The influence of comorbid anxiety on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder

The interplay of personality pathology and treatment outcome in psychosomatic psychotherapy: A longitudinal analysis using latent change score modelling

INTRODUCTION

While ample data demonstrate the effectiveness of inpatient psychosomatic treatment, clinical observation and empirical evidence demonstrate that not all patients benefit equally from established therapeutic methods. Especially patients with a comorbid personality disorder often show reduced therapeutic success compared to other patient groups. Due to the heterogeneous and categorical personality assessment, previous studies indicated no uniform direction of this influence. This complicates the derivation of therapeutic recommendations for mental disorders with comorbid personality pathology.

METHODS

Analyzing n = 2094 patients from German university hospitals enrolled in the prospective "MEPP" study, we tested the dynamic interaction between dimensionally assessed personality functioning and psychopathology of anxiety and depression.

RESULTS

Longitudinal structural equation modelling replicated the finding that the severity of symptoms at admission predicts symptom improvement within the same symptom domain. In addition, we here report a significant coupling parameter between the baseline level of personality function and the change in general psychopathology - and vice versa.

DISCUSSION AND CONCLUSION

These results imply that personality pathology at admission hinders the therapeutic improvement in anxiety and depression, and that improvement of personality pathology is hindered by general psychopathology. Furthermore, the covariance between both domains supports the assumption that personality functioning and general psychopathology cannot be clearly distinguished and adversely influence each other. A dimensional assessment of the personality pathology is therefore recommendable for psychotherapy research and targeted therapeutic treatment.

Interpersonal Psychotherapy: A Review of Theory, History, and Evidence of Efficacy

Interpersonal psychotherapy (IPT) is an empirically validated treatment for mood disorders, anxiety disorders, eating disorders, and trauma. IPT is based on the concept of "relational frame"-that an individual's experience of psychological distress impacts those around them, and that their social support network impacts the distressed individual. This concept, along with the specific techniques and tools that flow from it and the theoretical bases of IPT (attachment and interpersonal theory) make IPT unique. In this article we review the theoretical bases of IPT (attachment and communication) and provide a brief history of IPT, as well as the evidence supporting its use for a variety of disorders. We also describe its application to groups, adolescents, and other diverse populations. Future directions for research and treatment development are proposed, particularly research in the area of combining IPT with other psychotherapeutic modalities.

The influence of depression and anxiety on cognition in people with multiple sclerosis: a cross-sectional analysis

There are conflicting findings about the relationships between depression, anxiety, and cognitive dysfunction in people with multiple sclerosis (MS), and a paucity of research has examined the cumulative influence on cognition of depression plus anxiety. This study aimed to determine whether elevated symptoms of depression and anxiety alone or in combination are associated with worse cognition in people with MS. In this cross-sectional analysis, people with MS consecutively seen at a tertiary neuropsychiatry clinic completed the Hospital Anxiety and Depression Scale for symptoms of depression (HADS-D) and anxiety (HADS-A), and the Minimal Assessment of Cognitive Function in MS for cognitive indices. Accounting for covariates, regression models predicted cognitive indices from scores for HADS-D, HADS-A, and the interaction. Of 831 people with MS, 72% were female, mean age was 43.2 years, and median Expanded Disability Status Scale score was 2.0. Depressive symptoms were independently predictive of lower verbal fluency (Controlled Oral Word Association Test, p < 0.01), verbal learning (California Verbal Learning Test-II (CVLT-II) total learning, p = 0.02), verbal delayed recall (CVLT-II delayed recall, p < 0.01), and processing speed (Symbol Digit Modalities Test, p < 0.01; three-second Paced Auditory Serial Addition Test (PASAT), p = 0.05; two-second PASAT, p = 0.01). Anxiety in people with depression predicted decreased visuospatial function (Judgment of Line Orientation, p = 0.05), verbal learning (p < 0.01), verbal delayed recall (p < 0.01), visuospatial recall (Brief Visuospatial Memory Test-Revised, p = 0.02), and executive function (Delis-Kaplan Executive Function System, p < 0.01). Anxiety alone was not independently predictive of cognition. In conclusion, depression, especially with comorbid anxiety, is associated with cognitive dysfunction in people with MS.

Demand management processes to improve access to cognitive-behavioral therapies for anxiety disorders: a grounded theory study

Introduction

Anxiety disorders are impactful mental health conditions for which evidence-based treatments are available, notably cognitive-behavioral therapies (CBTs). Even when CBTs are available, demand-side factors limit their access, and actors in a position to perform demand management activities lack a framework to identify context-appropriate actions.

