No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Abstract
• This chapter provides contemporary descriptions of the mood disorders and of the means of diagnosing and assessing the presence, type, and severity of mood disturbances. It also surveys what is known about the prevalence of these disorders and factors that increase the likelihood that a given individual will experience a mood disorder. It reviews contemporary treatments for depression with a focus on theories and treatments with the strongest research evidence. The mood disorders are understood as arising from a complex interplay of genetic vulnerabilities, early life experiences, and acute and chronic stressors throughout life. Reflecting the etiologic heterogeneity of the mood disorders, contemporary treatments span the range from brain stimulation therapies to medicines to a variety of psychosocial interventions. With a few exceptions, the chapter focuses on adults with major depression and bipolar I disorder, as these are among the most common, impairing, and well studied of the mood disorders. It concludes with the major achievements in mood disorders and probable directions for practice, research, and training in the area. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
• This chapter provides contemporary descriptions of the mood disorders and of the means of diagnosing and assessing the presence, type, and severity of mood disturbances. It also surveys what is known about the prevalence of these disorders and factors that increase the likelihood that a given individual will experience a mood disorder. It reviews contemporary treatments for depression with a focus on theories and treatments with the strongest research evidence. The mood disorders are understood as arising from a complex interplay of genetic vulnerabilities, early life experiences, and acute and chronic stressors throughout life. Reflecting the etiologic heterogeneity of the mood disorders, contemporary treatments span the range from brain stimulation therapies to medicines to a variety of psychosocial interventions. With a few exceptions, the chapter focuses on adults with major depression and bipolar I disorder, as these are among the most common, impairing, and well studied of the mood disorders. It concludes with the major achievements in mood disorders and probable directions for practice, research, and training in the area. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
... Similarly, a survey of students at a large American public university [3] showed that 71% reported increased stress and anxiety due to the COVID-19 outbreak. Specific stressors included fear and worry about their own health a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 risk of mental ill-health and are associated with a range of psychological disorders [22][23][24]. The shark fin profile, which is characterized by below average scores for Tension, Depression, Anger, Vigor, and Confusion, combined with very high Fatigue scores, has been linked to athletic injury [25] and poor adherence to safety procedures in high-risk vocations [26]. ...
The COVID-19 pandemic has affected university students globally. Our study investigated mental health indicators among higher degree by research (HDR) students at a regional university in Queensland, Australia. A total of 231 HDR students (female = 137, male = 94) completed the Brunel Mood Scale to assess the constructs of Tension, Depression, Anger, Vigor, Fatigue, and Confusion. A subset of 11 students participated in three focus groups to explore their experiences. Results showed that reported mood among HDR students was generally more negative than population norms, although more positive than moods reported previously during the pandemic. A total of 52 participants (22.5%) reported mood profiles that indicated elevated risk of mental ill-health. Mood profiles varied significantly by gender, age, study mode (full-time/part-time), location (on-campus/online), and citizenship (domestic/international). Quantitative data were supported by focus group findings, which identified mental health and wellbeing as key themes of concern to HDR students. Our findings indicate that support mechanisms to safeguard the mental health and wellbeing of HDR students should be a priority for universities.
The authors tested the cognitive vulnerability hypotheses of depression with a retrospective behavioral high-risk design. Individuals without current Axis I diagnoses who exhibited either negative or positive cognitive styles were compared on lifetime prevalence of depressive and other disorders and the clinical parameters of depressive episodes. Consistent with predictions, cognitively high-risk participants had higher lifetime prevalence than low-risk participants of major and hopelessness depression and marginally higher prevalence of minor depression. These group differences were specific to depressive disorders. The high-risk group also had more severe depressions than the low-risk group, but not longer duration or earlier onset depressions. The risk group differences in prevalence of depressive disorders were not mediated by current depressive symptoms.
Random regression models (RRMs) were used to investigate the role of initial severity in the outcome of 4 treatments (cognitive–behavior therapy [CBT], interpersonal psychotherapy [IPT], imipramine plus clinical management [IMI-CM], and placebo plus clinical management [PLA-CM]) for outpatients with major depressive disorder seen in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Initial severity of depression and impairment of functioning significantly predicted differential treatment effects. A larger number of differences than previously reported were found among the active treatments for the more severely ill patients; this was due, in large part, to the greater power of the present statistical analyses.
