Dyadic discord at baseline is associated with lack of remission in the acute treatment of chronic depression.

BACKGROUND: Dyadic discord, while common in depression, has not been specifically evaluated as an outcome predictor in chronic major depressive disorder. This study investigated pretreatment dyadic discord as a predictor of non-remission and its relationship to depressive symptom change during acute treatment for chronic depression. METHOD: Out-patients with chronic depression were randomized to 12 weeks of treatment with nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy or their combination. Measures included the Marital Adjustment Scale (MAS) and the Inventory of Depressive Symptomatology - Self Report (IDS-SR30). Of 681 original patients, 316 were partnered and 171 of these completed a baseline and exit MAS, and at least one post-baseline IDS-SR30. MAS scores were analysed as continuous and categorical variables ('dyadic discord' v. 'no dyadic discord' defined as an MAS score >2.36. Remission was defined as an IDS-SR30 of 14 at exit (equivalent to a 17-item Hamilton Rating Scale for Depression of 7). RESULTS: Patients with dyadic discord at baseline had lower remission rates (34.1%) than those without dyadic discord (61.2%) (all three treatment groups) (chi2=12.6, df=1, p=0.0004). MAS scores improved significantly with each of the treatments, although the change was reduced by controlling for improvement in depression. Depression remission at exit was associated with less dyadic discord at exit than non-remission for all three groups [for total sample, 1.8 v. 2.4, t(169)=7.3, p<0.0001]. CONCLUSIONS: Dyadic discord in chronically depressed patients is predictive of a lower likelihood of remission of depression. Couple therapy for those with dyadic discord may increase remission rates.

Women with hypoactive sexual desire disorder compared to normal females: a functional magnetic resonance imaging study.

Lack of sexual interest is the most common sexual complaint among women. However, factors affecting sexual desire in women have rarely been studied. While the role of the brain in integrating the sensory, attentional, motivational, and motor aspects of sexual response is commonly acknowledged as important, little is known about specific patterns of brain activation and sexual interest or response, particularly among women. We compared 20 females with no history of sexual dysfunction (NHSD) to 16 women with hypoactive sexual desire disorder (HSDD) in a functional magnetic resonance imaging (fMRI) study that included assessment of subjective sexual arousal, peripheral sexual response using a vaginal photoplethysmograph (VPP), as well as brain activation across three time points. Video stimuli included erotic, sports, and relaxing segments. Subjective arousal to erotic stimuli was significantly greater in NHSD participants compared with HSDD. In the erotic-sports contrast, NHSD women showed significantly greater activation in the bilateral entorhinal cortex than HSDD women. In the same contrast, HSDD females demonstrated higher activation than NHSD females in the medial frontal gyrus (Brodmann area (BA) 10), right inferior frontal gyrus (BA 47) and bilateral putamen. There were no between group differences in VPP-correlated brain activation and peripheral sexual response was not significantly associated with either subjective sexual response or brain activation patterns. Findings were consistent across the three experimental sessions. The results suggest differences between women with NHSD and HSDD in encoding arousing stimuli, retrieval of past erotic experiences, or both. The findings of greater activation in BA 10 and BA 47 among women with HSDD suggest that this group allocated significantly more attention to monitoring and/or evaluating their responses than NHSD participants, which may interfere with normal sexual response.

In the mind's eye: provider and patient attitudes on functional brain imaging.

Success in functional neuroimaging has brought the promise of quantitative data in the form of brain images to the diagnosis of disorders of the central nervous system for which only qualitative clinical criteria have previously existed. Even though the translation of research to clinical neuroimaging for conditions such as major depression may not be available yet, rapid innovation along this trajectory of discovery to implementation compels exploration of how such information will eventually affect providers and patients. Clinical neuroethics is devoted to elucidating ethical challenges prior to and during the transfer of new research capabilities to the bedside. Through a model of proactive ethics, clinical neuroethics promotes the development of responsible social and public policies in response to new diagnostic and prognostic capabilities for the benefit of patients and their families, and for providers within the health care systems in which they practice. To examine views about the potential interaction of clinical neuroimaging and depression, we surveyed both mental health providers and outpatients and inpatients diagnosed with major depressive disorder. From responses of 52 providers and 72 patients, we found high receptivity to brain scans for treatment tailoring and choice, for improving understanding of and coping with disease, and for mitigating the effects of stigma and self-blame. Our results suggest that, once ready, roll out of the fully validated technology has significant potential to reduce social burden associated with highly stigmatized illnesses like depression.

