Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating

OBJECTIVE

This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy.

METHOD

Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores.

RESULTS

Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores.

CONCLUSION

Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Beliefs About Traumatic Memories, Thought Control Strategies, and the Impact on PTSD Symptoms After a Natural Disaster

ABSTRACT

This study aimed to investigate the relationships among self-reported meta-memory beliefs, thought control strategies ( i.e. , distraction, reappraisal, worry, social control, and punishment), and posttraumatic stress disorder (PTSD) symptomology, among a sample of earthquake survivors ( N = 412). Correlational analysis and structural equation modeling were used on the responses and showed that stronger positive and negative meta-memory beliefs, and greater worry and punishment, were associated with greater PTSD symptom severity. The results also indicated that meta-memory beliefs had a prominent indirect influence toward PTSD symptomology via their effects toward thought control strategies. Follow-up analysis of variance indicated that those with a history of mental health difficulties reported higher levels of PTSD symptom severity, were more likely to score in the range of clinically relevant PTSD, and had a stronger tendency to negatively appraise unwanted thinking styles. The results of this research provide overall support for the validity of the metacognitive model for PTSD.

A Tale of Childhood Loss, Conditional Acceptance and a Fear of Abandonment: A Qualitative Study Taking a Narrative Approach to Eating Disorders

Eating disorders (EDs) are serious mental health illnesses, yet there is a need to better understand the illness experience to improve treatment outcomes. Qualitative research, and narrative approaches in particular, can elicit life stories that allow for the whole illness journey to be explored. This study aimed to explore the experiences of women with a history of an ED, identifying the life events they perceived were relevant to the onset of their ED through to recovery. Interviews were conducted with 18 women with lived experience of an ED. Through structural narrative analysis, an overarching storyline of childhood loss contributing to a belief of conditional acceptance, fear of abandonment and struggle to seek emotional support due to the fear of being a burden was identified. Negative experiences with the health sector were common. These findings have implications for the way medical professionals respond to help seeking and deliver treatment.

Modified metacognitive therapy for anorexia nervosa: An open trial in an outpatient setting

OBJECTIVE

Current evidence indicates treatment for adults with anorexia nervosa (AN) requires improvement given recovery rates are low to moderate, and relapse rates are high. Metacognitive therapy (MCT) is an effective treatment for anxiety and depressive disorders. This study evaluates if MCT can be successfully modified to treat AN in a naturalistic clinical setting.

METHOD

Twenty-four patients with AN participated in an open trial of modified metacognitive therapy (MCT-AN). Twelve of the 24 patients (50%) completed treatment. MCT was modified to include components specific to eating disorders. The MCT-AN was delivered by clinical psychologists who had undertaken training in MCT in a specialist outpatient service. Group and single participant data analyses were undertaken on those who completed treatment.

RESULTS

As well as statistically significant differences from pre- to posttreatment in the group data there were also clinically significant improvements at the individual patient level for eating disorder and depressive symptoms, as well as weight. The mean number of therapy sessions was 18.

DISCUSSION

These findings indicate that MCT-AN may be a promising intervention in the treatment of AN, warranting further investigation.

PUBLIC SIGNIFICANCE

Treatment for anorexia nervosa in adults requires improvement. Research indicates that Metacognitive therapy (MCT) is an effective treatment for anxiety and depression and may be applicable to the eating disorders. This small open trial suggests that MCT can be modified successfully to treat patients with anorexia nervosa (AN). The results are preliminary and require further research to provide more evidence on the effectiveness of this treatment for AN.

The effect of temperament and character on body dissatisfaction in women with bulimia nervosa: The role of low self‐esteem and depression

Objective

Method

Results

Conclusions

Low self‐esteem and depression were examined as mediators of associations between temperament and character dimensions and body dissatisfaction in women with bulimia nervosa.

Harm avoidance contributed significantly to body dissatisfaction.

The association between harm avoidance and body dissatisfaction was mediated by low self‐esteem alone and depression and low self‐esteem in serial.

Long-term efficacy of metacognitive therapy and cognitive behaviour therapy for depression

OBJECTIVE

To examine the two-year outcomes for depression, anxiety, cognitive and global social functioning after cognitive behavioural therapy (CBT) and metacognitive therapy (MCT) for depression.

METHOD

Participants were 31 adults with a diagnosis of major depressive disorder in a randomised pilot study comparing MCT and CBT. Therapy modality differences in change in depression and anxiety symptoms, dysfunctional attitudes, metacognitions, rumination, worry and global social functioning were examined at the two-year follow-up for those who completed therapy.

RESULTS

Significant improvements, with large effect sizes, were evident for all outcome variables. There were no significant differences in outcome between CBT and MCT. The greatest change over time occurred for depression and anxiety. Large changes were evident for metacognitions, rumination, dysfunctional attitudes, worry and global social functioning. Sixty-seven percent had not experienced a major depression and had been well during all of the past year, prior to the follow-up assessment.

CONCLUSION

The finding at end treatment, of no modality specific differences, was also evident at two-year follow-up. Although CBT and MCT targeted depression, improvements were much wider, and although CBT and MCT take different approaches, both therapies produced positive change over time across all cognitive variables. CBT and MCT provide treatment options, that not only improve the longer-term outcome of depression, but also result in improvements in anxiety, global social functioning and cognitive status.

The five year outcome of major depression: Effects of baseline variables and type of treatment

BACKGROUND

Depression is commonly a relapsing or chronic disorder. Long-term outcome is therefore important. We report on the outcome of major depression five years after receiving treatment with medication or psychotherapy.

METHODS

472 patients were treated in three consecutive randomised controlled trials in one clinical research centre. 298 were followed up at five years. Of these, 106 patients were treated with medications, while the remaining 192 were given psychotherapy. The a priori outcome measure was mood symptoms in the two years prior to the assessment.

RESULTS

The majority (56%) of patients had no depressive symptoms in the prior two years. One third (32%) had fluctuating depression, while 12% were chronic depressed. Predictors of outcome were few; baseline severity, suicidality, personality pathology, and type of treatment. Those receiving medication did somewhat worse, even when adjusted for this group's higher depression severity, suicidality and personality pathology at baseline.

CONCLUSIONS

Long-term depressive symptoms are common after evidence-based treatment, although over half the patients appear to recover. Psychotherapy may be superior to medication in reducing the level of symptoms in the longer term. Personality remains one of the few baseline predictors of long-term outcome.

The metacognitive model of post-traumatic stress disorder and metacognitive therapy for post-traumatic stress disorder: A systematic review

The metacognitive model of post-traumatic stress disorder (PTSD) implicates metacognitive beliefs, meta-memory beliefs and metacognitive control strategies in perpetuating and maintaining symptoms of PTSD. Despite this expanding area of research, the evidence for the metacognitive model of PTSD has not been reviewed. A systematic review according to the PRISMA statement was conducted. Searches across MEDLINE, PubMed and PsycNET, as well as reference lists of the included studies (2004 to March 2020), yielded 221 records. Two independent reviewers screened articles, which were included where the impact of the constructs of interest on PTSD symptoms was investigated within the framework of the metacognitive model for PTSD. Eighteen articles were included in the review. Eleven studies were determined to have good methodological robustness. Metacognitive therapy for PTSD demonstrated reductions in symptoms from pretreatment to post-treatment, which were maintained at follow-up. Predictors of greater PTSD symptom severity included metacognitive beliefs, meta-memory beliefs, and worry, punishment, thought suppression, experiential avoidance, and rumination. Overall, support was found for the validity of the metacognitive model of PTSD.

