Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone

Personalized digital intervention for depression based on social rhythm principles adds significantly to outpatient treatment

We conducted a 16-week randomized controlled trial in psychiatric outpatients with a lifetime diagnosis of a mood and/or anxiety disorder to measure the impact of a first-of-its-kind precision digital intervention software solution based on social rhythm regulation principles. The full intent-to-treat (ITT) sample consisted of 133 individuals, aged 18-65. An exploratory sub-sample of interest was those individuals who presented with moderately severe to severe depression at study entry (baseline PHQ-8 score ≥15; N = 28). Cue is a novel digital intervention platform that capitalizes on the smartphone's ability to continuously monitor depression-relevant behavior patterns and use each patient's behavioral data to provide timely, personalized "micro-interventions," making this the first example of a precision digital intervention of which we are aware. Participants were randomly allocated to receive Cue plus care-as-usual or digital monitoring only plus care as usual. Within the full study and depressed-at-entry samples, we fit a mixed effects model to test for group differences in the slope of depressive symptoms over 16 weeks. To account for the non-linear trajectory with more flexibility, we also fit a mixed effects model considering week as a categorical variable and used the resulting estimates to test the group difference in PHQ change from baseline to 16 weeks. In the full sample, the group difference in the slope of PHQ-8 was negligible (Cohen's d = -0.10); however, the Cue group demonstrated significantly greater improvement from baseline to 16 weeks (p = 0.040). In the depressed-at-entry sample, we found evidence for benefit of Cue. The group difference in the slope of PHQ-8 (Cohen's d = -0.72) indicated a meaningfully more rapid rate of improvement in the intervention group than in the control group. The Cue group also demonstrated significantly greater improvement in PHQ-8 from baseline to 16 weeks (p = 0.009). We are encouraged by the size of the intervention effect in those who were acutely ill at baseline, and by the finding that across all participants, 80% of whom were receiving pharmacotherapy, we observed significant benefit of Cue at 16 weeks of treatment. These findings suggest that a social rhythm-focused digital intervention platform may represent a useful and accessible adjunct to antidepressant treatment (https://clinicaltrials.gov/ct2/show/NCT03152864?term=ellen+frank&draw=2&rank=3).

Dose effect of psilocybin on primary and secondary depression: a preliminary systematic review and meta-analysis

BACKGROUND

Previous studies have shown that psilocybin has antidepressant effects. In the current study, we aim to explore the dose effects of psilocybin on primary (major depression patients) and secondary depression (depressed cancer patients).

METHODS

Published studies concerning psilocybin for depression were retrieved. In accordance with PRISMA guidelines, 6 databases (PubMed, Embase, Web of Science, Cochrane Library, Clinicaltrials.gov 2.3 and WanFang database) were searched for research studies published or still in progress from inception to 30 November, 2020, with language restricted to English and Chinese. Hedges' g of Beck Depression Inventory (BDI) score changes was calculated as the primary outcome.

RESULTS

7 articles were finally included, with a total of 136 participants. In terms of efficacy, Hedges' g was 1.289 (95%CI=[1.020, 1.558], heterogeneity I²=50.995%, p<0.001). As psilocybin dose increases within a certain range, the antidepressive effect declines and then increases, with 30-35 mg/70 kg achieving the optimal therapeutic effect. Subgroup analysis suggested that the antidepressive effect of psilocybin was extremely significant at a relatively high dose (30-35mg/70kg: Hedges' g=3.059, 95%CI=[2.269, 3.849], p<0.001), long-term (>1month: Hedges' g=1.123, 95%CI=[0.861, 1.385], p<0.001) and when used in primary depression patients (Hedges' g=2.190, 95%CI=[1.423, 2.957], p<0.001).

LIMITATIONS

Only a small number of studies can be identified of variable quality, thus our conclusions remain preliminary.

CONCLUSIONS

Our preliminary results have shown that psilocybin exerts a rapid effect in reducing depressive symptom on primary and secondary depression. The optimal dose of psilocybin may be 30-35mg/70kg or higher; future clinical trials are warranted for further evaluation on its effect.

