Weeks Of Acute Treatment Research Articles

Youth self-harm and the role of reasons for living and hope: A secondary analysis from a randomized controlled trial

Self-harm (SH) is one of the strongest predictors of eventual death by suicide. This study examines the potential protective role of reasons for living (RFL) and hope in youth with a history of self-harm using data from a randomized control trial (RCT) of brief cognitive behavioural therapy (BCBT). A single-blind, pilot RCT examined the efficacy of BCBT for suicide prevention versus an attentional control in youth aged 15-25 admitted to hospital following self-harm. Subjects’ reasons for living and hope were measured weekly by the Reasons for Living Scale (RFL) and Adult Hope Scale (AHS), respectively, for 10 weeks of acute treatment. Logistic regression was performed to evaluate whether baseline RFL and AHS scores predicted repeat self-harm. Mann-Whitney U tests were used to compare median RFL and AHS scores. Our study did not find associations between reasons for living or hope and repeat self-harm in youth. Treatment with BCBT was also not associated with improved scores on either measure.

Identifying subgroups with differential response to CBASP versus Escitalopram during the first eight weeks of treatment in outpatients with persistent depressive disorder

There exists little empirical evidence helping clinicians to select the most effective treatment for individual patients with persistent depressive disorder (PDD). This study identifies and characterizes subgroups of patients with PDD who are likely to benefit more from an acute treatment with psychotherapy than from pharmacotherapy and vice versa. Non-medicated outpatients with PDD were randomized to eight weeks of acute treatment with the Cognitive Behavioral Analysis System of Psychotherapy (CBASP; n = 29) or escitalopram plus clinical management (ESC/CM; n = 31). We combined several baseline variables to one composite moderator and identified two subgroups of patients: for 56.0%, ESC/CM was associated with a greater reduction in depression severity than CBASP, for the remaining 44.0%, it was the other way around. Patients likely to benefit more from ESC/CM were more often female, had higher rates of moderate-to-severe childhood trauma, more adverse life events and more previous suicide attempts. Patients likely to benefit more from CBASP were older, had more often an early illness onset and more previous treatments with antidepressants. Symptomatic response, remission, and reductions in symptom severity occurred more often in those patients treated with their likely more effective treatment condition. The findings suggest that the baseline phenotype of patients with PDD moderates their benefit from acute treatment with CBASP relative to ESC/CM. Once confirmed in an independent sample, these results could serve to guide the choice between primarily psychotherapeutic or pharmacological treatments for outpatients with PDD.

Factors affecting time to remission for inpatients with bipolar mania – A naturalistic Taiwanese study

BackgroundBipolar disorder is a complicated and chronic mental disorder. This study investigated factors affecting time to remission for inpatients with bipolar mania after 4 weeks of acute treatment. MethodsThis naturalistic study recruited inpatients with bipolar mania for acute treatment. Symptom severity was assessed using the Young Mania Rating Scale (YMRS) at weeks 0, 1, 2, 3, and 4. Patients were included if they had had assessments at weeks 0 and 1 Remission was defined as an YMRS score ≤ 12. The Cox regression analysis was used to analyze factors associated with time to remission after 4 weeks of acute treatment. ResultsFour hundred and forty-nine patients entered the analysis. Seventy-one of the 449 subjects (15.8%) reached symptomatic remission within 4 weeks of acute treatment. Using forward multivariate Cox regression analysis, comorbid substance use disorders, earlier age at onset, and greater manic symptom severity at baseline found to be statistically significant predictors of a longer time to reach remission after 4 weeks of treatment. LimitationsAs a retrospective chart review and naturalistic design, placebo effect and potentially confounding factors such as the possibility of missing records may have limited our results. ConclusionsEarly identification and intervention with integrated therapy is considered to shorten time to remission for patients at high risk of poor treatment outcome. More studies are needed in other real-world settings to generalize our results.

Hopelessness as a Predictor of Suicide Ideation in Depressed Male and Female Adolescent Youth.

