Effects of Scheduled Waiting for Psychotherapy in Patients With Major Depression.

The role of nonspecific factors in the outcome of psychotherapy is poorly understood. To study the effects of pretreatment expectancy of scheduled psychotherapy, we examined the effects of an agreed waiting time on the outcome of psychodynamic psychotherapy. Thirty-three treatment-naive outpatients with major depressive disorder were randomly selected to start psychotherapy either directly (DG; n = 17) or after waiting for 6 months (WG; n = 16). In WG, 18% to 60% of the total decline in symptoms took place during the waiting time. After 1 year of active psychotherapy, the anxiety score declined significantly only in WG, and the total length of treatment needed was shorter in WG. No other outcome differences between WG and DG were found. We conclude that scheduled waiting associates with a significant decline in depressive symptoms. Scheduled waiting should be regarded as a preparatory treatment and not as an inert nontreatment control.

Baseline symptom severity predicts serotonin transporter change during psychotherapy in patients with major depression.

AIMS: The role of the serotonin transporter (SERT) in the pathophysiology of depression is unclear and only a few follow-up studies exist. Our aim was to measure changes in SERT availability during psychodynamic psychotherapy in patients with major depression over a follow-up time of 12 or 18 months. METHODS: The patients were studied with iodine-123 labelled 2ß-carbomethoxy-3ß-(4-iodophenyl) serial single-photon emission tomography imaging and clinical rating scales of symptoms. RESULTS: Changes in SERT availability had no correlation with the change of symptoms, but the change of SERT availability during psychotherapy in the midbrain was predicted by the baseline severity of the clinical symptoms measured by the Symptom Checklist Depression Scale and the Symptom Checklist Global Severity Index. With cut-off values applied, it was found that SERT availabilities increased in patients with high baseline symptoms, and decreased in patients with low baseline symptoms. CONCLUSIONS: Together with our earlier finding of decreased SERT in patients with depression, these results indicate a state-dependent and possibly a compensatory role of decreased SERT availability in depression.

The patient-therapist interaction and the recognition of affects during the process of psychodynamic psychotherapy for depression.

The perceptions of patients (n = 25) and their therapists about psychodynamic psychotherapy for depression were assessed during the first treatment year using 23 scales. Patients and therapists independently evaluated the impact of depression on the therapeutic experience of the patients. The estimations of the impact of depression by the patients and therapists were concordant in the majority of the subjects, reflecting mutual tuning and a working alliance. The roles of affects and frustrating subjects in the treatment relationship were evaluated as significantly different by the patients and the therapists. The results highlight the importance of working on the expression of affects in the psychotherapy of depression.

Reality of auditory verbal hallucinations.

Distortion of the sense of reality, actualized in delusions and hallucinations, is the key feature of psychosis but the underlying neuronal correlates remain largely unknown. We studied 11 highly functioning subjects with schizophrenia or schizoaffective disorder while they rated the reality of auditory verbal hallucinations (AVH) during functional magnetic resonance imaging (fMRI). The subjective reality of AVH correlated strongly and specifically with the hallucination-related activation strength of the inferior frontal gyri (IFG), including the Broca's language region. Furthermore, how real the hallucination that subjects experienced was depended on the hallucination-related coupling between the IFG, the ventral striatum, the auditory cortex, the right posterior temporal lobe, and the cingulate cortex. Our findings suggest that the subjective reality of AVH is related to motor mechanisms of speech comprehension, with contributions from sensory and salience-detection-related brain regions as well as circuitries related to self-monitoring and the experience of agency.

Serotonin-transporter-linked promoter region polymorphism and serotonin transporter binding in drug-naïve patients with major depression.

