“Our results were encouraging because depression is so common. It’s one of the costliest disorders internationally,” said lead author Sally Merry, M.D., a pediatric psychiatrist with the department of psychological medicine at the University of Auckland in New Zealand.

Depression can erode young people’s enjoyment of daily life, undercut their social relationships and school performance, and increase their risk of substance use, according to Tamar Mendelson, PhD., an assistant professor at the Johns Hopkins Bloomberg School of Public Health who focuses on strategies to prevent mental illnesses. She notes that a first episode of depression dramatically increases the risk of subsequent episodes, initiating what is often a recurring course of illness.

Preventing depression and other mental illnesses is critical for many reasons, said Mendelson. “For one, there are far too few clinicians to treat all the people suffering from depression and other mental illnesses.” She also points out that even effective, evidence-based treatments for depression do not work for all individuals. Even when care is available, many people with depression or other mental illnesses avoid seeking help because of stigma.

“By intervening before the start of a disorder, prevention strategies have the potential to avert a chronic, episodic course of mental illness. Thus, prevention efforts with children and adolescents are particularly critical,” Mendelson said.

The research team analyzed 53 studies, completed in various countries. The studies included a total of 14,406 participants between the ages of 5 and 19. The youngsters involved were free of depressive disorder at the time they began to participate in the prevention programs.

Young people who participated in prevention programs were significantly less likely to have a depressive disorder in the year following the program than youth who did not participate. The effect was the same whether the interventions were targeted toward a specific subset of children, such as just boys, or universal. The prevention programs were diverse and generally involved groups. “Group-based prevention strategies may offer a means of reaching more individuals than most treatment approaches,” said Mendelson. She added that prevention strategies are often less stigmatizing and therefore more acceptable to people than mental health treatments.

Most of the psychological interventions included some components of cognitive behavioral therapy. Other psychological programs emphasized self-efficacy, stress reduction techniques and methods for handling trauma and maintaining optimism.

Both Merry and Mendelson noted that with widespread depression among young people, these findings have importance for many audiences including young people and their parents, school personnel and healthcare professionals who serve children and families. Policy makers concerned with improving public health and controlling the massive costs associated with depression are also likely to be interested. In many countries, note the authors, “governments are keen to take action” to limit the massive human and financial costs associated with depression.

Material adapted from Health Behavior News Service, part of the Center for Advancing Health.

Reference
Merry, S.N., et al. (2011). Psychological and educational interventions for preventing depression in children and adolescents. The Cochrane Library, Issue 12, published online December 7.

For the study, researchers in the U.K. interviewed 29 women who were being treated for anorexia nervosa at clinics throughout the south of England. The interviews asked questions about how the women view their condition, including their understanding of it, how they feel about compulsory treatment, and their thoughts about the impact of anorexia on decision-making. Although the researchers did not ask about authenticity or identity, almost all of the participants spoke in terms of an “authentic self,” the researchers write, “and, for almost all, the relationship between anorexia nervosa and this authentic self was a significant issue.”

Participants characterized this relationship in different ways. Many saw anorexia nervosa as separate from their real self. Some expressed the idea of a power struggle between their real and inauthentic self. Others said that other people could provide support to enable the authentic self to gain strength within the struggle.

The researchers interpret the patients’ notion of their illness as separate from their authentic self as a sign of hope. “Conceptualizing the anorexic behavior as an inauthentic part of the self may well be a valuable strategy for many in helping to overcome it,” the authors write.

The authors also say that, in their view, the distinction between an authentic and an inauthentic self is not necessarily the same as a lack of capacity for decision-making and cannot justify overriding a patient’s refusal to consent to treatment, although they believe that their findings give grounds for not simply acquiescing to refusals of help.

“Some authorities argue that compulsory treatment should never be used for anorexia nervosa,” they write. “We believe, however, that we should take seriously the possibility that a person in the throes of anorexia nervosa may be experiencing substantial inner conflict, even though the person may not be expressing that feeling at the time.”

The authors conclude that clinicians need to monitor patients’ views over time and that if the inner conflict persists, it suggests a lack of capacity for decision-making and, therefore, a risk of significant harm. In this case, they say, “perhaps the evidence from these accounts is sufficient to override treatment refusal in the person’s best interest.”

An unanswered question is whether patients who regard anorexia nervosa as an inauthentic part of the self are most likely to respond to treatment.

“A question of empirical study is whether those who separate the anorexic self from a perceived authentic self are more successful at overcoming anorexia nervosa than those who do not,” the researchers write.

Material adapted from The Hastings Center.

People suffering from depression have a tendency towards unhelpful abstract thinking and over-general negative thoughts, such as viewing a single mistake as evidence that they are useless at everything. Concreteness training (CNT) is a novel and unique treatment approach that attempts to directly target this tendency. Repeated practice of CNT exercises can help people to shift their thinking style.

CNT teaches people how to be more specific when reflecting on problems. This can help them to keep difficulties in perspective, improve problem-solving and reduce worry, brooding, and depressed mood. This study provided the first formal test of this treatment for depression in the NHS.

121 individuals who were currently experiencing an episode of depression were recruited from GP practices. They took part in the clinical trial and were randomly allocated into three groups. A third received their usual treatment from their GP, plus CNT, while some were offered relaxation training in addition to their usual treatment, and the remainder simply continued their usual treatment. All participants were assessed by the research team after two months and then three and six months later to see what progress they had made.

The CNT involved the participants undertaking a daily exercise in which they focused on a recent event that they had found mildly to moderately upsetting. They did this initially with a therapist and then alone using an audio CD that provided guided instructions. They worked through standardized steps and a series of exercises to focus on the specific details of that event and to identify how they might have influenced the outcome.

CNT significantly reduced symptoms of depression and anxiety, on average reducing symptoms from severe depression to mild depression during the first two months and maintaining this effect over the following three and six months. On average, those individuals who simply continued with their usual treatment remained severely depressed.

Although concreteness training and relaxation training both significantly reduced depression and anxiety, only concreteness training reduced the negative thinking typically found in depression. Moreover, for those participants who practiced it enough to ensure it became a habit, CNT reduced symptoms of depression more than relaxation training.

Professor Edward Watkins of the University of Exeter said: “This is the first demonstration that just targeting thinking style can be an effective means of tackling depression. Concreteness training can be delivered with minimal face-to-face contact with a therapist and training could be accessed online, through CDs or through smartphone apps. This has the advantage of making it a relatively cheap form of treatment that could be accessed by large numbers of people. This is a major priority in depression treatment and research, because of the high prevalence and global burden of depression, for which we need widely available cost-effective interventions.”

The researchers are now calling for larger effectiveness clinical trials so that the feasibility of CNT as part of the NHS’s treatment for depression can be assessed.

Published in the journal Psychological Medicine, this study was carried out by a team from the Mood Disorders Centre, which is a partnership between the NHS and the University of Exeter and the Peninsula College of Medicine and Dentistry, a joint entity of the Universities of Exeter and Plymouth and the NHS in the South West.

Material adapted from University of Exeter.

Medical evidence reports that juvenile fibromyalgia syndrome affects 2% to 7% of school age children. Similar to adult cases, the juvenile form of the disorder primarily strikes adolescent girls. Both adult and juvenile fibromyalgia patients experience widespread musculoskeletal pain, fatigue, as well as sleep and mood disturbances. Previous studies show that juvenile fibromyalgia patients are burdened with substantial physical, school, social and emotional impairments. However, studies investing treatment for the juvenile form of the disorder are limited.

For the current trial, led by Dr. Susmita Kashikar-Zuck from the Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children’s Hospital Medical Center in Ohio, investigators recruited 114 adolescents between the ages of 11 and 18 years who were diagnosed with juvenile fibromyalgia. The trial was conducted at four pediatric rheumatology centers between December 2005 through 2009, with participants randomized to cognitive-behavioral therapy (treatment group) or fibromyalgia education (control group), receiving eight weekly individual therapy sessions and two additional sessions in the six months following the end of active therapy.

Analyses showed that both patient groups displayed significant reduction in functional disability, pain, and depressive symptoms at the end of the trial. Pediatric participants in the cognitive-behavioral therapy group reported a significantly greater reduction in functional disability compared to those receiving fibromyalgia education. The therapy group had a 37% improvement in disability compared to 12% in the education cohort. Both groups had scores in the non-depressed range by the end of the study, but pain reduction was not clinically significant — a decrease in pain of less than 30% for either group.

The drop-out rate was low with over 85% of participants attending all therapy sessions and no study-related adverse events were reported by investigators.

“Our trial confirms that cognitive-behavioral therapy is a safe and effective treatment for reducing functional disability and depression in patients with juvenile fibromyalgia,” concludes Dr. Kashikar-Zuck. “When added to standard medical care, cognitive-behavioral therapy helps to improve daily functioning and overall well-being for adolescents with fibromyalgia.”

Material adapted from Wiley-Blackwell.

Reference
“A Randomized Clinical Trial of Cognitive Behavioral Therapy for the Treatment of Juvenile Fibromyalgia.” Susmita Kashikar-Zuck, Tracy V. Ting, Lesley M Arnold, Judy Bean, Scott W. Powers, T. Brent Graham, Murray H. Passo, Kenneth N. Schikler, Philip J. Hashkes, Steven Spalding, Anne M. Lynch-Jordan, Gerard Banez, Margaret M. Richards and Daniel J. Lovell. Arthritis & Rheumatism; Published Online: November 22, 2011 (DOI: 10.1002/art.30644).

Background
Recent studies have shown that symptoms of clinical depression can arise in children as young as 3, and may in fact be an early manifestation of a childhood mood disorder. However, no studies have investigated the best way to treat the disorder among children so young. In addition, many established psychosocial treatments for depression in adults and older youth, such as cognitive behavioral therapy or interpersonal therapy, might not be a good fit to the developmental needs of very young children.

Yet research has shown that very early behavioral interventions can have a significant impact on the trajectory of conduct problems and neuro-developmental disorders like autism or some developmental delays. These findings suggest that very early intervention for a mood disorder could potentially head off depression later in life.

Toward that end, Joan Luby, M.D., of Washington University and colleagues conducted a preliminary pilot study comparing a novel form of psychotherapy called Parent Child Interaction Therapy -Emotion Development (PCIT-ED) with a psycho-educational program. PCIT includes hands-on components aimed at strengthening the parent-child relationship by teaching positive play techniques and coaching parents through the process, and training parents in methods for handling noncompliance and disruptive behavior. PCIT has already been shown to be effective for treating disruptive disorders among preschoolers. The Emotion Development component was designed to help the parent enhance the child’s ability to recognize emotions in self and others and more effectively regulate intense emotions.

The psycho-education program — the control condition — educated parents in small groups about child development. It emphasized emotional and social development but did not include individual coaching or practice sessions with the parents and their children.

The researchers randomly assigned 54 preschoolers (aged 3-7) and their parents to either PCIT-ED or to the psycho-education program. Each program was conducted over a 12-week period.

Results of the Study
After 12 weeks, depression symptoms among the preschoolers significantly declined in both groups. The group receiving PCIT-ED also showed improvements in levels of anxiety, hyperactivity, conduct problems, hostility and inattention, whereas the group receiving the psycho-education program showed improvements in separation anxiety.

In addition, the PCIT-ED group showed improvements in a child’s executive functioning and his or her ability to recognize and regulate emotions, compared to the control condition. The PCIT-ED group also reported reduced parenting stress and decreases in maternal depression, whereas the psycho-education group did not.

Significance
The results indicate that PCIT-ED is acceptable to families and may be beneficial. The researchers conclude that a full-scale randomized controlled trial is warranted.

What’s Next
While intriguing, the findings are preliminary only and should be interpreted with caution until further research can be conducted.

Material adapted from NIMH.

Reference
Luby J, Lenze S and Tillman R. A novel early intervention for preschool depression: findings from a pilot randomized controlled trial. Journal of Child Psychology and Psychiatry. Online ahead of print Oct. 31, 2011.

Cognitive reframing focuses on thinking differently by “reframing” negative or untrue assumptions and thoughts into ones that promote adaptive behavior and lessen anxiety and depression. Cognitive reframing can be offered by a trained primary health care provider or by a mental health care professional.

Several studies have focused on psychosocial intervention in dementia care, but this is the first review that focused on the effectiveness of cognitive reframing in particular. The review appears in the latest issue of The Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research.

Led by Myrra Vernooij-Dassen Ph.D., of the Radboud University Nijmegen Medical Centre in the Netherlands, the review looked at whether caregivers benefited from various interventions to provide education about dementia and whether their beliefs about caregiving responsibilities and their own needs could be changed.

“We found that changing their thinking and understanding helps a lot to allow more positive feelings to emerge and to reduce distress,” Vernooij-Dassen said.

Caregivers who received a cognitive reframing intervention had fewer symptoms of anxiety and depression and felt less stress or distress related to their caregiving. While reframing helped caregivers manage their stress, it did not change the burden of being a dementia caregiver or their coping skills. However, reframing may also lead to a more positive relationship with the person who has dementia.

“When a caregiver is able to reframe self-defeating cognitions into more constructive reasoning, it is a major change,” said Vernooij-Dassen.

The evidence review comprised eleven randomized controlled trials involving family caregivers of people with dementia. None of the trials focused solely on cognitive reframing, but they all used cognitive reframing as the main component in their intervention. Caregivers ranged in age from 19 to 84. The majority of participants — 40.2 percent — were caring for a spouse.

Dementia symptoms include diminished reasoning, memory, social and language skills that can alter a person’s ability to function in daily life. Alzheimer’s disease is the most common form of advanced dementia.

“Alzheimer’s is a chronic, progressive, fatal disease and caregiving at home for someone with the disease is fraught with many challenges but also rewards,” said, Beth Kallmyer, M.S.W., senior director of constituent services for the Alzheimer’s Association, a non-profit advocacy organization.

Kallmyer said the Alzheimer’s Association encourages caregivers to reach out for assistance and take care of themselves. “Because of the progressive, debilitating nature of the disease and the extended length of the caregiving process, multiple services are needed to provide comprehensive support and education to dementia caregivers.”

Tools to decrease stress for family dementia caregivers will be even more important in years to come as people continue to live longer. Kallmyer said cognitive reframing is one among many appropriate interventions as part of a package of individual support for caregivers. “More research is needed overall for improving our knowledge of how to best support and educate caregivers.”

Vernooij-Dassen emphasized dementia caregivers don’t need to go it alone. “When they need support, reframing their thinking and understanding about dementia can yield positive results.”

Material adapted from Health Behavior News Service, part of the Center for Advancing Health.

Reference
Vernooij-Dassen, M. et al. Cognitive reframing for carers of people with dementia. Cochrane Database of Systematic Reviews 2011. Issue 11.

Consequently, a major goal of the U.S. Department of Health and Human Service’s National Strategy for Suicide Prevention has been to increase rates of follow-up care after discharge for patients who come to the emergency department (ED) due to suicidal behavior.

Now, a new study by UCLA researchers shows that a specialized mental health intervention for suicidal youth can help. Reporting in the November issue of the journal Psychiatric Services, Joan Asarnow, a professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA, and colleagues show that a family-based intervention conducted while troubled youths were still being treated in the ED led to dramatic improvements in linking these youths to outpatient treatment following their discharge.

