Recommendations for treating depression in community-based older adults

OBJECTIVE: To present recommendations for community-based treatment of late-life depression to public health and aging networks. METHODS: An expert panel of mental health and public health researchers and community-based practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness from a systematic literature review of articles published through 2005. RESULTS: The expert panel strongly recommended depression care management-modeled interventions delivered at home or at primary care clinics. The panel recommended individual cognitive behavioral therapy. Interventions not recommended as primary treatments for late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, including group psychotherapy and psychotherapies other than cognitive behavioral therapy. CONCLUSIONS: This interdisciplinary expert panel determined that recommended interventions should be disseminated throughout the public health and aging networks, while acknowledging the challenges and obstacles involved. Interventions that were not recommended or had insufficient evidence often did not treat depression primarily and/or did not include a clinically depressed sample while attempting to establish efficacy. These interventions may provide other benefits, but should not be presumed to effectively treat depression by themselves. Panelists also identified primary prevention of depression as a much under-studied area. These findings should aid individual clinicians as well as public health decision makers in the delivery of population-based mental health services in diverse community settings.     

Technology-Based Advances in the Management of Depression

Depression remains under-recognised and under-treated despite it being more disabling than any other medical disorder and the availability of effective protocol-based psychotherapy and pharmacotherapy treatments. Prevailing psychotherapy seldom employs evidence-based treatments, continuing instead the use of idiosyncratic psychotherapies of dubious value.Computer interview programs have been developed and evaluated that have the potential to make protocol-based psychotherapy of proven efficacy available over the Internet. Interactive voice response (IVR) makes these programs even more accessible through any touch-tone telephone.COPE? is a self-help program for patients with depression that combines a series of booklets, videotapes and IVR telephone calls. One trial reported significant reductions in Hamilton Depression Rating Scale scores in patients with depression who completed a 12-week COPE? program.Impediments to dissemination of these computer tools that complement, supplement and reinforce best practice values include developer’s limited knowledge of business practices and the slow change of practice paradigms.     

Long-term follow-up of depression among patients in the community and in family practice settings. A systematic review

BACKGROUND: Current knowledge about the long-term outcome of depression is largely based on the results of studies performed with the small selection of patients who are referred to psychiatric professionals. However, because of the high prevalence of depression in the community and in primary care, information about the longterm outcome in these populations is indispensable if physicians are to offer the best possible care in these settings. METHODS: We performed a literature search to identify relevant papers published between 1970 and 1999 on original long-term follow-up studies of depression in community and primary care populations. The included studies were of adult populations with depression based on diagnostic criteria and a follow-up of at least 5 years. Data about recurrences, relapses, psychopathology, disability, or quality of life at follow-up were examined. RESULTS: We found 8 studies that fulfilled our criteria. The reported rates of recurrence or depression at follow-up were between 30% and 40%. Higher rates were found in the younger and older age groups. Data about other predictors of outcome, health status, and the relation between treatment and outcome did not justify any hard conclusions. CONCLUSIONS: The long-term outcome of depression in the community and in primary care is rarely studied. The results of available studies are difficult to compare because of the large differences in populations and methods. Nevertheless, these studies suggest that the longterm prognosis of depression in the community and in primary care is not as poor as in psychiatry.     

Improving psychotherapy research: The example of mindfulness based interventions

The increasing number and sophistication of available psychotherapies suggests that a critical appraisal of the methodological issues of psychotherapy studies is highly needed. Several key questions regarding the efficacy of a given intervention, the understanding of whether positive effects observed following the delivery of a psychotherapeutic intervention are specifically attributable to the intervention itself or to other “non specific” factors, such as benefit expectations, therapist attention and support, and the possibility of improving psychotherapy research need an answer. This, in turn, could provide clinicians with more rigorous information about psychotherapy outcomes and could properly address several shortcomings that are frequently observed in current psychotherapy studies. Accordingly, in this editorial I will highlight some of the most important critical issues that a well designed psychotherapy study should take into account, including the need for appropriate control groups, appropriate randomization and blinding procedures, and the importance of performing appropriately powered studies that include a sufficiently long follow-up period. Finally, I will build on my expertise in the field of mindfulness based interventions, in particular mindfulness based stress reduction and mindfulness based cognitive therapy, to show how such issues have been and can be successfully implemented in the design of future psychotherapy studies.     

The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial

Objective:

To evaluate the long‐term efficacy of three psychotherapies for anorexia nervosa.

