city-owned electronic system Administração Geral dos Hospitais (AGHOS), a database covering all hospital admissions in the public health system of Porto Alegre, which represents 70% of residents.7 The city has about 466 contracted psychiatric beds in 11 institutions (general hospitals and specialized hospitals); the number of beds per institution varies from 10 to 150. Admissions are regulated by two psychiatric emergency services with 14 beds each operating at 200% of their capacity. To calculate 5-year prevalence estimates, the numerator was the number of patients with at least one admission between 2013 and 2017. Readmissions were excluded using the consolidated information of the system, which considers the patient’s name, demographic information and registration records, because our main objective was to calculate the overarching prevalence for the overall time frame. The denominator was the total number of residents (1,478,229 people), extracted from estimates issued by Fundação de Economia e Estatística (FEE),8 available for the years 2013 to 2016. Estimates were adjusted to reflect only the number of residents who depend solely on the public system for healthcare, i.e., 70% of the residents (1,034,760 people). We also calculated the rates of the main diagnosis, based on the discharge code, defined according to criteria from the International Classification of Diseases, 10th revision (ICD-10).9 We created 14 broad categories that encompass 59 ICD-10 codes included in the database (data available as online-only supplementary material). For patients admitted more than once, and for those admitted with more than one diagnosis, one ICD-10 code was randomly selected. For calculating trends over time, we used a time series decomposition analysis that separates time trends from seasonal influences. For these analyses, all first-time admissions and readmissions were used, given the aim to investigate the general trends in admissions over time. The institutional review boards from Hospital de Clínicas de Porto Alegre and Secretaria da Saúde de Porto Alegre approved the study.

Results Overall there were 32,608 admissions to public mental health inpatient units in the city over the 5 years analyzed, totaling 16,794 patients admitted at least once (and 15,814 readmissions). The number of admissions per patient ranged from 1 to 44 over this time period (median=1). The overall 5-year prevalence Trends Psychiatry Psychother. 2020;42(1) – 87

Mental disorders requiring inpatient care - Salum et al.

of patients admitted was 1.62% in the total population, 0.01% in children, 1.12% in adolescents, 2.28% in adults and 0.93% in the elderly. The prevalence of mental disorders among individuals admitted to a hospital varied according to age (Table 1 and Figures S1 and S2, available as onlineonly supplementary material). In general, drug-related and mood disorders were the most prevalent disorders in adolescents and adults, mood and alcohol-related disorders in elderly, and mood and autism spectrum disorders in children. According to time series decomposition analysis, the trends of all admissions over time revealed a slight seasonal variation, with the lowest number of admissions occurring in May and the highest in November (Figure 1). There was also a linear trend showing an increase in the number of admissions from 2013 to the midst of 2014, dropping in 2015, with a monthly mean of admissions of 543.2 (SD=69.34) in the following years.

elderly, but rare in children. A prevalence of 1.62% was found for the total population, with higher rates in adults. The most common diagnoses in the total sample were drug-related disorders, followed by mood, alcohol-related and psychotic disorders, but there were important differences across the age groups. There was a linear trend showing an increase in the number of admissions from 2013 to the midst of 2014, which again dropped in 2015 and subsequent years. To the best of the authorsâ&#x20AC;&#x2122; knowledge, this is the first study to investigate the prevalence of people with mental disorders admitted to inpatient care units in a large Brazilian city, whereas previous efforts to estimate rates of inpatient utilization were limited to specific hospital settings,10,11 Brazilian states,12-14 and age groups.15,16 Notwithstanding, those previous studies did not investigate the prevalence of first-time hospitalizations in these populations, since they did not exclude rehospitalizations, but rather investigated temporal trends or frequencies of hospital records according to groups of disorders. Moreover, most of those studies used data from the Information Technology Department of the Brazilian Unified Health System (DATASUS), which is limited to estimating current hospitalization rates, as new records are created after 30 days of the previous hospitalization, and it is not possible to discriminate

Discussion According to our results, over the past 5 years, inpatient admissions due to mental disorders were relatively common in adolescents, adults and in the

Table 1 - Estimated prevalence of mental disorder requiring inpatient admission over 5 years, stratified by age group Average population size (2013-2016) Children (0-9 years)

Adolescents (10-19 years)

Adults (20-59 years)

Elderly (â&#x2030;Ľ60 years)

Total

125,849

137,856

598,654

172,399

1,034,760

Disorders*

Prevalence

Autism spectrum

29.4

0.00397%

1.100

0.01233%

0.059

0.00134%

0.000

0.00000%

0.179

0.00290%

Intellectual disability

11.8

0.00159%

3.105

0.03482%

151

1.108

0.02522%

0.376

0.00348%

207

1.233

0.02000%

Organic syndrome

0.0

0.00000%

0.065

0.00073%

0.220

0.00501%

2.693

0.02494%

0.441

0.00715%

Conduct

11.8

0.00159%

100

6.468

0.07254%

0.066

0.00150%

0.000

0.00000%

111

0.661

0.01073%

Obsessivecompulsive

0.0

0.00000%

0.000

0.00000%

0.073

0.00167%

0.063

0.00058%

0.065

0.00106%

Alcohol-related

0.0

0.00000%

0.323

0.00363%

1,500

11.002

0.25056%

442

27.677

0.25638%

1,947 11.593

0.18816%

Drug-related

5.9

0.00079%

612

39.586

0.44394%

5,649

41.433

0.94362%

3.381

0.03132%

6,316 37.609

0.61038%

Eating

0.0

0.00000%

0.323

0.00363%

0.132

0.00301%

0.063

0.00058%

0.143

0.00232%

Personality

0.0

0.00000%

1.488

0.01668%

0.499

0.01136%

0.125

0.00116%

0.554

0.00899%

Mood

35.3

0.00477%

532

34.411

0.38591%

4,037

29.610

0.67435%

706

44.208

0.40952%

Dissociative

0.0

0.00000%

0.000

0.00000%

0.029

0.00067%

0.063

0.00058%

0.030

0.00048%

Anxious/phobic

0.0

0.00000%

0.129

0.00145%

0.081

0.00184%

0.063

0.00058%

0.083

0.00135%

Psychotic

0.0

0.00000%

184

11.902

0.13347%

2,117

15.527

0.00334%

336

21.039

0.19490%

Others

5.9

0.00079%

0.906

0.01016%

0.147

0.00334%

0.250

0.00232%

0.232

0.00377%

100

0.01351% 1,546

100

1.12146%

13,634

100

2.27744%

1,597

100

0.92634%

16,794

100

1.62299%

Total

* According to the International Classification of Diseases, 10th revision (ICD-10). If the patient was admitted due to distinct ICD-10 codes in the 5 years analyzed, only one ICD-10 code was randomly selected.

88 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

5,281 31.446

2,637 15.702

0.51036%

0.25484%

Mental disorders requiring inpatient care - Salum et al.

between new admissions and new records of the same hospitalization that continued (the unit of analysis is the record, not the individual).13,15 In order to compare the proportion of people affected by mental disorders in the community and estimate access to inpatient care, it is important to investigate evidence from community samples. Only one study using probabilistic sampling was conducted in the city of Porto Alegre in 1991 using a community sample.17 That study showed that mental disorders affected 42.5% of the sample, with 33.7% of those with a mental disorder utilizing treatment from a mental health professional. The most common diagnoses in that study were phobias (14.1%), followed by depressive states (10.2%), anxiety disorders (9.6%) and alcohol abuse/dependence (9.2%). Drug abuse/ dependence was not assessed in that study. If we assume those rates are still valid in the community, we can observe that phobias and anxiety disorders are less likely to require inpatient care, because the number of admissions due to these conditions were very low in our sample; conversely, depressive states, alcohol-

related and psychotic disorders were the leading causes of inpatient admission. Studies conducted in different Brazilian states have investigated time series and changes in records of psychiatric admissions using DATASUS.12-14 Two of them found a >50% increase in the number of hospitalizations in the states of Minas Gerais (between 2001 and 2013)12 and SĂŁo Paulo (between 2000 and 2015).14 In SĂŁo Paulo, hospitalization rates per group of disorders decreased in almost all groups, with the exception of substance-related disorders, where there was a substantial increase (107%, 91% for men and 203% for women in the period).14 In Minas Gerais, there was a linear trend towards a decrease in the proportional number of hospitalization records due to schizophrenia in the period, with an increasing tendency for mood and substance-related disorders.12 In both studies, the decrease in the supply of beds was cited as a factor related to the decrease in the number of hospitalization records. Another study, in the state of Rio Grande do Sul (whose capital is Porto Alegre),13 investigated changes

Figure 1 - Time series decomposition analysis for all admissions over the 5 years analyzed (n=32,608) Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 89

Mental disorders requiring inpatient care - Salum et al.

in hospitalization records in a smaller period (2000 to 2004). There was a small decrease in the number of records in the period (about 5%), with a decrease in the linear trend in the proportion of hospitalizations due to schizophrenia and an increase in mood disorders (with stability for substance-related disorders). A probable explanation for the decrease in the number of hospitalizations and admission records in our study and in the country concerns the closure of psychiatric beds in Brazil.18 The psychiatric reform in the country has determined the replacement of beds in specialized hospitals with beds in general hospitals, and this process has not been occurring as recommended, resulting in a scenario of bed shortage and underfunding. No nationally or regionally representative studies of prevalence are currently available; the most recent epidemiological study performed in the country was conducted in the city of São Paulo.19 That study showed a 12-month prevalence of mental disorders of 30% (20% anxiety, 11% mood, 4.2% impulse control, 3.6% substance/drug), of which 10% were found to be severe. Also, that study showed that only 23.2% of severe disorders receive any mental health treatment, which represents 2.3% of the population of São Paulo (the authors, however, did not differentiate between outpatient and inpatient care). This is important when establishing public policies, and when estimating the demand of specialized mental health support in a city, despite some limitations commented on below. This study has several strengths. First, to our knowledge, this is the first study to report the prevalence of psychiatric admissions in a citywide database in Brazil, with the possibility of estimating the actual prevalence of cases. Second, we were able to estimate the most common diagnoses in different age ranges, which is very helpful for service planning. However, there are also some limitations that should be considered. First, inpatient care is ultimately dependent on the number of psychiatric beds available, and this might directly impact the number of admitted patients. Second, data are limited to admissions that occurred in the public system, because the private sector is independent, but covers about 30% of the population of the city. Because the number of private beds in the city are estimated to account for half of the total number of beds in the city, our numbers are likely to be underestimated by the non-representation of this segment. Finally, ICD-10 diagnoses were registered based on clinical evaluation only and do not consider comorbid diagnoses. To minimize the effect of biased reporting of ICD-10 codes, we combined several diagnoses into groups of broad diagnostic categories, which are more likely to be consistent. 90 – Trends Psychiatry Psychother. 2020;42(1)

Evaluation of the prevalence of mental disorders in severely ill patients, such as psychiatric inpatients, is a first step toward a more accurate and systematic management process, where public policies and resource allocation rely on availability and information, directing efforts according to the actual demand of each city.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

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15. Ritter PL, Dal-Pai D, Belmonte-de-Abreu P, Camozzato A. Trends in elderly psychiatric admissions to the Brazilian public health care system. Rev Bras Psiquiatr. 2016;38:314-7. 16. Santos V dos, Fernández A. Child and adolescent mental health services in Brazil: structure, use and challenges. Rev Bras Saúde Matern Infant. 2014;14:319-29. 17. Almeida-Filho N, Mari J de J, Coutinho E, França JF, Fernandes J, Andreoli SB. Brazilian multicentric study of psychiatric morbidity. Methodological features and prevalence estimates. Br J Psychiatry. 1997;171:524-9. 18. Loch AA, Gattaz WF, Rössler W. Mental healthcare in South America with a focus on Brazil: past, present, and future. Curr Opin Psychiatry. 2016;29:264-69.

