Concurrent Psychotherapy Research Articles

Dose-Effect of Children’s Psychosocial Rehabilitation on the Daily Functioning of Youth with Serious Emotional Disturbance

Children’s psychosocial rehabilitation (CPSR) is a promising but under-evaluated home- and community-based treatment for children with serious emotional disturbance (SED). CPSR addresses the functional impairments of children with SED through an asset-based, skill-building approach that involves multiple systems in the child’s life. The present study evaluated the effectiveness of CPSR by examining the relationship between the number of hours of CPSR received (dose) and changes in children’s daily functioning (effect). Data came from a retrospective review of medical charts at a site with a well-specified CPSR model. Trained raters assessed children’s functioning at intake and 4 months post-intake using the Child and Adolescent Functional Assessment Scale or the Preschool and Early Childhood Functional Assessment Scale. After controlling for initial severity of impairment and receipt of concurrent psychotherapy and medication, regression analyses revealed children receiving larger doses of CPSR exhibited better daily functioning and had better odds of achieving clinically significant improvement than children receiving lower doses of CPSR. Findings suggest CPSR is a beneficial treatment for children with SED. Further study of this innovative treatment is warranted.

Psychiatric Treatment Received by Primary Care Patients With Panic Disorder With and Without Agoraphobia

Psychiatric Treatment Received by Primary Care Patients With Panic Disorder With and Without Agoraphobia

The Effects of a Multidisciplinary Approach to Treatment in the Recovery of Males and Females Diagnosed with Anorexia Nervosa in the Presence and Absence of Co-Morbid Obsessive Compulsive Disorders

ABSTRACT The objectives of this study were to evaluate whether a multidisciplinary residential treatment program for eating disorders had a positive impact in the recovery of 107 individuals (72 females and 35 males) diagnosed with anorexia nervosa (AN) in the presence and absence of comorbid obsessive-compulsive disorders (OCD) and to explore gender differences in the response to treatment. Residential treatment used concurrent psychotherapy, which combines group, family, and individual therapies in a multidisciplinary approach. The results show that symptoms of depression decreased and weight increased during treatment in all patients groups. Symptoms were more severe in individuals with comorbid OCD and improvements were more pronounced in males compared to females.

Child and Adolescent Clinical Psychopharmacology Made Simple

There are many informative books available on the topic of psychopharmacology, but it is difficult to find concise and informative guidelines for treating children and adolescents. In addition, most psychiatric medications are not approved for use in children, and the U.S. Food and Drug Administration has placed limitations on using certain medications with this population. Practicing psychopharmacology with children and adolescents is not only more challenging clinically, it is also a much riskier practice clinically and medicolegally than practicing adult psychopharmacology; this book addresses these issues in a very precise manner. Dr. Preston, a well-known leader in teaching clinical psychopharmacology, has combined his knowledge with that of Dr. O'Neal (a psychiatrist) and Dr. Talaga (a psychiatric pharmacist) to produce a brief but informative practice guide for mental health and medical professionals alike. The book is well organized, with an introductory chapter that highlights current issues in prescribing psychiatric medications for children and adolescents followed by succinct chapters on each diagnostic category. This book also covers diagnoses such as autism, Tourette's disorder, and tic disorder, which are often omitted. I am not aware of a comparable book on the market that addresses treatment issues in an equally brief yet informative manner. This book addresses several pertinent issues in treating children and adolescents, including specific medical guidelines as well as often neglected yet vital contributory issues such as family dynamics, social variables, and cultural issues. Also included in this text are important concepts that might be overlooked by clinicians who are not used to treating this population; these include clinically significant changes in hepatic metabolism that accompany puberty, the need for concurrent psychotherapy with any psychopharmacology, the reality that parents who do not 100% endorse your treatment will often sabotage it, and the fact that clinicians who treat these patients will be prescribing mainly off-label and to a population that receives significant negative media coverage in regards to psychiatry. This book is easy to read and is based on both relevant clinical experience and sound research. In a book this size that covers a topic this big, there are bound to be omissions, and most of the omissions noted were secondary only to the depth allowed in a reference-based publication. However, I did discover some omissions that most likely should have been included. For example, very little coverage was given to the use of atypical antipsychotics for childhood bipolar disorder, which is out of step with current research and practice. Aside from mainly minor omissions, this book covered a very broad, difficult, and contentious psychiatric specialty in a very informative manner. I would recommend this book to my peers.