We examined hopelessness as a predictor of suicide ideation in depressed youth after acute medication treatment. A total of 158 depressed adolescents were administered the Children's Depression Rating Scale-Revised (CDRS-R) and Columbia Suicide Severity Rating Scale (C-SSRS) as part of a larger battery at baseline and at weekly visits across 6weeks of acute fluoxetine treatment. The Beck Hopelessness Scale (BHS) was administered at baseline and week 6. A negative binomial regression model via a generalized estimating equationanalysis of repeated measures was used to estimate suicide ideation over the 6weeks of acute treatment from baseline measure of hopelessness. Depression severity and gender were included as covariates in the model. The negative binomial analysis was also conducted separately for the sample of males and females (in a gender-stratified analysis). Mean CDRS-R total scores were 60.30±8.93 at baseline and 34.65±10.41 at week 6. Mean baseline and week 6 BHS scores were 9.57±5.51 and 5.59±5.38, respectively. Per the C-SSRS, 43.04% and 83.54% reported having no suicide ideation at baseline and at week 6, respectively. The analyses revealed that baseline hopelessness was positively related to suicide ideation over treatment (p=.0027), independent of changes in depression severity. This significant finding persisted only for females (p=.0024). These results indicate the importance of early identification of hopelessness.

Cognitive Behavioral Analysis System of Psychotherapy versus Escitalopram in Chronic Major Depression

Background: A specific psychotherapy for chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), was compared to escitalopram (ESC). Methods: Sixty patients with chronic major depression were randomized to ‘CBASP' (22 sessions) or ‘ESC plus clinical management' (ESC/CM) at two treatment sites. The primary outcome measure was the score on the Montgomery-Asberg Depression Rating Scale (MADRS) after 8 weeks of acute treatment assessed by blinded raters. In the case of nonimprovement (<20% reduction in the MADRS score), the other condition was augmented for the following 20 weeks of extended treatment. Secondary end points were, among others, depressive symptoms, remission (MADRS score of ≤9) and response rates (reduction of MADRS score of ≥50%) 28 weeks after randomization. Results: An intent-to-treat analysis revealed that clinician-rated depression scores decreased significantly after 8 and 28 weeks with no significant differences between the groups. The response rates after 28 weeks of treatment were high (CBASP: 68.4%, ESC/CM: 60.0%), and the remission rates were moderate (CBASP: 36.8%, ESC/CM: 50.0%) with neither group being superior. Nonimprovers to the initial treatment caught up with the initial improvers in terms of depression scores and response and remission rates by the end of the treatment after being augmented with the respective other condition. Conclusions: CBASP and ESC/CM appear to be equally effective treatment options for chronically depressed outpatients. For nonimprovers to the initial treatment, it is efficacious to augment with medication in the case of nonresponse to CBASP and vice versa.

Lithium or an atypical antipsychotic drug in the management of treatment-resistant depression: a systematic review and economic evaluation

