BackgroundGreater homework adherence in cognitive behavioral therapy (CBT) is associated with positive treatment outcomes. However, the problems emerging from CBT homework use are common and affect adherence. In recent years, gamification has been explored to increase intervention adherence, but not yet in relation specifically to homework assignments. ObjectiveIn this study, the aim was to gain a better understanding of obstacles to CBT homework and the use of gamification to overcome these. MethodsConcept mapping, a method to organize related information visually, was used in this study. For the 1-day face-to-face concept mapping session, 7 therapists (32 to 55 y, 6 females) participated and generated items based on 2 focal questions of interest. The generated items were grouped on perceived similarity, and each individual item was rated on (1) severity and difficulty (focal question 1) and (2) importance, acceptance by therapist, and acceptance by patient (focal question 2). The item groups on perceived similarity were inserted into computer software. Based on multidimensional scaling and hierarchical cluster analyses, item clusters were generated by the computer software and were presented to the therapists. The therapists were asked for their preference for the number of items a cluster should contain. ResultsThrough brainstorming, the therapists collectively generated a list of 29 possible reasons for not doing homework by patients. In the same manner, a list of 38 game design elements that could help patients make CBT homework was generated. External factors (eg, no time due to crisis situations) and lack of motivation (eg, not aspiring to a therapy goal) were perceived as the most important reasons for patients not to do homework. External and symptoms-unrelated internal factors were considered by therapists as the most difficult for patients to change for improved homework adherence. The game design elements, facilitation, and rewards were rated as most important to help patients do homework. These elements were also seen as most accepted by therapists. ConclusionsFacilitation of doing homework and rewards seem to have the potential to tackle some of the external factors and lack of motivation to make CBT homework that patients could have. Conclusions were limited by the small number of participating therapists. Future research is needed on the effects of specific game design elements, the number of these elements, their combinations, and patients’ preferences.

Background Common mental disorders such as anxiety, depressive, and somatoform disorders often have a chronic course, with a substantial proportion of patients not responding adequately to standard treatments. Dysfunctional personality traits appear to contribute to treatment resistance. Schema therapy (ST) targets early maladaptive schemas and has proven effective for personality disorders. This pilot study examines the feasibility and outcome of group ST for non-responding patients with common mental disorders. Material and methods Seventy-nine outpatients with anxiety, obsessive-compulsive, depression, or somatoform disorders who had not responded sufficiently to prior treatment, participated in this study. A six-week ST introduction group was offered, followed by a diagnosis-specific ST group for up to 30 weeks. Feasibility was assessed through dropout rates and the Client Satisfaction Questionnaire (CSQ-8). Clinical outcomes were measured using the Beck Anxiety Inventory (BAI), the Patient Health Questionnaire (PHQ-9), and the World Health Organization Disability Assessment Schedule (WHODAS 2.0), before and after treatment and at three month follow up. Results Dropout rates were moderate, and participant satisfaction was high, indicating strong acceptability and engagement. Significant improvements were observed in anxiety, depression, and disability, with benefits persisting at 3 months after treatment. Limitations The non-controlled design limits causal conclusions. Also, mechanisms of change remain unclear. Although controlled for, high rates of missing data weaken the robustness of findings. Conclusions These findings suggest that group-ST may be a feasible and potentially effective treatment for non-responding patients and are consistent with prior evidence indicating that schema therapy could have broader applicability beyond personality disorders.

Background: To clarify the working mechanisms of psychotherapy for obsessive-compulsive disorder (OCD), we studied the neural effects of two psychotherapies: cognitive behavioral therapy with exposure and response prevention (CBT-ERP) and inference-based cognitive behavioral therapy (I-CBT). Methods: Fifty-five individuals with OCD completed an emotional processing task during fMRI before and after 20 weekly psychotherapy sessions, using general fear and OCD-related visual stimuli. Forty-two healthy controls performed the task once. We used Bayesian region-of-interest analyses to assess changes in brain activation in prefrontal, limbic, sensory, subcortical, and visual areas, and their association with symptom improvement. Results: After treatment, the CBT-ERP group (N=28) showed strong credible evidence for decreased activation across all brain regions during fear (but not OCD) versus neutral stimuli, especially in treatment responders. Conversely, the I-CBT group (N=27) showed increased activation during fear versus neutral stimuli in the precentral gyrus and lateral occipital cortex (LOC), which correlated with symptom improvement. A similar but weaker pattern was observed for OCD-related stimuli. Across all ROIs, baseline fear-related activity was associated with symptom improvement in CBT-ERP, while lower baseline activity was associated with improvement in I-CBT in, amongst others, the precentral gyrus and dorsolateral prefrontal cortex. Lower baseline LOC activation during OCD-related stimuli was linked to symptom improvement after both psychotherapies. Conclusions: The results support mechanism of action of CBT-ERP on fear reduction and of I-CBT on sensory engagement. Visual brain activity during emotional processing may predict treatment response across psychotherapies. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT03929081 ### Funding Statement This study was funded by ZonMW (Grant No. 636310004). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The ethics committee of VU Medical Center gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes According to European law (GDPR) data containing potentially identifying or sensitive patient information are restricted; our data involving clinical participants are therefore not freely available but are available from the corresponding author upon reasonable request.

