Neuropsychological outcomes after psychosocial intervention for depression in Parkinson's disease.

The authors describe neuropsychological outcomes in people with Parkinson's disease (PD) after their participation in an NIH-sponsored, randomized, controlled trial of cognitive-behavioral treatment for depression. Improvements in mood were associated with modest gains in verbal memory and executive functioning over the 10-week treatment period and accounted for greater variance in neuropsychological outcomes at the end of treatment than other known correlates of cognitive functioning in PD, such as disease severity, age, and education. Baseline working memory and executive skills were also associated with depression improvement over time.

Barriers to mental health care utilization in Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is frequently complicated by co-occurring psychiatric problems such as depression and anxiety that negatively affect the course and management of the illness. Yet, in most cases, these psychiatric comorbidities are neither recognized nor treated to remission. The primary purpose of this study was to identify and describe barriers to mental health care utilization for people with PD. Secondary objectives included the assessment of attitudes and preferences regarding the need for mental health services in the PD community and the acceptability of telehealth interventions as a method for improving access and quality of care. METHODS: A total of 769 people with PD completed an anonymous cross-sectional questionnaire assessing barriers to mental health care utilization in this medical population. Respondents were drawn from a national sample. RESULTS: Commonly endorsed barriers to mental health care utilization in PD reflect the patients' incomplete understanding of mental health problems, access issues, and illness-specific concerns, as well as the inadequate screening and detection of psychiatric complications by medical providers and the need for more effective treatments in this medical population. Several demographic, medical, and psychiatric variables also influenced the likelihood of accessing mental health care. Interest in telehealth approaches to mental health treatment was high and, in several instances, correlated with perceived barriers to mental health care utilization. CONCLUSIONS: People with PD may encounter a multitude of barriers that impede their pursuit of mental health care. Clinical implications are discussed and further research is needed to replicate and extend these findings.

Telephone-based cognitive-behavioral therapy for depression in Parkinson disease.

BACKGROUND: Although face-to-face cognitive-behavioral therapy (CBT) was found to be beneficial for the treatment of depression in Parkinson disease (dPD) in a recent randomized-controlled trial, access to care was identified as a critical issue that needs to be addressed in order to improve the management of this nonmotor complication in PD. The purpose of this study was to examine the feasibility and effect of telephone-based CBT for dPD. METHODS: Twenty-one depressed people with PD participated in a National Institutes of Health-sponsored uncontrolled pilot trial of telephone-based CBT in an academic medical center from October 2009 to February 2011. The Hamilton Depression Rating Scale was the primary outcome. Treatment was provided to people with PD for 10 weeks, modified for delivery over the phone, and supplemented with 4 separate phone-based caregiver educational sessions. Assessments were completed at baseline and 5 (midpoint), 10 (end-of-treatment), and 14 weeks (follow-up) post-enrollment. RESULTS: Twenty (95%) people with PD completed the study treatment. Phone-based CBT was associated with significant improvements in depression, anxiety, negative thoughts, and coping. Mean Hamilton Depression Rating Scale change from baseline to week 10 was 7.91 points (P < .001, Cohen d = 1.21). CONCLUSIONS: Telephone-based CBT may be a feasible and helpful approach for treating dPD and warrants further exploration in randomized-controlled trials. Results were comparable to those observed in the few in-person cognitive-behavioral treatment studies for dPD conducted to date.

Escitalopram reduces hot flashes in nondepressed menopausal women: A pilot study.

BACKGROUND: Hot flashes are one of the most troubling manifestations of menopause, affecting about 80% of women. Due to recent controversies about hormone replacement therapy, many women seek alternative treatments. The use of antidepressants to treat hot flashes and other menopausal symptoms has been an active area of investigation. However, the majority of past research in this area has included women with significant medical or psychiatric histories that may influence treatment response. This was the first study to examine the impact of escitalopram on hot flashes, mood, sleep, and quality of life in a sample of healthy nondepressed menopausal women. METHODS: This study enrolled 25 menopausal women who had no significant psychiatric or medical history. All women were treated with escitalopram (10 to 20 mg flexibly dosed) for 8 weeks. The active treatment phase was preceded by a single-blind placebo lead-in period. RESULTS: Over the course of the study, women reported significant decreases in both hot flash frequency and severity as well as improvements in dysphoria, anxiety, quality of life, and sleep. CONCLUSION: These preliminary findings suggest that escitalopram may be a feasible and effective option for treating hot flashes and other menopausal symptoms in healthy women who might not ordinarily consider antidepressant treatment.

Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms.

PURPOSE: Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few well-accepted and properly evaluated interventions to manage such patients. METHODS: We tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care. RESULTS: A significantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as "very much improved" or "much improved" compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confidence interval, 1.9-8.8; P<.001). The intervention's effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to significant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up. CONCLUSIONS: This time-limited, CBT-type intervention significantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial.

BACKGROUND: Patients diagnosed as having somatization disorder (SD) who present with a lifetime history of multiple, medically unexplained physical symptoms represent a significant challenge to health care providers. To date, no psychotherapeutic or pharmacologic intervention has been found to produce clinically meaningful improvement in symptoms or functioning of patients with SD. We examined the efficacy of cognitive-behavioral therapy (CBT) for SD. METHODS: Eighty-four participants meeting criteria for SD were randomly assigned to 1 of 2 conditions: (1) standard medical care augmented by a psychiatric consultation intervention or (2) a 10-session, manualized, individually administered CBT regimen added to the psychiatric consultation intervention. Assessments were conducted at baseline and 3, 9, and 15 months after baseline. The primary outcome measure was the severity scale of the Clinical Global Impression Scale for Somatization Disorder (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-reported measures of physical functioning and somatic symptoms, and health care utilization assessed via medical records. RESULTS: Fifteen months after baseline, somatization symptoms were significantly less severe in the group treated with CBT (0.84 points on the CGI-SD 7-point scale) (P<.001). Patients treated with CBT also were significantly more likely to be rated as either very much improved or much improved than patients treated with only augmented standard medical care (40% [n = 17] vs 5% [n = 2]). Cognitive-behavioral therapy was associated with greater improvements in self-reported functioning and somatic symptoms and a greater decrease in health care costs. CONCLUSION: For patients diagnosed as having SD, CBT may produce clinical benefits beyond those that result from the current state-of-the-art treatment.

Cognitive behavior therapy for menopausal hot flashes: two case reports.

Two case reports of women treated with an individual cognitive behavioral treatment (CBT) for menopausal hot flashes are presented. Both women reported substantial improvements in the number of hot flashes experienced as well as in their quality of life as measured by the Menopause Quality of Life Scale (MENQOL), the Hamilton Rating Scale for Depression (HAM-D), and the Hamilton Rating Scale for Anxiety (HAM-A). Improvements in hot flashes and quality of life were maintained 6 months after treatment ended. It is hypothesized that CBT reduces hot flashes by reducing central sympathetic activation, perceptions of stress, and self-critical thoughts. The long-term efficacy of CBT for hot flashes should be examined in large controlled clinical trials.

The value of pseudoneurological symptoms for assessing psychopathology in primary care.

OBJECTIVE: This study sought to examine the relationship between pseudoneurological symptoms (PNS) and somatic and psychiatric symptom severity, physical functioning, and psychiatric comorbidity. METHODS: Interview and questionnaire data were obtained from 120 patients with somatization who participated in a study assessing the efficacy of cognitive-behavioral therapy. Measures elicited information on psychiatric diagnoses, anxiety and depressive symptom levels, somatic symptoms, and physical functioning. Statistical analyses examined the relationship between PNS and the diagnosis of somatization disorder, physical and psychiatric symptom severity, and psychiatric comorbidity. RESULTS: Roughly half of the sample had a history of four or more PNS. Results showed that having four or more PNS was not predictive of somatization disorder. However, having four or more PNS was found to be significantly correlated with the severity of anxiety, depression, somatic complaints, and physical dysfunction. These associations were identified while controlling for the symptom count of nonpseudoneurological symptoms, the presence of somatization disorder, and the presence of chronic painful physical conditions. In addition, having four or more PNS was significantly associated with a higher likelihood of receiving a diagnosis of major depression, dysthymia, panic disorder, and generalized anxiety disorder. CONCLUSIONS: A history of four or more PNS is common among somatizing patients in primary care and associated with a more severe clinical presentation, even after controlling for other factors known to be associated with severity. Four or more PNS may identify a distinct subgroup of somatization and serve as a clinical indicator for identifying psychiatric disorders in primary care. Future studies should explore the assessment of PNS using briefer measures. Furthermore, PNS should be evaluated with samples more representative of US primary care populations, as well as samples that include adequate representation from other ethnic backgrounds (eg, African-American, Asian, etc.).

