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Saccaro LF, Tassone M, Tozzi F, Rutigliano G. Proton magnetic resonance spectroscopy of N-acetyl aspartate in first depressive episode and chronic major depressive disorder: A systematic review and meta-analysis. J Affect Disord 2024; 355:265-282. [PMID: 38554884 DOI: 10.1016/j.jad.2024.03.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
N-acetyl aspartate (NAA) is a marker of neuronal integrity and metabolism. Deficiency in neuronal plasticity and hypometabolism are implicated in Major Depressive Disorder (MDD) pathophysiology. To test if cerebral NAA concentrations decrease progressively over the MDD course, we conducted a pre-registered meta-analysis of Proton Magnetic Resonance Spectroscopy (1H-MRS) studies comparing NAA concentrations in chronic MDD (n = 1308) and first episode of depression (n = 242) patients to healthy controls (HC, n = 1242). Sixty-two studies were meta-analyzed using a random-effect model for each brain region. NAA concentrations were significantly reduced in chronic MDD compared to HC within the frontal lobe (Hedges' g = -0.330; p = 0.018), the occipital lobe (Hedges' g = -0.677; p = 0.007), thalamus (Hedges' g = -0.673; p = 0.016), and frontal (Hedges' g = -0.471; p = 0.034) and periventricular white matter (Hedges' g = -0.478; p = 0.047). We highlighted a gap of knowledge regarding NAA levels in first episode of depression patients. Sensitivity analyses indicated that antidepressant treatment may reverse NAA alterations in the frontal lobe. We highlighted field strength and correction for voxel grey matter as moderators of NAA levels detection. Future studies should assess NAA alterations in the early stages of the illness and their longitudinal progression.
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Affiliation(s)
- Luigi F Saccaro
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Campus Biotech, 9 Chemin des Mines, 1202 Geneva, Switzerland; Department of Psychiatry, Geneva University Hospital, 1205 Geneva, Switzerland.
| | - Matteo Tassone
- Department of Pathology, University of Pisa, via Savi 10, 56126 Pisa, Italy
| | - Francesca Tozzi
- Bio@SNS laboratory, Scuola Normale Superiore, 56124 Pisa, Italy
| | - Grazia Rutigliano
- Department of Pathology, University of Pisa, via Savi 10, 56126 Pisa, Italy; Institute of Clinical Sciences, Imperial College London, MRI Steiner Unit, Hammersmith Hospital Campus, Du Cane Road, W12 0NN London, United Kingdom of Great Britain and Northern Ireland
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Ishizuka K, Ishiguro T, Nomura N, Inada T. Autistic traits as predictors of persistent depression. Eur Arch Psychiatry Clin Neurosci 2022; 272:211-216. [PMID: 34286407 DOI: 10.1007/s00406-021-01292-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/04/2021] [Indexed: 11/26/2022]
Abstract
Persistent depression has been suggested to be associated with autistic traits in people of working age. This study aimed to clarify which autistic characteristics at the initial visit were associated with persistent depression at the 12 week follow-up in a primary care setting. Newly depressed outpatients aged 24-59 years with no history of autism were asked to complete the 50-item autism spectrum quotient (AQ) and the Beck depression inventory (BDI) at baseline and 12 week follow-up (N = 123, males: 48%, age: 37.7 ± 9.15 years). Nearly 40% of participants had an AQ score ≥ 26. Significant differences were observed between the group with remitted depression (N = 43) and those with persistent depression (N = 80) in educational years and AQ "attention switching" and "attention to detail" subscale scores. In addition, a statistically significant decrease in the total AQ and the "communication" and "imagination" scores were observed in the remitted group, while no such change was observed in the group with persistent depression. It remains unclear whether the self-perceived severity of communication and imagination traits in persistent depression was due to the state of persistent depression or a kind of premorbid autistic trait. The results suggest that high levels of autistic traits are frequently present in adults with depression. High "attention switching" and "attention to detail" scores in AQ screening at the first visit might predict the persistence of depressive symptoms after 12 weeks in adults with depression, while total AQ scores, especially for "communication" and "imagination" items, might be state-dependent.
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Affiliation(s)
- Kanako Ishizuka
- Health Support Center, Nagoya Institute of Technology, Gokiso-cho, Showa-ku, 466-8555, Nagoya, Aichi, Japan
- Department of Child and Adolescent Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, 466-8550, Nagoya, Aichi, Japan
| | - Tomomi Ishiguro
- Hidamari Kokoro Clinic, 156 Goida, 490-1111, Ama, Aichi, Japan
| | - Norio Nomura
- Hidamari Kokoro Clinic, 156 Goida, 490-1111, Ama, Aichi, Japan
| | - Toshiya Inada
- Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, 466-8550, Nagoya, Aichi, Japan.
