Relationship of variability in residual symptoms with recurrence of major depressive disorder during maintenance treatment.

OBJECTIVE: To investigate how residual symptoms from an index episode of major depressive disorder may be associated with recurrence, the authors conducted a trial involving four maintenance treatment approaches and examined 1) whether the level and variability of residual symptoms differed among the maintenance treatment conditions and 2) whether greater symptom variability is associated with a higher likelihood of recurrence and more rapid recurrence. METHOD: Patients enrolled in a maintenance treatment study (N=114) were randomly assigned to one of four maintenance treatment conditions: imipramine plus interpersonal psychotherapy, imipramine alone, interpersonal psychotherapy alone, or no active treatment. Residual symptoms were characterized both as continuous variables (mean values and coefficients of variation for Hamilton Depression Rating Scale and Global Assessment Scale [GAS] scores) and as a categorical variable, the percentage of maintenance evaluations with a Hamilton depression scale score > or =8 (e.g., with a symptom peak). RESULTS: Analysis of variance revealed no differences among the four treatment conditions in patients' levels of residual symptoms or symptom variability assessed as a continuous variable, but patients in the combined treatment group had fewer symptom peaks, compared to those in the placebo and interpersonal psychotherapy groups. Cox proportional hazards modeling showed that higher coefficients of variation for both the Hamilton depression scale and the GAS scores and a greater percentage of evaluations with symptom peaks were associated with shorter survival times. CONCLUSIONS: A higher level of symptom variability during maintenance treatment is associated with higher risk for recurrence of depression and may provide a specific target for maintenance treatments.

Prospective assessment of sexual function in women treated for recurrent major depression.

Although multiple factors may influence the sexual function of depressed women over the course of treatment, the independent contributions of these factors are poorly understood. The current study examined the effects of depression, SSRI treatment, and sexual partner availability on women's sexual function. The sexual function of 68 recurrently depressed women was assessed at 3-month intervals over a 1-year course of treatment with interpersonal psychotherapy with or without adjunctive SSRI treatment. Random regression models assessing changes in sexual function were conducted to test the effects of three time-dependent covariates: depression symptom scores, sexual partner availability, and SSRI medication status. Controlling for the other variables, depressive symptoms were associated with decrements in sexual desire, sexual cognition/fantasy, sexual arousal, orgasmic function, and global evaluations of sexual function. SSRI treatment was associated with orgasmic difficulty only. The availability of a sexual partner was associated with increased sexual arousal, orgasmic function, and sexual behavior. Among treatment remitters, patient reports of severe sexual dysfunction did not change over the course of treatment, although mild improvement was observed in patients' global assessment of the quality of their sexual function. This report illustrates the prevalence and persistence of sexual dysfunction in this sample, and highlights the importance of monitoring both pharmacologic and psychosocial variables that can affect the sexual function of recurrently depressed women throughout the course of treatment.

A pilot study of community mental health care for depression in a supermarket setting.

OBJECTIVE: Women with depression whose diagnosis is made in community mental health clinics attend relatively few treatment sessions. A pilot project was undertaken to test the feasibility of providing psychotherapy for depressed women in a supermarket, a novel setting that may minimize barriers to care such as stigma associated with visiting a mental health clinic. METHODS: Twelve women who met DSM-IV criteria for a depressive disorder were recruited from a rural mental health clinic and offered 16 weekly sessions of supportive psychotherapy with cognitive-behavioral elements in an administrative conference room of a local supermarket. Outcomes measured were treatment attendance, depressive symptoms, and satisfaction with treatment. RESULTS: Six of the women completed the study. For the entire group, the mean number of sessions attended was 5.2. Those who completed the study attended an average of 8.7 sessions and showed significant improvement on measures of depression and anxiety. They rated their treatment experience as "very satisfactory." For the two therapists, conducting therapy in the supermarket presented some logistical problems, such as limited access to telephones and the absence of a check-in desk. The therapists also reported that providing therapy in this setting was challenging to their professional identities. CONCLUSIONS: The women in the study found treatment in the supermarket to be an appealing alternative to the mental health clinic because of greater accessibility, a perceived reduction in stigma, and convenient "one-stop shopping" for both groceries and mental health treatment.

Acute nicotine reinforcement, but not chronic tolerance, predicts withdrawal and relapse after quitting smoking.

Little research has examined the association of tobacco dependence with nicotine tolerance or reinforcement in a clinical sample. Smokers preparing to quit smoking participated in laboratory sessions to assess nicotine tolerance on subjective, cardiovascular, and performance measures and to assess nicotine reinforcement using a choice procedure. Participants were then provided with individual counseling (but no medication), made a quit attempt, and were followed for 1 year to determine clinical outcome, as determined by postquit withdrawal and days to relapse. Nicotine tolerance was unrelated to either withdrawal or relapse. However, acute nicotine reinforcement was significantly related to both greater withdrawal and faster relapse. Results challenge the common assumption that nicotine tolerance is closely related to dependence but suggest that nicotine reinforcement may have theoretical and clinical significance for dependence.