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.     

The Behavioral Treatment of Childhood Nocturnal Enuresis

Nocturnal enuresis is a relatively common childhood disorder. Although many treatments have been attempted, the most popular methods have been pharmacotherapy, individual psychotherapy, and behavioral conditioning. Of these, the most effective is behavioral conditioning with a urine alarm. The author reviews the enuresis literature and provides recommendations for use of the urine alarm approach.     

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.     

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.     

Therapeutic Implications of Pharmacotherapy: Current Trends and Ethical Issues

The use of psychotropic medications (pharmacotherapy) in conjunction with psychotherapy is regarded as the standard of care for many mental health disorders. Counselors, therefore, need to be knowledgeable about psychopharmacology to monitor its impact on the therapeutic relationship and on client outcome. Discussed are potential ethical dilemmas with pharmacotherapy interventions, case studies demonstrating proper support of pharmacotherapy with diverse clientele, and critical elements of master's level training in psychopharmacology.     

Anchoring the Panic Disorder Severity Scale

The Panic Disorder Severity Scale (PDSS) is a clinician-administered measure of panic disorder symptom severity widely used in clinical research. This investigation sought to provide clinically meaningful anchor points for the PDSS both in terms of clinical severity as measured by the Clinical Global Impression-Severity Scale (CGI-S) and to extend its clinical meaningfulness by examining its association with quality of life. A total of 63 individuals with a primary diagnosis of panic disorder were assessed on completion of a 6- or 8-week psychotherapy or pharmacotherapy trial for the treatment of panic disorder. As expected, the PDSS was correlated with both the CGI-S and quality of life. These results provide further support for the validity and clinical utility of the PDSS and provide simple anchors to help guide the potential use of the PDSS scale to measure treatment progress in clinical practice.     

Ersch?pfung und Depression in der Schwangerschaft

For women pregnancy represents a condition of intense physical and psychological changes which subject the pregnant women to a number of potentially stressful situations. Hormonal changes during pregnancy predispose to exhaustion and therefore to an increased vulnerability to affective disorders. Depression is one of the most commonly diagnosed psychiatric disorders in the female population with an increased incidence during the reproductive years. Recent studies showed that approximately 10?C13% of patients suffer from a depressive episode in the perinatal period requiring specialized treatment including psychotherapy and/or pharmacotherapy. Underestimation of this condition and a lack of proper management can hinder normal mother-child bonding leading to impaired cognitive and emotional long-term development of the child. In this article the medical literature related to the prevalence and clinical presentation of depression during the perinatal period and its association to maternal exhaustion is reviewed. The clinical implications and therapeutic options are discussed.     

Exercise as psychotherapy

The use of exercise as a psychotherapeutic agent is reviewed. The benefits of exercise are considered to impact both physiological processes and psychological factors such as self-esteem and more efficacious self-talk. The possibility of the use of exercise as an adjunct to both pharmacotherapy and psychotherapy is suggested.     

Psychopharmacological therapy of deviant sexual behavior

Psychopharmacological approaches to controlling male deviant sexual behavior, especially sexual recidivism and sexual deviants on probation, have been reported in psychiatric literature. In Europe, the drug cyproterone acetate, and in the United States, medroxyprogesterone acetate, Provera, and in the long-acting form, Depo-Provera, have all benefitted exhibitionists and pedophiliacs, and reduced sex drive in sexual deviants. The combination of pharmacotherapy and either psychotherapy or behavioral therapy has been the most effective approach to reducing the sex drive of sexual deviants.     

Psychotherapy of depression: current status, future directions

This article reviews recent studies of psychotherapy for treatment of depression. There is evidence that cognitive behavioral and interpersonal therapies are useful treatments for depressed outpatients, roughly comparable to antidepressant pharmacotherapy. Pharmacotherapy and psychotherapy do not, however, necessarily treat the same patients and there is emerging evidence of a neurobiological "boundary" that may delimit therapy response. Psychotherapy plus pharmacotherapy combinations appear particularly useful for outpatients with more severe, recurrent depressions. Depression-focused psychotherapy may also provide an important alternative to an indefinite course of maintenance pharmacotherapy for patients at high risk for recurrence.     

Identification of Real and Artifactual Moderators of Effect Size in Meta-Analysis

This article argues that while meta-analytic studies are widely used in psychological literature, heterogeneity and the potential for confounding remain major problems in the interpretation of meta-analytic study results. The article demonstrates the use of exploratory analysis including graphical methods prior to meta-analysis, and introduces a methodology to screen for artifactual effects. These procedures are illustrated on effect size data comparing depression treatment outcome from psychotherapy versus pharmacotherapy. Results support prior findings of a nonsignificant difference in effect size between the two treatments. They also support findings that treatment type accounts for only a very small proportion of outcome variance. However, the results indicate that some previously reported covariates of depression treatment outcome may be artifactual.     