Methods

We conducted a constructivist grounded theory study in Quebec, Canada, to model demand management targets to improve access to CBTs for anxiety disorders. We recruited key informants with diverse experiences using purposeful, then theoretical sampling. We analyzed data from 18 semi-directed interviews and 20 documents through an iterative coding process centered around constant comparison.

Results

The resulting model illustrates how actors can target clinical-administrative processes fulfilling the demand management functions of detection, evaluation, preparation, and referral to help patients progress on the path of access to CBTs.

Discussion

Modeling clinical-administrative processes is a promising approach to facilitate leveraging the competency of actors involved in demand management at the local level to benefit public mental health.

The influence of parental rearing style on the incidence of panic disorder, major depressive disorder and the comorbidity among Chinese college students

BACKGROUND

Panic disorder (PD), major depressive disorder (MDD), and the comorbidity (PD&MDD) in college students have caused a heavy disease burden for individuals and families. However, little was known for the comorbidity, especially the impact of parental rearing style on the incidence of the PD&MDD comorbidity.

METHODS

A cohort study was conducted among 6652 Chinese college students. Composite International Diagnostic Interview (CIDI-3.0) was used for disease diagnosis. The parental rearing styles were measured by the Egna Minnen Beträffande Uppfostran (EMBU) scale and factor analysis was used to reduce the dimension of the EMBU scale. Multinomial logistic regression models were used to determine the relationships between parenting styles and disease incidence. SPSS version 26.0 was used for all statistical analyses.

RESULTS

The 1-year incidence of PD, MDD, and PD&MDD comorbidity was 0.27 %, 2.04 %, and 0.21 %, respectively. Emotional warmth mode (OR = 0.753, 95%CI: 0.631-0.899, P < 0.01) were only negatively correlated with major depressive disorder. However, punishment denial mode (OR = 1.857, 95%CI: 1.316-2.620, P < 0.01) and over-participation mode (OR = 1.862, 95%CI: 1.176-2.949, P < 0.01) were positively correlated with the comorbidity of panic disorder and major depressive disorder.

LIMITATIONS

The limited follow-up period was only 1 year in this study which had impacted the collection of new onset cases.

CONCLUSIONS

Parental rearing style has a long-term influence on the psychiatric status of college students. Parenting style interventions working as the second level of mental disorder prevention will play an important role in MDD, PD and comorbidity prevention.

Effect of interpersonal psychotherapy on social functioning, overall functioning and negative emotions for depression: A meta-analysis

BACKGROUND

Interpersonal psychotherapy (IPT) has been widely used for depression. However, current studies of IPT have been restricted to depressive symptoms, and the results for improving social functioning were controversial.

METHODS

A comprehensive literature search of randomized controlled trials (RCTs) was conducted through eleven databases. Data analysis was performed by RevMan5.3, and effects were summarized by using a random effects model of mean differences with 95 % confidence intervals.

RESULTS

From 2443 records, eleven studies met inclusion and exclusion criteria were used for meta-analysis. The results showed that IPT had significant effects on improving social functioning (SMD: -0.53, 95 % CI: -0.80 to -0.26), reducing depression (SMD: -0.49, 95 % CI: -0.80 to -0.19) and anxiety (SMD: -0.90, 95 % CI: -1.28 to -0.52), but the effect on the overall functioning (SMD: -0.37, 95 % CI: -0.73 to -0.01) is not obvious. Moreover, subgroup analysis showed that IPT was effective in improving social functioning in adolescent depression (SMD: -0.35, 95 % CI: -0.58 to -0.13) and perinatal depression (SMD: -1.01, 95 % CI: -1.35 to -0.67), while there was no significant difference in the adult depression group (SMD: -0.39, 95 % CI: -1.05 to 0.27).

LIMITATION

The blind method cannot be carried out in most studies due to the particularity of psychotherapy, heterogeneity in some results.

CONCLUSION

IPT has a significant effect on improving social functioning and reducing depression and anxiety, while the effect on overall functioning requires further research. Overall, IPT is one of the effective nonpharmacological treatments for depression.

