Cognitive behavior approach to loss of clinical effect during long-term antidepressant treatment: a pilot study

Effects of Positive Psychotherapy for People with Psychosis: A Systematic Review and Meta-Analysis

This study evaluates positive psychotherapy's effects on the well-being and psychiatric symptoms of people with psychosis. A systematic search was conducted using 10 electronic databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis was performed using the R 4.2.0 program to estimate the effect size. Seventeen studies were included in the systematic review and 14 in meta-analysis. Positive psychotherapy for people with psychosis had significant effects on subjective and psychological well-being and psychiatric symptoms. Further, country, age, and session were significant moderators. Thus, positive psychotherapy improves the well-being and psychiatric symptoms of people with psychosis.

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis

Objectives

The aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).

Methods

A systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.

Results

Thirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.

Conclusions

In patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.

Systematic review registration number

PROSPERO 2018: CRD42018103142.

A Patient Stratification Approach to Identifying the Likelihood of Continued Chronic Depression and Relapse Following Treatment for Depression

Background: Subgrouping methods have the potential to support treatment decision making for patients with depression. Such approaches have not been used to study the continued course of depression or likelihood of relapse following treatment. Method: Data from individual participants of seven randomised controlled trials were analysed. Latent profile analysis was used to identify subgroups based on baseline characteristics. Associations between profiles and odds of both continued chronic depression and relapse up to one year post-treatment were explored. Differences in outcomes were investigated within profiles for those treated with antidepressants, psychological therapy, and usual care. Results: Seven profiles were identified; profiles with higher symptom severity and long durations of both anxiety and depression at baseline were at higher risk of relapse and of chronic depression. Members of profile five (likely long durations of depression and anxiety, moderately-severe symptoms, and past antidepressant use) appeared to have better outcomes with psychological therapies: antidepressants vs. psychological therapies (OR (95% CI) for relapse = 2.92 (1.24–6.87), chronic course = 2.27 (1.27–4.06)) and usual care vs. psychological therapies (relapse = 2.51 (1.16–5.40), chronic course = 1.98 (1.16–3.37)). Conclusions: Profiles at greater risk of poor outcomes could benefit from more intensive treatment and frequent monitoring. Patients in profile five may benefit more from psychological therapies than other treatments.

Well-being Therapy in Depressive Disorders

A specific brief psychotherapeutic intervention aimed at empowering psychological well-being, the so-called Well-Being Therapy (WBT), has been manualized in 2016 by Giovanni Fava and has shown to be effective in randomized controlled trials. WBT is based on the multidimensional model of psychological well-being developed by Marie Jahoda which encompasses environmental mastery, personal growth, purpose in life, autonomy, self-acceptance, positive relations with others, and balance of psychic forces. WBT aims at promoting the achievement of an optimal-balanced functioning between the dimensions of psychological well-being, and such a balance is subsumed under the rubric of euthymia. There are evidences that WBT may be a suited clinical approach for second- or third-line treatment of depressive disorders with particular reference to decreasing vulnerability to relapse and modulating psychological well-being and mood. It has been also proposed a role of WBT in depressive disorders in clinical conditions such as treatment resistance, loss of antidepressant clinical efficacy, persistent post-withdrawal disorders, trauma exposure, and medical disease comorbidity. The present chapter provides an overview of the possible applications of WBT as treatment of depressive disorders.

