Showing papers in "Depression and Anxiety in 2012"

Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis.

Abstract: Virtual reality exposure therapy (VRET) is a promising intervention for the treatment of the anxiety disorders. The main objective of this meta-analysis is to compare the efficacy of VRET, used in a behavioral or cognitive-behavioral framework, with that of the classical evidence-based treatments, in anxiety disorders. A comprehensive search of the literature identified 23 studies (n = 608) that were included in the final analysis. The results show that in the case of anxiety disorders, (1) VRET does far better than the waitlist control; (2) the post-treatment results show similar efficacy between the behavioral and the cognitive behavioral interventions incorporating a virtual reality exposure component and the classical evidence-based interventions, with no virtual reality exposure component; (3) VRET has a powerful real-life impact, similar to that of the classical evidence-based treatments; (4) VRET has a good stability of results over time, similar to that of the classical evidence-based treatments; (5) there is a dose-response relationship for VRET; and (6) there is no difference in the dropout rate between the virtual reality exposure and the in vivo exposure. Implications are discussed.

Emotion dysregulation model of mood and anxiety disorders.

Abstract: In this review, we present a transdiagnostic emotion dysregulation model of mood and anxiety disorders. This model posits that a triggering event, in conjunction with an existing diathesis, leads to negative or positive affect, depending on the person's affective style. Mood and anxiety disorders are the result of emotion dysregulation of negative affect, coupled with deficiencies in positive affect. The theoretical background of the model is discussed and a range of clinical applications of the model is described.

The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and implications.

Abstract: BACKGROUND: Clinical and neurobiological evidence for a dissociative subtype of posttraumatic stress disorder (PTSD) has recently been documented. A dissociative subtype of PTSD is being considered for inclusion in the forthcoming Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to address the symptoms of depersonalization and derealization found among a subset of patients with PTSD. This article reviews research related to the dissociative subtype including antecedent, concurrent, and predictive validators as well as the rationale for recommending the dissociative subtype. METHODS: The relevant literature pertaining to the dissociative subtype of PTSD was reviewed. RESULTS: Latent class analyses point toward a specific subtype of PTSD consisting of symptoms of depersonalization and derealization in both veteran and civilian samples of PTSD. Compared to individuals with PTSD, those with the dissociative subtype of PTSD also exhibit a different pattern of neurobiological response to symptom provocation as well as a differential response to current cognitive behavioral treatment designed for PTSD. CONCLUSIONS: We recommend that consideration be given to adding a dissociative subtype of PTSD in the revision of the DSM. This facilitates more accurate analysis of different phenotypes of PTSD, assist in treatment planning that is informed by considering the degree of patients' dissociativity, will improve treatment outcome, and will lead to much-needed research about the prevalence, symptomatology, neurobiology, and treatment of individuals with the dissociative subtype of PTSD. Language: en

Transcranial magnetic stimulation (tms) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice

Abstract: Background Few studies have examined the effectiveness of transcranial magnetic stimulation (TMS) in real-world clinical practice settings Methods Forty-two US-based clinical TMS practice sites treated 307 outpatients with Major Depressive Disorder (MDD), and persistent symptoms despite antidepressant pharmacotherapy Treatment was based on the labeled procedures of the approved TMS device Assessments were performed at baseline, week 2, at the point of maximal acute benefit, and at week 6 when the acute course extended beyond 6 weeks The primary outcome was change in the Clinician Global Impressions-Severity of Illness from baseline to end of acute phase Secondary outcomes were change in continuous and categorical outcomes on self-report depression scales (9-Item Patient Health Questionnaire [PHQ-9], and Inventory of Depressive Symptoms-Self Report [IDS-SR]) Results Patients had a mean ± SD age of 486 ± 142 years and 668% were female Patients received an average of 25 (± 24) antidepressant treatments of adequate dose and duration without satisfactory improvement in this episode There was a significant change in CGI-S from baseline to end of treatment (−19 ± 14, P < 0001) Clinician-assessed response rate (CGI-S) was 580% and remission rate was 371% Patient-reported response rate ranged from 564 to 415% and remission rate ranged from 287 to 265%, (PHQ-9 and IDS-SR, respectively) Conclusion Outcomes demonstrated response and adherence rates similar to research populations These data indicate that TMS is an effective treatment for those unable to benefit from initial antidepressant medication

Toward an account of clinical anxiety predicated on basic, neurally mapped mechanisms of Pavlovian fear-learning: The case for conditioned overgeneralization

Abstract: The past two decades have brought dramatic progress in the neuroscience of anxiety due, in no small part, to animal findings specifying the neurobiology of Pavlovian fear-conditioning. Fortuitously, this neurally mapped process of fear learning is widely expressed in humans, and has been centrally implicated in the etiology of clinical anxiety. Fear-conditioning experiments in anxiety patients thus represent a unique opportunity to bring recent advances in animal neuroscience to bear on working, brain-based models of clinical anxiety. The current presentation details the neural basis and clinical relevance of fear conditioning, and highlights generalization of conditioned fear to stimuli resembling the conditioned danger cue as one of the more robust conditioning markers of clinical anxiety. Studies testing such generalization across a variety of anxiety disorders (panic, generalized anxiety disorder, and social anxiety disorder) with systematic methods developed in animals will next be presented. Finally, neural accounts of overgeneralization deriving from animal and human data will be described with emphasis given to implications for the neurobiology and treatment of clinical anxiety.

