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Abstract
The issue of placebo response and the extent of its effect on psychotherapy is complex for two specific reasons: i) Current standards for drug trials, e.g., true placebo interventions, double-blinding, cannot be applied to most psychotherapy techniques, and ii) some of the "nonspecific effects" in drug therapy have very specific effects in psychotherapy, such as the frequency and intensity of patient-therapist interaction. In addition, different psychotherapy approaches share many such specific effects (the "dodo bird verdict") and lack specificity with respect to therapy outcome. Here, we discuss the placebo effect in psychotherapy under four aspects: a) nonspecific factors shared with drug therapy (context factors); b) nonspecific factors shared among all psychotherapy traditions (common factors); c) specific placebo-controlled options with different psychotherapy modalities; and d) nonspecific control options for the specific placebo effect in psychotherapy. The resulting framework proposes that the exploration and enumeration of context factors, common factors, and specific factors contributes to the placebo effects in psychotherapy.
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Affiliation(s)
- Paul Enck
- Psychosomatic Medicine and Psychotherapy, Department of Internal Medicine VI, University Hospital Tübingen, Tübingen, Germany
| | - Stephan Zipfel
- Psychosomatic Medicine and Psychotherapy, Department of Internal Medicine VI, University Hospital Tübingen, Tübingen, Germany
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Gatchel RJ, Reuben DB, Dagenais S, Turk DC, Chou R, Hershey AD, Hicks GE, Licciardone JC, Horn SD. Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy. THE JOURNAL OF PAIN 2018; 19:837-851. [DOI: 10.1016/j.jpain.2018.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/16/2018] [Accepted: 02/22/2018] [Indexed: 01/13/2023]
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Purgato M, Gastaldon C, Papola D, van Ommeren M, Barbui C, Tol WA. Psychological therapies for the treatment of mental disorders in low- and middle-income countries affected by humanitarian crises. Cochrane Database Syst Rev 2018; 7:CD011849. [PMID: 29975811 PMCID: PMC6513488 DOI: 10.1002/14651858.cd011849.pub2] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND People living in humanitarian settings in low- and middle-income countries (LMICs) are exposed to a constellation of stressors that make them vulnerable to developing mental disorders. Mental disorders with a higher prevalence in these settings include post-traumatic stress disorder (PTSD) and major depressive, anxiety, somatoform (e.g. medically unexplained physical symptoms (MUPS)), and related disorders. A range of psychological therapies are used to manage symptoms of mental disorders in this population. OBJECTIVES To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (Wiley), MEDLINE (OVID), Embase (OVID), and PsycINFO (OVID), with results incorporated from searches to 3 February 2016. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing psychological therapies versus control conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) to treat adults and children with mental disorders living in LMICs affected by humanitarian crises. DATA COLLECTION AND ANALYSIS We used standard Cochrane procedures for collecting data and evaluating risk of bias. We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy); at medium term (one to four months after therapy); and at long term (six months or longer). GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) was used to assess the quality of evidence for post-traumatic stress disorder (PTSD), depression, anxiety and withdrawal outcomes. MAIN RESULTS We included 36 studies (33 RCTs) with a total of 3523 participants. Included studies were conducted in sub-Saharan Africa, the Middle East and North Africa, and Asia. Studies were implemented in response to armed conflicts; disasters triggered by natural hazards; and other types of humanitarian crises. Together, the 33 RCTs compared eight psychological treatments against a control comparator.Four studies included children and adolescents between 5 and 18 years of age. Three studies included mixed populations (two studies included participants between 12 and 25 years of age, and one study included participants between 16 and 65 years of age). Remaining studies included adult populations (18 years of age or older).Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). Psychological therapies were categorised mainly as cognitive-behavioural therapy (CBT) in 23 comparisons (including seven comparisons focused on narrative exposure therapy (NET), two focused on common elements treatment approach (CETA), and one focused on brief behavioural activation treatment (BA)); eye movement desensitisation and reprocessing (EMDR) in two comparisons; interpersonal psychotherapy (IPT) in three comparisons; thought field therapy (TFT) in three comparisons; and trauma or general supportive counselling in two comparisons. Although interventions were described under these categories, several psychotherapeutic elements were common to a range of therapies (i.e. psychoeducation, coping skills).In adults, psychological therapies may substantially reduce endpoint PTSD symptoms compared to control conditions (standardised mean difference (SMD) -1.07, 95% confidence interval (CI) -1.34 to -0.79; 1272 participants; 16 studies; low-quality evidence). The effect is smaller at one to four months (SMD -0.49, 95% CI -0.68 to -0.31; 1660 participants; 18 studies) and at six months (SMD -0.37, 95% CI -0.61 to -0.14; 400 participants; five studies). Psychological therapies may also substantially reduce endpoint depression symptoms compared to control conditions (SMD -0.86, 95% CI -1.06 to -0.67; 1254 participants; 14 studies; low-quality evidence). Similar to PTSD symptoms, follow-up data at one to four months showed a smaller effect on depression (SMD -0.42, 95% CI -0.63 to -0.21; 1386 participants; 16 studies). Psychological therapies may moderately reduce anxiety at endpoint (SMD -0.74, 95% CI -0.98 to -0.49; 694 participants; five studies; low-quality evidence) and at one to four months' follow-up after treatment (SMD -0.53, 95% CI -0.66 to -0.39; 969 participants; seven studies). Dropout rates are probably similar between study conditions (19.5% with control versus 19.1% with psychological therapy (RR 0.98 95% CI 0.82 to 1.16; 2930 participants; 23 studies, moderate quality evidence)).In children and adolescents, we found very low quality evidence for lower endpoint PTSD symptoms scores in psychotherapy conditions (CBT) compared to control conditions, although the confidence interval is wide (SMD -1.56, 95% CI -3.13 to 0.01; 130 participants; three studies;). No RCTs provided data on major depression or anxiety in children. The effect on withdrawal was uncertain (RR 1.87 95% CI 0.47 to 7.47; 138 participants; 3 studies, low quality evidence).We did not identify any studies that evaluated psychological treatments on (symptoms of) somatoform disorders or MUPS in LMIC humanitarian settings. AUTHORS' CONCLUSIONS There is low quality evidence that psychological therapies have large or moderate effects in reducing PTSD, depressive, and anxiety symptoms in adults living in humanitarian settings in LMICs. By one to four month and six month follow-up assessments treatment effects were smaller. Fewer trials were focused on children and adolescents and they provide very low quality evidence of a beneficial effect of psychological therapies in reducing PTSD symptoms at endpoint. Confidence in these findings is influenced by the risk of bias in the studies and by substantial levels of heterogeneity. More research evidence is needed, particularly for children and adolescents over longer periods of follow-up.
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Affiliation(s)
- Marianna Purgato
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryPiazzale LA Scuro 10VeronaItaly37134
- University of VeronaCochrane Global Mental HealthVeronaItaly
| | - Chiara Gastaldon
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryPiazzale LA Scuro 10VeronaItaly37134
- University of VeronaCochrane Global Mental HealthVeronaItaly
| | - Davide Papola
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryPiazzale LA Scuro 10VeronaItaly37134
- University of VeronaCochrane Global Mental HealthVeronaItaly
| | - Mark van Ommeren
- World Health OrganizationDepartment of Mental Health and Substance AbuseAvenue AppiaGenevaSwitzerlandCH‐1211
| | - Corrado Barbui
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryPiazzale LA Scuro 10VeronaItaly37134
- University of VeronaCochrane Global Mental HealthVeronaItaly
| | - Wietse A Tol
- Johns Hopkins Bloomberg School of Public HealthDepartment of Mental Health624 N BroadwayHampton HouseBaltimoreMarylandUSA
- HealthRight InternationalPeter C. Alderman Program for Global Mental HealthNew YorkUSA
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Lorenzo-Luaces L, Zimmerman M, Cuijpers P. Are studies of psychotherapies for depression more or less generalizable than studies of antidepressants? J Affect Disord 2018. [PMID: 29522947 DOI: 10.1016/j.jad.2018.02.066] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The generalizability of findings from studies exploring the efficacy of psychotherapy and antidepressants has been called into question in part because studies exclude many patients. Despite this, the frequency with which psychotherapy and antidepressant studies use specific inclusion and exclusion criteria has never been compared. We explored the exclusion criteria used in psychotherapy and pharmacotherapy studies from 1995 to 2014. METHOD Systematic literature searches were conducted in PubMed, Medline, PsycINFO, and Embase of published randomized controlled trials (RCTs) of the treatment of major depressive disorder (MDD) in adults with either antidepressants (vs. placebos) or psychotherapy (vs. placebos, treatments as usual, or other controls). RESULTS Most psychotherapy (81%) and antidepressant (100%) trials excluded patients with milder symptoms as well as patients with elevated suicidal risk (56-75%), psychotic symptoms (84-88%), or substance misuse (75-81%). Psychotherapy studies were less likely to exclude patients on the basis of brief episode duration (0% vs. 48%) and co-morbid Axis I disorders (6% vs. 27%). However, psychotherapy studies excluded patients with more severe symptoms more frequently (38%) than antidepressant studies (8%). CONCLUSIONS Overall, psychotherapy studies appear somewhat more inclusive than antidepressant studies. On average, antidepressant studies appear to target patients with more chronic and severe, as well as more purely depressive presentations.
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Affiliation(s)
- Lorenzo Lorenzo-Luaces
- Indiana University, Department of Psychological and Brain Sciences, 1101 E 10th St, Bloomington, IN 47405, United States.