Patients with treatment-resistant depression (TRD) are those with major depressive disorder that has not responded adequately to treatment. The causes of depression are not fully understood, although there is evidence to suggest that depression is a complex interaction among biological, genetic, psychosocial and environmental factors. Strategies available for the treatment of patients with TRD include pharmacological, non-pharmacological, and psychological and psychosocial interventions. Pharmacological treatment options include switching to a different antidepressant, the addition of another antidepressant of a different class, or use of an augmenting agent, such as anticonvulsants, lithium or atypical antipsychotics (AAPs). However, there is limited evidence available on the effectiveness of these strategies in the treatment of TRD. To estimate the clinical effectiveness and cost-effectiveness of augmentation of selective serotonin reuptake inhibitor (SSRI) antidepressant therapy with either lithium or an AAP drug in the management of people with treatment-resistant unipolar depression, defined as failure to respond to two or more antidepressant drugs in their current episode of depression. Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, PsycINFO and NHS Economic Evaluation Database (NHS EED). All databases were searched from inception to August 2011. Additional data were obtained from manufacturers. Systematic reviews of studies evaluating clinical effectiveness, economic analyses and quality of life (QoL) were executed. Quality assessment according to predefined criteria was undertaken independently by two reviewers. Pairwise meta-analyses and mixed-treatment comparisons (MTCs) using both fixed- and random-effects models were undertaken based on intention-to-treat analyses. A probabilistic de novo mathematical model was developed to synthesise the available data on costs and clinical outcomes from the UK NHS perspective over a 1-year time horizon (8 weeks of acute treatment captured by a decision tree and 10 months of maintenance treatment captured by a Markov model). Twelve randomised controlled trials (RCTs) were identified in the review of clinical effectiveness literature; 10 considered SSRI + AAP compared with SSRI + placebo/no treatment, one considered SSRI + AAP compared with SSRI + lithium and one considered SSRI + lithium compared with SSRI + placebo. The RCTs included in the primary analyses used fluoxetine as the background SSRI and olanzapine as the AAP. Results of the MTC showed a non-significant trend in favour of lithium augmentation for response [lithium a priori odds ratio (OR) 1.29; 95% credible interval (CrI) 0.11 to 5.32; lithium post hoc OR 4.15; 95% CrI 0.25 to 20.34 (the trial informing the comparison with lithium reported response using two different definitions)], mean change in Montgomery-Åsberg Depression Rating Scale score from baseline (mean difference - 1.47, 95% CrI - 9.10 to 6.41) and all-cause withdrawals (OR 0.74, 95% CrI 0.10 to 2.66). Four economic evaluations (none directly addressing the review question) and 17 studies that reported on QoL were identified and summarised in narrative reviews. The results of the de novo modelling indicate that augmentation of SSRI with lithium dominates augmentation of an SSRI with AAP (i.e. it resulted in cost savings of £905 per person per year and generated more health benefits, estimated to be 0.03 quality-adjusted life-years). However, sensitivity analyses showed that the model was highly sensitive to changes in acute treatment efficacy (response and remission) or discontinuation. The model was not sensitive to changes in other parameters. In patients with TRD, there is a lack of direct evidence comparing the clinical effectiveness of augmenting an SSRI with an AAP compared with augmenting with lithium. RCTs were identified which facilitated comparison of adding AAP with adding lithium via a MTC. However, variations in the definitions of response implemented in the RCTs, together with differences in patient baseline characteristics across RCTs, introduce bias into the analysis. The direction and extent of the bias is uncertain. Augmentation of SSRIs with lithium or AAP is likely to be beneficial in people with TRD. Clinical evaluation based on the limited evidence identified in this research indicates no statistically significant difference between the two augmentation strategies. Cost-effectiveness analyses suggest that augmentation with lithium is less expensive and more effective than augmentation with AAP. However, the uncertainty in the clinical estimates of discontinuation and treatment response is reflected in the model results. A RCT comparing the two augmentation strategies, reporting relevant outcomes, including QoL, is needed. PROSPERO CRD42011001464.

Effectiveness of Lurasidone for Patients With Schizophrenia Following 6 Weeks of Acute Treatment With Lurasidone, Olanzapine, or Placebo

The primary objective was to evaluate the safety and tolerability of lurasidone, a new atypical antipsychotic agent, in the longer-term treatment of schizophrenia (DSM-IV). Persistence of symptom improvement was assessed as a secondary outcome. Patients who completed a 6-week, double-blind, placebo-controlled study evaluating the efficacy of fixed doses of once-daily lurasidone (40 or 120 mg) or olanzapine 15 mg (to confirm assay sensitivity) were eligible to receive flexibly dosed lurasidone 40 to 120 mg/d in this 6-month, open-label extension study (conducted from March 2008 to December 2009). Assessments of safety and tolerability were conducted at open-label baseline, at day 10, and monthly thereafter. Of 254 enrolled patients, 113 (44.5%) completed 6 months of open-label treatment. During the open-label study (month 6 observed cases), small decreases were observed in mean weight (-0.1 kg) and median lipid levels (total cholesterol, -6.5 mg/dL; low-density lipoprotein, 0.0 mg/dL; high-density lipoprotein, 0.0 mg/dL; triglycerides, -8.5 mg/dL). Patients previously treated with olanzapine (n = 69) experienced decrease in weight and improvement in lipid levels, whereas patients previously treated with lurasidone (n = 115) or placebo (n = 62) experienced minimal changes. No clinically meaningful changes were observed in median prolactin levels. The 2 most commonly reported adverse events were akathisia (13.0%) and insomnia (11.0%). Persistent antipsychotic efficacy of lurasidone was shown for patients who had previously received lurasidone, olanzapine, or placebo; further reductions from open-label baseline to final visit were observed in mean PANSS total score (-8.7) for all patients. Open-label treatment with flexibly dosed lurasidone (40-120 mg/d) was generally safe, well tolerated, and effective over a 6-month period in patients who had completed a preceding 6-week, double-blind study.

