Interpersonal psychotherapy (IPT) has shown efficacy in randomized controlled trials. No reports exist on IPT for depressed patients with severe psychiatric comorbidities in public outpatient clinics. This pilot feasibility study assessed preliminary effectiveness and patient satisfaction with IPT for depressed patients with psychiatric comorbidities in municipal outpatient care in Turku, Finland. Because lengthy treatment strains mental healthcare resources, this trial also assessed the potential for IPT, a time-limited treatment, to discharge patients successfully.
Seven clinicians in two municipal clinics were briefly trained to deliver IPT, while clinicians in two other clinics provided treatment as usual (TAU). Twenty-six patients with moderate to severe major depressive disorder received IPT for 16 weeks, and a control group (n = 20) received TAU. Seventy-six percent of patients had concurrent anxiety disorders, 73% personality disorders and 20% alcohol dependence. As 61% of patients received concurrent pharmacotherapy, the study lacked statistical power to find outcome differences between treatment groups.
Depressive symptoms, social functioning and self-perceived health improved notably in both groups. The mean Hamilton Depression Rating Scale (HAMD) score decreased from 20 to 10. Using HAMD = 7 as a cutoff, 28.3% of patients achieved remission. Patients receiving IPT reported significantly greater satisfaction with their treatment and were more often able to terminate treatment after 16 sessions.
Both treatments were effective in this small, highly comorbid sample. Conducting IPT appeared feasible in municipal outpatient clinics and offered some advantages over TAU. It was possible to train staff quickly. These results warrant a further, larger randomized trial.
The purpose of the present study was to investigate the effectiveness of cognitive-behavioural group treatment of panic disorder and agoraphobia in a clinical setting. Fifty-three patients were offered treatment and assessed before, after and at follow-up 1 1/2-2 years after treatment. The study included an informal waiting-list control group of 40 patients. The investigation group achieved better outcome on most analyses with 47.2% found to be panic-free after treatment compared with 12.5% in the control group. Treatment gains were durable with 66.7% without panic attacks at follow-up. Most patients, however, still had major psychological problems after treatment. The outcomes of cognitive-behavioural group treatment of panic disorder in this study were modest compared with most controlled studies, possibly due to an unselected patient group with a high degree of agoraphobia.
Comment In: Nord J Psychiatry. 2005;59(3):16516195115
The association between mood disorders and personality disorders (PDs) is complicated clinically, conceptually, and neurobiologically. There is a need for recommendations to assist clinicians in treating these frequently encountered patients.
The literature was reviewed with the purpose of identifying clinically relevant themes. MedLine searches were supplemented with manual review of the references in relevant papers. From the extant evidence, consensus-based recommendations for clinical practice were developed.
Key issues were identified with regards to the overlap of PDs and mood disorders, including whether certain personality features predispose to mood disorders, whether PDs can reliably be recognized if there is an Axis I disorder present, whether personality disturbances arise as a consequence or are a forme fruste of mood disorders, and whether personality traits or disorders modify treatment responsiveness and outcome of mood disorders.
This paper describes consensus-based clinical recommendations that arise from a consideration of how signals from the literature can impact clinical practice in the treatment of patients with comorbid mood and personality pathology. Additional treatment studies of patients with the comorbid conditions are required to further inform clinical practice.
Eating disorders are diseases of both the body and the psyche. Early treatment focuses on restoration of nutritional status and somatic health, including psycho-educational counselling and support offered to the patient and his/her family. Diagnosis and treatment require a multidisciplinary approach. Psychological factors related to the condition should be assessed. The most severe weight loss should be reversed before psychotherapeutic treatment. Nutritional counselling is recommended, and the benefits of individual and/or family therapy are considered in accordance with the patient's age, development, symptomatology and comorbid psychiatric disorders. Medication is useful in the treatment of bulimia nervosa and certain comorbid symptoms of anorexia nervosa. Early admission to treatment and active therapy are associated with a more favourable prognosis.
The Danish health services encounter a growing number of refugees who suffer from the effects of persecution and torture. To be a traumatised refugee in a foreign culture often causes psychological reactions and biological changes, and, at the same time, adaptation to a new culture is a demanding existential challenge. The condition is rather poorly described by the diagnoses "post-traumatic stress disorder" and "enduring personality change after catastrophic experience". These conditions can cause difficulties both diagnostically and treatment-wise, as the trauma story can awaken violent reactions in the doctor, and because the symptoms can be so culturally framed they are difficult to interpret. The prognosis depends on a number of issues pertaining to the patient, the trauma, and the patient's overall state after the trauma. At best, the prognosis is relatively good, but in a number of cases the patient's state becomes chronic and disabling. At present, the recommended treatment is a combination of psychotherapy, psychopharmacological treatment, physiotherapy, and social initiatives. There is still uncertainty as to the optimal treatment, and the organisational situation regarding treatment in Denmark is unclear.
Both depression and chronic obstructive pulmonary disease (COPD) are prevalent, severe and often comorbid disorders. There is a risk of undertreatment for depression in patients with COPD as depressive symptoms, including suicidal tendencies, can erroneously be conceptualised as an understandable reaction to COPD and not as signs of an independent depressive disorder. In this context, the comorbidity rates of COPD and depression, the risk of suicidal behaviour in patients with COPD, and the evidence base for pharmaco- and psychotherapy in these patients are reviewed. Because symptoms of depression and COPD overlap it remains unclear how far the prevalence of major depression in COPD exceeds that in the general population. The suicide risk appears to be increased in COPD. Methodological studies providing evidence for the antidepressant efficacy of antidepressants or psychotherapy in patients with COPD are lacking. Recommendations for clinicians on how to separate depression from an understandable reaction to COPD are provided. Given the profound effects of depression on quality of life, life expectancy, COPD prognosis and suicide risk it is important to carefully diagnose and treat depression in patients with COPD according to national guidelines.
