Mindfulness-based cognitive therapy (MBCT) is a group-based psychosocial intervention designed to enhance self-management of prodromal symptoms associated with depressive relapse.
To compare rates of relapse in depressed patients in remission receiving MBCT against maintenance antidepressant pharmacotherapy, the current standard of care.
Patients who met remission criteria after 8 months of algorithm-informed antidepressant treatment were randomized to receive maintenance antidepressant medication, MBCT, or placebo and were followed up for 18 months.
Outpatient clinics at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and St Joseph's Healthcare, Hamilton, Ontario.
One hundred sixty patients aged 18 to 65 years meeting DSM-IV criteria for major depressive disorder with a minimum of 2 past episodes. Of these, 84 achieved remission (52.5%) and were assigned to 1 of the 3 study conditions.
Patients in remission discontinued their antidepressants and attended 8 weekly group sessions of MBCT, continued taking their therapeutic dose of antidepressant medication, or discontinued active medication and were switched to placebo.
Relapse was defined as a return, for at least 2 weeks, of symptoms sufficient to meet the criteria for major depression on module A of the Structured Clinical Interview for DSM-IV.
Intention-to-treat analyses showed a significant interaction between the quality of acute-phase remission and subsequent prevention of relapse in randomized patients (P = .03). Among unstable remitters (1 or more Hamilton Rating Scale for Depression score >7 during remission), patients in both MBCT and maintenance treatment showed a 73% decrease in hazard compared with placebo (P = .03), whereas for stable remitters (all Hamilton Rating Scale for Depression scores =7 during remission) there were no group differences in survival.
For depressed patients achieving stable or unstable clinical remission, MBCT offers protection against relapse/recurrence on a par with that of maintenance antidepressant pharmacotherapy. Our data also highlight the importance of maintaining at least 1 long-term active treatment in unstable remitters.
Cites: Arch Gen Psychiatry. 2004 Jan;61(1):34-4114706942
The major goal of mental health services is to improve mental health and thus also life satisfaction. However, studies assessing factors associated with life satisfaction during recovery from depression are lacking.
A 6-year natural follow-up of 121 depressive out-patients was carried out with questionnaires at baseline, 1/2, 1, 2 and 6 years completed. A structured diagnostic interview was conducted. Throughout the follow-up, clinical status was assessed with several psychometric scales for life satisfaction (LS), depression (BDI, HDRS), hopelessness (HS), functional ability (GAF, SOFAS) and general psychopathology (SCL).
Men and women did not differ in their improvement in life satisfaction. Altogether, 77% of the patients at baseline and 22% at the end were dissatisfied. Life satisfaction on 6-year follow-up was associated with baseline lower interpersonal sensitivity (SCL subscale) and concurrently being loved by someone as well as with baseline and concurrent good self-rated health and wealth. The satisfied were better off in terms of all clinical variables, regardless of the measurement time. Depressive symptoms and hopelessness were the strongest concurrent clinical correlates of LS after 6 years.
Mental health was strongly related to life satisfaction throughout the follow-up, while most of the non-clinical factors were not. Alleviating depression and interpersonal sensitivity and supporting social networks should be focused on in psychiatric treatment in order to improve life satisfaction among depressive patients.
Empirical evidence on whether patients' mental health and functioning will be more improved after long-term than short-term therapy is scarce. We addressed this question in a clinical trial with a long follow-up.
In the Helsinki Psychotherapy Study, 326 out-patients with mood or anxiety disorder were randomly assigned to long-term psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT) and were followed for 10 years. The outcome measures were psychiatric symptoms, work ability, personality and social functioning, need for treatment, and remission.
At the end of the follow-up, altogether 74% of the patients were free from clinically elevated psychiatric symptoms. Compared with SPP, LPP showed greater reductions in symptoms, greater improvement in work ability and higher remission rates. A similar difference in symptoms and work ability was observed in comparison with SFT after adjustment for violations of treatment standards. No notable differences in effectiveness between SFT and SPP were observed. The prevalence of auxiliary treatment was relatively high, 47% in SFT, 58% in SPP and 33% in LPP, and, accordingly, the remission rates for general symptoms were 55, 45 and 62%, respectively.
After 10 years of follow-up, the benefits of LPP in comparison with the short-term therapies are rather small, though significant in symptoms and work ability, possibly due to more frequent use of auxiliary therapy in the short-term therapy groups. Further studies should focus on the choice of optimal length of therapy and the selection of factors predicting outcome of short- v. long-term therapy.
Limited information exists regarding the associations between impairment, symptoms, helpfulness of treatments, and service needs after initial treatment of children with attention-deficit/hyperactivity disorder (ADHD).
The aims of this study were to examine persistence rates and associations between parent-reported symptoms, impairment, helpfulness of treatments, and service needs in a retrospective follow-up study of children with ADHD.
Parents of 214 children with a mean age of 12.6 years (SD?=?2.1) who were diagnosed with ADHD at five child and adolescent mental health clinics (CAMHS) completed questionnaires 1-10 years (mean?=?3.7 years, SD?=?2.2) after baseline assessment. The response rate was 43.4%. A community comparison group (n?=?110) was recruited from the same area.
Approximately two-thirds (60.3%) of the sample fulfilled the DSM-IV symptom criteria of ADHD at follow-up, 84.3% were functionally impaired, and most children (84.7%) were on medication. Inattentive and emotional symptoms were the strongest predictors of impairment across impairment areas. Perceived helpfulness of different treatments varied from 71.8-88.7%, and no significant difference was found between the ADHD sub-groups regarding reported helpfulness. 'Adjustment of the school situation' was the most frequent service need, and approximately half of the parents reported needs for care co-ordination. Children fulfilling the symptom criteria of the ADHD Combined sub-group were most impaired and had most service needs.