19. Andrade LH, Wang Y-P, Andreoni S, Silveira CM, Alexandrino-Silva C, Siu ER, et al. Mental disorders in megacities: findings from the São Paulo Megacity Mental Health Survey, Brazil. PloS One. 2012;7:e31879.

Correspondence: Lucas Spanemberg, MD, PhD Hospital São Lucas da PUCRS, Unidade de Internação Psiquiátrica Av. Ipiranga, 6690, Jardim Botânico 90610-000 - Porto Alegre, RS - Brazil Tel.: +55 (51) 997256293 E-mail: lucas.spanemberg@pucrs.br

Trends Psychiatry Psychother. 2020;42(1) – 91

Trends

Review Article

in Psychiatry and Psychotherapy

Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review Terapia cognitivo-comportamental para depressão resistente ao tratamento em adultos e adolescentes: uma revisão sistemática Stephanie Zakhour,1

Antonio E. Nardi,1 Michelle Levitan,1 Jose Carlos Appolinario1,2,3,4

Abstract

Resumo

Objective: To conduct a systematic review of literature on use and efficacy of cognitive-behavioral therapy (CBT) for treatment of treatment-resistant depression in adults and adolescents. Methods: We performed a systematic review according to the Prisma Guidelines of literature indexed on the PubMed, SciELO, Psychiatry Online, Scopus, PsycArticles, Science Direct and the Journal of Medical Case Reports databases. Randomized controlled trials, open studies and case reports were included in the review. Results: The searches returned a total of 1,580 articles, published from 1985 to 2017. After applying the inclusion criteria, 17 articles were selected, their complete texts were read and 8 were included in this review. Four of these studies were randomized controlled trials with adults, one of which covered a post-study follow-up period; two were randomized controlled trials with adolescents, one of which presented follow-up data; one was an open study; and one was a case report. The studies provide good quality and robust evidence on the topic addressed. Conclusions: A combination of CBT with pharmacotherapy for treatment-resistant patients shows a decrease in depressive symptoms. CBT can be an effective type of therapy for adults and adolescents with treatment-resistant depression. Keywords: Cognitive-behavioral therapy, major depressive disorder, treatment-resistant depressive disorder.

Objetivos: Realizar uma revisão sistemática sobre o uso da terapia cognitivo-comportamental (TCC) e sua eficácia no tratamento da depressão resistente ao tratamento em adultos e adolescentes. Métodos: Realizamos uma revisão sistemática utilizando os critérios do Prisma Guidelines, nos seguintes bancos de dados: PubMed, SciELO, Psychiatry Online, Scopus, PsycArticles, Science Direct e Journal of Medical Case Reports. Estudos controlados randomizados, estudos abertos e relatos de casos foram incluídos neste estudo. Resultados: A pesquisa retornou um total de 1.580 artigos, publicados de 1985 até 2017. Após aplicarmos os critérios de inclusão, 17 artigos foram selecionados, seus textos completos foram lidos e 8 foram incluídos nesta revisão. Do total, quatro eram estudos controlados randomizados com adultos, tendo um incluído um período de seguimento pós-estudo; dois eram estudos controlados randomizados com adolescentes, tendo um apresentado dados de seguimento; um era um estudo aberto; e o último era um relato de caso. Os estudos apresentaram boa qualidade e evidências robustas sobre o tópico abordado. Conclusões: A combinação de TCC com tratamento medicamentoso para pacientes resistentes ao tratamento mostra uma diminuição dos sintomas depressivos. A TCC pode ser um tipo eficaz de terapia para adultos e adolescentes com depressão resistente ao tratamento. Descritores: Terapia cognitivo-comportamental, transtorno depressivo maior, transtorno depressivo resistente a tratamento.

1 Ambulatório de Depressão Resistente ao Tratamento (DeReTrat), Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. 2 Programa de Pós-Graduação, IPUB, UFRJ, Rio de Janeiro, RJ, Brazil. 3 Grupo de Obesidade e Transtornos Alimentares, IPUB, UFRJ, Rio de Janeiro, RJ, Brazil. 4 Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), UFRJ, Rio de Janeiro, Brazil.

Submitted Dec 12 2018, accepted for publication May 12 2019. Epub Mar 02 2020. Suggested citation: Zakhour S, Nardi AE, Levitan M, Appolinario JC. Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review. Trends Psychiatry Psychother. 2020;42(1):92-101. http://dx.doi.org/10.1590/2237-6089-2019-0033 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 92-101

Review of CBT for TRD in adults and adolescents - Zakhour et al.

Introduction Treatment-resistant depression (TRD) is diagnosed when patients who suffer from major depressive disorder (MDD) are unable to achieve an adequate therapeutic response despite using one or more antidepressants.1 TRD is a relatively common occurrence in clinical practice with adult populations, with up to 50 to 60% of patients not achieving adequate response following antidepressant treatment.2 Moreover, only about 60% of adolescents with depression will show an adequate clinical response to antidepressant treatment.3 In addition, 40% of adolescents will not respond to treatment and thus suffer from TRD. TRD is associated with greater severity than MDD and is associated with risk of suicide. A study by Bergfeld et al.4 showed that 30% of patients with TRD attempt suicide at least once during their lifetime. The usual treatment for moderate to severe depression (also called treatment as usual [TAU]) is based on use of medication such as selective serotonin reuptake inhibitor (SSRI) antidepressants. Although this treatment has shown efficacy in some cases, many will not respond to treatment even after several trials.5 Therefore, treating TRD is a considerable challenge. Several pharmacological strategies have been proposed to deal with patients who do not respond to TAU and these interventions include combined treatments. Many studies have shown the importance of psychotherapy in combination with TAU as an important strategy for management of TRD. Nakagawa et al.6 conducted a randomized controlled trial with the aim of investigating the effectiveness of CBT in TRD patients. Their study included outpatients randomly assigned to CBT combined with TAU or to TAU alone and the primary outcome was alleviation of depressive symptoms. They found that supplementary CBT alleviated depressive symptoms at 16 weeks and that the treatment effect was maintained for at least 12 months. Other authors have tested the efficacy of this strategy in an adolescent population. Brent et al.3 conducted a randomized controlled study (TORDIA) with the objective of evaluating the best treatment option for adolescents aged 12 to 18 years (either switching medications or adding CBT to the treatment). Participants were treated for 12 weeks (TAU alone and TAU+CBT) and the results showed that for adolescents with depression that did not respond to TAU, the combination of CBT with switching to another medication resulted in a higher rate of clinical response than a medication switch alone. A recent systematic review and meta-analysis by Li et al.7 assessed the effectiveness of CBT and other related

interventions for treatment of patients with TRD. The authors included randomized controlled trials performed with adults over 18 years old who were suffering from TRD and were allocated to CBT and/or other forms of interventions. Patients were assessed using validated designed to assess depression, such as the 17-item Hamilton Rating Scale for Depression (HRSD-17), the 21item Hamilton Rating Scale for Depression (HAMD-21), the Beck Depression Inventory-II (BDI-II) or the Patient Health Questionnaire-9 (PHQ-9). The authors selected six out of 526 studies identified: two trials that used CBT, two trials that applied mindfulness-based cognitive therapy (MBCT), one that adapted rumination-focused cognitive-behavioral therapy (RFCBT) and one that used smartphone CBT. They reported that these interventions were effective for treatment of TRD symptoms and that the effects were maintained at 6-month follow-up. However, one of the most significant criticisms of this review is that inclusion of several different types of CBT and CBT-based interventions could have impacted the findings. There is a need to look at more homogeneous intervention groups such as CBT alone or MBCT alone. The purpose of this review therefore differs from the one described above because our aim is to conduct a systematic review to examine the efficacy of CBT alone, with no other CBT based interventions, for treatment and alleviation of depressive symptoms in TRD. Moreover, to examine whether CBT reduces depressive symptoms in TRD compared to TAU alone, our study included randomized controlled trials, open trials and case reports and is not restricted to adult populations, but also includes studies with adolescents (age < 18), since few studies have addressed this subset.

Methods We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines throughout this systematic review.8 Eligibility criteria Studies were selected and included in the present review according to the following criteria: 1) studies assessing the efficacy of CBT in TRD, 2) randomized controlled trials (RCTs), long-term follow-up studies derived from RCTs, open trials and case studies are included, 3) inclusion of participants that meet criteria for TRD defined in Trevino et al.,1 4) inclusion of studies that only use face-to-face CBT as a treatment model, 5) inclusion of both adolescent (12-18 years old) and adult populations, and 6) inclusion of studies that used validated instruments to assess depressive symptoms. Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 93

Review of CBT for TRD in adults and adolescents - Zakhour et al.