Meditative Therapies for Reducing Anxiety: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract: BACKGROUND Anxiety disorders are among the most common psychiatric disorders; meditative therapies are frequently sought by patients with anxiety as a complementary therapy. Although multiple reviews exist on the general health benefits of meditation, no review has been focused on the efficacy of meditation for anxiety specifically.

Early interventions for PTSD: a review

Abstract: The high prevalence of trauma exposure and subsequent negative consequences for both survivors and society as a whole emphasize the need for secondary prevention of posttraumatic stress disorder. However, clinicians and relief workers remain limited in their ability to intervene effectively in the aftermath of trauma and alleviate traumatic stress reactions that can lead to chronic PTSD. The scientific literature on early intervention for PTSD is reviewed, including early studies on psychological debriefing, pharmacological, and psychosocial interventions aimed at preventing chronic PTSD. Studies on fear extinction and memory consolidation are discussed in relation to PTSD prevention and the potential importance of immediate versus delayed intervention approaches and genetic predictors are briefly reviewed. Preliminary results from a modified prolonged exposure intervention applied within hours of trauma exposure in an emergency room setting are discussed, along with considerations related to intervention reach and overall population impact. Suggestions for future research are included. Prevention of PTSD, although currently not yet a reality, remains an exciting and hopeful possibility with current research approaches translating work from the laboratory to the clinic.

Attention biases, anxiety, and development: Toward or away from threats or rewards?

Abstract: Research on attention provides a promising framework for studying anxiety pathophysiology and treatment. The study of attention biases appears particularly pertinent to developmental research, as attention affects learning and has down-stream effects on behavior. This review summarizes recent findings about attention orienting in anxiety, drawing on findings in recent developmental psychopathology and affective neuroscience research. These findings generate specific insights about both development and therapeutics. The review goes beyond a traditional focus on biased processing of threats and considers biased processing of rewards. Building on this work, we then turn to the treatment of pediatric anxiety, where manipulation of attention to threat and/or reward may serve a therapeutic role as a component of Attention Bias Modification Therapy.

The anxiety spectrum and the reflex physiology of defense: from circumscribed fear to broad distress.

Abstract: Guided by the diagnostic nosology, anxiety patients are expected to show defensive hyperarousal during affective challenge, irrespective of the principal phenotype. In the current study, patients representing the whole spectrum of anxiety disorders (i.e., specific phobia, social phobia, panic disorder with or without agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder (GAD), posttraumatic stress disorder(PTSD)), and healthy community control participants, completed an imagery-based fear elicitation paradigm paralleling conventional intervention techniques. Participants imagined threatening and neutral narratives as physiological responses were recorded. Clear evidence emerged for exaggerated reactivity to clinically relevant imagery—most pronounced in startle reflex responding. However, defensive propensity varied across principal anxiety disorders. Disorders characterized by focal fear and impairment (e.g., specific phobia) showed robust fear potentiation. Conversely, for disorders of long-enduring, pervasive apprehension and avoidance with broad anxiety and depression comorbidity (e.g., PTSD secondary to cumulative trauma, GAD), startle responses were paradoxically diminished to all aversive contents. Patients whose expressed symptom profiles were intermediate between focal fearfulness and broad anxious-misery in both severity and chronicity exhibited a still heightened but more generalized physiological propensity to respond defensively. Importantly, this defensive physiological gradient—the inverse of self-reported distress—was evident not only between but also within disorders. These results highlight that fear circuitry could be dysregulated in chronic, pervasive anxiety, and preliminary functional neuroimaging findings suggest that deficient amygdala recruitment could underlie attenuated reflex responding. In summary, adaptive defensive engagement during imagery may be compromised by long-term dysphoria and stress—a phenomenon with implications for prognosis and treatment planning. Depression and Anxiety 29:264–281, 2012.

Comorbidity and disease burden in the National Comorbidity Survey Replication (NCS-R).

Abstract: The National Comorbidity Survey Replication (NCS-R) is supported by the National Institute of Mental Health (NIMH; U01-MH60220) with supplemental support from the Robert Wood Johnson Foundation (RWJF; Grant 044780. Additional support for the preparation of this work was provided by the Mental Health Burden Study (NIMH; HHSN271200700030C). We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. These activities were supported by the National Institute of Mental Health (R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481)

Transdiagnostic versus diagnosis‐specific cbt for anxiety disorders: a preliminary randomized controlled noninferiority trial