The purpose of this study was to provide an experimental test of the theory of change put forth by A. T. Beck, A. J. Rush, B. F. Shaw, and G. Emery (1979) to explain the efficacy of cognitive–behavioral therapy (CT) for depression. The comparison involved randomly assigning 150 outpatients with major depression to a treatment focused exclusively on the behavioral activation (BA) component of CT, a treatment that included both BA and the teaching of skills to modify automatic thoughts (AT), but excluding the components of CT focused on core schema, or the full CT treatment. Four experienced cognitive therapists conducted all treatments. Despite excellent adherence to treatment protocols by the therapists, a clear bias favoring CT, and the competent performance of CT, there was no evidence that the complete treatment produced better outcomes, at either the termination of acute treatment or the 6-month follow-up, than either component treatment. Furthermore, both BA and AT treatments were just as effective as CT at altering negative thinking as well as dysfunctional attributional styles. Finally, attributional style was highly predictive of both short- and long-term outcomes in the BA condition, but not in the CT condition.
Introduction
Diagnosing Cushing’s syndrome (CS) can be a challenge,
especially in ACTH-dependent CS, when it comes to detecting the origin of ACTH secretion.
Materials and methods
Retrospective data were collected on 170 patients with ACTH-dependent CS (149 CD, 21 EAS) referring to two endocrinology units, focusing on three non-invasive tests: dexamethasone 8 mg overnight challenge (HDDST); corticotrophin-releasing hormone (CRH) assay and the desmopressin (DDAVP) test.
Results
Patients with EAS were slightly older and had higher ACTH, serum and urinary cortisol levels than patients with CD (p < 0.01). CD patients had a stronger ACTH and cortisol response after CRH injection (p < 0.0001), and a more pronounced reduction in cortisol levels after HDDST (p < 0.0001). A threshold percentage ACTH increase after CRH stimulation of 72.4 % was able to identify CD with a sensitivity (SE) of 76 % (95 % CI 68–83) and a specificity (SP) of 100 % (95 % CI 83–100). As for HDDST, a cortisol suppression >52.7 % below the basal level suggested a pituitary origin with a SE of 88 % (95 % CI 81–93) and a SP of 90 % (95 % CI 68–99). There were no cases of EAS with positive responses to both these tests. Increases in ACTH and cortisol levels after the DDAVP test were also higher in CD than in EAS (p < 0.01), though the SE and SP were lower.
Conclusions
Patients with CD showed a stronger response to HDDST and CRH, and the adopted cut-offs showed a good SE and SP in discriminating them from patients with EAS. Concordant tests indicated CD when positive, whereas no response to either test was highly suggestive of EAS. The DDAVP test was of limited utility in the diagnostic phase. In conclusion, the choice of tests may play an important part in the differential diagnosis of ACTH-dependent CS.
In this study of cognitive-behavioral therapy for depression, many patients experienced large symptom improvements in a single between sessions. These sudden gains' average magnitude was 11 Beck Depression Inventory points, accounting for 50% of these patients' total improvement. Patients who experienced sudden gains were: less depressed than the other patients at posttreatment, and they remained so IB months later. Substantial cognitive changes were observed in the therapy sessions preceding sudden gains, but few cognitive! changes were observed in control sessions, suggesting that cognitive change in the pregain sessions triggered the sudden gains, improved therapeutic alliances were also observed in the therapy sessions immediately after the sudden gains, as were additional cognitive changes, suggesting a three-stage model for these patients' recovery: preparation --> critical session/sudden gain --> upward spiral.
Major depression is a disabling psychiatric illness with complex origins. Life stress (childhood adversity and recent stressful events) is a robust risk factor for depression. The relationship between life stress and Val66Met polymorphism in the brain-derived neurotrophic factor (BDNF) gene has received much attention. The aim of the present work was to review and conduct a meta-analysis on the results from published studies examining this interaction.
A literature search was conducted using PsychINFO and PubMed databases until 22 November 2013. A total of 22 studies with a pooled total of 14,233 participants met the inclusion criteria, the results of which were combined and a meta-analysis performed using the Liptak-Stouffer z-score method.
The results suggest that the Met allele of BDNF Val66Met significantly moderates the relationship between life stress and depression (P = 0.03). When the studies were stratified by type of environmental stressor, the evidence was stronger for an interaction with stressful life events (P = 0.01) and weaker for interaction of BDNF Val66Met with childhood adversity (P = 0.051).
The interaction between BDNF and life stress in depression is stronger for stressful life events rather than childhood adversity. Methodological limitations of existing studies include poor measurement of life stress.
Advances in personalized medicine require the identification of variables that predict differential response to treatments as well as the development and refinement of methods to transform predictive information into actionable recommendations.
To illustrate and test a new method for integrating predictive information to aid in treatment selection, using data from a randomized treatment comparison.
