Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders

The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation

BACKGROUND

There is increasing international interest in the concept of mental well-being and its contribution to all aspects of human life. Demand for instruments to monitor mental well-being at a population level and evaluate mental health promotion initiatives is growing. This article describes the development and validation of a new scale, comprised only of positively worded items relating to different aspects of positive mental health: the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS).

METHODS

WEMWBS was developed by an expert panel drawing on current academic literature, qualitative research with focus groups, and psychometric testing of an existing scale. It was validated on a student and representative population sample. Content validity was assessed by reviewing the frequency of complete responses and the distribution of responses to each item. Confirmatory factor analysis was used to test the hypothesis that the scale measured a single construct. Internal consistency was assessed using Cronbach's alpha. Criterion validity was explored in terms of correlations between WEMWBS and other scales and by testing whether the scale discriminated between population groups in line with pre-specified hypotheses. Test-retest reliability was assessed at one week using intra-class correlation coefficients. Susceptibility to bias was measured using the Balanced Inventory of Desired Responding.

RESULTS

WEMWBS showed good content validity. Confirmatory factor analysis supported the single factor hypothesis. A Cronbach's alpha score of 0.89 (student sample) and 0.91 (population sample) suggests some item redundancy in the scale. WEMWBS showed high correlations with other mental health and well-being scales and lower correlations with scales measuring overall health. Its distribution was near normal and the scale did not show ceiling effects in a population sample. It discriminated between population groups in a way that is largely consistent with the results of other population surveys. Test-retest reliability at one week was high (0.83). Social desirability bias was lower or similar to that of other comparable scales.

CONCLUSION

WEMWBS is a measure of mental well-being focusing entirely on positive aspects of mental health. As a short and psychometrically robust scale, with no ceiling effects in a population sample, it offers promise as a tool for monitoring mental well-being at a population level. Whilst WEMWBS should appeal to those evaluating mental health promotion initiatives, it is important that the scale's sensitivity to change is established before it is recommended in this context.

The road to recovery from depression--don't drive today with yesterday's map

The issue of recovery is getting increasing attention in depression research, particularly after the publication of the STAR*D results. The paper analyzes some issues which may hinder effective treatment of major depressive disorders: the inadequacies of a cross-sectional DSM assessment without clinical differentiation of the extent, development and seriousness of the disturbances (staging); over-emphasis on and prolongation of drug treatment, without paying attention to problems related to tolerance; neglect of the active role of the patient in achieving recovery, with the integration of psychotherapeutic strategies in a sequential model. If we are able to remove the conceptual obstacles which obstruct our view of depression and silence the sound of propaganda, we may then become aware of a different scenario in mood disorders and be able to develop therapeutic strategies of enduring quality.

Prodromal stage of major depression

AIM

The aim of this review was to survey the available literature on prodromal symptoms of unipolar major depression.

METHODS

Both a computerized (Medline) and a manual search of the literature were performed.

RESULTS

In a substantial proportion of patients with depression a prodromal phase can be identified. There is a relationship between residual and prodromal symptomatology (the rollback phenomenon).

CONCLUSIONS

Appraisal of prodromal phase of major depression has important implications as to pathophysiological models of disease and relapse prevention. It may allow a staging system of depressive illness that may yield more enduring results in the therapeutic efforts.

Well-being therapy in school settings: a pilot study

BACKGROUND

There is increasing interest in the psychobiological mechanisms of resilience and psychological well-being. It is conceivable that activation of such mechanisms in the school setting may entail long-term benefits, both in terms of the developmental process and of prevention of distress. This study wants to apply and test the efficacy of a school-based intervention protocol derived from well-being therapy (WBT) compared to cognitive-behavioral strategies.

METHODS

School interventions were performed in a population of 111 students randomly assigned to: (a) a protocol using theories and techniques derived from cognitive-behavioral therapy; (b) a protocol derived from WBT. Assessment before and after interventions was performed using two self-rating scales: Kellner's Symptom Questionnaire and Ryff's Psychological Well-Being Scales.

RESULTS

Both school-based interventions resulted in a comparable improvement in symptoms and psychological well-being.

CONCLUSIONS

This new well-being-enhancing strategy could play an important role in the prevention of psychological distress in school settings and in promoting optimal human functioning among children.

