Pilot study of interpersonal psychotherapy versus supportive psychotherapy for dysthymic patients with secondary alcohol abuse or dependence

The efficacy of individual humanistic-experiential therapies for the treatment of depression: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy of individual humanistic-experiential therapies (HEPs) for depression.

METHOD

Database searches (Scopus, Medline, and PsycINFO) identified RCTs comparing any HEP intervention with a treatment-as-usual (TAU) control or active alternative intervention for the treatment of depression. Included studies were assessed using the Risk of Bias 2 tool and narratively synthesized. Post-treatment and follow-up effect sizes were aggregated using random-effects meta-analysis and moderators of treatment effect were explored (PROSPERO: CRD42021240485).

RESULTS

Seventeen RCTs, synthesized across four meta-analyzes, indicated HEP depression outcomes were significantly better than TAU controls at post-treatment (g = 0.41, 95% CI [0.18, 0.65], n = 735), but not significantly different at follow-up (g = 0.14, 95% CI [-0.30, 0.58], n = 631). HEP depression outcomes were comparable to active treatments at post-treatment (g = -0.09, 95% CI [-0.26, 0.08], n = 2131), but significantly favored non-HEP alternative interventions at follow-up (g = -0.21, 95% CI [-0.35, -0.07], n = 1196).

CONCLUSION

Relative to usual care, HEPs are effective in the short-term and comparable to non-HEP alternative interventions at post-treatment, but not at follow-up. However, imprecision, inconsistency, and risk of bias concerns were identified as limitations of the evidence included. Future large-scale trials of HEPs with equipoise between comparator conditions are required.

Pre-surgery optimization of patients' expectations to improve outcome in heart surgery: Study protocol of the randomized controlled multi-center PSY-HEART-II trial

The PSY-HEART-I trial indicated that a brief expectation-focused intervention prior to heart surgery improves disability and quality of life 6 months after coronary artery bypass graft surgery (CABG). However, to investigate the clinical utility of such an intervention, a large multi-center trial is needed to generalize the results and their implications for the health care system. The PSY-HEART-II study aims to examine whether a preoperative psychological intervention targeting patients' expectations (EXPECT) can improve outcomes 6 months after CABG (with or without heart valve replacement). EXPECT will be compared to Standard of Care (SOC) and an intervention providing emotional support without targeting expectations (SUPPORT). In a 3-arm multi-center randomized, controlled, prospective trial (RCT), N = 567 patients scheduled for CABG surgery will be randomized to either SOC alone or SOC and EXPECT or SOC and SUPPORT. Patients will be randomized with a fixed unbalanced ratio of 3:3:1 (EXPECT: SUPPORT: SOC) to compare EXPECT to SOC and EXPECT to SUPPORT. Both psychological interventions consist of 2 in-person sessions (à 50 minute), 2 phone consultations (à 20 minute) during the week prior to surgery, and 1 booster phone consultation post-surgery 6 weeks later. Assessment will occur at baseline approx. 3-10 days before surgery, preoperatively the day before surgery, 4-6 days later, and 6 months after surgery. The study's primary end point will be patients' illness-related disability 6 months after surgery. Secondary outcomes will be patients' expectations, subjective illness beliefs, quality of life, length of hospital stay and blood sample parameters (eg, inflammatory parameters such as IL-6, IL-8, CRP). This large multi-center trial has the potential to corroborate and generalize the promising results of the PSY-HEART-I trial for routine care of cardiac surgery patients, and to stimulate revisions of treatment guidelines in heart surgery.

Supportive Evidence: Brief Supportive Psychotherapy as Active Control and Clinical Intervention

OBJECTIVE

Supportive psychotherapy has long had an undeservedly weak reputation. This review aims to describe the use of manualized, time-limited brief supportive psychotherapy (BSP) and its testing in clinical trials across three decades. Although numerous clinical descriptions of supportive psychotherapy exist, its use is reportedly widespread, and several supportive psychotherapies have been used in psychotherapy trials, BSP is the first and sole supportive psychotherapy manualized for research. BSP was designed as a nondirective, affect-focused, bare-bones common-factors treatment.

METHODS

Collecting data from the nine randomized controlled trials involving BSP, eight of them published, the author presents a narrative summary of findings.

RESULTS

Eight trials addressed mood disorders and one addressed social anxiety disorder. Sample size varied. Most BSP trials resulted in "dead heat" comparable outcomes. BSP generally showed large effect sizes for improvement on the primary outcome variable (range d=0.62-1.01). Delivering it won over some therapists from exposure-based backgrounds.

