中国老年心理问题的评估、预警与干预示范研究总体方案:中国纵向老龄化研究

Summary

Cognitive and depressive disorders are common in elderly Chinese and are becoming an increasingly important public health problem, partly because of the rapid aging of the population. To help address this issue China''s national government has funded a major study to establish national standards for the early identification, evaluation and treatment of common psychological disorders in the elderly. The present paper describes the overall methodology of this study. Fifteen centers in eight provinces will recruit representative samples of subjects aged 60 and over, collect a detailed history, conduct a physical and neurological examination, administer a comprehensive battery of psychological tests, and carry out a diagnostic exam using the Structured Clinical Interview for DSM-IV (SCID). These subjects will participate in follow-up evaluations one year and three years after the initial evaluation. Subsamples of subjects with mild cognitive impairment (MCI) and subclinical depression will be enrolled in randomized controlled trials of a cognitive training program (for MCI) or group cognitive behavioral therapy (for subclinical depression). The results of the study will be used to estimate the prevalence of cognitive and affective disorders in the elderly, to develop a standard screening procedure for these conditions that can be promulgated nationally, and to promote the use of specific interventions that can prevent the development of dementia in persons with MCI and the development of depressive episodes in elderly individuals with subclinical depression.     

Psychological treatments for adults and children with epilepsy: Evidence‐based recommendations by the International League Against Epilepsy Psychology Task Force

Given the significant impact that psychosocial factors and epilepsy treatments can have on the health‐related quality of life (HRQOL) of individuals with epilepsy and their families, there is great clinical interest in the role of psychological evaluation and treatments to improve HRQOL and comorbidities. Therefore, the International League Against Epilepsy (ILAE) charged the Psychology Task Force with the development of recommendations for clinical care based on evaluation of the evidence from their recent Cochrane review of psychological treatments in individuals with epilepsy. The literature search for a recent Cochrane review of randomized controlled trials investigating psychological treatments for individuals with epilepsy constitutes the key source of evidence for this article. To provide practical guidance to service providers, we provide ratings on study research designs based on (1) the American Academy of Neurology's Level of Evidence system and (2) the Grading of Recommendations, Assessment, Development, and Evaluation system. This paper is the culmination of an international collaboration process involving pediatric and adult psychologists, neurologists, psychiatrists, and neuropsychiatrists. The process and conclusions were reviewed and approved by the ILAE Executive Committee. The strongest evidence for psychological interventions was identified for the most common mental health problems, including depression, neurocognitive disturbances, and medication adherence. Psychological interventions targeting the enhancement of HRQOL and adherence and a decrease in comorbidity symptoms (anxiety, depression) should be incorporated into comprehensive epilepsy care. There is a range of psychological strategies (ie, cognitive behavioral therapy and mindfulness‐based therapies) that show promise for improving the lives of persons with epilepsy, and clinical recommendations are provided to assist epilepsy health care providers in treating the comorbidities and challenges associated with epilepsy and its treatments.     

Psychological treatment for bipolar disorders

Abstract. The increased acceptance of stress-vulnerability models of severe mental disorders and of brief evidence-based psychological treatments in their treatment has finally led to increased interest in the role of psychotherapies in bipolar disorders. This paper reviews the results from randomised controlled trials of psychological therapies as an adjunct to standard medications. The evidence suggests that the addition of a psychological therapy may significantly reduce symptoms, enhance social adjustment and functioning, and reduce relapses and hospitalisations in patients with bipolar disorder. However, the methodological problems in the published randomised controlled trials and the heterogeneity in the outcomes achieved (some therapies reduce manic but not depressive relapses, others have the opposite effect) suggests that further studies are required to fully establish the place of these approaches in day to day practice.     

