The clinical effectiveness of evidence-based interventions for depression: a pragmatic trial in routine practice

Association between Dietary Antioxidant Capacity in Midlife and Depressive Symptoms in Late Life: The Singapore Chinese Health Study

Preclinical and limited epidemiological studies suggest that oxidative stress may be implicated in geriatric depression. Our study investigated the association between midlife dietary total antioxidant capacity (TAC) and depressive symptoms in late life among 13,712 participants in a population-based cohort of Chinese in Singapore. At baseline (1993-1998), intake of antioxidants from diet and supplements at a mean age of 52.4 years was estimated using a validated food frequency questionnaire to derive two dietary TAC indices from vitamins C and E, carotenoids and flavonoids: the Comprehensive Dietary Antioxidant Index (CDAI) and Vitamin C Equivalent Antioxidant Capacity (VCEAC). At follow-up 3 (2014-2016), when participants were at a mean age of 72.5 years, depressive symptoms were assessed using the Geriatric Depression Scale, and depression, defined as having ≥5 symptoms, was presented in 3173 (23.1%) participants. Both CDAI and VCEAC indices were inversely associated with odds of depressive symptoms in a stepwise manner: the OR (95% CI) comparing the extreme quartiles was 0.73 (0.64-0.83; Ptrend < 0.01) for the CDAI and 0.77 (0.68-0.87; Ptrend < 0.01) for the VCEAC. Specifically, higher intakes of vitamin C, carotenoids, and flavonoids were associated with a lower likelihood of depressive symptoms. Our findings support the recommendation of an antioxidant-rich diet for the prevention of depression.

Patients with Clinically Elevated Depressive Symptoms Report Improvements in Mood, Pain, and Functioning following Participation in Interdisciplinary Pain Rehabilitation

OBJECTIVE

Chronic pain and depression frequently co-occur and exacerbate one another; therefore, it is important to treat both conditions to improve patient outcomes. The current study evaluates an interdisciplinary pain rehabilitation program (IPRP) with respect to the following questions: 1) How do clinically elevated depressive symptoms impact pain-related treatment outcomes? and 2) To what extent does IPRP participation yield reliable and clinically significant change in depressed mood?

METHODS

Participants in this study included 425 adults who engaged in a 10-week IPRP and completed self-report measures of pain, mood, and functioning at intake and discharge. Participants were categorized into 4 groups based on self-reported depressive symptoms (PROMIS Depression): within normal limits (WNL; n = 121), Mild (n = 115), Moderate (n = 153), and Severe (n = 36).

RESULTS

Participants reported significant improvement in pain, pain-related life interference, health-related quality of life, pain catastrophizing, and depressed mood regardless of initial symptom level. In addition, 43.4% of patients with Mild, Moderate, or Severe depressed mood reported reliable and clinically significant improvement in depressive symptoms and 30.3% were in remission at the end of treatment.

CONCLUSIONS

These findings support the assertion that IPRPs represent an effective treatment for patients with comorbid chronic pain and depression and that participation is associated with improvement in both conditions.

The clinical effectiveness of an algorithm-guided treatment program for depression in specialized mental healthcare: A comparison with efficacy trials

BACKGROUND

Doubts exist on whether effects found in randomized controlled trials (RCTs) are directly generalizable to daily clinical practice. This study aimed (a) to investigate the effectiveness of treatment options within an algorithm-guided treatment (AGT) program for depression and compare their effectiveness with outcomes of efficacy trials and (b) to assess the relation between treatment continuity and outcomes.

METHODS

This naturalistic study linked treatment data from January 2012 to November 2014 from a Dutch mental healthcare provider, to routine outcome monitoring (ROM) data (N = 351). Effectiveness of the treatment options (pharmacotherapy, psychotherapy and their combination) was compared to the efficacy reported in the meta-analyses. We included treatment continuity as binary variable "early terminators versus completers of the recommended number of treatment sessions".

RESULTS

Remission rates for psychotherapy (38% [95% CI: 32-45]), pharmacotherapy (31% [95% CI: 22-42]) and combination therapy (46% [95% CI: 19-75]) were respectively lower, comparable, and comparable to those reported in the meta-analyses. Similarly, response rates were respectively lower (24% [95% CI: 19-30]), lower (21% [95% CI: 13-31]), and comparable (46% [95% CI: 19-75]) to meta-analyses results. A similar share of early terminators and completers achieved remission and response.