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.     

Beyond the therapeutic hour: an exploratory pilot study of using technology to enhance alliance and engagement within face-to-face psychotherapy

In this paper we introduce and investigate the capacity for a novel, technologically advanced system (goACT) to enhance face-to-face psychotherapy. Specifically, we explore the capacity for goACT to enhance therapeutic alliance (TA) and engagement, and reduce distress. Using a mixed-methods, multiple-baseline design we present the first study to examine the utility, effectiveness and user experience of goACT in a university psychology clinic setting. The introduction of between-session goACT use was staggered across patients (N = 7). Patients completed weekly measures of mood, patient-rated TA and clinician-rated engagement. Semi-structured interviews were used to qualitatively understand user experience of the system. Methodological limitations impacted the generalisability of multiple-baseline findings, yet qualitative results provide a significant contribution to the literature and groundwork upon which further study can be built. Results indicated that goACT built engagement and TA via novel change processes that were associated with expanding the parameters of the therapeutic encounter beyond the one-hour session. Change processes that underpin the qualitative success of goACT are discussed in terms of their theoretical implications. goACT is likely to be a useful tool for enhancing the quality and quantity of traditional face-to-face psychotherapy.     

Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.     

Sad Kids,Sad Media? Applying Mood Management Theory to Depressed Adolescents' Use of Media

Mood management studies typically have found that adults will select media that enhance positive moods and reduce negative moods. In this study, adolescents diagnosed with major depressive disorder and control adolescents without psychiatric disorders were called on customized cell phones up to 4 times a day and asked about their current mood state and media use for five extended weekends across an 8-week period. Mood effects on subsequent media use, mood during media consumption, and media effects on subsequent mood were examined. Results indicated that adolescents who consumed fun media tended to do so in a way that sustained, rather than enhanced their prior positive mood levels during and after consumption-if they turned to media. Adolescents in more negative moods did not often use media to improve their moods. When they did, boys were more likely than girls to use media that ultimately reduced negative mood levels. Findings are discussed in light of the literature on mood management, adolescence, and depression.     

Adjunctive psychotherapy for bipolar disorder: effects of changing treatment modality

In a randomized, controlled trial, the authors studied an adjunctive, individual psychotherapy, interpersonal and social rhythm therapy (IPSRT) for bipolar disorder. After stabilizing participants with episode appropriate pharmacotherapy and either IPSRT or intensive clinical management (CM), participants were reassigned to IPSRT or CM in conjunction with pharmacotherapy for 2 years of preventative treatment. Early results (n = 82) suggest that altering participants' treatment assignment at entry to the preventative phase is related to risk of recurrence. Participants remaining in the same treatment for both acute and preventative phases had lower rates of recurrence (< 20% vs. > 40%) and levels of symptomatology over the subsequent 52 weeks than those reassigned to the alternate modality. This finding, consistent with the authors' philosophy that bipolar patients benefit from stable routines, suggests that disruptions in the psychosocial treatment plan contribute to worse outcomes.     

药物、心理及联合治疗缓解抑郁症之比较

针对抑郁症治疗完全缓解率低,运用临床思维方法,依靠循证医学证据,首先分析了抗抑郁药物的选择、优化、更换和联合用药的治疗效益。然后辩证分析并比较了药物与心理治疗,以及药物与心理治疗的单独与联合应用对重性抑郁急性和长期治疗的疗效,以及严重重性抑郁、严重慢性抑郁的短期和长期疗效以及费用效益,为确定治则、选择治法提供帮助。     

Psychotherapy and survival in cancer: the conflict between hope and evidence

Despite contradictory findings, the belief that psychotherapy promotes survival in people who have been diagnosed with cancer has persisted since the seminal study by D. Spiegel, J. R. Bloom, H. C. Kramer, and E. Gottheil (1989). The current authors provide a systematic critical review of the relevant literature. In doing so, they introduce some considerations in the design, interpretation of results, and reporting of clinical trials that have not been sufficiently appreciated in the behavioral sciences. They note endemic problems in this literature. No randomized clinical trial designed with survival as a primary endpoint and in which psychotherapy was not confounded with medical care has yielded a positive effect. Among the implications of the review is that an adequately powered study examining effects of psychotherapy on survival after a diagnosis of cancer would require resources that are not justified by the strength of the available evidence.     

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.