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

Interpersonal psychotherapy (IPT) has demonstrated efficacy for depression but yielded negative results for substance disorders. Alcohol abuse frequently complicates mood disorders. This pilot study compared IPT with brief supportive psychotherapy (BSP) for dysthymic disorder and alcohol abuse. We hypothesized that effect sizes would suggest greater IPT efficacy for both diagnoses, despite limited statistical power. Subjects with primary DSM-IV dysthymic disorder and secondary alcohol abuse/dependence were randomly assigned 16 weeks of IPT (N = 14) or BSP (N = 12). Patients in both treatments reported improved depressive symptoms and alcohol abstinence. IPT had a large and BSP a moderate effect size in depression, whereas BSP had a moderate and IPT a small effect size in percentage of days abstinent. This pilot study offers initial data on IPT and BSP for comorbid chronic depression and alcohol abuse/dependence. Results suggest IPT may have specific antidepressant benefits for dysthymic alcoholic patients but not in treating alcoholism.     

Emotion-focused psychotherapy for patients with panic disorder.

OBJECTIVE: Recent studies have suggested that most patients treated for panic disorder receive forms of psychotherapy other than cognitive behavior therapy, even though there is little information about the efficacy of such treatments or how they compare to proven active treatments. The authors compared one of these other forms, emotion-focused psychotherapy (given to 30 patients with panic disorder), to results obtained with recommended standard treatment (either cognitive behavior therapy [N=36] or imipramine [N=22]). The authors also compared emotion-focused psychotherapy to results obtained in subjects given pill placebo (N=24). METHOD: Subjects met DSM-IV criteria for panic disorder with no more than mild agoraphobia. Treatment consisted of approximately 3 months of weekly visits followed by 6 monthly maintenance visits. Assessments were conducted after each treatment phase and at a follow-up visit after 6 months of no treatment. RESULTS: Emotion-focused psychotherapy was less effective for symptoms of panic disorder than treatment with either cognitive behavior therapy or imipramine; results obtained with emotion-focused psychotherapy after the acute and maintenance phases were similar to those seen with placebo. Treatment expectations were not different among the different groups. Patients receiving emotion-focused psychotherapy had the highest completion rate. CONCLUSIONS: The results suggest that emotion-focused psychotherapy (a supportive form of psychotherapy) has low efficacy for the treatment of panic disorder. However, emotion-focused psychotherapy may be superior to medical management in helping patients stay in treatment.     

Difficult-to-treat depression: the role of contexts and comorbidities.

In this review, we examine several special psychosocial contexts, including pregnancy and motherhood, that may seriously interfere with depressed patients' ability or willingness to engage and remain in treatment for their depression. We also explore the kinds of often-unrecognized subsyndromal comorbidities, such as panic-agoraphobic spectrum, that may complicate conventional treatments for depression or prevent depressed patients from remaining engaged long enough to fully benefit from treatment. We argue that psychotherapy can play a crucial role in addressing the special psychosocial contexts and the kinds of comorbidities experienced by the patient with difficult-to-treat depression. For difficult-to-treat depression during pregnancy and motherhood, preliminary data from several studies suggest that 8-24 sessions of weekly interpersonal psychotherapy (IPT), often followed by monthly maintenance IPT, is a promising long-term treatment for both middle- and low-income women. For difficult-to-treat depression with panic-agoraphobic subsyndromal features, preliminary results suggest that an integrated treatment approach, combining IPT for depression and cognitive-behavioral treatment for coexisting symptoms of panic, leads to higher depression response rates. These data imply that tailoring treatments to patients' specific needs and circumstances may be the real key to making depression less difficult to treat.     

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

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

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.     

A crossover study of focused cognitive therapy for panic disorder.