Treating Acute Stress Disorder and Posttraumatic Stress Disorder with Cognitive Behavioral Therapy or Structured Writing Therapy: A Randomized Controlled Trial

Background: Writing assignments have shown promising results in treating traumatic symptomatology. Yet no studies have compared their efficacy to the current treatment of choice, cognitive behavior therapy (CBT). The present study evaluated the efficacy of structured writing therapy (SWT) and CBT as compared to a waitlist control condition in treating acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Methods: A randomized controlled trial was conducted at an outpatient clinic. Participants (n = 125) (a) satisfied DSM-IV criteria for ASD or PTSD, (b) were 16 years or older, (c) were sufficiently fluent in Dutch or English, (d) had no psychiatric problems except ASD or PTSD that would hinder participation or required alternative clinical care, and (e) received no concurrent psychotherapy. Treatment consisted of five 1.5-hour sessions of CBT or SWT for participants with ASD or acute PTSD and ten 1.5-hour sessions for participants with chronic PTSD. Outcome measures included the Structured Clinical Interview for DSM-IV, Impact of Event Scale, Beck Depression Inventory, State-Trait Anxiety Inventory and the Dissociative Experiences Scale. Results: At posttest and follow-up, treatment was associated with improved diagnostic status and lower levels of intrusive symptoms, depression and state anxiety, while a trend was noted for the reduction of avoidance symptoms. Treatment did not result in lower levels of trait anxiety or dissociation. No differences in efficacy were detected between CBT and SWT. Conclusions: The present study confirmed the efficacy of CBT for ASD and PTSD and identified SWT as a promising alternative treatment.

The Clinical Dilemma of Using Medications in Substance-Abusing Adolescents and Adults with Attention-Deficit/Hyperactivity Disorder: What Does the Literature Tell Us?

Adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUD) are increasingly recognized in clinical practice. The role of pharmacological treatment for ADHD in these comorbid individuals remains unclear. A systematic review of the medical literature was conducted through PubMed, supplemented with data from scientific presentations, to evaluate the role of medication treatment of ADHD in substance abusing individuals with ADHD. Meta-analysis was used to evaluate the effects of medication therapy on ADHD and SUD outcomes in general, while specifically addressing trial design, trial duration, retention, class of medication, age group, concurrent psychotherapy, and outcome in both SUD and ADHD domains. Four studies in adolescents and five studies in adults with ADHD plus SUD were identified (two controlled and seven open studies; n = 222 subjects). The standard mean difference (SMD) indicated statistically significant improvements in ADHD and SUD that were not maintained when evaluating controlled studies only. Albeit limited by power, trial duration, retention rate, and age group did not influence outcome. No worsening of SUD or drug-drug interactions were observed in any of the studies. The results could not be accounted for by any single study or by publication bias. Treating ADHD pharmacologically in individuals with ADHD plus SUD has a moderate impact on ADHD and SUD that is not observed in controlled trials and does not result in worsening of SUD or adverse interactions specific to SUD. Further controlled trials evaluating the effect of novel combinations of psychotherapy and ADHD pharmacotherapy on SUD relapse in these groups are warranted.

Are chronic low back pain outcomes improved with co-management of concurrent depression?

ObjectiveTo discuss the role of depression in chronic lower back pain and comment on appropriate methods of screening and co-management.Data SourcesThe current scientific literature was investigated using the online web databases CINAHL, Medline/PUBMED, Proquest, Meditext and from manual library searches.Data ExtractionDatabases were searched from 1980 to the present (2005). Articles were searched with the key words "depression" and "low back pain". Over three hundred articles were sourced and articles were then selected on their relevance to the chronic spinal pain states that present to manual therapy practitioners.Data synthesisPain is a subjective awareness of peripheral nociceptive stimulation, projected from the thalamus to the cerebral cortex with each individual's pain experience being mediated by his or her psychological state. Thus a psychological component will often be associated with any painful experience. A number of studies suggest (among other things) that the incidence of depression predicts chronicity in lower back pain syndromes but that chronic lower back pain does not have the reciprocal action to predict depression.ConclusionThe aetiology of chronic pain is multifactorial. There is sufficient evidence in the literature to demonstrate a requirement to draw treatment options from many sources in order to achieve a favourable pain relief outcome. The treatment should be multimodal, including mental and emotional support, counseling and herbal advice. While a strong correlation between depression and chronic low back pain can be demonstrated, an apparent paucity of literature that specifically addresses the patient response to chiropractic treatment and concurrent psychotherapy identifies the need for prospective studies of this nature to be undertaken. It is likely that multimodal/multidisciplinary treatment approaches should be encouraged to deal with these chronic lower back pain syndromes.