May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance

In recent years there has been a considerable debate on antidepressant drugs. Continued drug treatment with antidepressant medications may stimulate processes that run counter to the initial acute effects of a drug. The oppositional model of tolerance may explain loss of treatment efficacy during maintenance treatment and the fact that some side effects tend to occur only after a certain time. These processes may also direct the illness into a treatment-unresponsive course, including manifestations of bipolar disorder or paradoxical reactions. When drug treatment ends, oppositional processes no longer encounter resistance, resulting in potential onset of new withdrawal symptoms, persistent post-withdrawal disorders, hypomania, and resistance to treatment if it is reinstituted. In all these cases, antidepressant medications may constitute a form of iatrogenic comorbidity, which increases chronicity and vulnerability to depressive episodes. Antidepressant medications are essential drugs for the treatment of major depressive episodes. They are less likely, however, to provide protection for relapse prevention. Current prescription practices need to be reformulated in light of consideration of vulnerabilities and adverse effects of treatment. The oppositional model of tolerance provides a conceptual framework for weighing all these elements in the individual case. The model does not appear to apply to all patients who undergo treatment with AD, but only to a part of them. Studying the variables that are associated with such occurrence in certain patients and not in others would be one of the most important tasks of current therapeutic research. Current diagnostic systems in psychiatry do not consider the iatrogenic components of psychopathology, and can be applied to only patients who are drug free. They are suited for a patient who no longer exists: most of the cases that are seen in psychiatric clinical practice receive psychotropic drugs and such treatment is likely to affect prognosis and treatment choices.

Well-being therapy in depression: New insights into the role of psychological well-being in the clinical process

A specific psychotherapeutic strategy for increasing psychological well-being and resilience, well-being therapy (WBT), has been developed and validated in a number of randomized controlled trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one's self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage effectively one's life, and a sense of self-determination. The evidence supporting the use of WBT and its specific contribution when it is combined with other psychotherapeutic techniques is still limited. However, the insights gained by the use of WBT may unravel innovative approaches to assessment and treatment of mood and anxiety disorders, to be confirmed by controlled studies, with particular reference to decreasing vulnerability to relapse and modulating psychological well-being and mood. An important characteristic of WBT is self-observation of psychological well-being associated with specific homework. Such perspective is different from interventions that are labeled as positive but are actually distress oriented. Another important feature of WBT is the assumption that imbalances in well-being and distress may vary from one illness to another and from patient to patient. Customary clinical taxonomy and evaluation do not include psychological well-being, which may demarcate major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same diagnosis.

Psychological well-being and depression from pregnancy to postpartum among primiparous and multiparous women

BACKGROUND

The bulk of research on motherhood has focused on perinatal depression, largely overlooking indicators of women's positive mental health which can likewise have pervasive consequences on family functioning.

OBJECTIVE

The aim of the present study was to address this issue by exploring the impact of parity and childbirth on both women's perinatal depression and psychological well-being.

METHODS

A convenience sample of 81 women was followed during pregnancy (Time 1) and postpartum (Time 2). At both times, participants completed the Edinburgh Depression Scale and the Psychological Well-being Scales, measuring perceived autonomy, environmental mastery, personal growth, positive relations, purpose in life, and self-acceptance.

RESULTS

Significant negative correlations were observed between depression and psychological well-being dimensions. ANCOVA and mixed ANOVA analyses showed that depression levels did not differ between primiparous and multiparous women, or between pre- and postpartum assessments. By contrast, after childbirth, primiparous women reported higher values of environmental mastery and self-acceptance than multiparous women. In addition, levels of self-acceptance and personal growth increased from pregnancy to postpartum among primiparous women, while no differences were detected over time in the scores of all the psychological well-being dimensions among multiparous women.

CONCLUSIONS

This study highlighted some dimensions of positive psychological functioning that specifically contribute to women's well-being in the transition to motherhood, and their different relevance for primiparous and multiparous mothers. Future trials are needed to integrate this information in tailored intervention for the promotion of mothers' complete mental health.

Predictors of longitudinal outcomes after unstable response to acute-phase cognitive therapy for major depressive disorder

After patients with major depressive disorder (MDD) respond to acute-phase cognitive therapy (CT), continuation-phase treatments may be applied to improve long-term outcomes. We clarified which CT responders experience remission, recovery, relapse, and recurrence by testing baseline demographic, clinical, and personality variables. The sample of CT responders at higher risk of relapse (N = 241) was randomized to 8 months of continuation-phase CT, double-blinded fluoxetine, or pill placebo, and followed 24 months (Jarrett & Thase, 2010). Patients with lower positive emotionality and behavioral activation at the end of acute-phase CT showed increased risk for relapse/recurrence of MDD. In addition, patients with lower positive emotionality and behavioral activation, as well as higher residual depression (including emotional, cognitive, and social facets), showed decreased probability of remission (≥6 continuous weeks of minimal or absent symptoms) after acute-phase CT. Finally, patients with greater residual depression, as well as younger age and earlier MDD onset, showed decreased probability of recovery (≥35 continuous weeks of minimal or absent symptoms) after acute-phase CT. Moderator analyses did not reveal differential prediction across the continuation phase treatment arms. These results may help clinicians gauge the prognoses and need for continuation treatment among MDD patients who respond to acute-phase CT.

