Different Forms Of Psychotherapy Research Articles

Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE)

BackgroundCluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients.ObjectiveIn this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators.MethodsThis is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18–65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months.DiscussionThis is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons.Trial registrationNL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

Beyond the specific factors versus common factors debate: Lacan’s four discourses informing Wampold and Imel’s contextual model of psychotherapy efficacy

This article is a critical reflection on the limitations of current metatheoretical models of psychotherapy efficacy that have emerged from the historic specific factors versus common factors debate. It argues that while Wampold and Imel’s (2015) contextual model of psychotherapy efficacy does capture the importance of the real relationship occurring across diverse modalities of psychotherapy, it inadequately accounts for important differences in psychotherapy relationships stemming from the different intersubjective contexts produced by different modalities of psychotherapy. This leaves Wampold and Imel’s contextual model open to criticism from Butler and Strupp’s (1986) earlier warning against producing a new “uniformity myth” of the therapeutic relationship. Lacan’s four discourses are introduced and discussed as a theoretical framework helpful for distinguishing different intersubjective contexts occurring in different forms of psychotherapy, with the implication that these contexts may produce distinct, qualitatively different kinds of psychotherapy effects.

Integrative psychotherapy of patients with schizophrenic spectrum disorders

IntroductionPsychotherapy of patients suffering from schizophrenic disorders remains controversial. There are promising descriptions of psychothereputic interventions in combination with pharmacological treatment. Some empirical studies show that different forms of psychotherapy are effective. However, there are few models to combine different psychotherapeutic strategies in a comprehensive way.ObjectivesWe here propose a model of integrative psychotherapy that is based on the therapeutic alliance and the general principles of understanding and communication. It comprises interpersonal, behavioral, psychodynamic, and existential elements.MethodsTheoretical principles of different psychotherapeutic schools are applied hermeneutically to a case of schizophrenia. Thus, general methods of psychotherapy gain contextual meaning by the analysis of an individual narrative. The patient himself assessed and approved his case report.ResultsAfter remission of the acute symptoms, integrative psychotherapy played the major role in the recovery of a young musician. It is shown how the therapeutic alliance and communication in a general sense interacted with behavioral, cognitive, psychodynamic, and existential techniques. It is demonstrated narratively how recovery was facilitated, adjunct to pharmacological treatment, by method-integrative psychotherapy. Basic cognitive-behavioral techniques ensured at first the stabilization of the patient. Then psychodynamic remembering, repeating, and working through became possible. Finally, existential topics and creative solutions dominated the sessions.ConclusionsPsychotherapeutic method-integration is necessary to treat patients with various mental disorders especially schizophrenia. We propose an ABCDE-Model that comprises the following principles: Therapeutic alliance (A); behavior change (B); cognitive reflection on dysfunctional meanings and beliefs (C); psychodynamic remembering, repeating, and working through (D); and existential understanding and communication (E).

The Integration of Mainstream Psychotherapies in an Epistemological Framework

Different forms of psychotherapy often construct theories and techniques based on different epistemological frameworks. Because of epistemological conflicts, some psychotherapy seems incompatible with each other. However, the problems encountered in psychotherapy are complex and multifaceted, and each psychotherapy has shown its shortcomings. So many researchers and practitioners were trying to use a combination of treatment techniques and integrate various psychotherapy in a treatment plan. Integrating different schools of psychotherapy requires an epistemological framework that can accommodate different psychotherapy to help them develop their strengths and prevent conflict. This paper proposed an epistemological framework based on system theory and the uncertainty principle. Through this framework, this paper attempted to reinterpret some of the mainstream psychotherapy and identified the underlying factors that are effective in their treatment. Finally, this paper put forward the methods and directions of integrating these psychotherapies into an epistemological framework.

On Psychosomatic Problems in Dentistry.

In their daily practice dentists frequently have patients showing signs of stress-related oral manifestations in different forms. Stress-related aetiology of oral changes are still not investigated enough, and present a subgroup of psychosomatic diseases which had been recognized in medicine a long time ago. Recognition of such psychological or emotional disturbance needs deep evaluation "per exclusionem", and is beneficial for both the patient and clinician. Psychological management should be taken into consideration when treating patients with these psychosomatic disorders. Therapeutic approach comprises different forms of psychotherapy and medication as well.

