The Sequential Combination of Pharmacotherapy and Psychotherapy in Mood Disorders

Neurocognitive changes in depressed patients in psychodynamic psychotherapy, therapy with fluoxetine and combination therapy

BACKGROUND

Randomized controlled trials (RCTs) examining the efficacy of different forms of therapy for depression are relatively common. However, there are not many RCTs comparing neurocognitive effects of these treatments. Neurocognitive changes across three types of treatment for depression were compared. Long-term psychodynamic psychotherapy (LTPP) was compared with fluoxetine treatment, and their combination, in the treatment of moderate depression.

METHODS

A 272 adult patients with beck depression inventory (BDI) scores 20-35 were randomized to receive LTPP, fluoxetine monotherapy or their combination for a 24 months period. The Wechsler adult intelligence scale version III (WAIS-III) was the primary neuropsychological measure.

RESULT

Multilevel mixed model analyses indicated that there were neurocognitive changes within and between treatments, with statistically significant differences over time (p>.01). LTPP and combined treatment seemed to be more efficacious in modifying specific areas of cognition than fluoxetine alone.

LIMITATIONS

Sample very homogenous, threatening external validity.

CONCLUSIONS

LTPP and its combination with fluoxetine demonstrated to be effective for specific neurocognitive increasing in patients with moderate depression. This study suggests marked differences over time in the neurocognitive effects between the three treatment forms compared. Results found here may be of clinical relevance for building bridges between pharmacotherapy and psychodynamic psychotherapy.

Psicoterapia psicodinâmica e tratamento biológico com fluoxetina: comparação de resposta cognitiva em pacientes deprimidos

A depressão é uma doença grave, com repercussões importantes no humor e na cognição. Tratamentos farmacológicos e/ou psicoterápicos estão comumente indicados. O presente estudo objetivou avaliar e comparar a cognição de pacientes deprimidos antes e após 12 meses de tratamento com fluoxetina ou psicoterapia psicodinâmica. Cento e oitenta pacientes foram divididos em dois grupos, e avaliados por meio da WAIS-III. Os resultados mostraram uma melhora significativa em diferentes subtestes da WAIS-III. A MANOVA indicou que há uma diferença significativa entre os grupos nas pontuações médias obtidas na reavaliação 12 meses após o início dos tratamentos. Os resultados sugerem que a psicoterapia psicodinâmica e a terapia com fluoxetina agem de forma diferente na cognição de pacientes deprimidos.

Staging of mental disorders: systematic review

BACKGROUND

The staging method, whereby a disorder is characterized according to its seriousness, extension, development and features, is attracting increasing attention in clinical psychology and psychiatry. The aim of this systematic review was to critically summarize the tools that are available for reproducing and standardizing the clinical intuitions that are involved in a staging formulation.

METHODS

A comprehensive research was conducted on the MEDLINE, PsycINFO, EMBASE and Cochrane databases from inception to May 2012. The following search terms were used: 'stage/staging' AND 'psychiatric disorder/mental disorder/schizophrenia/mood disorder/anxiety disorder/substance use disorder/eating disorder'.

RESULTS

A total of 78 studies were identified for inclusion in the review. We discussed studies addressing or related to the issue of staging in a number of mental disorders (schizophrenia, unipolar depression, bipolar disorder, panic disorder, substance use disorders, anorexia and bulimia nervosa). The literature indicates that disorders have a longitudinal development or a treatment history that can be categorized according to stages. We proposed staging formulations for the above-mentioned psychiatric disorders.

CONCLUSION

Staging models offer innovative assessment tools for clinical psychologists and psychiatrists. Characterizing each stage of an illness demarcates major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same psychiatric diagnosis. A stage 0 to denote an at-risk condition does not appear to be warranted at the current state of research.

Clinical judgment in psychiatry. Requiem or reveille?

BACKGROUND

There is increasing awareness of a crisis in psychiatric research and practice. Psychopathology and clinical judgment are often discarded as non-scientific and obsolete methods. Yet, in their everyday practice, psychiatrists use observation, description and classification, test explanatory hypotheses, and formulate clinical decisions.

AIM

The aim of this review was to examine the clinical judgment in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy.

METHODS

A MEDLINE search from inception to August 2011 using the keywords "clinical judgment" and "clinimetric" in relation to psychiatric illness for articles in English language was performed. It was supplemented by a manual search of the literature. Choice of items was based on their established or potential incremental increase in clinical information compared with use of standard diagnostic criteria. The most representative examples were selected.

RESULTS

Research on clinical judgment has disclosed several innovative assessment strategies: the use of diagnostic transfer stations instead of diagnostic endpoints using repeated assessments, subtyping versus integration of different diagnostic categories, staging, macro-analysis, extension of clinical information beyond symptomatic features. Evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment. CONCLUSIONS. A renewed interest in clinical judgment may yield substantial advances in clinical assessment and treatment. A different clinical psychiatry is available and can be practiced now.

Major depressive disorder: new clinical, neurobiological, and treatment perspectives

In this Seminar we discuss developments from the past 5 years in the diagnosis, neurobiology, and treatment of major depressive disorder. For diagnosis, psychiatric and medical comorbidity have been emphasised as important factors in improving the appropriate assessment and management of depression. Advances in neurobiology have also increased, and we aim to indicate genetic, molecular, and neuroimaging studies that are relevant for assessment and treatment selection of this disorder. Further studies of depression-specific psychotherapies, the continued application of antidepressants, the development of new treatment compounds, and the status of new somatic treatments are also discussed. We address two treatment-related issues: suicide risk with selective serotonin reuptake inhibitors, and the safety of antidepressants in pregnancy. Although clear advances have been made, no fully satisfactory treatments for major depression are available.

Positive Affect Stimulation and Sustainment (PASS) Module for Depressed Mood: A preliminary investigation of treatment-related effects

Positive affective functioning (PAF) is critical to the development, course and treatment of depressive symptoms. Targeting key features of PAF during treatment may provide a new angle through which to improve affective functioning and reduce symptoms. The current study was a treatment development trial for the Positive Affect Stimulation and Sustainment (PASS) Module. PASS is conceptualized as a means of capitalizing on positive events (e.g. planned through behavioral activation) by enhancing and sustaining positive affective states through savoring, and establishing positive attributions and expectancies. Participants were 27 female college students with dysphoric symptoms. There was a moderate effect of PASS on depressive symptoms. There was also a significant within session increase in positive affect from pre to post session among the PASS group, relative to active control; and a significant decrease in positive affect from pre (baseline) to post (follow-up) treatment among the control group, relative to PASS. Results provide preliminary evidence for the efficacy of the treatment module among young adults with depressed mood, and lay the foundation for future research.