Gary Epstein-Lubow

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).

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.

Medication burden in bipolar disorder: A chart review of patients at psychiatric hospital admission

Individuals with bipolar disorder (BD) often receive complex polypharmacy regimens as part of treatment, yet few studies have sought to evaluate patient characteristics associated with this high medication burden. This retrospective chart review study examined rates of complex polypharmacy (i.e., ≥4 psychotropic medications), patterns of psychotropic medication use, and their demographic and clinical correlates in a naturalistic sample of adults with bipolar I disorder (BDI; N=230) presenting for psychiatric hospital admission. Using a computer algorithm, a hospital administrator extracted relevant demographic, clinical, and community treatment information for analysis. Patients reported taking an average of 3.31 (S.D.=1.46) psychotropic medications, and 5.94 (S.D.=3.78) total medications at intake. Overall, 82 (36%) met criteria for complex polypharmacy. Those receiving complex polypharmacy were significantly more likely to be female, to be depressed, to have a comorbid anxiety disorder, and to have a history of suicide attempt. Women were significantly more likely than men to be prescribed antidepressants, benzodiazepines, and stimulants, even after controlling for mood episode polarity. Study data highlight the high medication burden experienced by patients with BD, especially those who are acutely symptomatic. Data also highlight the particularly high medication burden experienced by women with BD; a burden not fully accounted for by depression.

Association of dementia with early rehospitalization among Medicare beneficiaries

Preventable hospital readmissions have been recognized as indicators of hospital quality, a source of increased healthcare expenditures, and a burden for patients, families, and caregivers. Despite growth of initiatives targeting risk factors associated with potentially avoidable hospital readmissions, the impact of dementia on the likelihood of rehospitalization is poorly characterized. Therefore, the primary objective of this retrospective cohort study was to investigate whether dementia was an independent predictor of 30-day readmissions. Administrative claims data for all admissions to Rhode Island hospitals in 2009 was utilized to identify hospitalizations of Medicare fee-for-service beneficiaries with a diagnosis of Alzheimers Disease or other dementias. Demographics, measures of comorbid disease burden, and other potential confounders were extracted from the data and the odds of 30-day readmission to any United States hospital was calculated from conditional logistic regression models. From a sample of 25,839 hospitalizations, there were 3908 index admissions of Medicare beneficiaries who fulfilled the study criteria for a dementia diagnosis. Nearly 20% of admissions (n=5133) were followed by a readmission within thirty days. Hospitalizations of beneficiaries with a dementia diagnosis were more likely to be followed by a readmission within thirty days (adjusted odds ratio (AOR) 1.18; 95% CI, 1.08, 1.29), compared to hospitalizations of those of without dementia. Controlling for discharge site of care did not attenuate the association (AOR 1.21; 95% CI, 1.10, 1.33).

Research to Reduce the Suicide Rate Among Older Adults: Methodology Roadblocks and Promising Paradigms

The National Institute of Mental Health and the National Action Alliance for Suicide Prevention have requested input into the development of a national suicide research agenda. In response, a working group of the American Association for Geriatric Psychiatry has prepared recommendations to ensure that the suicide prevention dialogue includes older adults, a large and fast-growing population at high risk of suicide. In this Open Forum, the working group describes three methodology roadblocks to research into suicide prevention among elderly persons and three paradigms that might provide directions for future research into suicide prevention strategies for older adults.

Acceptance-based Behavior Therapy for Depression with Psychosis: Results from a Pilot Feasibility Randomized Controlled Trial

Acceptance-based depression and psychosis therapy (ADAPT), a mindfulness/acceptance-based behavioral activation treatment, showed clinically significant effects in the treatment of depression with psychosis in a previous open trial. The goal of the current study was to further test the feasibility of ADAPT to determine the utility of testing it in a future clinical trial, following a stage model of treatment development. Feasibility was determined by randomizing a small number of patients (N=13) with comorbid depression and psychosis to medication treatment as usual plus enhanced assessment and monitoring versus ADAPT for 4 months of outpatient treatment. Both conditions were deemed acceptable by patients. Differences in between-subjects effect sizes favored ADAPT posttreatment and were in the medium to large range for depression, psychosocial functioning, and experiential avoidance (ie, the target mechanism). Thus ADAPT shows promise for improving outcomes compared with medications alone and requires testing in a fully powered randomized trial.