| | - Mark Zimmerman
- Brown University School of Medicine, Department of Psychiatry and Human Behavior, United States
| | - Pim Cuijpers
- VU University Amsterdam, Department of Clinical, Neuro, and Developmental Psychology, The Netherlands
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Abstract
BACKGROUND Couple therapy for depression has the twofold aim of modifying negative interaction patterns and increasing mutually supportive aspects of intimate relationships, changing the interpersonal context of depression. Couple therapy is included in several guidelines among the suggested treatments for depression. OBJECTIVES 1. The main objective was to examine the effects of couple therapy compared to individual psychotherapy for depression.2. Secondary objectives were to examine the effects of couple therapy compared to drug therapy and no/minimal treatment for depression. SEARCH METHODS The Cochrane Common Mental Disorders Group Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) and PsycINFO (Ovid) were searched to 19 February 2018. Relevant journals and reference lists were checked. SELECTION CRITERIA Randomised and quasi-randomised controlled trials examining the effects of couple therapy versus individual psychotherapy, drug therapy, or no treatment/minimal treatment for depression were included in the review. DATA COLLECTION AND ANALYSIS We considered as primary outcomes the depressive symptom level, the depression persistence, and the dropouts; the relationship distress level was a secondary outcome. We extracted data using a standardised spreadsheet. Where data were not included in published papers, we tried to obtain the data from the authors. We synthesised data using Review Manager software version 5.3. We pooled dichotomous data using the relative risk (RR), and continuous data calculating the standardised mean difference (SMD), together with 95% confidence intervals (CIs). We employed the random-effects model for all comparisons and also calculated a formal test for heterogeneity, the natural approximate Chi2 test. MAIN RESULTS We included fourteen studies from Europe, North America, and Israel, with 651 participants. Eighty per cent of participants were Caucasian. Therefore, the findings cannot be considered as applicable to non-Western countries or to other ethnic groups in Western countries. On average, participants had moderate depression, preventing the extension of results to severely depressed patients. Almost all participants were aged between 36 and 47 years.There was no evidence of difference in effect at the end of treatment between couple therapy and individual psychotherapy, either for the continuous outcome of depressive symptoms, based on nine studies with 304 participants (SMD -0.17, 95% CI -0.44 to 0.10, low-quality evidence), or the proportion of participants remaining depressed, based on six studies with 237 participants (RR 0.94, 95% CI 0.72 to 1.22, low-quality evidence). Findings from studies with 6-month or longer follow-up confirmed the lack of difference between the two conditions.No trial gave information on harmful effects. However, we considered rates of treatment discontinuation for any reason as a proxy indicator of adverse outcomes. There was no evidence of difference for dropout rates between couple therapy and individual psychotherapy, based on eight studies with 316 participants (RR 0.85, 95% CI 0.51 to 1.41, low-quality evidence).Few data were available for the comparison with drug therapy. Data from a small study with 12 participants showed no difference for the continuous outcome of depressive symptoms at end of treatment (SMD -0.51, 95% CI -1.69 to 0.66, very low-quality evidence) and at 6-month follow-up (SMD -1.07, 95% CI -2.45 to 0.31, very low-quality evidence). Data on dropouts from two studies with 95 participants showed a clear advantage for couple therapy (RR 0.31, 95% CI 0.15 to 0.61, very low-quality evidence). However, this finding was heavily influenced by a single study, probably affected by a selection bias favouring couple therapy.The comparison between couple therapy plus drug therapy and drug therapy alone showed no difference in depressive symptom level, based on two studies with 34 participants (SMD -1.04, 95% CI -3.97 to 1.89, very low-quality evidence) and on dropouts, based on two studies with 45 participants (RR 1.03, 95% CI 0.07 to 15.52, very low-quality evidence).The comparison with no/minimal treatment showed a large significant effect favouring couple therapy both for depressive symptom level, based on three studies with 90 participants: (SMD -0.95, 95% CI -1.59 to -0.32, very low-quality evidence) and persistence of depression, based on two studies with 65 participants (RR 0.48, 95% CI 0.32 to 0.70, very low-quality evidence). No data were available for dropouts for this comparison.Concerning relationship distress, the comparison with individual psychotherapy showed that couple therapy appeared more effective in reducing distress level at the end of treatment, based on six studies with 187 participants (SMD -0.50, CI -0.97 to -0.02, very low-quality evidence) and the persistence of distress, based on two studies with 81 participants (RR 0.71, 95% CI 0.51 to 0.98, very low-quality evidence). The quality of evidence was heavily affected by substantial heterogeneity (I2 = 59%). In the analysis restricted to studies including only distressed couples, no heterogeneity was found and the effect in distress level at the end of treatment was larger (SMD -1.10, 95% CI -1.59 to -0.61). Very few data on this outcome were available for other comparisons.We assessed the certainty of the evidence using the GRADE system. The results were weakened by the low quality of evidence related to the effects on depressive symptoms, in comparison with individual psychotherapy, and by very low quality evidence for all other comparisons and for the effects on relationship distress. Most studies were affected by problems such as the small number of cases, performance bias, assessment bias due to the non-blinding outcome assessment, incomplete outcome reporting and the allegiance bias of investigators. Heterogeneity was, in particular, a problem for data about relationship distress. AUTHORS' CONCLUSIONS Although there is suggestion that couple therapy is as effective as individual psychotherapy in improving depressive symptoms and more effective in improving relations in distressed couples, the low or very low quality of the evidence seriously limits the possibility of drawing firm conclusions. Very few data were available for comparisons with no/minimal treatment and drug therapy. Future trials of high quality should test in large samples with a long follow-up of the effects of couple therapy in comparison to other interventions in discordant couples with a depressed partner, considering the role of relationship quality as a potential effect mediator in the improvement of depression.
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Affiliation(s)
- Angelo Barbato
- IRCCS‐Istituto di Ricerche Farmacologiche Mario NegriUnit for quality of care and rights promotion in mental health, Department of NeuroscienceVia La Masa 19MilanoItaly20156
| | - Barbara D'Avanzo
- IRCCS‐Istituto di Ricerche Farmacologiche Mario NegriUnit for quality of care and rights promotion in mental health, Department of NeuroscienceVia La Masa 19MilanoItaly20156
| | - Alberto Parabiaghi
- IRCCS‐Istituto di Ricerche Farmacologiche Mario NegriUnit for quality of care and rights promotion in mental health, Department of NeuroscienceVia La Masa 19MilanoItaly20156
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Bekhuis E, Schoevers R, de Boer M, Peen J, Dekker J, Van H, Boschloo L. Symptom-Specific Effects of Psychotherapy versus Combined Therapy in the Treatment of Mild to Moderate Depression: A Network Approach. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:121-123. [PMID: 29495015 PMCID: PMC5969070 DOI: 10.1159/000486793] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/16/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Ella Bekhuis
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands,*Ella Bekhuis, Department of Psychiatry, University Medical Center Groningen, PO Box 30.001, NL-9700 RB Groningen (The Netherlands), E-Mail
| | - Robert Schoevers
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marrit de Boer
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap Peen
- Research Department, Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Jack Dekker
- Research Department, Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Henricus Van
- Research Department, Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Lynn Boschloo
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Holmes EA, Ghaderi A, Harmer CJ, Ramchandani PG, Cuijpers P, Morrison AP, Roiser JP, Bockting CLH, O'Connor RC, Shafran R, Moulds ML, Craske MG. The Lancet Psychiatry Commission on psychological treatments research in tomorrow's science. Lancet Psychiatry 2018; 5:237-286. [PMID: 29482764 DOI: 10.1016/s2215-0366(17)30513-8] [Citation(s) in RCA: 323] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 11/10/2017] [Accepted: 11/24/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Emily A Holmes
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Ata Ghaderi
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Catherine J Harmer
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Trust Foundation, Warneford Hospital, Oxford, UK
| | | | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Heath Trust, Manchester, UK; School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Jonathan P Roiser
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Claudi L H Bockting
- Academic Medical Center, Department of Psychiatry, University of Amsterdam, Amsterdam, Netherlands
| | - Rory C O'Connor
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Roz Shafran
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Michelle L Moulds
- School of Psychology, The University of New South Wales, UNSW, Sydney, NSW, Australia
| | - Michelle G Craske
- Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
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Hartogs BM, Bartels-Velthuis AA, Van der Ploeg K, Bos EH. Heart Rate Variability Biofeedback Stress Relief Program for Depression. Methods Inf Med 2018; 56:419-426. [DOI: 10.3414/me16-02-0033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
SummaryBackground: Depressive disorders often have a chronic course and the efficacy of evidence-based treatments may be overestimated.Objective: To examine the effectiveness of the Heart Rate Variability Stress Reduction Program (SRP) as a supplement to standard treatment in patients with depressive disorders.Methods: The SRP was individually administered in eight weekly sessions. Seven participants completed the full protocol and were enrolled in a single-subject ABA multiple baseline experimental design. To perform interrupted time-series analyses, daily measures were completed in a diary (depression, resilience, happiness, heart coherence and a personalized outcome measure).Results: Five out of seven patients improved in depressed mood and/or a personalized outcome measure. The effect of treatment was reversed in four patients during the withdrawal phase. One patient reliably improved on depression, whereas two patients recovered on autonomy and one on social optimism. No consistent relationship was found between the heart rate variability-related level of coherence and self-reported mood levels.Conclusions: The SRP is beneficial in some domains and for some patients. A prolonged treatment or continued home practice may be required for enduring effects. The intervention had more clinical impact on resilience-related outcome measures than on symptoms. The small sample size does not permit generalization of the results. We recommend future investigation of the underlying mechanisms of the SRP.
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Kline AC, Cooper AA, Rytwinksi NK, Feeny NC. Long-term efficacy of psychotherapy for posttraumatic stress disorder: A meta-analysis of randomized controlled trials. Clin Psychol Rev 2017; 59:30-40. [PMID: 29169664 DOI: 10.1016/j.cpr.2017.10.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/18/2017] [Accepted: 10/24/2017] [Indexed: 11/25/2022]
Abstract
Psychotherapies are well established as efficacious acute interventions for posttraumatic stress disorder (PTSD). However, the long-term efficacy of such interventions and the maintenance of gains following termination is less understood. This meta-analysis evaluated enduring effects of psychotherapy for PTSD in randomized controlled trials (RCTs) with long-term follow-ups (LTFUs) of at least six months duration. Analyses included 32 PTSD trials involving 72 treatment conditions (N=2935). Effect sizes were significantly larger for active psychotherapy conditions relative to control conditions for the period from pretreatment to LTFU, but not posttreatment to LTFU. All active interventions demonstrated long-term efficacy. Pretreatment to LTFU effect sizes did not significantly differ among treatment types. Exposure-based treatments demonstrated stronger effects in the posttreatment to LTFU period (d=0.27) compared to other interventions (p=0.005). Among active conditions, LTFU effect sizes were not significantly linked to trauma type, population type, or intended duration of treatment, but were strongly tied to acute dropout as well as whether studies included all randomized patients in follow-up analyses. Findings provide encouraging implications regarding the long-term efficacy of interventions and the durability of symptom reduction, but must be interpreted in parallel with methodological considerations and study characteristics of RCTs.
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Affiliation(s)
- Alexander C Kline
- PTSD Treatment and Research Program, Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, OH 44106-7123, USA.
| | - Andrew A Cooper
- PTSD Treatment and Research Program, Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, OH 44106-7123, USA
| | - Nina K Rytwinksi
- Walsh University, School of Behavioral and Health Sciences, 2020 East Maple St., North Canton, OH, USA, 44720
| | - Norah C Feeny
- PTSD Treatment and Research Program, Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, OH 44106-7123, USA
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Mantani A, Kato T, Furukawa TA, Horikoshi M, Imai H, Hiroe T, Chino B, Funayama T, Yonemoto N, Zhou Q, Kawanishi N. Smartphone Cognitive Behavioral Therapy as an Adjunct to Pharmacotherapy for Refractory Depression: Randomized Controlled Trial. J Med Internet Res 2017; 19:e373. [PMID: 29101095 PMCID: PMC5695656 DOI: 10.2196/jmir.8602] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 09/02/2017] [Accepted: 09/23/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the treatment of major depression, antidepressants are effective but not curative. Cognitive behavioral therapy (CBT) is also effective, alone or in combination with pharmacotherapy, but accessibility is a problem. OBJECTIVE The aim is to evaluate the effectiveness of a smartphone CBT app as adjunctive therapy among patients with antidepressant-resistant major depression. METHODS A multisite, assessor-masked, parallel-group randomized controlled trial was conducted in 20 psychiatric clinics and hospitals in Japan. Participants were eligible if they had a primary diagnosis of major depression and were antidepressant-refractory after taking one or more antidepressants at an adequate dosage for four or more weeks. After a 1-week run-in in which participants started the medication switch and had access to the welcome session of the app, patients were randomized to medication switch alone or to medication switch plus smartphone CBT app via the centralized Web system. The smartphone app, called Kokoro-app ("kokoro" means "mind" in Japanese), included sessions on self-monitoring, behavioral activation, and cognitive restructuring presented by cartoon characters. The primary outcome was depression severity as assessed by masked telephone assessors with the Patient Health Questionnaire-9 (PHQ-9) at week 9. The secondary outcomes included the Beck Depression Inventory-II (BDI-II) and Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER). RESULTS In the total sample (N=164), 81 participants were allocated to the smartphone CBT in addition to medication change and 83 to medication change alone. In the former group, all but one participant (80/81, 99%) completed at least half, and 71 (88%) completed at least six of eight sessions. In the intention-to-treat analysis, patients allocated the CBT app scored 2.48 points (95% CI 1.23-3.72, P<.001; standardized mean difference 0.40) lower on PHQ-9 than the control at week 9. The former group also scored 4.1 points (95% CI 1.5-6.6, P=.002) lower on BDI-II and 0.76 points (95% CI -0.05 to 1.58, P=.07) lower on FIBSER. In the per-protocol sample (comfortable with the smartphone app, still symptomatic, and adherent to medication with mild or less side effects after run-in), the intervention group (n=60) scored 1.72 points (95% CI 0.25-3.18, P=.02) lower on PHQ-9, 3.2 points (95% CI -0.01 to 6.3, P=.05) lower on BDI-II, and 0.75 points (95% CI 0.03-1.47, P=.04) lower on FIBSER than the control (n=57). The treatment benefits were maintained up to week 17. CONCLUSIONS This is the first study to demonstrate the effectiveness of a smartphone CBT in the treatment of clinically diagnosed depression. Given the merits of the mobile mental health intervention, including accessibility, affordability, quality control, and effectiveness, it is clinically worthwhile to consider adjunctive use of a smartphone CBT app when treating patients with antidepressant-resistant depression. Research into its effectiveness in wider clinical contexts is warranted. TRIAL REGISTRATION Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik).