Cognitive Therapy to Prevent Depressive Relapse in Adults

The high prevalence, frequent relapse, and recurrence of major depressive disorder (MDD) increase its personal and societal costs. Cognitive therapy (CT) aims to decrease depressive symptoms and prevent relapse/recurrence. We review prevention evidence for acute, continuation, and maintenance CTs for patients whose depression is active, remitted, and recovered, respectively. Evidence suggests that patients relapse less often after discontinuing acute phase CT versus discontinuing pharmacotherapy. Continuation CT further decreases relapse relative to inactive controls and similarly to active pharmacotherapy. Maintenance CT may decrease recurrence but needs rigorous evaluation. Post-acute CT's preventive effects appear greater for higher-risk patients (e.g., with residual depressive symptoms, unstable acute-phase treatment response, childhood trauma, more prior depressive episodes), although risks may vary by specific CTs.

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Effectiveness of psychological interventions in preventing recurrence of depressive disorder: meta-analysis and meta-regression

BACKGROUND

Major depression is probably best seen as a chronically recurrent disorder, with patients experiencing another depressive episode after remission. Therefore, attention to reduce the risk of relapse or recurrence after remission is warranted. The aim of this review is to meta-analytically examine the effectiveness of psychological interventions to reduce relapse or recurrence rates of depressive disorder.

METHODS

We systematically reviewed the pertinent trial literature until May 2014. The random-effects model was used to compute the pooled relative risk of relapse or recurrence (RR). A distinction was made between two comparator conditions: (1) treatment-as-usual and (2) the use of antidepressants. Other sources of heterogeneity in the data were explored using meta-regression.

RESULTS

Twenty-five randomised trials met inclusion criteria. Preventive psychological interventions were significantly better than treatment-as-usual in reducing the risk of relapse or recurrence (RR=0.64, 95% CI=0.53-0.76, z=4.89, p<0.001, NNT=5) and also more successful than antidepressants (RR=0.83, 95% CI=0.70-0.97, z=2.40, p=0.017, NNT=13). Meta-regression showed homogeneity in effect size across a range of study, population and intervention characteristics, but the preventive effect of psychological intervention was usually better when the prevention was preceded by treatment in the acute phase (b=-1.94, SEb=0.68, z=-2.84, p=0.005).

LIMITATIONS

Differences between the primary studies in methodological design, composition of the patient groups and type of intervention may have caused heterogeneity in the data, but could not be evaluated in a meta-regression owing to poor reporting.

CONCLUSIONS

We conclude that there is supporting evidence that preventive psychological interventions reduce the risk of relapse or recurrence in major depression.

Discontinuation of antidepressants during attempts to conceive: a pilot trial of cognitive behavioral therapy for the prevention of recurrent depression

BACKGROUND

Many women discontinue antidepressants (ADs) when trying to conceive, although risk of depressive relapse is high. We examined the feasibility and potential clinical effect of cognitive behavioral therapy for the prevention of recurrence (CBT-PR) for women with a history of recurrent major depressive disorder (MDD) who planned to discontinue maintenance AD treatment for pregnancy.

METHODS

This was an open preliminary study of CBT-PR in women (N = 12) planning or early in pregnancy with remitted MDD on maintenance ADs with a plan to discontinue ADs for pregnancy. Participants received 12 sessions of CBT-PR during the acute phase and optional monthly booster sessions during follow-up. Participants were assessed monthly during the acute phase and then twice additionally during follow-up by an independent rater using mood scales (depression module of the Mini-International Neuropsychiatric Interview and Montgomery-Åsberg Depression Rating Scale); pregnancy status was also assessed.