Information source and search strategy Searches were run on PubMed, SciELO, Psychiatry Online, Scopus, PsycArticles, Science Direct, and the Journal of Medical Case Reports using combinations of the Medical Subject Headings (MeSH) terms “cognitive behavioral therapy,” “cognitive behavior therapy,” “cognitive psychotherapy”, “cognitive therapy”, “cognition therapy,” “treatment-resistant depression”, “refractory depression” and “therapy resistant depression”. Additional records were identified from other sources by searching references lists of the studies found in databases. The search was last run on April 8, 2019. No restriction was placed on language of publication. Study selection The lead author of this study independently screened the articles identified for appropriateness for inclusion. Non-randomized controlled trials, literature review studies, systematic reviews and studies that used types of therapy other than CBT were excluded from the systematic review. Data collection process and data items Data collection was conducted independently by the lead author of this systematic review. The titles and abstracts identified by the initial search were screened to determine their relevance to the review. Articles that did not meet the inclusion criteria were excluded at this stage and then the full texts of potentially relevant studies were examined. The lead author of this review selected articles independently. Risk of bias in individual studies Only the randomized controlled trials selected for the review study were assessed for quality and risk of bias. The Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS) was used.9 Data synthesis This systematic review is presented as a narrative synthesis measuring the efficacy of adding CBT treatment for adults and adolescents who suffer from TRD.

Results Study selection A total of 1,576 articles were found by database searches. Additional records (n = 4) were identified by searching the references lists of the studies found. Hence, a total of 1,580 articles published from 1985 to 2017 were identified for the systematic review. After 94 – Trends Psychiatry Psychother. 2020;42(1)

removing duplicate articles (n = 19) and excluding studies on the basis of title (n = 1535), 26 were retained for further consideration. Nine of these were excluded after reading the abstracts. Nine of the 17 remaining articles assessed for eligibility were excluded after reading the full texts, because they did not meet inclusion criteria and were non-randomized controlled studies. Finally, 8 studies were included in the systematic review: 4 randomized controlled trials,6,10-12 one of which is a long-term follow-up RCT11 assessing the efficacy of CBT in adults suffering from TRD; 2 randomized controlled trials3,13 assessing the efficacy of CBT in adolescents suffering from TRD, one of which is a long-term followup RCT13; 1 open trial14; and 1 case report.15 The search and selection process for articles is illustrated in a flow diagram (see Figure 1). Study characteristics Participants’ characteristics A total of 1,056 patients were enrolled in the 8 studies analyzed in this systematic review, 722 of whom were adults and 334 of whom were adolescents. Of these, 364 adults (78.16% female, mean age 30.68) and 166 adolescents (69.9% female, mean age 16.0) received CBT treatment in addition to TAU, compared to 358 adults (65.1% female, mean age 44.9) and 168 adolescents (69.6% female, mean age 15.8) who received TAU alone. Six of the studies included both genders,3,6,10-14 while two of them only included women.14,15 Methods Six studies3,6,10-13 selected for the review were randomized controlled trials published in English. The participants in these studies were randomly assigned to different types of intervention groups in order to compare them and detect results. One study14 was an open trial using only one group of participants and administering the intervention to all participants. Finally, one study15 was a case report that used the case of a woman receiving individual CBT therapy to illustrate whether CBT is effective for TRD. Intervention characteristics The randomized controlled trials in this systematic review analyzed two types of interventions: TAU alone or TAU + CBT. Participants in the open trial study14 and the case study15 received only CBT as treatment modality. In all cases, TAU was prescribed by psychiatrists: TAU is treatment of these patients with medication only. Psychiatrists usually use SSRI antidepressants for TAU. In the studies included in this systematic review, CBT was facilitated by therapists with at least a masters

Review of CBT for TRD in adults and adolescents - Zakhour et al.

degree in a mental health field and prior experience in CBT3,15; by four psychiatrists, 1 clinical psychologist with a Masters degree and 1 psychiatric nurse6; by two experienced and well-trained therapists under the supervision of a PhD-level clinical psychologist who had six years’ experience in treating depressed patients with cognitive therapy14; by therapists who received at least 1 day of training specific to the trial from an experienced CBT therapist and trainer and weekly supervision from skilled CBT supervisors at each center11; and, finally, by therapists with a master’s degree in a mental health field and a license permitting provision of therapy, trained for 35 hours in a face-to-face workshop.12 All of the participants were assessed with validated scales that assess depressive symptoms and most of them were followed-up for at least 12 months after intervention.

Table 1 lists additional descriptive characteristics, the first author, year of publication, study design, intervention, session length, duration of follow-up, instruments and main findings. Outcomes In all studies, the primary outcome assessed was alleviation of depressive symptoms measured using validated scales and compared from baseline to at least 12-month follow-up and as much as 40-month follow-up. Risk of bias within studies We utilized the RCT-PQRS to assess the risk of bias in individual studies.9 The results are summarized in Tables 2 and 3. Only the randomized controlled trials

Records identified in

Additional records identified

database searches

from other sources

(n = 1,576)

(n = 4)

Duplicates removed (n = 19)

Records screened (n = 1,561)

Records excluded after reading titles and abstracts (n = 1,544)

Full-text articles excluded, with reasons (n = 9)

Full-text articles assessed for eligibility (n = 17)

• Non-randomized controlled trials (n = 5) • Included other types of treatment (n = 2) • Evaluated different

Studies included

outcomes (n = 2)

in the present review (n = 8) Figure 1 - Prisma flow diagram illustrating study selection process. Trends Psychiatry Psychother. 2020;42(1) – 95

Review of CBT for TRD in adults and adolescents - Zakhour et al.

were assessed for quality and risk of bias. All randomized controlled studies were rated as low risk of bias. Results of individual studies Randomized controlled trials In a randomized controlled trial by Nakagawa et al.,6 a total of 80 patients aged 20-65 years old (mean = 39.5) were selected to participate in the study. All participants had at least a minimal degree of TRD and a score of ≥16

on the GRID-Hamilton Depression Rating Scale (GRIDHDRS). All eligible participants were randomly allocated to receive CBT plus TAU or TAU alone with 12-month follow-up. Those who received CBT plus TAU were offered 16 individual 50-minutes sessions scheduled weekly with up to 4 additional sessions. SSRIs were the most common antidepressant medication prescribed for the TAU only group. The primary outcome of this study was alleviation of depressive symptoms measured by

Table 1 - Descriptive details of studies included in this systematic review Year of publication

Study design

Intervention

Frequency and duration of intervention

Instruments

Main findings

Brent3

2008

RCT

TAU, CBT

12 weeks

TAU: 30-60 minutes CBT: 60-90 minutes

6 and 12 weeks

CDRS-R, BDI, SIQ-Jr, CGI-I, CGAS

CBT plus a switch to either medication regimen showed a higher response rate (54.8%) than a medication switch alone (40.5%) and there was no difference in response rate between venlafaxine and a second SSRI.

Nakagawa6

2017

RCT

TAU, Individual CBT

16 sessions + 4 additional sessions

50 minutes

12 months

GRID-HDRS, QIDS-SR, HPQ

Patients with TRD may benefit from supplementing TAU with CBT.

Wiles10

2013

RCT

TAU, Individual CBT

12 sessions + 6 additional sessions

50-60 minutes

12 months

BDI, ICD-10

CBT + TAU was effective for reducing depressive symptoms and improving quality of life in patients with TRD.

Wiles11

2016

FollowUp RCT

TAU, Individual CBT

12 sessions + 6 additional sessions

50-60 minutes

3-5 years

BDI, SF-12, PHQ-9, GAD7, EQ-5D-5L

The CBT intervention reduced depressive symptoms and improved quality of life over an average of 46 months.

Lopez12

2014

RCT

TAU, Individual CBT

18 sessions

IAI

BDI, QIDS

Participants showed a more rapid reduction in depressive symptoms over time and more CBT participants reached full symptom remission.

Emslie13

2010

RCT

TAU, CBT

12 weeks

TAU: 30-60 minutes CBT: 60-90 minutes

24 weeks

CDRS-R, BDI, CGAS, CGIS, BHS, SIQJr, CBQ-A, DUS-U, DUS-I

Of the 334 adolescents, only 261 participants (78.1%) were included in the 24-week assessment and 20% did not complete the assessment. The results showed that only 38.9% of 334 adolescents on the TORDIA trial achieved remission by 24 weeks.

Miller14

1985

Open trial

TAU, CBT, SST

28 sessions over a period averaging 22 weeks

IAI

BDI, HDRS

4 of the 6 patients exhibited complete improvement on measures of depression symptomatology.

Bannan15

2005

Case report

Venlafaxine, CBT

12 sessions (CBT) 375 mg daily (venlafaxine)

IAI

BDI, BHI, BAI

Clear improvements on assessments of mood and hopelessness and in social and occupational functioning.

First author

Session length

Duration of followup

BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BHI = Beck Hopelessness Inventory; BHS = Beck Hopelessness Scale; CBQ-A = Conflict Behavior Questionnaire – Adolescent version; CBT = cognitive-behavioral therapy; CDRS-R = Children’s Depression Rating Scale Revised; CGAS = Children’s Global Assessment Scale; CGI-I = Clinical Global Impressions-Improvement Subscale; CGIS = Clinical Global Impression Severity; DUS-I = Drug Use Screening Inventory – Impairment; DUS-U = Drug Use Screening Inventory – Use; EQ-5D-5L = standardized generic measure of health status used as part of the economic evaluation; GAD-7 = 7-Item Generalized Anxiety Disorder assessment; GRID-HDRS = 17-item GRID-Hamilton Depression Rating Scale; HDRS = Hamilton Depression Rating Scale; HPQ = Work Performance Questionnaire; IAI = immediately after intervention; ICD-10 = International Classification of Disease; NM = not mentioned; PHQ-9 = Patient Health Questionnaire-9; QIDS-SR = Depressive Symptomatology Self-Report; RCT = randomized controlled trial; SF-12 = 12-Item Short-Form Health Survey; SIQ-Jr = Suicide Ideation Questionnaire-Jr-4; SST = social skills training; TAU = treatment as usual (pharmacotherapy); TRD = treatment-resistant depression.

