Cognitive-behavioral and psychodynamic group psychotherapy in treatment of geriatric depression

A meta-analysis of CBT efficacy for depression comparing adults and older adults

INTRODUCTION

This meta-analysis investigates CBT treatment efficacy fordepression, and compares outcomes between adults (young and middle aged) and older adults (OA).

METHODOLOGY

Effect sizes (Hedges' g) were obtained from 37 peer-reviewed RCTs, 25 adult papers (participant n = 2948) and 12 OA papers (participant n = 551), and analysed with the random effects model.

RESULTS

No significant difference between age groups is reported in terms of CBT efficacy for depression compared to other treatments (Q_between (1) = 0.06, p = .89), with the overall effect favouring CBT over any other treatments (g = 0.48, 95 % CI = 0.29-0.68). The same pattern of results was found when restricting studies to those which used active control conditions (Q_between (1) = 0.03, p = .86) or passive control conditions (Q (1) = 2.45, p = .12).

DISCUSSION

No significant differences in efficacy for CBT treatment for depression are found when comparing adults and OA. CBT is as efficacious with OA as with adults.

Management of burning mouth Syndrome: A position paper of the Chinese Society of Oral Medicine

BACKGROUND

Burning mouth syndrome is a syndrome with tongue as the main affected site and burning pain as the main complaint. Although a variety of therapies have been reported to treat BMS, there is a lack of widely recognized therapies and it is still a dilemma for clinicians to treat BMS.

OBJECTIVE

To develop the position paper and provide the references for clinical practice of BMS in China.

METHODS

Under the guidance of WHO (World Health Organization) Handbook for Guideline Development, we used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach as a tool to develop this position paper in the following steps: setting up the groups, formulating the clinical questions and choosing the outcomes, retrieving and synthesizing of evidence, assessing the evidence, investigating the patients' values and preferences, developing the recommendations, reviewing the recommendations, and writing the position paper.

RESULTS

The 27 recommendations were formed from the following 7 aspects: pre-treatment examination, removal of stimuli, medication, physical therapy, psychological therapy, and antipsychotics. There are 3 strong recommendations and 12 weak recommendations in pre-treatment examination and removal of stimuli, as well as 12 weak recommendations in therapies.

CONCLUSION

The Chinese position paper for management of BMS has been developed, which could provide the references for clinical practice of BMS in China. Twenty-seven recommendations were formed based on consensus of experts on the balance of benefits vs side effects, evidence, cost, and patients' values and preferences, although the quality of evidence is relatively low.

Cognitive–behavioural therapy with older people

Cognitive–behavioural therapy (CBT) is an effective treatment for a number of psychiatric disorders in adults of all ages. With the proportion of the population aged 65 or over increasing steadily, it is important to be aware of how the CBT needs of this age group can be best met. This article provides an overview of CBT and the historical context of using it with older people. Although an understanding of the individual, irrespective of age, is at the core of CBT, potential modifications to the procedure and content aimed at optimising its effectiveness for older people are discussed.

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes.

Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried.

Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need.

Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy.

Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders.

Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

The Efficacy of Group Therapy for Depression

This article reviews the empirical research on the efficacy of group therapy for depressive disorders from 1970 to 1986. The review was undertaken in light of a multidimensional classification system designed to clarify differences between conceptual and measurement parameters of the various studies. The results suggest that group interventions have shortterm efficacy in the alleviation of depressive symptomatology with an outpatient population. Although more research needs to be done before definitive conclusions can be drawn, the availablefollow-up data suggest that lasting well-being would be anticipated following successful group inten'ention. As there was nofocus on the process-outcome interaction, no conclusions could be drawn about factors responsible for the positive outcome found.

Cognitive-behavioural therapy versus psychodynamic psychotherapy for the treatment of depression: a critical review of evidence and current issues

Two of the most popular psychotherapeutic approaches to treat depression are cognitive-behavioural therapy and psychodynamic psychotherapy, yet little consensus has been reached concerning which therapy is most beneficial for the treatment of depression. A review of the literature revealed that, while cognitive-behavioural therapy and psychodynamic psychotherapy are the most effective psychotherapeutic modalities for the treatment of depression, evidence suggests that neither of these modalities is superior to the other. Furthermore, multiple issues plague the studies investigating these treatments. Efficacy and effectiveness are often confounded, while rates of remission and response are often far less than might be expected from such highly regarded and widely used treatments. Severity of depression appears to moderate treatment outcomes, yet many studies overlook this, while the impact that the aetiology of a patient’s depression has on treatment outcomes is largely ignored in the literature. Additionally, a majority of studies have focused on therapies of short duration, which often have poor follow-up results. Finally, mechanisms of change in the treatment of depression have been ignored to a large extent, but there is some evidence that non-specific therapeutic factors may be more important than specific therapeutic techniques in producing positive treatment outcomes. These issues need to be closely examined and resolved if researchers and clinicians are serious about optimising treatments, improving outcomes, and adequately addressing the serious problem of depression.

