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Sun J, Zhang B, Xu W, Li P, Zhang D, Zhao B, Wang Z, Wang B. Effectiveness of repetitive transcranial magnetic stimulation for insomnia disorder on fear memory extinction: study protocol for a randomised controlled trial. Trials 2024; 25:396. [PMID: 38898471 PMCID: PMC11186137 DOI: 10.1186/s13063-024-08198-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Fear memory extinction is closely related to insomnia. Repetitive transcranial magnetic stimulation (rTMS) is safe and effective for treating insomnia disorder (ID), and it has been shown to be an efficient method for modulating fear extinction. However, whether rTMS can improve fear extinction memory in ID patients remains to be studied. In this study, we specifically aim to (1) show that 1 Hz rTMS stimulation could improve fear extinction memory in ID patients and (2) examine whether changes in sleep mediate this impact. METHODS AND DESIGN We propose a parallel group randomised controlled trial of 62 ID participants who meet the inclusion criteria. Participants will be assigned to a real rTMS group or a sham rTMS group. The allocation ratio will be 1:1, with 31 subjects in each group. Interventions will be administered five times per week over a 4-week period. The assessments will take place at baseline (week 0), post-intervention (week 4), and 8-week follow-up (week 8). The primary outcome measure of this study will be the mean change in the Pittsburgh Sleep Quality Index (PSQI) scores from baseline to post-intervention at week 4. The secondary outcome measures include the mean change in skin conductance response (SCR), fear expectation during fear extinction, Insomnia Severity Index (ISI), Zung Self-Rating Anxiety Scale (SAS), and the Zung Self-Rating Depression Scale (SDS). DISCUSSION This study will be the first examination of the impact of rTMS on fear memory extinction in ID patients. TRIAL REGISTRATION Chinese Clinical Trials Register ChiCTR2300076097. Registered on 25 September 2021.
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Affiliation(s)
- Jingjing Sun
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Bidan Zhang
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Wenyue Xu
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Panpan Li
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Danwei Zhang
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Bei Zhao
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Zhoubing Wang
- Zhenjiang Mental Health Center, Zhenjiang, Jiangsu, 212001, China
| | - Bin Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, No. 5 Ankang Lane, Dewai Avenue, Xicheng District, Beijing, 100088, China.
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100191, China.
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2
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Gostoli S, Nicolucci L, Malaguti C, Patierno C, Carrozzino D, Balducci C, Zaniboni S, Lodi V, Petio C, Rafanelli C. Mental Illness and Work-Related Limitations in Healthcare Workers: A Preliminary Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159098. [PMID: 35897498 PMCID: PMC9332465 DOI: 10.3390/ijerph19159098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/23/2022] [Indexed: 02/04/2023]
Abstract
This retrospective observational study investigated hospital staff requests for job fitness visits, addressed to occupational medicine. Specific objectives were to analyze: (1) health workers’ requests, sociodemographic characteristics, psychiatric diagnoses, assigned doctor’s fit notes, and (orthopedic, psychiatric) limitations; (2) associations between psychiatric diagnoses, sociodemographic (sex, age), and work-related (job, department) characteristics; (3) associations between the same psychiatric diagnoses/orthopedic limitations, fit notes, and/or psychiatric limitations. Data of St. Orsola-Malpighi Polyclinic health workers (N = 149; F = 73.8%; mean age = 48 ± 9.6 years), visited by both the occupational medicine physician and psychiatrist (January 2016−May 2019), were analyzed. 83.2% of the sample presented with at least one psychiatric diagnosis, including mood (47%), anxiety (13.4%), and anxious-depressive (10.7%) disorders. Significant differences between psychiatric diagnoses according to sex and fit notes (both p < 0.01) have been found, whereas no significant associations based on age and work-related characteristics have been observed. Analysis of frequencies of participants with the same psychiatric diagnosis (orthopedic limitation being equal), according to doctor’s fit notes and psychiatric work limitations, showed a high heterogeneity of assignments. The current occupational medicine procedure for fit notes/job limitations assignments does not allow taking into consideration clinical factors possibly associated with more specific assignments. To standardize the procedure and translate the psychiatrist’s clinical judgment into practice, further studies to test the usefulness of clinimetrics, which might represent a reliable approach in considering different fit notes and job limitations, are needed.
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Affiliation(s)
- Sara Gostoli
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
| | - Laura Nicolucci
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
| | - Carlotta Malaguti
- Department of Psychiatry, Bologna University Hospital Authority St. Orsola-Malpighi Polyclinic IRCCS, 40138 Bologna, Italy;
| | - Chiara Patierno
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
| | - Danilo Carrozzino
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
| | - Cristian Balducci
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
| | - Sara Zaniboni
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
- Department of Management, Technology and Economics, ETH Zürich, 8092 Zürich, Switzerland
| | - Vittorio Lodi
- Occupational Health Unit, Bologna University Hospital Authority St. Orsola-Malpighi Polyclinic IRCCS, 40138 Bologna, Italy;
| | - Carmine Petio
- Department of Psychiatry, Bologna University Hospital Authority St. Orsola-Malpighi Polyclinic IRCCS, 40138 Bologna, Italy;
- Correspondence: ; Tel.: +39-051-2142383
| | - Chiara Rafanelli
- Department of Psychology, University of Bologna, 40127 Bologna, Italy; (S.G.); (L.N.); (C.P.); (D.C.); (C.B.); (S.Z.); (C.R.)
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3
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Fava GA. An Editor's Journey Ends, but the Journal's Mission Continues. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:218-226. [PMID: 35724641 DOI: 10.1159/000524654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, New York, New York, USA
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4
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AlSalem M, AlHarbi MA, Badeghiesh A, Tourian L. Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review. Medicine (Baltimore) 2020; 99:e23708. [PMID: 33371117 PMCID: PMC7748330 DOI: 10.1097/md.0000000000023708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 12/03/2022] Open
Abstract
Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians' knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.
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Affiliation(s)
- Moayyad AlSalem
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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Wang HX, Wang L, Zhang WR, Xue Q, Peng M, Sun ZC, Li LP, Wang K, Yang XT, Jia Y, Zhou QL, Xu ZX, Li N, Dong K, Zhang Q, Song HQ, Zhan SQ, Min BQ, Fan CQ, Zhou AH, Guo XH, Li HB, Liang LR, Yin L, Si TM, Huang J, Yan TY, Cosci F, Kamiya A, Lu J, Wang YP. Effect of Transcranial Alternating Current Stimulation for the Treatment of Chronic Insomnia: A Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Clinical Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:38-47. [PMID: 31846980 DOI: 10.1159/000504609] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Not all adults with chronic insomnia respond to the recommended therapeutic options of cognitive behavioral therapy and approved hypnotic drugs. Transcranial alternating current stimulation (tACS) may offer a novel potential treatment modality for insomnia. OBJECTIVES This study aimed to examine the efficacy and safety of tACS for treating adult patients with chronic insomnia. METHODS Sixty-two participants with chronic primary insomnia received 20 daily 40-min, 77.5-Hz, 15-mA sessions of active or sham tACS targeting the forehead and both mastoid areas in the laboratory on weekdays for 4 consecutive weeks, followed by a 4-week follow-up period. The primary outcome was response rate measured by the Pittsburgh Sleep Quality Index (PSQI) at week 8. Secondary outcomes were remission rate, insomnia severity, sleep onset latency (SOL), total sleep time (TST), sleep efficiency, sleep quality, daily disturbances, and adverse events at the end of the 4-week intervention and at the 4-week follow-up. RESULTS Of 62 randomized patients, 60 completed the trial. During the 4-week intervention, 1 subject per group withdrew due to loss of interest and time restriction, respectively. Based on PSQI, at 4-week follow-up, the active group had a higher response rate compared to the sham group (53.4% [16/30] vs. 16.7% [5/30], p = 0.009), but remission rates were not different between groups. At the end of the 4-week intervention, the active group had higher response and remission rates than the sham group (p < 0.001 and p = 0.026, respectively). During the trial, compared with the sham group, the active group showed a statistically significant decrease in PSQI total score, a shortened SOL, an increased TST, improved sleep efficiency, and improved sleep quality (p < 0.05 or p < 0.001). Post hoc analysis revealed that, in comparison with the sham group, the active group had improved symptoms, except for daily disturbances, at the end of the 4-week intervention, and significant improvements in all symptoms at the 4-week follow-up. No adverse events or serious adverse responses occurred during the study. CONCLUSION The findings show that the tACS applied in the present study has potential as an effective and safe intervention for chronic insomnia within 8 weeks.
