Evaluating an e-mental health program (“deprexis”) as adjunctive treatment tool in psychotherapy for depression: design of a pragmatic randomized controlled trial

Background Major depressive disorder (MDD) places a significant disease burden on individuals as well as on societies. Several web-based interventions for MDD have shown to be effective in reducing depressive symptoms. However, it is not known whether web-based interventions, when used as adjunctive treatment tools to regular psychotherapy, have an additional effect compared to regular psychotherapy for depression. Methods/design This study is a currently recruiting pragmatic randomized controlled trial (RCT) that compares regular psychotherapy plus a web-based depression program (¿deprexis¿) with a control condition exclusively receiving regular psychotherapy. Adults with a depressive disorder (N?=?800) will be recruited in routine secondary care from therapists over the course of their initial sessions and will then be randomized within therapists to one of the two conditions. The primary outcome is depressive symptoms measured with the Beck Depression Inventory (BDI-II) at three months post randomization. Secondary outcomes include changes on various indicators such as anxiety, somatic symptoms and quality of life. All outcomes are again assessed at the secondary endpoint six months post randomization. In addition, the working alliance and feasibility/acceptability of the treatment condition will be explored. Discussion This is the first randomized controlled trial to examine the feasibility/acceptability and the effectiveness of a combination of traditional face-to-face psychotherapy and web-based depression program compared to regular psychotherapeutic treatment in depressed outpatients in routine care.

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe

PURPOSE: Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. METHODS: We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. RESULTS: We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. DISCUSSION: The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. CONCLUSION: Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.

The Effectiveness of Psychological Interventions for the Treatment of Erectile Dysfunction: Systematic Review and Meta-Analysis, Including Comparisons to Sildenafil Treatment, Intracavernosal Injection, and Vacuum Devices

In contrast to the impressive advances in somatic research of erectile dysfunction (ED), scientific literature shows contradictory reports on the results of psychotherapy for the treatment of ED. Authors conducted a meta-analysis to evaluate the effectiveness of psychological interventions for the treatment of ED compared to oral drugs, local injection, vacuum devices, or other psychological intervention. Distinct sources of randomized controlled trials (RCTs) were searched: electronic databases (between 1966 and 2007), cross checking of references, and contact with scientific societies. For dichotomous outcomes the pooled relative risks were calculated and for continuous outcomes mean differences between interventions. Statistical heterogeneity was addressed. Eleven RCTs involving 398 men met the inclusion criteria. There is evidence that group therapy improves ED. Focused sex group therapy showed greater efficacy than control group. Men randomized to receive psychotherapy plus sildenafil showed significant improvement of ED and were less likely than those receiving only sildenafil to drop out. Regarding to the effectiveness of psychological interventions for the treatment of ED compared to local injection and vacuum devices no difference was found. Melnik T, Soares BGO, and Nasello AG. The effectiveness of psychological interventions for the treatment of erectile dysfunction: Systematic review and meta-analysis, including comparisons to sildenafil treatment, intracavernosal injection, and vacuum devices. J Sex Med 2008;5:2562-2574.

Face off? Emotionsausdruck und (soziale) Identität aus psychologischer Perspektive

In this article we focus on the emotional basis of face perception. In addition, the most important findings concerning epidemiology and etiology of body dysmorphic disorder (BDD) will be reviewed and related to face perception. BDD can be seen as an emotional disorder in which fundamental errors in terms of information processing, especially concerning faces occur. Emotional information is misinterpreted. Both, emotional misinterpretation as well as errors in face perception and recognition are part of the disorder. The relevance of BDD respective to esthetic surgery is discussed. Alternative options for patients such as psychotherapy or pharmacotherapy for this disorder are also related to.

A Meta-Analysis of the Effectiveness of Military and Veterans Affairs (VA) Combat-Related PTSD Programs

A meta-analysis was conducted to examine the effectiveness of 55 treatment outcomes reported by military and Veterans Affairs (VA) treatment centers for combat-related posttraumatic stress disorder (PTSD). The analysis includes 46 tested treatment outcomes derived from 21 psychotherapy studies, and nine tested treatment outcomes derived from seven pharmacotherapy studies, which were obtained through PsychINFO and PsychARTICLES database searches, as well as a reference search. Analysis of all treatment outcomes suggested a statistically significant, and meaningful, decrease in PTSD symptoms between baseline and post-treatment time points, t(54) = 9.27, p < .001, d = 0.35. Additionally, analysis of outcomes between psychotherapy and pharmacotherapy treatments resulted in statistically significant differences in PTSD assessment scores at post-test, indicating a greater degree of change for psychotherapy than for pharmacotherapy.

