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Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review
Trends in Psychiatry and Psychotherapy
Review Article
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Anthony Paulo Sunjaya, 1
Arlends Chris, 1 Dewi Novianti 2
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 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
1 Faculty of Medicine, Tarumanagara University, Jakarta, Indonesia. 2 Department of Public Health and Family Medicine, Faculty of Medicine, Tarumanagara University, Jakarta, Indonesia. 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/10.1590/2237-6089- 2019-0024
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 one’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,
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.
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
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.
Results and discussion
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).
Pubmed 2003-2017 12 Citation(s) Elsevier Clinical Key 2003-2017 29 Citation(s)
Science Direct 2003-2017 49 Citation(s)
High Wire 2003-2017 0 Citation(s) ProQuest 2003-2017 35 Citation(s)
86 Non-Duplicate Citations Screened
Inclusion/Exclusion Criteria Applied
29 Articles Retrieved
Inclusion/Exclusion Criteria Applied
15 Articles Included 57 Articles Excluded After Title/Abstract Screen
14 Articles Excluded After Full Text Screen
Sample size varied across studies, ranging from 15 25 to 241 24 patients, with a follow-up duration ranging between 5 weeks 26 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
Ref. no.
23
Title
Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder
Table 1 - Summary of telepsychiatry studies included in the review
Author
Germain et al.
Country
Canada
Methodology
Design
RCT
Sample size
Face-to-face 31 patients vs. telepsychiatry 16 patients
Parameter compared
SCID-IV MPSS BDI
Result
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.
24
Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial O’Reilly et al. Canada
25
Efficacy of an Internetbased intervention for posttraumatic stress disorder in Iraq: a pilot study
Wagner et al. Germany
26
Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab wartraumatized patients
Wagner et al. Germany RCT Face-to-face 254 patients vs. telepsychiatry 241 patients BSI GSI CSQ
Pilot study Telepsychiatry 15 patients
PDS HSCL-25 Skala Quality of Life (EUROHIS)
RCT Telepsychiatry 55 patients
PDS and Working Alliance Inventory 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).
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).
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.
27
Long-term effects of an internet-based treatment for posttraumatic stress Knaevelsrud & Maercker Germany
28
Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial Knaevelsrud & Maercker Germany Follow up study after RCT 34 telepsychiatry patients 18 months post-therapy IES-R DASS
RCT
WLC 47 patients vs. telepsychiatry 49 patients IES-R SCL-90 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.
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
Ref. no.
29
Title
Brief Internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial
Author
Kersting et al.
Country
Germany
Table 1 (cont.)
Methodology
Design
RCT
Sample size
WLC 113 patients vs. telepsychiatry 115 patients
Parameter compared
IES-R SCL-90 Inventory of Complicated Grief
Result
Significantly better improvements in PTSD symptoms, grief, depression and anxiety in telepsychiatry group. Improvements persisted for 12 months post-therapy.
30
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 Open trial
31
A therapist-assisted Internet-based CBT intervention for posttraumatic stress disorder: preliminary results Klein et al. Australia
32
Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder Spence et al. Australia Open trial
RCT
33
34
35
Chinese My Trauma Recovery, a web-based intervention for traumatized persons in two parallel samples: randomized controlled trial
Wang et al.
China
Web-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients: randomized controlled trial Knaevelsrud et al. Iraq
Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet Lange et al. The Netherlands RCT
RCT
RCT
36
Delivery of self-training and education for stressful situations (DESTRESSPC): a randomized trial of nurse assisted online selfmanagement for PTSD in primary care Engel et al. United States of America RCT Telepsychiatry 22 patients
Telepsychiatry 16 patients
PTSD Scale MINI Anxiety Disorders Interview PCL IES-R DASS WHOQOLBREF TSQ TAQ
IES-R TAQ TSQ
WLC 21 patients vs. telepsychiatry 23 patients PCL
Telepsychiatry 183 patients
PDS SCL-90 CSE PCC SFI
WLC 80 patients vs. telepsychiatry 79 patients
PDS
WLC 32 patients vs. telepsychiatry 69 patients SCL-90
Face-to-face 37 patients vs. telepsychiatry 43 patients PCL
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.
Telepsychiatry only through e-mail. Therapy for 10 weeks. Significant improvements in PTSD symptoms, good patient-doctor relation. Improvement in PTSD symptoms reported.