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Affiliation(s)
- Hong-Xing Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China, .,Beijing Key Laboratory of Neuromodulation, Beijing, China, .,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China,
| | - Li Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wen-Rui Zhang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing Xue
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mao Peng
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhi-Chao Sun
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Ping Li
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Department of Neurology, Beijing Puren Hospital, Beijing, China
| | - Xiao-Tong Yang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu Jia
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi-Lin Zhou
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhe-Xue Xu
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ning Li
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kai Dong
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qian Zhang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hai-Qing Song
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shu-Qin Zhan
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bao-Quan Min
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chun-Qiu Fan
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ai-Hong Zhou
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiu-Hua Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing, China
| | - Hai-Bin Li
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing, China
| | - Li-Rong Liang
- Department of Epidemiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lu Yin
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Tian-Mei Si
- Peking University Sixth Hospital, Beijing, China
| | - Jing Huang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian-Yi Yan
- School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Atsushi Kamiya
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jie Lu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu-Ping Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
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6
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Fava GA. The Age of Transition. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 90:1-4. [PMID: 33080595 DOI: 10.1159/000511544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/13/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, New York, USA,
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7
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Guu TW, Mischoulon D, Sarris J, Hibbeln J, McNamara RK, Hamazaki K, Freeman MP, Maes M, Matsuoka YJ, Belmaker RH, Jacka F, Pariante C, Berk M, Marx W, Su KP. International Society for Nutritional Psychiatry Research Practice Guidelines for Omega-3 Fatty Acids in the Treatment of Major Depressive Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 88:263-273. [PMID: 31480057 DOI: 10.1159/000502652] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 08/11/2019] [Indexed: 11/19/2022]
Abstract
Major depressive disorder (MDD) is a complex mental illness with unmet therapeutic needs. The antidepressant effects of ω-3 polyunsaturated fatty acids (n-3 PUFAs) have been widely reported. The subcommittee of the International Society for Nutritional Psychiatry Research organized an expert panel and conducted a literature review and a Delphi process to develop a consensus-based practice guideline for clinical use of n-3 PUFAs in MDD. The guideline focuses on 5 thematic areas: general concepts, acute treatment strategy, depression recurrence monitoring and prevention, use in special populations, and potential safety issues. The key practice guidelines contend that: (1) clinicians and other practitioners are advised to conduct a clinical interview to validate clinical diagnoses, physical conditions, and measurement-based psychopathological assessments in the therapeutic settings when recommending n-3 PUFAs in depression treatment; (2) with respect to formulation and dosage, both pure eicosapentaenoic acid (EPA) or an EPA/docosahexaenoic acid (DHA) combination of a ratio higher than 2 (EPA/DHA >2) are considered effective, and the recommended dosages should be 1-2 g of net EPA daily, from either pure EPA or an EPA/DHA (>2:1) formula; (3) the quality of n-3 PUFAs may affect therapeutic activity; and (4) potential adverse effects, such as gastrointestinal and dermatological conditions, should be monitored, as well as obtaining comprehensive metabolic panels. The expert consensus panel has agreed on using n-3 PUFAs in MDD treatment for pregnant women, children, and the elderly, and prevention in high-risk populations. Personalizing the clinical application of n-3 PUFAs in subgroups of MDD with a low Omega-3 Index or high levels of inflammatory markers might be regarded as areas that deserve future research.
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Affiliation(s)
- Ta-Wei Guu
- Departments of Psychiatry and Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan.,Division of Psychiatry, Departments of Internal Medicine, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - David Mischoulon
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jerome Sarris
- NICM, Health Research Institute, Western Sydney University, Westmead, New South Wales, Australia.,Department of Psychiatry, The Melbourne Clinic, Professorial Unit, Melbourne University, Melbourne, Victoria, Australia
| | - Joseph Hibbeln
- Section on Nutritional Neuroscience, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland, USA
| | - Robert K McNamara
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kei Hamazaki
- Department of Public Health, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Marlene P Freeman
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yutaka J Matsuoka
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - R H Belmaker
- Ben Gurion University of the Negev, Beersheba, Israel
| | - Felice Jacka
- IMPACT SRC, Food and Mood Centre, School of Medicine, Faculty of Health, Deakin University, Sydney, New South Wales, Australia
| | - Carmine Pariante
- Stress, Psychiatry and Immunology Laboratory, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Michael Berk
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Wolfgang Marx
- IMPACT SRC, Food and Mood Centre, School of Medicine, Faculty of Health, Deakin University, Sydney, New South Wales, Australia
| | - Kuan-Pin Su
- Departments of Psychiatry and Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan, .,College of Medicine, China Medical University, Taichung, Taiwan,
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8
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Rosenblat JD, Kurdyak P, Cosci F, Berk M, Maes M, Brunoni AR, Li M, Rodin G, McIntyre RS, Carvalho AF. Depression in the medically ill. Aust N Z J Psychiatry 2020; 54:346-366. [PMID: 31749372 DOI: 10.1177/0004867419888576] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill. METHODS Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary. RESULTS Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation. LIMITATIONS Non-systematic review of the literature. CONCLUSION Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.
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Affiliation(s)
- Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Paul Kurdyak
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, VIC, Australia.,The University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, VIC, Australia.,Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia.,Centre of Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia
| | - Michael Maes
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, VIC, Australia.,Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Andre R Brunoni
- Service of Interdisciplinary Neuromodulation (SIN), Laboratory of Neuroscience (LIM27) and National Institute of Biomarkers in Neuropsychiatry (INBioN), Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Madeline Li
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Andre F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
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9
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Fava GA, Rafanelli C. Iatrogenic Factors in Psychopathology. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 88:129-140. [PMID: 31085917 DOI: 10.1159/000500151] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/04/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Chiara Rafanelli
- Department of Psychology, University of Bologna, Bologna, Italy,
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10
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Fava GA, Carrozzino D, Lindberg L, Tomba E. The Clinimetric Approach to Psychological Assessment: A Tribute to Per Bech, MD (1942-2018). PSYCHOTHERAPY AND PSYCHOSOMATICS 2019; 87:321-326. [PMID: 30269137 DOI: 10.1159/000493746] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Bologna, .,Department of Psychiatry, State University of New York at Buffalo, Buffalo, New York,
| | - Danilo Carrozzino
- Department of Psychological, Health, and Territorial Sciences, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Lone Lindberg
- Psychiatric Research Unit, Psychiatric Centre North Zealand, Copenhagen University Hospital, Hillerød, Denmark
| | - Elena Tomba
- Department of Psychology, University of Bologna, Bologna, Italy
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Fava GA, Guidi J, Rafanelli C, Rickels K. The Clinical Inadequacy of the Placebo Model and the Development of an Alternative Conceptual Framework. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:332-340. [PMID: 29131050 DOI: 10.1159/000480038] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 08/07/2017] [Indexed: 12/11/2022]
Abstract
Placebo effects are often attributed to clinical interactions and contextual factors that affect expectations of the patient about the treatment and result in symptom changes. The prevailing conceptualization consists of an undifferentiated placebo response that needs to be minimized in controlled investigations and maximized in clinical practice. However, treatment outcome is the cumulative result of the interaction of several classes of variables with a selected treatment: living conditions (housing, nutrition, work environment, social support), patient characteristics (age, sex, genetics, general health conditions, personality, well-being), illness features and previous therapeutic experience, self-management, and treatment setting (physician's attitude and attention, illness behavior). Such variables may be therapeutic or countertherapeutic, and are unlikely to be simply additive. In certain patients their interactive combination may lead to clinical improvement, whereas in other cases it may produce no effect, and, in a third group, it may lead to worsening of the condition. Maximizing patients' expectations does not necessarily result in sustained effects and, in due course, may actually lead to worsening of the condition (violation of expectations). In this paper, we outline a multifactorial conceptual model that may have implications for the design of clinical trials as well as for clinical practice, with special reference to psychopharmacology and psychotherapy. The effects of drug treatment may be potentiated by specific nonpharmacological treatment strategies, and this synergism may disclose significant differences against placebo. Medical outcomes may be unsatisfactory not because technical interventions are missing, but because our conceptual models and thinking are inadequate.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Bologna, Italy
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12
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Zwerenz R, Becker J, Knickenberg RJ, Siepmann M, Hagen K, Beutel ME. Online Self-Help as an Add-On to Inpatient Psychotherapy: Efficacy of a New Blended Treatment Approach. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:341-350. [PMID: 29131090 DOI: 10.1159/000481177] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 08/30/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Depression is one of the most frequent and costly mental disorders. While there is increasing evidence for the efficacy of online self-help to improve depression or prevent relapse, there is little evidence in blended care settings, especially combined with inpatient face-to-face psychotherapy. Therefore, we evaluated whether an evidence-based online self-help program improves the efficacy of inpatient psychotherapy. METHODS A total of 229 depressed patients were randomly allocated either to an online self-help program (intervention group [IG]; Deprexis) or an active control group (CG; weekly online information on depression) in addition to inpatient psychodynamic psychotherapy. Both groups had access to their respective experimental intervention for 12 weeks, regardless of inpatient treatment duration. Reduction of depressive symptoms, as measured with the Beck Depression Inventory-II, was the primary outcome at the end of the intervention (T2). RESULTS Depressive symptoms were statistically significantly lower in the IG compared to the active CG at T2 with a moderate between-group effect size of d = 0.44. The same applied to anxiety (d = 0.33), quality of life (d = 0.34), and self-esteem (d = 0.38) at discharge from inpatient treatment (T1). No statistically significant differences were found regarding dysfunctional attitudes (d = 0.14) and work ability (d = 0.08) at T1. CONCLUSIONS This is the first evidence for blended treatment combining online self-help with inpatient psychotherapy. The study opens new and promising avenues for increasing the efficacy of inpatient psychotherapy. Future studies should determine how integration of online self-help into the therapeutic process can be developed further.
