Standard Psychiatric Treatment Research Articles

The benefits of hearing voices groups: more findings from a US national study

ABSTRACT Background Hearing voices peer-support groups (HVGs) are spreading widely as an alternative or supplement to standard psychiatric treatments for the distress that can accompany unshared perceptions or extreme states. Yet although people in dozens of countries clearly find HVGs useful, their precise mechanisms of action and distinctive benefits are not fully understood. Analyzing the effectiveness of these groups is increasingly important as mental health resources stretch to the breaking point in many parts of the world. Methods Using an inductive phenomenological method, our collaborative team of voice-hearers and researchers analyzed the experiences of 119 HVG members in the US, who provided detailed voice hearing histories and accounts of group participation. Results Results indicated that HVGs offer four distinct types of benefits, affording members an opportunity to: (1) examine the voice hearing experience in itself; (2) discern the meanings of voices and explore them within a biographical context; (3) receive validation for cultural or spiritual ways of understanding voices; and (4) develop a sense of shared experience and camaraderie with other voice-hearers. Discussion These participant-defined benefits are quite different from standard outcome measures, suggesting new avenues for research to understand the diverse appeal of HVGs

A Case of Creutzfeldt–Jakob disease with psychiatric presentation

ABSTRACT Creutzfeldt–Jakob disease (CJD) belongs to the group of fatal neurodegenerative disorders known as prion diseases. We are going to describe the case of a 54-year-old married man who initially presented with rapidly progressive cognitive decline along with behavioral symptoms and was subsequently diagnosed with probable CJD. He presented with 1½ months history of disinhibited behavior, decreased social interaction, persecutory ideas, food refusal, and decreased sleep along with cognitive decline. On examination, the patient had myoclonus and ataxia. Routine blood investigations, serological tests, and autoimmune and paraneoplastic profiles were normal. Injection haloperidol 2.5 mg intramuscular for behavioral symptoms was given with no improvement. The cerebrospinal fluid study revealed positive results for 14-3-3 protein. The patient was diagnosed with probable CJD and subsequently passed away within 1 month of presentation. Thus, CJD should be kept in the differential diagnosis of patients with cognitive decline and persistent behavioral symptoms despite standard psychiatric treatment.

The Various Faces of Creutzfeldt-Jakob Disease (CJD); a Case of CJD Presenting as Psychosis in a Middle-Aged Woman

AimsCreutzfeldt-Jakob disease (CJD) is a rare, progressive, fatal neurodegenerative disorder caused by an abnormal glycoprotein known as the prion protein. The core features include progressive cognitive decline, cerebellar dysfunction, personality changes, and visual disturbances. Although psychiatric symptoms are rare, they can be the primary symptom of CJD, and such presentations can pose diagnostic difficulties. In this paper, we describe the case of Ms. R, who manifested psychotic symptoms as the first signs of CJD.MethodsMs. R, was a 49-year-old white British female not previously known to psychiatric services, who presented with acute onset of florid psychotic symptoms. Her symptoms included auditory hallucinations, paranoia, and thought disorder. She was treated with antipsychotics for over four weeks, following her admission, but no improvement was seen. Instead, her psychosis worsened with cognitive decline, mutism, and the appearance of neurological symptoms such as jerky body movement, ataxia, and falls. All screening blood tests, chest X-ray, and CT abdomen were normal. The MRI, however revealed few patches of high T2/FLAIR signal in the deep white matter. Cerebrospinal fluid showed increased protein. Neurologist reviews suggested the possibility of sporadic CJD (sCJD) as a probable diagnosis. As her condition deteriorated, she became comatose and died four months after the appearance of the first psychiatric symptoms.ResultsIt can be challenging to diagnose CJD since the clinical picture overlaps with other neuropsychiatric and neurodegenerative conditions. It requires the presence of relevant clinical findings along with positive CSF, EEG, or MRI findings to make a probable diagnosis. Regarding our case, some noteworthy observations were psychosis as the initial symptom, relatively delayed onset of neurological signs, rapid deterioration with brief duration of illness. The MRI findings were typical of those seen in sCJD, although the EEG did not suggest sCJD. A differential of variant CJD was considered because of her age, prominent psychiatric symptoms, and delayed neurological signs.ConclusionCreutzfeldt-Jakob disease course is rapidly progressive, and majority of patients die within one year. Therefore, awareness of early clinical features is of great significance. Among other things, this would enable patients and their families time to understand the nature of CJD, prognosis and prepare advanced directives. This case adds to the growing number of atypical presentation of CJD as well as pointing to an expanding spectrum of the disease. Therefore, clinicians should consider CJD in the differential diagnosis of new-onset psychosis, particularly if symptoms persist and worsen despite standard psychiatric treatment.

