Brandon A. Gaudiano

Hatha yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research.

Background The purpose of this article is to review the evidence for the efficacy of hatha yoga for depression and possible mechanisms by which yoga may have an impact on depression, and to outline directions for future research. Methods Literature review and synthesis. Results and Conclusions A literature search for clinical trials examining yoga for depression uncovered eight trials: 5 including individuals with clinical depression, and 3 for individuals with elevated depression symptoms. Although results from these trials are encouraging, they should be viewed as very preliminary because the trials, as a group, suffered from substantial methodological limitations. We would argue, however, that there are several reasons to consider constructing careful research on yoga for depression. First, current strategies for treating depression are not sufficient for many individuals, and patients have several concerns about existing treatments. Yoga may be an attractive alternative to or a good way to augment current depression treatment strategies. Second, aspects of yoga—including mindfulness promotion and exercise—are thought to be “active ingredients” of other successful treatments for depression. Third, there are plausible biological, psychological, and behavioral mechanisms by which yoga may have an impact on depression. We provide suggestions for the next steps in the study of yoga as a treatment for depression. (Journal of Psychiatric Practice 2010;16:22–33).

Social Skills Training Augments the Effectiveness of Cognitive Behavioral Group Therapy for Social Anxiety Disorder.

Cognitive Behavioral Group Therapy (CBGT) is the most widely researched intervention program for social anxiety disorder (SAD, also known as social phobia), with a number of studies demonstrating its effectiveness. Another common treatment, social skills training (SST), has also been shown to be efficacious for SAD. The present study compared the standard CBGT intervention with a protocol in which SST was integrated into CBGT. Participants met diagnostic criteria for the generalized subtype of SAD, and most also met criteria for avoidant personality disorder and other comorbid Axis I disorders. The results revealed improvement in a variety of outcome measures for both treatments, but significantly greater gains for the CBGT plus SST condition. In fact, the effect sizes obtained for this treatment were among the largest found to date in any study of SAD. Clinical implications are discussed, and directions for future research are suggested.

Mindfulness interventions for psychosis: A meta-analysis

BACKGROUND An increasing number of mindfulness interventions are being used with individuals with psychosis or schizophrenia, but no known meta-analysis has investigated their effectiveness. OBJECTIVE To evaluate the efficacy of mindfulness interventions for psychosis or schizophrenia, we conducted an effect-size analysis of initial studies. DATA SOURCES A systematic review of studies published in journals or in dissertations in PubMED, PsycINFO or MedLine from the first available date until July 25, 2013. REVIEW METHODS A total of 13 studies (n=468) were included. RESULTS Effect-size estimates suggested that mindfulness interventions are moderately effective in pre-post analyses (n=12; Hedges g=.52). When compared with a control group, we found a smaller effect size (n=7; Hedges g=.41). The obtained results were maintained at follow-up when data were available (n=6; Hedges g=.62 for pre-post analyses; results only approached significance for controlled analyses, n=3; Hedges g=.55, p=.08). Results suggested higher effects on negative symptoms compared with positive ones. When combined together, mindfulness, acceptance, and compassion strongly moderated the clinical effect size. However, heterogeneity was significant among the trials, probably due to the diversity of interventions included and outcomes assessed. CONCLUSION Mindfulness interventions are moderately effective in treating negative symptoms and can be useful adjunct to pharmacotherapy; however, more research is warranted to identify the most effective elements of mindfulness interventions.

Cognitive behavior therapy for generalized social anxiety disorder in adolescents: A randomized controlled trial

Early identification and treatment of social anxiety disorder (SAD) is critical to prevent development of a chronic course of symptoms, persistent functional impairment, and progressive psychiatric comorbidity. A small but growing literature supports the effectiveness of cognitive behavior therapy (CBT) for anxiety disorders, including SAD, in adolescence. The present randomized controlled trial evaluated the efficacy of group vs. individual CBT for adolescents with generalized SAD in relation to an educational/supportive psychotherapy that did not contain specific CBT elements. All three treatments were associated with significant reductions in symptoms and functional impairment, and in improved social skills. No differences between treatments emerged on measures of symptoms, but the CBT conditions demonstrated greater gains on behavioral measures. The implications of the findings are discussed.

Open Trial of Vinyasa Yoga for Persistently Depressed Individuals: Evidence of Feasibility and Acceptability.

The aim of this study was to assess the acceptability and feasibility of Vinyasa yoga as an adjunctive treatment for depressed patients who were not responding adequately to antidepressant medication. The authors also planned to ask participants for qualitative feedback on their experience of the class and to assess change over time in depression and in possible mediating variables. The authors recruited 11 participants in 1 month for an 8-week open trial of yoga classes. They found that 10 participants completed follow-up assessments, 9 of 10 were positive about their experience, and all provided feedback about what was and was not helpful about yoga, as well as barriers to class attendance. Over the 2-month period, participants exhibited significant decreases in depression symptoms and significant increases in an aspect of mindfulness and in behavior activation. This pilot study provided support for continuing to investigate Vinyasa yoga as an adjunct treatment for depression. The next step required is a rigorous randomized clinical trial.