Method:

Participants were women with broadly defined anorexia nervosa who had participated in a RCT comparing specialized psychotherapies (cognitive behavior therapy, CBT, and interpersonal psychotherapy, IPT) with a control condition (specialist supportive clinical management, SSCM), and attended long‐term follow‐up assessment (mean 6.7 years ± 1.2).

Results:

Forty three of the original sample of 56 women participated in long‐term follow‐up assessment (77%). No significant differences were found on any pre‐selected primary, secondary or tertiary outcome measures among the three psychotherapies at long‐term follow‐up assessment. Significantly different patterns of recovery were identified for the psychotherapies across time on the primary global outcome measure. Although SSCM was associated with a more rapid response than IPT, by follow‐up all three treatments were indistinguishable.

Discussion:

Potential implications for the timing of interventions to improve treatment response in anorexia nervosa are critically examined. © 2010 by Wiley Periodicals, Inc. Int J Eat Disord 2010     

Depression in users of depo-medroxyprogesterone acetate

Prevalence of depression is high among poor, young, Hispanic inner city women. Depot-medroxyprogesterone acetate (DMPA) is a popular contraceptive choice in this group. DMPA labelling suggests that depression may worsen with use: In order to identify any association of DMPA use with worsening depression, we surveyed an English-speaking subset of DMPA users in a Title-X funded family planning clinic. Eighty women completed the CES-D scale on two occasions: once about four weeks after a DMPA injection when the subject would have been exposed to the highest blood levels, and once immediately prior to an injection when recent blood levels of the drug would be somewhat lower (or absent preceding the first injection). The median CES-D score was 14. The scores were not related to timing of the test (pre- or post-injection). The depression scores were somewhat higher among those women receiving their first DMPA injection during the study period (i.e., unexposed women) and among those women who had received four or more injections. Scores were unrelated to age or parity, but were somewhat higher in women who reported fewer years of education or a recent adverse pregnancy outcome. These data provide little evidence of increasing depression with long-term use of DMPA and no evidence of a short-term effect of dose (within the contraceptive range) on mood. Women at risk of depression should not be denied DMPA as a contraceptive choice.     

The depressed patient.

SAdness and normal grief are distinguished from pathological grief and depression by intensity, duration, precipitating events, and the quality of psychopathological features. Depression is evaluated as a final common pathway of potential psychodynamic, genetic, psychosocial, physiological, and personality characteristics or events. The clinical entity of depression is diagnosed by describing some of each of the affective, behavioral, and cognitive changes concomitant with depression. The clinical entity of depression is further differentiated for purposes of treatment into the categories of bipolar depression (manic-depressive illness), unipolar depression (psychotic depressive reaction or involutional melancholia), neurotic depression, and secondary depression (secondary to somatic disease, drugs, or to other psychiatric disorders). The immediate treatment depends on the type of depression diagnosed. Unipolar and bipolar depressions respond to specific pharmacologic therapy and supportive care. Neurotic and characterologic depressions respond to supportive or insight psychotherapy with possible brief adjunctive anti-anxiety or hypnotic medication. All of the treatment modalities, with the possilbe exception of insight psychotherapy, can be effected very adequately by the primary care physician who is given clear diagnostic and assessment guidelines with specific treatment approaches.     

The effectiveness of various postpartum depression treatments and the impact of antidepressant drugs on nursing infants

BACKGROUND: Postpartum depression is seen in approximately 13% of women who have recently given birth; unfortunately, it often remains untreated. Important causes for undertreatment of this disorder are providers' and patients' lack of information about the effectiveness of various treatments, and their concerns about the impact of treatment on nursing infants. This article presents research-based evidence on the benefits of various treatments for postpartum depression and their potential risks to nursing infants. METHODS: The medical literature on postpartum depression treatment was reviewed by searching MEDLINE and Current Contents using such key terms as "postpartum depression," "treatment," "therapy," "psychotherapy," and "breastfeeding." Results and CONCLUSIONS: There is evidence that postpartum depression improves with antidepressant drug therapy, estrogen, individual psychotherapy, nurse home visits, and possibly group therapy. Of the more frequently studied antidepressant drugs in breastfeeding women, paroxetine, sertraline, and nortriptyline have not been found to have adverse effects on infants. Fluoxetine, however, should be avoided in breastfeeding women. By administering effective treatment to women with postpartum depression, we can positively impact the lives of mothers, their infants, and other family members.     

What are the helpful factors in psychotherapy for anorexia nervosa?

