Short-term Therapies Research Articles

Mixing Apples and Oranges and Other Methodological Problems with a Meta-Analysis of Long Term Psychodynamic Psychotherapy

Current trends in mental health practice indicate that mental health practitioners, including clinical social workers, are tending to move away from psychodynamic approaches and are favoring short-term empirically supported approaches such as cognitive-behavioral therapy (CBT). Recently, the presumption that long-term psychodynamic psychotherapy (LTPP) approaches lack empirical support has been challenged, however, with the publication in major peer reviewed journals of meta-analyses that are claimed to demonstrate its equality to or superiority over empirically supported short-term therapies for some conditions. The present article examines the methodology employed in one particular meta-analysis which compared LTPP to short term therapies and the studies upon which the analysis was based. We found that major methodological and statistical flaws with the meta-analysis and with the individual studies preclude drawing any conclusions regarding the efficacy of LTPP.

Zero-order controlled release of ciprofloxacin-HCl from a reservoir-based, bioresorbable and elastomeric device

A reservoir-based device constructed of a completely biodegradable elastomer can enable several new implantation and insertion options for localized drug therapy, particularly in the case of urological therapies. We performed an in vitro performance evaluation of an implantable, bio-resorbable device that supplies short-term controlled release of ciprofloxacin-HCl (CIP). The proposed device functions through a combination of osmosis and diffusion mechanisms to release CIP for short-term therapies of a few weeks duration. Poly(glycerol- co-sebacic acid) (PGS) was cast in a tubular geometry with solid drug powder packed into its core and a micro-machined release orifice drilled through its wall. Drug release experiments were performed to determine the effective release rate from a single orifice and the range of orifice sizes in which controlled zero-order release was the main form of drug expulsion from the device. It is demonstrated that PGS is sufficiently permeable to water to allow the design of an elementary osmotic pump for drug delivery. Indeed, PGS's water permeability is several orders of magnitude larger than commonly used cellulose acetate for elementary osmotic pumps.

Maintenance of gains following experiential therapies for depression.

Follow-up data across an 18-month period are presented for 43 adults who had been randomly assigned and had responded to short-term client-centered (CC) and emotion-focused (EFT) therapies for major depression. Long-term effects of these short-term therapies were evaluated using relapse rates, number of asymptomatic or minimally symptomatic weeks, survival times across an 18-month follow-up, and group comparisons on self-report indices at 6- and 18-month follow-up among those clients who responded to the acute treatment phase. EFT treatment showed superior effects across 18 months in terms of less depressive relapse and greater number of asymptomatic or minimally symptomatic weeks, and the probability of maintaining treatment gains was significantly more likely in the EFT treatment than in the CC treatment. In addition, follow-up self-report results demonstrated significantly greater effects for EFT clients on reduction of depression and improvement of self-esteem, and there were trends in favor of EFT, in comparison with CC, on reduction of general symptom distress and interpersonal problems. Maintenance of treatment gains following an empathic relational treatment appears to be enhanced by the addition of specific experiential and gestalt-derived emotion-focused interventions. Clinical and theoretical implications of these findings are presented.

Follow-up outcome in short-term group therapy for complicated grief.

Simon Fraser UniversityThis study investigated 4 types of outcome over a 6-month follow-up period for 84psychiatric outpatients who had been treated for complicated grief using short-termgroup therapy. The 4 types differed in regard to whether and when patients achievedclinically signiÞcant change on a primary grief outcome variable. Approximately halfof the patients achieved clinically signiÞcant change by the end of treatment andmaintained it over follow-up (maintenance). Another quarter of the patients reportedclinically signiÞcant change, but only at follow-up (delayed recovery). A few patientsachieved clinically signiÞcant change at the end of treatment, but not at follow-up(relapse). Finally, nearly a quarter of the patients failed to achieve clinically signiÞcantchange (nonrecovery). The Þndings suggest that investigators look beyond the end oftreatment when assessing improvement in patients treated with short-term grouptherapy for complicated grief. Inclusion of delayed recovery patients can substantiallymodify conclusions about the usefulness of short-term therapies for complicated grief.Delayed recovery patients differed from the other types of patients on greater perceivedsocial support and greater change during the follow-up period.Keywords: follow-up outcome, delayed recovery, short-term group therapy, compli-cated grief

Direct Diagnosis and Management of Emotional Factors in Chronic Headache Patients

Somatization, anxiety, depression and personality disorders are common features of many patients with chronic headaches. Intensive short-term dynamic psychotherapy (ISTDP) is a brief therapy method developed specifically to treat patients with this cluster of somatic problems, symptoms and maladaptive behaviours through focusing on how the patient handles emotional experiences. It also contains a direct method of assessing the somatic discharge pathways of both emotions and anxiety, thus allowing direct observation of somatization in the case of many chronic headache sufferers. In this review, we summarize the extant literature on emotional factors in headache, review the evidence for short-term dynamic therapies in somatic problems and describe the assessment and treatment method of ISTDP we use routinely with chronic headache sufferers.