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.
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.
Telepsychiatry for 45 minutes, twice weekly for 5 weeks. 62% cured from PTSD post-therapy (OR 74.19). Improvements remained 3 months post-therapy.
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.
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.
Ref. no.
37
Title
Guided internet-delivered cognitive behavior therapy for post-traumatic: a randomized controlled trial
Author
Ivarsson et al.
Country
Sweden
Table 1 (cont.)
Methodology
Design
RCT
Sample size
WLC 31 patients vs. telepsychiatry 31 patients
Parameter compared
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 months’ 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 areas 33 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,
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 month 33 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
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.
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 declared concerning the publication of this article.
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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.
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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
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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;1:33- 40. 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
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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 Appolinario 1,2,3,4
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.
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/10.1590/2237- 6089-2018-0081), 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. Madruga 1,3
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/0000-0003- 3203-3889.
Trends Psychiatry Psychother. 2020;42(1):112.
Instructions for authors
Updated March 2017
Aims and scope
Trends in Psychiatry and Psychotherapy is a peer-reviewed, multidisciplinary journal that assures rapid publication of current and original research papers and authoritative reviews produced by expert national and international bodies. The journal covers the broad spectrum of clinical psychiatry and basic science, with a focus on the interaction between experimental and clinical research. Other types of articles whose primary focus is to help translate fundamental discoveries from basic science into the reality of clinical psychiatric practice will also be considered (see types of articles accepted below). These may include papers on psychological processes and behavior, neuropsychology, psychopharmacology, clinical neuroscience, psychotherapy, and other areas of relevance to one or more aspects of psychopathology and psychiatry.
The journal is published quarterly and is the official scientific publication of Associação de Psiquiatria do Rio Grande do Sul (APRS, Brazil). The journal is fully open access (www.scielo.br/trends), and there are no publication fees. The journal’s manuscript submission web site is available at http://mc04.manuscriptcentral.com/trends-scielo. These instructions are based on the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals published by the International Committee of Medical Journal Editors (ICMJE).
Language
All manuscripts should be submitted in English. Only manuscripts written in clear and understandable language will be sent to peer review.
Peer review process
Manuscripts submitted to Trends in Psychiatry and Psychotherapy are initially screened for plagiarism (built-in tool available in the submission system) and evaluated with regard to conformity with the journal’s scope and editorial line. If the paper is in accordance with the journal’s editorial policies and with the present Instructions for Authors, it will be submitted to review by at least two reviewers selected by the editors; the reviewers remain anonymous throughout the review process. Within 60 days, the authors are informed of either the acceptance, rejection, or need for revisions in the article, as requested by the Editorial Board. A decision letter and the reviewers’ comments are emailed to the authors. Authors are requested to return revised manuscripts within 30 days and to provide a letter with detailed responses to each of the reviewers’ comments. Failure to re-submit the article within 30 days will cause the paper to be withdrawn from the submission system. Revised manuscripts are sent back to reviewers for reassessment. At this time, a new decision is made, for either the acceptance, rejection, or need for additional revisions. Based on the reviewers’ comments, the editors make the final decision.
Manuscript preparation
Types of articles accepted
1) Editorials: Critical and thorough comments written by the editors and/or invited authors with renowned experience in the topic being addressed. 2) Trends: Articles published in this section present criticism or address controversies in a trendy topic. These articles are generally invited, but interested contributors are encouraged to contact the Editor. 3) Original Articles: These articles present original research data and should contain all the necessary relevant information so as to enable the reader to repeat the experiment and evaluate results and conclusions. Original articles should include the following sections: Introduction, Method, Results, Discussion, Conclusion, and other subtitles, when necessary. The research should have been conducted in accordance with the Helsinki Declaration, and the authors should clearly describe, in the Methods section, the existence and use of an informed consent form, as well as approval
of the study protocol by the ethics committee of the institution where the study was carried out (or compliance with institutional and national standards for the care and use of laboratory animals, where applicable). These articles should be up to 4,500 words long and should contain no more than six tables or figures. These manuscripts should include a structured abstract with no more than 250 words and subtitles that reflect the text structure. 4) Brief Communications: Original but shorter manuscripts, with preliminary results or results of immediate relevance.
