Differential efficacy of cognitive behavioral therapy and psychodynamic therapy for major depression: a study of prescriptive factors.

BACKGROUND: Minimal efficacy differences have been found between cognitive behavioral therapy (CBT) and psychodynamic therapies for depression, but little is known about patient characteristics that might moderate differential treatment effects. We aimed to generate hypotheses regarding such potential prescriptive factors. METHOD: We conducted post-hoc model-based recursive partitioning analyses alongside a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy (SPSP). Severely depressed patients received additional antidepressant medication. We included 233 adults seeking treatment for a major depressive episode in psychiatric outpatient clinics, who completed post-treatment assessment. Post-treatment mean Hamilton Depression Rating Scale scores constituted the main outcome measure. RESULTS: While treatment differences (CBT v. SPSP) were minimal in the total sample of patients (d = 0.04), model-based recursive partitioning indicated differential treatment efficacy in certain subgroups of patients. SPSP was found more efficacious among moderately depressed patients receiving psychotherapy only who showed low baseline co-morbid anxiety levels (d = -0.40) and among severely depressed patients receiving psychotherapy and antidepressant medication who reported a duration of the depressive episode of ⩾1 year (d = -0.31), while CBT was found more efficacious for such patients reporting a duration <1 year (d = 0.83). CONCLUSIONS: Our findings are observational and need validation before they can be used to guide treatment selection, but suggest that knowledge of prescriptive factors can help improve the efficacy of psychotherapy for depression. Depressive episode duration and co-morbid anxiety level should be included as stratification variables in future randomized clinical trials comparing CBT and psychodynamic therapy.

Nutritional impact of sodium reduction strategies on sodium intake from processed foods.

BACKGROUND/OBJECTIVES: Sodium intake in the Netherlands is substantially above the recommended intake of 2400 mg/day. This study aimed to estimate the effect of two sodium reduction strategies, that is, modification of the composition of industrially processed foods toward the technologically feasible minimum level or alteration of consumers' behavior on sodium intake in the Netherlands. SUBJECTS/METHODS: Data from the Dutch National Food Consumption Survey (2007-2010) and the Food Composition Table (2011) were used to estimate the current sodium intake. In the first scenario, levels in processed foods were reduced toward their technologically feasible minimum level (sodium reduction in processed foods scenario). The minimum feasible levels were based on literature searches or expert judgment. In the second scenario, foods consumed were divided into similar food (sub)groups. Subsequently, foods were replaced by low-sodium alternatives (substitution of processed foods scenario). Sodium intake from foods was calculated based on the mean of two observation days for the current food consumption pattern and the scenarios. RESULTS: Sodium levels of processed foods could be reduced in most food groups by 50%, and this may reduce median sodium intake from foods by 38% (from 3042 to 1886 mg/day in adult men). Substitution of foods may reduce sodium intake by 47% (from 3042 to 1627 mg/day in adult men), owing to many low-sodium alternatives within food groups. CONCLUSIONS: In the Netherlands, reduction of sodium intake by modification of food composition or by alteration of behavior may substantially reduce the median sodium intake from foods below the recommended sodium intake.

[Defence style and therapeutic technique as predictors of the outcome of psychodynamic psychotherapy in depression]. / Afweerstijl en therapeutische techniek als voorspellers voor uitkomst van psychodynamische psychotherapie bij depressie.

BACKGROUND: In psychodynamic psychotherapy it is assumed that insight-fostering interventions lead to better results when used with patients who have relatively strong personality structures. AIM: To investigate to what extent the use of supportive or insight-fostering interventions is determined by sociodemographic variables, the severity, duration and recurrence of depression and defence style and to find out whether the type of intervention used can predict the treatment outcome of psychotherapy in depression. METHOD: The study-group consisted of 147 depressed patients with or without a comorbid personality disorder who had been treated with supportive PsychoDynamic Therapy (PDT) with or without medication and for whom the Therapist Evaluation Form (TEF) was available. On the TEF the therapist assessed the patients' defence style and the therapeutic technique that was used. The most important outcome measure was the Hamilton Depression Rating Scale (HAM-D). RESULTS: No correlation was found between technique used and sociodemographic characteristics or the severity and duration of the depression. Insight-fostering interventions were related to better treatment outcomes. Not only age and educational level but also defence style turned out to be confounding variables in the relationship between technique and outcome. We found no interaction between treatment success and insight-fostering interventions in patients who used mature defence styles. CONCLUSION: In our study it was defence style as evaluated by the therapist rather than the technique used which was the strongest independent predictor of a successful outcome. This indicates that patients with primitive defence styles may also benefit from insight-fostering interventions.