The intellectual crisis of psychiatric research

The aim of this paper was to examine the intellectual crisis and the potential sources of reveille in clinical research in psychiatry. Current prevailing conceptual models in psychiatry are critically examined, with particular reference to neurobiology, clinical psychopharmacology, assessment, and the therapeutic process. Biological reductionism, neglect of individual responses to treatment, massive propaganda from the pharmaceutical industry, misleading effects of psychometric theory on clinical assessment, and lack of consideration of multiple therapeutic ingredients and of the role of psychological well-being are identified as major sources of an intellectual crisis in psychiatric research. The conceptual crisis of psychiatry is shared by other areas of clinical medicine and stems from a narrow concept of science that neglects clinical observation, the basic method of medicine. A unified concept of health and disease may yield new clinical insights in psychiatric disorders, and may result in therapeutic efforts of more enduring quality than current strategies.

Treatment-resistant depression in adolescents: recognition and management

Approximately 20% of adolescents experience at least one depressive episode by the time they enter their adult years. For most adolescents, depression, although serious, either remits spontaneously or responds to treatment. For a smaller but significant proportion of adolescents, however, depression can be long-lasting and relatively unresponsive to initial treatment. In this article the authors provide an operational definition of treatment-resistant depression, identify factors associated with treatment nonresponse, describe an approach to the management of treatment-resistant depression, and advance suggestions for promising avenues of research.

Clinical characteristics of depressed patients with comorbid diabetes mellitus

Both diabetes and depression are highly prevalent. Patients with diabetes experience higher rates of depression compared to the general population. When present, depression is associated with an increase in the morbidity and mortality of diabetes, suggesting the importance of treatment in this population. The objective of the present study was to characterize depressive characteristics in depressed patients with and without comorbid diabetes. Seventeen patients with type 1 or type 2 diabetes were drawn from outpatient clinical trials. Depressed patients without diabetes were identified from the same studies. Unpaired t-tests and multiple chi-square analyses were used to compare demographic and clinical characteristics between the samples. Diabetic patients in our sample were more depressed and reported lower levels of somatic well-being and contentment compared to non-diabetic patients. The samples did not differ significantly along other dimensions of depression, including course of illness, response to previous treatments and comorbid conditions. These findings suggest that depressed diabetic patients are more similar than not to non-diabetic depressed patients, although important differences exist.

Well-being therapy of generalized anxiety disorder

BACKGROUND

There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD.

METHODS

Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel's Clinical Interview for Depression, Ryff's Psychological Well-being Scales and Kellner's Symptom Questionnaire. A one-year follow-up was undertaken.

RESULTS

Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up.

CONCLUSIONS

These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

[Cognitive-behavioral therapy in prevention of depression relapses and recurrences: a review]

OBJECTIVES

To revise theories and the available evidence about Cognitive Behavioral Therapy (CBT) role on the relapse and recurrence prevention of depressive episodes.

METHODS

Review of random and controlled clinical trials that investigated CBT efficacy on the relapse and recurrence prevention of depressive episodes. The following databases were used: Medline, Lilacs, Cochrane, Biosis and Embase. The reference sections of the selected articles, review articles and specialized books were consulted.

RESULTS

Fifteen studies with different experimental design were found, several with methodological problems. The majority of them compared CBT with antidepressants at the acute treatment phase. In 12 studies CBT significantly lowered the relapse/recurrence rate. Recent papers pointed to the CBT usefulness for treating residual depressive symptoms as a recurrence prevention strategy.

CONCLUSION

CBT was effective for the depression relapse reduction. Its relationship with antidepressants as a prevention tool and CBT strategies (using it only in the acute phase, or during acute and maintenance phases, or after antidepressants withdrawal as a maintenance treatment, or focusing residual symptoms) need to be better investigated.

Psychological and/or educational interventions for the prevention of depression in children and adolescents

BACKGROUND

Depression is the fourth most important disease in the estimation of the burden of disease Murray 1996 and is a common problem with prevalence rates estimated to be as high as 8% in young people. Depression in young people is associated with poor academic performance, social dysfunction, substance abuse, suicide attempts, and completed suicide (NHMRC 1997). This has precipitated the development of programmes aimed at preventing the onset of depression. This review evaluates evidence for the effectiveness of these prevention programmes.

