Adjunctive yoga v. health education for persistent major depression: a randomized controlled trial.

BACKGROUND: The objective of this study was to determine whether hatha yoga is an efficacious adjunctive intervention for individuals with continued depressive symptoms despite antidepressant treatment. METHOD: We conducted a randomized controlled trial of weekly yoga classes (n = 63) v. health education classes (Healthy Living Workshop; HLW; n = 59) in individuals with elevated depression symptoms and antidepressant medication use. HLW served as an attention-control group. The intervention period was 10 weeks, with follow-up assessments 3 and 6 months afterwards. The primary outcome was depression symptom severity assessed by blind rater at 10 weeks. Secondary outcomes included depression symptoms over the entire intervention and follow-up periods, social and role functioning, general health perceptions, pain, and physical functioning. RESULTS: At 10 weeks, we did not find a statistically significant difference between groups in depression symptoms (b = -0.82, s.e. = 0.88, p = 0.36). However, over the entire intervention and follow-up period, when controlling for baseline, yoga participants showed lower levels of depression than HLW participants (b = -1.38, s.e. = 0.57, p = 0.02). At 6-month follow-up, 51% of yoga participants demonstrated a response (⩾50% reduction in depression symptoms) compared with 31% of HLW participants (odds ratio = 2.31; p = 0.04). Yoga participants showed significantly better social and role functioning and general health perceptions over time. CONCLUSIONS: Although we did not see a difference in depression symptoms at the end of the intervention period, yoga participants showed fewer depression symptoms over the entire follow-up period. Benefits of yoga may accumulate over time.

Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures.

OBJECTIVE: There have been few treatment trials for psychogenic nonepileptic seizures (PNES). Some psychotherapies have been shown to improve PNES and comorbid symptom outcomes. We evaluated a pharmacologic intervention to test the hypothesis that sertraline would reduce PNES. METHODS: We conducted a pilot, double-blind, randomized, placebo-controlled trial in an academic medical hospital with epilepsy center outpatients. Subjects aged 18 to 65 years diagnosed with video-EEG-confirmed PNES were treated with flexible-dose sertraline or placebo over 12 weeks. Seizure calendars and symptom scales were charted prospectively. Secondary outcome measures included psychiatric symptom scales and psychosocial variables. RESULTS: Thirty-eight subjects enrolled, and 26 (68%) completed the trial. Thirty-three subjects with nonzero nonepileptic seizure rates at baseline were included in intent-to-treat analysis of the primary outcome. Subjects assigned to the sertraline arm experienced a 45% reduction in seizure rates from baseline to final visit (p = 0.03) vs an 8% increase in placebo (p = 0.78). Secondary outcome scales revealed no significant between-group differences in change scores from baseline to final visit, after adjustment for differences at baseline. CONCLUSIONS: PNES were reduced in patients treated with a serotonin selective reuptake inhibitor, whereas those treated with placebo slightly increased. This study provides feasibility data for a larger-scale study. LEVEL OF EVIDENCE: This study provides Class II evidence that flexible-dose sertraline up to a maximum dose of 200 mg is associated with a nonsignificant reduction in PNES rate compared with a placebo control arm (risk ratio 0.51, 95% confidence interval 0.25-1.05, p = 0.29), adjusting for differences at baseline.

Use of item response theory to understand differential functioning of DSM-IV major depression symptoms by race, ethnicity and gender.

BACKGROUND: Psychological literature and clinical lore suggest that there may be systematic differences in how various demographic groups experience depressive symptoms, particularly somatic symptoms. The aim of the current study was to use methods based on item response theory (IRT) to examine whether, when equating for levels of depression symptom severity, there are demographic differences in the likelihood of reporting DSM-IV depression symptoms. METHOD: We conducted a secondary analysis of a subset (n=13 753) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset, which includes a large epidemiological sample of English-speaking Americans. We compared data from women and men, Hispanics and non-Hispanic Whites, African Americans and Whites, Asian Americans and Whites, and American Indians and Whites. RESULTS: There were few differences overall, although the differences that we did find were primarily limited to somatic symptoms, and particularly appetite and weight disturbance. CONCLUSIONS: For the most part, individuals responded similarly to the criteria used to diagnose major depression across gender and across English-speaking racial and ethnic groups in the USA.

Relationship quality among HIV patients and their caregivers.

