Giovanni A. Fava

Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders.

BACKGROUND There is increasing awareness of the prognostic value of residual symptomatology in affective disorders and of the need for specific therapeutic strategies in this phase of illness. The aims of the study were to apply a novel, short-term psychotherapeutic approach for increasing well-being, based on Ryffs conceptual model, to remitted patients with affective disorders and to compare the results with those obtained with symptom-oriented cognitive behavioural strategies. METHODS Twenty patients with affective disorders (major depression, panic disorder with agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder) who had been successfully treated by behavioural or pharmacological methods were randomly assigned to a well-being enhancing therapeutic strategy (well-being therapy) or cognitive-behavioural treatment of residual symptoms. RESULTS Both well-being and cognitive-behavioural therapies were associated with a significant reduction of residual symptoms. However, a significant advantage of well-being therapy over cognitive-behavioural strategies was observed with observer-rated methods. DISCUSSION These preliminary results suggest the feasibility of well-being therapy in the residual stage of affective disorders. Further research should determine its value as a relapse-preventive strategy in specific mood and anxiety disorders.

Subclinical symptoms in mood disorders: pathophysiological and therapeutic implications

BACKGROUND The aim of this review was to survey the available literature on prodromal and residual symptoms of unipolar major depression and bipolar disorder. METHODS Both a computerized (Medline) and a manual search of the literature were performed. RESULTS In a substantial proportion of patients with affective disorders a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon). CONCLUSIONS Appraisal of subclinical symptomatology in mood disorders has important implications for pathophysiological models of disease and relapse prevention. In depression, specific treatment of residual symptoms may improve long-term outcome, by acting on those residual symptoms that progress to become prodromes of relapse. In bipolar disorder, decrease of subclinical fluctuations and improvement of level of functioning by specific therapeutic strategies may add to the benefits provided by lithium prophylaxis.

Increasing Psychological Well‐Being and Resilience by Psychotherapeutic Methods

A specific psychotherapeutic strategy for increasing psychological well-being and resilience, well-being therapy, has been developed and validated in a number of randomized controlled trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of ones self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage effectively ones life, and a sense of self-determination. A decreased vulnerability to depression and anxiety has been demonstrated after well-being therapy in high-risk populations. There are important implications for the state/trait dichotomy in psychological well-being and for the concept of recovery in mood and anxiety disorders.

Well-Being Therapy of Generalized Anxiety Disorder

Background: There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD. Methods: Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel’s Clinical Interview for Depression, Ryff’s Psychological Well-being Scales and Kellner’s Symptom Questionnaire. A one-year follow-up was undertaken. Results: Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up. Conclusions: These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

Well-Being Therapy: Conceptual and Technical Issues

Well-being therapy is a short-term, well-being-enhancing psychotherapeutic strategy. It is based on Carol D. Ryff’s multidimensional model of psychological well-being, encompassing environmental mastery, personal growth, purpose in life, autonomy, self-acceptance and positive relations with others. Its conceptual and technical issues are described. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological and psychotherapeutic treatments, in body image disorders and in psychosomatic medicine. The first validation studies appeared to be promising. The technique is in its preliminary stage of development and may undergo major changes in the next years. It is hoped it may herald a new trend of psychotherapy research and practice in the current symptom-oriented settings.

The concept of recovery in major depression

BACKGROUND There is increasing literature on the unsatisfactory degree of remission that current therapeutic strategies yield in unipolar depression. The aims of this review were to survey the available literature on residual symptoms of depression, to introduce new targets for therapy and to outline a more stringent definition of recovery. METHOD Studies were identified by using MEDLINE (English language articles published from 1967 to June 2006; keywords: recovery, remission, residual symptoms, sequential treatment, drugs and psychotherapy, related to depressive disorder and depression) and a manual search of the literature and Index Medicus for the years 1960-2006. RESULTS Most patients report residual symptoms despite apparently successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology. The concept of recovery should involve psychological well-being. CONCLUSIONS Appraisal of subclinical symptomatology in depression has important implications for pathophysiological models of disease and relapse prevention. New therapeutic strategies for improving the level of remission, such as treatment on residual symptoms that progress to become prodromes of relapse, may yield more lasting benefits.