OBJECTIVES

To determine whether psychological and/or educational interventions (both universal and targeted) are effective in reducing risk of depressive disorder by reducing depressive symptoms immediately after intervention or by preventing the onset of depressive disorder in children and adolescents over the next one to three years.

SEARCH STRATEGY

The Cochrane Depression, Anxiety and Neurosis Group trials register (August 2002), MEDLINE (1966 to December Week 3 2002), EMBASE (1980 to January Week 2 2003), PsychInfo (1886 to January Week 2 2003) and ERIC (1985 to December 2002) were searched. In addition, conference abstracts, the reference lists of included studies, and other reviews were searched and experts in the field were contacted.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers based on the methods sections. The determinants for inclusion were that the trial include a psychological and/or educational prevention programme for young people aged 5 to 19 years-old, who did not meet DSM or ICD criteria for depression and/or did not fall into the clinical range on standardised, validated, and reliable rating scales of depression.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was assessed by two independent reviewers according to a list of pre-determined criteria, which were based on quality ratings devised by Moncrieff and colleagues (Moncrieff 2001). Outcome data was extracted and entered into Revman 4.2. Means and standard deviations for continuous outcomes and number of events for dichotomous outcomes were extracted where available. For trials where the required data were not reported or could not be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and described, but not included in the meta-analysis. Results were presented for each type of intervention: targeted or universal interventions; and educational or psychological interventions and if data were provided, by gender. Where possible data were combined in meta-analyses to give a treatment effect across all trials. Sensitivity analysis were conducted on studies rated as "adequate" or "high" quality, that is with a score over 22, based on the scale by Moncrieff et al (Moncrieff 2001). The presence of publication bias was assessed using funnel plots.

MAIN RESULTS

Studies were divided into those that compared intervention with an active comparison or placebo (i.e. a control condition that resembles the intervention being investigated but which lacks the elements thought to be active in preventing depression) and those that used a "wait-list" or no intervention comparison group. Only two studies fell into the former category and neither showed effectiveness although one study was inadequately powered to show a difference and in the other the "placebo" contained active therapeutic elements, reducing the ability to demonstrate a difference from intervention. Psychological interventions were effective compared with non-intervention immediately after the programmes were delivered with a significant reduction in scores on depression rating scales for targeted (standardised mean difference (SMD) of -0.26 and a 95% confidence interval (CI) of -0.40 to -0.13 ) but not universal interventions (SMD -0.21, 95% CI -0.48, 0.06), with a significant effect maintained on pooling data (SMD -0.26, 95% CI -0.36, -0.15). While small effect sizes were reported, these were associated with a significant reduction in depressive episodes. The overall risk difference after intervention translates to "numbers needed to treat" (NNT) of 10. The most effective study is the targeted programme by Clarke (Clarke 2001) where the initial effect size of -0.46 is associated with an initial risk difference of -0.22 and NNT 5. There was no evidence of effectiveness for educational interventions. Reports of effectiveness for boys and girls were contradictory. The quality of many studies was poor, and only two studies made allocation concealment explicit. Sensitivity analysis of only high quality studies did not alter the results significantly. The only analysis in which there was significant statistical heterogeneity was the sub-group analysis by gender where there was variability in the response to different programmes for both girls and boys. For the most part funnel plots indicate findings are robust for short term effects with no publication bias evident. There are too few studies to comment on whether there is publication bias for studies reporting long-term (12-36 month) follow-up.

REVIEWER'S CONCLUSIONS

Although there is insufficient evidence to warrant the introduction of depression prevention programmes currently, results to date indicate that further study would be worthwhile. There is a need to compare interventions with a placebo or some sort of active comparison so that study participants do not know whether they are in the intervention group or not, to investigate the impact of booster sessions to see if effectiveness immediately after intervention can be prolonged, ideally for a year or longer, and to consider practical implementation of prevention programmes when choosing target populations. Until now most studies have focussed on psychological interventions. The potential effectiveness of educational interventions has not been fully investigated. Given the gender differences in prevalence, and the change in these that occurs in adolescence with a disproportionate increase in prevalence rates for girls, it is likely that girls and boys will respond differently to interventions. Although differences have been reported in studies in this review the findings are contradictory and a more definitive delineation of gender specific responses to interventions would be helpful.

