Working with HIV/AIDS sufferers: "when good enough is not enough"

The authors begin by examining the intrapsychic implications that HIV/AIDS presents after knowledge of infection. Using examples drawn from two cases, they explore how knowledge of infection precipitates an insidious traumatizing process that comprises a number of key defensive strategies and dynamic processes. Particular kinds of defensive splitting, projective dynamics, and key identifications, as well as the collapse of the symbolic function, are isolated as being central to understanding the traumatizing process. With this in mind, the role and aim of the insight-oriented therapist is considered. The authors argue that much of the therapeutic work in this area revolves around a central organizing fantasy about the limitations of "good enough" objects in helping them with their diagnosis and its implications. This is linked to a number of technical dilemmas that the therapist will inevitability have to face if he or she chooses to work analytically. Particular technical problems explored include: 1. the management of frame deviations, 2. the therapist's role/s, 3. the use of interpretation, and 4. countertransference experience and enactment.     

Solving interpersonal problems correlates with symptom improvement in interpersonal psychotherapy: preliminary findings

Interpersonal psychotherapy (IPT) research has addressed outcome more than mechanism. This study used the novel Interpersonal Psychotherapy Outcome Scale (IPOS) to test the theoretical axiom that symptomatic improvement in IPT reflects resolution of interpersonal problem areas. The IPOS rates change in focal interpersonal problem areas on a 5-point scale. Patients (N = 24) and therapists (N = 7) in a time-limited IPT outcome study of dysthymic disorder, and patients (N = 11) in an open trial for posttraumatic stress disorder, completed the IPOS at treatment termination. All responding dysthymic subjects (N = 24) and therapists (N = 21) reported interpersonal gains: dysthymic patients scored 4.39 (SD = 0.52) out of 5, therapists 4.27 (0.53). Posttraumatic stress disordered patients rated 4.75 (0.34). Patient and therapist IPOS ratings correlated with objectively measured symptomatic improvement with full or trend statistical significance. Despite methodological limitations, initial testing of the IPOS supports the theorized link between resolving interpersonal crises and improvement in IPT.     

Levetiracetam does not alter body weight: analysis of randomized, controlled clinical trials

INTRODUCTION: Increases in body weight gain are important, and clinically significant adverse effects of several antiepileptic drugs (AED) including valproate and gabapentin. Weight gain may contribute to medication non-compliance, discontinuation, and importantly, may have secondary medical implications as well. Levetiracetam (LEV) is indicated for adjunctive treatment of partial seizures. The objective of the present evaluation was to examine the effects of LEV treatment on body weight in adult patients. METHODS: We analyzed data derived from four prospective, placebo-controlled randomized, clinical trials conducted in both in the US and Europe. Patients included in the present analysis were both men and women, greater than 16 years old, and who had LEV exposure for at least 1 month. Body weight was measured at baseline and at the final LEV study visit. Data are analyzed for all patients, by gender, body mass index (BMI), duration of LEV exposure and by concomitant AED treatment. Wilcoxan Signed Rank, or Rank Sum test used where appropriate, with significance assigned at P<0.05. Data are presented as mean values+/-1 S.D. RESULTS: Nine-hundred and seventy patients (age=37.5 years, 54% men/46% women) were evaluated. There were no significant differences in baseline demographics between LEV (n=631) or placebo (n=339) treated patient groups. Mean LEV dose and duration of treatment were 2053 mg/day (maximum dose of 4000 mg/day) and 125 days (maximum=181 days), respectively. Concomitant AED therapy included CBZ, PHT, VPA, PB, GBP, LTG, and VGB. For LEV-treated patients, no significant changes in body weight were noted. Mean body weight at baseline versus final study visit for LEV was 74.3+/-16.6 kg and 74.3+/-16.6 kg, respectively. For placebo-treated patients, baseline versus end of treatment weight was 72.4+/-15.4 kg and 72.7+/-15.9 kg, respectively, representing a slight, yet clinically trivial increase. Clinically significant weight change as defined as >7% change from baseline weight, occurred in 9% of LEV-treated patients (4.5% had increase in weight/4.5% decrease) versus 9.4% (5.9% had increase/3.5% decrease) in placebo-treated patients. Weight changes were not significantly different between groups. Neither baseline BMI, gender, or background AEDs, appeared to predispose to significant weight change for LEV-treated patients. CONCLUSIONS: We conclude that treatment with LEV at clinically relevant dosages is not associated with significant weight change. LEV would, therefore, appear to be a weight neutral AED.     

