Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

Background Depression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence. Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression. Design A therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions). Method Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used. Discussion We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression. Trial registration ISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Kunnossapidon alihankinnan tutkiminen ja seurannan kehittäminen sementtitehtaalla

Työn tavoitteena oli antaa tarkka kuva Lappeenrannan sementtitehtaan kunnossapidon alihankkijoiden työtunneista ja -kustannuksista sekä jakaa ne eri kunnossapitodimensioiden kesken. Jotta alihankkijoiden tekemien töiden seurannasta tulisi jatkuvaa, seurannan toteutukselle on luotu arkirutiineihin soveltuva toimintamalli. Työtunnit ja -kustannukset on laskettu ostolaskujen perusteella ajalta 1.1.2000 – 31.5.2003. Teoriaosuudessa on käsitelty kunnossapitotoimintaa, sen seurantaa ja kustannuslaskentaa, jonka tarkoituksena on pohjustaa työtuntien ja -kustannusten jakoperusteita empiirisessä osassa. Empiria on aloitettu laskemalla kaikki sementtitehtaalle tehdyt työtunnit ja -kustannukset, joista sitten on eroteltu kunnossapidon, muiden toimintojen ja projektien osuudet erikseen. Kustannuksia on vertailtu budjettiarvoihin. Kunnossapidon työtunneista on tehty benchmarkingia kahdeksan sementtitehtaan kesken. Työn lopuksi on laadittu toimintamalli kunnossapidon alihankinnan jatkuvan seurannan toteuttamiseksi. Seuranta toteutetaan toiminnanohjausjärjestelmässä syöttämällä kustannusten ohessa tehtyjen tuntien määrä ja laittamalla yhteen tiliöintiulottuvuuteen toimittajanumero. Jatkokehityskohteena esitetään toiminnanohjaus- ja kunnossapitojärjestelmän integrointia, jolloin tunteja ja kustannuksia voidaan seurata työnumeroittain.

DBS in Dystonia and Other Hyperkinetic Movement Disorders.

OPINION STATEMENT: The diagnosis and appropriate treatment of hyperkinetic movement disorders require a work up of potentially reversible metabolic, infectious and structural disorders as well as side effects of current medication. In pharmacoresistant movement disorders with a disabling impact on quality of life, deep brain stimulation (DBS) should be considered. At different targets, DBS has become an established therapy for Parkinson's disease (GPi-STN), tremor (VIM) and primary dystonia (GPi) with reasonable perioperative risks and side effects, established guidelines and some clinical and radiological predictive factors. In contrast, for other hyperkinetic movement disorders, including secondary dystonia, Gilles de la Tourette, chorea and ballism, only few data are available. Definite targets are not well defined, and reported results are of less magnitude than those of the recognized indications. In this expanding therapeutical field without worked out recommendations, an individual approach is needed with DBS indication assessment only after rigorous multidisciplinary scrutiny, restricted to expert centres.