Impact of Baseline Characteristics on the Effectiveness of Disorder-Specific Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Supportive Psychotherapy in Outpatient Treatment for Persistent Depressive Disorder

Importance: In the treatment of persistent depressive disorder (PDD), disorder-specific Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has been shown to be superior to Supportive Psychotherapy (SP) in outpatients. It remains to clear which subgroups of patients benefit equally and differentially from both psychotherapies. Objective: To identify those patient-level baseline characteristics that predict a comparable treatment effectiveness of CBASP and SP and those that moderate the differential effectiveness of CBASP compared to SP. Design, setting and participants: In this analysis of a 48-week multicenter randomized clinical trial comparing CBASP to SP in adult antidepressant-free outpatients with early-onset PDD, we evaluated baseline variables from the following domains as potential predictors and moderators of treatment effectiveness: socio-demography, clinical status, psychosocial and global functioning, life quality, interpersonal problems, childhood trauma, treatment history, preference for psychotherapy, and treatment expectancy. Interventions: A 48-week treatment program with 32 sessions of either CBASP or SP. Main outcomes and measures: Depression severity measured by the 24-item Hamilton Rating Scale for Depression (HRSD-24) at week 48. Results: From N = 268 randomized outpatients, N = 209 completed the 48-week treatment program. CBASP completers had significantly lower post-treatment HRSD-24 scores than SP completers (meanCBASP=13.96, sdCBASP= 9.56; meanSP= 16.69, sdSP= 9.87; p = 0.04). A poor response to both therapies was predicted by higher baseline levels of clinician-rated depression, elevated suicidality, comorbid anxiety, lower social functioning, higher social inhibition, moderate-to-severe early emotional or sexual abuse, no preference for psychotherapy, and the history of at least one previous inpatient treatment. Moderator analyses revealed that patients with higher baseline levels of self-rated depression, comorbidity of at least one Axis-I disorder, self-reported moderate-to-severe early emotional or physical neglect, or at least one previous antidepressant treatment, had a significantly lower post-treatment depression severity with CBASP compared to SP (all p < 0.05). Conclusions and relevance: A complex multifactorial interaction between severe symptoms of depression, suicidality, and traumatic childhood experiences characterized by abuse, social inhibition, and anxiety may represent the basis of non-response to psychotherapy in patients with early onset PDD. Specific psychotherapy with CBASP might, however, be more effective and recommendable for a variety of particularly burdened patients compared to SP.

Development of an Innovative Treatment Paradigm for Intimate Partner Violence Victims With Depression and Pain Using Community-Based Participatory Research

Intimate partner violence (IPV) is a public health issue with complex physical health, mental health and social consequences that can exacerbate survivors' barriers to health care engagement and support. Furthermore, health care professionals are often unaware of or feel ill-equipped to address survivors' complex needs. Depression and chronic pain are particularly prevalent co-occurring problems for survivors and can impede engagement and outcomes in traditional health care. This study's purpose was to understand what interventions might be more responsive to survivors' myriad needs, particularlly those with depression and pain. Survivors were involved with the design, execution, analysis, and interpretation of results, based on community-based participatory research principles. Intervention development happened in two phases: the first consisted of focus groups with survivors to inform the intervention and the second included intervention design, informed by a community advisory board (CAB). Thirty-one survivors participated in Phase 1, and they reported preferring a range of support including formal help-seeking, informal coping strategies, and spirituality. In Phase 2, the CAB (comprised of survivors, health care professionals, and researchers) identified three distinct aspects of a comprehensive IPV intervention: (a) education regarding both the complex health issues and available local resources; (b) an integrated consultation service for providers to seek recommendations for responding to the full spectrum of survivors' needs; and (c) a trauma-informed, accessible clinic. Academic medical centers could not have designed this intervention in isolation; survivors and providers played an integral part of this process, and continue to inform our current work.

