Severity of unipolar depression and choice of treatment.

The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (Elkin et al., Archives of General Psychiatry, 46, 971-982; 1989) reported treatment-by-severity interactions favouring pharmacotherapy for more depressed outpatients, on a minority of relevant comparisons. The present study reports secondary analyses from a similar, preexisting data set in which treatment-by-severity interactions are systematically investigated with depressed outpatients treated either with nondirective psychotherapy, behaviour therapy, pharmacotherapy, or relaxation/placebo. Despite multiple severity measures and variable severity cut scores, no treatment was differentially effective in improving more severely depressed patients. Also, there was little difference across symptom severity levels in the proportions of recovered patients between treatment groups. Finally, dynamic cluster analysis demonstrated that the proportion of pharmacotherapy nonresponders (20%) did not differ from the proportion of nonresponders in behaviour therapy or placebo groups. It is concluded that this failure to replicate the NIMH trial findings can not be attributed to treatment differences, populations or statistical power. The suggestion that pharmacotherapy be the treatment of choice for more severely depressed outpatients appears to be unjustified on the basis of available evidence.     

Changes in personality pathology after pharmacotherapy and combined therapy for depressed patients

The central question addressed by this article is whether courses of treatment consisting of pharmacotherapy or pharmacotherapy combined with psychotherapy (combined therapy) produce different changes in personality pathology at follow-up after 40 weeks. We also examined whether recovery from depression has an influence on outcome. The study population consisted of 128 outpatients in whom personality pathology and severity of depression were determined at the start of the study. For 72 patients, personality pathology and severity of depression were determined again after 40 weeks. Of the group of 72 patients, 25 patients received only pharmacotherapy for 6 months, and 47 patients received combined treatment (pharmacotherapy and psychodynamic supportive psychotherapy). The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. The combined therapy condition consisted of 16 sessions of Short Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy. In the combined therapy condition there was a significant reduction in personality pathology in patients who recovered from depression but also in patients who had not. In the pharmacotherapy condition the significant decrease was restricted to patients who recovered from depression. The results were most striking for Cluster C psychopatology. Patients with cluster B pathology changed the least. Depressed patients with comorbid personality pathology appear to benefit most from a combination of pharmacotherapy and a form of short, psychodynamic, supportive psychotherapy.     

心理治疗循证实践中“证据”的四个基本问题

循证实践正在成为西方心理治疗发展的主流方向。但如何理解循证实践的"证据"仍是见仁见智。部分社会大众甚至心理学专家仅将"循证"当作一种"修辞"或"时尚",顾名思义地界定"证据",或按主观信仰随意地选择与应用"证据"。文章以"证据"为研究焦点,试图建构系统理解"证据"的全面图景,探讨了心理治疗循证实践中关于"证据"的4个基本问题:(1)从历史考察与理论分析的视角出发,探讨了"心理治疗为什么需要证据";(2)从证据的类型范围、生产者及存在形式三个视角,描述了"心理治疗存在哪些证据";(3)从证据的科学程度、研究设计的严谨程度及解决实践问题的契合程度出发,阐述了"哪些证据才是好的证据";(4)从6个步骤推广证据及创新研究设计两个方面展开,分析了"在现实世界中如何推广与应用证据"。     

Acceptability of Psychotherapy, Pharmacotherapy, and Self-Directed Therapies in Australians Living with Chronic Hepatitis C

Despite the prevalence of psychiatric co-morbidity in chronic hepatitis C (CHC), treatment is under-researched. Patient preferences are likely to affect treatment uptake, adherence, and success. Thus, the acceptability of psychological supports was explored. A postal survey of Australian CHC outpatients of the Royal Adelaide Hospital and online survey of Australians living with CHC was conducted, assessing demographic and disease-related variables, psychosocial characteristics, past experience with psychological support, and psychological support acceptability. The final sample of 156 patients (58 % male) had significantly worse depression, anxiety, stress, and social support than norms. The most acceptable support type was individual psychotherapy (83 %), followed by bibliotherapy (61 %), pharmacotherapy (56 %), online therapy (45 %), and group psychotherapy (37 %). The most prominent predictor of support acceptability was satisfaction with past use. While individual psychotherapy acceptability was encouragingly high, potentially less costly modalities including group psychotherapy or online therapy may be hampered by low acceptability, the reasons for which need to be further explored.     