“Youths who are treated for suicidal behavior in emergency departments are at very high risk for future attempts,” said Asarnow, the study’s first author. “Because a large proportion of youths seen in the ED for suicide don’t receive outpatient treatment after discharge, the United States National Strategy for Suicide Prevention identifies the ED as an important suicide prevention site. So, a national objective is to increase the rates of mental health follow-up treatment for suicidal patients coming out of EDs.”

But how to encourage this with youths when they are at their most vulnerable? The study involved 181 suicidal youths at two EDs in Los Angeles County, with a mean age of 15. Sixty-nine percent were female, and 67 percent were from racial or ethnic minority groups. For 53 percent of the participants, their emergency department visit was due to a suicide attempt. The remainder were seen because they had thoughts of suicide.

The youths were randomly assigned to either the usual ED treatment or an enhanced mental health intervention that involved a family-based crisis-therapy session designed to increase motivation for outpatient follow-up treatment and improve the youths’ safety, supplemented by telephone contacts aimed at supporting families in linking to further outpatient treatment.

The results of the study show that the enhanced mental health intervention was associated with higher rates of follow-up treatment. Of the participants in the enhanced intervention, 92 percent received follow-up treatment after discharge, compared with 76 percent in the standard ED treatment arm — a clinically significant difference. While the results are positive, the study is only a first step, according to Asarnow, who also directs UCLA’s Youth Stress and Mood Program.

“The results underscore the urgent need for improved community outpatient treatment for suicidal youths,” she said. “Unfortunately, the follow-up data collected at about two months after discharge did not indicate clinical or functioning differences among youths who received community outpatient treatment and those who did not.”

Still, Asarnow said, the data from the new study underscores the critical importance of this work. To address the need for effective follow-up treatment for troubled youths, the UCLA Youth Stress and Mood Program has major research trials in progress aimed at evaluating outpatient treatments for preventing suicide and suicide attempts.

Funding for the study was provided by the Centers for Disease Control and Prevention, the National Institute of Mental Health and the American Foundation for Suicide Prevention.
Other authors included Larry Baraff, Robert Suddath, John Piacentini, Mary Jane Rotheram-Borus and Lingqi Tang, all of UCLA; Michele Berk and Charles Grob of Harbor–UCLA Medical Center, Los Angeles Biomedical Research Institute; Mona Devich-Navarro of Santa Monica College; and Daniel Cohen of Johns Hopkins University.

Material adapted from University of California, Los Angeles (UCLA), Health Sciences.

In an article published in the January 2011 issue of Perspectives on Psychological Science, Kazdin and his co-author, Stacey Blase, also at Yale University, urge psychological scientists to rethink the current mental health system in order to make adequate treatment available and accessible to all who need it.

Now, in the latest issue of Perspectives on Psychological Science, several eminent scientists have come forth in response to Kazdin and Blase’s article, highlighting important points that will need to be addressed before the mental health care system can be overhauled, including:

• Understanding what works and for whom: Psychological scientists Varda Shoham, of the University of Arizona-Tucson and Thomas R. Insel, Director of the National Institute of Mental Health, contend that knowing which treatments work won’t matter unless we know how to target the interventions to the people who will benefit most. “In the absence of such knowledge,” they argue, “we risk treatment decisions guided by accessibility to resources rather than patient needs – the very problem Kazdin and Blase aim to solve.”
• Integrating several levels of care: Marc S. Atkins and Stacy L. Frazier at the University of Illinois at Chicago argue that “only a comprehensive and integrated public health model can adequately address the pervasive societal problems that underlie our country’s mental health needs.” Adopting such a public health approach will require that we pay attention to all levels of mental health care, distributing resources equally from the prevention to intervention stage of the treatment process.
• Identifying optimal methods of delivery: According to Brian Yates of American University, we have to find more effective ways to deliver treatment – “methods that use less therapist time, less client time, minimize client transportation costs as well as brick-and-mortar space, and use less of other increasingly scarce and costly resources.”

While the notion of rethinking the current approach to mental health care seems like an incredibly daunting endeavor, there is some hope. As the authors of one commentary point out, the United States Department of Veterans Affairs has already developed and implemented new and innovative programs to address the mental health of its veterans.

Together, these commentaries offer frank insights into the challenges we face in trying to address the mental health burden in the United States.

Material adapted from Association for Psychological Science.

In one report, Katie Weinger, Ed.D., of the Joslin Diabetes Center, Boston, and colleagues, evaluated the efficacy of a behavioral intervention for improving glycemic control among patients with long-duration poorly controlled diabetes. The trial randomized 222 adults with diabetes to three treatment groups: structured behavioral treatment (included a five-session manual-based, educator-led structural intervention with cognitive behavioral strategies), group attention control (educator-led attention control group education program) and individual control (unlimited individual nurse and dietitian education sessions for six months).

The authors found that all participants, regardless of treatment group, showed glycemic improvement, however the structured behavioral group showed greater improvements compared to the other two treatment groups. Additionally, participants with type 2 diabetes showed greater improvement than patients with type 1 diabetes. Quality of life, number of daily glucose meter checks and frequency of diabetes self-care did not differ by type of intervention over time; however, patients with type 2 diabetes showed higher quality of life scores than patients with type 1. The authors concluded that, “a structured, cognitive behavioral program is more effective than two control interventions in improving glycemia in adults with long-duration diabetes.”

In a second report, JoAnn Sperl-Hillen, M.D., of HealthPartners Research Foundation and HealthPartners Medical Group, Minneapolis, and colleagues evaluated a total of 623 adults from Minnesota and New Mexico with type 2 diabetes and glycosylated hemoglobin (HbA1c) concentrations of 7 percent or higher. Participants were randomized to receive either group education, individual education or usual care (no assigned education; control group).

The authors found that individual education resulted in better glucose control in patients with established suboptimally controlled diabetes than did group education. Although mean (average) HbA1c concentrations decreased across all treatment groups, levels decreased significantly more in the individual education group (-0.51 percent) when compared with the group education (-0.27 percent) and the usual care (-0.24 percent) groups. Participants in the individual education group also were more likely to have HbA1c levels at or below 7 percent than participants in either the group education or usual care treatments. “In conclusion, among patients with type 2 diabetes of relatively long duration and HbA1c levels of 7 percent or higher, short-term glucose control improved more in those receiving individual diabetes education than in those receiving group diabetes education or assigned to no education,” the authors write.

A third study, conducted by Dominick L. Frosch, Ph.D., of the Palo Alto Medical Foundation Research Institute, Palo Alto, Calif., and colleagues examined the effectiveness of disease management programs among socially and economically disadvantaged patients with poorly controlled diabetes. The study included 201 patients (72 percent African American or Latino; 74 percent with annual incomes of less than or equal to $15,000) with poorly controlled diabetes. Participants were randomized to receive either an intervention package consisting of a 24-minute video behavior support intervention with a workbook and five sessions of telephone coaching by a trained diabetes nurse (treatment group), or a 20-page brochure developed by the National Diabetes Education Program (control group).

The authors found that most participants in both the treatment group (94.3 percent) and control group (93.5 percent) had received the assigned treatment materials and the majority (88.5 percent in the treatment group and 89.8 percent in the control group) rated the clarity of the information presented as good, very good, or excellent at the one-month follow-up. Across treatment groups there was a significant overall reduction in mean (average) HbA1c levels from study initiation to six-month follow-up; however differences between the groups were not significant. The authors also found that differences in other clinical measures (including blood lipid levels and blood pressure) and measures of diabetes knowledge and self-care behaviors were also non-significant.

“More intensive and therefore more expensive interventions may be a worthwhile investment to lower the high costs associated with poorly managed diabetes in the long term; however, larger structural interventions also may be necessary to overcome the many challenges faced by these severely disadvantaged patients,” the authors conclude.

Material adapted from JAMA.

References
Arch Intern Med. Published online October 10, 2011. doi:10.1001/archinternmed.2011.502; doi:10.1001/archinternmed.2011.507; doi:10.1001/archinternmed.2011.497.

“Mental health professionals often give up on the lowest-functioning cases of schizophrenia and may say that they are not capable of improving,” said Paul Grant, PhD, lead author of the study and assistant professor in Psychiatry at Penn’s Perelman School of Medicine. “Our results suggest that cognitive therapy can improve quality of life, reduce symptoms, and promote recovery in these patients. This intervention can help these patients improve to the point where they may be able to move up to the next level in psychosocial functioning – i.e. going from being unemployed to volunteering part-time; not being in school to enrolling in night classes; not socializing to having a weekly social contact and making a friend or two.”

Between 2 and 3 million American adults have schizophrenia. Although antipsychotic medications have been demonstrated to reduce hallucinations and delusions, one-third to one-half of patients with schizophrenia continue to experience residual symptoms or cannot tolerate medications. In the United States, nearly $63 billion is spent annually on overall direct treatment costs and indirect costs incurred due to lost employment and productivity, for an average of between $26,000 and $31,000 per patient, which is 5 times greater than the per-patient cost of depression.

“Our study suggests that cognitive therapy might have utility to help reduce public health costs for the most expensive per-patient psychiatric population while simultaneously improving patients’ quality of life,” said Aaron T. Beck, MD, senior author of the study and professor emeritus of Psychiatry at Penn. Dr. Beck is considered the ‘Father of Cognitive Therapy,’ which transformed the understanding and treatment of many psychiatric conditions, including depression, suicidal behavior, generalized anxiety, panic attacks, and eating disorders.

In this randomized, single-blind, controlled trial, 60 adults with schizophrenia from Philadelphia received either cognitive therapy plus standard treatment, or standard treatment alone. Standard treatment included antipsychotic medication, at least, as well as psychosocial services provided by local community mental health centers.

In adapting cognitive therapy for this patient population, researchers focused on highlighting the patients’ interests, assets and strengths. The intervention was intentionally designed to promote recovery by helping patients identify and achieve concrete goals for improving quality of life and reintegration into society. Treatment targeted specific defeatist beliefs (“if I partially fail it is as bad as being a complete failure”) that earlier research by Grant and Beck identified as blocks to the patients engaging in constructive activity.

By 18 months, patients in the cognitive therapy group entered into what researchers called “a dynamic cycle of recovery.” The treatment encouraged patients to set goals related to their everyday functioning, and they became motivated to engage in tasks that moved them out of their withdrawn state. This increase in activity and motivation put the patients more in touch with reality and reduced hallucinations, delusions, and disorganized speech. The cycle continued as engagement in activity led to better functional outcomes and motivation, which facilitated continued improvement of symptoms.

These patients have more potential than their care providers and family members may have thought possible, according to Drs. Grant and Beck. The next stage is to train community therapists to deliver the recovery-oriented cognitive therapy in community mental health agencies.

The research was supported by a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression (Dr Beck) and by grants from the Heinz Foundation and the Barbara and Henry Jordan Foundation.

Material adapted from Penn Medicine.

“Chronic PTSD is tenacious and disabling. Short-term interventions without prior assessment or diagnosis have failed to prevent PTSD,” the authors write as background information in the study. “Preventing posttraumatic stress disorder (PTSD) is a pressing public health need.”

Researchers conducted a study to compare early and delayed exposure-based, cognitive and pharmacological interventions for preventing PTSD. Study participants were selected from consecutively admitted survivors of traumatic events at Hadassah Hospital in Jerusalem, through a telephone-based interview a mean (average) 9.61 days after the traumatic event occurred. Patients identified as having symptoms of acute stress disorder during the telephone interview were referred for clinical assessment, and those who met PTSD symptom criteria during assessment were invited to receive treatment.

The authors randomly assigned consenting patients to one of four intervention groups: prolonged exposure (PE), cognitive therapy (CT), a double-blind comparison of treatment with a selective serotonin reuptake inhibitor (SSRI) vs. placebo, or a waiting list (WL) control group. The study design allowed participants to decline treatment options they did not desire, and to be randomly assigned to one of the remaining treatment groups. Participants in the WL group who met PTSD criteria at the five-month follow-up received PE at that time, to compare the effects of a delayed intervention on PTSD symptoms. Prolonged exposure included psychoeducation, training in breathing control, prolonged imaginal exposure to traumatic memories and in vivo exposure to avoided situations. Cognitive therapy included identifying and challenging negative automatic thoughts and modifying underlying cognitive schemas. Participants in each of these groups received 12 weekly 1.5-hour sessions administered by clinical psychologists with prior PTSD treatment experience. PTSD prevalence was determined using the Clinician-Administered PTSD Scale (CAPS).

Following randomization, 63 participants started PE, 40 started CT, 93 were placed on the waiting list, and 46 were in the SSRI and placebo subgroups (23 in each group). At the five-month follow-up, the prevalence of PTSD in the PE and CT groups (21.4 percent and 18.2 percent, respectively) were significantly less than in the WL, SSRI and placebo groups (58.2 percent, 61.9 percent and 55.6 percent, respectively). The analysis showed significant group differences in CAPS and mean (average) PTSD Symptom Scale-Self Report scores at five months, showing fewer PTSD symptoms in the PE and CT groups compared with the WL, SSRI and placebo groups. At the five-month follow-up, 57 WL participants had PTSD and were eligible for delayed PE and 41 started treatment at that time.

At the nine-month follow-up, the prevalence of PTSD in the PE, CT, and WL groups were 21.2 percent, 22.8 percent, and 22.9 percent, respectively while rates for the SSRI and placebo subgroups (42.1 percent and 47.1 percent, respectively) remained higher. Analysis also showed significant group differences in CAPS and mean PTSD Symptom Scale-Self Report scores at nine months, showing fewer PTSD symptoms in the PE, CT and WL groups compared with the SSRI and placebo groups. Participants with partial PTSD before treatment onset did similarly well with and without treatment.

“The results of our study show that there are significant and similar preventive effects of PE and CT,” the authors conclude. “Our finding suggests that delaying the intervention does not increase the risk of chronic PTSD. Thus, a delayed intervention is an acceptable option when early clinical interventions cannot be provided (e.g., during wars, disasters, or continuous hostilities).”

Material adapted from JAMA.

Reference
Arch Gen Psychiatry. Published online October 3, 2011. doi:10.1001/archgenpsychiatry.2011.127.

“Obsessive-compulsive disorder affects up to 1 in 50 people, is evident across development, and is associated with substantial dysfunction and psychiatric comorbidity. Randomized controlled trial findings support the efficacy of pharmacotherapy with serotonin reuptake inhibitors (SRIs), cognitive behavior therapy [CBT] involving exposure plus response prevention, and combined treatment. However, a paucity of expertise in pediatric OCD prevents most families from accessing exposure plus response prevention or combined treatment. Outcome data for pharmacotherapy alone, the most widely available treatment indicate that partial response is the norm and clinically significant residual symptoms often persist even after an adequate trial,” according to background information in the article.

Researchers conducted a study to examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management. The 12-week randomized controlled trial was conducted at 3 academic medical centers between 2004 and 2009, involving 124 outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis. Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions.

The researchers found that at 12 weeks the percentages of participants who had at least a 30 percent reduction in their Children’s Yale-Brown Obsessive Compulsive Scale baseline score were 68.6 percent in the plus CBT group, 34.0 percent in the plus instructions in CBT group, and 30.0 percent in medication management only-group. Comparisons showed that the plus CBT strategy was superior to both the medication management only strategy and the plus instructions in CBT strategy. The plus instructions in CBT strategy was not statistically better than medication management only.