Semantic Distances in Depression: Relations Between ME and PAST, FUTURE, JOY, SADNESS, HAPPINESS

Using the Semantic Distance Task, we investigated the semantic distances between ME and five metaphorically conceptualized notions: PAST, FUTURE, JOY, SADNESS, and HAPPINESS. Three Polish-speaking groups participated in the study: depressive subjects ([Formula: see text]), patients in remission ([Formula: see text]), and non-depressed individuals ([Formula: see text]). T-test and the Kruskal-Wallis nonparametric equivalent of ANOVA analyses showed that subjects in remission placed ME significantly farther away from PAST than non-depressed individuals and depressed patients. Data mining algorithms indicated the distances ME-SADNESS, ME-PAST, and ME-FUTURE as the three strongest predictors of group membership. We interpret the findings in the light of a contrast effect and defense mechanisms. We propose that intergroup differences are especially prominent in tasks requiring creation of semantic associative relations, that is, in the first stage of conceptual processing. We suggest treating the results as confirmation that Beck's theory of depression applies at the level of notion comprehension, proving that processing of key concepts in depression symptoms (particularly PAST) runs differently in all three groups under consideration.

Predictors of Response to Behavioral Treatments Among Children With ADHD-Inattentive Type

The goal of the study was to examine baseline characteristics-child gender, IQ, age, internalizing problems, symptoms of hyperactivity/impulsivity (HI), oppositional defiant disorder, and sluggish cognitive tempo, and parent income, education, attention deficit/hyperactivity disorder (ADHD) severity, and anxiety/depression (A/D)-associated with response to behavioral treatments for ADHD, predominantly inattentive type. We employed data from 148 children (M = 8.7 years), 58% male, and 57% Caucasian in a randomized clinical trial. Positive treatment response was defined as (a) 5 or fewer inattentive symptoms and (b) a decrease of at least 3 inattentive symptoms from baseline to posttreatment. Child HI, parental A/D, and child IQ were associated with positive response, as follows: Child HI had a main effect in which it was negatively associated with treatment response (36% with 2 or more HI symptoms were positive responders vs. 59% of those with 1 or no symptoms) that was qualified by parental A/D and child IQ. When children had 2 or more symptoms of HI and higher parental A/D, positive response rate was low at 25%; when children had 2 or more symptoms of HI, low parental A/D, and an IQ of 105 or higher, positive response rate was 85%. Furthermore, the group with the poorest response rate (25%) had parents who self-reported greater ADHD severity, and the group with a relatively good rate of positive response (59%) had the lowest number of oppositional defiant disorder symptoms. Likelihood of positive response to our behavioral treatment for ADHD-I is dependent on child and parent factors.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

Effect of adjuvant sleep hygiene psychoeducation and lorazepam on depression and sleep quality in patients with major depressive disorders: results from a randomized three-arm intervention

BACKGROUND

Sleep disturbances are a common co-occurring disturbance in patients with major depressive disorders (MDDs) and accordingly deserve particular attention. Using a randomized design, we investigated the effects of three different adjuvant interventions on sleep and depression among patients with MDD: a sleep hygiene program (SHP), lorazepam (LOR), and their combination (SHP-LOR).

METHODS

A total of 120 outpatients with diagnosed MDD (mean age: 48.25 years; 56.7% females) and treated with a standard SSRI (citalopram at 20-40 mg at therapeutic level) were randomly assigned to one of the following three conditions: SHP (n=40), LOR (1 mg/d; n=40), SHP-LOR (1 mg/d; n=40). At the beginning and at the end of the study 8 weeks later, patients completed two questionnaires, the Pittsburgh Sleep Quality Index to assess sleep and the Beck Depression Inventory to assess symptoms of depression.

RESULTS

Sleep disturbances decreased over time and in all groups. No group differences or interactions were observed. Symptoms of depression decreased over time and in all three groups. Reduction in symptoms of depression was greatest in the SHP-LOR group and lowest in the LOR group.