BACKGROUND:To clarify the working mechanisms of psychotherapy for obsessive-compulsive disorder (OCD), we studied the neural effects of two psychotherapies: cognitive behavioral therapy with exposure and response prevention (CBT-ERP) and inference-based cognitive behavioral therapy (I-CBT). METHODS:Fifty-five individuals with OCD completed an emotional processing task during fMRI before and after 20 weekly psychotherapy sessions, using general fear and OCD-related visual stimuli. We used Bayesian region-of-interest analyses to assess changes in brain activation in prefrontal, limbic, sensory, subcortical, and visual areas, and their association with symptom reduction. RESULTS:After treatment, both the CBT-ERP (N = 28) and I-CBT group (N = 27) showed strong credible evidence for increased activation of the lateral occipital cortex (LOC) and decreased activation of, amongst others, the dorsolateral prefrontal cortex in both the fear and OCD contrast. Symptom reduction was associated with activity decreases after CBT-ERP, mainly in the OCD contrast. Symptom reduction was associated with increased activity in the I-CBT group, particularly in the medial prefrontal cortex. Across all ROIs, higher baseline fear-related activity was associated with symptom reduction in CBT-ERP, while lower baseline activity was associated with symptom reduction in I-CBT in the precentral gyrus and dorsolateral prefrontal cortex. Lower baseline LOC activation during OCD-related stimuli was linked to symptom reduction after both psychotherapies. CONCLUSIONS:CBT-ERP and I-CBT showed overlapping changes in brain activity after treatment, although these changes related to symptom reduction in opposite directions, suggesting the two treatments achieve their effects through distinct mechanisms. Visual brain activity during emotional processing may predict treatment response across psychotherapies.

Anxiety-related disorders (ARD), including posttraumatic stress disorder (PTSD) and obsessive–compulsive disorder (OCD), are highly prevalent mental health conditions. The peak prevalence of ARD in women coincides with the critical period of family planning, pregnancy, and child-rearing, affecting 1 in 5 women. This poses several challenges, including fears of passing anxiety on to children, worsening of symptoms during pregnancy or postpartum, and concerns about how therapy affects pregnancy outcomes. Clinicians frequently lack the expertise to adequately address these concerns. This may result in clinicians being cautious about starting treatment. This narrative review provides insights from the literature along with practical recommendations to facilitate decision-making with these challenges. This narrative review provides a review of existing literature on ARD and pregnancy, synthesizing key findings from relevant theoretical and empirical studies. Results show that ARD tend to cluster within families, driven by both genetic and environmental factors. During pregnancy and postpartum, ARD are particularly prevalent, and maternal anxiety is associated with an increased risk of preterm birth and low birth weight. Psychotherapy, including exposure therapy, is effective and is overall beneficial for pregnant women, although in specific cases, it can also worsen the anxiety, with no known adverse effects on pregnancy outcomes. SSRI use requires consideration of risks and benefits. Preventive strategies to reduce anxiety vulnerability in offspring are scarce. In conclusion, addressing ARD in (prospective) parents is essential, given the potential negative impact on both parents and children. Clinical awareness is needed to optimize care for this population.