These communications should be up to 1,500 words long and should include only one table or figure. The text should be divided into the following sections: Introduction, Method, Results, and Discussion. These articles should contain a structured abstract with no more than 200 words and subtitles that reflect the text structure. 5) Review Articles: Systematic and updated reviews about issues considered to be relevant for the journal’s editorial line. These articles are aimed at reviewing and critically assessing the knowledge available on a specific topic, including comments on other authors’ studies. They should be up to 4,500 words long, and the number of tables and figures should not exceed a total of six. There is not a fixed text structure for these articles, but they should be accompanied by a structured abstract with no more than 250 words and subtitles that reflect the text structure. 6) Letters to the Editors: These are limited to comments on papers published in the journal. Texts should be brief, with no more than 500 words. Only one table and one figure are allowed.
Preparing the manuscript
1. General principles
The text of articles reporting original research should be divided into Introduction, Methods, Results, and Discussion sections, but subheadings within these sections may be needed to further organize their content. Other types of articles, such as meta-analyses, may require different formats, while narrative reviews and editorials may have less structured or unstructured formats. All pages should be numbered. Electronic formats have created opportunities for adding details or sections, layering information, cross-linking, or extracting portions of articles in electronic versions. Supplementary electronic-only material should be submitted and sent for peer review simultaneously with the primary manuscript.
2. Authorship and Acknowledgments
The ICMJE recommends that authorship be based on the following four criteria: □ Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND □ Drafting the work or revising it critically for important intellectual content; AND □ Final approval of the version to be published; AND □ Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
In addition to being accountable for the parts of the work he or she has done, an author should be able to identify which co-authors are responsible for specific other parts of the work. In addition, authors should have confidence in the integrity of the contributions of their co-authors. The corresponding author takes primary responsibility for communication with the journal during the manuscript submission, peer review, and publication process.
All those designated as authors should meet all four criteria for authorship, and all who meet the four criteria should be identified as authors. It is the collective responsibility of the authors to determine that all people named as authors meet all four criteria. Those who do not meet all four criteria should be acknowledged.
The Acknowledgments section should disclose any sources of financial support received by the study. In addition, this section should acknowledge people, groups or institutions which have made important contributions to the study but do not meet the criteria for authorship (e.g., technical assistance, statistical analysis, writing, etc.).
3. Reporting guidelines
Reporting guidelines have been developed for different study designs; examples include CONSORT for randomized trials, STROBE for observational studies, PRISMA for systematic reviews and meta-analyses, and STARD for studies of
diagnostic accuracy. Authors are encouraged to follow these guidelines. Moreover, authors of review manuscripts are encouraged to describe the methods used for locating, selecting, extracting, and synthesizing data; this is mandatory for systematic reviews.
Randomized clinical trials. Trends in Psychiatry and Psychotherapy will only accept for publication clinical trials that have been registered in Clinical Trials Registries. The registration number will be disclosed at the end of the abstract. In the text, whenever a registration number is available, authors should list that number the first time they use a trial acronym to refer to the trial they are reporting or to other trials that they mention in the manuscript.
4. Manuscript sections
The following are general requirements for reporting within sections of all study designs and manuscript formats.
Title Page
General information about an article and its authors is presented on a manuscript title page. This page should include the article title, author information, any disclaimers, sources of support, word count, and the number of tables and figures. Detailed instructions are provided below. 1) Article title. The title should provide a distilled description of the complete article and should include information that, along with the Abstract, will make electronic retrieval of the article sensitive and specific. Whenever deemed appropriate, information about the study design should be a part of the title (particularly important for randomized trials and systematic reviews and meta-analyses). 2) A short title of no more than 50 characters should be provided. 3) Author information should include full names typed exactly as they should appear in print, emails, and main affiliation(s). The name of the department(s) and institution(s) or organization(s) where the work should be attributed should be specified. 4) The corresponding author should be identified, and a full mailing address (including ZIP code), telephone and fax numbers, and an email address should be provided. 5) Source(s) of support. These include grants, equipment, drugs, and/or other support that facilitated conduct of the work described in the article or the writing of the article itself. Any relevant role of the funder in the study should be disclaimed. Studies that have received no financial support should indicate so. 6) Conflict of interest declaration. Conflict of interest information for each author needs to be part of the manuscript. A general statement should be included in the title page, attesting to the existence (or non-existence) of any conflicts of interest concerning the publication of the article. In addition, all authors are required to fill and submit an ICMJE conflict of interest disclosure form (one for each author) at the time of submission. 7) Articles based on academic theses or dissertations, or previously presented at scientific meetings, should disclose this on the title page. Please provide as many details as possible (e.g., the title of the original work, year, name of institution/venue/event, etc.). 8) A word count for the paper’s text, excluding the abstract, acknowledgments, tables, figure legends, and references, should be provided. 9) The date of the last literature review performed by the authors on the manuscript topic should be informed.