The researchers add that the findings from this and other studies highlight the importance of disseminating CBT for pediatric OCD into community settings so that affected children have options beyond medication management alone. “Furthermore, [the findings from this study] indicate that these dissemination efforts should focus on making the full CBT protocol more widely available in such settings rather than on attempting to create and disseminate truncated versions of this efficacious form of treatment. Toward these ends, research must focus on developing, evaluating, and comparing various models for disseminating CBT beyond the academic medical context.”

Material adapted from JAMA.

Reference
JAMA. 2011;306[11]:1224-1232.

Dr Gary Winship, of the University’s School of Education, part of the project team, said: “With its qualities of cold resistance and suitability for moulding, we believe creative play through clay could be an exciting alternative therapy for young people suffering from a range of mental health vulnerabilities.

“Anecdotally, it may offer potential therapeutic effects through the cathartic venting of emotions through banging, squashing, bending or breaking the clay.”

The £25,000, one-year project will focus on young people who are currently accessing local mental health services through the NHS and may be dealing with a range of psychosocial personality problems, anger issues, anxiety, and depression, which has often also led to their exclusion from school.

The researchers believe that the process of group sculpting could offer the added benefit of improving the ability of the youngsters to talk to other young people their own age, reducing the sense of isolation that many experience.

The project will also look at how clay therapy could be developed by health professionals as a way of more successfully engaging with young people who suffer from autistic spectrum disorders and Attention Deficit Hyperactivity Disorder (ADHD).

The project was one of two chosen to receive support as part of an innovative interdisciplinary, cross-faculty Arts, Humanities and Health Communication Sandpit held recently.

Bringing together around 30 people from across the University, the NHS and the voluntary sector, the event, directed by Dr Victoria Tischler from the School of Community Health Sciences, aimed to identify shared interests, formulate ideas and act as a springboard for research proposals for healthcare projects involving the elderly and adolescents.

A pot of £35,000 in pump priming grant funding provided by the University’s Faculty of Arts, School of Nursing, Midwifery and Physiotherapy, Faculty of Medicine and Health Sciences, Research Innovation Services and the Centre for Advanced Studies was available for proposals demonstrating the most potential.

The remaining £10,000 funding was awarded to a project which will examine the informal language used by teenagers in emails to health websites to improve the success of face-to-face consultations in healthcare settings.

Young people often find it difficult, embarrassing or uncomfortable to speak to healthcare professionals, which can sometimes lead to a failure to disclose and address serious healthcare concerns around sensitive issues such as mental health or sexual health.

However, they are often far more open and explicit when communicating by email to health websites. A team including Dr Dick Churchill in the University’s Division of Primary Care and involving academics from Medicine, English Studies, Clinical Sciences and Psychology, will draw on the language used in these emails to create innovative video and simulation resources to train health professionals and empower adolescents to communicate more effectively in healthcare settings.

The recent sandpit event aimed to support the development of the Health Humanities, a cross-disciplinary approach applying the theory, knowledge and practice of arts and humanities to healthcare.

The University of Nottingham has appointed the world’s first Professor in Health Humanities, Paul Crawford in the School of Nursing, Midwifery and Physiotherapy, who alongside Dr Tischler and colleagues has recently formed the International Health Humanities Network to direct and develop research and teaching in this area.

A follow-up to the recent sandpit will be held during August to provide mentoring and guidance to the research projects developed through the event with a view to increasing success in applying for funding from external sources.

Material adapted from University of Nottingham.

The study, conducted by Keith King, PhD, a professor at the University of Cincinnati College of Education, Criminal Justice and Human Services, will be published online Aug. 11 and in the print edition Aug. 16.

“The overwhelming majority of students felt Surviving the Teens helped them to learn suicide warning signs, suicide and depression risk factors, how to effectively cope with stress, steps to take if they or a friend felt suicidal, and how to talk to their parents and friends about their problems,” says Cathy Strunk, RN, suicide prevention expert in the division of Psychiatry at Cincinnati Children’s who developed Surviving the Teens.

The program is one of the few suicide prevention programs to have data supporting its effectiveness.

Strunk taught the Surviving the Teens curriculum to more than 6,000 high school students in Warren, Butler and Hamilton counties during the 2008-2009 school year. For this study, more than 900 were surveyed before going through the program and after completing the program. More than 400 were surveyed three months later.

Among the findings in self-reported behaviors, feelings, intentions and attitudes three months following the program compared to pre-test:

• Students who reported considering suicide decreased 65 percent, from 4.2 percent of students to 1.5 percent.
• Students who reported planning to attempt suicide decreased 48 percent, from 9.9 percent of students to 5.2 percent.
• Students who reported having attempted suicide decreased 67 percent, from 5.2 percent of students to 1.7 percent.
• Students who reported feeling sad and hopeless decreased 26 percent, from 22.6 percent of students to 16.8 percent.

“The program taught students how to have more self-confidence and how to engage in positive behavior, which lessens the risk of them contemplating suicide,” says Strunk.

The survey administered immediately after completing the program showed that:

• Nearly 72 percent of students intended to talk more to their parents about their problems, nearly 81 percent intended to talk to their friends more about their problems, and nearly 90 percent intended to encourage their friends to talk more to them about their problems.
• Students’ knowledge of depression risk factors suicide risk factors, and suicide warning signs increased significantly.
• Students’ intent to seek help when suicidal increased.

“This study focused on students’ self-reporting, so it is unclear how closely their feelings and attitudes mirror actual behavior,” says Michael Sorter, MD, director of Psychiatry at Cincinnati Children’s and study co-author. “This is something we need to look at in the future. Even though we don’t claim that Surviving the Teens is the answer to suicidal behavior, we are very encouraged by the research so far indicating how helpful the program might be.”

Strunk and the division of Psychiatry at Cincinnati Children’s created Surviving the Teens to provide information, resources and support to help guide teens and families through the ups and downs of life. The curriculum focuses on educating students about the warning signs of suicide in either themselves or friends and how they can get help if they or their friends have suicidal feelings. The program includes a component called Steps to Last™, which assists students in understanding what steps they need to take if they, their friends or family members need help.

According to the National Institute of Mental Health, suicide is the third leading cause of death in children ages 15-24.

Material adapted from Cincinnati Children’s Hospital Medical Center.

The study was the first randomized clinical trial to demonstrate an intervention that raises hope in patients with acute coronary syndrome, a condition that includes chest pain and heart attack. Previous research has shown that hope and its opposite, hopelessness, have an impact on how patients face uncertain futures.

“The study shows that a spiritual retreat like the Medicine for the Earth program can jumpstart and help to maintain a return to psycho-spiritual well-being,” says study lead author Sara Warber, M.D., associate professor of family medicine at the U-M Medical School and director of U-M’s Integrative Medicine program. “These types of interventions may be of particular interest to patients who do not want to take antidepressants for the depression symptoms that often accompany coronary heart disease and heart attack.”

The findings were published in the July issue of Explore: the Journal of Science and Healing.

The retreat group was compared to two other groups: one received standard cardiac care and the other participated in a lifestyle change retreat run by the U-M Cardiovascular Center that focused on nutrition, physical exercise and stress management.

The spiritual retreat portion of the study was conducted at the Windrise Retreat Center in Metamora, Michigan, about 50 miles north of Detroit. In the Medicine for the Earth program, participants are encouraged to see themselves as part of an interconnected web of life. The approach is founded on the work of co-author Sandra Ingerman, M.A., who wrote the book Medicine for the Earth: How to Transform Personal and Environmental Toxins, which emphasizes principles of love, harmony, beauty, unity and peace.

The study used a number of standard mental and physical benchmarks to assess the success of the program.

The spiritual retreat group went from a baseline score of 12 on the Beck Depression Inventory, indicating mild to moderate depression, to an improved score of 6 immediately afterward, a 50-percent reduction. Their scores remained that low half a year later. The lifestyle group saw their scores drop from 11 to 7 and remain there. The control group’s score started at 8 and went down to 6.

Participants also showed marked improvement in their scores on a test measuring hope. Scores on the State Hope Scale can range from 6 to 48, with higher scores indicating greater hope. All three study groups started with average scores between 34 and 36. After the spiritual retreat, participants’ average scores rose and stayed at 40 or above, while the other two groups’ averages remained significantly lower, ranging from 35 to 38, three and six months later.

“Our work adds an important spiritual voice to the current discussion of the importance of psychological well-being for patients facing serious medical issues, such as acute coronary artery disease,” Warber says.

Additional Authors: Jenna Wunder, M.P.H., Alyssa Northrop, M.P.H., Brenda Gillespie Ph.D., Katherine Smith M.P.H., Katherine S. Rhodes, Ph.D., Melvyn Rubenfire, M.D., all of U-M. Vera L. Moura, M.D., of University of North Carolina at Chapel Hill. Kate Durda, M.A., independent teacher of Medicine for the Earth.

Disclosures: Ingerman and Durda make some income teaching Medicine for the Earth trainings. Sandra Ingerman makes some royalties on her book, Medicine for the Earth. Both donated their time for this study.

Material adapted from University of Michigan Health System.

Reference
“Healing the Heart: A Randomized Pilot Study of a Spiritual Retreat for Depression in Acute Coronary Syndrome Patients,” Explore: The Journal of Science and Healing, July 2011.

At the American Academy of Dermatology’s Summer Academy Meeting 2011 in New York, dermatologist and clinical psychologist Richard G. Fried, MD, PhD, FAAD, of Yardley, Pa., discussed the skin-psyche connection and how incorporating various stress management techniques into a dermatologic treatment regimen can help patients with skin conditions feel better physically and emotionally.

“Stress is personal so what might be stressful for one person may be a non-stressor or even exhilarating for someone else,” explained Dr. Fried. “In terms of how stress can exacerbate or even initiate a skin condition, we are talking about distress, such as feelings of anger, anxiety, depression or tension, and how these emotional states translate to physiological problems.”

To understand the complex relationship between stress/distress and the skin, Dr. Fried noted it is important to consider the biological response that happens when a person experiences stress. Neuropeptides, the chemicals released by skin’s nerve endings, are the skin’s first line of defense from infection and trauma. When responding to protect the skin, neuropeptides can create inflammation and an uncomfortable skin sensation, such as numbness, itching, sensitivity or tingling. However, Dr. Fried explained that stressful situations can cause neuropeptides to be inappropriately released, which can lead to a flare of skin conditions.

“Until recently, it was thought that neuropeptides only stayed in the skin when they were released,” said Dr. Fried. “But we now know that they travel to the brain and ultimately increase the reuptake of neurotransmitters – meaning that stress depletes the chemicals that regulate our emotions, such as serotonin, norepinephrine, and dopamine. For example, when psoriasis patients feel stressed about their condition, it can aggravate their symptoms and lead to a further decline in their emotional state, which becomes a vicious cycle.”

To help patients combat stress-aggravated skin conditions, Dr. Fried recommends that appropriate stress management strategies be used in conjunction with traditional dermatologic therapies. These strategies include psychotherapy, cognitive behavioral therapy, meditation, hypnosis, tai chi, yoga, antidepressants, and beta blockers.

Dr. Fried noted that stress management makes patients feel more empowered and in control, which can make them more likely to comply with a treatment plan for their skin condition and see improvement.

“In my practice, I find that patients with chronic skin conditions tend to withdraw from normal, everyday activities and sometimes ‘shut down’ emotionally, which can really impact their personal lives,” said Dr. Fried. “In addition, when you are withdrawn and have more time alone, it can make your symptoms seem more pronounced and you can end up feeling worse. That’s why it is so important for patients to seek a treatment plan from their dermatologist to help reduce their stress level and break the cycle of stress-related flares.”

Dr. Fried added that the skin barrier function, which is the skin’s protective outer layer, can be impaired by stress as well. Stress can make the skin more permeable, more sensitive and more reactive, which is why dermatologists recommend the use of over-the-counter moisturizers to enhance the skin barrier function. If stress compromises the skin’s barrier function, more irritants, allergens, and bacteria can penetrate the skin and cause problems. Specifically, stress can make a person’s rosacea more red or acne lesions more inflamed and more persistent. It can worsen hives, fever blisters, psoriasis and seborrheic dermatitis.

“Visiting a dermatologist can provide patients with hope and a treatment plan for their skin problem,” said Dr. Fried. “A simple explanation as to the cause and treatment of a patient’s skin condition can decrease their level of distress. Alleviating or minimizing stress goes a long way in improving their overall health.”

Material adapted from American Academy of Dermatology (AAD).

“Throughout the war and thereafter, the Northern Ugandan communities have been confronted with large numbers of formerly abducted children, adolescents, and young adults returning after their rescue, flight, or release. The successful reintegration of these former child soldiers continues to be a major challenge,” according to background information in the article. “Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers.”

Verena Ertl, Ph.D., of Bielefeld University, Bielefeld, Germany, and colleagues conducted a randomized controlled trial to test the feasibility and effectiveness of narrative exposure therapy for the treatment of former child soldiers with posttraumatic stress disorder (PTSD). Narrative exposure therapy is a short-term, trauma-focused treatment developed for use in low-resource countries affected by crises and conflict. During narrative exposure therapy the participant constructs a detailed chronological account of his or her own biography in cooperation with a therapist to reconstruct fragmented memories of traumatic events and to achieve habituation.

The trial included 85 former child soldiers with PTSD from a population-based survey of 1,113 Northern Ugandans ages 12 to 25 years. The study was conducted in camps for internally displaced persons between November 2007 and October 2009. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD, depression, and related impairment were assessed using various analytic tools before treatment and at 3 months, 6 months, and 12 months postintervention. Treatments were carried out in 8 sessions by trained local lay therapists, directly in the communities.

The researchers found that PTSD symptom severity was significantly more improved in the narrative exposure therapy group than in the academic catch-up and waiting-list groups. In one measure of clinically significant change, 20 of 25 participants (80 percent) in the narrative exposure therapy group were found to have improved with regard to PTSD severity. “In the academic catch-up and waiting-list conditions, 11 of 23 (47.8 percent) and 14 of 28 (50 percent), respectively, showed clinically relevant improvement. Subgroup comparisons revealed that improvement was significantly greater in the narrative exposure therapy group vs. the academic catch-up group and the narrative exposure therapy vs. the waiting-list groups,” the authors write. At 12 months, 68 percent of the narrative exposure therapy participants, 52.2 percent of the academic catch-up participants, and 53.6 percent of the waiting-list participants no longer fulfilled criteria for PTSD.

Also, a larger within-treatment effect size was seen in the narrative exposure therapy group, with a 51.6 percent reduction in the PTSD symptom score from pretreatment assessment to 12-month follow-up compared with the academic catch-up group (30.9 percent symptom severity reduction) and the waiting-list group (30.4 percent symptom severity reduction).

“Moreover, results indicated that there were additional positive effects of treatment on associated problems not primarily targeted, such as depression, suicidal ideation, feelings of guilt, and important indicators of readjustment such as stigmatization and functioning,” the researchers add.

The authors note that the findings of this study indicate that narrative exposure therapy can be applied successfully by community-based lay therapists without a mental health or medical background.