Increased Maintenance of Obsessive-Compulsive Disorder Remission after Integrated Serotonergic Treatment and Cognitive Psychotherapy Compared with Medication Alone

Background: Both medication and psychotherapy are effective in obsessive-compulsive disorder (OCD). However, they both have disadvantages. We aimed at studying the long-term effectiveness of integrated treatment compared with medication alone. Methods: A private practice sample of 20 consecutive patients with OCD (DSM-III-R) who achieved remission or marked improvement [Yale-Brown Obsessive-Compulsive Scale (YBOCS) score ≤10 and Global Assessment of Functioning (GAF) scale score ≧70] after drug treatment (clomipramine or selective serotonin reuptake inhibitors for 12–24 months) with or without concurrent cognitive psychotherapy were followed up. In the integrated treatment group, psychotherapy was started on the second or third visit and was timed to end after medication. Efforts were applied to integrate treatments within a biopsychosocial theoretical framework. As randomisation was not feasible in the study setting, treatment allocation was based on patients’ preference. Patients were assessed before treatment, after treatment and at each follow-up contact with the YBOCS, the Hamilton Depression Rating Scale, and the GAF scale. Kaplan-Meier survival analysis was performed on the time to OCD relapse. Results: Of the factors studied (gender, age, duration of disorder, severity of OCD symptoms at baseline), only treatment was associated with outcome. Of 10 patients treated with medication alone, 8 relapsed. Of 10 patients who received integrated treatment, only 1 relapsed. The estimated mean survival time was significantly higher (p < 0.001) in the integrated treatment group (132 months, 95% CI 107–157) than in the medication group (25 months, 95% CI 12–38). Conclusions: Although our results need confirmation by further, more robust studies, the long-term superiority of integrated treatment over medication alone was large. Patients with OCD might have viable options other than long-term drug treatment.

Concurrent Group and Individual Psychotherapy in a Psychiatric Day Hospital for Depressed Elderly

Concurrent psychotherapy is used in various settings for patients of different diagnoses and ages. The concurrent group and individual psychotherapy of older adults with depressive disorders in a psychiatric day hospital is described, emphasizing phases of treatment and transference and countertransference themes uniquely relevant to working with depressed elderly patients in a day hospital. Case examples are offered to illustrate these issues. The special technical considerations that need to be utilized when multiple therapists and settings are present are described. The model employs the use of an integrative, interactive group therapy, along with various other group treatments and antidepressant medication, with individual therapy serving a subordinate but organizing role.

Increased Probability of Remaining in Remission from Panic Disorder with Agoraphobia after Drug Treatment in Patients Who Received Concurrent Cognitive-Behavioural Therapy: A Follow-Up Study

Background: Many short-term trials suggested that the combination of psychotherapy with medication might be more effective than either treatment alone. However, only few studies examined the long-term effectiveness of this combination. Methods: A private practice sample of consecutive patients with DSM-III-R panic disorder with agoraphobia who achieved remission after drug treatment with or without concurrent cognitive-behavioural psychotherapy were followed up. Patients were assessed before treatment, after treatment and at each follow-up contact with the Marks-Sheehan Phobia Scale, the Hamilton Anxiety Rating Scale, and the Hamilton Depression Rating Scale. Kaplan-Meier survival analysis was performed on the time to panic disorder relapse. Cox regression analysis was used to control for the possible confounding effect of factors other than treatment. Results: Of patients who received medication alone (n = 32), 25 (78.1%) relapsed, prevalently (65.6%) during the first year. The estimated mean survival time was 12 months (95% CI 7–17). Of patients who received integrated treatment (n = 21), only 3 (14.3%) relapsed. The estimated mean survival time was 65 months (95% CI 44–86). Treatment was the only variable associated with the occurrence of relapse, with a hazard ratio of 12.6 (95% CI 2.5–63.3) for patients who received only medication. Conclusions: Some methodological limitations, such as treatment allocation by preference, suggest caution in the interpretation of our results. However, the long-term therapeutic advantage of integrated treatment over medication alone was large and independent from known prognostic factors. The long-term effectiveness of integrated treatment should be tested with a randomised controlled trial.

