Ari Zaretsky

A Randomized Controlled Trial of Psychoeducation or Cognitive-Behavioral Therapy in Bipolar Disorder: A Canadian Network for Mood and Anxiety Treatments (CANMAT) Study [CME]

OBJECTIVEnBipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder.nnnMETHODnThis single-blind randomized controlled trial was conducted between June 2002 and September 2006. A total of 204 participants (ages 18-64 years) with DSM-IV bipolar disorder type I or II participated from 4 Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of cognitive-behavioral therapy or 6 sessions of group psychoeducation. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week.nnnRESULTSnBoth treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Eight percent of subjects dropped out prior to receiving psychoeducation, while 64% were treatment completers; rates were similar for cognitive-behavioral therapy (6% and 66%, respectively). Psychoeducation cost

Preparing International Medical Graduates for Psychiatry Residency: A Multi-Site Needs Assessment

180 per subject compared to cognitive-behavioral therapy at

Quality education: A pilot quality improvement curriculum for psychiatry residents

1,200 per subject.nnnCONCLUSIONSnDespite longer treatment duration and individualized treatment, cognitive-behavioral therapy did not show a significantly greater clinical benefit compared to group psychoeducation. Psychoeducation is less expensive to provide and requires less clinician training to deliver, suggesting its comparative attractiveness.nnnTRIAL REGISTRATIONnClinicalTrials.gov identifier: NCT00188838.

Neuroimaging Week: A Novel, Engaging, and Effective Curriculum for Teaching Neuroimaging to Junior Psychiatric Residents

ObjectiveDespite the growing number of international medical graduates (IMGs) training in medicine in Canada and the United States, IMG-specific challenges early in psychiatry residency have not been fully explored. Therefore, the authors conducted a needs-assessment survey to determine the needs of IMGs transitioning into psychiatry residency.MethodUsing a 15-item online questionnaire, authors conducted a needs-assessment of IMG residents in five Canadian psychiatry residency programs. The survey examined IMGs’ perceived difficulties with the transition into psychiatry residency, educational needs, and demographic data. Data were analyzed with descriptive statistics and Mann-Whitney tests.ResultsIMGs identified the following difficulties with their transition into residency: understanding the healthcare system, medical documentation, and evidence-based medicine/mental health. Language barriers and social isolation were significant factors affecting the transition into residency for residents who did not speak English as their first language. Residents who lived in Canada 12 months or less had greater perceived difficulties in psychotherapy knowledge and adapting to the Canadian healthcare system; 88% of IMGs reported having little- or- no IMG-specific preparation for psychiatry residency from their psychiatry program; however, 69% reported that they would use IMG resources if offered; 63% felt that faculty in their program should undergo training to assist with IMG transition.ConclusionSeveral perceived challenges, needs, and gaps in training were reported by IMGs in Canadian psychiatry residency programs. The results of this survey will be used to inform future curriculum development to facilitate IMG transition into psychiatry postgraduate training programs. We thank the survey working group, and, especially, Drs. N. Roberts, M. Hasnain, H. Haensel, T. Callanan and K. Skakum, J. Parent, and the postgraduate office administrative staff for each program for their assistance with survey dissemination. We also thank the Canadian Psychiatric Association Membership Affairs Committee and Members-in-Training Committee for their input in this project. We appreciate the time and effort of the participating international medical graduates from the five psychiatry residency programs.

Psychosocial Interventions for Bipolar Disorder and Coping Style Modification: Similar Clinical Outcomes, Similar Mechanisms?

Background: A series of Institute of Medicines reports have highlighted the need for greater quality improvement (QI) training in medical education; however, few formal QI curricula for medical trainees have been described in the literature. Aim: The objective of this study was to develop a contextual QI curriculum involving a QI workshop and longitudinal QI projects (QIPs) for psychiatry trainees. Methods: We examined psychiatry residents’ attitudes on QI training following their exposure to a physician-manager curriculum using focus group methodology. Focus group data were used to inform revisions to the QI curriculum. Following the curriculum revisions, we administered a resident questionnaire to elicit resident perceptions on the modified QI curriculum. Results: Focus group data from 40 psychiatry residents at the University of Toronto identified the following themes: challenges with QIP workload, difficulties of QI workshop integration into the curriculum, and value of the experiential component of the QIP. Of the 26 residents, 18 completed the resident questionnaire on the revised curriculum and reported an enhanced appreciation of QI in their current clinical practice. Conclusion: The study results suggest that this experiential format warrants further exploration as a model for QI training in medicine.