Neoadjuvant/presurgical treatments

In this article the term 'neoadjuvant' is used to describe pre-operative treatment for 3 months or more for large (usually ≥ 3 cm) operable cancers before surgery. Clinical response and pathological response are important end-points. The term 'presurgical' refers to treatment of short duration (around 2 weeks) before surgery, sometimes referred to as a 'window of opportunity' study. This approach can be used for any size of cancer provided it can be core biopsied, and the endpoints are molecular markers. Traditional goals of neoadjuvant therapy include the following: • to improve survival; • to downstage so that inoperable cancers become operable or so that conservative surgery can replace mastectomy; • to identify short-term clinical or molecular markers of response to predict long-term outcome as a prelude to (or as a substitute for) adjuvant trials; • to predict outcome and plan further treatment in the individual patient; and • to identify the molecular mechanisms that underlie response and resistance to treatment. Short-term presurgical therapies can have similar aims with the proviso being that this treatment will not lead to downstaging and that clinical and pathological response rates are unrealistic end-points. Current evidence suggests that there is no survival benefit from neoadjuvant chemotherapy [1]. The question has not thus far been addressed in a large neoadjuvant endocrine therapy trial. Neoadjuvant chemotherapy has been shown to downstage and reduce the need for mastectomy in some but by no means all women [1]. The same is true for neoadjuvant endocrine therapy; about 40% of mastectomies can be avoided with preoperative aromatase inhibitor therapy [2].

Personal Accounts: Community Psychiatry in the 1960s: A History Lesson

Personal Accounts: Community Psychiatry in the 1960s: A History Lesson

Psychoanalytic and psychodynamic therapies for depression: the evidence base

This article argues that the current approach to guideline development for the treatment of depression is not supported by the evidence: clearly depression is not a disease for which treatment efficacy is best determined by short-term randomised controlled trials. As a result, important findings have been marginalised. Different principles of evidence-gathering are described. When a wider range of the available evidence is critically considered the case for dynamic approaches to the treatment of depression can be seen to be stronger than is often thought. Broadly, the benefits of short-term psychodynamic therapies are equivalent in size to the effects of antidepressants and cognitive–behavioural therapy (CBT). The benefits of CBT may occur more quickly, but those of short-term psychodynamic therapies may continue to increase after treatment. There may be a ceiling on the effects of short-term treatments of whatever type. Longer-term psychodynamic treatments may improve associated social, work and personal dysfunctions as well as reductions in depressive symptoms.

T08-P-05 Doing sexual homeworks is healthful. Do you want to know why?

The authors introduce their long-term experience as sex-therapist with sexual homeworks methodical practise, prescribed to patients with sexual inadequacy during short-term therapies. Now positive results are widely recognized but it isn’t fully clear how the homeworks support behavioural and cognitive changes. To explain required changes, the authors assume that: a) sexual system is perfect somato-psychical pattern; b) change pathways are assimilable to learning pathways; c) most of the neuro-psychological and neurophysiologic experimental studies results can be tranferred to sexologic area; d) performed sexual homework effectiveness isn’t related to different therapists; e) homeworks are effective when used in different systems (i.e. stroke with hemiplegia). Several experimental researches results on C.N.S emphasize wide neuronal plasticity of the brain; not only in single areas differences between several people but also as possible variabilty of single person's cyto-architecture of cerebral cortex. The latter changes are strictly related to the stimulus or to the context changes. Furthermore, the changes on functional network happen after stimulus or context short-termed variations. The authors consider the homework as a part of a programme, a prescription of behavioural experience together with perceptive task, given to patients who agree to carry out them. The prescribed performance, “actively” done, could perturb the present neuronal network (related to “symptomatic unit”), could put the system in crisis and lastly let new neuronal correlations come out (or … come in). In this regard, the sex-therapist could be the catalyst, the strategically oriented perturber.