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Affiliation(s)
| | | | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Hissei Imai
- Department of Health Promotion and Human Behavior, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | | | | | - Naohiro Yonemoto
- Department of Biostatistics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Qi Zhou
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nao Kawanishi
- Advanced Telecommunications Research Institute International, Kyoto, Japan
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Time to remission from mild to moderate depressive symptoms: One year results from the EVIDENT-study, an RCT of an internet intervention for depression. Behav Res Ther 2017; 97:154-162. [DOI: 10.1016/j.brat.2017.07.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/24/2022]
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Cuijpers P, Gentili C. Psychological treatments are as effective as pharmacotherapies in the treatment of adult depression: a summary from Randomized Clinical Trials and neuroscience evidence. ACTA ACUST UNITED AC 2017; 20:273. [PMID: 32913741 PMCID: PMC7451304 DOI: 10.4081/ripppo.2017.273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Claudio Gentili
- Department of General Psychology, University of Padua, Italy
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Bernecker SL, Coyne AE, Constantino MJ, Ravitz P. For whom does interpersonal psychotherapy work? A systematic review. Clin Psychol Rev 2017; 56:82-93. [PMID: 28710917 DOI: 10.1016/j.cpr.2017.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 06/08/2017] [Accepted: 07/03/2017] [Indexed: 12/11/2022]
Abstract
The efficacy of interpersonal psychotherapy (IPT) to treat depression and other disorders is well established, yet it remains unknown which patients will benefit more from IPT than another treatment. This review summarizes 46years of clinical trial research on patient characteristics that moderate the relative efficacy of IPT vs. different treatments. Across 57 studies from 33 trials comparing IPT to pharmacotherapy, another psychotherapy, or control, there were few consistent indicators of when IPT would be more or less effective than another treatment. However, IPT may be superior to school counseling for adolescents with elevated interpersonal conflict, and to minimal controls for patients with severe depression. Cognitive-behavioral therapy may outpace IPT for patients with avoidant personality disorder symptoms. There was some preliminary evidence that IPT is more beneficial than alternatives for patients in some age groups, African-American patients, and patients in an index episode of depression. The included studies suffered from several limitations and high risk of Type I and II error. Obstacles that may explain the difficulty in identifying consistent moderators, including low statistical power and heterogeneity in samples and treatments, are discussed. Possible remedies include within-subjects designs, manipulation of single treatment ingredients, and strategies for increasing power such as improving measurement.
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Affiliation(s)
- Samantha L Bernecker
- Department of Psychological and Brain Sciences, University of Massachusetts, Tobin Hall, 135 Hicks Way, Amherst, MA 01003-9271, USA.
| | - Alice E Coyne
- Department of Psychological and Brain Sciences, University of Massachusetts, Tobin Hall, 135 Hicks Way, Amherst, MA 01003-9271, USA.
| | - Michael J Constantino
- Department of Psychological and Brain Sciences, University of Massachusetts, Tobin Hall, 135 Hicks Way, Amherst, MA 01003-9271, USA.
| | - Paula Ravitz
- Department of Psychiatry, University of Toronto, Mount Sinai Hospital, 600 University Ave., Toronto, ON M5G 1X5, Canada.
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Cordero-Andrés P, González-Blanch C, Umaran-Alfageme O, Muñoz-Navarro R, Ruíz-Rodríguez P, Medrano LA, Hernández-de Hita F, Pérez-Poo T, Cano-Vindel A. Tratamiento psicológico de los trastornos emocionales en atención primaria: fundamentos teóricos y empíricos del estudio PsicAP. ANSIEDAD Y ESTRÉS 2017. [DOI: 10.1016/j.anyes.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVES This study aims to investigate existing evidence for the effectiveness of psychological treatments and/or antidepressant medication as a treatment for those diagnosed with moderate levels of depression. METHODS A PRISMA systematic review of articles using electronic research databases (2000-2014) was conducted to identify studies investigating the effectiveness of psychotherapy and/or medication as a treatment for people with moderate levels of depression. Search terms included moderate depression, psychotherapy and/or medication, depressive disorders, antidepressants, psychotherapy, mental health services, and randomized-controlled trial (RCT). The included studies were then assessed, extracted, and synthesised. RESULTS A total of 14 studies met the inclusion criteria (11 RCTs and three additional studies) for this review. The findings of the systematic review indicate that there is limited evidence available specific to the treatment of moderate depression and that this research seems to suggest that psychotherapy or combined treatment has a beneficial effect. CONCLUSIONS Given that depression is one of the biggest challenges the world faces at present, further research is required to examine the effectiveness of treatment for different levels of depression severity.
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Díaz-García A, González-Robles A, Fernández-Álvarez J, García-Palacios A, Baños RM, Botella C. Efficacy of a Transdiagnostic internet-based treatment for emotional disorders with a specific component to address positive affect: Study protocol for a randomized controlled trial. BMC Psychiatry 2017; 17:145. [PMID: 28424068 PMCID: PMC5397807 DOI: 10.1186/s12888-017-1297-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/01/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Emotional disorders (ED) are among the most prevalent mental disorders. However, less than 50% of people suffering from ED receive the appropriate treatment. This situation has led to the development of new intervention proposals based on the transdiagnostic perspective, which tries to address the underlying processes common to ED. Most of these programs focus primarily on down-regulating negative affectivity, rather than increasing strengths and up-regulating positive affectivity. The data suggest the existence of disturbances in positive affectivity in these disorders, and so new interventions focusing on these problems are greatly needed. It is also essential to provide assistance to all the people in need. Information and Communication Technologies can be very useful. This study aims to evaluate the efficacy of a transdiagnostic Internet-based treatment for ED in a community sample. The protocol includes traditional CBT components, as well as a specific component to address positive affect. We intend to test this protocol, including this specific component or not, versus a waiting list control group. Moreover, we aim to test the differential effect of this specific component, and study the effectiveness (in terms of patients' acceptance) of using a self-applied Internet-based program. This paper presents the study protocol. METHODS The study is a randomized controlled trial. 207 participants will be randomly assigned to: a)Transdiagnostic Internet-based protocol (TIBP), b)Transdiagnostic Internet-based protocol + positive affect component (TIBP + PA), or c)a Waiting List control group (WL). Primary outcomes measures will be the BDI-II, the BAI, and the PANAS. Secondary outcomes will include diagnosis-specific measures of the principal disorder. Participants' treatment acceptance will also be measured. Participants will be assessed at pre-, post-treatment, and 3- and 12- month follow-ups. The data will be analyzed based on the Intention-to-treat principle. Per protocol analyses will also be performed. DISCUSSION To the best of our knowledge, this is the first study of a transdiagnostic Internet-based treatment for ED with a specific component to up-regulate positive affectivity. This intervention could contribute to improve the efficiency and effectiveness of current treatment programs for ED, promote the dissemination of EBTs, and help to decrease the high prevalence of ED. TRIAL REGISTRATION ClinicalTrial.gov: NCT02578758 . Registered 15 October 2015.
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Affiliation(s)
| | | | | | - Azucena García-Palacios
- Universitat Jaume I, Castellón, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain
| | - Rosa María Baños
- Universidad de Valencia, Valencia, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain
| | - Cristina Botella
- Universitat Jaume I, Castellón, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain
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Oren-Yagoda R, Björgvinsson T, Aderka IM. The relationship between positive affect and negative affect during treatment for major depressive disorder. Psychother Res 2017; 28:958-968. [PMID: 28277040 DOI: 10.1080/10503307.2017.1292066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The present study examined the relationship between positive affect (PA) and negative affect (NA) along the course of combined cognitive behavior therapy and pharmacological treatment for major depressive disorder (MDD). METHOD Participants were 165 individuals who sought treatment for MDD in a partial hospital setting. Participants' PA, NA, and depressive symptoms were measured at pre- and post-treatment and PA and NA were measured at up to 10 additional measurements along the course of treatment. RESULTS Results indicated that PA at pre-treatment predicted depressive symptoms at post-treatment above and beyond NA and the PA*NA interaction. However, an analysis of patterns of change during treatment using lower level mediational modeling in a multilevel framework indicated that NA predicted subsequent PA to a greater extent than vice versa. CONCLUSION Though many treatments for MDD predominantly focus on reducing NA, our findings suggest that PA may be an important predictor of outcome in treatment for MDD, and that the inclusion of interventions to increase the experience of PA may help improve the efficacy of treatment.
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Affiliation(s)
- Roni Oren-Yagoda
- a Department of Psychology, Faculty of Social Sciences , University of Haifa , Haifa , Israel
| | | | - Idan M Aderka
- a Department of Psychology, Faculty of Social Sciences , University of Haifa , Haifa , Israel
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Weitz E, Kleiboer A, van Straten A, Hollon SD, Cuijpers P. Individual patient data meta-analysis of combined treatments versus psychotherapy (with or without pill placebo), pharmacotherapy or pill placebo for adult depression: a protocol. BMJ Open 2017; 7:e013478. [PMID: 28193851 PMCID: PMC5318563 DOI: 10.1136/bmjopen-2016-013478] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION There are many proven treatments (psychotherapy, pharmacotherapy or their combination) for the treatment of depression. Although there is growing evidence for the effectiveness of combination treatment (psychotherapy + pharmacotherapy) over pharmacotherapy alone, psychotherapy alone or psychotherapy plus pill placebo, for depression, little is known about which specific groups of patients may respond best to combined treatment versus monotherapy. Conventional meta-analyses techniques have limitations when tasked with examining whether specific individual characteristics moderate the effect of treatment on depression. Therefore, this protocol outlines an individual patient data (IPD) meta-analysis to explore which patients, with which clinical characteristics, have better outcomes in combined treatment compared with psychotherapy (alone or with pill placebo), pharmacotherapy and pill placebo. METHODS AND ANALYSIS Study searches are completed using an established database of randomised controlled trials (RCTs) on the psychological treatment of adult depression that has previously been reported. Searches were conducted in PubMed, PsycInfo, Embase and the Cochrane Central Register of Controlled Trials. RCTs comparing combination treatment (psychotherapy + pharmacotherapy) with psychotherapy (with or without pill placebo), pharmacotherapy or pill placebo for the treatment of adult depression will be included. Study authors of eligible trials will be contacted and asked to contribute IPD. Conventional meta-analysis techniques will be used to examine differences between studies that have contributed data and those that did not. Then, IPD will be harmonised and analysis using multilevel regression will be conducted to examine effect moderators of treatment outcomes. DISSEMINATION Study results outlined above will be published in peer-reviewed journals. Study results will contribute to better understanding whether certain patients respond best to combined treatment or other depression treatments and provide new information on moderators of treatment outcome that can be used by patients, clinicians and researchers. TRIAL REGISTRATION NUMBER CRD42016039028.