At follow-up, children were highly symptomatic and impaired, despite a high rate of persistent medication treatment. The findings underline the need for more tailored treatment and co-ordinated care over time.
We aimed to study whether patient-reported outcomes, measured by quality of life (QoL) and functional class, are sensitive to pleural effusion (PLE) in patients with heart failure (HF), and to study changes in QoL and functional class during follow-up of PLE.
A cohort of 62 patients from an outpatient HF clinic was included. The amount of PLE was quantified using a pocket-sized ultrasound imaging device. Self-reports of QoL and functional class were collected using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the New York Heart Association (NYHA) functional classification.
At baseline, 26 (42%) patients had PLE of which 19 (31%) patients had moderate to severe amounts of PLE. Patients with no to mild PLE had a lower MLHFQ score (mean 42, SD 21) compared with patients with a moderate to severe amount of PLE (mean 55, SD 24), p=0.03. For 28 patients (45%) with follow-up data, we observed a linear improvement of the MLHFQ-score (3.2, 95% CI 1.2 to 5.1) with each centimetre reduction of PLE. Correspondingly, patient-reported NYHA-class followed the same pattern as the MLHFQ-score.
Our study indicates that patient-reported outcome measures as MLHFQ may be sensitive tools to identify patients with HF at highest risk of symptomatic PLE and that treatment targeting reduction of PLE during follow-up is essential to improvement of QoL and functional capacity of outpatients with HF.
Collaborative practices allow physicians and pharmacists to comanage pharmacotherapy to maximize the benefits of medication regimens. The Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia (TEAM) study compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention, where pharmacists requested laboratory tests and adjusted medication dosage, to the usual care (UC) for patients under treatment with lipid-lowering medication.
In a qualitative study nested within the TEAM study, the perceptions of physicians, pharmacists, and patients regarding the PPCC model, interprofessional collaboration, and the clinicians' willingness to implement the model in their practice were explored.
In the area of Montreal (Quebec, Canada), TEAM study participants assigned to the PPCC group were invited to participate. Individual semistructured interviews with physicians (n=7) and 2 six-member focus groups with pharmacists (n=12) and patients (n=12) were analyzed using a phenomenological approach.
The vast majority of participants reported PPCC was more structured and systematic than the UC they had received previously, wherein physicians prescribe and adjust pharmacotherapy and pharmacists provide the counseling and dispense medications. Many patients felt they received better follow-up and reported being reassured and well informed, making them more inclined to care for themselves better. These feelings were attributed largely to the pharmacists' accessibility and ability to communicate with them easily. Given the physician shortage, physicians perceived interprofessional collaboration as almost inevitable. They considered PPCC to be safe and effective. However, obstacles were also identified. Physicians were concerned that it might alter their special relationship with patients and threaten their overall medical follow-up. Pharmacists felt enthusiastic about their new role, but found PPCC time consuming and thought it might not be applicable to all the patients.
PPCC model was highly appreciated by patients, and clinicians saw it as beneficial to patients. However, several obstacles still have to be overcome before the model can be implemented in the current health care context.
The GAIN Substance Problem Scale (SPS) measures alcohol and drug problem severity within a DSM-IV-TR framework. This study builds on prior psychometric evaluation of the SPS by using Rasch analysis to assess scale unidimensionality, item severity, and differential item functioning (DIF).
Participants were attending residential or outpatient treatment in Alberta and Ontario, Canada, respectively (n=372). Rasch analyses modeled a latent problem severity continuum using SPS scores at treatment admission and 6-week follow-up. We examined DIF by gender, treatment modality (outpatient vs. residential), and assessment timing (baseline vs. follow-up).
Model fit was good overall, supporting unidimensionality and a single underlying continuum of substance problem severity. Relative to person severity, however, the range of item severities was narrow. Items were too severe for many clients to endorse, particularly at follow-up. Overall, the rank order of item severities was stable across gender, treatment modality, and time point. Although traditional Rasch criteria indicated a number of statistically significant and substantive DIF estimates across modality and time points, effect size indices did not suggest a net effect on total scale scores.
The analysis broadly supports use of the SPS as an additive measure of global substance severity in men and women and both residential and outpatient settings. Although DIF was not a major concern, there was evidence of item redundancy and suboptimal matching between items and persons. Findings highlight potential opportunities for further improving this scale in future research and clinical applications of the GAIN.
Mental health problems in childhood and adolescence are an important public health concern. The general aim of Finnish health policy is to offer equal services for all inhabitants according to need, irrespective of socio-economic background or place of residence. Here, we assess equity in access to psychiatric care in a long-term nationwide follow-up study from birth to early adulthood.
All 60 069 children born in Finland in 1987 were followed up through health registers from 1987 to 2008. The cohort members' use of specialized psychiatric outpatient and inpatient care was assessed and linked to their socio-economic status and residential area.
Altogether, 14.4% of the cohort members had received specialized psychiatric care during the follow-up. Females used significantly more specialized psychiatric outpatient care than males. In addition, the use of specialized psychiatric care was more common among young people with a poor socio-economic background and those living in urban areas.
A notable number of the young adults born in Finland in 1987 used specialized psychiatric care during their childhood and adolescence. Use was clearly defined by sex and residential area, as well as by parental socio-economic status and education. The data indicate that equity in access to mental health services should be highlighted in health policies, as contemporary outpatient mental health care has not been equally available for people living within and outside urban areas.