Stationsäquivalente Behandlung (StäB) im Vergleich mit vollstationärer Behandlung: 12-Monats-Follow-up einer gematchten Kohortenstudie

Effectiveness of Inpatient Equivalent Home Treatment (IEHT) was examined in comparison to standard psychiatric inpatient treatment. IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity. This retrospective matched control study used routine data of 86 patients (IEHT, n = 43, standard inpatient treatment n = 43). Readmission rates and cumulative hospital days were compared within a 12-month-follow-up time period. The readmission rate was lower and cumulative treatment days were longer after IETH. However, both group differences were not statistically significant. The present study indicates that IEHT is not inferior to standard inpatient treatment in terms of the risk of readmission.

THE EFFECTIVENESS OF SHORT-TERM PSYCHODYNAMIC PSYCHOTHERAPY IN DEPRESSION AND ANXIETY DISORDERS

ABSTRACT Short-term psychodynamic psychotherapy (STPP) is a treatment modality for depressive disorder, anxiety disorder, and personality disorders. In this study, we aimed to assess the effectiveness of the STPP programme in patients with depression and anxiety who were partially responsive to previous treatments. Participants were consisted of 36 patients, 27 of whom were female and 9 were male. A total of 12 sessions of STPP were applied to the patients included in the study, sessions lasting 45 minutes, every 2 weeks, for 6 months. During the STPP procedure, the nature of unconscious conflicts was tried to be understood. The quality of object relations and defence mechanisms were evaluated. The elements of resistance, transference, and counter-transference were examined. Psychodynamic formulation was formed. Treatment goals were determined together with the patient. In this direction, psychotherapeutic strategies have been developed. We evaluated pre- and post-treatment effectiveness according to clinical variables and also the change in self-destructive behaviours. Scales measuring their psychiatric status were administered at base-line, pre-and post-treatment. The primary outcome measures were depression and anxiety scores. At the end of STPP, depression, and anxiety scores were all significantly decreased. A significant improvement was observed in 94% of our patients who could not achieve adequate improvement with previous treatment interventions. During the psychotherapy process, none of the patients attempted suicide and there was a significant decrease in self-destructive behaviours. These findings suggest that STPP is an effective treatment in patients with anxiety disorders and depression, who have not achieved adequate response to previous standard psychiatric treatments.

Gratitude and patience moderate meaning struggles and suicidal risk in a cross-sectional study of inpatients at a Christian psychiatric hospital.

Suicidal behavior is a leading cause of injury and death, so research identifying protective factors is essential. Research suggests gratitude and life hardships patience are character strengths that might protect against the deleterious association of struggles with ultimate meaning and suicide risk. However, no studies have evaluated their utility among people experiencing acute/severe mental health concerns. We tested the protective function of gratitude and life hardships patience with cross-sectional data from adults (Mage =31.83years; SD=14.84; range=18-82) hospitalized in a Christian psychiatric inpatient facility (Mstay =6.37days, SD=4.64). Gratitude and life hardships patience moderated the positive relation between meaning struggles and suicide risk. Specifically, gratitude and life hardships patience protected against meaning struggles as a risk factor for suicide through mechanisms separate from ameliorating depressive symptoms. Findings provide initial support for gratitude and patience interventions as an adjunct to standard psychiatric treatment for minimizing suicide risk.