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Ambulatory emotional reactivity to negative daily life events predicts remission from major depressive disorder

Major depressive disorder (MDD) is often associated with altered emotional reactivity. However, the functional significance of altered emotional reactivity in MDD is uncertain. This study was the first to examine the predictive relationship between intensely sampled ambulatory emotional reactivity and the clinical course of MDD. Forty-six outpatients who met criteria for MDD underwent six days of experience sampling of their ambulatory reactivity to everyday negative and positive life events. After experience sampling, all outpatients received pharmacotherapy with supportive psychotherapy and were followed clinically for 18 months. At one month, less emotional reactivity to negative and positive daily events predicted higher depressive symptom severity. Importantly, patients who exhibited less negative emotional reactivity to daily negative life events were less likely to recover from MDD over the 18 month follow-up. Relationships between ambulatory emotional reactivity and MDD course were not accounted for by the duration or the severity of initial MDD symptoms. Diminished ambulatory emotional reactivity appears to be functionally significant in depression. Intensive sampling of ambulatory emotions may have utility for predicting the clinical course of MDD.     

Quality of object relations as a moderator of the relationship between pattern of alliance and outcome in short-term individual psychotherapy

In this study, we investigated the personality variable quality of object relations (QOR) as a moderator of the relationship between the pattern of the therapeutic alliance and treatment outcome in two forms (interpretive, supportive) of short-term individual psychotherapy. In a sample of 72 psychiatric outpatients who completed interpretive therapy, QOR emerged as a moderator for the outcome factor general symptomatology and dysfunction. For high-QOR patients, an increasing level of alliance was directly related to benefit, whereas for low-QOR patients, a decreasing level of alliance was directly related to benefit. An explanation for these findings emphasized the importance of patients repeating their typical pattern of maladaptive interpersonal behavior in the therapy sessions in the context of the therapist working with the transference. In a sample of 72 psychiatric outpatients who completed supportive therapy, QOR did not emerge as a moderator. These findings in combination with evidence from previous studies suggest that QOR should be investigated as a moderator variable in future studies of short-term psychotherapy.     

Short-Term Psychoanalytic Supportive Psychotherapy for Depressed Patients

Short-Term Psychoanalytic Supportive Psychotherapy (SPSP) is a face-to-face, individual psychotherapy, consisting of sixteen sessions in six months (first eight weekly, then eight fortnightly sessions). It is rooted in psychoanalytic theory. Its primary aim is to cure depression. A secondary goal is to reduce a patient's vulnerability to depression. The emphasis is on supportive techniques that counter regression and foster psychological growth. The putative process consists in experiencing a relational dissonance, i.e., feeling two contradictory relationships in the therapeutic situation simultaneously, one determined by the past, the other by the present. We assume an important curative factor is to experience, mostly unconsciously, an adequate gratification of developmental needs inadequately met in early infancy and, therefore, manifesting themselves in the archaic aspects of the therapeutic relationship. SPSP unfolds as a discourse in which we distinguish nine levels. Each regards a specific subject, which at that level is the focus of the interaction between patient and therapist. The efficacy of SPSP in ambulatory patients presenting a DSM-IV defined, mild to moderate major depressive disorder has been tested in five randomized clinical trials. The results have been aggregated in a mega-analysis. They suggest that, in the treatment of outpatients with mild to moderate major depressive disorder, SPSP and pharmacotherapy are equally efficacious and that the combination of SPSP and pharmacotherapy is more efficacious than pharmacotherapy alone but not than SPSP alone. We, therefore, consider SPSP a valuable extension to the existing options for the treatment of depressed patients.     