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Affiliation(s)
- Rüdiger Zwerenz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
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13
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McKenna L, Marks EM, Hallsworth CA, Schaette R. Mindfulness-Based Cognitive Therapy as a Treatment for Chronic Tinnitus: A Randomized Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:351-361. [PMID: 29131084 DOI: 10.1159/000478267] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tinnitus is experienced by up to 15% of the population and can lead to significant disability and distress. There is rarely a medical or surgical target and psychological therapies are recommended. We investigated whether mindfulness-based cognitive therapy (MBCT) could offer an effective new therapy for tinnitus. METHODS This single-site randomized controlled trial compared MBCT to intensive relaxation training (RT) for chronic, distressing tinnitus in adults. Both treatments involved 8 weekly, 120-min sessions focused on either relaxation (RT) or mindfulness meditation (MBCT). Assessments were completed at baseline and at treatment commencement 8 weeks later. The primary outcomes were tinnitus severity (Tinnitus Questionnaire) and psychological distress (Clinical Outcomes in Routine Evaluation - Non-Risk, CORE-NR), 16 weeks after baseline. The analysis utilized a modified intention-to-treat approach. RESULTS A total of 75 patients were randomly allocated to MBCT (n = 39) or RT (n = 36). Both groups showed significant reductions in tinnitus severity and loudness, psychological distress, anxiety, depression, and disability. MBCT led to a significantly greater reduction in tinnitus severity than RT, with a mean difference of 6.3 (95% CI 1.3-11.4, p = 0.016). Effects persisted 6 months later, with a mean difference of 7.2 (95% CI 2.1-2.3, p = 0.006) and a standardized effect size of 0.56 (95% CI 0.16-0.96). Treatment was effective regardless of initial tinnitus severity, duration, or hearing loss. CONCLUSIONS MBCT is effective in reducing tinnitus severity in chronic tinnitus patients compared to intensive RT. It also reduces psychological distress and disability. Future studies should explore the generalizability of this approach and how outcome relates to different aspects of the intervention.
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Tebala GD. The Emperor's New Clothes: a Critical Appraisal of Evidence-based Medicine. Int J Med Sci 2018; 15:1397-1405. [PMID: 30275768 PMCID: PMC6158662 DOI: 10.7150/ijms.25869] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/27/2018] [Indexed: 12/20/2022] Open
Abstract
Evidence-Based Medicine (EBM) is the way we are expected to deliver our healthcare in the 21st century. It has been described as the integration of information from best available evidence with the doctor's experience and the patient's point of view. Unfortunately, the original meaning of EBM has been lost and the worldwide medical community has shifted the paradigm to Guidelines-Based Medicine, that has displaced the figures of the doctor and the patient from the decision-making process and relegated them to mere executor and final target of decisions taken by someone else. Problems related to the reliability of evidence and to the way guidelines are constructed, implemented and followed are discussed in detail. It is mandatory that the whole medical community takes responsibility and tries to reverse this apparently inexorable process so to re-establish a proper evidence-based care, where patients and their healing relation with practitioners are at the centre and where doctors are able to critically evaluate the available evidence and use it in light of their personal experience and knowledge.
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Affiliation(s)
- Giovanni D. Tebala
- East Kent Hospitals University, William Harvey Hospital, Ashford, Kent, United Kingdom
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15
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Maslej MM, Bolker BM, Russell MJ, Eaton K, Durisko Z, Hollon SD, Swanson GM, Thomson JA, Mulsant BH, Andrews PW. The Mortality and Myocardial Effects of Antidepressants Are Moderated by Preexisting Cardiovascular Disease: A Meta-Analysis. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:268-282. [PMID: 28903117 DOI: 10.1159/000477940] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 05/30/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antidepressants (ADs) are commonly prescribed medications, but their long-term health effects are debated. ADs disrupt multiple adaptive processes regulated by evolutionarily ancient biochemicals, potentially increasing mortality. However, many ADs also have anticlotting properties that can be efficacious in treating cardiovascular disease. We conducted a meta-analysis assessing the effects of ADs on all-cause mortality and cardiovascular events in general-population and cardiovascular-patient samples. METHODS Two reviewers independently assessed articles from PubMed, EMBASE, and Google Scholar for AD-related mortality controlling for depression and other comorbidities. From these articles, we extracted information about cardiovascular events, cardiovascular risk status, and AD class. We conducted mixed-effect meta-analyses testing sample type and AD class as moderators of all-cause mortality and new cardiovascular events. RESULTS Seventeen studies met our search criteria. Sample type consistently moderated health risks. In general-population samples, AD use increased the risks of mortality (HR = 1.33, 95% CI: 1.14-1.55) and new cardiovascular events (HR = 1.14, 95% CI: 1.08-1.21). In cardiovascular patients, AD use did not significantly affect risks. AD class also moderated mortality, but the serotonin reuptake inhibitors were not significantly different from tricyclic ADs (TCAs) (HR = 1.10, 95% CI: 0.93-1.31, p = 0.27). Only "other ADs" were differentiable from TCAs (HR = 1.35, 95% CI: 1.08-1.69). Mortality risk estimates increased when we analyzed the subset of studies controlling for premedication depression, suggesting the absence of confounding by indication. CONCLUSIONS The results support the hypothesis that ADs are harmful in the general population but less harmful in cardiovascular patients.