Material adapted from JAMA.

Reference
JAMA. 2011;306[5]:503-512.

Researcher Bradley Appelhans, PhD

The new, proposed neurobehavioral model is highlighted in an article in the August issue of the Journal of the American Dietetic Association.

“Typically, overweight and obese patients receive education about dietary contributions to weight gain, and they are simply encouraged to fight the powerful urge to eat the delicious foods that are available almost everywhere in the environment, and instead, make dietary choices consistent with weight loss,” said Brad Appelhans, PhD, clinical psychologist and obesity researcher in the Rush University Prevention Center and lead author of the article. “Yet, we know this approach rarely works. Even highly motivated and nutritionally informed patients struggle to refrain from highly palatable foods that are high in sugar, salt, and unhealthy fats.”

The suggestion that individuals become or remain obese due to their unhealthy personal choices or a lack of willpower to make healthy choices is also stigmatizing to patients and unlikely to motivate them to lose weight. The new model adopts a scientifically informed framework that clarifies how personal choice is affected by biological and environmental factors.

The three neurobehavioral processes consistently implicated in obesity and overeating are food reward, inhibitory control, and time discounting.

1. Food Reward – is largely mediated by the mesolimbic dopamine system, a neural pathway in the brain also known as the reward circuit. Food reward includes both the experience of pleasure one receives from eating and the motivational drive to obtain and consume highly palatable foods. Those with greater sensitivity to reward have stronger food cravings for sweet and fatty foods. This biologically-based sensitivity, coupled with easy access to delicious snacks and fast food outlets, makes one highly vulnerable to overeating and weight gain.
2. Inhibitory Control – Beyond the intensity of food cravings is the ability to suppress urges to eat high-calorie foods. Controlling behavior despite a strong motivation to eat is largely mediated by the brain’s prefrontal cortex, which is considered critical for self-control, planning, and goal-directed behavior. The dorsolateral region of the prefrontal cortex has been implicated in the decision to engage inhibitory processes for the purpose of self-regulation, and this brain area becomes activated when dieters choose healthy food options over tastier options.
3. Time Discounting – A third factor that likely contributes to the low success rates of dietary interventions for obesity is the human tendency to devalue delayed rewards.

“Most of us would rather receive $200 today rather than $300 a year from now,” said Appelhans. Similarly, the immediate pleasure from eating has a greater effect on decision making than the more delayed health benefits of weight loss.

The link between time discounting and body weight is reflected neuroanatomically because it is governed by the same brain regions associated with food reward and inhibitory control – the mesolimbic dopamine system and the prefrontal cortex.

“Obesity is heavily influenced by genetic vulnerabilities and a toxic food environment,” said Appelhans. “However, counselors can help patients control their weight through strategies focused on the interaction between the brain and the environment, rather than the traditional approach of encouraging patients to simply ignore or fight food cravings and eat fewer calories than they expend.”

A few strategies recommended by the researchers include:

• In order to combat food reward, patients can remove high fat foods they crave from personal environments such as the home and workplace to prevent the activation of the reward circuitry.
• Limit the impact of reward on food choice by shopping with a grocery list or using online grocers.
• Practice stress management techniques since stress promotes overeating and obesity by enhancing food reward processing.
• Avoid situations such as buffets and restaurants that challenge inhibitory control.
• Focus on achieving short-term behavioral goals, such as cooking a healthy dinner on three nights of the week rather than focusing on long-term weight loss goals.

Dr. Appelhans is affiliated with the Rush University Prevention Center, which specializes in the behavioral, medical, and nutritional management of obesity and other risk factors for heart disease and diabetes.

Material adapted from Rush University Medical Center.

The UH Graduate College of Social Work (GCSW) joins Baylor College of Medicine and the Neurorehabilitation: Neurons to Networks Traumatic Brain Injury Center of Excellence at the Michael E. DeBakey Veterans Affairs Medical Center (VA) for a pilot project to assess the feasibility of using virtual reality environments to treat alcohol abuse issues in veterans.

“Our goal is to help them stop their drinking. The basis is standard relapse prevention therapy sessions, but we augment it using virtual environments,” said professor Patrick Bordnick, director of the GCSW’s Virtual Reality Lab. “The virtual environments allow a patient to practice coping skills in the environments that trigger the cravings and relapse.”

A recent report from the National Institute on Drug Abuse (NIDA) indicated alcohol abuse is dangerously high among returning veterans, increasing their vulnerability to other abuses, such as illicit drugs or behaviors such as drinking and driving. The eight-week project targets 10-20 veterans, who range in age from 19 to 64 and are living with a traumatic brain injury and/or post traumatic stress syndrome. Results from this study will be used to create a larger study.

With their therapist nearby, veterans will wear a virtual reality helmet to place them in the environments. Using a controller, participants will navigate bar settings, parties or convenient stores where avatars will personalize their interaction, addressing the veteran by name and allowing him or her to practice coping skills. There also is an environment where the participant is home alone.

“This will be a full-sensory experience where participants will see items that may trigger their alcohol cravings, such as food or cigarettes. They’ll hear sporting events on televisions, glasses clinking or the murmur of bar patrons. They’ll also smell the food, smoke or their alcoholic drink of choice,” Bordnick said. “This experience is as close to the real thing as possible, but conducted in a safe clinical environment with their therapist.”

Bordnick is a pioneer in virtual reality research for use to assess and treat addictions and phobias. Through grants from National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, the National Institutes of Health and others, Bordnick has used virtual reality environments to study smoking and alcohol addictions, post traumatic stress in returning veterans.

Material adapted from University of Houston.

Researcher Amy Przeworski, PhD

Individuals with GAD frequently put social relationships with family, friends, or coworkers at the top of their lists of worries, but the negative methods they use to cope — from over nurturing to extreme detachment—may be destructive.

Przeworski and colleagues at Penn State University observed that people in therapy for GAD manifested their worries in different ways based on how they interact with other people. In two studies, the researchers found four distinct interactive styles prominent among people with GAD — intrusive, cold, nonassertive, and exploitable.  Both studies supported the presence of these four interpersonal styles and their significant role in how people with GAD manifested their worrying.

“All individuals with these styles worried to the same extent and extreme, but manifested those worries in different ways,” Przeworski said.

Take the examples of two people with similar worries about someone’s health and safety. One person may exhibit that worry through frequent intrusive expressions of concern for the other person. Think of the parent or spouse who calls every five minutes to get an update on what’s happening. Another person may exhibit the worry by criticizing the behaviors that the person believes to be careless or reckless.

“The worry may be similar, but the impact of the worry on their interpersonal relationships would be extremely different. This suggests that interpersonal problems and worry may be intertwined,” Przeworski says.

She suggests that therapies to treat GAD should target both the worry and the related interpersonal problems.

Most treatments for GAD rely on cognitive behavioral therapy, a treatment that is usually successful for about 60 percent of people, a percentage considered successful in therapy. However, one way to improve therapy for worriers may be to integrate techniques that target the interpersonal relationship problems.

The researchers published their findings in the article, “Interpersonal Pathoplasticity in Individuals With Generalized Anxiety Disorder,” in the Journal of Abnormal Psychology and called for integrating the therapies for worrying and relationship issues.

In addition to Przeworski, contributing to the study were Pennsylvania State University researchers: Michelle G. Newman, Aaron L. Pincus, Michele B. Kasoff, Alissa S. Yamasaki and Louis G. Castonguay. The research was part of larger study supported by the National Institute of Mental Health.

Material adapted from Case Western Reserve University.

Researcher Sonja Lyubomirsky

PAIs are intentional activities such as performing acts of kindness, practicing optimism, and counting one’s blessing gleaned from decades of research into how happy and unhappy people are different. This new approach has the potential to benefit depressed individuals who do not respond to pharmacotherapy or are not able or willing to obtain treatment, is less expensive to administer, is relatively less time-consuming and promises to yield rapid improvement of mood symptoms, holds little to no stigma, and carries no side effects.

More than 16 million U.S. adults – about 8 percent of the population – suffer from either major or chronic depression. About 70 percent of reported cases either do not receive the recommended level of treatment or do not get treated at all, according to the National Institute of Mental Health. Globally, the World Health Organization estimates that depression affects more than 100 million people.

Although antidepressants can be lifesaving for some individuals, initial drug therapy produces full benefits in only 30 percent to 40 percent of patients. Even after trying two to four different drugs, one-third of people will remain depressed.

The research team – Kristin Layous and Joseph Chancellor, graduate students at UC Riverside; Sonja Lyubomirsky, professor of psychology and director of the Positive Psychology Laboratory at UC Riverside; and Lihong Wang, M.D., and P. Murali Doraiswamy, M.B.B.S., FRCP, of Duke University – conducted a rigorous review of previous studies of PAIs, including randomized, controlled interventions with thousands of normal men and women as well as functional MRI scans in people with depressive symptoms.

“Over the last several decades, social psychology studies of flourishing individuals who are happy, optimistic and grateful have produced a lot of new information about the benefits of positive activity interventions on mood and well-being,” Lyubomirsky said. However, such findings have not yet entered mainstream psychiatric practice.

“Very few psychiatrists collaborate with social scientists and no one in my field ever reads the journals where most happiness studies have been published. It was eye-opening for me as a psychopharmacologist to read this literature,” Doraiswamy said.

Lyubomirsky said that after she and Doraiswamy exchanged notes, “the obvious question that popped up was whether we can tap into the PAI research base to design interventions to galvanize clinically depressed people to move past the point of simply not feeling depressed to the point of flourishing.”

Although the paper found that positive activity interventions are effective in teaching individuals ways to increase their positive thinking, positive affect, and positive behaviors, only two studies specifically tested these activities in individuals with mild depression.

In one of these studies, lasting improvements were found for six months. Effective PAIs used in the study included writing letters of gratitude, counting one’s blessings, practicing optimism, performing acts of kindness, meditating on positive feelings toward others, and using one’s signature strengths, all of which can be easily implemented into a daily routine at low cost.

People often underestimate the long-term impact of practicing brief, positive activities, Lyubomirsky said. For example, if a person gets 15 minutes of positive emotions from counting her blessings, she may muster the energy to attend the art class she had long considered attending, and, while in class, might meet a friend who becomes a companion and confidant for years to come. In this way, even momentary positive feelings can build long-term social, psychological, intellectual, and physical skills and reserves.

The researchers’ review of brain imaging studies also led them to theorize that PAIs may act to boost the dampened reward/pleasure circuit mechanisms and reverse apathy – a key benefit that does not usually arise from treatment with medication alone.

“The positive activities themselves aren’t really new,” said Layous, the paper’s lead author. “After all, humans have been counting their blessings, dreaming optimistically, writing thank you notes, and doing acts of kindness for thousands of years. What’s new is the scientific rigor that researchers have applied to measuring benefits and understanding why they work.”

A major benefit of positive activities is that they are simple to practice and inexpensive to deliver.

“If we’re serious about tackling a problem as large as depression, we should be as concerned about the scalability of our solutions as much as their potency,” Chancellor said,

While PAIs appear to be a potentially promising therapy for mild forms of depression,” Doraiswamy cautioned, “they have not yet been fully studied in people with moderate to severe forms of depression. We need further studies before they can be applied to help such patients.”

Kim Jobst, a physician and editor-in-chief of the Journal of Alternative and Complimentary Medicine, said the review provides one location in which to reference all relevant PAI findings to date, and includes recommendations that should prove useful to researchers, clinicians and the public. The journal is devoted to publishing research about novel and unconventional treatment approaches.

Material adapted from University of California – Riverside.

Download / Reference
Kristin Layous, Joseph Chancellor, Sonja Lyubomirsky, Lihong Wang, & P. Murali Doraiswamy. Delivering Happiness: Translating Positive Psychology Intervention Research for Treating Major and Minor Depressive Disorders. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE, Volume 17, Number 8, 2011, pp. 1–9.

Researcher Michael Sharpe, MD

“People with these symptoms make up one-third of all clinic visits, but the outcomes are poor,” said study author Michael Sharpe, MD, of the University of Edinburgh in Scotland.

Previous studies have shown that intense cognitive behavioral therapy can reduce the symptoms, distress, and disability in people with these symptoms, but there are obstacles to providing this therapy. Many people do not feel psychological treatment is appropriate and resist referrals to mental health services, and therapists trained in cognitive behavioral therapy are not available in all communities.

Cognitive behavioral therapy, also known as CBT, aims to improve people’s physical symptoms, emotional state, and functioning by helping them to understand, and where necessary change, how they think about and respond to their symptoms and life situation.

For the study, the researchers developed a self-help workbook especially for patients with physical symptoms that was based on the therapy. A total of 62 people were given the workbook and over three months had up to four half-hour hour sessions guiding them in the use of the book with a nurse at their neurologist’s office in addition to their usual medical care. They were compared to 63 people who received only their usual medical care. Most of the participants also had psychiatric diagnoses, such as panic disorder, anxiety disorder, and depression.

After three months, the people who received the extra therapy were approximately twice as likely to report improvements in their overall health as those who did not receive the extra therapy. A total of 13 percent more people who received the extra therapy reported that their health was “better” or “much better” than those who received only their usual care.

After six months, there was no longer a significant difference in improvements in overall health between the two groups. However, those receiving the extra therapy continued to have greater improvement in their symptoms than those who received the usual care and also in their physical functioning. They were also more satisfied with their treatment.

“This study suggests that cognitive behavioral therapy-based guided self-help may be a new and potentially useful first step in improving the management of these challenging symptoms,” Sharpe said. “This approach needs further evaluation but can be a potentially effective and cost-effective first step toward providing more help for these often neglected patients.”

Material adapted from American Academy of Neurology (AAN).

Researcher Devin Mueller

This is the first time that a therapeutic treatment has been shown to block the retrieval of memories associated with drug addiction, a major reason many addicts experience relapse, says Mueller. The research is published in the August issue of the journal Neuropsychopharmacology (“Inhibition of β-Adrenergic Receptors Induces a Persistent Deficit in Retrieval of a Cocaine-Associated Memory Providing Protection against Reinstatement.”)

Cocaine is one of the worst drug addictions to kick, with about 80 percent of those trying to quit experiencing a relapse within six months.

“Right now, there are no FDA-approved medications that are known to successfully treat cocaine abuse,” says Mueller, “only those that are used to treat the symptoms of cocaine withdrawal, which are largely ineffective at preventing relapse.”

The effects of propranolol were long-lasting and could be permanent, he says, even without subsequent doses and even in the presence of stimuli known to induce relapse.

Currently, “exposure therapy” is used to help recovering addicts suppress their drug-seeking behavior. In this therapy, the patient is repeatedly exposed to stimuli that provoke cravings but do not satisfy them. Done repeatedly over time, the patient experiences less craving when presented with those stimuli.

The success of exposure therapy, however, is limited. Combining therapy with the use of propranolol, says Mueller, would boost the effectiveness of the treatment.

Propranolol was chosen for the memory study because it has been used before to ease some withdrawal symptoms experienced by recovering cocaine addicts. Those using the drug were able to continue exposure therapy for longer periods than those without the drug. But Mueller adds that propranolol has never been tested for use with memory extinction before.