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Herzog P, Häusler S, Normann C, Brakemeier EL. Negative Effects of a Multimodal Inpatient CBASP Program: Rate of Occurrence and Their Impact on Treatment Outcome in Chronic and Treatment-Resistant Depression. Front Psychiatry 2021; 12:575837. [PMID: 34434122 PMCID: PMC8381360 DOI: 10.3389/fpsyt.2021.575837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/06/2021] [Indexed: 01/04/2023] Open
Abstract
Background: A growing number of studies indicate that the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is effective in treating chronic depression. However, there is no systematic research into possible negative effects. Therefore, the objectives of the study were to investigate the rate of occurrence of negative effects of an inpatient CBASP program and their impact on treatment response. Methods: Patients with chronic depression and treatment resistance who completed the 12-week multimodal inpatient CBASP treatment program in an open trial (N = 52) retrospectively completed the Inventory for the Assessment of Negative Effects of Psychotherapy (INEP) during follow-up data collection. Severity of depressive symptoms was assessed self- and observer-rated at admission, discharge, and 6 months follow-up. Rates of occurrence of negative effects were calculated and binary logistic regression analyses were conducted to determine the relationship to treatment outcome. Results: The results indicate that 92.3% of patients reported having experienced at least one negative effect and 45.2% indicated dependence on their therapist. Stigmatization and financial concerns as well as intrapersonal changes were reported by about one-third. Only dependence on the therapist negatively impacted treatment outcome in both outcome measures. Conclusions: While almost all patients reported at least one negative effect of a multimodal inpatient CBASP treatment program, most of the reported negative effects appear to be benign. However, dependence on the therapist seems to have a negative impact on treatment outcome. If these results can be replicated in future large-scale, randomized controlled prospective studies, CBASP therapists should be aware of possible dependence and consciously address it during treatment.
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Affiliation(s)
- Philipp Herzog
- Department of Clinical Psychology and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Sophia Häusler
- Department of Clinical Psychology and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
- Center for Mind, Brain and Behavior, University of Marburg and Justus Liebig University Giessen, Marburg, Germany
- Psychosomatic Clinic, Schön Klinik Bad Arolsen, Bad Arolsen, Germany
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Frick A, Thinnes I, Stangier U. Metta-based group meditation and individual cognitive behavioral therapy (MeCBT) for chronic depression: study protocol for a randomized controlled trial. Trials 2020; 21:20. [PMID: 31907002 PMCID: PMC6945547 DOI: 10.1186/s13063-019-3815-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression is a widespread disorder with severe impacts for individuals and society, especially in its chronic form. Current treatment approaches for persistent depression have focused primarily on reducing negative affect and have paid little attention to promoting positive affect. Previous studies have shown that metta meditation increases positive affect in chronically depressed patients. Results from previous trials provide evidence for the efficacy of a stand-alone metta meditation group treatment in combination with mindfulness-based approaches. Further research is needed to better understand the implementation of meditation practice into everyday life. Therefore, mindfulness and metta meditation in a group setting are combined with individual cognitive behavioral therapy (CBT) into a new, low-intensity, cost-effective treatment ("MeCBT") for chronic depression. METHODS/DESIGN In this single-center, randomized, observer-blinded, parallel-group clinical trial we will test the efficacy of MeCBT in reducing depression compared to a wait-list control condition. Forty-eight participants in a balanced design will be allocated randomly to a treatment group or a wait-list control group. Metta-based group meditation will be offered in eight weekly sessions and one additional half-day retreat. Subsequent individual CBT will be conducted in eight fortnightly sessions. Outcome measures will be assessed at four time points: before intervention (T0); after group meditation (T1); after individual CBT (T2); and, in the treated group only, at 6-month follow-up (T3). Changes in depressive symptoms (clinician rating), assessed with the Quick Inventory of Depressive Symptoms (QIDS-C) are the primary outcome. We expect a significant decline of depressive symptoms at T2 compared to the wait-list control group. Secondary outcome measures include self-rated depression, mindfulness, benevolence, rumination, emotion regulation, social connectedness, social functioning, as well as behavioral and cognitive avoidance. We will explore changes at T1 and T2 in all these secondary outcome variables. DISCUSSION To our knowledge this is the first study to combine a group program focusing on Metta meditation with state-of-the art individual CBT specifically tailored to chronic depression. Implications for further refinement and examination of the treatment program are discussed. TRIAL REGISTRATION ISRCTN, ISRCTN97264476. Registered 29 March 2018 (applied on 14 December 2017)-retrospectively registered.