Cognitive change processes in a group cognitive behavior therapy of depression

The present study attempted to examine the causal relationships among changes in automatic thoughts, dysfunctional attitudes, and depressive symptoms in a 12-week group cognitive behavior therapy (GCBT) program for depression. In all, 35 depressed patients attending the GCBT program were monitored with the Automatic Thoughts Questionnaire, Dysfunctional Attitudes Scale, and Beck Depression Inventory at the pre-treatment, 4th and 8th sessions, and post-treatment. The results were as follows: (1) GCBT reduces negative cognitions; (2) changes in automatic thoughts and dysfunctional attitudes lead to change in depressive symptoms; and (3) automatic thoughts play a mediating role between dysfunctional attitudes and depression. The findings taken as a whole support the Causal Cognition Model of depression. (C) 2003 Elsevier Science Ltd. All rights reserved.

Depresión en pacientes con epilepsia: Revisión sistemática de la literatura

Esta revisión sistemática de la literatura tuvo como objetivo investigar sobre la depresión en personas con epilepsia en la última década (2005-2015), enfocándose en identificar en el paciente con epilepsia: características sociodemográficas, prevalencia de la depresión, tipos de intervención para el manejo de la depresión, factores asociados con la aparición y el mantenimiento de la depresión y por último, identificar las tendencias en investigación en el estudio de la depresión en pacientes con epilepsia. Se revisaron 103 artículos publicados entre 2005 y 2015 en bases de datos especializadas. Los resultados revelaron que la prevalencia de depresión en pacientes con epilepsia es diversa y oscila en un rango amplio entre 3 y 70 %, por otro lado, que las principales características sociodemográficas asociadas a la depresión está el ser mujer, tener un estado civil soltero y tener una edad comprendida entre los 25 y los 45 años. A esto se añade, que los tratamientos conformados por terapia psicológica y fármacos, son la mejor opción para garantizar la eficacia en los resultados del manejo de la depresión en los pacientes con epilepsia. Con respecto a los factores asociados a la aparición de la depresión en pacientes con epilepsia, se identificaron causas tanto neurobiológicas como psicosociales, asimismo los factores principales asociados al mantenimiento fueron una percepción de baja calidad de vida y una baja auto-eficacia. Y finalmente los tipos de investigación más comunes son de tipo aplicado, de carácter descriptivo, transversales y de medición cuantitativa.

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)

BACKGROUND PTSD is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms.Guidelines suggest a combination of both psychological therapy and pharmacotherapy may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either intervention alone. OBJECTIVES To assess whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately. SEARCH STRATEGY Searches were conducted on the trial registers kept by the CCDAN group (CCDANCTR-Studies and CCDANCTR-References) to June 2010. The reference sections of included studies and several conference abstracts were also scanned. SELECTION CRITERIA Patients of any age or gender, with chronic or recent onset PTSD arising from any type of event relevant to the diagnostic criteria were included. A combination of any psychological therapy and pharmacotherapy was included and compared to wait list, placebo, standard treatment or either intervention alone. The primary outcome was change in total PTSD symptom severity. Other outcomes included changes in functioning, depression and anxiety symptoms, suicide attempts, substance use, withdrawal and cost. DATA COLLECTION AND ANALYSIS Two or three review authors independently selected trials, assessed their 'risk of bias' and extracted trial and outcome data. We used a fixed-effect model for meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference and standardised mean difference were used to summarise continuous measures. MAIN RESULTS Four trials were eligible for inclusion, one of these trials (n =24) was on children and adolescents. All used an SSRI and prolonged exposure or a cognitive behavioural intervention. Two trials compared combination treatment with pharmacological treatment and two compared combination treatment with psychological treatment. Only two trials reported a total PTSD symptom score and these data could not be combined. There was no strong evidence to show if there were differences between the group receiving combined interventions compared to the group receiving psychological therapy (mean difference 2.44, 95% CI -2.87, 7.35 one study, n=65) or pharmacotherapy (mean difference -4.70, 95% CI -10.84 to 1.44; one study, n = 25). Trialists reported no significant differences between combination and single intervention groups in the other two studies. There were very little data reported for other outcomes, and in no case were significant differences reported. AUTHORS' CONCLUSIONS There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

Can a targeted psychological intervention be effective for young people following a first manic episode? Results from an 18-month pilot study.