Interpersonal subtypes in social phobia: diagnostic and treatment implications

Interpersonal assessment may provide a clinically useful way to identify subtypes of social phobia. In this study, we examined evidence for interpersonal subtypes in a sample of 77 socially phobic outpatients. A cluster analysis based on the dimensions of dominance and love on the Inventory of Interpersonal Problems-Circumplex Scales (Alden, Wiggins, & Pincus, 1990) found 2 interpersonal subtypes of socially phobic patients. These subtypes did not differ on pretreatment global symptom severity as measured by the Brief Symptom Inventory (Derogatis, 1993) or diagnostic comorbidity but did exhibit differential responses to outpatient psychotherapy. Overall, friendly-submissive social phobia patients had significantly lower scores on measures of social anxiety and significantly higher scores on measures of well-being and satisfaction at posttreatment than cold-submissive social phobia patients. We discuss the results in terms of interpersonal theory and the clinical relevance of assessment of interpersonal functioning prior to beginning psychotherapy with socially phobic patients.     

Forgiveness, Gratitude, and Well-Being: The Mediating Role of Affect and Beliefs

Forgiveness and gratitude are positive psychological characteristics that are connected to well-being. This study examined these connections in an understudied population of psychotherapy outpatients and examined the extent to which affect and beliefs mediated these relationships. Participants were 72 outpatients who completed a battery of assessments as part of a standard intake protocol. Results showed that forgiveness and gratitude were both positively and strongly associated with well-being and largely, though not completely, mediated by affect and belief. Forgiveness and gratitude may have an important place in the positive psychologist’s repertoire of well-being enhancing techniques and exercises in general, and may be particularly powerful with a clinical psychotherapy population.     

Psychotropic medication from an object relations theory perspective: an analysis of vignettes from group psychotherapy

In this article we explore the content and dynamics of patients' verbalizations within a "living with medications" group. Patients' perceptions of their psychotropic medications are interpreted and classified within the framework of object relations theory. One's perception of the role of medication in one's life can serve as a gateway to one's inner world and the way that he or she perceives authority figures, peers, and oneself. We suggest that working through patients' relationships with their medications can help them to achieve better integration of internal object relations. Discussing patients' views about medications should therefore be seen as an important part of psychotherapy with many individuals. Such a discussion may enhance and improve efficacy of both psychotherapy and pharmacotherapy. It is of particular importance in group therapy, within milieu environments and with individuals reluctant to explicitly discuss interpersonal matters. Vignettes from the group sessions illustrate the way in which discussing medication advances group process.     

Providing a treatment rationale for PTSD: Does what we say matter?

Little is understood about the factors that influence a woman's preference for a particular type of treatment after an assault. Furthermore, it remains unclear the extent to which providing detailed information such as the mechanism underlying a treatment or its side effects can affect a client's treatment preference for psychotherapy or pharmacotherapy. The current study of 324 women with varying degrees of trauma exposure and posttraumatic stress symptoms experimentally manipulated the content of treatment rationales for two common PTSD treatments: sertraline (SER) and prolonged exposure (PE). Specifically, both information regarding the hypothesized mechanism of the treatment and treatment side effects were manipulated. In general, personal reactions were more positive and credibility was stronger for psychotherapy than pharmacotherapy. This preference for the psychotherapy persisted regardless of specific information presented in the treatment rationale. For those reporting heightened hyperarousal and those of minority status, there was an increased likelihood of more positive reactions to sertraline. The results highlight assessment of treatment-related beliefs and preferences early on in the therapeutic process. Ultimately, understanding the factors that shape treatment preferences may contribute to the development of personalized treatment strategies that integrate preferences and attitudes about treatment as a way of bolstering adherence and outcome.     

