Daniel I. Galper

Exercise as an augmentation treatment for nonremitted major depressive disorder: a randomized, parallel dose comparison.

OBJECTIVE Most patients with major depressive disorder (MDD) require second-step treatments to achieve remission. The Treatment with Exercise Augmentation for Depression (TREAD) study was designed to test the efficacy of aerobic exercise as an augmentation treatment for MDD patients who had not remitted with antidepressant treatment. METHOD Eligible participants in this randomized controlled trial were sedentary individuals (men and women aged 18-70 years) diagnosed with DSM-IV nonpsychotic MDD who had not remitted with selective serotonin reuptake inhibitor (SSRI) treatment. Participants were recruited through physician referrals and advertisements. A total of 126 participants were randomized to augmentation treatment with either 16 kcal per kg per week (KKW) or 4 KKW of exercise expenditure for 12 weeks while SSRI treatment was held constant. Supervised sessions were conducted at The Cooper Institute, Dallas, Texas, with additional home-based sessions as needed to fulfill the weekly exercise prescription. The primary outcome was remission (as determined by a score ≤ 12 on the Inventory of Depressive Symptomatology, Clinician-Rated). The study took place between August 2003 and August 2007. RESULTS There were significant improvements over time for both groups combined (F₁,₁₂₁ = 39.9, P < .0001), without differential group effect (group effect: F₁,₁₃₄ = 3.2, P = .07; group-by-time effect: F₁,₁₁₉ = 3.8, P = .06). Adjusted remission rates at week 12 were 28.3% versus 15.5% for the 16-KKW and 4-KKW groups, respectively, leading to a number needed to treat (NNT) of 7.8 for 16 KKW versus 4 KKW. Men, regardless of family history of mental illness, and women without a family history of mental illness had higher remission rates by week 12 with higher-dose (women, 39.0%; men, 85.4%) than with lower-dose exercise (women, 5.6%; men, 0.1%) (women: t₉₅ = 2.1, P = .04; men: t₈₈ = 5.4, P < .0001) (NNT: women, 3.0; men, 1.2). CONCLUSIONS There was a trend for higher remission rates in the higher-dose exercise group (P < .06), with a clinically meaningful NNT of 7.8 in favor of the high exercise dose. Significant differences between groups were found when the moderating effects of gender and family history of mental illness were taken into account and suggest that higher-dose exercise may be better for all men and for women without a family history of mental illness. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00076258.

Effects of Adjunctive Swedish Massage and Vibration Therapy on Short-Term Postoperative Outcomes: A Randomized, Controlled Trial

OBJECTIVE To examine the effects of adjunctive postoperative massage and vibration therapy on short-term postsurgical pain, negative affect, and physiologic stress reactivity. DESIGN Prospective, randomized controlled trial. The treatment groups were: (1) usual postoperative care (UC); (2) UC plus massage therapy; or (3) UC plus vibration therapy. SETTING The University of Virginia Hospital Surgical Units, Gynecology-Oncology Clinic, and General Clinical Research Center. SUBJECTS One hundred and five (N = 105) women who underwent an abdominal laparotomy for removal of suspected cancerous lesions. INTERVENTIONS All patients received UC with analgesic medication. Additionally, the massage group received standardized 45-minute sessions of gentle Swedish massage on the 3 consecutive evenings after surgery and the vibration group received 20-minute sessions of inaudible vibration therapy (physiotones) on the 3 consecutive evenings after surgery, as well as additional sessions as desired. OUTCOME MEASURES Sensory pain, affective pain, anxiety, distress, analgesic use, systolic blood pressure, 24-hour urine free cortisol, number of postoperative complications, and days of hospitalization. RESULTS On the day of surgery, massage was more effective than UC for affective (p = 0.0244) and sensory pain (p = 0.0428), and better than vibration for affective pain (p = 0.0015). On postoperative day 2, massage was more effective than UC for distress (p = 0.0085), and better than vibration for sensory pain (p = 0.0085). Vibration was also more effective than UC for sensory pain (p = 0.0090) and distress (p = .0090). However, after controlling for multiple comparisons and multiple outcomes, no significant differences were found. CONCLUSIONS Gentle Swedish massage applied postoperatively may have minor effects on short-term sensory pain, affective pain, and distress among women undergoing an abdominal laparotomy for removal of suspected malignant tissues.

