Humor Associated With Positive Outcomes in Individual Psychotherapy.

Considerable anecdotal evidence points to the usefulness of humor in the therapeutic process, but empirical evidence is lacking. The purpose of this study, conducted in Belgium, was to search for an association between humor and therapy outcomes in a population of 110 adult psychotherapy clients who attended at least 10 therapy sessions. Clients and their therapist evaluated the frequency and intensity of humorous events, as well as therapy effectiveness, therapeutic alliance, perceived hope, and pleasure in participating in therapy sessions. A strong positive correlation was observed between humor and therapy effectiveness, from both client (rs=0.40; p<0.001) and therapist perspectives (rs=0.37; p<0.001). The link between humor and therapy effectiveness remained significant in subgroups of clients with more severe illness, although these clients reported less humor in their therapy sessions. Further research is needed to determine whether humor enhances outcomes or whether positive outcomes trigger occurrence of humor.

Loss of treatment benefit when heroin-assisted treatment is stopped after 12 months.

PURPOSE: In 2013, during a recent heroin-assisted treatment trial, participants in heroin-assisted treatment (HAT) decreased significantly more their street heroin use than participants in oral methadone treatment. After the trial, HAT was discontinued. To examine whether the treatment benefits were sustained three months after the trial, the use of street heroin by the participants was analyzed in a follow-up study. RESULTS: At the follow-up assessment, street heroin use increased in the experimental group. The two groups no longer showed a significant difference (p=0.55) in the level of street heroin use. CONCLUSION: A predetermined and forced end of HAT was followed by a significant increase in the level of street level use.

Efficacy of Heroin-assisted Treatment In Belgium: A Randomised Controlled Trial.

BACKGROUND/AIMS: Heroin-assisted treatment (HAT) can improve the condition of heroin addicts still using street heroin after a methadone treatment. In Belgium, a new trial compared the efficacy of a HAT to existing methadone maintenance treatment. METHODS: In this randomised controlled trial, HAT was limited to 12 months. Participants were assessed every 3 months. They were responders if they showed improvement on the level of street heroin use, health or criminal involvement. RESULTS: 74 participants were randomised in the trial. The experimental group (n = 36) counted 30% of responders more than the control group (n = 38) at each assessment point (p < 0.05), except at 12 months where the difference (11%) was no longer significant (p = 0.35). Still, after 12 months, participants in the experimental group reported significantly greater improvements (p < 0.05) than the control group on the level of street heroin use and on the level of physical and mental health. Both groups reported significantly less criminal acts after 12 months (p < 0.001), but with no significant difference between the groups. CONCLUSIONS: This trial confirms the short-term efficacy of HAT for severe heroin addicts, who already failed methadone treatment.

Estimation of the Time Interval between the Administration of Heroin and the Sampling of Blood in Chronic Inhalers.

To develop a model for estimating the time delay between last heroin consumption and blood sampling in chronic drug users. Eleven patients, all heroin inhalers undergoing detoxification, were included in the study. Several plasma samples were collected during the detoxification procedure and analyzed for the heroin metabolites 6-acetylmorphine (6AM), morphine (MOR), morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G), according to a UHPLC/MSMS method. The general linear mixed model was applied to time-related concentrations and a pragmatic four-step delay estimation approach was proposed based on the simultaneous presence of metabolites in plasma. Validation of the model was carried out using the jackknife technique on the 11 patients, and on a group of 7 test patients. Quadratic equations were derived for all metabolites except 6AM. The interval delay estimation was 2-4 days when only M3G present in plasma, 1-2 days when M6G and M3G were both present, 0-1 day when MOR, M6G and M3G were present and <2 h for all metabolites present. The 'jackknife' correlation between declared and actual estimated delays was 0.90. The overall precision of the delay estimates was 8-9 h. The delay between last heroin consumption and blood sampling in chronic drug users can be satisfactorily predicted from plasma heroin metabolites.

What is important in being cured from: does discordance between physicians and patients matter? (2).