A Dynamic Psychotherapy Group for the Elderly

This paper describes a dynamic group for elderly chronically mentally ill patients within a day hospital setting. It highlights some of the difficulties of working psychodynamically with older people, but also suggests that psychological mindedness can be learnt as part of the process. Dependency issues can be confronted, facilitating increased autonomy and self-esteem.

Group psychoeducative cognitive-behaviour therapy for mixed anxiety and depression with older adults

OBJECTIVES

There is a dearth of older adult evidence regarding the group treatment for co-morbid anxiety and depression. This research evaluated the effectiveness of a low-intensity group psychoeducational approach.

METHOD

Patients attended six sessions of a manualised cognitive-behavioural group. Validated measures of anxiety, depression and psychological well-being were taken at assessment, termination and six-week follow-up from patients, who also rated the alliance and their anxiety/depression at each group session. Staff rated patients regarding their functioning at assessment, termination and six-week follow-up. Outcomes were categorised according to whether patients had recovered, improved, deteriorated or been harmed. Effect sizes were compared to extant group interventions for anxiety and depression.

RESULTS

Eight groups were completed with 34 patients, with a drop-out rate of 17%. Staff and patient rated outcome measures showed significant improvements (with small effect sizes) in assessment to termination and assessment to follow-up comparisons. Over one quarter (26.47%) of patients met the recovery criteria at follow-up and no patients were harmed. Outcomes for anxiety were better than for depression with the alliance in groups stable over time.

CONCLUSION

The intervention evaluated shows clinical and organisational promise. The group approach needs to be further developed and tested in research with greater methodological control.

Empirically supported methods of short-term psychodynamic therapy in depression - towards an evidence-based unified protocol

CONTEXT

There is evidence that psychotherapy is helpful in depressive disorders, with no significant differences between psychotherapies. For psychodynamic therapy (PDT) various models prove to be efficacious. Thus, the evidence for PDT is "scattered" between different forms of PDT, also implying problems in training of psychotherapy and in transferring research to clinical practice. A unified protocol based on empirically-supported methods of PDT in depression may contribute to solve these problems

METHODS

Systematic search for randomized controlled trials fulfilling the following criteria: (a) individual psychodynamic therapy (PDT) of depressive disorders, (b) treatment manuals or manual-like guidelines, (c) PDT proved to be efficacious compared to control conditions, (d) reliable measures for diagnosis and outcome, and (f) adult patients.

FINDINGS

Fourteen RCTs fulfilled the inclusion criteria. By a systematic review of the applied methods of PDT seven treatment components were identified. A high consistency between components was found. The components were conceptualized in the form of seven interrelated treatment modules.

CONCLUSIONS

A unified psychodynamic protocol for depression may enhance the empirical status of PDT, facilitate both the training in psychotherapy and the transfer of research to clinical practice and may have an impact on the health care system.

Cognitive-Behaviour Therapy for Depression: Empirical Findings and Methodological Issues in the Evaluation of Outcome

The aim of this paper is to examine the treatment-outcome literature related to cognitive-behaviour therapy for depression in adults. Evidence for the effectiveness of cognitive-behaviour therapy is obtained from comparisons with waiting-list controls, non-specific controls, and other treatments, including pharmacotherapy. Short term effects are superior to those obtained with waitinglist controls, but are at least equivalent to pharmacotherapy. Longer term effects are difficult to evaluate due to methodological problems in such studies, particularly the lack of maintenance medication comparison groups. Nevertheless, the long term effects appear to be promising. Issues and data concerning the prediction and prevention of relapse are discussed. It is recommended that future research should focus on broader assessment goals and include cost-benefit analyses.

Group psychotherapies for depression in persons with HIV: A systematic review

Studies investigating effectiveness of group psychotherapy intervention in depression in persons with HIV have showed varying results with differing effect sizes. A systematic review of randomized controlled trials of group psychotherapy in depression in persons with HIV has been conducted to present the best available evidence in relation to its effect on depressive symptomatology. Electronic databases were searched to identify randomized controlled trials. Selected studies were quality assessed and data extracted by two reviewers. If feasible, it was planned to conduct a meta-analysis to obtain a pooled effect size of group psychotherapeutic interventions on depressive symptoms. Odds ratio for drop out from group was calculated. The studies were assessed for their quality using the Quality Rating Scale and other parameters for quality assessment set out by COCHRANE. The quality of reporting of the trials was compared against the Consolidated Standards of Reporting Trials (CONSORT) checklist for non-pharmacological studies (CONSORT-NPT). Four studies met the full inclusion criteria for systematic review. The trials included in the review examined group interventions based on the Cognitive behavioral therapy model against other therapeutic interventions or waiting list controls. In all four studies, group psychotherapy was an effective intervention for reducing depressive symptoms in persons with HIV in comparison to waiting list controls. The reported benefits from the group psychotherapy in comparison to active controls were less impressive. There were no statistically significant differences in drop outs at post treatments across group psychotherapy, wait list control, and other active interventions. The methodological quality of the studies varied. The quality of reporting of the studies was sub-optimal. The results of this systematic review support that group psychological interventions for depression in persons with HIV have a significant effect on depressive symptomatology. This review also indicates that group cognitive behavioral therapies are an acceptable psychological intervention for persons with HIV and comorbid depression.

