Cognitive predictors of response to interpersonal and social rhythm therapy in mood disorders.

BACKGROUND: There has been increasing interest in examining the potential moderating effects that cognitive functioning has on treatment outcome in bipolar disorder (BD) and major depressive disorder (MDD). Therefore, the aim of this exploratory study was to examine the relationship between baseline cognitive function and treatment outcome in individuals with mood disorders who completed 12 months of interpersonal and social rhythm therapy (IPSRT), and were randomised to receive adjunctive cognitive remediation (CR) or no additional intervention. METHODS: Fifty-eight patients with mood disorders (BD, n = 36, MDD, n = 22), who were randomised to IPSRT-CR or IPSRT, underwent cognitive testing at baseline and completed follow-up mood measures after 12 months. General linear modelling was used to examine the relationship between baseline cognitive function (both objective and subjective) and change in mood symptom burden, and functioning, from baseline to treatment-end. RESULTS: Poorer baseline attention/executive function was associated with less change in mood symptom burden, particularly depressive symptoms, at treatment-end. Additionally, slower psychomotor speed at baseline was associated with less improvement in mania symptom burden. Subjective cognitive function at baseline was not related to change in mood symptom burden at treatment-end, and neither objective nor subjective cognitive function was associated with functional outcome. LIMITATIONS: Due to the exploratory nature of the study, there was no correction for multiple comparisons. CONCLUSION: Aspects of objective cognitive function were associated with treatment outcomes following psychotherapy. Further large-scale research is required to examine the role that cognitive function may have in determining various aspects of mood disorder recovery.

Further evidence for slow binocular rivalry rate as a trait marker for bipolar disorder.

OBJECTIVE: Binocular rivalry refers to a situation where contradictory information is presented simultaneously to the same location of each eye. This leads to the alternation of images every few seconds. The rate of alternation between images has been shown to be slower in euthymic participants with bipolar disorder than in healthy controls. The alternation rate is not uniformly slowed in bipolar disorder patients and may be influenced by clinical variables. The present study examined whether bipolar disorder patients have slower alternation rates, examined the influence of depression and explored the role of clinical variables and cognitive functions on alternation rate. METHOD: Ninety-six patients with bipolar disorder and 24 control participants took part in the study. Current mood status and binocular rivalry performance were analysed with nonparametric tests. A slow and a normal alternation group were created by median split. We subsequently explored the distribution of several clinical variables across these groups. Further, we investigated associations between alternation rate and various cognitive functions, such as visual processing, memory, attention and general motor speed. RESULTS: The median alternation rate was significantly slower for participants with bipolar disorder type I (0.39 Hz) and for participants with bipolar spectrum disorder (0.43 Hz) than for control participants (0.47 Hz). Depression had no effect on alternation rate. There were no differences between participants with bipolar disorder type I and type II and in regard to medication regime and predominance of one rivalry image. There were also no differences in regard to the clinical variables and no significant associations between alternation rate and the cognitive functions explored. CONCLUSION: We replicated a slowing in alternation rate in some bipolar disorder participants. The alternation rate was not affected by depressed mood or any of the other factors explored, which supports views of binocular rivalry rates as a trait marker in bipolar disorder.

"I really don't know whether it is still there": ambivalent acceptance of a diagnosis of bipolar disorder.

Questioning a diagnosis of bipolar disorder is not surprising given the chronic and fluctuating nature of the illness. Qualitative research using thematic analysis was used to derive an understanding of the process patients used to make sense of their diagnosis of bipolar disorder. The findings suggested that receiving a diagnosis was an active process. Factors such as fluctuating moods, changing diagnoses or misdiagnosis, difficulties patients have differentiating self from illness, mistrust in mental health services, and experiences of negative side effects of medication can contribute to ambivalence about the diagnosis and lead to relapse. These findings highlight the need for clinicians to focus on patients' perceptions of bipolar disorder and work with the ambivalence in the process of facilitating greater acceptance. This has the potential for reducing relapses through increased adherence with treatment.

A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent.

