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

An interdisciplinary multimodal integrative healthcare program for depressive and anxiety disorders

Objective

Although multimodal interventions are recommended in patients with severe depressive and/or anxiety disorders, available evidence is scarce. Therefore, the current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, for patients with (comorbid) depressive and/or anxiety disorders.

Methods

Participants were 3,900 patients diagnosed with a depressive and/or anxiety disorder. The primary outcome was Health-Related Quality of Life (HRQoL) measured with the Research and Development-36 (RAND-36). Secondary outcomes included: (1) current psychological and physical symptoms measured with the Brief Symptom Inventory (BSI) and (2) symptoms of depression, anxiety, and stress measured with the Depression Anxiety Stress Scale (DASS). The healthcare program consisted of two active treatment phases: main 20-week program and a subsequent continuation-phase intervention (i.e., 12-month relapse prevention program). Mixed linear models were used to examine the effects of the healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of 12-month relapse prevention program (T3).

Results

Results showed significant improvements from T0 to T2 for the primary variable (i.e., RAND-36) and secondary variables (i.e., BSI/DASS). During the 12-month relapse prevention program, further significant improvements were mainly observed for secondary variables (i.e., BSI/DASS) and to a lesser extent for the primary variable (i.e., RAND-36). At the end of the relapse prevention program (i.e., T3), 63% of patients achieved remission of depressive symptoms (i.e., DASS depression score ≤ 9) and 67% of patients achieved remission of anxiety symptoms (i.e., DASS anxiety score ≤ 7).

Conclusion

An interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, seems effective for patients suffering from depressive and/or anxiety disorders with regard to HRQoL and symptoms of psychopathology. As reimbursement and funding for interdisciplinary multimodal interventions in this patient group has been under pressure in recent years, this study could add important evidence by reporting on routinely collected outcome data from a large patient group. Future studies should further investigate the long-term stability of treatment outcomes after interdisciplinary multimodal interventions for patients suffering from depressive and/or anxiety disorders.

Meta-Analysis of the Effect of Psychotherapy in an Inpatient Setting: Examining the Moderating Role of Diagnosis and Therapeutic Approach

OBJECTIVE

The current meta-analysis investigates the efficacy of psychotherapy during psychiatric hospitalization and examines the moderating role of diagnosis and therapeutic approach.

METHODS

We conducted systematic searches in literature databases, including PubMed, PsycInfo, and Google Scholar. In total, 37 samples were included for the meta-analysis with a total of 4,443 patients. The primary outcome was the standardized mean differences in clinical status measured by symptomatic and functional measures.

RESULTS

The meta-analysis of 22 samples without a control group resulted in the upper end of the medium effect size for the overall effect of treatment during psychiatric hospitalization that included psychotherapy (k = 22, Cohen's d = 0.70, and 95% Cl 0.36 to 1.04). The meta-analysis of 15 samples with a control group resulted in the upper end of the low effect size for the contribution of psychotherapy to the improvement of patients' clinical status measured by symptomatic and functional measures (k = 15, Cohen's d = 0.43, and 95% CI 0.06 to 0.81). No significant effects were uncovered for psychotherapy orientation. Diagnosis was found to moderate the contribution of psychotherapy in an inpatient setting to the improvement of patients' clinical condition.

CONCLUSION

Psychotherapy during psychiatric hospitalization may be an effective treatment. Across the various samples, psychotherapy has a moderate effect on the reduction of psychiatric symptoms beyond the overall effect of ward treatment.

Metacognitive reflection and insight therapy in an inpatient setting: Transforming messianism to a coherent mission

Metacognitive reflection and insight therapy (MERIT) is an integrative form of psychotherapy which seeks to help adults with serious mental illness make sense of the psychosocial challenges and possibilities they face and decide how to respond to them and direct their own recovery. In this article, we present an adaptation of MERIT to the context of an inpatient ward with an accompanied case illustration. Specifically, we describe how this approach is supported by a broad intersubjective framework, followed by a presentation of processes and contents of the treatment. Special attention is given to the concurrent improvements in reflective abilities and overall well-being of the patient. The unique role that psychotherapy in general, and approaches that emphasize reflective processes in particular, play during acute crises in an inpatient setting is discussed.

Psychological treatment of depression in institutional settings: A meta-analytic review

BACKGROUND

Many depressed patients are treated in institutional settings. The number of studies focusing on psychotherapies for depressed patients in institutional settingsis limited, and only a few up-to-date meta-analyses have integrated the results of these studies.

METHODS

We conducted a meta-analysis of 32 randomized trials with 37 comparisons between psychotherapy and control conditions, examining the effects of psychotherapy for adult patients in institutional settings with depressive disorders.

RESULTS

We found that psychotherapy had a significant, small to moderate effect on depressive symptoms (g=0.42; 95% CI: 0.29~0.56), with low to moderate heterogeneity (I²=33; 95% CI: 0~55). The effects remained small but significant after adjustment for publication bias (g=0.27; 95% CI: 0.12~0.42) and in the studies with low risk of bias (g=0.32; 95% CI: 0.11~0.52). The effects were largely retained at 9 to 15 months follow-up and still significant, again after adjustment for publication bias and in studies with low risk of bias. We found no significant difference across types of institutional settings, including psychiatric inpatient settings and nursing homes, although no studies with a low risk of bias were available in nursing homes.