An Open Trial of a New Acceptance-Based Behavioral Treatment for Major Depression With Psychotic Features

Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of behavioral activation and acceptance and commitment therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to 6 months of Acceptance-Based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through posttreatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.

Does the dexamethasone suppression test reliably discriminate between psychotic and nonpsychotic major depression?: an exploratory analysis of potential confounds.

Previous research has shown that psychotic major depression (PMD) is often associated with higher rates of nonsuppression on the dexamethasone suppression test (DST) compared with nonpsychotic major depression (NMD), suggesting the potential importance of cortisol hypersecretion in the psychotic subtype of the disorder. However, these patient groups also are known to differ from one another on a variety of other clinical variables, and there are numerous factors independent of diagnostic status known to affect the DST. Thus, we investigated possible confounds that could help account for the apparent DST abnormalities in PMD sometimes reported in past research. Hospitalized patients with PMD (n = 11) and NMD (n = 58) were compared on the DST and other clinical variables. As expected, PMD patients showed significantly higher rates of DST nonsuppression (55% vs. 24%; p = 0.04). However, PMD patients also had significantly higher levels of anxiety severity (p = 0.01). The higher rates of nonsuppression in the PMD group were attenuated when these patients were compared with a subsample of NMD patients matched on anxiety severity (55% vs. 55%). Implications for future research on biological markers of PMD are discussed.

Demographic and clinical characteristics associated with comorbid cannabis use disorders (CUDs) in hospitalized patients with bipolar I disorder

BACKGROUND Published data suggest that cannabis use is associated with several negative consequences for individuals with bipolar disorder (BD), including new manic episode onset, psychosis, and functional disability. Yet much less is known about cannabis use disorders (CUDs) in this population, especially in more acutely symptomatic groups. METHODS To evaluate correlates of CUD comorbidity in BD, a retrospective chart review was conducted for 230 adult patients with bipolar I disorder (BDI) who were admitted to a university-affiliated private psychiatric hospital. Using a computer algorithm, a hospital administrator extracted relevant demographic and clinical data from the electronic medical record for analysis. RESULTS Thirty-six (16%) had a comorbid CUD. CUD comorbidity was significantly associated with younger age, manic/mixed episode polarity, presence of psychotic features, and comorbid nicotine dependence, alcohol use disorder (AUD), and other substance use disorders, but was associated with decreased likelihood of anxiety disorder comorbidity. With the exception of manic/mixed polarity and AUD comorbidity, results from multivariate analyses controlling for the presence of other SUDs were consistent with univariate findings. CONCLUSION Patients with BD and comorbid CUDs appear to be a complex population with need for enhanced clinical monitoring. Given increasing public acceptance of cannabis use, and the limited availability of evidenced-based interventions targeted toward CUDs in BD, psychoeducation and other treatment development efforts appear to be warranted.

Neuropsychiatric Symptoms in an Inpatient Parkinson’s Disease Sample

Background. Neuropsychiatric symptoms are common in idiopathic Parkinsons disease (PD), and hospitalization for delirium, depression, psychosis, and anxiety is sometimes required. A minimal amount of data exists on these patients. Methods. Charts of all patients admitted to a psychiatric hospital between 2006 and 2009 with a diagnosis of PD were reviewed. Forty-three met entry criteria and were reviewed. Initial and discharge diagnoses, comorbid psychiatric diagnoses, length of stay, and living arrangements before and after hospitalization are described. Results. Consistent with previous research, this study showed evidence of comorbid psychiatric disorders within PD. Conclusions. The long-term goal of this area of study would be to reduce neuropsychiatric symptoms and improve quality of life in order to reduce inpatient hospital stays.