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Affiliation(s)
- Artjom Frick
- Institute for Psychology - Department of Clinical Psychology and Psychotherapy, Goethe University Frankfurt, Varrentrappstr. 40-42, 60486 Frankfurt am Main, Germany
| | - Isabel Thinnes
- Institute for Psychology - Department of Clinical Psychology and Psychotherapy, Goethe University Frankfurt, Varrentrappstr. 40-42, 60486 Frankfurt am Main, Germany
| | - Ulrich Stangier
- Institute for Psychology - Department of Clinical Psychology and Psychotherapy, Goethe University Frankfurt, Varrentrappstr. 40-42, 60486 Frankfurt am Main, Germany
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Seidl E, Padberg F, Bauriedl-Schmidt C, Albert A, Daltrozzo T, Hall J, Renneberg B, Seidl O, Jobst A. Response to ostracism in patients with chronic depression, episodic depression and borderline personality disorder a study using Cyberball. J Affect Disord 2020; 260:254-262. [PMID: 31513969 DOI: 10.1016/j.jad.2019.09.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Social exclusion (ostracism) can lead to interactional frustration and may play an important role as trigger and symptom amplifier in affective disorders. To investigate immediate emotional and behavioral reactions as well as coping, social exclusion can be mimicked in experimental situations, e.g. in the Cyberball paradigm, a virtual ball tossing game which is well established in social psychology. The present cross-diagnostic study compares the responses to social exclusion in patients with chronic depression (CD), episodic depression (ED) and borderline personality disorder (BPD) in comparison to a healthy control group. METHODS After baseline characterization, 120 participants (29 patients with CD, 20 with ED, 28 with BPD and 43 healthy controls) played Cyberball with two virtual players and complete exclusion after three times receiving the ball. Thereafter, standard questionnaires were applied for measuring needs, threats, inner tension, emotions and behavioral intentions. RESULTS Patients with CD showed a higher intensity of ostracism and aversive impact, as well as the wish to escape the situation (behavioral intention) compared to ED. In most categories, CD and ED had scores between BPD and healthy controls (with this sequence) and with BPD patients showing the largest difference to healthy controls. LIMITATIONS The assessment did neither include objective behavioral measures (which is a general limitation in the majority of studies using Cyberball) nor any biological variables. The sample sizes of the diagnostic subgroups were moderate. CONCLUSIONS These findings support the hypothesis that social exclusion situations lead to a more aversive emotional and behavioral reaction in CD compared to ED. Psychological and biological underpinnings of these reactions should be addressed in future transdiagnostic studies. Moreover, psychotherapy in CD should focus on specific needs of CD patients for developing a functional coping in threatening interpersonal situations.
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Affiliation(s)
- Elias Seidl
- Dr. von Haunersches Kinderspital, University of Munich, Lindwurmstr. 4a, Munich, D-80337, Germany.
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | | | - Anna Albert
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Tanja Daltrozzo
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Jonathan Hall
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Babette Renneberg
- Department of Psychology, Free University of Berlin, Berlin, Germany
| | - Otmar Seidl
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Andrea Jobst
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
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Fjermestad-Noll J, Ronningstam E, Bach B, Rosenbaum B, Simonsen E. Characterological depression in patients with narcissistic personality disorder. Nord J Psychiatry 2019; 73:539-545. [PMID: 31517547 DOI: 10.1080/08039488.2019.1664630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Depressive symptoms often occur in patients with personality disorders. Along the lines of the precious concepts of reactive and melancholic forms of depression, two different patterns of depressive symptoms can be identified. Reactive forms of depression is considered to be related to dysfunction of emotional regulation and social functioning, and to personality disorders. This study aimed at exploring the pattern of depressive symptoms in patients with Narcissistic Personality Disorder (NPD) compared to a group of depressed patients without Personality Disorder (PD). The Newcastle Diagnostic Depression Scale (NDDS) is a clinical instrument designed to differentiate reactive depression from melancholic depression. Method: The study investigated patterns of depressive symptoms in 117 out-patients, divided into two groups. One group containing 56 patients with depressive symptoms by no PD and the other group comprised of 61 patients with depressive symptoms and NPD. The participants were interviewed using the Newcastle Diagnostic Depression Scale. Results: There was a significant difference between the groups, as the NPD group suffered from reactive forms of depression. The NPD group showed a pattern of depressive symptoms characterized by fluctuation of the depressive state, without time demarcation of depressive episode, ruminations preoccupied with hostility and accusatory feelings towards other, but not self-accusatory feelings, fluctuation suicidal ideation triggered by external events accompanied by parasuicidal behavior, lack of neuro-vegetative symptoms such as insomnia with early wakening, loss of appetite and weight loss. The No PD group showed the opposite pattern. Conclusion: Based on these results NDDS is considered to be an applicable instrument for identifying personality pathology in patients with depressive symptoms, by recognizing the specific pattern. This is thought to be important for adequate treatment planning.