A prospective study on the outcome of anorexia nervosa gives the opportunity to compare three different forms of psychotherapies: single interview (1–2), brief psychotherapy (3–20), and regular psychotherapy. There were no differences among the three groups on selection and all other criteria, such as weight loss, duration of illness, social background, level of education, sexual attitude, etc. In the follow-up 4 to 14 years later, there were no differences in outcome among the groups. The regular psychotherapy group was slightly worse off than the two others, but not to a significant degree. The possibility of a negative selection for this group is discussed.     

当代心理治疗四大流派治疗方法述评

精神分析疗法、行为疗法、人本疗法和认知疗法是当代心理治疗的4种基本疗法,其他疗法都是建立在这4种基本疗法基础之上而发展起来的。鉴于此,该文分别对这4种疗法的内涵和基本方法进行了述评,并就心理治疗研究及其在中国的发展做了小结与展望。     

National registry and DNA-bank of patients with congenital heart disease: the CONCOR-project

Although survival of patients with congenital heart disease has dramatically improved since surgical repair has become available, cure is seldom achieved. Exact data on long-term outcome are not available, however, because a national registry is lacking. Furthermore, little is known about the role of genetic defects in the development of congenital heart disease. The CONCOR-project (CONgenital CORvitia) has been set up to facilitate the investigation of the long-term outcome and molecular basis of specific congenital heart defects and their treatment. It will also facilitate the development of an efficient organisational structure for the improvement of healthcare for patients with congenital heart disease.     

Interventions: what works, what doesn't?

This review examines the evidence for the effectiveness of occupational stress interventions. Three types of interventions are considered: psychotherapy and counselling services, stress management training, and organizational level interventions. The review concludes that there is good evidence that, for specific mental health problems, formal psychotherapy is effective in terms of reducing individual symptoms. Other forms of intervention have been less well evaluated. The evidence that exists indicates that counselling services and stress management training have modest but short-term effects on individual well-being. Organizational interventions have insignificant effects on individual well-being and on organizational outcomes.     

Performance and quality of life outcome in patients completing concomitant chemoradiotherapy protocols for head and neck cancer

This study evaluated post-treatment performance and quality of life (QOL) outcome in head and neck cancer (HNC) patients treated with organ preservat ion, intens ive chemoradiotherapy (FHX). Participants were 47 Stage II-IV HNC patients with no evidence of disease at least one year post-completion of organ preservation, concomitant FHX treatment. Patients were assessed via a semi-structured in-person interview, standardized measures of QOL (FACT-H, CES-D), performance (PSS-HN) and patients' perception of residual side effects. Disease, treatment and toxicity data were retrieved from medical charts and protocol records. The most salient performance impairment was inability to eat a normal solid food diet, with 50% of patients able to eat soft foods or take liquids only. This specific functional deficit was not related to global QOL, nor to specific quality of life dimensions. Dry mouth, the most frequent and severe residual effect, was not associated with outcome diet, depression or QOL. Residual pain, seen in only 15% of patients, appeared to influence both functional and QOL parameters as well as being a marker for other troublesome symptoms. Twenty-three per cent of patients were depressed; depression was associated with past problems related to alcohol abuse. Decreased QOL and increased depressive symptomatology were related to total number and severity of residual effects. The data highlight the importance of systematic study of QOL dimensions and caution against making assumptions about patients' experience of particular disease and treatment sequelae.     

Binge eating disorder: current knowledge and future directions

Binge eating disorder (BED) is a newly characterized eating disorder that encompasses individuals who have severe distress and dysfunction due to binge eating, but who do not regularly engage in inappropriate compensatory behaviors. While relatively uncommon in the general community, BED becomes more prevalent with increasing severity of obesity. BED is associated with early onset of obesity, frequent weight cycling, body shape disparagement, and psychiatric disorders. These associations occur independent of the degree of obesity. Although many individuals with BED have good short-term weight loss regardless of treatment modality, as a group they may be prone to greater attrition during weight-loss treatment and more rapid regain of lost weight. Current treatments geared toward binge eating behaviors include antidepressant medications, cognitive behavioral psychotherapy, and interpersonal psychotherapy; however, these treatments have little efficacy in promoting weight loss, and only modest success in long-term reduction of binge eating. As a significant proportion of obese individuals entering weight-loss treatment and research programs are likely to meet criteria for BED, those conducting clinical research should be aware of this distinct subgroup and determine the contribution of BED to outcome measures.     

Predictors of Adequate Depression Treatment among Medicaid-Enrolled Adults

Objective. To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment.
Data Source. Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008.
Study Design. We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period ( N =1,098).
Principal Findings. Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment.
Conclusions. Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.     