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Affiliation(s)
- Marta M Maslej
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, ON, Canada
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Hartmann JA, McGorry PD, Schmidt SJ, Amminger GP, Yuen HP, Markulev C, Berger GE, Chen EYH, de Haan L, Hickie IB, Lavoie S, McHugh MJ, Mossaheb N, Nieman DH, Nordentoft M, Riecher-Rössler A, Schäfer MR, Schlögelhofer M, Smesny S, Thompson A, Verma SK, Yung AR, Nelson B. Opening the Black Box of Cognitive-Behavioural Case Management in Clients with Ultra-High Risk for Psychosis. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:292-299. [PMID: 28903120 DOI: 10.1159/000477551] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/12/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cognitive-behavioural therapy (CBT) is the first-choice treatment in clients with ultra-high risk (UHR) for psychosis. However, CBT is an umbrella term for a plethora of different strategies, and little is known about the association between the intensity and content of CBT and the severity of symptomatic outcome. METHODS A sample of 268 UHR participants received 6 months of CBT with case management (CBCM) in the context of the multi-centre NEURAPRO trial with monthly assessments of attenuated psychotic symptoms (APS). Using multilevel regressions and controlling for the initial severity of APS, the associations between (1) number of CBCM sessions received and severity of APS and (2) specific CBCM components and severity of APS were investigated. RESULTS In month 1, a higher number of sessions and more assessment of symptoms predicted an increase in APS, while in month 3, a higher number of sessions and more monitoring predicted a decrease in the level of APS. More therapeutic focus on APS predicted an overall increase in APS. CONCLUSIONS Our findings indicate that the association between intensity/content of CBCM and severity of APS in a sample of UHR participants depends on the length of time in treatment. CBCM may positively impact the severity of APS later in the course of treatment. Therefore, it would seem important to keep UHR young people engaged in treatment beyond this initial period. Regarding the specific content of CBCM, a therapeutic focus on APS may not necessarily be beneficial in reducing the severity of APS, a possibility in need of further investigation.
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Affiliation(s)
- Jessica A Hartmann
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
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Wong SYS, Zhang DX, Li CCK, Yip BHK, Chan DCC, Ling YM, Lo CSL, Woo DMS, Sun YY, Ma H, Mak WWS, Gao T, Lee TMC, Wing YK. Comparing the Effects of Mindfulness-Based Cognitive Therapy and Sleep Psycho-Education with Exercise on Chronic Insomnia: A Randomised Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018. [PMID: 28647747 DOI: 10.1159/000470847] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mindfulness-based cognitive therapy (MBCT) is a potential treatment for chronic insomnia. We evaluated the efficacy of MBCT for insomnia (MBCT-I) by comparing it with a sleep psycho-education with exercise control (PEEC) group. METHODS Adults with chronic primary insomnia (n = 216) were randomly allocated to the MBCT-I or PEEC group. The MBCT-I included mindfulness and psycho-education with cognitive and behavioural components under cognitive behavioural therapy for insomnia. PEEC included psycho-education of sleep hygiene and stimulus control, and exercises. Any change in insomnia severity was measured by the Insomnia Severity Index (ISI). Secondary outcomes included sleep parameters measured by a sleep diary, health service utilisation, absence from work and mindfulness measured by the Five Facet Mindfulness Questionnaire. RESULTS The ISI score significantly decreased in the MBCT-I group compared with the PEEC group at 2 months (i.e., post-intervention) (p = 0.023, effect size [95% CI] -0.360 [-0.675, -0.046]) but not at 5 or 8 months. Treatment response rates and remission rates based on the ISI cut-off scores were not significantly different between groups. Wake time after sleep onset (WASO) was less in the MBCT-I group at 2 and 5 months. At 8 months, both groups showed a reduced ISI score, sleep onset latency and WASO, and increased sleep efficiency and total sleep time; however, no group differences were seen. Other outcome measures did not significantly improve in either group. CONCLUSIONS Long-term benefits were not seen in MBCT-I when compared with PEEC, although short-term benefits were seen.
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Aldi GA, Bertoli G, Ferraro F, Pezzuto A, Cosci F. Effectiveness of pharmacological or psychological interventions for smoking cessation in smokers with major depression or depressive symptoms: A systematic review of the literature. Subst Abus 2018; 39:289-306. [PMID: 29436984 DOI: 10.1080/08897077.2018.1439802] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Smokers with major depressive disorder (MDD) or depressive symptoms (DS) represent a subgroup in need of attention, since they have specific clinical features and prognosis. METHODS A systematic review of the literature (Cochrane, MEDLINE, ScienceDirect, Web of Science databases from inception to June 2017) of randomized clinical trials assessing the effectiveness of pharmacological, psychological, or combined interventions for smoking cessation in subjects with current or past MDD/DS without medical or comorbid psychiatric disorder(s) was run following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Twenty-seven studies met the inclusion criteria. Nicotine, varenicline, and staged-care intervention were more effective in smokers with current MDD; nicotine and fluoxetine plus nicotine were more effective in smokers with DS; naltrexone and nicotine plus fluoxetine were more effective in smokers with severe current DS. Cognitive-behavioral therapy and cognitive and behavioral cessation and relapse prevention skills training were superior to placebo in smokers with past MDD. CONCLUSIONS More research is needed into effectively addressing smoking in people with concurrent mental disorder. Data currently available need to be confirmed in randomized trials aimed at replicating the results and disentangling the effects of each therapeutic ingredient when a combination therapy is proposed. Studies on tolerability of treatments are warranted, as well as those aimed at identifying factors of vulnerability to adverse effects.
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Affiliation(s)
- Giulia A Aldi
- a Department of Health Sciences , University of Florence , Florence , Italy
| | - Giuly Bertoli
- a Department of Health Sciences , University of Florence , Florence , Italy
| | - Francesca Ferraro
- a Department of Health Sciences , University of Florence , Florence , Italy
| | - Aldo Pezzuto
- b Cardiopulmonary Department , S. Andrea Hospital-Sapienza University Rome , Rome , Italy
| | - Fiammetta Cosci
- a Department of Health Sciences , University of Florence , Florence , Italy
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The Effect of Cognitive Intervention on Cognitive Improvement in Patients with Dementia. Dement Neurocogn Disord 2018; 17:23-31. [PMID: 30906388 PMCID: PMC6427996 DOI: 10.12779/dnd.2018.17.1.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 12/29/2022] Open
Abstract
Background and Purpose The effect of cognitive intervention in patients with dementia is inconsistent. This study sought to find out the effect of cognitive intervention by measuring interval change between before and after intervention. Methods We evaluated cognitive changes according to clinical diagnostic group across Gangwon province for 940 patients with dementia diagnosed at hospital clinics and 2,975 subjects without dementia. All subjects were treated with cognitive intervention. They underwent a cognitive and mood assessment before and after intervention. We used interval change of Mini-Mental State Examination (MMSE) scores as a primary measure of interventional outcome. Results Changes in mean MMSE score were significantly different between the non-dementia group and the dementia group (p=0.016), with changes of 0.7±2.4 and 1.0±3.7 points (±standard deviation), respectively. Cognitive improvement regarding completion of session was significantly higher in the dementia group (p=0.001), with changes of 0.41±4.51 for uncompleted group and 1.30±3.22 points for completed ones. Lower initial MMSE scores, lower age, and type of intervention were found to be independent predictive factors of subsequent cognitive changes as indicated by mean MMSE scores. Conclusions These findings suggest that cognitive intervention might be useful for patients with dementia. Their response to treatment might be related to the type of intervention.
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Fava GA, Tomba E, Bech P. Clinical Pharmacopsychology: Conceptual Foundations and Emerging Tasks. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:134-140. [PMID: 28490035 DOI: 10.1159/000458458] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/27/2017] [Indexed: 12/29/2022]
Abstract
The aim of this critical review was to outline emerging trends and perspectives of clinical pharmacopsychology, an area of clinical psychology that is concerned with the psychological effects of medications. The historical development of clinical pharmacopsychology is outlined, with discussion of its most representative expressions and reference to current challenges of clinical research, with particular reference to clinimetrics. The domains of clinical pharmacopsychology encompass the clinical benefits of psychotropic drugs, the characteristics that predict responsiveness to treatment, the vulnerabilities induced by treatment (side effects, behavioral toxicity, iatrogenic comorbidity), and the interactions between drug treatment and psychological variables. Its aim is to provide a comprehensive assessment of the clinical important changes that are concerned with (a) wanted and expected treatment effects, (b) treatment-induced unwanted side effects, and (c) the patient's own personal experience of a change in terms of well-being and/or quality of life. Clinical pharmacopsychology offers a unifying framework for the understanding of clinical phenomena in medical and psychiatric settings. Research in this area deserves high priority.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Bologna, Italy
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21
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From Evidence Based Medicine to Medicine Based Evidence. Am J Med 2017; 130:1246-1250. [PMID: 28711551 DOI: 10.1016/j.amjmed.2017.06.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/15/2017] [Accepted: 06/15/2017] [Indexed: 11/20/2022]
Abstract
Evidence based medicine, using randomized controlled trials and meta-analyses as the major tools and sources of evidence about average results for heterogeneous groups of patients, developed as a reaction against poorly designed observational treatment research and physician reliance on personal experience with other patients as a guide to decision-making about a patient at hand. However, these tools do not answer the clinician's question: "Will a given therapeutic regimen help my patient at a given point in her/his clinical course?" We introduce fine-grained profiling of the patient at hand, accompanied by comparative evidence of responses from approximate matches to this patient on whom a contemplated treatment has/has not been administered. This represents medicine based evidence that is tuned to decision-making for the particular patient.