RESULTS

Over the 24 weeks of the trial, 75% (n = 9) of participants did not restart ADs and did not relapse to depression. Of the 3 who reintroduced AD, 2 experienced a depressive relapse, whereas one did not meet full criteria for MDD. Adherence to the intervention was very good with all participants completing all therapy sessions and assessments.

CONCLUSIONS

Cognitive behavioral therapy for the prevention of recurrence seems feasible and may provide protection for women with recurrent depression on ADs who discontinue their medication while trying to conceive. The extent to which euthymia is sustainable with CBT-PR requires further study; the results of which may broaden treatment choices for women in anticipation of and during pregnancy.

The long-term effects of psychotherapy added to pharmacotherapy on morning to evening diurnal cortisol patterns in outpatients with major depression

BACKGROUND

Psychotherapy added to pharmacotherapy results in greater improvement in clinical outcomes than does pharmacotherapy alone. However, few studies examined how psychotherapy coupled with pharmacotherapy could produce a long-term protective effect by improving the psychobiological stress response.

METHODS

The researchers recruited 63 subjects with major depressive disorder (MDD) in an outpatient department of psychiatry at a general hospital. The randomly assigned subjects formed 2 groups: 29 in combined therapy (COMB) and 34 in monotherapy (MT). The COMB included 8 weekly body-mind-spirit group psychotherapy sessions added to pharmacotherapy. MT consisted of pharmacotherapy only. The outcome measures, collected at the subjects' homes, included the Beck Depression Inventory II (BDI-II), the State Trait Anxiety Inventory (STAI) and salivary cortisol on awakening, 45 min after awakening, and at 12.00, 17.00 and 21.00 h. Evaluation of outcome measures was at baseline condition, and at months 2 (end of additional psychotherapy), 5 and 8.

RESULTS

While the decreases in symptoms of depression were similar between COMB and MT (p > 0.05), the reductions in anxiety state were greater in COMB than in MT during the 8-month follow-up (p < 0.05). A steeper diurnal cortisol pattern more likely occurred in COMB than in MT in the 3 follow-up periods (p < 0.05, p <0.001 and p < 0.01).

CONCLUSIONS

The superior outcomes of group psychotherapy added to pharmacotherapy for MDD outpatients could relate to decreasing the anxiety state and to producing long-term impacts on positive stress endocrine outcomes seen as a steeper diurnal cortisol pattern.

Optimal duration of combined psychotherapy and pharmacotherapy for patients with moderate and severe depression: a meta-analysis

BACKGROUND

To investigate the most effective duration of combined psychotherapy and pharmacotherapy for achieving remission and preventing relapse in depressive patients as compared to pharmacotherapy alone.

METHODS

A systematic review of English articles using PubMed, EMBASE, Web of Science, the Cochrane Library, and PsychINFO was performed in September 2009. Clinical studies comparing pharmacotherapy alone with pharmacotherapy in combination with a psychological intervention for depression treatment that reported response, remission or relapse as outcomes were included in the analysis. For each of the studies, clinical binary outcomes such as response, remission or relapse were extracted.

RESULTS

All pooled analyses were based on random-effects models. Twenty-one article describing the influence of additional psychotherapy on remission and 15 articles reporting the influence on relapse in depression were included in the analysis. Patients receiving combined treatment experienced remission more often than those receiving pharmacotherapy alone, with the highest odds ratio OR, 2.36; 95% CI, 1.58-3.55 observed at 4months after commencing the treatment. Patients receiving pharmacotherapy alone also demonstrated a higher risk for relapse compared to those receiving combined treatment.

LIMITATIONS

We restricted our search to only English language publications. Studies investigating relapse or recurrence rates are often of small size.

CONCLUSION

Pharmacotherapy enhanced with psychotherapy is associated with a higher probability of remission and a lower risk of relapse, as compared to antidepressants alone for depression treatment. Receiving psychotherapy in both the acute and continuation phases is the most effective option. Further research is needed to investigate the influence of additional psychotherapy on different patients.

Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis

BACKGROUND

Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD.

METHOD

Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis.