LIMITATIONS

We included different types of institutional settings, although we did not find a significant difference between settings. The number of studies was small and risk of bias was high in a considerable number of trials.

CONCLUSIONS

This meta-analysis provides evidence for a small to moderate and sustained effect of psychotherapy in patients in institutional settings with depression.

Defense Mechanisms and Treatment Response in Depressed Inpatients

The study investigated the extent to which defensive functioning and defense mechanisms predict clinically meaningful symptomatic improvement within brief psychodynamic psychotherapy for recurrent and chronic depression in an inpatient setting. Treatment response was defined as a reduction in symptom severity of 46% or higher from the baseline score on the Montgomery-Asberg Depression Rating Scale (MADRS). A subsample of 41 patients (19 responders and 22 non-responders) from an RCT was included. For each case, two sessions (the second and the penultimate) of brief inpatient psychodynamic psychotherapy (a manualized 12-session therapy program developed in Lausanne) were transcribed and then coded using the Defense Mechanism Rating Scales (DMRS) and the Psychotic Defense Mechanism Rating Scales (P-DMRS), an additional scale developed to study psychotic defenses. Results showed that defensive functioning and mature and immature defense changed during psychotherapy and predicted treatment response. Patient's defenses observed throughout therapy also predicted treatment response at 12-month follow-up. The addition of psychotic defenses allows a better prediction of the treatment response. Overall, these results are in line with previous research and provide further validation of defensive functioning as a predictor of outcomes and a mechanism of change in psychotherapy.

Efficacy of a fasting-mimicking diet in functional therapy for depression: A randomised controlled pilot trial

OBJECTIVE

This randomized controlled trial examined the efficacy of adding a fasting-mimicking diet to a structured psychotherapy protocol for treating depression.

DESIGN

Of 20 patients with depression, 10 were randomly assigned to psychotherapy and dieting (i.e., experimental group) and the other 10 to psychotherapy only (i.e., control group). Patients in both groups received 20 individual sessions of functional therapy along with nutrition consultation. Patients in the control group were instructed to maintain their usual daily diets.

RESULTS

Both treatments were effective in reducing depression as well as increasing self-esteem and quality of life. The experimental group showed improved self-esteem and psychological quality of life as well as a reduction in their mean body mass index, in comparison to the control group.

CONCLUSIONS

The study revealed initial evidence of the efficacy of combining psychotherapy with a fasting-mimicking diet to treat depression and its correlates.

The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF)

There is considerable diversity in how treatment-resistant depression (TRD) is defined. However, every definition incorporates the concept that patients with TRD have not benefited sufficiently from one or more adequate trials of antidepressant treatment. This review examines the issues fundamental to the systematic evaluation of antidepressant treatment adequacy and resistance. These issues include the domains of interventions deemed effective in treatment of major depressive episodes (e.g., pharmacotherapy, brain stimulation, and psychotherapy), the subgroups of patients for whom distinct adequacy criteria are needed (e.g., bipolar vs. unipolar depression, psychotic vs. nonpsychotic depression), whether trials should be rated dichotomously as adequate or inadequate or on a potency continuum, whether combination and augmentation strategies require specific consideration, and the criteria used to evaluate the adequacy of treatment delivery (e.g., dose, duration), trial adherence, and clinical outcome. This review also presents the Antidepressant Treatment History Form: Short-Form (ATHF-SF), a completely revised version of an earlier instrument, and details how these fundamental issues were addressed in the ATHF-SF.

Efficacy of inpatient psychotherapy for major depressive disorder: a meta-analysis of controlled trials

OBJECTIVE

This meta-analysis investigates the efficacy of inpatient psychotherapy in major depressive disorders compared to control conditions.

METHODS

In total, 14 studies were entered into the meta-analysis with a total of 1.080 patients. Primary outcome was the standardized mean differences in self-rated depression outcomes. A priori planned subgroup analyses included the influence of different control conditions: (a) no psychiatric inpatient treatment (e.g., waitlist control), (b) treatment as usual (TAU; e.g., non-manualized clinical management), (c) TAU determined by study design (manualized/'placebo' control condition), as well as number of sessions and influence of self- vs. clinician ratings.

RESULTS

The meta-analysis of 19 available comparisons resulted in a moderate pooled effect size showing a small and statistically significant benefit of the psychotherapeutic intervention over control conditions (g = 0.24, P < 0.001, I²  = 0%). This corresponds to a number needed to treat of 7.4. The effects of the interventions were stable over 12-month follow-up (g = 0.21, P < 0.01, I²  = 30%). Comparisons with waitlist or non-standardized control treatments tended to be associated with larger effect sizes than standardized control treatments.

CONCLUSIONS

Despite some limitations (small number of studies), this meta-analysis provides evidence for a small but sustained effect of inpatient psychotherapy in patients with major depressive disorders.