Combined medication and psychotherapy in the treatment of chronic mood disorders

Prior mood disorder diagnoses do not relate to current mood disorder symptoms or patient-reported disease severity in rotator cuff patients

BACKGROUND

Surgery for rotator cuff syndrome does not always produce symptom improvement. Biological factors may explain some symptoms, but mood disorder symptoms may also contribute. The purpose of this study is to examine the interaction between disease severity, prevalence of mood disorder diagnoses, and current mood disorder symptoms in preoperative rotator cuff patients.

METHODS

A prospective cohort of patients aged 35-75 years with unilateral rotator cuff disease awaiting surgery participated. Demographics, psychiatric history, the Hospital Anxiety & Depression Scale, and the Western Ontario Rotator Cuff index were collected. Descriptive and univariate statistical testing was performed.

RESULTS

Of 140 participants (75M:65W) aged 55 ± 8 years, 34 reported a prior diagnosis of a mood disorder. There was a moderate positive relationship between disease severity and current depression and anxiety scores. Women were more likely to carry a diagnosis of a mood disorder, but there were no differences in current symptom levels between genders. No differences were found in patient-reported outcome measure scores between patients with and without a mood disorder diagnosis.

DISCUSSION

Current mood disorder symptoms were associated with greater disease severity, whereas the presence of a past mood disorder diagnosis was not. Awareness of this relationship may reduce bias about past mood disorder diagnoses during decision-making.

The effectiveness of individual interpersonal psychotherapy as a treatment for major depressive disorder in adult outpatients: a systematic review

BACKGROUND

This systematic review describes a comparison between several standard treatments for major depressive disorder (MDD) in adult outpatients, with a focus on interpersonal psychotherapy (IPT).

METHODS

Systematic searches of PubMed and PsycINFO studies between January 1970 and August 2012 were performed to identify (C-)RCTs, in which MDD was a primary diagnosis in adult outpatients receiving individual IPT as a monotherapy compared to other forms of psychotherapy and/or pharmacotherapy.

RESULTS

1233 patients were included in eight eligible studies, out of which 854 completed treatment in outpatient facilities. IPT combined with nefazodone improved depressive symptoms significantly better than sole nefazodone, while undefined pharmacotherapy combined with clinical management improved symptoms better than sole IPT. IPT or imipramine hydrochloride with clinical management showed a better outcome than placebo with clinical management. Depressive symptoms were reduced more in CBASP (cognitive behavioral analysis system of psychotherapy) patients in comparison with IPT patients, while IPT reduced symptoms better than usual care and wait list condition.

CONCLUSIONS

The differences between treatment effects are very small and often they are not significant. Psychotherapeutic treatments such as IPT and CBT, and/or pharmacotherapy are recommended as first-line treatments for depressed adult outpatients, without favoring one of them, although the individual preferences of patients should be taken into consideration in choosing a treatment.

A naturalistic trial of brief psychodynamic therapy for recurrent major depression

We examined disposition, course, and outcome for 100 outpatients offered short-term individual dynamic therapy as a primary treatment for recurrent major depression. Evaluations using the Hamilton Rating Scale for Depression (HAM-D) were conducted regularly during the year after referral. Patients failing to show a response (50% decrease in pre-treatment HAM-D scores) were referred for consultation regarding "augmentation" of therapy with antidepressant medication. Nineteen referrals failed to meet inclusion-exclusion criteria, reflecting therapist overestimation of the severity of patients' depressive symptoms; referring therapists also missed other salient clinical issues. Fourteen patients completed assessments but did not start therapy; "decliners" were more likely to report previous admissions and thus may have opted for hospitalization. Sixty-seven patients started therapy; 18 dropped out (26.9%). Of the 49 therapy completers, 23 (46.9%) did not receive augmented treatment; 20 (40.8%) demonstrated evidence of recovery during the year while 3 (6.1%) did not. Of the 26 patients (53.1%) prescribed antidepressants, 16 (32.7%) demonstrated evidence of recovery and 10 (20.4%) did not. Patient clusters also showed distinct trajectories of change on the HAM-D over the year after referral. Patients who received augmented treatment but showed no evidence of recovery scored significantly higher on indices of alexithymia. Clinical implications of the findings are considered.

Combined brief dynamic therapy and pharmacotherapy in the treatment of major depressive disorder: a pilot study

BACKGROUND

The relative efficacy of supplemental psychotherapy in the treatment of depression is still a matter of debate. Moreover, the superiority of brief dynamic therapy (BDT) over supportive psychotherapies is not well established. The aim of this study is to compare the efficacy of BDT added to medication with that of brief supportive psychotherapy (BSP) added to medication in the treatment of major depressive disorder.

METHOD

A 12-month randomized clinical trial compared BDT (n = 18) with BSP (n = 17) combined with antidepressants in outpatients with major depressive disorder. Both psychotherapies were added during the first 6 months of the trial; all patients continued to be treated with only pharmacotherapy (paroxetine or citalopram) in the following 6-month continuation phase. Efficacy was assessed using the 17-item Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety and the Clinical Global Impression (CGI). The data analysis was conducted on two samples: the per-protocol (PP) sample and the observed-cases (OC) sample.