Development of Clinical Practice Guidelines

Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, high-quality guidelines can facilitate shared decision making and identify gaps in knowledge.

Current status of mind-body interventions for vascular complications of diabetes.

Impaired peripheral blood flow causes complications, disabilities, expenses, and deaths among persons with diabetes mellitus. Many individuals suffer from lower-extremity pain, reduced functional status, and impaired quality of life. Current conventional treatments include lifestyle modification, exercise, medication, and surgery. However, these approaches are often impractical or insufficient. Thermal biofeedback, however, alone or in conjunction with other mind-body techniques, improves peripheral circulation, pain, neuropathy, ulcer healing, ambulatory activity, and quality of life. It is noninvasive, inexpensive, and consistent with community-based approaches to diabetes self-management. As an adjunct to the medical management of diabetes, thermal biofeedback may help ameliorate some of the vascular complications.

Assessment practices of professional psychologists: Results of a national survey.

Psychological assessment has been a defining area of practice, training, and research for professional psychologists since the field’s inception. We conducted the present survey of professional psychologists as a follow-up to surveys conducted by the American Psychological Association in the 1990s to describe (a) current psychological assessment practices and trends; (b) demographic factors and beliefs associated with assessment use; (c) barriers discouraging assessment use; and (d) factors that may encourage psychologists to make assessments a larger part of their practices. Our survey supports the common perception that, in general, assessment represents a smaller part of the practices of professional psychologists than before managed care; however, for psychologists in some specialty areas and settings (e.g., forensic psychology, inpatient settings), assessment represents a significant portion of their work. Moreover, the large majority of psychologists believe psychological assessment is a valuable aid in making diagnostic decisions and treatment recommendations. Many psychologists identify that greater coverage by third-party payers, as well as having access to less costly assessment instruments, would enable greater use of assessment.

P226 A Multidisciplinary Approach To Creating Behavioral Health Guidelines: Challenges Of Adhering To IOM Standards

Background In 2010 our organisation began creating evidence-based clinical practice guidelines for behavioural health, focusing initially on depression, PTSD, and obesity, following emerging IOM standards. Context Selected challenges in five areas: 1. Terminology. For many years, our organisation used guideline terminology that was inconsistent with the field. 2. Representation. Given the diverse types of professionals in behavioural health and the breadth/depth of each topic, attaining sufficiently diverse panel membership has been challenging. 3. Stakeholders. Obtaining the patient perspective has been challenging, particularly given the stigma and privacy concerns often associated with mental health. 4. Systematic Reviews. The high cost of developing de novo systematic reviews, especially for large scope topic areas, is limiting. 5. Education. Professionals have varying knowledge and lexicons for the process, requiring education, particularly surrounding non-financial conflicts of interest. Description of Best Practice •Terminology- Implemented organisation-wide systemic change in lexicon via change in organisation policy and routine dissemination. •Representation- Used multi-step consensus nomination process to assemble multidisciplinary panels. •Stakeholders- Using multi-tiered approach to involve stakeholders via Consultation, Participation, and Communication models and outreach to mental health peer support programmes. •Systematic Reviews- Applied Delphi poll method in topic scoping/refinement to work within organisational resources. Other mechanisms to enhance resources include topic nominations to AHRQ, possible organisational partnerships, and developing products from guidelines. •Education- Creating a series of self-study educational modules on guideline development. Lessons for Guideline Developers and Others Our challenges and resolutions could be helpful to others in guideline development.