Learning oriented physiotherapy (LOP) in anxiety and depression: an 18 months multicentre randomised controlled trial (RCT)

Aim Although many patients with anxiety and depression suffer from muscular pain and bodily dysfunctions, body is largely ignored in treatment. The aim of this study was to investigate the effectiveness of Learning Oriented Physiotherapy (LOP), based on recent knowledge about overlapping brain networks and the need of awakening body awareness in order to synchronise body and mind. Methods Patients with moderate anxiety and/or depression referred to three outpatient psychiatric clinics in Norway during October 2014 to January 2016 were invited to participate. Of eligible patients, 42 were randomised to LOP and 39 to standard psychiatric treatment (controls). Self-reports of anxiety and depression (HADS), health-related quality of life (EQ-5D-5L) and global health (EQ-VAS) were recorded every 6 months from baseline (T1) to 18 months after (T4). Mixed linear model (MLM) analysis was used to estimate overall differences between groups. Results After 1 year of follow-up, LOP participants reported higher quality of life and perceived global health than controls. At the end of the trial, there were no mean differences in health outcomes between groups, but LOP participants showed an overall faster rate of recovery than controls. Conclusions LOP may be as effective as conventional therapies for patients with moderate anxiety and depression.

Introducing mother-baby interaction therapy for mothers with postpartum depression and their infants

Postpartum depression (PPD) and other perinatal mental health disorders have profound adverse effects on maternal-infant interaction and child health. However, standard psychiatric treatment does not necessarily improve the quality of mother-infant interaction. The purpose of this article is to describe the evidence-based CARE intervention and its translation to practice as Mother-Baby Interaction (MBI) Therapy to promote infant outcomes by supporting mothers’ sensitive, responsive, and contingent interactions with their infants. Two vignettes illustrate MBI. We advocate that MBI needs to be a requisite adjunct treatment for PPD, and other perinatal mental health disorders, to promote maternal functioning, and positive long-term infant health outcomes.

Impact of Psychotherapy in Psychosis: A Retrospective Case Control Study.

Background: The need for psychological therapies for psychosis has become apparent since long-term antipsychotic drug treatment has a range of adverse side effects, with moderate therapeutic effects at best.Aims: To investigate whether the psychotherapeutic approach, dialogue therapy (DT) is associated with improvements of symptoms and functioning beyond standard psychiatric treatment (ST) in both schizophrenia and other psychosis.Methods: A retrospective case-control design, comparing 54 patients with different psychoses who received DT with 54 patients in a control group receiving ST was carried out. The groups were matched on diagnosis, age, sex, and treatment start. Outcome measures were Global assessment of functioning (GAF) scores, medications at follow up, and hospital stays after completed outpatient treatment.Results: Mean time in treatment from inclusion to follow-up was 3 years and 5 months. At follow-up, GAF functioning (GAF-F) and GAF symptom (GAF-S) scores both were significantly higher in the DT group than the ST group. Effect sizes (Cohen's d) were large; 1.8 for GAF-S and 2.1 for GAF-F. At follow-up, the use of psychoactive drugs was significantly reduced despite a shorter time in psychotherapy in the DT group compared to the ST group. Days of hospitalizations after end of treatment in the study period were significantly reduced in both groups compared to the period before start of treatment.Conclusions: The findings from this exploratory study are consistent with the possibility that dialogue therapy may lead to improvements in symptoms and functioning compared to standard treatment in psychosis.