Prevalence and prediction of dropout during depression treatment in routine outpatient care: an observational study

Efficacious treatments are available for major depressive disorder (MDD), but treatment dropout is common and decreases their effectiveness. However, knowledge about prevalence of treatment dropout and its risk factors in routine care is limited. The objective of this study was to determine the prevalence of and risk factors for dropout in a large outpatient sample. In this retrospective cohort analysis, routinely collected data from 2235 outpatients with MDD who had a diagnostic work-up between 2014 and 2016 were examined. Dropout was defined as treatment termination without achieving remission before the fourth session within six months after its start. Total and item scores on the Dutch Measure for Quantification of Treatment Resistance in Depression (DM-TRD) at baseline, and demographic variables were analyzed for their association with dropout using logistic regression and elastic net analyses. Data of 987 subjects who started routine outpatient depression treatment were included in the analyses of which 143 (14.5%) dropped out. Higher DM-TRD-scores were predictive for lower dropout odds [OR = 0.78, 95% CI = (0.70-0.86), p < 0.001]. The elastic net analysis revealed several clinical variables predictive for dropout. Higher SES, higher depression severity, comorbid personality pathology and a comorbid anxiety disorder were significantly associated with less dropout in the sample. In this observational study, treatment dropout was relatively low. The DM-TRD, an easy-to-use clinical instrument, revealed several variables associated with less dropout. When applied in daily practice and combined with demographical information, this instrument may help to reduce dropout and increase treatment effectiveness.

Comparing the associations of three psychometric scales at baseline with long-term prognosis of depression over a 10-year period

OBJECTIVE

The Depression and Somatic Symptoms Scale (DSSS), a free scale, includes depression (DS) and somatic (SS) subscales. This study aimed to compare the associations of the baseline DSSS, Hamilton Depression Rating Scale (HAMD) and Hospital Anxiety and Depression Scale (HADS) scores with the outcome of depression over a 10-year follow-up period.

METHODS

Two hundred ninety outpatients with major depressive disorder (MDD) were enrolled and were followed-up at the 6-month, 2-year, and 10-year points. The three scales were administered at each follow-up. Multiple linear regressions were used to compare the associations.

RESULTS

In a comparison of the HAMD, DS, and HADS-depression, the HAMD and DS scores at baseline were most strongly associated with the HAMD score at two (6-month and 2-year) and one (10-year) follow-up points, respectively. In a comparison of the HAMD, DS, SS, HADS-depression, and HADS-anxiety, the SS and HAMD scores at baseline were most strongly associated with the HAMD score at two (6-month and 10-year) and one (2-year) follow-up points, respectively.

CONCLUSIONS

The DS, SS, and HAMD scores at baseline were significantly associated with the long-term outcome of depression. Scales or subscales assessing somatic symptoms might be more strongly associated with the outcome of depression.

A multidimensional investigation of anxiety sensitivity and depression outcomes in cognitive-behavioral group therapy

We examined how anxiety sensitivity - the fear of symptoms of anxiety due to their perceived harmful effects - and gender are associated with treatment trajectory and outcomes in a large outpatient sample (N = 278) who received 14-weeks of cognitive-behavioral group therapy (CBGT) for depression. Three dimensions of anxiety sensitivity (cognitive, physical, and social concerns) and depression were assessed at pre-treatment, and the latter was assessed weekly during treatment. Latent growth curve models supported a link between cognitive concerns (fears of losing control over thoughts) and greater improvement in depression near the end of treatment (i.e., weeks 10-14); gender did not moderate trajectory. Gender (i.e., identifying as a woman) and greater physical concerns (fears of physical consequences of arousal symptoms) were associated with completion of < 8 sessions. Results suggest that those with more cognitive concerns might require greater time in treatment and/or benefit most from the focus on maladaptive assumptions and core beliefs in later CBGT sessions. Future research, including investigation of intervening variables, may elucidate the mechanisms through which greater physical concerns and gender are associated with treatment non-completion. Results supported differential associations of anxiety sensitivity dimensions with depression treatment outcomes, though further research attention is needed.