[Effect of schema-focused therapy on depression, anxiety and maladaptive cognitive schemas in the elderly]

INTRODUCTION

Depression is one of the most frequent mental disorders in older people, known to increase rates of disability and mortality. Depression in late life, commonly accompanied by multiple medical illnesses, reduces quality of life and is a strong risk factor for suicide. Despite its clinical significance, depression remains underdiagnosed and inadequately treated in older patients. Cognitive-behavioural psychotherapies have the most empirical support in treating late-life depression, and are recommended by numerous guidelines in this indication. Group interventions are also recommended for older adults because they offer peer support, mitigate social isolation, encourage shared empathy and provide a context for peer feedback help from the group. Previous studies have shown that maladaptive schemas have an important role in the development or maintenance of depression and anxiety in older people, either as risk factors or as vulnerability markers, but there are no studies that have examined the effectiveness of schema-focused therapy to improve depression in late life.

OBJECTIVES

The main goals of the present study were to explore the relationship of maladaptive schemas with depression and anxiety severity in aged inpatients, and to evaluate the efficacy of a cognitive-behavioural individual and group treatment program that includes schema-focused therapy on depression, anxiety, and cognitive schemas activation.

METHODS

The sample consisted of aged depressed inpatients (n=51) treated in a psychiatric unit. Participants completed measures of depression (Geriatric Depression Scale [GDS]) and anxiety (State-Trait Anxiety Inventory [STAI]) severity and maladaptive schemas (Cognitive Inventory of Subjective Distress [CISD]) at pre- and post-intervention (mean hospital stay: 4weeks).

RESULTS

The maladaptive schemas Loss of Individuality, Refusal of Assistance and Vulnerability are more activated in our sample of depressed subjects with regard to the reference population. Most of specific maladaptive schemas (except Fear of Losing Control) were significantly correlated to depression and anxiety-state severity. The GDS and the STAI scores, and the activation of five of seven maladaptive schemas measured by the CISD decreased significantly after treatment.

DISCUSSION

This study confirms the results of previous research and shows that specific maladaptive schemas are related to depression and anxiety severity in clinically depressed aged patients. Contrary to other previous studies, we find that the activation of maladaptive schemas can decrease during a group psychotherapeutic program that includes schema-focused therapy. These findings support the feasibility of individual and group schema-focused therapy to assist older people suffering from depression effectively.

Treatment of depression in late life

This paper updates the 1996 review of treatment approaches published in the Am J Geriatr Psychiatry (1996;4[suppl 1]:S51-S65 [see ref33]) and a chapter in A Guide to Treatments that Work (Nathan PE, Gorman JM, eds), Oxford University Press, New York, 1998 [see ref 54]:. The major focus is on psychophannacoiogy with attention also to the évidence for the efficacy of psychotherapeutic and somatic approaches.

Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects

This systematic review evaluates the efficacy of psychosocial interventions for the acute treatment of late-life depression and identifies predictors of treatment outcomes and moderators of treatment effects. Problem-solving therapy, cognitive behavioral therapy, and treatment initiation and participation program have supportive evidence of efficacy, pending replication. Although the data on predictors of treatment outcomes and moderators of treatment effects are preliminary, it appears that baseline anxiety and stress level, personality disorders, endogenous depression, and reduced self-rated health predict worse depression outcomes. Future research may examine the moderating effects of baseline depression severity and identify other clinical or demographic moderators.

Is group psychotherapy effective in older adults with depression? A systematic review

OBJECTIVE

Earlier reviews and meta-analyses have consistently concluded that psychological treatment of depression is effective in older adults. We conducted a systematic review randomised controlled trials of group psychotherapy to present the best available evidence in relation to its effectiveness in older adults with depressive disorders.

METHODS

Electronic databases were searched to identify randomised controlled trials. Selected studies were quality assessed and data extracted by two reviewers.

RESULTS

Six trials met the inclusion criteria. The trials included in the review examined group interventions based on the cognitive behavioural therapy (CBT) model with active therapeutic interventions or waiting list controls. Group psychotherapy is an effective intervention in older adults with depression in comparison to waiting list controls, the overall effect size is very modest (MD = -3.92, 95%CI: -6.18, -1.67). The reported benefits of group intervention in comparison to other active interventions did not reach statistical significance. The benefits of group psychotherapy were maintained at follow-up. The quality of the studies varied and studies were heterogeneous.

CONCLUSIONS

Although quality of many studies was not optimal, the results of this meta analysis support the results of earlier meta analyses. Group cognitive behavioural therapy is effective in older adults with depression.

