Adolescents with major depression who received cognitive behavioral therapy (CBT) after responding to an antidepressant were less likely to experience a relapse or recurrence of symptoms compared to teens who did not receive CBT, according to a small, NIMH-funded pilot study published in the December 2008 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Background
Studies have found that adults with depression who have responded to medication treatment are less likely to have a relapse if they receive CBT during the follow-up treatment phase, according to researchers Betsy Kennard, Psy.D., of the University of Texas Southwestern Medical Center, and colleagues. Scientists theorize that initial antidepressant treatment may help improve symptoms enough so that a patient becomes more receptive to CBT or other psychosocial component. Kennard and colleagues aimed to determine if a similar sequential treatment strategy would be effective with depressed adolescents.

In this pilot study, 46 depressed youths ages 11 to 18 who had responded to 12 weeks of treatment with the antidepressant fluoxetine (Prozac) were randomly assigned to either six months of continued medication management (MM), or to medication management plus cognitive behavioral therapy (MM+CBT) designed to prevent relapse.

Results of the Study
Kennard and colleagues found that the youths who received only MM were significantly more likely to relapse than the youths who received MM+CBT. The researchers estimated that 37 percent of those in the MM group were likely to relapse, while 15 percent of those in the MM+CBT group were likely to relapse. Patients getting MM+CBT also reported higher rates of satisfaction compared to those getting MM only.

Significance
This pilot study demonstrates that, as in adult studies, introducing CBT in follow-up treatment after a patient responds to antidepressant treatment may be a promising strategy in preventing relapse among depressed adolescents.

What’s Next
The researchers currently are conducting a larger trial of MM+CBT to further evaluate the effectiveness of this treatment strategy in youths with depression.

Reference
Kennard B, et al. Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2008 Dec; 47(12):1395-1404

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Posted at the National Institute of Mental Health (NIMH)
5 December 2008

Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly

The perception that therapists and their techniques play the most significant role in influencing the outcome of treatment is challenged in a new research review, launched today at the Annual Conference of the British Association for Counselling & Psychotherapy in Telford.

The book, Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly, written by Professor Mick Cooper of the University of Strathclyde, concludes that the most important factor in successful therapy is a client, or patient, who is motivated and engaged and who is able to use therapy to build on his or her strengths. Professor Cooper also finds that a strong relationship between therapist and client is one of the best indicators of a positive therapeutic outcome, and is far more significant than a therapist's particular techniques and approach.

The review is published at a time when the government has recently committed £173 million a year to be spent on Cognitive Behavioural Therapy (CBT) as part of its Improving Access to Psychological Therapies programme. Professor Cooper, of Strathclyde's Faculty of Education, said: "Many clients will benefit from CBT but there is a danger in putting too much emphasis on the type of therapy that a therapist provides, rather than the therapist's ability to relate to his or her client in caring and understanding ways, and the needs and preferences of individual clients. "Rather than moving towards a therapeutic 'monoculture', we need to be able to provide people with a range of therapies and therapists, so that they can choose the one that best suits them and build on their particular strengths." This finding is supported by the work of eminent American psychologist Barry Duncan and colleagues. They wrote in 2004 that "clients, not therapists, make therapy work."

The book, which is the first reader-friendly summary of research findings in the field, also offers advice to people who are considering seeing a therapist, on their choice of practitioner and the best type of therapy available to them. Professor Cooper said: "Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. "Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. "Ask yourself whether you like your therapist and feel respected by them – the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

Professor Cooper also suggested that people experiencing a specific psychological disorder, such as a phobia, may wish to consult the website of the National Institute for Clinical Excellence (NICE) to find out which kind of therapy has the strongest evidence base for their problem. If, however, a particular therapy is not on the list, it is almost certainly because it has yet to be tested, rather than because it has been proven to be ineffective.

Psychodynamic psychotherapy lasting for at least a year is effective and superior to shorter-term therapy for patients with complex mental disorders such as personality and chronic mental disorders, according to a meta-analysis published in the October 1 issue of JAMA.

Evidence indicates that short-term psychodynamic psychotherapy is insufficient for a considerable proportion of patients with complex mental disorders, i.e., patients with multiple or chronic mental disorders or personality disorders. Some studies suggest that long-term psychodynamic psychotherapy (LTPP) may be helpful for these patients, according to background information in the article. LTPP is therapy in which emphasis is placed on more interpretive or supportive interventions, depending on the patient's needs, and that involves careful attention to the therapist-patient interaction.