Mental disorders in adolescents, youth, and adults in the RPS Birth Cohort Consortium (Ribeirão Preto, Pelotas and São Luís), Brazil

Although depression and anxiety are known to result in disabilities and workplace and health system losses, population-based studies on this problem are rare in Brazil. The current study assessed the prevalence of mental disorders in adolescents, youth, and adults and the relationship to sociodemographic characteristics in five birth cohorts (RPS) in Ribeirão Preto (São Paulo State), Pelotas (Rio Grande do Sul State), and São Luís (Maranhão State), Brazil. Major depressive episode, suicide risk, social phobia, and generalized anxiety disorder were assessed with the Mini International Neuropsychiatric Interview. Bootstrap confidence intervals were estimated and prevalence rates were stratified by sex and socioeconomic status in the R program. The study included 12,350 participants from the cohorts. Current major depressive episode was more prevalent in adolescents in São Luís (15.8%; 95%CI: 14.8-16.8) and adults in Ribeirão Preto (12.9%; 95%CI: 12.0-13.9). The highest prevalence rates for suicide risk were in adults in Ribeirão Preto (13.7%; 95%CI: 12.7-14.7), and the highest rates for social phobia and generalized anxiety were in youth in Pelotas, with 7% (95%CI: 6.3-7.7) and 16.5% (95%CI: 15.4-17.5), respectively. The lowest prevalence rates of suicide risk were in youth in Pelotas (8.8%; 95%CI: 8.0-9.6), social phobia in youth in Ribeirão Preto (1.8%; 95%CI: 1.5-2.2), and generalized anxiety in adolescents in São Luís (3.5%; 95%CI: 3.0-4.0). Mental disorders in general were more prevalent in women and in individuals with lower socioeconomic status, independently of the city and age, emphasizing the need for more investment in mental health in Brazil, including gender and socioeconomic determinants.

On the Road to Personalized Psychotherapy: A Research Agenda Based on Cognitive Behavior Therapy for Depression

In this conceptual paper, we outline the many challenges on the road to personalized psychotherapy, using the example of cognitive behavior therapy (CBT) for depression. To optimize psychotherapy for the individual patient, we need to find out how therapy works (identification of mechanisms of change) and for whom it works (identification of moderators). To date, psychotherapy research has not resulted in compelling evidence for or against common or specific factors that have been proposed as mechanisms of change. Our central proposition is that we need to combine the "how does it work?"-question with the "for whom does it work?"-question in order to advance the field. We introduce the personalized causal pathway hypothesis that emphasizes the links and distinction between individual patient differences, therapeutic procedures and therapy processes as a paradigm to facilitate und understand the concept of personalized psychotherapy. We review the mechanism of change literature for CBT for depression to see what we have learned so far, and describe preliminary observational evidence supporting the personalized causal pathway hypothesis. We then propose a research agenda to push the ball forward: exploratory studies into the links between individual differences, therapeutic procedures, therapy processes and outcome that constitute a potential causal pathway, making use of experience sampling, network theory, observer ratings of therapy sessions, and moderated mediation analysis; testing and isolation of CBT procedures in experiments; and testing identified causal pathways of change as part of a personalized CBT package against regular CBT, in order to advance the application of personalized psychotherapy.

Comorbidity with more anxiety disorders associated with a poorer prognosis persisting at the 10-year follow-up among patients with major depressive disorder

OBJECTIVE

No study has investigated the association between number of anxiety disorders (NADs) and long-term outcome over 10 years among patients with major depressive disorder (MDD). This study investigated this issue.

METHODS

At baseline, 290 outpatients with MDD were enrolled, 149 with at least one anxiety disorder (AD). Subjects were followed-up at six-month, two-year, and 10-year points. The Structured Clinical Interview for DSM-IV-TR was used to confirm psychiatric diagnoses. NADs at baseline was recorded. The Hamilton Depression Rating Scale (HAMD), the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), and the somatic subscale (SS) of the Depression and Somatic Symptoms Scale were employed. Generalized Estimating Equation models were used for statistical analysis.

RESULTS

MDD patients with ADs had greater depression, anxiety, and somatic severities at the three follow-up points than those without. NADs was significantly and positively correlated with the three dimensions and total duration of pharmacotherapy at follow-up. NADs was independently associated with symptom severity after controlling for depression and anxiety at baseline and pharmacotherapy. When the DSM-5 criteria for ADs were applied, the results were unchanged. Specific phobia, panic disorder and social phobia, and panic disorder and specific phobia were independently associated with depression, anxiety, and somatic symptoms, respectively.

LIMITATION

Pharmacotherapy at follow-up was not controlled. The three follow-up intervals were unequal.

CONCLUSIONS

Comorbidity with more ADs was associated with a poorer prognosis. The negative impacts of ADs on MDD persisted at the ten-year follow-up point. NADs was associated with the long-term prognosis of MDD.

The association between the socioeconomic status and anxiety-depression comorbidity in patients with psoriasis: a nationwide population-based study

BACKGROUND

Numerous studies have indicated that comorbid anxiety and depression are associated with a more severe course of illness. Yet generally, the study of the effect of psoriasis on patients' mental health has considered anxiety and depression to be separate states.

