Janet Wingrove

Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial

BACKGROUND About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). AIMS To test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. METHOD Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150). RESULTS Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. CONCLUSIONS This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

Impulsivity : A state as well as trait variable. Does mood awareness explain low correlations between trait and behavioural measures of impulsivity ?

Abstract This report concerns a small scale study using a set of visual analogue scales designed to assess state impulsivity (the STIMP), a well established measure of trait impulsivity (the I7) and two behavioural tasks that have frequently been used as measures of impulsivity: circle tracing and time perception. As in previous research, trait impulsivity showed little if any correlation with performance on the behavioural tasks. However, self-ratings of impulsive mood state were associated with slower circle tracing. This suggests that people who become aware that they are likely to behave impulsively compensate by slowing down their responses. This could explain in part the low correlations found between trait and behavioural measures of impulsivity in this and previous studies. It is argued that this compensation may only be possible in situations of low temptation. Further research is needed to explore the role of mood, mood awareness and strategies of self-regulation in impulse control.

Pilot Study of Mindfulness-Based Cognitive Therapy for Trainee Clinical Psychologists

BACKGROUND It is recommended that Mindfulness-Based Cognitive Therapy (MBCT) instructors should undertake MBCT themselves before teaching others. AIM To investigate the impact of MBCT (modified for stress not depression) on trainee clinical psychologists. METHOD Twenty trainees completed questionnaires pre- and post-MBCT. RESULTS There was a significant decrease in rumination, and increases in self-compassion and mindfulness. More frequent home practice was associated with larger decreases in stress, anxiety and rumination, and larger increases in empathic concern. Only first-year trainees showed a significant decrease in stress. Content analysis of written responses indicated that the most commonly reported effects were increased acceptance of thoughts/feelings (70%), increased understanding of what it is like to be a client (60%), greater awareness of thoughts/feelings/behaviours/bodily sensations (55%) and increased understanding of oneself and ones patterns of responding (55%). Participants reported increased metacognitive awareness and decentring in relation to negative thoughts. Eighty-five percent reported an impact on their clinical work by the end of the course. CONCLUSIONS Trainee psychologists undergoing MBCT experienced many of the psychological processes/effects that they may eventually be helping to cultivate in clients using mindfulness interventions, and also benefits in their general clinical work.

Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study.

UNLABELLED Cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS; sometimes known as myalgic encephalomyelitis). However, only a minority of patients fully recover after CBT; thus, methods for improving treatment outcomes are required. This pilot study concerned a mindfulness-based cognitive therapy (MBCT) intervention adapted for people with CFS who were still experiencing excessive fatigue after CBT. The study aimed to investigate the acceptability of this new intervention and the feasibility of conducting a larger-scale randomized trial in the future. Preliminary efficacy analyses were also undertaken. Participants were randomly allocated to MBCT or waiting list. Sixteen MBCT participants and 19 waiting-list participants completed the study, with the intervention being delivered in two separate groups. Acceptability, engagement and participant-rated helpfulness of the intervention were high. Analysis of covariance controlling for pre-treatment scores indicated that, at post-treatment, MBCT participants reported lower levels of fatigue (the primary clinical outcome) than the waiting-list group. Similarly, there were significant group differences in fatigue at 2-month follow-up, and when the MBCT group was followed up to 6 months post-treatment, these improvements were maintained. The MBCT group also had superior outcomes on measures of impairment, depressed mood, catastrophic thinking about fatigue, all-or-nothing behavioural responses, unhelpful beliefs about emotions, mindfulness and self-compassion. In conclusion, MBCT is a promising and acceptable additional intervention for people still experiencing excessive fatigue after CBT for CFS, which should be investigated in a larger randomized controlled trial. KEY PRACTITIONER MESSAGE Only about 30% of people with chronic fatigue syndrome (CFS) recover after cognitive behaviour therapy (CBT); thus, methods for improving treatment outcomes are needed. This is the first pilot randomized study to demonstrate that a mindfulness-based intervention was associated with reduced fatigue and other benefits for people with CFS who were still experiencing excessive fatigue after a course of CBT. Levels of acceptability, engagement in the intervention and rated helpfulness were high. A larger-scale randomized controlled trial is required.

The impact of comorbid personality difficulties on response to IAPT treatment for depression and anxiety

UNLABELLED The UKs Improving Access to Psychological Therapies (IAPT) initiative provides evidence-based psychological interventions for mild to moderate common mental health problems in a primary care setting. Predictors of treatment response are unclear. This study examined the impact of personality disorder status on outcome in a large IAPT service. We hypothesised that the presence of probable personality disorder would adversely affect treatment response. METHOD We used a prospective cohort design to study a consecutive sample of individuals (n = 1249). RESULTS Higher scores on a screening measure for personality disorder were associated with poorer outcome on measures of depression, anxiety and social functioning, and reduced recovery rates at the end of treatment. These associations were not confounded by demographic status, initial symptom severity nor number of treatment sessions. The presence of personality difficulties independently predicted reduced absolute change on all outcome measures. CONCLUSIONS The presence of co-morbid personality difficulties adversely affects treatment outcome among individuals attending for treatment in an IAPT service. There is a need to routinely assess for the presence of personality difficulties on all individuals referred to IAPT services. This information will provide important prognostic data and could lead to the provision of more effective, personalised treatment in IAPT.