Abstract: Transdiagnostic cognitive-behavioral treatments for anxiety disorders have been gaining increased attention and empirical study in recent years in response to amassing data suggesting more similarities among anxiety disorder diagnoses than differences [1,2,3]. Symptom overlap tends to be the norm rather than the exception, and several authors have suggested the existence of shared underlying pathology across the anxiety disorders [1, 4, 5]. Additionally, rates of co-occurring Axis I disorders are extremely high, with comorbidity among the anxiety and depressive disorders reaching approximately 55%[6]. Transdiagnostic treatments are designed to focus on the commonalities among the anxiety disorders, and recent studies have suggested that transdiagnostic CBT can be beneficial for clients with co-occurring anxiety and depressive disorders [7] and complex anxiety diagnoses such as anxiety disorder not otherwise specified [8]. Additional impetus to investigate transdiagnostic treatment protocols relates to practical issues that often arise in providing anxiety treatments in clinical settings. Transdiagnostic group CBT may be preferable in settings where it is not feasible to provide a variety of diagnostically homogeneous groups[9], such as sparsely populated regions where it would be difficult to populate diagnosis-specific groups in a timely manner, or settings with a high demand for services and limited resources for providing individual or diagnosis-specific group treatments. Furthermore, the dissemination of empirically supported treatments for anxiety may be eased with transdiagnostic CBT since therapists could receive training in a single CBT treatment for anxiety rather than multiple, disorder-specific treatments[10]. Transdiagnostic treatment models have generally shown evidence of efficacy, although the standards of comparison have been limited. Erickson[11], for example, reported the results of an uncontrolled trial of a transdiagnostic group CBT program for 70 individuals with an anxiety disorder diagnosis. His results suggested significant decreases in self-reported anxiety and depression among clients completing the 11-week treatment. Further, six-month follow-up data from 16 participants suggested maintenance of treatment gains. Norton[12] reported the results of an open trial of the transdiagnostic CBGT using mixed-effects regression modeling of session-by-session anxiety data from 52 participants with an anxiety disorder. Results indicated that participants tended to improve over treatment, with no differential outcome for any primary or comorbid diagnoses. Effect sizes (d = 1.68) were comparable to average treatment effects reported in meta-analyses of diagnosis-specific CBT for anxiety diagnoses (see[13,14]). Ellard and colleagues[15] reported data from 15 participants undergoing an open trial of individual transdiagnostic CBT for emotional disorders, reporting that 11 (73%) were treatment responders and 9 (60%) achieved high end-state functioning. Norton and Hope[16] published the first randomized controlled trial of a 12-week transdiagnostic group treatment and found that approximately 67% of those receiving treatment, as compared to none of the waitlist controls, showed a reduction in diagnostic severity to subclinical levels. In a secondary analysis of the treatment data, Norton et al.[17] also noted significant decreases in depressive symptoms and the diagnostic severity of depressive disorders among those receiving treatment. Erickson et al.[18] also randomized 152 patients to either an 11-week CBGT program or a delayed treatment control condition. The immediate treatment group improved more than the delayed treatment controls at post-treatment. When diagnostic categories were examined separately, however, only patients with primary panic disorder showed greater improvement than controls, possibly due to the reduced sample sizes of these subgroup analyses. In a randomized clinical trial of a similar transdiagnostic anxiety treatment, Schmidt et al.[19] found that post-treatment outcomes on measures of anxiety (d's ranged from 1.31 to 1.62), depression (d = .70), and clinician-rated severity (d = 1.18) were also superior among patients receiving transdiagnostic anxiety treatment compared to waitlist controls. Importantly, these gains were maintained at six-month follow-up. Finally, Craske et al.[20,21] found evidence that a transdiagnostic computer-assisted CBT delivered in primary care settings was superior to usual care[20], and outcomes were similar across diagnoses[21]. Further, their data[21] suggested high acceptability and participation among both patients and practitioners. Norton[22] described a randomized clinical trial examining the efficacy of a 12-week transdiagnostic group CBT program in comparison to a 12-week comprehensive relaxation training program. Results from 87 treatment initiators suggested significant and statistically equivalent/non-inferior outcomes across conditions, although relaxation was associated with a greater rate of dropout despite no differences in treatment credibility. No evidence was found for any differential effects of transdiagnostic CBT for any primary or comorbid diagnoses. McEvoy and Nathan[23] utilized a benchmarking strategy—comparing observed effect sizes to those obtained from methodologically-similar studies—to compare the efficacy of their transdiagnostic CBT intervention for anxiety and depression to similar published efficacy trials. Data from 143 participants attending at least three sessions (30 with anxiety disorders, 38 with depressive disorders, 75 with comorbid anxiety and depressive disorders) indicated treatment effect sizes, reliable change indices, and clinically significant change indices that were highly similar to those obtained in methodologically similar diagnosis-specific treatment studies for major depressive disorder or specific anxiety disorder diagnoses. Finally, Norton and Philipp[24] reported a meta-analysis on the efficacy of transdiagnostic anxiety treatments, and noted a strong average within-group effect (d = 1.29) across studies. Although these previous studies demonstrate the efficacy of transdiagnostic treatments in reducing anxiety symptoms, what is not established is the comparative efficacy of transdiagnostic anxiety treatments to well-established diagnosis-specific group CBT protocols for specific anxiety disorders. The primary aim of the current study was to investigate the efficacy of a transdiagnostic anxiety treatment by comparison to group CBT treatments that specifically target individual diagnoses of panic disorder, social anxiety disorder, and generalized anxiety disorder using a treatment non-inferiority methodology[25]. Non-inferiority methods differ from traditional null hypothesis significance testing in that the null hypothesis tested is of treatment inferiority and the alternative hypothesis, should the null be rejected at α = .05, is of treatment non-inferiority. It was hypothesized that all participants would show a significant reduction in anxiety over the course of treatment, and that outcomes in the transdiagnostic and diagnosis-specific conditions would be non-inferior.