The relationship of psychological well-being to distress and personality

BACKGROUND

The concept of psychological well-being has been neglected for a long time in scientific literature. Over the last decades, however, many psychometric instruments have been developed to measure it. The aim of the present study was to analyze the concept of psychological well-being and its relationship to distress and personality traits. It is clinically and empirically important to establish where the measures of well-being are located in relation to symptomatology indices and personality traits.

METHODS

A sample of 450 subjects in the general population completed three self-rating scales for the assessment of symptomatology (Kellner's Symptom Questionnaire), psychological well-being (Ryff's Psychological Well-Being Scales, PWB), and personality traits (Cloninger's Tridimensional Personality Questionnaire). The assessment was repeated after 1 month. Pearson's coefficient was used to analyze PWB test-retest reliability and correlations between well-being, distress and personality indicators. Exploratory factor analysis was performed for both assessments.

RESULTS

Test-retest Pearson's coefficients were satisfactory for all six PWB scales. Exploratory factor analyses showed a 4- or 5-factor structure, where well-being, distress and personality remained separated. PWB scales were negatively and significantly correlated with all symptom scales, but only with one personality dimension, TPQ Harm Avoidance. Mean-level differences by gender showed that in general women significantly presented with lower levels of well-being (except in Positive Relations) and higher levels of distress and personality disturbances.

CONCLUSIONS

The results suggest that the relationship of well-being to distress and personality is complex. Psychological well-being could not be equated with the absence of symptomatology or with personality traits. PWB scales measure an attitude toward optimal functioning that is crucial for a comprehensive consideration of individuals in clinical settings.

Psychological aspects of traumatic injury in children and adolescents

Each year millions of children are exposed to some form of extreme traumatic stressor. These traumatic events include natural disasters (e.g., tornadoes, floods, hurricanes), motor vehicle accidents, life-threatening illnesses and associated painful medical procedures (e.g., severe burns, cancer, limb amputations), physical abuse, sexual assault, witnessing domestic or community violence, kidnapping, and sudden death of a parent. During times of war, violent and nonviolent trauma (e.g., lack of fuel and food) may have terrible effects on children's adjustment. The events of September 11, 2001 and the unceasing suicidal attacks in the Middle East underscore the importance of understanding how children and adolescents react to disasters and terrorism. The body of literature related to children and their responses to disasters and trauma is growing. Mental health professionals are increasing their understanding about what factors are associated with increased risk (vulnerability) and affect how children cope with traumatic events. Researchers recognize that children's responses to major stress are similar to adults' (reexperiencing the event, avoidance, and arousal) and that these responses are not transient. A review of the literature indicates that PTSD is the most common psychiatric disorder after traumatic experiences, including physical injuries. There is also evidence for other comorbid conditions, including mood, anxiety, sleep, conduct, learning, and attention problems. In terms of providing treatment, CBT emerges as the best validated therapeutic approach for children and adolescents who experienced trauma-related symptoms, particularly symptoms associated with anxiety or mood disorders. The best approach to the injured child requires injury and pain assessment followed by specific interventions, such as pain management, brief consultation, and crisis intervention immediately after the specific traumatic event. Family support also may be necessary to help the family through this difficult period. The main conclusion that arises from the research on resilience in development is that extraordinary resilience and recovery power of children depend on basic human protective systems operating in their favor. This finding has produced a fundamental change in the framework for understanding and helping children at high risk or already in trouble. This shift is evident in a changing conceptualization of the goals of prevention and intervention that currently address competence and problems. Strategies for fostering resilience described in this article should be tested in future controlled psychotherapy trials to verify their efficacy on children's protective factors.

Residual symptoms in elderly major depression remitters

OBJECTIVE

To assess residual symptoms in severe geriatric major depression in remission, and to determine baseline clinical and sociodemographic predictors of residual symptoms in remitters.

METHOD

A total of 108 elderly patients with unipolar major depression were evaluated and treated naturalistically for 9 months so as to record the predictors of residual symptoms in remitters. In order to reduce the likelihood of confusing residual symptoms with normal effects of age, 30 control subjects were also monitored.

RESULTS

Seventy-nine patients (73.1%) were considered remitters and 82.3% of remitters showed residual symptoms. Medical burden, chronic stress and subjective social support were the only variables which predicted the severity of residual symptoms in remitters.