Psychoanalytic psychotherapy with adolescents: challenges, technical problems, and treatment outcome

Psychoanalytic treatment of adolescents has a long tradition and is currently one of the most frequent treatments in this age group. However, not many studies document the efficacy of psychoanalytic treatments of adolescents. This article analyses the background of this deficit by focusing on recent changes in symptomatology, the widespread diagnostic insecurity and the special challenges, which such treatment demands of the therapist. The task of researching the efficacy of adolescent psychotherapy is of considerable complexity. Recent own studies about efficacy of adolescent therapy will be presented. The evidence suggests that different approaches in therapy (psychoanalytic vs. psychodynamic) are of similar efficacy. However, long-term treatments ensure a consolidation of symptom reduction. The inclusion of different perspectives (adolescent, parents, therapist) and work with parents may be effective.     

When action is not enough: tool-use reveals tactile-dependent access to Body Schema

Proper motor control of our own body implies a reliable representation of body parts. This information is supposed to be stored in the Body Schema (BS), a body representation that appears separate from a more perceptual body representation, the Body Image (BI). The dissociation between BS for action and BI for perception, originally based on neuropsychological evidence, has recently become the focus of behavioural studies in physiological conditions. By inducing the rubber hand illusion in healthy participants, Kammers et al. (2009) showed perceptual changes attributable to the BI to which the BS, as indexed via motor tasks, was immune. To more definitively support the existence of dissociable body representations in physiological conditions, here we tested for the opposite dissociation, namely, whether a tool-use paradigm would induce a functional update of the BS (via a motor localization task) without affecting the BI (via a perceptual localization task). Healthy subjects were required to localize three anatomical landmarks on their right arm, before and after using the same arm to control a tool. In addition to this classical task-dependency approach, we assessed whether preferential access to the BS could also depend upon the way positional information about forearm targets is provided, to subsequently execute the same task. To this aim, participants performed either verbally or tactually driven versions of the motor and perceptual localization tasks. Results showed that both the motor and perceptual tasks were sensitive to the update of the forearm representation, but only when the localization task (perceptual or motor) was driven by a tactile input. This pattern reveals that the motor output is not sufficient per se, but has to be coupled with tactually mediated information to guarantee access to the BS. These findings shade a new light on the action-perception models of body representations and underlie how functional plasticity may be a useful tool to clarify their operational definition.     

Capacity of persons with mental retardation to consent to participate in randomized clinical trials

OBJECTIVE: Adults with mental retardation have histories of cognitive and adaptive deficits posing unique ethical challenges for research consent assessment. This study examined the capacity of persons with mental retardation to consent to participate in randomized clinical trials. METHOD: A total of 150 adults (50 each with mild and moderate mental retardation and 50 comparison subjects without mental retardation) responded to a set of consent questions for a hypothetical randomized clinical trial testing a medication for aggressive disorders. Intelligence, adaptive behavior, medical treatment history, and consent history were evaluated. Univariate and multivariate methods were used to compare performance across and within groups. RESULTS: Comparison subjects scored significantly higher on measures of consent capacity than participants with mild mental retardation, who scored higher than those with moderate mental retardation. Most subjects with mental retardation were able to make a participation choice, and many understood research methods and appreciated the protagonist's disorder and the consequences of participation. Almost half of those with mild mental retardation understood human subject protections. Performance was weakest on understanding the purpose of research and reasoning about whether to participate, suggesting vulnerability to the therapeutic misconception. Psychiatric and experiential factors did not predict consent capacity. CONCLUSIONS: While adults with mental retardation as a group showed consent deficits, many attained consent capacity scores comparable to those of comparison subjects. Investigators should consider individual differences and a consent format suited to deficits in language, memory, and attention before restricting consent opportunities for persons with mental retardation.     

Rating scales as outcome measures for clinical trials in neurology: problems, solutions, and recommendations

Have state-of-the-art clinical trials failed to deliver treatments for neurodegenerative diseases because of shortcomings in the rating scales used? This Review assesses two methodological limitations of rating scales that might help to answer this question. First, the numbers generated by most rating scales do not satisfy the criteria for rigorous measurements. Second, we do not really know which variables most rating scales measure. We use clinical examples to highlight concerns about the limitations of rating scales, examine their underlying rationales, clarify their implications, explore potential solutions, and make some recommendations for future research. We show that improvements in the scientific rigour of rating scales can improve the chances of reaching the correct conclusions about the effectiveness of treatments.     