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Affiliation(s)
- Erica Weitz
- Department of Clinical, Neuro and Developmental Psychology, and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annet Kleiboer
- Department of Clinical, Neuro and Developmental Psychology, and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology, and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Psychotherapy Versus Pharmacotherapy of Depression: What's the Evidence? ZEITSCHRIFT FUR PSYCHOSOMATISCHE MEDIZIN UND PSYCHOTHERAPIE 2017; 62:190-5. [PMID: 27439555 DOI: 10.13109/zptm.2016.62.2.190] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Depression may be treated by psychotherapy or pharmacotherapy or their combination. There is an ongoing debate whether one of these approaches is possibly superior. A recent meta-analysis reported results in favour of pharmacotherapy. METHODS Individual studies and meta-analyses on the comparative efficacy of psychotherapy vs. pharmacotherapy were reviewed. RESULTS Evidence suggests that psychotherapy and pharmacotherapy are equally efficacious in the short-term, but psychotherapy is superior in the long-term. For the recently stated hypothesis that pharmacotherapy is superior to psychotherapy in studies without a pill placebo condition, which implies equally including a positive expectancy effect for both pharmacotherapy and psychotherapy no evidence was found. CONCLUSION Depression may be treated by psychotherapy or pharmacotherapy with equivalent results in the short-term and advantages for psychotherapy in the long-term. As the rates of response and remission are still limited in both treatments, further improvement of treatments is required.
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Prescott D, White ND. When Is Pharmacotherapy Initiation Beneficial in Patients With Depressive Disorders? Am J Lifestyle Med 2017; 11:220-222. [PMID: 30202334 DOI: 10.1177/1559827616686051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Psychotherapy and pharmacotherapy are the most common treatments utilized in patients diagnosed with depressive disorders. Their efficacy in remitting symptoms and restoring patients to baseline functioning has been established throughout the literature; however, questions still remain on whether pharmacotherapy is necessary in all patients and if used, when initiation is most beneficial. Current guidelines recommend initiating only psychotherapy in patients with mild depression and advancing to pharmacotherapy as appropriate. Evidence-based literature has shown pharmacotherapy to have a significant and independent treatment effect in depressive disorders compared with psychotherapy. Combination treatment with both modalities has also shown to be beneficial for remitting depressive symptoms in this patient population. Therefore, treatment should be individualized for each specific patient based on severity of disease, history of depression and response to treatment, cost of treatment, and patient preference.
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Affiliation(s)
- Drew Prescott
- Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | - Nicole D White
- Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
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McCusker J, Cole M, Lambert S, Yaffe M, Ciampi A, Belzile E. Baseline Psychological Treatment Reduces the Effect of Coaching in a Randomised Trial of a Depression Self-Care Intervention. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:67-72. [PMID: 27310241 PMCID: PMC5302106 DOI: 10.1177/0706743716648299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore the effects of baseline psychological and antidepressant medication treatment in a trial of lay telephone coaching in a low-intensity, supported depression self-care intervention. METHOD A single blind, individually randomised, pragmatic trial was conducted among primary care adults with chronic physical conditions and comorbid depressive symptoms. Eligible subjects were randomised to receive a depression self-care toolkit with (intervention group) or without (control group) telephone coaching provided by trained lay coaches. For this brief communication, a secondary analysis of the trial data focused on the effects of baseline psychological and antidepressant treatments on mental health outcomes (Patient Health Questionnaire 9 [PHQ-9], SF-12 Mental Component Summary [MCS], Generalized Anxiety Disorder 7 [GAD-7]) and satisfaction with the intervention. RESULTS In total, 223 patients were randomised, and 165 (74.0%) completed both 3- and 6-month follow-ups. There were 2 significant interactions of baseline treatment and study group for 6-month mental health outcomes. A significant benefit of coaching on 6-month PHQ-9 was seen only among participants who were not receiving baseline psychological treatment. A smaller interaction was found for baseline antidepressant medications and 6-month mental health. There was a significant main effect for baseline psychological treatment and lower 6-month satisfaction. CONCLUSIONS Depressed patients receiving baseline psychological treatment may not benefit from lay coaching offered as part of a low-intensity depression self-care intervention.
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Affiliation(s)
- Jane McCusker
- 1 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec.,2 St. Mary's Research Centre, Montreal, Quebec
| | - Martin Cole
- 3 Department of Psychiatry, McGill University, Montreal, Quebec.,4 Geriatric Psychiatry Division, St. Mary's Hospital Center, Montreal, Quebec
| | - Sylvie Lambert
- 2 St. Mary's Research Centre, Montreal, Quebec.,5 Ingram School of Nursing, McGill University, Montreal, Quebec
| | - Mark Yaffe
- 6 Department of Family Medicine, McGill University, Montreal, Quebec.,7 Family Medicine Centre, St. Mary's Hospital Center, Montreal, Quebec
| | - Antonio Ciampi
- 1 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec.,2 St. Mary's Research Centre, Montreal, Quebec
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Li M, Kennedy EB, Byrne N, Gérin-Lajoie C, Katz MR, Keshavarz H, Sellick S, Green E. Systematic review and meta-analysis of collaborative care interventions for depression in patients with cancer. Psychooncology 2016; 26:573-587. [PMID: 27643388 DOI: 10.1002/pon.4286] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 08/17/2016] [Accepted: 09/15/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Previous systematic reviews have found limited evidence for the effectiveness of pharmacological and psychological interventions for the management of depression in patients with cancer. This paper provides the first meta-analysis of newer collaborative care interventions, which may include both types of treatment, as well as integrated delivery and follow-up. Meta-analyses of pharmacological and psychological interventions are included as a comparison. METHODS A search of MEDLINE, EMBASE, PsycINFO, and the Cochrane Library from July 2005 to January 2015 for randomized controlled trials of depression treatments for cancer patients diagnosed with a major depressive disorder, or who met a threshold on a validated depression rating scale was conducted. Meta-analyses were conducted using summary data. RESULTS Key findings included eight reports of four collaborative care interventions, eight pharmacological, and nine psychological trials. A meta-analysis demonstrated that collaborative care interventions were significantly more effective than usual care (standardized mean difference = -0.49, p = 0.003), and depression reduction was maintained at 12 months. By comparison, short-term (up to 12 weeks), but not longer-term effectiveness was demonstrated for both pharmacological and psychological interventions. CONCLUSIONS Collaborative care interventions have newly emerged as multidisciplinary care delivery models, which may result in more long-term depression remission. This review also updates previous findings of modest evidence for the effectiveness of both pharmacological and psychological interventions for threshold depression in cancer patients. Research designs focusing on combined treatments and delivery systems may best further the limited evidence-base for the management of depression in cancer.
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Affiliation(s)
- Madeline Li
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Erin B Kennedy
- Cancer Care Ontario, Program in Evidence-based Care/McMaster University, Hamilton, Ontario, Canada
| | - Nelson Byrne
- Trillium Health Partners, Mississauga Halton-Central West Regional Cancer Program, Mississauga, Ontario, Canada
| | | | - Mark R Katz
- Stronach Regional Cancer Centre, Southlake Regional Health Centre, Ontario, Canada
| | - Homa Keshavarz
- Cancer Care Ontario, Program in Evidence-based Care/McMaster University, Hamilton, Ontario, Canada
| | - Scott Sellick
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - Esther Green
- Nursing and Psychosocial Oncology, Cancer Care Ontario, Toronto, Ontario, Canada
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Abstract
Major depressive disorder (MDD) is a debilitating disease that is characterized by depressed mood, diminished interests, impaired cognitive function and vegetative symptoms, such as disturbed sleep or appetite. MDD occurs about twice as often in women than it does in men and affects one in six adults in their lifetime. The aetiology of MDD is multifactorial and its heritability is estimated to be approximately 35%. In addition, environmental factors, such as sexual, physical or emotional abuse during childhood, are strongly associated with the risk of developing MDD. No established mechanism can explain all aspects of the disease. However, MDD is associated with alterations in regional brain volumes, particularly the hippocampus, and with functional changes in brain circuits, such as the cognitive control network and the affective-salience network. Furthermore, disturbances in the main neurobiological stress-responsive systems, including the hypothalamic-pituitary-adrenal axis and the immune system, occur in MDD. Management primarily comprises psychotherapy and pharmacological treatment. For treatment-resistant patients who have not responded to several augmentation or combination treatment attempts, electroconvulsive therapy is the treatment with the best empirical evidence. In this Primer, we provide an overview of the current evidence of MDD, including its epidemiology, aetiology, pathophysiology, diagnosis and treatment.
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Affiliation(s)
- Christian Otte
- Department of Psychiatry and Psychotherapy, Charité University Medical Center, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Stefan M Gold
- Department of Psychiatry and Psychotherapy, Charité University Medical Center, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Brenda W Penninx
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - Carmine M Pariante
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Amit Etkin
- Department of Psychiatry and Behavioural Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David C Mohr
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alan F Schatzberg
- Department of Psychiatry and Behavioural Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Feixas G, Bados A, García-Grau E, Paz C, Montesano A, Compañ V, Salla M, Aguilera M, Trujillo A, Cañete J, Medeiros-Ferreira L, Soriano J, Ibarra M, Medina JC, Ortíz E, Lana F. A DILEMMA-FOCUSED INTERVENTION FOR DEPRESSION: A MULTICENTER, RANDOMIZED CONTROLLED TRIAL WITH A 3-MONTH FOLLOW-UP. Depress Anxiety 2016; 33:862-9. [PMID: 27103215 PMCID: PMC5074295 DOI: 10.1002/da.22510] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 03/22/2016] [Accepted: 03/26/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Since long ago it has been asserted that internal conflicts are relevant to the understanding and treatment of mental disorders, but little research has been conducted to support the claim. The aim of this study was to test the differential efficacy of group cognitive behavioral therapy (CBT) plus an intervention focused on the dilemma(s) detected for each patient versus group individual CBT plus individual CBT for treating depression. A comparative controlled trial with a 3-month follow-up was conducted. METHODS One hundred twenty-eight adults meeting criteria for MDD and/or dysthymia, presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct, assessed by the repertory grid technique) and who had completed seven sessions of group CBT were randomly assigned to eight sessions of individual manualized CBT or dilemma-focused therapy (DFT). The Beck Depression Inventory-II was administered at baseline, at the end of therapy and after 3 months' follow-up. RESULTS Multilevel mixed effects modeling yielded no significant differences between CBT and DFT with the intention-to-treat sample. Equivalent effect sizes, remission, and response rates were found with completers as well. In combination with group CBT, both individual CBT and DFT significantly reduced depressive symptoms. CONCLUSIONS Both conditions obtained comparable results to those in the literature. Thus, the superiority of the adjunctive DFT was not demonstrated. Working with dilemmas can be seen as a promising additional target in the psychotherapy of depression, but further research is still required.