Data from a trial of antidepressant medications (N = 104) versus cognitive behavioral therapy (N = 50) for Major Depressive Disorder were used to produce predictions of post-treatment scores on the Hamilton Rating Scale for Depression (HRSD) in each of the two treatments for each of the 154 patients. The patient's own data were not used in the models that yielded these predictions. Five pre-randomization variables that predicted differential response (marital status, employment status, life events, comorbid personality disorder, and prior medication trials) were included in regression models, permitting the calculation of each patient's Personalized Advantage Index (PAI), in HRSD units.
For 60% of the sample a clinically meaningful advantage (PAI≥3) was predicted for one of the treatments, relative to the other. When these patients were divided into those randomly assigned to their "Optimal" treatment versus those assigned to their "Non-optimal" treatment, outcomes in the former group were superior (d = 0.58, 95% CI .17-1.01).
This approach to treatment selection, implemented in the context of two equally effective treatments, yielded effects that, if obtained prospectively, would rival those routinely observed in comparisons of active versus control treatments.
This article summarizes characteristics of major depressive disorder (MDD) in the Oregon Adolescent Depression Project, using data from 816 participants (56% female; 89% White). Contrasting four developmental periods (childhood, 5.0–12.9 years of age; adolescence, 13.0–17.9; emerging adulthood, 18.0–23.9; adulthood, 24–30), we examine MDD incidence/recurrence, gender, comorbidity, duration, and suicide attempts across periods. MDD first incidence was lower in childhood compared to subsequent periods and higher in emerging adulthood than in adulthood. Cumulative incidence was 51%. Recurrence was lower during childhood than remaining periods, which did not differ. Female gender predicted first-incident MDD in all four periods but was unassociated with recurrence. Comorbidity rates were comparable across periods. MDD duration was greater in childhood than in remaining periods. Suicide attempt rates were significantly higher during adolescence than during either emerging adulthood or adulthood. Depression research should focus on MDD during emerging adulthood, adolescent suicidal behavior, the continuing role of gender into adulthood, and the ubiquity of MDD.
Importance
Genome-wide association studies (GWASs) indicate that single-nucleotide polymorphisms in the CACNA1C and ANK3 genes increase the risk for bipolar disorder (BD). The genes influence neuronal firing by modulating calcium and sodium channel functions, respectively. Both genes modulate γ-aminobutyric acid–transmitting interneuron function and can thus affect brain regional activation and interregional connectivity.Objective
To determine whether the genetic risk for BD associated with 2 GWAS-supported risk single-nucleotide polymorphisms at CACNA1C rs1006737 and ANK3 rs10994336 is mediated through changes in regional activation and interregional connectivity of the facial affect–processing network.Design, Setting, and Participants
Cross-sectional functional magnetic resonance imaging study at a research institute of 41 euthymic patients with BD and 46 healthy participants, all of British white descent.Main Outcomes and Measures
Blood oxygen level–dependent signal and effective connectivity measures during the facial affect–processing task.Results
In healthy carriers, both genetic risk variants were independently associated with increased regional engagement throughout the facial affect–processing network and increased effective connectivity between the visual and ventral prefrontal cortical regions. In contrast, BD carriers of either genetic risk variant exhibited pronounced reduction in ventral prefrontal cortical activation and visual-prefrontal effective connectivity.Conclusions and Relevance
Our data demonstrate that the effect of CACNA1C rs1006737 and ANK3 rs10994336 (or genetic variants in linkage disequilibrium) on the brain converges on the neural circuitry involved in affect processing and provides a mechanism linking BD to genome-wide genetic risk variants.
Both patients’ competence in the coping skills taught in cognitive therapy (CT) and patients’ endorsement of dysfunctional cognitions following a sad mood induction [i.e., their cognitive reactivity (CR)] have been found to predict risk of relapse following a successful course of CT for depression. We examined the relationship between these constructs, specifically whether CT skills would be related to less CR following a mood induction among patients who responded to a course of CT. In a sample of 28 depressed patients, post-treatment CT skills were significantly related to less CR in response to a sad mood induction procedure (β = −.29). This relation was not accounted for by individual differences in mood reactivity. We discuss these findings as a key step in developing a more complete understanding of the role of CT coping skills and CR as markers of patients’ vulnerability to relapse.
There is growing recognition that bipolar disorder (BPD) has a spectrum of expression that is substantially more common than the 1% BP-I prevalence traditionally found in population surveys.
To estimate the prevalence, correlates, and treatment patterns of bipolar spectrum disorder in the US population.
Direct interviews.
Households in the continental United States.
A nationally representative sample of 9282 English-speaking adults (aged >or=18 years).