CONCLUSION

Residual symptoms in elderly patients with major depression in remission should not only be attributed exclusively to intrinsic factors of the illness or the age of the individual patient, but also to external factors.

Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy

This article describes the main characteristics and technical features of a novel psychotherapeutic strategy, well-being therapy. This paper outlines the background of its development, the structure of well-being therapy, its key concepts and technical aspects. Well-being therapy is based on Ryff's multidimensional model of psychological well-being, encompassing six dimensions: autonomy, personal growth, environmental mastery, purpose in life, positive relations and self-acceptance. The goal of this therapy is improving the patients' levels of psychological well-being according to these dimensions, using cognitive-behavioral techniques. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive-behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological or psychotherapeutic treatments and in body image disturbances. The clinical studies supporting its efficacy are illustrated.

Residual symptoms in depression: an emerging therapeutic target

Residual symptoms, despite successful response to therapy, appear to be the rule in unipolar depression. Most of the residual symptoms occur in the prodromal phase of illness. Residual symptoms are associated with biological correlates, mainly involving the hypothalamic-pituitary-adrenal (HPA) axis and the sleep architecture. They are powerful predictors of relapse. These findings have led to the hypothesis that residual symptoms upon recovery may progress to become prodromal symptoms of relapse. A sequential strategy (encompassing pharmacotherapy in the acute phase of illness and cognitive behavioral therapy in its residual phase) has been developed and was found to be effective in decreasing relapse rate in controlled studies. A largely untested assumption in unipolar depression is that pharmacological strategies that are effective in the short term are the most suitable for postacute and residual phases or maintenance. The literature on subclinical symptomatology calls for specific, stage-oriented, therapeutic approaches. The efficacy of antidepressant drugs may be assessed not only on differential remission rates, but also on differential amount of residual symptomatology after response.

Evaluation eines kognitiv-verhaltenstherapeutischen Gruppenprogramms für depressive Jugendliche und junge Erwachsene

Zusammenfassung. Im Rahmen der vorliegenden Studie wurde ein Gruppenprogramm in Anlehnung an den Adolescent Coping with Depression Course (CWD-A) der Arbeitsgruppe um Lewinsohn bei depressiven Jugendlichen und jungen Erwachsenen erprobt und auf seine Wirksamkeit hin überprüft. Das hochstrukturierte, psychoeduktive Gruppenprogramm wird in Kursen mit vier bis acht Teilnehmern über 10 zweistündige Sitzungen durchgeführt. Es werden vor allem soziale und kognitive Fertigkeiten, die Planung angenehmer Aktivitäten, Kommunikations- und Problemlösefertigkeiten sowie Entspannungsübungen fokussiert, deren Vermittlung über protokollierte Selbstbeobachtung, Rollenspiele und Verhaltensübungen realisiert wird. Bisher fanden vier Kurse mit insgesamt 24 Teilnehmern statt, die Depressionen in subklinischer oder klinisch relevanter Ausprägung bzw. komorbide depressive Störungen aufwiesen. Erste Analysen zeigen neben einer signifikanten Verringerung depressiver Symptomatik und irrationalen Denkens auch eine bedeutsame Zunahme erwünschter Verhaltens- und Erlebensweisen wie angenehmer Aktivitäten, Peerintegration, Optimismus und psychologischen Wohlbefindens. Zum Zeitpunkt des Kursendes waren 56 % der ursprünglich depressiven Teilnehmer remittiert.

Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder

Patients with major depressive disorder remain at risk for relapse following remission and often continue to experience subthreshold symptoms. This study compared the rate of relapse of major depressive disorder and the prevalence of residual depressive symptoms during the continuation phase for patients treated with fluoxetine dose increase alone or in combination with cognitive therapy. A total of 132 outpatients with major depressive disorder who achieved remission with 8 weeks of treatment with fluoxetine 20 mg had the dose increased to 40 mg. They were randomized to receive cognitive therapy or medication management alone and were followed for up to 28 weeks for depressive relapse and change in depressive symptoms. A total of 47 (35.6%) out of 132 patients did not complete the 28-week continuation phase. Rates of discontinuation or relapse did not differ significantly between the groups. Change in residual symptoms or wellbeing as measured by Hamilton Depression Scale score or Symptom Questionnaire self-report also did not differ between groups. In this sample of outpatients in continuation phase treatment for major depressive disorder, the combination of cognitive therapy and fluoxetine 40 mg failed to yield any significant benefit in symptoms or relapse rates over fluoxetine 40 mg alone during 28 weeks of follow-up.