New developments in cognitive-behavioural therapy for mood disorders.

ObjectiveNeuroimaging techniques are increasingly important in psychiatric research and clinical practice, but few postgraduate psychiatry programs offer formal training in neuroimaging. To address this need, the authors developed a course to prepare psychiatric residents to use neuroimaging techniques effectively in independent practice.MethodsThe authors present the format and curriculum of a highly interactive, 5- day intensive neuroimaging course, taught by psychiatry, neurology, radiology, nuclear medicine, and sleep medicine staff, covering psychiatrically oriented neuroanatomy; neuroimaging techniques and principles; clinical skills, including interpretation of computed tomography and MRI in neuro- psychiatric cases; and formal approaches to critiquing neuroimaging research and applying its findings to clinical practice. Detailed questionnaires assessed the subjective and objective impact of the course on residents’ knowledge of, and attitudes toward, neuroimaging in psychiatry before and after the course.ResultsTwenty-five first- year residents completed the questionnaires. Participants were enthusiastic about the content and interested in improving their skills in interpreting clinical neuroimaging studies. By the end of the course, residents also reported large gains in subjective comfort level with neuroimaging literature appraisal and functional neuroanatomy and believed that the course was effective in meeting their own specific learning objectives. Objective measures showed significant gains in most areas of the curriculum.ConclusionThis short, intensive course effectively teaches clinically oriented neuroimaging principles to psychiatric residents and can be readily adapted to other postgraduate programs or continuing medical education.

Are dependency and self-criticism risk factors for major depressive disorder?

Objective: To investigate changes in the use of coping styles in response to early symptoms of mania in cognitive-behavioural therapy (CBT), compared with psychoeducation, for bipolar disorder. Method: Data were drawn from a randomized controlled trial comparing CBT and psychoeducation. A subsample of 119 participants completed the Coping Inventory for the Prodromes of Mania and symptom assessments before treatment and 72 weeks later. Results: Both CBT and psychoeducation were associated with similar improvements in symptom burden. Both treatments also produced equivalent improvements in stimulation reduction and problem-directed coping styles, but no statistically significant change on the endorsement of help-seeking behaviours. A treatment interaction showed that a reduction in denial and blame was present only in the CBT treatment condition. Conclusions: CBT and psychoeducation have similar impacts on coping styles for the prodromes of mania. The exception to this is denial and blame, which is positively impacted only by CBT but which does not translate into improved outcome. Given the similar change in coping styles and mood burden, teaching patients about how to cope in adaptive ways with the symptoms of mania may be a shared mechanism of change for CBT and psychoeducation.

Depressive symptoms and alcohol consumption among nonalcoholic depression patients treated with desipramine.