AIMS: Both the serotonin transporter and its genetic regulation by the serotonin-transporter-linked polymorphic region have a role in the pathophysiology of depression. Most of the previous studies have found no influence of serotonin-transporter-linked polymorphic region allelic variation on serotonin transporter binding in healthy controls or patients with major depression. Due to the inconsistency of the previous findings, we compared single photon emission computed tomography imaging with the serotonin-transporter-linked polymorphic region genotype in patients with major depressive disorder. METHODS: A total of 23 drug-naïve patients with major depressive disorder were genotyped and brain imaged with ([123I])nor-beta-CIT single photon emission computed tomography. The severity of depression was evaluated with the 17-item Hamilton depression rating scale. RESULTS: Depressed patients homozygous for the short allele had lower ([123I])nor-beta-CIT binding in the medial prefrontal cortex, but not in the midbrain, compared with the other genotypes. CONCLUSION: The decreased medial prefrontal cortical serotonin transporter binding in the patients homozygous for the short allele may be linked to altered function of the serotonin-transporter-linked polymorphic region gene expressed in these patients, especially in the medial prefrontal cortex.

Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy on personality and social functioning 10 years after start of treatment.

The evidence on potentially greater benefits of psychoanalysis (PA) vs. long-term psychodynamic psychotherapy (LPP) is scarce. This study compared the effectiveness of PA and LPP on personality and social functioning during a 10-year follow-up from the beginning of the treatments. The eligible patients, 41 self-selected for PA and 128 assigned to LPP, were 20-45 years of age and had anxiety or mood disorder. Outcomes were analyzed using ten standard measures of personality and social functioning, carried out 5-9 times during the follow-up. Different change patterns by time in PA and LPP emerged, suggesting less benefit of PA during the first years of follow-up and more benefit in most outcomes thereafter. Greater post-treatment improvement in PA than in LPP was seen up to 1-2 years after PA had ended in more mature defense style (DSQ), level of personality organization (LPO), more positive self-concept (SASB), more improved social adjustment (SAS-SR) and sense of coherence (SOC). However, at the 10-year follow-up the differences were non-significant. In conclusion, PA may give some additional benefits when long-term aims are linked to personality and social functioning. The relatively small differences and higher costs in comparison to LPP may restrict the feasibility of PA.

Midbrain serotonin and striatum dopamine transporter binding in double depression: a one-year follow-up study.

Data on neurobiological differences between major depression (MD) and double depression (DD) are scarce. We examined the striatum dopamine (DAT) and midbrain serotonin transporter (SERT) binding of [123I] nor-beta-CIT in DD patients (n=8) and compared it to that in MD patients (n=11) and healthy controls (n=19). Drug-naïve patients and controls were imaged by single-photon emission computed tomography at baseline, and the patients also after one year of psychodynamic psychotherapy. Both DD and MD groups had lower midbrain [123I] nor-beta-CIT binding compared with the controls. Baseline 17-item Hamilton Depression Rating Scale (HAM-D-17) scores significantly decreased in both groups after one year of psychotherapy (DD: t=3.55, p=0.009; MD: t=5.86, p<0.001). No differences between the DD and MD groups were observed in age-adjusted baseline striatum or midbrain [123I] nor-beta-CIT binding or its change during psychotherapy. Age-adjusted baseline striatum [123I] nor-beta-CIT binding correlated inversely with the duration of both dysthymia (rho=-0.76, p=0.03) and MD (rho=-0.83, p=0.01) in the DD group. No such finding was observed in the MD group (rho=0.26, p=0.44). Baseline HAM-D-17 did not correlate with the change in striatum or midbrain [123I] nor-beta-CIT binding in either group. In conclusion, our findings suggest that when using midbrain [123I] nor-beta-CIT binding as a marker of SERT binding, no differences are detectable between patients with DD and MD. However, low striatum [123I] nor-beta-CIT binding, a marker of DAT binding, may be associated with a longer illness duration in dysthymia.

Changes in midbrain serotonin transporter availability in atypically depressed subjects after one year of psychotherapy.

