Showing papers by "Robert Gallop published in 2008"

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression.

Abstract: This study followed treatment responders from a randomized controlled trial of adults with major depression. Patients treated with medication but withdrawn onto pill-placebo had more relapse through 1 year of follow-up compared to patients who received prior behavioral activation, prior cognitive therapy, or continued medication. Prior psychotherapy was also superior to medication withdrawal in the prevention of recurrence across the 2nd year of follow-up. Specific comparisons indicated that patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication, and patients previously exposed to behavioral activation did almost as well relative to patients withdrawn from medication, although the difference was not significantly different. Differences between behavioral activation and cognitive therapy were small in magnitude and not significantly different across the full 2-year follow-up, and each therapy was at least as efficacious as the continuation of medication. These findings suggest that behavioral activation may be nearly as enduring as cognitive therapy and that both psychotherapies are less expensive and longer lasting alternatives to medication in the treatment of depression.

Antidepressant medications v. cognitive therapy in people with depression with or without personality disorder.

Abstract: Background There is conflicting evidence about comorbid personality pathology in depression treatments. Aims To test the effects of antidepressant drugs and cognitive therapy in people with depression distinguished by the presence or absence of personality disorder. Method Random assignment of 180 out-patients with depression to 16 weeks of antidepressant medication or cognitive therapy. Random assignment of medication responders to continued medication or placebo, and comparison with cognitive therapy responders over a 12-month period. Results Personality disorder status led to differential response at 16 weeks; 66% v. 44% (antidepressants v. cognitive therapy respectively) for people with personality disorder, and 49% v. 70% (antidepressants v. cognitive therapy respectively) for people without personality disorder. For people with personality disorder, sustained response rates over the 12-month follow-up were nearly identical (38%) in the prior cognitive therapy and continuation-medication treatment arms. People with personality disorder withdrawn from medication evidenced the lowest sustained response rate (6%). Despite the poor response of people with personality disorder to cognitive therapy, nearly all those who did respond sustained their response. Conclusions Comorbid personality disorder was associated with differential initial response rates and sustained response rates for two well-validated treatments for depression.

The impact of development of acute lung injury on hospital mortality in critically ill trauma patients.

Abstract: Objective: The additional impact of development of acute lung injury on mortality in severely-injured trauma patients beyond baseline severity of illness has been questioned. We assessed the contribution of acute lung injury to in-hospital mortality in critically ill trauma patients. Design: Prospective cohort study. The contribution of acute lung injury to in-hospital mortality was evaluated in two ways. First, multivariable logistic regression models were used to test the independent association of acute lung injury with in-hospital mortality while adjusting for baseline confounding variables. Second, causal pathway models were used to estimate the amount of the overall association of baseline severity of illness with in-hospital mortality that is attributable to the interval development of acute lung injury. Setting: Academic level 1 trauma center. Patients: Two hundred eighty-three critically ill trauma patients without isolated head injury and with an Injury Severity Score ≥16 were evaluated for development of acute lung injury in the first 5 days after trauma. Measurements and Main Results: Of the 283 patients, 38 (13.4%) died. The unadjusted mortality rate was nearly three-fold greater in the acute lung injury group (23.9% vs. 8.4%; odds ratio = 3.36; 95% confidence interval 1.67-6.77; p = 0.001). Acute lung injury remained an independent risk factor for death after adjustment for age, baseline Acute Physiologic and Chronic Health Evaluation III score, Injury Severity Score, and blunt mechanism of injury (odds ratio = 2.87; 95% confidence interval 1.29-6.37; p = 0.010). Forty percent of the total association of the baseline Acute Physiologic and Chronic Health Evaluation III score with mortality occurred via an indirect association through acute lung injury, and the remaining 60% via a direct effect. Conclusions: Development of acute lung injury in critically ill trauma patients without isolated head injury contributes independently to in-hospital mortality beyond baseline severity of illness measures. In addition, a significant portion of the association between baseline illness severity and risk of death in these patients might be explained by the interval development of acute lung injury.

Potential Reasons Why Physicians Underuse Lung-Protective Ventilation: A Retrospective Cohort Study Using Physician Documentation