Diet selection and animal state: an integrative framework

In the present paper we deal with the problems of explaining and predicting diet selection of animals under controlled conditions, i.e. conditions that can be described and in which any influences of the environment can be either controlled or at least monitored. Diet selection is considered within an integrative framework of feeding behaviour that views both food intake and diet selection as an outcome of the animal's internal state and knowledge of the feeding environment. Three questions that arise from the framework are considered: (1) how do animals learn about foods available to them as a choice? (2) what changes in internal state affect diet selection? (3) how much time is needed for a change in the animal's internal state to be detected and for it to react to this change through a modification of its diet selection? It is proposed that animals have developed behavioural mechanisms that allow them to recognize foods on the basis of their nutritional as well as other properties. The rate at which animals learn about foods depends largely on the extent of the animal's deficiency and on the extent of the post-ingestive consequences induced by the foods. There is little evidence that animals modify their diet selection in response to short-term systemic fluctuation of their internal environment. On the other hand, long-term changes in the internal state of the animal lead to consequent long-term changes in diet selection. The time needed for a change in diet selection to be observed depends on the deviation created in the animal's internal state, either as a result of a physiological change or as a consequence of feeding. Thus, a more appropriate question to consider is not 'what time period matters to the animal?' but 'how much change or deviation in the internal state is the animal prepared to accept?'     

The role for vitamin B-6 as treatment for depression: a systematic review

BACKGROUND: Major depression is the leading cause of disability worldwide, and among the 10 most frequent indications for using alternative medicine therapies, especially dietary supplements. OBJECTIVE: To assess the evidence evaluating vitamin B-6 supplementation as treatment for depression. METHODS: Medline, Psychinfo, AMED, and Cochrane Controlled Trials Register were searched from database inception through September 2001. All randomized controlled trials, controlled clinical trials, intervention studies, case-control studies, reviews, and case reports examining the evidence behind vitamin B-6 in depression among humans were selected. No limits were placed for demographics or co-morbidities. Only English language papers were abstracted and assessed for trial quality. Two abstractors independently evaluated each study, then reconciled findings. As data were available, between group treatment effect size was noted or, as needed, calculated. When studies reported outcome effects using multiple measures, data were abstracted to permit the greatest possible comparisons among papers. RESULTS: Ten articles met inclusion criteria; three reviews, one case report, five RCTs, and one intervention study. There was no common outcome measure among all studies, eliminating opportunity for direct comparison of effect sizes. As an alternate means of comparison, effects were plotted as they related to the null hypothesis. CONCLUSION: Viewed as a whole, meaningful treatment effect of vitamin B-6 for depression in general was not apparent. However, examination of papers addressing depression in pre-menopausal women only, reveals a consistent message about the value of using vitamin B-6 supplementation. Further study of vitamin B-6 as independent and adjuvant therapy for hormone related depression in women is indicated.     

The Use of Dream Work in Supervision

Dreams provide important material in the practice of psychotherapy and counselling. A logical but somewhat controversial extension is to use dreams in the supervision of psychotherapy or counselling. Literature on the use of dreams is becoming increasingly available in humanistic and experiential psychotherapies. Thus the practice of working with dreams is accessible to most counsellors. One major problem exists in using dreams in supervision: because of real authority systems, the supervisee may not be prepared to risk disclosing at the level produced by dream work. Five case studies of counselors using their dream work in supervision are given. Two involved countertransference issues and three involved staff development issues.     

Interim analysis of continuous long-term endpoints in clinical trials with longitudinal outcomes

This paper discusses interim analysis for clinical trials where the primary endpoint is observed at a specific long-term follow-up time, but where repeated measures of the same outcome are also taken at earlier times. Methods are considered for improving the efficiency with which the long-term treatment difference is estimated, making use of information from shorter-term follow-up times. This approach to interim analysis has previously been studied for binary endpoints assessed at two time points during follow-up. Here we adapt and extend this methodology to include continuous endpoints assessed at an arbitrary number of follow-up times, making use of methods for analysing multivariate normal data subject to monotone missingness and unstructured mean and covariance relationships. The magnitude of efficiency gains obtained by using short-term measurements is considered, as well as how these gains depend on the number and timing of the short-term measurements. Sequential analysis of treatment differences is discussed, including the extent to which efficiency gains translate into reductions in the expected duration of a sequentially monitored trial. The methods are illustrated on a data set involving a placebo-controlled comparison of longitudinal cholesterol measurements.