Psychotherapy with Children and Adolescents with First Episode Psychosis: Limitations of the Research

Empirical studies of children and adolescents at high-risk for psychosis and those with first episode psychosis include investigations of the associated risk factors, neurobiological correlates and longitudinal trajectories and the use of pharmacological and psychosocial interventions, but few studies compare the impact of different forms of psychotherapy with each other or with multimodal treatment with both psychotherapy and psychotropic medication. There is a scarcity of trials that compare the efficacy and long-term outcome of cognitive behavioral therapy, psychodynamic psychotherapy and family therapy with these vulnerable youth even though evidence has been accumulating about their positive impact with children, adolescents and adults with many psychiatric disorders. Research on first episode psychosis in children and adolescents needs to be enhanced by studies that ascertain the benefits of cognitive behavior therapy, psychodynamic psychotherapy, and family therapy and their role in combined treatment.

PO-01-029 Treatment of people with unusual sexual interests

Paraphilic thoughts and behaviors are quite widespread in the population. Approximately half of the general population has paraphilic thoughts or interests, but not everyone needs psychotherapeutic help. Studies about paraphilic disorders mostly contain samples with sex offenders. The care-givers need guides on how to place and how to handle expressed atypical sexual interests. With help from case studies the difference between a paraphilic disorder and an unusual sexual interest will be shown and criteria for treatment indications will be developed. Standardized risk assessment and actual treatment approaches will be presented. The focus lies on psychotherapeutic treatment. Psychotherapy is indicated and can be helpful when a patient's paraphilic interests are responsible for mental distress or when they involve another person’s psychological distress, injury, or death. For a reasonable treatment (psychotherapy, medication), a standardized risk assessment and knowledge about different forms of psychotherapy are necessary. For treatment of paraphilic interests or disorder which may endanger the patient or others special knowledge about risk assessment is needed. For patients suffering from paraphilic thoughts and/or behaviors without the risk to harm other people different kinds of treatment (p.e. affirmative psychotherapy, couples therapy) can be helpful.

A randomized controlled trial of a nursing psychotherapeutic intervention for anxiety in adult psychiatric outpatients.

To evaluate the short-term efficacy of a psychotherapeutic intervention in nursing on Portuguese adult psychiatric outpatients with the nursing diagnosis "anxiety." Several efficacious forms of treatment for anxiety are available, including different forms of psychotherapy and pharmacotherapy. However, literature tends to favour findings from studies on the efficacy of psychotherapies and therapies provided by nurses to the detriment of those arising from studies on the efficacy of nursing psychotherapeutic interventions (interventions which are classified, for instance, on Nursing Interventions Classification). Randomized controlled trial. The study was performed, between November 2016 - April 2017, at a psychiatry outpatient ward. Participants were randomly allocated to an intervention group (N=29) or a treatment-as-usual control group (N=31). Patients in the intervention group received psychopharmacotherapy with interventions integrated in the Nursing Interventions Classification for the nursing diagnosis "anxiety." A treatment-as-usual control group received only psychopharmacotherapy (if applicable). Anxiety level and anxiety self-control were the primary outcomes. Patients from both groups had reduced anxiety levels, between the pre-test and the posttest assessment; however, according to analysis of means, patients in the intervention group displayed significantly better results than those of the control group. Furthermore, only patients in the intervention group presented significant improvements in anxiety self-control. This study demonstrated the short-term efficacy of this psychotherapeutic intervention model in nursing in the decrease of anxiety level and improvement of anxiety self-control in a group of psychiatric outpatients with pathological anxiety. NCT02930473.

Sophisticated sleep improves our brains: Our advanced cognitive and social skills might derive from the evolution of improved sleep quality; today, sleep therapy could help with mental health issues and learning.

