THE MORE IT IS NEEDED,THE LESS IT IS WANTED: ATTITUDES TOWARD FACE‐TO‐FACE INTERVENTION AMONG DEPRESSED PATIENTS UNDERGOING ONLINE TREATMENT

Many individuals suffering from depression do not actively seek treatment. Self‐help strategies represent low‐threshold treatment options that are particularly relevant for milder cases. The present study addressed two important issues: (1) we examined depressed individuals’ motives and attitudes that may represent barriers to face‐to‐face treatment; (2) we examined if the participation in an online treatment program facilitates or compromises their willingness to undergo face‐to‐face treatment. We recruited 210 participants with depression for a trial on the efficacy of an online treatment program for depression. Participants were randomly allocated either to a self‐help treatment (Deprexis) or to a wait‐list control group. All participants filled out a newly developed 42‐item questionnaire called Psychotherapy Expectations, Concerns, and Hopes Inventory (PECHI). The scale measures attitudes toward face‐to‐face treatment and was administered at baseline and 8 weeks later. Principal component analysis of the PECHI revealed five dimensions: hope for symptomatic improvement, fear of poor alliance with the therapist, skill acquisition, skepticism and resentment of psychotherapy, and self‐stigma. Attitudes toward treatment were stable over time and neither modulated by group status nor by self‐reported or objective symptom decline. Correlation analyses revealed that current levels of depression and well‐being were potent predictors of attitudes toward treatment, suggesting that when the patient feels more depressed, doubts about the effectiveness of therapy emerge more strongly. To conclude, results suggest that Deprexis neither promotes nor reduces negative attitudes toward psychotherapy, nor does it increase barriers to enter face‐to‐face treatments. An alarming paradox emerged: when a depressed person is in greatest need of help, motivation to seek face‐to‐face treatment is lowest. Depression and Anxiety 00:1‐11, 2012. © 2012 Wiley Periodicals, Inc.     

Light microscopic Golgi study of mitral/tufted cells in the accessory olfactory bulb of the adult rat.

Mitral/tufted cells (MTCs) of the accessory olfactory bulb (AOB) of adult rats were investigated light microscopically with the rapid Golgi method. The somata of the MTCs, appearing ovoid or triangular in shape, are distributed throughout the external plexiform layer. The soma size varies from small to large (12-26 microns). Apical dendrites originating from the soma enter the glomerular layer to provide branches that form the glomerular arbors. After making a glomerular arbor, some dendrites develop a second arbor (en passant and terminal arbors, respectively). The MTCs have a very diverse dendritic branching pattern and most have a variable number of glomerular arbors per cell (up to 6); we have tentatively classified the MTCs into simple, intermediate, and complex. Of the glomerular arbors, 80% have a diameter of less than 50 microns. The glomerular arbors have been classified as baskets (small spherical or ovoid) with short loopy processes; balls of yarn (large and nearly spherical) with loosely intermingled thick loops; and bushes (small to large and rather polymorphic) with irregular processes. The MTCs send dendritic arbors to terminate in one or more glomeruli where they are arranged in several different types of endings. Since it is generally believed that the dendrites of mitral and tufted cells of the main olfactory bulb terminate in only one glomerulus, the difference in the termination of the dendrites of the MTCs may represent a morphological characteristic that is relevant to the coding and/or integration of sensory information.     

Integrating Individual and Group-based Offence-focussed Psychological Treatments: Towards a Model for Best Practice

This review explored outcomes of individual and group-based offence-focussed psychological treatments in studies published between 1 January 1990 and 31 August 2014. Very few high-quality studies using individual treatments (n = 13) were identified. There were even fewer comparisons of individual versus group-based treatment (n = 2); several studies incorporating both individual and group-based treatment components for high-risk high-need clients were also identified. Extant findings suggest comparable outcomes for group-based and individual treatment. In concluding, we adopt a pragmatic perspective and propose a model for conceptualising the role of individual treatment in offender rehabilitation and its relationship to group-based offence-focussed treatments. Group-based treatments are promoted due to their larger evidence base. Individual interventions may prepare clients for group treatment, and/or promote treatment gains when stable internal factors impair responsivity. Individual treatments may also help prevent high-risk clients from engaging in problem behaviours that may result in their removal from the programme. On occasions, individual treatments may be necessary to provide another treatment pathway when group treatments are not possible. Identifying and attending to responsivity factors through both individual and group-based treatments increases the likelihood that rehabilitation efforts are sensitive to each participant's needs.     