AIMS: The influence of discordance in what is important in being cured from depression on clinical outcome at 6 months, assessed with a divergence index. METHODS: 304 outpatients treated for depression by general practitioners or by psychiatrists and completing a 6-month treatment period: a divergence index (divergence between physician and patient view on what is important in being cured from depression) was calculated for each physician-patient pair. The relation between this index and outcome at 6 months was analyzed (including depressive, anxious and somatic symptom severity, positive effect, functional impairment and quality of life (psychological and social relations). RESULTS: Response rates (50% improvement) were 65.9% for depressive symptomatology and 46.2% for anxious symptomatology. The subgroup with a poor physician-patient agreement (highest quartile) on expectations had a worse clinical outcome than the subgroup with an excellent physician-patient agreement (lowest quartile): differences in response rate between these groups ranged from 9% to 27%; this difference reached statistical significance for 3 outcome variables (anxiety, positive effect and social relationships). CONCLUSIONS: The study shows that outcomes with standard antidepressant drugs are still suboptimal and that discordance between what patients׳ and physicians׳ consider important in the definition of cure from depression significantly influences clinical outcomes at 6 months.

What is important in being cured from depression? Discordance between physicians and patients (1).

AIMS: The comparison of what physicians and patients consider important in being cured from depression. METHODS: 426 outpatients (in primary care and in psychiatric care) with a clinical diagnosis of major depression were included: at the start of antidepressant treatment, the importance of a range of items for being cured from depression (depressive, anxious and somatic symptoms, positive affect, functional impairment, quality of life) was assessed in physicians and patients separately and a ranking was made; after 3 months of treatment, the importance of these items for being cured from depression was re-assessed in the patients. RESULTS: The items ranked top 10 by physicians mainly contain depressive symptoms while those ranked top 10 by patients mainly contain positive affect items and this attention to positive affect even increases at 3 months follow-up and is higher in patients with recurrent depression than in patients with a first episode of depression. Somatic symptoms consistently get the lowest ranking, as well in physicians as in patients. CONCLUSIONS: Physicians differ significantly from patients in what they consider important for 'being cured from depression': physicians mainly focus on alleviation of depressive symptoms while patients mainly focus on the restoration of positive affect.

The downward spiral of mental disorders and educational attainment: a systematic review on early school leaving.

BACKGROUND: Most psychiatric disorders present symptom patterns that cause severe impairment on the emotional, cognitive and social level. Thus, adolescents who suffer from a mental disorder risk finding themselves in a downward spiral caused by the reciprocal association of psychological symptoms and negative school experiences that may culminate in early school leaving. In addition to previous collective work that mainly focused on school refusing behaviour among children and was presented as an expert's opinion, the following systematic review fills the knowledge gap by providing a structured overview of the bidirectional association between mental health and secondary school dropout based on a sound methodology and with a particular focus on mediating factors. METHODS: Four electronic databases were searched from January 1990 until June 2014. Selected references were assessed for study details, main results, mediating factors and methodological limitations. Standardized risk of bias assessment was conducted. RESULTS: Mood and anxiety disorders seemed to have a less consequential direct effect on early school leaving than substance use and disruptive behaviour disorders. The association between externalizing disorders and educational attainment was even stronger when the disorder occurred early in life. On the other hand, internalizing disorders were reported to develop as a consequence of school dropout. Only few studies had addressed gender differences, with discrepant results. Socio-economic background, academic achievement and family support were identified as significant mediating factors of the association between mental disorders and subsequent educational attainment. CONCLUSIONS: Findings suggested a strong association between mental health and education, in both directions. However, most studies focused on mediating factors that could not be targeted by intervention programs.

Prevalence and clinical characteristics of remission during treatment in generalized anxiety.

