RESUMO
BACKGROUND: Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression. METHODS: For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level. RESULTS: Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [B = -0.49, 95% confidence interval (CI) -0.61 to -0.37, p < 0.0001] and for patients with a depressive episode duration of >2 years rather than <1 year (B = -0.68, 95% CI -1.31 to -0.05, p = 0.03) and than 1-2 years (B = -0.86, 95% CI -1.66 to -0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias. CONCLUSIONS: To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression.
Assuntos
Psicoterapia Breve , Psicoterapia Psicodinâmica , Adulto , Humanos , Depressão/terapia , Psicoterapia Psicodinâmica/métodos , Psicoterapia Breve/métodos , Antidepressivos/uso terapêutico , Resultado do Tratamento , PsicoterapiaRESUMO
The authors present the results from a 3-year follow-up among 170 patients who had participated in the original randomized study, which consisted of three treatment conditions: (a) 3-month abandonment psychotherapy (AP) delivered by certified psychotherapists, (b) AP delivered by nurses, and (c) treatment as usual in a psychiatric crisis center. All subjects were recruited at the emergency room after a suicide attempt and met diagnostic criteria for borderline personality disorder and major depression. Psychotic symptoms, bipolar disorder, and mental retardation were exclusion criteria. At 3-year follow-up, 134 (78.8%) subjects had blind, reliable assessment by clinical psychologists. The intent-to-treat analysis indicated that those patients who had received AP during acute treatment had better global functioning, improved work adjustment, and less unemployment/disability at 3-year follow-up. No differences were found as a function of type of therapist delivering AP. The data confirm that short-term AP gains in psychosocial functioning are sustained over the longer term.
RESUMO
PURPOSE: We examined the efficacy of adding short-term psychodynamic psychotherapy (STPP) to antidepressants in the treatment of depression by means of a systematic review and meta-analysis of individual participant data, which is currently considered the most reliable method for evidence synthesis. RESULTS: A thorough systematic literature search resulted in 7 studies comparing combined treatment of antidepressants and STPP versus antidepressant mono-therapy (n = 3) or versus antidepressants and brief supportive psychotherapy (n = 4). Individual participant data were obtained for all these studies and totaled 482 participants. Across the total sample of studies, combined treatment of antidepressants and STPP was found significantly more efficacious in terms of depressive symptom levels at both post-treatment (Cohen's d = 0.26, SE = 0.10, p = .01) and follow-up (d = 0.50, SE = 0.10, p < .001). This effect was most apparent at follow-up and in studies examining STPP's specific treatment efficacy. Effects were still apparent in analyses that controlled for risk of bias and STPP quality in the primary studies. CONCLUSIONS: These findings support the evidence-base of adding STPP to antidepressants in the treatment of depression. However, further studies are needed, particularly assessing outcome measures other than depression and cost-effectiveness, as well as examining the relative merits of STPP versus other psychotherapies as added to antidepressants.
Assuntos
Antidepressivos/uso terapêutico , Depressão/terapia , Psicoterapia Psicodinâmica/métodos , Adulto , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The aim of this study was to investigate the prevalence and clinical characteristics of the DSM IV major depressive disorder (MDD) among patients admitted to the General Internal Medicine Service of the Geneva University Hospital. METHOD: 557 patients admitted to the IM of the Geneva University Hospital aged 18 to 70 were investigated. Each subject was assessed by a clinical psychologist using the SCID (Structured Clinical Interview Depression for DSM-IV) questionnaire. RESULTS: 69 patients (12.4%) met diagnostic criteria for MDD (men: 8.8%, women: 16.9%, p=.004). Among subjects with major depression, depressed mood (97%), fatigue (91%), and diminished interest and pleasure (81%) were the most prevalent symptoms. Recurrent thoughts of death were present in 48% of depressed patients. CONCLUSIONS: This study raises further evidence that an elevated proportion of patients admitted to an acute care general internal medicine facility meet DSM IV criteria for MDD with nearly half of depressed patients suffering from recurrent thoughts of death. It emphasizes the necessity of a targeted, continuous, and active support given by the psychiatry liaison service in the internal medicine setting.