New Drugs for Old Folks: The Evidence‐Based Argument for Newer Antidepressants

QUESTION: What are the comparative benefits and drawbacks of the newer medicinal and botanical therapies for depression?BACKGROUND: Depressive symptoms and disorders are prevalent and one of the leading causes of disability worldwide. The first generation of antidepressants, the tricyclic agents and monoamine oxidase inhibitors, represented a major therapeutic advance. Nonetheless, dangerous side effects and potential lethality in overdose limited their use. Seniors with a clinically significant level of depressive symptoms were more likely to receive a benzodiazepine than an antidepressant.1 Difficulty distinguishing depression from self‐limiting reactions to acute illness and injury also kept the generalist's threshold for prescribing an antidepressant high. The introduction and proliferation of selective serotonin reuptake inhibitors for the treatment of depression promised a golden era of psychopharmacology similar to that previously experienced with the pharmacotherapy of cardiovascular disease. However, further data on recurrence rates, the frequency with which patients discontinue treatment and greater experience with the newer agents have blunted the initial enthusiasm. The newer agents may be safer but they are not as easy to use as originally advertised, and there are so many of them. As a result, for generalists who prescribe the majority of antidepressants, the art of individualized treatment is stretched far beyond the science needed for an informed decision. This is even more the case for the youngest and oldest patients and those whose symptom presentation or physical conditions confound accepted diagnoses. Until large‐scale, multi‐site studies with representative rather than highly selected patient samples are completed, literature reviews such as Williams et al.'s will be crucial.DATA SOURCES: The authors review data from the Cochrane Collaboration Depression, Anxiety and Neurosis Group's specialized registry of 8451 clinical trials, meta‐analyses, and expert opinion in the English and non‐English language literature from 1980 to January 1998.STUDY SELECTION CRITERIA: Randomized trials of the selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and St. John's wort that reported clinical outcomes.DATA EXTRACTION: Two individuals independently abstracted the studies for descriptive synthesis in which some data were pooled using a random‐effects model.MAIN RESULTS: Most of the trials evaluated acute‐phase outpatient treatment of major depression in middle‐aged adults. Newer antidepressants were superior to placebo for major depression and dysthymia by a relative benefit factor of 1.6 to 1.7. Slightly more than half those receiving an antidepressant had a substantial reduction in symptoms compared with one‐third of patients who responded similarly to placebo. The new antidepressants were effective for both geriatric and primary care patients. No single agent or group emerged as preferred. Efficacy was nearly identical from one agent to another, whether old or new. Although adverse effect profiles differed substantially, overall discontinuation rates between the older and newer agents were comparable. St. John's wort was clearly superior to placebo but not to low‐dose first‐generation tricyclics (imipramine, amytriptyline, monoamine) in either efficacy or drop‐out rates. Data on the treatment of subsyndromal depression, depression in patients with comorbid physical or mental illness, and depression among adolescents were insufficient for a meaningful interpretation.CONCLUSION: The newer agents are safe and effective. The evidence does not support their absolute superiority over the second‐generation tricyclic nortriptyline, although they have supplanted the first‐generation antidepressants in clinical practice. Further information is needed regarding newer agents for the treatment of mood disorders beyond major depression and among more representative clinical populations. Data on the options for persons not responding to the initial prescription, those who will require concurrent psychotherapy, and the relative clinical and economic benefits of botanicals over the newer agents are insufficient. The treatment data deficiency is most striking among adolescents and ethnic minority groups.