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Affiliation(s)
| | - Elsa Ronningstam
- Harvard Medical School, Clinical Psychologist, McLean Hospital , Belmont , MA , USA
| | - Bo Bach
- Center for Personality Disorder Research, Psychiatric Research Unit , Region Zealand , Denmark
| | - Bent Rosenbaum
- Institute of Psychology, University of Copenhagen , Copenhagen , Denmark
| | - Erik Simonsen
- Department of Clinical Medicine, University of Copenhagen , Copenhagen , Denmark
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Köhler S, Chrysanthou S, Guhn A, Sterzer P. Differences between chronic and nonchronic depression: Systematic review and implications for treatment. Depress Anxiety 2019; 36:18-30. [PMID: 30300454 DOI: 10.1002/da.22835] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/20/2018] [Accepted: 08/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is still uncertainty if and to what extent chronic depression (CD) presents with specific features especially in contrast to the nonchronic course of major depressive disorder (non-CD). This systematic review aims to summarize the existing literature regarding sociodemographic factors, psychopathology, and course of disease in patients with CD in comparison to patients with non-CD. METHODS A structured database search (MEDLINE, PsycINFO, Web of Science, CENTRAL) was performed. All studies comparing CD with non-CD patients were included. Twenty-eight studies, including cohort studies, cross-sectional studies, and observational studies, were identified in which both subgroups were diagnosed according to DSM-IV or DSM-5, respectively. Primary outcome were group comparisons focused on sociodemographic factors, childhood adversity, onset of the disorder, comorbidities, severity and course of the depressive symptoms, and specific psychopathology. RESULTS Patients with CD had an earlier onset of depressive symptoms, higher rates of psychiatric comorbidities, and a complicated treatment course (e.g., higher rates of suicidality) compared to non-CD. We also found some evidence for specific features in the psychopathology of CD patients (submissive and hostile interpersonal styles) in contrast to non-CD patients. Results were inconsistent with regard to childhood maltreatment. No differences were found regarding the severity of depressive symptoms and most sociodemographic factors. CONCLUSION Despite some inconsistencies, the results of this review verified important differences between CD and non-CD. However, future research is needed to characterize especially the specific psychopathology of CD in comparison to non-CD patients to develop more tailored treatment strategies.
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Affiliation(s)
- Stephan Köhler
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Sophia Chrysanthou
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Anne Guhn
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Philipp Sterzer
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
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8
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Jobst A, Sabaß L, Hall D, Brücklmeier B, Buchheim A, Hall J, Sarubin N, Zill P, Falkai P, Brakemeier EL, Padberg F. Oxytocin plasma levels predict the outcome of psychotherapy: A pilot study in chronic depression. J Affect Disord 2018; 227:206-213. [PMID: 29100154 DOI: 10.1016/j.jad.2017.10.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Oxytocin is associated with bonding and social deficits in psychiatric disorders and has also been discussed as a potential therapeutic intervention to augment psychotherapy. The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a specific form of psychotherapy for chronic depression, an illness in which interpersonal deficits play a major role. In this pilot study, we investigated whether Oxytocin plasma levels predict the clinical outcome of chronic depressive patients after CBASP. METHODS Sixteen patients with chronic depression participated in a 10-week CBASP inpatient program. Oxytocin plasma levels were measured before and after participants played a virtual ball-tossing game (Cyberball) that mimics social exclusion. Clinical outcome after CBASP was evaluated with the Beck Depression Inventory-II (BDI-II) and the 24-item Hamilton Depression Rating Scale (HAMD-24). RESULTS After CBASP, depressive symptoms decreased significantly: the response rates were 44% (BDI-II) and 50% (HAMD-24); and the remission rates, 38% (BDI-II) and 44% (HAMD-24). Lower oxytocin plasma levels at baseline correlated with smaller changes in BDI-II scores, but not with the change in HAMD-24 scores. LIMITATIONS The limitations of our study were the small sample size, concomitant and non-standardized pharmacotherapy, and lack of a controlled design and a follow-up period. CONCLUSIONS Our study provides first evidence that oxytocin plasma levels may predict the outcome of psychotherapy in chronic depression. These findings need to be replicated in larger randomized, controlled trials.