The influence of successful prophylactic drug treatment on cognitive dysfunction in bipolar disorders

BACKGROUND

Cognitive variables such as negative self-evaluations have been discussed as vulnerability factors for depressive syndromes. In the context of bipolar disorders dysfunctional cognitive structures have received little interest as these patients seem to be less disturbed during the euthymic interval than patients with major depression.

METHODS

In the present study, the self-esteem of remitted patients with DSM-III-R diagnosis of major depression (n=20), bipolar disorder (n=20) and healthy controls (n=20) was measured with the Frankfurt Self-concept Scale (FSKN).

RESULTS

1) Statistical analysis by analysis of variance (ANOVA) showed no significant differences as to age, sex, etc. between the psychiatric groups. The clinical groups showed lower self-esteem ratings in comparison to healthy controls. 2) Four groups (T1-T4) of remitted patients with bipolar disorders (20 in each group) were successfully maintained on mood stabilizers (lithium or carbamazepine) and classified by the duration of their episode-free period. T1 included those who were episode-free for only the week before discharge from hospital. T2 were symptom-free for <30 months. T3 were episode-free for >30 months and <60 months. T4 were episode-free for >60 months. The comparison of their FSKN self-esteem ratings by ANOVA suggests that self-esteem improves during successful prophylactic treatment. A posteriori contrasts indicate a normalized self-esteem after a bipolar episode-free period of at least 47 months.

CONCLUSIONS

Dysfunctional cognitions can be demonstrated in unipolar as well as in bipolar patients. Successful episode-preventive medication with mood stabilizers seems to counteract lowered self-esteem. Adjunctive cognitive therapy might help to optimize the long-term course of bipolar disorder.

Psychological well-being in rheumatoid arthritis: relationship to 'disease' variables and affective disturbance

BACKGROUND

Resilience is likely to be important in understanding psychological responses to chronic physical illnesses. This study aimed to examine one measure of resilience--Ryff's operationalized measure of psychological well-being (PWB)--in rheumatoid arthritis. It was hypothesized that PWB would be influenced by age and gender in the same way as in community samples, and that the absence of current mood disorder would be associated with high PWB.

METHODS

Rheumatology clinic outpatients (n = 104) were assessed for pain, disease activity, disability, depression and anxiety. PWB was assessed using Ryff's six-subscale model. The measured variables were used in a logistic regression analysis to model the absence of clinically important mood disorder.

RESULTS

The expected variations in PWB according to age and gender were largely absent, with the overall findings suggesting that chronic illness in general, rather than arthritis in particular, affects PWB. Significant bivariate correlations were found between depression and pain, disease activity, disability and all six PWB subscales. However, in the regression analysis, only the PWB environmental mastery subscale and self-rated disability made significant contributions to the absence of mood disturbance, and their inclusion in the regression model correctly classified 81% of the total sample.

CONCLUSIONS

These results require replication in a longitudinal study, but indicate the potential value of using PWB among people with rheumatoid arthritis to screen for individuals who may be particularly vulnerable to developing depression. It might be appropriate to target such people with focused psychological interventions.

Executive function in patients with remitted bipolar disorder and schizophrenia and its relationship with functional outcome

BACKGROUND

Recent studies have reported that differences in cognitive performance between schizophrenic and bipolar patients seem to be smaller than expected. Patients with schizophrenia have consistently shown frontal executive dysfunctions, but studies regarding executive abilities in bipolar patients are scarce and discrepant. As executive function has been associated with psychosocial functioning in schizophrenia, we wanted to investigate if such a relationship is also present in bipolar disorder and the differences between the two groups.

METHODS

Executive function was assessed in 49 euthymic (at least 6 months in remission, Hamilton Depression Rating Scale < or = 8 and Young Mania Rating Scale < or = 6) bipolar and in 49 schizophrenic, residual-type (with at least 1 year without acute exacerbation and predominant negative symptomatology) patients, by the Wisconsin Card Sorting Test (WCST), FAS Test (COWAT) and Trail Making Test. Baseline clinical and psychosocial variables were controlled and psychopathology evaluated by means of the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The two groups showed a similar pattern of cognitive deficits in tests of executive function, except for the number of categories achieved in the WCST, which was significantly lower in the schizophrenic group (F = 7.26; p = 0.009). Functional outcome was predicted by the negative syndrome (PANSSN) and perseverative errors (WCST) in schizophrenic patients, and general psychopathology (PANSSG) was the best predictor of functional outcome in the bipolar group.