Affective-cognitive behavioral therapy for fibromyalgia: a randomized controlled trial.

A randomized controlled trial was conducted to assess the efficacy of an individually administered form of cognitive behavioral treatment for fibromyalgia. In an additive design, 76 patients diagnosed with fibromyalgia were randomly assigned to either the experimental treatment (affective-cognitive behavioral therapy, 10 individual sessions, one per week) administered concurrently with treatment-as-usual or to an unaugmented treatment-as-usual condition. Statistical analysis conducted at the end of treatment (3 months after the baseline assessment) and at a followup (9 months after the baseline assessment) indicated that the patients receiving the experimental treatment reported less pain and overall better functioning than control patients, both at posttreatment and at followup. The implications of these findings for future research are discussed.

Predictors of treatment response to cognitive-behavioral therapy for depression in Parkinson's disease.

OBJECTIVE: The purpose of this study was to examine predictors of treatment response to cognitive-behavioral therapy (CBT) for depression in Parkinson's disease (PD). METHOD: The sample comprised 80 depressed (DSM-IV criteria) adults with PD (60% male) and their caregivers who participated in an National Institutes of Health-sponsored randomized-controlled trial of CBT vs. clinical monitoring from April 2007 until July 2010. Individually administered CBT was provided to people with PD for 10 weeks, modified to address the unique needs of the medical population, and supplemented with up to 4 separate caregiver educational sessions. Treatment response was defined a priori as a rating of depression much improved or very much improved on the Clinical Global Impression-Improvement Scale or ≥ 50% reduction in the baseline Hamilton Depression Rating Scale score. It was hypothesized (a priori) that caregiver participation in treatment, motor disability, psychiatric comorbidity, and executive functioning would be significant predictors of response to CBT at end-of-treatment (Week 10) and short-term follow-up (Week 14). RESULTS: At Week 10, caregiver participation was the only significant predictor of treatment response in the CBT group. At Week 14, both caregiver participation and executive functioning predicted response to CBT. Treatment group, baseline depression severity, executive functioning, motor disability, psychiatric comorbidity, marital status, and caregiver burden were also related to change in depression scores, for all participants, in secondary and exploratory models. CONCLUSIONS: Caregiver participation may enhance acute treatment response to psychosocial interventions for depression in PD. Further research is needed to extend and replicate these findings.

Cognitive-behavioral therapy for depression in Parkinson's disease: a randomized, controlled trial.

OBJECTIVE: Despite the negative effects of depression in Parkinson's disease, there is currently no evidence-based standard of care. The purpose of this study was to examine the efficacy of individually administered cognitive-behavioral therapy (CBT), relative to clinical monitoring (with no new treatment), for depression in this medical population. METHOD: Eighty depressed (based on DSM-IV criteria) patients with Parkinson's disease participated in a randomized, controlled trial of CBT relative to clinical monitoring (1:1 ratio) in an academic medical center from April 2007 to July 2010. All patients continued to maintain stable medication regimens under the care of their personal physicians. The 17-item Hamilton Depression Rating Scale (HAM-D) total score was the primary outcome. CBT was modified to meet the unique needs of the Parkinson's disease population and provided for 10 weeks. Assessments were completed by blind raters at baseline and 5 (midpoint), 10 (end of treatment), and 14 weeks (follow-up evaluation) postrandomization. RESULTS: The CBT group reported greater reductions in depression (change in HAM-D score) than the clinical monitoring group. At week 10, the mean HAM-D score change was 7.35 for CBT relative to 0.05 for clinical monitoring. CBT was also superior to clinical monitoring on several secondary outcomes (i.e., Beck Depression Inventory scores, anxiety, quality of life, coping, Parkinson's disease symptom ratings). There were more treatment responders in the CBT group than the clinical monitoring group (56% versus 8%, respectively). CONCLUSIONS: CBT may be a viable approach for the treatment of depression in Parkinson's disease. Further research is needed to replicate and extend these findings.