Beliefs about Memory Questionnaire: psychometric properties in a natural disaster sample

Several theories exist regarding the role of memory in the development of PTSD. The metacognitive model of PTSD contends beliefs about trauma memory are pivotal in the development and maintenance of PTSD. The Beliefs About Memory Questionnaire (BAMQ) was developed to measure metacognitive beliefs about trauma memory. This study aimed to test the psychometric properties of the BAMQ and its relationship to PTSD in a community sample of 674 adults exposed to the 2010-2011 Canterbury earthquakes and Queensland floods. Participants completed a series of online, self-report questionnaires between October and December 2012, exploring thinking and memory processes related to their experience of a natural disaster. Factor analysis validated the two-factor, positive and negative structure of the BAMQ. Convergent, concurrent, and discriminant validity was established through positive relationships with relevant metacognitive beliefs, thought control variables, and risk factors related to PTSD. Logistic regression revealed scores on the BAMQ predicted clinically significant symptoms of PTSD. The psychometric properties of the BAMQ suggest the instrument is a valuable addition to the assessment of metacognitive beliefs about trauma memory, and the utility of the BAMQ in the prediction of clinically significant symptoms of PTSD.

Improvement in cognitive function in young people with bipolar disorder: Results from participants in an 18-month randomised controlled trial of adjunctive psychotherapy

OBJECTIVE

To examine the effects of 18 months of intensive stabilisation with medication management and Interpersonal and Social Rhythm Therapy or Non-specific Supportive Clinical Management on cognitive function in young people with bipolar disorder. Determinants of change in cognitive function over the 18 months of the trial were also examined.

METHOD

Patients aged 15-36 years with Bipolar I Disorder, Bipolar II Disorder and Bipolar Not Otherwise Specified were recruited. From a battery of cognitive tests, change scores for pre-defined domains of cognitive function were created based on performance at baseline and follow-up. Change was compared between the two therapy groups. Regression analysis was used to determine the impact of a range of clinical variables on change in cognitive performance between baseline and follow-up.

RESULTS

One hundred participants were randomised to Interpersonal and Social Rhythm Therapy (n = 49) or Non-specific Supportive Clinical Management (n = 51). Seventy-eight patients underwent cognitive testing at baseline and 18 months. Across both groups, there were significant improvements in a Global Cognitive Composite score, Executive Function and Psychomotor Speed domains from baseline to 18 months. Lower scores at baseline on all domains were associated with greater improvement over 18 months. Overall, there was no difference between therapies in change in cognitive function, either in a global composite score or change in domains.

CONCLUSION

While there was no difference between therapy groups, intensive stabilisation with psychological therapy was associated with improved cognitive function, particularly in those patients with poorer cognitive function at baseline. However, this was not compared with treatment as usual so cannot be attributed necessarily to the therapies.

Predictors of Posttraumatic Stress Symptom Trajectories Following the Fatal 2011 Christchurch, New Zealand Earthquake

People respond differently to potentially traumatic events. To explore predictors of a chronic and delayed trajectory of posttraumatic stress symptoms (PTSS) after a natural disaster, we analyzed psychometric data collected from 412 residents of Christchurch, New Zealand after a 6.3 magnitude earthquake struck in February 2011. Participants from suburbs with different levels of socioeconomic status (SES) and earthquake impact completed a door-to-door survey 4-7 months after the earthquake (Time 1; N = 600) and again 10-11 months after the earthquake (Time 2; N = 412). The survey included the Acute Stress Disorder Scale, the Patient Health Questionnaire's nine-item Depression subscale, and the Generalized Anxiety Disorder-7 scale, along with single-item measures of variables including aftershock anxiety and family tension. Hobfoll's conservation of resources theory was used to guide data interpretation. High levels of depression, odds ratio (OR) = 1.24, and anxiety, OR = 1.24, at Time 1 significantly predicted membership in the chronic trajectory. Predictors of a delayed onset of symptoms included increased aftershock anxiety, OR = 1.29, and family tension, OR = 1.35, over time, as well as living in an area defined as being of low, OR = 5.36, or medium, OR = 11.39, SES. Results highlight risk factors for elevated PTSS and resources that individuals can use to offset threatened loss. These findings have implications for service providers, agencies, and the public.

Earthquake brain: Impairment of spatial memory following long-term earthquake-related stress

OBJECTIVES

The primary aim of this study was to investigate neuropsychological function in patients with earthquake-related posttraumatic stress disorder, compared with earthquake-exposed but resilient controls. We hypothesised that individuals with posttraumatic stress disorder would have poorer neuropsychological performance on tests of verbal and visuospatial learning and memory compared with the earthquake-exposed control group. The availability of groups of healthy patients from previous studies who had been tested on similar neuropsychological tasks prior to the earthquakes allowed a further non-exposed comparison.

METHOD

In all, 28 individuals with posttraumatic stress disorder and 89 earthquake-exposed controls completed tests of verbal and visuospatial learning and memory and psychomotor speed. Further comparisons were made with non-exposed controls who had been tested before the earthquakes.

RESULTS

No significant difference in performance on tests of verbal or visuospatial memory was found between the earthquake-exposed groups (with and without posttraumatic stress disorder), but the posttraumatic stress disorder group was significantly slowed on tests of psychomotor speed. Supplementary comparison with historical, non-exposed control groups showed that both earthquake-exposed groups had poorer performance on a test of visuospatial learning.

CONCLUSION

The key finding from this study is that there were no differences in verbal or visuospatial learning and memory in individuals with posttraumatic stress disorder compared with similarly earthquake-exposed controls. Compared with non-exposed controls, both earthquake-exposed groups had poorer performance on a test of visuospatial (but not verbal) learning and memory. This offers preliminary evidence suggesting that it is earthquake (trauma) exposure itself, rather than the presence of posttraumatic stress disorder that affects aspects of neuropsychological functioning. If replicated, this may have important implications for how information is communicated in a post-disaster context.

Patient predictors of response to cognitive behaviour therapy and schema therapy for depression

OBJECTIVE

Few studies have examined differential predictors of response to psychotherapy for depression. Greater understanding about the factors associated with therapeutic response may better enable therapists to optimise response by targeting therapy for the individual. The aim of the current exploratory study was to examine patient characteristics associated with response to cognitive behaviour therapy and schema therapy for depression.

METHODS

Participants were 100 outpatients in a clinical trial randomised to either cognitive behaviour therapy or schema therapy. Potential predictors of response examined included demographic, clinical, functioning, cognitive, personality and neuropsychological variables.