CONCLUSION

Executive function was a good predictor of functional outcome in the schizophrenic group, whereas clinical variables were more predictive of the bipolar one. Patterns of cognitive disturbances in tasks of executive function are similar in both groups but quantitatively more marked in schizophrenia.

Psychological well-being and residual symptoms in remitted patients with panic disorder and agoraphobia

BACKGROUND

Little is known about psychological well-being in remitted patients with panic disorder and agoraphobia and its interactions with residual symptoms.

METHODS

Thirty patients with panic disorder and agoraphobia who displayed a successful response to exposure therapy, and 30 control subject matched for sociodemographic variables, were administered both observer-rated and self-rated scales for assessing residual symptoms and well-being.

RESULTS

Patients had significantly more residual symptoms -- as assessed by the Clinical Interview for Depression (CID) and the Symptom Questionnaire (SQ) -- than controls. They also had significantly less environmental mastery, personal growth, purpose in life and self-acceptance -- as measured by the Psychological Well-being Scales (PWB) -- and less SQ physical well-being than controls.

LIMITATION

The findings apply to patients with panic disorders who had been treated by behavioral methods and may be different in drug-treated subjects.

CONCLUSIONS

The results indicate that successful reduction of symptomatology in panic disorder cannot be equated to a pervasive recovery (encompassing psychological well-being) and may pave the way for sequential therapeutic strategies of more enduring quality.

Assessment of subclinical symptoms and psychological well-being in depression

A substantial body of research suggests that subclinical symptoms characterize the longitudinal course of major depression and have important pathophysiological and treatment implications. Specific treatment of residual symptoms may in fact improve longterm outcome, by acting on those residual symptoms that progress to become prodromes of relapse. The assessment of psychological well-being is also important, since its absence may create conditions of vulnerability to possible adversities. The route of recovery, thus, lies not exclusively in alleviating the negative, but in engendering the positive.

The prevalence and differential diagnosis of subclinical depressive syndromes in inpatients 60 years and older

BACKGROUND

Depressive syndromes that do not comply with the diagnostic criteria for specific depressive disorders are designated as 'subclinical' or 'subsyndromal' depressive syndromes. Using our own data from a clinical study, this paper outlines the significance of subclinical depressive syndromes and demonstrates the problems of differentiating between depressive and subclinical depression (SD) syndromes and organic mood disorders especially in an elderly population with medical comorbidity.

METHODS

Two hundred and sixty-two patients aged 60 years and older in a general hospital were investigated, using a clinical psychiatric interview, expert ratings and self-report scales after extensive internal medical diagnostic evaluation.

RESULTS

When, without further differentiation as to their origin, all symptoms required by symptom checklists according to ICD-10 were considered for the diagnosis of major depression (MD), 35.5% of the study participants fulfilled the diagnostic criteria. After differentiating for etiology of symptoms, MD was found in only 14.1%, SD was diagnosed in 17.6% and organic mood disorder in 12.2% of the study participants. In another 41 patients (15.6%), symptoms of depression not fulfilling ICD-10 criteria were classified as being of organic or drug-induced origin. SD patients were in a mean position between nondepressive and depressive patients with regard to social isolation and physical impairment; women were overrepresented in the depressive and subdepressive groups.

CONCLUSIONS

SD and organic mood disorder are common and helpful diagnostic categories in the elderly. The results show that in old age there is substantial danger of confounding MD, SD and organic mood disorder, thus leading to erroneously high prevalence rates of MD and underestimations of organic mood disorder if depressive symptoms are recorded only by self-report scales or a symptom checklist. Both internal and psychosomatic-psychotherapeutic competence as well as a liaison service in general hospitals are necessary for the differential diagnosis of MD, SD and organic mood disorder in the elderly with medical comorbidity.