Aim: There is a scarce literature describing psychological interventions for a young, first-episode cohort who have experienced psychotic mania. This study aimed to assess whether a manualized psychological intervention could be effective in reducing symptomatology and relapse, and improve functional outcome in this population. Methods: The study was an open-label design, drawn from a larger pharmacotherapy trial. All participants in the pharmacotherapy trial were offered a manualized psychological intervention in addition to case management. Inclusion in the psychotherapy group was based on participant's choice, and on completion of four or more of the eight modules offered. All clinical files were audited to ensure accuracy of group allocation. Forty young people aged 15 to 25 years old who had experienced a manic episode with psychotic features were recruited into the study, with 20 people in the combined treatment as usual plus psychotherapy group (P+TAU), and an equal number of matched control participants who received treatment as usual (TAU) within the same service. All participants were prescribed antipsychotic and mood-stabilizing medication. Symptomatic, functional and relapse measures were taken both at baseline and at 18-month follow-up. Results: Manic symptoms improved significantly for both groups, with no differences between groups. Depression scores and overall symptom severity were significantly lower in the P + TAU group. No differences were evident between groups with regard to numbers or type of relapse. The P + TAU group had significantly better social and occupational functioning after 18 months. Conclusion: This study suggests that a manualized psychological intervention targeted to a first-episode population can be effective in reducing depression and overall symptom severity, and can improve functional outcome following a first episode of psychotic mania.

Des soins de qualité pour la dépression en première ligne : une contribution à l’amélioration de l’état de santé de la population québécoise

Contexte De nombreuses études, utilisant des indicateurs de qualité variés, ont démontré que la qualité des soins pour la dépression n’est pas optimale en première ligne. Peu de ces études ont examiné les facteurs associés à la réception d’un traitement adéquat, en particulier en tenant compte simultanément des caractéristiques individuelles et organisationnelles. L'association entre un traitement adéquat pour un épisode dépressif majeur (EDM) et une amélioration des symptômes dépressifs n'est pas bien établie dans des conditions non-expérimentales. Les objectifs de cette étude étaient de : 1) réaliser une revue systématique des indicateurs mesurant la qualité du traitement de la dépression en première ligne ; 2) estimer la proportion de patients souffrant d’EDM qui reçoivent un traitement adéquat (selon les guides de pratique clinique) en première ligne ; 3) examiner les caractéristiques individuelles et organisationnelles associées à l’adéquation du traitement pour la dépression ; 4) examiner l'association entre un traitement minimalement adéquat au cours des 12 mois précédents et l'évolution des symptômes dépressifs à 6 et 12 mois. Méthodes La littérature sur la qualité du traitement de la dépression a été examinée en utilisant un ensemble de mots-clés (« depression », « depressive disorder », « quality », « treatment », « indicator », « adequacy », « adherence », « concordance », « clinical guideline » et « guideline ») et « 360search », un moteur de recherche fédérée. Les données proviennent d'une étude de cohorte incluant 915 adultes consultant un médecin généraliste, quel que soit le motif de consultation, répondant aux critères du DSM-IV pour l’EDM dans la dernière année, nichés dans 65 cliniques de première ligne au Québec, Canada. Des analyses multiniveaux ont été réalisées. Résultats Bien que majoritairement développés à partir de guides de pratique clinique, une grande variété d'indicateurs a été observée dans la revue systématique de littérature. La plupart des études retenues ont utilisé des indicateurs de qualité rudimentaires, surtout pour la psychothérapie. Les méthodes utilisées étaient très variées, limitant la comparabilité des résultats. Toutefois, quelque soit la méthode choisie, la plupart des études ont révélé qu’une grande proportion des personnes souffrant de dépression n’ont pas reçu de traitement minimalement adéquat en première ligne. Dans notre échantillon, l’adéquation était élevée (> 75 %) pour un tiers des indicateurs de qualité mesurés, mais était faible (< 60 %) pour près de la moitié des mesures. Un peu plus de la moitié de l'échantillon (52,2 %) a reçu au moins un traitement minimalement adéquat pour la dépression. Au niveau individuel, les jeunes adultes (18-24 ans) et les personnes de plus de 65 ans avaient une probabilité moins élevée de recevoir un traitement minimalement adéquat. Cette probabilité était plus élevée pour ceux qui ont un médecin de famille, une assurance complémentaire, un trouble anxieux comorbide et une dépression plus sévère. Au niveau des cliniques, la disponibilité de la psychothérapie sur place, l'utilisation d'algorithmes de traitement, et le mode de rémunération perçu comme adéquat étaient associés à plus de traitement adéquat. Les résultats ont également montré que 1) la réception d'au moins un traitement minimalement adéquat pour la dépression était associée à une plus grande amélioration des symptômes dépressifs à 6 et à 12 mois; 2) la pharmacothérapie adéquate et la psychothérapie adéquate étaient toutes deux associées à de plus grandes améliorations dans les symptômes dépressifs, et 3) l'association entre un traitement adéquat et l'amélioration des symptômes dépressifs varie en fonction de la sévérité des symptômes au moment de l'inclusion dans la cohorte, un niveau de symptômes plus élevé étant associé à une amélioration plus importante à 6 et à 12 mois. Conclusions Nos résultats suggèrent que des interventions sont nécessaires pour améliorer la qualité du traitement de la dépression en première ligne. Ces interventions devraient cibler des populations spécifiques (les jeunes adultes et les personnes âgées), améliorer l'accessibilité à la psychothérapie et à un médecin de famille, et soutenir les médecins de première ligne dans leur pratique clinique avec des patients souffrant de dépression de différentes façons, telles que le développement des connaissances pour traiter la dépression et l'adaptation du mode de rémunération. Cette étude montre également que le traitement adéquat de la dépression en première ligne est associé à une amélioration des symptômes dépressifs dans des conditions non-expérimentales.