Version 3.0 of the World Health Organization's Composite International Diagnostic Interview, a fully structured lay-administered diagnostic interview, was used to assess DSM-IV lifetime and 12-month Axis I disorders. Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Indicators of clinical severity included age at onset, chronicity, symptom severity, role impairment, comorbidity, and treatment.
Lifetime (and 12-month) prevalence estimates are 1.0% (0.6%) for BP-I, 1.1% (0.8%) for BP-II, and 2.4% (1.4%) for subthreshold BPD. Most respondents with threshold and subthreshold BPD had lifetime comorbidity with other Axis I disorders, particularly anxiety disorders. Clinical severity and role impairment are greater for threshold than for subthreshold BPD and for BP-II than for BP-I episodes of major depression, but subthreshold cases still have moderate to severe clinical severity and role impairment. Although most people with BPD receive lifetime professional treatment for emotional problems, use of antimanic medication is uncommon, especially in general medical settings.
This study presents the first prevalence estimates of the BPD spectrum in a probability sample of the United States. Subthreshold BPD is common, clinically significant, and underdetected in treatment settings. Inappropriate treatment of BPD is a serious problem in the US population. Explicit criteria are needed to define subthreshold BPD for future clinical and research purposes.
Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression.
We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = -0.62 to d = -0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = -0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = -0.30, 95% credibility interval [CrI] [-0.54 to -0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [-0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [-0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions.
Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments. Please see later in the article for the Editors' Summary.
Background
Current diagnostic systems for mental disorders rely upon presenting signs and symptoms, with the result that current definitions do not adequately reflect relevant neurobiological and behavioral systems - impeding not only research on etiology and pathophysiology but also the development of new treatments.
Discussion
The National Institute of Mental Health began the Research Domain Criteria (RDoC) project in 2009 to develop a research classification system for mental disorders based upon dimensions of neurobiology and observable behavior. RDoC supports research to explicate fundamental biobehavioral dimensions that cut across current heterogeneous disorder categories. We summarize the rationale, status and long-term goals of RDoC, outline challenges in developing a research classification system (such as construct validity and a suitable process for updating the framework) and discuss seven distinct differences in conception and emphasis from current psychiatric nosologies.
Summary
Future diagnostic systems cannot reflect ongoing advances in genetics, neuroscience and cognitive science until a literature organized around these disciplines is available to inform the revision efforts. The goal of the RDoC project is to provide a framework for research to transform the approach to the nosology of mental disorders.
Although cognitive behaviour therapy (CBT) and pharmacotherapy are equally effective in the acute treatment of adult depression, it is not known how they compare across the longer term. In this meta-analysis, we compared the effects of acute phase CBT without any subsequent treatment with the effects of pharmacotherapy that either were continued or discontinued across 6-18 months of follow-up.
We conducted systematic searches in bibliographical databases to identify relevant studies, and conducted a meta-analysis of studies meeting inclusion criteria.
Mental healthcare.
Patients with depressive disorders.
CBT and pharmacotherapy for depression.
Relapse rates at long-term follow-up.
9 studies with 506 patients were included. The quality was relatively high. Short-term outcomes of CBT and pharmacotherapy were comparable, although drop out from treatment was significantly lower in CBT. Acute phase CBT was compared with pharmacotherapy discontinuation during follow-up in eight studies. Patients who received acute phase CBT were significantly less likely to relapse than patients who were withdrawn from pharmacotherapy (OR=2.61, 95% CI 1.58 to 4.31, p<0.001; numbers-needed-to-be-treated, NNT=5). The acute phase CBT was compared with continued pharmacotherapy at follow-up in five studies. There was no significant difference between acute phase CBT and continued pharmacotherapy, although there was a trend (p<0.1) indicating that patients who received acute phase CBT may be less likely to relapse following acute treatment termination than patients who were continued on pharmacotherapy (OR=1.62, 95% CI 0.97 to 2.72; NNT=10).
We found that CBT has an enduring effect following termination of the acute treatment. We found no significant difference in relapse after the acute phase CBT versus continuation of pharmacotherapy after remission. Given the small number of studies, this finding should be interpreted with caution pending replication.
Objective To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression.
Design Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care.
Setting Primary care and community settings.
Participants 2470 patients with depression.
Interventions Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions).
Main outcome measures Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions.
Results Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient −0.1 (95% CI −0.19 to −0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant.