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Affiliation(s)
- Guillem Feixas
- Faculty of Psychology, University of Barcelona, Barcelona, Spain.
- Institute for Brain, Cognition and Behavior (IR3C), University of Barcelona, Barcelona, Spain.
| | - Arturo Bados
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | | | - Clara Paz
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
- Institute for Brain, Cognition and Behavior (IR3C), University of Barcelona, Barcelona, Spain
| | - Adrián Montesano
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
- Institute for Brain, Cognition and Behavior (IR3C), University of Barcelona, Barcelona, Spain
| | - Victoria Compañ
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | - Marta Salla
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | - Mari Aguilera
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | - Adriana Trujillo
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
- Institute for Brain, Cognition and Behavior (IR3C), University of Barcelona, Barcelona, Spain
| | | | | | - José Soriano
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Joan C Medina
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
- Institute for Brain, Cognition and Behavior (IR3C), University of Barcelona, Barcelona, Spain
| | - Eliana Ortíz
- Faculty of Psychology, University of Barcelona, Barcelona, Spain
- Institute for Brain, Cognition and Behavior (IR3C), University of Barcelona, Barcelona, Spain
| | - Fernando Lana
- Parc de Salut Mar, Santa Coloma de Gramenet, Barcelona, Spain
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Notzon S, Alferink J, Arolt V. [Late-onset depression : Pathophysiology, diagnostics and treatment]. DER NERVENARZT 2016; 87:1017-29. [PMID: 27531211 DOI: 10.1007/s00115-016-0193-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Late-onset depression (LOD) is defined as depression manifesting for the first time in later life. Up to now, there has been no exact definition of the lower age limit for LOD. Psychopathological symptoms of LOD do not fundamentally differ from depression in other phases of life; however, cognitive deficits are typically more pronounced. The LOD is associated with an increased risk of developing dementia. Imaging studies show reduction in gray matter volume and white matter lesions caused by vascular diseases. The occurrence of depression with vascular lesions of the brain is also referred to as "vascular depression". The diagnostic procedure includes a detailed medical history and the observation of psychopathological changes, physical examination, laboratory tests, electroencephalograph (EEG), electrocardiograph (ECG) and magnetic resonance imaging (MRI) of the head and neuropsychological tests to measure cognitive deficits. Psychotherapy is an effective treatment option. Selective serotonin reuptake inhibitors are the first-line pharmacological therapy.
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Affiliation(s)
- S Notzon
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A9, 48149, Münster, Deutschland.
| | - J Alferink
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A9, 48149, Münster, Deutschland
| | - V Arolt
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A9, 48149, Münster, Deutschland
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Kleiboer A, Smit J, Bosmans J, Ruwaard J, Andersson G, Topooco N, Berger T, Krieger T, Botella C, Baños R, Chevreul K, Araya R, Cerga-Pashoja A, Cieślak R, Rogala A, Vis C, Draisma S, van Schaik A, Kemmeren L, Ebert D, Berking M, Funk B, Cuijpers P, Riper H. European COMPARative Effectiveness research on blended Depression treatment versus treatment-as-usual (E-COMPARED): study protocol for a randomized controlled, non-inferiority trial in eight European countries. Trials 2016; 17:387. [PMID: 27488181 PMCID: PMC4972947 DOI: 10.1186/s13063-016-1511-1] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/17/2016] [Indexed: 12/28/2022] Open
Abstract
Background Effective, accessible, and affordable depression treatment is of high importance considering the large personal and economic burden of depression. Internet-based treatment is considered a promising clinical and cost-effective alternative to current routine depression treatment strategies such as face-to-face psychotherapy. However, it is not clear whether research findings translate to routine clinical practice such as primary or specialized mental health care. The E-COMPARED project aims to gain knowledge on the clinical and cost-effectiveness of blended depression treatment compared to treatment-as-usual in routine care. Methods/design E-COMPARED will employ a pragmatic, multinational, randomized controlled, non-inferiority trial in eight European countries. Adults diagnosed with major depressive disorder (MDD) will be recruited in primary care (Germany, Poland, Spain, Sweden, and the United Kingdom) or specialized mental health care (France, The Netherlands, and Switzerland). Regular care for depression is compared to “blended” service delivery combining mobile and Internet technologies with face-to-face treatment in one treatment protocol. Participants will be followed up at 3, 6, and 12 months after baseline to determine clinical improvements in symptoms of depression (primary outcome: Patient Health Questionnaire-9), remission of depression, and cost-effectiveness. Main analyses will be conducted on the pooled data from the eight countries (n = 1200 in total, 150 participants in each country). Discussion The E-COMPARED project will provide mental health care stakeholders with evidence-based information and recommendations on the clinical and cost-effectiveness of blended depression treatment. Trial registration France: ClinicalTrials.gov NCT02542891. Registered on 4 September 2015; Germany: German Clinical Trials Register DRKS00006866. Registered on 2 December 2014; The Netherlands: Netherlands Trials Register NTR4962. Registered on 5 January 2015; Poland: ClinicalTrials.Gov NCT02389660. Registered on 18 February 2015; Spain: ClinicalTrials.gov NCT02361684. Registered on 8 January 2015; Sweden: ClinicalTrials.gov NCT02449447. Registered on 30 March 2015; Switzerland: ClinicalTrials.gov NCT02410616. Registered on 2 April 2015; United Kingdom: ISRCTN registry, ISRCTN12388725. Registered on 20 March 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1511-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annet Kleiboer
- Section Clinical Psychology, Vrije Universiteit Amsterdam and EMGO+ Institute for Health Care and Research, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
| | - Jan Smit
- Department of Psychiatry, VU University Medical Centre and EMGO+ Institute for Health Care and Research, Amsterdam, The Netherlands
| | - Judith Bosmans
- Department of Health Sciences, Vrije Universiteit Amsterdam and EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Jeroen Ruwaard
- Section Clinical Psychology, Vrije Universiteit Amsterdam and EMGO+ Institute for Health Care and Research, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.,Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden
| | - Naira Topooco
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Tobias Krieger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Cristina Botella
- Department of Psychology and Technology, Jaume University, Castellon, Spain.,Department of Personalidad, Evaluación y Tratamiento Psicológicos, Valencia, Spain
| | - Rosa Baños
- Department of Personalidad, Evaluación y Tratamiento Psicológicos, Valencia, Spain
| | | | - Ricardo Araya
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Arlinda Cerga-Pashoja
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Roman Cieślak
- Department of Psychology, Szkoła Wyzsza Psychologii Społeczne, University of Social Sciences and Humanities, Warsaw, Poland
| | - Anna Rogala
- Department of Psychology, Szkoła Wyzsza Psychologii Społeczne, University of Social Sciences and Humanities, Warsaw, Poland
| | - Christiaan Vis
- Section Clinical Psychology, Vrije Universiteit Amsterdam and EMGO+ Institute for Health Care and Research, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
| | - Stasja Draisma
- Department of Psychiatry, VU University Medical Centre and EMGO+ Institute for Health Care and Research, Amsterdam, The Netherlands
| | - Anneke van Schaik
- Department of Psychiatry, VU University Medical Centre and EMGO+ Institute for Health Care and Research, Amsterdam, The Netherlands
| | - Lise Kemmeren
- Department of Psychiatry, VU University Medical Centre and EMGO+ Institute for Health Care and Research, Amsterdam, The Netherlands
| | - David Ebert
- Department of Clinical Psychology, Philipps University, Marburg, Germany
| | - Matthias Berking
- Department of Clinical Psychology, Philipps University, Marburg, Germany
| | - Burkhardt Funk
- Institut für elektronische Geschäftsprozesse, Leuphana University Lüneburg, Lüneburg, Germany
| | - Pim Cuijpers
- Section Clinical Psychology, Vrije Universiteit Amsterdam and EMGO+ Institute for Health Care and Research, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
| | - Heleen Riper
- Section Clinical Psychology, Vrije Universiteit Amsterdam and EMGO+ Institute for Health Care and Research, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.,Department of Psychiatry, VU University Medical Centre and EMGO+ Institute for Health Care and Research, Amsterdam, The Netherlands
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77
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Fansi A, Jehanno C, Lapalme M, Drapeau M, Bouchard S. Efficacité de la psychothérapie comparativement à la pharmacothérapie dans le traitement des troubles anxieux et dépressifs chez l’adulte : une revue de la littérature. SANTE MENTALE AU QUEBEC 2016. [DOI: 10.7202/1036098ar] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Dans l’optique de l’amélioration d’une couverture de la psychothérapie au Québec, le ministère de la Santé et des Services sociaux a confié à l’Institut national d’excellence en santé et en services sociaux le mandat d’évaluer l’efficacité de la psychothérapie comparée à la pharmacothérapie dans le traitement des adultes souffrant de troubles anxieux et dépressifs. Une mise à jour d’une revue de la littérature récente et de bonne qualité a été effectuée grâce à une revue des revues systématiques traitant de la psychothérapie comparée à la pharmacothérapie dans le traitement des adultes anxieux et dépressifs avec un horizon temporel compris entre 2009 et 2013. Le niveau de l’ensemble de la preuve scientifique permet de dire que de manière générale, il n’y a pas de différence significative entre la psychothérapie et la pharmacothérapie sur le plan de la réduction des symptômes des patients souffrant de troubles anxieux ou dépressifs modérés, ce qui indique une efficacité comparable de ces deux modes de traitement. Cependant, les avantages de la psychothérapie sont maintenus plus longtemps après la fin du traitement que ceux des médicaments. La psychothérapie offre donc une meilleure protection contre la rechute. Par ailleurs, la combinaison de la psychothérapie et de la pharmacothérapie présente une efficacité supérieure à celle de la psychothérapie seule dans les cas chroniques ou graves.
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Affiliation(s)
- Alvine Fansi
- M.D., Ph. D., Institut national d’excellence en santé et en services sociaux (INESSS)
- Département des sciences de la santé communautaire
- Centre de recherche Hôpital Charles-LeMoyne
- Chaire de recherche du Canada en Évaluation et Amélioration du Système de Santé
- EASY, Université de Sherbrooke
| | - Cedric Jehanno
- B. Sc., MBA, Institut national d’excellence en santé et en services sociaux (INESSS)
| | - Micheline Lapalme
- Ph. D., Institut national d’excellence en santé et en services sociaux (INESSS)
| | - Martin Drapeau
- Ph. D., Département de psychologie du counselling et de psychiatrie, Université McGill
| | - Sylvie Bouchard
- B. Pharm., D.P.H., M. Sc., MBA, Institut national d’excellence en santé et en services sociaux (INESSS)
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78
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Dunlop BW. Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2016; 14:156-173. [PMID: 31975799 PMCID: PMC6519650 DOI: 10.1176/appi.focus.20150042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.