LIMITATIONS

A substantial proportion of patients had incomplete ROM data after data linkage. Limited set of patient characteristics to check for selection bias.

CONCLUSIONS

Despite the more heterogeneous patient population in clinical practice, the effectiveness of an AGT program, emphasizing strict guideline adherence, approached that found in RCTs. A fixed number of treatment sessions may not suit all individual patients.

Outcomes, skill acquisition, and the alliance: Similarities and differences between clinical trial and student therapists

Considerable evidence from clinical trials supports the efficacy of cognitive therapy (CT) of depression. Less is known about outcomes when provided in other contexts, such as when provided by student therapists. We conducted a non-randomized comparison of student therapists vs. clinical trial therapists on change in depressive symptoms, dropout, change in CT skills, and therapeutic alliance among 100 clients with moderate to severe depression. Treatment manual and duration were the same. Clients treated by student therapists had largely comparable outcomes on depressive symptom change, therapeutic alliance, and CT skills. Results supported non-inferiority of student therapists on change in depressive symptoms, but non-inferiority was not supported when using an interviewer evaluated measure of depression. Evidence of non-inferiority was also obtained for client CT skills and therapeutic alliance. In fact, conventional superiority analyses indicated student therapists outperformed clinical trial therapists on alliance and CT skills. The rate of dropout among student therapists (30%) was numerically higher than among clinical trial therapists (17%) and our results did not support non-inferiority on dropout. CT provided by student therapists can achieve outcomes similar to those in a clinical trial, but more research about dropout is needed.

Research on the Development of Theme Trends and Changes of Knowledge Structures of Drug Therapy Studies on Major Depressive Disorder Since the 21st Century: A Bibliometric Analysis

BACKGROUND

Antidepressant treatment is one of the most effective ways of relieving or curing depressive symptoms in patients with major depressive disorder (MDD). Although many studies have explored the efficacy, tolerability, adverse reactions, and functional mechanism of the disease, there has been no systematic evaluation of the relevant results in this field.

AIM

This paper aims to analyze the theme trends and knowledge structure of drug therapy studies on MDD since the 21^st century by employing bibliometric analysis.

METHODS

Literature published in PubMed and related to drug therapy studies on MDD were retrieved between 2001 and 2018 in 6-year increments. After extracting major Medical Subject Headings (MeSH) terms/MeSH subheadings, bi-clustering analysis, social network analysis, and strategic diagrams were employed to complete bibliometric analysis.

RESULTS

Overall, 1,577, 2,680, 2,848 relevant research articles were retrieved for the periods during 2001-2006, 2007-2012, and 2013-2018, respectively. In line with strategic diagrams, the main undeveloped and peripheral theme clusters during 2001-2006 were functional mechanisms of antidepressants in pathophysiology, neuroendocrinology and neural biochemistry. These themes were replaced during 2007-2012 by clinical efficacy and influencing factors of antidepressants with or without psychotherapy, mechanisms of adverse reactions of antidepressants, and predictive studies of clinical therapeutic effects of antidepressants based on brain imaging. During 2013-2018 application and evaluation of new antidepressant agents, early identification and prevention of suicide of patients with MDD, as well as genetic- or bio-markers affecting the response and efficacy of antidepressants were the primary themes. Based on social network analyses, emerging hotspots, such as antidepressive agents, second-generation/adverse effects, depressive disorder, major/metabolism, psychotherapy/methods, and brain/drug effects could be identified during 2007-2012 and 2013-2018.

CONCLUSIONS

These undeveloped theme clusters and emerging hotspots can be helpful for researchers to clarify the current status of their respective fields and future trends, and to generate novel ideas that may launch new research directions.

Connectivity patterns of cognitive control network in first episode medication-naive depression and remitted depression

BACKGROUND

Cognitive dysfunctions, such as impaired cognitive control, are frequently observed in patients with major depressive disorder (MDD). Although the cognitive control network (CCN) is widely considered a core feature of major depressive disorder (MDD), the relationship between cognitive dysfunction and symptom dimensions remains unclear. This study investigated differences in resting-state functional connectivity of the cognitive control network (CCN) between first-episode medication-naive MDD patients and remitted MDD.