Self-report and clinician-rated measures of depression severity: can one replace the other?

Abstract: BACKGROUND: It has been suggested that clinician-rated scales and self-report questionnaires may be interchangeable in the measurement of depression severity, but it has not been tested whether clinically significant information is lost when assessment is restricted to either clinician-rated or self-report instruments. The aim of this study is to test whether self-report provides information relevant to short-term treatment outcomes that is not captured by clinician-rating and vice versa. METHODS: In genome-based drugs for depression (GENDEP), 811 patients with major depressive disorder treated with escitalopram or nortriptyline were assessed with the clinician-rated Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Rating Scale for Depression (HRSD), and the self-report Beck Depression Inventory (BDI). In sequenced treatment alternatives to relieve depression (STAR*D), 4,041 patients treated with citalopram were assessed with the clinician-rated and self-report versions of the Quick Inventory of Depressive Symptomatology (QIDS-C and QIDS-SR) in addition to HRSD. RESULTS: In GENDEP, baseline BDI significantly predicted outcome on MADRS/HRSD after adjusting for baseline MADRS/HRSD, explaining additional 3 to 4% of variation in the clinician-rated outcomes (both P Language: en

Transdiagnostic treatment for anxiety and depression.

Abstract: Michelle G. Craske Ph.D., is Professor of Psychology and of Psychiatry and Biobehavioral Sciences, and Director of the Anxiety Disorders Research Center, at UCLA. She has published extensively in the area of fear and anxiety disorders, including over 300 scientific articles, four books on the topics of the etiology and treatment of anxiety disorders, gender differences in anxiety, translation from the basic science of fear learning to treating phobias and anxiety disorders, and principles and practice of cognitive behavioral therapy, as well as several self-help books and therapist guides. In addition, she has been the recipient of National Institute of Mental Health funding for research projects pertaining to risk factors for anxiety disorders and depression among children and adolescents, the cognitive and physiological aspects of anxiety and panic attacks, neural mediators of behavioral treatments for anxiety disorders, fear extinction mechanisms of exposure therapy, and the development and dissemination of treatments for anxiety and related disorders. She is presently Associate Editor for Behaviour Research and Therapy a scientific board member for the Anxiety Disorders Association of America a member of the DSM-5 Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group, and Chair of the Anxiety Disorders Subworkgroup. She is also a member of the APA Clinical Treatment Guidelines Advisory Steering Committee for the development of practice guidelines.

The dissociative subtype of ptsd: a replication and extension

Abstract: Background The nature of the relationship between dissociation and posttraumatic stress disorder (PTSD) has clinical and nosological importance. The aim of this study was to evaluate the evidence for a dissociative subtype of PTSD in two independent samples and to examine the pattern of personality disorder (PD) comorbidity associated with the dissociative subtype of PTSD. Methods Latent profile analyses were conducted on PTSD and dissociation items reflecting derealization and depersonalization in two samples of archived data: Study 1 included 360 male Vietnam War Veterans with combat-related PTSD; Study 2 included 284 female Veterans and active duty service personnel with PTSD and a high base rate of exposure to sexual trauma. Results The latent profile analysis yielded evidence for a three-class solution in both samples: the model was defined by moderate and high PTSD classes and a class marked by high PTSD severity coupled with high levels of dissociation. Approximately 15% of the male sample and 30% of the female sample were classified into the dissociative class. Women (but not men) in the dissociative group exhibited higher levels of comorbid avoidant and borderline PD diagnoses. Conclusions Results provide support for a dissociative subtype of PTSD and also suggest that dissociation may play a role in the frequent co-occurrence of PTSD and borderline PD among women. These results are pertinent to the on-going revisions to the DSM and suggest that consideration should be given to incorporating a dissociative subtype into the revised PTSD criteria. Depression and Anxiety 00:1–10, 2012. © 2012 Wiley Periodicals, Inc.

Evidence for a dissociative subtype of PTSD by latent profile and confirmatory factor analyses in a civilian sample.

