Psychotherapy of refractory depressions.

Psychotherapy is a potentially valuable intervention for treatment-resistant depression. This review provides a brief, general overview of the use of psychotherapy to treat depression and more focused consideration of time-limited interpersonal, behavioral, and cognitive behavioral strategies for patients who are not responsive to antidepressant medication. Effective strategies emphasize individualized assessment, psychoeducation, a high level of structure and therapist activity, operationalized short-term goals, self-help and homework activities, and an empirical-collaborative approach to treatment.

Bipolar depression: an underestimated treatment challenge.

We sought to determine whether depressive and mixed/cycling episodes were as responsive to standardized pharmacotherapeutic interventions as were manic episodes in bipolar 1 patients. As part of the Maintenance Therapies in Bipolar Disorder (MH29618, E. Frank, PI) study, forty-two acutely ill bipolar 1 patients who had been randomly assigned to one of two preliminary phase non-pharmacologic treatment strategies (interpersonal and social rhythm therapy [IPSRT] or a standard medication clinic approach) were treated according to a standardized pharmacotherapeutic protocol.

A measure of readiness for substance abuse treatment. Psychometric properties of the RAATE-R interview.

The Recovery Attitude and Treatment Evaluator-Research (RAATE-R) scale is a structured interview that assesses readiness for substance abuse treatment in five subscales: resistance to treatment, resistance to continuing care, bio-medical acuity, psychological acuity, and environmental/ social problems. Psychometric properties, based on an interrater reliability analysis of 23 raters and administration of the scale to 116 cocaine-dependent outpatients, included high interrater reliability, high internal consistency, independence of subscales, and a factor structure that partially supports the scale's original design. The authors discuss limitations of these conclusions and the lack of concurrent validity with a self-report measure of therapy readiness.

Fluoxetine treatment of patients with major depressive disorder who failed initial treatment with sertraline.

Background: This study was conducted to determine if patients with major depressive disorder who had previously failed treatment with one serotonin selective reuptake inhibitor (SSRI) would respond to a different SSRI.

Method: Adult outpatients (N = 106) with DSM-III-R major depressive disorder and a history of either intolerance (N = 34) or nonresponse (N = 72) to treatment with sertraline were treated with fluoxetine (mean dose = 37.2 mg/day) in a standardized, open-label, 6-week clinical trial.

Cognitive therapy with inpatients.

Psychotherapeutic interventions often play a major role in the treatment of patients who are hospitalized for depression. Much of the "therapeutic milieu" of the inpatient unit includes patient participation in group psychotherapy and in one-on-one psychotherapy with staff members. These interventions are designed not only to be primary treatments for depression, but are also used to enhance patients' compliance with pharmacotherapy.

Gender differences in cognitive diathesis-stress domain match: implications for differential pathways to depression.

The frequency of cognitive diathesis-stress match was compared in a sample of depressed women and men to investigate hypotheses positing gender differences in the relation of cognitive diathesis-stress factors to depression. Depressed women were more likely to have experienced a match between a cognitive diathesis and a preonset negative stressor compared with depressed men. Comparisons of women and men on the cognitive and stress variables singly yielded differences in stress variables but not in cognitive variables.

Treatment outcome in recurrent major depression: a post hoc comparison of elderly ("young old") and midlife patients.

Objective: The authors compared response rates, the temporal course of response to acute treatment, and relapse rates during continuation treatment of elderly and midlife patients with recurrent major depression.

Method: They analyzed results from two separate controlled studies of maintenance therapies for recurrent major depression, in which 148 elderly patients (mean age = 67.9 years) and 214 midlife patients (mean age = 38.

A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia.

Background: Despite the high prevalence of dysthymia and its associated morbidity, few controlled trials have evaluated the efficacy of antidepressant medication for this disorder. A 12-week, double-blind, placebo-controlled, randomized, multicenter trial was performed to evaluate the safety and efficacy of sertraline hydrochloride and imipramine hydrochloride in treating dysthymia.

Methods: A total of 416 outpatients (271 women and 145 men) aged 25 to 65 years with DSM-III-R-defined, early-onset, primary dysthymia without concurrent major depression were randomized to 12 weeks of treatment with sertraline, imipramine, or placebo.

Recent developments in the pharmacotherapy of mood disorders.

This article reviews recent developments in the pharmacotherapy of mood disorders. Pharmacotherapy is the best studied and most widely validated approach for acute phase treatment and prevention of relapse-recurrence for patients with major depression, dysthymia, and bipolar affective disorder. Antidepressants are also the mainstay of inpatient treatment and, when considered together with electroconvulsive therapy, represent the first line of treatment for the most severe and incapacitating forms of depression.

Hypothalamic-pituitary-adrenocortical activity and response to cognitive behavior therapy in unmedicated, hospitalized depressed patients.