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders,Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders

Abstract

Objectives. This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. Methods. The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. Results. This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. Conclusions. To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.     

Treatment‐resistant bipolar depression: towards a new definition

Objective: To summarize the conceptual and operational definitions of treatment‐resistant bipolar depression and to review the evidence‐based therapeutic options. Method: Structured searches of PubMed, Index Medicus, Excerpta Medica and Psyclit conducted in December 2008. Results: Criteria for treatment resistance in bipolar depression are commonly based on concepts stemming from treatment resistance as defined for unipolar depression, an approach that proved to be inadequate. In fact, the addition of an ad hoc criterion based on lithium and other mood stabilizer unresponsiveness after reaching adequate plasma levels appears to be a patch that attempts to take into account the uniqueness of bipolar depression but fails to become operational. Recent data from randomized clinical trials of new anticonvulsants and second‐generation antipsychotics should lead to the development of a modern definition of treatment‐resistant bipolar depression, and specific therapeutic algorithms. Conclusion: We suggest a redefinition of resistant bipolar I and II depression. We propose different degrees of severity within bipolar depression in a stepwise manner.     

Psychopharmacological treatment differences in autogenous and reactive obsessions: A retrospective chart review

Background: Identification of homogeneous subgroups of obsessive compulsive disorder (OCD) patients may have important implications for improving effective treatment options. It has been proposed that obsessive thoughts can be classified into two subtypes, i.e. autogenous and reactive obsessions. Although it has been shown that patients with autogenous obsessions may display a worse response to treatment, no studies have yet addressed whether there is a different need for the psychopharmacological treatment options in the subtypes of OCD patients. Aim: To investigate the clinical characteristics and treatment differences between autogenous (A-OCD) and reactive (R-OCD) subtypes of OCD patients. Methods: Both OCD subgroups (n = 50 for A-OCD, n = 130 for R-OCD) were compared with each other in terms of their demographic and clinical parameters. Odds ratio values for gender, treatment options, co-morbidity, severity of OCD, and response to treatment were computed. Multivariate hierarchical regression analyses were performed to identify any predictors for treatment options, severity of OCD, and response to treatment. Results: Our results indicated that the A-OCD and R-OCD groups differed from each other on some demographic and clinical variables in addition to their psychopharmacological treatment needs. Patients in the A-OCD group were found to be prescribed an atypical antipsychotic 2.3 times more likely than the R-OCD group. The odds for a combination treatment, or the improvement of OCD symptoms from baseline levels did not differ between the two subtypes of obsession groups. Conclusions: Autogenous and reactive subtypes of obsessions may need to be offered different psychopharmacological treatment options.     

Treatment of post-traumatic stress disorder in people with dementia: a structured literature review

Post-traumatic stress disorder (PTSD) is associated with cognitive dysfunctions and is an independent risk factor for dementia. A recent study has found the prevalence of PTSD in people with dementia is 4.7%–7.8%. However, little is known about the effectiveness of PTSD treatment for people with dementia. The primary aim of the current study is to review previous studies on the treatment of PTSD in people with dementia. A structured literature review was performed using a ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ analysis in PubMed, Embase, PsycINFO and CINAHL. Two independent researchers screened titles and abstracts. The inclusion criteria were: PTSD symptoms present, diagnosis of dementia, PTSD treatment form described and effects of the treatment mentioned. Articles that matched these criteria were included and content and quality were analyzed. We included nine articles, all case reports, with a total of 11 cases. The discussed treatment options are eye movement desensitisation and reprocessing (EMDR) (n = 3), prolonged exposure (n = 1), cognitive behavioural therapy (n = 1) and pharmacological treatment (n = 4). All articles reported a positive effect of the intervention on several monitored symptoms. Evidence for positive effects and feasibility of EMDR were most reliable, and it was applied in two articles of sufficient quality published in 2018 and 2019. EMDR ‘on-the-spot’ was described with positive effect in one article in which three cases were discussed. The quality of included papers ranged from insufficient to sufficient. This review shows that people with PTSD and dementia can benefit from PTSD treatment. EMDR, prolonged exposure, acceptance and commitment therapy and pharmacological treatment are applicable in this population. EMDR treatment is most described in this population (n = 5) and shows positive results, and the studies are of sufficient quality (n = 3). Further research in the form of a randomised controlled trial is required to study the effectivity of different treatment interventions in this population.     