H-coil repetitive transcranial magnetic stimulation for treatment resistant major depressive disorder: An 18-week continuation safety and feasibility study

Objective. Evidence has shown that repetitive transcranial magnetic stimulation (rTMS) can be effective as an acute treatment for major depressive disorder (MDD). However, few studies have examined the safety and feasibility of rTMS as a long-term\\continuation treatment. Deep-TMS is a novel tool enabling deeper stimulation than standard coils. The current study examined the safety and feasibility of repetitive deep-TMS continuation treatment for MDD over the course of 18 weeks, following 4 weeks of acute treatment. Method. A total of 29 MDD patients were enrolled in the study. rTMS sessions (20 Hz) were given for a total of 22 weeks, divided into: 4 weeks of acute daily treatments, followed by 18 weeks of continuation treatments. Clinical evaluations were performed weekly throughout the study. Results. A significant decrease from baseline in Hamilton Depression Rating Scale (HDRS) score was found at the end of the acute phase, and maintained throughout the study (P < 0.0001). The Kaplan–Meier estimated probability of response was 46.15% (SE = 9.78%) at the end of the acute phase, and 81.12% (SE = 9.32%) at the end of the study (22 weeks). probability of remission at the end of the acute phase was 26.92% (SE = 8.70%) and 71.45% (SE = 10.99%) at the end of the study. Response in the acute phase was indicative of response in the continuation phases. The procedure was generally well tolerated and no adverse events were reported. Conclusion. The results suggest that H-coil deep-TMS administered continuation treatment can help maintain an antidepressant effect for 18 weeks, following 4 weeks of acute treatment.

Comparative efficacy of the Cognitive Behavioral Analysis System of Psychotherapy versus supportive psychotherapy for early onset chronic depression: design and rationale of a multisite randomized controlled trial.

BackgroundEffective treatment strategies for chronic depression are urgently needed since it is not only a common and particularly disabling disorder, but is also considered treatment resistant by most clinicians. There are only a few studies on chronic depression indicating that traditional psycho- and pharmacological interventions are not as effective as in acute, episodic depression. Current medications are no more effective than those introduced 50 years ago whereas the only psychotherapy developed specifically for the subgroup of chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), faired well in one large trial. However, CBASP has never been directly compared to a non-specific control treatment.Methods/DesignThe present article describes the study protocol of a multisite parallel-group randomized controlled trial in Germany. The purpose of the study is to estimate the efficacy of CBASP compared to supportive psychotherapy in 268 non-medicated early-onset chronically depressed outpatients. The intervention includes 20 weeks of acute treatment with 24 individual sessions followed by 28 weeks of continuation treatment with another 8 sessions. Depressive symptoms are evaluated 20 weeks after randomisation by means of the 24-item Hamilton Rating Scale of Depression (HRSD). Secondary endpoints are depressive symptoms after 12 and 48 weeks, and remission after 12, 20, and 48 weeks. Primary outcome will be analysed using analysis of covariance (ANCOVA) controlled for pre-treatment scores and site. Analyses of continuous secondary variables will be performed using linear mixed models. For remission rates, chi-squared tests and logistic regression will be applied.DiscussionThe study evaluates the comparative effects of a disorder-specific psychotherapy and a well designed non-specific psychological approach in the acute and continuation treatment phase in a large sample of early-onset chronically depressed patients.Trial registrationClinicalTrials.gov (NCT00970437).