In the past decades, sleep researchers have been quietly accumulating knowledge about the physiology of sleep. Without any real health application for this knowledge, however, the public and the press have slept blissfully through most of their breakthroughs. Yet, recent findings about the evolution of sleep in humans and the effects of sleep disruption on human health seem to have finally woken the public up. A recent paper from David Samson and Charles Nunn, evolutionary anthropologists from Duke University in the USA, puts forward the hypothesis that humans have evolved more efficient sleep patterns than other primates and that this is because “[e]arly humans experienced selective pressure to fulfill sleep needs in the shortest time possible” [1]. This efficient slumber, the authors argue, might have contributed to setting our ancestors on the evolutionary path toward human civilization. The New York Times , among other newspapers, covered the publication, which follows in the wake of research indicating that human sleep patterns have stayed largely stable during the course of human evolution, from hunter‐gatherers to modern city dwellers [2]. Both of these insights provide evolutionary context for the health impact of too little sleep, with both epidemiological and clinical research showing that sleep disruption has a negative effect on health and well‐being. More recently, however, there is evidence that sleep has distinctly positive therapeutic potential to treat a variety of phobias and other psychotic conditions. The evolutionary study that attracted media attention raises interesting questions about the co‐evolution of sleep and human cognitive faculties. Samson and Nunn suggest that sleep became subject to strong selective pressures—“including increased predation risk […] threats from intergroup conflict, and benefits arising from increased social interaction” [1]—when our ancestors moved down from the trees and onto the savannah. As a result, …

The search for universal transdiagnostic and trans-therapy change processes: Evidence for intolerance of uncertainty

The search for universal processes associated with symptom change across emotional disorders and different forms of psychotherapy offers hope of increased theoretical parsimony and treatment efficiencies. This study investigated whether intolerance of uncertainty (IU) is a universal process by examining whether changes in IU were associated with changes in symptoms across three different cognitive behavior therapy protocols for depression (n=106), social anxiety disorder (n=88), or generalized anxiety disorder (n=62) in a community mental health clinic. IU was associated with reductions in repetitive negative thinking in all treatments, which is consistent with IU being a transdiagnostic and ‘trans-therapy’ process of change. Changes in IU were also associated with symptom relief in the social anxiety disorder and generalized anxiety disorder groups, but not in the depression group. Implications of these findings are discussed within the broader literature of transdiagnostic approaches to emotional disorders.

Psychotherapy in Hospitals in Brazil and Some Contributions from Psychoanalysis: A Historical Study

Psychotherapeutic practice in hospitals in Brazil started in the 1950s even before the profession of psychologist in the country was formalized, and has been building a fairly rich history because it is differentiated according to the development of the practice over the decades as a function of the various clinical methods associated with it, as a consequence of the policies and/or different theoretical orientations that have underpinned it. Twenty years after this practice began, during the 1970s, the field of mental health was configured as a major center of absorption of psychologists in an attempt to change the prevailing medical model. It is at that time that we can first see the formation of multidisciplinary teams linked to psychotherapy treatments. When we examine the relationship between the advancement of the practice and its theoretical foundations, in a field where political orientations toward the practice carried no less weight, we realize that this entire movement has led to important developments in the history of psychology in general. In order to specify what clinical practice in hospitals has contributed to psychology in general, it is necessary to follow its guidelines over the decades, where we can confirm that a certain prevalence of psychoanalysis has been and is being established. To the extent that it is characterized as a discourse directed at the subject, it is fundamental that it allows for situating the work in the hospital in an exchange with the medical field in such a way that each field may sustain its own particularities, respect their differences, and contribute, each in their own way, toward the advancement of clinical work. From the 1950s through today, clinical practice highlights a concern with asserting subjectivity in hospitals where the contributions of some psychoanalytical developments to different forms of psychotherapy have not been lacking.

Age moderates response to acceptance and commitment therapy vs. cognitive behavioral therapy for chronic pain.

The purpose of this study was to examine age differences in response to different forms of psychotherapy for chronic pain. We performed a secondary analysis of 114 adults (ages 18-89 years) with a variety of chronic, nonmalignant pain conditions randomly assigned to 8 weeks of group-administered acceptance and commitment therapy (ACT) or cognitive behavioral therapy (CBT). Treatment response was defined as a drop of at least three points on the Brief Pain Inventory-interference subscale. Older adults were more likely to respond to ACT, and younger adults to CBT, both immediately following treatment and at 6-month follow-up. There were no significant differences in credibility, expectations of positive outcome, attrition, or satisfaction, although there was a trend for the youngest adults (ages 18-45 years) to complete fewer sessions. These data suggest that ACT may be an effective and acceptable treatment for chronic pain in older adults.