RESULTS

Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659-0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674-1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463-0.912).

CONCLUSIONS

We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.

New modalities of assessment and treatment planning in depression: the sequential approach

The sequential model of treatment for depression, i.e. the use of psychotherapy in patients who have remitted from a major depressive disorder after a course of pharmacotherapy, is an intensive two-stage approach that derives from the awareness that one course of treatment is unlikely to provide a solution to all the symptoms of patients. The aim of the sequential approach is to provide different types of treatment for as long as considered necessary in different phases of illness as determined by repeated assessments. The treatment strategies are chosen on the basis of the symptoms identified and not as predefined options. The sequential model emphasizes consideration of subclinical and residual symptomatology according to the organizing principles of macro-analysis (a relationship between co-occurring symptoms and problems is established on the basis of where treatment should commence in the first place). Diagnostic endpoints (i.e. DSM diagnoses), the customary guidance of treatment planning, are replaced by conceptualization of disorders as 'transfer stations', which are amenable to longitudinal verification and modification. The aim of this systematic review was to survey the literature concerned with the sequential approach to the treatment of depression. Randomized controlled trials were identified using MEDLINE and a manual search of the literature. In seven of the eight studies that were identified, the sequential use of pharmacotherapy and psychotherapy was found to improve long-term outcome after termination of treatment compared with clinical management and treatment as usual. Nevertheless, data on this approach are limited and more studies are necessary for detailing the various clinical steps associated with it. The sequential approach calls for a re-assessment of the design of comparative clinical trials. It allows randomization of patients who are already in treatment and assignment of them to treatment alternatives according to stages of development of their illness and not simply to disease classification. The model is thus more in line with the chronicity of mood disorders compared to the standard randomized controlled trial, which is based on the acute disease model.

Differential effects of well-being promoting and anxiety-management strategies in a non-clinical school setting

The aim of the present study was to examine the differential effects of strategies for promotion of psychological well-being (Well-Being Therapy, WBT) and removal of distress (Anxiety Management, AM) in a non-clinical school setting.162 students attending middle schools in Northern Italy were randomly assigned to: (a) a protocol derived from WBT; (b) an anxiety-management protocol (AM). The students were assessed immediately before and after the interventions, and after 6 months using: Psychological Well-Being Scales (PWB), Symptom Questionnaire (SQ) and the Revised Children's Manifest Anxiety Scale (RCMAS). In school children, well-being and symptom focused interventions produced slightly different effects on psychological dimensions. WBT, by facilitating progression toward positive and optimal functioning, may integrate symptom-centered strategies.

School intervention for promoting psychological well-being in adolescence

OBJECTIVE

to test the efficacy of a new school program for the promotion of psychological well-being. In this study a school program for promoting psychological well-being has been compared to an attention-placebo intervention in a high school setting.

METHODS

Nine classes (227 students) were randomly assigned to: a) Well-Being intervention (5 classes); b)attention-placebo (4 classes). Assessment was performed at pre and post-intervention, and after six months using: 1) Symptom Questionnaire (SQ); 2) Psychological Well-Being Scales (PWB); 3) Revised Children's Manifest Anxiety Scale (RCMAS).

RESULTS

A significant effect of WB school intervention in improving Personal Growth (PWB), and in decreasing distress (Somatization (SQ), Physical Well-being (SQ), Anxiety (SQ), and RCMAS Physiological Anxiety) emerged.

CONCLUSIONS

A school intervention based on promoting positive emotions and well-being was effective not only in increasing psychological well-being among adolescents, but also in decreasing distress, in particular anxiety and somatization.

Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners

BACKGROUND

Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled "Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management," which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden.

METHODS

Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management.

RESULTS

After the intervention, experimental group patients rated their HRQoL less positively (P = .038) and tended to report more anxiety (P = .077) compared with controls. Care partners rated their stress at a lower level (P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others.

CONCLUSION

Further exploration of the impact of disease-management interventions in patients with advanced lung disease and their care partners is needed using both qualitative and quantitative methodology. Disease-management interventions have the potential to positively affect patients with advanced lung disease and their care partners.