Different lens or different picture? Comparing methods of defining dramatic change in psychotherapy

Objectives: Differing methodologies that identify dramatic change in psychotherapy have been thought to be capturing similar phenomena. We compared three methods—percentage improvement-50% (PI-50), rapid response (RR), and sudden gains (SG)—to identify similarities and differences between these approaches. Methods: Using a large database (n?=?11,764) from a western university counseling center, we examined client characteristics (including initial severity and number of sessions in a course of treatment) and treatment outcomes (including overall change and meeting clinically significant criteria) using the Outcome Questionnaire-45. Results: Approximately 47% of clients (n?=?5516) met criteria for one or more of the dramatic change definitions examined. Only 498 clients (3.7%) met criteria for all three methods, while 1349 (11.5%) met criteria for only one; RR identified the most clients (41.9%) and SG identified the fewest (4.9%). All definitions were associated with higher rates of clinically significant change at termination. Compared to those who recovered gradually, dramatic changers showed higher initial severity and more overall change. RR showed fewer sessions and PI-50 and SG showed more sessions than those who recovered gradually. Conclusions: Given these differences, consensus needs to be reached in the literature regarding the definition of dramatic change. We call for further theory development and research to help formulate a definition that can be simply applied and that more fully and parsimoniously captures the phenomenon of dramatic change.     

Integrating technology and targeted treatment to improve narrative production in aphasia: A case study

Background: Studies of aphasic sentence production have identified a number of promising approaches to improving performance at the single sentence level, but these studies have typically failed to show measurable effects on multi‐sentence productions (spontaneous or narrative speech). The difficulty for aphasic speakers of producing connected speech during therapy is likely to contribute to this effect. Computer software that allows patients to record, replay, and concatenate partial utterances has shown promise in allowing narrative‐level practice during treatment of even severely non‐fluent patients.

Aims: This single‐case study continues research using SentenceShaper ^®, a computer program that supports speakers' productions while they are being formulated. The goal is to investigate the utility of a two‐step treatment that supplements improvements achieved from use of the software alone with explicit structural treatment (of multi‐clause sentences).

Methods & Procedures: We describe an aphasic speaker (CI) with severely non‐fluent, fragmented, and agrammatic speech who participated in two treatment phases. Initially, as in previous studies, CI practised producing narratives (based on wordless picture books or silent videos) while using SentenceShaper, with no explicit focus on specific syntactic elements. This phase produced marked structural improvement, so a second treatment, focused on the production of multi‐clause sentences, was designed to exploit his success using the system. Following a period of targeted treatment on such structures, CI practiced producing narratives that incorporated these structures with the help of SentenceShaper. Structural analyses based on the Quantitative Production Analysis system compared Baseline and Post‐treatment 1 performance, and then compared improvements Post‐treatment 1 with those shown after treatment 2.

Outcomes & Results: Structural measures (including mean sentence length, proportion of words in sentences and sentence well‐formedness) improved significantly from Baseline following Treatment 1, and improved significantly again following Treatment 2, such that sentence length and well‐formedness moved into the normal range.

Conclusions: Results indicate that this combined approach may be helpful in improving the connected speech of even chronic and severely non‐fluent speakers. The characteristics of this aphasic speaker that might have contributed to this outcome, and the limitations of this study, are considered.     

Analysis of youtube as a source of information for peripheral neuropathy

Introduction: YouTube is an important resource for patients. No study has evaluated the information on peripheral neuropathy disseminated by YouTube videos. In this study, our aim was to perform a systematic review of information on YouTube regarding peripheral neuropathy. Methods: The Web site ( www.youtube.com ) was searched between September 19 and 21, 2014, for the terms “neuropathy,” “peripheral neuropathy,” “diabetic neuropathy,” “neuropathy causes,” and “neuropathy treatment.” Results: Two hundred videos met the inclusion criteria. Healthcare professionals accounted for almost half of the treatment videos (41 of 92; 44.6%), and most came from chiropractors (18 of 41; 43.9%). Alternative medicine was cited most frequently among the treatment discussions (54 of 145, 37.2%), followed by devices (38 of 145, 26.2%), and pharmacological treatments (23 of 145, 15.9%). Conclusions: Approximately half of the treatment options discussed in the videos were not evidence‐based. Caution should be exercised when YouTube videos are used as a patient resource. Muscle Nerve 53 : 27–31, 2016     

Cognitive-behavioral treatment of persistent functional somatic complaints and pediatric anxiety: an initial controlled trial