Abstract: BACKGROUND: Dissociative symptoms are increasingly recognized in individuals with posttraumatic stress disorder (PTSD). The aim of this study was to investigate the prevalence of derealization and depersonalization symptoms via latent profile analyses (LPAs) in a civilian PTSD sample and examine the relationship between PTSD and dissociative symptoms via factor analytic methods. METHODS: A civilian sample of individuals with PTSD predominantly related to childhood abuse (n = 134) completed a diagnostic interview for PTSD and comorbid psychiatric disorders. LPAs and confirmatory factor analyses (CFAs) were performed on the severity scores for PTSD, derealization, and depersonalization symptoms. RESULTS: LPAs extracted three groups, one of which was uniquely characterized by high derealization and depersonalization symptoms, and accounted for 25% of the sample. Individuals in the dissociative subgroup also showed a higher number of comorbid Axis I disorders and a more significant history of childhood abuse and neglect. CFAs suggested the acceptance of a five factor solution in which dissociative symptoms are distinct from but correlate significantly with the core PTSD symptom clusters. CONCLUSIONS: The results from LPAs and CFAs are concordant with the concept of a dissociative subtype in patients with PTSD and suggest that symptoms of derealization-depersonalization and the core symptoms of PTSD are positively correlated. Thought should be given to including a dissociative subtype of PTSD in the DSM-5. Language: en

Diagnostic overlap of generalized anxiety disorder and major depressive disorder in a primary care sample.

Abstract: Background—Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are highly comorbid. A possible explanation is that they share four symptoms according to the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition – Text Revision (DSMIV-TR). The present study addressed the symptom overlap of people meeting DSM-IV-TR diagnostic criteria for GAD, MDD, or both to investigate whether comorbidity might be explained by overlapping diagnostic criteria. Methods—Participants (N = 1,218) were enrolled in the Coordinated Anxiety Learning and Management (CALM) study (a randomized effectiveness clinical trial in primary care). Hypotheses were: 1) the comorbid GAD/MDD group would endorse the overlapping symptoms more than the non-overlapping symptoms, and 2) the comorbid GAD/MDD group would endorse the overlapping symptoms more than GAD only or MDD only groups, whereas differences would not occur for non-overlapping symptoms. Results—The overlapping GAD/MDD symptoms were endorsed more by the comorbid group than the MDD group but not the GAD group when covarying for total symptom endorsement. Similarly, the comorbid group endorsed the overlapping symptoms more than the non-overlapping symptoms and did not endorse the non-overlapping symptoms more than the GAD or MDD groups when covarying for total symptom endorsement. Conclusions—The results suggest that comorbidity of GAD and MDD is strongly influenced by diagnostic overlap. Results are discussed in terms of errors of diagnostic criteria, as well as models of shared psychopathology that account for diagnostic criteria overlap.

Screening for depression in adolescents: validity of the patient health questionnaire in pediatric care

Abstract: BACKGROUND: This study examines the criterion validity of the Patient Health Questionnaire 9-item (PHQ-9) and 2-item (PHQ-2) version as a depression-screening instrument for adolescents. METHODS: Three hundred twenty-two adolescents aged 13-16 were recruited from pediatric hospitals. Criterion validity of the PHQ-9 and PHQ-2 was assessed against diagnoses of any depressive disorder provided by a structured diagnostic interview. Areas under the receiver operating characteristics curve (AUCs) and sensitivities and specificities at optimal cutoff points were computed for both versions of the PHQ. Besides the dimensional algorithm, a categorical algorithm was applied for the PHQ-9. Validity measures of both scoring procedures of the PHQ-9 as well as PHQ-2 were compared statistically. In addition, unaided clinical depression diagnoses by the attending pediatricians were evaluated. RESULTS: Using the dimensional algorithm, the AUCof the PHQ-9 (93.2%) was significantly higher than that of the PHQ-2 (87.2%). At optimal cutoffs, there was no significant difference in sensitivity (PHQ-9: 90.0%, PHQ-2: 85.0%), but in specificity (PHQ-9: 86.5%, PHQ-2: 79.4%). Although the categorical algorithm of the PHQ-9 was most specific (94.7%), sensitivity was just above chance (52.5%). The unaided clinical diagnoses yielded a sensitivity of 12.5% and a specificity of 96.0%. CONCLUSIONS: The dimensional algorithm of the PHQ-9 demonstrated high criterion validity, whereas the categorical algorithm should not be applied due to its low sensitivity. Even though the PHQ-2 performed well, validity of the PHQ-9 was still superior. Hence, the PHQ-9 can be recommended as depression screener for adolescents to improve recognition rates in pediatric care. Language: en

An examination of the influence of a sequential treatment on the course and impact of dissociation among women with PTSD related to childhood abuse

Abstract: BACKGROUND: It has been proposed that posttraumatic stress disorder (PTSD) patients who experience significant dissociation upon exposure to traumatic reminders may do less well in trauma-focused therapies. We explored whether a sequenced two-component treatment in which an emotion regulation skills training module preceding exposure would improve outcomes for those with significant dissociation. METHODS: Analyses were conducted on data from an RCT in which 104 women with PTSD related to childhood abuse were assigned to one of three treatment conditions: Skills Training in Affective and Interpersonal Regulation (STAIR) followed by Narrative Story Telling (NST; STAIR/NST), STAIR followed by supportive counseling (SC; STAIR/SC), or SC followed by NST (SC/NST). RESULTS: Baseline dissociation was associated with differential outcome such that at low levels of dissociation the three treatments were equally effective but at higher levels STAIR/NST resulted in greater reductions in dissociative symptoms. Level of baseline dissociation did not moderate the effect of the treatments on PTSD outcome. At all levels of baseline dissociation, STAIR/NST produced better PTSD outcome. At posttreatment, however, participants with high dissociation treated with STAIR/NST continued to improve during follow-up, those treated with STAIR/SC maintained gains, and those treated with SC/NST experienced loss of posttreatment PTSD symptom gains. CONCLUSIONS: The differential results observed among the treatments depending on severity of dissociation at baseline and at posttreatment suggest the potential clinical utility of identifying a dissociative subtype of PTSD and of the benefits of sequenced, phase-oriented treatment approaches. Language: en