When agreeing with the patient is not enough: a schizophrenic woman requests pregnancy termination

In this article, we discuss the ethical dilemma health care providers faced when Rebecca, a pregnant schizophrenic patient who lacked decision-making capacity, inconsistently requested elective pregnancy termination. When a patient's decision-making capacity is severely impaired, how does the physician balance obligations to protect the patient from harm (beneficence) while also respecting her reproductive preferences and decisions (respect for autonomy)? Rebecca suffers from polysubstance abuse and paranoid schizophrenia characterized by disorganized thought and speech, auditory hallucinations, and delusional ideas. She arrived 14+ weeks pregnant and unaccompanied at an obstetric clinic requesting an abortion. This is her second and final request. On all prior and subsequent occasions, she was either ambivalent or said she wanted to continue the pregnancy. After the consulting psychiatrist determined that she lacked decision-making capacity, steps were taken to address ethical and clinical issues. The steps included treating her schizophrenia to see if she could regain decision-making capacity; identifying a surrogate and using a shared decision-making model; and devising strategies to protect Rebecca and her fetus without resorting to excessive paternalism. Rebecca continued her pregnancy. Due to poor adherence to medical regimen and inadequate social support, Rebecca's schizophrenia was poorly controlled and she continued to use drugs during the pregnancy. She delivered a term baby who was soon removed from her custody. Despite some people's desire to protect Rebecca by complying with her request for abortion, we conclude that to do so would be ethically unjustified. To treat a decisionally impaired patient's requests for abortion as autonomous is disrespectful of the vulnerable patient because such paternalism fails to respect the patient's liberty and the surrogate's authority.     

Antisocial personality disorder is not enough: a reply to Sreenivasan, Weinberger, and Garrick

This commentary seeks to extend the recent article by Sreenivasan et al, which supports the contention that case law history allows for the commitment of a sexually violent predator/sexually dangerous person (SVP/SDP) based on a diagnosis of antisocial personality disorder and absent a paraphilic condition. We argue that a clear sexual disorder must be present before a person can be found to be an SVP/SDP. A diagnosis of antisocial personality disorder is not enough.     

Short psychodynamic supportive psychotherapy, antidepressants, and their combination in the treatment of major depression: a mega-analysis based on three randomized clinical trials

The efficacy of Short Psychodynamic Supportive Psychotherapy (SPSP) has not yet been compared with pharmacotherapy. A mega-analysis based on three original Randomized Clinical Trials (RCTs) was performed. Patients with (mild to moderate) major depressive disorder were randomized in (24 weeks) SPSP (n = 97), pharmacotherapy (n = 45), or their combination (n = 171). Efficacy was assessed by the Hamilton Depression Rating Scale (HDRS), Clinical Global Impression of Severity and of Improvement (CGI-S), the Symptom Checklist (SCL; depression subscale) and the Quality of Life Depression Scale (QLDS). Pearson chi(2) calculations were used to compare success rates. Analyses of covariance (ANCOVAs) were used to test inter-group differences. Success rates indicated that independent observers (HDRS) found no differences in symptom reduction between SPSP and pharmacotherapy (P = 0.214), but therapists (CGI-S, P = 0.026), and patients (SCL, P = 0.036) favored SPSP. Combined therapy was found superior to pharmacotherapy by all three (patients (P = 0.000), therapists (P = 0.024), independent observers (P = 0.024)). Independent observers (P = 0.062) and therapists (P = 0.430) found no differences between combined therapy and SPSP, but patients (P = 0.016) found combined therapy to be superior. As far as quality of life is concerned, success rates indicated that patients (QLDS) found no differences between SPSP and pharmacotherapy (P = 0.073) or between SPSP and combined therapy (P = 0.217). However, they found combined therapy superior to pharmacotherapy (P = 0.015). The results of the mega-analysis suggest that combined therapy is more efficacious than pharmacotherapy. SPSP and pharmacotherapy seem equally efficacious, except for some indications that patients and therapists favor SPSP for symptom reduction. Combined therapy and SPSP also seem equally efficacious, except that patients think that the first is better in symptom reduction.     