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Affiliation(s)
- Boadie W Dunlop
- Dr. Dunlop is with the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia (e-mail: )
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79
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Karyotaki E, Smit Y, Holdt Henningsen K, Huibers MJH, Robays J, de Beurs D, Cuijpers P. Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. J Affect Disord 2016; 194:144-52. [PMID: 26826534 DOI: 10.1016/j.jad.2016.01.036] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/12/2016] [Accepted: 01/15/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The present meta-analysis aimed to examine to what extent combined pharmacotherapy with psychotherapy results in a different response to treatment compared to psychotherapy or pharmacotherapy alone in adults with major depression at six months or longer postrandomization. METHODS A systematic literature search resulted in 23 randomized controlled trials with 2184 participants. Combined treatment was compared to either psychotherapy or anti-depressant medication alone in both the acute phase and the maintenance phase. Odds ratios of a positive outcome were calculated for all comparisons. RESULTS In acute phase treatment, combined psychotherapy with antidepressants outperformed antidepressants alone at six months or longer postrandomization in patients with major depressive disorder (OR=2.93, 95%CI 2.15-3.99, p<0.001). Heterogeneity was zero (95%CI 0-57%, p>0.05). However, combined therapy resulted in equal response to treatment compared to psychotherapy alone at six months or longer postrandomization. As for the maintenance treatment, combined maintenance psychotherapy with antidepressants resulted in better-sustained treatment response compared to antidepressants at six months or longer postrandomization (OR=1.61, 95%CI 1.14-2.27, p<0.05). Heterogeneity was zero (95%CI 0-68%, p>0.05). CONCLUSIONS Combined therapy results in a superior enduring effect compared to antidepressants alone in patients with major depression. Psychotherapy is an adequate alternative for combined treatment in the acute phase as it is as effective as combined treatment in the long-term.
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Affiliation(s)
- E Karyotaki
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University medical centre, Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University medical centre, Amsterdam, The Netherlands.
| | - Y Smit
- Independant researcher, The Netherlands
| | | | - M J H Huibers
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University medical centre, Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University medical centre, Amsterdam, The Netherlands
| | - J Robays
- Belgian Health Care Knowledge Centre, KCE, Brussels, Belgium
| | - D de Beurs
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University medical centre, Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University medical centre, Amsterdam, The Netherlands
| | - P Cuijpers
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University medical centre, Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University medical centre, Amsterdam, The Netherlands
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80
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Prasko J, Grambal A, Kasalova P, Kamardova D, Ociskova M, Holubova M, Vrbova K, Sigmundova Z, Latalova K, Slepecky M, Zatkova M. Impact of dissociation on treatment of depressive and anxiety spectrum disorders with and without personality disorders. Neuropsychiatr Dis Treat 2016; 12:2659-2676. [PMID: 27799774 PMCID: PMC5074730 DOI: 10.2147/ndt.s118058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The central goal of the study was to analyze the impact of dissociation on the treatment effectiveness in patients with anxiety/neurotic spectrum and depressive disorders with or without comorbid personality disorders. METHODS The research sample consisted of inpatients who were hospitalized in the psychiatric department and met the ICD-10 criteria for diagnosis of depressive disorder, panic disorder, generalized anxiety disorder, mixed anxiety-depressive disorder, agoraphobia, social phobia, obsessive compulsive disorder, posttraumatic stress disorder, adjustment disorders, dissociative/conversion disorders, somatoform disorder, or other anxiety/neurotic spectrum disorder. The participants completed these measures at the start and end of the therapeutic program - Beck Depression Inventory, Beck Anxiety Inventory, a subjective version of Clinical Global Impression-Severity, Sheehan Patient-Related Anxiety Scale, and Dissociative Experience Scale. RESULTS A total of 840 patients with anxiety or depressive spectrum disorders, who were resistant to pharmacological treatment on an outpatient basis and were referred for hospitalization for the 6-week complex therapeutic program, were enrolled in this study. Of them, 606 were statistically analyzed. Data from the remaining 234 (27.86%) patients were not used because of various reasons (103 prematurely finished the program, 131 did not fill in most of the questionnaires). The patients' mean ratings on all measurements were significantly reduced during the treatment. Also, 67.5% reached at least minimal improvement (42.4% showed moderate and more improvement, 35.3% of the patients reached remission). The patients without comorbid personality disorder improved more significantly in the reduction of depressive symptoms than those with comorbid personality disorder. However, there were no significant differences in change in anxiety levels and severity of the mental issues between the patients with and without personality disorders. Higher degree of dissociation at the beginning of the treatment predicted minor improvement, and also, higher therapeutic change was connected to greater reduction of the dissociation level. CONCLUSION Dissociation is an important factor that influences the treatment effectiveness in anxiety/depression patients with or without personality disorders resistant to previous treatment. Targeting dissociation in the treatment of these disorders may be beneficial.
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Affiliation(s)
- Jan Prasko
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Ales Grambal
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Petra Kasalova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Dana Kamardova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Marie Ociskova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Michaela Holubova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc; Psychiatric Department, Hospital Liberec, Liberec, Czech Republic
| | - Kristyna Vrbova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Zuzana Sigmundova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Klara Latalova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital Olomouc, Olomouc
| | - Milos Slepecky
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra, Slovak Republic
| | - Marta Zatkova
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra, Slovak Republic
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81
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González-Robles A, García-Palacios A, Baños R, Riera A, Llorca G, Traver F, Haro G, Palop V, Lera G, Romeu JE, Botella C. Effectiveness of a transdiagnostic internet-based protocol for the treatment of emotional disorders versus treatment as usual in specialized care: study protocol for a randomized controlled trial. Trials 2015; 16:488. [PMID: 26519046 PMCID: PMC4628388 DOI: 10.1186/s13063-015-1024-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/21/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Emotional disorders (depression and anxiety disorders) are highly prevalent mental health problems. Although evidence showing the effectiveness of disorder-specific treatments exists, high comorbidity rates among emotional disorders limit the utility of these protocols. This has led some researchers to focus their interest on transdiagnostic interventions, a treatment perspective that might be more widely effective across these disorders. Also, the current way of delivering treatments makes it difficult provide assistance to all of the population in need. The use of the Internet in the delivery of evidence-based treatments may help to disseminate treatments among the population. In this study, we aim to test the effectiveness of EmotionRegulation, a new transdiagnostic Internet-based protocol for unipolar mood disorders, five anxiety disorders (panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder and anxiety disorder not otherwise specified), and obsessive-compulsive disorder in comparison to treatment as usual as provided in Spanish public specialized mental health care. We will also study its potential impact on basic temperament dimensions (neuroticism/behavioral inhibition and extraversion/behavioral activation). Expectations and opinions of patients about this protocol will also be studied. METHODS/DESIGN The study is a randomized controlled trial. 200 participants recruited in specialized care will be allocated to one of two treatment conditions: a) EmotionRegulation or b) treatment as usual. Primary outcome measures will be the BAI and the BDI-II. Secondary outcomes will include a specific measure of the principal disorder, and measures of neuroticism/behavioral inhibition and extraversion/behavioral activation. Patients will be assessed at baseline, post-treatment, and 3- and 12-month follow-ups. Intention to treat and per protocol analyses will be performed. DISCUSSION Although the effectiveness of face-to-face transdiagnostic protocols has been investigated in previous studies, the number of published transdiagnostic Internet-based programs is still quite low. To our knowledge, this is the first randomized controlled trial studying the effectiveness of a transdiagnostic Internet-based treatment for several emotional disorders in public specialized care. Combining both a transdiagnostic approach with an Internet-based therapy format may help to decrease the burden of mental disorders, reducing the difficulties associated with disorder-specific treatments and facilitating access to people in need of treatment. Strengths and limitations are discussed. TRIAL REGISTRATION ClinicalTrials.gov NCT02345668 . Registered 27 July 2015.
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Affiliation(s)
- Alberto González-Robles
- University Jaume I, Research Building II, Office NB2128DD, Vicente Sos Baynat Avenue, Castellon, 12071, Spain.
| | - Azucena García-Palacios
- University Jaume I, Research Building II, Office NB2128DD, Vicente Sos Baynat Avenue, Castellon, 12071, Spain.
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain.
| | - Rosa Baños
- Universidad de Valencia, Valencia, Spain.
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain.
| | - Antonio Riera
- University Jaume I, Research Building II, Office NB2128DD, Vicente Sos Baynat Avenue, Castellon, 12071, Spain.
| | - Ginés Llorca
- Psychiatry Service, Consorcio Hospitalario Provincial de Castellón, Castellon, Spain.
| | - Francisco Traver
- Psychiatry Service, Consorcio Hospitalario Provincial de Castellón, Castellon, Spain.
| | - Gonzalo Haro
- Psychiatry Service, Consorcio Hospitalario Provincial de Castellón, Castellon, Spain.
- School of Medicine, Universidad CEU Cardenal Herrera, Castellon, Spain.
| | - Vicente Palop
- Psychiatry Service, Departamento de Salud de la Ribera, Hospital Universitario de La Ribera, Valencia, Spain.
| | - Guillem Lera
- Psychiatry Service, Departamento de Salud de la Ribera, Hospital Universitario de La Ribera, Valencia, Spain.
| | - José Enrique Romeu
- Psychiatry Service, Departamento de Salud de la Ribera, Hospital Universitario de La Ribera, Valencia, Spain.
| | - Cristina Botella
- University Jaume I, Research Building II, Office NB2128DD, Vicente Sos Baynat Avenue, Castellon, 12071, Spain.
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain.
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82
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Psychosocial interventions for people with diabetes and co-morbid depression. A systematic review. Int J Nurs Stud 2015; 52:1625-39. [DOI: 10.1016/j.ijnurstu.2015.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 04/07/2015] [Accepted: 05/29/2015] [Indexed: 12/14/2022]
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83
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Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull 2015; 115:183-201. [PMID: 26311502 DOI: 10.1093/bmb/ldv034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION OR BACKGROUND Depression frequently fails to respond to initial treatment. SOURCES OF DATA Predominantly meta-analyses and RCTs but supplemented where necessary by additional data and the authors' clinical experience. AREAS OF AGREEMENT A systematic assessment to identify remedial causes of poor response should be followed by planned sequential treatment trials. Joint decision making by the patient and clinician is essential. Strategies with the strongest support are antidepressant augmentation with lithium or second generation antipsychotics and adding cognitive behavioural treatment. Electroconvulsive therapy is highly effective in resistant depression but there is a high relapse rate when treatment ends. AREAS OF CONTROVERSY Some pharmacological strategies have inconsistent data (e.g. antidepressant combinations, T3 augmentation) or limited preliminary data (e.g. ketamine, antidepressant augmentation with pramipexole). The efficacy of vagus nerve stimulation, deep brain stimulation and repetitive transcranial magnetic stimulation is unclear. GROWING POINTS A greater understanding of the causes of depression may assist the development of more effective treatments. AREAS TIMELY FOR DEVELOPING RESEARCH Role of glutamate antagonists and psychological treatments, other than cognitive behavioural therapy, as adjunctive treatments.