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Affiliation(s)
- A Jobst
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany.
| | - L Sabaß
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany; Hochschule Fresenius, University of Applied Sciences, Munich, Germany
| | - D Hall
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - B Brücklmeier
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - A Buchheim
- Department of Psychology, Clinical Psychology, University of Innsbruck, Austria
| | - J Hall
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - N Sarubin
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany; Hochschule Fresenius, University of Applied Sciences, Munich, Germany
| | - P Zill
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - P Falkai
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - E-L Brakemeier
- Psychologische Hochschule Berlin (PHB), Berlin, Germany; Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Germany
| | - F Padberg
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
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Schnell K, Herpertz SC. Emotion Regulation and Social Cognition as Functional Targets of Mechanism-Based Psychotherapy in Major Depression With Comorbid Personality Pathology. J Pers Disord 2018; 32:12-35. [PMID: 29388896 DOI: 10.1521/pedi.2018.32.supp.12] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article characterizes functional systems as targets of integrated modular psychotherapy for episodes of major depression (MD) with a comorbid condition of borderline personality disorder (BPD) or chronic depression (CD). Both types of comorbidities to MD are conceptualized as a trait-like concept dominated by impairments in interpersonal functioning. Despite differences in psychopathology, existing data show significant similarities in impairments of emotion regulation and social cognition in BPD and CD, thought to reflect common disease mechanisms linked to early-life adversity. The preexistence of BPD and CD and related functional impairments inhibits the remission of episodic MD and calls for mechanism-based interventions that complement existing treatments of MD by targeting these dysfunctions. Contemporary methods of psychotherapy already provide interventions to address such complicated states of comorbidity by specifically improving dysfunctions of emotion regulation and social cognition. We suggest a layout of modular interventions that can address identified dysfunctions in comorbid MD.
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Affiliation(s)
- Knut Schnell
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany.,Asklepios Center for Psychiatry and Psychotherapy Göttingen, Göttingen, Germany
| | - Sabine C Herpertz
- Department of General Psychiatry, University Hospital Heidelberg, Heidelberg, Germany
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Negt P, Brakemeier EL, Michalak J, Winter L, Bleich S, Kahl KG. The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials. Brain Behav 2016; 6:e00486. [PMID: 27247856 PMCID: PMC4864084 DOI: 10.1002/brb3.486] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/16/2016] [Accepted: 04/01/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Chronic depression is a severe and disabling condition. Compared to an episodic course, chronic depression has been shown to be less responsive to psychopharmacological and psychological treatments. The cognitive behavioral analysis system of psychotherapy (CBASP) has been developed as a specific psychotherapy for chronic depression. However, conflicting results concerning its efficacy have been reported in randomized-controlled trials (RCT). Therefore, we aimed at examining the efficacy of CBASP using meta-analytical methods. METHODS Randomized-controlled trials assessing the efficacy of CBASP in chronic depression were identified by searching electronic databases (PsycINFO, PubMed, Scopus, Cochrane Central Register of Controlled Trials) and by manual searches (citation search, contacting experts). Searching period was restricted from the first available entry to October 2015. Identified studies were systematically reviewed. The standardized mean difference Hedges' g was calculated from posttreatment and mean change scores. The random-effects model was used to compute combined overall effect sizes. A risk of publication bias was addressed using fail-safe N calculations and trim-and-fill analysis. RESULTS Six studies comprising 1.510 patients met our inclusion criteria. The combined overall effect sizes of CBASP versus other treatments or treatment as usual (TAU) pointed to a significant effect of small magnitude (g = 0.34-0.44, P < 0.01). In particular, CBASP revealed moderate-to-high effect sizes when compared to TAU and interpersonal psychotherapy (g = 0.64-0.75, P < 0.05), and showed similar effects when compared to antidepressant medication (ADM) (g = -0.29 to 0.02, ns). The combination of CBASP and ADM yielded benefits over antidepressant monotherapy (g = 0.49-0.59, P < 0.05). LIMITATIONS The small number of included studies, a certain degree of heterogeneity among the study designs and comparison conditions, and insufficient data evaluating long-term effects of CBASP restrict generalizability yet. CONCLUSIONS We conclude that there is supporting evidence that CBASP is effective in the treatment of chronic depression.