Bipolar disorder: improving diagnosis and optimizing integrated care.

Bipolar disorder is a chronic, severe condition commonly causing substantial mortality and psychosocial morbidity. Challenges in recognition can delay the institution of appropriate management, whereas misdiagnosis may initiate pharmacologic interventions that adversely affect the condition's course. Pharmacotherapy remains the foundation of treatment. In addition to efficacy, tolerability is an important consideration in medication choice, particularly for long-term maintenance because of its impact on adherence. Mood stabilizers are the classic treatments for bipolar disorder. Newer agents such as atypical antipsychotics may offer efficacy and/or tolerability advantages compared with other medications. The role of antidepressants in bipolar disorder remains controversial. Growing evidence indicates that adjunctive psychosocial interventions improve long-term functioning; consequently, psychologists are becoming increasingly involved in the long-term care of patients with bipolar disorder. This review seeks to update psychologists and related healthcare professionals on recent advances and the current limitations in the diagnosis and treatment of bipolar disorder.

Patient's therapeutic skill acquisition and response to psychotherapy, alone or in combination with medication.

BACKGROUND: We tested the hypotheses that the addition of medication to psychotherapy enhances participation in the latter by: (1) speeding the acquisition of the psychotherapy's targeted skill; and (2) facilitating higher skill level acquisition. METHOD: Participants were 431 chronically depressed patients who received Cognitive Behavioral Analysis System of Psychotherapy (CBASP), alone (N=214) or in combination with nefazodone (N=217), as part of a randomized chronic depression study (Keller et al. 2000). CBASP, developed specifically to treat chronic depression, uses a specific procedure, 'situational analysis' to help patients engage in more effective goal-oriented interpersonal behaviours. At the end of each session, therapists rated patients on their performance of situational analysis. Outcome on depressive symptoms was assessed with the 24-item Hamilton Rating Scale for Depression. RESULTS: Although reductions in depression were significantly greater in combined treatment compared to CBASP alone, there were no between-group differences in either the rate of skill acquisition or overall skill level at the end of treatment. Proficiency in the use of the main skill taught in psychotherapy at treatment midpoint predicted outcome independently of medication status and of baseline depressive severity. CONCLUSIONS: Effective participation in CBASP, as reflected by proficiency in the compensatory skill taught in psychotherapy, is not enhanced by the addition of medication and does not mediate the between-group difference in depression outcome.

Is clinical depression distinct from subthreshold depressive symptoms? A review of the continuity issue in depression research.

Resolving whether subthreshold depressive symptoms exist on a continuum with unipolar clinical depression is important for progress on both theoretical and applied issues. To date, most studies have found that individuals with subthreshold depressive symptoms resemble cases of major depressive disorder along many important dimensions (e.g., in terms of patterns of functional impairment, psychiatric and physical comorbidity, familiality, sleeping EEG, and risk of future major depression). However, such manifest similarities do not rule out the possibility of a latent qualitative difference between subthreshold and diagnosable depression. Formal taxonomic analyses, intended to resolve the possibility of a latent qualitative distinction, have so far yielded contradictory findings. Several large-sample latent class analyses (LCA) have identified latent clinical and nonclinical classes of unipolar depression, but LCA is vulnerable to identification of spurious classes. Paul Meehl's taxometric methods provide a potentially conservative alternative way to identify latent classes. The one comprehensive taxometric analysis reported to date suggests that self-report depression symptoms occur along a latent continuum but exclusive reliance on self-report depression measures and incomplete information regarding sample base rates of depression makes it difficult to draw strong inferences from that report. We conclude that although most of the evidence at this time appears to favor both a manifest and latent continuum of unipolar depression symptomatology, several important issues remain unresolved. Complete resolution of the continuity question would be speeded by the application of both taxometric techniques and LCA to a single large sample with a known base rate of lifetime diagnosed depressives.

Emotional experiencing: to facilitate or regulate?