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Transtorno Depressivo Maior/epidemiologia , Pacientes Internados/estatística & dados numéricos , Adulto , Idoso , Anedonia , Estudos de Coortes , Transtorno Depressivo Maior/psicologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Fadiga/epidemiologia , Fadiga/psicologia , Feminino , Departamentos Hospitalares/estatística & dados numéricos , Humanos , Pacientes Internados/psicologia , Medicina Interna , Masculino , Pessoa de Meia-Idade , Prevalência , Suíça/epidemiologia , Adulto JovemRESUMO
This study investigated whether crisis intervention (CI) at the General Hospital is a suitable management strategy among borderline patients referred to the emergency room (ER) for deliberate self-harm. Two patient cohorts (n=200) meeting DSM-IV Borderline Personality Disorder criteria, were prospectively assessed for repeated deliberate self-harm and service consumption. At ER discharge, 100 subjects received CI, while 100 comparison subjects (recruited before the implementation of CI) were assigned to treatment as usual (TAU). At 3-month follow-up, a high proportion of repeated deliberate self-harm and hospitalization in the global study sample was found. However rates were lower in the CI group: 8% repeated deliberate self-harm and 8% psychiatric hospitalization, versus 17% and 56% in the TAU group. The global expenditure for psychiatric hospitalization was 728,840 Swiss Francs (CHF) for CI and 914,340 for TAU. This study indicates that associated with mean hospitalization/relapse rates, CI may be a suitable management strategy for acutely suicidal borderline patients.
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Transtorno da Personalidade Borderline/psicologia , Transtorno da Personalidade Borderline/terapia , Intervenção em Crise/métodos , Hospitais Gerais , Comportamento Autodestrutivo/terapia , Adulto , Feminino , Seguimentos , Hospitais Gerais/estatística & dados numéricos , Humanos , Masculino , Estudos Prospectivos , Comportamento Autodestrutivo/psicologia , Suíça , Adulto JovemRESUMO
The therapeutic alliance is considered as one of the active relational factors to improve the outcome of patients engaged in a psychotherapeutic process. Our objective was to examine the role played by the therapeutic alliance in psychodynamic versus supportive psychotherapy. We examined data from a previously published randomized controlled study. Outpatients suffering from depression (n=74) received the same antidepressant (clomipramine) and were randomized into two groups, receiving either psychodynamic or supportive psychotherapy. Subjects were assessed at inclusion (Structured Clinical Interview for DSM-IV Disorders, SCID), during treatment and at discharge (Global Assessment Scale, Hamilton Depression Rating Scale, Helping Alliance questionnaire). Over time, the therapeutic alliance improved regardless of condition, and the relationship between alliance and outcome strengthened. This relationship was significant only among patients assigned to the supportive therapy condition. These data suggest that although the therapeutic alliance is an important factor in psychodynamic treatment, additional ingredients may be involved in its superiority compared to supportive therapy.
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Depressão/psicologia , Depressão/terapia , Relações Enfermeiro-Paciente , Processos Psicoterapêuticos , Psicoterapia Breve , Adulto , Idoso , Análise de Variância , Antidepressivos Tricíclicos/uso terapêutico , Clomipramina/uso terapêutico , Depressão/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Índice de Gravidade de Doença , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
We update the epidemiology, diagnostic process, significant clinical features as well as main treatment and prevention issues in the field of antepartum depression, a widespread condition with significant relevance to primary care. During pregnancy, one forth women exhibit clinical symptoms of depression and such maternal depression may have disruptive effects on infants attachment process, marital relationships, family cohesion and work adjustment. Strenghts and limitations of psychotherapy, antidepressant medication and psychiatric hospitalisation are reviewed with a special accent on the specific ethical and scientific issues associated with the clinical dilemma of risks balance evaluation and medication treatment choice with these patients.
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Depressão Pós-Parto/diagnóstico , Depressão Pós-Parto/terapia , Tomada de Decisões , Depressão Pós-Parto/epidemiologia , Feminino , HumanosRESUMO
Stalking is a recently described syndrome including a pattern of repeated intrusion and seeking for intimate relationship with another person that is unwanted. Such behaviour is perceived as an explicit threat from a victim who experiences fear. Recent studies indicate that stalking is an important legal and clinical issue with elevated prevalence rates especially among women (10%) eventually with dramatic consequences. Furthermore stalking situation are important in psychiatric practice especially among patients referred to emergency room and crisis intervention. A specific form of "treatment barrier" comes along with stalking and will be discussed. Judiciary actions are often necessary before it is possible to plan a treatment.
