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Recent research: half a dozen papers relevant to psychotherapy

Here are half a dozen papers relevant to psychotherapy.   The first two throw some light on the question of whether it matters which form of established psychotherapy one uses to treat a particular depression sufferer - bearing in mind Cuijpers et al's recent meta-analysis suggesting that " ... there are no large differences in efficacy between the major psychotherapies for mild to moderate depression".  Conradi and colleagues' study found that cognitive-behavioural therapy (CBT) outperformed standard primary care depression treatment only for people who had already experienced four or more prior depressive episodes.  This finding parallels research on mindfulness-based cognitive therapy (MBCT) which seems specifically effective only in helping those who have already experienced at least three depressive episodes.  Both CBT and MBCT may act partly by tackling rumination.  In this Conradi study however, CBT was used to treat active depression whereas, so far, major trials of MBCT have been aimed at preventing relapse in those who have recovered from depression.  In the second of these papers, which provide some guidance on when to choose which form of psychotherapy for which depression sufferer, Oxman et al found that problem-solving treatment for primary care (PST-PC) outperformed standard treatment for minor depression, particularly for those with a highly avoidant coping style.

The third paper - by Roemer et al - showed good response in generalized anxiety disorder (GAD) sufferers treated with Acceptance & Commitment Therapy (ACT).  ACT, as with CBT in the first study already mentioned, probably partly acts by reducing rumination - see for example the blog posting earler this month on The bus driver metaphor.  It would be interesting to see if ACT is simply another reasonably effective therapy for GAD, or whether it has anything extra to offer over other already established CBT approaches.  For that information, we'll probably need to wait for a head-to-head trial.

The fourth study, detailed in this blog posting, is a systematic review by McDaid et al on treatments to help people bereaved through suicide.  Searching for good research proved tricky with few adequate studies available.  What research there was tended to focus on famiy or group interventions - with some signs of encouraging benefit.  The authors concluded "Further ... sound evidence is required to confirm whether interventions are helpful and, if so, for whom."

The fifth study - by Alim and colleagues - looks at factors associated with resilience in people who had experienced a range of severe traumas.  Fascinatingly the authors found that " ... purpose in life emerged as a key factor associated with both resilience and recovery, and mastery was also significantly associated with recovery."  Interestingly this links back to the study already mentioned on ACT and GAD.  It suggests that ACT's focus on values and meaning may be as important as its focus on mindfulness.  In a linked, freely viewable in full text editorial, Freedman wrote "Learning how some of us cope and sometimes even triumph is as much our concern as psychiatrists as investigating how some of us have not."     

Conradi, H. J., P. de Jonge, et al. (2008). "Cognitive-behavioural therapy v. usual care in recurrent depression." The British Journal of Psychiatry 193(6): 505-506.  [Abstract/Full Text
We examined in a primary care sample whether acute-phase cognitive-behavioural therapy (CBT) would be more effective than usual care for patients with multiple prior episodes of depression. Depression outcome was based on a 3-monthly administered Beck Depression Inventory (BDI) during a 2-year follow-up. We confirmed that in patients with four or more prior episodes, CBT outperformed usual care by four points on the BDI, but not in patients with three or fewer prior episodes. Subsequent analyses suggested that CBT may be able to tackle cognitive problems related to rumination in patients with recurrent depression.

Oxman, T. E., M. T. Hegel, et al. (2008). "Problem-solving treatment and coping styles in primary care for minor depression." J Consult Clin Psychol 76(6): 933-43.  [PubMed]
Research was undertaken to compare problem-solving treatment for primary care (PST-PC) with usual care for minor depression and to examine whether treatment effectiveness was moderated by coping style. PST-PC is a 6-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in 2 academic, primary care clinics. Those subjects who were eligible were randomized (N = 151), and 107 subjects completed treatment (57 PST-PC, 50 usual care) and a 35-week follow-up. Analysis with linear mixed modeling revealed significant effects of treatment and coping, such that those in PST-PC improved at a faster rate and those initially high in avoidant coping were significantly more likely to have sustained benefit from PST-PC.