RESULTS

Individuals with chronic depression and increased levels of pre-treatment negative automatic thoughts had a poorer response to both cognitive behaviour therapy and schema therapy. A treatment type interaction was found for verbal learning and memory. Lower levels of verbal learning and memory impairment markedly impacted on response to schema therapy. This was not the case for cognitive behaviour therapy, which was more impacted if verbal learning and memory was in the moderate range.

CONCLUSION

Study findings are consistent with the Capitalisation Model suggesting that therapy that focuses on the person's strengths is more likely to contribute to a better outcome. Limitations were that participants were outpatients in a randomised controlled trial and may not be representative of other depressed samples. Examination of a variety of potential predictors was exploratory and requires replication.

Prevalence of cognitive impairment in major depression and bipolar disorder

OBJECTIVES

The current study examines prevalence of cognitive impairment in four mood disorder samples, using four definitions of impairment. The impact of premorbid IQ on prevalence was examined, and the influence of treatment response.

METHODS

Samples were: (i) 58 inpatients in a current severe depressive episode (unipolar or bipolar), (ii) 69 unmedicated outpatients in a mild to moderate depressive episode (unipolar or bipolar), (iii) 56 outpatients with bipolar disorder, in a depressive episode, and (iv) 63 outpatients with bipolar disorder, currently euthymic. Cognitive assessment was conducted after treatment in Studies 1 (6 weeks of antidepressant treatment commenced on admission) and 2 (16-week course of cognitive behaviour therapy or schema therapy), allowing the impact of treatment response to be assessed. All mood disorder samples were compared with healthy control groups.

RESULTS

The prevalence of cognitive impairment was highest for the inpatient depression sample (Study 1), and lowest for the outpatient depression sample (Study 2). Substantial variability in rates was observed depending on the definition of impairment used. Correcting cognitive performance for premorbid IQ had a significant impact on the prevalence of cognitive impairment in the inpatient depression sample. There was minimal evidence that treatment response impacted on prevalence of cognitive impairment, except in the domain of psychomotor speed in inpatients.

CONCLUSIONS

As interventions aiming to improve cognitive outcomes in mood disorders receive increasing research focus, the issue of setting a cut-off level of cognitive impairment for screening purposes becomes a priority. This analysis demonstrates important differences in samples likely to be recruited depending on the definition of cognitive impairment and begins to examine the importance of premorbid IQ in determining who is impaired.

Brain activation during processing of genuine facial emotion in depression: Preliminary findings

OBJECTIVE

The current study aimed to examine the neural correlates of processing genuine compared with posed emotional expressions, in depressed and healthy subjects using a novel functional magnetic resonance imaging (fMRI) paradigm METHOD: During fMRI scanning, sixteen depressed patients and ten healthy controls performed an Emotion Categorisation Task, whereby participants were asked to distinguish between genuine and non-genuine (posed or neutral) facial displays of happiness and sadness.

RESULTS

Compared to controls, the depressed group showed greater activation whilst processing genuine versus posed facial displays of sadness, in the left medial orbitofrontal cortex, caudate and putamen. The depressed group also showed greater activation whilst processing genuine facial displays of sadness relative to neutral displays, in the bilateral medial frontal/orbitofrontal cortex, left dorsolateral prefrontal cortex, right dorsal anterior cingulate, bilateral posterior cingulate, right superior parietal lobe, left lingual gyrus and cuneus. No differences were found between the two groups for happy facial displays.

LIMITATIONS

Relatively small sample sizes and due to the exploratory nature of the study, no correction was made for multiple comparisons.

CONCLUSION

The findings of this exploratory study suggest that depressed individuals may show a different pattern of brain activation in response to genuine versus posed facial displays of sadness, compared to healthy individuals. This may have important implications for future studies that wish to examine the neural correlates of facial emotion processing in depression.

Three-year follow-up after psychotherapy for young people with bipolar disorder

OBJECTIVES

(1) To examine the differences between interpersonal and social rhythm therapy (IPSRT) and specialist supportive care (SSC) in the longer term impacts of IPSRT and SSC on cumulative depression and mania symptoms over a further 78-week follow-up period post treatment. (2) To calculate the survival time before recurrence of a new mood episode over the 3-year period.

METHODS

One hundred young people with bipolar disorder aged between 15 and 36 years who had been randomized to treatment with either IPSRT or SSC for 78 weeks were followed up for a subsequent 78 weeks. The Longitudinal Interval Follow-up Evaluation was completed at 26-week intervals. A Mann-Whitney U test was used to determine if there were significant differences between therapy types and a Kaplan-Meier survival analysis was used to determine time to recurrence. Cox regression was used to assess the association between time to relapse and therapy type.

RESULTS

There were no significant differences between therapies at each of the data points for either depression or mania scores. The mean change in depression and mania in both groups was significantly different for all three follow-up data points. The actuarial cumulative recurrence rates were 53% for IPSRT and 49% for SSC. There was no significant difference between the groups in time to recurrence.

CONCLUSIONS

While there were no significant differences between the two therapies, there was an overall reduction in symptoms in both therapies. There may be sustained benefits in providing intensive psychotherapies in conjunction with pharmacotherapy for young people with bipolar disorder.

Predictors of premature termination from psychotherapy for anorexia nervosa: Low treatment credibility, early therapy alliance, and self-transcendence

OBJECTIVE

Failure to complete treatment for anorexia nervosa (AN) is- common, clinically concerning but difficult to predict. This study examines whether therapy-related factors (patient-rated pretreatment credibility and early therapeutic alliance) predict subsequent premature termination of treatment (PTT) alongside self-transcendence (a previously identified clinical predictor) in women with AN.

METHODS

56 women aged 17-40 years participating in a randomized outpatient psychotherapy trial for AN. Treatment completion was defined as attending 15/20 planned sessions. Measures were the Treatment Credibility, Temperament and Character Inventory, Vanderbilt Therapeutic Alliance Scale and the Vanderbilt Psychotherapy Process Scale. Statistics were univariate tests, correlations, and logistic regression.

RESULTS

Treatment credibility and certain early patient and therapist alliance/process subscales predicted PTT. Lower self-transcendence and lower early process accounted for 33% of the variance in predicting PTT.

DISCUSSION

Routine assessment of treatment credibility and early process (comprehensively assessed from multiple perspectives) may help clinicians reduce PTT thereby enhancing treatment outcomes.

A nurse-led education and cognitive behaviour therapy-based intervention among adults with uncontrolled type 2 diabetes: A randomised controlled trial

RATIONALE, AIMS AND OBJECTIVES

Diabetes mellitus is associated with significant morbidity, mortality, and escalating health care costs. Research has consistently demonstrated the importance of glycaemic control in delaying the onset, and decreasing the incidence, of both the short-term and long-term complications of diabetes. Although glycaemic control is difficult to achieve and challenging to maintain, it is key to reducing negative disease outcomes. The aim of this study was to determine whether a nurse-led educational intervention alone or a nurse-led intervention using education and acceptance and commitment therapy (ACT) was effective in reducing hemoglobin A_1c (HbA_1c ) in people living with uncontrolled type 2 diabetes compared to usual care.

