Peter Paul A. Mersch

Seasonal affective disorder and latitude: a review of the literature.

BACKGROUND The aim of the study is to investigate the relationship between the prevalence of SAD and latitude. METHODS An overview of the epidemiological literature on the prevalence of SAD is given and studies relevant for the latitudinal dependency of prevalence will be analyzed and discussed. RESULTS The mean prevalence of SAD is two times higher in North America compared to Europe. Over all prevalence studies, the correlation between prevalence and latitude was not significant. A significant positive correlation was found between prevalence and latitude in North America. For Europe there was a trend in the same direction. CONCLUSIONS The influence of latitude on prevalence seems to be small and other factors like climate, genetic vulnerability and social-cultural context can be expected to play a more important role. Additional controlled studies taking these factors into account are necessary to identify their influence.

THE TREATMENT OF SOCIAL PHOBIA - THE DIFFERENTIAL EFFECTIVENESS OF EXPOSURE IN-VIVO AND AN INTEGRATION OF EXPOSURE IN-VIVO, RATIONAL-EMOTIVE THERAPY AND SOCIAL SKILLS TRAINING

Thirty-four social phobic patients were treated with either exposure in vivo or an integrated treatment, consisting of rational emotive therapy, social skills training and exposure in vivo. Comparison with a waiting-list control group showed the effectiveness of both treatments. Contrary to expectations, the integrated approach was not superior over exposure in vivo alone. Also, the long-term effectiveness of both treatments was equally good.

SOCIAL PHOBIA - INDIVIDUAL-RESPONSE PATTERNS AND THE LONG-TERM EFFECTS OF BEHAVIORAL AND COGNITIVE INTERVENTIONS - A FOLLOW-UP-STUDY

In this study the long-term effectiveness of Social Skills Training (SST) and Rational Emotive Therapy (RET), on social phobia was studied, as well as the differential influence of patient characteristics on treatment effectiveness. Fifty-seven patients were assessed 14 months after the post-test. Results showed that long-term effectiveness was independent of the response-pattern of the patients. Comparisons between methods, irrespective of the response-pattern of the patients, showed no differences in effectiveness in favor of either SST or RET. Explorative analysis indicated the potential predictive power for treatment-outcome of confederate ratings of overt behavior on the SSIT. Patients who needed additional treatment appeared to perform significantly worse on this measure at the pretest. No factors could be traced that predict relapse after a relatively successful treatment.

The reliability and validity of the Seasonal Pattern Assessment Questionnaire: a comparison between patient groups

BACKGROUND The Seasonal Pattern Assessment Questionnaire (SPAQ) is a frequently used screening instrument in the research on Seasonal Affective Disorder (SAD). Nevertheless, studies on its reliability and validity are relatively scarce. In the present study the reliability and the contrast validity of the SPAQ are investigated. METHODS SAD patients, selected by means of a clinical interview, non-seasonal depressed out-patients, non-depressed out-patients, and a control group, are contrasted to estimate the discriminating power of the SPAQ. Also, the reliability and factor structure of the seasonality and the climate subscales are investigated. To study food intake the Seasonal Food Preference Questionnaire (SFPQ) was developed. RESULTS The SAD criterion of the SPAQ shows good specificity (94%), but a low sensitivity (44%). Discriminant analysis shows sufficient ability to classify subjects (81% correctly classified). The Global Seasonality Scale has a good internal consistency. It consists of two factors, a psychological factor and a food factor. The SFPQ is sensitive for carbohydrate intake by SAD patients. LIMITATIONS Most SAD patients had received treatment and completed the SPAQ while they were not depressed, which may have influenced the sensitivity. CONCLUSIONS The SPAQ is not sensitive enough to be considered a diagnostic instrument for SAD. Nevertheless, it is accurate enough to be used as a screenings instrument. The only false positives were found in the depressive group. The accuracy of prevalence Figs. can be improved by completion of the SPAQ in the summer months, combined with the completion of a depression scale.

Nonverbal interpersonal sensitivity and persistence of depression : Perception of emotions in schematic faces

Deficits in the decoding of facial emotional expressions may play a role in the persistence of depression. In a prospective longitudinal study, 33 depressed outpatients (30 major depression, 2 dysthymia, and 1 cyclothymic disorder) judged schematic faces with respect to the emotions they expressed (fear, happiness, anger, sadness, disgust, surprise, rejection, and invitation) at admission (T0) and again 6 and 30 weeks later. Severity of depression (BDI) was assessed at these three times. Those patients who perceived less sadness, rejection, or anger in faces at T0 were less likely to show a favorable course of depression after 6 weeks (sadness, anger) or after 30 weeks (sadness, rejection, anger). These relationships could not be ascribed to initial levels of depression, age, or gender. The perception of sadness and rejection did not change over time, and therefore may have trait-like qualities. Depression appears to be more persistent in the subgroup that is hyposensitive to (negative) facial signals.

Psychophysiological and subjective reactions of social phobics and normals to facial stimuli.