CONCLUSIONS

Despite its perennial role as an unfavored control condition, BSP held its own in competition with more symptom-focused therapies, usually producing a dead-heat outcome. The findings indicate the importance of psychotherapeutic common factors and the potency of BSP as an active treatment condition.

A History of Childhood Maltreatment Has Substance- and Sex-Specific Effects on Craving During Treatment for Substance Use Disorders

RATIONALE

Childhood maltreatment (CM) leads to detrimental mental health outcomes, such as substance use disorders (SUD). This study examined prevalence and severity of all five types of CM with respect to specific substances and sex in treatment-seeking individuals with SUD. The influences of type of CM and symptoms of depressiveness, anxiety, and perceived stress on substance craving at admission as well as craving reduction during SUD treatment were examined.

METHODS

N = 546 patients in treatment for SUD and N = 109 individuals in opioid maintenance treatment filled out questionnaires regarding CM (Childhood Trauma Questionnaire) and psychopathologies. Substance craving was assessed throughout treatment using the Mannheim Craving Scale. Group differences in CM, type of substance and sex were examined. General linear models were applied to examine influences on substance craving.

RESULTS

Higher prevalence and severity of all five subtypes of CM were observed in individuals with SUD compared to the general population. Women were more severely affected by emotional and sexual abuse than men. Patients with cannabis use disorder reported more severe experiences of emotional abuse compared to all other substances. Craving at admission to treatment was influenced by emotional abuse, however, symptoms of depressiveness, anxiety, and perceived stress contributed to craving at admission or craving reduction during treatment.

CONCLUSION

CM relates to SUD and should be incorporated in prevention and treatment of SUD. Underlying mechanisms of the association might relate to impairments in processing and regulation of stress, emotions, and interpersonal relations following a history of CM.

Contemporary Supportive Therapy: A Review of History, Theory, and Evidence

Supportive psychotherapy interventions were developed as a part of psychodynamic psychotherapy work, and supportive psychotherapy was historically considered to be the default form of therapy only for lower-functioning patients. These roots unfortunately have resulted in supportive psychotherapy being viewed as an inferior form of treatment. In reality, supportive psychotherapy is a practical and flexible form of psychotherapy that helps patients with a wide range of psychiatric illnesses, including mood disorders, anxiety disorders, posttraumatic stress disorder, schizophrenia, personality disorders, eating disorders, body dysmorphic disorder, and substance use disorders. In addition, supportive psychotherapy can be well-suited to higher-functioning patients, as well as to patients who are chronically lower-functioning. There is also evidence to support the use of supportive psychotherapy in patients with certain medical illnesses, including coronary artery disease, some gastrointestinal illnesses, HIV infection, and certain types of cancer. The goals of supportive psychotherapy include helping patients to understand emotional experiences, improving affective regulation and reality-testing, making use of their most effective coping strategies, and engaging in collaborative problem solving to reduce stressors and increase effective engagement with support systems.

Nonprofessional Peer Support to Improve Mental Health: Randomized Trial of a Scalable Web-Based Peer Counseling Course

BACKGROUND

Millions of people worldwide are underserved by the mental health care system. Indeed, most mental health problems go untreated, often because of resource constraints (eg, limited provider availability and cost) or lack of interest or faith in professional help. Furthermore, subclinical symptoms and chronic stress in the absence of a mental illness diagnosis often go unaddressed, despite their substantial health impact. Innovative and scalable treatment delivery methods are needed to supplement traditional therapies to fill these gaps in the mental health care system.

OBJECTIVE

This study aims to investigate whether a self-guided web-based course can teach pairs of nonprofessional peers to deliver psychological support to each other.

METHODS

In this experimental study, a community sample of 30 dyads (60 participants, mostly friends), many of whom presented with mild to moderate psychological distress, were recruited to complete a web-based counseling skills course. Dyads were randomized to either immediate or delayed access to training. Before and after training, dyads were recorded taking turns discussing stressors. Participants' skills in the helper role were assessed before and after taking the course: the first author and a team of trained research assistants coded recordings for the presence of specific counseling behaviors. When in the client role, participants rated the session on helpfulness in resolving their stressors and supportiveness of their peers. We hypothesized that participants would increase the use of skills taught by the course and decrease the use of skills discouraged by the course, would increase their overall adherence to the guidelines taught in the course, and would perceive posttraining counseling sessions as more helpful and their peers as more supportive.

RESULTS

The course had large effects on most helper-role speech behaviors: helpers decreased total speaking time, used more restatements, made fewer efforts to influence the speaker, and decreased self-focused and off-topic utterances (ds=0.8-1.6). When rating the portion of the session in which they served as clients, participants indicated that they made more progress in addressing their stressors during posttraining counseling sessions compared with pretraining sessions (d=1.1), but they did not report substantive changes in feelings of closeness and supportiveness of their peers (d=0.3).