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James JE. Reviving Cochrane's contribution to evidence-based medicine: bridging the gap between evidence of efficacy and evidence of effectiveness and cost-effectiveness. Eur J Clin Invest 2017; 47:617-621. [PMID: 28675422 DOI: 10.1111/eci.12782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/30/2017] [Indexed: 12/27/2022]
Abstract
Throughout the quarter century since the advent of evidence-based medicine (EBM), medical research has prioritized 'efficacy' (i.e. internal validity) using randomized controlled trials. EBM has consistently neglected 'effectiveness' and 'cost-effectiveness', identified in the pioneering work of Archie Cochrane as essential for establishing the external (i.e. clinical) validity of health care interventions. Neither Cochrane nor other early pioneers appear to have foreseen the extent to which EBM would be appropriated by the pharmaceutical and medical devices industries, which are responsible for extensive biases in clinical research due to selective reporting, exaggeration of benefits, minimization of risks, and misrepresentation of data. The promise of EBM to effect transformational change in health care will remain unfulfilled until (i) studies of effectiveness and cost-effectiveness are pursued with some of the same fervour that previously succeeded in elevating the status of the randomized controlled trial, and (ii) ways are found to defeat threats to scientific integrity posed by commercial conflicts of interest.
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Somatization in Parkinson's Disease: A systematic review. Prog Neuropsychopharmacol Biol Psychiatry 2017; 78:18-26. [PMID: 28522290 DOI: 10.1016/j.pnpbp.2017.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/25/2017] [Accepted: 05/13/2017] [Indexed: 11/21/2022]
Abstract
The current systematic review study is aimed at critically analyzing from a clinimetric viewpoint the clinical consequence of somatization in Parkinson's Disease (PD). By focusing on the International Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive electronic literature research strategy on ISI Web-of-Science, PsychINFO, PubMed, EBSCO, ScienceDirect, MEDLINE, Scopus, and Google Scholar databases. Out of 2.926 initial records, only a total of 9 studies were identified as clearly relevant and analyzed in this systematic review. The prevalence of somatization in PD has been found to range between 7.0% and 66.7%, with somatoform disorders acting as clinical factor significantly contributing to predict a progressive cognitive impairment. We highlighted that somatization is a highly prevalent comorbidity affecting PD. However, the clinical consequence of such psychiatric symptom should be further evaluated by replacing the clinically inadequate diagnostic label of psychogenic parkinsonism with the psychosomatic concept of persistent somatization as conceived by the Diagnostic Criteria for Psychosomatic Research (DCPR).
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Fava GA. Evidence-based medicine was bound to fail: a report to Alvan Feinstein. J Clin Epidemiol 2017; 84:3-7. [PMID: 28532614 DOI: 10.1016/j.jclinepi.2017.01.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 01/31/2017] [Indexed: 11/19/2022]
Abstract
John Ioannidis has provided a lucid account, in the form of a report to David Sackett, of how evidence-based medicine (EBM) was hijacked to serve vested interests: major randomized controlled trials are largely done by and for the benefit of the industry; meta-analyses and guidelines are flooded with conflicts of interest; national and federal research funds are unable to address basic clinical questions. Nonetheless, EBM would remain a worthwhile goal. In this paper, in the form of a report to Alvan Feinstein, it is argued that current developments were largely predictable. EBM certainly gave an important contribution to questioning unsubstantiated therapeutic claims. Time has come, however, to become aware of its considerable limitations, including overall reductionism and insufficient consideration of problems related to financial conflicts of interest. EBM does not represent the scientific approach to medicine: it is only a restrictive interpretation of the scientific approach to clinical practice. EBM drives the prescribing clinician to an overestimated consideration of potential benefits, paying little attention to the likelihood of responsiveness and to potential vulnerabilities in relations to the adverse effects of treatment. It is time to substitute the fashionable popularity of a strategy developed outside of clinical medicine with models and research based on the insights of clinical judgment and patient-doctor interaction, as Feinstein had outlined.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, viale Berti Pichat 5, 40127 Bologna, Italy; Department of Psychiatry, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA.
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Fava GA, Cosci F, Sonino N. Current Psychosomatic Practice. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 86:13-30. [PMID: 27884006 DOI: 10.1159/000448856] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/03/2016] [Indexed: 11/19/2022]
Abstract
Psychosomatic research has advanced over the past decades in dealing with complex biopsychosocial phenomena and may provide new effective modalities of patient care. Among psychosocial variables affecting individual vulnerability, course, and outcome of any medical disease, the role of chronic stress (allostatic load/overload) has emerged as a crucial factor. Assessment strategies include the Diagnostic Criteria for Psychosomatic Research. They are presented here in an updated version based on insights derived from studies carried out so far and encompass allostatic overload, type A behavior, alexithymia, the spectrum of maladaptive illness behavior, demoralization, irritable mood, and somatic symptoms secondary to a psychiatric disorder. Macroanalysis is a helpful tool for identifying the relationships between biological and psychosocial variables and the individual targets for medical intervention. The personalized and holistic approach to the patient includes integration of medical and psychological therapies in all phases of illness. In this respect, the development of a new psychotherapeutic modality, Well-Being Therapy, seems to be promising. The growth of subspecialties, such as psychooncology and psychodermatology, drives towards the multidisciplinary organization of health care to overcome artificial boundaries. There have been major transformations in health care needs in the past decades. From psychosomatic medicine, a land of innovative hypotheses and trends, many indications for changes in the current practice of medicine are now at hand. The aim of this critical review is to outline current and potential clinical applications of psychosomatic methods.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Bologna, Italy
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Carvalho AF, Sharma MS, Brunoni AR, Vieta E, Fava GA. The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:270-88. [PMID: 27508501 DOI: 10.1159/000447034] [Citation(s) in RCA: 365] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/24/2016] [Indexed: 11/19/2022]
Abstract
Newer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.
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Affiliation(s)
- André F Carvalho
- Department of Clinical Medicine and Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
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Fulcheri M, Carrozzino D. The clinical consequence of positive mental health in psychotherapy. RESEARCH IN PSYCHOTHERAPY 2017; 20:280. [PMID: 32913745 PMCID: PMC7451366 DOI: 10.4081/ripppo.2017.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/18/2017] [Accepted: 06/20/2017] [Indexed: 11/23/2022]
Abstract
The current commentary is aimed at critically analyzing the document Psychotherapies for Anxiety and Depression: benefits and costs by focusing on specific theoretical concepts and empirical evidences arising from research studies fulfilled in the area of study of Clinical and Health Psychology. Specifically, the following were the main topics on which we are focused on: i) the clinical consequence potentially resulting from considering the psychological well-being and the euthymia condition as the main targets of a psychotherapeutic treatment; ii) a critical reappraisal of the clinical inadequacy of the evidence based model in psychotherapy; iii) clinimetrics as a clinically based measurement method for evaluating the psychological well-being of a patient after a psychotherapeutic intervention.