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Affiliation(s)
- Philip Negt
- Department of Psychiatry, Social Psychiatry and Psychotherapy Hannover Medical School Hannover Germany
| | - Eva-Lotta Brakemeier
- Department for Clinical Psychology and Psychotherapy Berlin University of Psychology Berlin Germany
| | - Johannes Michalak
- Department of Psychology and Psychotherapy Witten/Herdecke University Witten Germany
| | - Lotta Winter
- Department of Psychiatry, Social Psychiatry and Psychotherapy Hannover Medical School Hannover Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy Hannover Medical School Hannover Germany
| | - Kai G Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy Hannover Medical School Hannover Germany
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Schnell K, Hochlehnert A, Berger M, Wolff J, Radtke M, Schramm E, Normann C, Herpertz SC. Leitlinienentsprechende stationäre psychiatrisch-psychotherapeutische Behandlung der chronischen Depression. DER NERVENARZT 2016; 87:278-85. [PMID: 26940212 DOI: 10.1007/s00115-016-0084-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- K Schnell
- Klink für Allgemeine Psychiatrie, Universitätsklinikum Heidelberg, Voßstr. 4, 69115, Heidelberg, Deutschland.
| | - A Hochlehnert
- Zentrum für Psychosoziale Medizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Berger
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - J Wolff
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - M Radtke
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - E Schramm
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - C Normann
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - S C Herpertz
- Klink für Allgemeine Psychiatrie, Universitätsklinikum Heidelberg, Voßstr. 4, 69115, Heidelberg, Deutschland
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Jobst A, Brakemeier EL, Buchheim A, Caspar F, Cuijpers P, Ebmeier KP, Falkai P, Jan van der Gaag R, Gaebel W, Herpertz S, Kurimay T, Sabaß L, Schnell K, Schramm E, Torrent C, Wasserman D, Wiersma J, Padberg F. European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe. Eur Psychiatry 2016; 33:18-36. [PMID: 26854984 DOI: 10.1016/j.eurpsy.2015.12.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/12/2015] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. METHODS We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. RESULTS We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. DISCUSSION The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. CONCLUSION Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.
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Affiliation(s)
- A Jobst
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - E-L Brakemeier
- Department of Clinical Psychology and Psychotherapy, Berlin University of Psychology, Berlin, Germany
| | - A Buchheim
- Department of Psychology, Clinical Psychology, University of Innsbruck, Innsbruck, Austria
| | - F Caspar
- Institute of Psychology, University of Bern, Bern, Switzerland
| | - P Cuijpers
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
| | - K P Ebmeier
- Department of Psychiatry, Division of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - P Falkai
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | | | - W Gaebel
- Department of Psychiatry und Psychotherapy, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - S Herpertz
- Department of Psychiatry and Psychotherapy, University of Heidelberg, Heidelberg, Germany
| | - T Kurimay
- Institute of Behaviour Sciences, Semmelweis University, Budapest, Hungary
| | - L Sabaß
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - K Schnell
- Department of Psychiatry and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - E Schramm
- Department of Psychiatry and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - C Torrent
- Clinical Institute of Neuroscience, Hospital Clinic Barcelona, CIBERSAM, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - D Wasserman
- National Centre for Suicide Research and Prevention of Mental lll-Health (NASP), Karolinska Institutet, Stockholm, Sweden
| | - J Wiersma
- Department of Psychiatry, GGZinGeest, Amsterdam, The Netherlands
| | - F Padberg
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany.
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Ildirli S, Şair YB, Dereboy F. Persistent Depression as a Novel Diagnostic Category: Results from the Menderes Depression Study. Noro Psikiyatr Ars 2015; 52:359-366. [PMID: 28360740 DOI: 10.5152/npa.2015.7589] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 09/20/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Persistent depressive disorder (PDD) introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 as a novel diagnostic category represents a consolidation of two separate DSM-IV categories, chronic major depressive disorder (MDD) and dysthymic disorder. The present study aims to investigate the frequency and clinical as well as socio-demographic correlates of PDD in comparison with those of episodic MDD among patients seeking treatment for depressive symptoms. METHODS Participants were 140 depressive out-and in-patients under treatment at the psychiatry clinic of the Adnan Menderes University Research Hospital. Each patient was assessed by means of a structured clinical interview (SCID-I) and relevant psychometric instruments including the Hamilton Depression Inventory and Eskin Suicidal Behavior Inventory. RESULTS Among the depressive patients, 61% fulfilled the criteria for PDD and 39% for episodic MDD. As compared with patients with episodic MDD, the PDD patients were older (d=.54), lower in educational attainment (d=.55), more likely to have comorbid generalized anxiety disorder (OR=3.7), and more prone to report symptoms of anxiety, hopelessness, pessimism, and somatic complaints. Nevertheless, the PDD patients displayed heterogeneous characteristics with respect to clinical severity and suicidal behavior. CONCLUSION Our findings suggest that majority of depressive patients, including those fulfilling the criteria for MDD, have been suffering from a persistent ailment rather than an episodic disorder. Clinicians with a cross-sectional perspective are more likely to diagnose MDD, whereas those with a longitudinal perspective are more likely to identify PDD in the majority of depressive patients. The incorporation of both of these perspectives into DSM-5 in a complementary manner will possibly enhance our insight into depressive disorders and improve our treatment results.