Physical symptoms and psychosocial correlates of somatization in pediatric primary care.

A group of children, aged 8 to 13 years, presenting to their pediatricians with multiple medically unexplained physical symptoms (MUPS) were compared with a control group of children from the identical age range who were, according to their pediatricians, free of unexplained physical symptoms. The groups were compared on both self-reported and parented-rated scales assessing physical symptoms and psychosocial functioning. The multiple MUPS group, relative to controls, exhibited significantly higher levels of parent-reported emotional/behavioral symptoms and a trend toward higher patient-reported anxiety than controls. Parents' and child's reports of symptomatology were modestly correlated. Symptom patterns characteristic of pediatric somatization differed as a function of whether child or parent reports were analyzed. Methodological issues in research on pediatric somatization were addressed and some directions for future research emerged.

Cognitive behavioral therapy for somatoform disorders.

Patients presenting with somatoform disorders often incur excessive health care charges and fail to respond to standard treatment. The purpose of this article is to provide an overview of the diagnostic criteria and demographic and clinical characteristics of each somatoform disorder and to examine the research assessing the efficacy of cognitive behavioral therapy (CBT) for each disorder. The review shows that CBT has received some empirical support for somatization, hypochondriasis, and body dysmorphic disorder. However, there are few data on the impact of treatment on health care use, especially when the cost of CBT is factored into the equation. Too few methodologically sound studies have been published on the treatment of conversion disorder or of pain disorder to make any conclusions.

Ramelteon for the treatment of insomnia in menopausal women.

OBJECTIVE: Sleep disturbances have been reported to be one of the most troubling manifestations of menopause. While hormone replacement therapy (HRT) has historically been considered a first-line treatment for menopausal insomnia, many women are now seeking alternative treatments due to concerns about the risks and side-effects of HRT. The goal of this study was to evaluate the effect of ramelteon, a selective melatonin receptor agonist, for the treatment of menopausal insomnia. STUDY DESIGN: A total of 20 healthy peri- and postmenopausal women with insomnia participated in this six-week, prospective, open-label trial of ramelteon (8 mg) at an academic medical centre. Participants completed sleep-wake diaries on a daily basis for six weeks. Self-report measures of sleep impairment, daytime functioning, quality of life and mood were also completed on a bi-weekly basis. RESULTS: Significant improvements in latency to sleep onset, total sleep time and sleep efficiency were observed in diary data while gains in sleep quality, sleep impairment, daytime functioning, quality of life and mood were found in self-report measures. There was no evidence of tolerance or rebound over the course of the trial. CONCLUSIONS: Overall, results suggest that ramelteon is an effective non-hormonal approach for the treatment of insomnia in menopause. Randomized-controlled trials are needed to further evaluate the efficacy of this intervention.

New directions in the treatment of somatization.

Patients who have multiple medically unexplained symptoms have baffled and perplexed health care professionals for many years. Given the substantial costs of somatization to both patients and the health care system, there is a pressing need for effective treatments. This article describes a recently developed, evidence-based psychosocial treatment for medically unexplained symptoms and the therapeutic rationale that underlies it. The authors' work provides efficacious treatment options for this refractory and debilitating set of disorders.

Cognitive-behavioral therapy for depression in Parkinson's disease: a pilot study.