CONCLUSION

The pattern of results suggests that all three adjuvant treatments improved symptoms of sleep disturbances and depression, with greater benefits for the SHP-LOR for symptoms of depression, but not for sleep. Nevertheless, risks and benefits of benzodiazepine prescriptions should be taken into account.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Predictors of dropout from internet-based self-help cognitive behavioral therapy for insomnia

Dropout from self-help cognitive-behavioral therapy for insomnia (CBT-I) potentially diminishes therapeutic effect and poses clinical concern. We analyzed the characteristics of subjects who did not complete a 6-week internet-based CBT-I program. Receiver operator characteristics (ROC) analysis was used to identify potential variables and cutoff for predicting dropout among 207 participants with self-report insomnia 3 or more nights per week for at least 3 months randomly assigned to self-help CBT-I with telephone support (n = 103) and self-help CBT-I (n = 104). Seventy-two participants (34.4%) did not complete all 6 sessions, while 42 of the 72 (56.9%) dropped out prior to the fourth session. Significant predictors of non-completion are total sleep time (TST) ≥ 6.82 h, Hospital Anxiety and Depression Scale depression score ≥ 9 and Insomnia Severity Index score < 13 at baseline in this ranking order. Only TST ≥ 5.92 h predicts early dropout. Longer TST and less severe insomnia predict dropout in this study of self-help CBT-I, in contrast to shorter TST as a predictor in 2 studies of face-to-face CBT-I, while greater severity of depression predicts dropout in both this study and a study of face-to-face CBT-I. Strategies for minimizing dropout from internet-based CBT-I are discussed.

Effectiveness of cognitive behavioral therapy in public mental health: comparison to treatment as usual for treatment-resistant depression

State mental health systems have been leaders in the implementation of evidence-based approaches to care for individuals with severe mental illness. Numerous case studies of the wide-scale implementation of research-supported models such as integrated dual diagnosis treatment and assertive community treatment are documented. However, relatively few dissemination efforts have focused on cognitive behavioral therapy (CBT) for individuals with major depression despite evidence indicating its efficacy with this population. A multi-site effectiveness trial of CBT was conducted within the Texas public mental health system. Eighty-three adults with major depression received CBT from community clinicians trained through a workshop and regular consultation with a master clinician. Outcomes were compared to a matched sample of individuals receiving pharmacotherapy. Outcome measures used included the quick inventory of depressive symptomatology and beck depression inventory. Individuals receiving CBT showed greater improvements in depression symptoms than those in the comparison group. Greater pre-treatment symptom severity predicted better treatment response, while the presence of comorbid personality disorders was associated with poorer outcomes.

The promise of cognitive behavior therapy for treatment of severe mental disorders: a review of recent developments

Cognitive behavior therapy (CBT), as exemplified by the model of psychotherapy developed and refined over the past 40 years by A.T. Beck and colleagues, is one of the treatments of first choice for ambulatory depressive and anxiety disorders. Over the past several decades, there have been vigorous efforts to adapt CBT for treatment of more severe mental disorders, including schizophrenia and the more chronic and/or treatment refractory mood disorders. These efforts have primarily studied CBT as an adjunctive therapy, i.e., in combination with pharmacotherapy. Given the several limitations of state-of-the-art pharmacotherapies for these severe mental disorders, demonstration of clinically meaningful additive effects for CBT would have important implications for improving public health. This paper reviews the key developments in this important area of therapeutics, providing a summary of the current state of the art and suggesting directions for future research.

Who is at risk for having persistent insomnia symptoms? A longitudinal study in the general population in Korea

OBJECTIVES

Our study had three goals: (1) to investigate the longitudinal course of insomnia symptoms over 4 years (3 time points) by analyzing the trajectory of insomnia symptoms for all participants, (2) to compare persistent insomnia symptom to nonpersistent insomnia symptom groups on mental health and quality of life (QoL), and (3) to conduct exploratory analyses on the relative contribution of multiple factors to persistence of insomnia symptoms.

METHODS

Our population-based longitudinal study utilized a community-based sample from the Korean Genome and Epidemiology study (KoGES). Participants were 1247 individuals (40.1% men; mean age, 54.3±7.1 years). Insomnia, QoL (measured by 12-item Short-Form health survey [SF-12]), sleep-interfering behaviors, and depression (measured by the Beck Depression Inventory [BDI]) were followed with biennial examinations at 3 data points spaced 2 years apart (baseline, time 1, and time 2).