In order to develop a drug treatment for overcoming relapse, the next step in the research is to determine where in the brain propranolol acts to mediate the retrieval of cocaine-associated memories.

Material adapted from University of Wisconsin – Milwaukee.

Researchers from the Technical University of Lisbon and Bangor University enrolled overweight and obese women on a year-long weight loss program. Half the women were given general health information about good nutrition, stress management, and the importance of looking after yourself. The other half attended 30 weekly group sessions (the behavioral intervention plan) where issues such as exercise, emotional eating, improving body image and the recognition of, and how to overcome, personal barriers to weight loss and lapses from the diet were discussed.

On the behavioral intervention plan, women reported that the way they thought about their body improved and that concerns about body shape and size were reduced. Compared to the control group they were better able to self-regulate their eating and they lost much more weight – losing on average 7% of their starting weight compared to less than 2% for the control group.

Dr. Teixeira from Technical University of Lisbon, who led the research, said, “Body image problems are very common amongst overweight and obese people, often leading to comfort eating and more rigid eating patterns, and are obstacles to losing weight. Our results showed a strong correlation between improvements in body image, especially in reducing anxiety about other peoples’ opinions, and positive changes in eating behavior. From this we believe that learning to relate to your body in healthier ways is an important aspect of maintaining weight loss and should be addressed in every weight control program.”

Material adapted from BioMed Central.

Download / Reference
Eliana V Carraca, Marlene N Silva, David Markland, Paulo N Vieira, Claudia S Minderico, Luis B Sardinha and Pedro J Teixeira (in press). Body image change and improved eating self-regulation in a weight management intervention in women. International Journal of Behavioral Nutrition and Physical Activity.

This prospective observational cohort study included 38,717 (mean age: 45 years; 76% female) public sector employees who responded to a survey in 1997, 2000–2001, and/or 2004 and had no history of depression at entry. Dispositional optimism and pessimism were assessed via the revised Life Orientation Test and linked to individual records of indicators of depression onset in comprehensive national health registers, and of long-term psychotherapy for depression in particular.

During a mean follow-up of 4.0 years, 1,616 (4%) incident cases of depression were observed. Of them, 79 started long-term, state-subsidized psychotherapy for depression. A 1-unit increase in mean optimism score was associated with a 38% lower likelihood of initiating psychotherapy as a treatment for depression and a 32% lower likelihood of depressive disorder in general during follow-up.

Pessimism score was not associated with initiation of psychotherapy for depression, but a 1-unit increase in pessimism score was associated with a 28% increase in the likelihood of depressive disorder. These findings were robust to adjustments for demographics, health risk behaviors, and somatic diseases at baseline.

This study suggests that although both low optimism and high pessimism increase the risk for depression, only low optimism influences the initiation of psychotherapy as a treatment modality for depression. This could imply that depressed patients with low optimism should receive more attention in the beginning of the depressive episode than patients with high optimism.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Karlsson, H., Kronström, K., Nabi, H., Oksanen, T., Salo, P., Virtanen, M., Suominen, S., Kivimäki, M., & Vahtera, J. Low Level of Optimism Predicts Initiation of Psychotherapy for Depression: Results from the Finnish Public Sector Study. Psychother Psychosom 2011; 80:238-244.

Researcher Jennifer Lau

Having shown in the lab that positive or negative styles of thinking can be induced in adolescents without any anxiety problems, the team now wants to see if it is possible to change the negative thoughts that can drive problems in teenagers with high anxiety.

The researchers from Oxford University, along with a colleague at the Institute of Psychiatry, published their findings in the Springer journal Child Psychiatry and Human Development.

‘It’s thought that some people may tend to draw negative interpretations of ambiguous situations,’ explains Dr. Jennifer Lau who led the work at the Department of Experimental Psychology at Oxford University. ‘For example, I might wave at someone I recently met on the other side of the street. If they don’t wave back, I might think they didn’t remember me – or alternatively, I might think they’re snubbing me. People with anxiety are more likely to assume the latter interpretation. These negative thoughts are believed to drive and maintain their feelings of low mood and anxiety. If you can change that negative style of thinking, perhaps you can change mood in anxious teenagers.’

Adolescence appears to be a general period of vulnerability when problems with anxiety and depression can first emerge, and new treatments are needed. Cognitive behaviour therapy, for example, doesn’t work for everyone and it may not be available everywhere.

Estimates vary about prevalence of anxiety among teenagers, but it could be around 10-15%. The teenage years are a period when biological changes coincide with the development of areas of the brain involved in emotional control and with big social changes, such as changing schools and friendship groups, and first romantic interests. Yet despite this, anxiety and depression in adolescents has remained a rather neglected area of study compared with adults.

‘Of course it’s normal for teenagers to be worried about exams, friends, social acceptance, and about the future generally,’ says Dr Lau. ‘But anxiety can become a problem when it becomes persistent or is out of proportion to the situation. For example, when someone is doing well at school but still worries all the time and can’t control the worry. In some extreme cases kids avoid going to school because they are anxious. This is not being just a little bit worried.’

Dr. Lau and colleagues set out to assess whether simple training tasks carried out at a computer screen can change the reactions teenagers have to imagined social situations, leading them to take either more positive interpretations of the situations or more negative.

Thirty-six healthy teenagers from schools in Oxfordshire and Buckinghamshire took part in the study, and were randomly allocated to receive training designed to boost positive readings of scenarios or negative readings. The training consisted of working through a set of short scenarios involving social situations that are familiar – such as reading a comment about your photo on facebook – but ambiguous in how you might respond to them emotionally. The volunteers then had to complete these ambiguous stories, being prompted to give answers which tended to resolve the situation in either a positive way or a negative way – depending on what type of training they were allocated to in the study.

Following this period of training, the researchers assessed if there was any difference in how likely participants were to rate further scenarios as positive or negative. Volunteers’ mood was also assessed throughout the study.

The researchers found that the training task was able to induce different interpretation biases in the teenagers. Those who received positive training tended to endorse positive readings of the ambiguous scenarios, while those who received the negative training were more likely to view the scenarios more negatively. It suggests that the approach is able to shift teenager’s interpretations of situations, at least in this laboratory setting.

Dr. Lau says: ‘Although these results are early, and among a limited number of healthy teenagers, we hope this approach to encourage positive interpretations of events will prove to be a powerful tool. If we are able to intervene early and effectively in teenagers with anxiety, we may be able to prevent later adult problems.

‘The next steps are to give people with high levels of anxiety these training tasks to see if it helps change their mood over significant periods of time.’

Material adapted from Springer.

Reference
‘The plasticity of adolescent cognitions: Data from a novel cognitive bias modification training task’ by Jennifer Y F Lau et al. is published online in the journal Child Psychiatry and Human Development. DOI 10.1007/s10578-011-0244-3.

Forty-three children (ages 5–7) with SAD and their parents were assigned to either a 16-session disorder-specific SAD treatment program including parent training and classical cognitive-behavioral therapy (CBT) components, or to a 12-week waiting list
group. Categorical and/or continuous data for anxiety, impairment/distress, and quality of life were collected at baseline, after treatment/waiting list condition, and at a 4-week follow-up.

Intention-to-treat analyses indicate that 76.19% of children allocated to the treatment group no longer fulfilled DSM-IV criteria for SAD at follow-up, compared to 13.64% in the waiting list group. In addition, between 91 and 100% of children rated themselves or were rated by their father, mother, or therapist as very much or much improved on the global success rating immediately after treatment. Results indicated large time 
by treatment condition interaction effect sizes (d = 0.98 – 1.41) across informants for reduction of distress/avoidance in separation situations for the treatment condition.

Further, parents reported significant improvements in impairment/distress in the child’s major life domains and the
 child’s quality of life. Treatment gains were maintained at the 4-week follow-up assessment.

In summary, short-term efficacy of Cognitive-Behavioral Therapy (CBT) for Separation Anxiety Disorder was found to be very effective in young children.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Schneider, S., Blatter-Meunier, J., Herren, C., Adornetto, C., In-Albon, T., & Lavallee, K. Disorder-Specific Cognitive-Behavioral Therapy for Separation Anxiety Disorder in Young Children: A Randomized Waiting-List-Controlled Trial. Psychother Psychosom 2011;80:206-215

Worrying prolongs stress-related physiology, mediates the effects of stressors on common somatoform symptoms, and predicts cardiovascular morbidity. The Authors of this study tested the effectiveness of a guided self-help intervention aimed at reducing worrying. This ‘worry postponement and disengagement’ intervention requires people to reschedule worries to a specific moment of the day during which thinking about worry topics, in a prestructured manner, is promoted.

They tested whether this intervention reduced severe health complaints as experienced by outpatients suffering from work stress. Additionally, they investigated if this 2-week intervention enhanced a standard stress management group therapy (SMT) by delivering the intervention to patients awaiting SMT. A crucial assumption was that decreasing perseverative thoughts is a prerequisite for SMT to be fully effective.

Sixty-two patients participated, suffering from DSM-IV axis I diagnoses of adjustment disorder, unspecified somatoform disorder (burnout), or severe work problems (axis IV). Participants provided informed consent and completed the Subjective Health Complaints questionnaire (SHC) [6], the State Trait Anxiety Inventory – trait version (STAI-T), and the Beck Depression Inventory – second version (BDI-II). They were then randomly allocated to 1 of 3 conditions: worry postponement and disengagement (WPD; n = 22), registering worry frequency and duration (worry registration; WR; n = 15) or a waitlist control condition: treatment as usual (TAU; n = 25).

Participants were asked to practice the intervention (WPD or WR) for 2 weeks, after which SMT started. Outcome measures were sent to participants at the end of SMT and at a 3-month follow-up. At the end of the investigation, the most innovative overall finding was that participants who had received the WPD intervention showed the largest decreases in somatoform, anxiety, and to a lesser extent depressive symptoms. However, these effects were only apparent when WPD was compared to a waitlist control group and not when comparing the WPD intervention to the mere registering of worries. This could imply that the simple intervention of registering worries is already sufficient to improve SMT.

Clearly, more research is needed, for example into the temporal differences in the reduction of symptoms and into different pretreatment interventions. However, this preliminary study is the first to suggest that a ‘pretreatment’ intervention directed at a crucial pathogenic process, i.e. worry, might enhance a cognitive-behavioral group therapy.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Verkuil, B., Brosschot, J.F., Korrelboom, K., Reul-Verlaan, R., & Thayer, J.F. Pretreatment of Worry Enhances the Effects of Stress Management Therapy: A Randomized Clinical Trial. Psychother Psychosom 2011;80:189-190.

Future randomized controlled studies should examine whether this intensive CBASP program is more effective than standard psychiatric interventions or CBASP outpatient treatment.

Cognitive behavioral analysis system of psychotherapy (CBASP) was initially developed as an outpatient treatment for chronic depression. It integrates cognitive-emotional, behavioral, interpersonal, and psychodynamic theories and strategies by addressing directly the specific psychopathology of chronic depression. Given the high degree of suicidality, comorbidity, and therapy resistance in chronic depression, however, many of these patients require inpatient treatment.

In this study, the investigators report on a first specialized program for chronic depression that adapted CBASP to an inpatient setting and evaluated the feasibility and short- and long-term outcome. The new CBASP group therapy focuses on a modified approach for conducting situation analysis and on Kiesler’s circle training with the extensive use of role playing and shaping. The entire treatment team was trained in CBASP; regular workshops and weekly supervisions for both the team and the individual therapists were conducted. Specific CBASP elements were implemented in other accompanying treatments, such as nurse encounters, physiotherapy, music therapy, and occupational group therapy. A patient support group was established to avoid relapse after discharge. Patients received optimized pharmacotherapy in addition to the CBASP program in compliance with current national and international guidelines for depression treatment.

Ten inpatients with severe chronic depression according to DSM-IV were included in this pilot study. The SCID I and II were used for diagnosis. Early trauma and life events were assessed by using the Childhood Trauma Questionnaire (CTQ). Follow-up data were collected 6 months after discharge. Concerning feasibility, all patients completed the treatment. The CBASP concept proved to be feasible and there were no major difficulties integrating the concept into the daily clinical routine.

The 24-item version of the Hamilton Depression Rating Scale (HAMD) served as the primary outcome measure and the Beck Depression Inventory (BDI) as the secondary measure. T-tests for paired samples revealed significant improvements and large effect sizes in the primary outcome HAMD-24 (p = 0.000) and in the BDI (p = 0.002). Treatment response was defined a priori as a reduction in symptom severity of at least 50% on the HAMD, and remission was defined as a score of 10 or less on the HAMD scale.

Six out of the 10 patients were classified as responders and 4 of these fulfilled the remission criterion. Exploratory analyses revealed that the nonresponders had a significantly higher number of personality disorders (p = 0.038). Finally, the 6-month naturalistic follow-up assessments were completed by 9 out of the 10 patients. Outpatient psychotherapy was continued by 6 patients (CBASP: 3, cognitive-behavioral therapy:2, schema therapy: 1), 9 patients were still on pharmacotherapy, and 6 patients regularly attended the CBASP support group. The findings on short- and long-term outcomes as well as on feasibility of the inpatient CBASP program are promising.

However, response rates were lower in this in-patient study than those in outpatient CBASP studies. This might be a consequence of the inclusion of a more severely ill patient sample with high comorbidity, long duration of the depressive episode, and high levels of therapy resistance. Concerning follow-up data, it is remarkable that the patients who remitted remained in remission over 6 months, that all patients had improved satisfaction with psychosocial domains, and that only 1 patient relapsed.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Brakemeier, E.-L., Engel, V., Schramm, E., Zobel, I., Schmidt, T., Hautzinger, M., Berger, M., Normann, C.: “Feasibility and Outcome of Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronically Depressed Inpatients: A Pilot Study,” Psychother Psychosom 2011;80:191-194.

Researcher Donald Penzien

He said the costs of prescription prophylactic drugs – the kind chronic migraine sufferers take every day to prevent onset – may not seem much even at several dollars a day.

“But those costs keep adding up with additional doctor visits and more prescriptions,” Penzien said. “The cost of behavioral treatment is front-loaded. You go to a number of treatment sessions but then that’s it. And the benefits last for years.”

Published in the June issue of the journal Headache, the study compared the costs over time of several types of behavioral treatments with prescription-drug treatments. The research team included investigators from Wake Forest University, UMMC and the University of Mississippi.

The researchers found that after six months, the cost of minimal-contact behavioral treatment was competitive with pharmacologic treatments using drugs costing 50 cents or less a day. Minimal-contact treatment is when a patient sees a therapist a few times, but largely practices the behavioral techniques at home, aided by literature or audio recordings.

After one year, the minimal-contact method was nearly $500 cheaper than pharmacologic treatment.

“We have a whole armamentarium of behavioral treatments and their efficacy has been proven. But headache sufferers are only getting a tip of these options,” said Dr. Timothy Houle, associate professor of anesthesiology and neurology at Wake Forest University, and the study’s principal investigator. “One reason is people think behavioral treatment costs a lot. Now with this study, we know that the costs are actually comparable, if not cheaper, in the long run.”

At a time when health-care costs are under national scrutiny, the study offers a framework for comparing costs that researchers can update and use for years to come.