BACKGROUND:Childhood trauma (CT) is robustly associated with suicide ideation (SI) and attempts (SA) in individuals with depressive and/or anxiety disorders. However, pathways underlying these associations and whether they differ between suicide ideation only (SI+SA-) and suicide ideation with attempt (SI+SA+) remain unclear. Variables that may statistically account for CT-SI+SA- and CT-SI+SA+ associations were examined. METHODS:Data from 1572 respondents with a 12-month depressive and/or anxiety disorder from the Netherlands Study of Depression and Anxiety were used. The NEMESIS childhood trauma interview (0-8 score) measured CT severity. Single and multiple-mediator models via generalized structural equation modeling (GSEM) were used to investigate whether psychosocial, personality, lifestyle and biological variables showed indirect associations consistent with mediation of the association between CT and suicide outcomes. RESULTS:Higher CT scores were associated with SI+SA- (OR = 1.51, 95% CI: 1.32-1.73) and SI+SA+ (OR = 2.68, 95% CI: 2.21-3.27). In single mediator models, personality traits, insomnia, low social support and loneliness statistically accounted for a part of the association between CT and both outcomes. Interleukin-6 statistically accounted for a small portion of the CT-SI+SA+ link. In multiple-mediator models, direct effects reduced by 65.6% (SI+SA-) and 39.1% (SI+SA+) and aggression, insomnia, social support (both outcomes), neuroticism, introversion, hopelessness (SI+SA-) and locus of control (SI+SA+) remained significant. LIMITATIONS:The cross-sectional design limits causal inferences. CONCLUSION:Multiple personality traits, insomnia and lower social support statistically accounted for a portion of the association between CT and suicide outcomes. Especially aggression, insomnia and social support may represent actionable suicide prevention targets, pending longitudinal validation.

BACKGROUND AND HYPOTHESIS:Patients on hemodialysis therapy often experience a high burden of mental and physical health symptoms. We developed a guided internet-based self-help problem-solving therapy (IPST) targeted on practical daily life issues. While we did not find an effect for all patients, we hypothesized that an internet intervention might be effective in younger patients below 65 years of age. In this post-hoc secondary subgroup analysis we divided our study population based on age to study the effect of our intervention on depressive- and dialysis-related symptoms. METHODS:Chronic hemodialysis patients with a depression score on the Beck Depression Inventory (BDI-II) of ≥10, were randomized into a five modules guided IPST or a care-as-usual control group. The study population was stratified by age (< 65 and ≥ 65 years). The primary outcome was depressive symptoms (BDI-II). Secondary outcomes were anxiety (BAI), health-related quality of life (HRQoL) and dialysis related symptoms (DSI). Analyses were performed using linear mixed models. RESULTS:122 out of 190 randomized patients completed post-intervention measurements. In 25 younger patients (age < 65), a significant effect was found in reduction of BDI-II (-30 %, p = 0.04) and DSI (presence of symptoms: -27 %, p = 0.001; level of distress: -25 %, p = 0.03). No effect was seen on BAI or HRQoL. In the older population (n = 29), no effect of the intervention was found on any outcomes. CONCLUSION:An easy to implement guided IPST showed a clinically relevant decrease in depressive symptoms and dialysis related physical symptoms in hemodialysis patients aged below 65 years although results should be interpreted cautiously given the post-hoc design. TRIAL REGISTRATION:Dutch Trial Register: Trial NL6648 (NTR6834) (prospectively registered 13th November 2017).

Background: Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment for obsessive-compulsive disorder (OCD). The neurobiological mechanisms of rTMS in OCD have been incompletely characterized. We compared clinical outcomes and changes in task-based brain activation following 3 different rTMS protocols, all combined with exposure and response prevention. Methods: In this 3-arm proof-of-concept randomized trial, 61 treatment-refractory adult patients with OCD received 16 sessions of rTMS immediately before exposure and response prevention over 8 weeks, with task-based functional magnetic resonance imaging scans and clinical assessments before and after treatment. Patients received high-frequency rTMS to the left dorsolateral prefrontal cortex (n = 19 [13 women/6 men]), high-frequency rTMS to the left presupplementary motor area (preSMA) (n = 23 [13 women/10 men]), or control rTMS to the vertex (n = 19 [13 women/6 men]). Changes in task-based functional magnetic resonance imaging activation before/after treatment were compared using both a Bayesian region of interest and a general linear model whole-brain approach. Results: Mean OCD symptom severity decreased significantly in all treatment groups (Delta = -10.836, p < .001, 95% CI -12.504 to -9.168), with no differences between groups. Response rate in the entire sample was 57.4%. The dorsolateral prefrontal cortex rTMS group showed decreased planning-related activation after treatment that was associated with greater symptom improvement. No group-level activation changes were observed for the preSMA and vertex rTMS groups. Participants in the preSMA group with greater symptom improvement showed decreased error-related activation, and symptom improvement in the vertex group was associated with increased inhibition-related activation. Conclusions: rTMS to preSMA and dorsolateral prefrontal cortex combined with exposure and response prevention led to activation decreases in targeted task networks in individuals showing greater symptom improvement, although we observed no differences in symptom reduction between groups.