OBJECTIVE: This study sought to determine the short- and long-term effects of focused cognitive therapy for panic disorder. METHOD: Thirty-three psychiatric outpatients with the DSM-III diagnosis of panic disorder were randomly assigned to either 12 weeks of individual, focused cognitive therapy or 8 weeks of brief supportive psychotherapy based on principles of client-centered therapy. The patients who received supportive psychotherapy were subsequently given the opportunity to cross over to cognitive therapy for 12 weeks. Patients were rated for panic and depression before therapy, after 4 and 8 weeks of therapy, and at 6-month and 1-year follow-up. RESULTS: Clinician ratings and self-ratings of panic frequency and intensity indicated that the focused cognitive therapy group achieved significantly greater reductions in panic symptoms and general anxiety after 8 weeks of treatment than did the group that received brief supportive psychotherapy. At 8 weeks, 71% of the cognitive therapy group were panic free, compared to 25% of the psychotherapy group. Moreover, 94% of the psychotherapy patients elected to cross over to 12 weeks of cognitive therapy. At 1-year follow-up, 87% of the group that received cognitive therapy only and 79% of the group that crossed over into cognitive therapy remained free of panic attacks. CONCLUSIONS: Focused cognitive therapy offers a promising nonpharmacological alternative for the treatment of panic disorder.     

Family-based interpersonal psychotherapy for depressed preadolescents: an open-treatment trial

Aim: To conduct an open‐treatment trial to evaluate the feasibility, acceptability and clinical outcomes of using a family‐based adaptation of Interpersonal Psychotherapy for Depressed Adolescents with a sample of preadolescents (ages 9–12) presenting for outpatient treatment for depression. Methods: Sixteen preadolescents who met criteria for a depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition participated in this open‐treatment trial of family‐based interpersonal psychotherapy (FB‐IPT). Parents chose whether their preadolescents should receive FB‐IPT only (n = 10) or FB‐IPT with antidepressant medication (n = 6). Pre‐ and post‐treatment assessments included clinician‐administered measures of depression and global functioning, and parent‐ and child‐reported anxiety symptoms. Results: FB‐IPT was associated with high treatment compliance rates (88%) and was associated with significant decreases in preadolescents' depressive and anxiety symptoms. Preadolescents who received FB‐IPT only were as likely as those receiving FB‐IPT and medication to have significant reductions in depressive symptoms and anxiety symptoms, and to experience significant improvement in global functioning. Parents were more likely to choose combination treatment when their depressed preadolescents had a comorbid anxiety disorder. Conclusions: Further research on FB‐IPT is needed to establish its efficacy as compared with usual outpatient treatment, its ability to be disseminated to child clinicians with varying levels of training and in adequately powered randomized controlled trials that can detect group differences.     

A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder

BACKGROUND: Cognitive-behavioral therapy (CBT) has documented efficacy for the treatment of binge eating disorder (BED). Interpersonal psychotherapy (IPT) has been shown to reduce binge eating but its long-term impact and time course on other BED-related symptoms remain largely unknown. This study compares the effects of group CBT and group IPT across BED-related symptoms among overweight individuals with BED. METHODS: One hundred sixty-two overweight patients meeting DSM-IV criteria for BED were randomly assigned to 20 weekly sessions of either group CBT or group IPT. Assessments of binge eating and associated eating disorder psychopathology, general psychological functioning, and weight occurred before treatment, at posttreatment, and at 4-month intervals up to 12 months following treatment. RESULTS: Binge-eating recovery rates were equivalent for CBT and IPT at posttreatment (64 [79%] of 81 vs 59 [73%] of 81) and at 1-year follow-up (48 [59%] of 81 vs 50 [62%] of 81). Binge eating increased slightly through follow-up but remained significantly below pretreatment levels. Across treatments, patients had similar significant reductions in associated eating disorders and psychiatric symptoms and maintenance of gains through follow-up. Dietary restraint decreased more quickly in CBT but IPT had equivalent levels by later follow-ups. Patients' relative weight decreased significantly but only slightly, with the greatest reduction among patients sustaining recovery from binge eating from posttreatment to 1-year follow-up. CONCLUSIONS: Group IPT is a viable alternative to group CBT for the treatment of overweight patients with BED. Although lacking a nonspecific control condition limits conclusions about treatment specificity, both treatments showed initial and long-term efficacy for the core and related symptoms of BED.     