OBJECTIVE: Although the remission criteria for generalized anxiety are well defined, there is not much data available on the point prevalence of remission. The Measuring Impact of Remission in Anxiety Disorders in Belgium (MIRABEL) study is a naturalistic study designed to document the point prevalence of remission in patients treated for general anxiety and potential factors affecting this prevalence. METHODS: The study population consisted of 618 adult outpatients being treated for generalized anxiety. The sample is defined by the key symptoms of generalized anxiety disorder rather than by fulfilling the exact DSM-IV-TR diagnostic criteria. Remission was defined as a Hamilton Anxiety Scale (HAM-A) score of less than or equal to 7. To reduce the interrater reliability, the HAM-A was assessed by the attending physicians who had no specific training. Factors investigated as possibly related to remission included sociodemographic, disease and treatment characteristics. RESULTS: The point prevalence of remission in the study population was estimated at 13.3%. Remission prevalence varied with occupational status and severity of the current anxiety episode. Remission prevalence was lower in the presence of comorbidity and was proportional to the number of comorbid symptoms. Remitters took fewer medications but were treated longer. Remission prevalence was higher in patients who were taking antidepressants, but was lower in patients who were taking sedatives. CONCLUSIONS: These findings underline the poor prognosis of generalized anxiety.

Influence of COX-2 and OXTR polymorphisms on treatment outcome in treatment resistant depression.

Inflammatory pathways play a crucial role in the pathomechanisms of antidepressant efficacy. The aim of this study was to investigate whether a set of single nucleotide polymorphisms (SNPs) within cyclooxygenase-2 (COX-2, rs5275 and rs20417) and oxytocin receptor (OXTR, rs53576 and rs2254298) genes was associated with antidepressant treatment resistance, response or remission. Three hundred seventy-two patients were recruited in the context of a multicenter resistant depression study. They were genotyped for COX-2 and OXTR SNPs. Treatment resistance (according to two different definitions), response and remission were recorded. We did not observe any association between the genotypes or alleles of the selected SNPs within COX-2 and OXTR genes and treatment resistance, response and remission in the whole sample. Our results are consistent with those of some studies but not with those of other ones. Indeed, several factors could be involved in the discrepancy observed across studies. They include sample size, environmental factors, differences in ethnicity, different study designs, and different definitions of treatment resistance.

Do general practitioners and psychiatrists agree about defining cure from depression? The DEsCRIBE™ survey.

BACKGROUND: This study aimed to document the outcome dimensions that physicians see as important in defining cure from depression. The study also aimed to analyse physicians' attitudes about depression and to find out whether they affect their prescribing practices and/or the outcome dimensions that they view as important in defining cure. METHODS: A 51-item questionnaire based on six validated scales was used to rate the importance of several depression outcome dimensions. Physicians' attitudes about depression were also assessed using the Depression Attitude Scale. Overall, 369 Belgian physicians (264 general practitioners [GPs]; 105 psychiatrists) participated in the DEsCRIBE™ survey. RESULTS: GPs and psychiatrists strongly agreed that functioning and depressive symptomatology were most important in defining cure; anxious and somatic symptomatology was least important. GPs and psychiatrists differed in their attitudes about depression (p <0.001). Logistic regression revealed that the attitudes of GPs - but not psychiatrists - were significantly associated with their rates of antidepressant prescription (p < 0.001) and that certain attitudes predicted which outcome dimensions were seen as important in defining cure. CONCLUSIONS: Belgian GPs and psychiatrists strongly agreed on which criteria were important in defining cure from depression but differed in their attitudes about depression. The outcome dimensions that were considered important in defining cure were influenced by physicians' attitudes - this was more pronounced in GPs than in psychiatrists.

Psychosocial risk and protective factors of secondary school dropout in Luxembourg: the protocol of an exploratory case-control study.