Tryptophan Enhancement/Depletion and Reactions to Failure on a Cooperative Computer Game

Twenty-eight high trait hostility male volunteers played a “cooperative” computer game 4.5 hours after an amino acid drink enhanced with, or depleted of, tryptophan. Each trial involved steering a tank through minefields following directions from an unknown “partner.” Failure was experienced when the tank hit a mine or when time ran out. Subjects’ moods, verbal aggression, attributions of blame, vocal acoustics, and blood pressure were assessed. Differences between tryptophan groups were not significant for primary measures of anger and verbal aggression. However, depleted subjects reported greater increases in feelings of restlessness and incompetence, were less successful in avoiding mines and showed greater increases in blood pressure during the game. Subjects in both groups sent more negative ratings when they lost the game by virtue of hitting a mine rather than losing by running out of time. However, ratings of the depleted group were less influenced by the reason for losing the game. Also, vocal acoustics showed a group × reason-for-losing interaction in the high-frequency band. Tryptophan-depleted subjects with high scores on Behavioral-Activation-System-Drive were most likely to send negative ratings and those scoring high on Buss-Durkee Hostility Inventory Assault and Guilt to report increased anger after the game.

Trait Hostility and Prolactin Response to Tryptophan Enhancement/Depletion

This study investigated the relationship between trait hostility and aspects of serotonergic function by assessing the prolactin (PRL) response to acute tryptophan depletion and enhancement in 28 healthy male volunteers. Serum PRL was assessed immediately before, and 4.5 h after, administration of an amino acid drink enhanced with, or depleted of, the 5-HT precursor tryptophan. Trait hostility and ΔPRL (value at 4.5 h minus baseline) correlated negatively following enhancement and positively following depletion, indicating that the higher the hostility the smaller the change in PRL in either direction. This is consistent with previous research reporting an association between aggression and blunted neuroendocrine responses to serotonergic agents. The results indicate the possibility that, in people high on hostility, part of the serotonergic pathway that leads to modulation of PRL release is characterised by a stage with either low capacity relative to input availability or a strong negative feedback component.

Plasma tryptophan and trait aggression.

Many studies have reported correlations between measures of aggression and indices of serotonergic function, but most have studied patient or o¡ender populations and relatively few have investigated plasma concentrations of the serotonin precursor tryptophan.This study investigates the relationship between plasma concentrations of tryptophan and trait hostility, depression and anxiety in male healthy volunteers. Sixty-seven healthy male volunteers gave blood samples and completed trait questionnaires. Plasma tryptophan was positively correlated with the BussDurkee Hostility Inventory Total score and Motor Aggression subscale, but not with the Attitudinal Hostility subscale or with trait anxiety or depression. In conclusion, there is evidence for an association between high concentrations of plasma tryptophan and aggressive behaviour in men, presumably mediated by some aspect of central serotonergic function, which seems unlikely to be explained by high trait anxiety or depression.

Predicting outcome following psychological therapy in IAPT (PROMPT): a naturalistic project protocol

BackgroundDepression and anxiety are highly prevalent and represent a significant and well described public health burden. Whilst first line psychological treatments are effective for nearly half of attenders, there remain a substantial number of patients who do not benefit. The main objective of the present project is to establish an infrastructure platform for the identification of factors that predict lack of response to psychological treatment for depression and anxiety, in order to better target treatments as well as to support translational and experimental medicine research in mood and anxiety disorders.Methods/designPredicting outcome following psychological therapy in IAPT (PROMPT) is a naturalistic observational project that began patient recruitment in January 2014. The project is currently taking place in Southwark Psychological Therapies Service, an Improving Access to Psychological Therapies (IAPT) service currently provided by the South London and Maudsley NHS Foundation Trust (SLaM). However, the aim is to roll-out the project across other IAPT services. Participants are approached before beginning treatment and offered a baseline interview whilst they are waiting for therapy to begin. This allows us to test for relationships between predictor variables and patient outcome measures. At the baseline interview, participants complete a diagnostic interview; are asked to give blood and hair samples for relevant biomarkers, and complete psychological and social questionnaire measures. Participants then complete their psychological therapy as offered by Southwark Psychological Therapies Service. Response to psychological therapy will be measured using standard IAPT outcome data, which are routinely collected at each appointment.DiscussionThis project addresses a need to understand treatment response rates in primary care psychological therapy services for those with depression and/or anxiety. Measurement of a range of predictor variables allows for the detection of bio-psycho-social factors which may be relevant for treatment outcome. This will enable future clinical decision making to be based on the individual needs of the patient in an evidence-based manner. Moreover, the identification of individuals who fail to improve following therapy delivered by IAPT services could be utilised for the development of novel interventions.

The Neurochemistry and Psychopharmacology of Anger

Work investigating the relationship between neurotransmitter function and anger currently relies on indirect measures, such as levels of metabolites in cerebrospinal fluid, neuroendocrine challenges and monoamine depletion. The evidence from all three types of neurochemical study has supported deficient serotonin as the neurotransmitter most involved in angry aggression and to a lesser extent in the experience of anger itself. Experimental findings also demonstrate that a well-functioning 5-HT system is involved in anger regulation. Psychopharmacology studies support the experimental neurochemical work indicating the importance of individual differences in trait aggression, irrespective of diagnosis, in the experience and display of anger. Serotonergic antidepressants have been shown not only to have positive effects on reducing anger-related emotions but also to increase affiliative or cooperative behaviour. Mood stabilisers and antipsychotics with effects on 5-HT reduce anger and irritability in various patient groups. Selective noradrenergic antidepressants improve negative mood and can also exert pro-social effects but effects on anger per se have not been demonstrated.