Objective Traditional cognitive behavioral therapy (CBT) and inference-based CBT (I-CBT) are both effective interventions for obsessive-compulsive disorder (OCD). However, only about half of the patients seem to benefit sufficiently from these treatments. This study investigated whether pre-treatment anxiety and feared consequences (of not performing compulsions) predict OCD treatment outcome and whether these potential predictors have differential effects between CBT and I-CBT. Method Data from a previously completed randomized controlled trial were analyzed. A total of 197 patients were randomly assigned to CBT or I-CBT. The primary outcome was OCD symptom severity, assessed with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at posttreatment, 6-month and 12-month follow-up. Predictors included pre-treatment anxiety, using the Beck Anxiety Inventory (BAI), and feared consequences, using the Fixity of Belief Questionnaire (FBQ), both assessed at baseline. Linear mixed models analyses were performed while controlling for Y-BOCS baseline scores. Results Higher BAI scores and having no feared consequences did not significantly predict higher Y-BOCS scores, nor were the effects moderated by treatment condition. A substantial 40% of participants reported having no feared consequences. Discussion Pre-treatment anxiety severity and feared consequences did not predict worse treatment outcomes. These findings suggest that highly anxious patients and those without feared consequences of not performing their compulsions could benefit equally from both CBT and I-CBT.

The use of memory support strategies could help patients with major depressive disorder (MDD) to improve their memory for the content of therapy, leading to better treatment outcomes. Constructive memory support strategies prompt patients to construct new ideas. Non-constructive memory support strategies encourage the passive processing of therapy content. Building on previous work in a university setting, our goal was to investigate the effects of therapists’ natural use of memory support strategies in cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for MDD in routine clinical practice. In the context of a multicenter randomized trial, comparing once- versus twice weekly sessions of CBT and IPT for MDD in routine clinical practice, videos of therapy sessions from 75 patients during different phases of treatment (n = 67 between session 1–4, n = 59 between session 5–8, n = 56 between session 9–12) were rated on therapist use of memory support strategies and how the patient responded to the information given by the therapist (patient learning behavior). Hypotheses were investigated with mixed models. Memory support strategies were related to more patient learning behavior. Constructive memory support strategies were related to reduced depression in the next session, but not to recall or change in therapy skills or depression at the end of treatment. Memory support strategies might be beneficial in routine clinical practice in increasing patient learning behavior and reducing next session depression. Future studies should find out which strategy works for whom and whether a higher dose leads to change in depression over treatment.

BACKGROUND:Eating disorders (ED) are more prevalent in individuals with obsessive-compulsive disorder (OCD), and their co-occurrence is associated with higher symptom-severity, increased risk of additional comorbidities, including depression, and poorer treatment outcomes. However, little is known about the long-term course of OCD in patients with versus without comorbid ED. This study investigated the 6-year clinical course of OCD symptom-severity in patients with (OCD + ED) and without (OCD-ED) lifetime ED. METHODS:Within the Netherlands OCD Association (NOCDA) cohort, 382 participants with a DSM-IV OCD diagnosis were classified as OCD + ED (n = 46; 91 % women; mean age 34.5) or OCD-ED (n = 336; 52 % women; mean age 36.6). Lifetime ED diagnoses included anorexia nervosa (39 %) and binge-eating disorder (37 %). OCD and ED diagnoses, symptom severity, and clinical/demographic variables were assessed at baseline and after two, four, and six years. Linear mixed-effects models were used to examine group differences in OCD symptom trajectories. RESULTS:OCD + ED participants showed higher baseline obsessive-compulsive, depressive, and anxiety symptoms, and more comorbid posttraumatic stress disorder than OCD-ED patients. Despite these differences, both groups followed a comparable 6-year course of OCD symptom severity, with no significant between-group differences in symptom reduction. Y-BOCS scores decreased by 4.17 points in OCD-ED and 5.24 in OCD + ED; PADUA scores declined by 13.68 and 15.65 points, respectively. CONCLUSION:While OCD + ED patients showed a more significant clinical burden, comorbid ED did not significantly moderate long-term OCD symptom trajectories, suggesting a need for more intensive and/or longer treatment. The relatively small size of the OCD + ED group may be considered a limitation.