METHODS

We collected resting-state functional MRI (rs-fMRI) data from 22 first-episode medication-naive major depressive disorder (fMDD) patients, 20 patients previously diagnosed with MDD in the remitted phase of depression (rMDD), and 20 healthy controls (HC). The CCN was derived from fMRI images using independent component analysis (ICA), a data-driven image analysis method.

RESULTS

Changes in functional connectivity (FC) within the CCN was mainly attenuated in the right dorsolateral prefrontal cortex and the left inferior parietal lobule, while strengthened in the right dorsal anterior cingulate cortex and the right insula in both fMDD and rMDD groups. Compared with the fMDD group, the rMDD group had decreased FC in the bilateral insula and the right dorsolateral prefrontal cortex. Further analysis explored that the FC in the bilateral insula, the right dorsal anterior cingulate cortex and the right inferior parietal lobule were correlated positively cognitive disturbance factor scores in both patients groups.

CONCLUSIONS

These findings are in agreement with the previous findings that the cognitive control network are impaired in MDD. Furthermore, our results suggest that the alteration of CCN might underpin the cognitive disturbance and the distinct patterns of the CCN between fMDD and rMDD patients may be an important target for effective cognitive remediation in MDD.

Implementing evidence-based treatment protocols: Flexibility within fidelity

Efficacious psychological treatments exist for a variety of mental health conditions, but many who could benefit from these treatments do not receive them. Increasing efforts have been made to disseminate effective protocols, and several approaches for implementing such treatments have been proposed, including the use of protocols, principles, practices, and policies. We discuss the relative merits of disseminating protocols, and highlight the importance of employing flexibility within fidelity. We describe the benefits of using protocols, including their empirical support, guidance for decision making, and structure to facilitate training and enhance treatment integrity. We also address several criticisms that have been offered against protocols, citing data that indicates that many of the criticisms are not warranted.

Neurocognitive performance predicts treatment outcome with cognitive behavioral therapy for major depressive disorder

The current study examined the contribution of baseline neuropsychological functioning to the prediction of antidepressant outcome with cognitive behavioral therapy (CBT) for Major Depressive Disorder (MDD). We hypothesized that depressed participants who were more neurocognitively intact and had less rigid, negative thinking would respond better to CBT. Thirty-one MDD patients completed a comprehensive neuropsychological battery before initiation of CBT. A subgroup also completed a probabilistic reversal learning task. Depression severity was assessed with the Beck Depression Inventory (BDI); rigid, negative thinking was assessed with the Dysfunctional Attitudes Scale (DAS) and the Automatic Thoughts Questionnaire (ATQ) throughout treatment. Remitters were compared to non-remitters. Paradoxically, eventual remitters performed generally worse across the neuropsychological battery considered as a whole. Univariate testing showed a significant difference on only a single measure, the Continuous Performance Test d', when corrected for multiple comparisons. Baseline rigid, negative thinking did not predict treatment outcome. Results suggest that the structure of CBT may particularly benefit individuals with mild depression-related neurocognitive difficulties during a depressive episode. Further research is needed to examine these patient characteristics and their potential contribution to the mechanisms of CBT efficacy.

Assessing Personality Change with Blatt's Anaclitic and Introjective Configurations and Shedler-Westen Assessment Procedure Profiles: Two Case Studies in Psychodynamic Treatment

A growing body of empirical and clinical research attests to the influence of personality features on the development, course and outcome of psychotherapy. Over the last four decades, Blatt adopted a psychoanalytic and cognitive developmental approach in developing a theoretically and empirically grounded two-configurations model of personality. The main aim of this study was to evaluate possible changes in anaclitic and introjective configurations - as measured by the Depressive Experience Questionnaire (DEQ) (Blatt, D'Afflitti, & Quinlan, 1976) - set against simultaneous changes in personality profile measured by Shedler-Westen Assessment Procedure (SWAP-200). Two young patients, a man and a woman, characterized by different personality profiles - introjective and anaclitic, respectively - were assessed for one year in the context of a psychodynamic psychotherapy. A battery of instruments - Beck Depression Inventory II (BDI-II), Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders I and II, Defense Mechanism Rating Scale, DEQ and SWAP-200 - were administered at the beginning, during the assessment process, and after one year. Both patients displayed lower BDI-II scores, along with evident clinical progress. Defence profiles and Core Conflict Relationship Themes showed interesting developments, in keeping with the evolution of the psychotherapy process. Lastly, while DEQ profiles outlined substantial stability after one year, some important changes in SWAP-200 profiles - in particular with regard to Q factors - were observed. Although these findings should be considered as preliminary, these results appear to be consistent with the description of Self-criticism and Dependency as relatively stable personality dimensions. The potential influence of profile diversity - introjective vs anaclitic - on other key variables of the psychotherapy process is also discussed.