96 – Trends Psychiatry Psychother. 2020;42(1)

Review of CBT for TRD in adults and adolescents - Zakhour et al.

the GRID-HDRS. The results showed that alleviation of depressive symptoms at 16 weeks was greater in the CBT group than in the TAU group and that the beneficial effects of CBT were maintained over the 12-month follow-up period. 82.5% of those receiving CBT + TAU and 50% of those receiving TAU alone showed a â&#x2030;Ľ50% reduction in the GRID-HDRS. The CoBalT randomized controlled trial by Wiles et al.10 recruited 469 patients aged 18-75 years (mean 49.2) who had been compliant with an adequate dose of antidepressant medication for at least 6 weeks and

who all had a BDI score of 14 or more (mean 31.8). Participants with other disorders such as bipolar or psychotic disorder were excluded, as were participants who received CBT treatment in the previous 3 years. Participants were taking antidepressants at the time of randomization and were expected to continue with the drugs. In addition, they were randomly allocated to receive CBT plus TAU or TAU alone. Those who received CBT + TAU received 12 sessions of individual CBT lasting 50-60 minutes with a further six sessions: 90% of patients were followed up at 6 months and 84%

Table 2 - Randomized controlled trials of Psychotherapy Quality Rating Scale scores for clinical trials of cognitive-behavioral therapy for treatment-resistant depression Brent3

Nakagawa7

Wiles12

Lopez13

1. Diagnostic method and inclusion/exclusion criteria

2. Documentation/demonstration of reliability of diagnostic methodology

3. Description of relevant comorbidities

4. Description of numbers of subjects screened, included, and excluded

5. Treatment(s) (including control/comparison groups) are sufficiently described or referenced to allow for replication

6. The treatment being studied is treatment delivered

7. Therapist training and level of experience in the treatment(s) under investigation

8. Therapist supervision while treatment is being provided

9. Description of concurrent treatments allowed and administered

10. Validated outcome measure(s)

11. Primary outcome measure(s) specified in advance

12. Outcome assessment by raters blinded to treatment group and with established reliability

13. Discussion of safety and adverse events during study treatment(s)

14. Assessment of long-term post-termination outcome

15. Intent-to-treat method for data analysis, primary outcome

16. Description of dropouts and withdrawals

17. Appropriate statistical tests

18. Adequate sample size

19. Appropriate consideration of therapist and site effects

20. A priori relevant hypotheses that justify comparison group(s)

21. Comparison group(s) from same population and time frame as experimental group

22. Randomized assignment to treatment groups

23. Balance of allegiance to types of treatment by practitioners

24. Conclusions justified by sample, measures, and data analysis

25. Omnibus rating

Description of subjects

Definition and delivery of treatment

Outcome measures

Data analysis

Treatment assignment

Overall quality of study

Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 97

Review of CBT for TRD in adults and adolescents - Zakhour et al.

at 12 months. Their primary outcome was reduction in depressive symptoms of at least 50% compared with baseline as measured by the BDI. After 6 months, participants in the intervention group had a BDI score that was 5.7 points lower (less depressed). At 12-month follow-up, participants had a mean BDI score of 17.0. Hence, CBT as an adjunct to TAU was effective in reducing depressive symptoms in patients with TRD and effects were maintained over 12 months. In 2016, a long-term follow-up study derived from the above-mentioned RCT was conducted by Wiles et al.11 with the aim of assessing the long-term effectiveness of CBT as an adjunct to TAU. Patients from the first study10

were eligible for this one11 if they had not withdrawn during the 12 monthsâ&#x20AC;&#x2122; follow-up period. The primary outcome of the CoBalT follow-up was self-report of depressive symptoms assessed by the BDI score. One hundred and thirty-six of the 469 participants from the original CoBalT study10 participated in the follow-up CoBalt study.11 At trial entry, participants had a mean BDI score of 31.8, whereas at 46 months, the mean BDI score had reduced to 19.2, which was a similar score to results at 6 and 12-month follow-ups. CBT as an adjunct to TAU was effective in reducing depressive symptoms in patients with TRD and the effects were maintained over 46 months (3-5 years).

Table 3 - Randomized controlled trials of Psychotherapy Quality Rating Scale scores for long-term follow-up studies derived from samples randomized in Randomized controlled trials of cognitive-behavioral therapy for treatment-resistant depression Wiles14

Emslie16

1. Diagnostic method and inclusion/exclusion criteria

2. Documentation/demonstration of reliability of diagnostic methodology

3. Description of relevant comorbidities

4. Description of numbers of subjects screened, included, and excluded

5. Treatment(s) (including control/comparison groups) are sufficiently described or referenced to allow for replication

6. The treatment being studied is treatment delivered

7. Therapist training and level of experience in the treatment(s) under investigation

8. Therapist supervision while treatment is being provided

9. Description of concurrent treatments allowed and administered

10. Validated outcome measure(s)

11. Primary outcome measure(s) specified in advance

12. Outcome assessment by raters blinded to treatment group and with established reliability

13. Discussion of safety and adverse events during study treatment(s)

14. Assessment of long-term post-termination outcome

15. Intent-to-treat method for data analysis, primary outcome

16. Description of dropouts and withdrawals

17. Appropriate statistical tests

18. Adequate sample size

19. Appropriate consideration of therapist and site effects

20. A priori relevant hypotheses that justify comparison group(s)

21. Comparison group(s) from same population and time frame as experimental group

22. Randomized assignment to treatment groups

23. Balance of allegiance to types of treatment by practitioners

24. Conclusions justified by sample, measures, and data analysis

25. Omnibus rating

Description of subjects

Definition and delivery of treatment

Outcome measures

Data analysis

Treatment assignment

Overall quality of study

98 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

Review of CBT for TRD in adults and adolescents - Zakhour et al.

Lopez and Basco’s study12 was also a randomized controlled trial designed to assess the effectiveness of CBT in patients with TRD. 166 participants (19 to 74 years old and mostly Hispanic) were randomly assigned to a CBT + TAU group (83 participants, mean age 42.8) or to a TAU alone group (83 participants, mean age 43.2). Only those who had failed to achieve full remission of depression after two trials of medication and who had a Quick Inventory of Depressive Symptomatology (QIDS) score of 11 or greater (which means moderate symptomatology) were eligible to receive CBT consisting of 18 individual sessions. The baseline mean QIDS score was 17.9 and mean BDI score was 38.9. The results showed that, utilizing the final QIDS score, 36.7% of participants in CBT group had a clinically significant response to treatment (50% decrease) compared to 22.9% of those in the TAU group. Utilizing the BDI score, 57.5% demonstrated meaningful response to CBT. Finally, for adolescent populations, only one randomized controlled trial was found in the database results that assessed the efficacy of CBT in TRD adolescents: the TORDIA randomized controlled trial, published in 2008.3 The main outcome of this trial was improvement of depressive symptoms measured by validated scales. Participants were 334 adolescents aged 12 to 18 years (mean age 15.9), with clinically significant depression measured by the Children’s Depression Rating Scale Revised (CDRS-R) with a total score of at least 4 (at least moderate severity), despite being on treatment with an SSRI for at least 8 weeks (40 mg/day of fluoxetine or its equivalent). They were randomly assigned for 12 weeks to 1 of 4 treatment regimens: 1) switch to a second, different SSRI, 2) switch to a second, different SSRI + CBT, 3) switch to venlafaxine or 4) switch to venlafaxine + CBT with 12 months’ follow-up. Medication sessions lasted 30 to 60 minutes whereas CBT was 12 sessions of 60 to 90 minutes each. 54.8% of participants treated with CBT showed an adequate clinical response and a reduction in CDRS-R score (≥50%). CBT plus a switch to either medication showed a higher response rate (54.8%) than a medication switch alone (40.5%), but there was no difference in response rate between venlafaxine and a second SSRI. In 2010, Emslie et al.13 published a long-term follow-up study derived from the above-mentioned RCT, this time with the purpose of reporting on the outcome of participants in the TORDIA trial after 24 weeks of treatment. The same participants were included, however, following the initial 12 weeks, responders remained in the same blinded treatment arm for an additional 12 weeks. Medication visits were monthly, whereas CBT visits (mean of 2.8 sessions) were every other week for 2 months and monthly thereafter. Of

the 334 adolescents, only 261 participants (78.1%) were included in the 24-week assessment and 20% did not complete the assessment. Result showed that only 38.9% of 334 adolescents from the TORDIA trial achieved remission by 24 weeks. Open trial and case report studies An open trial by Miller et al.14 enrolled 6 female patients aged between 20 and 64 (mean age 39.7) who met the criteria of major depressive disorder, with an initial Beck Depression Inventory (BDI) score ≥19 and an initial Hamilton Depression Rating Scale (HDRS) score ≥17 with a failure to respond to an adequate trial of antidepressant medication (greater than 150 mg of imipramine or equivalent for three weeks). All 6 female patients received a mean of 28 sessions of CBT treatment with pharmacotherapy over a period averaging 22 weeks. Results showed that the mean BDI score dropped from 25.2 to 6.3 and the mean HDRS score from 23.8 to 8.7. In other words, 67% exhibited complete improvement on measures of depression symptomatology (BDI ≤ 9 and HDRS ≤ 7). Moreover, Bannan15 demonstrated through the use of a case study the effectiveness of applying CBT in the treatment of resistant depression. The case study is of a 25-year-old woman with an 18-month history of resistant depression who failed to respond to three therapeutic trials of antidepressants (paroxetine 50 mg/day for six weeks, sertraline 150 mg/day for four weeks and venlafaxine 225 mg/day for three weeks). Treatment was a CBT intervention of 12 sessions using validated scales such as the BDI, Beck Hopelessness Inventory (BHI) and Beck Anxiety Inventory (BAI) (for more details please see Table 1). Measurements were made pre-therapy, mid-therapy and post-therapy. The results showed that following 12 sessions of CBT, given in combination with a course of venlafaxine 375 mg daily, there were clear improvements in mood and in levels of hopelessness as well as in overall social and occupational functioning. These improvements were reflected in the rating scales: pre-therapy (BDI score = 31, BHI score = 16), mid-therapy (BDI score = 25, BHI score = 13) and post-therapy (BDI score = 16, BHI score = 7). The patient benefited from the combination of CBT + TAU.