ObjectiveIn psychiatric disorders, lifestyle factors are known to influence both the development and course of the illness. However, little is known about the longitudinal relationship between lifestyle factors and OCD symptom severity, including the potential bidirectional, prospective association between them. This study examines both the contemporaneous and two-year prospective relationships between lifestyle factors and OCD symptom severity, as well as the reverse relationship—namely, the influence of OCD severity on lifestyle factors.MethodsLongitudinal data spanning six consecutive years were obtained from the Netherlands Obsessive Compulsive Disorder Association study (NOCDA). We examined the lifestyle factors: smoking, alcohol and illicit drug use, physical activity, and body mass index (BMI). Mixed models and Generalized Estimating Equations were employed to analyze the contemporaneous and bidirectional prospective relationships between these lifestyle factors and OCD severity.ResultsDrug and alcohol use, BMI, and physical activity did not exhibit a significant contemporaneous relationship with OCD severity. Smoking was significantly associated with more severe OCD symptoms: however depression influenced this relationship. Using alcohol was significantly associated with lower OCD severity. Among females, alcohol use was significantly associated with lower OCD severity two years later. Moderate and high levels of physical activity were significantly associated with lower OCD symptom severity two years later, whereas other lifestyle factors did not significantly predict future OCD symptom severity. OCD symptom severity did not predict any lifestyle factor, except among females, where higher OCD severity was associated with lower drug use two years later.ConclusionPrevious studies on other psychiatric disorders have found that unhealthy lifestyle factors are associated with more severe psychiatric symptoms. It appears that OCD might differ in these aspects. In the present study, drug and alcohol use, higher BMI, and a composite score of unhealthy lifestyle factors were not associated with more severe OCD symptoms and did not predict greater symptom severity two years later. However, consistent with findings in other psychiatric disorders, higher levels of physical activity were significantly associated with lower OCD symptom severity two years later. Further research is needed to determine whether increasing physical activity could result in less severe OCD symptoms.

BACKGROUND:Self-esteem is an important psychological concept that can be measured explicitly (reflective processing) and implicitly (associative processing). The current study examined 1) the association between childhood trauma (CT) and both explicit and implicit self-esteem, and 2) whether self-esteem mediated the association between CT and depression/anxiety. METHODS:In 1479 adult participants of the Netherlands Study of Depression and Anxiety, CT was assessed with a semi-structured interview, depression/anxiety symptoms with self-report questionnaires and explicit and implicit self-esteem with the Rosenberg Self-Esteem Scale and Implicit Association Test, respectively. ANOVAs and regression analyses determined the association between CT (no/mild/severe CT), its subtypes (abuse/neglect) and self-esteem. Finally, we examined whether self-esteem mediated the relationship between CT and depression/anxiety. RESULTS:Participants with CT reported lower explicit (but not lower implicit) self-esteem compared to those without CT (p < .001, partial η2 = 0.06). All CT types were associated with lower explicit self-esteem (p = .05 for sexual abuse, p < .001 for other CT types), while only emotional neglect significantly associated with lower implicit self-esteem after adjusting for sociodemographic characteristics (p = .03). Explicit self-esteem mediated the relationship between CT and depression/anxiety symptoms (proportion mediated = 48-77 %). LIMITATIONS:The cross-sectional design precludes from drawing firm conclusions about the direction of the proposed relationships. CONCLUSIONS:Our results suggested that the relationship between CT and depression/anxiety symptoms can at least partly be explained by explicit self-esteem. This is of clinical relevance as it points to explicit self-esteem as a potential relevant treatment target for people with CT.

Objective: To test a multifaceted treatment program for patients with obsessive-compulsive disorder (OCD) who did not respond to regular cognitive behavior therapy (CBT). The treatment addresses several factors that may play a role in maintaining OCD. Methods: We designed a treatment consisting of a 6-day intensive, individual exposure in vivo with response prevention (ERP) format, with 24 therapist-assisted treatment hours at the patient’s home and 12 self-controlled ERP hours, including behavioral activation and family interventions. Next, we investigated the effect (obsessive-compulsive symptoms, comorbidity, functioning, quality of life, OCD-related interaction patterns) and feasibility (dropout, treatment satisfaction, and organization) of this program using pre-post-tests, pre-follow-up tests, and qualitative data from patients, family members, and therapists. Results: In a sample of 22 participants, obsessive-compulsive symptoms (Y-BOCS pre: 28.7, post: 15.9; Wilcoxon S-R tests P<0.01) improved significantly, as did most other effect measures. Results were largely, but not completely, preserved at 3-month follow-up. There was only 1 dropout. Patients, family members, and therapists were satisfied with the treatment. Implementation of the treatment did not pose difficulties. Conclusions: In nonresponders with OCD, a multifaceted, brief, intensive home-based ERP program targeting factors maintaining OCD is promising and feasible. Extra care is needed to maintain improvement.