Apprenticeship Model of Psychotherapy Training and Supervision: Utilizing Six Tools of Experiential Learning.

Apprenticeship experiences have existed for centuries asways to gradually introduce individuals to professionaltrades, skills, and roles. Cobblers, blacksmiths, attorneys,artists, healers, and surgeons have all learned as appren-tices. Traditional apprenticeships focus on specificmethods for carrying out physical skills instrumental toaccomplishing meaningful practical tasks (e.g., buildinga house). Apprenticeship learning occurs through a com-bination of observing, coaching, and practice. The cogni-tive apprenticeship model, initially described by Collins[1] and elaborated by Stalmeijer et al. [2, 3], shares thetraditional apprenticeship’s focus on learning complextasks from experts, but further emphasizes cognitive skillsof the teachers and learners, not as readily observable [1,2]. Cognitive psychotherapy skills refer to clinical reason-ing, the development of a differential diagnosis, and caseformulation. Cognitive skills also include the ability touse emotions, behaviors, precise therapeutic language,and the strategies, tactics, and interventions needed toconduct psychotherapy. Developing psychotherapeuticcognitive skills requires that both supervisor and residentexternalize or think out loud, sharing their thoughts, emo-tional process, and the rationales for their therapeuticchoices. The problems and tasks that supervisors addressare chosen to illustrate the effectiveness of a psychother-apeutic task, discuss mistakes, or demonstrate psychother-apeutic interventions so that psychiatric residents canpractice and improve their reflective psychological andemotion-focused skills.MethodsThe “Apprenticeship Model” is utilized as part of ourPsychotherapy Scholar’s Track (PST) described elsewhere indetail [4]. This track emphasizes use of the common factorsinfluencing psychotherapy outcomes. Residents learn a mini-mum of five psychotherapeutic modalities, including our brieftreatment model [5], psychodynamic, cognitive and behavioraltherapies, family, and group psychotherapies. We consistentlyuse symptom and functional rating scales at the beginning andendofthetreatmentstohelpresidentsquantifypatientoutcomes.Supervisors are a broadly trained scholarly group of psy-chiatrists and psychologists, having 8–45 years of experienceaspsychotherapists.Weareallsalariedpreceptors,workinginour university outpatient department, conducting apprentice-ship cases carved out of our preceptor time.Since no objective measures of psychotherapy supervi-sion competency have ever been consistently validated,we rely on faculty who by virtue of experience, tempera-ment, and reputation are thought to have the necessary“wisdom” and capabilities to teach the skills required toconduct several different forms of psychotherapy.“Wisdom” as used here, is defined by Sternberg [6, 7]as a clinician who has“a deeper understanding of reality,used toward a common good, encompassing the definingcharacteristics of concern for others, psychological under-standing of others, capacity for self-knowledge, the abilityto reframe information, the ability to take the long view ofproblems, readily admitting to and learning from mis-takes, maturity, intuition, and the ability to“see through”situations and circumstances. Our “wise” [6, 7] supervi-sors emphasize common factors affecting psychotherapyoutcomes and psychotherapeutic principles derived from avariety of theoretical perspectives.

Definition, assessment and rate of psychotherapy side effects.

Psychotherapy is often seen as a first line treatment, because patients and therapists consider this mode of treatment harmless in comparison, for instance, to drug treatment. This assumption is supported by the fact that there are only limited scientific reports on psychotherapy side effects (1,2). There is, however, some evidence which suggests that psychotherapy can have frequent or serious negative consequences, like all effective treatments (3–5). There are several reasons why awareness of psychotherapy side effects is limited and research on this issue is insufficient. First, the psychotherapist is the “producer” of treatment and therefore responsible, if not liable, for all negative effects, which results in a perceptional bias towards positive rather than negative effects (6). Second, psychotherapy does not only focus on symptoms but also on social behavior, so that the spectrum of possible negative effects is much broader than in pharmacotherapy (7). Third, there is even no consensus on what to call negative: for instance, when evaluating a manuscript on psychotherapy side effects, a reviewer wrote: “a divorce can be both positive and negative, and crying in therapy can reflect a painful experience but can also be a positive and therapeutic event”. Fourth, there is a lack of differentiation between side effects and therapy failure or deterioration of illness (8). Fifth, there are no generally accepted instruments for the assessment of psychotherapy side effects and no rules on how to plan scientific studies or monitor side effects in randomized controlled clinical trials (2).