E-health empowers patients with ulcerative colitis: a randomised controlled trial of the web-guided ‘Constant-care’ approach

BackgroundThe natural history of ulcerative colitis requires continuous monitoring of medical treatment via frequent outpatient visits. The European health authorities' focus on e-health is increasing. Lack of easy access to...

Symptom Improvement and Residual Symptoms during Acute Antidepressant Treatment in Pediatric Major Depressive Disorder

Knowing the timing of specific depressive symptom improvement will enable clinicians to prepare their patients well and improve treatment outcome, whereas recognizing which depressive symptoms may show delayed improvement will help clinicians to provide additional interventions early in treatment. In a prospective open-label fluoxetine study, we investigated the timing of depressive symptom improvement during acute treatment, and identified common remaining symptoms following 4, 8, and 12 weeks of acute treatment in depressed youths. A total of 168 children and adolescents, aged 7-18 years, with primary diagnoses of major depressive disorder (MDD) received 12 weeks of fluoxetine treatment. Youths were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia. The outcome measure included the Children's Depression Rating Scale-Revised. All depressive symptoms improved, particularly during the first 4 weeks of acute treatment. Forty-seven percent of remitters reported at least one residual symptom following 12 weeks, with most common residual symptoms being impaired school performance, insomnia, and irritability. Residual symptoms are common, even among remitters, at the end of 12 weeks of acute treatment. There is a need for clinicians to monitor symptom improvement and potentially provide additional interventions for the more resistant symptoms, such as insomnia and school performance.

Psychometric validation of the Dutch translation of the quality of life in reflux and dyspepsia (QOLRAD) questionnaire in patients with gastroesophageal reflux disease

BackgroundThe Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire is one of the best-characterized disease-specific instruments that captures health-related problems and symptom-patterns in patients with gastroesophageal reflux disease (GERD). This paper reports the psychometric validation of a Dutch translation of the QOLRAD questionnaire in gastroenterology outpatients with GERD.MethodsPatients completed the QOLRAD questionnaire at visit 1 (baseline), visit 2 (after 2, 4 or 8 weeks of acute treatment with esomeprazole 40 mg once daily), and visit 4 (after 6 months with on-demand esomeprazole 40 mg once daily or continuous esomeprazole 20 mg once daily). Symptoms were assessed at each visit, and patient satisfaction was assessed at visits 2 and 4.ResultsOf the 1166 patients entered in the study, 97.3% had moderate or severe heartburn and 55.5% had moderate or severe regurgitation at baseline. At visit 2, symptoms of heartburn and regurgitation were mild or absent in 96.7% and 97.7%, respectively, and 95.3% of patients reported being satisfied with the treatment. The internal consistency and reliability of the QOLRAD questionnaire (range: 0.83-0.92) supported construct validity. Convergent validity was moderate to low. Known-groups validity was confirmed by a negative correlation between the QOLRAD score and clinician-assessed severity of GERD symptoms. Effect sizes (1.15-1.93) and standardized response means (1.17-1.86) showed good responsiveness to change. GERD symptoms had a negative impact on patients' lives.ConclusionsThe psychometric characteristics of the Dutch translation of the QOLRAD questionnaire were found to be satisfactory, with good reliability and responsiveness to change, although convergent validity was at best moderate.

A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder

Self-administered cognitive behavior therapy (SCBT) has been shown to be an effective alternative to therapist-delivered treatment for panic disorder (PD). However, it is unknown whether combining SCBT and antidepressants can improve treatment. This trial evaluated the efficacy of SCBT and sertraline, alone or in combination, in PD. Patients (n=251) were randomized to 12 weeks of either placebo drug, placebo drug plus SCBT, sertraline, or sertraline plus SCBT. Those who improved after 12 weeks of acute treatment received treatment for an additional 12 weeks. Outcome measures included core PD symptoms (panic attacks, anticipatory anxiety, agoraphobic avoidance), dysfunctional cognitions (fear of bodily sensations, agoraphobic cognitions), disability, and clinical global impression of severity and improvement. Efficacy data were analyzed using general and generalized linear mixed models. Primary analyses of trends over time revealed that sertraline/SCBT produced a significantly greater rate of decline in fear of bodily sensations compared to sertraline, placebo/SCBT and placebo. Trends in other outcomes were not significantly different over time. Secondary analyses of mean scores at week 12 revealed that sertraline/SCBT fared better on several outcomes than placebo, with improvement being maintained at the end of continuation treatment. Outcome did not differ between placebo and either sertraline monotherapy or placebo/SCBT. Moreover, few differences emerged between the active interventions. This trial suggests that sertraline combined with SCBT may be an effective treatment for PD. The study could not confirm the efficacy of sertraline monotherapy or SCBT without concomitant medication or therapist assistance in the treatment of PD.