Mental disorders are common, crippling, and costly. Across mental disorders, insomnia is the most common complaint. Recent studies show that insomnia impedes overnight alleviation of emotional distress (Wassing, Benjamins, et al., 2019; Wassing, Lakbila-Kamal, et al., 2019). A meta-analysis of polysomnographic research in mental disorders suggested that sleep depth and rapid-eye movement (REM) variables may play a key role in psychiatric comorbidity (Baglioni et al., 2016). Indeed, insomnia may be the most important malleable transdiagnostic factor determining risk, severity, chronicity, and relapse of psychiatric disorders characterised by dysregulation of distress, affect, or emotion (Van Someren, 2021). Such disorders include depressive disorders, anxiety disorders, post-traumatic stress disorder (PTSD), and borderline personality disorder, together accounting for two-thirds of all psychiatric disorders. Strong benefits of treating co-occurring insomnia are shown for some disorders only (Hertenstein et al., 2022; Ho et al., 2016). Studies on depression, e.g., show that cognitive behavioural therapy for insomnia (CBT-I), strongly benefits recovery from major depressive disorder (MDD), and similar benefits have been reported for PTSD. However, insomnia has not been equally investigated in all psychiatric disorders characterised by dysregulated affect and emotion regulation. For instance, the effectiveness of CBT-I in anxiety disorders and borderline personality disorder is currently still being explored (Mason et al., 2022; Reesen et al., 2023; van Trigt et al., 2022). To date, few studies have transdiagnostically explored the co-occurrence of insomnia across multiple psychiatric dimensions at once. This is important because psychiatric disorders themselves more often than not occur comorbidly and which of the comorbid conditions links most strongly to insomnia is not known. We therefore conducted a cross-sectional online study and applied network analysis with the objective of mapping the relative frequency of insomnia in people with clinically relevant symptoms in one or more psychiatric domains of dysregulated affect and emotion regulation. This study offers a more complete transdiagnostic perspective on the relative presence of insomnia across psychiatric dimensions characterised by dysregulation of distress, affect, or emotion. Participants were recruited through a newsletter emailed to volunteers of the Netherlands Sleep Registry (www.slaapregister.nl), an online platform and database for extensive surveying of sleep, traits, life events, and health history. In all media communication to find registry volunteers, it is stressed that not only people with problems are welcome, but especially also normal and good sleepers, because ‘they have the key to the solution to understand and improve poor sleep’. The Netherlands Sleep Registry is not a population-based sample nor a fixed cohort; newsletter calls for participation usually attract more people recognising the topic of a study. The specific newsletter for the present study called for volunteers to participate in a study on mental wellbeing, with ‘stress’, ‘tension’ and ‘anxiety’ as examples. The only inclusion criterion was an age of ≥18 years. Thus, this study is not a prevalence study, but rather aimed to oversample people with common mental health issues—with or without sleep complaints. At their own convenience, participants completed the Insomnia Severity Index (ISI; Morin et al., 2011) to assess insomnia severity; the ultra-short version of the Borderline Personality Disorder Checklist (BPD-C; Wibbelink & Arntz, 2020) to assess the likely diagnostic presence of borderline personality disorder (BPD); and the Rapid Measurement Toolkit-20 (RMT20; Batterham et al., 2020) to assess the likely diagnostic presence of MDD, generalised anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), and PTSD. RMT20 items have been selected on their accuracy in assessing the disorders of interest. Indeed, validation in diagnosed people indicated that each of the disorders is recognised with excellent sensitivity (85%–93%) and specificity (73%–83%), outperforming previous diagnostic screeners (Batterham et al., 2020). A Dutch translation of the RMT20 was extensively validated for this study. For detailed information, see the Supporting Information (Data S1) section S1. Data were collected from March to June 2021 and the participants (n = 1496) had a mean (SD, range) age of 58 (13.1, 19–92) years. More participants were female (68.1%), compared to 31.7% males and 0.2% another gender. Our intentional oversampling approach succeeded in reaching a substantial number of participants that scored above the clinical cut-off for one or more psychiatric dimension (MDD, n = 258; GAD, n = 562; SAD, n = 273; PD, n = 171; PTSD, n = 319; BPD, n = 137). The large number of participants scoring above the clinical cut-off for the GAD dimension (n = 562) reflects its high comorbidity: previous work showed that the vast majority of people with GAD also have at least one other disorder (Wittchen et al., 1994). Occurrence of above-cut-off scores for more than one psychiatric dimension was high as well in our sample, indeed highest for GAD. In our reasonably-sized sample, our intentional oversampling of people with common mental health issues allowed for robust estimates of the frequency of co-occurring clinically relevant insomnia (ISI score ≥10), which was 96% in MDD, 90% in GAD, 93% in SAD, 93% in PD, 90% in PTSD, and 97% in