Conclusions The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
The present study represents one of the first comparisons of the long-term effectiveness of traditional cognitive behavior therapy (i.e., Beckian cognitive therapy; CT) and acceptance and commitment therapy (ACT). One hundred thirty-two anxious or depressed outpatients were randomly assigned to receive either CT or ACT, and were assessed at posttreatment (n=90) and at 1.5-year (n=91) follow-up. As previously reported, the two treatments were equivalently effective at posttreatment according to measures of depression, anxiety, overall (social/occupational/symptom-related) functioning, and quality of life. However, current results suggest that treatment gains were better maintained at follow-up in the CT condition. Clinical significance analyses revealed that, at follow-up, one-third more CT patients were in the clinically normative range in terms of depressive symptoms and more than twice as many CT patients were in the normative range in terms of functioning levels. The possible long-term advantage of CT relative to ACT in this population is discussed.
About one American in five receives a diagnosis of major depression over the course of a lifetime. That's despite the fact that many such patients have no mood disorder; they're not sad, but suffer from anxiety, fatigue, insomnia, or a tendency to obsess about the whole business. "There is a term for what they have," writes Edward Shorter, "and it's a good old-fashioned term that has gone out of use. They have nerves." In How Everyone Became Depressed, Edward Shorter, a distinguished professor of psychiatry and the history of medicine argues for a return to the old fashioned concept of nervous illness. These are, he writes, diseases of the entire body, not the mind, and as was recognized as early as the 1600s. Shorter traces the evolution of the concept of "nerves" and the "nervous breakdown" in western medical thought. He points to a great paradigm shift in the first third of the twentieth century, driven especially by Freud, that transferred behavioral disorders from neurology to psychiatry, spotlighting the mind, not the body. The catch-all term "depression" now applies to virtually everything, "a jumble of non-disease entities, created by political infighting within psychiatry, by competitive struggles in the pharmaceutical industry, and by the whimsy of the regulators." Depression is a real and very serious illness, he argues; it should not be diagnosed so promiscuously, and certainly not without regard to the rest of the body. Meloncholia, he writes, "the quintessence of the nervous breakdown, reaches deep into the endocrine system, which governs the thyroid and adrenal glands among other organs." In a learned yet provocative challenge to psychiatry, Shorter argues that the continuing misuse of "depression" represents nothing less than "the failure of the scientific imagination."
Since the original publication of this seminal work, acceptance and commitment therapy (ACT) has come into its own as a widely practiced approach to helping people change. This book provides the definitive statement of ACT—from conceptual and empirical foundations to clinical techniques—written by its originators. ACT is based on the idea that psychological rigidity is a root cause of a wide range of clinical problems. The authors describe effective, innovative ways to cultivate psychological flexibility by detecting and targeting six key processes: defusion, acceptance, attention to the present moment, self-awareness, values, and committed action. Sample therapeutic exercises and patient–therapist dialogues are integrated throughout.
New to This Edition
*Reflects tremendous advances in ACT clinical applications, theory building, and research.
*Psychological flexibility is now the central organizing focus.
*Expanded coverage of mindfulness, the therapeutic relationship, relational learning, and case formulation.
*Restructured to be more clinician friendly and accessible; focuses on the moment-by-moment process of therapy.
Personality has been defined as the state of being a person, possessing traits or character. Alternatively, it is said to refer to the physiological, intellectual, emotional, and physical characteristics of the individual, especially those that are seen by others. Humanistic theories of personality include person-centered gestalt, and existential approaches. While each of these schools of thought is quite distinctive in many ways, there are a number of fundamental epistemological and ontological assumptions that they share that characterize them as humanistic. These are first (a) the emphasis on subjectivity and (b) the emphasis on people as self-reflective agents (Heidegger, 1962; Jaspers, 1963; Perls, 1973; Polster & Polster, 1973; Rice & Greenberg, 1992; Rogers, 1965; Schneider & May, 1995; Taylor, 1975; Tiryakian, 1962).
The present system of conducting studies of promising antidepressant therapies has evolved through the collaborative efforts of government, industry, and academicians and is costly and inefficient. At least one third of the published clinical trials of approved antidepressants are negative for efficacy, which can be partly explained by the clinical and neurobiological heterogeneity of the depressive disorder and partly because of methodological inadequacies. Unfortunately, too little attention is given to ensuring the reliability of diagnoses and dependent measures, sample sizes are seldom large enough to detect modest yet honestly significant differences, and too many trials are pursued before dose-response characteristics are fully understood. At present, the only data beyond 1 year of treatment-and the only evidence about protection against recurrent depression-come during postmarketing or phase 4 of the drug development process. Moreover, efficacy data for depressed children and adolescents, bipolar depression, psychotic depression, dysthymia, and frail or medically ill elderly patients are rarely available at the time a drug is introduced. Thus, it is remarkable how little clinicians know about a new antidepressant at the time it is first approved for general use. Within a research strategy, tactics that ensure reliability, encourage attention to adherence, and lessen attrition at the outset of a study will increase the power and design sensitivity of a particular trial. Additionally, the issues of research funding-including division of the research pie-and the relationship of the Food and Drug Administration and investigators to the pharmaceutical industry and the National Institute of Mental Health need to be revisited. Finally, extension of a compound's patent life might be considered to expand the necessary postmarketing research. This article describes the process of conducting the clinical trials that support a New Drug Application, discusses issues in evaluating efficacy, and offers suggestions for modifying and improving the drug development process so that clinicians can better judge new drugs.
