Effects of adult inpatient group psychotherapy on attachment characteristics: An observational study comparing routine care to an untreated comparison group

Abstract

This study investigated the changes in attachment characteristics of patients undergoing inpatient group psychotherapy in routine care. We collected data from 265 consecutively recruited patients and 260 non-clinical control persons using self-report measures of attachment, depression, and socio-demographic characteristics. The effects of treatment on patients were analyzed using propensity score techniques (propensity strata and logit-transformed propensity scores) in combination with a generalized analysis of covariance. A moderate increase of attachment security was found which could be attributed to a decrease both in attachment anxiety and avoidance. Pre-post improvements in attachment with regard to romantic partnerships were stable after a 1-year follow-up. Furthermore, we found significant treatment-covariate interactions indicating that subjects with particularly high treatment propensities (propensities were highly correlated with depression and attachment anxiety) improved the most in terms of attachment security. Our results are encouraging for psychotherapeutic practice in that they provide evidence that long-term attachment improvements can be reached via psychotherapy. Our results will also provide a sound basis for future studies in the field of clinical attachment research, e.g., studies examining whether improved attachment security is correlated to symptom improvements in different psychological disorders.     

Predictors and moderators of outcome in child and adolescent anxiety and depression: a systematic review of psychological treatment studies

The aim of this literature review was to examine pre-treatment child and adolescent characteristics as predictors and moderators of outcome in psychotherapy treatment trials of anxiety and depressive disorders. A literature search was conducted using several databases and resulted in 45 published studies (32 anxiety studies and 13 depression studies) meeting predefined methodological criteria. Ten client demographic (age, gender, ethnicity, IQ) and clinical factors (duration, type of diagnosis, pre-treatment severity, comorbidity) were examined across studies. The majority of findings showed non-significant associations between demographic factors (gender and age) with treatment outcome for both the anxiety and the depression treatment trials. Some important differences between the results of the anxiety and depression treatment trials were found. The majority of findings for the anxiety studies suggest that there are no demographic or clinical factors that predict or moderate treatment outcome. For the depression studies, however, the findings suggest that baseline symptom severity and comorbid anxiety may impact on treatment response. Overall, existing studies of pre-treatment patient variables as predictors and moderators of anxiety and depression treatment outcome provide little consistent knowledge concerning for what type of patients and under what conditions treatments work. Suggestions for future research are discussed.     

Change in attachment anxiety is associated with improved depression among women with binge eating disorder

The study examined if the relationship between change in attachment insecurity and target symptom outcomes was moderated by treatment type. Women (N = 66) with binge eating disorder (BED) were randomly assigned to two treatment types: group cognitive-behavioral therapy (GCBT) or group psychodynamic-interpersonal psychotherapy (GPIP). Results indicated significant positive pre- to posttreatment changes in all attachment insecurity scales, but no difference between GCBT and GPIP on these changes. Change in attachment anxiety was related to improved depression for women completing GPIP, but not for women completing GCBT. This indicated a moderating effect of treatment type in explaining the relationship between change in attachment anxiety and improved depression. Changes in attachment anxiety may be important for symptom outcomes related to psychodynamic-interpersonal therapies. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Distinct but overlapping neural networks subserve depression and insecure attachment

Insecure attachment has been linked to depression and to outcome in psychotherapy. The neural mechanisms subserving the relationship between attachment security and depression are not well understood. We have developed a method to examine attachment-related brain activity in depression. Twenty-eight women, half depressed, viewed images of their mother, a female friend, and female strangers during fMRI scanning. The effects of depression and insecure attachment were determined with whole-brain multiple linear regression of blood-oxygen-level-dependent response against subjects’ Beck Depression Inventory and Adult Attachment Interview (AAI) coherence of mind scores. Interaction effects were analyzed with ANOVA. Activity associated with depression and with insecure attachment was found in the cortico-striato-thalamic circuits of affect regulation. For early attachment (mother–friend contrast), depression scores correlated with activation of cortical and sub-cortical components of these circuits, while attachment insecurity correlated with sub-cortical activity in the same circuitry. Depression and attachment insecurity correlated with both cortical and sub-cortical activities for mother–stranger, and areas of overlap and of enhancing interactions between depression and insecure attachment were found. For late attachment (friend–stranger contrast), only cortical effects were found. Depression and attachment insecurity may be subserved by similar but distinct components of affect regulating circuits. Their interactions may explain the greater difficulty of treating depression in insecurely attached patients and suggest a contributing role for insecure attachment in depression. Further, differential sub-cortical vs cortical encoding of early vs late attachment suggests a top-down model of late attachment, potentially relevant to psychotherapeutic outcome.     