Psychosomatic medicine: emerging trends and perspectives

Developments have occurred in all aspects of psychosomatic medicine. Among factors affecting individual vulnerability to all types of disease, the following have been highlighted by recent research: recent and early life events, chronic stress and allostatic load, personality, psychological well-being, health attitudes and behavior. As to the interaction between psychological and biological factors in the course and outcome of disease, the presence of psychiatric (DSM-IV) as well as subclinical (Diagnostic Criteria for Psychosomatic Research) symptoms, illness behavior and the impact on quality of life all need to be assessed. The prevention, treatment and rehabilitation of physical illness include the consideration for psychosomatic prevention, the treatment of psychiatric morbidity and abnormal illness behavior and the use of psychotropic drugs in the medically ill. In the past 60 years, psychosomatic medicine has addressed some fundamental questions, contributing to the growth of other related disciplines, such as psychoneuroendocrinology, psychoimmunology, consultation-liaison psychiatry, behavioral medicine, health psychology and quality of life research. Psychosomatic medicine may also provide a comprehensive frame of reference for several current issues of clinical medicine (the phenomenon of somatization, the increasing occurrence of mysterious symptoms, the demand for well-being and quality of life), including its new dialogue with mind-body and alternative medicine.

Positive affect and the other side of coping

Although research on coping over the past 30 years has produced convergent evidence about the functions of coping and the factors that influence it, psychologists still have a great deal to learn about how coping mechanisms affect diverse outcomes. One of the reasons more progress has not been made is the almost exclusive focus on negative outcomes in the stress process. Coping theory and research need to consider positive outcomes as well. The authors focus on one such outcome, positive affect, and review findings about the co-occurrence of positive affect with negative affect during chronic stress, the adaptive functions of positive affect during chronic stress, and a special class of meaning-based coping processes that support positive affect during chronic stress.

Treatment and recovery rate in depression: a critical analysis

The objective of this study was to evaluate the frequency and consequences of the presence of residual symptoms in patients treated for major depression. The literature specifically focused on recovery and residual symptomatology of depression was reviewed. Thirty per cent or more of treated patients present residual symptoms. These symptoms appear to be associated with a higher frequency and larger number of relapses and equally affect the outcome of depression in different age groups. They also seem to have a major impact on work and psychosocial functioning because of cognitive dysfunction and a reduction in social interaction affecting patients' quality of life. We found that there is scant literature on residual symptoms contrasting with the profuse reports on single or multiple antidepressant drug trials. Studies focusing on this important issue in the treatment of depression are needed.

Does effective lithium prophylaxis result in a symptom-free state of manic-depressive illness? Some thoughts on the fine-tuning of mood stabilization

Recovered depressive or manic-depressive patients on long-term lithium medication may show oscillations in their state of well-being, neuropsychological impairment, and subclinical mood disturbances. It remains an open question as to whether such changes should be labeled as "subthreshold" symptoms of depression or mania, as a particular syndromal entity not directly related to the "mood disorder," or as subtle side effects of lithium. Within a psychological theory of the action of lithium, mental effects of lithium must be postulated and should not be simply considered as side effects. Depending on medical common sense and economic restrictions, the optimization and fine-tuning of lithium prophylaxis may be advisable in selected cases, including counseling, family therapy, cognitive therapy, well-being therapy, or interpersonal psychotherapy. Also, a change of medication may be considered in patients with subjective or objective cognitive impairment.

Subclinical symptoms of panic disorder: new insights into pathophysiology and treatment

The aim of this review was to survey the available literature on prodromal and residual symptoms of panic disorder. Both a computerized (Medline) and a manual search of the literature were performed. In a substantial proportion of patients with panic disorder with agoraphobia a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon). Appraisal of subclinical symptomatology in panic disorder has important implications as to the pathophysiological model of disease, its conceptualization and treatment.

Well-being therapy: conceptual and technical issues

Well-being therapy is a short-term, well-being-enhancing psychotherapeutic strategy. It is based on Carol D. Ryff's multidimensional model of psychological well-being, encompassing environmental mastery, personal growth, purpose in life, autonomy, self-acceptance and positive relations with others. Its conceptual and technical issues are described. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological and psychotherapeutic treatments, in body image disorders and in psychosomatic medicine. The first validation studies appeared to be promising. The technique is in its preliminary stage of development and may undergo major changes in the next years. It is hoped it may herald a new trend of psychotherapy research and practice in the current symptom-oriented settings.