Short-Term Psychodynamic Psychotherapy with Mentalization-Based Techniques in Major Depressive Disorder patients: Relationship among alexithymia, reflective functioning, and outcome variables - A Pilot study.

OBJECTIVES: In depressed patients, recent advances have highlighted impairment in mentalizing: identifying and interpreting one's own or other's mental states. Short-Term Psychodynamic Psychotherapy (STPP) has proven to be effective in reducing symptoms and improving relational/functional abilities in these subjects. Therefore, the first aim of our study was to evaluate effectiveness of STPP with Mentalization-Based Techniques (STMBP) on their clinical outcomes and the second, to investigate Reflective Functioning and alexithymia concerning treatment outcomes in depressed subjects. DESIGN: A baseline evaluation of reflective functioning, alexithymia and depression was conducted before an STMBP treatment. Patients were re-tested successively after 40 weeks (T1) and in a follow-up after 1 year at the end of the treatment (T2). METHODS: A total of 24 patients principally diagnosed with Major Depressive Disorder (MDD) underwent a STMBP conducted by two expert therapists. Global Assessment Functioning (GAF), Toronto Alexithymia Scale-20 (TAS-20) and Hamilton Depression Rating Scale (HAM-D) data were collected at the baseline (T0) by two clinical therapists, along with RF scores rated by two trained raters. HAM-D, TAS-20 and GAF follow-ups were conducted at the end of the treatment after 40 weeks (T1) and after 1-year follow-up (T2). RESULTS: Results highlighted an improvement of both HAM-D and TAS-20 scores in our sample. Moreover, a negative correlation between RF and TAS-20 was found. Both HAM-D and RF at T0 influenced depressive outcomes at the end of the treatment. CONCLUSIONS: Results confirmed the effectiveness of STMBP in MDD, suggesting also an inverse association between RF and alexithymia. PRACTITIONER POINTS: Our study demonstrates how STMBP could be effective in MDD even after 40 sessions, maintaining its effect in a 1-year follow-up. STMBP improves subjective capability of reflecting on the mental states of oneself and others. Our intervention allows patients to orientate thoughts from inside to outside, reducing negative beliefs also in absence of a pharmacological therapy (during the follow-up).

Is it possible to assess subjective well-being among bipolar inpatients? An 18-week follow-up study.

OBJECTIVE: The study evaluates the association between subjective well-being and psychopathology in bipolar inpatients at the time of hospitalization and during a follow-up period. METHOD: One hundred twenty consecutive inpatients with a diagnosis of bipolar affective disorder were studied on admission (T0), at discharge (T1) and every 6 weeks for 18 weeks after hospitalization. The Young's Mania Rating Scale (YMRS) and the Hamilton Rating Scale for Depression (HAM-D) were used to determine affective symptoms, while subjective well-being was assessed by subjective well-being under neuroleptic (SWN). Associations between SWN and HAM-D or YMRS scores and between their changes were analyzed across the different time points by using Pearson correlation coefficients. Linear regression models were constructed using SWN as the dependent variable and demographic and clinical characteristics as possible predictors. RESULTS: At baseline, depression explained 24% and mania explained an additional 16% of baseline SWN variance. Changes in SWN and HAM-D total score displayed an inverse correlation during hospitalization and follow-up. End point severity of depression was associated with the end point SWN total score explaining additional 26% of SWN total score variance, whereas severity of mania was inversely associated with SWN total score. CONCLUSION: Data of this study provide further support for the need to consider the subjective well-being as a personal variable associated to psychopathological state in bipolar patients. However, results seem to be in line with authors who suggest to use other subjective quality of life scales in acute mania.

Role of COMT, 5-HT(1A) , and SERT genetic polymorphisms on antidepressant response to Transcranial Magnetic Stimulation.

