Traumatic brain injury, polytrauma, and pain: Challenges and treatment strategies for the polytrauma rehabilitation.

Problem: Chronic pain conditions are common sequelae of traumatic brain injury (TBI). Unfortunately, the incidence of TBI among personnel deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) is significant, and there is growing evidence that ongoing pain, particularly headaches, will be a primary concern for these individuals. Objective: This article synthesizes empirical data from civilian and veteran populations and clinical experience with OEF/OIF personnel with polytrauma to provide recommendations for the assessment and treatment of chronic pain among those with TBI. Conclusions: The available data signal the need for the incorporation of early and aggressive pain management strategies into existing treatment models. Challenges to providing effective pain management for OEF/OIF veterans are numerous and include comorbid cognitive, medical, and emotional impairments that complicate readjustment to civilian life. It is likely that the problem of polytrauma pain and associated comorbid conditions such as posttraumatic stress disorder and postconcussive syndrome will require the development of integrated approaches to clinical care which bridge traditional subspecialty divisions. A proposed model of treatment is presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Group psychotherapy for persons with traumatic brain injury: management of frustration and substance abuse

Residual emotional and behavioral difficulties in individuals who have sustained a traumatic brain injury (TBI) have been well documented in the literature. The issues are complex, interdependent, and often include substance abuse, depression, anxiety, chronic suicidal or homicidal ideation, poor impulse control, and significant degrees of frustration and anger. Often, preexisting psychological conditions and poor coping strategies are exacerbated by the trauma. Emotional and behavioral difficulties can interfere with the neurorehabilitation process at all levels. In acute rehabilitation, these issues have traditionally been addressed on an individual basis. However, in postacute settings, an interpersonal group format can be effectively implemented. The majority of individuals with TBI have minimal funding for long-term cognitive and behavioral remediation; often the only avenue available is support groups. This article will describe group psychotherapy models used with individuals with acute or postacute TBI within a comprehensive rehabilitation center. Interdisciplinary treatment of frustration and substance abuse and a continuum of care will be emphasized. Education, social support, skills development, interpersonal process, and cognitive-behavioral approaches will also be discussed. The psychotherapy groups focus on treatment of substance abuse and frustration management through education, social support, and development of interpersonal skills. Practical considerations of running such groups are presented.     

Interpersonal styles of chronically depressed outpatients: Profiles and therapeutic change.

Theoretical accounts posit that chronically depressed individuals are perceived as hostile and/or submissive, which compromises their ability to satisfy their interpersonal needs. The current study assessed the interpersonal tenets of McCullough's (2000) chronic depression theory and examined change in interpersonal functioning following McCullough's treatment for chronic depression (viz., Cognitive-Behavioral Analysis System of Psychotherapy; CBASP). Data derive from a randomized 12-week clinical trial that compared the efficacy of CBASP, nefazodone, and their combination for chronic depression. To assess patients' interpersonal impacts, CBASP therapists completed the Impact Message Inventory (IMI) following an early and a late session. IMI data were compared to normative and clinical comparison samples to assess depression-related interpersonal profiles and clinically significant change in interpersonal functioning. As predicted, chronically depressed patients were initially perceived as more submissive and hostile than the comparison groups. Patients' interpersonal impacts on their therapists changed in adaptive, theoretically predicted ways by the end of CBASP treatment, either with or without medication. Individual-level clinical significance data were less robust. The findings generally substantiate McCullough's interpersonal theory and provide preliminary evidence of change in interpersonal impacts following treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP).

Reviews the book, Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP) by James P. McCullough Jr. (see record 2006-11486-000). The premise of this book is that therapeutic neutrality does not apply to the psychotherapy of chronically depressed individuals, and that disciplined personal involvement is an efficacious and perhaps necessary component of their treatment. Cognitive behavioral analysis system of psychotherapy (CBASP) is a learning model, in which the therapist focuses on teaching patients to recognize the consequences of their behavior. McCullough addresses practical and theoretical objections to this therapeutic approach, which include fears of overinvolvement, and inappropriate behavior, and clinical risks of flooding patients with excessively personal information and content. Ultimately, most readers will finish reading this volume with many open questions, some specific to McCullough's approach, others related to the challenging condition of chronic depression itself. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of drug solubility, drug loading, and polymer molecular weight on drug release from Polyox tablets

BACKGROUND: This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. METHODS: A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. RESULTS: In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. CONCLUSIONS: Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.     