Les troubles liés aux événements traumatiques: dépistage, évaluation et traitements.

OBJECTIF Informer les médecins de première ligne concernant le dépistage, le diagnostic et le traitement des troubles psychologiques associés aux événements traumatiques. QUALITÉ DES DONNÉES Les recensions proviennent de recherches via les banques de données PsycLIT, PsyINFO, PILOTS et MEDLINE (de janvier 1985 à décembre 2000) utilisant les termes « acute stress disorder », « posttraumatic stress disorder », « traumatic stress », « psychotherapy », « psychosocial treatment », « treatment » et « pharmacotherapy ». Les recommandations concernant le traitement de l’état de stress aigu (ÉSA) et du trouble de stress post-traumatique (TSPT) reposent sur des données probantes provenant d’essais thérapeutiques d’excellente qualité. Les conclusions portant sur le diagnostic et l’évaluation reposent sur les plus récentes études épidémiologiques ainsi que sur des consensus et des opinions d’experts. PRINCIPAL MESSAGE Très souvent, l’ÉSA et le TSPT sont sous-diagnostiqués et sous-traités. Les médecins de famille sont susceptibles de recevoir des patients souffrant de ces troubles. Le dépistage précoce en première ligne repose sur une écoute attentive, sur une relation chaleureuse et sécurisante avec le patient et sur la recherche de difficultés d’adaptation en lien avec un événement traumatique. Idéalement, les individus souffrant d’un ÉSA ou d’un TSPT sont orientés vers une ressource spécialisée. Si de telles ressources ne sont pas accessibles, le médecin peut offrir des conseils et prescrire une médication en fonction des symptômes. CONCLUSION Les médecins de famille peuvent contribuer à identifier et traiter les patients souffrant de l’un ou l’autre de ces troubles.