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: Results of a randomized controlled trial

BACKGROUND

For severe and chronic depression, inpatient treatment may be necessary. Current guidelines recommend combined psychological and pharmacological treatments for moderate to severe depression. Results for positive effects of combined treatment for depressed inpatients are still ambiguous.

METHODS

This randomised controlled trial examined the efficacy of adding an intensive and brief psychodynamic psychotherapy (IBPP) to treatment-as-usual (TAU) for inpatients with DSM-IV major depressive episode. The primary outcomes were reduction in depression severity, and response and remission rates at post-treatment, 3-month and 12-month follow-up points.

RESULTS

A linear mixed model analysis (N=149) showed a higher reduction in the observer-rated severity of depressive symptoms at each follow-up point for the IBPP condition compared with the TAU condition (post-treatment ES=0.39, 95%CI 0.06-0.71; 3-month ES=0.46, 95%CI 0.14-0.78; 12-month ES=0.32, 95%CI 0.01-0.64). Response rate was superior in the IBPP group compared with the TAU group at all follow-up points (post-treatment OR =2.69, 95%CI 1.18-6.11; 3-month OR=3.47, 95%CI 1.47-8.25; 12-month OR=2.26, 95%CI 1.02-4.97). IBPP patients were more likely to be remitted 3 months (OR=2.82, 95%CI 1.12-7.10) and 12 months (OR=2.93, 95%CI 1.12-7.68) after discharge than TAU patients.

LIMITATIONS

Heterogeneous sample with different subtypes of depression and comorbidity.

CONCLUSIONS

IBPP decreased observer-rated depression severity up to 12 months after the end of treatment. IBPP demonstrated immediate and distant treatment responses as well as substantial remissions at follow-up. IBPP appears to be a valuable adjunct in the treatment of depressed inpatients.

Randomized Trial of Interpersonal Psychotherapy and Cognitive Behavioral Therapy for Major Depressive Disorder in a Community-Based Psychiatric Outpatient Clinic

BACKGROUND

Interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) are both evidence-based treatments for major depressive disorder (MDD). Several head-to-head comparisons have been made, mostly in the United States. In this trial, we compared the two treatments in a small-town outpatient psychiatric clinic in Sweden. The patients had failed previous primary care treatment and had extensive Axis-II comorbidity. Outcome measures were reduction of depressive symptoms and attrition rate.

METHODS

Ninety-six psychiatric patients with MDD (DSM-IV) were randomized to 14 sessions of CBT (n = 48) or IPT (n = 48). A noninferiority design was used with the hypothesis that IPT would be noninferior to CBT. A three-point difference on the Beck Depression Inventory-II (BDI-II) was used as noninferiority margin.

RESULTS

IPT passed the noninferiority test. In the ITT group, 53.5% (23/43) of the IPT patients and 51.0% (24/47) of the CBT patients were reliably improved, and 20.9% (9/43) and 19.1% (9/47), respectively, were recovered (last BDI score <10). The dropout rate was significantly higher in CBT (40%; 19/47) compared to IPT (19%; 8/43). Statistically controlling for antidepressant medication use did not change the results.

CONCLUSIONS

IPT was noninferior to CBT in a sample of depressed psychiatric patients in a community-based outpatient clinic. CBT had significantly more dropouts than IPT, indicating that CBT may be experienced as too demanding. Since about half the patients did not recover, there is a need for further treatment development for these patients. The study should be considered an effectiveness trial, with strong external validity but some limitations in internal validity.

Aro T, Mikkonen TN, O. Katila H. Psychotherapy effectiveness for major depression: a randomized trial in a Finnish community

BACKGROUND

The purpose of this study is to assess the relative effectiveness of Interpersonal Psychotherapy (IPT), Psychoeducative Group Therapy (PeGT), and treatment as usual (TAU) for patients with Major Depressive Disorder (MDD) in municipal psychiatric secondary care in one Finnish region.