On the AHCPR Depression in Primary Care guidelines: Further considerations for practitioners.

The majority of cases of clinical depression go unrecognized and untreated, despite the fact that depression is an eminently treatable disorder. The Agency for Health Care Policy and Research (AHCPR) recently published a set of clinical practice guidelines focused on depression in primary care settings. The review of the literature on which the guidelines are based is thorough and appropriate and should enhance the detection of depression and the quality of pharmacotherapy for depression. However, the guidelines encourage primary care physicians to provide pharmacotherapy to their depressed patients as the 1st line of treatment. The wisdom of this recommendation is questioned and revisions to the guidelines are suggested. Specifically, patients should be informed of the broad array of treatment options available and provided with a more balanced presentation of the potential benefits of psychotherapy for depression. Patients should decide which treatment alternative they wish to undergo. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Interpersonal psychotherapy of depression.

Reviews the book, Interpersonal psychotherapy of depression by Gerald L. Klerman, Myrna M. Weissman, Bruce J. Rounsaville, and Eve S. Chevron (1984). The authors state their intention to "describe the theoretical and empirical basis for interpersonal psychotherapy of depression," and also "offer a guide to the planning and conduct of the therapy." They do both, and waste no words. The book is organized into three parts. In the first part, the authors present an overview of the theory of the interpersonal approach of the use of interpersonal psychotherapy for depression, objectively offer both favorable and unfavorable findings from completed studies, and outline several studies in progress. The chapters in Part Two clarify how one conducts interpersonal therapy of depression. Part Three addresses the combination of psychotherapy with pharmacotherapy and the professional requirements of the therapist. This book is clearly written, well referenced, and easily understood by beginners who might not have the perspective, as well as by busy veterans who want to learn something new without plowing through mountains of theory and data. It would be useful for students in training, and extremely valuable to the legions of relatively inexperienced front-line mental health center therapists who are required to use time-limited approaches with depressed patients, often without having much structure for what they are doing. More experienced therapists who treat ambulatory depressed patients will add to their clinical skills and enjoy the process. The authors have turned their manual into a useful book that competes most favorably with other texts on short-term approaches to therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exercise therapy for patients with psychiatric disorders: Research and clinical implications.

There is now considerable evidence that regular exercise is (a) a viable, cost-effective, but underused treatment for mild to moderate depression that compares favorably to individual psychotherapy, group psychotherapy, and cognitive therapy, and (b) a necessary ingredient in effective behavioral treatments that reduce self-reported pain in individuals with chronic pain. Preliminary evidence also suggests that regular exercise deserves further attention as (a) a singular treatment for some anxiety disorders, for individuals suffering from body image disturbance, and for the reduction of problem behavior of developmentally disabled persons, and (b) an adjunct in treatment programs for schizophrenia, conversion disorder, and alcohol dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social problem solving and depressive symptoms over time: A randomized clinical trial of cognitive-behavioral analysis system of psychotherapy, brief supportive psychotherapy, and pharmacotherapy.

Objective: Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009). Method: Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks. Results: CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions. Conclusions: It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations

BACKGROUND: Few reliable correlates of treatment response in depression have emerged despite nearly 40 years of research. We examined the correlates of recovery in a "mega-analysis," or meta-analysis of original data, of 595 patients with major depressive disorder enrolled in 6 standardized treatment protocols. METHODS: All patients (mean age, 44 years; 31% male and 69% female) met criteria for nonbipolar, nonpsychotic primary major depressive disorder and were treated for 16 weeks with either cognitive behavior therapy or interpersonal psychotherapy alone (psychotherapy alone; n = 243) or interpersonal psychotherapy plus antidepressant pharmacotherapy (combined therapy; n = 352). The impact of treatment type, severity, study, and other covariates on recovery rates or time to recovery were examined by means of chi 2, log-rank tests, the Cox proportional hazards model, and sensitivity analyses. RESULTS: Whereas combined therapy was not significantly more effective than psychotherapy alone in milder depressions, a highly significant advantage was observed in more severe recurrent depressions. Poorer outcomes were also observed in women and older patients, although these effects were dependent on inclusion of particular studies. CONCLUSIONS: Mega-analysis is a powerful method for comparing the efficacy of treatments and examining correlates of response. Using this method, we found new evidence in support of the widespread clinical impression that combined therapy is superior to psychotherapy alone for treatment of more severe, recurrent depressions.     