BACKGROUND: Psychotherapy is an effective treatment method for depression, but no differences in the psychotherapy response have been found between the subtypes of depression. The effect of psychotherapy on neurotransmitter transporter functions has never been recorded in depressed subjects. METHODS: Depressive outpatients (N=19) received psychodynamic psychotherapy for 12 months. All subjects fulfilled the DSM-IV criteria for depression, and 8 were classified as having atypical depression. The severity of depression was assessed with the 29-item Hamilton Depression Rating Scale (HAM-D-29). Midbrain serotonin transporter (SERT) and striatum dopamine transporter (DAT) densities were recorded using single photon emission computed tomography (SPECT) brain imaging with the [123I]nor-beta-CIT radioligand before and after psychotherapy. RESULTS: Midbrain SERT density significantly increased during psychotherapy in atypicals but not in nonatypicals. There were no changes in the levels of DAT. CONCLUSIONS: The psychotherapy-related SERT elevation of atypically depressed subjects may be due to some unknown adaptive mechanisms inducing an increase in either the levels of SERT or serotonergic nerve terminals and therefore enhancing serotonergic activity and improving mood.

The impact of stimulus type and early motherhood on attentional processing.

The present study evaluated the impact of stimulus type and early motherhood on attentional processing. Auditory ERPs were recorded with a modified novelty oddball paradigm both in mothers who had recently given birth and in control women who were not in the state of early motherhood. Conventional tone pips were used as standards and deviants, and an infant cry served as an experimental stimulus of novelty value. Differences were revealed in the N100 amplitudes between the study groups with higher amplitudes in the mothers. A few days after childbirth the mothers seemed to be in a stage with an increased level of alertness and different types of surrounding stimuli may elicit a stronger arousal response than normally, not just those directly related to the new baby. The gating and the mechanisms of further processing of stimulus information were not different in mothers from controls and seemed to guarantee normal control of stimulus-elicited cognitive load in early motherhood.

Reduced midbrain serotonin transporter availability in drug-naïve patients with depression measured by SERT-specific [(123)I] nor-beta-CIT SPECT imaging.

Earlier results have indicated that serotonin transporter (SERT) availability is altered in major depression. We examined SERT density with a more serotonin-specific ligand and with a larger number of patients than in previous studies. Twenty-nine antidepressant-naïve patients with major depressive disorder (MDD) and 19 healthy age- and sex-matched controls were studied with SPECT using [(123)I] nor-beta-CIT as a ligand. The patients had a significantly lower (-10%) binding potential in the midbrain region than controls. No correlation with depression severity was found. These findings indicate that SERT availability in the midbrain area is reduced in depression, and that interindividual variation is considerable in both patients and controls.

Midbrain binding of [123I]nor-beta-CIT in atypical depression.

BACKGROUND: Altered serotonin (SERT) and dopamine transporter (DAT) densities have been recorded in major depression. Atypical depression (ATD) has been suggested to be connected to decreased serotonergic transmission, but no studies have been published on the association between brain serotonin transporter density and ATD. METHODS: PATIENTS with depression (n=29) were divided into three groups according to DSM-IV criteria: atypically depressed, melancholic patients, and "undifferentiated" patients. Depressive symptoms were evaluated with the 29-item Hamilton Depression Rating Scale (HAM-D-29). Single photon emission computed tomography (SPECT) with [(123)I]nor-beta-CIT was used to evaluate serotonin transporter density (SERT) in the midbrain and dopamine transporter density (DAT) in the striatum of patients and healthy controls (n=18). RESULTS: All subgroups except those with undifferentiated depression had lower SERT densities compared to controls. No significant differences were found in the densities between the subgroups. Atypical scores of HAM-D-29 were associated with SERT densities in the midbrain (beta=-0.40, t=-2.3, p=0.03), even after adjustment for age, gender and HAM-D-21 scores (beta=-0.39, t=-2.32, p=0.03). CONCLUSIONS: The association between atypical scores of HAM-D-29 and midbrain SERT densities suggests a relationship between serotonergic dysfunction and ATD.

Improvement in cognitive and psychosocial functioning and self image among adolescent inpatient suicide attempters.