Engineering physiologically controlled pacemaker cells with lentiviral HCN4 gene transfer

Research on biological pacemakers for the heart has so far mainly focused on short-term gene and cell therapies. To develop a clinically relevant biological pacemaker, long-term function and incorporation of autonomic modulation are crucial. Lentiviral vectors can mediate long-term gene expression, while isoform 4 of the Hyperpolarization-activated Cyclic Nucleotide-gated channel (encoded by HCN4) contributes to pacemaker function and responds maximally to cAMP, the second messenger in autonomic modulation. Action potential (AP) properties and pacemaker current (I(f)) were studied in single neonatal rat ventricular myocytes that overexpressed HCN4 after lentiviral gene transduction. Autonomic responsiveness and cycle length stability were studied using extracellular electrograms of confluent cultured monolayers. Perforated patch-clamp experiments demonstrated that HCN4-transduced single cardiac myocytes exhibited a 10-fold higher I(f) than non-transduced single myocytes, along with slow diastolic depolarization, comparable to pacemaker cells of the sinoatrial node, the dominant native pacemaker. HCN4-transduced monolayers exhibited a 47% increase in beating rate, compared to controls. Upon addition of DBcAMP, HCN4-transduced monolayers had beating rates which were 54% faster than baseline and significantly more regular than controls. Lentiviral vectors efficiently transduce cardiac myocytes and mediate functional gene expression. Because HCN4-transduced myocytes demonstrate an increase in spontaneous beating rate and responsiveness to autonomic modulation, this approach may be useful to create a biological pacemaker.

Metaphern und Affekt: Zusammenwirken im therapeutischen Prozess

In accordance with Freud's hypothesis about the nature of primary process thinking we analysed metaphors as possible tools for the integration of unconscious affective und cognitive representational processes which, besides being complementary to affective interactive dyadic behaviour, may be of curative value. Using videotapes of 10 fifteen-hour short-term therapies by very experienced therapists treating an unselected group of patients, facial affect and metaphoric language of the therapist and the patient as well as the temporal distance between the two was recorded. The density of metaphors was not significantly correlated with symptom reduction but with treatment satisfaction. However, symptom reduction correlated significantly with the frequency of interactive metaphors used by both the therapist and the patient. It could be shown that there is an optimal time window between facial affect and metaphor production beyond the here and now, but not as a long term memory.

Psicoterapia psicodinâmica e o tratamento do jogo patológico

The search for empirically based treatments for pathological gambling is in its infancy, with relatively few clinical trials and an absence of naturalistic studies. Treatment retention of gamblers has been a problem; cognitive-behavioral treatment and pharmacotherapy studies report especially high dropout rates. Psychodynamic approaches, with their emphasis on the therapeutic relationship, and the meaning of the patient's self-destructive and seemingly irrational behaviors, and on obstacles to self-forgiveness, might improve outcome. After a description of psychodynamic psychotherapy, the literature on both short-term and longer therapies is reviewed regarding their efficacy for a variety of disorders. With regard to pathological gambling, the author summarizes the early (1914-1970) psychoanalytic literature then reviews the more recent psychodynamic psychotherapy literature on pathological gambling. A review of the recent psychodynamic psychotherapy literature on pathological gambling failed to disclose a single randomized controlled study of treatment efficacy or effectiveness. However, there are eight positive outcome studies described as multi-modal eclectic; half of those seem to utilize psychodynamic approaches. Two of the more successful programs are described. A review of the outcomes literature for psychodynamic psychotherapy demonstrates efficacy for a variety of disorders sufficient to justify a clinical trial for pathological gambling. Short-term psychodynamic psychotherapy, with its focus on core issues, may be particularly applicable to the pathological gambler's need to avoid or escape intolerable affects and problems. Longer therapies may be needed to modify an avoidant coping style and defenses.

Testing the Effectiveness of Long-Term Psychodynamic Psychotherapy

Clinicians commonly administer long-term psychodynamic psychotherapy, despite limited evidence on its effectiveness. To address the lack of evidence, researchers conducted a 3-year, randomized trial comparing the effects of long-term psychodynamic, short-term psychodynamic, and short-term solution-focused therapies. Participants were 326 outpatients (age range, 20–45) with a DSM-IV mood disorder (85%) and/or anxiety disorder (44%). Long-term psychodynamic psychotherapy (LPP) involved …

Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi‐site prospective cohort study