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Affiliation(s)
- Saliha Ildirli
- Clinic of Psychiatry, Ermenek State Hospital, Karaman, Turkey
| | - Yaşan Bilge Şair
- Clinic of Psychiatry, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Ferhan Dereboy
- Department of Psychiatry, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
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Brockmeyer T, Kulessa D, Hautzinger M, Bents H, Backenstrass M. Differentiating early-onset chronic depression from episodic depression in terms of cognitive-behavioral and emotional avoidance. J Affect Disord 2015; 175:418-23. [PMID: 25679196 DOI: 10.1016/j.jad.2015.01.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 01/16/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although chronic depression is associated with lower global functioning and poorer treatment response than episodic depression, little is known about the differences between these two forms of depression in terms of psychological factors. Thus, the present study aimed at differentiating chronic and episodic depression regarding cognitive-behavioral and emotional avoidance that have been proposed as important risk factors for depression and promising targets for the treatment of depression. METHODS Thirty patients with early onset chronic depression were compared with 30 patients with episodic depression and 30 healthy, never-depressed controls in terms of self-reported cognitive-behavioral (social and non-social) and emotional avoidance. RESULTS Chronically depressed patients reported more avoidance than healthy controls in each of the measures. Moreover, they reported more cognitive-nonsocial and behavioral-nonsocial as well as behavioral-social and emotional avoidance (in the form of restricted emotional expression to others) than patients with episodic depression. This kind of emotional avoidance also separated best between chronically and episodically depressed patients. Furthermore, general emotion avoidance and behavioral-social avoidance were positively correlated with levels of depression in chronically depressed patients. LIMITATIONS The results are based on self-report data and should thus be interpreted with caution. Additionally, the cross-sectional design limits any causal conclusions. CONCLUSIONS The findings underscore the relevance of cognitive-behavioral and emotional avoidance in differentiating chronic from episodic depression and healthy controls and advocate a stronger focus on maladaptive avoidance processes in the treatment of chronic depression.
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Affiliation(s)
- Timo Brockmeyer
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
| | - Dominika Kulessa
- Institute of Clinical Psychology, Hospital Stuttgart, Prießnitzweg 24, 70374 Stuttgart, Germany; Department of Clinical Psychology, University of Tübingen, Schleichstr.4, 72076 Tübingen, Germany
| | - Martin Hautzinger
- Department of Clinical Psychology, University of Tübingen, Schleichstr.4, 72076 Tübingen, Germany
| | - Hinrich Bents
- Center for Psychological Psychotherapy, University of Heidelberg, Hauptstrasse 47-51, 69117 Heidelberg, Germany
| | - Matthias Backenstrass
- Institute of Clinical Psychology, Hospital Stuttgart, Prießnitzweg 24, 70374 Stuttgart, Germany
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Renner F, Arntz A, Leeuw I, Huibers M. Schematherapie für chronische Depressionen. VERHALTENSTHERAPIE 2014. [DOI: 10.1159/000365472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Clapp JD, Grubaugh AL, Allen JG, Oldham JM, Fowler JC, Hardesty S, Frueh BC. Interpersonal Change Following Intensive Inpatient Treatment. Psychiatry 2014; 77:247-62. [PMID: 25162133 PMCID: PMC4267225 DOI: 10.1521/psyc.2014.77.3.247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Persons admitted for inpatient psychiatric care often present with interpersonal difficulties that disrupt adaptive social relations and complicate the provision of treatment. Whereas domains of psychosocial functioning in this population demonstrate clear growth in response to intervention, the impact of treatment on more complex patterns of interpersonal behavior has been largely overlooked within the existing literature. Interpersonal profiles characteristic of psychiatric inpatients were identified in the current study to determine rates of transition to adaptive functioning following hospitalization. METHODS Personality disturbance was assessed in 513 psychiatric inpatients using the Inventory of Interpersonal Problems. Scores were analyzed within a series of latent profile models to isolate unique interpersonal profiles at admission and at discharge. Longitudinal modeling was then employed to determine rates of transition from dysfunctional to adaptive profiles. Relationships with background characteristics, clinical presentation, and treatment response were explored. RESULTS Normative, Submissive, and Hostile/Withdrawn profiles emerged at both admission and discharge. Patients in the Normative profile demonstrated relatively moderate symptoms. Submissive and Hostile/Withdrawn profiles were related to known risk factors and elevated psychopathology. Approximately half of the patients who had been identified as Submissive or Hostile/Withdrawn transitioned to the Normative profile by discharge. Transition status evidenced modest associations with background characteristics and clinical presentation. Treatment engagement and reduction of clinical symptoms were strongly associated with adaptive transition. CONCLUSION Maladaptive interpersonal profiles characteristic of psychiatric inpatients demonstrated categorical change following inpatient hospitalization. Enhanced therapeutic engagement and overall reductions in psychiatric symptoms appear to increase potential for interpersonal change.