The impact of dissociation on PTSD treatment with cognitive processing therapy

Abstract: Background: This secondary analysis of data from a randomized controlled trial of cognitive processing therapy (CPT) and its constituent components investigated whether dissociation decreased over the course of treatment primarily targeting symptoms of posttraumatic stress disorder (PTSD) and explored whether levels of dissociation predicted treatment outcome differentially by treatment condition. Methods: An intention to treat sample of 150 women were randomized to CPT, cognitive therapy only (CPT-C) or written trauma accounts only (WA). Dissociation was measured by the dissociation subscale of the Traumatic Stress Inventory and the Multiscale Dissociation Inventory. Results: Multilevel regression analyses revealed significant decreases in dissociation that did not vary as a function of treatment condition. Growth curve modeling revealed significant treatment condition by dissociation interactions such that the impact of pretreatment levels of dissociation impacted the treatment conditions differently. Conclusions: Women who endorsed low pretreatment levels of dissociation responded most efficiently to CPT-C, whereas women with the highest levels of dissociation, in particular high levels of depersonalization, responded better to CPT. Depression and Anxiety 29:718–730, 2012. C � 2012 Wiley Periodicals, Inc.

Killing in combat may be independently associated with suicidal ideation

Abstract: BACKGROUND: The United States military has lost more troops to suicide than to combat for the second year in a row and better understanding combat-related risk factors for suicide is critical. We examined the association of killing and suicide among war veterans after accounting for PTSD, depression, and substance use disorders. METHODS: We utilized a cross-sectional, retrospective, nationally representative sample of Vietnam veterans from the National Vietnam Veterans Readjustment Study (NVVRS). In order to perform a more in depth analysis, we utilized a subsample of these data, the NVVRS Clinical Interview Sample (CIS), which is representative of 1.3 million veterans who were eligible for the clinical interview by virtue of living in proximity to an interview site, located within 28 standard metropolitan regions throughout the United States. RESULTS: Veterans who had higher killing experiences had twice the odds of suicidal ideation, compared to those with lower or no killing experiences (OR = 1.99, 95% CI = 1.07-3.67), even after adjusting for demographic variables, PTSD, depression, substance use disorders, and adjusted combat exposure. PTSD (OR = 3.42, 95% CI = 1.09-10.73), depression (OR = 11.49, 95% CI = 2.12-62.38), and substance use disorders (OR = 3.98, 95% CI = 1.01-15.60) were each associated with higher odds of suicidal ideation. Endorsement of suicide attempts was most strongly associated with PTSD (OR = 5.52, 95% CI = 1.21-25.29). CONCLUSIONS: Killing experiences are not routinely examined when assessing suicide risk. Our findings have important implications for conducting suicide risk assessments in veterans of war. Depression and Anxiety 00:1-6, 2012. © 2012 Wiley Periodicals, Inc. Language: en

Disorder-Specific Mental Health Service Use for Mood and Anxiety Disorders: Associations with Age, Sex, and Psychiatric Comorbidity

Abstract: Background The objectives of this study are to examine the prevalence of disorder-specific mental health service use for mood and anxiety disorders, and relationships between helpseeking and age, sex, and psychiatric comorbidity. Methods The authors used Wave 2 data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), which included 34,653 adults. Cross-tabulations provided helpseeking prevalence rates for five anxiety disorders and three mood disorders by age and sex, as well as for individuals with and without comorbid anxiety and mood disorders. Logistic regression analyses explored the likelihood of helpseeking among younger and middle-aged adults in comparison to older adults. Results The prevalence of helpseeking was highest for panic disorder (45.3%) and dysthymia (44.5%) and lowest for specific phobias (7.8%). For each condition except panic disorder service use was most likely among middle-aged adults and especially unlikely among older individuals. Sex differences in treatment seeking favoring women showed only modest variability with age. Finally, the prevalence of helpseeking was generally lower among individuals without comorbid anxiety or mood disorders, and the hill-shaped influence of age on service use was attenuated in this pure group. Conclusions The results of this study highlight the highest prevalence of disorder-specific service use among middle-aged adults and women, and among individuals with panic disorder and dysthymia. For purposes of identifying groups who are in need of targeted efforts to increase service use, helpseeking was especially unlikely among people suffering from specific phobia, as well as among men and older adults.

Avoidance, safety behavior, and reassurance seeking in generalized anxiety disorder.