Cognitive hypnotherapy for major depressive disorder

Since the publication of the special issue on cognitive hypnotherapy in the Journal of Cognitive Psychotherapy: An International Quarterly (1994), there have been major developments in the application of hypnosis to the treatment of depression. However, there is no "one-size-fits-all" treatment for depressive disorders as the conditions represent a complex set of heterogeneous symptoms, involving multiple etiologies. It is thus important for therapists to promote a multimodal approach to treating depressive disorders. This article describes cognitive hypnotherapy (CH), an evidence-based multimodal psychological treatment that can be applied to a wide range of depressed patients. CH combines hypnosis with cognitive behavior therapy as the latter provides the best integrative lodestone for assimilating empirically supported treatment techniques derived from various psychotherapies.     

Supportive therapy for schizophrenia: possible mechanisms and implications for adjunctive psychosocial treatments

This article posits that the positive findings for supportive therapy (ST) in recent trials may indicate an important but undervalued aspect of psychosocial interventions for schizophrenia. In developing this thesis, we consider the possible mechanisms underlying the beneficial effects of ST observed in recent trials of cognitive behavioral therapy for schizophrenia. We place this evidence in the context of a review of psychological models of mental health, the therapeutic alliance, and research on social cognition and social support in schizophrenia. We conclude this article by describing a new theoretically driven intervention for schizophrenia, functional cognitive-behavioral therapy (FCBT), which improves functional outcomes by integrating evidence-based advances in cognitive behavioral therapy with the strengths of ST approaches.     

A systematic review of psychological interventions for excessive alcohol consumption among people with psychotic disorders

Baker AL, Hiles SA, Thornton LK, Hides L, Lubman DI. A systematic review of psychological interventions for excessive alcohol consumption among people with psychotic disorders. Objective: Excessive alcohol consumption is common among people with psychotic disorders. While there is an extensive literature on the efficacy of psychological treatments for excessive drinking, few studies have examined interventions addressing this issue among people with psychotic disorders. Method: Systematic searches in PubMed and PsycINFO were conducted to identify randomized controlled trials comparing manual-guided psychological interventions for excessive alcohol consumption among individuals with psychotic disorders. Of the 429 articles identified, seven met inclusion criteria. Data were extracted from each study regarding study sample characteristics, design, results, clinical significance of alcohol consumption results, and methodological limitations. Results: Assessment interviews, brief motivational interventions, and lengthier cognitive behavior therapy have been associated with reductions in alcohol consumption among people with psychosis. While brief interventions (i.e. 1-2 sessions) were generally as effective as longer duration psychological interventions (i.e. 10 sessions) for reducing alcohol consumption, longer interventions provided additional benefits for depression, functioning, and other alcohol outcomes. Conclusion: Excessive alcohol consumption among people with psychotic disorders is responsive to psychological interventions. It is imperative that such approaches are integrated within standard care for people with psychosis.     

Multimodal Cognitive Therapy: Combining Treatments That Bypass Cognitive Deficits and Deal With Reasoning and Appraisal Biases

The process of recovery in schizophrenia involves resolving persistent symptoms, addressing cognitive impairments, and improving functional outcomes. Our research group has demonstrated the efficacy of cognitive adaptation training (CAT)—a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists, and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior) for improving adherence to medications and functional outcomes in schizophrenia. Early CAT pilot studies utilizing some therapists with training in cognitive behavior therapy (CBT) techniques for psychosis found significant improvements in positive symptoms. More recent larger scale randomized clinical trials failed to replicate this finding with CAT therapists not trained in CBT techniques. Persistent psychotic symptoms substantially impair patients’ ability to adapt to life in the community. Cognitive behavior therapy for psychosis (CBTp) is an evidence-based practice for addressing persistent positive symptoms and the distress associated with them. CBTp decreases symptomatology and minimizes the negative effect of persisting symptoms upon individuals with this disorder. We now describe a home-delivered, multimodal cognitive treatment targeting functional outcomes and persistent positive symptoms for individuals with schizophrenia by utilizing both CAT and CBT techniques. We discuss the advantages and challenges of combining these 2 interventions, present a small retrospective data analysis to support their combination into a multimodal treatment, and describe the design of an ongoing randomized trial to investigate efficacy.     

Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review

OBJECTIVE: To review the literature on the cognitive-behavioral treatment of children and adolescents with anxiety and depressive disorders within the conceptual framework of evidence-based medicine. METHOD: The psychiatric and psychological literature was systematically searched for controlled trials applying cognitive-behavioral treatment to pediatric anxiety and depressive disorders. RESULTS: For both anxiety and depression, substantial evidence supports the efficacy of problem-specific cognitive-behavioral interventions. Comparisons with wait-list, inactive control, and active control conditions suggest medium to large effects for symptom reduction in primary outcome domains. CONCLUSIONS: From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents. Future research in this area will need to focus on comparing cognitive-behavioral psychotherapy with other treatments, component analyses, and the application of exportable protocol-driven treatments to divergent settings and patient populations.     

Evidence-based psychotherapy of schizophrenic disorders

In the past, treatment of schizophrenic disorders was limited to pharmacotherapy. Psychotherapy was not regarded as evidence-based. A number of randomised clinical trials have led to a different perspective during the last two decades. This paper highlights and discusses evidence-based strategies. In particular, cognitive behavioural therapy and family intervention have recently been recommended in evidence-based treatment guidelines. Additionally, psychoeducation and social skills training showed treatment effects. Psychotherapeutic treatment requires an individual case concept. Neuropsychological testing for cognitive deficits should be included in comprehensive assessment in order to avoid overstimulation and optimise rehabilitation. Major treatment goals are to reduce persistent symptoms and relapse rates.     

Onset of efficacy and tolerability following the initiation dosing of long-acting paliperidone palmitate: post-hoc analyses of a randomized, double-blind clinical trial

Background

Depression, cardiovascular disease (CVD) risk factors and cognitive impairment are important causes of disability and poor health outcomes. In combination they lead to an even worse prognosis. Internet or web-based interventions have been shown to deliver efficacious psychological intervention programs for depression on a large scale, yet no published studies have evaluated their impact among patients with co-existing physical conditions. The aims of this randomised controlled trial are to determine the effects of an evidence-based internet intervention program for depression on depressive mood symptoms, cognitive function and treatment adherence in patients at risk of CVD.

Methods/Design

This study is an internet-based, double-blind, parallel group randomised controlled trial. The trial will compare the effectiveness of online cognitive behavioural therapy with an online attention control placebo. The trial will consist of a 12-week intervention phase with a 40-week follow-up. It will be conducted in urban and rural New South Wales, Australia and will recruit a community-based sample of adults aged 45 to 75 years. Recruitment, intervention, cognitive testing and follow-up data collection will all be internet-based and automated. The primary outcome is a change in severity of depressive symptoms from baseline to three-months. Secondary outcomes are changes in cognitive function and adherence to treatment for CVD from baseline to three, six and 12-months.

Discussion

Prior studies of depression amongst patients with CVD have targeted those with previous vascular events and major depression. The potential for intervening earlier in these disease states appears to have significant potential and has yet to be tested. Scalable psychological programs using web-based interventions could deliver care to large numbers in a cost effective way if efficacy were proved. This study will determine the effects of a web-based intervention on depressive symptoms and adherence to treatment among patients at risk of CVD. In addition it will also precisely and reliably define the effects of the intervention upon aspects of cognitive function that are likely to be affected early in at risk individuals, using sensitive and responsive measures.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000085077     

2005 AES Annual Course: Evidence Used to Treat Women with Epilepsy

Summary:  Although most female-specific considerations for treatment of epilepsy cannot be answered by Class I evidence, significant progress in our knowledge base has occurred in the past few years. Open-label studies of progesterone supplementation showed promising results; an ongoing randomized trial may provide definitive evidence for therapeutic use of progesterone in women. A randomized trial of hormone replacement therapy demonstrated a dose-related increase in seizure frequency in postmenopausal women with epilepsy. The use of different AED regimens during pregnancy cannot be explored with randomized, controlled trials; we must rely on the best available evidence from ongoing observational studies. The consistent findings of large prospective pregnancy registries reveal a consistent pattern of amplified risk for major congenital malformations in pregnancies exposed to valproate. These registries have also highlighted the concern for the effect of shifting hormones on AED concentrations. An increased frequency of seizures during pregnancy has been noted with lamotrigine (LTG) and oxcarabazepine, both of which undergo glucuronidation. Other studies have demonstrated an increased clearance of LTG during pregnancy and with exogenous estrogen use. It may be prudent to closely monitor serum concentrations of these AEDs with hormonal changes. An increased risk for neurodevelopmental consequences has been demonstrated for the fetus exposed to AED polytherapy, valproic acid, or frequent maternal convulsive seizures. Preliminary information about breastfeeding with LTG and levetiracetam is available. These newly released findings provide the tools to begin to practice evidence-based medicine when treating our female patients during their reproductive and postmenopausal years.     

