Gilles Ambresin

Self-Rated Health and Long-Term Prognosis of Depression

PURPOSE Indicators of prognosis should be considered to fully inform clinical decision making in the treatment of depression. This study examines whether self-rated health predicts long-term depression outcomes in primary care. METHODS Our analysis was based on the first 5 years of a prospective 10-year cohort study underway since January 2005 conducted in 30 randomly selected Australian primary care practices. Participants were 789 adult patients with a history of depressive symptoms. Main outcome measures include risks, risk differences, and risk ratios of major depressive syndrome (MDS) on the Patient Health Questionnaire. RESULTS Retention rates during the 5 years were 660 (84%), 586 (74%), 560 (71%), 533 (68%), and 517 (66%). At baseline, MDS was present in 27% (95% CI, 23%–30%). Cross-sectional analysis of baseline data showed participants reporting poor or fair self-rated health had greater odds of chronic illness, MDS, and lower socioeconomic status than those reporting good to excellent self-rated health. For participants rating their health as poor to fair compared with those rating it good to excellent, risk ratios of MDS were 2.10 (95% CI, 1.60–2.76), 2.38 (95% CI, 1.77–3.20), 2.22 (95% CI, 1.70–2.89), 1.73 (95% CI, 1.30–2.28), and 2.15 (95% CI, 1.59–2.90) at 1, 2, 3, 4, and 5 years, after accounting for missing data using multiple imputation. After adjusting for age, sex, multimorbidity, and depression status and severity, self-rated health remained a predictor of MDS up to 5 years. CONCLUSIONS Self-rated health offers family physicians an efficient and simple way to identify patients at risk of poor long-term depression outcomes and to inform therapeutic decision making.

A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care

BACKGROUND Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care. METHODS 789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months. RESULTS Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables. LIMITATIONS Adult only cohort, self-report measures. CONCLUSIONS Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial

BackgroundA few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression.Methods/DesignThe study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention–to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher.DiscussionDespite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy.Trial registrationAustralian New Zealand Clinical Trial Registry (ACTRN12612000909820)

How does addressing patient's defenses help to repair alliance ruptures in psychodynamic psychotherapy?: An exploratory study.

Abstract Interpreting or addressing defenses is an important aspect of psychoanalytic technique. Previous research has shown that therapist addressing defenses (TADs) can produce a positive effect on alliance. The potential value of TADs during the process of alliance rupture and resolution has not yet been documented. We selected patients (n = 17) undertaking a short-term dynamic psychotherapy in which the therapeutic alliance, measured with the Helping Alliance Questionnaire and monitored after each session, showed a pattern of rupture and resolution. Two control sessions (5 and 15) were also selected. Presence of TADs was examined in each therapist interpretation. Compared with control sessions, rupture sessions were characterized by fewer TADs and especially fewer TADs addressing specifically intermediate—essentially neurotic—defenses. Resolution sessions were characterized by more TADs addressing specifically intermediate defenses. This confirms the link between therapist technique and alliance process in psychodynamic psychotherapy.

Does agomelatine have a place in the treatment of depression

Only as an alternative second line therapy for those with severe symptoms

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: Results of a randomized controlled trial

BACKGROUND For severe and chronic depression, inpatient treatment may be necessary. Current guidelines recommend combined psychological and pharmacological treatments for moderate to severe depression. Results for positive effects of combined treatment for depressed inpatients are still ambiguous. METHODS This randomised controlled trial examined the efficacy of adding an intensive and brief psychodynamic psychotherapy (IBPP) to treatment-as-usual (TAU) for inpatients with DSM-IV major depressive episode. The primary outcomes were reduction in depression severity, and response and remission rates at post-treatment, 3-month and 12-month follow-up points. RESULTS A linear mixed model analysis (N=149) showed a higher reduction in the observer-rated severity of depressive symptoms at each follow-up point for the IBPP condition compared with the TAU condition (post-treatment ES=0.39, 95%CI 0.06-0.71; 3-month ES=0.46, 95%CI 0.14-0.78; 12-month ES=0.32, 95%CI 0.01-0.64). Response rate was superior in the IBPP group compared with the TAU group at all follow-up points (post-treatment OR =2.69, 95%CI 1.18-6.11; 3-month OR=3.47, 95%CI 1.47-8.25; 12-month OR=2.26, 95%CI 1.02-4.97). IBPP patients were more likely to be remitted 3 months (OR=2.82, 95%CI 1.12-7.10) and 12 months (OR=2.93, 95%CI 1.12-7.68) after discharge than TAU patients. LIMITATIONS Heterogeneous sample with different subtypes of depression and comorbidity. CONCLUSIONS IBPP decreased observer-rated depression severity up to 12 months after the end of treatment. IBPP demonstrated immediate and distant treatment responses as well as substantial remissions at follow-up. IBPP appears to be a valuable adjunct in the treatment of depressed inpatients.

Brief Psychoanalytic Psychotherapy for Depressed Inpatient: Best Predictors of Response

Introduction A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. Our one-month randomized controlled trial of very brief psychotherapeutic treatment (12 sessions/4 weeks) showed especially medium to large between effect sizes (BES ranging from .53 to .89) at 3 months follow-up. Objectives This study aims at discovering the predictors of treatment response and remission at discharge and at 3 and 12 months follow-up. Methods The study was a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 167 consecutive adult inpatients with unipolar depression was recruited. Patients were randomly assigned to an adjunctive inpatient brief psychodynamic psychotherapy (IBPP) or psychiatric treatment-as-usual (TAU). The IBPP is a manualized very brief psychotherapeutic program in 12 sessions over 4 weeks. Response and remission were calculated on MADRS and QIDS-SR 16 . Variables included psychopathology (e.g., depression, symptom distress, diagnosis, comorbidity, suicidality, emotion regulation); history (e.g., childhood trauma, onset of the disorder); psychosocial role functioning (e.g., global functioning, social adjustment, Interpersonal functioning, quality of life); demographics ; and therapeutic alliance (with the therapist, with the clinical team). Results The two best predictors of response were (1) the treatment (psychotherapy) and (2) the alliance with the treatment team. Psychotherapy was the best predictor of remission. Conclusions Effective ways of treating depression in inpatient setting depend both on specific treatment programs and on general quality of the relationship with the clinical team.