CONCLUSIONS

The results provide proof of concept that nonprofessionals can learn basic counseling skills from a scalable web-based course. The course serves as a promising model for the development of web-based counseling skills training, which could provide accessible mental health support to some of those underserved by traditional psychotherapy.

Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017)

BACKGROUND

Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders.

METHODS

English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research.

RESULTS

IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment.

CONCLUSION

Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

A randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer

PURPOSE

Breast cancer (BC) is a risk factor for major depressive disorder (MDD), yet little research has tested the efficacy of different psychotherapies for depressed women with BC. This study, the largest to date, compared outcomes of three evidence-based, 12-week therapies in treating major depressive disorder among women with breast cancer.

METHODS

This randomized trial compared interpersonal psychotherapy (IPT), problem solving therapy (PST), and brief supportive psychotherapy (BSP). Conducted at the outpatient clinic of the New York State Psychiatric Institute/Columbia University, the trial offered bilingual treatment by treatment-specific psychotherapists supervised by treatment experts. The primary outcome was change in the Hamilton Depression Rating Scale (HAM-D) at 12 weeks. Secondary outcomes included other validated patient-reported outcomes for depression and quality of life.

RESULTS

Of 179 women with breast cancer screening positive for depression at the Columbia Cancer Center, 134 eligible patients signed informed treatment consent. Half of patients were Hispanic and economically disadvantaged. Most women had stage I (35.2%) or II (36.9%) BC; 9% had stage IV. The three brief psychotherapies showed similar improvements on the HAM-D, with large pre-post effect sizes (d ~ 1.0); a priori defined response rates were 35% for IPT, 50% for PST and 31% for BSP, and remission rates 25%, 30% and 27%, respectively. The three treatments also showed similar improvements in the Quality of Life Enjoyment and Satisfaction Questionnaire. Dropout was high, ranging from 37 to 52% across treatments. Predictors of dropout included having < 16 years of education and annual family income < $20,000.

CONCLUSIONS

Among patients who completed treatment, all three psychotherapies were associated with similar, meaningful improvements in depression. Physical distance between the oncology and psychiatric treatment sites might have contributed to high dropout. This study suggests various psychotherapy approaches may benefit patients with breast cancer and major depression.

Is Internet Addiction a Clinical Symptom or a Psychiatric Disorder? A Comparison With Bipolar Disorder

The general purpose of this review is to present an updated literature overview of neurobiological/clinical aspects of Internet addiction (IA), particularly of overlaps and differences with bipolar affective disorder (BPAD). Articles with clinical/neurobiological aspects of IA or similarities/differences with BPAD as main topics, from 1990 to present and written in English language, were included. Comorbidity between IA and other psychiatric disorders, including BPAD, is common. Dysfunctions in dopaminergic pathways have been found both in IA and in mood disorders. Most of investigations in IA support a chronic hypodopaminergic dysfunctional state in brain reward circuit and an excessive reward experience during mood elevation. Neuroimaging studies show prefrontal cortex abnormalities shared between addictive and bipolar patients. BPAD and IA present numerous overlaps, such as polymorphisms in nicotinic receptors genes, anterior cingulate/prefrontal cortex abnormalities, serotonin/dopamine dysfunctions, and good response to mood stabilizers. The future is to clarify diagnostic criteria to better define the IA/BPAD relationship.

Interpersonal psychotherapy for depression

Interpersonal psychotherapy is an evidence-based therapy, originally developed to treat major depression. It is cited in numerous good practice guidelines. The biopsychosocial signs of depression are understood in the context of current social and interpersonal stressors, defined in terms of role transitions, disputes, bereavements and sensitivities. In therapy, the patient learns to understand the interactions between symptoms and interpersonal difficulties and the ways in which they are mutually reinforcing. Patients are helped to break this pattern and achieve a reduction in depressive symptoms and improvement in interpersonal functioning through improved communication, expression of affect and proactive engagement with the current interpersonal network. The therapeutic relationship is used as a tool for exploring and modelling external relationships. This article outlines the background to interpersonal psychotherapy, the process of therapy and the expansion of the evidence base.

Optimizing preoperative expectations leads to a shorter length of hospital stay in CABG patients: Further results of the randomized controlled PSY-HEART trial

OBJECTIVE

To examine the effect of a preoperative expectation-optimizing psychological intervention on length of stay in the hospital and time spent in the Intensive Care Unit (ICU) in patients undergoing elective cardiac surgery.