RESULTS

Among individuals experiencing insomnia symptoms at baseline, the most common trajectory was to experience persistent nocturnal insomnia symptoms across all 3 time points. Those with persistent insomnia symptoms had significantly lower physical and mental QoL (measured by SF-12) and higher depression (measured by BDI) at time points compared to those without persistent nocturnal insomnia symptoms. A follow-up exploratory receiver operating characteristic curve (ROC) analysis identified poor sleep quality, frequent sleep-interfering behaviors, and low mental health QoL as the strongest predictors of persistent insomnia symptoms above other well-known risk factors.

CONCLUSIONS

In particular, an interaction between poor sleep quality, sleep-interfering behaviors, and mental health QoL appeared to be the strongest risk factor for persistent insomnia symptoms.

Detecting critical decision points in psychotherapy and psychotherapy + medication for chronic depression

OBJECTIVE

We sought to quantify clinical decision points for identifying depression treatment nonremitters prior to end-of-treatment.

METHOD

Data came from the psychotherapy arms of a randomized clinical trial for chronic depression. Participants (n = 352; 65.6% female; 92.3% White; mean age = 44.3 years) received 12 weeks of cognitive behavioral analysis system of psychotherapy (CBASP) or CBASP plus an antidepressant medication. In half of the sample, receiver operating curve analyses were used to identify efficient percentage of symptom reduction cut points on the Inventory of Depressive Symptoms-Self-Report (IDS-SR) for predicting end-of-treatment nonremission based on the Hamilton Rating Scale for Depression (HRSD). Sensitivity, specificity, predictive values, and Cohen's kappa for identified cut points were calculated using the remaining half of the sample.

RESULTS

Percentage of IDS-SR symptom reduction at Weeks 6 and 8 predicted end-of-treatment HRSD remission status in both the combined treatment (Week 6 cut point = 50.0%, Cohen's κ = .42; Week 8 cut point = 54.3%, Cohen's κ = .45) and psychotherapy only (Week 6 cut point = 60.7%, Cohen's κ = .41; Week 8 cut point = 48.7%, Cohen's κ = .49). Status at Week 8 was more reliable for identifying nonremitters in psychotherapy-only treatment.

CONCLUSIONS

Those with chronic depression who will not remit in structured, time-limited psychotherapy for depression, either with therapy alone or in combination with antidepressant medication, are identifiable prior to end of treatment. Findings provide an operationalized strategy for designing adaptive psychotherapy interventions.

Baseline patient characteristics as predictors of remission in interpersonal psychotherapy for depression

We examined patient characteristics as remission predictors in interpersonal psychotherapy (IPT) for depression (n=95). Four characteristic domains (sociodemographic, clinical/diagnostic, interpersonal, cognitive) were analyzed using receiver operating characteristic analysis. Remission was defined two ways: (a) posttreatment BDI-II beyond population-based cut-scores for reliable and clinically significant change, and (b) posttreatment BDI-II≤10. Across both definitions, patients most likely to remit had lower mean item ratings (<3.75 and<3.25, respectively) on the fearful attachment dimension of the Relationship Scales Questionnaire (χ2 =7.172, p<.01 and χ2 =7.792, p<.01, respectively). For the second definition only, more fearfully attached patients who were ≤25 years of age at index depression onset were more likely to remit (χ2 =7.617, p<.01) than those >25. The findings contribute to the scant literature on patient factors related to remission following IPT.

Dysfunctional attitudes as a moderator of pharmacotherapy and psychotherapy for chronic depression

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.

Depression treatment preferences of older white and Mexican origin men

OBJECTIVE

Among older white and Mexican origin male primary care patients, we examined preferences for features of depression care programs that would encourage depressed older men to enter and remain in treatment.

METHOD

Sixty-three (45 white, 18 Mexican origin) older men were recruited in six primary care clinics. All had clinical depression in the past year and/or were receiving depression treatment. Participants completed a conjoint analysis preference survey regarding depression treatments, providers and treatment enhancements.