METHODS

All adult patients (N = 1515) with MDD symptoms referred to secondary care in 2004-2006 were screened. Eligible, consenting patients were assigned randomly to 10-week IPT (N = 46), PeGT (N = 42), or TAU (N = 46) treatment arms. Antidepressant pharmacotherapy among study participants was evaluated. The Hamilton Depression Rating scale (HAM-D) was the primary outcome measure. Assessment occurred at 1, 5, 3, 6, and 12 months. Actual amount of therapists' labor was also evaluated. All statistical analyses were performed with R software.

RESULTS

All three treatment cells showed marked improvement at 12-month follow-up. At 3 months, 42 % in IPT, 61 % in PeGT, and 42 % in TAU showed a mean ≥50 % in HAM-D improvement; after 12 months, these values were 61 %, 76 %, and 68 %. Concomitant medication and limited sample size minimized between-treatment differences. Statistically significant differences emerged only between PeGT and TAU favoring PeGT. Secondary outcome measures (CGI-s and SOFAS) showed parallel results.

CONCLUSION

All three treatments notably benefited highly comorbid MDD patients in a public sector secondary care unit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02314767 (09.12.2014).

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

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.

Interpersonal psychotherapy as add-on for treatment-resistant depression: A pragmatic randomized controlled trial

BACKGROUND

Treatment-resistant depression (TRD) is an extremely prevalent clinical condition. Although Interpersonal Psychotherapy (IPT) is an established treatment for uncomplicated depression, its effectiveness has never before been studied in patients with TRD in real-world settings. We investigate IPT as an adjunct strategy to treatment as usual (TAU) for TRD patients in a pragmatic, randomized, controlled trial.

METHODS

A total of 40 adult patients with TRD (satisfying the criteria for major depressive disorder despite adequate antidepressant treatment) were recruited from a tertiary care facility for this pragmatic trial and blinded to the evaluator. Patients were randomized to one of two treatment conditions: (1) TAU - pharmacotherapy freely chosen by the clinician (n=23) and (2) TAU+IPT (n=17). Assessments were performed at weeks 8, 12, 19 and 24. Changes in the estimated means of the Hamilton Depression Rating Scale score were the primary outcome measure. Secondary outcomes included patient-rated scales and quality of life scales. We used a linear mixed model to compare changes over time between the two groups.

RESULTS

Both treatments lead to improvements in depressive symptoms from baseline to week 24 with no significant between group differences in either primary: TAU (mean difference: 4.57; CI95%: 0.59-8.55; d=0.73) vs. IPT+TAU (mean difference: 5.86, CI95%: 1.50-10.22; d=0.93) or secondary outcomes.

LIMITATIONS

Our relatively small sample limits our ability to detect differences between treatments.

CONCLUSIONS

Both treatments lead to equal improvements in depressive symptoms. We found no evidence to support adding IPT to pharmacotherapy in patients with TRD.

TRIAL REGISTRATION

ClinicalTrials.gov-NCT01896349.

Major depression treatment in Germany-descriptive analysis of health insurance fund routine data and assessment of guideline-adherence

BACKGROUND

Guideline oriented treatment strategies of Major depressive disorder (MDD) improve treatment outcomes and reduce risks of chronicity and recurrence.

AIMS

Description of routine treatment reality and analysis of guideline fidelity in first episode MDD in Germany. Indicators: patients with severe or psychotic depression or severe psychiatric comorbidities' treatment by specialists, adequate antidepressant pharmacotherapy, permanent treatment with more than one antidepressant, long-term benzodiazepine treatment and provision of psychotherapy.

METHOD

Descriptive analysis of routine data of the German statutory health insurance fund Barmer GEK in the index year 2011 that covers a population of 7,501,110.

RESULTS

236,843 patients were diagnosed a depressive episode. 53.0% of the patients with severe depression, 34.4% with psychotic depression and 50.9% with severe psychiatric comorbidities were treated by specialists; of the patients treated by a general practitioner 48.1% with severe and 47.3% with psychotic depression received an antidepressant; 9.7% of all patients with MDD got two antidepressants simultaneously; 8.3% received longterm benzodiazepine prescriptions; 26.1% got psychotherapy.