METHODS

In a randomized controlled trial, 124 patients prior to undergoing coronary artery bypass grafting (CABG) or CABG combined with heart valve surgery were randomized to either a) standard medical care alone (SMC) or an additional preoperative intervention, b) an additional expectation manipulation intervention (EXPECT) to optimize patients' expectations, or c) an additional supportive therapy (SUPPORT), containing the same amount of therapeutic attention but without a specific focus. Participants were followed-up post-operatively to assess their length of hospital stay and the time spent in the ICU.

RESULTS

Patients in both psychological intervention groups spent significantly less days in the hospital then patients in the SMC group (M(EXPECT)=12.62, M(SUPPORT)=14.13, M(SMC)=17.27, p=0.028). There was a significant linear trend (F(1112)=7.68, p=0.009) showing that the more specific the intervention patients received the shorter they stayed in the hospital. The effect of the intervention on time spent in the ICU was only marginally significant (M(EXPECT)=103.76, M(SUPPORT)=103.10, M(SMC)=158.45, p=0.066).

CONCLUSION

Changing patients' preoperative expectations via a psychological intervention leads to less days spent in the hospital. The psychological interventions are associated with positive cost-benefit ratios. Specific psychological mechanisms underlying the effect of our intervention remain unclear and need to be investigated further.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT01407055).

Preoperative optimization of patient expectations improves long-term outcome in heart surgery patients: results of the randomized controlled PSY-HEART trial

BACKGROUND

Placebo effects contribute substantially to outcome in most fields of medicine. While clinical trials typically try to control or minimize these effects, the potential of placebo mechanisms to improve outcome is rarely used. Patient expectations about treatment efficacy and outcome are major mechanisms that contribute to these placebo effects. We aimed to optimize these expectations to improve outcome in patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS

In a prospective three-arm randomized clinical trial with a 6 month follow-up, 124 patients scheduled for CABG surgery were randomized to either a brief psychological pre-surgery intervention to optimize outcome expectations (EXPECT); or a psychological control intervention focusing on emotional support and general advice, but not on expectations (SUPPORT); or to standard medical care (SMC). Interventions were kept brief to be feasible with a heart surgery environment; "dose" of therapy was identical for both pre-surgery interventions. Primary outcome was disability 6 months after surgery. Secondary outcomes comprised further clinical and immunological variables.

RESULTS

Patients in the EXPECT group showed significantly larger improvements in disability (-12.6; -17.6 to -7.5) than the SMC group (-1.9; -6.6 to +2.7); patients in the SUPPORT group (-6.7; -11.8 to 1.7) did not differ from the SMC group. Comparing follow-up scores and controlling for baseline scores of EXPECT versus SUPPORT on the variable disability only revealed a trend in favor of the EXPECT group (P = 0.09). Specific advantages for EXPECT compared to SUPPORT were found for mental quality of life and fitness for work (hours per week). Both psychological pre-surgery interventions induced less pronounced increases in pro-inflammatory cytokine concentrations reflected by decreased interleukin-8 levels post-surgery compared to changes in SMC patients and lower interleukin-6 levels in patients of the EXPECT group at follow-up. Both pre-surgery interventions were characterized by great patient acceptability and no adverse effects were attributed to them. Considering the innovative nature of this approach, replication in larger, multicenter trials is needed.

CONCLUSIONS

Optimizing patients' expectations pre-surgery helps to improve outcome 6 months after treatment. This implies that making use of placebo mechanisms has the potential to improve long-term outcome of highly invasive medical interventions. Further studies are warranted to generalize this approach to other fields of medicine.

TRIAL REGISTRATION

Ethical approval for the study was obtained from the IRB of the Medical School, University of Marburg, and the trial was registered at ( NCT01407055 ) on July 25, 2011.

LETS Act: a behavioral activation treatment for substance use and depression

Purpose

Substance use disorders (SUDs) often co-occur with major depressive disorder (MDD), yet treatments targeting this comorbidity are limited, especially in resource limited settings where individuals with SUDs often receive treatment.

Design/methodology/approach

Based upon principles of reinforcement and behavioral economic models of substance use, as well as the Brief Behavioral Activation Treatment for Depression (BATD; Lejuez et al., 2011), the Life Enhancement Treatment for Substance Use (LETS ACT; Daughters et al., 2008) was developed to meet the unique needs of patients with MDD-SUD comorbidity.

Findings

The current manuscript presents a summary of the theoretical foundations and key components of LETS ACT.

Originality/value

A specific focus on increasing dissemination via the flexible delivery dependent on patient and treatment setting characteristics is provided throughout.