[Diagnosis and therapy of depression in family practice]

Depression is one of the most prevalent mental disorders, according to Hungarian and international data. In Western- Europe, lifetime prevalence of major depression is 13%, while one-year prevalence is 4%. The prevalence of severe depressive symptoms is similar in Hungary: approximately 5 to 8% of all patients seen by primary care physicians suffer from some kind of depressive disorders. Depression is more prevalent in women and in the elderly. According to the World Health Organization, depression is the third most common disabling disorder. Patients with depression experience impaired quality of life, anxiety, sleep disturbances, alcohol and drug abuse, and different somatic disorders. Furthermore, depression is the most important risk factor for suicide. Primary care physicians have a crucial role in the screening and diagnosing of depressive disorders. Depressive disorders can exist not only in patients complaining about depressed mood, but also in patients with "medically unexplained symptoms" (headache, fatigue, abdominal pain, gastrointestinal symptoms, weight change). Primary care physicians should have appropriate knowledge about the different therapeutic options (including various psychotherapies, antidepressant medications and other treatment options) to be able to treat their patients properly. We review the literature about the significance and epidemiology of depression and summarize the diagnostic and therapeutic options of depressive disorders in primary care practice.

Well-being therapy for generalized anxiety disorder

Well-being therapy (WBT) aims to enhance psychological well-being based on Ryff's (1989) six dimensions: autonomy, personal growth, environmental mastery, purpose in life, positive relations, and self-acceptance. Previous studies have documented the efficacy of this psychotherapy in treating patients with mood and anxiety disorders and in preventing relapse in recurrent depression. We discuss and illustrate the use of WBT in generalized anxiety disorder. We present a case of a patient suffering from generalized anxiety disorder treated with cognitive-behavioral therapy followed by WBT.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Collaborative depression care, screening, diagnosis and specificity of depression treatments in the primary care setting

The identification, referral and specific treatment of midlife patients in primary care who are distressed by mood, anxiety, sleep and stress-related symptoms, with or without clinically confirmed menopausal symptoms, are confounded by many structural issues in the delivery of women's healthcare. Diagnosis, care delivery, affordability of treatment, time commitment for treatment, treatment specificity for a particular patient's symptoms and patient receptiveness to diagnosis and treatment all play roles in the successful amelioration of symptoms in this patient population. The value of screening for depression in primary care, the limitations of commonly used screening instruments relative to culture and ethnicity, and which clinical care systems make best use of diagnostic screening programs will be discussed in the context of the midlife woman. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) program illustrates the relatively high rate of unremitted patients, regardless of clinical setting, who are receiving antidepressants. Nonmedication treatment approaches, referred to in the literature as 'nonsomatic treatments', for depression, anxiety and stress, include different forms of cognitive-behavioral therapy, interpersonal therapy, structured daily activities, mindfulness therapies, relaxation treatment protocols and exercise. The specificity of these treatments, their mechanisms of action, the motivation and time commitment required of patients, and the availability of trained practitioners to deliver them are reviewed. Midlife women with menopausal symptoms and depression/anxiety comorbidity represent a challenging patient population for whom an individualized treatment plan is often necessary. Treatment for depression comorbid with distressing menopausal symptoms would be facilitated by the implementation of a collaborative care program for depression in the primary care setting.

Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects

Relapse and recurrence following response to acute-phase treatment for major depressive disorder (MDD) are prevalent and costly. In a meta-analysis of 28 studies including 1,880 adults, the authors reviewed the world's published literature on cognitive-behavioral therapies (CT) aimed at preventing relapse-recurrence in MDD. Results indicate that after discontinuation of acute-phase treatment, many responders to CT relapse-recur (29% within 1 year and 54% within 2 years). These rates appear comparable to those associated with other depression-specific psychotherapies but lower than those associated with pharmacotherapy. Among acute-phase treatment responders, continuation-phase CT reduced relapse-recurrence compared with assessment only at the end of continuation treatment (21% reduction) and at follow-up (29% reduction). Continuation-phase CT also reduced relapse-recurrence compared with other active continuation treatments at the end of continuation treatment (12% reduction) and at follow-up (14% reduction). The authors discuss implications for research and patient care and suggest directions, with methodological refinements, for future studies.