This study compared the effectiveness of process-experiential psychotherapy with one of its components, client-centered psychotherapy, in the treatment of (34) adults suffering from major depression. The client-centered treatment emphasized the establishment and maintenance of the Rogerian relationship conditions and empathic responding. The experiential treatment consisted of the client-centered conditions, plus the use of specific process-directive gestalt and experiential interventions at client markers indicating particular cognitive-affective problems. Treatments showed no difference in reducing depressive symptomatology at termination and six month follow-up. The experiential treatment, however, had superior effects at mid-treatment on depression and at termination on the total level of symptoms, self-esteem, and reduction of interpersonal problems. The addition, to the relational conditions, of specific active interventions at appropriate points in the treatment of depression appeared to hasten and enhance improvement.
Inclusion of premenstrual dysphoric disorder (PMDD) into the main text of the DSM has been a point of controversy for many years. The purpose of this article is to address the main concerns raised by opponents to its inclusion. Concerns are presented and countered in turn.
To identify the most prevalent arguments against inclusion of PMDD, we searched MEDLINE (1966-2012), PsycINFO (1930-2012), the Internet, and reference lists of identified articles during September 1-17, 2012, using the keywords PMDD, premenstrual syndrome (PMS), DSM, DSM-5, concerns, controversy, women, political power, workforce, courts, and history. The search was restricted to English-language publications. A total of 55 articles were identified and included. The most pressing arguments against inclusion were grouped by similarity and addressed if they were reported 5 or more times. Our review of the sources yielded 38 concerns regarding PMDD; 6 concerns were reported at least 5 times and are addressed in this article.
Evidence culled from historical and legal trends does not support the alleged societal use of PMS to harm women (eg, keeping women out of the workforce or using PMS against women in child custody disputes). Further, current epidemiologic research has answered all of the methodology criticisms of opponents. Studies have confirmed the existence of PMDD worldwide. The involvement of pharmaceutical companies in research has been questioned. However, irrespective of the level of association with industry, current research on PMDD has consistent results: PMDD exists in a minority of women.
Historically, the pain and suffering of women have been dismissed, minimized, and negated. Similarly, women with PMDD have often had their experience invalidated. With the preponderance of evidence in its favor, PMDD has been placed in the main text of the DSM-5, opening the door for affected women to receive the attention full diagnostic status provides.
Psychological interventions to treat mental health issues have developed remarkably in the past few decades. Yet this progress often neglects a central goal-namely, to reduce the burden of mental illness and related conditions. The need for psychological services is enormous, and only a small proportion of individuals in need actually receive treatment. Individual psychotherapy, the dominant model of treatment delivery, is not likely to be able to meet this need. Despite advances, mental health professionals are not likely to reduce the prevalence, incidence, and burden of mental illness without a major shift in intervention research and clinical practice. A portfolio of models of delivery will be needed. We illustrate various models of delivery to convey opportunities provided by technology, special settings and nontraditional service providers, self-help interventions, and the media. Decreasing the burden of mental illness also will depend on integrating prevention and treatment, developing assessment and a national database for monitoring mental illness and its burdens, considering contextual issues that influence delivery of treatment, and addressing potential tensions within the mental health professions. Finally, opportunities for multidisciplinary collaborations are discussed as key considerations for reducing the burden of mental illness.
© The Author(s) 2011.
So-called 'third wave' cognitive and behavioural therapies represents a new generation of psychological therapies that are increasingly being used in the treatment of psychological problems. However, the effectiveness and acceptability of third wave cognitive and behavioural therapy (CBT) approaches as a treatment for depression compared with other psychological therapies remain unclear.
1. To examine the effects of all third wave CBT approaches compared with all other psychological therapy approaches for acute depression.2. To examine the effects of different third wave CBT approaches (ACT, compassionate mind training, functional analytic psychotherapy, extended behavioural activation and metacognitive therapy) compared with all other psychological therapy approaches for acute depression.3. To examine the effects of all third wave CBT approaches compared with different psychological therapy approaches (psychodynamic, behavioural, humanistic, integrative, cognitive-behavioural) for acute depression.