Impact of Childhood Trauma on Treatment Outcome in the Treatment for Adolescents with Depression Study (TADS)

The impact of childhood trauma was examined in 427 adolescents (54% girls, 74% Caucasian, mean = 14.6, SD = 1.5) with major depressive disorder participating in the Treatment for Adolescents with Depression Study (TADS).TADS compared the efficacy of cognitive behavioral therapy (CBT), fluoxetine (FLX), their combination (COMB), and placebo (PBO). Teens were separated into four trauma history groups: (1) no trauma; (2) trauma, no abuse; (3) physical abuse; (4), and sexual abuse. The effects of treatment and trauma history on depression severity across 12 weeks of acute treatment, as measured by the Children's Depression Rating Scale-Revised (CDRS-R), were examined.A significant trauma-by-treatment-by-time interaction indicated that trauma history moderated treatment. The Week 12 primary efficacy findings previously reported by TADS were replicated in the no trauma group (n = 201): COMB = FLX > CBT = PBO. No significant differences in treatment arms were observed among the trauma, no abuse, or physical abuse group. Teens with a history of sexual abuse treated with COMB, FLX, and PBO showed significant and equivalent improvement on the CDRS-R (mean <45), whereas the mean CDRS-R for the CBT group tended to remain in the depressed range (mean >45). Baseline suicidality and self-reported depression were significantly related to a history of sexual abuse.The study was limited by the level of detail regarding childhood traumatic experiences. Results are discussed in terms of the implications for treating depressed adolescents with traumatic backgrounds.Clinical Trials Registry Information: Treatment for Adolescents with Depression Study; http://www.clinicaltrials.gov, NCT00006286.

Impact of Childhood Trauma on Treatment Outcome in the Treatment for Adolescents with Depression Study (TADS)

The impact of childhood trauma was examined in 427 adolescents (54% girls, 74% Caucasian, mean = 14.6, SD = 1.5) with major depressive disorder participating in the Treatment for Adolescents with Depression Study (TADS). TADS compared the efficacy of cognitive behavioral therapy (CBT), fluoxetine (FLX), their combination (COMB), and placebo (PBO). Teens were separated into four trauma history groups: (1) no trauma; (2) trauma, no abuse; (3) physical abuse; (4), and sexual abuse. The effects of treatment and trauma history on depression severity across 12 weeks of acute treatment, as measured by the Children's Depression Rating Scale-Revised (CDRS-R), were examined. A significant trauma-by-treatment-by-time interaction indicated that trauma history moderated treatment. The Week 12 primary efficacy findings previously reported by TADS were replicated in the no trauma group (n = 201): COMB = FLX > CBT = PBO. No significant differences in treatment arms were observed among the trauma, no abuse, or physical abuse group. Teens with a history of sexual abuse treated with COMB, FLX, and PBO showed significant and equivalent improvement on the CDRS-R (mean <45), whereas the mean CDRS-R for the CBT group tended to remain in the depressed range (mean >45). Baseline suicidality and self-reported depression were significantly related to a history of sexual abuse. The study was limited by the level of detail regarding childhood traumatic experiences. Results are discussed in terms of the implications for treating depressed adolescents with traumatic backgrounds.Clinical Trials Registry Information: Treatment for Adolescents with Depression Study; http://www.clinicaltrials.gov, NCT00006286.