Treatment of Major Depression in Later Life: A Life Cycle Perspective

The goal of this article is to provide a life-cycle perspective on the treatment of major depressive episodes in later life. Our studies have suggested that older patients appear to benefit as much, though perhaps more slowly, than mid-life patients from acute combined treatment (nortriptyline + interpersonal psychotherapy) of major depression. Given also the apparently higher relapse rate among the elderly, however, continuation treatment needs to be vigorous and closely monitored. The occurrence of severe life events prior to the index episode and the co-existence of an anxiety disorder both appear to prolong treatment response times, while chronic medical burden per seneither compromises response rates nor prolongs time to response. Self-rated perception of health improves with remission of depression in the elderly. As in mid-life patients, both antidepressant medication (nortriptyline) and interpersonal psychotherapy appear to possess chronic efficacy with respect to the prevention of recurrent episodes and prolongation of wellness. Finally, treatment of depression in the elderly results in improved quality of life, especially in domains of well being and coping. Particular challenges in the treatment of elderly patients are noncompliance and the prevention of suicide. The latter is closely linked to feelings of hopelessness, and these may be persistent in some patients.     

An open pilot study of interpersonal psychotherapy for panic disorder (IPT-PD)

Interpersonal psychotherapy (IPT) is a time-limited psychotherapy initially developed to treat depression. It has yet to be studied systematically for treatment of panic disorder. We modified IPT for the treatment of panic disorder and tested this treatment in an open clinical trial with 12 patients seeking treatment of DSM-IV panic disorder. Patients were assessed before during and after treatment. At completion of treatment, nine patients (75%) were independently categorized as responders (i.e., rated as much improved or very much improved on the Clinical Global Impression-Change Scale). Substantial improvement was found for panic symptoms, associated anxiety and depressive symptoms, and physical and emotional well-being. Degree of change in this sample approximated that obtained in studies using established treatments such as cognitive behavioral therapy. Results, though preliminary, suggest that IPT may have efficacy as a primary treatment of panic disorder. Further study is warranted.     

Change in attachment dimensions in women with binge-eating disorder following group psychodynamic interpersonal psychotherapy

Objective: To examine the role of attachment dimensions, including coherence of mind and reflective functioning, in developing and maintaining binge-eating disorder (BED) and in determining group psychotherapy outcomes for women with BED. We hypothesize that higher pre-treatment attachment dimension scores will predict better treatment outcomes for women with BED and will increase at follow-up. Method: Women with BED attended 16 sessions of group therapy and completed the Adult Attachment Interview (AAI) at pre-treatment. Participants completed outcome measures (i.e., binge-eating frequency and symptoms of depression) at pre-, post-, six months, and 12 months post-treatment. Treatment completers completed the AAI at six months post-treatment. Results: Treatment outcomes improved significantly from pre- to 12 months post-treatment. Greater Reflective Functioning scores at pre-treatment were related to greater decreases in binge eating across the four time points, whereas Coherence of Mind scores were not. For treatment completers, there were significant increases in Reflective Functioning at six months post-treatment, and about a third of treatment completers experienced clinically significant increases in both attachment dimensions at six months post-treatment. Conclusions: Greater reflective functioning at the outset is important for improvements in binge eating in the longer term and group psychotherapy can facilitate change in reflective functioning.     

Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy

OBJECTIVE: To improve interventions for depressed older adults, data are needed on the comparative effects of pharmacotherapy versus psychotherapy. Given that most older adults with clinically significant depressive symptoms do not have major depression, data on treatments for minor depression and dysthymia are especially needed. METHOD: Meta-analysis was used to integrate the results of 89 controlled studies of treatments focused on acute major depression (37 studies) and other depressive disorders (52 studies conducted with mixed diagnostic groups, including patients with major depression, minor depression, and dysthymia). A total of 5,328 older adults received pharmacotherapy or psychotherapy in these studies. RESULTS: Clinician-rated depression scores improved, on average, by 0.80 standard deviation (SD) units; self-rated depression scores improved by 0.76 SD units. Clinician-rated depression improved by 0.69 SD units in pharmacotherapeutic studies and by 1.09 SD units in psychotherapeutic studies. Self-rated depression improved by 0.62 SD units and 0.83 SD units, respectively. An interesting finding was the stronger improvements in clinician-rated depression among control subjects participating in medication studies, compared to those in psychotherapeutic studies. CONCLUSIONS: Available treatments for depression work, with effect sizes that are moderate to large. Comparisons of psychotherapy and pharmacotherapy must be interpreted with caution, in part because medication studies are more likely to use a credible active placebo, which may lead to smaller adjusted effect sizes in medication studies. Given that psychotherapy and pharmacotherapy did not show strong differences in effect sizes, treatment choice should be based on other criteria, such as contraindications, treatment access, or patient preferences.     

Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders

OBJECTIVE: This study compared the effectiveness of short-term dynamic psychotherapy and cognitive therapy for outpatients with cluster C personality disorders. METHOD: Patients (N=50) who met the criteria for one or more cluster C personality disorders and not for any other personality disorders were randomly assigned to receive 40 weekly sessions of short-term dynamic psychotherapy or cognitive therapy. The most common axis I disorders in the patient group were anxiety and depression diagnoses. Therapists were experienced, full-time clinicians and were receiving manual-guided supervision. Outcome variables included symptom distress, interpersonal problems, and core personality pathology. Measures were administered repeatedly during and after treatment, and change was assessed longitudinally by means of growth modeling procedures. RESULTS: The overall patient group showed, on average, statistically significant improvements on all measures during treatment and also during a 2-year follow-up period. Significant changes in symptom distress after treatment were found for the group of patients who received short-term dynamic psychotherapy but not for the cognitive therapy patients. Despite these differences in intragroup changes, no statistically significant differences between the short-term dynamic psychotherapy group and cognitive therapy group were found on any measure for any time period. Two years after treatment, 54% of the short-term dynamic psychotherapy patients and 42% of the cognitive therapy patients had recovered symptomatically, whereas approximately 40% of the patients in both groups had recovered in terms of interpersonal problems and personality functioning. CONCLUSIONS: Both short-term dynamic psychotherapy and cognitive therapy have a place in the treatment of patients with cluster C personality disorders. However, factors other than treatment modality may discriminate better between successful and poor outcomes. Such factors should be explored in future studies.     

Attachment style,relationship quality,and psychological distress in patients with psychogenic non-epileptic seizures versus epilepsy

ObjectivesPsychopathology levels are elevated in patients with psychogenic non-epileptic seizures (PNES) and those with epilepsy. However, patients with PNES report higher rates of trauma and neglect, poorer health-related quality of life (HRQoL), and an increased prevalence of insecure attachment. We examined to what extent attachment style and relationship quality with their main informal carer impact on levels of HRQoL, depression, and anxiety in patients with PNES versus those with epilepsy.MethodConsecutive patients with PNES (N = 23) and epilepsy (N = 72) completed questionnaires about attachment style, quality of their relationship with their main informal carer, seizure severity, HRQoL, depression, and anxiety.ResultsPatients with PNES reported higher levels of anxiety and depression and lower HRQoL than those with epilepsy. PNES: No significant correlations were found with HRQoL but depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with attachment avoidance, attachment anxiety, and relationship conflict, and negatively with relationship depth and support. Epilepsy: HRQoL correlated negatively with seizure severity, depression, anxiety, attachment avoidance, and attachment anxiety. Depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with seizure severity, attachment avoidance, and attachment anxiety. Correlations between measures of relationship quality and anxiety were stronger in patients with PNES versus those with epilepsy (zs = 2.66 to 2.97, ps < 0.004). Attachment style and relationship quality explained larger amounts of variance in depression (45%) and anxiety (60%) in the patients with PNES than those with epilepsy (16% and 13%).SignificanceLevels of anxiety and depression were higher in patients with PNES than those with epilepsy. Interpersonal problems were much more closely associated with anxiety and depression in patients with PNES than those with epilepsy. The findings support the use of therapeutic interventions for PNES focusing on attachment and relationship issues.     

Citalopram treatment of depression in Parkinson's disease: the impact on anxiety, disability, and cognition

Depression in Parkinson's disease (PD) is associated with faster progression of physical symptoms, greater decline in cognitive skills, and greater decline in the ability to care for oneself. The depression in these patients is also frequently comorbid with anxiety. There are no trials that provide data on the impact of depression treatment on anxiety, disability, and cognition in these patients. In this prospective, 8-week, open label trial, 10 patients with PD and major depression, without dementia, were given flexible doses of citalopram. Depression improved significantly and was associated with significant improvements in anxiety symptoms and functional impairment. The drug was well tolerated. This is the first study that provides data suggesting that treating depression in patients with PD may lead to improvements in anxiety and functional capacity. As with all nonrandomized, open-label trials at tertiary research centers, many nonspecific factors may have influenced the results.     