A model of time-effective group psychotherapy for patients with personality disorders: the clinical model

This article describes a model of time-limited psychotherapy for patients with personality disorders that emphasizes the group as a social microcosm. The patient population described is relatively high functioning, although the majority of the group members meet DSM-III-R (American Psychiatric Association, 1987) criteria for an Axis II diagnosis. The clinical model's key theoretical concepts, for example, interpersonal focus; active therapist stance; emphasis on group interaction and processes; use of time limits; primary care/intermittent treatment philosophy; and emphasis on patients' strengths, goals, and resources are described. The relationships between the phases of group therapy and the key theoretical concepts are delineated.     

The severity of major depression and choice of treatment in primary care practice.

The Agency for Health Care Policy and Research Depression Guideline Panel recommended pharmacotherapy as the 1st-line treatment for more severely depressed primary care patients, but research supporting its recommendation has not been conducted with this population. A post hoc analysis was conducted, therefore, with data gathered in a randomized controlled trial about the relationship between initial level of depressive severity and functional ability, treatment with nortriptyline hydrochloride (NT) or interpersonal psychotherapy (IPT), and clinical course over 8 months among primary care patients experiencing major depression. Treatment type was unrelated to clinical course among more severely depressed patients (baseline 17-item Hamilton Rating Scale for Depression [HRSD] score ≥20). However, less severely depressed patients (baseline 17-item HRSD score ≤19) who were prescribed NT improved significantly more rapidly during the initial 3 months of treatment than patients provided with IPT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Differential effects of treatments for chronic depression: A latent growth model reanalysis.

Objective: Psychotherapy–pharmacotherapy combinations are frequently recommended for the treatment of chronic depressive disorders. Our aim in this novel reanalysis of archival data was to identify patient subgroups on the basis of symptom trajectories and examine the clinical significance of the resultant classification on basis of differential treatment effects to psychotherapy (cognitive behavioral analysis system of psychotherapy), pharmacotherapy (nefazodone), and their combination. Method: We selected data for 504 patients diagnosed with chronic depression from archival data of a clinical trial (N = 681) and analyzed treatment courses (as assessed by the Hamilton Rating Scale for Depression) using growth mixture models, a contemporary exploratory analysis technique. Results: Three patient subgroups were identified from the typical patterns of change of depression severity during 12-week acute-phase treatment. Within these patient subgroups, differential treatment effects were evident: combination treatment clearly outperformed the 2 monotherapies in the largest patient subgroup, characterized by moderate depression severity, but not in the remaining 2 subgroups, characterized by low and severe depression at baseline. Patient characteristics prior to initiation of treatment enabled allocation of 61% of patients to these subgroups. Conclusions: Research on patient subgroups with different change patterns may support classifications of patients that indicate which treatment is most effective for which type of patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The mediating role of insight for long-term improvements in psychodynamic therapy.

Objective: According to psychoanalytic theory, interpretation of transference leads to increased insight that again leads to improved interpersonal functioning over time. In this study, we performed a full mediational analysis to test whether insight gained during treatment mediates the long-term effects of transference interpretation in dynamic psychotherapy. Method: This study is a randomized clinical trial with a dismantling design. One hundred outpatients seeking psychotherapy for depression, anxiety, personality disorders, and interpersonal problems were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment with the same therapists but without the use of transference interpretation. Interpersonal functioning and insight were measured pretreatment, posttreatment, and 1 year and 3 years after treatment termination. Results: Contrary to common expectation, patients with a life-long pattern of low quality of object relations and personality disorder pathology profited more from therapy with transference interpretation than from therapy with no transference interpretation. This long-term effect was mediated by an increase in the level of insight during treatment. Conclusions: Insight seems to be a key mechanism of change in dynamic psychotherapy. Our results bridge the gap between clinical theory and empirical research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depression among chronic pain patients: Cognitive-behavioral analysis and effect on rehabilitation outcome.