Background: Children and adolescents who seek medical treatment for persistent physical distress often suffer from co‐occurring anxiety disorders. Treatment options for this impaired population are limited. This study tests the feasibility and potential efficacy of a cognitive‐behavioral intervention targeting pain and anxiety for youth with impairing functional physical symptoms and anxiety disorders presenting to pediatricians for medical care. Methods: Children and adolescents (aged 8–16) experiencing somatic complaints, without an explanatory medical disorder (i.e., functional), were recruited from primary care and specialty (gastroenterologists and cardiologists) pediatricians. Forty children, primarily with gastrointestinal symptoms, who met criteria for a co‐occurring anxiety disorder, were randomly assigned to a cognitive‐behavioral treatment addressing pain and anxiety, Treatment of Anxiety and Physical Symptoms (TAPS), or to a waiting list control. Results: TAPS was found to be an acceptable treatment for this population and was superior to the waiting list condition. Eighty percent of children in TAPS were rated as treatment responders by independent evaluators compared with none of the controls. Overall, self‐ and parent ratings indicated reductions in children's somatic discomfort and anxiety following intervention. TAPS participants maintained clinical gains 3 months following treatment. Conclusions: The study supports the feasibility and preliminary efficacy of a cognitive‐behavioral intervention targeting co‐occurring physical distress and anxiety in youth presenting for medical treatment. Such an approach has the potential to exert broad impact on children's dysfunction and to minimize exposure to invasive, ineffective, and costly medical procedures and treatments. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria

The Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria is a publication of the Intercollegiate Committee of the Royal College of Psychiatrists. The overall goal of the Good Practice Guidelines is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynaecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counselling, psychotherapy), and hormonal and surgical treatments. The Good Practice Guidelines are based on the best available science and expert professional consensus. The Good Practice Guidelines articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, the Good Practice Guidelines recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the Good Practice Guidelines to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.     

Buccal midazolam or rectal diazepam for treatment of residential adult patients with serial seizures or status epilepticus

Nakken KO, Lossius MI. Buccal midazolam or rectal diazepam for treatment of residential adult patients with serial seizure or status epilepticus.
Acta Neurol Scand: 2011: 124: 99–103.
© 2011 John Wiley & Sons A/S. Objectives – To compare the efficacy and tolerability of buccal midazolam with rectal diazepam as emergency treatment in residential adults with convulsive or non‐convulsive serial seizures or status epilepticus (SE), and ascertain the preference between the two treatment options among the patients and the nursing staff. Materials and methods – The nursing staff of our residential epilepsy centre treated 80 episodes of serial seizures or SE lasting more than 5 min alternating with rectal diazepam or buccal midazolam. The dose of each study drug was tailored individually. The primary outcome measure was defined as cessation of seizure activity within 10 min without seizure relapse within 2 h. Results – Convulsive SE was treated promptly, after a mean of 6.2 min, and terminated faster with buccal midazolam than with rectal diazepam; i.e. after a mean of 2.8 vs 5.0 min, respectively (n = 0.012). The other subcategories of emergency situations were treated after a mean of 25.0 min, and the seizure activity ceased after a mean of 7.4 min in the diazepam group and 7.6 min in the midazolam group (NS). The success rate was 83.3% in the diazepam group and 74.4% in the midazolam group (NS). The difference was mostly due to slightly more seizure relapses during the first 2 h in the midazolam group. Both treatment options were well tolerated, temporary tiredness being the most frequently occurring adverse effect. All the nursing staff and six of the seven patients who gained experience with both treatment options favoured the buccal route. Conclusions – Buccal midazolam appeared to be at least as effective as rectal diazepam with little or no side effects. The buccal administration was easy to handle and socially more acceptable than the rectal route.     

A Position Paper on Neurofeedback for the Treatment of ADHD

This position paper provides the current evidence supporting the use of neurofeedback in the treatment of ADHD and recommendations on the implementation of neurofeedback in clinical practice. The paper also provides basic information regarding the diagnosis and psychophysiological etiology of ADHD. The paper does not focus on a specific age range of a clinical population. Unless otherwise noted, we are referring to all subtypes of ADHD (inattentive, hyperactive only, and combined). Conclusions and recommendation are based on the most recent research; however, we also refer to relevant historical studies that support our position on neurofeedback. The readers are strongly advised to research behavioral diagnostic criteria and testing methods elsewhere. This paper is not intended as a comprehensive educational tool for diagnosis or treatment of ADHD. Our purpose is to demonstrate the rationale and to reference the necessary support for neurofeedback in order to be recognized as a legitimate, scientific, and evidence-based intervention for the treatment of ADHD.     

