Predictors of dropout in a controlled clinical trial of psychotherapy for moderate depression

A significant number of psychotherapy clients remain untreated, and dropping out is one of the main reasons. Still, the literature around this subject is incoherent. The present study explores potential pre-treatment predictors of dropout in a sample of clients who took part in a clinical trial designed to test the efficacy of narrative therapy for major depressive disorder compared to cognitive-behavioral therapy. Logistic regression analysis showed that: (1) treatment assignment did not predict dropout, (2) clients taking psychiatric medication at intake were 80% less likely to drop out from therapy, compared to clients who were not taking medication, and (3) clients presenting anxious comorbidity at intake were 82% less likely to dropout compared to those clients not presenting anxious comorbidity. Results suggest that clinicians should pay attention to depressed clients who are not taking psychiatric medication or have no comorbid anxiety. More research is needed in order to understand this relationship.

Quelle place pour la psychothérapie dans la psychiatrie publique [What place for psychotherapy in public psychiatry?].

The question of the place of psychotherapy in psychiatric public care is posed in this article. We will address this question first by presenting two clinical and research programmes which were implemented in a clinical psychiatric unit, section Karl Jaspers (Service of General Psychiatry) of the Department of Psychiatry CHUV, in Lausanne with the collaboration of the University Institute of Psychotherapy. The first one puts forward psychodynamic psychotherapy of depressed inpatients; the clinical programme and the research questions on efficacy of this treatment are discussed. The second focuses on the early treatment of patients with Borderline Personality Disorder, in particular in its research question on the effect of the motive-oriented therapeutic relationship in this process. We conclude by underlining the convergences of the two programmes.

Psycho-oncological interventions and psychotherapy in the oncology setting.

A person who faces the diagnosis of cancer is subjected to changes within his body, but also with regard to his view of himself and his social relationships. Cancer-related psychological distress occurs frequently and has been reported to have different prevalence according to cancer type and stage of disease. Psychological disorders are known to be underdiagnosed and thus undertreated in the oncology setting, since clinicians might miss the symptoms of psychological distress, misinterpret them, or lack the time and resources to respond adequately. The main psychiatric disturbances observed in patients with cancer are adjustment disorders and affective disorders (anxiety and depression), which in the majority of patients are due to stressors related to the disease and pre-existing psychological vulnerabilities; however, they might also be a direct consequence of biological causes either resulting from treatment side effects or from modifications induced by the cancer. This chapter aims to provide theoretical and practical information concerning psycho-oncological approaches, complemented by some reflexions on their clinical and scientific evidence, focussing essentially on verbal psychological interventions and especially on psychotherapy in patients with cancer.

Psychothérapie en milieu somatique--quelles spécificités [Psychotherapy in the somatic field--what specificities?].

This article illustrates some of the specific aspects of the psychotherapeutic approach with medically ill patients. Our considerations are based on our daily work in CL Psychiatry and refer to the psychodynamic model, rooted in Freudian's thought. Characteristics are the setting, as well as the relationship with the patient and the interactions with the physicians as the "emergence" of the suffering body within the therapy. We therefore adopt specific approaches such as the work with the Auxiliary Ego and the narrative reconstruction. This paper illustrates our experiences applying the mentioned tools with patients suffering from chronic pain and cancer.

Psychodynamic psychotherapy in newly diagnosed cancer patients: a randomized controlled trial