AIM: This case study explains how a psychotherapy previously used with adults can be used with adolescents by focusing on the specific developmental issues associated with adolescence. BACKGROUND: Bipolar disorder is a damaging disorder to experience during the developmental phase of adolescence. Interpersonal social rhythm psychotherapy has been developed as an adjunct to medication for managing bipolar disorder and shows some promising outcomes in adults. DESIGN: This is a single case study design drawn from a larger randomised control trial of two psychotherapies for bipolar disorder. The case study addressed the question: How can Interpersonal social rhythm therapy be applied with adolescents who have bipolar disorder? METHOD: This study used a purposeful sampling process by selecting the youngest adolescent participating in the randomised control trial. All the subject's sessions of Interpersonal social rhythm therapy were taped, transcribed and analysed. The analysis involved describing the process of psychotherapy as it occurred over time, mapping the process as a trajectory across the three phases of psychotherapy experience and focusing the analysis around the impact of bipolar disorder and IPSRT on adolescent developmental issues, specifically the issue of identity development. RESULTS: Interpersonal social rhythm therapy allowed the therapist to address developmental issues within its framework. As a result of participation in the psychotherapy the adolescent was able to manage her mood symptoms and develop a sense of identity that was age-appropriate. CONCLUSION: Interpersonal social rhythm therapy provided the adolescent in the case study the opportunity to consider what it meant to have bipolar disorder and to integrate this meaning into her sense of self. RELEVANCE TO CLINICAL PRACTICE: Bipolar disorder is a chronic and recurring disorder that can have a serious impact on development and functioning. Interpersonal social rhythm therapy provides an approach to nursing care that enables adolescents to improve social functioning.

Plasma oxytocin levels in depression and their correlation with the temperament dimension of reward dependence.

Evidence suggests that the neuropeptide oxytocin plays a role in social affiliation. This behaviour may be related more to personality dimensions than specific psychiatric diagnoses. This study investigated the relationship between plasma oxytocin levels and personality dimensions using the Temperament and Character Inventory (TCI) in 60 outpatients with major depression. The strongest correlation was between plasma oxytocin levels and the temperament dimension of Reward Dependence (0.425 Pearson correlation). This suggested that 17% of the variance in plasma oxytocin levels was explained by the Reward Dependence scores. There was a significant positive correlation between plasma oxytocin levels and the Reward Dependence personality dimension.

The process of change in Interpersonal Psychotherapy (IPT) for depression: a case study for the new IPT therapist.

This case study involves a set of transcripts of Interpersonal Psychotherapy (IPT) sessions from the Christchurch Psychotherapy for Depression Study. The case study explores the techniques employed by the therapist for a depressed patient who has identified interpersonal disputes as the interpersonal area to focus on. The psychotherapeutic interventions utilized by the IPT therapist included: seeking information; exploring parallels in other relationships; exploring relationship patterns; exploring communication patterns; signalling what is significant; providing support, exploring affect; exploring options; problem-solving; drawing analogy; and challenging. The themes that emerged in the patient's response to IPT were: struggling, deconstructing, connecting, practicing and reconstructing.

Patterns of response and non-response in interpersonal psychotherapy: a qualitative study.

This qualitative analysis of response and non-response in interpersonal psychotherapy (IPT) was conducted on sessions that had been audiotaped for a randomized clinical trial designed to identify patient predictors of treatment response to psychotherapy for depression. A thematic analysis was conducted on ten sets of IPT sessions (120 hours) to explore the process of change. Analysis of these sessions revealed a pattern associated with improvement in mood. This pattern involved struggling with the symptoms; deconstructing interpersonal patterns; altering the pattern; and reconstructing a sense of self. Because the analysis revealed that not all participants' transcripts showed an engagement with this pattern, a further analysis revealed characteristics associated with response and non-response. These characteristics were: an ability to engage in multiple perspectives, an awareness of others' feelings, a desire to make change, a sense of self-responsibility, an ability to use a range of communication strategies, a desire to act cooperatively, and an ability to engage with the therapist.

Interpersonal psychotherapy: an effective psychotherapeutic intervention for mental health nursing practice.

Interpersonal psychotherapy (IPT) is well-recognized for the treatment of depression with many efficacy trials supporting its use, however, there is little discussion of its use in mental health nursing practice. This paper explores how IPT can be a useful intervention for mental health nursing practice and demonstrates the process of IPT with reference to a case study. The case study illustrates how IPT facilitates a shift for one woman from a passive subject position to a more self-assertive one. This shift was facilitated by identifying how she was constructing herself in relation to others by utilizing tactics of passivity and avoidance of conflict. The development of more satisfying subject positions facilitated an improvement in mood and recovery from depression.

Interpersonal psychotherapy: an effective psychotherapeutic intervention for mental health nursing practice.