Factors associated with symptomatic improvement and recovery from major depression in primary care patients

This article describes a post-hoc analysis of clinical and psychosocial factors and beliefs about health associated with treatment outcome in a sample of depressed primary care patients (N=181) randomly assigned to a standardized treatment or physician's usual care (UC). Different factors were found to predict clinical outcomes for treatment modality [UC vs. interpersonal psychotherapy (IPT) or nortriptyline (NT)] and the type of outcome evaluated (i.e., depressive symptoms at 8 months or symptomatic and functional recovery at 8 months). Factors associated with treatment-specific outcomes are also described. Consistent with prior studies, lower depressive symptom severity at 8 months was associated with higher baseline functioning, minimal medical co-morbidity, race, and standardized pharmacologic or psychotherapeutic treatment. Additionally, an interaction between treatment modality and health locus of control indicated that individuals perceiving more self-control of their health and who received a standardized treatment experienced greater depressive symptom reduction at 8 months. Factors associated with symptomatic and functional recovery from the depressive episode were also examined. Patients who received a standardized treatment (IPT or NT) perceived greater control of their health and lacked a lifetime generalized anxiety disorder or panic disorder were more likely to recover by month 8 than those who received usual care. While clinical severity and treatment adequacy play an important role in both symptomatic improvement and full recovery from a depressive episode, other key factors such as health beliefs and non-depressive psychopathology also influence recovery.     

Hypochondriacal concerns in panic disorder and major depressive disorder: a comparison

OBJECTIVE: To gain perspective on the relationship between hypochondriasis and panic disorder, we compared the occurrence of hypochondriasis in patients with panic disorder (N= 59) and major depressive disorder (N= 27). METHODS: Patients who participated in separate drug treatment trials were assessed at baseline and eight weeks using the Whiteley Index of Hypochondriasis. RESULTS: At baseline, the Whiteley Index score was greater for patients with panic disorder than for those with major depressive disorder. At eight weeks, a statistically significant reduction in the mean hypochondriasis score was observed in panic patients who had improved but not in major depressive patients who had improved. Modest correlations were observed between hypochondriasis and symptoms of panic and major depressive disorder, but in depressed patients, hypochondriasis was positively correlated with anxiety symptoms as well. CONCLUSION: A unique relationship appears to exist between hypochondriasis and panic disorder. The nature of this relationship and its implications for classification are discussed.     

Interpersonal psychotherapy for elderly patients in primary care.

OBJECTIVE: Interpersonal psychotherapy (IPT) is recommended in most depression treatment guidelines, but little is known about its effectiveness in real-life practice. This study investigates whether IPT, delivered by mental health workers to elderly patients with major depressive disorder, is more effective than usual general practitioners' care (CAU). METHODS: A pragmatic randomized, controlled trial was conducted in which 143 patients were allocated to IPT (10 sessions) or to CAU. PRIMary care Evaluation of Mental Disorders (PRIME-MD) and Montgomery Asberg Depression Rating Scale (MADRS) assessments were used as primary outcomes. RESULTS: IPT was significantly more effective in reducing the percentage of patients with a diagnosis of depression (PRIME-MD), but not in inducing remission (MADRS <10). Among treatment completers, IPT was superior in improving social and overall mental functioning. A post hoc analysis revealed that IPT was superior to CAU in moderately to severely depressed patients, but not significantly so in mildly depressed patients. CONCLUSIONS: IPT was more effective than CAU for elderly patients with moderate to severe major depressive disorder in general practice. Future research should focus on determinants of treatment outcome.     

Relationships between depressive symptoms and panic disorder symptoms during guided internet-delivered cognitive behavior therapy for panic disorder

Abstract

Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder.

Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed.

Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment.

Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.     

