Lesley A. Allen

Cognitive-behavioral therapy for depression in Parkinson's disease: a randomized, controlled trial.

OBJECTIVE Despite the negative effects of depression in Parkinsons disease, there is currently no evidence-based standard of care. The purpose of this study was to examine the efficacy of individually administered cognitive-behavioral therapy (CBT), relative to clinical monitoring (with no new treatment), for depression in this medical population. METHOD Eighty depressed (based on DSM-IV criteria) patients with Parkinsons disease participated in a randomized, controlled trial of CBT relative to clinical monitoring (1:1 ratio) in an academic medical center from April 2007 to July 2010. All patients continued to maintain stable medication regimens under the care of their personal physicians. The 17-item Hamilton Depression Rating Scale (HAM-D) total score was the primary outcome. CBT was modified to meet the unique needs of the Parkinsons disease population and provided for 10 weeks. Assessments were completed by blind raters at baseline and 5 (midpoint), 10 (end of treatment), and 14 weeks (follow-up evaluation) postrandomization. RESULTS The CBT group reported greater reductions in depression (change in HAM-D score) than the clinical monitoring group. At week 10, the mean HAM-D score change was 7.35 for CBT relative to 0.05 for clinical monitoring. CBT was also superior to clinical monitoring on several secondary outcomes (i.e., Beck Depression Inventory scores, anxiety, quality of life, coping, Parkinsons disease symptom ratings). There were more treatment responders in the CBT group than the clinical monitoring group (56% versus 8%, respectively). CONCLUSIONS CBT may be a viable approach for the treatment of depression in Parkinsons disease. Further research is needed to replicate and extend these findings.

Effectiveness of a Time-Limited Cognitive Behavior Therapy–Type Intervention Among Primary Care Patients With Medically Unexplained Symptoms

PURPOSE Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few well-accepted and properly evaluated interventions to manage such patients. METHODS We tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care. RESULTS A significantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as “very much improved” or “much improved” compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confidence interval, 1.9–8.8; P<.001). The intervention’s effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to significant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up. CONCLUSIONS This time-limited, CBT-type intervention significantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

Self-complexity and the persistence of depression.

Self-complexity, a measure of the structure of cognition involving the self, was used to predict the persistence of depression in patients diagnosed with major depression. Self-descriptions offered by depressed patients were analyzed using a clustering algorithm to model cognitive structure. Indices of positive and negative self-complexity, derived from the resulting models, were used to predict depressive symptomatology 9 months after the onset of a major depression. Negative self-complexity uniquely predicted subsequent levels of depression even after the effects of initial levels of depression, self-evaluation, and dysfunctional attitudes were statistically removed. Highly complex negative self-representation appears to be associated with poor recovery from a major depressive episode. Future studies examining the relationship between cognition and psychopathology should investigate, in addition to its content, the formal and structural properties of cognition.

Bupropion improves sexual functioning in depressed minority women: an open-label switch study.

Minority women often have a unique set of beliefs and expectations about medical treatment. At this time, there is a dearth of research looking at how depressed minority women respond to pharmacological interventions for the sexual concomitants of depression. This was the first study to examine the impact of a medication switch, from a selective serotonin reuptake inhibitor to bupropion SR, on the sexual functioning of depressed minority women. Eighteen minority women (5 Hispanic, 10 African American, 2 Asian American, and 1 Native American), who were experiencing poor tolerability and/or lack of efficacy on an adequate trial of a selective serotonin reuptake inhibitor for depression, along with low sexual desire, were enrolled in this prospective open-label study. The selective serotonin reuptake inhibitor and bupropion SR were cross-tapered with a target dose of 150 to 300 mg of bupropion SR. The patients were followed for 10 weeks, and measures of sexual functioning and depression (Hamilton Rating Scale for Depression) were administered in an academic medical setting. Data were collected from July 2003 to December 2004. In the group as a whole, there were significant improvements in desire (F1,17 = 34.86, P < 0.001), arousal (F1,17 = 25.99, P < 0.001), and orgasm (F1,17 = 20.16, P < 0.001), on the Changes in Sexual Functioning Questionnaire. African-American women demonstrated the greatest improvement in depression (F1,16 = 9.55, P = 0.006), desire (F1,16 = 8.62, P = 0.01), and arousal (F1,16 = 8.83, P = 0.009) after the medication switch. Overall, this intervention appeared to be an effective treatment of low sexual desire in a diverse group of depressed minority women. The majority of women successfully completed the trial and planned to continue using bupropion SR after their participation in the study.

Neuropsychological Outcomes After Psychosocial Intervention for Depression in Parkinson’s Disease

The authors describe neuropsychological outcomes in people with Parkinsons disease (PD) after their participation in an NIH-sponsored, randomized, controlled trial of cognitive-behavioral treatment for depression. Improvements in mood were associated with modest gains in verbal memory and executive functioning over the 10-week treatment period and accounted for greater variance in neuropsychological outcomes at the end of treatment than other known correlates of cognitive functioning in PD, such as disease severity, age, and education. Baseline working memory and executive skills were also associated with depression improvement over time.

Affective-Cognitive Behavioral Therapy for Fibromyalgia: A Randomized Controlled Trial

A randomized controlled trial was conducted to assess the efficacy of an individually administered form of cognitive behavioral treatment for fibromyalgia. In an additive design, 76 patients diagnosed with fibromyalgia were randomly assigned to either the experimental treatment (affective-cognitive behavioral therapy, 10 individual sessions, one per week) administered concurrently with treatment-as-usual or to an unaugmented treatment-as-usual condition. Statistical analysis conducted at the end of treatment (3 months after the baseline assessment) and at a followup (9 months after the baseline assessment) indicated that the patients receiving the experimental treatment reported less pain and overall better functioning than control patients, both at posttreatment and at followup. The implications of these findings for future research are discussed.

Affective-Cognitive Behavioral Therapy for Somatization Disorder

Somatization disorder is the most severe and refractory of the somatoform disorders. In this article, we provide an overview of somatization disorder, reviewing both the experimental psychopathology and treatment outcome literatures. We also describe a new psychosocial intervention that we developed to treat somatization disorder, affective-cognitive behavioral therapy. We attempt to place the treatment within the context of contemporary cognitive behavioral therapy.

Adaptive Inferential Feedback Partner Training: An Augmented Cognitive-Behavioral Approach

It has been clearly documented that social support exerts a salubrious impact on depression. Yet, standardized social support interventions, with the primary intent of alleviating a patient’s depression, have not been incorporated into evidence-based treatments for mood disorders. Not all types of support are necessarily beneficial. Inferential feedback is a subtype of social support that addresses an individual’s perception of the cause, meaning, and consequences of negative life events and may be either adaptive or maladaptive. A short-term adaptive inferential feedback (AIF) training manual was developed for the partners (e.g., friends, family members) of depressed patients. The present case examines the effectiveness of a standard 14-session cognitive-behavioral treatment augmented with 4 AIF partner-training sessions. Results suggest that this newly developed social support intervention may be feasible, well liked, and possibly beneficial to depressed patients. Further research is needed to investigate any incremental value of this intervention beyond standard cognitive-behavioral treatment.

Somatic Symptom Disorder

Physical symptoms with uncertain medical explanations are some of the most common presentations in primary care. As many as 25% of visits to primary care physicians are prompted by physical symptoms that lack any clear organic pathology [1]. Although some patients with medically unexplained physical symptoms experience mild and/or transient discomfort, others experience substantial discomfort, distress, and impairment in functioning [2,3]. It is these patients, those with impairing physical symptoms of unknown etiology, who are often refractory to standard medical treatment and overuse medical services [2].