Correlations between alexithymia and pain severity,depression, and anxiety among patients with chronic and episodic migraine

Aims: Some studies have found elevated alexithymia among patients with chronic pain, but the correlations between alexithymia and the severity of pain, depression, and anxiety among migraine patients are unclear. The aims of the present study were to investigate whether individuals suffering from episodic migraine (EM) differ from those with chronic migraine (CM) in regards to depression, anxiety, and alexithymia measures and to investigate the association of alexithymia with the results of depression and anxiety test inventories and illness characteristics. Methods: A total of 165 subjects with EM and 135 subjects with CM were studied. The Beck Depression Inventory (BDI), State–Trait Anxiety Inventory (STAI), and Toronto Alexithymia Scale (TAS) were administered to all subjects. The correlation between alexithymia and sociodemographic variables, family history of migraine and illness characteristics (pain severity, frequency of episode, duration of illness) were evaluated. Results: Compared with EM patients, the CM patients had significantly higher scores on measures of depression but not alexithymia and anxiety. There was a positive correlation between TAS scores and age and education in both migraine groups, but there was no correlation between TAS scores and other demographic variables. Depression and anxiety were significantly correlated with alexithymia in both migraine groups. Conclusion: Our results indicate that CM patients are considerably more depressive than EM patients. In this study, depression and anxiety were significantly correlated with alexithymia in both migraine groups. Our results demonstrate a positive association between depression, anxiety, and alexithymia in migraine patients.     

Predictors of psychotherapy alliance in Borderline Personality Disorder

Abstract

To better understand alliance formation with BPD patients, we examined the relationship between pre-treatment patient characteristics and alliance at baseline and 2 months. Thirty-five volunteers who enrolled in a RCT comparing dialectical behavior therapy (DBT) and supportive psychotherapy, with or without antidepressant medication in the treatment of suicidal behavior, were included in this analysis. Participants were administered the SCID-I and II, Beck Depression Inventory, Working Alliance Inventory, Beck Hopelessness Scale, and the State Trait Anxiety Inventory. Results: depression, anxiety and hopelessness predicted poorer patient-rated alliance at 2 months. Depression and anxiety did not correlate with alliance at the start of treatment, but strongly correlated with 2-month alliance, suggesting patient-rated alliance at 2 months was influenced by the course of treatment. Therapist-rated alliance was not associated with either mood or BPD symptoms. Our findings suggest that focusing on BPD patients' mood early in treatment may improve alliance formation     

Sequential treatment of mood and anxiety disorders

OBJECTIVE: Administration of treatments in a sequential order is a common practice in clinical medicine, but has received insufficient attention in psychiatry. The aim of this review was to survey the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood and anxiety disturbances. DATA SOURCES AND STUDY SELECTION: A review of the clinical trials in which treatment components were used in a sequential order (i.e., pharmacotherapy followed by psychotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another, or one psychotherapeutic technique following another) was performed. Studies were identified by using MEDLINE (English language articles published from 1967 to March 2005; keywords: sequential treatment, drugs and psychotherapy, combined treatment related to depressive disorder, bipolar disorder, depression, mania, anxiety disorders, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder) and a manual search of the literature and Index Medicus for the years 1960 to 2005. DATA SYNTHESIS: In unipolar recurrent depression, the sequential use of pharmacotherapy was found to reduce relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already undergoing treatment with mood stabilizers was also found to yield clinical benefits. In anxiety disorders, the sequential use of pharmacotherapy and psychotherapy was not found to improve long-term outcome. CONCLUSION: The sequential treatment of mood and anxiety disorders does not fall within the realm of maintenance strategies. It is an intensive, 2-stage approach, which is based on the fact that one course of treatment with a specific treatment (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the complex array of symptoms of patients with mood and anxiety disorders. The sequential model introduces a conceptual shift in current assessment methods.     

Psychotropic medication use, personality disorder and improvement in long-term dynamic psychotherapy

Patients receiving long-term dynamic psychotherapy often have both depression and personality disorders (PDs) and take medications concurrently. Our goal was to determine the extent of medication use in an outpatient sample and the relationships of medication use and PD status to diagnostic and symptom measures. Fifty-three patients (25 of whom were taking medications at intake) who entered a long-term psychodynamic psychotherapy study for the treatment of chronic or recurrent depression, anxiety, and/or PDs were followed up to 7 years. PD patients who received combined therapy showed significant improvement in functioning and distress, while those receiving only psychotherapy showed significant improvement in depression and distress. Non-PD patients receiving only psychotherapy showed significant improvement in functioning. Long-term dynamic psychotherapy was associated with improvement in symptoms and functioning for the sample as a whole. PD pathology and being on medications at intake acted as moderator variables: PD predicted a smaller effect size in depression and functioning, while medications predicted a smaller effect size in depression only.     

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.     