Antidepressant treatment for depression: total charges and therapy duration*

BACKGROUND: The economic costs of depression are significant, both the direct medical costs of care and the indirect costs of lost productivity. Empirical studies of antidepressant cost-effectiveness suggest that the use of selective serotonin reuptake inhibitors (SSRIs) may be no more costly than tricyclic antidepressants (TCAs), will improve tolerability, and is associated with longer therapy duration. However the success of depression care usually involves multiple factors, including source of care, type of care, and patient characteristics, in addition to drug choice. The cost-effective mix of antidepressant therapy components is unclear. AIMS OF THE STUDY: Our study evaluates cost and antidepressant-continuity outcomes for depressed patients receiving antidepressant therapy. Specifically, we determined the impact of provider choice for initial care, concurrent psychotherapy, and choice of SSRI versus TCA-based pharmacotherapies on the joint outcome of low treatment cost and continuous antidepressant therapy. METHODS: A database of private health insurance claims identifies 2678 patients who received both a diagnosis of depression and a prescription for an antidepressant during 1990-1994. Patients each fall into one of four groups according to whether their health care charges are high versus low (using the median value as the break point) and by whether their antidepressant usage pattern is continuous versus having discontinued pharmacotherapy early (filling fewer than six prescriptions). A bivariate probit model controlling for patient characteristics, co-morbidities, type of depression and concurrent treatment is the primary multivariate statistical vehicle for the cost-effective treatment situation. RESULTS: SSRIs substantially reduce the incidence of patients discontinuing pharmacotherapy while leaving charges largely unchanged. The relative effectiveness of SSRIs in depression treatment is independent of the patient's personal characteristics and dominates the consequences of other treatment dimensions such as seeing a mental health specialist and receiving concurrent psychotherapy. Initial provider specialty is irrelevant to the continuity of pharmacotherapy, and concurrent psychotherapy creates a tradeoff through reduced pharmacotherapy interruption with higher costs. DISCUSSION: Longer therapy duration is associated with SSRI-based pharmacotherapy (relative to TCA-based pharmacotherapy) and with concurrent psychotherapy. High cost is associated with concurrent psychotherapy and choice of a specialty provider for initial care. In our study cost-effective care includes SSRI-based pharmacotherapy initiated with a non-specialty provider. Previous treatment history and other unobserved factors that might affect antidepressant choice are not included in our model. IMPLICATIONS FOR HEALTH CARE PROVISION: The decision to use an SSRI-based pharmacotherapy need not consider carefully the patient's personal characteristics. Shifting depressed patients' pharmacotherapy away from TCAs to SSRIs has the effect of improving outcomes by lowering the incidence of discontinuation of pharmacotherapy while leaving largely unchanged the likelihood of having high overall health care charges. Targeted use of concurrent psychotherapy may be additionally cost-effective. IMPLICATIONS FOR HEALTH POLICIES: The interaction of various components of depression care can alter the cost-effectiveness of antidepressant therapy. Our results demonstrate a role for the non-specialty provider in initiating care and support increased use of SSRIs as first-line therapy for depression as a way of providing cost-effective care that is consistent with APA guidelines for continuous antidepressant treatment. IMPLICATIONS FOR FURTHER RESEARCH: Further research that improves our understanding of how decisions regarding provider choice, concurrent psychotherapy, and drug choice are made will improve our understanding of the effects treatment choices on the cost-effectiveness of depression care. We have suggested that targeted concurrent psychotherapy may prove to be cost-effective; research to determine groups most likely to benefit from the additional treatment would further enable clinicians and healthcare policy makers to form a consensus regarding a model for treating depression.

Antidepressant treatment for depression: total charges and therapy durationSource of funding: Research funded by Eli Lilly and Company. Drs. Croghan, Melfi, and Obenchain are employees and stockholders of Eli Lilly and Company. The study was performed while Dr. Kniesner was a Visiting Research Fellow at Eli Lilly and Company. It was also performed in partial fulfillment of the requirements for