Pretherapy Training for Group Cognitive Therapy with Depressed Older Adults

Cette étude portait sur l'utilité d'une procédure de préparation à la thérapie cognitive en groupe pour des personnes âgées souffrant de dépression. Vingt-neuf sujets furent assignés aléatoirement soit à une condition de préthérapie expérimentale, soit à une condition contrôle. Les sujets âgés de 65 ans ou plus présentaient un score d'au moins 14 au Questionnaire de Dépression de Beck ou à l'Échelle de Dépression Gériatrique, et Us n'avaient jamais eu d'expérience de la psychothérapie. La procédure de préthérapie fut élaborée à partir de la théorie socio-cognitive de Bandura et elle impliquait la persuasion verbale, l'expérience vicariante, ainsi que l'accomplissement de comportements. La préthérapie a amélioré la connaissance des sujets concernant la psychothérapie et elle a favorisé le développement d'une attitude centrée sur le problème pendant la thérapie. Toutefois le taux des abandons, la fidélité de la participation aux sessions, les attentes de rôle, et l'issue de la thérapie cognitive n'ont pas été influencés de manière significative par la préthérapie. Prenant en considération l'ensemble des sujets des deux conditions, 53.7 pour cent des sujets ont manifesté une amélioration cliniquement significative à la fin de l'intervention. Les implications pour la recherche et la pratique clinique font l'objet de la discussion.

Relations entre certaines caractéristiques des sujets et la réponse à la thérapie cognitive de la dépression avec des personnes âgées

Available research supports the therapeutic usefulness of cognitive therapy for depressed older adults. Few studies have addressed the issue of response prediction. This research investigates the associations between several pre-intervention characteristics of subjects and therapy outcomes in the context of a group intervention. The characteristics under study were severity of depressive symptommatology, endogenous depression profile, subjective health status, perceived social support, and frequency of cognitive depressive symptoms representing a negative view of oneself. A more severe depressive symptomatology and a more negative health perception were associated with a less favourable outcome of therapy. Although the majority of endogenous patients benefitted from the intervention, only a minority reached the level of symptom remission at the end of treatment. A more pronounced cluster of symptoms characterized by negative thoughts about oneself tended to be associated with a worse outcome. Perceived social support was unrelated to therapy outcome.

Les stratégies comportementales adoptées par les personnes âgées devant les sentiments dépressifs

In the present study, 50 French speaking elderly, living in a home for the aged, were asked to indicate situations which provoked depressive feelings and the strategies they used to cope with these situations. The results show marked differences between the depressed and the non-depressed elderly in the situations that provoke and/or maintain depressive feelings. In regard to the type of strategies reported to cope with depressive feelings, the results show that the depressed elderly not only reported employing fewer strategies, but also noted having less success in coping with these situations. The findings have implications for the clinical assessment and treatment of depression in the elderly.

Late-life depression with comorbid cognitive impairment and disability: nonpharmacological interventions

Less than half of older adults with depression achieve remission with antidepressant medications, and rates of remission are even poorer for those with comorbid conditions. Psychosocial interventions have been effective in treating geriatric depression, either alone or better yet, in combination with antidepressant medications. Traditional strategies for nonpharmacological treatment of late-life depression do not specifically address the co-occurring cognitive impairment and disability that is prevalent in this population. Newer therapies are recognizing the need to simultaneously direct treatment efforts in late-life depression towards the triad of depressive symptoms, cognitive dysfunction, and functional disability that is so often found in geriatric depression, and this comprehensive approach holds promise for improved treatment outcomes.

A review of empirically supported psychological therapies for mood disorders in adults

BACKGROUND

The mood disorders are prevalent and problematic. We review randomized controlled psychotherapy trials to find those that are empirically supported with respect to acute symptom reduction and the prevention of subsequent relapse and recurrence.

METHODS

We searched the PsycINFO and PubMed databases and the reference sections of chapters and journal articles to identify appropriate articles.

RESULTS

One hundred twenty-five studies were found evaluating treatment efficacy for the various mood disorders. With respect to the treatment of major depressive disorder (MDD), interpersonal psychotherapy (IPT), cognitive behavior therapy (CBT), and behavior therapy (BT) are efficacious and specific and brief dynamic therapy (BDT) and emotion-focused therapy (EFT) are possibly efficacious. CBT is efficacious and specific, mindfulness-based cognitive therapy (MBCT) efficacious, and BDT and EFT possibly efficacious in the prevention of relapse/recurrence following treatment termination and IPT and CBT are each possibly efficacious in the prevention of relapse/recurrence if continued or maintained. IPT is possibly efficacious in the treatment of dysthymic disorder. With respect to bipolar disorder (BD), CBT and family-focused therapy (FFT) are efficacious and interpersonal social rhythm therapy (IPSRT) possibly efficacious as adjuncts to medication in the treatment of depression. Psychoeducation (PE) is efficacious in the prevention of mania/hypomania (and possibly depression) and FFT is efficacious and IPSRT and CBT possibly efficacious in preventing bipolar episodes.