BACKGROUND: In Luxembourg, the extensive phenomenon of school dropout is a prime policy concern in the light of individual, social and economic consequences. Although the authorities report an overall decrease of the national dropout rate, the proportion of early school leavers who remain without any specific occupation is still alarming. Therefore, this study intends a shift of focus from system-inherent to individual factors, including mental health and family correlates, to provide a more comprehensive analysis of the dropout phenomenon. METHODS/DESIGN: The objectives of this study are to investigate the type and prevalence of psychiatric disorders among school dropouts and to compare the findings with those by a matched control group of regularly enrolled students. Furthermore, family variables and socioeconomic status will be analysed, as they are factors likely to interfere with both educational attainment and mental health. A trained psychologist will use structured interviews and self-report forms to investigate for mental health issues, information on schooling, socioeconomic situation and family life. Controls will be matched for gender, age, school type and educational grade. DISCUSSION: As school dropouts face a serious risk of long term professional and social marginalization, there is an evident need for action. Identifying psychosocial risk and protective factors of school dropout will deliver solid insight on how to conceive public health strategies for young people who may need a more customized support to carry out their academic potential. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01354236.

Depression alters "top-down" visual attention: a dynamic causal modeling comparison between depressed and healthy subjects.

Using functional magnetic resonance imaging (fMRI), we recently demonstrated that nonmedicated patients with a first episode of unipolar major depression (MDD) compared to matched controls exhibited an abnormal neural filtering of irrelevant visual information (Desseilles et al., 2009). During scanning, subjects performed a visual attention task imposing two different levels of attentional load at fixation (low or high), while task-irrelevant colored stimuli were presented in the periphery. In the present study, we focused on the visuo-attentional system and used "Dynamic Causal Modeling" (DCM) on the same dataset to assess how attention influences a network of three dynamically-interconnected brain regions (visual areas V1 and V4, and intraparietal sulcus (P), differentially in MDD patients and healthy controls. Bayesian model selection (BMS) and model space partitioning (MSP) were used to determine the best model in each population. The best model for the controls revealed that the increase of parietal activity by high attention load was selectively associated with a negative modulation of P on V4, consistent with high attention reducing the processing of irrelevant colored peripheral stimuli. The best model accounting for the data from the MDD patients showed that both low and high attention levels exerted modulatory effects on P. The present results document abnormal effective connectivity across visuo-attentional networks in MDD, which likely contributes to deficient attentional filtering of information.

Duloxetine in major depressed patients resistant to SSRIs and/or venlafaxine.

Several acute depression trials suggest that only 35% of the patients achieve remission state with antidepressant monotherapy. An increasing body of evidence is emerging suggesting that multi-action antidepressants might be more effective in treatment-resistant depressed patients than single-action agents. In this context, the purpose of the study was to assess the effectiveness of duloxetine in treatment-resistant major depressed outpatients. We performed a retrospective study assessing the efficacy of duloxetine in major depressed outpatients who did not achieve full symptom remission (CGI-S (severity) >=3) after treatment of adequate dose and duration (more than 8 weeks) with at least either one SSRI or the SNRI venlafaxine. We excluded patients with a severe medical illness and a personality disorder. CGI-S was used as a measure of symptom severity and administered before the prescription of duloxetine and 6 weeks later. The sample included 29 patients (9 M, 20 F). We observed a very significant decrease in CGI-S scores (4.86 ± 0.51 to 2.17 ± 1.44, p<0.0001) after treatment with duloxetine (dose between 60 and 120 mg). Remission was achieved in 48% of the patients. The tolerance was excellent. This study suggests the potential interest of duloxetine in some treatment-resistant depressed patients.

Fibromyalgia and related conditions: electromyogram profile during isometric muscle contraction.