METHODS

Adults over the age of 18 years, with a confirmed diagnosis of type 2 diabetes and HbA_1c outside of the recommended range (4%-7%, 20-53 mmol/mol) for 12 months or more, were eligible to participate. Participants were randomised to either a nurse-led education intervention, a nurse-led education plus ACT intervention, or a usual care. One hundred and eighteen participants completed baseline data collection (N = 34 education group, N = 39 education plus ACT, N = 45 control group). An intention to treat analysis was used.

RESULTS

A statistically significant reduction in HbA_1c in the education intervention group was found (P = .011 [7.48, 8.14]). At 6 months, HbA_1c was reduced in both intervention groups (education group -0.21 and education and ACT group -0.04) and increased in the control group (+0.32). A positive change in HbA_1c (HbA_1c reduced) was noted in 50 participants overall. Twice as many participants in the intervention groups demonstrated an improvement as compared to the control group (56% of the education group, 51% education plus ACT, and 24% control group.

CONCLUSIONS

At 6 months post intervention, HbA_1c was reduced in both intervention groups with a greater reduction noted in the nurse-led education intervention.

Predictors of posttraumatic growth 10-11 months after a fatal earthquake

OBJECTIVE

Posttraumatic growth (PTG) is a commonly observed phenomenon in the wake of a distressing event, capturing potentially beneficial effects for posttraumatic adaptation. However, it is not entirely clear what factors are essential for the development of PTG, especially after natural disasters. Most importantly, it is uncertain what type of relationship exists between posttraumatic stress symptoms (PTSS) and PTG. As yet, there is also no consensus on whether PTG can best be seen as a process outcome or as a coping mechanism. The current study aimed to elucidate these uncertainties.

METHOD

The study explored PTG in a community sample (N = 412) 10-11 months after a major earthquake in Christchurch, New Zealand. Nonsymptomatic predictors of PTG were assessed 4-7 months after the earthquake, and symptomatic predictors were assessed both 4-7 and 10-11 months after the earthquake, with PTG measured in the second assessment.

RESULTS

Results showed that the unique relationship between PTSS and PTG was modeled best both linearly and curvilinearly, suggesting that PTSS over a certain level shift from a positive association with PTG to a negative one. PTG was predicted by being female, having less household income, PTSS symptoms modeled linearly and curvilinearly at Time 1, and PTSS modeled linearly at Time 2.

CONCLUSION

Support was found for the coping model of PTG, suggesting the importance of fostering growth to manage posttraumatic distress. (PsycINFO Database Record

A nurse-led interdisciplinary approach to promote self-management of type 2 diabetes: a process evaluation of post-intervention experiences

RATIONALE, AIMS AND OBJECTIVES

Self-management of type 2 diabetes through diet, exercise and for many medications, are vital in achieving and maintaining glycaemic control in type 2 diabetes. A number of interventions have been designed to improve self-management, but the outcomes of these are rarely explored from a qualitative angle and even fewer through a process evaluation.

METHOD

A process evaluation was conducted using a qualitative design with participants randomized to an intervention. Seventy-three people living with type 2 diabetes and hyperglycaemia for a minimum of 1 year, randomized to one of two interventions (n = 34 to an education intervention and n = 39 to an education and acceptance and commitment therapy intervention) completed stage one of the process evaluation, immediately following the intervention through written feedback guided by open-ended questions. A purposive sample of 27 participants completed semi-structured interviews at 3 and 6 months post intervention. Interview data were transcribed and data analysed using a thematic analysis.

RESULTS

The majority of participants described an increase in knowledge around diabetes self-management and an increased sense of personal responsibility. Participants also described changes in self-management activities and reflected on the challenges in instigating and maintaining change to improve diabetes management.

CONCLUSION

The complexities of implementing change in daily life to improve glycaemic control indicate the need for ongoing support post intervention, which may increase and maintain the effectiveness of the intervention.

Earthquake Brain: Altered Recognition and Misclassification of Facial Expressions Are Related to Trauma Exposure but Not Posttraumatic Stress Disorder

OBJECTIVES

The study investigated facial expression recognition (FER) in posttraumatic stress disorder (PTSD) caused by exposure to earthquakes, and in particular whether people with this condition showed a bias toward interpreting facial expressions as threat-related emotions (i.e., as anger, fear, or disgust). The study included a trauma-exposed control group who had been similarly exposed to the earthquakes but had not developed PTSD. We hypothesized that individuals with PTSD would have increased sensitivity to threat-related facial emotions compared with the trauma-exposed control group. This would be shown by increased accuracy in recognition of threat-related emotions and the misinterpretation of neutral expressions to these emotions (i.e., misidentifying them as anger, fear, or disgust). The availability of a group of healthy controls from a previous study who had been tested on a similar task before the earthquakes allowed a further non-exposed comparison.

METHOD

Twenty-eight individuals with PTSD (71% female, mean age 42.8 years) and 89 earthquake-exposed controls (66% female, mean age 50.1 years) completed an FER task, which featured six basic emotions. Further comparisons were made with 50 non-exposed controls (64% female, mean age 38.5 years) who had been tested before the earthquakes.

RESULTS

There was no difference in sensitivity to threat-related facial expressions (as measured by accuracy in recognition of threat-related facial expressions and the misinterpretation of neutral expressions as threatening) in individuals with PTSD compared with similarly earthquake-exposed controls. Supplementary comparison with an historical, non-exposed control group showed that both earthquake-exposed groups had increased accuracy for the identification of all facial emotions and showed a bias in the misclassification of neutral facial expressions to the threat-related emotions of anger and disgust.

CONCLUSION

These findings suggest that it is exposure to earthquakes and repeated aftershocks, rather than the presence of PTSD that affects FER accuracy and misinterpretation. The importance of these biases in both PTSD and trauma-exposed controls needs further exploration and is an area for future research.

Assessing the distinctiveness of psychotherapies and examining change over treatment for anorexia nervosa with cognitive-behavior therapy, interpersonal psychotherapy, and specialist supportive clinical management

OBJECTIVE

Therapist adherence to cognitive-behavior therapy (CBT), interpersonal psychotherapy (IPT), and specialist supportive clinical management (SSCM) for anorexia nervosa (AN), was examined across three phases of therapy in a randomized clinical trial.

METHOD

Adherence in early, middle, and late phase therapy sessions from 53 of 56 participants in the trial was assessed using the CSPRS-AN by independent raters after listening to complete therapy sessions.

RESULTS

The three forms of psychotherapy were distinguishable by blind raters. Subscale scores were higher for the corresponding therapy than the other therapy modalities. In CBT and SSCM, a phase-by-therapy effect was found, with the CBT subscale highest for CBT, intermediate for SSCM, lowest for IPT, and elevated in the middle phase of CBT and SSCM. The SSCM subscale was highest for SSCM, intermediate for CBT, lowest for IPT, and elevated in the middle phase of SSCM. Adherence to activities around normalizing eating, weight gain, and education about anorexia nervosa was higher in SSCM than in either CBT or IPT.