Falk Leichsenring, D.Sc., of the University of Giessen, Germany, and Sven Rabung, Ph.D., of the University Medical Center Hamburg-Eppendorf, Hamburg, Germany, conducted a meta-analysis to examine the effectiveness of LTPP (lasting for at least a year, or 50 sessions) and whether it is superior to shorter psychotherapeutic treatments for complex mental disorders, including personality disorders, chronic mental disorders (defined as lasting at least a year) and multiple mental disorders. The researchers identified and included 23 studies for the meta-analysis (11 randomized controlled trials and 12 observational studies), involving a total of 1,053 patients receiving LTPP.

The authors found: "In this meta-analysis, LTPP was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning. Long-term psychodynamic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders, and chronic mental disorders. The effect sizes for overall outcome increased significantly between end of therapy and follow-up."

With regard to overall effectiveness, analysis indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96 percent of the patients in the comparison groups. The authors add that further research should evaluate the cost-effectiveness of LTPP.

An analysis of news media coverage of medical studies indicates that news articles often fail to report pharmaceutical company funding and frequently refer to medications by their brand names, both potential sources of bias, according to a study in the October 1 issue of JAMA.

New articles represent an important source of medical information for many patients, and even some physicians. "An increasingly recognized source of commercial bias in medical research is the funding of studies by companies with a financial interest in the results," the authors write. Little is known about how frequently news articles report the funding sources of the medical research they report on, or how frequently news articles use brand medication names instead of generic names, which could create commercial bias.

Michael Hochman, M.D., of the Cambridge Health Alliance and Harvard Medical School, Cambridge, Mass., and colleagues reviewed U.S. news articles from newspaper and online sources about pharmaceutical-funded medication studies to determine how frequently and prominently they indicate the funding source and how often they refer to medications by their brand vs. generic names. The studies were published in five major general medical journals (JAMA, New England Journal of Medicine, Lancet, Archives of Internal Medicine and the Annals of Internal Medicine). The researchers also surveyed editors at the 100 most widely circulated newspapers in the U.S. about their publications' practices on the reporting of company funding and the use of generic medication names.

The authors identified 306 news articles, of which 175 were from newspapers and 131 were from online sources. Among the 306 news articles about company-funded medication studies, the funding source for the studies was not reported in 42 percent of the articles. There was no significant difference in nonreporting rates between articles obtained from newspaper and online sources. Of the 306 news articles, 277 concerned medications with both generic and brand names. Among these 277 articles, 38 percent used only brand names and 67 percent used brand names in at least half of the medication references.

The survey of newspaper editors found that 88 percent indicated that his/her publication often or always reported company funding in articles about medical research, and that 77 percent reported that they often or always referred to medications by the generic names in articles about medical research. Three percent of editors indicated that their publication had a written policy stating that company funding should be reported in articles about medical research, while the editor at two percent of newspapers responded that his/her publication had a written policy stating that medications should be referred to predominantly by their generic names.

However, the editors' perceptions diverged from their publications' actual performances. A total of 104 newspaper articles were analyzed from publications for which editors reported always identifying company funding. Of these articles, 45 percent failed to cite company funding. Additionally, a total of 75 newspaper articles were analyzed from publications for which the editors reported always using generic names. Of these articles, 76 percent used brand names in at least half of the medication references.

"Our findings raise several concerns. For patients and physicians to evaluate new research findings, it is important that they know how the research was funded so they can assess whether commercial biases may have affected the results. Additionally, the use of generic medication names by the news media is preferable so that physicians and patients learn to refer to medications by their generic names, a practice that is likely to reduce medication errors and may decrease unnecessary health care costs," the authors write.

American children are approximately three times more likely to be prescribed psychotropic medication than children in Europe. A new study published today in BioMed Central's open access journal Child and Adolescent Psychiatry and Mental Health claims that the differences may be accounted for by regulatory practices and cultural beliefs about the role of medication in emotional and behavioural problems.

Julie Zito led a team of researchers from the USA, Germany and the Netherlands who investigated prescription levels in the three countries. She said, "Antidepressant and stimulant prevalence were three or more times greater in the US than in the Netherlands and Germany, while antipsychotic prevalence was 1.5 to 2.2 times greater".