The use of waitlists as control conditions in anxiety disorders research

Current evidence suggests that the strength of the psychological control condition greatly impacts treatment outcomes. Psychological controls can be grouped into three general classes: no-treatment or waitlist (delayed treatment), attention placebo or the best available treatment comparison. Of these three, the use of the waitlist condition is the most common and is used in up to 73% of published psychological treatment studies. Many psychological interventions are in use today based on the efficacy demonstrated in waitlist controlled trials. In the field of anxiety disorders, cognitive behavioural therapy (CBT) is considered a first-line treatment. Meta-analyses in anxiety disorders have revealed that effect sizes for CBT compared to waitlist controls are much higher than those found using psychological placebos as comparators. Furthermore, waitlists have been associated with deleterious effects and have been described as “no-cebos” in related conditions such as major depressive disorder. Despite these findings, the use of waitlist controls continues to be a mainstay in the psychological anxiety disorders literature. The purpose of this paper is to examine the use of waitlists with a focus on the anxiety disorders. Methodological and ethical issues associated with waitlist controls will be explored, as well the use of alternative psychological placebos.     

Diagnosis and treatment of mood disorders in persons with epilepsy

PURPOSE OF REVIEW: Epilepsy is a common, disabling neurological disorder associated with increased rates of comorbid psychiatric disorders as compared with the general population. RECENT FINDINGS: Mood disorders, especially major depression, appear to be more prevalent in persons with epilepsy than in those with the other chronic disorders and the general population. Depression may have more influence on quality of life than do cognitive and seizure factors. Although psychological, social, and vocational disabilities contribute to mood dysfunction in epilepsy, functional neuroimaging studies have consistently shown correlation of presence of cerebral abnormalities with increased severity of symptoms of depression. Most persons with epilepsy are not routinely screened for depression, and depression is subsequently treated in only a minority of patients. Although serotonin receptor density is greatest in brain regions commonly associated with epilepsy, such as the mesial temporal and prefrontal areas, no controlled trials have investigated the efficacy of serotonin reuptake inhibitors in persons with epilepsy. Optimal methods to identify and treat depression in epilepsy require substantial further research. SUMMARY: Depression is a common comorbid condition with significant negative effects on health status in persons with epilepsy, but additional understanding of the disorder is needed to improve diagnosis and treatment.     

孕激素治疗月经期癫痫的临床证据评价

目的 采用循证医学方法评价孕激素治疗月经期癫痫的疗效和药物不良反应,为月经期癫痫提供有循证依据的最佳治疗方案。方法 以月经期癫痫痫（catamenial epilepsy）、药物治疗（drugtherapy）、孕激素（progesterone）、四氢孕酮（allopregnanolone）、系统评价（systematic review）、随机对照试验（randomized controlled trials）等中英文词汇为检索词,分别检索万方数据库、维普期刊资源整合服务平台、中国知网中国知识基础设施工程、英国Cochrane图书馆、美国国立医学图书馆、Google学术搜索等国内外数据库,获得系统评价、随机对照试验、开放性试验、前瞻性或回顾性病例分析研究、病例观察研究和综述等文献,采用Jadad量表质量标准评价文献质量。结果 经筛选共纳入孕激素治疗月经期癫痫相关英文文献18篇,包括系统评价1篇、随机对照试验3篇、开放性试验1篇、前瞻性病例研究2篇、病例随访研究1篇、综述10篇。其中10篇为高质量文献（评分≥4分）,8篇为低质量文献（评分〈4分）。对各项临床试验治疗原则以及疗效和安全性评价显示：（1）孕激素作为抗癫痫药物的添加方案治疗月经期癫痫,可显著减少月经期癫痫发作频率,且安全性和耐受性良好。（2）天然孕激素和人工合成孕激素均可用于月经期癫痫的治疗。（3）孕激素治疗月经期癫痫的方式包括周期性孕激素治疗和抑制治疗,以前者更常用。结论 借助循证医学评价方法可为孕激素治疗月经期癫痫提供最佳临床证据。     