Abstract: BACKGROUND: Physicians often fail to use lung-protective ventilation (LPV) in patients with acute lung injury. OBJECTIVE: To use physician documentation to identify why physicians did not initiate or continue LPV in patients with acute lung injury. METHODS: This was a retrospective cohort study in a university hospital. The study period was September 2000 through November 2002. In our primary analysis, LPV was defined as use of a tidal volume ≤ 7.5 mL/kg predicted body weight (PBW). We also conducted a sensitivity analysis in which we defined LPV as use of a tidal volume ≤ 6.0 mL/kg PBW. RESULTS: In our primary analysis, in 42 (56%) of 75 cases, physicians used or intended to use LPV. Of these 42 subjects, 12 received LPV transiently, and 6 never received LPV, despite the fact that the physician ordered or documented LPV use. In 21 of the 33 remaining cases the physicians documented concerns or clinical criteria that may explain why LPV was not used: relative contraindications to LPV (n = 2), change of care goal to comfort care only (n = 1), rapid resolution of hypoxemia (n = 4), and consideration of alternative diagnoses for which LPV was not indicated (n = 14). Of the 12 cases where LPV was used transiently, diagnostic uncertainty (n = 6) was a common finding. The sensitivity analysis yielded explanations in similar proportions. CONCLUSIONS: LPV, once initiated, is often discontinued. Uncertainty in the diagnosis of acute lung injury appears to be an important barrier to initiating and continuing LPV, whereas concerns regarding metabolic acidosis and clinical changes (hypoxemia improved) may prevent the initiation of LPV. Even when physicians believe they are using LPV, they may not be, which suggests that protocol-implementation failure is an important barrier to use of LPV.

The role of the alliance and techniques in predicting outcome of supportive-expressive dynamic therapy for cocaine dependence.

Abstract: We examine the complex relations among therapeutic alliance, adherence to Supportive-Expressive Therapy (SET), therapist competence, and their interactions in predicting change in drug use. Experts rated early therapy sessions of cocaine dependent patients (n 108) randomized to SET as part of the Collaborative Cocaine Treatment Study. Moderate adherence to SET and competent delivery of SET were separately associated with poorer outcome. Further, strong alliance combined with low levels of SET adherence was associated with a better outcome than moderate or high levels. Moreover, the usage of nonprescribed techniques (i.e., Individual Drug Counseling [IDC]) by SET therapists predicted better outcome in a subsample (n 36), and SET patients receiving high levels of IDC adherence had less predicted drug use compared with those with high levels of SET techniques. Overall results may suggest that decreasing cocaine use through straightforward drug counseling techniques instead of trying to help patients understand the reasons for their use is a better initial road to recovery.

Causal mediation analyses for randomized trials

Abstract: In the context of randomized intervention trials, we describe causal methods for analyzing how post-randomization factors constitute the process through which randomized baseline interventions act on outcomes. Traditionally, such mediation analyses have been undertaken with great caution, because they assume that the mediating factor is also randomly assigned to individuals in addition to the randomized baseline intervention (i.e., sequential ignorability). Because the mediating factors are typically not randomized, such analyses are unprotected from unmeasured confounders that may lead to biased inference. We review several causal approaches that attempt to reduce such bias without assuming that the mediating factor is randomized. However, these causal approaches require certain interaction assumptions that may be assessed if there is enough treatment heterogeneity with respect to the mediator. We describe available estimation procedures in the context of several examples from the literature and provide resources for software code.

Effects of Family Violence on Psychopathology Symptoms in Children Previously Exposed to Maltreatment

Abstract: Although many studies suggest that family violence is associated with child psychopathology, multiple features of the home environment might account for this association, such as poverty and caregiver psychopathology. Studies are needed examining how change in psychopathology symptoms is affected by home violence, controlling for children's own developmental symptom histories and other predictors of psychopathology. This study used latent difference score structural equation modeling to test if witnessing home violence and/or experiencing harsh physical discipline predicted changes in psychopathology symptoms among 2,925 youth aged 5-16 years previously exposed to violence. Results demonstrated that harsh physical discipline predicted child-specific changes in externalizing symptoms, whereas witnessing violence predicted child-specific changes in internalizing symptoms across time. Implications for research and policy are discussed.

Sudden gains in the treatment of generalized anxiety disorder.

Abstract: The objective of this study was to investigate the prevalence and timing of sudden gains over the course of brief, psychodynamically oriented treatment for generalized anxiety disorder (GAD). Data were used from two studies of brief (i.e., 16-session) supportive-expressive psychotherapy for GAD. Anxiety symptoms were measured at every weekly treatment session. Sudden gains in anxiety symptoms were defined to parallel previous research on sudden gains in major depressive disorder (MDD). Overall, sudden gains were found for 11 of 68 participants (16.2%), with 4 (36.4%) of these patients experiencing reversals of these gains and losing over 50% of the sudden gain during subsequent treatment sessions. Applying a baseline severity cutoff and a duration criteria similar to those used in previous studies of sudden gains resulted in 10 of 29 (34.5%) patients showing sudden gains. Of these sudden gainers, 4 (40.0%) experienced a reversal and 7 (70%) experienced an upwards spike in symptoms during their psychotherapy course. When defined in a parallel fashion, rates of sudden gains in GAD are similar to those found in MDD, although anxiety symptoms are highly variable.

High psychiatric symptom severity is a moderator of substance abuse treatment outcomes among women in single vs. mixed gender group treatment.