The Search for Common Factors in Psychotherapy: Two Theoretical Models with Different Empirical Implications

The difficulties of demonstrating that any specific form of psychotherapy is more effective than any other has led to the formulation of the so-called Dodo Bird Verdict (that all forms of therapy are equally effective) and to the suggestion that what really matters for therapeutic efficiency are factors that are common to different forms of therapy. The term “common factors”, however, is seldom defined in an unambiguous way. In this paper, two different models of “common factors” are differentiated, and their implications are compared. The first model is referred to as the Relational-Procedural Persuasion (RPP) model and is primarily based on the writings of Frank and Wampold; according to this model effective psychotherapy requires a good therapeutic relationship, a specified therapeutic procedure, and a rhetorically skilful psychotherapist who persuades the client of a new explanation that provides new perspectives and meanings in life. The contents of these procedures and perspectives, however, are less important – according to this model, the treatment procedures are beneficial to the client because of the meaning attributed to these procedures rather than because of the specific nature of the procedures. The other model, the Methodological Principles and Skills (MPS) model, is based on the assumption that effective psychotherapy relies on common methodological principles that are instantiated in various ways in different forms of psychotherapy, and on the therapist’s capacity of applying these principles in a skillful way. According to this model, method matters, and it is possible to improve existing methods. Whereas the MPS model carries a hope for the improvement of psychotherapy, the RPP model implies a more pessimistic view of psychotherapy as forever bound by the limits of the Dodo Bird Verdict. It is concluded that psychotherapy research may benefit from using the MPS model as a working hypothesis, but that a comprehensive model of common factors in psychotherapy also needs to integrate important insights from the RPP model, as well as an understanding of the structural characteristics that psychotherapy shares with other kinds of social interaction.

Understanding Meta-Analyses and Systematic Reviews

Evidence-based practice is fundamentally about answering patient-centered questions. A pitfall in trying to answer such questions is finding 1 relevant study, appraising it, and making a clinical decision based on that single study. Sometimes a single study is all that exists, but in many cases there are multiple studies that address similar clinical questions. Systematic reviews (SR) and meta-analyses (MA) are frequently used to synthesize large amounts of information from different studies to get an overall assessment of the benefit of a specific treatment, diagnostic tool, or laboratory test, or the overall risk from a specific exposure.SR and MA are fundamentally different from review articles. A narrative review article is usually written by a content expert and can be an excellent way to get a broad overview of a topic, but does not necessarily answer a specific clinical question. The process the author used to select the articles for review is not usually transparent and could be biased, so a review article is impossible to replicate. A systematic review is a qualitative or quantitative synthesis of data and is typically narrow in scope, addressing a specific clinical question. Each study included in the SR is assessed for quality, and the process of study identification and selection is systematic and explicitly described. The risk of bias of each individual study is discussed. A meta-analysis quantitatively combines data from multiple studies (and potentially large numbers of patients) and therefore has increased statistical power. It is especially useful for finding statistically significant results from combining multiple small studies.While SR and MA do some of the work for you, they cannot be taken on faith. To appraise a SR or MA, look for:The SR by Leenarts et al on the effectiveness of different forms of psychotherapy for children who are victims of maltreatment, summarized in this issue of AAP Grand Rounds, includes some, but not all, of these features. The authors do a good job of searching for relevant studies and culling this list to include those that are pertinent. They also systematically assess the quality of the included studies. Unfortunately, there isn’t a pooled statistical assessment of the effectiveness of different interventions, and the heterogeneity of the included studies is minimally addressed. Thus, in this instance the reader is left to “trust” the authors’ conclusion on the effectiveness of trauma-focused cognitive behavioral therapy. Although this is somewhat unsatisfying, the strengths of the review by Leenarts et al help demonstrate why SR and MA can be valuable and practical ways of keeping up with the literature and answering clinical questions that help in the care of patients.