Discussion Summary of evidence This review systematically evaluated the efficacy of CBT for TRD in participants aged at least 12 years, based upon evidence from controlled studies that used Trends Psychiatry Psychother. 2020;42(1) – 99

Review of CBT for TRD in adults and adolescents - Zakhour et al.

validated instruments and scales. A recent article7 systematically reviewed the effectiveness of CBT for TRD patients, including other related types of therapies. However, to our knowledge, this is the first systematic review examining the efficacy of CBT only for treatment of resistant depression, including randomized controlled studies, open trials and case reports. It is also the first to review the efficacy of CBT on TRD for both adult and adolescent populations. Seventeen out of an initial list of 1580 articles were assessed for eligibility and 8 were included in this systematic review, comprising 6 randomized controlled trials, two of which described results for a follow-up period, 1 open trial and 1 case report. The randomized controlled trials demonstrated that the combination of CBT and TAU showed more rapid improvement in depressive symptoms. Overall, the evidence is sufficiently robust to confirm the efficacy of CBT for treatment of resistant depression in adult populations. One of the studies also showed that the effects of CBT can last for up to 3 to 5 years. The open trial also showed that symptoms are rapidly alleviated when CBT is combined with pharmacotherapy. Additionally, the case study of a woman who underwent CBT also demonstrated reduction in depressive symptomatology. All of these results were based on use of validated scales to assess depressive symptoms over 12 months of followup and even as much as 46 months of follow-up. Just one randomized controlled trial showed that the combination CBT + TAU was also effective in an adolescent population. It is known to be the first clinical trial to enroll adolescents with depression who were not responding to an evidence-based treatment. However, when a follow-up of the same study was conducted, the results showed that the effects of CBT did not last up to 24 weeks. The findings could be applicable to community samples, which, while often more ethnically diverse than the study sample, have comparable clinical complexity. Results address a relevant and important issue in the clinical aspect of a highly prevalent disease. When depressed patients do not respond to evidence-based interventions, healthcare providers and mental health experts should think of other strategies to manage these patients. This systematic review will help mental health experts by providing robust evidence that combination treatment for TRD patients is a choice that should be considered in their management, since it shows promising results for alleviation and reduction of depressive symptoms. Limitations There are several limitations to consider when interpreting this review. The first is that only four 100 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2020;42(1)

randomized controlled trials addressed this topic.6,10,12 Moreover, only one randomized controlled trial3 studied an adolescent population. Furthermore, there were insufficient data to conduct a meta-analysis, hence the absence of such an analysis in our systematic review.

Conclusions The difficulty of treating patients with TRD poses considerable challenges to healthcare providers and mental health experts. The challenge is greater because of the limited number of studies. Since the available findings are interesting and some demonstrate the efficacy of CBT for TRD patients, this study has provided further support for the contention that adding CBT to TRD treatment is a promising and effective approach. Significantly more CBT patients had clinically meaningful reductions in symptoms, according to the validated scales of depression used in the studies reviewed. However, it should be noted that there is a need to conduct additional studies of this topic. More specifically, further research is needed to investigate in greater detail whether adding CBT to TRD is beneficial in adolescents, since 40% of them will not respond to TAU treatment.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

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Review of CBT for TRD in adults and adolescents - Zakhour et al.

9. Kocsis JH, Gerber AJ, Milrod B, Roose SP, Barber J, Thase ME, et al. A new scale for assessing the quality of randomized clinical trials of psychotherapy. Compr Psychiatry. 2010;51:319-24. 10. Wiles N, Thomas L, Abel A, Ridgway N, Turner N, Campbell J, et al. Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial. Lancet. 2013;381:375-84. 11. Wiles NJ, Thomas L, Turner N, Garfield K, Kounali D, Campbell J, et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. Lancet Psychiatry. 2016;3:137-44. 12. Lopez MA, Basco MA. Effectiveness of cognitive behavioral therapy in public mental health: Comparison to treatment as usual for treatment-resistant depression. Adm Policy Ment Health. 2015;42:87-98. 13. Emslie GJ, Mayes T, Porta G, Vitiello B, Clarke G, Wagner KD, et al. Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes. Am J Psychiatry. 2010;167:782-91.

14. Miller IW, Bishop SB, Norman WH, Keitner GI. Cognitive/ behavioural therapy and pharmacotherapy with chronic, drugrefractory depressed inpatients: a note of optimism. Behav Cogn Psychother. 1985;13:320-7. 15. Bannan N. Multimodal therapy of treatment resistant depression: a study and analysis. Int J Psychiatry Med. 2005;35:27-39. 16. Abel A, Hayes AM, Henley W, Kuyken W. Sudden gains in cognitivebehavior therapy for treatment-resistant depression: processes of change. J Consult Clin Psychol. 2016;84:726.

Correspondence: Stephanie Zakhour Ambulatório de Depressão Resistente ao Tratamento (DeReTrat) Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ) Av. Vencelaus Brás, 71, Campus da Praia Vermelha 22290-140 - Rio de Janeiro, RJ - Brazil Tel.: + 55 (21) 964426645 E-mail: stephaniezakhour@hotmail.com

Trends Psychiatry Psychother. 2020;42(1) – 101

Trends

Review Article

in Psychiatry and Psychotherapy

Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of posttraumatic stress disorder (PTSD): a systematic review Anthony Paulo Sunjaya,1

Arlends Chris,1 Dewi Novianti2

Abstract Introduction: Post-traumatic stress disorder (PTSD) is one of the most common psychiatric disorders found among victims of disaster, kidnapping, accidents, sexual assaults and war in Indonesia. However, lacking and unequal distribution of psychiatric medical personnel remains a barrier to its management. This review aims to introduce and evaluate the potential contribution of telepsychiatry to the management of PTSD based on published literature. Methods: Original studies were obtained from PubMed, Science Direct, ProQuest, High Wire, and Elsevier Clinical Key databases. Results: A total of 125 articles were found, of which 15 articles (12 randomized controlled trials, 2 open trials and 1 pilot study) fulfilled the inclusion criteria. A total of 991 subjects were found with a follow-up period ranging between 5 weeks and 18 months. Telepsychiatry is an innovative use of technology to aid the delivery of PTSD treatments in areas difficult to reach. The quality of care given by telepsychiatry both through video conferencing as well as web- and application-based is comparable to that of face-to-face therapy. Patient satisfaction, quality of doctor-patient relationship also remains high, with lower costs and shorter therapeutic time when compared to face-to-face therapy. Conclusion: Various studies have shown that telepsychiatry is an effective solution for the management of PTSD. Studies have also reported that the quality of treatment through telepsychiatry is as effective as face-to-face therapy, with greater efficiency. Countries, especially those with a low patient-to-mental health professional ratio, should be encouraged to develop telepsychiatry systems to manage PTSD. Keywords: Telepsychiatry, post-traumatic stress disorder, telemedicine.

Introduction Globally, around 61% of males and 50% of females will face at least one traumatic event throughout their life. Traumatic events include war, violence (sexual violence, physical attacks, etc.), kidnappings, torture, terrorism, road accidents and natural disasters. Sexual violence, witnessing a tragic death or horrifying injury

1 Faculty of Medicine, Tarumanagara University, Jakarta, Indonesia. University, Jakarta, Indonesia.

during one’s childhood is also one of the main causes of lifelong trauma.1 The World Health Organization (WHO) in 2013 reported that an average 3.6% of the world’s population suffers from post-traumatic stress disorder (PTSD), with a distribution of 28.5% in the Western Pacific and 27.4% in Southeast Asia.2 In Indonesia, the most recent national health survey conducted by the Ministry of Health in 2018

Department of Public Health and Family Medicine, Faculty of Medicine, Tarumanagara

Submitted Mar 22 2019, accepted for publication Jun 17 2019. Suggested citation: Sunjaya AP, Chris A, Novianti D. Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review. Trends Psychiatry Psychother. 2020;42(1):102-110. http://dx.doi.org/10.1590/2237-60892019-0024 APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 102-110

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reported that the prevalence of psychiatric disorders was 9.8%, rising from 6% in 2013, although there were no specific data on the prevalence of PTSD.3 This may be a result of an increase in the number of sex-related cases,4 violent criminal offenses,5 road accidents,6 all of which are main triggers of PTSD. Furthermore, terrorism, forced evictions and increasing competition in life have also contributed to the rise in PTSD cases in Indonesia, especially in disaster-prone areas.7-9 PTSD is a psychiatric disorder caused by traumatic events or a series of traumatic events involving oneself, others or their loved ones and having resulted in death, serious injuries or both.10 Patients with PTSD show signs of anxiousness, fear, repeated flashbacks of the traumatic event, avoidance of objects, locations etc. associated with the event; they withdraw themselves emotionally (emotional numbing) and respond overwhelmingly to similar events.11-13 PTSD does not always appear immediately after the triggering event, but may appear within weeks or even 30 years after the event has occurred.10 Symptoms also fluctuate over time and especially worsen during periods of stress. Without proper management, only 30% of patients recover on their own, 40% will always present minor symptoms and 10% worsen over time. A poorer prognosis is observed among children and the elderly, due to their greater emotional vulnerability and poor coping mechanisms.10 Untreated PTSD has been proven to affect both cognitive and learning function. Patients with PTSD have difficulties in concentration, cognition and emotion management, which can negatively impact their interpersonal relations and impair their decision-making skills in life. PTSD also lowers work and academic achievements. In the end, PTSD can lower oneâ&#x20AC;&#x2122;s quality of life, productivity and inadvertently lead to huge social costs to society.14,15 Although PTSD leads to numerous negative consequences, patients with PTSD are often not managed adequately. This is potentially caused by lack of awareness among PTSD sufferers as well as difficulty receiving therapy, due to the scarcity of psychiatric medical resources.10,12,16 Currently, there are many different types of psychotherapy available for PTSD, such as prolonged exposure, cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR), all of which have been proven effective in managing patients with PTSD.12 Psychotherapy does not involve the use of medications, but instead aims to change the way someone feels about the trauma that they have faced.10 The lack of psychiatric health professionals such as psychiatrists, clinical psychologists and psychiatric

nurses, as well as limited access to and distribution of these services are among the several barriers in managing PTSD throughout the world, especially in developing countries. In 2018, it was reported that there were only 773 psychiatrists (0.32 per 100,000 population) and 451 clinical psychologists (0.15 per 100.000 population) in Indonesia, severely low numbers compared to the WHO recommendations of 1 psychologist and psychiatrist per 30,000 population or 3.33 per 100,000 population. Distribution of psychiatric care also remains uneven and mostly concentrated in urban areas. These factors have made PTSD treatment become rare and expensive in many developing countries, including Indonesia.12,16 Telemedicine Telemedicine refers to the remote provision of medical services, i.e., distant from the medical professional, through the use of information technology to aid in the exchange of health information for the purpose of diagnosis, management and prevention of diseases, research and evaluation, and also to improve the knowledge of health professionals with the sole aim of improving health care for both the community and society.17 Telemedicine links doctors from a referral center/hospital to health professionals and patients elsewhere, in their homes, community health centers, etc., through the use of various telecommunication media such as satellite and fiber optics.18-20 In 2016, the WHO reported that 77% of 125 countries throughout the world had implemented telemedicine. One of the main reasons behind telemedicine use is its ability to provide health care to remote areas, which are difficult to reach by health professionals.21 Telemedicine is also able to facilitate training of volunteers as well as health professionals both in remote areas and during natural disasters.17,22 Hence, telemedicine has great potential in bridging the current need for better PTSD management throughout in Indonesia and similar developing countries with a low mental health professional to population ratio. The use of telemedicine for the care of psychiatric patients is referred to as telepsychiatry.2,23,24 This review therefore aims to evaluate the potential of telepsychiatry as an alternative solution to overcome the barriers to better PTSD care in Indonesia and other countries.