Interpersonal psychotherapy (IPT) is well-recognized for the treatment of depression with many efficacy trials supporting its use. However, there is little discussion of its use in mental health nursing practice. This paper explores how IPT can be a useful intervention for mental health nursing practice and demonstrates the process of IPT with reference to a case study. The case study illustrates how IPT facilitates a shift for one woman from a passive subject position to a more self-assertive one. This shift was facilitated by identifying how she was constructing herself in relation to others by utilizing tactics of passivity and avoidance of conflict. The development of more satisfying subject positions facilitated an improvement in mood and recovery from depression.

Thyroid indices and response to fluoxetine and nortriptyline in major depression.

We investigated: (i) the status of thyroid hormones and their clinical correlates in patients with major depression; (ii) changes in thyroid hormone status after treatment with fluoxetine versus nortriptyline; and (iii) whether blunted thyrotropin-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) challenge predicts improvement after 6 weeks of fluoxetine versus nortriptyline treatment. Patients with major depression entering a treatment trial were assessed with the Structured Clinical Interview for DSM-III-R and were rated on the Montgomery-Asberg Depression Rating Scale (MADRS). Blood samples were taken for TSH, thyroxine (T4) and free thyroxine (FT4) measurement, and the maximum TSH response (deltamaxTSH) to a TRH challenge test was undertaken. Patients were then randomly assigned to receive fluoxetine or nortriptyline for six weeks. At 6 weeks, patients repeated the thyroid hormone assessment and completed the MADRS. Mean concentrations of TSH, T4, FT4 and deltamaxTSH were within reference ranges. T4 and FT4 levels decreased significantly after treatment in responders, but not in nonresponders. After treatment, deltamaxTSH concentrations decreased significantly in patients who responded to fluoxetine, and increased in patients who responded to nortriptyline. Patients with deltamaxTSH blunting at pretreatment were more likely to be male, to have higher MADRS scores and have a history of alcohol and drug dependence. Patients with a pretreatment deltamaxTSH of < 3.0 microm/ml showed greater improvement on the MADRS when treated with fluoxetine than if treated with nortriptyline. We observed a decrease in T4 and FT4 in responders to treatment with fluoxetine or nortriptyline. Positive relationships between deltamaxTSH blunting and alcohol and drug abuse and severity of depression were found. Patients with blunted deltamaxTSH responded better to fluoxetine than to nortriptyline. It is suggested that a blunted DmaxTSH may reflect a predominantly serotonergic disturbance in this group of patients with major depression.

Effects of comorbidity and early age of onset in young people with Bipolar Disorder on self harming behaviour and suicide attempts.

BACKGROUND: The age of the first episode of illness in Bipolar Disorder has been shown to be an important predictor of outcome with early onset, particularly onset before puberty, associated with greater comorbidity, a poorer quality of life and greatest impairment in functioning. METHODS: Baseline data from a psychotherapy study was used to examine the prevalence of other comorbid psychiatric conditions and the impact of onset at an early age on both self harming behaviour and suicide attempts in young people with Bipolar Disorder. RESULTS: This study of 100 adolescents and young adults (aged 15-36 years) with Bipolar Disorder showed that comorbid conditions were very common, even at the start of their bipolar illness. Comorbidity increased as the age of onset decreased with very early onset (<13 years) patients bearing the greatest burden of disease. Greater comorbidity also significantly increased the risk of having self harmed and attempted suicide with high lethal intent. Self harming behaviour was predicted by having a lifetime diagnoses of Borderline Personality Disorder and Panic Disorder along with an early age of onset of Bipolar Disorder. In contrast, previous suicide attempts were predicted by greater comorbidity and not by very early (<13 years) age of onset.

Recovery from depression: a discourse analysis of interpersonal psychotherapy.

This paper describes a discourse analysis of the process of interpersonal psychotherapy (IPT) in the recovery from depression. It demonstrates how IPT is an effective treatment strategy for mental health nurses to utilise in the treatment of depression. The discourse analysis highlights how the development of more meaningful subject positions enables one woman to recover from her depression. The process of recovery is underpinned by an understanding of women's depression as promoted by contemporary social and cultural expectations for detachment and reflexivity. This paper shows how IPT provides an opportunity for recovery from depression for one woman by facilitating a reconstruction of her subject positions in relation to others. The discourse analysis revealed that the therapist facilitated this through the use of a range of techniques: seeking information, exploring beliefs/values/assumptions, exploring communication patterns, exploring affective responses and exploring alternative subject positions.