RESULTS

The data suggest that white men preferred medication over counseling [odds ratio (OR): 1.64 95% confidence interval (CI): 1.12-2.41], while Mexican origin men preferred counseling (OR: medication over counseling: 0.28, 95% CI: 0.12-0.66). Both white and Mexican origin men preferred treatment that included family involvement (vs. none) (white: OR: 1.60, 95% CI 1.12-2.30; Mexican origin: OR: 3.31 95% CI 1.44-7.62) and treatment for insomnia (vs. treatment for alcohol use) (white: OR: 1.72, 95% CI 1.01-2.91; Mexican origin: OR: 3.93 95% CI 1.35-11.42). White men also preferred treatment by telephone (OR: 1.80, 95% CI 1.12-2.87).

CONCLUSIONS

Findings could inform development of patient-centered depression treatment programs for older men and suggest strategies, such as attention to sleep problems, which providers may employ to tailor treatment to preferences of older men.

Prediction of the outcome of short- and long-term psychotherapy based on socio-demographic factors

BACKGROUND

Socio-demographic factors predict the outcome of short-term psychotherapy (STT) in the treatment of mood and anxiety disorders, but information on the prediction for long long-term therapy (LPP) is lacking. We aimed to compare the prediction of changes in psychiatric symptoms afforded by socio-demographic factors across two treatment conditions, short- versus long-term psychotherapy.

METHODS

In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorders, aged 20-46 years, were randomly assigned to STT or LPP. Socio-demographic factors (i.e. age, gender, education, employment status, marital status, and living arrangement) were self-reported. Psychiatric symptoms were measured by the Symptom Check List, Global Severity Index (SCL-90-GSI) and Anxiety scale (SCL-90-Anx), and the Beck Depression Inventory (BDI) at baseline and seven times during a three-year follow-up period.

RESULTS

Socio-demographic factors were found to predict symptom development during follow-up irrespective of the baseline symptom level. Patients in a relatively good position, i.e. married and highly educated patients benefited from STT, whereas patients in less advantaged positions, i.e. homemakers, lone parents, and divorced patients needed LPP or did not benefit from either therapy. In several categories of socio-demographic factors, the extent to which a patient's background predicted the outcome of the psychotherapy varied according to whether general, anxiety or depressive symptoms were studied.

LIMITATIONS

We were unable to assess widows and pensioners. For ethical reasons, a no-treatment control group with a long follow-up could not be included in the study design.

CONCLUSIONS

Socio-demographic factors may need to be considered in the selection of patients for short- and long-term therapy.

Psychotherapy and pharmacotherapy: a contemporary perspective

A contemporary perspective on psychotherapy and pharmacotherapy views both treatments as somatic in nature. Abandoning Cartesian dualism frees the clinician to consider therapeutic options based on the best available evidence rather than falsely dichotomizing approaches as biological or psychological. Evidence-based medicine is a helpful though limited paradigm upon which to base treatment decisions. Instead, clinicians should strive for an evidence-informed approach that is patient centered. This approach is illustrated in relation to depressive illness where moderators of outcome are examined (illness severity, history of trauma, personality disorders, patient preference) that will influence clinical recommendations on combining treatment. Psychotherapy is increasingly proving to be a valuable therapeutic modality across the severity spectrum, a finding at odds with current treatment practices.

A longitudinal study of depression from 1 to 5 years after spinal cord injury

OBJECTIVE

To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury.

DESIGN

Longitudinal cohort study.

SETTING

SCI Model System.

PARTICIPANTS

Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher.

RESULTS

Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found.

CONCLUSION

In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

A generalist's guide to treating patients with depression with an emphasis on using side effects to tailor antidepressant therapy