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Comportamento Obsessivo/psicologia , Comportamento Social , Vítimas de Crime/psicologia , Medo/psicologia , HumanosAssuntos
Serviços de Emergência Psiquiátrica/organização & administração , Guias como Assunto/normas , Cooperação Internacional , Agitação Psicomotora/terapia , Qualidade da Assistência à Saúde/organização & administração , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Prevenção do Suicídio , Currículo/normas , Europa (Continente) , Humanos , Internato e Residência/organização & administração , Estudos Multicêntricos como Assunto/normas , Psiquiatria/educação , Agitação Psicomotora/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Suicídio/psicologia , Estados UnidosRESUMO
OBJECTIVES: Depressive disorders are overrepresented among the patients admitted to non-psychiatric units in general hospitals. However, the majority of depressed patients fail to be identified within this care setting. Since a self-administered questionnaire (Patient Health Questionnaire, PHQ-9) has given encouraging results in English and Spanish, new research should test its criterion validity in a French-speaking environment. DESIGN: The study included 292 patients admitted to the internal medicine units of the University Hospitals of Geneva. Each patient filled the PHQ-9; 212 patients also underwent a blinded DSM-IV diagnostic assessment by a psychiatrist. METHODS: In order to assess the validity of PHQ-9 against the gold standard of the psychiatrist's DSM-IV diagnosis, we calculated overall accuracy, sensitivity, specificity, positive predictive value and Cohen kappa coefficients. We also studied the relationship between the PHQ-9 diagnostic and the severity of depression. Finally, analysis focused on the presence of a diagnosis of depression. RESULTS: Within the framework of the study, PHQ-9 showed an acceptable level of specificity. However, its sensitivity in detecting major depression was low (about 50% of false-negative results). As regards the overall presence of depressive disorders, this instrument performed hardly any better (35% of false negatives). Other characteristics of the population under investigation may have affected the data. CONCLUSIONS: The French version of PHQ-9 demonstrated low sensitivity as compared with psychiatrist-established diagnosis of DSM-IV A criterion and major depressive episode.
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Transtorno Depressivo/diagnóstico , Departamentos Hospitalares , Medicina Interna , Saúde Mental , Psicometria/instrumentação , Inquéritos e Questionários/normas , Transtorno Depressivo/psicologia , Feminino , França , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Escalas de Graduação Psiquiátrica , Reprodutibilidade dos Testes , Autoavaliação (Psicologia) , Sensibilidade e Especificidade , Índice de Gravidade de DoençaRESUMO
Depression is the most frequent psychiatric disorder and is associated with marked distress and work impairment. General practitioners are primarily involved in the treatment of these patients, but they lack specific training and the most important target to enhance access to suitable care. Systematic referral to a psychiatrist is not always recommended, not well accepted from the everyday patient and totally unfeasible due to the lack of therapists' vacancy. Well structured psychiatric counseling may be a valuable alternative in order to lower misdiagnosis and to improve the treatment. This paper reports the rationale of a pilot program aimed to disseminate the provision of such aid. This program extends the consultation-liaison to outpatient and may have a clinical and economic impact with relevance to depression treatment policies.
Assuntos
Depressão/terapia , Terapia Combinada , Humanos , Atenção Primária à SaúdeRESUMO
BACKGROUND: Depressive disorders are overrepresented among patients admitted to nonpsychiatric units of general hospitals, but the majority of depressed patients are not identified in this setting. Effective and well-tolerated treatments and reliable diagnostic criteria, together with new assessment tools (self-administered or not), have been developed with encouraging results. Nevertheless, few studies have utilized standardized instruments and extensive clinical interviews by well-trained psychiatrists to assess depression. New research should test these tools in a French-speaking environment. METHODS: The investigation covered 292 patients aged 18-65 who were admitted over a period of 6 months to the internal medicine units of Geneva University Hospitals. Each patient filled in a self-administered questionnaire for depression [Patient Health Questionnaire (PHQ-9)]; 212 patients were also evaluated by a psychiatrist using DSM-IV diagnostic assessment and the Hamilton Depression Rating Scale during the first week of their hospital stay; both assessments were single-blinded. RESULTS: Psychiatric clinical interviews identified a high proportion (26.9%) of depressive disorders (37% among women) for all diagnoses; 11.3% (17.3% among women) of the patients met the DSM-IV criteria for major depression. The PHQ-9 identified depressive disorders among 34.9% of patients (42% among women) and identified a major depressive syndrome among 18.4% of patients (29.6% among women). Physicians in the internal medicine unit identified only about half the depressive patients; at the time of psychiatric examination, fewer than one in four patients was receiving antidepressant therapy. CONCLUSIONS: Our findings confirm the results of previous investigations, which showed that the failure to detect and treat depression is a major health problem among patients admitted to nonpsychiatric units of a general hospital.
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Transtorno Depressivo Maior/reabilitação , Departamentos Hospitalares , Medicina Interna/métodos , Adolescente , Adulto , Idoso , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/psicologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Hospitalização , Hospitais Gerais , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Índice de Gravidade de Doença , Método Simples-Cego , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Chemical restraint is controversial. Appropriate use is ill-defined and chemical restraint may be overutilized. During the period of an unrelated observational study for patients with acute psychomotor agitation in a psychiatric emergency service, we noticed a significant reduction in the number of involuntary intramuscular injections administered. RESULTS: We observed a 27% decrease (P=.015) in the number of involuntary intramuscular injections in the 3-month observational study period, compared to 3-month periods before and after the study. CONCLUSION: We suggest that the observation process itself may have been beneficial and may have reduced the incidence of unnecessary intramuscular injections.