Innovative child and adolescent treatment research for anxiety and depressive disorders

‘‘Taking it to the Streets: Advancing the Dissemination of CBT’’ was the theme of the annual meeting of the Association for Behavioral and Cognitive Therapies (ABCT) held in Orlando, Florida in November 2008. ABCT is an interdisciplinary organization comprising researchers, clinicians, and trainees who are committed to development, implementation, and dissemination of behavioral, cognitive, and other evidence-based interventions. Historically, the ABCT annual meetings have had a preponderance of presentations focused on the treatment of anxiety and depressive disorders, and the 2008 meeting was no exception. Below are some of the highlights of this year’s convention. Treatments for childhood anxiety were evaluated in the Child/Adolescent Anxiety Multimodal Treatment Study (CAMS), a multisite National Institute of Mental Health (NIMH)-supported trial comparing the efficacy of cognitive-behavior therapy (CBT), sertraline, pill placebo, and a combination of CBT and sertraline for treating children and adolescents with Generalized Anxiety Disorder, Social Phobia, and/or Separation Anxiety Disorder. Study investigators presented a symposium focused on the primary outcomes of CAMS, the largest (n5 488) and first ever randomized clinical trial for childhood anxiety. Results indicated that the combined intervention led to significantly better response rates than CBT alone or sertraline alone (81% versus 60% and 55%, Po.001), whereas the monotherapies were not significantly different from each other. All three active conditions were superior to pill placebo (23.7% response rate, Po.001). John Walkup, M.D. and colleagues emphasized that clinicians can recommend three options for treating child and adolescent anxiety based on treatment availability and family preferences. Paul Rohde, Ph.D. from the Oregon Research Institute presented the findings of the continuation and maintenance treatments provided in the multisite Treatments of Adolescents with Depression Study (TADS). TADS examined the impact of psychosocial and psychopharmacological interventions on the achievement and maintenance of sustained treatment response for depression, comparing the effectiveness of fluoxetine (FLX), CBT, combination therapy (COMB), and pill placebo with clinical management (PBO). Following 12 weeks of acute treatment, patients in the FLX, CBT, and COMB conditions received 6 weeks of continuation treatment (intensity based on degree of response to acute treatment) followed by three maintenance treatment sessions scheduled over 18 weeks. Patients continued in the same treatment conditions assigned during acute treatment. Among the 39% (n5 95) of patients who had not achieved a sustained response (two consecutive ratings of a full response in assessments conducted 6 weeks apart) at the end of the acute treatment, sustained response rates during continuation and maintenance treatments were as follows: 80% COMB, 62% FLX, and 77% CBT (difference not significant). These results indicate that for most depressed adolescents who do not achieve a sustained response during acute treatment, extra time and treatment will result in the desired treatment effect. Although CAMS and TADS studied treatments for either anxiety or depression, respectively, Robin Weersing, Ph.D. from San Diego State University and University of California, San Diego presented the results of a pilot effectiveness study of a brief, integrated cognitive-behavioral approach to treat children with anxiety and/or depressive disorders in a primary-care setting. The eight-session treatment adapted and combined two CBT protocols, one for anxiety and one for depression, with a focus on ‘‘graded engagement’’ (a combination of exposure and behavioral activation). Children aged 8–17 (n5 60) with diagnoses of depression and/or anxiety were randomized to receive either the brief behavioral treatment or outside referral. Results at 12 weeks indicated that children in the brief CBT condition demonstrated significantly greater clinical global improvement and symptom reduction than children in the control group. Children with comorbid diagnoses demonstrated significant reductions in both anxious and depressive symptoms, suggesting the feasibility of a

Remission and Recovery in the Treatment for Adolescents With Depression Study (TADS): Acute and Long-Term Outcomes