DISCUSSION

Ensuring the distinctiveness of therapies in existing clinical trials with differential treatment outcome is essential. Research on adherence to therapy modalities has the potential to help understanding of the effective components of new and existing treatments for AN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:958-962).

Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy

Cognitive-behavioural therapy (CBT) is the recommended treatment for binge eating, yet many individuals do not recover, and innovative new treatments have been called for. The current study compares traditional CBT with two augmented versions of CBT; schema therapy, which focuses on early life experiences as pivotal in the history of the eating disorder; and appetite-focused CBT, which emphasises the role of recognising and responding to appetite in binge eating. 112 women with transdiagnostic DSM-IV binge eating were randomized to the three therapies. Therapy consisted of weekly sessions for six months, followed by monthly sessions for six months. Primary outcome was the frequency of binge eating. Secondary and tertiary outcomes were other behavioural and psychological aspects of the eating disorder, and other areas of functioning. No differences among the three therapy groups were found on primary or other outcomes. Across groups, large effect sizes were found for improvement in binge eating, other eating disorder symptoms and overall functioning. Schema therapy and appetite-focused CBT are likely to be suitable alternative treatments to traditional CBT for binge eating.

Prospective rates of suicide attempts and nonsuicidal self-injury by young people with bipolar disorder participating in a psychotherapy study

OBJECTIVE

Bipolar disorder is a chronic relapsing disorder associated with high rates of suicide, suicide attempts and nonsuicidal self-injury. The study aimed to prospectively identify the rates of suicide attempts and nonsuicidal self-injury in young people participating in an adjunctive randomised controlled psychotherapy for bipolar disorder and to identify differences in individuals who engaged in nonsuicidal self-injury, made suicide attempts or did both.

METHOD

In all, 100 participants aged 15-36 years with bipolar disorder received 78 weeks of psychotherapy and were followed up for a further 78 weeks. Data were collected using the Longitudinal Interval Follow-up Evaluation.

RESULTS

Suicide attempts reduced from 11% at baseline to 1% at the end of follow-up (week 156). Similarly, self-harm reduced from 15% at baseline to 7% at the end of follow-up. Individuals who engaged in both nonsuicidal self-injury and made suicide attempts differed from those with who only made suicide attempts, engaged in nonsuicidal self-injury or did neither. They were characterised by a younger age of illness onset and higher comorbidity.

CONCLUSION

Adjunctive intensive psychotherapy may be effective in reducing suicide attempts and nonsuicidal self-injury and warrants further attention. Particular attention needs to be paid to individuals with early age of onset of bipolar disorder.

Childhood predictors of lifetime suicide attempts and non-suicidal self-injury in depressed adults

OBJECTIVE

Adverse childhood experiences are well-recognized risk factors for a variety of mental health issues, including depression, suicide attempts and non-suicidal self-injury. However, less is known about whether childhood adversity, in the form of low parental care, overprotection and abuse, is associated with suicide attempt and non-suicidal self-injury within a sample of depressed adults.

METHOD

The sample of outpatients (n = 372) was drawn from two randomized depression trials. Childhood adversity variables, depression severity, age of first depressive episode (major depression episode onset), lifetime suicide attempt and non-suicidal self-injury were recorded at baseline. The association between variables and outcome measures was examined using partial correlations, univariate and multivariate logistic regressions.

RESULTS

Low maternal care was significantly associated with suicide attempt; low paternal care was associated with non-suicidal self-injury; overprotection was not associated with either outcome. Other risk factors for suicide attempt were major depression episode onset and baseline depression severity. Major depression episode onset was also a risk factor for non-suicidal self-injury. Abuse, regardless of how it was measured, was not significantly associated with either behaviour after adjusting for its correlations with low maternal or paternal care.

CONCLUSION

In this sample of depressed adults, the quality of ongoing, intra-familial relationships, as measured by levels of parental care, had a greater impact on suicide attempt and non-suicidal self-injury than abuse. As the findings were not a priori hypotheses, they require replication. Although the cross-sectional study design limits causal determination, the findings suggest different childhood risk factors for suicide attempt and non-suicidal self-injury and underscore the impact of low parental care on these two behaviours. These findings signal to clinicians the importance of asking specifically about suicide attempts, and non-suicidal self-injury, as well as levels of parental care in childhood. When endorsed, low parental care may be considered an important factor in contextualizing a patient's depression and potential risk for suicide and non-suicidal self-injury.

No change in neuropsychological dysfunction or emotional processing during treatment of major depression with cognitive-behaviour therapy or schema therapy

BACKGROUND

Impaired neuropsychological functioning is a feature of major depression. Previous studies have suggested that at least some aspects of neuropsychological functioning improve with successful treatment of major depression. The extent to which medications may affect the degree of normalization of these functions is unclear. The aim of the current study was to examine the course of neuropsychological functioning during treatment of major depression with cognitive-behaviour therapy (CBT) or schema therapy (ST).

METHOD

A total of 69 out-patients with a primary diagnosis of major depression and 58 healthy controls completed mood ratings, neuropsychological measures, and measures of emotional processing at baseline and after 16 weeks. Participants were randomized after baseline assessment to a year-long course of CBT or ST. Patients reassessed at 16 weeks were medication-free throughout the study.

RESULTS

Significant neuropsychological impairment was evident at baseline in depressed participants compared with healthy controls. After 16 weeks of psychotherapy, mean depression rating scores fell more than 50%. However, no neuropsychological measures showed convincing evidence of significant improvement and emotional processing did not change.

CONCLUSIONS

Persisting impairment in neuropsychological functioning after the first 16 weeks of CBT or ST suggests a need to modify psychological treatments to include components targeting cognitive functioning.

Predictors of response to CBT and IPT for depression; the contribution of therapy process

Little is known about the factors that contribute to a positive psychotherapy outcome. There is still considerable debate as to whether specific factors (e.g. severity of symptoms, comorbidity) or nonspecific factors (e.g. alliance, therapy process) are most important in influencing outcome. This study examined the additional contribution that therapeutic process and alliance made to previously identified specific predictors of response to CBT and IPT for depression over the course of therapy. The previously identified specific factors were belief that childhood reasons caused the depression, recurrent depression, perceptions about how logical therapy was and comorbid personality disorder symptoms. One hundred and sixty five adult outpatients with major depression were treated for depression in a randomised clinical trial examining predictors of response to Cognitive Behavior Therapy and Interpersonal Psychotherapy. All therapy sessions were audiorecorded to enable objective ratings of therapeutic process and alliance. Process factors - patient psychic distress, patient participation and patient alliance had the strongest associations with outcome. The early and middle stage of therapy process did not account for any additional variance other than that previously identified by the patient predictors, however, at the end stage of therapy process contributed a further 14%.

Changes in neuropsychological function after treatment with metacognitive therapy or cognitive behavior therapy for depression

BACKGROUND

Metacognitive therapy (MCT) is an innovative treatment model addressing patterns of negative thinking seen in emotional disorders. Unlike cognitive behavior therapy (CBT), MCT has strategies targeting dysfunctional cognitive and metacognitive processes underlying perseverative thinking patterns and attentional biases. The aim of this pilot study was to compare changes in neuropsychological functioning related to executive function and attention in outpatients with depression following treatment with MCT or CBT.