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Affiliation(s)
- Mario Fulcheri
- Department of Psychological, Health, and Territorial Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Danilo Carrozzino
- Department of Psychological, Health, and Territorial Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Psychiatric Research Unit, Psychiatric Centre North Zealand, Copenhagen University Hospital, Hillerød, Denmark
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Yoshinaga N, Matsuki S, Niitsu T, Sato Y, Tanaka M, Ibuki H, Takanashi R, Ohshiro K, Ohshima F, Asano K, Kobori O, Yoshimura K, Hirano Y, Sawaguchi K, Koshizaka M, Hanaoka H, Nakagawa A, Nakazato M, Iyo M, Shimizu E. Cognitive Behavioral Therapy for Patients with Social Anxiety Disorder Who Remain Symptomatic following Antidepressant Treatment: A Randomized, Assessor-Blinded, Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:208-17. [PMID: 27230862 DOI: 10.1159/000444221] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 01/17/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although antidepressants are still a commonly used treatment for social anxiety disorder (SAD), a significant proportion of patients fail to remit following antidepressants. However, no standard approach has been established for managing such patients. This study aimed to examine the effectiveness of cognitive behavioral therapy (CBT) as an adjunct to usual care (UC) compared with UC alone in SAD patients who remain symptomatic following antidepressant treatment. METHODS This was a prospective randomized open-blinded end-point study with two parallel groups (CBT + UC, and UC alone, both for 16 weeks) conducted from June 2012 to March 2014. SAD patients who remain symptomatic following antidepressant treatment were recruited, and a total sample size of 42 was set based on pilot results. RESULTS Patients were randomly allocated to CBT + UC (n = 21) or UC alone (n = 21). After 16 weeks, adjusted mean reduction in the Liebowitz Social Anxiety Scale from baseline for CBT + UC and UC alone was -40.87 and 0.68, respectively; the between-group difference was -41.55 (-53.68 to -29.42, p < 0.0001). Response rates were 85.7 and 10.0% for CBT + UC and UC alone, respectively (p < 0.0001). The corresponding remission rates were 47.6 and 0.0%, respectively (p = 0.0005). Significant differences were also found in favor of CBT + UC for social anxiety symptoms, depressive symptoms, and functional impairment. CONCLUSIONS Our results suggest that in SAD patients who have been ineffectively treated with antidepressants, CBT is an effective treatment adjunct to UC over 16 weeks in reducing social anxiety and related symptoms.
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Affiliation(s)
- Naoki Yoshinaga
- Organization for Promotion of Tenure Track, University of Miyazaki, Miyazaki, Japan
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Braun C, Bschor T, Franklin J, Baethge C. Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:171-9. [PMID: 27043848 DOI: 10.1159/000442293] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use. METHODS We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs). RESULTS Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01). CONCLUSIONS Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.
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Affiliation(s)
- Cora Braun
- Department of Psychiatry and Psychotherapy, University of Cologne Medical School, Cologne, Germany
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Jeong JH, Na HR, Choi SH, Kim J, Na DL, Seo SW, Chin J, Park SA, Kim EJ, Han HJ, Han SH, Yoon SJ, Lee JH, Park KW, Moon SY, Park MH, Choi MS, Han IW, Lee JH, Lee JS, Shim YS, Kim JY. Group- and Home-Based Cognitive Intervention for Patients with Mild Cognitive Impairment: A Randomized Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:198-207. [PMID: 27230861 DOI: 10.1159/000442261] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 11/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND We examined the efficacy of group-based cognitive intervention (GCI) and home-based cognitive intervention (HCI) in amnestic mild cognitive impairment (aMCI) and intervention effects on serum brain-derived neurotrophic factor (BDNF). METHODS In this randomized and rater-blinded trial, 293 patients with aMCI from 18 nationwide hospitals were randomized: 96 to the GCI group, 98 to the HCI group and 99 to the control group. For 12 weeks, subjects receiving GCI participated twice per week in group sessions led by trained instructors, and those receiving HCI completed homework materials 5 days per week. They were assessed at baseline, postintervention (PI) and at the 6-month follow-up after the intervention. The primary endpoint was the change from baseline to PI in the modified Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-Cog). RESULTS In comparison to the controls (a 0.8-point decrease), the subjects receiving GCI (a 2.3-point decrease, p = 0.01) or HCI (a 2.5-point decrease, p = 0.02) showed significant improvements in the modified ADAS-Cog at PI, respectively. By the 6-month follow-up, those receiving GCI or HCI had better scores in the modified ADAS-Cog than the controls. The changes in BDNF levels significantly correlated with the changes in the modified ADAS-Cog in the GCI (r = -0.29, p = 0.02 at PI) and HCI (r = -0.27, p = 0.03 at 6-month follow-up) groups, respectively. CONCLUSIONS The GCI and HCI resulted in cognitive improvements in aMCI. An enhanced brain plasticity may be a component of the mechanism underpinning the cognitive improvements associated with the cognitive interventions.
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Affiliation(s)
- Jee Hyang Jeong
- Department of Neurology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, South Korea
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Lambert MJ. Maximizing Psychotherapy Outcome beyond Evidence-Based Medicine. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 86:80-89. [PMID: 28183083 DOI: 10.1159/000455170] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/17/2016] [Indexed: 11/19/2022]
Abstract
Despite evidence that psychotherapy has a positive impact on psychological disorders, 30% of patients fail to respond during clinical trials, and as many as 65% of patients in routine care leave treatment without a measured benefit. In addition, therapists appear to overestimate positive outcomes in their patients relative to measured outcomes and are particularly poor at identifying patients at risk for a negative outcome. These problems suggest the need for measuring and monitoring patient treatment response over the course of treatment while applying standardized methods of identifying at-risk cases. Computer-assisted methods for measuring, monitoring, identifying potential deteriorators, and providing feedback to clinicians are described along with a model that explains why feedback is likely to be beneficial to patients. The results of 12 clinical trials are summarized and suggest that deterioration rates can be substantially reduced in at-risk cases (from baseline rates of 21% down to 13%) and that recovery rates are substantially increased in this subgroup of cases (from a baseline of 20% up to 35%) when therapists are provided this information. When problem-solving methods are added to feedback, deterioration in at-risk cases is further reduced to 6% while recovery/improvement rates rise to about 50%. It is suggested that the feedback methods become a standard of practice. Such a change in patterns of care can be achieved through minimal modification to routine practice but may require discussions with patients about their clinical progress.
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Zerwas SC, Watson HJ, Hofmeier SM, Levine MD, Hamer RM, Crosby RD, Runfola CD, Peat CM, Shapiro JR, Zimmer B, Moessner M, Kordy H, Marcus MD, Bulik CM. CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 86:47-53. [PMID: 27883997 PMCID: PMC5143175 DOI: 10.1159/000449025] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/02/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F). METHOD In a two-site, randomized, controlled noninferiority trial, we tested the hypothesis that CBT4BN would not be inferior to CBTF2F. A total of 179 adult patients with BN (2.6% males) received up to 16 sessions of group CBT over 20 weeks in either CBT4BN or CBTF2F, and outcomes were compared at the end of treatment and at the 12-month follow-up. RESULTS At the end of treatment, CBT4BN was inferior to CBTF2F in producing abstinence from binge eating and purging. However, by the 12-month follow-up, CBT4BN was mostly not inferior to CBTF2F. Participants in the CBT4BN condition, but not CBTF2F, continued to reduce their binge-eating and purging frequency from the end of treatment to the 12-month follow-up. CONCLUSIONS CBT delivered online in a group chat format appears to be an efficacious treatment for BN, although the trajectory of recovery may be slower than face-to-face group therapy. Online chat groups may increase accessibility of treatment and represent a cost-effective approach to service delivery. However, barriers in service delivery such as state-specific license and ethical guidelines for online therapists need to be addressed.