Aims: (i) To describe the prevalence and profile of newly diagnosed cancer patients motivated for psychotherapy and (ii) To evaluate its effectiveness.Methods: Between 2006 and 2009, every new patient of the Oncology Service of the University Hospital Lausanne was informed of the opportunity to benefit from psychotherapeutic support. Patients were randomly assigned to an immediate or delayed (4 month waiting list) psychodynamicoriented psychotherapeutic intervention, formalized as short intervention (1-4 sessions) or brief psychotherapy (16 sessions). Patients with no interest were asked to participate in an observational group. Socio-demographic and medical data, anxiety and depression (HADS, SCL-90), alexithymia (TAS) and quality of life were evaluated for all groups at baseline and 1, 4, 8 and 12-months follow-up. Results: Of 1973 patients approached, 1024 were excluded, mainly because of organisational reasons (living too far away, interfering treatments, etc.), ageN75 years, life expectancyb1 year or language difficulties. One fourth (N=530) refused to participate and 229 patients accepted to be followed in the observational group. Patients interested in psychological support (N=190, 94 in immediate and 96 in delayed intervention) were younger, predominantly female and symptomatic (higher depression and anxiety scores); 56% engaged in 1-4 and 44% in 16 sessions.Conclusions: The naturalistic design of this study revealed relevant questions regarding (i) the design of such studies (untargeted intervention, choice of measurement, etc.), (ii) the type of interventions (pro-active approaches of men, those unable to speak the language or who can not leave home) and (iii) the profile of patients accepting support. A complete analysis will be presented at the congress.Keywords: Psychotherapy, psycho-oncology, cancer, methodology, interventions

Gm(1,2,4,10,21) and Km(1) factors in vitreous humor.

The presence of Gm(1,2,4,10,21) and Km(1) factors in vitreous humor taken from human corpses was investigated. The results revealed a good agreement between the factors detected in this biological material and in blood. Their presence in vitreous humor is independent of the secretor type.

Are there positive emotions in short-term dynamic psychotherapy or is it all Freude-less ?

Psychodynamic therapists are often suspicious of positive emotions and consider them to be nothing more than a form of denial or of another defense aiming to diminish painful or difficult affects. Positive emotions seem to exist only through the absence of negative emotions or as something that may happen outside of therapy. On the other hand, clinicians also agree that psychoanalytic work could not be successful without such positive emotions as interest, pleasure, surprise and creativity. Contemporary psychoanalytic thinking and new research findings in the area of relationship regulation are likely to give positive emotions an increasingly prominent place in dynamically oriented therapies. With today's emphasis on the therapeutic relationship and intersubjectivity, the time appears right to integrate positive emotions more formally into psychodynamic clinical theories.

Change in defense mechanisms and coping over the course of short-term dynamic psychotherapy for adjustment disorder.

Short-term dynamic psychotherapy (STDP) has rarely been investigated with regard to its underlying mechanisms of change, even if psychoanalytic theory informs us about several potential putative mechanisms of change in patients. Change in overall defensive functioning is one. In this study, we explored the role of overall defensive functioning, by comparing it on the process level with the neighbouring concept of overall coping functioning. A total of N=32 patients, mainly presenting adjustment disorder, were included in the study. The patients underwent STDP up to 40 sessions; three sessions per psychotherapy were transcribed and analyzed by using two observer-rating scales: Defense Mechanism Rating Scales (Perry, 1990) and Coping Action Patterns (Perry, Drapeau, Dunkley, & Blake, 2005). Hierarchical linear modeling was applied to model the change over the course of therapy and relate it to outcome. Results suggest that STDP has an effect on the target variable of overall defensive functioning, which was absent for overall coping functioning. Links with outcome confirm the importance of the effect. These results are discussed from methodological and clinical viewpoints.

Assimilation process in a psychotherapy with a client presenting schizoid personality disorder

The assimilation of problematic experiences has been studied as change processes in psychotherapies of different client populations. Several theory-building case studies using the assimilation model have shown how important a meaning bridge is in such change processes. In a client presenting schizoid personality disorder the creation of meaning as an affect-evoking process may be a particularly important stage in the change process. The present case study aims to apply the assimilation model to a psychotherapy process with a highly disturbed client and focuses on the creation of a meaning bridge in the process. Moreover, the assimilation analysis focuses on the effect of an external person, i.e. the partner or the therapist, when responding to the client's unassimilated problematic experiences. Their effects on the client's assimilation processes are discussed.