This review provides a guide to the primary care physician for diagnosing and managing depression. To identify relevant articles, a PubMed search (ending date parameter, October 15, 2009) was conducted using the keywords depression, antidepressants, side effects, adverse effects, weight gain, sexual dysfunction, and sleep disturbance, and the reference lists of relevant articles were hand searched. This review explores the challenges in diagnosing depression that will and will not respond to antidepressants (ADs) and describes the value of 2-question screening instruments followed by in-depth questioning for positive screening results. It underscores the implications of veiled somatic presentations in which underlying depression is missed, leading to fruitless and expensive medical work-ups. Following this survey of the difficulties in diagnosing depression, the 4 options generalists have for treating a patient with depression are discussed: watchful waiting, antidepressant therapy, psychotherapy, and psychiatric referral. This review proposes that physicians, once they decide to prescribe, use AD side effects to advantage by selecting medications to minimize negative and maximize positive possibilities, thereby improving adherence. It focuses on the 3 most troubling adverse effects-sleep disturbance, sexual dysfunction, and weight gain. It provides AD-prescribing principles to assist primary care physicians in successfully managing depression and appropriately referring patients to a psychiatrist. Antidepressant therapy is not a panacea for treating patients with depression. An approach blending enlightened observation, medications, and psychotherapy often helps depressed patients recover to their former baselines.

Combined Pharmacotherapy and Cognitive-Behavioral Therapy for Anxiety Disorders: Medication Effects, Glucocorticoids, and Attenuated Treatment Outcomes

Despite the success of both pharmacologic and cognitive-behavioral interventions for the treatment of anxiety disorders, the combination of these modalities in adults has not resulted in substantial improvements in outcome relative to either strategy alone, raising questions about whether there are interfering effects that attenuate the magnitude of combination treatment benefits. In this article, we introduce an accounting of potential interference effects that expands upon arguments asserting the necessity of arousal for successful fear exposure. Specifically, recent advances in the study of the effects of cortisol on memory--suggesting that glucocorticoids are crucial to the learning of emotional material--have led us to posit that the attenuation of glucocorticoid activity by anxiolytic medications may interfere with extinction learning in exposure-based therapies. Implications for the efficacy of combination treatments for the anxiety disorders are discussed.

Relief of chronic or resistant depression (Re-ChORD): a pragmatic, randomized, open-treatment trial of an integrative program intervention for chronic depression

BACKGROUND

Chronic depression is a particularly disabling mood disorder and treatment outcomes are poor with either psychotherapy or pharmacotherapy alone. There is growing evidence that an integrative treatment approach may be optimal. A novel multi-modal, multi-disciplinary treatment program, Re-ChORD, was developed at the University of British Columbia and evaluated in this pilot study.

METHODS

Re-ChORD consisted of guidelines-based medication management, and group-based interpersonal psychotherapy and occupational therapy. A randomized, parallel-groups, open-treatment trial was conducted comparing Re-ChORD to treatment as usual (TAU). Inclusion criteria were current depression (17-item Ham-D > or = 15) and a diagnosis of a chronic depressive disorder. The primary outcome variable was clinical remission (17-item Ham-D < or = 7) at 4 month assessment.

RESULTS

A total of 64 patients were randomised to Re-ChORD (N=34) and TAU (N=30). Under both intention to treat (ITT) and completer analyses, the remission rate was significantly higher in the Re-ChORD than TAU groups. Treatment effect size for remission was of medium magnitude (22.2% and 29.6% over TAU under ITT and completer analyses).

LIMITATIONS

We did not collect sufficient follow-up data to investigate maintenance of gains. Re-ChORD shares elements with other combined treatments, and the present positive findings cannot be interpreted as being specific to the Re-ChORD program.

CONCLUSIONS

Consistent with growing evidence that integrative treatments are necessary for chronic depressive disorders, Re-ChORD was demonstrated in this pilot study to produce significantly greater rates of remission than treatment as usual. A larger-scale trial is warranted.

Longitudinal course of adolescent depression: neuroendocrine and psychosocial predictors

OBJECTIVE

The study examined whether cortisol measures are associated with the clinical course of depression in adolescents. Furthermore, the study evaluated whether the relationship between cortisol and clinical course is moderated by environmental stress and/or social support.

METHOD

Fifty-five adolescents with depression (age range 13-18 years) were recruited. In addition to a systematic diagnostic assessment, information was obtained on environmental stress and social support. Urinary free cortisol measures were collected on three consecutive nights during the index episode. Clinical follow-up evaluations were conducted at regular intervals over a 5-year period, documenting recovery from the index depressive episode and recurrent episodes. Information on environmental stress and social support also was gathered during each follow-up assessment.