METHODS

Forty-eight participants referred for outpatient treatment of depression were randomized to 12 weeks of MCT (n = 23) or CBT (n = 25). Mood severity and neuropsychological functioning were assessed at pretreatment, 4 weeks, and at end treatment (12 weeks).

RESULTS

There were no significant group differences at pretreatment or 4 weeks on any neuropsychological test, although overall both groups showed a small improvement by 4 weeks. At end treatment, the MCT group demonstrated significantly greater improvement in performance on a task requiring spatial working memory and attention than the CBT group. Changes in executive functioning and attention were independent of change in mood symptoms.

CONCLUSIONS

MCT may have an advantage over CBT in improving aspects of executive function, including attention. MCT's emphasis on attentional training and flexible control of thinking may have a beneficial effect on neuropsychological functioning, consistent with the purported mechanism of action.

Randomized, controlled trial of Interpersonal and Social Rhythm Therapy for young people with bipolar disorder

OBJECTIVE

This randomized, controlled clinical trial compared the effect of interpersonal and social rhythm therapy (IPSRT) to that of specialist supportive care (SSC) on depressive outcomes (primary), social functioning, and mania outcomes over 26-78 weeks in young people with bipolar disorder receiving psychopharmacological treatment.

METHODS

Subjects were aged 15-36 years, recruited from a range of sources, and the patient groups included bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified. Exclusion criteria were minimal. Outcome measures were the Longitudinal Interval Follow-up Evaluation and the Social Adjustment Scale. Paired-sample t-tests were used to determine the significance of change from baseline to outcome period. Analyses of covariance were used to determine the impact of therapy, impact of lifetime and current comorbidity, interaction between comorbidity and therapy, and impact of age at study entry on depression.

RESULTS

A group of 100 participants were randomized to IPSRT (n = 49) or SSC (n = 51). The majority had bipolar I disorder (78%) and were female (76%), with high levels of comorbidity. After treatment, both groups had improved depressive symptoms, social functioning, and manic symptoms. Contrary to our hypothesis, there was no significant difference between therapies. There was no impact of lifetime or current Axis I comorbidity or age at study entry. There was a relative impact of SSC for patients with current substance use disorder.

CONCLUSIONS

IPSRT and SSC used as an adjunct to pharmacotherapy appear to be effective in reducing depressive and manic symptoms and improving social functioning in adolescents and young adults with bipolar disorder and high rates of comorbidity. Identifying effective treatments that particularly address depressive symptoms is important in reducing the burden of bipolar disorder.

Metacognitive therapy versus cognitive behavioural therapy for depression: a randomized pilot study

OBJECTIVE

Metacognitive therapy (MCT) is one of the newer developments within cognitive therapy. This randomized controlled pilot study compared independently applied MCT with cognitive behavioural therapy (CBT) in outpatients with depression to explore the relative speed and efficacy of MCT, ahead of a planned randomized controlled trial.

METHOD

A total of 48 participants referred for outpatient therapy were randomized to up to 12 weeks of MCT or CBT. Key outcomes were reduction in depressive symptoms at week 4 and week 12, measured using the independent-clinician-rated Quick Inventory of Depressive Symptomatology16. Intention-to-treat and completer analyses as well as additional methods of reporting outcome of depression are presented.

RESULTS

Both therapies were effective in producing clinically significant change in depressive symptoms, with moderate-to-large effect sizes obtained. No differences were detected between therapies in overall outcome or early change on clinician-rated or self-reported measures. Post-hoc analyses suggest that MCT may have been adversely affected by greater comorbidity.

CONCLUSIONS

In this large pilot study conducted independently of MCT's developers, MCT was an effective treatment for outpatients with depression, with similar results overall to CBT. Insufficient power and imbalanced comorbidity limit conclusions regarding comparative efficacy so further studies of MCT and CBT are required.

Impact of average household income and damage exposure on post-earthquake distress and functioning: A community study following the February 2011 Christchurch earthquake

Post-traumatic stress, depression and anxiety symptoms are common outcomes following earthquakes, and may persist for months and years. This study systematically examined the impact of neighbourhood damage exposure and average household income on psychological distress and functioning in 600 residents of Christchurch, New Zealand, 4-6 months after the fatal February, 2011 earthquake. Participants were from highly affected and relatively unaffected suburbs in low, medium and high average household income areas. The assessment battery included the Acute Stress Disorder Scale, the depression module of the Patient Health Questionnaire (PHQ-9), and the Generalized Anxiety Disorder Scale (GAD-7), along with single item measures of substance use, earthquake damage and impact, and disruptions in daily life and relationship functioning. Controlling for age, gender and social isolation, participants from low income areas were more likely to meet diagnostic cut-offs for depression and anxiety, and have more severe anxiety symptoms. Higher probabilities of acute stress, depression and anxiety diagnoses were evident in affected versus unaffected areas, and those in affected areas had more severe acute stress, depression and anxiety symptoms. An interaction between income and earthquake effect was found for depression, with those from the low and medium income affected suburbs more depressed. Those from low income areas were more likely, post-earthquake, to start psychiatric medication and increase smoking. There was a uniform increase in alcohol use across participants. Those from the low income affected suburb had greater general and relationship disruption post-quake. Average household income and damage exposure made unique contributions to earthquake-related distress and dysfunction.

Bulimia nervosa-nonpurging subtype: closer to the bulimia nervosa-purging subtype or to binge eating disorder?

OBJECTIVE

DSM-5 has dropped subtyping of bulimia nervosa (BN), opting to continue inclusion of the somewhat contentious diagnosis of BN-nonpurging subtype (BN-NP) within a broad BN category. Some contend however that BN-NP is more like binge eating disorder (BED) than BN-P. This study examines clinical characteristics, eating disorder symptomatology, and Axis I comorbidity in BN-NP, BN-P, and BED groups to establish whether BN-NP more closely resembles BN-P or BED.

METHOD

Women with BN-P (n = 29), BN-NP (n = 29), and BED (n = 54) were assessed at baseline in an outpatient psychotherapy trial for those with binge eating. Measures included the Structured Clinical Interviews for DSM-IV, Eating Disorder Examination, and Eating Disorder Inventory-2.

RESULTS

The BN-NP subtype had BMIs between those with BN-P and BED. Both BN subtypes had higher Restraint and Drive for Thinness scores than BED. Body Dissatisfaction was highest in BN-NP and predicted BN-NP compared to BN-P. Higher Restraint and lower BMI predicted BN-NP relative to BED. BN-NP resembled BED with higher lifetime BMIs; and weight-loss clinic than eating disorder clinic attendances relative to the BN-P subtype. Psychiatric comorbidity was comparable except for higher lifetime cannabis use disorder in the BN-NP than BN-P subtype

DISCUSSION

These results suggest that BN-NP sits between BN-P and BED however the high distress driving inappropriate compensatory behaviors in BN-P requires specialist eating disorder treatment. These results support retaining the BN-NP group within the BN category. Further research is needed to determine whether there are meaningful differences in outcome over follow-up.