Esquizofrenia: intervenção em Instituição Pública de Saúde

Les premiers concepts de schizophrénie comprenaient des définitions non-spécifiques sur le trouble schizophrénique. Ce n est qu en 1980 que Crow a proposé la classification la plus connue pour ce trouble: la distinction en soustypes I et II, de symptomatologie positive ou négative, les symptômes du syndrome positif correspondant aux hallucinations et aux délires et ceux du syndrome négatif au repli affectif et à la pauvreté du discours. Bien que la thérapie médicamenteuse présente des avancées dans le traitement de la maladie, la psychothérapie est la plus indiquée pour remédier aux préjudices sociaux et interpersonnels que celle-ci provoque. L objectif de cette étude est de relater une intervention comportementale, dans un Centre de Soins Psychosocial, auprès d une patiente de 19 ans, en utilisant des Exercices de Réadaptation Psychosociale (SAT) en tant que la possibilité de traitement de la schizophrénie. Ce processus a contribué à une réduction du stéréotype de la maladie chez la jeune patiente, considérant qu elle a élargi son répertoire social et a rendu possible des avancées dans les sphères psychologique, sociale et professionnelle.

Level of incongruence during cardiac rehabilitation and prediction of future CVD-related hospitalizations plus all-cause mortality

Independent of traditional risk factors, psychosocial risk factors increase the risk of cardiovascular disease (CVD). Studies in the field of psychotherapy have shown that the construct of incongruence (meaning a discrepancy between desired and achieved goals) affects the outcome of therapy. We prospectively measured the impact of incongruence in patients after undergoing a cardiac rehabilitation program. We examined 198 CVD patients enrolled in a 8–12 week comprehensive cardiac rehabilitation program. Patients completed the German short version of the Incongruence Questionnaire and the SF-36 Health Questionnaire to measure quality of life (QoL) at discharge of rehabilitation. Endpoints at follow-up were CVD-related hospitalizations plus all-cause mortality. During a mean follow-up period of 54.3 months, 29 patients experienced a CVD-related hospitalization and 3 patients died. Incongruence at discharge of rehabilitation was independent of traditional risk factors a significant predictor for CVD-related hospitalizations plus all-cause mortality (HR 2.03, 95% CI 1.29–3.20, p = .002). We also found a significant interaction of incongruence with mental QoL (HR .96, 95% CI .92–.99, p = .027), i.e. incongruence predicted poor prognosis if QoL was low (p = .017), but not if QoL was high (p = .74). Incongruence at discharge predicted future CVD-related hospitalizations plus all-cause mortality and mental QoL moderated this relationship. Therefore, incongruence should be considered for effective treatment planning and outcome measurement.

Cognitive-Behavioural Analysis System of Psychotherapy (CBASP), a drug, or their combination: differential therapeutics for persistent depressive disorder: a study protocol of an individual participant data network meta-analysis.

INTRODUCTION Despite important advances in psychological and pharmacological treatments of persistent depressive disorders in the past decades, their responses remain typically slow and poor, and differential responses among different modalities of treatments or their combinations are not well understood. Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) is the only psychotherapy that has been specifically designed for chronic depression and has been examined in an increasing number of trials against medications, alone or in combination. When several treatment alternatives are available for a certain condition, network meta-analysis (NMA) provides a powerful tool to examine their relative efficacy by combining all direct and indirect comparisons. Individual participant data (IPD) meta-analysis enables exploration of impacts of individual characteristics that lead to a differentiated approach matching treatments to specific subgroups of patients. METHODS AND ANALYSIS We will search for all randomised controlled trials that compared CBASP, pharmacotherapy or their combination, in the treatment of patients with persistent depressive disorder, in Cochrane CENTRAL, PUBMED, SCOPUS and PsycINFO, supplemented by personal contacts. Individual participant data will be sought from the principal investigators of all the identified trials. Our primary outcomes are depression severity as measured on a continuous observer-rated scale for depression, and dropouts for any reason as a proxy measure of overall treatment acceptability. We will conduct a one-step IPD-NMA to compare CBASP, medications and their combinations, and also carry out a meta-regression to identify their prognostic factors and effect moderators. The model will be fitted in OpenBUGS, using vague priors for all location parameters. For the heterogeneity we will use a half-normal prior on the SD. ETHICS AND DISSEMINATION This study requires no ethical approval. We will publish the findings in a peer-reviewed journal. The study results will contribute to more finely differentiated therapeutics for patients suffering from this chronically disabling disorder. TRIAL REGISTRATION NUMBER CRD42016035886.