Kosteneffektivität ambulanter Psychotherapie

Background

There is a lack of cost-effectiveness analyses (CEA) of psychotherapeutic treatments.

Material and methods

Cost-effectiveness analysis was applied to a sub-sample of 122 psychotherapy outpatients who participated in a large longitudinal study on outpatient psychotherapy (TRANS-OP study). Participants received either psychodynamic psychotherapy (PD, n=69) or cognitive behavioral therapy (CBT, n=53). Effectiveness (change in symptomatic impairment over 2 years) was assessed via the German version of the Outcome Questionnaire (OQ-45.2). Direct health care costs during a 2-year period (psychotherapy and other health care utilizations) were obtained from health insurance claims. Cost-effectiveness analysis methods included incremental cost-effectiveness ratios (ICER) and the net benefit regression approach.

Results

Cost-effectiveness analyses showed no significant differences between the two treatments, neither head-to-head, nor with regard to advantages in certain subgroups of psychotherapy outpatients. A slight dominance of CBT in costs was not maintained after controlling for covariates.

Conclusion

Provided that pivotal covariates such as treatment need are taken into account, cost-effectiveness analyses can contribute to a more equitable distribution of psychotherapeutic resources.     

精神科住院患者团体心理治疗准备性会谈与治疗后访谈初探

精神科住院患者团体心理治疗较门诊患者团体心理治疗存在临床情境的特殊性,本研究探索将准备性会谈与治疗后访谈纳入治疗计划,治疗前向患者普及住院治疗、心理治疗的知识,澄清团体心理治疗的形式、目标、内容,了解患者对团体心理治疗的疑问、期望,允许患者做出是否参加治疗的决定,并在治疗后的访谈中强化疗效因子。     

The Sequential Combination of Pharmacotherapy and Psychotherapy in Mood Disorders

The aim of this review was to consider the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood disorders. Review of the clinical trials where treatment components were used in a sequential order were identified by using MEDLINE, a manual search of the literature and the Index Medicus. In unipolar recurrent depression, the sequential use of pharmacotherapy and psychotherapy was found to improve relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already assuming mood stabilizers was also found to yield clinical benefits. The sequential model has the potential for improving the logic and timing of interventions. A conceptual shift in current assessment methods (staging) is needed.     

A training analysis for psychoanalytic psychotherapists

For historical reasons, psychoanalytic psychotherapy has been regarded as a second-class treatment in comparison with psychoanalysis, and standards for training in it have lagged behind those for psychoanalysis. However, psychoanalytic psychotherapy is the treatment of choice for many healthier (or higher-level) patients who cannot receive analysis for any reason, and also for a large population of more-disturbed patients who are not appropriate for psychoanalysis. Mastering techniques of psychoanalytic psychotherapy may be as difficult as mastering those of psychoanalysis, and should require comparable theoretical training, supervision, and personal treatment. This "development lag" in the training of psychoanalytic psychotherapists has taken place for several reasons: (1) Psychoanalytic ideas first emerged in America in the context of a new movement toward an electric, but dynamic psychiatry from which psychoanalysis had to establish its separate identity. (2) Psychotherapy was associated with techniques of suggestion and manipulation from which psychoanalysis wished to separate. (3) Because psychotherapy was seen as an inferior form of therapy which required little training, institutes were slow in being established, and reluctant to require a "training analysis." It is suggested that with the full training of psychoanalytic psychotherapists, this discipline may be regarded as a profession comparable to psychoanalysis. It is further suggested that the optimal treatment for the full training of the psychoanalytic psychotherapist is psychoanalysis, and that a "training psychotherapy" is not an adequate substitute, but may provide a transitional step to resolve initial resistances and to prepare the therapist for a training analysis.     