Abstract
Abstracts should be no longer than 250 words. The abstract should provide the context or background for the study and should state the study’s purpose, basic procedures (selection of study participants, settings, measurements, analytical methods), main findings (giving specific effect sizes and their statistical and clinical significance, if possible), and principal conclusions. It should emphasize new and important aspects of the study or observations, note important limitations, and not overinterpret findings. Because abstracts are the only substantive portion of the article indexed in many electronic databases, and the only portion many readers read, authors need to ensure that they accurately reflect the content of the article. For clinical trials, the clinical trial registration number will be disclosed at the end of the abstract.
Keywords
Following the abstract, three to six keywords should be provided in accordance with the Medical Subject Headings (MeSH, http://www.nlm.nih.gov/mesh/meshhome.html). If possible, a Brazilian Portuguese translation of the abstract
(resumo) and keywords (palavras-chave) should also be provided; in this case, the palavras-chave should be compliant with the DeCS database (DeCS – Descritores em Ciências da Saúde, http://decs.bvs.br/).
Statistical analysis
Describe statistical methods with enough detail to enable a knowledgeable reader with access to the original data to judge its appropriateness for the study and to verify the reported results. When possible, quantify findings and present them with appropriate indicators of measurement error or uncertainty (such as confidence intervals). Avoid relying solely on statistical hypothesis testing, such as p values, which fail to convey important information about effect size and precision of estimates. References for the design of the study and statistical methods should be to standard works when possible (with pages stated). Define statistical terms, abbreviations, and symbols. Specify the statistical software package and version used. Distinguish prespecified from exploratory analyses, including subgroup analyses.
For additional guidance on how to prepare each section of the main text, please refer to the Recommendations.
References
Authors should provide direct references to original research sources whenever possible. Although references to review articles can be an efficient way to guide readers to a body of literature, review articles do not always reflect original work accurately. On the other hand, extensive lists of references to original work on a topic can use excessive space. Do not use conference abstracts as references; they can be cited in the text, in parentheses. References to papers accepted but not yet published should be designated as “in press.” Information from manuscripts submitted but not accepted should be cited in the text as “unpublished observations” with written permission from the source. Avoid citing a “personal communication” unless it provides essential information not available from a public source, in which case the name of the person and date of communication should be cited in parentheses in the text. The accuracy of references is the responsibility of the authors.
References should be numbered consecutively in the order in which they are first mentioned in the text. Identify references in text, tables, and legends by superscript Arabic numerals. References cited only in tables or figure legends should be numbered in accordance with the sequence established by the first identification in the text of the particular table or figure.
References should be listed at the end of the article according to their order of citation in the text and should comply with the style set forth in the NLM’s International Committee of Medical Journal Editors (ICMJE) Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals: Sample References webpage. The titles of journals should be abbreviated according to the style used for MEDLINE (www.ncbi.nlm.nih.gov/nlmcatalog/journals). These resources are regularly updated as new media develop, and currently include guidance for print documents; unpublished material; audio and visual media; material on CD-ROM, DVD, or disk; and material on the Internet. Please consult published issues for style details. An EndNote style can also be downloaded from the Instructions & Forms section at our submission web site (http://mc04.manuscriptcentral.com/trends-scielo).
Journal article example: Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
Tables
Tables should complement, not duplicate information contained in the text. They should not exceed 30,000 characters (including spaces); larger tables may be considered if the authors justify their need. Tables should not be submitted as images, but should be created using specific word processor tools. Do not underline or draw lines inside the tables. Do not insert spaces to separate columns. Number tables consecutively in the order of their first citation in the text using Arabic numerals and supply a title for each.
Titles in tables should be short but self-explanatory, containing information that allows readers to understand the table’s content without having to go back to the text. Be sure that each table is cited in the text. Give each column a short or an abbreviated heading. Authors should place explanatory matter in footnotes, not in the heading. Explain all nonstandard abbreviations in footnotes, and use symbols to explain information if needed (*, †, ‡, §, ||, ¶, **, ††, etc.).