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Affiliation(s)
- Peter M Haddad
- Neuroscience and Psychiatry Unit, University of Manchester, Stopford Building, Oxford Rd, Manchester M13 9PT, UK Greater Manchester West Mental Health NHS Foundation Trust, Cromwell House, Eccles, Salford M30 0GT, UK
| | - Peter S Talbot
- Wolfson Molecular Imaging Centre, University of Manchester, 27 Palatine Road, Manchester M20 3LJ, UK
| | - Ian M Anderson
- Neuroscience and Psychiatry Unit, University of Manchester, Stopford Building, Oxford Rd, Manchester M13 9PT, UK
| | - R Hamish McAllister-Williams
- Institute of Neuroscience, Newcastle University, Wolfson Research Centre, Campus for Ageing and Vitality, Westgate Road, Newcastle upon Tyne NE4 5PL, UK Northumberland, Tyne and Wear NHS Foundation Trust, Regional Affective Disorders Service, Campus for Ageing and Vitality, Westgate Road, Newcastle upon Tyne NE4 5PR, UK
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84
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Reay RE, Mulcahy R, Wilkinson RB, Owen C, Shadbolt B, Raphael B. The Development and Content of an Interpersonal Psychotherapy Group for Postnatal Depression. Int J Group Psychother 2015; 62:221-51. [DOI: 10.1521/ijgp.2012.62.2.221] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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85
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Cooper AA, Conklin LR. Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials. Clin Psychol Rev 2015; 40:57-65. [DOI: 10.1016/j.cpr.2015.05.001] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 04/07/2015] [Accepted: 05/13/2015] [Indexed: 01/19/2023]
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86
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Kim E, Im EO. Korean-Americans' Knowledge about Depression and Attitudes about Treatment Options. Issues Ment Health Nurs 2015; 36:455-63. [PMID: 26241572 PMCID: PMC5334467 DOI: 10.3109/01612840.2014.997846] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this pilot study was to explore first-generation Korean-Americans' knowledge about depression and attitudes about depression treatment options. Self-report survey data were gathered from 73 first-generation Korean-Americans (KAs) using instruments developed for this study. The data were analyzed using descriptive and inferential statistics including t-tests. Data indicated participants lacked knowledge about depression. Among all depression treatment options, exercise was the option that first-generation KAs were most willing to try and was rated as having the least shame attached to it. Taking an antidepressant was the option KAs reported being most unwilling to try and had the highest shame attached to it. No significant differences in knowledge about depression and attitudes about depression treatment options were found between low and high acculturation groups, with the exception that the high acculturation group demonstrated more agreement than the low acculturation group with the item that emotional symptoms, such as mood changes, can be depression symptoms. These results suggest that initiating depression treatment with exercise may be the most acceptable starting point in treating depression in first-generation KA immigrants.
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Affiliation(s)
- Eunjung Kim
- University of Washington, Family and Child Nursing , Shoreline, Washington , USA
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87
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Cleare A, Pariante CM, Young AH, Anderson IM, Christmas D, Cowen PJ, Dickens C, Ferrier IN, Geddes J, Gilbody S, Haddad PM, Katona C, Lewis G, Malizia A, McAllister-Williams RH, Ramchandani P, Scott J, Taylor D, Uher R. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015; 29:459-525. [PMID: 25969470 DOI: 10.1177/0269881115581093] [Citation(s) in RCA: 414] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.
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Affiliation(s)
- Anthony Cleare
- Professor of Psychopharmacology & Affective Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - C M Pariante
- Professor of Biological Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - A H Young
- Professor of Psychiatry and Chair of Mood Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - I M Anderson
- Professor and Honorary Consultant Psychiatrist, University of Manchester Department of Psychiatry, University of Manchester, Manchester, UK
| | - D Christmas
- Consultant Psychiatrist, Advanced Interventions Service, Ninewells Hospital & Medical School, Dundee, UK
| | - P J Cowen
- Professor of Psychopharmacology, Psychopharmacology Research Unit, Neurosciences Building, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - C Dickens
- Professor of Psychological Medicine, University of Exeter Medical School and Devon Partnership Trust, Exeter, UK
| | - I N Ferrier
- Professor of Psychiatry, Honorary Consultant Psychiatrist, School of Neurology, Neurobiology & Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J Geddes
- Head, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - S Gilbody
- Director of the Mental Health and Addictions Research Group (MHARG), The Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - P M Haddad
- Consultant Psychiatrist, Cromwell House, Greater Manchester West Mental Health NHS Foundation Trust, Salford, UK
| | - C Katona
- Division of Psychiatry, University College London, London, UK
| | - G Lewis
- Division of Psychiatry, University College London, London, UK
| | - A Malizia
- Consultant in Neuropsychopharmacology and Neuromodulation, North Bristol NHS Trust, Rosa Burden Centre, Southmead Hospital, Bristol, UK
| | - R H McAllister-Williams
- Reader in Clinical Psychopharmacology, Institute of Neuroscience, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - P Ramchandani
- Reader in Child and Adolescent Psychiatry, Centre for Mental Health, Imperial College London, London, UK
| | - J Scott
- Professor of Psychological Medicine, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - D Taylor
- Professor of Psychopharmacology, King's College London, London, UK
| | - R Uher
- Associate Professor, Canada Research Chair in Early Interventions, Dalhousie University, Department of Psychiatry, Halifax, NS, Canada
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88
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Veteran satisfaction and treatment preferences in response to a posttraumatic stress disorder specialty clinic orientation group. Behav Res Ther 2015; 69:75-82. [PMID: 25898342 DOI: 10.1016/j.brat.2015.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 03/26/2015] [Accepted: 04/11/2015] [Indexed: 11/22/2022]
Abstract
To maximize accessibility to evidence-based treatments for posttraumatic stress disorder (PTSD), the United States Department of Veterans Affairs (VA) has widely disseminated cognitive processing therapy (CPT) and prolonged exposure (PE) therapy to VA clinicians. However, there is a lack of research on veteran preferences when presented with a range of psychotherapy and medication options. This study uses a mixed-method approach to explore veteran satisfaction with a VA PTSD specialty clinic pre-treatment orientation group, which provides education about available PTSD treatment options. This study also tested differences in treatment preference in response to the group. Participants were 183 US veterans. Most were White, male, and referred to the clinic by a VA provider. Results indicated high satisfaction with the group in providing an overview of services and helping to inform treatment choice. Most preferred psychotherapy plus medications (63.4%) or psychotherapy only (30.1%). Participants endorsed a significantly stronger preference for CPT versus other psychotherapies. PE was significantly preferred over nightmare resolution therapy and present-centered therapy, and both PE and cognitive-behavioral conjoint therapy were preferred over virtual reality exposure therapy. Results suggest that by informing consumers about evidence-based treatments for PTSD, pre-treatment educational approaches may increase consumer demand for these treatment options.
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89
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Button KS, Turner N, Campbell J, Kessler D, Kuyken W, Lewis G, Peters TJ, Thomas L, Wiles N. Moderators of response to cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care. J Affect Disord 2015; 174:272-80. [PMID: 25527998 DOI: 10.1016/j.jad.2014.11.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/27/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Stratified medicine aims to improve clinical and cost-effectiveness by identifying moderators of treatment that indicate differential response to treatment. Cognitive behavioural therapy (CBT) is often offered as a 'next-step' for patients who have not responded to antidepressants, but no research has examined moderators of response to CBT in this population. We aimed, therefore, to identify moderators of response to CBT in treatment resistant depression. METHODS We used linear regression to test for interactions between treatment effect and 14 putative moderator variables using data from the CoBalT randomised controlled trial. This trial examined the effectiveness of CBT given in addition to usual care (n=234) compared with usual care alone (n=235) for primary care patients with treatment resistant depression. RESULTS Age was the only variable with evidence for effect modification (p Value for interaction term=0.012), with older patients benefiting the most from CBT. We found no evidence of effect modification by any other demographic, life, illness, personality trait, or cognitive variable (p≥0.2). CONCLUSIONS Given the largely null findings, a stratified approach that might limit offering CBT is premature; CBT should be offered to all individuals where antidepressant medication has failed.
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Affiliation(s)
- Katherine S Button
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK; Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Nicholas Turner
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - John Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - David Kessler
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Willem Kuyken
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | - Tim J Peters
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Laura Thomas
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
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90
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Abstract
Cognitive-behavioral therapy (CBT) is an efficacious first-line therapy for patients with major depressive disorder (MDD). Due to the limited accessibility of CBT, long wait lists result in delayed treatment, which may affect treatment outcomes. The goal of this pilot study was to obtain preliminary data from a randomized controlled trial to determine whether delayed CBT reduces the effectiveness of the therapy compared to immediate CBT in patients with MDD receiving pharmacotherapy. Patients were randomized to receive immediate CBT (n=18) or to begin CBT after 6 months (n=20) and received 14 weekly sessions, followed by two additional booster sessions. During the active treatment months, patients in the immediate group demonstrated reductions in scores on the Beck Depression Inventory II (BDI-II) that were similar to those in the delayed CBT group. However, when the analysis was performed using only data from patients in the delayed group who were still in a depressive episode, there was an overall greater decrease in BDI-II scores in the immediate group vs. the delayed group over the active treatment months, but not specifically at the 6-month endpoint. These findings suggest delays in depression treatment, similar to what occurs with real-world wait list times, may not have a significant impact on the effectiveness of CBT in patients who are already receiving treatment as usual. However, such delays may affect the effectiveness of CBT in those patients who remain depressed during the time delay. A larger trial is necessary to confirm these findings. (Journal of Psychiatric Practice 2015;21:107-113).
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91
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Abstract
PURPOSE OF REVIEW Much has been learned from the 400 randomized trials on psychotherapies for adult depression that have been conducted, but much is also still unknown. In this study some recent attempts to further reduce the disease burden of depression through psychotherapies are reviewed. RECENT FINDINGS In the past, many new psychotherapies have promised to be more effective than existing treatments, usually without success. We describe recent research on two new therapies, acceptance and commitment therapy and cognitive bias modification, and conclude that both have also not shown to be more effective than existing therapies. A growing number of studies have also focused on therapies that may be successful in further reducing the disease burden, such as treatments for chronic depression and relapse prevention. Other studies are aimed at scaling up psychological services, such as the training of lay health counselors in low-income and middle-income countries, telephone-based, and internet-based therapies. SUMMARY Psychotherapies are essential tools in the treatment of adult depression. Randomized trials have shown that these treatments are effective, and by focusing on key issues, such as chronic depression, relapse, and scaling them up, psychotherapies contribute more and more to the reduction of the disease burden of depression.
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92
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Burger H, Bockting CLH, Beijers C, Verbeek T, Stant AD, Ormel J, Stolk RP, de Jonge P, van Pampus MG, Meijer J. Pregnancy Outcomes After a Maternity Intervention for Stressful Emotions (PROMISES): A Randomised Controlled Trial. ADVANCES IN NEUROBIOLOGY 2015; 10:443-459. [PMID: 25287553 DOI: 10.1007/978-1-4939-1372-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
UNLABELLED There is ample evidence from observational prospective studies that maternal depression or anxiety during pregnancy is a risk factor for adverse psychosocial outcomes in the offspring. However, to date no previous study has demonstrated that treatment of depressive or anxious symptoms in pregnancy actually could prevent psychosocial problems in children. Preventing psychosocial problems in children will eventually bring down the huge public health burden of mental disease. The main objective of this study is to assess the effects of cognitive behavioural therapy in pregnant women with symptoms of anxiety or depression on the child's development as well as behavioural and emotional problems. In addition, we aim to study its effects on the child's development, maternal mental health, and neonatal outcomes, as well as the cost-effectiveness of cognitive behavioural therapy relative to usual care.We will include 300 women with at least moderate levels of anxiety or depression at the end of the first trimester of pregnancy. By including 300 women, we will be able to demonstrate effect sizes of 0.35 or more on the total problems scale of the Child Behaviour Checklist 1.5-5 with alpha 5 % and power (1-beta) 80 %.Women in the intervention arm are offered 10-14 individual cognitive behavioural therapy sessions, 6-10 sessions during pregnancy and 4-8 sessions after delivery (once a week). Women in the control group receive care as usual.Primary outcome is behavioural/emotional problems at 1.5 years of age as assessed by the total problems scale of the Child Behaviour Checklist 1.5-5 years.Secondary outcomes are mental, psychomotor and behavioural development of the child at age 18 months according to the Bayley scales; maternal anxiety and depression during pregnancy and postpartum; and neonatal outcomes such as birth weight, gestational age and Apgar score, health-care consumption and general health status (economic evaluation). TRIAL REGISTRATION NTR2242.