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Renner F, Arntz A, Leeuw I, Huibers M. Treatment for chronic depression using schema therapy. ACTA ACUST UNITED AC 2013. [DOI: 10.1111/cpsp.12032] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shankman SA, Campbell ML, Klein DN, Leon AC, Arnow BA, Manber R, Keller MB, Markowitz JC, Rothbaum BO, Thase ME, Kocsis JH. Dysfunctional attitudes as a moderator of pharmacotherapy and psychotherapy for chronic depression. J Psychiatr Res 2013; 47:113-21. [PMID: 23102821 PMCID: PMC3501539 DOI: 10.1016/j.jpsychires.2012.09.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 08/23/2012] [Accepted: 09/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Individuals with chronic depression exhibit heterogeneous responses to treatment. Important individual differences may therefore exist within this particularly difficult to treat population that act as moderators of treatment response. METHOD The present study examined whether pretreatment levels of dysfunctional attitudes (DA) moderated treatment response in a large sample of chronically depressed individuals. Data were taken from the Research Evaluating the Value of Augmenting Medication with Psychotherapy (REVAMP) treatment study--a multi-site treatment and augmentation study of 808 chronically depressed individuals. REVAMP comprised two phases: 1) a 12-week open-label antidepressant trial and 2), a subsequent phase, in which phase 1 non-remitters (N = 491) were randomized to either receive an ongoing medication algorithm alone, medication plus cognitive behavioral analysis system of psychotherapy, or medication plus brief supportive psychotherapy. RESULT In phase 1, compared to the pharmacotherapy response of patients with lower DA scores, the response for patients with higher DA scores was steeper, but leveled off toward the end of the phase. In phase 2, DA predicted a differential response in the medication only arm, but not in the two psychotherapy + medication conditions. Specifically, in the phase 2 medication only condition, patients with higher DA improved while those with lower DA scores did not. CONCLUSION These results indicate that the relation between DA and treatment response in chronic depression is complex, but suggest that greater DA may be associated with a steeper reduction and/or better response to pharmacotherapy.
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Affiliation(s)
- Stewart A Shankman
- Department of Psychology, University of Illinois at Chicago, IL 60607, USA.
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Steidtmann D, Manber R, Arnow BA, Klein DN, Markowitz JC, Rothbaum BO, Thase ME, Kocsis JH. Patient treatment preference as a predictor of response and attrition in treatment for chronic depression. Depress Anxiety 2012; 29:896-905. [PMID: 22767424 PMCID: PMC3463778 DOI: 10.1002/da.21977] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/04/2012] [Accepted: 06/09/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Findings regarding the relationship between patient treatment preference and treatment outcome are mixed. This is a secondary data analysis investigating the relationship between treatment preference, and symptom outcome and attrition in a large two-phase depression treatment trial. METHODS Patients met DSM-IV criteria for chronic forms of depression. Phase I was a 12-week, nonrandomized, open-label trial in which all participants (n = 785) received antidepressant medication(s) (ADM). Phase I nonremitters were randomized to Phase II, in which they received 12 weeks of either cognitive-behavioral system of psychotherapy (CBASP) + ADM (n = 193), brief supportive psychotherapy (BSP) + ADM (n = 187), or ADM only (n = 93). Participants indicated their treatment preference (medication only, combined treatment or no preference) at study entry. Symptoms were measured at 2-week intervals with the 24-item Hamilton Rating Scale for Depression (HAM-D). RESULTS A large majority of patients reported a preference for combined treatment. Patients who preferred medication only were more likely to endorse a chemical imbalance explanation for depression, whereas those desiring combined treatment were more likely to attribute their depression to stressful experiences. In Phase I, patients who expressed no treatment preference showed greater rates of HAM-D symptom reduction than those with any preference, and patients with a preference for medication showed higher attrition than those preferring combined treatment. In Phase II, baseline treatment preference was not associated with symptom reduction or attrition. CONCLUSIONS Treatment preferences may moderate treatment response and attrition in unexpected ways. Research identifying factors associated with differing preferences may enable improved treatment retention and response.
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Affiliation(s)
- Dana Steidtmann
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305–5722, USA.
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