BACKGROUND: Psychiatric treatment of suicidal youths is often difficult and non-compliance in treatment is a significant problem. This prospective study compared characteristics and changes in cognitive functioning, self image and psychosocial functioning among 13 to 18 year-old adolescent psychiatric inpatients with suicide attempts (n = 16) and with no suicidality (n = 39) METHODS: The two-group pre-post test prospective study design included assessments by a psychiatrist, a psychologist and medical staff members as well as self-rated measures. DSM-III-R diagnoses were assigned using the SCID and thereafter transformed to DSM-IV diagnoses. Staff members assessed psychosocial functioning using the Global Assessment Scale (GAS). Cognitive performance was assessed using the Wechsler Adult Intelligence Scale, while the Offer Self-Image Questionnaire (OSIQ) was used to assess the subjects' self-image. ANCOVA with repeated measures was used to test changes from entry to discharge among the suicide attempters and non suicidal patients. Logistic regression modeling was used to assess variables associated with an improvement of 10 points or more in the GAS score. RESULTS: Among suicide attempter patients, psychosocial functioning, cognitive performance and both the psychological self and body-image improved during treatment and their treatment compliance and outcome were as good as that of the non-suicidal patients. Suicidal ideation and hopelessness declined, and psychosocial functioning improved. Changes in verbal cognitive performance were more pronounced among the suicide attempters. Having an improved body-image associated with a higher probability of improvement in psychosocial functioning while higher GAS score at entry was associated with lower probability of functional improvement in both patient groups. CONCLUSION: These findings illustrate that a multimodal treatment program seems to improve psychosocial functioning and self-image among severely disordered suicidal adolescent inpatients. There were no changes in familial relationships, possibly indicating a need for more intensive family interventions when treating suicidal youths. Multimodal inpatient treatment including an individual therapeutic relationship seems recommendable for severely impaired psychiatric inpatients tailored to the suicidal adolescent's needs.

The association of parental alcohol abuse and depression with severe emotional and behavioural problems in adolescents: a clinical study.

BACKGROUND: Earlier studies have indicated associations between parental psychiatric problems, such as depression, and substance abuse and adolescent problems. AIMS: This study aimed to determine whether parental psychiatric problems are associated with problems and problem behaviour in adolescents in a clinical sample. METHODS: The study subjects were 70 outpatient adolescents (age 13-18 years, boys 30%) and their parents. The adolescents were assessed using the structural clinical interview for DSM-III-R (SCID) and a semi-structured questionnaire, and the parents were interviewed using a semi-structured questionnaire. RESULTS: Maternal alcohol abuse and depression were associated with serious problems, especially among girls, and paternal alcohol abuse was associated with adolescent health-compromising behaviour. Maternal depression and alcohol abuse had no association with adolescent health-compromising behaviour. Maternal depression without alcohol abuse was associated with the diagnosis of major depressive disorder in adolescents, but not with other adolescent problems, while paternal depression without alcohol abuse was not associated with any adolescent problems. CONCLUSIONS: Despite the small study sample, these findings indicate that parental psychiatric problems and alcohol abuse are correlated with adolescent psychological problems and should be considered and assessed when assessing adolescents.

Good working alliance and psychotherapy are associated with positive changes in cognitive performance among adolescent psychiatric inpatients.

The effects of therapeutic relationships on the treatment outcome in 45 adolescent inpatients, aged 14 to 18 years, were assessed using the Working Alliance Inventory, the Wechsler Adult Intelligence Scale, the Global Assessment Scale, and The Offer Self-Image Questionnaire at entry and on discharge. Multivariate analysis revealed that a better quality of working alliance and a greater number of therapy sessions were significantly associated with positive change in cognitive performance during treatment.

Nascent body ego: metapsychological and neurophysiological aspects.

For Freud, body ego was the organizing basis of the structural theory. He defined it as a psychic projection of the body surface. Isakower's and Lewin's classical findings suggest that the body surface experiences of nursing provide the infant with sensory-affective stimulation that initiates a projection of sensory processes towards the psychic realm. During nursing, somato-sensory, gustatory and olfactory modalities merge with a primitive somatic affect of satiation, whereas auditory modality is involved more indirectly and visual contact more gradually. Repeated regularly, such nascent experiences are likely to play a part in the organization of the primitive protosymbolic mental experience. In support of this hypothesis, the authors review findings from a neurophysiological study of infants before, during and after nursing. Nursing is associated with a significant amplitude change in the newborn electroencephalogram (EEG), which wanes before the age of 3 months, and is transformed at the age of 6 months into rhythmic 3-5 Hz hedonic theta-activity. Sucking requires active physiological work, which is shown in a regular rise in heart rate. The hypothesis of a sensory-affective organization of the nascent body ego, enhanced by nursing and active sucking, seems concordant with neurophysiological phenomena related to nursing.