Psychotherapy in schizophrenia: a retrospective controlled study

ABSTRACT Introduction Although pharmacological interventions have been the mainstay of treatment for schizophrenia, there has been a growing recognition of the importance of psychotherapy. Aims To investigate whether a novel psychotherapeutic approach, dialog therapy (DT), has an effect beyond standard psychiatric treatment (ST) in schizophrenia. Methods Twenty-four patients diagnosed with schizophrenia and treated with DT and 24 patients matched on age, sex, and diagnosis receiving ST were included in the study. Results At follow-up after a mean of 4 years and 1 month, the DT group had significantly higher scores on the GAF functions (GAF-F) and GAF symptoms (GAF-S) subscales compared to the ST group. Effect sizes (Cohen’s d) were very large, 238 for GAF-S and 241 for GAF-F. The number and doses of psychoactive drugs were significantly lower in the DT group compared to the ST group at follow-up, despite a shorter time in psychotherapy in the DT group. Conclusions This study provides preliminary evidence that dialog therapy may lead to improvements in symptoms and functioning compared to standard psychiatric treatment.

Psychiatric event in multiple sclerosis: could it be the tip of the iceberg?

Multiple sclerosis (MS) is a chronic progressive inflammatory disease of the central nervous system. Psychiatric comorbidities are highly prevalent in patients with MS, and can have drastic impact on quality of life and interpersonal relationships. Despite this high prevalence, whether psychiatric manifestations may represent the first signs of MS is still debatable. This constitutes an important issue, since early diagnosis of “psychiatric-onset MS” would result in prompt management, which usually ameliorates long-term prognosis. Here, we discuss clinical and radiological hints that suggest a diagnosis of psychiatric-onset MS. Briefly, this entity should be considered in healthy patients presenting with late-onset psychiatric symptoms, with or without cognitive decline, and with negative family history of psychiatric diseases. A thorough neurological exam is crucial to detect any subtle neurological signs. Brain magnetic resonance imaging is recommended to rule out frontotemporal lesions that might explain the clinical picture. Poor response to standard psychiatric treatments provides additional evidence for the diagnosis of an organic disease (e.g., MS). Combining psychopharmaceuticals with intravenous corticosteroids would result in good outcomes, but patients should be monitored carefully for possible psychiatric exacerbation, a common side effect of steroids.

The Impact of Aerobic Exercise on Brain-Derived Neurotrophic Factor and Neurocognition in Individuals With Schizophrenia: A Single-Blind, Randomized Clinical Trial.

Individuals with schizophrenia display substantial neurocognitive deficits for which available treatments offer only limited benefits. Yet, findings from studies of animals, clinical and nonclinical populations have linked neurocognitive improvements to increases in aerobic fitness (AF) via aerobic exercise training (AE). Such improvements have been attributed to up-regulation of brain-derived neurotrophic factor (BDNF). However, the impact of AE on neurocognition, and the putative role of BDNF, have not been investigated in schizophrenia. Employing a proof-of-concept, single-blind, randomized clinical trial design, 33 individuals with schizophrenia were randomized to receive standard psychiatric treatment (n = 17; "treatment as usual"; TAU) or attend a 12-week AE program (n = 16) utilizing active-play video games (Xbox 360 Kinect) and traditional AE equipment. Participants completed assessments of AF (indexed by VO2 peak ml/kg/min), neurocognition (MATRICS Consensus Cognitive Battery), and serum-BDNF before and after and 12-week period. Twenty-six participants (79%) completed the study. At follow-up, the AE participants improved their AF by 18.0% vs a -0.5% decline in the TAU group (P = .002) and improved their neurocognition by 15.1% vs -2.0% decline in the TAU group (P = .031). Hierarchical multiple regression analyses indicated that enhancement in AF and increases in BDNF predicted 25.4% and 14.6% of the neurocognitive improvement variance, respectively. The results indicate AE is effective in enhancing neurocognitive functioning in people with schizophrenia and provide preliminary support for the impact of AE-related BDNF up-regulation on neurocognition in this population. Poor AF represents a modifiable risk factor for neurocognitive dysfunction in schizophrenia for which AE training offer a safe, nonstigmatizing, and side-effect-free intervention.

Multifactorial determinants of the neurocognitive effects of electroconvulsive therapy.