Psychotherapy for depression: a randomized clinical trial comparing schema therapy and cognitive behavior therapy

BACKGROUND

The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression.

METHODS

In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders.

RESULTS

ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders.

LIMITATIONS

This study needs replication.

CONCLUSIONS

This preliminary research indicates that ST may provide an effective alternative therapy for depression.

Maternal care and paternal protection influence response to psychotherapy treatment for adult depression

BACKGROUND

Adverse childhood experiences of neglect, overprotection and abuse, well-recognized risk factors for the development of adult psychopathology, were examined as predictors of response to psychotherapy treatment for adults with depression.

METHODS

Outpatients in a randomized clinical trial of interpersonal psychotherapy (IPT) or cognitive-behavioral therapy (CBT) completed the parental bonding instrument (PBI) at baseline to establish levels of care and protection. Childhood abuse was asked about using clinical interviews. The PBI variables were examined in tertiles while the abuse variables were categorized as "none," "some," and "severe." Associations between these childhood adversities and treatment response were examined in those who completed the trial.

RESULTS

Of 177 outpatients with depression who were randomized, 159 completed an adequate trial of therapy. Within these 159 patients, 57% were categorized as responders to treatment. The mean percentage improvement on the MADRS was 57.7% (±31.4). Across both treatments, patients reporting intermediate levels of maternal care had the best response to treatment. Also across both treatments, the interaction effects of maternal care and paternal protection by treatment were statistically significant. Examining the two therapies independently, maternal care and paternal protection were associated with a differential response to IPT but not CBT. Reports of abuse, whether physical, emotional or sexual, did not impact treatment response.

LIMITATIONS

This study examined patients who completed treatment, which may have attenuated the findings. Two categories of childhood adversity were measured although a range of other adverse childhood experiences exist. The results were from exploratory analyses and require replication.

CONCLUSIONS

Maternal care, demonstrating a robust main effect across treatments, appears to be the childhood variable most strongly associated with response to psychotherapy in this sample. In addition, maternal care and paternal protection were associated with a differential response to treatment. These results suggest that the quality of on-going intra-familial relationships has a greater impact on treatment response than experiences of abuse. The findings may aid clinicians in selecting which psychotherapy to use, depending on a patient's childhood history.

Further evidence for slow binocular rivalry rate as a trait marker for bipolar disorder

OBJECTIVE

Binocular rivalry refers to a situation where contradictory information is presented simultaneously to the same location of each eye. This leads to the alternation of images every few seconds. The rate of alternation between images has been shown to be slower in euthymic participants with bipolar disorder than in healthy controls. The alternation rate is not uniformly slowed in bipolar disorder patients and may be influenced by clinical variables. The present study examined whether bipolar disorder patients have slower alternation rates, examined the influence of depression and explored the role of clinical variables and cognitive functions on alternation rate.

METHOD

Ninety-six patients with bipolar disorder and 24 control participants took part in the study. Current mood status and binocular rivalry performance were analysed with nonparametric tests. A slow and a normal alternation group were created by median split. We subsequently explored the distribution of several clinical variables across these groups. Further, we investigated associations between alternation rate and various cognitive functions, such as visual processing, memory, attention and general motor speed.

RESULTS

The median alternation rate was significantly slower for participants with bipolar disorder type I (0.39 Hz) and for participants with bipolar spectrum disorder (0.43 Hz) than for control participants (0.47 Hz). Depression had no effect on alternation rate. There were no differences between participants with bipolar disorder type I and type II and in regard to medication regime and predominance of one rivalry image. There were also no differences in regard to the clinical variables and no significant associations between alternation rate and the cognitive functions explored.

CONCLUSION

We replicated a slowing in alternation rate in some bipolar disorder participants. The alternation rate was not affected by depressed mood or any of the other factors explored, which supports views of binocular rivalry rates as a trait marker in bipolar disorder.

Measuring therapist adherence in psychotherapy for anorexia nervosa: Scale adaptation, psychometric properties, and distinguishing psychotherapies

Abstract An adaptation of the Collaborative Study Psychotherapy Rating Scale (CSPRS) was used to rate therapist adherence to three psychotherapies for anorexia nervosa. One audiotaped psychotherapy session from each of 30 patients was rated independently by two raters. Analysis of the psychometric properties of the instrument revealed good interrater agreement and high internal consistency. For all three therapies, therapists were rated as exhibiting significantly more behaviors appropriate to the therapy to which patients were randomized than the other two therapies, indicating very satisfactory adherence to therapy. The three therapies were clearly distinguishable by raters unaware of therapy condition using the modified CSPRS.

Comparison of neuropsychological functioning and emotional processing in major depression and social anxiety disorder subjects, and matched healthy controls

OBJECTIVES

Few studies of neuropsychological function in major depression have examined emotional processing or the impact of gender. Patients have also been compared with highly selected control participants and rarely with other patient groups. The objective of this study was to compare neuropsychological function in a major depressive episode (MDE) with a group of patients with an anxiety disorder, social anxiety disorder (SAD), and healthy controls, to include measures of emotional processing and to analyse the effects of gender on neuropsychological function and emotional processing in these groups.

METHOD

One hundred and one medication-free patients with MDE, 30 patients with SAD and 76 healthy control participants were recruited. The groups were matched for age and estimated premorbid intelligence and education. Subjects performed a battery of neuropsychological tests assessing; verbal learning and memory, visuospatial learning and memory, attention, executive function and psychomotor performance. They also performed a task measuring the accuracy of recognition of facial emotional expressions.

RESULTS

Compared with healthy participants and those with SAD, patients with MDE were significantly impaired in verbal learning and spatial working memory. The SAD group misclassified significantly more neutral expressions as angry and fewer as sad, compared with the MDE group and healthy controls, but there were no significant differences between the MDE group and healthy controls. The profile of performance was the same regardless of gender.

CONCLUSIONS

The study confirms a significant impairment in neuropsychological function in a clinical sample of outpatients with MDE, which is likely to have important implications for day-to-day functioning and treatment.

Childhood-, teenage-, and adult-onset depression: diagnostic and individual characteristics in a clinical sample

BACKGROUND

The age at which a depressive episode is first experienced may be associated with particular individual and clinical characteristics. This study compares individual, clinical, and family characteristics across individuals who experienced their first major depressive episode when a child, teenager, or adult.

METHODS

Participants were 372 depressed outpatients who participated in 2 completed randomized trials for depression. The first compared fluoxetine and nortriptyline, whereas the second compared cognitive behavior therapy and interpersonal psychotherapy. Assessment across the studies included structured clinical interviews for Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I/II diagnoses and a range of self-report measures of symptoms, functioning, and childhood experiences.

RESULTS

Participants with childhood- and teenage-onset depression had a greater number of comorbid Axis I diagnoses, were more likely to meet criteria for Avoidant and Paranoid personality disorder (PD), and were more likely to have attempted suicide than those with adult-onset depression. Those with teenage-onset depression were more likely to meet criteria for a PD than those with adult-onset depression. Participants with childhood- and teenage-onset depression reported lower perceptions of paternal care before the age of 16 years, compared to participants with adult-onset depression.