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Affiliation(s)
- Huibert Burger
- Department of General Practice, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands,
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93
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Fountoulakis KN, McIntyre RS, Carvalho AF. From Randomized Controlled Trials of Antidepressant Drugs to the Meta-Analytic Synthesis of Evidence: Methodological Aspects Lead to Discrepant Findings. Curr Neuropharmacol 2015; 13:605-15. [PMID: 26467410 PMCID: PMC4761632 DOI: 10.2174/1570159x13666150630174343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 01/20/2023] Open
Abstract
During the last decade, several meta-analytic studies employing different methodological approaches have had inconsistent conclusions regarding antidepressant efficacy. Herein, we aim to comment on methodological aspects that may have contributed to disparate findings. We initially discuss methodological inconsistencies and limitations related to the conduct of individual antidepressant randomized controlled trials (RCTs), including differences in allocated samples, limitations of psychometric scales, possible explanations for the heightened placebo response rates in antidepressant RCTs across the past two decades as well as the reporting of conflicts of interest. In the second part of this article, we briefly describe the various meta-analyses techniques (e.g., simple random effects meta-analysis and network meta-analysis) and the application of these methods to synthesize evidence related to antidepressant efficacy. Recently published antidepressant metaanalyses often provide discrepant results and similar results often lead to different interpretations. Finally, we propose strategies to improve methodology considering real-world clinical scenarios.
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Affiliation(s)
| | | | - André F Carvalho
- 6, Odysseos str (1st Parodos Ampelonon str.), 55535 Pylaia Thessaloniki, Greece.
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94
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Penttilä M, Jääskeläinen E, Hirvonen N, Isohanni M, Miettunen J. Author's reply: To PMID 25252316. Br J Psychiatry 2014; 205:499-500. [PMID: 25452607 DOI: 10.1192/bjp.205.6.499a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Matti Penttilä
- Matti Penttilä, Oulu University Institute of Clinical Medicine and Oulu University Hospital, ; Erika Jääskeläinen, Noora Hirvonen, Matti Isohanni, Oulu University Hospital, Jouko Miettunen, Oulu University Hospital and Medical Research Center Oulu, Finland
| | - Erika Jääskeläinen
- Matti Penttilä, Oulu University Institute of Clinical Medicine and Oulu University Hospital, ; Erika Jääskeläinen, Noora Hirvonen, Matti Isohanni, Oulu University Hospital, Jouko Miettunen, Oulu University Hospital and Medical Research Center Oulu, Finland
| | - Noora Hirvonen
- Matti Penttilä, Oulu University Institute of Clinical Medicine and Oulu University Hospital, ; Erika Jääskeläinen, Noora Hirvonen, Matti Isohanni, Oulu University Hospital, Jouko Miettunen, Oulu University Hospital and Medical Research Center Oulu, Finland
| | - Matti Isohanni
- Matti Penttilä, Oulu University Institute of Clinical Medicine and Oulu University Hospital, ; Erika Jääskeläinen, Noora Hirvonen, Matti Isohanni, Oulu University Hospital, Jouko Miettunen, Oulu University Hospital and Medical Research Center Oulu, Finland
| | - Jouko Miettunen
- Matti Penttilä, Oulu University Institute of Clinical Medicine and Oulu University Hospital, ; Erika Jääskeläinen, Noora Hirvonen, Matti Isohanni, Oulu University Hospital, Jouko Miettunen, Oulu University Hospital and Medical Research Center Oulu, Finland
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95
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Leichsenring F, Schauenburg H. Empirically supported methods of short-term psychodynamic therapy in depression - towards an evidence-based unified protocol. J Affect Disord 2014; 169:128-43. [PMID: 25194781 DOI: 10.1016/j.jad.2014.08.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/22/2014] [Accepted: 08/04/2014] [Indexed: 12/28/2022]
Abstract
CONTEXT There is evidence that psychotherapy is helpful in depressive disorders, with no significant differences between psychotherapies. For psychodynamic therapy (PDT) various models prove to be efficacious. Thus, the evidence for PDT is "scattered" between different forms of PDT, also implying problems in training of psychotherapy and in transferring research to clinical practice. A unified protocol based on empirically-supported methods of PDT in depression may contribute to solve these problems METHODS Systematic search for randomized controlled trials fulfilling the following criteria: (a) individual psychodynamic therapy (PDT) of depressive disorders, (b) treatment manuals or manual-like guidelines, (c) PDT proved to be efficacious compared to control conditions, (d) reliable measures for diagnosis and outcome, and (f) adult patients. FINDINGS Fourteen RCTs fulfilled the inclusion criteria. By a systematic review of the applied methods of PDT seven treatment components were identified. A high consistency between components was found. The components were conceptualized in the form of seven interrelated treatment modules. CONCLUSIONS A unified psychodynamic protocol for depression may enhance the empirical status of PDT, facilitate both the training in psychotherapy and the transfer of research to clinical practice and may have an impact on the health care system.
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Affiliation(s)
- Falk Leichsenring
- Clinic of Psychosomatics and Psychotherapy, University of Giessen, Ludwigstrasse 76, 35392 Giessen, Germany.
| | - Henning Schauenburg
- Clinic for General Internal Medicine and Psychosomatics, University of Heidelberg, Germany
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96
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Picardi A, Gaetano P. Psychotherapy of mood disorders. Clin Pract Epidemiol Ment Health 2014; 10:140-58. [PMID: 25493093 PMCID: PMC4258697 DOI: 10.2174/1745017901410010140] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/22/2014] [Accepted: 09/28/2014] [Indexed: 11/22/2022]
Abstract
In the last decades, psychotherapy has gained increasing acceptance as a major treatment option for mood disorders. Empirically supported treatments for major depression include cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT), behavioural therapy and, to a lesser extent, short-term psychodynamic psychotherapy. Meta-analytic evidence suggests that psychotherapy has a significant and clinically relevant, though not large, effect on chronic forms of depression. Psychotherapy with chronic patients should take into account several important differences between patients with chronic and acute depression (identification with their depressive illness, more severe social skill deficits, persistent sense of hopelessness, need of more time to adapt to better circumstances). Regarding adolescent depression, the effectiveness of IPT and CBT is empirically supported. Adolescents require appropriate modifications of treatment (developmental approach to psychotherapy, involvement of parents in therapy). The combination of psychotherapy and medication has recently attracted substantial interest; the available evidence suggests that combined treatment has small but significant advantages over each treatment modality alone, and may have a protective effect against depression relapse or recurrence. Psychobiological models overcoming a rigid brain-mind dichotomy may help the clinician give patients a clear rationale for the combination of psychological and pharmacological treatment. In recent years, evidence has accumulated regarding the effectiveness of psychological therapies (CBT, family-focused therapy, interpersonal and social rhythm therapy, psychoeducation) as an adjunct to medication in bipolar disorder. These therapies share several common elements and there is considerable overlap in their actual targets. Psychological interventions were found to be useful not only in the treatment of bipolar depressive episodes, but in all phases of the disorder.
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Affiliation(s)
- Angelo Picardi
- Mental Health Unit, National Centre of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Rome, Italy
| | - Paola Gaetano
- Italian Society for Behavioural and Cognitive Therapy (SITCC), Rome, Italy
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97
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Graham BM, Callaghan BL, Richardson R. Bridging the gap: Lessons we have learnt from the merging of psychology and psychiatry for the optimisation of treatments for emotional disorders. Behav Res Ther 2014; 62:3-16. [DOI: 10.1016/j.brat.2014.07.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 02/08/2023]
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98
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99
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Kwon OY, Park SP. Depression and anxiety in people with epilepsy. J Clin Neurol 2014; 10:175-88. [PMID: 25045369 PMCID: PMC4101093 DOI: 10.3988/jcn.2014.10.3.175] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 02/19/2014] [Accepted: 02/21/2014] [Indexed: 11/17/2022] Open
Abstract
Many recent epidemiological studies have found the prevalence of depression and anxiety to be higher in people with epilepsy (PWE) than in people without epilepsy. Furthermore, people with depression or anxiety have been more likely to suffer from epilepsy than those without depression or anxiety. Almost one-third of PWE suffer from depression and anxiety, which is similar to the prevalence of drug-refractory epilepsy. Various brain areas, including the frontal, temporal, and limbic regions, are associated with the biological pathogenesis of depression in PWE. It has been suggested that structural abnormalities, monoamine pathways, cerebral glucose metabolism, the hypothalamic-pituitary-adrenal axis, and interleukin-1b are associated with the pathogenesis of depression in PWE. The amygdala and the hippocampus are important anatomical structures related to anxiety, and γ-aminobutyric acid and serotonin are associated with its pathogenesis. Depression and anxiety may lead to suicidal ideation or attempts and feelings of stigmatization. These experiences are also likely to increase the adverse effects associated with antiepileptic drugs and have been related to poor responses to pharmacological and surgical treatments. Ultimately, the quality of life is likely to be worse in PWE with depression and anxiety than in PWE without these disorders, which makes the early detection and appropriate management of depression and anxiety in PWE indispensable. Simple screening instruments may be helpful for in this regard, particularly in busy epilepsy clinics. Although both medical and psychobehavioral therapies may ameliorate these conditions, randomized controlled trials are needed to confirm that.
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Affiliation(s)
- Oh-Young Kwon
- Department Neurology and Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sung-Pa Park
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
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100
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Goldberg JS, Bell CE, Pollard DA. Revisiting the monoamine hypothesis of depression: a new perspective. PERSPECTIVES IN MEDICINAL CHEMISTRY 2014; 6:1-8. [PMID: 24737931 PMCID: PMC3981571 DOI: 10.4137/pmc.s11375] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
As the incidence of depression increases, depression continues to inflict additional suffering to individuals and societies and better therapies are needed. Based on magnetic resonance spectroscopy and laboratory findings, gamma aminobutyric acid (GABA) may be intimately involved in the pathophysiology of depression. The isoelectric point of GABA (pI = 7.3) closely approximates the pH of cerebral spinal fluid (CSF). This may not be a trivial observation as it may explain preliminary spectrophotometric, enzymatic, and HPLC data that monoamine oxidase (MAO) deaminates GABA. Although MAO is known to deaminate substrates such as catecholamines, indoleamines, and long chain aliphatic amines all of which contain a lipophilic moiety, there is very good evidence to predict that a low concentration of a very lipophilic microspecies of GABA is present when GABA pI = pH as in the CSF. Inhibiting deamination of this microspecies of GABA could explain the well-established successful treatment of refractory depression with MAO inhibitors (MAOI) when other antidepressants that target exclusively levels of monoamines fail. If further experimental work can confirm these preliminary findings, physicians may consider revisiting the use of MAOI for the treatment of non-intractable depression because the potential benefits of increasing GABA as well as the monoamines may outweigh the risks associated with MAOI therapy.
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Affiliation(s)
- Joel S Goldberg
- Durham Veterans Affairs Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Clifton E Bell
- Department of Chemistry, Winston-Salem State University, Winston-Salem, North Carolina, USA
| | - David A Pollard
- Department of Chemistry, Winston-Salem State University, Winston-Salem, North Carolina, USA
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