Is It the Symptom or the Relation to It? Investigating Potential Mediators of Change in Acceptance and Commitment Therapy for Psychosis

Cognitive and behavioral interventions have been shown to be efficacious when used as an adjunct to pharmacotherapy for psychotic disorders. However, little previous research has investigated potential mediators of change in psychological treatments for psychosis. Acceptance and mindfulness-based therapies do not focus on directly reducing the psychotic symptoms themselves, but instead attempt to alter the patients relationship to symptoms to decrease their negative impact. The current study examined this issue with data from a previously published randomized trial comparing brief treatment with Acceptance and Commitment Therapy (ACT) versus treatment as usual for hospitalized patients with psychotic symptoms (Gaudiano & Herbert, 2006a). Results showed that the believability of hallucinations at posttreatment statistically mediated the effect of treatment condition on hallucination-related distress. Hallucination frequency did not mediate outcome. The current study is a first step toward understanding the potential mechanisms of action in psychological treatments for psychosis.

Written emotional disclosure: a controlled study of the benefits of expressive writing homework in outpatient psychotherapy.

Abstract The current study investigated the extent to which outpatient psychotherapy clients benefited from Pennebakers expressive writing protocol (Pennebaker & Beall, 1986) adapted for use as a homework intervention. Participants were randomly assigned to written emotional disclosure or writing control conditions. Pre- and postintervention outcome measures were collected for three consecutive therapy sessions. Clients in the written emotional disclosure group showed significantly greater reductions in anxiety and depressive symptoms as well as greater overall progress in psychotherapy in comparison to the writing control group. Results suggest that emotional disclosure writing homework, in conjunction with outpatient psychotherapy, facilitates therapeutic process and outcome.

Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study.

OBJECTIVE The aim of this study was to examine the sensitivity and specificity of the suicide item on the 9-item Patient Health Questionnaire (PHQ-9) when compared to a structured interview (the Structured Clinical Interview for DSM-IV; SCID-I mood module) in primary care patients with elevated depression symptoms. METHOD In this cross-sectional study, we analyzed data from 166 patients from 2 primary care clinics, 1 in Rhode Island and 1 in Massachusetts, who were enrolled in studies that focused on depression in primary care. Of the total participants, 101 were enrolled in the survey study, and 65 were screened for or enrolled in either an open trial or a pilot randomized controlled trial. Data were collected between May 2004 and May 2009. RESULTS We found that the specificity of the PHQ-9 suicide screening item was 0.84 and sensitivity was 0.69 for the sample as a whole. CONCLUSIONS This study suggests that the routine use of the PHQ-9 may be useful in primary care practice in that it may identify individuals at risk for suicide who would not otherwise have been identified. However, denial of suicidality on the PHQ-9 should be probed further if there are other risk factors for suicide present. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00541957.

Improving Treatment Adherence in Bipolar Disorder A Review of Current Psychosocial Treatment Efficacy and Recommendations for Future Treatment Development

Treatment adherence is a frequent problem in bipolar disorder, with research showing that more than 60% of bipolar patients are at least partially nonadherent to medications. Treatment nonadherence is consistently predictive of a number of negative outcomes in bipolar samples, and the discontinuation of mood stabilizers places these patients at high risk for relapse. Several types of adjunctive treatment (family, psychoeducational, cognitive-behavioral) have been investigated for improving symptoms and functioning in bipolar patients with some success. To date, less attention has been paid to developing treatments specifically to promote treatment adherence to and engagement with pharmacological as well as behavioral treatments in patients with bipolar disorder. First, we review the effects of adjunctive interventions specifically on treatment adherence outcomes in 14 published clinical trials. Based on this empirical knowledge base, we present a preliminary description of the treatment strategies that appear most promising for improving adherence. The article also provides research recommendations for developing more effective interventions for the purpose of improving bipolar treatment adherence. Finally, special treatment considerations, including the potential impact of comorbid substance abuse and bipolar depression, are discussed.

Depressive symptom profiles and severity patterns in outpatients with psychotic vs nonpsychotic major depression

BACKGROUND Previous research suggests that patients with psychotic major depression (PMD) may differ from those with nonpsychotic major depression (NMD) not only in psychotic features but also in their depressive symptom presentation. The present study contrasted the rates and severity of depressive symptoms in outpatients diagnosed with PMD vs NMD. METHOD The sample consisted of 1112 patients diagnosed with major depression, of which 60 (5.3%) exhibited psychotic features. Depressive symptoms were assessed by trained diagnosticians at intake using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and supplemented by severity items from the Schedule for Affective Disorders and Schizophrenia. RESULTS Patients with PMD were more likely to endorse the presence of weight loss, insomnia, psychomotor agitation, indecisiveness, and suicidality compared with NMD patients. Furthermore, PMD patients showed higher levels of severity on several depressive symptoms, including depressed mood, appetite loss, insomnia, psychomotor disturbances (agitation and retardation), fatigue, worthlessness, guilt, cognitive disturbances (concentration and indecisiveness), hopelessness, and suicidal ideation. The presence of psychomotor disturbance, insomnia, indecisiveness, and suicidal ideation was predictive of diagnostic status even after controlling for the effects of demographic characteristics and other symptoms. CONCLUSIONS These findings are consistent with past research suggesting that PMD is characterized by a unique depressive symptom profile in addition to psychotic features and higher levels of overall depression severity. The identification of specific depressive symptoms in addition to delusions/hallucinations that can differentiate PMD vs NMD patients can aid in the early detection of the disorder. These investigations also provide insights into potential treatment targets for this high-risk population.