CONCLUSIONS

The newer psychological interventions are as efficacious as and more enduring than medications in the treatment of MDD and may enhance the efficacy of medications in the treatment of BD.

Exploring the feasibility and efficacy of a telehealth stroke self-management programme: a pilot study

PURPOSE

Moving On after STroke (MOST) is an established self-management programme for persons with stroke and their care partners. Through 18 sessions over 9 weeks, each including discussion and exercise, participants learn about goal-setting, problem-solving, exercise, and community-reintegration skills. This study was undertaken to evaluate the feasibility and efficacy of telehealth delivery of MOST.

METHOD

Efficacy was evaluated using an experimental non-randomized trial comparing a telehealth MOST intervention group (T-MOST) (n = 10) with a waiting list control group (WLC) (n = 8). Outcome measures included the Berg Balance Scale (BBS), the Reintegration to Normal Living Index, the Stroke-Adapted Sickness Impact Profile, Goal Attainment Scaling, and the Geriatric Depression Scale. The feasibility evaluation included attendance rates, focus groups, and facilitator logs. In MOST Telehealth, one co-facilitator was local and the other was connected by videoconference.

RESULTS

Attendance rates for persons with stroke (83.9%, SD = 2.6) and care partners (76.7%, SD = 2.9) and participant and facilitator experiences indicated feasibility of this mode of programme delivery. There was a significant difference in BBS scores between the T-MOST group and the WLC group (mean difference -4.27, 95%CI: -6.66 to -1.87). Participants reported additional benefits, including increased motivation and awareness of partners' needs. Videoconferencing was reported to decrease their sense of isolation.

CONCLUSION

It appears feasible to deliver the MOST programme with two facilitators, one connected by videoconference and one in person. In addition, preliminary evidence suggests that the programme is associated with improved well-being in persons with stroke and their care partners. Practitioners delivering self-management programmes may consider wider dissemination using videoconferencing.

Group psychotherapy: an additional approach to burning mouth syndrome

INTRODUCTION

Glossodynia or burning mouth syndrome (BMS) is a common and poorly understood disorder. Its treatment is uncertain. Otherwise, there is some evidence of the importance of psychological factors in the genesis of this disease.

OBJECTIVES

Verify the usefulness of group psychotherapy as an adjuvant therapeutic method in the treatment of BMS. CASUISTICS AND METHODS: The study group consisted of 64 consecutive patients with a clinical diagnosis of BMS seen at the Stomatology Outpatient Clinic, ENT Department, Sao Paulo University Medical School, between May 2002 and May 2007. All the patients were submitted to physical examination, laboratorial screening tests, psychological assessment (Crown-Crisp Experimental Inventory), and answered a short form of the McGill Pain Questionnaire. Only 44 patients who did not show any abnormality in the protocol exams entered the study. Twenty-four of them underwent group psychotherapy. Twenty patients received placebo. Chi-square test was applied to compare the results of treatment with or without psychotherapy.

RESULTS

There were 15 men and 29 women in the study group. Tongue burning was the main complaint of the patients. Improvement of symptoms was reported by 17 (70.8%) of the patients undergoing psychotherapy, while among those who did not eight (40%) had improvement of symptoms (P=.04).

CONCLUSION

Psychological assessment demonstrated a close correlation between symptoms and psychological factors, suggesting that group psychotherapy is an important alternative to conventional treatment methods.

Cognitive behavioural therapy and reminiscence techniques for the treatment of depression in the elderly: a systematic review

Psychotherapy, including cognitive behavioural therapy (CBT), reminiscence and general psychotherapy (GPT), is viewed as effective treatment for depression, but its efficacy in older people is not well defined. This systematic review included 14 randomized controlled trials that assessed the efficacy of psychotherapy for treating depression in elderly people (> or = 55 years). The results of this meta-analysis showed that, compared with placebo, psychotherapy was more effective in reducing depression scores (standardized mean difference -0.92; 95% confidence interval -1.21, -0.36). Subgroup analysis showed that CBT, reminiscence and GPT were all more effective than placebo; psychotherapy as an adjunct to antidepressant medication did not increase effectiveness. There was no significant difference between CBT and reminiscence in improving depression. A higher drop-out rate was observed in studies that did not include psychotherapy versus those that did, although this difference was not statistically significant. Thus, various general formats of psychotherapy are effective for treating depression in older people, although psychotherapy does not significantly increase the effectiveness of anti-depressant medication.

Brief dynamic therapy combined with pharmacotherapy in the treatment of major depressive disorder: long-term results

BACKGROUND

There is a paucity of controlled trials examining the efficacy of brief dynamic psychotherapy (BDT) in the treatment of major depressive disorder, especially in a long-term perspective. The aim of the present study is to evaluate recurrence rates in unipolar major depressed patients who are responsive to acute phase combined treatment with BDT plus pharmacotherapy in comparison with patients initially treated with pharmacotherapy alone.