The present study was conducted to examine the feasibility and effect of an individual cognitive-behavioral treatment (CBT) for depression that was modified to meet the unique needs of the PD patient and incorporated a separate social support intervention for caregivers. Fifteen PD patients with Major Depressive Disorder participated in the study with a caregiver. Patients received 10-14 sessions of modified individual CBT. Caregivers attended 3-4 psychoeducational sessions, occurring separately from the patients treatment sessions, which focused on strategies for offering appropriate support, and ways to respond to the patients' negative thoughts in a targeted manner. Patients experienced a significant reduction in depressive symptoms and negative cognitions, and an increased perception of social support over the course of treatment. Gains were maintained at 1-month follow-up. In conclusion, individual CBT, when modified appropriately, may be a feasible and effective option for PD depression. Larger, randomized controlled trials are needed to further evaluate the efficacy of this intervention and to identify specific mechanisms of change.

Bupropion improves sexual functioning in depressed minority women: an open-label switch study.

Minority women often have a unique set of beliefs and expectations about medical treatment. At this time, there is a dearth of research looking at how depressed minority women respond to pharmacological interventions for the sexual concomitants of depression. This was the first study to examine the impact of a medication switch, from a selective serotonin reuptake inhibitor to bupropion SR, on the sexual functioning of depressed minority women. Eighteen minority women (5 Hispanic, 10 African American, 2 Asian American, and 1 Native American), who were experiencing poor tolerability and/or lack of efficacy on an adequate trial of a selective serotonin reuptake inhibitor for depression, along with low sexual desire, were enrolled in this prospective open-label study. The selective serotonin reuptake inhibitor and bupropion SR were cross-tapered with a target dose of 150 to 300 mg of bupropion SR. The patients were followed for 10 weeks, and measures of sexual functioning and depression (Hamilton Rating Scale for Depression) were administered in an academic medical setting. Data were collected from July 2003 to December 2004. In the group as a whole, there were significant improvements in desire (F1,17 = 34.86, P < 0.001), arousal (F1,17 = 25.99, P < 0.001), and orgasm (F1,17 = 20.16, P < 0.001), on the Changes in Sexual Functioning Questionnaire. African-American women demonstrated the greatest improvement in depression (F1,16 = 9.55, P = 0.006), desire (F1,16 = 8.62, P = 0.01), and arousal (F1,16 = 8.83, P = 0.009) after the medication switch. Overall, this intervention appeared to be an effective treatment of low sexual desire in a diverse group of depressed minority women. The majority of women successfully completed the trial and planned to continue using bupropion SR after their participation in the study.

Somatic complaints in primary care: further examining the validity of the Patient Health Questionnaire (PHQ-15).

The authors examined the reliability and validity of the PHQ-15, a measure of current somatic complaints. An index of medically unexplained symptoms was used as a key criterion. Data were utilized from medical outpatients enrolled in a treatment study for moderate-to-severe somatization (N=172). Approximately 68% of the sample was Hispanic. Results showed that the PHQ-15 was moderately related to a history of medically unexplained symptoms among non-Hispanic participants. Results indicated ethnic differences on the validity profile of the PHQ-15 showing that the criterion variables were less predictive of the PHQ-15 among Hispanics than among non-Hispanics. Also, among the Hispanic group, the PHQ-15 was less related to medically unexplained symptoms and more to psychiatric distress. General support was provided for using the PHQ-15 with clinical samples composed of non-Hispanics. Also, the PHQ-15 appears to measure medically unexplained symptoms, psychiatric distress, and physical functioning. Further study is recommended to better evaluate ethnic variations and other types of validity for the PHQ-15.

Social cognitive complexity and depression: cognitive complexity moderates the correlation between depression self-ratings and global self-evaluation.

The authors studied the psychometric characteristics of a standardized data-collection method for assessing the complexity of an individual's cognitions about self and other people (social cognitive complexity). A total of 437 college undergraduates were assessed using this method and concurrently assessed for depression, self-deception, impression management, self-esteem, and positive/negative affectivity. It was found that a measure of overall social cognitive complexity was internally consistent and demonstrated concurrent and discriminant validity. In particular, a composite measure of the complexity of both positive and negative cognitions of self and other was associated with greater self-reported depression, after controlling for the other variables studied (, impression management). It was also found that social cognitive complexity moderated the degree of global self-evaluation in self-reported depression, such that global self-evaluation accounted for a considerably higher amount of the variance of depression in low-complex individuals than it did in high-complex individuals.