Well-being therapy in school settings: a pilot study

BACKGROUND

There is increasing interest in the psychobiological mechanisms of resilience and psychological well-being. It is conceivable that activation of such mechanisms in the school setting may entail long-term benefits, both in terms of the developmental process and of prevention of distress. This study wants to apply and test the efficacy of a school-based intervention protocol derived from well-being therapy (WBT) compared to cognitive-behavioral strategies.

METHODS

School interventions were performed in a population of 111 students randomly assigned to: (a) a protocol using theories and techniques derived from cognitive-behavioral therapy; (b) a protocol derived from WBT. Assessment before and after interventions was performed using two self-rating scales: Kellner's Symptom Questionnaire and Ryff's Psychological Well-Being Scales.

RESULTS

Both school-based interventions resulted in a comparable improvement in symptoms and psychological well-being.

CONCLUSIONS

This new well-being-enhancing strategy could play an important role in the prevention of psychological distress in school settings and in promoting optimal human functioning among children.

Cognitive change process during group cognitive behaviour therapy for depression

BACKGROUND

This study extended that of Kwon and Oei [Kwon, S.M., Oei, T.P.S., 2003. Cognitive change processes in a group cognitive behavior therapy of depression. J. Behav. Ther. Exp. Psychiatry, 3, 73-85], which outlined a number of testable models based on Beck's cognitive theory of depression. Specifically, the current study tested the following four competing models: the causal, consequential, fully and partially interactive cognitive models in patients with major depressive disorder.

METHODS

A total of 168 clinically depressed outpatients were recruited into a 12-week group cognitive behaviour therapy program. Data was collected at three time points: baseline, mid- and at termination of therapy using the ATQ, DAS and BDI. The data were analysed with Amos 4.01(Arbuckle, J.L., 1999. Amos 4.1. Smallwaters, Chicago.) structural equation modelling.

RESULTS

Results indicated that dysfunctional attitudes, negative automatic thoughts and symptoms of depression reduced significantly during treatment. Both the causal and consequential models equally provided an adequate fit to the data. The fully interactive model provided the best fit. However, after removing non-significant pathways, it was found that reduced depressive symptom contributed to reduced depressogenic automatic thoughts and dysfunctional attitudes, not the reverse.

CONCLUSION

These findings did not fully support Beck's cognitive theory of depression that cognitions are primary in the reduction of depressed mood.

Well-being therapy of generalized anxiety disorder

BACKGROUND

There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD.

METHODS

Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel's Clinical Interview for Depression, Ryff's Psychological Well-being Scales and Kellner's Symptom Questionnaire. A one-year follow-up was undertaken.

RESULTS

Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up.

CONCLUSIONS

These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

Changing perspectives in the nutritional management of disease

There have been substantial changes in the nutritional management of many diseases in the last 20 years, which have been accompanied by a growing recognition of its importance. Many of the changes in clinical nutrition have been associated with the introduction of standards, clinical audit and the implementation of evidence-based practice, which has led to a re-evaluation of some established dietary interventions using a hierarchy-of-evidence approach. Although there are few randomised controlled trials on which to base such work, the examination of other, often less-robust, evidence has led to some traditional dietary interventions being modified. Examples in gastroenterology include the use of low-fat diets in gall bladder disease and the restriction of protein in hepatic encephalopathy, where the current evidence suggests that neither should be used routinely in clinical practice. Where therapeutic dietary restrictions are required, as with low-Na diets in ascites, there is very little information on how these restrictions influence total nutrient intake and, if intake is impaired, how the detrimental effects of an inadequate intake should be balanced with the therapeutic effects of restriction. Studies are required to ensure that nutritional interventions are not only effective but also free from undesirable side effects. The mode and timing of the delivery of nutritional support has also been re-evaluated and the benefits of early enteral feeding have been recognised. The delivery of dietary advice is a new area that is being considered, with practitioners in clinical nutrition using behaviour-change skills to facilitate optimum nutrition rather than simply providing patients with advice. For such developments to continue in clinical nutrition it is essential that all practice should be systematically evaluated and, where necessary, modified in the light of sound current research findings, and that gaps in our present knowledge base are identified and addressed.