“We thought, ‘Wouldn’t it be fun to model this and see how it comes out over time?’” Penzien said. “All the figures are there so if someone disagrees with it, they can plug in their own numbers.”

The researchers did not compare the effectiveness of methods, nor did they calculate the costs over time of individual drugs, since dosages and prices vary widely. Rather, they figured the per-day costs of each method based on fees of physicians and psychologists. For the physician group, they added in the cost of prescription beta-blocker drugs at various prices.

For instance, among the psychologists surveyed, one-on-one behavioral sessions cost between $70 and $250 for the intake visit and $65 and $200 for follow-up visits. That put the median intake cost at $175 and median follow-up cost at $125 for a median 10 visits.

The researchers calculated the median cost of pharmacologic approaches at $250 for the intake session and a professional fee of $140 per session. Median time to the first follow-up was 52.2 days, rising to 60 for the second with a median five visits per year.

To get information on behavioral treatments, the researchers surveyed members of the Behavioral Issues Group of the American Headache Society. For figures on pharmacologic treatments, the researchers surveyed a group of Headache Society-member physicians they knew treated substantial numbers of headache sufferers.

The most expensive behavioral treatment method – individual sessions with a psychologist in clinic – cost more than pharmacologic treatment with $6-a-day drugs in the first months. But at about five months, individual sessions become competitive. After a year, they are cheaper than all methods except treatment with drugs costing 50 cents or less a day.

Overall, group therapy and minimal-contact behavioral treatment were cost-competitive with even the cheapest medication treatment in the initial months. At one year, they become the least-expensive headache treatment choice.

Material adapted from University of Mississippi Medical Center .

The study, funded by the MS Society, was led by Professor Nadina Lincoln, of the University’s Institute of Work, Health and Organisations. She said: “These are very encouraging findings as many people with MS have problems with depression and anxiety and there are few treatments provided in NHS clinical services to address these. It is important that the psychological effects of MS are fully recognized as they can have a devastating effect on people’s lives.”

Depression and anxiety are common among sufferers of MS, a disabling neurological condition that affects around 100,000 people in the UK.

Previous studies have suggested that depression in MS can lead to patients failing to take their medication and a reduced quality of life. National Institute for Health and Clinical Excellence (NICE) guidelines also recognize that many people with both MS and depression or anxiety would prefer not to take antidepressants and recommends that psychological therapies should be offered as an alternative.

For the Nottingham study researchers recruited MS patients currently attending clinics run by Nottingham University Hospitals NHS Trust, as well as inviting referrals from specialist MS nurses and placing adverts in publications produced by the MS Society. The volunteers were asked to complete questionnaires about how MS affects their daily lives and the extent to which they felt in control.

The patients were then randomly divided into two groups of just over 70 people. One group received all the usual care offered to MS and were put on a waiting list to receive group therapy at the end of the study.

The other group were invited to attend a course of six two-hour sessions of group therapy attended by up to eight participants at a time. Each session was led by a research psychologist, supervised by a qualified clinical psychologist with experience of working with people with MS.

Each session focussed on a topic, such as worry, gloom, and relationships and was followed by practical exercises in strategies to cope with emotional problems and group discussion. They finished with relaxation exercises and group members were given tasks centered on practicing coping strategies between sessions.

To assess the effectiveness of the sessions, questionnaires were sent to the participants at both four and eight months later and the results of those who received treatment were compared to those on the waiting list only.

The researchers found that those MS sufferers who attended the group sessions had fewer problems with anxiety and depression, the impact of the disease on their daily lives was reduced, and their quality of life improved.

In terms of potential savings to the NHS, the researchers have also collected information on cost, which will be submitted for a future publication. They found that costs were reduced by £470 per patient for those who attended the therapy sessions compared with usual care. It was shown to almost halve the cost of visits to the GP, falling from £11,340 at the start of the study to just £5,832 at the eight month follow up. The costs of outpatient hospital visits were also slashed from £32,592 at the beginning of the study to £21,534 at the eight-month follow-up.

The next stage of the research will be to assess whether the group therapy approach works equally well in other centres through a larger study with the hope that the treatment could potentially be provided through NHS services for those with MS.

Dr. Susan Kohlhass from the MS Society said: “Knowing group-based sessions can reduce anxiety and depression is a strong development towards improving the quality of peoples’ lives with MS. We are committed to funding work that will imminently benefit people with the condition and this is a great example. The next stage will be to find if this approach is as effective in other areas of the country.”

Future research will greatly benefit from the MS Society-supported MS Register project. The MS Register is the world’s first (in any condition) that brings together information submitted by people, alongside data provided by clinicians and other routinely collected information. MS patients can register through their own portal via www.ukmsregister.org which is now open to anyone with MS. The register will facilitate access to research studies, while the information from clinicians will come through a different portal. Nottingham is one of five centers where this project, coordinated by a team from the University of Swansea, is being piloted initially.

The study, which is due to be published in the journal Multiple Sclerosis, involved a multidisciplinary team of researchers from the University’s Institute of Work, Health and Organisations, Division of Rehabilitation and Ageing, Division of Clinical Neurology and Trent Research and Development Support Unit in collaboration with the University of Swansea. The study was funded with a grant from the Multiple Sclerosis Society.

Material adapted from University of Nottingham.

Download / Reference
Lincoln, Nadja B. et.al. “Evaluation of an adjustment group for people with multiple sclerosis and low mood: a randomized controlled trial“, Multiple Sclerosis, May 25, 2011, DOI 10.1177/1352458511408753.

Results show that about 21 percent of participants with insomnia (65 of 303) reported having suicidal thoughts or wishes during the past two weeks. Group cognitive-behavioral therapy for insomnia produced a statistically significant post-treatment reduction in suicidal ideation. Treatment sessions were conducted weekly until the final two sessions, which were conducted bi-weekly.

According to the authors, a growing body of evidence suggests that self-reported insomnia and poor sleep quality constitute modifiable risk factors for suicide. Sleep complaints also are listed among the top suicide warning signs by the Substance Abuse and Mental Health Service Administration. However, no previous studies had evaluated the impact of a sleep intervention on suicidal ideation.

“This is the first investigation to show that a sleep-targeted intervention has a therapeutic impact on suicide risk specifically,” said lead author Rebecca Bernert, PhD, a fellow in the Department of Psychiatry and Behavioral Sciences at Stanford University in California. “This suggests that a treatment focus on sleep disturbances may have important implications for the prevention of suicidal behaviors.”

The study involved 303 community outpatients between 18 and 88 years of age who completed group cognitive behavioral therapy for insomnia. The Beck Depression Inventory, which includes a question about suicidal thoughts or wishes, was administered at both baseline and post-treatment.

According to the Centers for Disease Control and Prevention, the most recent data available indicate that the national suicide rate increased from 2008 to 2009, when suicide became the 10th-leading cause of death in the U.S. There were 36,547 deaths attributed to suicide in 2009, which was more than twice as many deaths as those that were attributed to homicide.

Last year at SLEEP 2010, Bernert reported that highly variable sleep schedules predicted increases in suicidal risk at one week and three weeks. Sleep irregularity also predicted greater mood lability, which in turn predicted elevated suicidal symptoms.

Individuals experiencing emotional distress or a suicidal crisis are encouraged to call the toll-free National Suicide Prevention Lifeline, a 24-hour crisis hotline, at 1-800-273-TALK. Those suffering from persistent sleep problems are encouraged to consult a sleep expert at one of more than 2,200 AASM-accredited sleep disorders centers across the U.S.

Material adapted from American Academy of Sleep Medicine.

“People seem to agree on what the office of a good therapist would look like and, especially, what it wouldn’t look like,” said Jack Nasar, co-author of the study and professor of city and regional planning at Ohio State University.

“Whether it is through cultural learning or something else, people think they can judge therapists just based on their office environment.”

Nasar conducted the study with Ann Sloan Devlin, professor of psychology at Connecticut College. Their study appears online in the Journal of Counseling Psychology and will appear in a future print edition.

The research involved several experiments in which people viewed 30 digital color photographs of actual psychotherapist offices in Manhattan. All were taken by photographer Saul Robbins as part of an artistic project, and he gave permission to the researchers to use the photographs in the study.

The photos showed a view of the therapist’s chair and surrounding office from the perspective of where the client would sit.

Altogether, 242 college students participated in the studies – about 60 percent of whom had seen a therapist themselves. The researchers found no difference in results between those who had seen a therapist and those who hadn’t, men and women, people of different ages, or residents of a small Northeastern town and residents of a large Midwestern city, suggesting the results are generalizable, Nasar said.

Before the study began, 12 graduate students rated each of the 30 offices on a wide range of characteristics, such as neatness, spaciousness, and amount of personalization.

In the first study, students were asked to imagine visiting a therapist for an emotional problem. As they looked at each photo, they were asked to rate each office for the quality of care expected and how comfortable they would feel in it. They rated these qualities on a seven point scale from very poor to very good.

Participants said they would be more comfortable and expect better care in offices that had been rated as more orderly and that had more personal touches, such as a pillow, diplomas hanging on the wall, or photos. They also thought more highly of therapists whose offices had a “softer” feel – those that had cushioned chairs, carpeting, table lamps, plants, and throw rugs.

In a second study, participants thought orderly, personalized, and softer offices had therapists who were bolder and more qualified. Offices rated as softer were viewed as having friendlier therapists.

A third study asked participants to view the photos and simply write the first thought or feeling that came to mind regarding a patient’s likely experience in the office, the therapist who occupied the office, and the office itself.

And in a final study, the researchers asked the participants to choose which offices they would want to go to if they had to see a therapist, and which ones they would most want to avoid.

“The top-rated offices also pointed to the importance of softness and order,” Nasar said. “For the top five offices, participants most frequently described the office as comfortable, nice, clean, warm and inviting.”

In contrast, the bottom five offices were described as cluttered, cramped, messy, uncomfortable, and unprofessional.

Nasar said there was more agreement about which offices were the worst than about which were the best.

“People have less agreement about what makes an office good, but the negative aspects really stood out to them in a consistent way,” he said.

Therapists who worked in the top five rated offices were also seen more favorably – more organized, professional, friendly, experienced – than those in the bottom five offices.

However, there was also gender stereotypes associated with the offices, Nasar said. The therapists in the top-rated offices were more likely to be seen as men, whereas those in the bottom-rated offices were more often identified as women in the open-ended comments.

Participants in this study thought they would get better therapists in some offices, and that might be true, Nasar said. Research shows that judgments about people from the places they occupy are often accurate.

Even if the judgments are not accurate, therapists should take the look of their offices seriously.

“These results suggest that someone visiting a therapist in a low-rated office for the first time may not want to come back.

“It may seem obvious that people will judge someone by the office they keep, but we found that these offices vary a great deal. There are therapists out there who don’t know or who don’t care that they are sending out bad signals to their clients.”

Nasar said therapists should take these findings to heart.

“I would tell therapists to keep their offices soft and friendly looking. Put up your diplomas and personalize the office. Arrange everything in a neat and orderly way and keep it that way.”

Material adapted from Ohio State University.

“The consequences of this unmet need are great,” report the authors. “The interactive nature of the two disorders leads to poorer depression and substance abuse treatment outcomes compared with the outcomes when only one disorder is treated.”

Katherine E. Watkins, M.D., M.S.H.S., from RAND Corporation, Santa Monica, Calif., and colleagues conducted the study at four Behavioral Health Services facilities in Los Angeles County, Calif. Between August 2006 and January 2009, the sites alternated every four months between usual care for substance abuse and usual care plus cognitive behavioral therapy as modeled in the Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) study. The intervention comprised 16 two-hour BRIGHT sessions over the course of eight weeks.

Initially, 1,262 patients were screened for participation in the study. The researchers enrolled 140 patients in the intervention group and 159 patients in the control group. On average, participants scored in the clinically severe range on a scale of depression symptoms and nearly half (45.8%) had a past 12-month depressive disorder.

On the depression-symptom instrument used in the study, patients receiving the intervention generally had mild symptoms and patients receiving usual care alone generally had moderate symptoms at three months. At three months, 55.8 percent of patients in the BRIGHT group had minimal symptoms, compared with 33.6 percent in the control group; at six months, these numbers increased to 63.9 percent and 43.8 percent, respectively. Among patients no longer living in a treatment center at the six-month mark, those in the intervention group had fewer days of problem substance abuse and fewer drinking days than did those in the usual care group.

With the study, the authors hope to address a gap in the substance abuse treatment system, particularly in the public sector. They note that the BRIGHT intervention involved substance abuse counselors, as opposed to other mental health professionals and resources that some substance abuse programs cannot access.

“The study demonstrates that it is possible to develop the capacity of substance abuse programs to deliver evidence-based mental health care by enhancing the skills and expanding the clinical roles of substance abuse counselors,” the researchers state. This is important, they add, because “Lack of access to efficacious depression treatment for substance abusers is an important public health problem.”

Material adapted from JAMA.

Reference
Arch Gen Psychiatry. 2011;68[6]:577-584

Two prior randomized controlled trials (RCTs) have shown the efficacy of STEPPS training. In both RCTs, patients with borderline features who did not meet strict DSM-IV criteria for BPD were excluded.

The authors of this study investigated the effectiveness of STEPPS in a sample representative of routine clinical practice and examined whether DSM-IV diagnosis and/or baseline severity were related to differential effectiveness. Patients whom their practicing clinician diagnosed with BPD were randomized to STEPPS plus adjunctive individual therapy (STEPPS, n=84) or to treatment as usual (n=84). STEPPS recipients showed more improvement on measures of general and BPD-specific psychopathology as well as quality of life than treatment as usual recipients, both at the end of treatment and at a 6-month follow-up.

Presence of DSM-IV-diagnosed BPD was not related to differential treatment effectiveness, but dimensional measures of symptom severity were; STEPPS was superior to treatment as usual, particularly in patients with higher baseline severity scores. The findings show the effectiveness of STEPPS in a ‘real-world’ sample, and underscore the importance of dimensional versus categorical measures of personality disturbance.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Bos, E.H., van Wel, E.B., Appelo, M.T., & Verbraak, M.J.P.M. Effectiveness of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Borderline Personality Problems in a ‘Real-World’ Sample: Moderation by Diagnosis or Severity? Psychother Psychosom 2011;80:173-181.

A recent study from the Center for Addictions Research and Services of the Boston University School of Social Work attempted to answer this question. Dr. Maryann Amodeo and her colleagues interviewed 172 frontline addiction workers from community-based organizations that had received funding from the Center for Substance Abuse Treatment (CSAT) / Substance Abuse Mental Health Services Administration (SAMHSA) to implement EBPs.  Qualitative interviews, ones that allowed participants to express themselves in their own words, rather than a forced-choice response questionnaire, were used in this study.

Amodeo and her colleagues chose to focus on four common EBPs in the substance abuse treatment field.

Two were individually-oriented approaches:

1. Motivational Interviewing (MI), a brief approach that targets and builds on client motivation to change.
2. Cognitive-Behavioral Therapy (CBT), a theoretical umbrella under which a host of present-focused techniques involve identifying and modifying triggers for substance abuse, especially clients’ thought patterns, and reinforcing sobriety-related activities.