Monitoring the effects of adult psychotherapy in routine practice in Switzerland: A feasibility trial

Background: Several studies have been published on the effects of psychotherapy in routine practice. Complementing traditional views summarised as 'dose-effect models', Stiles et al. put forward data consistent with the responsive regulation model underlining the importance of the client's active participant role in defining length of treatment. One may ask what level of change reached by a patient is considered to be the 'good enough level' (GEL) and if it is related to the duration of psychotherapy. Aims: The main objective of the present feasibility trial was to monitor the patient's session-by-session evolution using a self-report questionnaire in order to define the GEL, i.e. the number of sessions necessary for the patient to reach significant change. Method: A total of N=13 patients undergoing psychotherapy in routine practice participated in the study, completing the Outcome Questionnaire - 45.2 (OQ-45), which assesses the symptom level, interpersonal relationships and social role after every psychotherapy session. The data was analysed using multi-level analyses (HLMs). Results: High feasibility of fine-grained assessment of effects of psychotherapy in routine practice in Switzerland was shown; response rates being acceptable; however, detailed analysis of the GEL was not feasible within the short study time-frame. Conclusions: Reflections on the political context of monitoring in the specific case of routine psychiatric practice in Switzerland are discussed.

Early change in defence mechanisms and coping in short-term dynamic psychotherapy: relations with symptoms and alliance.

Several patient-related variables have already been investigated as predictors of change in psychodynamic psychotherapy. Defensive functioning is one of them. However, few studies have investigated adaptational processes, encompassing defence mechanisms and coping, from an integrative or comparative viewpoint. This study includes 32 patients, mainly diagnosed with adjustment disorder and undergoing time-limited psychodynamic psychotherapy lasting up to 40 sessions, and will focus on early change in defence and coping. Observer-rater methodology was applied to the transcripts of two sessions of the first part of the psychotherapeutic process. It is assumed that the contextual-relational variable of therapeutic alliance intervenes as moderator on change in adaptational processes. Results corroborated the hypothesis, but only for coping, whereas for defences, overall functioning remained stable over the first 20 sessions of psychotherapy. These results are discussed within the framework of disentangling processes underlying adaptation, i.e., related to issues on trait and state aspects, as well as the role of the therapeutic alliance.

Impact of personality on termination of short-term group psychotherapy in depressed elderly outpatients

Objective Termination in group psychotherapy is an essential phase of the psychotherapeutic process, yet its clinical determinants remain largely unknown, especially in elderly patients. The aim of this study was to assess how patients' personality traits influence their way of leaving a short-term psychotherapy group as well as a larger therapeutic community program. <p>Method Personality traits were assessed with the NEO Five-Factor Inventory in 24 elderly depressed outpatients. Patients' terminations from the group as well as from the community were ranked into four classes according to their appropriateness (completeness of experience and ability to deal with feelings of separation). Results Neuroticism was not related to the quality of termination. In contrast, agreeableness and openness to experience were strongly associated with successful termination. Conscientiousness and extraversion may have a differential impact depending on the type of group (group psychotherapy versus therapeutic community). Conclusion Personality traits may be important clinical determinants of the quality of termination process in both group psychotherapy and therapeutic community settings for elderly depressed patients.

Psychodynamic psychotherapy in newly diagnosed cancer patients: a randomized controlled trial