Background: The economic costs of depression are significant, both the direct medical costs of care and the indirect costs of lost productivity. Empirical studies of antidepressant cost-effectiveness suggest that the use of selective serotonin reuptake inhibitors (SSRIs) may be no more costly than tricyclic antidepressants (TCAs), will improve tolerability, and is associated with longer therapy duration. However the success of depression care usually involves multiple factors, including source of care, type of care, and patient characteristics, in addition to drug choice. The cost-effective mix of antidepressant therapy components is unclear. Aims of the Study: Our study evaluates cost and antidepressant-continuity outcomes for depressed patients receiving antidepressant therapy. Specifically, we determined the impact of provider choice for initial care, concurrent psychotherapy, and choice of SSRI versus TCA-based pharmacotherapies on the joint outcome of low treatment cost and continuous antidepressant therapy. Methods: A database of private health insurance claims identifies 2678 patients who received both a diagnosis of depression and a prescription for an antidepressant during 1990–1994. Patients each fall into one of four groups according to whether their health care charges are high versus low (using the median value as the break point) and by whether their antidepressant usage pattern is continuous versus having discontinued pharmacotherapy early (filling fewer than six prescriptions). A bivariate probit model controlling for patient characteristics, co-morbidities, type of depression and concurrent treatment is the primary multivariate statistical vehicle for the cost-effective treatment situation. Results: SSRIs substantially reduce the incidence of patients discontinuing pharmacotherapy while leaving charges largely unchanged. The relative effectiveness of SSRIs in depression treatment is independent of the patient's personal characteristics and dominates the consequences of other treatment dimensions such as seeing a mental health specialist and receiving concurrent psychotherapy. Initial provider specialty is irrelevant to the continuity of pharmacotherapy, and concurrent psychotherapy creates a tradeoff through reduced pharmacotherapy interruption with higher costs. Discussion: Longer therapy duration is associated with SSRI-based pharmacotherapy (relative to TCA-based pharmacotherapy) and with concurrent psychotherapy. High cost is associated with concurrent psychotherapy and choice of a specialty provider for initial care. In our study cost-effective care includes SSRI-based pharmacotherapy initiated with a non-specialty provider. Previous treatment history and other unobserved factors that might affect antidepressant choice are not included in our model. Implications for Health Care Provision: The decision to use an SSRI-based pharmacotherapy need not consider carefully the patient's personal characteristics. Shifting depressed patients' pharmacotherapy away from TCAs to SSRIs has the effect of improving outcomes by lowering the incidence of discontinuation of pharmacotherapy while leaving largely unchanged the likelihood of having high overall health care charges. Targeted use of concurrent psychotherapy may be additionally cost-effective. Implications for Health Policies: The interaction of various components of depression care can alter the cost-effectiveness of antidepressant therapy. Our results demonstrate a role for the non-specialty provider in initiating care and support increased use of SSRIs as first-line therapy for depression as a way of providing cost-effective care that is consistent with APA guidelines for continuous antidepressant treatment. Implications for Further Research: Further research that improves our understanding of how decisions regarding provider choice, concurrent psychotherapy, and drug choice are made will improve our understanding of the effects treatment choices on the cost-effectiveness of depression care. We have suggested that targeted concurrent psychotherapy may prove to be cost-effective; research to determine groups most likely to benefit from the additional treatment would further enable clinicians and healthcare policy makers to form a consensus regarding a model for treating depression. Copyright © 2000 John Wiley & Sons, Ltd.

Effect of Mental Health Specialty Care on Antidepressant Length of Therapy

Treatment of depression with medications and psychotherapy clearly is efficacious, but not all patients require such intensive therapy. In this report, we examine the costs and effects of dual treatment on a population of employees and their families with depression. We sought to determine the costs and length of medication treatment consequences of providing mental health specialty care to antidepressant-treated individuals. A quasi-experimental retrospective design was used to examine the administrative data of 2678 antidepressant users whose insurance claims are included in the MarketScan database. The primary measure used was joint cost-continuity of antidepressant medication. Patients receiving concurrent psychotherapy were more likely to achieve length of antidepressant treatment consistent with current recommendations. The cost-consequence ratio for concurrent treatment was $4062/1% improvement in the number of adequately treated individuals. Adding psychotherapy to treatment with medication appears to improve the efficacy of antidepressant treatment. The incremental costs suggest that it is a valuable addition in most cases and should be considered cost-effective.

Concurrent psychotherapy and pharmacotherapy in the treatment of depression and anxiety in cancer patients.

Over the past 30 years, numerous studies have compared the relative effectiveness of psychotherapy, pharmacotherapy, and concurrent therapeutic approaches in treatment of common psychiatric disorders, such as depression and anxiety. Generally, these studies have demonstrated that the combined approach is somewhat more effective in treating the disorder in question, as well as in preventing relapse. A number of theories regarding the reasons for this finding have been proposed. The application of this therapeutic approach to the specific population of cancer patients has not been studied in systematic research. This paper briefly reviews the studies comparing the efficacies of various treatment approaches for depression, discusses reasons for the efficacy of such an approach, and outlines a series of reasons why this may be the preferred model for intervening with cancer patients.