Materials and methods Data source The databases searched to obtain the articles included PubMed, Science Direct, ProQuest, High Wire, Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 103

Telepsychiatry for managing PTSD - Sunjaya et al.

and Elsevier Clinical Key. The search strategies used included availability of full text written in English and published from January 2003 to December 2017. The following keywords were used: “post-traumatic stress disorder or delayed stress disorder” and “telepsychiatry or telemedicine or telehealth or e-health or teleconsultation or video conference or telecare AND psychiatry.” When multiple articles deriving from the same study were found, only the most recent publication was included. An approach based on title, abstract, and full text was used to evaluate the relevance of articles.

carried out through telepsychiatry with any method or length of time; 2) parameters related to the control of symptoms, therapeutic alliance, economic effects were reported; 3) studies compared telepsychiatry use vs. routine care; or 4) studies compared patients treated with telepsychiatry vs. another type of management with placebo as control. Studies not meeting these criteria were excluded from this review.

Study selection Studies were included if they were original studies and if they had one of the following designs: randomized controlled trial (RCT), case-control study, and cohort study. Ideally, PTSD in the studies should be diagnosed in accordance to the criteria found in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA).13 In addition, studies were included if: 1) they included patients with PTSD and management was

Our initial search resulted in 125 articles, of which 39 were excluded due to duplicate citations. Fifty-seven were then excluded on the basis of title and abstract. Of the remaining 29 studies, 13 were excluded because they did not meet the inclusion criteria, 2 reported on acute stress disorder and not PTSD, 4 were editorials, 5 studied substance abuse with PTSD rather than PTSD alone, and 2 were duplicate publications of the same study. Finally, 15 articles were found that fulfilled all of our inclusion criteria: 12 RCTs, 2 open trials, and 1 pilot study (Figure 1).

Results and discussion

Pubmed

Elsevier Clinical Key

Science Direct

High Wire

ProQuest

2003-2017

12 Citation(s)

29 Citation(s)

49 Citation(s)

0 Citation(s)

35 Citation(s)

86 Non-Duplicate Citations Screened

Inclusion/Exclusion

57 Articles Excluded

Criteria Applied

After Title/Abstract Screen

29 Articles Retrieved

Inclusion/Exclusion

14 Articles Excluded

Criteria Applied

After Full Text Screen

15 Articles Included

Figure 1 - Data selection flow chart 104 – Trends Psychiatry Psychother. 2020;42(1)

Telepsychiatry for managing PTSD - Sunjaya et al.

Sample size varied across studies, ranging from 1525 to 24124 patients, with a follow-up duration ranging between 5 weeks26 and 18 months.27 The total number of subjects considering all studies was 991. The majority of studies were published from 2010 onwards and conducted in developed nations. Five studies were conducted in Germany,25-29 three in Australia,30-32 two in Canada,23,24 and the remainder were one each from China,33 Iraq,34 the Netherlands,35 the United States of America,36 and Sweden.37

Effectiveness and quality of therapy Fourteen of the studies evaluated documented that the effectiveness of telepsychiatry was similar to that of face-to-face therapy, although with varying levels of improvements (Table 1). Germain et al. compared CBT administered to PTSD patients face to face and through teleconference for 16-25 weeks and reported a significant reduction in frequency and severity of PTSD symptoms in both groups post-therapy. No significant differences in

Table 1 - Summary of telepsychiatry studies included in the review Methodology Ref. no.

Parameter compared

Title

Author

Country

Design

Sample size

Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder

Germain et al.

Canada

RCT

Face-to-face 31 patients vs. telepsychiatry 16 patients

SCID-IV MPSS BDI

Significant improvements in PTSD symptoms, level of depression, anxiety, daily function and perception of health in both groups. No significant difference in effectiveness between CBT face-toface vs. telepsychiatry.

Result

Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial

Oâ&#x20AC;&#x2122;Reilly et al.

Canada

RCT

Face-to-face 254 patients vs. telepsychiatry 241 patients

BSI GSI CSQ

Clinical outcome in face-to-face and telepsychiatry equivalent (improvement in GSI: 6.9 vs. 7.2). No difference in patient satisfaction between both groups. Cost analysis showed 10% cost savings in telepsychiatry group (total cost USD 108,549 vs. USD 88,311).

Efficacy of an Internetbased intervention for posttraumatic stress disorder in Iraq: a pilot study

Wagner et al.

Germany

Pilot study

Telepsychiatry 15 patients

PDS HSCL-25 Skala Quality of Life (EUROHIS)

Conducted with Arabic patients. Significant improvement in symptoms of PTSD, depression, anxiety. Better quality of life post-therapy. Effect size for PTSD Scale (1.57), depression (1.51), anxiety (1.50), and quality of life (1.17).

Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab wartraumatized patients

Wagner et al.

Germany

RCT

Telepsychiatry 55 patients

PDS and Working Alliance Inventory

Telepsychiatry for 45 minutes, twice weekly for 5 weeks (total of 10 sessions). High patient satisfaction throughout study. Better patient satisfaction correlated with symptom improvement.

Long-term effects of an internet-based treatment for posttraumatic stress

Knaevelsrud & Maercker

Germany

Follow up study after RCT

34 telepsychiatry patients 18 months post-therapy

IES-R DASS

Pre and post-therapy data were compared. Improvements in PTSD, depression and anxiety symptoms remained for 18 months post-therapy. Only 24% needed additional face-toface therapy support.

Internet-based treatment for Knaevelsrud PTSD reduces distress and & Maercker facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial

Germany

RCT

WLC 47 patients vs. telepsychiatry 49 patients

IES-R SCL-90

Conducted with German patients. Significant difference in symptoms between telepsychiatry and control group. High patient satisfaction (86% satisfied, low dropout of 16%). Improvement remained during followup 3 months post-therapy. Continued on next page

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Table 1 (cont.) Methodology Ref. no.

Parameter compared

Result

WLC 113 patients vs. telepsychiatry 115 patients

IES-R SCL-90 Inventory of Complicated Grief

Significantly better improvements in PTSD symptoms, grief, depression and anxiety in telepsychiatry group. Improvements persisted for 12 months post-therapy.

Open trial

Telepsychiatry 22 patients

PTSD Scale MINI Anxiety Disorders Interview PCL IES-R DASS WHOQOLBREF TSQ TAQ

69.2% cured from PTSD after 10 weeks of telepsychiatry. 3 months post-therapy, the percentage of cured patients increased to 77%. Patient satisfaction of 69%. High-quality doctor-patient relationship (87.5%). Average total therapy time: 194.5 minutes.

Australia

Open trial

Telepsychiatry 16 patients

IES-R TAQ TSQ

Telepsychiatry only through e-mail. Therapy for 10 weeks. Significant improvements in PTSD symptoms, good patient-doctor relation. Improvement in PTSD symptoms reported.

Spence et al.

Australia

RCT

WLC 21 patients vs. telepsychiatry 23 patients

PCL

Telepsychiatry effective in reducing PTSD symptoms (61% improved in telepsychiatry group vs. 21% in control group). Efficient, only required therapeutic time < 2 hours (SD 97 minutes), shorter than face-to-face therapy. High patient satisfaction (81% satisfied, 95% will recommend to friends). Improvements remained 3 months post-therapy.

Chinese My Trauma Recovery, a web-based intervention for traumatized persons in two parallel samples: randomized controlled trial

Wang et al.

China

RCT

Telepsychiatry 183 patients

PDS SCL-90 CSE PCC SFI

Telepsychiatry samples from both urban and rural areas. Improvement in PTSD symptoms for both types of patients. Improvements remain even 3 months post-therapy during follow up.

Web-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients: randomized controlled trial

Knaevelsrud et al.

Iraq

RCT

WLC 80 patients vs. telepsychiatry 79 patients

PDS

Telepsychiatry for 45 minutes, twice weekly for 5 weeks. 62% cured from PTSD post-therapy (OR 74.19). Improvements remained 3 months post-therapy.

Interapy: a controlled Lange et al. randomized trial of the standardized treatment of posttraumatic stress through the internet

The Netherlands

RCT

WLC 32 patients vs. telepsychiatry 69 patients

SCL-90

Conducted through Interapy platform: psychoeducation, screening and therapy for PTSD. Significant improvements in trauma symptoms and psychopathology in telepsychiatry group vs. WLC. Large effect size. More than 50% of patients reported significant improvements especially in symptoms of depression and avoidance.

Delivery of self-training and education for stressful situations (DESTRESSPC): a randomized trial of nurse assisted online selfmanagement for PTSD in primary care

United States of America

RCT

Face-to-face 37 patients vs. telepsychiatry 43 patients

PCL

War veterans. Effect of telepsychiatry for 8 weeks better than standard face-to-face therapy (effect size 0.47 measured 12 weeks post-therapy). Greatest improvement found 12 months post-therapy, which reduced when therapy was stopped.

Title

Author

Country

Design

Sample size

Brief Internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial

Kersting et al.

Germany

RCT

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

Klein et al.

Australia

A therapist-assisted Internet-based CBT intervention for posttraumatic stress disorder: preliminary results

Klein et al.

Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder

Engel et al.

Continued on next page

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Table 1 (cont.) Methodology Ref. no. 37

Title

Author

Country

Design

Sample size

Parameter compared

Guided internet-delivered cognitive behavior therapy for post-traumatic: a randomized controlled trial

Ivarsson et al.

Sweden

RCT

WLC 31 patients vs. telepsychiatry 31 patients

CAPS IES-R PDS

Result Eight weeks of therapy using online module on psychoeducation, breathing exercises, imaginal and in vivo exposure, cognitive restructuring, relapse prevention. Feedback and therapist support once weekly online. Significant improvements in PTSD symptoms, with effect size between group IES-R (d=1.25) and PDS (d=1.24). Improvements in symptoms remained 1 year post-therapy.