LIMITATIONS

the analyses depends on the indicators definitions that cannot cope with the variety of individual treatment path; comparison with guidelines was complicated by a large fraction of patients with recurrent MDD that was wrongly diagnosed with first episode depression; due to the data structure, not all guideline recommendations could be examined

CONCLUSIONS

Routine practice was oriented upon the guidelines recommendations. However some aspects could be identified that bear potential for improvements.

Treating comorbid anxiety and depression: Psychosocial and pharmacological approaches

Comorbid anxiety with depression predicts poor outcomes with a higher percentage of treatment resistance than either disorder occurring alone. Overlap of anxiety and depression complicates diagnosis and renders treatment challenging. A vital step in treatment of such comorbidity is careful and comprehensive diagnostic assessment. We attempt to explain various psychosocial and pharmacological approaches for treatment of comorbid anxiety and depression. For the psychosocial component, we focus only on generalized anxiety disorder based on the following theoretical models: (1) “the avoidance model”; (2) “the intolerance of uncertainty model”; (3) “the meta-cognitive model”; (4) “the emotion dysregulation model”; and (5) “the acceptance based model”. For depression, the following theoretical models are explicated: (1) “the cognitive model”; (2) “the behavioral activation model”; and (3) “the interpersonal model”. Integration of these approaches is suggested. The treatment of comorbid anxiety and depression necessitates specific psychopharmacological adjustments as compared to treating either condition alone. Serotonin reuptake inhibitors are considered first-line treatment in uncomplicated depression comorbid with a spectrum of anxiety disorders. Short-acting benzodiazepines (BZDs) are an important “bridging strategy” to address an acute anxiety component. In patients with comorbid substance abuse, avoidance of BZDs is recommended and we advise using an atypical antipsychotic in lieu of BZDs. For mixed anxiety and depression comorbid with bipolar disorder, we recommend augmentation of an antidepressant with either lamotrigine or an atypical agent. Combination and augmentation therapies in the treatment of comorbid conditions vis-à-vis monotherapy may be necessary for positive outcomes. Combination therapy with tricyclic antidepressants, gabapentin and selective serotonin/norepinephrine reuptake inhibitors (e.g., duloxetine) are specifically useful for comorbid chronic pain syndromes. Aripiprazole, quetiapine, risperidone and other novel atypical agents may be effective as augmentations. For treatment-resistant patients, we recommend a “stacking approach” not dissimilar from treatment of hypertension In conclusion, we delineate a comprehensive approach comprising integration of various psychosocial approaches and incremental pharmacological interventions entailing bridging strategies, augmentation therapies and ultimately stacking approaches towards effectively treating comorbid anxiety and depression.

Observing the determinants of the psychotherapeutic process in depressive disorders. A clinical case study within a psychodynamic approach

This paper focuses on the relationship between depressive disorders, personality configurations, and mental functioning. A one-year treatment of a young man with the diagnosis of Depression is presented: the clinical and empirical points of view are described in depth through an assessment at the beginning and at one year after of an oriented psychodynamic psychotherapy. SCID I and II and HAMRS were administered to the patient in assessment phase. In the same phase he filled in BDI-II, and DEQ; the psychotherapist completed SWAP-200. These clinician instruments were used again after 1 year of the treatment. The PDM point of view is also presented. All sessions are audiotaped: 12 verbatim transcripts were coded with the Defense Mechanisms Rating Scale and CCRT. The results show a decrease in depressive symptoms, a change in some personality configurations, but a substantial invariance of the introjective profile, and a modification in mental functioning.

Preliminary results of a randomized controlled trial carried out with a fixed combination of S-adenosyl-L-methionine and betaine versus amitriptyline in patients with mild depression

Background

S-adenosyl-L-methionine (SAMe), a safe, endogenous, pleiotropic methyl donor well known for its antidepressant role, has been assumed to have a possible role in increasing plasma levels of compounds known to be able to raise cardiovascular risk. Although the issue is still being debated, betaine (trimethylglycine), a specific methyl donor involved in the homocysteine circuit, may be able to reduce such a risk and/or, by determining a sparing effect on endogenous SAMe, may be able to improve the clinical efficiency of SAMe itself. Indeed, preliminary results have shown clinical improvement determined by an add-on therapy with betaine administered along with SAMe, versus SAMe alone, to patients affected by mild/moderate depression.