Therapist Use of Specific and Nonspecific Strategies Across Two Affect-Focused Psychotherapies for Depression: Role of Adherence Monitoring

Psychotherapists routinely use both specific and non-specific strategies to deliver empirically supported treatments (ESTs). Psychotherapy adherence monitoring has traditionally focused on assessing therapist use of EST-specific strategies (to distinguish between ESTs), paying less attention to non-specific techniques common to multiple psychotherapies. This study used the Collaborative Study Psychotherapy Rating Scale (CSPRS) to evaluate therapist use of both specific and non-specific techniques in two affect-focused ESTs for depression. Blinded raters evaluated 180 recorded sessions of interpersonal psychotherapy (IPT) and brief supportive psychotherapy (BSP). Because IPT and BSP both emphasize attention to affective states and developing a warm therapy relationship, we expected overlap across scales measuring therapist warmth, empathy, and focus on feelings. In contrast, we expected differences in scales measuring therapist directiveness, as well as IPT- and BST-specific interventions. Results showed raters displayed good inter-rater reliability on primary subscales and could discriminate between two treatments with considerable overlap. Both IPT and BSP therapists used similarly high levels of non-specific, facilitative interventions. Expectedly, IPT therapists were more directive and used more IPT-specific strategies, while BSP therapists utilized more non-directive, supportive strategies. Unexpectedly, BSP therapists showed greater focus on feelings than IPT therapists. Exploratory analyses suggested that greater focus on feelings in early sessions was associated with greater depressive symptom reduction in the first eight weeks of treatment for both ESTs. Additional treatment adherence research is needed to investigate both shared and distinctive features of ESTs, as well as the effect of the relative use of specific versus non-specific interventions on psychotherapy outcomes.

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe

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.

Randomized trial of telephone-delivered acceptance and commitment therapy versus cognitive behavioral therapy for smoking cessation: a pilot study

OBJECTIVE

We conducted a pilot randomized trial of telephone-delivered acceptance and commitment therapy (ACT) versus cognitive behavioral therapy (CBT) for smoking cessation.

METHOD

Participants were 121 uninsured South Carolina State Quitline callers who were adult smokers (at least 10 cigarettes/day) and who wanted to quit within the next 30 days. Participants were randomized to 5 sessions of either ACT or CBT telephone counseling and were offered 2 weeks of nicotine replacement therapy (NRT).

RESULTS

ACT participants completed more calls than CBT participants (M = 3.25 in ACT vs. 2.23 in CBT; p = .001). Regarding satisfaction, 100% of ACT participants reported their treatment was useful for quitting smoking (vs. 87% for CBT; p = .03), and 97% of ACT participants would recommend their treatment to a friend (vs. 83% for CBT; p = .06). On the primary outcome of intent-to-treat 30-day point prevalence abstinence at 6 months postrandomization, the quit rates were 31% in ACT versus 22% in CBT (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 0.7-3.4). Among participants depressed at baseline (n = 47), the quit rates were 33% in ACT versus 13% in CBT (OR = 1.2, 95% CI = 1.0-1.6). Consistent with ACT's theory, among participants scoring low on acceptance of cravings at baseline (n = 57), the quit rates were 37% in ACT versus 10% in CBT (OR = 5.3, 95% CI = 1.3-22.0).

CONCLUSIONS

ACT is feasible to deliver by phone, is highly acceptable to quitline callers, and shows highly promising quit rates compared with standard CBT quitline counseling. As results were limited by the pilot design (e.g., small sample), a full-scale efficacy trial is now needed.

Is Interpersonal Psychotherapy Infinitely Adaptable? A Compendium of the Multiple Modifications of IPT

We employed standard literature search techniques and surveyed participants on the International Society for Interpersonal Psychotherapy listserve (isiptlist@googlegroups.com) to catalogue the multiple and highly creative ways in which Klerman's and Weissman's original concept of interpersonal psychotherapy (IPT) has been modified to meet the needs of a vast range of patient populations. Focusing first on adaptations of the individual treatment model for subgroups of adult patients, we next describe further adaptations of four major off-shoots of IPT: interpersonal counseling (IPC), IPT for adolescents (IPT-A), group IPT (IPT-G) and most recently, brief IPT (IPT-B). We then discuss IPT "in-laws," those treatments that have married IPT with of other forms of psychotherapy for patients with bipolar disorder, panic symptomatology, and substance abuse. We conclude with that although there have been myriad successful adaptations of IPT, there remain some conditions for which IPT adaptations have not been found to be efficacious.

Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis

BACKGROUND AND AIMS

To review published studies on the effectiveness of combining cognitive-behavioural therapy (CBT) and motivational interviewing (MI) to treat comorbid clinical and subclinical alcohol use disorder (AUD) and major depression (MDD) and estimate the effect of this compared with usual care.