METHODS

Subjects for this study were 92 patients who met criteria for remission at the end of a 6-month acute treatment phase for major depressive disorder, single episode, with combined therapy (BDT plus pharmacotherapy) versus pharmacotherapy alone. 41 (64.1%) subjects were remitters to combined treatment and 51 (61.4%) were remitters to antidepressants alone. The study included a 6-month continuation treatment trial with pharmacotherapy and a following perspective, naturalistic 48-month follow-up (without any treatment).

RESULTS

Patients who received combined treatment, in comparison with those who were treated with pharmacotherapy alone, show a significant lower rate of recurrences of depressive episodes at 48-months naturalistic follow up (27.5% in comparison with 46.9%: chi(2)=3.525; df=1; p=.048).

LIMITATIONS

Inclusion and exclusion criteria may limit the generalizability of the results. Furthermore it may be unclear whether the effect is attributable to BDT per se as opposed to extra time with a therapist.

CONCLUSIONS

The significant lower recurrence rates in a 48-month follow-up in the group of patients treated with the addition of BDT to medication in the acute phase support the view of the advantage in the long-term outcome of adding psychotherapeutic intervention to pharmacotherapy in the acute therapy of unipolar major depression.

Developing an intervention for depressed, chronically medically ill elders: a model from COPD

BACKGROUND

Geriatric depression preferentially afflicts individuals with chronic medical illnesses. Disability, hopelessness, lack of acceptance of antidepressant treatment, and limited problem-solving skills contribute to poor treatment adherence, compromised outcomes, and chronically experienced adversity.

METHODS

This paper uses depression comorbid with chronic obstructive pulmonary disease (COPD) as a model entity to develop an approach for integrating treatment components essential for improving treatment adherence and outcomes.

RESULTS

The behavioral inertia of depression and its coexisting cognitive problems reduce adherence to the sustained and complex demands of the COPD rehabilitation regimen and antidepressant treatment. An intervention identifying reasons for poor treatment adherence and offering direct instructions for addressing them can be combined with problem-solving therapy to target treatment adherence, depressive symptoms, and disability.

CONCLUSIONS

An intervention focusing on treatment adherence and problem-solving skills development may serve as the platform for administering specific treatments to address the interacting problems of depressed medically ill patients.

The Empirical Status of Psychodynamic Therapies

The goal of the current review is to examine the evidence for the efficacy of dynamic psychotherapy, primarily focusing on studies that meet the rigorous criteria proposed by Chambless & Hollon (1998). We examine whether any progress has been made over the past decade in evaluating the efficacy of dynamic psychotherapy using well-controlled randomized designs. Over the past decade, multiple studies have been published supporting the efficacy of dynamic psychotherapy for the treatment of specific mental disorders. Dynamic psychotherapy should now be included as a possibly efficacious treatment for panic disorder and borderline personality disorder, as well as the original designation of possibly efficacious in the treatment of opiate dependence. In the context of medication usage, dynamic psychotherapy should be considered efficacious in the treatment of major depressive disorder (MDD). Studies suggest that dynamic psychotherapy has great promise as a monotherapy for MDD and alcohol dependence and thus should be evaluated further.

The effectiveness of group cognitive behaviour therapy for unipolar depressive disorders

This paper evaluates the effectiveness of group cognitive behaviour therapy (GCBT) as an intervention for unipolar depressive disorders. PsychINFO and PubMed databases were selected to generate the 34 papers used for this review. Our results showed that effect sizes for GCBT over the control conditions range from small (0.1) to large (2.87) with the mean effect size of 1.10. The pre-post treatment effect sizes for GCBT range from 0.30 to 3.72 with a mean of 1.30. Convergent evidence was demonstrated across different outcome measures of GCBT. Our findings indicated that GCBT yielded outcomes better than no-treatment controls and was comparable with other treatments (including both bona fide and non-bona fide comparison treatments). It was concluded that GCBT was effective for the treatment of Unipolar depression and thus can be used with confidence. There is now an urgent need to develop and evaluate a coherent GCBT theory, in particular the roles of group processes in GCBT, before further major advancement in this area can be made.

Psychotherapeutic treatments for older depressed people

BACKGROUND

Despite a number of reviews advocating psychotherapy for the treatment of depression, there is relatively little evidence based on randomised controlled trials that specifically examines its efficacy in older people.

OBJECTIVES

To examine the efficacy of psychotherapeutic treatments for depression in older people.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 11/9/2006. The International Journal of Geriatric Psychiatry and Irish Journal of Psychiatry were handsearched. Reference lists of previous published systematic reviews, included/excluded trial articles and bibliographies were scrutinised. Experts in the field were contacted..

SELECTION CRITERIA

All randomised controlled trials that included older adults diagnosed as suffering from depression (ICD or DSM criteria) were included. All types of psychotherapeutic treatments were included, categorised into cognitive behavioural therapies (CBT), psychodynamic therapy, interpersonal therapy and supportive therapies.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed, using odds ratios for dichotomous outcomes and weighted mean differences (WMD) for continuous outcomes, with 95% confidence intervals. Primary outcomes were a reduction in severity of depression, usually measured by clinician rated rating scales. Secondary outcomes, including dropout and life satisfaction, were also analysed.