Despite the increasing attention to caregivers of HIV patients, no previous study has systematically investigated the effects of the relationship quality between an HIV patient and their caregiver. The present study assessed 176 dyads consisting of an HIV-infected patient and their self-identified 'caregiver'. Relationship quality was measured by the Family Assessment Device (FAD). Dependent measures included the Beck Depression Inventory, SF-36 Physical Functioning Scale, Caregiver Strain Index and 4-day HIV treatment adherence. A substantial proportion of HIV patient-caregiver dyads reported difficulties in their relationships (17-66% depending upon FAD scale). The level of relationship difficulties was not strongly related to the type of patient-caregiver relationship. However, the quality of the HIV patient-caregiver relationship was significantly associated (p<0.05) with caregiver depression and burden as well as HIV patient depression, physical functioning and HIV medication adherence, even when the potential effects of length of HIV infection and social support were controlled. These results suggest that relationship quality is impaired in many patient-caregiver dyads and is uniquely associated with levels of depression, caregiver burden and treatment adherence.

Cognitive-behavioral treatment for depression in smoking cessation.

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention.

OBJECTIVE: This study investigated whether a preventive intervention based on the principles of interpersonal psychotherapy administered to pregnant women would reduce the risk of postpartum major depression. METHOD: Thirty-seven pregnant women receiving public assistance who had at least one risk factor for postpartum depression were randomly assigned to a four-session group intervention or to a treatment-as-usual condition. Thirty-five of the women completed the study. Structured diagnostic interviews were administered to assess for postpartum major depression. RESULTS: Within 3 months after they gave birth, six (33%) of the 18 women in the treatment-as-usual condition had developed postpartum major depression, compared with none of the 17 women in the intervention condition. CONCLUSIONS: A four-session interpersonal-therapy-oriented group intervention was successful in preventing the occurrence of major depression during a postpartum period of 3 months in a group of financially disadvantaged women.

Family functioning and suicidality in depressed adults.

This study examined the association between suicidality, family factors, and clinical and diagnostic variables in depressed adult inpatients. The subjects were 121 depressed adult inpatients living with a family member or significant other. Demographic, clinical, and diagnostic information about the patient, and subjective and observer ratings of family functioning were obtained. Trained interviewers rated families of suicidal depressed patients as more dysfunctional than families of patients with no history of attempted suicide. In a logistic regression model, earlier age of depression onset, number of psychiatric hospitalizations, and objectively rated poorer family communication were associated with a history of a prior suicide attempt. Also, modest evidence suggested that patients with a prior suicide attempt perceived their families as more dysfunctional than did their respective family members. Variations in family functioning are associated with different degrees of suicidality. However, prospective longitudinal designs would elucidate the causal relation between family dysfunction and suicidal behavior.

Personality and family functioning in families of depressed patients.

In this cross-sectional study, the authors attempted to identify correlates of family functioning in 86 couples with a depressed member during the acute phase of the patient's depression. Demographic variables, psychiatric status, and personality traits of both the patient and spouse were investigated as potential predictors of family functioning. Regression analyses indicated that lower levels of personality pathology in the patient, higher levels of patient conscientiousness, and less psychological distress in the spouse were associated with healthier family functioning. Future research implications and clinical importance of these findings are discussed.

Why fix what isn't broken? A rejoinder to Ridenour, Daley, & Reich.

Ridenour, Daley, & Reich (2000) suggest that the Family Assessment Device should be reorganized. We disagree and provide further reasons why such a reorganization is unwise.

"Factor analyses of the family assessment device," by Ridenour, Daley, & Reich.

Ridenour, Daley, and Reich conducted a series of factor analyses using the correlational matrix of the subscale scores of the Family Assessment Device (FAD), published in Family Process, December, 1999. They conclude that "the FAD subscales be reorganized from their current seven-subscale format" (p. 507). We propose that this suggestion for reorganization is premature and based on the inappropriate application of an "internal consistency" model of scale construction to the FAD. We further suggest that the most important criteria regarding an assessment instrument are those of reliability, validity, and clinical utility. In the absence of this kind of data regarding alternative organizations of the FAD, we believe that the original subscales remain the best choice.

Combined treatment for patients with double depression.

BACKGROUND: Patients with double depression (major depression + dysthymia) have a particularly chronic course of illness, yet few studies have investigated treatments for these patients. METHODS: 26 inpatients with double depression were assigned to two types of treatment: (1) pharmacotherapy and (2) combined treatment (pharmacotherapy + cognitive-behavioral psychotherapy). Treatment began while the patients were in the hospital and continued for 20 weeks after discharge. Comprehensive assessments were conducted at the end of treatment as well as at 6- and 12-month follow-up assessments. RESULTS: The results indicated that double-depressed patients who received the combined treatment had significantly lower levels of depression and higher social functioning at the end of treatment. However, no significant differences between groups were found at the follow-up assessments. CONCLUSIONS: These results suggest that the addition of cognitive-behavioral psychotherapy may produce an improved short-term outcome for patients with double depression.