Comparative bioethics in bipolar and epilepsy research.

RATIONALE: AEDs are increasingly evaluated for efficacy in bipolar disorders utilizing double-blind, placebo-controlled, randomized clinical trials (RCTs) as required by the FDA. However, the risk to patients is under-estimated in trial design. Bipolar depression has a significant risk for suicide; bipolar episodes can lead to kindling with increased long-term morbidity; rapid regression may occur during the placebo phase or during dose ranging trials with resultant active suicide status. The associated risks mandate that the ethics of FDA-required protocols are addressed. METHOD: Comparative analysis and literature review of bipolar and epilepsy research designs. RESULTS: In psychiatry, all INDs require RCTs for approval. In epilepsy, AEDs are initially approved as add-on agents only. Once AEDs have demonstrated add-on efficacy, cross-over studies comparing active AEDs, sub-optimal dosing paradigms, new-onset, and pre-surgical inpatient placebo trials are utilized to prove efficacy of the new AED in monotherapy. Ethical considerations to avoid seizures and to minimize risks to subjects have led to newer clinical trial designs. CONCLUSIONS: The FDA initially requires add-on studies with new AEDs due to the risk of seizures during the placebo phase. The author argues that bipolar research warrants similar add-on studies to prove efficacy because the risk of suicide and increased long-term morbidity in the bipolar population is as significant as the risk of seizures in the epilepsy population. Although the number of patients needed to prove statistical efficacy would increase, the safety of such research would also markedly increase. The author further concludes that with the risk of suicide during bipolar research, ethical considerations require increased frequency of patient contact with a significant other co-signing the informed consent for research and serving as a contact for the coordinator.     

Cognitive pharmacotherapy of Alzheimer's disease and other dementias.

OBJECTIVE: The objective of this paper is to review the randomized controlled trials (RCTs) on the pharmacotherapy of Alzheimer's disease and other dementias and to provide evidence-based recommendations for treatment of the cognitive impairment associated with these disorders. METHOD: A Medline search was conducted for RCTs, using the following key words: Alzheimer's disease, dementia, therapy, cholinesterase inhibitor, donepezil, rivastigmine, and galantamine. Studies were critically appraised, followed by a review of published major clinical practice guidelines. Recommendations for treatment were made based on best available evidence. RESULTS: The pharmacotherapy of Alzheimer's disease should include the meticulous management of vascular risk factors (for example, hypertension, diabetes, cholesterol, and stroke prophylaxis) and consideration for supplementation with folate, vitamin B complex, and vitamin E. Patients should be offered at least 1 trial of a cholinesterase inhibitor, with the possibility of another trial if the first is poorly tolerated or ineffective. Patients with vascular dementia and dementia with Lewy bodies should also be offered treatment with cholinesterase inhibitors. At this time, we lack sufficient data to recommend the use of hormone replacement or antiinflammatory therapy for treatment of dementia as the primary indication. CONCLUSION: Reasonable evidence exists to provide recommendations for the pharmacotherapy of dementia. Treatment will likely result in modest but important benefits to patients, caregivers, and society.     

Psychotherapy for anxiety disorders in childhood and adolescence--what is evidence-based?