For many patients with neuropsychiatric illnesses, standard psychiatric treatments with mono or combination pharmacotherapy, psychotherapy, and transcranial magnetic stimulation are ineffective. For these patients with treatment-resistant neuropsychiatric illnesses, a main therapeutic option is electroconvulsive therapy (ECT). Decades of research have found ECT to be highly effective; however, it can also result in adverse neurocognitive effects. Specifically, ECT results in disorientation after each session, anterograde amnesia for recently learned information, and retrograde amnesia for previously learned information. Unfortunately, the neurocognitive effects and underlying mechanisms of action of ECT remain poorly understood. The purpose of this paper was to synthesize the multiple moderating and mediating factors that are thought to underlie the neurocognitive effects of ECT into a coherent model. Such factors include demographic and neuropsychological characteristics, neuropsychiatric symptoms, ECT technical parameters, and ECT-associated neurophysiological changes. Future research is warranted to evaluate and test this model, so that these findings may support the development of more refined clinical seizure therapy delivery approaches and efficacious cognitive remediation strategies to improve the use of this important and widely used intervention tool for neuropsychiatric diseases.

The different faces of Creutzfeldt-Jacob Disease CJD in psychiatry

ObjectiveCreutzfeldt-Jacob Disease (CJD) is a rapidly progressive spongiform disease of the central nervous system. Psychiatric symptoms, though considered rare, can be the presenting symptoms of CJD and impose diagnosis difficulties. We reviewed prospectively our database to identify the frequency of psychiatric symptoms as identifying symptoms among our community. MethodsWe included all patients in Sheba Medical Center who were diagnosed with CJD between the years 2006 and 2012. Data were collected retrospectively. ResultsTwenty-three patients with CJD were admitted to our hospital during this 6-year period. Among them, 10 (44%) were diagnosed first as “psychiatric patients” due to psychiatric presenting symptoms. ConclusionIn our series, the frequency of misleading psychiatric symptom was 44%. Clinicians should therefore include CJD in their differential diagnoses of new onset dementia, particularly when associated psychosis and depression symptoms persist and worsen, despite standard psychiatric treatments.

Atypical antipsychotics for psychosis in adolescents

Atypical antipsychotics for psychosis in adolescents

Hearing voices peer support groups: a powerful alternative for people in distress

Hearing voices peer support groups offer a powerful alternative to mainstream psychiatric approaches for understanding and coping with states typically diagnosed as “hallucination.” In this jointly authored first-person account, we distill what we have learned from 10 years of facilitating and training others to facilitate these groups and what enables them to work most effectively in the long term. Having witnessed the transformative power of these groups for people long considered unreachable as well as for those who receive some benefit from standard psychiatric treatment, we describe effects that cannot easily be quantified or studied within traditional research paradigms. We explain the structure and function of hearing voices peer support groups and the importance of training facilitators to acquire the skills necessary to ensure that groups operate safely, democratically, and in keeping with the theories and principles of the Hearing Voices Network. The greater use of first-person experience as evidence in deciding what works or does not work for people in extreme distress is advocated; randomized designs or statistically significant findings cannot constitute the only bases for clinical evaluations (Elisabeth Svanholmer, in Romme et al. 2009, p. 151).

Long‐term effect of combined interpersonal psychotherapy and pharmacotherapy in a randomized trial of depressed patients

Evaluation of the long-term benefits of combined pharmacological and psychotherapeutic depression treatment and the differential impact of early childhood trauma. A randomized trial was conducted in 124 in-patients with a diagnosis of major depressive disorder comparing 5 weeks of interpersonal psychotherapy plus pharmacotherapy (IPT) with medication plus clinical management (CM). The study included a prospective, naturalistic follow-up 3, 12 and 75 months after in-patient treatment. The Hamilton Rating Scale for Depression (HRSD) served as the primary outcome measure. Patients in both treatments reduced their depressive symptoms between baseline and 5-year follow-up significantly with a faster decrease early in the follow-up phase. The time rate of change and acceleration on the HRSD was higher for patients in the combination therapy group. The contrast between the conditions at year 5 was non-significant. However, 28% of the IPT patients showed a sustained remission compared with 11% of the CM patients (P = 0.032). Early adversity was found to be a moderator of the relationship between treatment and outcome. In the long-term, a combination of psycho- and pharmacotherapy was superior in terms of sustained remission rates to standard psychiatric treatment. Early trauma should be assessed routinely in depressed patients.