Consuming a diet complying with front-of-pack label criteria may reduce cholesterol levels: a modeling study.

BACKGROUND/OBJECTIVES: Front-of-pack nutrition labels can help consumers to make healthier choices and stimulate healthier product development. This is the first modeling study to investigate the potential impact on cholesterol levels of consuming a diet consisting of products that comply with the criteria for a 'healthier choice logo'. SUBJECTS/METHODS: National food consumption and food composition data were used to estimate the nutrient intake of the Dutch adult population (18-70 years) before and after replacing foods that did not comply with the choices front-of-pack label criteria. Different scenarios were established. The difference in cholesterol levels in the Dutch population was assessed before and after replacement by means of equations from meta-analyses that calculate how blood lipids change when diet composition changes. RESULTS: After replacing non-complying products with products, which comply with the label's criteria (maximum scenario), saturated fatty acids median intake reduced from 14.5 to 9.8 en%. Trans-fatty acids reduced from 0.95 to 0.57 en%. The average predicted changes in low-density lipoprotein and total cholesterol levels were -0.25 and -0.31 mmol/l, respectively. Because high-density lipoprotein (HDL) cholesterol levels reduced as well (-0.05 mmol/l), overall, the result was a slightly positive change in the total cholesterol/HDL ratio (-0.03). CONCLUSIONS: Our findings suggest that the consumption of foods complying with the criteria for a front-of-pack label could contribute moderately to cardiovascular risk reduction via influencing blood lipids. These findings were independent of other potential effects on related health outcomes.

State of the art in benefit-risk analysis: food and nutrition.

Benefit-risk assessment in food and nutrition is relatively new. It weighs the beneficial and adverse effects that a food (component) may have, in order to facilitate more informed management decisions regarding public health issues. It is rooted in the recognition that good food and nutrition can improve health and that some risk may be acceptable if benefit is expected to outweigh it. This paper presents an overview of current concepts and practices in benefit-risk analysis for food and nutrition. It aims to facilitate scientists and policy makers in performing, interpreting and evaluating benefit-risk assessments. Historically, the assessments of risks and benefits have been separate processes. Risk assessment is mainly addressed by toxicology, as demanded by regulation. It traditionally assumes that a maximum safe dose can be determined from experimental studies (usually in animals) and that applying appropriate uncertainty factors then defines the 'safe' intake for human populations. There is a minor role for other research traditions in risk assessment, such as epidemiology, which quantifies associations between determinants and health effects in humans. These effects can be both adverse and beneficial. Benefit assessment is newly developing in regulatory terms, but has been the subject of research for a long time within nutrition and epidemiology. The exact scope is yet to be defined. Reductions in risk can be termed benefits, but also states rising above 'the average health' are explored as benefits. In nutrition, current interest is in 'optimal' intake; from a population perspective, but also from a more individualised perspective. In current approaches to combine benefit and risk assessment, benefit assessment mirrors the traditional risk assessment paradigm of hazard identification, hazard characterization, exposure assessment and risk characterization. Benefit-risk comparison can be qualitative and quantitative. In a quantitative comparison, benefits and risks are expressed in a common currency, for which the input may be deterministic or (increasingly more) probabilistic. A tiered approach is advocated, as this allows for transparency, an early stop in the analysis and interim interaction with the decision-maker. A general problem in the disciplines underlying benefit-risk assessment is that good dose-response data, i.e. at relevant intake levels and suitable for the target population, are scarce. It is concluded that, provided it is clearly explained, benefit-risk assessment is a valuable approach to systematically show current knowledge and its gaps and to transparently provide the best possible science-based answer to complicated questions with a large potential impact on public health.

Patient satisfaction in treatment for cervical pathology.