In the preceding several decades, both empirical research and advances in the theoretical literatures of diverse schools of thought suggest that greater client in-session emotional experiencing is related to therapeutic change. What has yet to be explored and explicated are the variables that indicate when, and with whom, facilitating emotional experiencing may be most and least helpful. This article offers an exploration of the clinical and empirical literatures that bear on this issue. It also suggests preliminary client and therapist variables that point either toward or away from the therapeutic facilitation of client emotional experiencing.

Private high school students are at risk for bulimic pathology.

The objective of this study was to assess whether private high school students constitute a group that is at high risk for eating pathology. Female and male public and private high school students (N = 465) were compared on self-reported eating disordered attitudes and behaviors. Private high school students reported elevated eating disordered attitudes and behaviors when compared with students from public schools. The results were somewhat stronger for females than males. The findings suggest that private high school students are a group at high risk for eating pathology. The identification of such high risk groups may facilitate etiologic studies and aid in the implementation of targeted prevention programs.

A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression.

BACKGROUND: Patients with chronic forms of major depression are difficult to treat, and the relative efficacy of medications and psychotherapy is uncertain. METHODS: We randomly assigned 681 adults with a chronic nonpsychotic major depressive disorder to 12 weeks of outpatient treatment with nefazodone (maximal dose, 600 mg per day), the cognitive behavioral-analysis system of psychotherapy (16 to 20 sessions), or both. At base line, all patients had scores of at least 20 on the 24-item Hamilton Rating Scale for Depression (indicating clinically significant depression). Remission was defined as a score of 8 or less at weeks 10 and 12. For patients who did not have remission, a satisfactory response was defined as a reduction in the score by at least 50 percent from base line and a score of 15 or less. Raters were unaware of the patients' treatment assignments. RESULTS: Of the 681 patients, 662 attended at least one treatment session and were included in the analysis of response. The overall rate of response (both remission and satisfactory response) was 48 percent in both the nefazodone group and in the psychotherapy group, as compared with 73 percent in the combined-treatment group. (P<0.001 for both comparisons). Among the 519 subjects who completed the study, the rates of response were 55 percent in the nefazodone group and 52 percent in the psychotherapy group, as compared with 85 percent in the combined-treatment group (P<0.001 for both comparisons). The rates of withdrawal were similar in the three groups. Adverse events in the nefazodone group were consistent with the known side effects of the drug (e.g., headache, somnolence, dry mouth, nausea, and dizziness). CONCLUSIONS: Although about half of patients with chronic forms of major depression have a response to short-term treatment with either nefazodone or a cognitive behavioral-analysis system of psychotherapy, the combination of the two is significantly more efficacious than either treatment alone.

Severity of child maltreatment, pain complaints and medical utilization among women.

High medical utilization in adults has been linked to both reported history of childhood abuse and mental health problems. However, few studies have explored relationships between abuse severity and psychological distress to identify subgroups with unique utilization patterns and medical complaints. This study compared two groups of psychologically distressed, high utilizers. One group (DS) was comprised of those with psychological distress, who reported a history of child sexual abuse (CSA); the other group (DSP) consisted of those with psychological distress, who reported CSA plus a history of childhood physical abuse. The groups were compared on severity of sexual and nonsexual child maltreatment, medical complaints and medical utilization. From a convenience sample of 206 females age 20-63, recruited while waiting for a physician appointment in a primary care clinic, we compared 25 DSPs to 33 DSs. Compared with DSs, DSPs reported significantly more severe: (1) sexual abuse including completed intercourse; (2) emotional abuse; (3) emotional neglect; and (4) psychological distress. DSPs also showed a nonsignificant trend towards more severe physical neglect. In addition to being significantly higher on emergency room visits, DSPs were marginally higher than DSs on nonpsychiatric outpatient visits. DSPs had significantly more frequent chronic and acute pain complaints at emergency room (ER) visits. Headaches were the most frequently coded diagnosis at ER visits in this sample. DSPs accounted for 89% of these ER visits attributable to headaches. The interaction of psychological distress and reported severity of child maltreatment reveals subgroups with unique utilization patterns and medical complaints. Physicians should screen patients for child maltreatment severity and psychological distress and should be involved in mental health referral where necessary.