The other interventions focused on the broader environmental level:

1. Adolescent Community Reinforcement Approach (A-CRA), a behavioral approach, that aims to supplant reinforcers for substance abuse with environmental contingencies (particularly those applied by family members) that are supportive of recovery.
2. Assertive Community Treatment (ACT): a team treatment approach that delivers comprehensive, individually tailored case management services for clients who suffer both from severe mental illness, as well as substance-use disorders.

The authors of this study found that different barriers to implementation accompanied each type of EBP.  Barriers were categorized as having to do with the following:

1. EBP characteristics: barriers having to do with the intervention itself. Thirty-eight percent of A-CRA participants responded in this category as A-CRA requires what is perceived as a burdensome certification process in order to practice the model.
2. Practitioner or Organizational barriers: those having to do with philosophical or practical barriers that arise with the practitioner or the organization. More than half (54%) of MI respondents named barriers in this category.  Front-line workers complained of not receiving sufficient training in order to implement the model well. Another barrier was the conflict between the philosophy of staff and/or the organization, which tended toward an Alcoholics Anonymous perspective, and the assumptions underlying Motivational Interviewing.
3. Client characteristics. A majority of those implementing CBT (67%) named barriers in this category. Specifically, they mentioned client resistance to CBT, clients’ lack of cognitive ability, and poor attendance. Thirty-three percent of practitioners of A-CRA complained that it was inflexible to meet individualized client needs, and they had the added challenge of engaging parents in treatment as the model demands.
4. Resources. A lack of resources, particularly housing, in the community was named as a major barrier for ACT (82% of participants).

Implications
Since respondents in this study were all from SAMHSA-funded programs that demanded, as part of their funding, that evidence-based practice was implemented, the agencies in which they worked are likely more advanced in terms of their receptivity to and knowledge of EBP’s.  Therefore, barriers in other community-based agencies are bound to loom even larger.

This study identified specific, real-world barriers that have to do with the difficulty of implementing EBPs in community-based agencies.  Developers of these models, as well as trainers, need to be aware of barriers and find ways to dispel them.  EBPs may also require more extensive training than is currently being offered in order for practitioners to feel comfortable and competent in applying them.  Finally, treatment manuals should include instruction on possible obstacles to implementation and present ways to overcome them.

Reference
Amodeo,M.,et al.Barriers to Implementing evidence-based practices in addiction treatment programs: Comparing staff reports on Motivational Interviewing, Adolescent Community Reinforcement Approach. Assertive Community Treatment, and Cognitive-behavioral Therapy. Evaluation and Program Planning (2011), doi:10.1016/j.evalprogplan.2011.02.005

This research study was conducted with patients suffering from fibromyalgia from the provinces of Granada, Almería and Córdoba, Spain. They undertook a basal test at the beginning of the treatment, a post-basal test four weeks after the intervention, and another post-basal test eight weeks after the intervention, at the end of the study.

Treatment at home
The researchers applied a relaxation technique based on guided imagery and music therapy to patients in a series of sessions conducted by a researcher. Patients were given a CD to listen at home. Then, researchers measured a number of variables associated to the main symptoms of fibromyalgia – such as pain intensity, quality of life, and the impact of the condition on patient’s daily life, sleep disorders, anxiety, depression, self-efficiency, and well-being. Then, patients were given the chance to participate in their own treatment through an understanding of their condition.

Fibromyalgia is a chronic condition that affects and conditions patients’ social, personal and working life. The study used a multidisciplinary approach to treatment developed by a team of physicians, pysiotherapists, experts in physical activity and sport, psychologists, and nurses. According to University of Granada researchers, their study confirms that the art of relaxation with guided imagery and receptive music therapy have proven effective in the alternative symptomatic treatment of this condition. The low cost, easy implementation, numerous advantages, and the fact that patients can get involved in their treatment at home are some of the many advantages of this technique.

The researchers state that “further empirical research studies are needed to address other physiological variables associated with the well-being generated by these two techniques, and that analyze patients’ self-efficiency and personal power to get involved in their own treatment.

This research was conducted by María Dolores Onieva Zafra, at the Department of Nursery of the University of Granada, and coordinated by professors Adelaida Castro Sánchez, Carmen Moreno y Guillermo Matarán. The results obtained in this study were published in the journal Pain Management Nursing.

Material adapted from University of Granada.

In this study, the researchers recruited 63 subjects with major depressive disorder (MDD) in an outpatient department of psychiatry at a general hospital. The randomly assigned subjects formed 2 groups: 29 in combined therapy (COMB) and 34 in monotherapy (MT). The COMB included 8 weekly body-mind-spirit group psychotherapy sessions added to pharmacotherapy. MT consisted of pharmacotherapy only. The outcome measures, collected at the subjects’ homes, included the Beck Depression Inventory II (BDI-II), the State Trait Anxiety Inventory (STAI), and salivary cortisol on awakening, 45 min after awakening, and at several points throughout the day.

Evaluation of outcome measures was at baseline condition, and at months 2 (end of psychotherapy), 5, and 8. At the end of investigation, while the decreases in symptoms of depression were similar between COMB and MT (p > 0.05), the reductions in anxiety state were greater in COMB than in MT during the 8-month follow-up (p < 0.05). A steeper diurnal cortisol pattern more likely occurred in COMB than in MT in the 3 follow-up periods (p < 0.05, p < 0.001 and p < 0.01).

The superior outcomes of group psychotherapy added to pharmacotherapy for outpatients with MDD could relate to decreasing the anxiety state and to producing long-term impacts on positive stress endocrine outcomes seen as a steeper diurnal cortisol pattern.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference / Abstract
Hsiao, F.-H.; Jow, G.-M.; Lai, Y.-M.; Chen, Y.-T.; Wang, K.-C.; Ng, S.-M.; Ho, R.T.H.; Chan, C.L.W.; & Yang, T.-T. The Long-Term Effects of Psychotherapy Added to Pharmacotherapy on Morning to Evening Diurnal Cortisol Patterns in Outpatients with Major Depression. Psychother Psychosom 2011;80:166-172.

A total of 182 hypochondriacal participants (139 women, mean = 42.1 years of age) were randomly assigned to a CBT or control group. All participants completed self-report measures of hypochondriasis that exceeded a predetermined threshold on 2 successive occasions (inclusion criteria). CBT consisted of 6 weekly, 90-min sessions. The control subjects received the usual medical care during the same period.

Three questionnaires (Whiteley Index, Health Anxiety Inventory, and Somatic Symptom Inventory) were used to assess hypochondriacal symptoms, and the Symptom Checklist 90R was used to assess anxiety and other psychological symptoms. These were administered before the intervention and at 6 and 12 months after the completion of the intervention.

Scores on the 3 measures of hypochondriasis were significantly decreased after treatment in the CBT compared with the control group. Anxiety and other psychological symptoms also showed significant reductions in the CBT group. High levels of pretreatment anxiety predicted decreases in the 3 hypochondriasis scores after controlling for the effects of depression, age, sex, educational level, employment status, and marital status. In short, high anxiety at entry into the CBT program predicted a better treatment outcome.

Material adapted from Journal of Psychotherapy and Psychosomatics

Reference
Nakao, M. ; Shinozaki, Y. ; Ahern, D.K. ; Barsky, A.J. Anxiety as a Predictor of Improvements in Somatic Symptoms and Health Anxiety Associated with Cognitive-Behavioral Intervention in Hypochondriasis. Psychother Psychosom 2011;80:151-158.

An experimental CBGT manual was developed and added to ‘treatment as usual,’ and results were compared with treatment as usual alone. Intention-to-treat analysis showed that there was no difference between groups in terms of time until any relapse (p = 0.414). When considering type of relapse, there was still no difference in either depressive (p = 0.068) or manic episodes (p = 0.221). Although occurrence of episodes also did not differ between groups (p = 0.59), median time to relapse was longer for patients treated with CBGT compared to the treatment as usual group (p = 0.011).

Time to recurrence and number of episodes were not different in the group of patients treated with CBGT. However, median time to relapse was shorter in the treatment as usual group. Studies with larger samples may help to clarify whether this CBGT approach prevents new episodes of bipolar disorder. These findings also indicated that CBGT is feasible in euthymic patients with bipolar disorder and should be investigated in future studies.

Material adapted from Journal of Psychotherapy and Psychosomatics

Reference
Gomes, B.C. ; Abreu, L.N. ; Brietzke, E. ; Caetano, S.C. ; Kleinman, A. ; Nery, F.G. ; Lafer, B. A Randomized Controlled Trial of Cognitive Behavioral Group Therapy for Bipolar Disorder. Psychother Psychosom 2011;80:144-150.

They report the results of a cluster randomized trial in which groups of maternity clinics in 14 municipalities in Finland were randomized to an intervention. The intervention comprised physical activity and dietary counseling, and was compared with a control arm in which usual care was offered.

The researchers find that babies born to women in the intervention arm had a roughly 44% reduced risk of being large for gestational age. However, they failed to show that the lifestyle interventions resulted in a reduced risk of gestational diabetes in women participating in the trial.

The authors comment that, “The findings of our study emphasize counseling on the topics of physical activity, diet, and weight gain in maternity care especially for women at risk for gestational diabetes in order to prevent large for gestational age newborns possibly causing problems in delivery, and both the mother’s and the child’s later weight development.”

Material adapted from Public Library of Science.

Download / Reference
Luoto R, Kinnunen TI, Aittasalo M, Kolu P, Raitanen J, et al. (2011). Primary Prevention of Gestational Diabetes Mellitus and Large-for-Gestational-Age Newborns by Lifestyle Counseling: A Cluster-Randomized Controlled Trial. PLoS Med 8(5): e1001036. doi:10.1371/journal.pmed.1001036

Their findings are published online in the June issue of Springer’s Journal of Clinical Psychology in Medical Settings, specially dedicated to contemporary psychological advances as they apply to soldiers and their families [2].

The stressful experiences that characterize the Operation Iraqi Freedom/Operation Enduring Freedom war fighting environments have produced significant numbers of returning military personnel at risk of developing PTSD. At the same time, virtual reality (VR) has stepped into clinical practice as a result of technological advances that have made it feasible and cost-effective to run VR systems on a personal computer.

What Rizzo and team’s work shows is that VR is able to deliver exposure therapy – the number one therapy recommended for PTSD – by immersing returning soldiers in simulations of trauma-relevant environments. The emotional intensity of the scenes can be precisely controlled by the clinician in collaboration with the patients’ wishes. VR allows multi-sensory and context-relevant cues that evoke the trauma without exclusively relying on the patient to actively remember and imagine actual experiences (as is required in traditional exposure approaches).

Rizzo and team review their immersive virtual reality exposure therapy (VRET) system for combat-related PTSD. Their application consists of a series of virtual scenarios, based on accounts by returning soldiers of what it is like out there in a war environment.

Their clinical results to date are encouraging. One test in particular found that 80 percent of those who completed treatment with this system showed clinically meaningful reductions in PTSD, anxiety, and depressive symptoms. In addition, anecdotal evidence from patient reports suggests improvements in their everyday lives for at least three months after treatment.

The researchers are also exploring other applications for their system, including stress resilience training (i.e., to teach soldiers coping strategies prior to deployment to better prepare them for the types of emotional challenges they are likely to encounter in the combat environment). Another area of interest for the system is the identification of those soldiers who are ready to get back into the field versus those who need further treatment or more time between deployments.

According to the authors, this new approach to psychotherapy has widespread ramifications: “The current generation of young military personnel, having grown up with digital gaming technology, may actually be more attracted to and comfortable with participation in virtual reality exposure therapy. The need for treatments to address the mental health needs of our military personnel, alongside the virtual revolution that has taken place, has led to a state of affairs which stands to transform the vision of future clinical practice and research.”

Material adapted from Springer Science+Business Media.

References
1. Rizzo A et al (2011). Virtual reality goes to war: a brief review of the future of military behavioral healthcare. Journal of Clinical Psychology in Medical Settings; DOI 10.1007/s10880-011-9247-2. Available at http://www.springerlink.com/content/03533254r5q65p86/

2. Special issue, June 2011 “Strengthening Our Soldiers (SOS) and Their Families: Contemporary Psychological Advances Applied to Wartime Problems.”

The aim of this study is to explore whether psychotherapeutic treatment yields health gains for patients cluster A personality disorders. The study was conducted between March 2003 and June 2008 in 6 mental health care centers in the Netherlands with a sample of 57 patients with a DSM-IV-TR axis II cluster A diagnosis. Patients were assigned to 3 settings of psychotherapeutic treatment (outpatient, day hospital, inpatient), and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45) and quality of life (EQ-5D) using multilevel statistical modelling. As the study was non-randomized.

Patients in the day hospital and inpatient group improved substantially in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life. Patients in the outpatient group showed less improvement. Direct comparison of the improvement of psychiatric symptoms showed significant results in favor of day hospital (p=0.046) and inpatient (p=0.01) treatment as compared to outpatient treatment. However, due to substantial baseline differences, this direct comparison should be judged carefully.

In summary, cluster A psychopathology is not contraindicated for psychotherapy, and patients appeared to benefit from treatment. This is especially true for more intensive forms like inpatient and day hospital treatment. Future research should focus more on psychotherapeutic treatment to gain further insight into effective treatment options for this patient group.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Bartak, A.; Andrea, H.; Spreeuwenberg, M.D.; Thunnissen, M.; Ziegler, U.M.; Dekker, J.; Bouvy, F.; Hamers, E.F.M.; Meerman, A.M.M.A. ; Busschbach, J.J.V.; Verheul, R.; Stijnen, T.; Emmelkamp, P.M.G. Patients with Cluster A Personality Disorders in Psychotherapy: An Effectiveness Study. Psychother Psychosom 2011;80:88-99.

The thesis entitled, “The enigmatic knowledge of intensive care patients,” aims to increase knowledge about what it is like to be critically ill and how experience-based knowledge is of significance to teaching in an intensive care context.

“The knowledge I am highlighting stands in contrast to scientific knowledge,”, says Sven-Tore Dreyer Fredriksen, who himself is an intensive care nurse Associate Professor at Harstad University College, Norway, since 1998.

The severe stress patients experience during a critical illness is worsened by nurses not being able to catch and manage the patients’ own possibilities to master the situation.

“The existential situation characterized by marginalization is often one that could be handled better by the patient, if the patient is seen and supported,” continues Dreyer Fredriksen.

The first three sub-studies of the thesis cover patients giving accounts of stress related to body, space, and relationship, about the experience of body, power, and movement during a critical stage of the illness, and about the physical experience of time spent with relatives.

”The findings show that the body is affected by disrupted sleep, pain, anxiety, and loss of control over both body and situation,” says Dreyer Fredriksen.

A sense of “stress related to space” arises by the room becoming a mirror of the situation, representing life but also the fear of dying. The patient’s horizontal position causes disempowerment. Stress is often related to contexts of observation and treatment. Stress in the intensive care unit affects relationships, at the expense of a sense of safety and hope among others.

Intensive care patients experience disempowerment and limitations to movement, which has an impact on the dependence on others, causing conflict.

”The patient handles the situation by mobilizing his or her family, [while] at the same time as another way of protecting oneself can be to exclude oneself from family matters. The struggle for survival can also be managed by the use of gallows humor and the cry for help,” continues Dreyer Fredriksen.