Specialist drug treatment is critical to overdose prevention; methadone maintenance is effective, but we lack evidence for other modalities. We evaluate the impact of a range of treatments for opiate dependence on overdose mortality. Prospective cohort study of 10,454 heroin users entering treatment 1998-2001 in Italy followed-up for 10,208 person-years in treatment and 2,914 person-years out of treatment. Standardized overall mortality ratios (SMR) estimate excess mortality risk for heroin users in and out of treatment compared to the general population. Cox models compare the hazard ratio (HR) of overdose between heroin users in treatment and out of treatment. There were 41 overdose deaths, 10 during treatment and 31 out of treatment, generating annual mortality rates of 0.1% and 1.1% and SMRs of 3.9 [95% confidence interval (CI) 2.8-5.4] and 21.4 (16.7-27.4), respectively. Retention in any treatment was protective against overdose mortality (HR 0.09 95% CI 0.04-0.19) compared to the risk of mortality out of treatment, independent of treatment type and potential confounders. The risk of a fatal overdose was 2.3% in the month immediately after treatment and 0.77% in the subsequent period; compared to the risk of overdose during treatment the HR was 26.6 (95% CI 11.6-61.1) in the month immediately following treatment and 7.3 (3.3-16.2) in the subsequent period. We demonstrate that a range of treatments for heroin dependence reduces overdose mortality risk. However, the considerable excess mortality risk in the month following treatment indicates the need for greater health education of drug users and implementation of relapse and overdose death prevention programmes. Further investigation is needed to measure and weigh the potential benefits and harms of short-term therapies for opiate use.

Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up

Insufficient evidence exists for a viable choice between long- and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two short-term therapies in the treatment of mood and anxiety disorders. In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment. Primary outcome measures were depressive symptoms measured by self-report Beck Depression Inventory (BDI) and observer-rated Hamilton Depression Rating Scale (HAMD), and anxiety symptoms measured by self-report Symptom Check List Anxiety Scale (SCL-90-Anx) and observer-rated Hamilton Anxiety Rating Scale (HAMA). A statistically significant reduction of symptoms was noted for BDI (51%), HAMD (36%), SCL-90-Anx (41%) and HAMA (38%) during the 3-year follow-up. Short-term psychodynamic psychotherapy was more effective than long-term psychodynamic psychotherapy during the first year, showing 15-27% lower scores for the four outcome measures. During the second year of follow-up no significant differences were found between the short-term and long-term therapies, and after 3 years of follow-up long-term psychodynamic psychotherapy was more effective with 14-37% lower scores for the outcome variables. No statistically significant differences were found in the effectiveness of the short-term therapies. Short-term therapies produce benefits more quickly than long-term psychodynamic psychotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term therapies. However, more research is needed to determine which patients should be given long-term psychotherapy for the treatment of mood or anxiety disorders.

Implementation Strategies for Emergency Medical Services Within Stroke Systems of Care

Stroke remains the third leading cause of death and a leading cause of long-term disability among Americans, despite advances in stroke prevention, diagnosis, treatment, and rehabilitation. Approximately 700 000 individuals suffer a new or recurrent stroke each year.1 Advances over the past decade in acute stroke care, including the introduction of fibrinolytic and other short-term therapies, have highlighted the critical roles of emergency medical services (EMS) agencies and emergency medical services systems (EMSS) in optimizing stroke care.2–7 In this context, the term “EMS” refers to the full scope of prehospital services necessary for the acute care of patients with stroke, including 9-1-1 activation and dispatch, emergency medical response, triage and stabilization in the field, and transport by ground or air ambulance to a hospital or between facilities. The term “EMSS” refers to the delivery systems for EMS that may be organized on a local, regional, statewide, or nationwide basis.8 EMSS involves the organization of public and private resources for the delivery of emergency medical care. These systems include the community, emergency medical and healthcare personnel, public safety agencies, emergency facilities, and critical care units. The dissemination of public information and education, provision of professional training, and development of disaster planning and standardized record keeping also are key elements of EMSS. Additionally, EMSS must address issues related to communication, transportation, access to care, patient transfer, mutual aid (the sharing of resources across EMSS), and system review and evaluation.9 The successful integration of one (and often multiple) EMSS is critical to ensuring the effectiveness of a stroke system of care. The American Stroke Association (ASA), a division of the American Heart Association (AHA), is dedicated to improving stroke prevention, treatment, and rehabilitation through research, education, advocacy, and the development of scientifically based standards and guidelines. In 2004, the …

Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity — A randomized clinical trial on depressive and anxiety disorders

BackgroundInsufficient evidence exists about the effect of different therapies on work ability for patients with psychiatric disorders. The present study compares improvements in work ability in two short-term therapies and one long-term therapy. MethodsIn the Helsinki Psychotherapy Study, 326 outpatients with depressive or anxiety disorder were randomly assigned to long-term and short-term psychodynamic psychotherapy, and solution-focused therapy. The patients were followed for 3 years from the start of treatment. Primary outcome measures were the Work Ability Index (WAI), the Work-subscale (SAS-Work) of the Social Adjustment Scale (SAS-SR), Perceived Psychological Functioning Scale, the prevalence of patients employed or studying, and the number of sick-leave days. ResultsWork ability was statistically significantly improved according to WAI (15%), SAS-Work (17%), and Perceived Psychological Functioning Scale (21%) during the 3-year follow-up. No differences in the work ability scores were found between two short-term therapies. The short-term therapies showed 4–11% more improved work ability scores than long-term therapy at the 7 month follow-up point. During the second year of follow-up, no significant differences were found between therapies. After 3 years of follow-up, long-term therapy was more effective than the short-term therapies with 5–12% more improved scores. No differences in the prevalence of individuals employed or studying or in the number of sick-leave days were found between therapies during follow-up. ConclusionsShort-term therapies give benefits more quickly than long-term therapy on work ability but in the long run long-term therapy is more effective than short-term therapies. More research is needed to confirm these findings.