Identify statistical measures of variations, such as standard deviation and standard error of the mean. If you use data from another published or unpublished source, obtain permission and acknowledge that source fully.
Additional tables containing backup data too extensive to publish in print may be appropriate for publication in the electronic version of the journal, as supplementary online material, or made available to readers directly by the authors.
An appropriate statement should be added to the text to inform readers that this additional information is available and where it is located. Submit such tables for consideration with the paper so that they will be available to the peer reviewers.
Figures
Digital images of manuscript illustrations (all referred to as “Figure”) should be submitted in a suitable format for print publication (preferably .tif, with a minimum resolution of 300 dpi). Letters, numbers, and symbols on figures should be clear and consistent throughout, and large enough to remain legible when the figure is reduced for publication. Figures should be made as self-explanatory as possible. Titles and detailed explanations belong in the legends, not on the illustrations themselves.
Figures should be numbered consecutively according to the order in which they have been cited in the text. If a figure has been published previously, acknowledge the original source and submit written permission from the copyright holder to reproduce it. Permission is required irrespective of authorship or publisher except for documents in the public domain.
Photographs should not allow patient identification.
In the manuscript, legends for illustrations should be on a separate page, with Arabic numerals corresponding to the illustrations. When symbols, arrows, numbers, or letters are used to identify parts of the illustrations, identify and explain each one clearly in the legend.
5. Units of Measurement
Measurements of length, height, weight, and volume should be reported in metric units (meter, kilogram, or liter) or their decimal multiples. Temperatures should be in degrees Celsius. Blood pressures should be in millimeters of mercury.
6. Abbreviations and symbols
Use only standard abbreviations; use of nonstandard abbreviations can be confusing to readers. Avoid abbreviations in the title of the manuscript. The spelled-out abbreviation followed by the abbreviation in parenthesis should be use on first mention unless the abbreviation is a standard unit of measurement.
7. Drugs
Drugs should be referred to by their generic name only.
Submitting the manuscript
Manuscripts submitted to Trends in Psychiatry and Psychotherapy should not have been published elsewhere in whole or in part and should not have been or be submitted simultaneously for publication in any other journal(s). Previous presentation of the manuscript as abstract or poster at scientific meetings (conferences, workshops, etc.) is allowed, but should be informed on the title page.
Submissions to Trends should be made using the ScholarOne Manuscripts online system, available at http://mc04. manuscriptcentral.com/trends-scielo. Registration (login and password) is required on first access, prior to submission.
The submission system has several required fields and also some optional fields. One of the required fields is related to the indication of potential reviewers for the submitted manuscript. Authors should inform the name, email address and affiliation of five preferred reviewers, i.e., experts in the field who do not have conflicts of interest that may impede them from revising the authors’ work (for example, indicated reviewers should not be from the same institutions as authors).
The final decision on the reviewers assigned for each manuscript lies with the editors.
All manuscripts should be accompanied by ICMJE conflict of interest disclosure forms for each author. A cover letter including the following information is also recommended.
□A full statement to the editor about all submissions and previous reports that might be regarded as redundant publication of the same or very similar work. Any such work should be referred to specifically and referenced in the new paper. Copies of such material should be included with the submitted paper to help the editor address the situation. □ A statement of financial or other relationships that might lead to a conflict of interest, if that information is not included in the manuscript itself. □ A statement on authorship. It is the collective responsibility of the authors to determine that all people named as authors meet all authorship criteria. All authors should have read and approved the version submitted. □ Contact information for the corresponding author, if that information is not included in the manuscript itself.
The letter or form should give any additional information that may be helpful to the editor, such as the type or format of article that the manuscript represents. If the manuscript has been submitted previously to another journal, it is helpful to include the previous editor’s and reviewers’ comments with the submitted manuscript, along with the authors’ responses to those comments. Editors encourage authors to submit these previous communications. Doing so may expedite the review process and encourages transparency and sharing of expertise.
The manuscript must also be accompanied by permission to reproduce previously published material, use previously published illustrations, report information about identifiable persons, or to acknowledge people for their contributions.
For system support and information on the status of submitted manuscripts, please contact Denise Arend at trends. denise@gmail.com. For general information about the journal, please contact the editorial office at trends@aprs.org.br.