Aim

To evaluate the safety and antidepressant role played by the association of SAMe plus betaine versus amitriptyline administered in untreated individuals with a recent diagnosis of mild depression.

Methods

This small, open-label, randomized, observational study enrolled 64 individuals with a diagnosis of mild depression according to the Zung Self-Rating Depression Scale. After randomization, they were treated with either Laroxyl^® (amitriptyline, 75 mg/day) or DDM Metile^® (enteric-coated SAMe, 500 mg/day, plus betaine, 250 mg/day) for 12 months. Assessment of clinical scores and tolerability was performed at T=0 and after 3, 6, and 12 months.

Results

After 3 months, both treatments showed a small and not statistically significant improvement. After 6 and 12 months, both treated groups demonstrated a more noticeable improved response, although the group treated with SAMe plus betaine showed better results in terms of score, number of individuals in remission, and side effects. Compliance was overlapping in both treatments.

Conclusion

The association of SAMe plus betaine seems to be a safe and effective tool to counteract mild depression and also when used as monotherapy in subjects with a recent diagnosis.

Effectiveness of cognitive behavioral group therapy for depression in routine practice

BACKGROUND

Previous research has shown that cognitive- behavioral group therapy (group CBT) is an effective treatment for depression. However, the effectiveness of this approach in routine care needs more research. The current study retrospectively examines the outcomes of patients who received group CBT for depression at a psychiatric outpatient clinic between 2003 and 2013.

METHODS

Based on patient records, 143 patients were identified as having received the treatment, and 88 patients were included in the outcome analyses. The Beck Depression Inventory (BDI-II) score was the main outcome measure.

RESULTS

The dropout rate was 17.5%. The average BDI-II score decreased from 28.5 to 18.5 from pre-treatment to post-treatment and remained stable at 3-months follow-up. The effect sizes at post-treatment and follow-up were large (d = .97 and d = 1.10, respectively). At post-treatment, 44% of the patients showed a significant improvement in depression, including 30% who recovered; at follow-up, the proportions increased to 57% and 40%, respectively. No predictors of dropout or treatment response were found.

CONCLUSIONS

Group CBT for depression can be delivered in routine care settings with good results. However, there are still many patients who drop out or do not benefit from treatment.

[Interpersonal psychotherapy from research to practice]

THEORETICAL BACKGROUND

Interpersonal therapy (IPT) is a brief, structured psychotherapy initially intended to treat adult depression that was developed in the 1970s and manualized in 1984 by G. Klerman and his team. Two main theories served as a basis for its design: Bowlby's attachment theory and communication theory. Klerman theorized that tensions and problems in interpersonal relationships (i.e. disputes) cause psychological distress in vulnerable individuals that may lead to a major depressive episode. Clinical and epidemiological studies have shown that an insecure attachment style is strongly associated with lifetime depression. Severe depressive episodes have been correlated with avoidant attachment in women.

THERAPY STRUCTURE AND TECHNIQUES

IPT is based on the hypothesis that recent or ongoing disturbances in interpersonal relationships either trigger or follow the onset of mood disorder. In practice, IPT assists patients in analysing their interpersonal relationship modes, correlating their relational states with their mood and in learning to use better communication. Resolving difficulties in interpersonal relationships through the use of better communication skills promotes the improvement of depressive symptoms. Klerman identified four interpersonal areas that seem to be highly correlated with depressive episodes: grief (a close and important personal relation who has died), interpersonal disputes (conflicts with significant people such as a spouse or another close family member), role transition (significant life changes such as retirement, parenthood or chronic and invalidating illness) and interpersonal deficits (patients who have limited social contacts and few interpersonal relations). Classically, IPT is planned around 12-16 weekly sessions. During the initial sessions, the therapist will explore all existing interpersonal relations and any significant dysfunctions, both recent and ongoing. Following this interview, the area the patient considers as driving the current depressive episode will be designated as the focus of therapy. Evaluation of depressive symptoms by a quantitative measure (i.e. Visual Analogue Scale) and qualitative measures (activity, pleasure, quality of life) reoccurs at each session. During the intermediate sessions, therapy uses current situations and events in the designated area that particularly affect the patient's mood. Coping, communication and decision-making skills are gradually improved through a number of techniques. These include non-directive and directive exploration, clarification, encouragement of affect, and communication analysis. The therapeutic relationship is empathetic and encouraging of all progress the patient makes. The final phases close the therapy and help the patient to plan future actions and improvements.