The relationship of childhood sexual abuse and depression with somatic symptoms and medical utilization.

BACKGROUND: Previous research suggests that childhood sexual abuse is associated with high rates of retrospectively reported medical utilization and medical problems as an adult. The goal of this study was to determine if abused females have higher rates of medical utilization using self-report and objective measures, compared with non-abused females. A further goal was to determine whether findings of prior research would be replicated when childhood physical abuse level was controlled. This study also examined the moderating impact of depressed mood on current health measures in this population. METHODS: Six hundred and eight women recruited from a health maintenance organization completed self-report measures of health symptoms for the previous month and doctor visits for the previous year. Objective doctor records over a 2 year period were examined for a subset of 136 of these women. RESULTS: Results showed significantly more self-reported health symptoms and more self-reported doctor visits in abused participants compared with those who reported no childhood history of sexual abuse. Objective doctor visits demonstrated the same pattern with abused participants exhibiting more visits related to out-patient surgery and out-patient internal medicine. In addition, persons who were both sexually abused and depressed tended to visit the emergency room more frequently and to have more in-patient internal medicine and ophthalmology visits than sexually abused participants who reported low depressed mood and non-abused controls. CONCLUSIONS: These results replicate prior studies and suggest that current depression may moderate the relationship between sexual abuse and medical problems in adulthood.

Childhood sexual abuse, psychological distress, and medical use among women.

OBJECTIVE: This study examined the relationships between reported history of childhood sexual abuse (CSA), psychological distress, and medical utilization among women in a health maintenance organization (HMO) setting. METHODS: Participants were 206 women aged 20 to 63 years who were recruited from an HMO primary care clinic waiting area. Participants were classified, using screening questionnaires and the revised Symptom Checklist 90, as 1) CSA-distressed, 2) distressed only, 3) CSA only, or 4) control participants. Medical utilization rates were generated from the computerized database of the HMO for 1) nonpsychiatric outpatient, 2) psychiatric outpatient, 3) emergency room (ER), and 4) inpatient admissions. RESULTS: CSA-distressed and distressed only groups both used significantly more nonpsychiatric outpatient visits than CSA only and control participants but were not different from one another. CSA only and control participants did not differ on nonpsychiatric outpatient utilization. CSA-distressed participants used significantly more ER visits and were more likely to visit the ER for pain-related complaints than other participants. Among CSA-distressed participants, those who met criteria for physical abuse had significantly more ER visits than those who did not. There were no differences among the four groups in inpatient utilization rates. CONCLUSIONS: Psychological distress is associated with higher outpatient medical utilization, independent of CSA history. History of CSA with concomitant psychological distress is associated with significantly higher ER visits, particularly for those with a history of physical abuse. History of CSA without distress is not associated with elevated rates of medical utilization. Screening for psychological distress, CSA, and physical abuse may help to identify distinct subgroups with unique utilization patterns.

Psychotherapy for depression: current and future directions in research, theory, practice and public policy.

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.

Psychologists' beliefs about the prevalence of childhood sexual abuse: the influence of sexual abuse history, gender, and theoretical orientation.

OBJECTIVE: This study examined the influence of sexual abuse history, gender, theoretical orientation, and age on beliefs about the prevalence of childhood sexual abuse among clinical and counseling psychologists. METHOD: A mail survey design was used in this study. Participants were randomly selected from the American Psychological Association membership database. There were 615 psychologists who completed self-report measures on beliefs about the prevalence of childhood sexual abuse and demographic characteristics. RESULTS: Overall, clinicians' scores on the prevalence of childhood sexual abuse were moderate. There were significant gender differences on beliefs, suggesting that women were more likely believe that childhood sexual abuse is a common occurrence compared to men. Multiple regression analysis indicated that clinician characteristics (history of sexual abuse, gender, and theoretical orientation) were significantly related to beliefs about the prevalence of childhood sexual abuse. However, these characteristics only accounted for a small amount of the overall variance predicting beliefs. CONCLUSIONS: These results suggest that clinicians do not hold extreme beliefs regarding the prevalence of childhood sexual abuse. Moreover, certain clinician characteristics are associated with their beliefs, which in turn, may impact their clinical judgment and treatment decisions. Furthermore, much of the variance was unaccounted for in the model indicating that psychologists' beliefs are complex and are not unduly influenced by their personal characteristics. Implications for clinical practice and future research are discussed.