RESULTS

Consistent with prior reports, the majority of adolescents (92.2%) recovered from the initial depressive episode. A substantial proportion of the recovered youth (42.6%) experienced a subsequent episode during the follow-up period. Higher cortisol levels were associated with a longer time to recovery from the index depressive episode. The effect of cortisol on recovery was moderated by social support. The combination of elevated cortisol and recent stressful experiences predicted recurrence, whereas a higher level of social support was protective against recurrence.

CONCLUSIONS

These data, in conjunction with prior literature, suggest that depression reflects an underlying neurobiological vulnerability that may predispose individuals with high vulnerability to chronic, recurrent episodes. Psychosocial factors, independently or in combination with an underlying neurobiological vulnerability, also play an important role in determining the clinical course of depression.

COMORBIDITY BETWEEN DEPRESSIVE AND ADDICTIVE DISORDERS IN ADOLESCENTS: ROLE OF STRESS AND HPA ACTIVITY

Adolescents are at heightened risk for the development of both depressive and addictive disorders. These two disorders frequently co-occur in adolescents and are associated with significant morbidity and mortality. Given the substantial economic and psychosocial burden associated with the comorbid condition, the identification of causal mechanisms associated with their co-occurrence is of great public health importance. Evidence indicates that psychosocial stress contributes to the initiation and maintenance of both depressive and addictive disorders. Research suggests that the limbic-hypothalamic-pituitary-adrenal (LHPA) axis also may be important in the development of depression as well as addictive disorders. Using a diathesis-stress model, this review will examine the interactions between stressful experiences and LHPA axis in increasing the risk for depressive and addictive disorders in adolescents. Emerging evidence suggests that the high rates of comorbidity between these two disorders may be explained, in part, by high levels of stress and altered LHPA activity. Clinical implications of these associations will be discussed.

Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial

BACKGROUND AND PURPOSE

Depression after stroke is prevalent, diminishing recovery and quality of life. Brief behavioral intervention, adjunctive to antidepressant therapy, has not been well evaluated for long-term efficacy in those with poststroke depression.

METHODS

One hundred one clinically depressed patients with ischemic stroke within 4 months of index stroke were randomly assigned to an 8-week brief psychosocial-behavioral intervention plus antidepressant or usual care, including antidepressant. The primary end point was reduction in depressive symptom severity at 12 months after entry.

RESULTS

Hamilton Rating Scale for Depression raw score in the intervention group was significantly lower immediately posttreatment (P<0.001) and at 12 months (P=0.05) compared with control subjects. Remission (Hamilton Rating Scale for Depression <10) was significantly greater immediately posttreatment and at 12 months in the intervention group compared with the usual care control. The mean percent decrease (47%+/-26% intervention versus 32%+/-36% control, P=0.02) and the mean absolute decrease (-9.2+/-5.7 intervention versus -6.2+/-6.4 control, P=0.023) in Hamilton Rating Scale for Depression at 12 months were clinically important and statistically significant in the intervention group compared with control.

CONCLUSIONS

A brief psychosocial-behavioral intervention is highly effective in reducing depression in both the short and long term.

Clinical practice recommendations for depression

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

The moderation of an early intervention program for anxiety and depression by specific psychological symptoms

The current study examined the influence of a number of psychological factors on the effectiveness of an early intervention program targeting anxiety and depression in a non-clinical sample of college students. The early intervention program comprised elements of the cognitive-behavioral analysis system of psychotherapy (McCullough, 2000) delivered in a 2-hour computer-based educational program. Participants completed measures of depression, anxiety, and general distress prior to the intervention program and then again 8 weeks later. Additionally, participants were assessed for past major depression, sleep related difficulties, a number of anxiety disorders, and suicide ideation. Moderation of the effectiveness of the early intervention program by these factors depended on the dependent variable of interest, specifically: the effectiveness of the intervention program on symptoms of depression was moderated by insomnia; symptoms of anxiety by past post-traumatic stress disorder (PTSD) and specific phobia as well as sleep problems related to nightmares; and symptoms of general negative affect by social phobia and suicide ideation. Implications are discussed.