Medication treatment for eating disorders

Existing studies of medication treatment for eating disorders have tended to focus on the acute phase of recovery. In the case of Anorexia Nervosa, most studies have been carried out in inpatients, the goal being more rapid or greater weight gain, and medication effects have been marginal at best. For Bulimia Nervosa, antidepressants have been found to be superior to placebo in the short term treatment of outpatients not receiving concurrent psychotherapy, but their long term utility is questionable. We are now entering a second phase of progress in which the role of medication in an overall treatment plan and in all phases of recovery is being explored. In addition, the utility of medication treatment for related syndromes, such as Binge Eating Disorder, remains to be more fully assessed.

Recognizing Dissociative Disorders in Patients With Chemical Dependency

Atypical relapses and unusually intense emotional pain in patients being treated for chemical dependency can alert clinicians to the possibility of comorbid dissociative disorders. The DES can be given as a simple screening instrument. Diagnoses should be based on a follow-up clinical interview and may be supported by administration of the DDIS or SCID-D. Referral for concurrent individual psychotherapy to a clinician knowledgeable about dissociative disorders is recommended.

Effect of a long‐lasting gonadotrophin hormone‐releasing hormone agonist in six cases of severe male paraphilia

Six men with severe paraphilia had been treated with depot gonadotrophin luteinizing releasing hormone analogue (GnRHa) (triptorelin 3.75 mg per month intramuscularly). In 5 cases, the treatment ended their deviant sexual behavior and markedly decreased their sexual fantasies and activities without further significant side effects than those related to hypoandrogenism. This clinical improvement was parallel to the gradual decrease of plasma testosterone level to castration values within the first month. The beneficial effect of this treatment had been maintained at follow-up varying from 7 months to 3 years. One patient interrupted the treatment at the end of the first year and relapsed within 10 weeks. GnRHa treatment, which leads to reversible castration, may constitute a promising treatment of paraphilic behavior and may favor the possibility of concurrent psychotherapy.

Pelvic pain and pelvic venous congestion

AbstractMany women undergo laparoscopy for the investigation of chronic pelvic pain with negative results. Pelvic venography has facilitated the identification of pelvic venous congestion which is an important cause of otherwise unexplained pelvic pain. The use of ultrasound has indicated a possible causal relationship with ovarian dysfunction. Psychological studies have been limited by methodological problems but have indicated differences which might account for perception of physiological sensation as painful, and have pointed to antecedent factors such as child sexual abuse. Pelvic pain with venous congestion responds well to treatment by ovarian suppression with medroxyprogesterone acetate and the duration of benefit is enhanced by concurrent psychotherapy.

Nonphysician Psychotherapist- Physician Pharmacotherapist: A New Model for Concurrent Treatment

In the last century the mental health field has vacillated between a biologic versus a psychologic model of the mind. Only in the last two decades have proponents of both views calmly discussed their virtues and limitations. As a result, clinicians have begun to promulgate the concept of an integrated, concurrent psychotherapy and pharmacotherapy. While this debate has raged in the psychiatric field there has been a parallel proliferation of nonphysician mental health professionals. Most of these mental health clinicians come from training programs steeped in the traditions of a psychodynamically based treatment that occurs within the interpersonal context. Today more and more of these clinicians compete for the increasing population of those seeking relief. The result of these two movements has been the introduction of a unique form of treatment in which a patient sees two therapists. In this triangular treatment, the pharmacotherapist prescribes medications and the psychotherapist provides the interpersonal therapy. In order for all practitioners to participate in this form of triadic treatment they must appraise themselves of not only the historical debates preceding this therapeutic concordance but of the transference and countertransference potentials. Some patients can have idealizing, magical, and nurturing transferences toward either therapist in the triangular relationship. Other patients can be narcissitically wounded, with a negative devaluing response toward either therapist. Paralleling the patient's transference distortions are the therapists' countertransference reactions. These can run from the omnipotent identification with the patient's idealization to the devalued, distancing response toward oneself or the patient. If these distortions are not checked they can intrude on the treatment, acting out the patient's internal split self-object representations and ultimately sabotaging treatment. Successful attention to transference and countertransference phenomena can lead to an enhanced treatment in which the biologic and psychologic treatments have a synergistic effect. Only then will we be capable of fully evaluating and researching the positive and negative effects of combined psychotherapy and pharmacotherapy with two different therapists. The outgrowth of this research will be improved patient care by enhancing our capacity to identify those patients and therapists who are good candidates for this triangular treatment relationship.