This study aimed to analyse the satisfaction levels of patients treated for cervical dysplasia. At the Orbis Medical Center, all cases of abnormal cervical cytology are referred for colposcopy; however, there are three possible routings for patients: i) Patients are informed by the gynecologist about the colposcopy in a visit to the outpatient clinic, and colposcopy is planned in a second visit; ii) patients are informed by the gynecologist immediately before the colposcopy (a single visit); or iii) patients are called by a nurse practitioner 1-2 weeks prior to the colposcopy. The nurse practitioner informs patients about their Pap smear result, the colposcopy procedure and the follow-up (single visit plus telephone conversation). Patient satisfaction was analysed in the diagnostic and occasionally in the therapeutic colposcopies, with regards to information, treatment, appeasement and number of visits. The issue of whether the introduction of nurse practitioners improved patient satisfaction was also assessed. Patient satisfaction questionnaires were sent to all 593 patients who underwent a colposcopic examination for the first time following an abnormal smear test result. Data were analysed using SPSS 14.0. For statistical analyses, χ(2) tests and the Mann-Whitney U test were used. P<0.05 was considered to be statistically significant. The response rates did not differ significantly among the three groups of patients. In general, patient satisfaction regarding care was high (96%). The role of the nurse practitioner was rated highly (8.0-8.4). Although there were differences in the number of visits and satisfaction regarding the information provided, patient satisfaction did not differ significantly between groups 1 and 3. Patients in group 2 were significantly less satisfied with regard to almost all analysed data. In conclusion, the single visit procedure is extremely efficient. Patient satisfaction did not differ significantly between groups 1 and 3, but group 2 patients were significantly less satisfied. The introduction of nurse practitioners improves patients' knowledge, comfort and satisfaction. Furthermore, it reduces the number of visits required. Efficient treatment strategies were introduced and patient satisfaction was increased.

Speed of action: the relative efficacy of short psychodynamic supportive psychotherapy and pharmacotherapy in the first 8 weeks of a treatment algorithm for depression.

OBJECTIVE: To examine the efficacy and speed of action of short-term psychodynamic supportive psychotherapy (SPSP) in comparison to pharmacotherapy (PhT) in the acute treatment of depression. METHOD: This study reported on the first 8 weeks of a treatment algorithm for depression. 70 patients with a depressive episode according to DSM-IV were randomized to PhT, 71 patients were randomized to SPSP. The acceptability of the psychotherapy was greater than pharmacotherapy. RESULTS: At the end of the first 8 weeks of treatment, attrition rates were similar in both conditions. PhT-patients were better off at 4 weeks according to two of the four measures The superiority of PhT was clearer on the self-report than on the independent measure. CONCLUSIONS: There are signs that the benefits of PhT over SPSP--where detected--are short-lived and cover mostly the first month of treatment. The progression of these patients through the rest of their treatments, and afterwards, will be reported in further contributions.

A study of the serotonin transporter in the prefrontal cortex in late-life depression and Alzheimer's disease with and without depression.

Previous studies investigating the serotonin transporter (SERT) in depression have been inconsistent and included a large proportion of subjects who had committed suicide. In Alzheimer's disease studies have generally reported a reduction in SERT density but have not compared Alzheimer's disease subjects with and without comorbid major depression. We conducted a post mortem study of SERT density in the prefrontal cortex in normal elderly, a group of elderly depressed subjects and in Alzheimer's disease subjects with and without major depression. A post mortem study comparing SERT density in the prefrontal cortex in elderly controls (n = 10), subjects with major depression (n = 8) and subjects with Alzheimer's disease with (n = 9) and without (n = 5) comorbid major depression. We used autoradiography to measure the density of [3H]CN-IMI binding (non-specific binding determined with citalopram) to the SERT in the prefrontal cortex. We found a marked reduction in specific SERT binding in the prefrontal cortex in Alzheimer's disease subjects compared with both control (P = 0.002) and depressed subjects (P = 0.004) but no difference in SERT binding between depressed and control subjects or between Alzheimer's disease subjects with and without depression. Our study confirms previous reports of a reduction in SERT binding in Alzheimer's disease but indicates this reduction is not greater in Alzheimer's disease subjects who also have had major depression. In a group of subjects more typical of late-life depression we did not identify any alterations in SERT density.