BDI = Beck Depression Inventory; BSI = Brief Symptom Inventory; CAPS = Clinician-administered PTSD Scale; CSE = Trauma Coping Self-Efficacy Scale; CSQ = Client Satisfaction Questionnaire; DASS = Depression, Anxiety Stress Scale; EUROHIS = Quality of Life Scale; GSI = Global Severity Index; HSCL-25 = Hopkins Symptom Check List-25; IES-R = Impact of Event Scale Revised; MINI = Mini-International Neuropsychiatric Interview; MPSS = Modified PTSD Symptom Scale; OR = odds ratio; PCC = post-traumatic cognitive changes; PCL = PTSD Checklist; PDS = PTSD Scale; PTSD = post-traumatic stress disorder; RCT = randomized controlled trial; SCID-IV = Structured Clinical Interview; SCL-90 = Depression and Anxiety Symptom Checklist; SD = standard deviation; SFI = Social Functioning Impairment; TAQ = Therapeutic Alliance Questionnaire; TSQ = Treatment Satisfaction Questionnaire; WHOQOL-BREF = World Health Organization Quality of Life instrument-Abbreviated version; WLC = wait list control.

effectiveness were found between both groups.23,24,33 In a similar study by Klein et al. using online CBT, 69.2% of PTSD patients showed significant post-therapy improvements in symptoms; that number increased to 77% at 3 monthsâ&#x20AC;&#x2122; post-therapy follow-up.30 Even when different PTSD inventories (e.g., PTSD Scale, the World Health Organization Quality of Life instrument-Abbreviated version, the Beck Depression Inventory, etc.) were used to compare therapy results, telepsychiatry was still shown to provide significantly better outcomes compared to the control groups.23-37 It should be noted that while there are several psychotherapeutic strategies that are effective in managing PTSD patients, such as CBT, EMDR and prolonged exposure, all studies published so far on telepsychiatry have used CBT. The lack of direct contact between physician and patients, and the use of asynchronized telepsychiatry methods in several studies may hinder the implementation of EMDR or prolonged exposure, as they require active physician feedback. Further studies are hence still required especially on the effectiveness of telepsychiatry combined with these two other treatment methods, as are comparisons between the effectiveness of all three methods when delivered through telepsychiatry. Effectiveness in specific patient groups The use of telepsychiatry for PTSD has also been studied in specific patient groups, with telepsychiatry being found effective on both the elderly and children, for instance.38 Likewise, the method has been tested in both urban and rural areas33 and found to be effective.

Its use has also been found to be effective in studies conducted in various regions such as the Middle East,25,26 Asia,33 Europe,28,35 America,36 and Australia.30-32 Finally, telepsychiatry was able to manage PTSD regardless of the triggering event, and has been tested on patients with PTSD caused by war (veterans),25,26,34,36,39 natural disasters,33 post-partum,29 and other types of traumas. Similarly to other psychiatric disorders, PTSD still raises stigma in many areas of the world. Hence, patients may fear seeking direct help and attend faceto-face consultations with mental health professionals even when they are accessible. Telepsychiatry can help in managing these patients as it can provide a secure and private environment to patients, from the comfort of their own place. This may help patients be more eager to seek help and increase interaction with mental health professionals. Long-term effects For telepsychiatry to be feasible, it should not only provide acute improvements but also remain effective in the long run. In the RCT conducted by Klein et al., at 3 months post-telepsychiatry for 10 weeks, 77% of the patients still reported improvements in their PTSD severity, with good patient satisfaction and an average doctor-patient interaction of fewer than 200 minutes.30 Furthermore, in another RCT led by Ivarsson et al. involving PTSD patients and using a fully Internet-based module, without any direct doctor-patient interaction, significant improvement in depression and anxiety as well as in post-therapy quality of life was reported, Trends Psychiatry Psychother. 2020;42(1) â&#x20AC;&#x201C; 107

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persisting even 1 year post-therapy.37 The study by Kersting et al. also reported similar improvement in symptoms remaining for one year post-therapy.29 Knaevelsrud & Maercker reported that improvement of symptoms remained even at 18 months post-therapy.27 Effect on quality of doctor-patient relationship and patient satisfaction One of the main impacts of telepsychiatry is the reduction of doctor-patient interaction. However, as shown in the study by Klein et al., doctor-patient relationship quality was reported to remain high, at 87.5%.30 Spence et al. also reported that 81% of telepsychiatry users were satisfied with the care received and 95% would recommend it to others.32 Knaelvelsrud et al. also reported a low dropout rate in the telepsychiatry group (16%) and that 86% of users reported being satisfied.28 Furthermore, the study by Malhotra et al. involving children even showed a higher satisfaction rate in the telepsychiatry group compared to the face-to-face therapy group.38 Similar patient satisfaction findings were also reported by O’Reilly et al.24 and Wagner et al.26 Length of therapy The therapeutic length of telepsychiatry for PTSD differed across the different studies evaluated. Some were performed for as short as 1 month33 while some were 6 months long.23 However, it was shown that a minimum therapy of 1 month was already able to significantly reduce PTSD symptoms, with improvements remaining even post-therapy.33,37 On average, therapeutic time with telepsychiatry was also shorter compared to face-to-face therapy: the study by Klein et al. reported a therapeutic time of around 3 hours with telepsychiatry compared to 12 hours with face-to-face therapy.30 Shorter therapy durations were reported in other studies with as less as <2 hours in the study by Spence et al.32 These results were also supported by other authors, such as Wagner et al.26 and Knaevelsrud et al.34 Web- and application-based telepsychiatry While telepsychiatry can facilitate remote faceto-face therapy with psychiatrists and psychologists through video conferencing, its greatest utility to provide treatment for the masses lies in the use of specialty software designed for patient self-help in managing PTSD. Software can be web- or applicationbased, including a step by step PTSD management curriculum for patients. For example, web-based My Trauma Recovery has been proven to be effective when 108 – Trends Psychiatry Psychother. 2020;42(1)

implemented to help manage PTSD among earthquake victims in Wenchuan, China, in the year 2008.33 Telepsychiatry software has also been implemented successfully for other psychiatric disorders, including PTSD, in the Netherlands, through the web-based software Interapy.35 Mobile applications have also been utilized for the screening and management of PTSD patients, especially post-war veterans in the United States.39 Simpler forms of telepsychiatry such as through e-mail have also been found to be successful, as shown by Klein et al.31 Cost-efficiency Only two studies have reported on the economic effects of telepsychiatry use in managing PTSD. Klein et al. reported that telepsychiatry was 3.7 times cheaper compared to face-to-face therapy. The costs of the two modalities were AUD 373 for telepsychiatry and AUD 1,380 for conventional face-to-face therapy.30 This result was also supported by O’Reilly et al., though at a lesser difference: cost analysis showed that utilizing telepsychiatry would save at least 10% per patient compared to face-to-face therapy (USD 394 vs. 439) and 16% per visit compared to the cost of in-person service (USD 265 vs. 315). This lower cost results from the fact that telepsychiatry reduces the need for travel and accommodation expenses, as well as higher psychiatrist fees to compensate for time lost due to travel. O’Reilly et al. also reported that the savings provided by telepsychiatry were proven to be greater than the technical costs of setting up and maintaining a telepsychiatry system.24 Notwithstanding, two studies reporting on an economic analysis of telepsychiatry underscored that these results should be viewed with caution and may not be generalizable to all settings.24,30 For instance, synchronized telepsychiatry is hypothetically most beneficial in settings with a large number of PTSD patients, located in remote or disaster-stricken areas with a low patient-to-mental health professional ratio. In urban areas or developed nations with adequate patient-to-mental health professional ratios, these systems may be more cost-effective compared to faceto-face therapy.24 However, the use of web- and application-based asynchronized telepsychiatry as explained earlier may be a cost-effective solution in most settings: even though this modality requires a substantial start-up investment, therapy costs are relatively low in the long run, as they require limited patient/mental health professional interaction. The rise of artificial intelligence systems in the future may further reduce these costs.

Telepsychiatry for managing PTSD - Sunjaya et al.

Practical implications The use of telepsychiatry in managing PTSD has been found to provide care for patients with comparable effectiveness and similar patient satisfaction as well as quality of doctor patient relationship when compared with face-to-face therapy.23,24,33,38 Improving accessibility and efficiency remains one of the main reasons for utilizing telepsychiatry. The growth of communication technologies such as the use of wireless technology, satellites, solar technology and fiber optics has made the implementation of telepsychiatry more feasible than ever. Reduced costs and therapeutic time as reported by various studies are also important benefits. Still, these results should be taken with caution, as only a few studies have evaluated the cost-effectiveness of telepsychiatry interventions. The lack of studies conducted in developing and less technologically developed areas are also concerning, as there may be additional setup costs and training required before telepsychiatry systems can be developed in these areas. It is believed that telepsychiatry can improve not only the management of PTSD, but also screening and early diagnosis, as currently implemented by the Department of Veteran Affairs in the United States, and also for post-disaster areas, such as in Pakistan.40,41 To date, the majority of studies originate from developed nations, especially Europe, and further studies are needed to examine the efficacy of telepsychiatry in developing and underdeveloped nations in Asia and Africa, which are lacking in psychiatric services. Similarly to the implementation of new technologies in other fields, the application of telepsychiatry still faces several barriers, including limited connectivity, lack of human resources and lack of telepsychiatry equipment. In addition, e-health guidelines and regulations need to be developed to address issues such as doctor-patient confidentiality, data privacy, etc. This review has shown that studies tend to focus only on parameters of efficacy, rarely analyzing the economic aspects of telepsychiatry (only two studies provided an economic analysis). Therefore, economic feasibility remains an important aspect to look into, especially when considering the implementation of telepsychiatry in developing nations and the coverage of this system by insurance plans. When these barriers can be addressed, the implementation of telepsychiatry could hopefully be able to make treatment for PTSD and other psychiatric disorders more affordable and reachable to the masses.

Limitations This review article suffers limitations in only being able to synthesize previously published journal articles and trials that are accessible to the authors. It should be noted that the studies included were based on published reports and take into account that studies reporting positive results are more readily accepted for publication as compared with studies reporting negative results. Also, most studies reviewed originate from developed countries, and there is a lack of studies reporting on telepsychiatry use in developing nations such as Asia and Africa, where it is best utilized to help bridge the currently low patient-to-mental health professional ratio. Furthermore, studies on its utilization in less technologically developed areas, with low literacy rates, as well as remote in location are also lacking in number.

Conclusions Various studies have pointed to telepsychiatry as an effective and efficient way to manage PTSD. The quality of care given by telepsychiatry, both through video conferencing and web- and application-based, is comparable to that of face-to-face therapy, although most studies published so far are from developed nations. Patient satisfaction and quality of doctor-patient relationship also remain high, with therapeutic time comparable to that of face-to-face therapy. Countries, especially those with a low patient-to-mental health professional ratio, should be encouraged to develop telepsychiatry systems to manage PTSD.