Detecting and defusing cognitive traps: metacognitive intervention in schizophrenia

Until recently, psychological therapy for schizophrenia was considered harmful or inefficient by many clinicians. The reservation against psychotherapy is partly rooted in the assumption that delusions in particular and schizophrenia in general are not amenable to psychological understanding and represent 'utter madness'. However, meta-analyses suggest that cognitive intervention is effective in ameliorating schizophrenia symptoms. In addition, evidence has accumulated that cognitive biases, such as jumping to conclusions, are involved in the pathogenesis of schizophrenia positive symptoms, particularly delusions. A recently developed group program, called metacognitive training (MCT), is presented targeting these biases. MCT is a hybrid of psychoeducation, cognitive remediation and cognitive-behavioural therapy. This review introduces new evidence on cognitive biases involved in the pathogenesis of schizophrenia and demonstrates how the MCT raises the patients' (metacognitive) awareness to detect and defuse such 'cognitive traps'. At the end, a new individualized variant entitled MCT+ is presented targeting individual delusional ideas. Finally, empirical results are summarized that speak in favour of the feasibility and efficacy of MCT. Recent studies assert marked cognitive biases in schizophrenia. MCT has evolved as a feasible and effective complement of standard psychiatric treatment.

Nutrition, mood and behaviour: a review.

To conduct a critical review of recent empirical research regarding mood, behaviour and nutrition factors including essential fatty acids, macronutrients, micronutrients and food additives. A literature search of databases Medline, PsycInfo, CINAHL and Embase up to October 2008. The search emphasised empirical research published in the last 10 years and also included older literature. Studies in both adults and children were addressed. Research into omega-3 fatty acids has been substantial but evidence for their potential in treating mood and behaviour is modest. In comparison, there has been much less research into carbohydrate and protein intakes and little evidence for their ability to influence mood and behaviour. Recent trials with food additives suggest their removal from the diet may benefit susceptible children with hyperactivity disorders. Micronutrient supplementation appears to improve mood only in those who were initially deficient in micronutrients. More stringent research designs such as longitudinal studies and the use of biologically inert placebos within randomised controlled trials are needed before supplemental use of omega-3 fatty acids to treat disorders of mood and behaviour can be recommended. Caution is advised regarding the indiscriminate use of diets free of artificial food additives in managing hyperactivity disorders, as they may place an undue burden on individuals and their families. Should omega-3 fatty acid supplementation or the elimination of certain food additives be established as effective, they may provide cost-effective, accessible and well-tolerated adjuncts to standard psychiatric treatments for mood and behavioural disturbances.

The relationship of treatment preferences and experiences to outcome in generalized anxiety disorder (GAD)

The relationship of treatment preferences and experiences to outcome was explored in patients with generalized anxiety disorder (GAD). Patients were randomly allocated to either affect-focused body psychotherapy (ABP) (N=26) or standard psychiatric out-patient treatment (N=17). Initial preferences and subsequent experiences of treatment interventions were measured using a questionnaire focusing on support, inward reflection, concrete and directive problem solving, and affective expression. Outcome was assessed after 1 and 2 years in relation to symptom change. ABP patients reported being helped by supportive and reflective treatment interventions to a greater extent than controls. ABP patients also had more positive experiences of supportive and emotionally expressive interventions than they had expected at initial assessment. When patients were divided into two groups on the basis of patterns of preferences and experiences using cluster analysis, it was found that differences in outcome were considerably more marked for clusters than treatment groups. It is concluded that treatment preferences may have considerable interpersonal potential in therapy; how therapists utilize this potential may be important for improving outcome.