This study addressed two issues concerning the theoretical and clinical relevance of depression to chronic pain: (a) whether reliable differences among depressed, mildly depressed, and nondepressed chronic pain patients could be identified and (b) whether depression influenced participation in or outcome following a rehabilitation program. To address the first issue, four theoretical constructs were measured by multiple scales. Multivariate analyses of each construct revealed significant differences between the three groups on instrumental activities and coping skills, with more depressed individuals reporting lower levels of functioning and less support. An analysis of the second issue revealed that depressed pain patients showed a greater tendency to drop out of treatment. Outcome did not vary with depression among treatment completers. The results reveal the need to consider a cognitive-behavioral model of depression secondary to chronic pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treating depressed primary care patients improves their physical, mental, and social functioning

BACKGROUND: This study describes the functioning of primary care patients with major depressive disorder, the relationship of medical comorbidity to functional status, and the effects of depression-specific treatment on functional status after 8 months. METHODS: Patients were randomized to a protocol intervention (nortriptyline hydrochloride or interpersonal psychotherapy) or to usual care with the patient's physician in a clinical trial of primary care treatments of depression. Their functional status was evaluated using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Global Assessment Scale. Medical comorbidity was assessed with the Duke Severity of Illness Checklist. The Hamilton Rating Scale for Depression and Beck Depression Inventory were used to measure depressive severity. Assessments were conducted at baseline and at 1, 2, 4, and 8 months after randomization. RESULTS: At baseline, patients reported substantial impairments in the functional domains as assessed by the SF-36 and Global Assessment Scale. Severity of general medical illness and depression were not correlated. Greater medical comorbidity was associated with diminished physical, but not psychological, functioning. Mean scores on SF-36 scales and the Global Assessment Scale improved significantly during the 8 months of follow-up. Patients assigned to protocol treatments showed greater improvement, compared with those assigned to usual care, on the SF-36 mental summary scale and most individual scales but not on the SF-36 physical summary scale. However, patients who completed protocol treatment also experienced significant improvement on the physical summary scale. Medical comorbidity was only a weak predictor of outcome. CONCLUSIONS: Primary care patients with major depressive disorder report substantial impairments in physical, psychological, and social functioning on initial assessment. Severity of baseline medical comorbidity did not correlate with severity of depression and only weakly correlated with functional status at 8 months. Functional impairments improve with time, but standardized depression-specific treatment is associated with greater improvement in more domains of functioning than is a physician's usual care.     

Predictors of the generation of episodic stress: A longitudinal study of late adolescent women.

The effects of depression and Axis I comorbidity on subsequent self-generated life stress were examined in a longitudinal sample of 134 late adolescent women. The results indicated that specific forms of psychopathology constitute a risk factor for future self-generated episodic stress, even when controlling for prior chronic stress. Comorbid depression had a particularly salient effect in the prediction of stress related to interpersonal conflicts. The effects of family psychopathology and sociotropy were mediated through participant psychiatric status, whereas autonomy made an independent contribution to the prediction of episodic stress. These results support C. Hammen's (1991) stress generation model in a community sample, demonstrating how individuals with depression play a role in the creation of stress, and also refine prior work by showing that only the comorbid form of depression is associated with subsequent conflict-related stress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study.

This preliminary study evaluated the effectiveness of psychotherapy treatment for adult clinical depression provided in a natural setting by benchmarking the clinical outcomes in a managed care environment against effect size estimates observed in published clinical trials. Overall results suggest that effect size estimates of effectiveness in a managed care context were comparable to effect size estimates of efficacy observed in clinical trials. Relative to the 1-tailed 95th-percentile critical effect size estimates, effectiveness of treatment provided in this setting was observed to be between 80% (patients with comorbidity and without antidepressants) and 112% (patients without comorbidity concurrently on antidepressants) as compared to the benchmarks. Because the nature of the treatments delivered in the managed care environment were unknown, it was not possible to make conclusions about treatments. However, while replications are warranted, concerns that psychotherapy delivered in a naturalistic setting is inferior to treatments delivered in clinical trials appear unjustified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)