We searched the Cochrane Depression, Anxiety and Neurosis Group Specialised Register (CCDANCTR to 01/01/12), which includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies and relevant reviews for additional published and unpublished studies. An updated search of CCDANCTR restricted to search terms relevant to third wave CBT was conducted in March 2013 (CCDANCTR to 01/02/13).
Randomised controlled trials that compared various third wave CBT with other psychological therapies for acute depression in adults.
Two review authors independently identified studies, assessed trial quality and extracted data. Study authors were contacted for additional information where required. We rated the quality of evidence using GRADE methods.
A total of three studies involving 144 eligible participants were included in the review. Two of the studies (56 participants) compared an early version of acceptance and commitment therapy (ACT) with CBT, and one study (88 eligible participants) compared extended behavioural activation with CBT. No other studies of third wave CBT were identified. The two ACT studies were assessed as being at high risk of performance bias and researcher allegiance. Post-treatment results, which were based on dropout rates, showed no evidence of any difference between third wave CBT and other psychological therapies for the primary outcomes of efficacy (risk ratio (RR) of clinical response 1.14, 95% confidence interval (CI) 0.79 to 1.64; very low quality) and acceptability. Results at two-month follow-up showed no evidence of any difference between third wave CBT and other psychological therapies for clinical response (2 studies, 56 participants, RR 0.22, 95% CI 0.04 to 1.15). Moderate statistical heterogeneity was indicated in the acceptability analyses (I(2) = 41%).
Very low quality evidence suggests that third wave CBT and CBT approaches are equally effective and acceptable in the treatment of acute depression. Evidence is limited in quantity, quality and breadth of available studies, precluding us from drawing any conclusions as to their short- or longer-term equivalence. The increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies to compare various third wave CBT approaches with other psychological therapy approaches to inform clinicians and policymakers on the most effective forms of psychological therapy in treating depression.
Studies of families and twins show the importance of genetic factors affecting susceptibility to bipolar disorder and suggest substantial genetic and phenotypic complexity. Robust and replicable genome-wide significant associations have recently been reported in genome-wide association studies at several common polymorphisms, including variants within the genes CACNA1C, ODZ4, and NCAN. Strong evidence exists for a polygenic contribution to risk (ie, many risk alleles of small effect). A notable finding is the overlap of susceptibility between bipolar disorder and schizophrenia for several individual risk alleles and for the polygenic risk. By contrast, genomic structural variation seems to play a smaller part in bipolar disorder than it does in schizophrenia. Together, these genetic findings suggest directions for future studies to delineate the aetiology and pathogenesis of bipolar disorder, indicate the need to re-evaluate our diagnostic classifications, and might eventually pave the way for major improvements in clinical management.
It is my thesis in this paper that we should re-examine and re-evaluate that very special way of being with another person which has been called empathic. I believe we tend to give too little consideration to an element which is extremely important both for the understanding of personality dynamics and for effecting changes in personality and behavior. It is one of the most delicate and powerful ways we have of using ourselves. In spite of all that has been said and written on this topic, it is a way of being which is rarely seen in full bloom in a relationship. I will start with my own somewhat faltering history in relation to this topic. Personal Vacillations Very early in my work as a therapist I discovered that simply listening to my client, very attentively, was an important way of being helpful. So when I was in doubt as to what I should do, in some active way, I listened. It seemed surprising to me that such a passive kind of interaction could be so useful. A little later a social worker, who had a background of Rankian training, helped me to learn that the most effective approach was to listen for the feelings, the emotions whose patterns could be discerned through the client's words. I believe she was the one who suggested that the best response was to "reflect" these feelings back to the client-- "reflect" becoming in time a word which made me cringe. But at that time it improved my work as therapist, and I was grateful. Then came my transition to a full-time university position where, with the help of students, I was at last able to scrounge equipment for recording our interviews. I cannot exaggerate the excitement of our learnings as we clustered about the machine which enabled us to listen to ourselves, playing over and over some puzzling point at which the interview clearly went wrong, or those moments in which the client moved significantly forward. (I still regard this as the one best way of learning to improve oneself as a therapist.) Among many lessons from these recordings, we came to realize that listening to feelings and "reflecting" them was a vastly complex process. We discovered that we could pinpoint the therapist response which caused a fruitful flow of significant expression to become superficial and unprofitable. Likewise we were able to spot the remark which turned a client's dull and desultory talk into a focused selfexploration. In such a context of learning it became quite natural to lay more stress upon the content of the therapist response than upon the empathic quality of the listening. To this extent we became heavily conscious of the techniques which the counselor or therapist was using. We became expert in analyzing, in very minute detail, the ebb and flow of the process in each interview, and
Over the past 50 years, there has been an astonishing increase in severe mental illness in the United States. The percentage of Americans disabled by mental illness has increased fivefold since 1955, when Thorazine-remembered today as psychiatry's first "wonder" drug-was introduced into the market. The number of Americans disabled by mental ill- ness has nearly doubled since 1987, when Prozac-the first in a second generation of wonder drugs for mental illness-was introduced . There are now nearly 6 million Ameri- cans disabled by mental illness, and this number increases by more than 400 people each day. Areview of the scientific literature reveals that it is our drug-based paradigm of care that is fueling this epidemic . The drugs increase the likelihood that a person will become chronically ill, and induce new and mote severe psychiatric symptoms in a significant percentageof patients.