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Affiliation(s)
- Stephanie C. Zerwas
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599
| | - Hunna J. Watson
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599,School of Paediatrics and Child Health, Faculty of Medicine, Dentistry, and Health Sciences, The University of Western Australia, Stirling Highway, Crawley, Western Australia, Australia 6009,School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, Australia 6102
| | - Sara M. Hofmeier
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599
| | - Michele D. Levine
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburgh, PA 15213
| | - Robert M. Hamer
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599,Department of Biostatistics, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599
| | - Ross D. Crosby
- Neuropsychiatric Research Institute, 120 Eighth Street South Fargo, ND 58107,Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Fargo, ND 58102
| | | | - Christine M. Peat
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599,Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Jennifer R. Shapiro
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599
| | - Benjamin Zimmer
- Center for Psychotherapy Research, University of Heidelberg, Bergheimer Str. 54, 69115 Heidelberg, Germany
| | - Markus Moessner
- Center for Psychotherapy Research, University of Heidelberg, Bergheimer Str. 54, 69115 Heidelberg, Germany
| | - Hans Kordy
- Center for Psychotherapy Research, University of Heidelberg, Bergheimer Str. 54, 69115 Heidelberg, Germany
| | - Marsha D. Marcus
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburgh, PA 15213
| | - Cynthia M. Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599,Department of Nutrition, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, NC 27599,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Wilkinson ST, Wright D, Fasula MK, Fenton L, Griepp M, Ostroff RB, Sanacora G. Cognitive Behavior Therapy May Sustain Antidepressant Effects of Intravenous Ketamine in Treatment-Resistant Depression. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 86:162-167. [PMID: 28490030 PMCID: PMC5516265 DOI: 10.1159/000457960] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/24/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Ketamine has shown rapid though short-lived antidepressant effects. The possibility of concerning neurobiological changes following repeated exposure to the drug motivates the development of strategies that obviate or minimize the need for longer-term treatment with ketamine. In this open-label trial, we investigated whether cognitive behavioral therapy (CBT) can sustain or extend ketamine's antidepressant effects. METHODS Patients who were pursuing ketamine infusion therapy for treatment-resistant depression were invited to participate in the study. If enrolled, the subjects initiated a 12-session, 10-week course of CBT concurrently with a short 4-treatment, 2-week course of intravenous ketamine (0.5 mg/kg infused over 40 min) provided under a standardized clinical protocol. RESULTS Sixteen participants initiated the protocol, with 8 (50%) attaining a response to the ketamine and 7 (43.8%) achieving remission during the first 2 weeks of protocol. Among ketamine responders, the relapse rate at the end of the CBT course (8 weeks following the last ketamine exposure) was 25% (2/8). On longer-term follow-up, 5 of 8 subjects eventually relapsed, the median time to relapse being 12 weeks following ketamine exposure. Among ketamine remitters, 3 of 7 retained remission until at least 4 weeks following the last ketamine exposure, with 2 retaining remission through 8 weeks following ketamine exposure. Ketamine nonresponders did not appear to benefit from CBT. CONCLUSIONS CBT may sustain the antidepressant effects of ketamine in treatment-resistant depression. Well-powered randomized controlled trials are warranted to further investigate this treatment combination as a way to sustain ketamine's antidepressant effects.
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Affiliation(s)
- Samuel T. Wilkinson
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511,Connecticut Mental Health Center, New Haven, CT 06519
| | - DaShaun Wright
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511
| | - Madonna K. Fasula
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511,Connecticut Mental Health Center, New Haven, CT 06519
| | - Lisa Fenton
- Veterans Affairs Hospital, West Haven, CT 06516
| | - Matthew Griepp
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511,Connecticut Mental Health Center, New Haven, CT 06519
| | - Robert B. Ostroff
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511,Connecticut Mental Health Center, New Haven, CT 06519
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Radua J, Grunze H, Amann BL. Meta-Analysis of the Risk of Subsequent Mood Episodes in Bipolar Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 86:90-98. [PMID: 28183076 DOI: 10.1159/000449417] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 08/24/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Reported relapse and recurrence rates in bipolar disorder (BD) differ significantly between studies. Most data originate from highly selective patients participating in sponsored randomized controlled trials with narrow inclusion criteria. To estimate the true risk of a subsequent mood episode (SME) under real-world conditions, we conducted a meta-analysis of rates of SME as reported in naturalistic BD studies. METHODS PubMed, ScienceDirect, Scopus, and Web of Knowledge were searched until July 2015. Studies reporting the time until the emergence of an SME, from which individual data or Kaplan-Meier plots with censors marked could be retrieved, were included. RESULTS Twelve studies comprising 5,837 patients met the inclusion criteria. The median time to an SME in adults after an index episode was 1.44 years. The risk of an SME was 44% during the first year. Not having a SME during this first year lowered this risk to 19% in the second year. The risk was higher in bipolar II disorder (BD-II) than in bipolar I disorder (BD-I; HR = 1.5). In BD-I, the risk of a subsequent manic, mixed, or depressive mood episode was higher after an index episode of the same polarity (HR = 1.89-5.14). The overall risk of an SME was higher in patients with persisting subsyndromal symptoms (HR = 2.17). CONCLUSIONS The data from this study provide a more reliable estimate of the risk of an SME in BD in real-world settings. Further research into the longitudinal course of BD-II is warranted to confirm its role as a risk factor for SME.
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Affiliation(s)
- Joaquim Radua
- FIDMAG Germanes Hospitalàries, Sant Boi de Llobregat, Spain
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Abstract
In 1968, DiMascio and Shader provided a conceptual framework for behavioral toxicity of psychotropic drugs (ie, the pharmacological actions of a drug that, within the dose range in which it has been found to possess clinical utility, may produce alterations in mood, perceptual, cognitive, and psychomotor functions that limit the capacity of the individual or constitute a hazard to one's well-being). A drug effect such as sedation or motor stimulation may be considered adverse for one patient and yet therapeutic and desired for another patient; within the same patient, it may be of value at one stage of one's illness and adverse at a later stage. The concept of behavioral toxicity encompasses adverse events that may be limited to the period of drug administration and/or persist long after their discontinuation. These latter phenomena can be subsumed under the rubric of iatrogenic comorbidity. Behavioral toxicity may ensue with any type of medical drug. Examples related to antidepressant drug use (onset of suicidality and aggression, switching from unipolar to bipolar course, withdrawal phenomena upon discontinuation, postwithdrawal persistent disorders) are discussed. Consideration of potential vulnerability to adverse events including behavioral toxicity should be placed in the context of the benefits that treatment may entail.
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Kordy H, Wolf M, Aulich K, Bürgy M, Hegerl U, Hüsing J, Puschner B, Rummel-Kluge C, Vedder H, Backenstrass M. Internet-Delivered Disease Management for Recurrent Depression: A Multicenter Randomized Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 85:91-8. [PMID: 26808817 DOI: 10.1159/000441951] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Strategies to improve the life of patients suffering from recurrent major depression have a high relevance. This study examined the efficacy of 2 Internet-delivered augmentation strategies that aim to prolong symptom-free intervals. METHODS Efficacy was tested in a 3-arm, multicenter, open-label, evaluator-blind, randomized controlled trial. Upon discharge from inpatient mental health care, 232 adults with 3 or more major depressive episodes were randomized to 1 of 2 intervention groups (SUMMIT or SUMMIT-PERSON) or to treatment as usual (TAU) alone. Over 12 months, participants in both intervention arms received, in addition to TAU, intense monitoring via e-mail or a smartphone, including signaling of upcoming crises, assistance with personal crisis management, and facilitation of early intervention. SUMMIT-PERSON additionally offered regular expert chats. The primary outcome was 'well weeks', i.e. weeks with at most mild symptoms assessed by the Longitudinal Interval Follow-Up Evaluation, during 24 months after the index treatment. RESULTS SUMMIT compared to TAU reduced the time with an unwell status (OR 0.48; 95% CI 0.23-0.98) through faster transitions from unwell to well (OR 1.44; 95% CI 0.83-2.50) and slower transitions from well to unwell (OR 0.69; 95% CI 0.44-1.09). Contrary to the hypothesis, SUMMIT-PERSON was not superior to either SUMMIT (OR 0.77; 95% CI 0.38-1.56) or TAU (OR 0.62; 95% CI 0.31-1.24). The efficacy of SUMMIT was strongest 8 months after the intervention. CONCLUSIONS The fully automated Internet-delivered augmentation strategy SUMMIT has the potential to improve TAU by reducing the lifelong burden of patients with recurrent depression. The fact that the effects wear off suggests a time-unlimited extension.