Anxiety disorders are the most frequent mental disorders in children and adolescents. They are also an important risk factor for psychological disturbances in adulthood and require adequate treatment. The effectiveness of psychotherapy in the treatment of anxiety disorders today can no longer be questioned. However, a meta-analysis of treatment studies shows that so far, only cognitive-behavior therapy has proved, on the basis of randomized, controlled trials (RCT), to be successful in the treatment of anxiety disorders in children and adolescents. Regardless of whether the cognitive behavior therapy took place individually or in a group, or whether it was carried out with the child alone or with the inclusion of the family, no differences in the effectiveness were found. The follow-up data show that the therapy success persisted for several years and that it was not limited only to the symptoms of anxiety. Although for many psychotherapeutic interventions there is still no empirical basis, initial RCT prove the short-term effectiveness of psychopharmacological treatment (SSRI). The central, empirically validated psychotherapeutic interventions include psychoeducation, cognitive treatment of dysfunctional thoughts, and systematic exposure to the situation triggering anxiety. These interventions will be presented briefly and open questions in psychotherapy research will be discussed in the conclusion.     

Treatment of depression in patients with epilepsy: problems, pitfalls, and some solutions

Many people with epilepsy suffer from comorbid depression. Despite this, there have been few studies addressing the treatment of depression in this population, and the literature on psychiatric management techniques in patients with epilepsy is composed largely of opinions rather than evidence from randomized, controlled trials or other systematic investigations. Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors, can be used to treat patients with epilepsy and comorbid depression. Nonpharmacological treatment options include vagus nerve stimulation, transcranial magnetic stimulation, and psychological therapies including cognitive-behavioral therapy, individual or group psychotherapy, patient support groups, family therapy, and counseling. Another important area that remains largely uninvestigated is psychiatric research in patients with epilepsy in non-Western cultures (with the exception of Japan). Factors such as problems with access to and acceptability of therapies in many developing nations have further implications for the treatment of psychiatric disorders in epilepsy.     

A systematic review of the behavioral effects of levetiracetam in adults with epilepsy,cognitive disorders,or an anxiety disorder during clinical trials

This report reviews behavioral adverse events occurring among adults receiving levetiracetam (LEV) or placebo who participated in short-term, placebo-controlled studies in epilepsy (1023), cognitive disorders (719), or anxiety disorders (1510) and epilepsy patients (1393) observed in long-term trials. Behavioral events (affective, psychotic, and suicidal symptoms) were significantly more common among epilepsy patients than cognition or anxiety patients treated with LEV for similar durations (P=0.022). Affective symptoms occurring at 1% or more often in epilepsy placebo-controlled trials included depression (3.8% LEV-2.1% placebo), nervousness (3.8%-1.8%), hostility (2.3%-0.9%), anxiety (1.8%-1.1%), and emotional lability (1.7%-0.2%). Patients with cognitive and anxiety disorders had lower incidences of these symptoms. The incidence of behavioral events in LEV-treated epilepsy patients was lower than rates reported for some other antiepileptic drugs. These data support the hypothesis that some feature related to epilepsy is the cause of many behavioral events rather than the addition of a specific antiepileptic drug.     

Nothing new since «Little Hans» and «Little Peter»? Psychotherapy for anxiety disorders in childhood and adolescence

Anxiety disorders are among the most frequent psychological disorders in childhood and adolescence. They are characterized by early onset, tend to remain stable over time, and act as a significant risk factor for developing a psychological disorder in adulthood. Over the last few years, research has shown that anxiety disorders in children and adolescents can be treated effectively. However, to date only cognitive behavioral therapy (CBT) has received convincing empirical support as an effective psychotherapeutic treatment. Evidence for the effectiveness of other psychotherapeutic treatments such as nonbehavioral family therapy or psychodynamic interventions is rather scant. Recent randomized controlled trials (RCT) proved CBT to be effective from preschool age onwards. Contrary to long-held beliefs, however, the involvement of parents in a treatment program does not appear to be crucial to therapeutic outcome. Issues regarding the effectiveness of disorder-specific treatments and the combination of psychotherapeutic treatments with the application of selective serotonin reuptake inhibitors (SSRIs) are increasingly being taken up in recent studies. In addition to ?classic? cognitive behavioural treatment programs there are some promising suggestions for the effectiveness of novel treatment methods such as attention bias modification or computer-assisted behavioral therapy.