No one treatment is likely to affect all patients with a disorder in the same way. A treatment highly effective for some may be ineffective or even harmful for others. Statistically significant or not, the effect sizes of many treatments tend to be small. Consequently, emphasis in clinical research is gradually shifting (1) to increased focus on effect sizes and (2) to discovery and documentation of moderators of treatment effect on outcome in randomized clinical trials, that is, personalized medicine, in which individual differences between patients are explicitly acknowledged. How to test a null hypothesis of moderation of treatment outcome is reasonably well known. The focus here is on how, under parametric assumptions, to define the strength of moderation, that is, a moderator effect size, either for scientific purposes or for assessment of clinical significance, in order to compare moderators and choose among them and to develop a composite moderator, which might more strongly moderate the effect of a treatment on outcome than any single moderator that might ultimately provide guidance for clinicians as to whom to prescribe what treatment. Copyright © 2013 John Wiley & Sons, Ltd.
In
Emotion-Focused Therapy for Depression, Leslie S. Greenberg and Jeanne C. Watson provide a manual for the emotion-focused therapy (EFT) of depression. Their approach is supported by studies in which EFT for depression was compared with cognitive-behavioral therapy and client-centered therapy. The approach has been refined to apply specifically to the treatment of this pervasive and often intractable disorder. The authors discuss the nature of depression and its treatment, examine the role of emotion, present a schematic model of depression and an overview of the course of treatment, and suggest who might benefit. Written with a practical focus rather than the more academic theoretical style of previous books that established the theoretical grounds and scientific viability of working with emotion in psychotherapy, this book aims to introduce practitioners to the idea of using this approach to work with a depressed population. The book covers theory, case formulation, treatment, and research in a way that makes this complex form of therapy accessible to all readers. Particularly valuable are the case examples, which demonstrate the deliberate and skillful use of techniques to leverage emotional awareness and thus bring about change. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
this chapter will describe Interpersonal Psychotherapy (IPT) for depression, including the theoretical and empirical bases, efficacy studies, and derivative forms, and will also make recommendations for its use in clinical practice
Interpersonal Psychotherapy (IPT) is based on the observation that major depression—regardless of symptom patterns, severity, presumed biological or genetic vulnerability, or the patients' personality traits—usually occurs in an interpersonal context, often an interpersonal loss or dispute / IPT is a brief, weekly psychotherapy that is usually conducted for 12 to 16 weeks, although it has been used for longer periods of time with less frequency as maintenance treatment for recovered depressed patients with major depression / the focus is on improving the quality of the depressed patients' current interpersonal functioning and the problems associated with the onset of depression (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Behavioral activation is a positive approach to treating depression. Working within this framework the therapist helps clients to see depression not as something inside of them but as a natural consequence of the way they cope with the shifting contexts of daily life. There is no search for mental illness, skill deficits, or distortions in thinking. Rather, the therapist coaches the client to engage in activities that will lead to a more rewarding life. This book is arranged in 3 parts. Part I reviews theories of depression and various treatments for depression, particularly pharmacological treatments, cognitive therapy, and behavioral therapy. Part II describes the behavioral activation treatment approach and provides ample case transcript material. Part III looks at problems that can arise in therapy and at future opportunities for the use of behavioral activation. Combining practical, theoretical, and empirical discussions, this book will be of value to a wide range of clinicians, students, and anyone interested in the treatment of depression. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
argue that the ultimate failure of American pragmatism within scientific psychology was due to a subtle but crucial problem, beginning with James himself / also argue that the varieties of scientific contextualism make sense when this problem is identified and solved
the models of stable truth / the fluid model: truth and consequences / the common error of contextualists: dogmatism [James: the first contextualistic dogmatist, Skinner: more contextualistic dogmatism] / the two contextualisms [descriptive contextualism, functional contextualism, goals and forms of contextualism] (PsycINFO Database Record (c) 2012 APA, all rights reserved)