Objective: Surprisingly little research supports the hypothesis that depressions characterized by objective measures of neurobiological dysregulation respond poorly to psychotherapy. Moreover, relevant studies testing this hypothesis have been compromised by low rates of neurobiological abnormality in outpatient samples. The authors therefore investigated response to cognitive behavior therapy in relation to pretreatment measures of hypothalamic-pituitary-adrenocortical (HPA) activity in hospitalized, yet unmedicated, patients.

The role of Axis II comorbidity in the management of patients with treatment-resistant depression.

A significant proportion of antidepressant nonresponders have personality disorders. The relationship between antidepressant resistance and personality pathology is far from straightforward, however, and reflects a disproportionate "burden" of negative prognostic correlates, psychosocial risk factors, and problems that compromise effective therapeutic relationships. An important clinical ground rule is to avoid the reductionistic logical tautology that explains antidepressant failure as a consequence of personality disorder and, by implication, that the patient may deserve to suffer.

Antidepressant options: venlafaxine in perspective.

Depression is often related to disturbances of norepinephrine and serotonin neurochemical systems within the brain that affect functional neurobehavioral systems. Classes of antidepressant agents have been developed that directly affect proposed brain neurochemical alterations. Many of the differences among antidepressant agents, particularly in safety and tolerability, can be attributed to their differing effects on receptor blockade and neurotransmitter reuptake.

The role of psychotherapy in the treatment of depression: review of two practice guidelines.

We review two recent practice guidelines' assessments of the role of psychotherapy in the treatment of major depression in adults. We examine the practice guideline published by the American Psychiatric Association (APA) and that published by the Depression Guideline Panel of the Agency for Health Care Policy and Research. We focus on the guidelines' evaluations of psychotherapies, their statements about the role of psychotherapy in first-line treatment of depression, and the procedures they recommend for choosing among psychotherapies.

Racial effects on the clinical presentation of alcoholics at a psychiatric hospital.

Despite the clinical importance of race effects on comorbidity and symptom patterns in recent community studies, little is known about such effects in various treatment facilities. This study evaluated the effect of race on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. The factor that most strongly distinguished the racial groups was socioeconomic status (SES).

Abnormal electroencephalographic sleep profiles in major depression: association with response to cognitive behavior therapy.

Background: To test the hypothesis that depressed patients with selected neurobiologic disturbances are less responsive to psychotherapy, we examined responses to cognitive behavior therapy in relation to electroencephalographic sleep profiles.

Methods: Under a prospective, case-control design, 90 outpatients with probable or definite endogenous major depression (Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria) were stratified into abnormal and normal sleep subgroups (on the basis of an empirically validated electroencephalographic sleep profile) and more severe and less severe depression subgroups (on the basis of pretreatment Hamilton scores). Response to 16 weeks of treatment was analyzed for both intention-to-treat and completers (n = 82) samples.

Gender effects on the clinical presentation of alcoholics at a psychiatric hospital.

Despite the clinical importance of gender effects on symptom patterns and comorbidity patterns in alcoholics, little is known about such effects in treatment facilities other than alcoholism treatment centers. This study evaluated the effect of gender on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. It demonstrated that major depression and accompanying depressive and anxiety-related symptoms are more prominent in female alcoholics than in male alcoholics, whereas antisocial personality disorder and antisocial symptoms are more prominent in male alcoholics presenting to a psychiatric hospital.

Electroencephalographic sleep profiles in single-episode and recurrent unipolar forms of major depression: I. Comparison during acute depressive states.

The current study was conducted to examine if recurrent depression is associated with more severe disturbances of all-night EEG sleep profiles than single-episode depressions. Unmedicated sex- and age-matched groups of 22 single-episode (SE) and 44 recurrent unipolar (RU) outpatients with DSM-III-R/SADS/RDC major depression underwent 2 consecutive nights of EEG sleep recording. Multivariate analyses of covariance (MANCOVAs) and/or analyses of covariance (ANCOVAs) were performed on six sets of sleep measures.

Toward an integration of psychologic, social, and biologic factors in depression: effects on outcome and course of cognitive therapy.

The present study attempted to integrate key variables from 3 major domains of theory in depression (cognition, stress, and psychobiology) that are typically studied separately in analyses of course and response to cognitive therapy. Dysfunctional attitudes, negative life events, or sleep electroencephalogram were assessed in 53 outpatients before treatment with cognitive therapy. High levels of dysfunctional attitudes were found to be associated with poorer response to treatment but not for those patients who had experienced a severe negative life event.

MAOIs in the contemporary treatment of depression.

We review the literature on the effectiveness of the monoamine oxidase inhibitors (MAOIs) and present metaanalyses of controlled trials comparing the FDA-approved MAOIs with both placebo and comparator tricyclic antidepressants. For outpatients, metaanalyses with intent-to-treat samples revealed generally comparable overall efficacy for phenelzine, isocarboxazid, and tranylcypromine. Drug-placebo differences were 29.