The use of antidepressants, like Prozac, and stimulants, like Ritalin, in children has been the subject of a great deal of controversy and this study quantifies the differences in practice between the US and Western Europe. The authors claim that the differences may be partly due to different diagnostic classification systems, "The US trend of increasing bipolar diagnosis in children and adolescents does not reflect European practice". The authors also mention government cost restrictions in Europe, the larger number of child psychiatrists per capita in the US and the use of two or more different psychotropic drugs in a single year in US children as possible explanations.

Zito concludes that, "Direct to consumer drug advertising, which is common in the US, is also likely to account for some of the differences. The increased use of medication in the US also reflects the individualist and activist therapeutic mentality of US medical culture".

In a study that may significantly advance the understanding of how cognitive-behavioral therapy affects the brain, researchers have shown that significant changes in activity in certain regions of the brain can be produced with as little as four weeks of daily therapy in patients with obsessive-compulsive disorder (OCD). The discovery could have important clinical implications, according to principal investigator Sanjaya Saxena, M.D., Director of the Obsessive-Compulsive Disorders Program at the University of California, San Diego (UCSD) School of Medicine, whose findings are published on line this week in the journal Molecular Psychiatry.

“The study is exciting because it tells us more about how cognitive-behavioral therapy works for OCD and shows that both robust clinical improvements and changes in brain activity occur after only four weeks of intensive treatment," said Saxena.

OCD is an anxiety disorder in which individuals have unreasonable fears or worries that they try to manage through ritualized compulsive behaviors to reduce the anxiety. For example, a patient may experience the urgent need to engage in certain rituals, such as hand washing or repeatedly checking that the oven is off or the front door is locked.

Past studies using functional brain imaging studies of patients with OCD have demonstrated that elevated activity along the frontal-subcortical circuits of the brain decreases in response to treatment with serotonin reuptake inhibitor (SRI) medications or cognitive-behavioral therapy. However, clinical improvement of OCD symptoms was expected to require up to 12 weeks of behavioral therapy or medication treatment, the standard treatments for OCD. Only a handful of studies have looked at how therapy affects brain function, and all previous studies had examined changes over several months of treatment.

Saxena and colleagues at the David Geffen School of Medicine at UCLA made two novel discoveries in their study of 10 OCD patients and 12 control subjects. “First of all, we discovered significant changes in brain activity solely as the result of four weeks of intensive cognitive-behavioral therapy,” said Saxena. “Secondly, these changes were different than those seen in past studies after a standard 12-week therapeutic approach using SRI medications or weekly behavioral therapy.” The researchers obtained positron emission tomography (PET) scans of the ten OCD patients both before and after they received four weeks of a therapy known as “exposure and response prevention,” which gradually desensitizes patients to things that provoke obsessional fears or worries. “This is the primary kind of therapy used for OCD. It teaches patients to pay attention to their internal experiences and tolerate scary thoughts without having to act on them,” said Saxena. “They learn that nothing terrible happens if they refrain from their usual compulsive behaviors.”

The normal control subjects received no treatment and were scanned twice, several weeks apart, and metabolic changes in the brain were compared between the two groups. After four weeks of therapy and without any changes in medication, the OCD patients showed significant improvements in OCD symptoms, depression, anxiety and overall functioning. The PET scans of OCD patients demonstrated significant decreases in glucose metabolism – a measure of brain cell activity – in the right and left thalamus after treatment. These are areas of the brain involved in OCD and where changes have been seen in numerous past studies after longer-term treatment.

However, the PET scans in this study also showed a significant increase in activity in an area of the brain called the right dorsal anterior cingulate cortex, a region involved in reappraisal and suppression of negative emotions. Increasing activity in this region corresponded to the OCD patients’ improvement in clinical symptoms after the four-week course of intensive therapy. Activity in this area had previously been found to increase after cognitive-behavioral therapy for major depression. Therefore, the researchers theorize that response to cognitive-behavioral therapy across a variety of disorders may require activation of the dorsal anterior cingulate cortex, according to Saxena.

An interview with Albert Ellis, developer of Rational Emotive Behavior Therapy (REBT). The groundbreaking treatment rests on the premise that most of our emotional problems are based on irrational beliefs.

A common drug [propranolol] administered in the first hours following trauma to patients deemed to be at risk of developing post-traumatic stress disorder (PTSD) reduced the occurrence of PTSD, according to a study led by researchers at the University of Lille, France [in 2003].

While the study involved a small number of subjects, its results are encouraging, says its senior author, Charles Marmar, MD, associate chief of staff for mental health at the San Francisco VA Medical Center and professor and vice chair of psychiatry at University of California, San Francisco.