Differences in latency to first pharmacological treatment (duration of untreated illness) in anxiety disorders: a study on patients with panic disorder, generalized anxiety disorder and obsessive–compulsive disorder

The latency to first pharmacological treatment (duration of untreated illness or 'DUI') is supposed to play a major role in terms of outcome in psychotic conditions. Interest in the field of affective disorders and, in particular, of duration of untreated anxiety, has been recently registered as well. However, a preliminary epidemiologic investigation of the phenomenon is necessary. The present study was aimed to investigate and compare age at onset, age at first pharmacological treatment and DUI in a sample of patients affected by different anxiety disorders. DUI was defined as the interval between the onset of the specific anxiety disorder and the administration of the first adequate pharmacological treatment in compliant subjects. Study sample included 350 patients, of both sexes, with a DSM-IV-TR diagnosis of panic disorder (n = 138), generalized anxiety disorder (n = 127) and obsessive-compulsive disorder (n = 85). Panic disorder was associated with the shortest DUI (39.5 months), whereas obsessive-compulsive disorder was associated with the longest latency to treatment (94.5 months) (F = 13.333; P < 0.0001). Patients with generalized anxiety disorder showed a mean DUI of 81.6 months. Present results indicate that patients with different anxiety disorders may wait for years (from 3 up to 8) before receiving a first adequate pharmacological treatment. Differences in terms of age at onset, age at the first pharmacological treatment and, ultimately, in DUI in specific anxiety disorders may depend on multiple clinical and environmental factors. Latency to non-pharmacological interventions (e.g. psychoeducation and different forms of psychotherapy) needs to be addressed and correlated with DUI in future studies.

2843 – The problem of side effects in psychotherapy: adverse treatment reactions or unwanted events

The side effects of drugs are deemed so important that their pubblication are strictly regulated by national health agency. But no one agency requires such warnings connected to other mental health including Psychotherapy. In contrast to all pharmacotherapy studies in groups of patients, there is precious little information about the safety of psychotherapeutic interventions, which are also, in some patients and in some instances, associated with events that need to be noted. Actually empirical research on the negative effects of psychotherapy is largely insufficient, partly there is a lack of theoretical concept on how to define, classify and assess psychotherapy effects. This is a badly understudied issue, but of high clinical relevance, given that these treatments are so frequently recommended for the management of patients with psychopathological problems. And while there are many different forms of psychotherapy, virtually all of them share the matter discussed in this paper. Unfortunately, many psychotherapists won't discuss or acknowledge about side effects, despite they occour all the time. Some plausible definitions are considered as unwanted events, adverse reactions, deterioration of illness, malpractice reactions, treatment emergent reactions, treatment non response, therapeutic risks, controindications. Now that psychotherapy has become an accepted and effective option within the health care community, researchers and therapists need to do a better job of describing and examining the negative side effects of psychotherapy. Recognition of effects have to be a characteristic of good therapists and treatments, to improve the quality of care.

Recent progress in the understanding and treatment of nonepileptic seizures

There has been a steady increase in the number of publications about (psychogenic) nonepileptic seizures (NES) over the past two decades. This review focuses on work published in the past 3 years. It summarizes the most important developments in terms of diagnosis, cause, clinical manifestations and treatment of NES. Several recent studies demonstrate the scope and limitation of questionnaire-based and conversation analytic approaches to the differential diagnosis of epilepsy and NES. Experimental work has revealed that patients with NES have increased levels of physiological arousal at rest which are associated with abnormal mental processing. There is a growing understanding of the meaning and clinical significance of the heterogeneous manifestations of NES. Several studies document the therapeutic potential of an early and effective communication of the diagnosis of NES. A number of randomized controlled or uncontrolled long-term follow-up pilot studies suggest that different forms of psychotherapy are effective for NES. Recent research has improved our understanding of NES as a biopsychosocial disorder. Clear diagnostic and management pathways for patients with NES are likely to emerge in the near future.

The continuum of unipolar depression - bipolar II depression - bipolar I depression: different treatments indicated?