BACKGROUND: Transcranial Magnetic Stimulation (TMS) is an effective technique in the treatment of depression, specifically in drug-resistant patients. However, there is little data available on the influence of genetic variables on TMS response. METHODS: We analyzed the role of three genetic polymorphisms that affected the antidepressant response: serotonin transporter promoter region (SERTPR) polymorphism, 5-HT(1A) serotonergic receptor promoter region polymorphism (rs6295), and the coding region of COMT gene polymorphism (rs4680). Ninety patients with a major depressive drug-resistant episode due to a Major Depressive Disorder or to a Bipolar Disorder were included in our study. Patients underwent high frequency TMS, focused on the left prefrontal cortex, for 2 weeks. At study completion, the response rate was 45.5%. Effects of gene polymorphisms on clinical improvement were analyzed with an analysis of variance with each gene (SERTPR, 5-HT(1A) , and COMT) as factors and the Hamilton Rating Scale for Depression variation from baseline to the end of the treatment as a dependent variable. RESULTS: We found a significant model in which three factors were not significant (diagnosis, COMT, and SERTPR), whereas factor 5-HT(1A) showed a significant influence on the outcome, with patients with C/C genotype showing a greater improvement than G/G and C/G and no difference between G/G and C/G. CONCLUSION: According to our data, 5-HT(1A) polymorphism may play a role in influencing TMS response. The effect of COMT and SERTPR did not reach statistical significance. The analysis of these and other candidate genes in larger samples could help explain genetic influence on TMS response.

Short-term psychodynamic psychotherapy versus treatment as usual for depressive and anxiety disorders: a randomized clinical trial of efficacy.

This randomized clinical trial aimed to evaluate the clinical efficacy of short-term psychodynamic psychotherapy (STPP) in the treatment of patients suffering from anxiety or depressive disorders, as compared with a control case sample composed of patients undergoing treatment as usual (TAU). Sixty patients with depressive or anxiety disorders according to DSM IV-TR were randomly assigned in a 1:1 ratio to an intervention group (STPP) or control group for 12 months (T1). Primary outcome measures were the Symptom Checklist 90-Revised (SCL-90-R), the Inventory of Interpersonal Problems (IIP), and the Clinical Global Impression Improvement Scale. Intention to treat analysis revealed that patients who received STPP showed significantly more improvements in comparison with those who were in the TAU group on Clinical Global Impression Improvement Scale and IIP measures. This study offers evidence that STPP is an effective treatment for patients with anxiety or depressive disorders, and it could be more effective than TAU in improving interpersonal problems as measured by IIP.

Expressed emotion in wives of myocardial infarction patients: an exploratory feasibility study.

INTRODUCTION: We assessed the emotional components expressed by the spouses of patients at the first episode of acute myocardial infarction (AMI) and considered potential underlying links among these components and the course of the cardiac symptoms over time. This was an exploratory prospective cohort study. METHODS: A sample of 50 consecutive male inpatients with a diagnosis of AMI and their wives was studied. At baseline spouses were assessed with the Camberwell Family Interview and ratings of Expressed Emotion were made. Patients completed the State-Trait Anxiety Inventory (STAI XI-X2) and the Beck's Depression Inventory (BDI). After 12 months (T1), during appropriate treatment by a cardiologist blinded to the Expressed Emotion ratings, the existence or absence of serious adverse events (death or hospitalizations because of cardiac causes) were determined as an all-or-none phenomenon. Stepwise logistic regression analysis was performed to estimate associations among illness course and Expressed Emotion subscales, STAI X1-X2, BDI scores and clinical variables. RESULTS: High family Emotional Overinvolvement (EOI) scores were associated with higher study entry levels of depression (P = 0.003) among the patients and high Warmth was related to higher score on state anxiety scale (P = 0.000). Poor illness course at T1 was associated with high EOI [P = 0.005, exp(B) = 0.502, 95% confidence interval 0.308-0.818]. CONCLUSION: The association among wives' emotional profile, patients' psychological variables and illness course suggested the importance of a family assessment and of interventions directed towards changing emotional behaviours which could threaten the patient's psychological adjustment and the clinical course following a heart attack.

New perspectives on techniques for the clinical psychiatrist: Brain stimulation, chronobiology and psychiatric brain imaging.