OBJECTIVE

To measure the association between psoriasis and anxiety, depression and anxiety-depression co-occurrence among patients according to their socioeconomic statuses (SES).

METHODS

A nationwide population-based study of psoriasis patients and age and gender frequency-matched controls (n = 255 862) was designed. Diagnostic data were obtained from Clalit Health Services, the largest managed care organization in Israel. This database was established using continuous real-time input from healthcare providers, pharmacies, medical care facilities and administrative computerized operating systems.

RESULTS

After controlling for demographic and clinical variables, psoriasis was associated with anxiety (OR 1.11, 95% CI 1.01-1.23, P < 0.05), depression (OR 1.17, 95% CI 1.08-1.26, P < 0.001), and anxiety and depression co-occurrence (OR 1.32, 95% CI 1.21-1.45, P < 0.001) among patients with low SES, yet was associated only with anxiety (OR 1.15 95% CI 1.04-1.27, P < 0.001) but not depression or comorbid anxiety-depression among patients with high SES. Survival analyses indicated that between the ages of 40 and 60, the cumulative probability of psoriasis patients with low SES to suffer from anxiety, depression and their co-occurrence inclined more sharply with age as compared to psoriasis patients with high SES.

CONCLUSIONS

As psoriasis patients with low SES are prone to suffer from more severe courses of anxiety and depression, the choice of treatment of psoriasis should address the SES as well as the underlying psychiatric disease.

What is anxious depression? Overlap and agreement between different definitions

Anxiety is common in depressed patients. However, a problem with the research on the significance of anxiety in depressed patients is that anxiety has been characterized in different ways. Little research has examined the concordance and overlap between the various definitions of anxious depression. With research on the DSM-5 anxious distress specifier just beginning, it will be important to understand how defining anxious depression according to DSM-5 agrees with previously studied definitions. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the DSM-5 anxious distress specifier and 6 other approaches towards defining anxious depression. Three hundred thirty-one patients with a principal diagnosis of major depressive disorder were evaluated with semi-structured diagnostic interviews. The mean number of anxious depression definitions met was 4.7 (SD = 2.1). Only 4.2% (n = 14) of the 331 patients did not meet any anxious depression definition, and 28.1% (n = 93) met all 7 definitions. The level of agreement between the definitions was significant, albeit modest (median kappa = .28). The modest association between the different definitions of anxious depression suggests that the results based on one approach towards subtyping may not generalize to the DSM-5 anxious distress specifier. It therefore cannot be assumed that the DSM-5 anxious distress specifier is valid just because other definitions of anxious depression have been shown to be valid.

Do comorbid social and other anxiety disorders predict outcomes during and after cognitive therapy for depression?

BACKGROUND

Cognitive therapy (CT) improves symptoms in adults with major depressive disorder (MDD) plus comorbid anxiety disorder, but the specific type of anxiety may influence outcomes. This study compared CT outcomes among adults with MDD plus social, other, or no comorbid anxiety disorders.

METHODS

Outpatients with recurrent MDD (N = 523, including 87 with social and 110 with other comorbid anxiety disorders) received acute-phase CT. Higher risk responders (n = 241 with partial or unstable response) were randomized to 8 months of continuation treatment (CT or clinical management plus fluoxetine or pill placebo), followed by 24 months of assessment. Lower risk responders (n = 49) were assessed for 32 months without additional research treatment. Depression, anxiety symptoms, and social avoidance were measured repeatedly.

RESULTS

Other (non-social), but not social, anxiety disorders predicted elevated depression and anxiety symptoms throughout and after acute-phase CT. Social, but not other, anxiety disorder predicted greater reduction in depressive symptoms during acute-phase CT and elevated social avoidance during and after acute-phase CT.

LIMITATIONS

Anxiety disorders were assessed only before acute-phase treatment. The anxiety symptom measure was brief. Generalization to other patient populations and treatments is unknown.

CONCLUSIONS

Non-social comorbid anxiety disorders may reduce the efficacy of acute-phase CT for MDD by diminishing both short- and longer term outcomes relative to depressed patients without comorbid anxiety disorders. Comorbid social anxiety disorder may increase relative reductions in depressive symptoms during acute-phase CT for MDD, but patients with comorbid social anxiety disorder may require specialized focus on social avoidance during CT.