ObjectiveWe examine remission rate probabilities, recovery rates, and residual symptoms across 36 weeks in the Treatment for Adolescents with Depression Study (TADS). MethodThe TADS, a multisite clinical trial, randomized 439 adolescents with major depressive disorder to 12 weeks of treatment with fluoxetine, cognitive–behavioral therapy, their combination, or pill placebo. The pill placebo group, treated openly after week 12, was not included in the subsequent analyses. Treatment differences in remission rates and probabilities of remission over time are compared. Recovery rates in remitters at weeks 12 (acute phase remitters) and 18 (continuation phase remitters) are summarized. We also examined whether residual symptoms at the end of 12 weeks of acute treatment predicted later remission. ResultsAt week 36, the estimated remission rates for intention-to-treat cases were as follows: combination, 60%; fluoxetine, 55%; cognitive–behavioral therapy, 64%; and overall, 60%. Paired comparisons reveal that, at week 24, all active treatments converge on remission outcomes. The recovery rate at week 36 was 65% for acute phase remitters and 71% for continuation phase remitters, with no significant between-treatment differences in recovery rates. Residual symptoms at the end of acute treatment predicted failure to achieve remission at weeks 18 and 36. ConclusionsMost depressed adolescents in all three treatment modalities achieved remission at the end of 9 months of treatment.

Psychotherapy as monotherapy for the treatment of bipolar II depression: a proof of concept study

We conducted a proof of concept study to determine the feasibility of using an individual psychotherapy, Interpersonal and Social Rhythm Therapy (IPSRT), as monotherapy for the acute treatment of bipolar II depression. Unmedicated individuals (n = 17) meeting DSM-IV criteria for bipolar II disorder and currently depressed received weekly psychotherapy (IPSRT) for 12 weeks. After 12 weeks of acute treatment, individuals received an additional 8 weeks of follow-up treatment consisting of continued weekly IPSRT with supplementary lamotrogine for IPSRT non-responders. By week 12, 41% (n = 7) of the sample responded to IPSRT monotherapy (defined as > or =50% reduction in depression scores without an increase in mania scores), 41% (n = 7) dropped out of or were removed from the study, and 18% (n = 3) did not respond to treatment. By week 20, 53% (n = 9) had achieved a response and 29% (n = 5) achieved a full remission of symptoms. Interpersonal and Social Rhythm Therapy appears to be a promising intervention for a subset of individuals with bipolar II depression. A randomized controlled trial is needed to systematically evaluate the efficacy of IPSRT as an acute monotherapy for bipolar II depression.

The role of readiness to change in response to treatment of adolescent depression.

The effect of readiness to change on treatment outcome was examined among 332 adolescents (46% male, 74% Caucasian), ages 12 through 17 years (M = 14.6, SD = 1.5), with major depressive disorder who were participating in the Treatment for Adolescents With Depression Study (TADS). TADS is a randomized clinical trial comparing the effectiveness of fluoxetine (an antidepressant medication), cognitive-behavioral therapy, their combination, and a pill placebo. An abbreviated Stages of Change Questionnaire was used to obtain 4 readiness to change scores: precontemplation, contemplation, action, and maintenance. The association between each readiness score and depression severity across 12 weeks of acute treatment for depression, as measured by the Children's Depression Rating Scale--Revised, was examined. Although treatment response was not moderated by any of the readiness scores, baseline action scores predicted outcome: Higher action scores were associated with better outcome regardless of treatment modality. Furthermore, treatment effects were mediated by change in action scores during the first 6 weeks of treatment, with increases in action scores related to greater improvement in depression. Assessing readiness to change may have implications for tailoring treatments for depressed adolescents.

Physician Withdrawal Checklist (PWC-20)

Anxiety disorders are the most common mental illnesses in the United States. Despite having a number of medication options readily available, benzodiazepines (BZs) and antidepressants have achieved remission rates of only 35% after 8 weeks of acute treatment. In the development of new anxiolytics, particularly those that affect the gamma-aminobutyric acid system, it is essential to assess the new compound's potential to cause discontinuation symptoms after stopping the medication as part of both short- and long-term treatment. This report describes the development of the 20-item Penn Physician Withdrawal Checklist (PWC), a smaller version of the original 35-item PWC, and examines its validity, internal consistency, test-retest and interrater reliability, and factor structure. The PWC scores, assessed at the peak of withdrawal severity, were selected from 143 of our patients for an orthogonal factor analysis. Our results suggest that the Penn Physician Withdrawal Checklist is a simple and accurate method to assess anxiolytic discontinuation symptoms.