MAIN RESULTS

The search identified nine trials of cognitive behavioural and psychodynamic therapy approaches, together with a small group of 'active control' interventions. No trials relating to other psychotherapeutic approaches and techniques were found. A total of seven trials provided sufficient data for inclusion in the comparison between CBT and controls. No trials compared psychodynamic psychotherapy with controls. Based on five trials (153 participants), cognitive behavioural therapy was more effective than waiting list controls (WMD -9.85, 95% CI -11.97 to -7.73). Only three small trials compared psychodynamic therapy with CBT, with no significant difference in treatment effect indicated between the two types of psychotherapeutic treatment. Based on three trials with usable data, CBT was superior to active control interventions when using the Hamilton Depression Rating Scale (WMD -5.69, 95% CI -11.04 to -0.35), but equivalent when using the Geriatric Depression Scale (WMD -2.00, 95% CI -5.31 to 1.32).

AUTHORS' CONCLUSIONS

Only a small number of studies and patients were included in the meta-analysis. If taken on their own merit, the findings do not provide strong support for psychotherapeutic treatments in the management of depression in older people. However, the findings do reflect those of a larger meta-analysis that included patients with broader age ranges, suggesting that CBT may be of potential benefit.

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.

Community-based treatment of late life depression an expert panel-informed literature review

OBJECTIVES

To present findings from an expert panel-informed literature review on community-based treatment of late-life depression.

METHODS

A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions.

RESULTS

A total of 3,543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions.

CONCLUSIONS

While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

The development of depression during psychodynamic group psychotherapy among subjects in substance abuse remission

The aim of the present study was to examine the development of self-reported depression during psychodynamic group therapy among patients manifesting a history of substance use-related problems between 1993-2000. Subjects (n = 100) were prospectively followed with respects to depression levels at intake and after 6, 12, and 18 month in therapy. Depression was measured with the Beck Depression Inventory. Overall, there was a significant decrease in depression after 18 months in therapy. The development of depression in different subgroups was also analyzed.

Psychodynamic psychotherapies: Evidence-based practice and clinical wisdom

This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are: Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based, Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.

Depression in late life: review and commentary

Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.

Skating to where the puck is going to be: a plan for clinical trials and translation research in mood disorders

As part of the National Institute of Mental Health Strategic Plan for Mood Disorders Research effort, the Clinical Trials and Translation Workgroup was asked to define priorities for clinical trials in mood disorders and for research on how best to translate the results of such research to clinical practice settings. Through two face-to-face meetings and a series of conference calls, we established priorities based on the literature to date and what was known about research currently in progress in this area. We defined five areas of priority that cut across developmental stages, while noting that research on adult mood disorders was at a more advanced stage in each of these areas than research on child or geriatric disorders. The five areas of priority are: 1) maximizing the effectiveness and cost-effectiveness of initial (acute) treatments for mood disorders already known to be efficacious in selected populations and settings when they are applied across all populations and care settings; 2) learning what further treatments or services are most likely to reduce symptoms and improve functioning when the first treatment is delivered well, but the mood disorder does not remit or show adequate improvement; 3) learning what treatments or services are most cost-effective in preventing recurrence or relapse and maintaining optimal functioning after a patient's mood disorder has remitted or responded maximally to treatment; 4) developing and validating clinical, psychosocial, biological, or other markers that predict: a) which treatments are most effective, b) course of illness, c) risk of adverse events/tolerability and acceptability for individual patients or well-defined subgroups of patients; 5) developing clinical trial designs and methods that result in lower research costs and greater generalizability earlier in the treatment development and testing process. A rationale for the importance of each of these priorities is provided.

Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression

Over the past 20 years, numerous studies have investigated the efficacy of psychotherapy for treating late life depression and, to a lesser degree, the efficacy of psychotherapy combined with antidepressant medication. Of the intervention studies, cognitive-behavioral therapy and interpersonal psychotherapy combined with antidepressant medication have the largest base of evidence in support of their efficacy for late life depression. To a lesser degree, there is support for stand-alone interpersonal psychotherapy, brief dynamic therapy, and life review treatments. The purpose of this review is to present data on the acute and long-term effects of cognitive-behavioral therapy, interpersonal psychotherapy, brief dynamic therapy, and combined antidepressant medication and psychotherapy to discuss the generalizability of these interventions, and to discuss future research directions and the need for increased opportunities for this area of research.

Cognitive therapy of depression: pretreatment patient predictors of outcome

This review examines the role of patient predictors of outcome in cognitive therapy of depression. Studies that meet eligibility criteria are reviewed for demonstrated linkage between various predictors (i.e., pretreatment severity, historical features, demographic predictors, dysfunctional attitudes and other cognitive features, and treatment acceptability) and outcome, and several effects are found. Notably, high pretreatment severity scores are associated with poorer response to cognitive therapy, as are high chronicity, younger age at onset, an increased number of previous episodes, and marital status. High pretreatment levels of dysfunctional attitudes and certain beliefs about the nature of depression were also found to predict differential response to cognitive therapy of depression. Limitations of the research and directions for further investigations of patient predictors of outcome in cognitive therapy of depression are provided.