Treatment of recurrent depression: a sequential psychotherapeutic and psychopharmacological approach

The chronic and recurrent nature of major depressive disorder is receiving increasing attention. Approximately eight of ten people experiencing a major depressive episode will have at least one more episode during their lifetime, i.e. recurrent major depressive disorder. In the 1990s, prolonged or lifelong pharmacotherapy emerged as the main therapeutic tool for preventing relapses of depression. This therapeutic approach is based on the effectiveness of antidepressant drugs compared with placebo in decreasing relapse risk and on the improved tolerability profile of the newer antidepressants compared with their older counterparts. However, outcome after discontinuation of antidepressant therapy does not seem to be affected by the duration of administration. Loss of clinical effects, despite adequate compliance, has also emerged as a vexing clinical problem. The use of intermittent pharmacotherapy with follow-up visits is an alternative therapeutic option. This leaves patients with periods free of drugs and adverse effects and takes into account that a high proportion of patients would discontinue the antidepressant anyway. However, the problems of resistance (that a drug treatment may be associated with a diminished chance of response in subsequent treatments in those patients whose symptoms successfully responded to it but who discontinued it) and of discontinuation syndromes are substantial disadvantages of this therapeutic approach. In recent years, several controlled trials have suggested that sequential use of pharmacotherapy in the treatment of the acute depressive episode and psychotherapy in its residual phase may improve long-term outcome. Patients, however, need to be motivated for psychotherapy, and skilled therapists have to be available. Despite an impressive amount of research into the treatment of depression, there is still a paucity of studies addressing the specific problems that prevention of recurrent depression entails. It is important to discuss with the patient the various therapeutic options and to adapt strategies to the specific needs of patients.

The relationship of psychological well-being to distress and personality

BACKGROUND

The concept of psychological well-being has been neglected for a long time in scientific literature. Over the last decades, however, many psychometric instruments have been developed to measure it. The aim of the present study was to analyze the concept of psychological well-being and its relationship to distress and personality traits. It is clinically and empirically important to establish where the measures of well-being are located in relation to symptomatology indices and personality traits.

METHODS

A sample of 450 subjects in the general population completed three self-rating scales for the assessment of symptomatology (Kellner's Symptom Questionnaire), psychological well-being (Ryff's Psychological Well-Being Scales, PWB), and personality traits (Cloninger's Tridimensional Personality Questionnaire). The assessment was repeated after 1 month. Pearson's coefficient was used to analyze PWB test-retest reliability and correlations between well-being, distress and personality indicators. Exploratory factor analysis was performed for both assessments.

RESULTS

Test-retest Pearson's coefficients were satisfactory for all six PWB scales. Exploratory factor analyses showed a 4- or 5-factor structure, where well-being, distress and personality remained separated. PWB scales were negatively and significantly correlated with all symptom scales, but only with one personality dimension, TPQ Harm Avoidance. Mean-level differences by gender showed that in general women significantly presented with lower levels of well-being (except in Positive Relations) and higher levels of distress and personality disturbances.

CONCLUSIONS

The results suggest that the relationship of well-being to distress and personality is complex. Psychological well-being could not be equated with the absence of symptomatology or with personality traits. PWB scales measure an attitude toward optimal functioning that is crucial for a comprehensive consideration of individuals in clinical settings.

Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy

This article describes the main characteristics and technical features of a novel psychotherapeutic strategy, well-being therapy. This paper outlines the background of its development, the structure of well-being therapy, its key concepts and technical aspects. Well-being therapy is based on Ryff's multidimensional model of psychological well-being, encompassing six dimensions: autonomy, personal growth, environmental mastery, purpose in life, positive relations and self-acceptance. The goal of this therapy is improving the patients' levels of psychological well-being according to these dimensions, using cognitive-behavioral techniques. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive-behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological or psychotherapeutic treatments and in body image disturbances. The clinical studies supporting its efficacy are illustrated.