The diagnosis and management of panic disorder

The diagnosis of panic disorder without agoraphobia can very often be quite difficult because of the similarity with physical disorders particularly in the cardiac, gastrointestinal or neurological systems. The distinction must be made between panic attacks appearing as medical problems and medical problems appearing as panic attacks. Sometimes the diagnosis of panic attacks is made only after the medical diagnoses have been excluded. Panic disorder with agoraphobia however is much easier to detect if one carefully traces the historical development of agoraphobia and carefully distinguishes between the anxiety produced by agoraphobia and the panic attacks related to panic disorder. Panic disorder must also be distinguished from other anxiety disorders since the treatment for panic disorder still is quite specific. Once diagnosed however, the treatment of panic disorder without agoraphobia is rather simple. It involves the use of a benzodiazepine, either alprazolam or clonazopam, and perhaps the concomitant use of either imipramine or phenelzine sulfate for the rapid control of anxiety symptoms and continued treatment of the disorder. It is also very helpful to have the patient in psychotherapy either using a supportive or cognitive approach. If the patient has a panic disorder with agoraphobia, the pharmacological approach is the same, with the initiation of treatment using either alprazolam or clonazopam, but the psychotherapeutic approach is somewhat different in that behavioral therapy is emphasized rather than purely supportive or cognitive approaches. Given the fact that 1%-2% of the population is at risk for panic disorder, it is important that the condition be rapidly recognized and treated effectively since the currently available modalities of treatment result in almost total resolution of symptoms. Some individuals will remain on medication for several years while others will find it possible to decrease and/or discontinue their medications after only a few months or a few years. There is little excuse at this point for this disorder to be ineffectively diagnosed or treated.     

The treatment of panic disorder

PURPOSE OF REVIEW: The aim of this article is to provide an updated review of studies and recommendations published from August 2003 to August 2004 on the treatment of panic disorder. RECENT FINDINGS: Cognitive-behavioral psychotherapy remains the treatment of choice for panic disorder. Recent studies confirm selective serotonin reuptake inhibitors as the first-choice drugs in treating panic disorder. Recommendations for (adjunctive) high-potency benzodiazepines have been published. Psychoeducation and combined pharmacotherapy/psychotherapy improve treatment response. Optimal long-term treatment of panic disorder involves adequate medication and duration of treatment, since relapse is frequent. SUMMARY: Recent studies confirm that cognitive-behavioral therapy, alone or in combination with drug therapy, remains the treatment of choice for panic disorder. Long-term treatment is often necessary due to the chronicity of the illness.     

Efficacy of interpersonal psychotherapy for postpartum depression

BACKGROUND: Postpartum depression causes women great suffering and has negative consequences for their social relationships and for the development of their infants. Research is needed to evaluate the efficacy of psychotherapy for postpartum depression. METHODS: A total of 120 postpartum women meeting DSM-IV criteria for major depression were recruited from the community and randomly assigned to 12 weeks of interpersonal psychotherapy (IPT) or to a waiting list condition (WLC) control group. Subjects completed interview and self-report assessments of depressive symptoms and social adjustment every 4 weeks. RESULTS: Ninety-nine of the 120 patients completed the protocol. Hamilton Rating Scale for Depression (HRSD) scores of women receiving IPT declined from 19.4 to 8.3, a significantly greater decrease than occurred in the WLC group (19.8 to 16.8). The Beck Depression Inventory (BDI) scores of women who received IPT declined from 23.6 to 10.6 over 12 weeks, a significantly greater decrease than occurred in the WLC group (23.0 to 19.2). A significantly greater proportion of women who received IPT recovered from their depressive episode based on HRSD scores of 6 or lower (37. 5%) and BDI scores of 9 or lower (43.8%) compared with women in the WLC group (13.7% and 13.7%, respectively). Women receiving IPT also had significant improvement on the Postpartum Adjustment Questionnaire and the Social Adjustment Scale-Self-Report relative to women in the WLC group. CONCLUSIONS: These findings suggest that IPT is an efficacious treatment for postpartum depression. Interpersonal psychotherapy reduced depressive symptoms and improved social adjustment, and represents an alternative to pharmacotherapy, particularly for women who are breastfeeding.     

Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management

Approximately one quarter of patients who present to physicians for treatment of chest pain have panic disorder. Panic disorder frequently goes unrecognized and untreated among patients with chest pain, leading to frequent return visits and substantial morbidity. Panic attacks may lead to chest pain through a variety of mechanisms, both cardiac and noncardiac in nature, and multiple processes may cause chest pain in the same patient. Panic disorder is associated with elevated rates of cardiovascular diseases, including hypertension, cardiomyopathy, and, possibly, sudden cardiac death. Furthermore, patients with panic disorder and chest pain have high rates of functional disability and medical service utilization. Fortunately, panic disorder is treatable; selective serotonin reuptake inhibitors, benzodiazepines, and cognitive-behavioral psychotherapy all effectively reduce symptoms. Preliminary studies have also found that treatment of patients who have panic disorder and chest pain with benzodiazepines results in reduction of chest pain as well as relief of anxiety.     

Use of selective serotonin reuptake inhibitors for the treatment of childhood panic disorder: a pilot study.

This preliminary study examines the effectiveness and safety of selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder in children and adolescents. In a prospective open label study, 12 children and adolescents with panic disorder were treated with SSRIs, and if necessary, with benzodiazepines, for a period of 6-8 weeks and were followed for approximately 6 months. During the trial, clinician-based and self-report rating scales for anxiety and depression, functioning, and side effects, were administered. Using the Clinical Global Impression Scale (CGIS) 75% of patients showed much to very much improvement with SSRIs without experiencing significant side effects. After controlling for changes in depressive symptoms, self-report and clinician-based anxiety scales also showed significant improvement. At the end of the trial, 67% of patients no longer fulfilled criteria for panic disorder and 4 patients remained with significant residual symptoms. In conclusion, SSRIs appear to be a safe and promising for the treatment of children and adolescents with panic disorder, however, randomized controlled trials evaluating the effects of SSRIs and other interventions (e.g., cognitive therapy) for treating panic disorder in children and adolescents are warranted. It appears that until the SSRIs begin to exert their effects, a benzodiazepine adjunct treatment might be helpful for patients with severe panic disorder.     

Open trial of psychodynamic psychotherapy for panic disorder: a pilot study

OBJECTIVE: This report contains preliminary data from an open trial of brief psychodynamic psychotherapy for panic disorder. METHOD: Fourteen patients with primary DSM-IV panic disorder completed a 24-session, twice-weekly course of psychodynamic psychotherapy. Other psychiatric treatment was not permitted throughout the 12-week treatment period and the 6-month follow-up. Symptoms were assessed at baseline, treatment termination, and 6-month posttermination follow-up (40 weeks). RESULTS: Statistically significant, clinically meaningful improvements appeared in panic, depression, anxiety, and functional impairment both at treatment termination and at 6-month follow-up. CONCLUSIONS: Psychodynamic monotherapy can be used successfully to retain and treat patients with panic disorder. Psychodynamic interventions warrant further study for patients with panic disorder.     

Comparative outcomes among the problem areas of interpersonal psychotherapy for depression

Background: Although interpersonal psychotherapy (IPT) is an efficacious treatment for acute depression, the relative efficacy of treatment in each of the four IPT problem areas (grief, role transitions, role disputes, interpersonal deficits) has received little attention. We evaluated the specificity of IPT by comparing treatment success among patients whose psychotherapy focused on each problem area. Moreover, we sought to understand how the patient characteristics and interpersonal problems most closely linked to the onset of a patient's current depression contributed to IPT success. Methods: Patients meeting DSM‐IV criteria for an episode of major depressive disorder ( n =182) were treated with weekly IPT. Remission was defined as an average Hamilton Rating Scale for Depression 17‐item score of 7 or below over 3 weeks. Personality disorders were diagnosed using the Structured Clinical Interview for DSM‐IV Personality Disorders. Results: Contrary to our prediction that patients whose treatment was focused on interpersonal deficits would take longer to remit, survival analyses indicated that patients receiving treatment focused on each of the four problem areas did not differ in their times to remission. Nor were patients in the interpersonal deficits group more likely to have an Axis II diagnosis. Patients whose treatment focused on role transitions remitted faster than those whose treatment focused on role disputes, after controlling for covariates. Conclusion: With skillful use of IPT strategies and tactics and with careful medication management where appropriate, patients in this study whose treatment focused on each problem area were treated with equal success by trained IPT clinicians. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.