RESULTS

Thirty-two patients completed the study. Although at the end of the combined therapies (T2) no differences emerged between the two treatment approaches, the group of patients treated with BDT showed a further clinical improvement at the end of the study (T3): a significant reduction in symptomatology emerged on the HAM-D (PP sample: F = 75.154, p = 0.03; OC sample: F = 67.149, p = 0.022) and on the CGI total scores (PP sample: F = 78.527, p = 0.016; OC sample: F = 74.104, p = 0.007). The difference in remission rates on the HAM-D (75 vs. 12.5% at T3) is statistically significant favoring BDT.

CONCLUSIONS

BDT combined with antidepressants is preferable to supportive psychotherapy combined with medication in the treatment of outpatients with major depression.

Persistence of antidepressant treatment effects in a pharmacotherapy plus psychotherapy trial for active injection drug users

The objective of this study was to determine if combined psychotherapy and pharmacotherapy reduces reported depressive symptoms compared to an assessment only condition for active drug injectors over nine months. Using a randomized controlled trial at an outpatient academic research office, the researchers applied psychotherapy (eight sessions of cognitive behavioral therapy) plus pharmacotherapy (citalopram) to active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with symptoms persisting for at least three months, or major depression plus dysthymia, and a Modified Hamilton Rating Scale for Depression (MHRSD) score greater than 13. The MHRSD scale scores were then assessed at the completion of three, six, and nine months. Participants (n = 109) were 64% male and 82% Caucasian, with a mean baseline MHRSD score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and double-depression (17%). Study retention at nine months was 89%. At the completion of three months of acute treatment, 26% of combined treatment patients (n = 53), compared to 12% of control patients (n = 56), were in remission (p = .047). At both six and nine months, the between-group differences in remission rates and mean MHRSD scores were insignificant, although the overall mean MHRSD score decreased from baseline (p < .01). At all follow-up assessments, depression remission was significantly associated with lower heroin use. Among active drug injectors diagnosed with depression, symptoms decline over time. Combined treatment is superior to an assessment-only condition in depression remission rates at the end-of-treatment, but this difference does not persist.

Reductions in HIV risk behaviors among depressed drug injectors

OBJECTIVE

To determine if, by reducing depressive symptoms, combined psychotherapy and pharmacotherapy reduces HIV drug risk behavior compared to an assessment-only condition for active drug injectors over 9 months.

DESIGN

Randomized controlled trial.

SETTING

Outpatient academic research office.

PATIENTS

Active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with depressive features persisting for at least 3 months, or major depression plus dysthymia. In addition, participants had a Hamilton Rating Scale for Depression (MHRSD) score > 13.

INTERVENTION

Psychotherapy (8 sessions of cognitive behavioral therapy) plus antidepressant pharmacotherapy over 3 months.

MAIN OUTCOME MEASURES

HIV Risk Assessment Battery (RAB) drug scale scores measured at three, six and nine months, and depression remission (MHRSD score < or = 8).

RESULTS

Participants (n= 109) were 64% male, 82% Caucasian, with a mean baseline MHRSD score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and double-depression (17%). Overall, study retention at nine months was 89%. Reported HIV drug risk scores decreased sharply over the first 3 months and continued to decline throughout the follow-up period. Between group differences were not significant in the intention-to-treat analysis. However, highly adherent participants had significantly lower HIV drug risk scores at 3 months (p<05), but not 6 and 9 months. Depression remission was significantly associated with lower HIV drug risk scores at follow-ups.

CONCLUSIONS

Combined psychotherapy and pharmacotherapy did not produce a significant reduction in HIV drug risk beyond that seen in an assessment-only control group. The greatest declines in HIV drug risk were found in participants with high protocol adherence and those with depression remission.

Adherence to treatment of depression in active injection drug users

The impact of depression on drug users is extensive, serving as a trigger for high-risk injection practices and continued drug use. Yet the ability to retain active drug users in mental health treatment has never been tested clinically. We recruited injection drug users (IDU) for a randomized study of combined psychotherapy and pharmacotherapy for the treatment of depression. Among the 53 SCID-diagnosed depressed subjects assigned to the combined treatment group, 43.4% were "fully adherent" to treatment (75% or greater attendance at cognitive-behavioral therapy (CBT) sessions or 75% or greater adherence to the pharmacotherapy regimen). The correlation of CBT attendance and pharmacotherapy use was high (r(s) =.74). Persons with double depression (major depression plus dysthymia) were most likely to be fully adherent (p =.01); frequency of heroin use was inversely associated with adherence. Developing public health treatment interventions to engage out-of-treatment, dually-diagnosed IDUs is possible.

Therapeutic Alliance in Depression Treatment: Controlling for Prior Change and Patient Characteristics

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.

Cognitive-behavioral treatment for depression in smoking cessation

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

Cognitive-behavioral treatment for depression in smoking cessation

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

Cognitive-behavioral treatment for depression in alcoholism

Alcoholics with depressive symptoms score > or = 10 on the Beck Depression Inventory (A.T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) received 8 individual sessions of cognitive-behavioral treatment for depression (CBT-D, n = 19) or a relaxation training control (RTC; n = 16) plus standard alcohol treatment. CBT-D patients had greater reductions in somatic depressive symptoms and depressed and anxious mood than RTC patients during treatment. Patients receiving CBT-D had a greater percentage of days abstinent but not greater overall abstinence or fewer drinks per day during the first 3-month follow-up. However, between the 3- and 6-month follow-ups, CBT-D patients had significantly better alcohol use outcomes on total abstinence (47% vs. 13%), percent days abstinent (90.5% vs. 68.3%), and drinks per day (0.46 vs. 5.71). Theoretical and clinical implications of using CBT-D in alcohol treatment are discussed.