OBJECTIVES: To evaluate electromyogram (EMG) profiles in patients with three related conditions: fibromyalgia, chronic fatigue syndrome, and depression. METHODS: We studied 44 healthy volunteers, 22 patients with fibromyalgia, 11 patients with chronic fatigue syndrome, and 10 patients admitted for depression. The trapezius electromyogram was recorded during maximally sustained, bilateral, 90 degrees abduction of the shoulders. EMG signal frequency and amplitude were measured throughout the test. RESULTS: In the fibromyalgia group, isometric contraction duration was significantly shorter than in the other two patient groups (P<0.001) and the EMG frequency and amplitude pattern indicated premature discontinuation of the muscle contraction. Findings in the chronic fatigue patients were similar to those in the healthy controls. The patients with depression had a distinctive EMG profile characterized by excessive initial motor-unit recruitment with a shift in the frequency spectrum. CONCLUSIONS: Fibromyalgia was associated with a specific EMG pattern indicating premature discontinuation of the muscle contraction. Therefore, maximal voluntary muscle contraction tests may be of limited value for assessing function in fibromyalgia patients. Chronic fatigue syndrome patients had similar EMG findings to those in the healthy controls. The EMG alterations in the patients with depression were consistent with manifestations of psychomotor retardation.

The TaqI A DRD2 polymorphism in type II alcohol dependence: a marker of age at onset or of a familial disease?

Cloninger's type II is a severe, early-onset, male-limited, and genetically influenced, impulsive form of alcoholism. Significant association has been reported between the A1 allele of the D2 dopamine receptor (DRD2) gene, substance misuse and personality traits of impulsivity and novelty seeking. We assessed the association between the TaqI A DRD2 gene polymorphism with Cloninger's typology and family history of alcohol abuse, which is thought to be more frequent in type II alcoholics. Fifty-one male alcohol-dependent patients were discriminated between type I and type II according to age at onset of alcohol-related problems and interviewed about family history of alcoholism. The associations between DRD2 (A1 or A2 alleles), family history, and typology were assessed by Pearson's chi-square test. Although typology was not associated with the studied polymorphism, a higher rate of general family history of alcohol abuse was still observed in type II patients (chi(2)(1)=4.53; P=.033). Furthermore, the A1 allele of the DRD2 was significantly associated with paternal history of alcoholism (chi(2)(1)=4.66; P=.031) and male, first-degree, collateral history of alcoholism (chi(2)(1)=4.40; P=.036). Age at onset of alcohol-related problems as main discriminator between type I and type II alcohol dependence does not seem to be associated by the TaqI A DRD2 polymorphism. However, the A1 allele of the DRD2 may be a marker of male familial alcoholism, which has been associated with type II alcohol dependence.

Electroconvulsive therapy for depression in a patient with an intracranial arachnoid cyst.

Electroconvulsive therapy (ECT) has been frequently considered relatively contraindicated in patients with space-occupying lesions in the brain. After the 7 cases available in the literature, we describe the safe use of ECT in a depressive patient with arachnoid cyst. We provide a comprehensive review on this clinical association, and we conclude that even if the few data available are reassuring, careful neurological evaluation before the ECT treatment is indicated.

Abnormal neural filtering of irrelevant visual information in depression.

The pathophysiology of major depressive disorder (MDD) includes both affective and cognitive dysfunctions. We aimed to clarify how regions regulating affective processing interact with those involved in attention, and how such interaction impacts perceptual processing within sensory cortices. Based on previous work showing that top-down influences from attention can determine the processing of external inputs within early sensory cortices, we tested with functional magnetic resonance imaging (fMRI) whether MDD alters attentional ("top-down") effects on the neural filtering of irrelevant, nonemotional visual stimuli. The present fMRI study was conducted in 14 nonmedicated patients with a first episode of unipolar MDD and 14 matched controls. During scanning, subjects performed two tasks imposing two different levels of attentional load at fixation (easy or difficult), while irrelevant colored stimuli were presented in the periphery. Analyses of fMRI data revealed that MDD patients show (1) an abnormal filtering of irrelevant information in visual cortex, (2) an altered functional connectivity between frontoparietal networks and visual cortices, and (3) a hyperactivity in subgenual cingulate/medial orbitofrontal cortex that was modulated by attentional load. These results demonstrate that biological abnormalities contribute to the cognitive deficits seen in major depression, and clarify how neural networks implicated in mood regulation influence executive control and perceptual processes. These findings not only improve our understanding of the pathophysiological mechanisms underlying cognitive dysfunctions in MDD, but also shed new light on the interaction between cognition and mood regulation.