Why are empirically supported treatments for bulimia nervosa underutilized and what can we do about it?

Empirically supported therapies for bulimia nervosa, as well as for other disorders, are rarely utilized. Underutilization is frequently attributed to doubts among psychotherapists about the value of randomized controlled trials and professional resistance to the perceived constraints of manualized therapy. However, controversies about the usefulness of empirically supported therapies have been shaped by lack of access to adequate training and inexperience in delivering these treatments. A proposal for expanding training opportunities is presented along with discussion about how more intensive training for the practicing therapist would affect current controversies regarding the value and relevance of empirically supported therapies for bulimia nervosa and other disorders.

The effects of extending cognitive-behavioral therapy for binge eating disorder among initial treatment nonresponders.

OBJECTIVE: The study was designed with the aim of determining whether extending group cognitive-behavioral therapy (CBT) would enhance outcome among individuals with binge eating disorder (BED) who failed to stop binge eating after an initial 12-week CBT intervention. METHOD: Forty-six participants who met diagnostic criteria for BED were randomly allocated to either a 12-week group CBT intervention or a waiting list control condition. At the end of 12 weeks, treated participants who met clinical criteria for improvement subsequently received 12 sessions of behavioral weight loss. Remaining participants received 12 additional sessions of CBT for binge eating. RESULTS: Fifty percent of treated participants improved with the initial 12-week course of CBT. There was a strong trend for the extension of CBT to affect improvement in binge eating among initial nonresponders (6 of 14 subjects no longer met diagnostic criteria for BED). Overall, extending CBT led to clinical improvement in 66.7% of all treated participants, with treatment gains occurring through session 20. DISCUSSION: The results suggest that an extended course of CBT (i.e., longer than 12 weeks) will likely maximize the number of potential responders to treatment.

One-year follow-up of cognitive-behavioral therapy for obese individuals with binge eating disorder.

The results of a 1-year posttreatment follow-up of 93 obese women diagnosed as having binge eating disorder (BED) and treated with group cognitive-behavioral therapy (CBT) followed by weight loss treatment are described. The group as a whole maintained both reductions in binge eating and abstinence rates fairly well. However, they regained the weight lost during treatment. Those who stopped binge eating during CBT maintained a weight loss of 4.0 kg over the follow-up period. In contrast, those who continued to binge gained 3.6 kg. Twenty-six percent of those abstinent after CBT met criteria for BED at follow-up and had gained weight, whereas the remaining 74% had lost weight. Stopping binge eating appears critical to sustained weight loss in BED.

The aversiveness of specific emotional states associated with binge-eating in obese subjects.

OBJECTIVE: The aim of this study was to examine the hypothesis that non-purge-related binge-eating in obesity is maintained by a 'trade-off' in which a highly aversive emotional state is exchanged for a less aversive state. METHOD: Ninety-eight obese binge-eaters meeting the DSM-IV criteria for binge-eating disorder were contrasted with 65 non-binge-eating controls on their perceived distress associated with negative mood states usually experienced before and after binges. RESULTS: Binge-eaters reported significantly greater distress and lower tolerance of negative mood compared to controls. Furthermore, when compared with controls, binge-eaters reported that emotions typically reported before binges (e.g. anger) were more aversive than those reported after (e.g. guilt). CONCLUSIONS: These results were interpreted as supporting the 'trade-off' theory and have implications for the treatment of binge-eating disorder.

Maintenance following a very-low-calorie diet.

The authors posed 2 questions in this randomized study of maintenance procedures in which participants were followed for 15 months after completion of a very-low-calorie diet: Would stimulus narrowing during the reintroduction of solid food, achieved by the use of prepackaged foods, improve weight losses and the maintenance of those losses as compared with the use of regular food? Would reintroduction of foods dependent on progress in losing or maintaining weight be superior to reintroduction on a time-dependent basis? Neither the stimulus narrowing condition nor the reintroduction procedure enhanced either maximum weight loss or maintenance of those losses. The stimulus narrowing condition appeared to be poorly tolerated; compliance and attendance were poorer in this condition than in the regular food condition.