LIMITATIONS

Retrospective recall was used to classify individuals into childhood-, teenage-, and adult-onset groups and is subject to recall biases. The sample also consisted of treatment-seeking individuals.

CONCLUSION

There were relatively few differences between teenage and childhood depression. Depressive episodes that begin in childhood or teenage years are associated with more comorbid diagnoses, a higher likelihood of Avoidant and Paranoid PD, a greater likelihood of attempted suicide, and poorer perceptions of paternal care. Compared to adult-onset depression, childhood-onset depression is associated with greater comorbidity.

Patient predictors of response to cognitive behaviour therapy and interpersonal psychotherapy in a randomised clinical trial for depression

OBJECTIVES

This study examined patient predictors of response to interpersonal psychotherapy (IPT) and cognitive behaviour therapy (CBT).

METHOD

Participants were 177 adults with a primary diagnosis of major depressive disorder randomised to 16 weekly sessions of either IPT or CBT. Pre and post treatment depressive symptomatology was assessed by an independent clinician with the Montgomery Asberg Depression Rating Scale.

RESULTS

General predictors of response were perceived logic of therapy, recurrent depression and childhood reasons for depression (r² =.21). Only one differential predictor of treatment response was identified. Increasing comorbid personality disorder symptoms was associated with decreases in response to IPT but not CBT.

CONCLUSION

The results indicate that attention to specific pretreatment patient factors may enhance response to psychotherapy.

Measures of temperament and character are differentially impacted on by depression severity

BACKGROUND

Cloninger's Temperament and Character Inventory (TCI) is a widely used measure of personality. Two scales of the TCI, harm avoidance (HA) and self directedness (SD), have been shown to be influenced by depressed mood. We examined how the seven TCI scales and their subscales are correlated with depression severity before and after treatment. We also examined whether changes in personality measures could be attributed to changes in depression severity.

METHODS

Two clinical samples of depressed out-patients were recruited for trials to examine predictors of treatment response to antidepressants (N=195) and psychotherapies (N=177). Assessment included the Montgomery-Asberg depression rating scales (MADRS), Hopkins Symptom Checklist (SCL-90) and TCI at baseline and after treatment.

RESULTS

After treatment, in both samples, depression severity correlated significantly with HA and negatively with SD. Multiple regression analysis revealed that changes in SD and HA over treatment were related to improvement in depression. In the psychotherapy trial baseline MADRS scores correlated with low SD and high HA.

LIMITATIONS

The trial results are applicable to mild-moderately depressed out-patients.

CONCLUSIONS

Depression severity influences the total scales and most of the subscale measures of HA and SD. Some personality traits, as measured by the TCI, were not impacted upon by mood. Clinically mood should be taken into account when assessing personality measures of negative affect using the TCI.

The relationship of demographic, clinical, cognitive and personality variables to the discrepancy between self and clinician rated depression

BACKGROUND

The measurement of depression severity is an important aspect of both clinical and research practices. However, studies examining the self-report Beck Depression Inventory (BDI) and the clinician Hamilton Depression Rating Scale indicate only moderate correlations. The aim of this study was to examine the correlation between two self-report measures, the revised BDI, the Hopkins Symptom Checklist with the clinician rated, Montgomery-Asberg Depression Rating Scale. The secondary aim was to investigate patient factors which contribute to discordant ratings.

METHODS

Depression severity and demographic, clinical, personality, cognitive, and personality factors that may contribute to a self-report-clinician rated discrepancy were examined in 177 adult outpatients with a Major Depressive Episode (DSM-IV) participating in a randomised clinical trial comparing CBT and IPT for depression. All assessment was conducted prior to treatment randomisation.

RESULTS

Self-report and clinician rated depression were moderately correlated. Individuals with higher clinician rated depression severity, increased levels of rumination and females were more likely to have higher self-report rated depression (BDI-II and SCL-90) than clinician rated depression. In addition, younger patients and those with melancholic depression had higher BDI-II compared to MADRS scores.

LIMITATIONS

Results require replication.

CONCLUSIONS

Self-reported and observer rated depression were only moderately correlated. Researchers and clinicians interpreting the level of depression need to be cognizant of the patient factors that may contribute to either underreporting or overreporting self-report scores relative to observer ratings.

Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial

OBJECTIVE

Chlamydia trachomatis and Chlamydophila (Chlamydia) pneumoniae are known triggers of reactive arthritis (ReA) and exist in a persistent metabolically active infection state in the synovium, suggesting that they may be susceptible to antimicrobial agents. The goal of this study was to investigate whether a 6-month course of combination antibiotics is an effective treatment for patients with chronic Chlamydia-induced ReA.

METHODS

This study was a 9-month, prospective, double-blind, triple-placebo trial assessing a 6-month course of combination antibiotics as a treatment for Chlamydia-induced ReA. Eligible patients had to be positive for C trachomatis or C pneumoniae by polymerase chain reaction (PCR). Groups received 1) doxycycline and rifampin plus placebo instead of azithromycin; 2) azithromycin and rifampin plus placebo instead of doxycycline; or 3) placebos instead of azithromycin, doxycycline, and rifampin. The primary end point was the number of patients who improved by 20% or more in at least 4 of 6 variables without worsening in any 1 variable in both combination antibiotic groups combined and in the placebo group at month 6 compared with baseline.

RESULTS

The primary end point was achieved in 17 of 27 patients (63%) receiving combination antibiotics and in 3 of 15 patients (20%) receiving placebo. Secondary efficacy end points showed similar results. Six of 27 patients (22%) randomized to combination antibiotics believed that their disease went into complete remission during the trial, whereas no patient in the placebo arm achieved remission. Significantly more patients in the active treatment group became negative for C trachomatis or C pneumoniae by PCR at month 6. Adverse events were mild, with no significant differences between the groups.

CONCLUSION

These data suggest that a 6-month course of combination antibiotics is an effective treatment for chronic Chlamydia-induced ReA.

Childhood neglect and abuse as predictors of antidepressant response in adult depression

BACKGROUND

Childhood neglect and abuse are recognized as risk factors for depression, but are not often studied as predictors of treatment response in depression.

METHODS

Clinically depressed outpatients (n=195) were asked about childhood experiences before beginning a randomized antidepressant trial with either fluoxetine or nortriptyline. Three treatment outcomes were measured: Adequate trial, six-week response and two months sustained recovery.

RESULTS

Patients reporting low paternal care (paternal neglect), as measured by the Parental Bonding Instrument (PBI), were less likely to complete an adequate six-week trial of medication. Patients who reported high maternal protection (maternal overprotection) on the PBI had poorer treatment response in the short-term at six weeks, and longer term, for two months of sustained recovery. However, abuse, whether sexual, physical, or psychological in nature, did not predict treatment response.

CONCLUSIONS

The experience of having a neglectful father or an overprotective mother was more predictive of response to treatment for depression than abuse, suggesting that the quality of ongoing intra-familial relationships has a greater impact on treatment outcomes for depression than experiences of discrete abuse in childhood.