BPD. While an ISI score cut-off of ≥10 may be optimal for detecting insomnia cases (Bastien et al., 2001), some prefer a more stringent cut-off (ISI score ≥15) for clinical insomnia (Bastien et al., 2001). Also, with this cut-off most participants with clinically significant symptoms in a psychiatric dimension had co-occurring clinical insomnia: 81% in MDD, 63% in GAD, 77% in SAD, 82% in PD, 68% in PTSD, and 84% in BPD. Table 1 shows an overview of the results. Can we disentangle direct and indirect links of insomnia with each of the individual psychiatric dimensions to insomnia? Network analysis (Figure 1, see the Supporting Information [Data S1] section S2 for details) revealed that the severity of insomnia was most directly linked to the severity of symptoms of MDD, GAD, and BPD, while the severity of symptoms of SAD, PD, and PTSD was no longer directly associated with insomnia severity when accounting for the severity of the other comorbidities. The finding was confirmed by stepwise multivariate linear regression. Thus, while insomnia is highly prevalent across all assessed psychiatric dimensions, for SAD, PD, and PTSD the link to insomnia, at least as assessed with the ISI, is more likely indirect and through comorbid MDD, GAD, and BPD symptoms. Our findings strengthen the need for transdiagnostic attention to insomnia across affective and emotion regulation disorders. Insomnia is still not systematically inquired about in all these patients, and should be, the more because its treatment may not only be effective to improve sleep, but also has secondary benefits. The first-line treatment for insomnia, CBT-I, strongly benefits recovery from MDD and PTSD (Hertenstein et al., 2022; Ho et al., 2016). Concertedly, these present and previous findings call for urgent transdiagnostic evaluation of possibly dual effectiveness of adding CBT-I in the treatment of any psychiatric disorder characterised by dysregulated affect and emotion regulation. It is even conceivable that the best strategy would be to intervene on insomnia prior to commencing with regular psychological treatment for specific psychiatric disorders (Reesen et al., 2023), as good sleep is crucial to the recovery of emotional distress (Wassing, Benjamins, et al., 2019) and essential for efficient learning of new cognitions and behaviours, which are the fundamental requirements to successful CBT treatments of mental disorders. Joyce E. Reesen: Writing – original draft; writing – review and editing; methodology; formal analysis; funding acquisition. A.W. Hoogendoorn: Writing – review and editing; methodology; formal analysis. J. Leerssen: Writing – review and editing; supervision; funding acquisition. Jaap Lancee: Writing – review and editing; supervision. Tessa F. Blanken: Writing – review and editing; methodology; formal analysis. Neeltje M. Batelaan: Writing – review and editing; supervision. P. van Oppen: Writing – review and editing. P.J. Batterham: Writing – review and editing. Eus J.W. van Someren: Funding acquisition; writing – review and editing; supervision. We thank O. Lakbila-Kamal, S. Mastenbroek and S. van Trigt for their contribution to the implementation of the survey. We would also like to thank H. van Marle for his contribution to the RMT20 item formulation. This work has received funding from ZonMw Leefstijlgeneeskunde, project 555003203 and ZonMw Open Competition, project 09120011910032. Joyce E. Reesen and Jeanne Leerssen have been supported by Vrije Universiteit Amsterdam University Research Fellowships. All authors declare that they have no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. Data S1.Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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OBJECTIVE:Interpersonal and social rhythm therapy (IPSRT) was developed to empower patients with mood disorders by stabilizing underlying disturbances in circadian rhythms and by using strategies from interpersonal psychotherapy. Group IPSRT has not been studied with a transdiagnostic sample of patients across the life span with either major depressive disorder or bipolar disorder.METHODS:Thirty-eight outpatients, ages 26-80, with major depressive disorder or bipolar disorder in any mood state were recruited from clinics in the Netherlands and were treated with 20 sessions (two per week) of group IPSRT. Recruitment results, dropout rates, and session adherence were used to assess feasibility. The modified Client Satisfaction Questionnaire (CSQ) and a feedback session were used to measure treatment acceptability. Changes in mood symptoms, quality of life, and mastery were also measured.RESULTS:Participants' mean±SD age was 65.4±10.0 years. Participants were diagnosed as having major depressive disorder (N=14, 37%) or bipolar disorder (N=24, 63%). The dropout rate was relatively low (N=9, 24%). High CSQ scores (32.3±5.2 of 44.0 points) and low dropout rates indicated the acceptability and feasibility of group IPSRT for major depressive disorder and bipolar disorder. Quality of life 3 months after completion of treatment was significantly higher than at baseline (p<0.01, Cohen's d=-0.69). No significant differences were found between pre- and postintervention depressive symptom scores.CONCLUSIONS:Twice-weekly group IPSRT for older outpatients with major depressive disorder or bipolar disorder was feasible and acceptable. Future research should evaluate the short- and long-term efficacy of group IPSRT for major depressive disorder and bipolar disorder among patients of all ages.