The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine.

BACKGROUND: Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported. METHOD: We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples. RESULTS: Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples. CONCLUSION: These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression.

Lithium plus valproate as maintenance polypharmacy for patients with bipolar I disorder: a review.

Standard pharmacotherapy for the maintenance treatment of patients with bipolar I disorder consists of lithium, valproate, or carbamazepine. However, many patients fail to respond to monotherapy with any of these agents, and as a result, psychiatrists often resort to polypharmacy. Findings from some open-label trials and retrospective chart reviews suggest this approach may be useful, but in the few controlled trials that have been conducted, the results have been negative. One drug combination that warrants further study as maintenance therapy is lithium plus valproate. Each is approved by the U.S. Food and Drug Administration for treatment of acute mania, and lithium has demonstrated efficacy for maintenance treatment as well. Some preliminary evidence suggests that the combination can be effective for patients who do not respond to monotherapy, and it seems to be no more dangerous than monotherapy. Concomitant administration of lithium plus valproate does not significantly alter lithium pharmacokinetics, and statistically significant changes that arise in valproate pharmacokinetics are not clinically significant. Although it is not known whether the drugs interact to augment response, many of their effects in the central nervous system do differ, and there is no indication of pharmacodynamic interactions that oppose each other. Finally, some evidence suggests that lithium and valproate may differ with regard to clinical variables that predict response to treatment.

Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine.

BACKGROUND: The literature on predictors of response to treatment of nonchronic major depression has identified shorter duration of illness, acute onset, and less severity of illness as positive predictors. Unfortunately, there are almost no data on predictors of response to treatment for chronic depression. This study examined predictors of response to pharmacotherapy (sertraline or imipramine) in the treatment of outpatients who had DSM-III-R-defined chronic major or double depression. METHOD: The acute phase of the Chronic Major Depression and Double Depression Study is a double-blind, randomized, parallel-group 12-week comparison of sertraline and imipramine. Analyses are based on 623 patients who comprised the intent-to-treat sample, of whom 299 were nonresponders and 324 were responders, defined by a priori criteria as either remission or satisfactory therapeutic response. A stepwise logistic multiple regression analysis was performed on candidate clinical, psychosocial, and demographic variables previously identified as statistically significant in an attempt to develop a predictive model of positive antidepressant response. RESULTS: The sociodemographic variables that were predictive of positive response included living with spouse or partner or being at least a high school graduate. With regard to symptomatology and clinical history, responders had significantly lower baseline depression severity scores. In general, comorbid anxiety, substance abuse, and personality disorders did not influence rates of response. However, the presence of depressive personality traits was associated with a higher nonresponse rate. Among psychosocial variables, longer duration of personal relationships as well as higher baseline quality of life were associated with positive response. A stepwise logistic multiple regression identified 5 variables-living with spouse or partner, higher educational level, passive-aggressive personality, lower introverted-tense personality traits, and higher quality of life--that significantly and independently contributed to the predictive model. This model correctly classified 67% of patients. CONCLUSION: A higher baseline quality of life, living with spouse or partner, and having more education were the strongest predictors of response to acute pharmacotherapy among chronically depressed patients. Clinical variables and comorbidity were not identified as independent predictors, although personality traits did appear to influence treatment response. Overall, the predictive value of these baseline measures was modest, and therefore of limited clinical utility.

Cognitive-behavioral treatment for depression in alcoholism.

Alcoholics with depressive symptoms score > or = 10 on the Beck Depression Inventory (A.T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) received 8 individual sessions of cognitive-behavioral treatment for depression (CBT-D, n = 19) or a relaxation training control (RTC; n = 16) plus standard alcohol treatment. CBT-D patients had greater reductions in somatic depressive symptoms and depressed and anxious mood than RTC patients during treatment. Patients receiving CBT-D had a greater percentage of days abstinent but not greater overall abstinence or fewer drinks per day during the first 3-month follow-up. However, between the 3- and 6-month follow-ups, CBT-D patients had significantly better alcohol use outcomes on total abstinence (47% vs. 13%), percent days abstinent (90.5% vs. 68.3%), and drinks per day (0.46 vs. 5.71). Theoretical and clinical implications of using CBT-D in alcohol treatment are discussed.

Psychosocial factors and the long-term course of major depression.