METHODS

We conducted systematic literature searches in PubMed, PsycINFO and Embase up to June 2013 and identified additional studies through cross-references in included studies and systematic reviews. Twelve studies comprising 1721 patients met our inclusion criteria. The studies had sufficient statistical power to detect small effect sizes.

RESULTS

CBT/MI proved effective for treating subclinical and clinical AUD and MDD compared with controls, with small overall effect sizes at post-treatment [g=0.17, confidence interval (CI)=0.07-0.28, P<0.001 for decrease of alcohol consumption and g=0.27, CI: 0.13-0.41, P<0.001 for decrease of symptoms of depression, respectively]. Subgroup analyses revealed no significant differences for both AUD and MDD. However, digital interventions showed a higher effect size for depression than face-to-face interventions (g= 0.73 and g=0.23, respectively, P=0.030).

CONCLUSIONS

Combined cognitive-behavioural therapy and motivational interviewing for clinical or subclinical depressive and alcohol use disorders has a small but clinically significant effect in treatment outcomes compared with treatment as usual.

Randomized controlled trial of MICBT for co-existing alcohol misuse and depression: outcomes to 36-months

Integrated psychological treatment addressing co-existing alcohol misuse and depression has not been compared with single-focused treatment. This trial evaluates changes over 36 months following randomization of 284 outpatients to one of four motivational interviewing and cognitive-behavior therapy (MICBT) based interventions: (1) brief integrated intervention (BI); or BI plus 9 further sessions with (2) an integrated-, (3) alcohol-, or (4) depression-focus. Outcome measures included changes in alcohol consumption, depression (BDI-II: Beck Depression Inventory) and functioning (GAF: Global Assessment of Functioning), with average improvements from baseline of 21.8 drinks per week, 12.6 BDI-II units and 8.2 GAF units. Longer interventions tended to be more effective in reducing depression and improving functioning in the long-term, and in improving alcohol consumption in the short-term. Integrated treatment was at least as good as single-focused MICBT. Alcohol-focused treatment was as effective as depression-focused treatment at reducing depression and more effective in reducing alcohol misuse. The best approach seems to be an initial focus on both conditions followed by additional integrated- or alcohol-focused sessions.

The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression

OBJECTIVE

This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP).

METHOD

395 adults (57% female; Mage = 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16-20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change.

RESULTS

A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) = 62.48, p < .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) = 8.31, p = .004.

CONCLUSIONS

The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies.

Can psychotherapists function as their own controls? Meta-analysis of the crossed therapist design in comparative psychotherapy trials

OBJECTIVE

Clinical trials sometimes have the same therapists deliver more than 1 psychotherapy, ostensibly to control for therapist effects. This "crossed therapist" design makes controlling for therapist allegiance imperative, as therapists may prefer one treatment they deliver to the other(s). Research has established a strong relationship between principal investigators' allegiances and treatment outcome. Study therapists' allegiances probably also influence outcome, yet this moderating factor on outcome has never been studied.

DATA SOURCES

English language abstracts in PsycINFO and MEDLINE from January 1985 to December 2011 were searched for keywords psychotherapy and randomized trial.

STUDY SELECTION

The search yielded 990 abstracts that were searched manually. Trials using the same therapists in more than 1 condition were included.

DATA EXTRACTION

Thirty-nine studies fulfilled inclusion criteria. Meta-regression analyses assessed the influence of researchers' allegiance on treatment outcome, testing the hypothesis that studies poorly controlling for therapist allegiance would show stronger influence of researcher allegiance on outcome. A single-item measure assessed researchers' reported attempts to control for therapist allegiance.

RESULTS

Only 1 of 39 studies (3%) measured therapist treatment allegiance. Another 5 (13%) mentioned controlling for, without formally assessing, therapist allegiance. Most publications (67%) did not even mention therapist allegiance. In studies not controlling for therapist allegiance, researcher allegiance strongly influenced outcome, whereas studies reporting control for therapist allegiance showed no differential researcher allegiance. Researchers with cognitive-behavioral therapy allegiance described controlling for therapist allegiance less frequently than other researchers.

CONCLUSIONS

The crossed therapist design is subject to bias due to differential psychotherapist allegiance. Worrisome results suggest that researchers strongly allied to a treatment may ignore therapist allegiance, potentially skewing outcomes. All clinical trials, and especially crossed therapist designs, should measure psychotherapist allegiance to evaluate this possible bias.

Pilot study of treatment for major depression among women prisoners with substance use disorder

This study, the largest randomized controlled trial of treatment for major depressive disorder (MDD) in an incarcerated population to date, wave-randomized 38 incarcerated women (6 waves) with MDD who were attending prison substance use treatment to adjunctive group interpersonal psychotherapy (IPT) for MDD or to an attention-matched control condition. Intent-to-treat analyses found that IPT participants had significantly lower depressive symptoms at the end of 8 weeks of in-prison treatment than did control participants. Control participants improved later, after prison release. IPT's rapid effect on MDD within prison may reduce serious in-prison consequences of MDD.

Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: a systematic review

OBJECTIVE

Depression, anxiety and alcohol misuse frequently co-occur. While there is an extensive literature reporting on the efficacy of psychological treatments that target depression, anxiety or alcohol misuse separately, less research has examined treatments that address these disorders when they co-occur. We conducted a systematic review to determine whether psychological interventions that target alcohol misuse among people with co-occurring depressive or anxiety disorders are effective.

DATA SOURCES

We systematically searched the PubMed and PsychINFO databases from inception to March 2010. Individual searches in alcohol, depression and anxiety were conducted, and were limited to 'human' published 'randomized controlled trials' or 'sequential allocation' articles written in English.

STUDY SELECTION

We identified randomized controlled trials that compared manual guided psychological interventions for alcohol misuse among individuals with depressive or anxiety disorders. Of 1540 articles identified, eight met inclusion criteria for the review.

DATA EXTRACTION

From each study, we recorded alcohol and mental health outcomes, and other relevant clinical factors including age, gender ratio, follow-up length and drop-out rates. Quality of studies was also assessed.

DATA SYNTHESIS

Motivational interviewing and cognitive-behavioral interventions were associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms. Although brief interventions were associated with significant improvements in both mental health and alcohol use variables, longer interventions produced even better outcomes.

CONCLUSIONS

There is accumulating evidence for the effectiveness of motivational interviewing and cognitive behavior therapy for people with co-occurring alcohol and depressive or anxiety disorders.

The efficacy of non-directive supportive therapy for adult depression: a meta-analysis

The effects of non-directive supportive therapy (NDST) for adult depression have been examined in a considerable number of studies, but no meta-analysis of these studies has been conducted. We selected 31 studies on NDST from a comprehensive database of trials, examining psychotherapies for adult depression, and conducted meta-analyses in which NDST was compared with control groups, other psychotherapies and pharmacotherapy. We found that NDST is effective in the treatment of depression in adults (g=0.58; 95% CI: 0.45-0.72). NDST was less effective than other psychological treatments (differential effect size g=-0.20; 95% CI: -0.32 to -0.08, p<0.01), but these differences were no longer present after controlling for researcher allegiance. We estimated that extra-therapeutic factors (those processes operating in waiting-list and care-as-usual controls) were responsible for 33.3% of the overall improvement, non-specific factors (the effects of NDST compared with control groups) for 49.6%, and specific factors (the effects of NDST compared with other therapies) for 17.1%. NDST has a considerable effect on symptoms of depression. Most of the effect of therapy for adult depression is realized by non-specific factors, and our results suggest that the contribution of specific effects is limited at best.

Interpersonal psychotherapy for depression: a meta-analysis

OBJECTIVE

Interpersonal psychotherapy (IPT), a structured and time-limited therapy, has been studied in many controlled trials. Numerous practice guidelines have recommended IPT as a treatment of choice for unipolar depressive disorders. The authors conducted a meta-analysis to integrate research on the effects of IPT.

METHOD

The authors searched bibliographical databases for randomized controlled trials comparing IPT with no treatment, usual care, other psychological treatments, and pharmacotherapy as well as studies comparing combination treatment using pharmacotherapy and IPT. Maintenance studies were also included.

RESULTS

Thirty-eight studies including 4,356 patients met all inclusion criteria. The overall effect size (Cohen's d) of the 16 studies that compared IPT and a control group was 0.63 (95% confidence interval [CI]=0.36 to 0.90), corresponding to a number needed to treat of 2.91. Ten studies comparing IPT and other psychological treatments showed a nonsignificant differential effect size of 0.04 (95% CI=-0.14 to 0.21; number needed to treat=45.45) favoring IPT. Pharmacotherapy (after removal of one outlier) was more effective than IPT (d=-0.19, 95% CI=-0.38 to -0.01; number needed to treat=9.43), and combination treatment was not more effective than IPT alone, although the paucity of studies precluded drawing definite conclusions. Combination maintenance treatment with pharmacotherapy and IPT was more effective in preventing relapse than pharmacotherapy alone (odds ratio=0.37; 95% CI=0.19 to 0.73; number needed to treat=7.63).

CONCLUSIONS

There is no doubt that IPT efficaciously treats depression, both as an independent treatment and in combination with pharmacotherapy. IPT deserves its place in treatment guidelines as one of the most empirically validated treatments for depression.