Strakowski et al indicate that bipolar depression may need to be treated differently from unipolar depression because in bipolar depression antidepressants may be ineffective and may precipitate the risk of a switch to (hypo)mania (and induction of rapid cycling). While this could be a major argument to discriminate bipolar depression form unipolar depression, a critical appraisal of the available literature is indicated. First, are antidepressants ineffective in bipolar depression? Compared to around 1,500 randomized controlled trials (RCTs) with antidepressants in unipolar depression, there are around 15 RCTs in bipolar depression and only four of them exceeded 50 patients per treatment arm. Therefore, the main conclusion is that, compared to unipolar depression, bipolar depression is heavily understudied 1. Nevertheless, in a meta-analysis, antidepressants as a group appeared to be effective 1. Of the four larger studies, two reported positive results. The first study found that the combination of fluoxetine and olanzapine was more effective than placebo plus olanzapine 2. The second study reported response rates of 50-60% when sertraline, bupropion or venlafaxine was added to an ongoing treatment with mood stabilizers 3. The limitation of this study was the lack of a placebo arm. On the other hand, in a third study, paroxetine was not more effective than placebo, while two doses of quetiapine (300 and 600 mg/day) did separate from placebo 4. Finally, in the STEP-BD study, sertraline or bupropion as add-on to ongoing treatment with (among other medications) lithium or valproate was not found more effective than the addition of placebo 5. Although this is the largest study which investigated the efficacy of antidepressants in bipolar depression, it has major methodological limitations (e.g., patients were allowed to continue with another antidepressant during the first two weeks of the study; they could also use other drugs with an antidepressant effect, such as quetiapine, olanzapine and lamotrigine; 69% of the patients participated at the same time in a study comparing three different forms of psychotherapy with treatment as usual). It is clear that the conclusion that antidepressants are not effective cannot be drawn on the basis of this study. My overall conclusion is that, due to a lack of well designed RCTs, we can only state that it has not (yet) been proven that antidepressants are effective in bipolar depression. Second, do antidepressants cause a switch into (hypo)mania and rapid cycling? In our meta-analysis 1, we did not find that in the acute treatment of bipolar depression antidepressants were more often associated with a switch into (hypo)mania than placebo. However, in all studies comparing different antidepressants, the treatment arms with a tricyclic (TCA) were associated with a greater risk of switch into (hypo)mania than the treatment arms with other antidepressants, suggesting that TCAs have a greater risk of switch. Concerning the risk associated with long-term antidepressant treatment, we argued that there is a scarcity of randomized studies, and that the available studies all suffer from various forms of bias 6. Nevertheless, we concluded that antidepressants, when combined with a mood stabilizer, seemingly do not induce a switch into hypomania or mania. Ghaemi et al 7 presented a meta-analysis of seven RCTs in which antidepressants were used for at least 6 months. Three of these RCTs (total n=50) compared the effects of antidepressants monotherapy with placebo; five (total n=246) compared antidepressants plus a mood stabilizer versus a mood stabilizer alone (or in combination with placebo); and three (total n=108) compared antidepressants alone with a mood stabilizer alone. In most of the studies the antidepressant was a TCA. When combining all RCTs, the antidepressants yielded a significant 27% lower risk of a depressive recurrence versus control treatment without an antidepressant, but also a significant 72% greater risk for a manic recurrence. However, in RCTs with an antidepressant alone versus placebo, the only significant result was fewer depressive recurrences with the antidepressant, while in RCTs with an antidepressant alone versus a mood stabilizer alone (lithium), the only significant result was fewer manic recurrences with lithium. Therefore, my conclusion is that antidepressants do protect against depressive recurrences, while lithium does protect against manic recurrences. Whether antidepressants may accelerate episode frequency and/or cause other forms of destabilization in patients with bipolar disorder remains to be properly studied. In conclusion, there is not enough evidence to conclude that bipolar depression needs to be treated differently from unipolar depression. Especially in bipolar II depression, antidepressants still have a role even in monotherapy, as also suggested by recent guidelines 8,9. Therefore, bipolar I depression and unipolar depression should be seen as the ends of a continuum, with arbitrary demarcations and bipolar II depression in between.