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Affiliation(s)
- Hans Kordy
- Center for Psychotherapy Research, University of Heidelberg, Heidelberg, Germany
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Fava GA. The Hidden Costs of Financial Conflicts of Interest in Medicine. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 85:65-70. [PMID: 26807570 DOI: 10.1159/000442694] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/18/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Bologna, Italy; Department of Psychiatry, State University of New York at Buffalo, Buffalo, N.Y., USA
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Vîslă A, Flückiger C, grosse Holtforth M, David D. Irrational Beliefs and Psychological Distress: A Meta-Analysis. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 85:8-15. [PMID: 26609889 DOI: 10.1159/000441231] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 09/18/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Since the cognitive revolution of the early 1950s, cognitions have been discussed as central components in the understanding and treatment of mental illnesses. Even though there is an extensive literature on the association between therapy-related cognitions such as irrational beliefs and psychological distress over the past 60 years, there is little meta-analytical knowledge about the nature of this association. METHODS The relationship between irrational beliefs and distress was examined based on a systematic review that included 100 independent samples, gathered in 83 primary studies, using a random-effect model. The overall effects as well as potential moderators were examined: (a) distress measure, (b) irrational belief measure, (c) irrational belief type, (d) method of assessment of distress, (e) nature of irrational beliefs, (f) time lag between irrational beliefs and distress assessment, (g) nature of stressful events, (h) sample characteristics (i.e. age, gender, income, and educational, marital, occupational and clinical status), (i) developer/validator status of the author(s), and (k) publication year and country. RESULTS Overall, irrational beliefs were positively associated with various types of distress, such as general distress, anxiety, depression, anger, and guilt (omnibus: r = 0.38). The following variables were significant moderators of the relationship between the intensity of irrational beliefs and the level of distress: irrational belief measure and type, stressful event, age, educational and clinical status, and developer/validator status of the author. CONCLUSIONS Irrational beliefs and distress are moderately connected to each other; this relationship remains significant even after controlling for several potential covariates.
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Affiliation(s)
- Andreea Vîslă
- Department of Clinical Psychology and Psychotherapy, Babex015F;-Bolyai University, Cluj-Napoca, Romania
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Is energy healing an effective non-pharmacological therapy for improving symptom management of chronic illnesses? A systematic review. Complement Ther Clin Pract 2016; 25:26-41. [PMID: 27863608 DOI: 10.1016/j.ctcp.2016.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Emerging evidence suggests that some people living with non-communicable diseases (NCDs) have integrated energy healing into their self-management strategy, however little is known about its efficacy. PURPOSE To identify energy healing interventions that impacted positively on the symptom management outcomes for patients living in the community with various NCDs. METHODS A systematic review of energy healing interventions for the management of non-communicable disease related symptoms, conducted between 01 January 2000 and 21 April 2015, published in an English peer-reviewed journal. This review conforms to the PRISMA statement. RESULTS Twenty seven studies were identified that evaluated various energy healing interventions involving 3159 participants. Thirteen of the energy healing trials generated statistically significant outcomes. CONCLUSIONS Energy healing has demonstrated some improvement in illness symptoms, however high level evidence consistently demonstrating efficacy is lacking. Further more robust trials are required to better understand which elements of energy healing interventions are associated with positive outcomes.
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The clinical inadequacy of the DSM-5 classification of somatic symptom and related disorders: an alternative trans-diagnostic model. CNS Spectr 2016; 21:310-7. [PMID: 26707822 DOI: 10.1017/s1092852915000760] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The Diagnostic and Statistical of Mental Disorders, Fifth Edition (DSM-5) somatic symptom and related disorders chapter has a limited clinical utility. In addition to the problems that the single diagnostic rubrics and the deletion of the diagnosis of hypochondriasis entail, there are 2 major ambiguities: (1) the use of the term "somatic symptoms" reflects an ill-defined concept of somatization and (2) abnormal illness behavior is included in all diagnostic rubrics, but it is never conceptually defined. In the present review of the literature, we will attempt to approach the clinical issue from a different angle, by introducing the trans-diagnostic viewpoint of illness behavior and propose an alternative clinimetric classification system, based on the Diagnostic Criteria for Psychosomatic Research.
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Weiss LA, Westerhof GJ, Bohlmeijer ET. Can We Increase Psychological Well-Being? The Effects of Interventions on Psychological Well-Being: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2016; 11:e0158092. [PMID: 27328124 PMCID: PMC4915721 DOI: 10.1371/journal.pone.0158092] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 06/12/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is a rapidly growing interest in psychological well-being (PWB) as outcome of interventions. Ryff developed theory-based indicators of PWB that are consistent with a eudaimonic perspective of happiness. Numerous interventions have been developed with the aim to increase PWB. However, the effects on PWB measured as coherent outcome have not been examined across studies yet. This meta-analysis of randomized controlled trials of behavioral interventions aims to answer the question whether it is possible to enhance PWB. METHODS A systematic literature search was performed in PsycINFO, Cochrane and Web of Science. To be included, studies had to be randomized controlled trials of behavioral interventions with psychological well-being as primary or secondary outcome measure, measured with either Ryff's Psychological Well-Being Scales or the Mental Health Continuum-Short Form. The meta-analysis was performed using a random effects model. From the 2,298 articles found, 27 met the inclusion criteria. The included studies involved 3,579 participants. RESULTS We found a moderate effect (Cohen's d = 0.44; z = 5.62; p < .001). Heterogeneity between the studies was large (Q (26) = 134.12; p < .001; I2 = 80.62). At follow-up after two to ten months, a small but still significant effect size of 0.22 was found. There was no clear indication of publication bias. Interventions were more effective in clinical groups and when they were delivered individually. Effects were larger in studies of lower quality. CONCLUSIONS It appears to be possible to improve PWB with behavioral interventions. The results are promising for the further development and implementation of interventions to promote PWB. Delivering interventions face-to-face seems to be the most promising option. We recommend to keep including clinical groups in the research of psychological well-being. Heterogeneity is a limitation of the study and there is need for more high-quality studies.
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Affiliation(s)
- Laura A. Weiss
- Centre for eHealth and Well-being Research, Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Gerben J. Westerhof
- Centre for eHealth and Well-being Research, Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Ernst T. Bohlmeijer
- Centre for eHealth and Well-being Research, Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
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de Leon J, Baca-García E, Blasco-Fontecilla H. From the serotonin model of suicide to a mental pain model of suicide. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 84:323-9. [PMID: 26398763 DOI: 10.1159/000438510] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 07/08/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Ky., USA
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Altamura M, Porcelli P, Balzotti A, Massaro CRM, Bellomo A. Influence of DCPR syndromes in the psychosocial functioning of patients with major depressive and bipolar disorders. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 84:387-8. [PMID: 26402717 DOI: 10.1159/000437148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/23/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Mario Altamura
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Zilcha-Mano S, Roose SP, Barber JP, Rutherford BR. Therapeutic alliance in antidepressant treatment: cause or effect of symptomatic levels? PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:177-82. [PMID: 25832111 PMCID: PMC4417334 DOI: 10.1159/000379756] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have shown that in psychotherapy alliance is a predictor of symptomatic change, even while accounting for the temporal precedence between alliance and symptoms. However, the extent to which alliance predicts outcomes in psychopharmacology is yet to be fully investigated considering the fact that alliance can be the result, rather than the cause, of symptomatic change. The current prospective study examined whether the alliance predicts outcomes in psychopharmacology, while controlling for previous symptomatic change throughout the course of treatment. METHODS Data from a psychopharmacological randomized controlled trial for the treatment of adult major depression (n = 42), including the patients' rating of the alliance with the physicians, were analyzed. Multilevel models controlling for autoregressive lag of the dependent variable were used in all analyses to examine the effect of alliance on outcome. RESULTS The effect of alliance on outcome, while controlling for prior symptomatic levels, was significant and restricted to the middle phase of treatment (week 4, p = 0.005), when most of the reductions in symptoms were observed. Exploratory analyses of the differences between placebo and medication conditions suggest that the differences between the patients in their average alliance levels predicted a greater reduction in symptoms in the placebo compared to the medication conditions (p = 0.008). The main limitation is the small cohort size. CONCLUSIONS The findings suggest an effect of alliance on outcome in psychopharmacology, which is not merely the result of previous symptomatic levels. This effect may be more robust in conditions that do not include active treatment (placebo), possibly serving as a compensatory effect.
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Affiliation(s)
| | - Steven P. Roose
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
| | - Jacques P. Barber
- The Derner Institute of Advanced Psychological Studies, Adelphi University
| | - Bret R. Rutherford
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
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