Psychotherapy for the treatment of depression: a comprehensive review of controlled outcome research

Previous quantitative reviews of research on the efficacy of psychotherapy for depression have included only a subset of the available research or limited their focus to a single outcome measure. The present review offers a more comprehensive quantitative integration of this literature. Using studies that compared psychotherapy with either no treatment or another form of treatment, this article assesses (a) the overall effectiveness of psychotherapy for depressed clients, (b) its effectiveness relative to pharmacotherapy, and (c) the clinical significance of treatment outcomes. Findings from the review confirm that depressed clients benefit substantially from psychotherapy, and these gains appear comparable to those observed with pharmacotherapy. Initial analysis suggested some differences in the efficacy of various types of treatment; however, once the influence of investigator allegiance was removed, there remained no evidence for the relative superiority of any 1 approach. In view of these results, the focus of future research should be less on differentiating among psychotherapies for depression than on identifying the factors responsible for improvement.     

The Effectiveness of Brief Versus Intermediate Duration Psychodynamic Psychotherapy in the Treatment of Adjustment Disorder

Treatment studies and particularly psychotherapeutic treatment studies of patients suffering from an adjustment disorder are very scarce, leading to insufficient evidence regarding the efficacy of treatment in this population. Whereas timely psychotherapy is known to be of benefit in the treatment of adjustment disorders, the ideal duration of psychotherapeutic interventions is not known. This study examined whether a brief 12-session focused psychodynamic psychotherapy may be as efficient as a longer intermediate-term (1?year) psychodynamic psychotherapy in treating patients suffering from an adjustment disorder. Subjects (n?=?66) were randomly assigned to either brief or intermediate psychotherapy. They were assessed by self-report measures and clinician’s evaluation at baseline, end of therapy, and 9?months after therapy was terminated. The results showed a good overall improvement in the whole group. Furthermore, brief psychotherapy was found to be as good as intermediate psychotherapy both at the end of treatment and at follow-up. Although our study was not designed to confirm the efficacy of dynamic psychotherapy in the treatment of adjustment disorders, our results suggest that brief interventions may be good enough in adjustment disorder, thus allowing treatment of a greater number of patients without compromising for the quality and suitability of treatment.     

Psychotherapy and Pharmacotherapy Treatment Outcome Research in Pediatric Populations

Reviewed treatment interventions for pediatric populations involving the combination of pharmacotherapy or psychotherapy or either treatment employed alone. The literature revealed a dearth of psychotherapy and pharmacotherapy outcome studies, with the exception of investigations of children diagnosed with attention-deficit hyperactivity disorder (ADHD). Issues pertaining to design, including sample selection, treatment integrity and comparability, and placebo controls also are reviewed. A potpourri of other issues are noted including parental attitudes toward the use of medication versus psychotherapy, treatment adherence, and patient/provider relationship. For children diagnosed with ADHD, the use of stimulant medication appears to be superior to psychotherapy employed alone in managing the behavior of these children as well as their classroom functioning. Recommendations are made for multimodal trials that examine the combined and individual use of pharmacotherapies and psychotherapies for various developmental and psychiatric disorders that occur in childhood and adolescence. Future studies also need to address the durable effects of these treatment options.     

A controlled study of effectiveness and patient suitability for short-term group psychotherapy

A controlled, clinical trial investigation of short-term psychoanalytically oriented group psychotherapy (STG) was conducted which included eight psychotherapy groups led by experienced therapists. Patient psychological mindedness (PM) was investigated as a selection criterion and prognostic variable. Seventy-nine psychiatric outpatients experiencing prolonged or delayed grief reactions were matched for level of PM and then randomly assigned to STG or a wait list. There was repeated measurement of several areas and sources of outcome. Results indicated a strong main effect for STG but not for PM on outcome, and minimal evidence for an interaction effect. Benefits were maintained at six-month follow-up. Psychological mindedness emerged as highly predictive of attrition. A clinical discussion is presented wherein the efficacy of STG is considered as reflecting a good patient-treatment match.