Impact of comorbid anxiety in an effectiveness study of interpersonal psychotherapy for depressed adolescents

OBJECTIVE: To assess the impact of comorbid anxiety on treatment for adolescent depression in an effectiveness study of interpersonal psychotherapy for depressed adolescents (IPT-A). METHOD: A randomized clinical trial was conducted from April 1, 1999, through July 31, 2002. Sixty-three depressed adolescents, ages 12 to 18, received either IPT-A or treatment as usual delivered by school-based mental health clinicians. Adolescents with and without probable comorbid anxiety disorders were compared on depression and overall functioning. All analyses used an intent-to-treat design. RESULTS: Comorbid anxiety was associated with higher depression scores at baseline (p <.01) and poorer depression outcome posttreatment (p <.05). IPT-A was nonsignificantly more effective in treating the depression of adolescents with comorbid anxiety (p =.07). Adolescents whose depression and functioning improved during the course of treatment also showed an improvement in anxiety (p <.01), largely irrespective of treatment condition. CONCLUSIONS: Adolescents with comorbid depression and anxiety present with more severe depression and may be more difficult to treat. Structured treatments like IPT-A may be particularly helpful for comorbidly depressed adolescents as compared to supportive therapy.     

Speed of improvement in sleep disturbance and anxiety compared with core mood symptoms during acute treatment of depression in old age.

OBJECTIVES: The objective of this study was to examine the relative speed of improvement in sleep disturbance and anxiety symptoms compared with core mood symptoms in acute treatment of late-life major depression. METHOD: The authors conducted secondary analysis of acute treatment data in 470 older patients treated in three federally funded studies. The authors compared rates of improvement in three Hamilton Rating Scale for Depression symptom clusters after stratification by study. RESULTS: Anxiety symptoms improved more slowly with antidepressant monotherapy and with combined pharmacotherapy/psychotherapy, whereas sleep symptoms improved at a similar rate as core mood symptoms. CONCLUSIONS: Anxiety symptoms tend to persist in patients with late-life depression.     

Beliefs about psychotropic medication and psychotherapy among primary care patients with anxiety disorders

Primary health care clinics are increasingly providing psychiatric/psychological treatment of anxiety disorders, particularly for patients who do not have adequate access to specialty mental health services. Adequate treatment requires knowledge of and attention to patients' beliefs about available treatment options. The current investigation examined beliefs about psychotropic medications and psychotherapy among a sample of primary care patients with anxiety disorders. The influence of key demographic variables on strength of these beliefs was also explored. The presence of specific anxiety disorders was not found to impact strength of beliefs about either type of treatment. In contrast, there was a trend for the presence of depression to relate to more favorable attitudes toward psychotropic medication. Consistent with previous studies, ethnic minority patients reported less favorable attitudes toward both psychotropic medications and psychotherapy. These findings underscore the importance of assessing patient beliefs prior to the initiation of either psychotropic medications or psychotherapy across diagnostic and demographic groups. Practitioners should be particularly alert to the possibility that patients with anxiety disorders and members of ethnic minority groups may have less favorable attitudes toward treatment options. Treatment adherence may therefore be increased by addressing these beliefs directly.     

脑卒中后情感障碍的心理干预及帕罗西汀治疗的临床研究

目的 探讨脑卒中后情感障碍的发生率、脑卒中部位与情感障碍的关系,以及口服帕罗西汀合并早期心理干预对脑卒中后情感障碍患者日常生活能力和神经功能康复的影响.方法 采用抑郁自评量表(SDS)、焦虑自评量表(SAS)对181例脑卒中患者进行筛查,对脑卒中后同时出现抑郁和焦虑的54例患者随机分成治疗组和对照组,在接受脑血管病常规治疗的基础上,治疗组加用帕罗西汀和心理干预.采用斯堪的那维亚脑卒中量表(SSS)、Barthel指数(BI)、汉密尔顿抑郁量表(HAMD)、汉密尔顿焦虑量表(HAMA)分别于治疗前、治疗后2周、4周及6周末进行评测.结果 181例患者中发生情感障碍81例(44.75 %),其中66.67%(54例)同时出现抑郁和焦虑,情感障碍的发生与额叶、左侧大脑半球、基底节病灶有关(P<0.05～0.001);治疗后治疗组HAMD、HAMA、SSS评分减少和BI评分增加,与对照组比较差异有统计学意义(均P<0.01),治疗后2～6周显效率显著优于对照组(P<0.05～0.01).结论 脑卒中后抑郁/焦虑的发生与脑卒中部位相关;对脑卒中后抑郁/焦虑的患者应用帕罗西汀合并心理干预治疗能显著提高患者神经功能康复程度,促进生活能力的恢复.