Does Psychiatry Residency Training Reflect the "Real World" of Psychiatry Practice? A Survey of Residency Graduates

The authors determine whether Massachusetts General Hospital's residency graduates believed their training reflected their current practice activities. The authors surveyed 134 graduates from MGH and MGH-McLean residency classes from 1983 to 2003. Subjects ranked their satisfaction with different components of training on a scale of 1 to 6 and listed areas they wanted emphasized during residency. Sixty-six subjects (49%) returned surveys. Twenty respondents graduated in the 1980s (Cohort 1), 27 in the 1990s (Cohort 2), and 16 in the 2000s (Cohort 3). The most common activities included psychopharmacology, teaching, supervision, research, administration, psychodynamic therapy, and supportive therapy. Least common activities included geriatrics, addiction, and psychoanalysis. Satisfaction with training was high, as was relevance of training. Our graduates from 1983 to 2003 considered residency good preparation for the world of practice and reported that psychopharmacology should be emphasized during training. Respondents expressed a strong desire for continued training in psychodynamic therapy, despite growing emphasis on short-term therapies and biological treatments.

Recognition and Treatment of Menstrual Migraine

Menstrual migraine is a chronic disorder affecting approximately 12.6 million women in the United States. In spite of its widespread prevalence, menstrual migraine often goes undiagnosed. Characteristics of menstrual migraine, which include functional disability, increased headache severity, and lack of aura, are often overlooked, and therefore menstrual migraine is often underdiagnosed. Use of a 3-month diary to record migraine patterns can reveal the predictable patterns associated with menstrual migraine, and a diary is demonstrated to be a useful tool in diagnosis. Optimal treatment of menstrual migraine takes advantage of the predictability of the disorder. Treatment alternatives for menstrual migraine include acute therapy and short- or long-term preventive therapies. Acute therapy is given shortly after the migraine begins. Short-term preventive therapies are effective when administered during the time that menstrual migraine is most likely to occur; the treatment window is typically 2 days prior up to 3 days after the onset of menstruation. Providing triptans, nonsteroidal anti-inflammatory drugs, or estrogen supplements (gel or patches) during this window has been demonstrated to provide effective protection during the days when patients are at greatest risk for menstrual migraine. Alternatively, long-term preventive therapy may be required for recurrent headaches in patients with concomitant medical conditions for whom migraine therapy could serve a dual purpose. By recognizing the patterns associated with menstrual migraine, prompt, acute, or preventive therapy can be used to effectively manage the disorder and reduce its related disability.

Documented traditional cardiovascular risk factors and mortality in non–ST-segment elevation myocardial infarction

Although documented traditional cardiovascular risk factors (hypertension, diabetes, smoking, and dyslipidemia) increase the risk of developing coronary artery disease, their influence on the treatments and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI) has not been fully elucidated. Using data from the CRUSADE Quality Improvement Initiative, we sought to characterize the effect that the absence of documented traditional risk factors has on inhospital treatments and outcomes in a population of patients with NSTEMI treated in routine practice. We compared clinical characteristics and inhospital outcomes according to the presence and number of risk factors in 74,220 patients with NSTEMI (defined as creatine kinase-MB and/or troponin I/T values above the local upper limit of normal) treated in 476 US hospitals from January 2001 through March 2004. The 7755 (10.5%) patients with no documented traditional risk factors on admission were less likely to receive short-term guideline-recommended therapies and revascularization procedures. Despite a higher prevalence of normal left ventricular function and insignificant angiographic coronary artery disease, these patients had a slightly higher risk of adjusted inhospital mortality (odds ratio 1.15, 95% CI 1.03-1.29) compared with patients with any combination of risk factors. Patients without documented traditional cardiovascular risk factors represent 10.5% of the non-ST-segment elevation myocardial infarction population. Because the absence of documented traditional risk factors does not yield a favorable prognosis, further study is needed to delineate the effects of the interplay between novel and documented traditional risk factors and treatment differences on the outcomes of these patients.