Abstract: Background The behavioral symptoms of Generalized Anxiety Disorder (GAD) are not well characterized. This study examines behavioral symptoms in patients with GAD compared to healthy participants, their change during behavioral therapy, and their role for predicting short- and long-term outcome. Methods Secondary data analysis of 56 patients with DSM-IV GAD from a randomized controlled trial testing worry exposure (n = 29) and applied relaxation (n = 27), compared to 33 demographically matched healthy participants. Participants reported on attempts to control or prevent worry, specifically cognitive and behavioral avoidance, safety behavior, and reassurance, along with other GAD symptoms. The Hamilton Anxiety Scale served as immediate (post therapy) and the Penn State Worry Questionnaire as immediate and long-term (6-/12-month follow-up) treatment outcome measure. Results GAD patients engage significantly more in attempts to control or prevent worry as reflected in cognitive and behavioral avoidance, safety behavior, and reassurance seeking than healthy comparison participants. Behavior therapy significantly reduces these behavioral strategies without substantial indication of differential effects of treatment type. However, only patients remitting from GAD reach the low symptom level of healthy participants. The initial level of behavioral symptoms is irrelevant for immediate treatment success, but higher degrees of cognitive and behavioral avoidance and safety behavior at the end of treatment predict worse long-term outcome. Conclusions Behavioral symptoms appear to be relevant features in GAD that improve with successful treatment. Further research is warranted to examine whether inclusion of behavioral symptoms in the definition of GAD would have beneficial effects on diagnostic recognition and treatment. Depression and Anxiety 29:948-957, 2012. (C) 2012 Wiley Periodicals, Inc.

The importance of anxiety in both major depression and bipolar disorder

Abstract: Background Generalized anxiety disorder (GAD) is frequently co-morbid with major depression (MDD), and this becomes more so when the duration requirement is relaxed. Both anxiety diagnoses and anxious symptoms are more common in both unipolar and bipolar depression. This paper explores the relationship between anxious symptoms and GAD with both unipolar and bipolar depression. Method MDD and bipolar disorder (BPD) are compared in three important respects: the extent of their co-morbidity with anxious symptoms and GAD, the effects that anxiety has on outcome of MDD and BPD, and the effects that anxiety has on the probability of suicide in each disorder. Results Anxious diagnoses occur frequently in association with depressive disorders, albeit to a different extent in the various subtypes of depression. In both disorders, anxiety affects the outcome and makes suicidal thoughts, and completed suicide more likely. Conclusions Anxious phenomena should be assessed whenever a depressive disorder is diagnosed. It is likely that the raised expectancy of anxious phenomena is related to an individual's premorbid level of negative affect, and it is possible that suicidal phenomena are related to subthreshold hypomanic symptoms.

Brain activation to facial expressions in youth with PTSD symptoms

Abstract: OBJECTIVE: This study examined activation to facial expressions in youth with a history of interpersonal trauma and current posttraumatic stress symptoms (PTSS) compared to healthy controls (HC). DESIGN AND ANALYSIS: Twenty-three medication-naive youth with PTSS and 23 age- and gender-matched HC underwent functional magnetic resonance imaging (fMRI) while viewing fearful, angry, sad, happy, and neutral faces. Data were analyzed for group differences in location of activation, as well as timing of activation during the early versus late phase of the block. Using SPM5, significant activation (P Language: en

Personalized treatment of adult depression: medication, psychotherapy, or both? A systematic review

Abstract: Background Personalized medicine aims to identify which characteristics of an individual predict the outcome of a specific treatment, in order to get a better match between the individual and the treatment received We conducted a systematic review and meta-analysis of randomized trials comparing two treatments directly in a group of patients with a specific characteristic Methods We searched relevant studies from bibliographical databases and included trials comparing (1) medication with psychotherapy, (2) medication with combined treatment, and (3) psychotherapy with combined treatment, in specific target groups (a) with a predefined sociodemographic characteristic, (b) a specific type of depression, (c) a comorbid mental or somatic disorder, or (d) from a specific setting (outpatients, primary care) Results We included 52 studies with 4,734 depressed patients In these studies, 20 characteristics of the target groups were examined The results showed that medication is probably the best treatment for dysthymia, and combined treatments are more effective in depressed outpatients, as well as in depressed older adults However, in order to examine the 20 characteristics in the three categories of comparisons, 254 studies would be needed for having sufficient statistical power to show an effect size of g = 05 Currently, only 201% of these studies have been conducted Conclusions Although a considerable number of studies have compared medication, psychotherapy, and combined treatments, and some preliminary results are useful for deciding which treatment is best for which patient, the development of personalized treatment of depression has only just begun

Cognitive inflexibility as a prospective predictor of suicidal ideation among young adults with a suicide attempt history