Psychiatric disorders associated with Cushing's syndrome. Epidemiology, pathophysiology and treatment.

Cushing’s syndrome is caused by a chronic excess of glucocorticoids. A number of psychiatric and psychological disturbances may be associated with the condition, regardless of its aetiology. Major depression is the most common co-morbid disorder. Other psychopathological aspects of Cushing’s syndrome in adults include mania, anxiety disorders and cognitive dysfunction.The presence of depression connotes a severe clinical presentation and, in patients with hypothalamic-pituitary forms of Cushing’s syndrome, is prognostically useful. Inhibitors of corticosteroid production (e.g. ketoconazole, metyrapone, aminoglutethimide), rather than antidepressant drugs, are generally successful in relieving depressive symptoms, as well as other disabling symptoms. These drugs can be used to control symptoms prior to surgical treatment of Cushing’s syndrome.Long-standing hypercortisolism may cause some degree of irreversible pathological damage and induce highly individualised affective responses based on each patient’s psychological assets and liabilities. As a result, upon normalisation of cortisol levels, treatment may still be required, and should encompass both psychotherapeutic strategies (particularly cognitive-behavioural therapies that have been found to be effective in affective disorders) and psychotropic drug treatment [antidepressants such as tricyclic agents and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors]. In patients with severe anxiety, benzodiazepines (e.g. clonazepam in small doses) may also be helpful.

Psychosomatic Medicine: Emerging Trends and Perspectives

Developments have occurred in all aspects of psychosomatic medicine. Among factors affecting individual vulnerability to all types of disease, the following have been highlighted by recent research: recent and early life events, chronic stress and allostatic load, personality, psychological well-being, health attitudes and behavior. As to the interaction between psychological and biological factors in the course and outcome of disease, the presence of psychiatric (DSM-IV) as well as subclinical (Diagnostic Criteria for Psychosomatic Research) symptoms, illness behavior and the impact on quality of life all need to be assessed. The prevention, treatment and rehabilitation of physical illness include the consideration for psychosomatic prevention, the treatment of psychiatric morbidity and abnormal illness behavior and the use of psychotropic drugs in the medically ill. In the past 60 years, psychosomatic medicine has addressed some fundamental questions, contributing to the growth of other related disciplines, such as psychoneuroendocrinology, psychoimmunology, consultation-liaison psychiatry, behavioral medicine, health psychology and quality of life research. Psychosomatic medicine may also provide a comprehensive frame of reference for several current issues of clinical medicine (the phenomenon of somatization, the increasing occurrence of mysterious symptoms, the demand for well-being and quality of life), including its new dialogue with mind-body and alternative medicine.

Staging: a neglected dimension in psychiatric classification.

The staging method, whereby a disorder is characterized according to seriousness, extension and features, has achieved wide currency in medicine but is currently neglected in psychiatry. Studies addressing or related to the issue of staging in schizophrenia, unipolar depression, bipolar disorder and panic disorder are discussed. The phenomenological development of these mental disorders may be categorized according to stages.

Residual symptoms in depression: An emerging therapeutic concept

Cushings syndrome is due to chronic glucocorticoid excess that may have various etiologies. The most common endogenous form is pituitary-dependent bilateral adrenal hyperplasia, which is termed Cushings disease. Major depression occurs in more than half of the cases. The presence of depressive symptoms connotes severity of clinical presentation and, in patients with hypothalamic-pituitary forms, entails prognostic value. Medical treatment may be used while awaiting more definitive solutions for the illness by surgery. The inhibitors of steroid production (e.g., ketoconazole, metyrapone and aminoglutethimide), rather than antidepressant drugs, are generally successful in lifting depression as well as other disabling symptoms. Since central serotonergic regulation could have a role in the course of Cushings disease, serotonin antagonists (e.g., cyproheptadine, ritanserin and ketanserin) have been employed. Findings related to the pharmacological response of depression in Cushings disease were found to have implications for the pathophysiology of depression and the potential involvement of the hypothalamic-pituitary-adrenal axis (HPA axis) in resistance and tolerance to antidepressant drugs. The use of serotonergic drugs in Cushings disease may yield important insights in the understanding of serotonergic regulation both in Cushings disease and in the HPA axis in nonendocrine major depression.