Abstract: Objective: This exploratory study examined psychiatric symptom severity as a moderator of outcomes among women receiving either the Women's Recovery Group (WRG), a new manualized group treatment for substance use disorders combining single-gender group composition and women-focused content, or Group Drug Counseling (GDC), an empirically supported mixed-gender group treatment. Methods: We used a mixed model analysis of variance. Results: We found a significant 3-way interaction effect of treatment condition, time, and baseline Brief Symptom Inventory scores as well as Beck Depression Inventory scores. Conclusion: Single-gender group treatment may confer added benefit for women with substance abuse and high psychiatric symptom severity than mixed-gender treatment.

Supportive-Expressive Psychodynamic Therapy for Cocaine Dependence: A Closer Look

Abstract: Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically-oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12 month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 days per month at baseline to a mean of 1.3 days at 12 months.

A review on Monte Carlo simulation methods as they apply to mutation and selection as formulated in Wright-Fisher models of evolutionary genetics.

Abstract: A case has made for the use of Monte Carlo simulation methods when the incorporation of mutation and natural selection into Wright-Fisher gametic sampling models renders then intractable from the standpoint of classical mathematical analysis. The paper has been organized around five themes. Among these themes was that of scientific openness and a clear documentation of the mathematics underlying the software so that the results of any Monte Carlo simulation experiment may be duplicated by any interested investigator in a programming language of his choice. A second theme was the disclosure of the random number generator used in the experiments to provide critical insights as to whether the generated uniform random variables met the criterion of independence satisfactorily. A third theme was that of a review of recent literature in genetics on attempts to find signatures of evolutionary processes such as natural selection, among the millions of segments of DNA in the human genome, that may help guide the search for new drugs to treat diseases. A fourth theme involved formalization of Wright-Fisher processes in a simple form that expedited the writing of software to run Monte Carlo simulation experiments. Also included in this theme was the reporting of several illustrative Monte Carlo simulation experiments for the cases of two and three alleles at some autosomal locus, in which attempts were to made to apply the theory of Wright-Fisher models to gain some understanding as to how evolutionary signatures may have developed in the human genome and those of other diploid species. A fifth theme was centered on recommendations that more demographic factors, such as non-constant population size, be included in future attempts to develop computer models dealing with signatures of evolutionary process in genomes of various species. A brief review of literature on the incorporation of demographic factors into genetic evolutionary models was also included to expedite and stimulate further development on this theme.

Changes in Positive Quality of Life over the Course of Psychotherapy

Abstract: The objective of this study was to examine patients' reports of positive quality of life over the course of multiple forms of psychotherapy and disorders. Data from five studies using a common assessment battery were pooled to evaluate the magnitude of change in positive quality of life and explore the relation of change in positive quality of life to change in symptoms, and how these relations vary by disorder. Positive quality of life was measured at intake, termination, and during two post-treatment visits 6 and 12 months following termination. Results revealed that positive quality of life improves moderately over the course of psychotherapy and sustains the improvement through follow-up. Levels of positive quality of life and the degree of change in positive quality of life varied considerably by disorder. There also were moderate sized correlations between changes in positive quality of life and changes in symptomatic response and interpersonal functioning from intake to termination. Implications of the findings for clinical practice and future research are discussed.

Additional treatment services in a cocaine treatment study: level of services obtained and impact on outcome.

Abstract: The objective of this study was to examine the level of additional treatment services obtained by patients enrolled in the NIDA Cocaine Collaborative Study, a multi-center efficacy trial of four treatments for cocaine dependence, and to determine whether these services impact treatment outcome. Cocaine-dependent patients (N = 487) were recruited at five sites and randomly assigned to six months of one of four psychosocial treatments. Assessments were made at baseline, monthly during treatment, and at follow-ups at 9, 12, 15, and 18 months post-randomization. On average, patients received little or no additional treatment services during active treatment (first six months), but the rate of obtaining most services increased during the follow-up phase (month 7 to 18). In general, the treatment groups did not differ in the rates of obtaining non-protocol services. For all treatment groups, patients with greater psychiatric severity received more medical and psychiatric services during active treatment and follow-up. Use of treatment services was unrelated to drug use outcomes during active treatment. However, during the follow-up period, increased use of psychiatric medication, twelve-step attendance, and twelve-step participation was related to less drug use. The results suggest that during uncontrolled follow-up phases, additional non-protocol services may potentially confound the interpretation of treatment group comparisons in drug use outcomes.

Development and initial validation of a multi-domain self-report measure of work functioning.

Abstract: The need for a self-report measure of work functioning that is flexible to involvement in work across 3 domains (employment, school, and home) led to the development of the Work History Inventory (WHI). The WHI was administered to 185 patients who participated in psychotherapy studies and to 110 community control respondents who were not in treatment. The WHI Total score and subscales (Performance and Interpersonal) demonstrated adequate to good reliability. WHI scores correlated moderately with symptom measures and strongly with another work functioning measure. Changes across treatment indicated that the WHI Total and Performance scores increased significantly across psychotherapy. The WHI seems to be a reliable and valid instrument for measuring treatment related changes in work functioning.