Cognitive-behavioural therapy (CBT) for depression is an empirically validated, time-limited psychotherapy that leverages awareness of mood-linked changes in cognition and phenomenology to teach patients suffering from depression effective means to regulate affect and reduce symptoms. Its current standing as a front-line treatment for mood disorders can be traced to changes in the scientific study of psychotherapy outcomes that began over 30 years ago. CBT was one of the first psychotherapies for depression to be evaluated against active contrast conditions such as antidepressant pharmacotherapy. When the results of these trials indicated a rough parity in clinical outcomes,1-3 the efficacy of psychological treatment for depression could no longer be dismissed. In the same vein, the publication of Cognitive Therapy for Depression4 represented one of the first attempts to detail step-by-step therapy procedures for conceptualizing depression as the product of biased mental representation as well as behavioural and cognitive strategies designed to address this. The expansion of CBT treatments for anxiety, eating, and substance use disorders was premised on the same combination of compelling clinical evidence and the explication of technique. Well over a quarter of a century later, it might be tempting to conclude that the treatment of mood disorders within a cognitive-behavioural frame is a project largely completed-yet challenges do remain. This issues In Review section provides a view of the field that is both prospective and retrospective. It strives to look beyond the modal applications of CBT in mood disorders to highlight areas of potential future investigation and application. The sections pair of articles speak to the ever-expanding role of CBT in mood disorders. Kuyken et al5 report the most up-to-date conceptualizations of unipolar depression in the context of the cognitive model. In particular, they emphasize the diathesis-stress approach and multilevel schematic models to illuminate the intersection between biological vulnerability and psychopathology. Their writing also touches on some exciting new lines of evidence exploring the active ingredient in CBT and predictors of outcome. We are now beginning to collect evidence from neuroimaging studies to illustrate brain changes associated with effective CBT. These kinds of studies are at the vanguard of psychotherapy research. In particular, Goldapple et al6 have used functional imaging studies to demonstrate a different pattern of response in the brain when CBT is compared with paroxetine in the context of unipolar depression. Brain images of depression patients treated with paroxetine showed increased brain activity in the lateral cortices and suppression of limbic circuits in both the hippocampus and the subgenual cingulate, Area 25. In the same study, treatment response was associated with significant increases in hippocampal and dorsal cingulate activity and decreased activity in the dorsal, ventral, and medial frontal cortex. These opposite changes with CBT (relative to medication) in predominantly cortical brain regions, such as the medial frontal and dorsal cingulate, have been postulated to reflect regions primarily associated with attention, self-references, and reappraisal-areas specifically targeted by this form of psychotherapy. Characterization of adaptive and maladaptive functional interactions among these pathways is a critical step toward future development of evidenced-based algorithms that will optimize the diagnosis and treatment of individual patients suffering from depression. Further work by Siegle et al7 with fMRI has shown that patients whose sustained reactivity to emotional stimuli was low in the subgenual cingulated cortex and high in the amygdala displayed the strongest improvement with CBT. These novel lines of research are beginning to narrow the gap between brain and mind, informing not only an integrated depression network model but also clinical choices for treatment suitability and prognosis. …

Screen all for depression

Objective To determine whether dependent and self-critical personality traits are associated with specific types of life events and whether these traits change with pharmacotherapy. Method Overall, 142 depressed outpatients completing 8 weeks of fluoxetine treatment were administered the Life Experiences Survey (LES) at baseline and the Dysfunctional Attitude Scale (DAS) and Hamilton Depression Rating Scale (HDRS) at baseline and endpoint. Results The DAS dependency subscale, but not the self-criticism subscale, showed significant correlations with life events regardless of congruency. Baseline HDRS scores were positively correlated with both DAS subscales and total score. The DAS subscales, the total DAS score, and the HDRS all improved significantly with treatment. Conclusions These results confirm a growing body of research that has found an association between sociotropic or dependent personality traits and life events.

Is immediate adjunctive CBT more beneficial than delayed CBT in treating depression?: A Pilot Study.

Objective: There are few data addressing the effect of alcohol consumption on response to antidepressants among nonalcoholics with depression. Similarly, the effect of antidepressant treatment on alcohol consumption in this group is not yet understood. This study focuses on changes in depressive symptoms and alcohol consumption in response to treatment with desipramine. Method: Twenty-seven nonalcoholic outpatients with major depression (as determined by the Schedule for Affective Disorders and Schizophrenia-Lifetime Version) completed measures of depression (that is, the 17-item Hamilton Depression Rating Scale and the Beck Depression Inventory) and alcohol consumption at intake and after 5 weeks of open treatment with desipramine. Subjects were characterized as minimal or mild-to-moderate drinkers. Results: There was no significant difference between the groups with respect to effectiveness of antidepressant treatment. Analysis for repeated measures demonstrated that alcohol consumption with desipramine was significantly lower after treatment than at intake (F = 4.8, df 23:2, P < 0.01). Further, carbohydrate consumption was also significantly lower after treatment than at intake (F = 4.4, df 23:2, P < 0.05). Conclusions: Desipramine treatment appeared to result in decreases in alcohol consumption in nonalcoholic patients with depression. Further research is needed to elucidate the effect of alcohol consumption on the course and outcome of major depressive illness among nonalcoholics as well as the effect of antidepressant medication on alcohol consumption in this population.