CLINICAL TRIALS OF IPT AND DEVELOPMENTS

Several controlled clinical trials in adult populations have demonstrated the efficacy of IPT in treating Major Depressive Disorder (initial and recurrent episodes). It has been recommended as an appropriate treatment option in several guidelines. It can be provided in individual, couple or group formats. There remains an ongoing discussion of the efficacy of monthly maintenance sessions in recurrent depression. Since its conception, clinical trials have explored its use in specific populations such as adolescents and the elderly. IPT has also been the object of trial in other disorders such as post-partum depression, bipolar disorder, social phobia and eating disorders.

CONCLUSION

This article reviews the basic principles and objectives of this therapeutic model. Theoretical concepts and results from research are also discussed. The approach is briefly described and the various therapeutic phases are discussed. Clinical trials have shown that IPT is effective in treating major depressive disorder in a wide variety of populations. Further trials are necessary to determine its efficacy in other psychiatric disorders.

Predicting response to cognitive therapy and interpersonal therapy, with or without antidepressant medication, for major depression: a pragmatic trial in routine practice

BACKGROUND

Identifying patient characteristics that predict response within treatments (prognostic) or between treatments (prescriptive) can inform clinical decision-making. In this study, we sought to identify predictors of response to evidence-based treatments in a sample of depressed patients seeking help in routine practice.

METHODS

Data come from a pragmatic trial of 174 patients with major depression who received an evidence-based treatment of their own choice: cognitive therapy (CT), interpersonal therapy (IPT), antidepressant medication (ADM) alone or in combination with either of the two psychotherapies. Patient characteristics measured at baseline were examined to see if they predicted subsequent response as measured with the Beck Depression Inventory (BDI) over the course of 26 weeks of treatment, using mixed regression modeling.

RESULTS

Higher agoraphobia scores at baseline predicted more change in depression scores across treatments, irrespective of the treatment received. Physical functioning moderated the response to treatment: patients with high physical functioning fared better in combined treatment than patients with low physical functioning, whereas physical functioning did not predict a differential response in the psychotherapy group. Moreover, the lowest levels of physical functioning predicted an increase of depressive symptoms in combined treatment.

LIMITATIONS

A relatively small sample size, and selection of several predictors that were less theory-driven, which hampers the translation to clinical practice.

CONCLUSIONS

If replicated, the prognostic and prescriptive indices identified in this study could guide decision-making in routine practice. Development of more uniform requirements for the analysis and reporting of prediction studies is recommended.

Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy

BACKGROUND

Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy.

METHOD

In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point.

RESULTS

Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037).

CONCLUSIONS

In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.

More than just a pill. How to include psychosocial approaches sin the treatment of anxiety & depressive disorders

Anxiety and depressive disorders are the most common psychiatric disorders, causing high personal and economic burden. Psychosocial approaches, such as psychotherapy or mind-body instruction, along with self-help approaches, exercise, and proper sleep hygiene are effective solo or additive (to pharmacotherapy) strategies. Many physicians are less familiar with these methods for treating anxiety/depressive disorders. This article seeks to illuminate psychosocial approaches for depression and anxiety that act additively or independently of pharmacotherapy and explain how physicians can utilize them.

Optimal Experimental Design With Nesting of Persons in Organizations

This paper introduces optimal design of randomized experiments where individuals are nested within organizations, such as schools, health centers, or companies. The focus is on nested designs with two levels (organization, individual) and two treatment conditions (treated, control), with treatment assignment to organizations, or to individuals within organizations. For each type of assignment, a multilevel model is first presented for the analysis of a quantitative dependent variable or outcome. Simple equations are then given for the optimal sample size per level (number of organizations, number of individuals) as a function of the sampling cost and outcome variance at each level, with realistic examples. Next, it is explained how the equations can be applied if the dependent variable is dichotomous, or if there are covariates in the model, or if the effects of two treatment factors are studied in a factorial nested design, or if the dependent variable is repeatedly measured. Designs with three levels of nesting and the optimal number of repeated measures are briefly discussed, and the paper ends with a short discussion of robust design.