Disclosure No conflicts of interest publication of this article.

declared

concerning

the

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2018 [cited 2018 Sep 10]. http://www.bin.go.id/awas/ detil/458/4/20/07/2018/waspada-terhadap-pelecehan-seksualpada-anak-usia-dini 5. Republic of Indonesia, Indonesian National Police. National Criminal Information Center [online]. 2018 [cited 2018 Sep 10]. https://pusiknas.polri.go.id/kamtibmas.html 6. Republic of Indonesia, Ministry of Transportation. Transportation Statistics Book 1 Year 2017. Jakarta: Ministry of Transportation; 2017. 7. Chandra ZA. Pengaruh dukungan sosial keluarga terhadap kesembuhan penderita post traumatic stress disorder (PTSD) di pusat pelayanan terpadu (ppt) “mawar” rsud dr. fauziah bireuen tahun 2009 [thesis]. Medan: Universitas Sumatera Utara; 2009. 8. Erwina I. The influence of cognitive behavior therapy toward of post traumatic stress disorder on post earthquake population in air tawar barat urban village, north padang, west sumatera [thesis]. Depok: Universitas Indonesia; 2010. 9. Frankenberg E, Nobles J, Sumantri C. Community destruction and traumatic stress in post-tsunami Indonesia. J Health Soc Behav. 2012;53:498-514. 10. Sadock B, Sadock V. Kaplan and Sadock’s synopsis of psychiatry. 11th ed. Alphen aan den Rijn: Wolters Kluwer; 2014. 11. National Institute of Mental Health. National Institute of Mental Health | Post-Traumatic Stress Disorder (PTSD) [online]. [cited 2018 Oct 24]. http://www.nimh.nih.gov/health/topics/posttraumatic-stress-disorder-ptsd/index.shtml 12. Bomyea J, Lang AJ. Emerging interventions for PTSD: Future directions for clinical care and research. Neuropharmacology. 2012;62:607-16. 13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition. Arlington: American Psychiatric Association; 2013. 14. Central Java Provincial Research and Development Department. [Post traumatic stress disorder (post disaster traumatic stress disorder) in Central Java]. Semarang: Central Java Provincial Government; 2008. 15. Lubis FY, Dalimunthe KL. Impact of disaster event on student’s cognition achievement in SMAN 1 Pangalengan and SMA Aliyah Pangalengan, West Java, Indonesia. GSTF J Law Soc Sci. 2012;1:53-6. 16. Sebayang SK, Mawarpury M, Rosemary R. Jakarta Post [online]. 2018 [cited 2018 Oct 24]. https://www.thejakartapost.com/ academia/2018/11/06/less-than-1000-psychiatrists-for-260million-indonesians.html 17. World Health Organization. Telemedicine: Opportunities and developments in member states. Geneva: World Health Organization; 2010. 18. Solar Surya Indonesia. Solar Surya Indonesia [online]. 2013 [cited 2018 Oct 24]. http://solarsuryaindonesia.com/news/ mengintip-teknologi-mobil-tanggap-bencana-besutan-kominfo 19. InSight. Scheduled telepsychiatry services [online]. 2014 [cited 2018 October 24]. http://insighttelepsychiatry.com/scheduledtelepsychiatry-services-2/ 20. Vestal C. In rural SC, telepsychiatry cuts wait times for mental health exams from 4 days to 10 hours [online]. Medcity News. 2014 Jun 27 [cited 2018 Oct 24]. http://medcitynews.com/2014/06/ telepsychiatry-reduces-wait-times-psyciatric-exams-4-days-10hours-sc-hospital/ 21. World Health Organization. Global diffusion of eHealth: making universal health coverage achievable. Geneva: WHO/Global Observatory for eHealth; 2016. 22. Zafar A. International Telecommunication Union [online]. 2011 [cited 2018 Oct 24]. http://www.itu.int/ITU-D/ emergencytelecoms/events/Zimbabwe_2011/Applications%20 of%20telemedicine%20in%20Emergencies_Harare_2011_1.pdf 23. Germain V, Marchand A, Bouchard S, Drouin MS, Guay S. Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cogn Behav Ther. 2009;38:42-53. 24. O’Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? results from a randomized controlled equivalence trial. Psychiatric Serv. 2007;58:836-43.

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25. Wagner B, Schulz W, Knaevelsrud C. Efficacy of an Internet-based intervention for posttraumatic stress disorder in Iraq: A pilot study. Psychiatry Res. 2012;195:85-8. 26. Wagner B, Brand J, Schulz W, Knaevelsrud C. Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab war-traumatized patients. Depress Anxiety. 2012;29:646-51. 27. Knaevelsrud C, Maercker A. Long-term effects of an internetbased treatment for posttraumatic stress. Cogn Behav Ther. 2010;39:72-7. 28. Knaevelsrud C, Maercker A. Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry. 2007;7:13. 29. Kersting A, Dolemeyer R, Steinig J, Walter F, Kroker K, Baust K, et al. Brief Internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: A randomized controlled trial. Psychother Psychosom. 2013;82:372-81. 30. Klein B, Mitchell J, Abbott J, Shandley K, Austin D, Gilson K. A therapist-assisted cognitive behavior therapy internet intervention for posttraumatic stress disorder: Pre-, post- and 3-month followup results from an open trial. J Anxiety Disord. 2010;24:635-44. 31. Klein B, Mitchell J, Gilson K, Shandley K, Austin D, Kiropoulos L, et al. A therapist-assisted Internet-based CBT intervention for posttraumatic stress disorder: Preliminary results. Cogn Behav Ther. 2009;38:121-31. 32. Spence J, Titov N, Dear BF, Johnston L, Solley K, Lorian C, et al. Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder. Depress Anxiety. 2011;28:541-50. 33. Wang Z, Wang J, Maercker A. Chinese My Trauma Recovery, A web-based intervention for traumatized persons in two parallel samples: Randomized controlled trial. J Med Internet Res. 2013;15:e213. 34. Knaevelsrud C, Brand J, Lange A, Ruwaard J, Wagner B. Webbased psychotherapy for posttraumatic stress disorder in wartraumatized Arab patients: Randomized controlled trial. J Med Internet Res. 2015;17:e71. 35. Lange A, Rietdijk D, Hudcovicova M, van de Ven JP, Schrieken B, Emmelkamp PM. Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. J Consult Clin Psychol. 2003;71:901-9. 36. Engel CC, Litz B, Magruder KM, Harper E, Gore K, Stein N, et al. Delivery of self training and education for stressful situations (DESTRESS-PC): A randomized trial of nurse assisted online selfmanagement for PTSD in primary care. Gen Hosp Psychiatry. 2016;37:323-8. 37. Ivarsson D, Blom M, Hesser H, Carlbring P, Enderby P. Guided internet-delivered cognitive behavior therapy for post-traumatic: A randomized controlled trial. Internet Interventions. 2014;1:3340. 38. Malhotra S, Chakrabarti S, Shah R. Telepsychiatry: Promise, potential, and challenges. Indian J Psychiatry. 2013;55:3-11. 39. US Department of Veteran Affairs. US Department of Veteran Affairs [online]. 2016 [cited 2018 Oct 24]. http://www.ptsd. va.gov/public/materials/apps/PTSDCoach.asp 40. Norris AC. Essentials of Telemedicine and Telecare. West Sussex: John Wiley and Sons; 2002. 41. Ministry of Information and Technology Pakistan. Telemedicine: MoIT- Health Net [online]. 2008 [cited 2018 Oct 24]. http://www. telemedicine.pk/disaster%20management.html

Correspondence: Anthony Paulo Sunjaya Faculty of Medicine, Tarumanagara University Jl. Letjen S. Parman No. 1 11440 - Jakarta - Indonesia E-mail: anthony@doctors.web.id

Trends in Psychiatry and Psychotherapy

Corrigendum

http://dx.doi.org/10.1590/2237-6089-2020-4201 The authors of the article entitled “Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review” (doi: https://doi.org/10.1590/2237-6089-2019-0033), published in Trends in Psychiatry and Psychotherapy in ahead of print mode, have identified an error in the last author’s name: João Carlos Borges Appolinario should read Jose Carlos Appolinario. Below we present the correct version of the author byline: Stephanie Zakhour,1 Antonio E. Nardi,1 Michelle Levitan,1 Jose Carlos Appolinario1,2,3,4 And below the correct version of the Suggested citation: Suggested citation: Zakhour S, Nardi AE, Levitan M, Appolinario JC. Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review. Trends Psychiatry Psychother. 2020;00(0):000-000. http://dx.doi.org/10.1590/2237-6089-2019-0033

Trends Psychiatry Psychother. 2020;42(1):111.

APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 111-111

Trends in Psychiatry and Psychotherapy

Corrigendum

http://dx.doi.org/10.1590/2237-6089-2020-4202 The authors of the article entitled “HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo’s ‘Cracolândia’” (doi: https://dx.doi.org/10.1590/22376089-2018-0081), published in Trends in Psychiatry and Psychotherapy in ahead of print mode, have identified errors in the names of two authors: Michael G. McDonnel should read Michael G. McDonell, and André Miguel should read André C. Miguel. Below we present the correct version of the author byline: Ariadne Ribeiro,1,2,3 Alisson Trevizol,1,3 Oladunni Oluwoye,4 Sterling McPherson,5 Michael G. McDonell,4 Viviane Briese,1,2 André C. Miguel,1,3 Rosana C. Fratzinger,1,3 Ronaldo R. Laranjeira,1,3 Ana L. Alonso,1,3 Ana L. Karasin,1,3 Marcelo Ribeiro,1,2,3 Clarice S. Madruga1,3

And below the correct version of the Suggested citation: Suggested citation: Ribeiro A, Trevizol A, Oluwoye O, McPherson S, McDonell MG, Briese V, et al. HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo’s “Cracolândia.”. Trends Psychiatry Psychother. 2020;00(0):000-000. http:// dx.doi.org/10.1590/2237-6089-2018-0081

Also, the authors would like to include the following ORCID iD to Dr. André C. Miguel: https://orcid.org/0000-00033203-3889.

Trends Psychiatry Psychother. 2020;42(1):112.

APRS | CC-BY

Trends Psychiatry Psychother. 2020;42(1) – 112-112

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Trends - Volume 42 – Issue 1 – January-March 2020

Articles inside

Cross-cultural adaptation of the Brazilian version of the Questionnaire on Eating and Weight Patterns-5 (QEWP-5

Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review

Analysis of psychiatrists’ prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States