Comment In: Eur Respir J. 2014 Sep;44(3):570-125176950
Preliminary data support the implementation of individual metacognitive therapy (MCT) for depression. Given the focus of MCT on transpersonal processes, we hypothesized that this treatment should translate well to a group format. In this study, the effects and feasibility associated with group MCT for depression are reported.
Eleven patients who were consecutively referred by general practitioners to a specialist psychiatric practice in Norway participated in an open trial of the effects and feasibility associated with group MCT for depression. All of the patients met the DSM-IV criteria for major depressive disorder (MDD) and were monitored in a baseline period before attending 90-min weekly treatment sessions of group MCT for 10 weeks. The primary symptom outcome measure was severity of depression whilst secondary outcome measures included levels of anxiety, rumination and metacognitive beliefs. We also assessed recovery rates and changes in comorbid Axis I and Axis II diagnoses.
Large clinically significant improvements across all measures were detected at post-treatment and these were maintained at follow-up. Based on objectively defined recovery criteria, all patients were classified as recovered at post-treatment and 91% at 6 months follow-up. The intervention was also associated with significant reductions in comorbid diagnoses.
These preliminary data indicate that group MCT in the treatment of depression is effective, well accepted and it extends clinical application of MCT for depression to group formats as a potential cost-effective intervention.
This study explored the treatment preferences of 106 people with posttraumatic stress disorder (PTSD), pathological gambling (PG), or both. It is the first know study of its type for this comorbidity. Sixteen different treatment types were rated, with a broad array of modalities including manualized psychotherapies, medication, self-help, alternative therapies, coaching, and self-guided treatments (use of books and computerized therapy). A consistent finding was that PTSD treatments were rated more highly than PG treatments, even among those with both disorders. Further, of the sixteen treatment types, the sample expressed numerous preferences for some over others. For example, among PG treatments, self-help was the highest-rated. Among PTSD treatments, psychotherapies were the highest-rated; and individual therapy was rated higher than group therapy. For both PG and PTSD, medications were rated lower than other treatment types. Non-standard treatments (i.e., computerized treatment, books, coaching, family therapy, alternative therapies) were generally rated lower than other types. Discussion includes implications for the design of treatments, as well as methodological limitations.
Whether suicide victims having suffered from major depression differ in their characteristics and treatment of depression received in various settings prior to death has been unknown.
From a random sample representing all completed suicides in Finland within a 12-month period, cases with a best estimate diagnosis of current unipolar DSM-III-R major depression (N = 71) were comprehensively analyzed using the method of psychological autopsy. Suicide victims with major depression were classified according to treatment setting, and the victims in different settings--psychiatric care (N = 32), medical care (N = 27), and no contact with health care (N = 12)--were compared.
The sex distribution of suicides who had major depression was equal within psychiatric care; but in medical care or without contact with health care, 77% (30 of 39) were men (p = .018). Significantly more victims in psychiatric than in medical care had communicated to attending personnel their intent to commit suicide (59% [19 of 32] vs. 19% [5 of 27], p = .004). Antidepressants were received by 60% of victims in psychiatric care but only 16% in medical care (p = .002).
Suicide victims with major depression differ in sex distribution and communication of suicide intent among treatment settings, which may complicate the ability to generalize research findings, particularly from psychiatric to medical care. Promoting suicide prevention in major depressive disorders would seem to require improving not only the quality of treatment within psychiatric care, but also basic skills in recognizing and treating depression in medical care, especially for male patients.
The various major American and European guidelines for the treatment of depression provide similar basic principles of treatment, which include individualizing the treatment plan, preparing the patient for potential long-term treatment, providing measurement-based care, and treating to remission. While the guidelines are all evidence-based, certain factors can influence differences in specific recommendations, such as the consensus group's composition, underlying mandates, and cultural attitudes. The similarities and differences among 6 sets of guidelines from Europe and the Americas published in the past decade are reviewed here (American Psychiatric Association, British Association for Psychopharmacology, Canadian Network for Mood and Anxiety Treatments, National Institute for Health and Clinical Excellence, Texas Medication Algorithm Project, and World Federation of Societies of Biological Psychiatry). In the guidelines, mild depression has the most variance in treatment recommendations; some, but not all, guidelines suggest that it may resolve with exercise or watchful waiting, but psychotherapy or antidepressants could be used if initial efforts fail. Moderate and severe major depression carry broadly similar recommendations among the guidelines. First-line treatment recommendations for moderate major depressive disorder include antidepressant monotherapy, psychotherapy, and the combination of both. Severe depression may require the combination of an antidepressant and an antipsychotic, electroconvulsive therapy, or the combination of an antidepressant and psychotherapy. Benzodiazepines play a very limited role in the treatment of depression; if the patient has catatonic depression, acutely suicidal depression, or depression with symptoms of anxiety, agitation, or insomnia, benzodiazepines are recommended by some guidelines for short-term treatment only.