Fifty-nine subjects participated in a telephone follow-up interview 6 years after being hospitalized with a severe major depressive episode and 5 years after completing a 12 month follow-up study. Patient information was used to provide a rating of symptom-free (n = 19), episodic (n = 30), or chronic (n = 10) that described each patient's long-term course of illness. Few variables from the acute stage were related to long-term course of illness; however, early patterns of global and family functioning, number of life events, and rapid reduction in depressive symptomatology were found to be of prognostic significance. For patients whose depression is severe enough to warrant hospitalization, the pattern of functioning in the first few months after discharge from hospital is a strong indicator of the future long-term course.

A pilot study of lithium carbonate plus divalproex sodium for the continuation and maintenance treatment of patients with bipolar I disorder.

BACKGROUND: This pilot study compared the efficacy of lithium plus divalproex sodium with the efficacy of lithium alone for the continuation and maintenance treatment of patients with bipolar I disorder. METHOD: Twelve patients with bipolar I disorder as defined by the DSM-III-R were recruited and followed prospectively for up to 1 year. Each subject received lithium at serum levels of 0.8 to 1.0 mmol/L and a management/education session weekly or every 2 weeks. By random assignment, subjects received either divalproex sodium or placebo in conjunction with lithium. Divalproex sodium was adjusted to achieve a serum concentration of 50 to 125 micrograms/mL. Adjunctive medications were used on an as needed basis to treat psychosis, depression, and anxiety. The course of illness was monitored through use of the Longitudinal Interval Follow-up Examination. RESULTS: Subjects treated with the combination of lithium and divalproex were significantly less likely to suffer a relapse or recurrence (p = .014), but were significantly more likely to suffer at least one moderate or severe adverse side effect (p = .041). There was no significant difference between groups in the use of adjunctive medication. CONCLUSION: These results provide preliminary evidence of the risks and benefits of combining lithium with divalproex sodium for the continuation and maintenance treatment of bipolar I disorder.

Family functioning and mental illness: a comparison of psychiatric and nonclinical families.

The primary objective of the present investigation was to examine adaptive functioning in the families of patients with a wide range of psychiatric disorders. Seven dimensions of family functioning, as measured by the Family Assessment Device (FAD), were compared across families of patients with a schizophrenia spectrum disorder (n = 61), bipolar disorder (n = 60), major depression (n = 111), anxiety disorder (n = 15), eating disorder (n = 26), substance abuse disorder (n = 48), and adjustment disorder (n = 46). Families in each psychiatric group were also compared to a control group of nonclinical families (N = 353). Results indicated that regardless of specific diagnosis, having a family member in an acute phase of a psychiatric illness was a risk factor for poor family functioning compared to the functioning of control families. However, with few exceptions, the type of the patient's psychiatric illness did not predict significant differences in family functioning. Thus, having a family member with a psychiatric illness is a general stressor for families, and family interventions should be considered for most patients who require a psychiatric hospitalization for either the onset of, or an acute exacerbation of, any psychiatric disorder.

Prodromal and residual symptoms in bipolar I disorder.

The objective of the current study was to better understand the nature of prodromal and residual symptoms of mania and depression, as reported by patients with bipolar I disorder and their family members. Prodromal and residual symptoms of mania and depression were elicited from 74 patients with bipolar I disorder. In 45 cases, an adult family member provided similar information. Three clinicians classified the symptoms into six broad categories: behavioral, cognitive, mood, neurovegetative, social, and other. The clinicians also categorized symptoms as typical or idiosyncratic. Seventy-eight percent of the patients reported prodromal depressive symptoms and 87% reported prodromal manic symptoms; greater than half of the patients disclosed residual symptoms of depression (54%) and mania (68%). Within each of these four illness categories, cognitive symptoms were consistently the most common symptoms reported by patients. A substantial number of symptoms were idiosyncratic, particularly those reported for residual depression. Agreement between patient and family members on reported symptoms was strong for the prodromal phase of both polarities, but less so for the residual phases. These preliminary results suggest that patients with bipolar I disorder and their family members can identify prodromal and residual symptoms, that these symptoms are quite common, and that prodromal symptoms may be more prevalent or easier to identify than residual symptoms. Cognitive symptoms were consistently the most common symptoms reported by patients.

Combined medication and psychotherapy in the treatment of chronic mood disorders.

This article discusses the use of combined treatments for patients with chronic mood disorders. Although very little research concerning the efficacy of combined treatments for patients with chronic depression exists, clinical experience and limited available research suggest that combined treatment may be the most effective treatment option available for this population. The use of combination treatment involving pharmacotherapy, individual psychotherapy, and marital/family therapy is recommended to address the complex biopsychosocial issues involved in chronic mood disorders. Other theoretical and pragmatic issues concerning the delivery of combined treatment also are discussed.