A meta-(re)analysis of the effects of cognitive therapy versus 'other therapies' for depression

BACKGROUND

Cognitive therapy (CT) for depression has been found to be efficacious for the treatment of depression. In comparison to other psychotherapies, CT has been shown to be approximately equal to behavior therapies, but sometimes superior to 'other therapies.' The latter comparison is problematic given that 'other therapies' contain bona fide treatments as well as treatments without therapeutic rationale for depression.

METHOD

A meta-analysis was conducted for studies that compared CT to 'other therapies' in an earlier meta-analysis, except that in this meta-analysis 'other therapies' were classified as bona fide and non-bona fide.

RESULTS

The benefits of CT were found to be approximately equal to the benefits of bona fide non-CT and behavioral treatments, but superior to non-bona fide treatments.

CONCLUSIONS

The results of this study fail to support the superiority of CT for depression. On the contrary, these results support the conclusion that all bona fide psychological treatments for depression are equally efficacious.

Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach

This article reviews the efficacy of short-term psychodynamic psychotherapy (STPP) in depression compared to cognitive-behavioral therapy (CBT) or behavioral therapy (BT). In this review, only studies in which at least 13 therapy sessions were performed have been included, and a sufficient number of patients per group were treated (N > or = 20). With regard to outcome criteria, the results were reviewed for improvements in depressive symptoms, general psychiatric symptoms, and social functioning. Six studies met the inclusion criteria.

RESULTS

In 58 of the 60 comparisons (97%) performed in the six studies and their follow-ups, no significant difference could be detected between STPP and CBT/BT concerning the effects in depressive symptoms, general psychiatric symptomatology, and social functioning. Furthermore, STPP and CBT/BT did not differ significantly with regard to the patients that were judged as remitted or improved. According to a meta-analytic procedure described by R. Rosenthal (1991) the studies do not differ significantly with regard to the patients that were judged as remitted or improved after treatment with STPP or CBT/BT. The mean difference between STPP and CBT/BT concerning the number of patients that were judged as remitted or improved corresponds to a small effect size (post-assessment: phi = 0.08, follow-up assessment: phi = 0.12). Thus, STPP and CBT/BT seem to be equally effective methods in the treatment of depression. However, because of the small number of studies which met the inclusion criteria, this result can only be preliminary. Furthermore, it applies only to the specific forms of STPP that were examined in the selected studies and cannot be generalized to other forms of STPP. Further studies are needed to examine the effects of specific forms of STPP in both controlled and naturalistic settings. Furthermore, there are findings indicating that 16-20 sessions of both STPP and CBT/BT are insufficient for most patients to achieve lasting remission. Future studies should address the effects of longer treatments of depression.

Counselling and interpersonal therapies for depression: towards securing an evidence-base

Both generic counselling (delivered by BACP level counsellors in primary care settings) and the interpersonal therapies place a central value on the role and function of relationships--both within and outside the practice setting - as a vehicle for understanding and treating people presenting with depression. Recent studies have compared generic counselling with antidepressant medication, usual GP care, cognitive-behaviour therapy (CBT), and as an adjunct to GP care (i.e. in combination with GP care). Findings suggest either that there is no difference between generic counselling and other treatment conditions, or that there are small advantages to counselling over usual GP care but only in the short-term with such differences disappearing at 1-year. Studies investigating the interpersonal therapies (IPT) have established that the content of such therapies differ in their content from behavioural and cognitive therapies despite the outcomes being broadly similar. Considerable research effort has focused on the process of change in IP therapies. Important factors include the level of prior commitment by the patient to psychological therapy and their confidence in the therapist. Patients with well assimilated problems tend to do better in CBT than psychodynamic-interpersonal therapy. Therapists need to be flexible and responsive to patient needs particularly concerning interpersonal and attachment issues. Future research in counselling needs to identify the effective components of generic counselling and relate these to a theoretical base. In the IP therapies, there needs to be a greater focus on the change outside the therapy session and on the effectiveness of such therapies in non-research settings.

Treatment of depression in late life: psychotherapeutic interventions

Depression affects only a minority of older adults, but is a costly illness in terms of suffering, excess medical disability, increased use of health services, and mortality. Both pharmacological and psychotherapeutic interventions are effective for treating depression in late life. This paper reviews the background and empirical support for the efficacy of various psychotherapies for treating late life depression, including cognitive-behavioral, interpersonal, psychodynamic, life review, group, and family interventions. To date, cognitive-behavioral and interpersonal psychotherapies have most empirical support yet most studies have been conducted with relatively young, healthy, and White elderly. Studies of the efficacy of psychotherapeutic interventions for treating depression in minority and frail elderly are needed, as well as further studies of combination treatments across a range of care settings.