ABSTRACTBackgroundTaking patient preference into consideration has received increased attention in the last decades. We conducted a meta‐analysis to estimate the effects of patient preference on clinical outcome, satisfaction and adherence regarding treatment of depression and anxiety.MethodsPubmed, Embase, PsycINFO and Scopus were searched for (cluster) randomized controlled trials. Twenty‐six randomized controlled clinical trials were included, comprising 3670 participants, examining the effect of patient preference regarding treatment of anxiety and depression on clinical outcome, satisfaction and/or adherence.ResultsNo effect of patient preference was found on clinical outcome [d = 0.06, 95% CI = (−0.03, 0.15), p = 0.16, n = 23 studies]. A small effect of patient preference was found on treatment satisfaction [d = 0.33, 95% CI = (0.08, 0.59), p = 0.01, n = 6 studies] and on treatment adherence [OR = 1.55, 95% CI = (1.28, 1.87), p < 0.001, n = 22 studies].LimitationsPatient preference is a heterogeneous concept, future studies should strive to equalize operationalization of preference. Subgroup analyses within this study should be interpreted with caution because the amount of studies per analysed subgroup was generally low. Most studies included in this meta‐analysis focused on patients with depression. The small number of studies (n = 6) on satisfaction, prevents us from drawing firm conclusions.ConclusionsWhile this meta‐analysis did not find a positive effect of considering patient preference on clinical outcome, it was associated with slightly better treatment satisfaction and adherence. Accommodating preference of patients with anxiety and depression can improve treatment.Trial RegistrationPROSPERO: CRD42020172556

Background: The COVID-19 pandemic could be considered a 'symptom provocation test,' which may trigger specific OCD and other psychiatric symptoms. Therefore, we aimed to compare the long-term impact of the pandemic on fear of COVID-19, and contamination, depressive and anxiety symptoms in three groups: individuals with OCD with and without pre-pandemic contamination symptoms and healthy controls. Methods: From April 2020 to February 2022, we administered 16 online questionnaires on 138 persons with a lifetime diagnosis of OCD and 373 healthy controls. We evaluated outcomes related to fear of COVID-19, cleaning obsessions and compulsions, anxiety, and depressive symptoms. Using mixed models, we compared the trajectories among persons with OCD who had pre-pandemic contamination symptoms, those without such symptoms, and healthy controls. Results: Pre-pandemic contamination symptoms were significantly associated with higher fear of COVID-19, contamination symptoms, anxiety, and depressive symptoms. Persons with OCD without pre-pandemic contamination symptoms scored, on average, quite similarly to healthy controls. Conclusions: Only in persons with pre-pandemic contamination symptoms did the pandemic provoke more fear of COVID-19 and contamination symptoms than in controls. It seems that stress caused by external factors, does not tri trigger OCD symptoms unless there is a connection to the subtype of OCD.