The fourth sub-study covers how knowledge is conveyed in the situation, by the intensive care unit nurse. “The knowledge intensive care unit personnel subsequently convey to students is also different from the experience of the patients, and must therefore be seen as an important supplementary factor in public health work,” asserts Sven-Tore Dreyer Fredriksen.

Sven-Tore Dreyer Fredriksen will defend his DrPH thesis on May 16, 2011.

Material adapted from Nordic School of Public Health.

Reference
Sven-Tore Dreyer Fredriksen (2011). The enigmatic knowledge of intensive care patients – experience and interpretation based knowledge in intensive care tutoring. Dissertation Defense.

Even after the physical needs of quake survivors have been met, a small but significant number of people are expected to experience after-effects like upsetting memories, trouble sleeping, feelings of detachment, and irritability.

“A large truck rumbling by might trigger distressing memories,” says Rauch, who is also director of Serving Returning Veterans’ Mental Health (SeRV-MH), a program for veterans of the wars in Iraq and Afghanistan. “People need to know that the feelings they’re having are normal and can be treated.”

Sheila A.M. Rauch, Ph.D., of the VA and U-M (center), helps lead a workshop in Mito, Japan with Peter Turek, Ph.D., of the Medical University of South Carolina, and Shizu Ikeda of the Victim Support Center of Tokyo.

“We focus on confronting memories and reminders so people can start to integrate these traumatic experiences into their lives,” says Rauch, who notes disaster research shows about 20 percent of those who were directly affected will likely develop symptoms of PTSD. “We teach them to avoid avoidance.”

In late April, Rauch joined a team from the Medical University of South Carolina led by Peter Teurk, Ph.D. They conducted a two-day training workshop for mental health professionals and students at Tokiwa International Victimology Institute in Mito, Japan.

The workshop provided instruction in mental health responses to disasters and draft plans for PTSD screening and outreach in the coming weeks and months. In addition, they presented information on evidence-based psychotherapy techniques to address PTSD that may develop over the coming months and years. One emphasis of the instruction was on Prolonged Exposure, a therapy that focuses on confronting trauma memories and reminders.

“This is still going to be an ongoing trauma for many people,” Rauch says. “But in the next few months we expect to start identifying people who are experiencing continuing symptoms of distress that we would associate with PTSD.”

With the assistance of interpreters, the group also conducted a two-and-a-half-hour education session that was attended by 140 community leaders, who braved a dark and rainy night to attend. The session was broadcast live on national TV.

“Our biggest message to them was that it’s important to help people get back to normal life, to help reintroduce structure and stability,” Rauch explains. “And also to make sure that people know about effective treatments and have access to them.”

While they were there, the team was able to counsel one woman whose son was fearful of straying too far from the family’s “safe room” and would panic during the numerous, generally mild aftershocks. Shortly after their return, they received an e-mail update from the woman saying that the techniques had helped and that her son now even looked forward to outings.

Material adapted from University of Michigan Health System.

A new study published June 1 in Fertility and Sterility, a publication of the American Society of Reproductive Medicine, shows that women who participate in a mind-body program for stress reduction while undergoing IVF treatment have a significantly higher pregnancy rate than those who do not (52% versus 20%).

“The intersection of stress and fertility is a controversial one, but we do know that stress can reduce the probability of conception,” said principal investigator Alice Domar, Ph.D, OB/GYN, Beth Israel Deaconess Medical Center and Executive Director of the Domar Center for Mind/Body Health at Boston IVF.

In 1987, Domar introduced the Mind/Body Program for Infertility at the BIDMC main campus in Boston, later moving it to Boston IVF in Waltham in 2002. The goal of the program is to help couples learn effective relaxation and stress management strategies while attempting to conceive. The ten week stress management program focuses on “cognitive behavior therapy, relaxation training, negative health behavior modification, and social support components.”

To study the effects of the Mind/Body Program on IVF pregnancy outcomes, Domar’s team approached women who were about to begin treatment at Boston IVF and who met the study criteria: 40 years or under with normal hormonal levels. None of the participants had previously participated in a mind-body group.

Participants were randomized into a study group that entered the Mind/Body Program for Infertility or a control group who received no mind/body intervention. All patients underwent IVF treatment. Domar tracked the groups through two IVF cycles.

In the first cycle, there was no difference in conception rates between the study group and the control group. “We noticed that only half of the study group had begun the Mind/Body Program and those who had started the program were only a couple of sessions in,” said Domar. “This seemed to rule out the possibility of a placebo affect. The mere suggestion of help with stress, it seems, does not increase the pregnancy rate.”

In the second cycle, the majority of the patients in the study group had at least five sessions under their belts. “By that point, they had acquired some real life skills to deal with their stress,” said Domar. “And that’s when we saw the significant increase in pregnancy rates.”

Domar found that 52 percent of the women participating in the Mind/Body Program for Infertility became pregnant compared with 20 percent of the control group participants, a statistically significant difference.

“The study supports the theory that psychological distress may be an important detriment to IVF outcome,” the authors write.

“We worked with a small group, about a 100 women total, so we’ll need to continue with a larger group of patients to see if the results bear out,” said Domar. “But there is a strong indication that stress levels and IVF outcomes are linked and that intervening with mind/body therapies can help.”

Material adapted from Beth Israel Deaconess Medical Center.

“These patients can change mood in a matter of hours, moving from being cheerful and warm to be irritable and blue, [but] without reaching the prolonged states of bipolar disorder” explains Professor Fava. “This is a neglected disorder since there is no approved drug treatment for it. It is attributed to temperament, something you cannot do anything about it. But we discovered something else.” Moreover, the researchers noted that there is a lack of controlled studies of psychological treatment of cyclothymic disorder.

The aim of this investigation was to examine the benefits of the sequential combination of cognitive behavioral therapy (CBT) and well-being therapy (WBT) compared to clinical management (CM) in DSM-IV cyclothymic disorder. Sixty-two patients with DSM-IV cyclothymic disorder were randomly assigned to CBT/WBT (n = 31) or CM (n = 31). Both CBT/WBT and CM consisted of ten 45-min sessions every other week. An independent evaluator provided a blind assessment of patients before treatment, after therapy, and at 1- and 2-year follow-ups.

The outcomes measures included total score of the change version of the Clinical Interview for Depression and the Mania Scale. All analyses were performed on an intent-to-treat basis. Significant differences were found in all outcome measures with greater improvements after treatment in the CBT/WBT group compared to the CM group. Therapeutic gains were maintained at 1- and 2-year follow-ups. A sequential combination of CBT and WBT, which addresses both polarities of mood swings and comorbid anxiety, was found to yield significant and persistent benefits in cyclothymic disorder.

In an accompanying editorial, Professor Ross Baldessarini (Harvard Medical School), a leading expert in mood disorders, outlines the importance of these new findings. According to Baldessarini, as the complexity and subtyping of mood disorders continue to grow, there is increased challenge to support the concepts epidemiologically and clinically with a particular need to improve matching of phenotypes with genetic and other biological assessments.

“We discovered that cyclothymic disorder is essentially an abnormal reactivity to environmental stimuli. By decreasing the level of anxiety and tension and by increasing psychological well-being these mood swings may fade away” concludes Giovanni Fava. “There is a lot to be done, particularly in troubled adolescents”.

Material adapted from Journal of Psychotherapy and Psychosomatics

References
Fava, G.A.; Rafanelli, C.; Tomba, E.; Guidi, J.; Grandi, S. The Sequential Combination of Cognitive Behavioral Treatment and Well-Being Therapy in Cyclothymic Disorder. Psychother Psychosom 2011;80:136-143.

Baldessarini, R.J. ; Vázquez, G. ; Tondo, L. Treatment of Cyclothymic Disorder: Commentary. Psychother Psychosom 2011;80:131-135

The study indicates that psychotherapies emphasizing positive emotions, which can relieve stress and depression in white populations, may not work for Asians, who make up 60 percent of the world population.

The findings have implications for helping the Japanese recover from natural disasters and subsequent nuclear crisis in March, and for Chinese coping with post-traumatic stress following the 2008 Sichuan province earthquake.

“If we are to relieve some of the trauma from the tsunami and earthquakes, we have to be careful of imparting Western therapies,” said Janxin Leu, UW assistant professor of psychology. “I worry that if a therapy which relies on positive emotions and thinking is used with Asian patients, it will not be effective and may even make patients feel worse.”

Mindfulness therapies that encourage patients to pay attention to the good and the bad will likely work better, she said.

The researchers asked 633 college students – a mix of Asian immigrants, Asian Americans, and European Americans – to rate how much stress and depression they felt and how often they have been in a sad mood, felt worthless, or had sleep or appetite changes.

The participants also rated the intensity of the positive emotions that they felt, including feelings of serenity, joy, confidence, and attentiveness.

For European-American participants, there was a strong correlation showing that the more positive emotions they expressed, the less depression or stress they reported. The correlation was more subtle among Asian-Americans, but for Asians, there was no correlation between positive emotions and depression and stress.

The findings show that Asians interpret and react to positive emotions differently in regard to their mental health.

Upon winning an award, for instance, the researchers said that a typical response would be “I’m so happy that I’m afraid.” The award would trigger feelings of happiness for the achievement combined with concern that others would be jealous.

This blend of emotions is common among Asians, Leu said, and it may be shaped by Buddhist beliefs that happiness either leads to suffering or is impossible to obtain.

“Happiness signals that something bad will happen next; happiness is fleeting,” she said. Similarly, yin-and-yang attitudes may instill views that life is a natural balance of good and bad.

For Asians with depression, therapies likely to work the best are those that encourage patients to “observe when they feel good and bad and notice that both will disappear. Everything passes,” Leu said.

Co-authors of the paper are Jennifer Wang and Kelly Koo, both UW psychology graduate students. The journal Emotion published the study online March 28.

Material adapted from University of Washington.

Personality disorders (PDs) are starting to be viewed as treatable with a much better prognosis than previously thought. This is especially true when we consider outcome data from randomized controlled trials of psychotherapy. Despite the many promising developments in the PD treatment research literature, several important issues remain inadequately addressed. Among these is the issue concerning the optimal level of care for the psychotherapeutic treatment of PDs.

Level of care is a multi-dimensional construct that considers containment, intensity, structure, costs per day, and duration. Generally speaking, levels of care can be organized hierarchically on the basis of these dimensions (except duration) into inpatient hospitalisation, partial hospitalisation/day treatment, and outpatient treatment.

Recently in a landmark study, a group of Dutch investigators headed by Anna Bartak took on the challenges of studying the effectiveness of different levels of care in the treatment of PDs as part of the large project SCEPTRE (Study on Cost Effectiveness of Personality Disorder Treatment).

The 3-year study was conducted in 6 mental health care centers in the Netherlands and involved several hundred patients with DSM-IV-TR axis II diagnoses. At each participating center, patients were assigned to different modalities of psychotherapeutic treatment representing 3 levels of care: outpatient treatment, day treatment, and inpatient treatment.

An extensive battery of measures were administered to the patients before treatment assignment in order to assess a wide variety of baseline characteristics. Using intention-to-treat analysis, Bartak and colleagues compared the effectiveness of the different levels of care for the various outcome indices (psychiatric symptoms, social role functioning, interpersonal functioning, and quality of life).

Specific to Cluster C personality disorders (obsessive-compulsive, avoidant, and dependent), the study findings suggest that a level of care characterized by high degrees of containment, intensity, and structure for a relatively short duration may provide the greatest potential for improvement.

For patients with Cluster B personality disorders (histrionic, narcisistic, borderline, antisocial), the findings suggest that all 3 levels of care (outpatient, day treatment, inpatient) were effective (primarily borderline), yet even after accounting for the strong influence of baseline patient characteristics, there seemed to be a slight advantage for inpatient treatment.

In those diagnosed with Cluster A personality disorders, while the outcome findings seem to suggest a superiority of day treatment and inpatient treatment for primarily paranoid PD patients compared to outpatient treatment (at least in terms of psychiatric symptoms), the more cautious conclusion is that even for these patients there is not a contra-indication for psychotherapeutic treatment.

In summary, all these outcomes suggest that specialized inpatient psychotherapeutic treatment deserves to be considered as a valuable treatment option for patients with PD pathology. However, as discussed previously, long-term use of in-patient settings are generally discouraged. Whether this trend can be halted and reversed may depend on the outcomes of further investigations of different levels of care for PD patients.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference
Ogrodniczuk JS. New Directions in Treatment Research for Personality Disorders: Effectiveness of Different Levels of Care. Psychother Psychosom 2011;80:65–69.

Their findings, published online ahead of print in Medical Care, showed the intervention was successful in lowering patients’ blood pressure, increasing their physical activity by about four miles of walking per week, and easing their depressive symptoms.

“Depression is a common, treatable issue for many people who have diabetes,” says study lead author John Piette, Ph.D., a senior research scientist at the VA and professor of internal medicine at the U-M Medical School. “Unfortunately, most busy clinics cannot provide the level of intensive care these patients need. This study shows that telephone-delivered counseling can improve patients’ access to effective depression care, improve their cardiovascular health, and get them moving again.”

The cognitive behavior therapy helped the study participants address negative thought processes and behaviors that made it difficult for them to manage their diabetes and make healthy lifestyle choices, Piette says.

The physical activity component of the program used pedometers to help patients set walking goals and monitor their progress. Along with physical benefits, exercise also helps boost one’s mood.

Most patients entered the study with relatively good blood glucose control. So while the intervention did not lead to a drop in A1C, a common measurement of blood glucose levels, patients did see more than a 4-point improvement in their systolic blood pressure, walked about half a mile more per day, and reported an improvement in their general quality of life.

At the end of the year, 58 percent of patients who received the intervention had depression symptoms that were in remission, compared to only 39 percent of the patients who did not receive counseling.

“Health systems should consider routinely offering structured telephone psychotherapy to their patients with diabetes and depression,” says senior study author Marcia Valenstein, M.D., M.S., an associate professor of psychiatry at the U-M Medical School and VA research scientist. “Patients with depression and additional chronic medical conditions do better if their depression is addressed first, if it is addressed systematically, and if exercise is also encouraged. Delivering therapy by telephone makes it feasible to reach large numbers of patients who may not attend traditional in-person appointments.”

Methods: 291 patients with type 2 diabetes and significant depressive symptoms completed the study; 145 received the intervention, which consisted of 12 weeks of cognitive behavioral therapy over the phone, followed by nine monthly “booster” sessions. After six weeks, a pedometer-based walking program was introduced. Depression, coping, and quality-of-life measurements were taken using standardized scales.

Funding: The research was funded by grants from the National Institutes of Health, Michigan Diabetes Research and Training Center and the Michigan Institute for Clinical and Health Research.

Additional authors were: Caroline Richardson, M.D., of U-M and VA; Sonia Duffy, Ph.D., of U-M and VA; Joseph Himle, Ph.D., of U-M; and Trissa Torres, M.D.; Mark Vogel, Ph.D.; and Kimberly Barber, Ph.D., all of Genesys Health System, Flint, Mich.

Material adapted from University of Michigan Health System.

Reference
“A Randomized Trial of Telephonic Counseling Plus Walking for Depressed Diabetes Patients,” Medical Care. doi: 10.1097/MLR.0b013e318215d0c9