"The study is based on the new theory that PTSD is most likely to occur in patients who experience a particularly severe and prolonged response to trauma. If this model proves accurate after five or ten replications of studies like this one, it could have very profound ramifications. From a public health perspective, if you could identify the subgroup of people who are susceptible to PTSD, giving them this course of medication -- which is brief, very well tolerated and inexpensive -- could be very effective prevention [following major trauma] and may have great social relevance." The study appears in the November 1 issue of Biological Psychiatry. [read rest of article]

Also: The Memory Pill (60 Minutes video -- 26 Nov 2006)
Bad Memory? Wipe It Clean With New Pill (16 Jan 2006)

Why Does Cognitive Therapy Work?
By James Krehbiel

Cognitive-Behavioral Therapy for Somatization Disorder [abstract]
A Randomized Controlled Trial

Lesley A. Allen, PhD; Robert L. Woolfolk, PhD; Javier I. Escobar, MD; Michael A. Gara, PhD; Robert M. Hamer, PhD || Arch Intern Med 2006;166:1512-1518.

Background: Patients diagnosed as having somatization disorder (SD) who present with a lifetime history of multiple, medically unexplained physical symptoms represent a significant challenge to health care providers. To date, no psychotherapeutic or pharmacologic intervention has been found to produce clinically meaningful improvement in symptoms or functioning of patients with SD. We examined the efficacy of cognitive-behavioral therapy (CBT) for SD.

Methods:  Eighty-four participants meeting criteria for SD were randomly assigned to 1 of 2 conditions: (1) standard medical care augmented by a psychiatric consultation intervention or (2) a 10-session, manualized, individually administered CBT regimen added to the psychiatric consultation intervention. Assessments were conducted at baseline and 3, 9, and 15 months after baseline. The primary outcome measure was the severity scale of the Clinical Global Impression Scale for Somatization Disorder (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-reported measures of physical functioning and somatic symptoms, and health care utilization assessed via medical records.

Results:  Fifteen months after baseline, somatization symptoms were significantly less severe in the group treated with CBT (0.84 points on the CGI-SD 7-point scale) (P<.001). Patients treated with CBT also were significantly more likely to be rated as either very much improved or much improved than patients treated with only augmented standard medical care (40% [n = 17] vs 5% [n = 2]). Cognitive-behavioral therapy was associated with greater improvements in self-reported functioning and somatic symptoms and a greater decrease in health care costs.
Author Affiliations: Department of Psychiatry, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway (Drs Allen, Escobar, and Gara); Department of Psychology, Rutgers University, Piscataway (Dr Woolfolk); Department of Psychology, Princeton University, Princeton, NJ (Dr Woolfolk); and Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Dr Hamer).

When Alcoholics Anonymous and other 12-step programs are examined in controlled studies, a new review reports, scientists find no proof that they are superior to any other intervention in reducing alcohol dependence or alcohol-related problems.

The researchers, led by Marica Ferri of the Italian Agency for Public Health in Rome, found little to suggest that 12-step programs reduced the severity of addiction any more than any other intervention. And no data showed that 12-step interventions were any more — or any less — successful in increasing the number of people who stayed in treatment or reducing the number who relapsed after being sober.

Alcoholics Anonymous is a self-help group that offers emotional support for alcohol abstinence and holds that alcoholism is a spiritual and a medical disease. [read more]

New York Times
By Nicholas Bakalarp
Published: July 25, 2006

On his 150th anniversary, Freud's legacy is being dismantled by the ideas of his greatest challenger, Aaron Beck. Cognitive therapy is now the orthodox talking cure in Britain, and the government wants more of it. But with cognitive science comes a new battle for the meaning of the human mind.

After Freud by Alexander Linklater & Robert Harland
Prospect (June 2006)

...but researchers say side effects, interactions largely unknown. Read more about pediatric polypharmacy in this HealthDay News article.

The efficacy of cognitive therapy was evaluated in a University of Pennsylvania study of 120 suicide attempters from an emergency room. Half of the subjects received cognitive therapy and half received standard therapy. Over the course of an 18 month follow-up, 24.1% of those who got cognitive therapy made a second suicide attempt, compared to 41.6% of those who got standard treatment. Subjects who had received cognitive therapy also scored significantly lower on measurements of depression. Read more about the study:

Cognitive Therapy Halves Risk of Second Suicide Attempt
By Ed Edelson
HealthDay Reporter