This review summarizes a scientific dialogue between representatives in non-pharmacological treatment options of affective disorders. Among the recently introduced somatic treatments for depression those with most evidenced efficacy will be discussed. The first part of this article presents current opinions about the clinical applications of transcranial magnetic stimulation in the treatment of depression. The second part explains the most relevant uses of chronobiology in mood disorders, while the last part deals with the main perspectives on brain imaging techniques in psychiatry. The aim was to bridge gaps between the research evidence and clinical decisions, and reach an agreement on several key points of chronobiological and brain stimulation techniques, as well as on relevant objectives for future research.

Role of serotonergic gene polymorphisms on response to transcranial magnetic stimulation in depression.

Transcranial magnetic stimulation (TMS) has been extensively studied as a treatment for Major Depression. However, no data are available about the role of genetic variables on the response to this treatment. We analysed the role of two polymorphisms that influence the response to antidepressants: the polymorphisms of the serotonin transporter promoter region (SERTPR) and of the 5-HT(1A) serotonergic receptor promoter region (-1019C/G). Ninety-nine patients from two double-blind, randomised, sham-controlled TMS trials were enrolled. There was a significant influence (p=0.016) of the SERTPR polymorphism on treatment outcome, without differences between active and sham stimulation. Conversely, there was a significant (p=0.014) interaction between 5-HT(1A) genotype and type of stimulation: C/C patients showed a higher difference between active and sham stimulation, indicating that these patients benefited more by TMS than C/G and G/G subjects. Our sample has not the power to control for the possible influence of different medications on these results.

Transcranial magnetic stimulation in treatment-resistant depressed patients: a double-blind, placebo-controlled trial.

This 5-week, randomized, double-blind, placebo-controlled trial investigated the efficacy and tolerability of high frequency repetitive transcranial magnetic stimulation (rTMS) directed to the left prefrontal cortex in drug-resistant depressed patients. Fifty-four patients were randomly assigned to receive 10 daily applications of either real or sham rTMS. Subjects assigned to receive active stimulation were divided into two further subgroups according to the intensity of stimulation: 80% vs. 100% of motor threshold (MT). At study completion, the response rates were 61.1% (n=11), 27.8% (n=5) and 6.2% (n=1) for the 100% MT group, 80% MT group and sham group, respectively. A significant difference (Pearson chi(2) test) was found between the 100% MT and sham groups, while the 80% MT group did not differ significantly from the sham group. Between the two active groups, a marginally significant difference was observed. Analysis of variance with repeated measures on Hamilton Depression Rating Scale scores revealed a significantly different decrease over time of depressive symptomatology among the three treatment groups. Treatment response appeared to be unrelated to the demographic and clinical characteristics recorded, and on the whole the technique was well tolerated. The results of this double-blind trial showed that rTMS may be a useful and safe adjunctive treatment for drug-resistant depressed patients.

Does rTMS hasten the response to escitalopram, sertraline, or venlafaxine in patients with major depressive disorder? A double-blind, randomized, sham-controlled trial.

BACKGROUND/OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) has been mainly studied as adjunctive treatment for drug-resistant patients. We assessed the effectiveness of rTMS started concomitantly with antidepressant medications in non-drug-resistant major depressive disorder patients. We also evaluated if, among the 3 antidepressants administered, one had a better synergy with rTMS. METHOD: In this 5-week, double-blind, randomized, sham-controlled study, we recruited 99 inpatients suffering from a major depressive episode (DSM-IV criteria). They were randomly assigned to receive venlafaxine, sertraline, or escitalopram in combination with a 2-week period of sham or active 15-Hz rTMS on the left dorso-lateral prefrontal cortex. Data were gathered from February 2004 to June 2005. RESULTS: The active rTMS group showed a significantly faster reduction in Hamilton Rating Scale for Depression (HAM-D) scores compared with the sham group (p = .0029). The response and remission rates were significantly greater in the active rTMS group after the stimulation period (p = .002 and p = .003, respectively), but not at the endpoint. We found no significant difference in HAM-D score reduction among the 3 drugs administered, either in the active or in the sham group. CONCLUSION: These findings support the efficacy of rTMS in hastening the response to antidepressant drugs in patients with major depressive disorder. The effect of rTMS seems to be unaffected by the specific concomitantly administered drug.