Abstract: Background: Previous studies suggest that people attempt suicide because they are cognitively inflexible, but past research suggesting a link between cognitive inflexibility and suicidal thoughts and behavior has been limited by cross-sectional designs. This study examined whether cognitive inflexibility differentially and prospectively predicted suicidal ideation among young adults with and without a history of a suicide attempt. Methods: A sample of 45 young adults with (n = 13) or without (n = 32) a suicide attempt history completed the Wisconsin Card Sorting Test (WCST), a diagnostic interview, and self-report measures of hopelessness, depressive symptoms, and suicidal ideation, and were followed up 6 months later to reassess suicidal ideation. Results: Cognitive inflexibility, as measured by perseverative errors on the WCST, predicted suicidal ideation at 6-month follow-up, among suicide attempters, but not among nonattempters, adjusting for the presence of a baseline mood or anxiety diagnosis, hopelessness, and baseline suicidal ideation. Conclusions: Cognitive inflexibility may increase vulnerability to suicidal ideation over time among individuals with a previous suicide attempt history. Implications for interventions with suicide attempters are discussed. Depression and Anxiety 0:1-7, 2011. © 2011 Wiley Periodicals, Inc. Language: en

Proinflammatory and “resiliency” proteins in the csf of patients with major depression

Abstract: Background A number of studies have shown that elevated levels of inflammatory cytokines may promote depression and suicidal ideation and that neuroprotective peptides may decrease the response to stress and depression. In this study, cerebrospinal fluid (CSF) levels of three inflammatory cytokines (IL-1, IL-6, and tumor necrosis factor α (TNFα)) and two putative “resiliency” neuropeptides (brain-derived neurotrophic factor (BDNF) and neuropeptide Y (NPY)) were compared between patients with depression and healthy controls. Methods Eighteen patients with major depression and 25 healthy controls underwent a lumbar puncture; CSF samples were withdrawn and assayed for IL-1, IL-6, TNFα, BDNF, and NPY levels. Patients with depression were then entered into an 8-week treatment protocol and had repeated lumbar puncture procedures post-treatment. Results Contrary to prediction, we found that at baseline depressed patients had higher CSF NPY concentration compared to the normal comparison group. Within the depressed patients, we found several statistically significant correlations between elevated CSF cytokine levels and clinical severity. Conclusion Despite the small sample size, given the challenges in obtaining CSF from patients with depression these data are of interest in confirming some aspects of the inflammatory hypothesis of depression.

Role of anxiety sensitivity subfactors in suicidal ideation and suicide attempt history

Abstract: BackgroundAnxiety along with anxiety-related risk factors has been increasingly implicated in suicidal ideation and suicide attempts. One such risk factor, anxiety sensitivity (AS), refers to fear of anxiety-related sensations. Subfactors of AS, notably physical and cognitive concerns, seem to be re

The effectiveness of internet cognitive behavioural therapy for generalized anxiety disorder in clinical practice

Abstract: Background Clinical trials have demonstrated the efficacy of internet cognitive behavioral therapy (iCBT) in the treatment of generalized anxiety disorder (GAD). The current study aims to determine whether these efficacy findings, established under controlled research conditions, translate into effectiveness in practice. Methods The sample comprised 588 patients who completed at least one iCBT lesson for GAD through CRUfAD clinic (www.crufadclinic.org). This six-lesson course became available to primary care physicians to prescribe in 2009. Routine data collection included demographics, GAD symptomatology (GAD-7), psychological distress (K-10), and disability (WHODAS). Results All six lessons were completed by 324/588 (55.1%) patients. When compared with completers, noncompleters tended to be younger and based in rural locations. Prior to discontinuing the course, noncompleters demonstrated statistically significant reductions in psychological distress. For those who completed the course, effect sizes on all outcome measures were medium to large and over 60% of moderate-to-severe GAD cases met criteria for remission upon treatment completion. Conclusions The current study indicates that computerized CBT for GAD is effective in generating positive, clinically significant outcomes among typical patients treated under the usual conditions in primary care. Future research should focus on reducing treatment discontinuation among younger people and those based in rural locations.

Neurocircuitry of generalized anxiety disorder in adolescents: a pilot functional neuroimaging and functional connectivity study

Abstract: Background Dysfunction of neural systems responsible for the processing of emotional stimuli is hypothesized to be involved in the pathophysiology of generalized anxiety disorder (GAD) in adolescents. We used standard fMRI and functional connectivity analyses to examine the functional neurocircuitry of GAD in adolescents. Methods Ten adolescents with GAD and 10 healthy comparison subjects underwent fMRI while performing a continuous performance task with emotional and neutral distractors. Standard event-related voxel-wise fMRI and steady-state functional connectivity analyses were performed. Results Increased activation was observed in the left medial prefrontal cortex and right ventrolateral prefrontal cortex (VLPFC) in response to emotional images compared to neutral imagines in youth with GAD. Connectivity analyses using the right VLPFC seed region suggested decreased connectivity between this region and the bilateral medial prefrontal cortex. Connectivity analyses using the right amygdala seed region revealed decreased correlation with the posterior cingulate cortex in adolescents with GAD. The left amygdala seed region demonstrated increased connectivity with the ipsilateral precuneus in youth with GAD compared to healthy subjects. Conclusions In addition to increased activation of the medial prefrontal cortex and right VLPFC, we observed altered connectivity between the amygdala or VLPFC and regions, which subserve mentalization (e.g. posterior cingulate cortex, precuneus, and medial prefrontal cortex). This suggests that structures that regulate emotion and affect interact abnormally with key structures that are involved in mentalization, a process known to be disrupted in GAD.