Research to improve the quality of care for depression: alternatives to the simple randomized clinical trial

Recognition of gaps between evidence gained from mental health research and clinical practice in the community together with changes in treatment patterns and patient/provider preferences for care have led to interest in enhancements in the designs and analyses of clinical and community trials of mental health interventions. Gaps between clinical trials and community care include differences in populations and treatment strategies. To bridge these gaps, we propose enhancing the simple randomized trial with several different designs with the immediate aims of improving patient recruitment and adherence in psychiatric intervention studies thus bringing study designs more in line with clinical practice. The goals are to estimate treatment efficacy and effectiveness so that both internal and external validity are optimized. In this discussion, we address design and analytic issues with respect to a number of enhancements of the randomized trial design, including partial patient-provider preference designs, randomized encouragement and consent designs, fixed adaptive design, and random between- and within-patient adaptive designs. Each has advantages and disadvantages depending on the effect under investigation. Some of these enhancements, such as the fixed adaptive design, have begun to be implemented in effectiveness trials in mental health services research, but all are worthy of more attention.     

A 15-year national follow-up: legislation is not enough to reduce the use of seclusion and restraint

BACKGROUND: Seclusion and restraint are frequent but controversial coercive measures used in psychiatric treatment. Legislative efforts have started to emerge to control the use of these measures in many countries. In the present study, the nationwide trends in the use of seclusion and restraint were investigated in Finland over a 15-year span which was characterised by legislative changes aiming to clarify and restrict the use of these measures. METHOD: The data were collected during a predetermined week in 1990, 1991, 1994, 1998 and 2004, using a structured postal survey of Finnish psychiatric hospitals. The numbers of inpatients during the study weeks were obtained from the National Hospital Discharge Register. RESULTS: The total number of the secluded and restrained patients declined as did the number of all inpatients during the study weeks, but the risk of being secluded or restrained remained the same over time when compared to the first study year. The duration of the restraint incidents did not change, but the duration of seclusion increased. A regional variation was found in the use of coercive measures. CONCLUSION: Legislative changes solely cannot reduce the use of seclusion and restraint or change the prevailing treatment cultures connected with these measures. The use of seclusion and restraint should be vigilantly monitored and ethical questions should be under continuous scrutiny.     

A pilot randomized controlled clinical trial to improve antiepileptic drug adherence in young children with epilepsy

The primary aim was to examine the preliminary efficacy of a family tailored problem‐solving intervention to improve antiepileptic drug (AED) adherence in families of children with new‐onset epilepsy. Secondary aims were to assess changes in targeted mechanisms and treatment feasibility and acceptability. Fifty families (M_age = 7.6 ± 3.0; 80% Caucasian; 42% idiopathic localization related) completed baseline questionnaires and were given an electronic monitor to observe daily AED adherence. If adherence was ≤ 95% in the first 7 months of the study, families were randomized (Supporting Treatment Adherence Regimens (STAR): n = 11; Treatment as Usual (TAU): n = 12). Twenty‐one families were not randomized due to adherence being ≥95%. The STAR intervention included four face‐to‐face and two telephone problem‐solving sessions over 8 weeks. Significant group differences in adherence were found during active intervention (weeks 4–6; TAU = ?12.0 vs. STAR = 18.1, p < 0.01; and weeks session 6–8: TAU = ?9.7 vs. STAR = 15.3, p < 0.05). Children who received the STAR intervention exhibited improved adherence compared to children in the TAU group during active treatment. Significant changes in epilepsy knowledge and management were noted for the STAR group. Families expressed benefitting from the STAR intervention. Future studies should include a larger sample size and booster intervention sessions to maintain treatment effects over time.     

D-cycloserine does not improve but might slightly speed up the outcome of in-vivo exposure therapy in patients with severe agoraphobia and panic disorder in a randomized double blind clinical trial

d-cycloserine (DCS) - augmented exposure therapy has proven efficacy in the treatment of acrophobia, social phobia, panic disorder and OCD. Here we studied whether DCS can also improve the effect of cognitive behavioral therapy (CBT) in patients with agoraphobia and panic disorder. To this end, 39 patients with the diagnoses of agoraphobia and panic disorder were treated with 11 sessions of CBT including three individual in-vivo exposure sessions (flooding), augmented with either 50 mg of DCS (N = 20) or placebo (N = 19) in a randomized double blind design. Primary outcome was the total score of the panic and agoraphobia scale. Both groups profited considerably from therapy and DCS did not significantly improve this outcome (p = 0.475; η²_p = 0.01). However, there was a statistical trend (p = 0.075; η²_p = 0.17) in the more severely ill patients that DCS accelerated symptom reduction in the primary outcome at post-therapy. No serious adverse effects occurred during the trial. We conclude that in patients with agoraphobia and panic disorder, DCS seems to lack an additional benefit to efficient cbt, probably due to a floor effect. Nonetheless, the acceleration of symptom reduction in severely ill patients might represent a valuable treatment option deserving further investigation.