Late‐onset myasthenia gravis: A review when incidence in older adults keeps increasing

We define late‐onset myasthenia gravis (LOMG) when symptoms appear at ≥65 years of age. There has been a continuous increase in the incidence of LOMG with a clear male predominance. Commonly, patients present with focal (ocular or bulbar) weakness. A high index of suspicion required to achieve early diagnosis and to improve prognosis. Management options include acetylcholinesterase inhibitors, steroids, and immunosuppressants. The most controversial issue in treatment is thymectomy, because not enough data are available. Successful treatment is associated with improved survival, and death is often secondary to comorbidities. Muscle Nerve 48:705–710, 2013     

SCN2A channelopathies: Mechanisms and models

Variants in the SCN2A gene, encoding the voltage‐gated sodium channel Na_V1.2, cause a variety of neuropsychiatric syndromes with different severity ranging from self‐limiting epilepsies with early onset to developmental and epileptic encephalopathy with early or late onset and intellectual disability (ID), as well as ID or autism without seizures. Functional analysis of channel defects demonstrated a genotype‐phenotype correlation and suggested effective treatment options for one group of affected patients carrying gain‐of‐function variants. Here, we sum up the functional mechanisms underlying different phenotypes of patients with SCN2A channelopathies and present currently available models that can help in understanding SCN2A‐related disorders.     

Barriers to treatment among members of a mental health advocacy group in South Africa

Background: As part of an international survey of mental health advocacy groups, information pertinent to patients' concerns regarding their diagnosis and treatment was gathered from South African members of a depression and anxiety support group (n = 404). Methods: Questionnaires developed by GAMIAN, an international consortium of advocacy groups, were mailed along with explanatory letters and self-addressed envelopes to South African members and members in nine other countries, for completion. Of 1,000 questionnaires mailed in South Africa, 40.4 % were returned. Results: The sample comprised patient members with anxiety-only (39 %), depression-only (8 %), mixed anxiety-depression (26 %), and other diagnoses (27 %). While one-third of respondents reported onset of symptoms before the age of 20, most waited 3–5 years before seeking help. After making contact with the health system, respondents experienced further delays in obtaining a correct diagnosis. In many instances, respondents were poorly informed of diagnosis and treatment (25 %), and nearly half of all respondents discontinued treatment on account of side-effects. Conclusions: Attempts to improve awareness of mental illness, and better communication between physicians and their patients, might help to break down some of the barriers patients encounter when seeking help. Accepted: 13 May 2002     

The impact of treatment resistance on outcome and course of electroconvulsive therapy in major depressive disorder

Introduction

Major depressive disorder (MDD) is a common psychiatric disorder. Despite several treatment options, a subgroup of patients will not respond to the commonly used antidepressant treatments and thus express treatment resistance (TRD). TRD can be quantified with the Dutch Measure for Treatment Resistance in Depression (DM-TRD). Electroconvulsive therapy (ECT) is an effective treatment for MDD, also in TRD. Yet, the position of ECT as “treatment-of-last-resort” may decrease the likelihood of beneficial outcome. Our aim was to investigate the association between treatment resistance and outcome and course of ECT.

Methods

We performed a retrospective, multicenter cohort study with 440 patients of which data was retrieved from patient records as collected in the Dutch ECT Cohort database. Linear and logistic regression models were used to explore the association between level of treatment resistance and outcome of ECT. Median split was used to explore the differences between high and low level of TRD and course of treatment.

Results

A higher DM-TRD score was associated with significantly smaller reduction of depression symptoms (R² = 0.160; β = −2.968; p < 0.001) and lower chance of response (OR = 0.821 [95 CI: 0.760–0.888]; β = −0.197; p < 0.001). Low level TRD patients underwent fewer ECT sessions (mean 13 ± 6 SD vs. 16 ± 7 SD; p < 0.001) and fewer switches from right unilateral tot bifrontotemporal electrode placement (29% vs. 40%; p = 0.032).

Conclusion

Reserving ECT as “treatment-of-last-resort” in the treatment algorithm for MDD seems questionable, because in our study lower level of treatment resistance predicted more beneficial ECT-outcome. Moreover, providing ECT in less treatment resistant patients showed fewer needed ECT-sessions and less switches to BL electrode placement, which may decrease the risk for cognitive side-effects.