An effectiveness trial of group cognitive behavioral therapy for patients with persistent depressive symptoms in substance abuse treatment

CONTEXT

Although depression frequently co-occurs with substance abuse, few individuals entering substance abuse treatment have access to effective depression treatment.

OBJECTIVE

The Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) study is a community-based effectiveness trial that compared residential substance abuse treatment with residential treatment plus group cognitive behavioral therapy for depression delivered by substance abuse treatment counselors. We hypothesized that intervention clients would have improved depression and substance use outcomes compared with those of clients receiving usual care.

DESIGN

A nonrandomized controlled trial using a quasi-experimental intent-to-treat design in which 4 sites were assigned to alternate between the intervention and usual care conditions every 4 months for 2½ years.

SETTING

Four treatment programs in Los Angeles County.

PARTICIPANTS

We screened 1262 clients for persistent depressive symptoms (Beck Depression Inventory-II score >17). We assigned 299 clients to receive either usual care (n = 159) or usual care plus the intervention (n = 140). Follow-up rates at 3 and 6 months after the baseline interview were 88.1% and 86.2%, respectively, for usual care and 85.7% and 85.0%, respectively, for the intervention group.

INTERVENTION

Sixteen 2-hour group sessions of cognitive behavioral therapy for depression.

MAIN OUTCOME MEASURES

Change in depression symptoms, mental health functioning, and days of alcohol and problem substance use.

RESULTS

Intervention clients reported significantly fewer depressive symptoms (P < .001 at 3 and 6 months) and had improved mental health functioning (P < .001 at 3 months and P < .01 at 6 months). At 6 months, intervention clients reported fewer drinking days (P < .05) and fewer days of problem substance use (P < .05) on days available.

CONCLUSIONS

Providing group cognitive behavioral therapy for depression to clients with persistent depressive symptoms receiving residential substance abuse treatment is associated with improved depression and substance use outcomes. These results provide support for a new model of integrated care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01191788.

Alcohol use disorders in geriatrics

Alcohol use disorders cause significant morbidity and mortality in the geriatric population. This review article begins with a hypothetical case for illustration, asking what the primary care physician could do for a geriatric patient with alcohol abuse over a course of four office visits. Various aspects of alcohol use disorders in the geriatric population are reviewed, such as range of alcohol use, epidemiology, medical/psychiatric impact, detection, comprehensive treatment planning, modalities of psychotherapy, medication management, and resources for clinicians/patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Integrated psychological treatment for substance use and co-morbid anxiety or depression vs. treatment for substance use alone. A systematic review of the published literature

BACKGROUND

There is an increasing consensus in favour of integrated treatment of substance use disorders and co-morbid conditions, such as depression or anxiety. However, up till now no systematic reviews have been published.

METHODS

Based on a systematic search of MedLine and PsychInfo, 9 trials of integrated treatment for depression or anxiety plus substance use disorder were identified. Where possible, meta-analyses were carried out, using random effects models.

RESULTS

Meta-analyses were carried out for integrated treatment for depression and substance use disorders on a number of outcomes. No meta-analysis could be carried out for integrated treatment for anxiety and substance use disorders, due to multivariate reporting of outcomes in original articles. Integrated treatment for depression and substance abuse produced significant effects on percent days abstinent at follow-up. Differences in retention and symptoms were non-significant, but favoured the experimental condition. For studies of integrated treatment for co-morbid anxiety disorders and substance use disorders, no meta-analysis could be carried out. Several studies of integrated treatment for anxiety and substance use disorders reported that patients assigned to substance use treatment only fared better.

CONCLUSION

Psychotherapeutic treatment for co-morbid depression and substance use disorders is a promising approach, but is not sufficiently empirically supported at this point. Psychotherapeutic treatment for co-morbid anxiety and substance use disorders is not empirically supported. There is a need for more trials to replicate the findings from studies of integrated treatment for depression and substance use disorders, and for the development of new treatment options for co-morbid anxiety and substance use disorders.

Chronic depression: update on classification and treatment

A significant proportion of patients with depressive disorders suffer from chronic conditions. The DSM-IV recognizes several forms of chronic depression. Chronic depressions differ from nonchronic major depressive disorder (MDD) on many clinical, psychosocial, and familial variables. However, less support exists for current distinctions between the various forms of chronic depression. Antidepressant medications and at least some forms of psychotherapy are efficacious in treating chronic depression, and the combination of pharmacotherapy and psychotherapy appears to be superior to either monotherapy alone. Still, chronic depression is often inadequately treated, and many patients fail to respond or continue to experience residual symptoms after treatment. An important direction for future research is to elucidate the multiple pathways to chronic depression and to tailor treatments to specific etiopathogenetic subgroups.