Background and aims: More than 30% of cancer patients develop a psychiatric disorder during the evolution of their disease. While evidence exists, that psychotherapy can improve psychological distress, questions, such as the prevalence of patients accepting psychotherapy, treatment indications and effectiveness of psychotherapeutic interventions in the oncology setting remain unanswered. The aims were: (1) To assess the prevalence of newly diagnosed cancer patients motivated to engage in psychotherapeutic interventions; (2) to identify those who benefit; and (3) to evaluate their effectiveness. Methods: Every new patient of the Oncology Service at the University Hospital Lausanne was informed of the possibility of benefitting from psychotherapeutic support. Patients who accepted were randomly assigned to individual psychotherapy or to a 4-month waiting list. Psychotherapies were formalized as psychodynamicoriented short interventions (1-4 sessions) or brief psychodynamic psychotherapies (16 sessions). Patients who refused psychotherapy were asked to participate in an observational group. Socio-demographic and medical data, anxiety, depression, alexithymia and quality of life (SCL- 90, HADS, TAS, EORTC) of all participants were evaluated at base line and at 1, 4, 8 and 12 -months Follow- Up. Results: So far 1047 patients have been approached, 20% were included in the study (intervention n=68, observation n=122), 32% were excluded, 22% could not be contacted and 26% refused to participate. At baseline, patients who accepted psychotherapeutic support showed higher depression and anxiety scores (HADS, SCL-90) compared to controls. 56% benefited from 4 sessions of psychological support, 44% engaged in 16 sessions of brief psychodynamic therapy. Conclusions: The preliminary results of this ongoing trial suggest that a minority of newly cancer patients accept psychotherapeutic intervention. These patients are more depressed than controls. Their motivation for short interventions and for brief psychotherapies is comparable.

Change in defense mechanisms and coping patterns during the course of 2-year-long psychotherapy and psychoanalysis for recurrent depression: a pilot study of a randomized controlled trial.

Very little research has been conducted so far to study the potential mechanisms of change in long-term active psychological treatments of recurrent depression. The present pilot randomized controlled trial aimed to determine the feasibility of studying the change process occurring in patients during the course of 2-year-long dynamic psychotherapy, psychoanalysis, and cognitive therapy, as compared with clinical management. In total, eight outpatients presenting with recurrent depression, two patients per treatment arm, were included. All patients were randomly assigned to one of the four treatment conditions. Defense mechanisms and coping patterns were assessed using validated observer-rated methodology based on transcribed, semistructured follow-along independent dynamic interviews. The results indicated that, whereas some patients in the active treatments changed on the symptomatic levels, some others remained unchanged during the course of their 2-year-long treatment. However, with regard to potential mechanisms of change in these patients, changes in defense mechanisms and coping patterns were revealed to be important processes over time in successful therapies and, to a lesser extent, in less successful treatments. No change was found either on outcome or on the process measure for the control condition, that is, clinical management. These results are discussed along with previous data comparing change in defense mechanisms and coping during the course of treatments.

One minute of grief: Emotional processing in short-term dynamic psychotherapy for adjustment disorder.

OBJECTIVE: Depth of emotional processing has shown to be related to outcome across approaches to psychotherapy. Moreover, a specific emotional sequence has been postulated and tested in several studies on experiential psychotherapy (Pascual-Leone & Greenberg, 2007). This process-outcome study aims at reproducing the sequential model of emotional processing in psychodynamic psychotherapy for adjustment disorder and linking these variables with ultimate therapeutic outcome. METHOD: In this study, 32 patients underwent short-term dynamic psychotherapy. On the basis of reliable clinical change statistics, a subgroup (n = 16) presented with good outcome and another subgroup (n = 16) had a poor outcome in the end of treatment. The strongest alliance session of each case was rated using the observer-rated system Classification of Affective Meaning States. Reliability coefficients for the measure were excellent (κ = .82). RESULTS: Using 1 min as the fine-grained unit of analysis, results showed that the experience of fundamentally adaptive grief was more common in the in-session process of patients with good outcome, compared with those with poor outcomes (χ2 = 6.56, p = .01, d = 1.23). This variable alone predicted 19% of the change in depressive symptoms as measured by the Beck Depression Inventory at the end of treatment. Moreover, sequences of the original model were supported and related to outcome. CONCLUSIONS: These results are discussed within the framework of the sequential model of emotional processing and its possible relevance for psychodynamic psychotherapy. (PsycINFO Database Record (c) 2015 APA, all rights reserved).