Nine social phobics and 9 normal control subjects were exposed to slides of angry faces, happy faces, and neutral objects (i.e. flowers or mushrooms). Skin conductance responses (SCRs) to the stimuli and eyeblink rate (EBR) during stimulus exposure were recorded. In addition, subjects were asked to rate the stimuli in terms of pleasantness. While angry face stimuli elicited greater SCRs, stronger inhibition of EBR, and were evaluated more negatively than the other stimuli, there were no differences between social phobics and normals in these respects. Thus, the findings lend no support to the idea that social phobics are particularly sensitive to facial cues in general or to negative facial cues in particular.

Personality disorders and features in social phobia and panic disorder

The hypothesis that there is a specific relationship between social phobia (SP) and avoidant personality disorder (APD) was investigated. Using the Structured Clinical Interview for DSM-III-R Personality Disorders, we screened 32 patients with SP and 85 patients with panic disorder (PD) for the presence of personality disorders. Avoidant features were found significantly more often in SP than in PD, although the diagnosis of APD could not be established significantly more often. On the item level, APD Criterion 6 (fears being embarrassed) discriminated the strongest. Social phobics appeared to be more disturbed on Axis II than PD patients.

A randomized trial of cognitive-behavioral therapy or selective serotonin reuptake inhibitor or both combined for panic disorder with or without agoraphobia : Treatment results through 1-year follow-up

OBJECTIVE To establish the long-term effectiveness of 3 treatments for DSM-IV panic disorder with or without agoraphobia: cognitive-behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT + SSRI). As a secondary objective, the relationship between treatment outcome and 7 predictor variables was investigated. METHOD Patients were enrolled between April 2001 and September 2003 and were randomly assigned to treatment. Academic and nonacademic clinical sites participated. Each treatment modality lasted 1 year. Pharmacotherapists were free to choose between 5 SSRIs currently marketed in The Netherlands. Outcome was assessed after 9 months of treatment (posttest 1), after discontinuation of treatment (posttest 2), and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2). RESULTS In the sample (N = 150), 48% did not suffer from agoraphobia or suffered from only mild agoraphobia, while 52% suffered from moderate or severe agoraphobia. Patients in each treatment group improved significantly from pretest to posttest 1 on the primary outcome measures of level of anxiety (P < .001), degree of coping (P < .001), and remitter status (P < .001), as well as on the secondary outcome measures of depressive symptomatology (P < .001), and from pretest to posttest 2 for health-related quality of life (P < .001). Gains were preserved from posttest 2 throughout the follow-up period. Some superiority of CBT + SSRI and SSRI as compared with CBT was observed at posttest 1. However, at both follow-ups, differences between treatment modalities proved nonsignificant. Client satisfaction appeared to be high at treatment endpoint, while patients receiving CBT + SSRI appeared slightly (P < .05) more satisfied than those receiving CBT only. CONCLUSIONS No fall-off in gains was observed for either treatment modality after treatment discontinuation. SSRIs were associated with adverse events. Gains produced by CBT were slower to emerge than those produced by CBT + SSRI and SSRI, but CBT ended sooner. TRIAL REGISTRATION Netherlands Trial Register (www.trialregister.nl) Identifier: ISRCTN8156869.

Rate of improvement during and across three treatments for panic disorder with or without agoraphobia : Cognitive behavioral therapy, selective serotonin reuptake inhibitor or both combined

BACKGROUND Existing literature on panic disorder (PD) yields no data regarding the differential rates of improvement during Cognitive Behavioral Therapy (CBT), Selective Serotonin Reuptake Inhibitor (SSRI) or both combined (CBT+SSRI). METHOD Patients were randomized to CBT, SSRI or CBT+SSRI which each lasted one year including three months of medication taper. Participating patients kept record of the frequency of panic attacks throughout the full year of treatment. Rate of improvement on panic frequency and the relationship between rate of improvement and baseline agoraphobia (AG) were examined. RESULTS A significant decline in frequency of panic attacks was observed for each treatment modality. SSRI and CBT+SSRI were associated with a significant faster rate of improvement as compared to CBT. Gains were maintained after tapering medication. For patients with moderate or severe AG, CBT+SSRI was associated with a more rapid improvement on panic frequency as compared to patients receiving either mono-treatment. LIMITATIONS Frequency of panic attacks was not assessed beyond the full year of treatment. Second, only one process variable was used. CONCLUSIONS Patients with PD respond well to each treatment as indicated by a significant decline in panic attacks. CBT is associated with a slower rate of improvement as compared to SSRI and CBT+SSRI. Discontinuation of SSRI treatment does not result in a revival of frequency of panic attacks. Our data suggest that for patients without or with only mild AG, SSRI-only will suffice. For patients with moderate or severe AG, the combined CBT+SSRI treatment is recommended.

Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the treatment for panic disorder

The objective of this study was to assess the cost‐effectiveness of three empirically supported treatments for panic disorder with or without agoraphobia: cognitive behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT+SSRI).