Roemer, L., S. M. Orsillo, et al. (2008). "Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial." J Consult Clin Psychol 76(6): 1083-9.  [PubMed
Generalized anxiety disorder (GAD) is a chronic anxiety disorder, associated with comorbidity and impairment in quality of life, for which improved psychosocial treatments are needed. GAD is also associated with reactivity to and avoidance of internal experiences. The current study examined the efficacy of an acceptance-based behavioral therapy aimed at increasing acceptance of internal experiences and encouraging action in valued domains for GAD. Clients were randomly assigned to immediate (n = 15) or delayed (n = 16) treatment. Acceptance-based behavior therapy led to statistically significant reductions in clinician-rated and self-reported GAD symptoms that were maintained at 3- and 9-month follow-up assessments; significant reductions in depressive symptoms were also observed. At posttreatment assessment 78% of treated participants no longer met criteria for GAD and 77% achieved high end-state functioning; these proportions stayed constant or increased over time. As predicted, treatment was associated with decreases in experiential avoidance and increases in mindfulness.

McDaid, C., R. Trowman, et al. (2008). "Interventions for people bereaved through suicide: systematic review." The British Journal of Psychiatry 193(6): 438-443.  [Abstract/Full Text
Background Promoting the mental health of people bereaved through suicide is a key aim of the National Suicide Prevention Strategy. Aims To evaluate the effects of interventions to support people bereaved through suicide. Method We conducted a systematic review of data from controlled studies of interventions for people bereaved through suicide. Studies were identified using systematic searches, the methodological quality of included studies was assessed and narrative synthesis conducted. Results Eight studies were identified. None was UK-based and all but one study had substantial methodological limitations. When compared with no intervention, there was evidence of some benefit from single studies of a cognitive-behavioural family intervention of four sessions with a psychiatric nurse; a psychologist-led 10-week bereavement group intervention for children; and 8-week group therapy for adults delivered by a mental health professional and volunteer. The findings from studies comparing two or more active interventions were more equivocal. Conclusions Although there is evidence of some benefit from interventions for people bereaved by suicide, this is not robust. Further methodologically sound evidence is required to confirm whether interventions are helpful and, if so, for whom.

Alim, T. N., A. Feder, et al. (2008). "Trauma, Resilience, and Recovery in a High-Risk African-American Population." Am J Psychiatry 165(12): 1566-1575.  [Abstract/Full Text
OBJECTIVE: Despite increased risk for psychiatric disorders after trauma exposure, many people are able to adapt with minimal life disruption, and others eventually recover after a symptomatic period. This study examined psychosocial factors associated with resilience and recovery from psychiatric disorders in a high-risk sample of African American adults exposed to a range of severe traumas, who participated in structured diagnostic interviews. METHOD: The sample included 259 patients exposed to at least one severe traumatic event, recruited from primary care offices at Howard University and administered the Structured Clinical Interview for DSM-IV Axis I disorders. Multinomial logistic regression was used to identify potential psychosocial factors associated with resilience and recovery, including purpose in life, mastery, and coping strategies. RESULTS: Forty-seven patients had no lifetime psychiatric disorders (resilient), 85 met criteria for at least one past DSM-IV disorder but no current disorders (recovered), and 127 met criteria for at least one current DSM-IV disorder (currently ill). The resilient group was characterized by a significantly lower lifetime trauma load. Female gender was predictive of currently ill status. In the final model, purpose in life emerged as a key factor associated with both resilience and recovery, and mastery was also significantly associated with recovery. CONCLUSIONS: The identification of psychosocial factors associated with resistance to severe trauma can inform future studies of preventive and treatment interventions for high-risk populations. Further study is needed to determine which psychosocial factors are consistently associated with resilience and to what extent they can be modified through clinical intervention.

Freedman, R. (2008). "Coping, Resilience, and Outcome." Am J Psychiatry 165(12): 1505-1506.  [Free Full Text]  
Freely-viewable-in-full-text editorial that states "As psychiatrists we focus most of our efforts on treating people's illnesses, but it is occasionally helpful to consider the context in which their illnesses occur. Two articles in this issue of the Journal raise the issue of context in different ways. The first article is about reading skills in the general population, and the second is about the reactions of people who are the victims of trauma ... Just as Paracchini et al. do not know how individuals with the same genotype have different impairment in reading abilities, Alim et al. do not know how some women overcome trauma with a sense of purpose and mastery, while others do not. Sadly, physical assault seems to crush the ability of women to achieve purpose and mastery. However, the African American women in the Alim et al. study who showed resilience seemed to benefit from increased attendance at religious services, which has traditionally been a strong social support for many groups. Optimism and emotional expression also supported resilience. Many of these coping factors were positively correlated and may be an expression of a single underlying character strength.  Genetic risk for dyslexia and traumatic experiences-seemingly disparate, but both common in the general population-are examples of the perils that human beings confront from conception through adulthood. Yet, the majority of people exposed to these perils do not develop long-standing illness. Learning how some of us cope and sometimes even triumph is as much our concern as psychiatrists as investigating how some of us have not."


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