Nutritive sucking induces age-specific EEG-changes in 0-24 week-old infants.

Little is known how the brain of the newborn infant responds to the postnatal nutrition and care. No systematic studies exist in which the effects of nutritional and non-nutritional sucking on the brain activity of the infant were compared. We recorded the EEG activity of 40 infants at the ages of 0,6,12 and 24 weeks in four successive behavioral stages: while the infants were hungry and waiting for sucking, during non-nutritional and nutritional sucking, and during satiation after completed feeding. Quantitative EEG analysis was performed using occipital, parietal and central EEG channels. In the newborn infants, a significant reduction in the EEG power was found after nutritional sucking in the all EEG frequency bands studied (1-10Hz), which was paralleled by a significant behavioral alertness decline. This response decayed during the subsequent neonatal period and was completely absent at the age of 12 weeks. In 24-week-old infants, nutritional sucking was accompanied with an increase in rhythmic theta activity during which no significant alertness change took place. Non-nutritional sucking was connected with minor and non-significant effects on the EEG. We conclude that in newborn infants nutritional sucking has a direct effect on the EEG, which has a soothing character and is connected with an alertness decline. In 24-week-old infants the response to nutritional sucking is of a different type and consists of an organized, rhythmical theta activity in the EEG not directly linked with alertness change. Our findings suggest a developmental relationship between nursing and infant brain function with plausible affective and cognitive implications.

Electrical brain responses evoked by human faces in acute psychosis.

Patients with schizophrenia are known to have behavioral deficits in recognizing faces and facial expressions. However, the ability to process simple visual stimuli appears to be intact in first-episode psychosis. The aim of this study was to examine complex visual processing, especially the event-related potentials (ERPs) elicited by human faces, in early psychosis. Never-medicated patients in acute psychosis (n=18) were compared with healthy controls (n=19). Photographs of human faces were presented in a classic oddball paradigm requiring a motor response to a smiling face. Cerebral sources of ERPs were analyzed of the averaged responses, using minimum norm estimates, and dipole models. Face-sensitive response at 145 ms after the face stimuli was of significantly higher amplitude in our never-medicated patients, and the activity distribution between the groups was clearly different. At the early phase of a psychotic illness, these alterations in face-related neuronal network processes represent perceptual disturbance in psychosis, possibly including state and trait, as well as potential physiological compensatory features.

Four-month-old infants process own mother's voice faster than unfamiliar voices--electrical signs of sensitization in infant brain.

Four-month-old infants heard their own mother's voice and a voice of an unfamiliar female as "oddballs" in a stream of acoustic information. The neuronal processing from 50 to 500 ms (as evaluated with event-related brain potentials, ERPs) was expected to be obligatory and from 500 to 900 ms to include cognitive processing. There was a clear shift in the processing speed between the mother's and unfamiliar voices at around 350 ms. While earlier obligatory ERP components occurred at significantly shorter latency to the mother's voice, later endogenous components were significantly delayed relative to the unfamiliar voice. The amplitude differences between the experimental stimuli were clearest for the last ERP potential, which presumably includes largest cognitive component. The size of the potential was significantly lower for mother than for unfamiliar voice. The results suggest that the behaviorally well-documented mutual sensitization between infant and mother and the special importance of output from mother is seen as an enhanced arousal to mother's voice and as signs of a clear memory template for own mother's voice at very early age.

Coping and defending as risk factors for breast cancer in patients with breast disease; a prospective case-control study in Kuopio, Finland.

BACKGROUND: The purpose of this study was to assess the role of coping and defending mechanisms as a risk factor for breast cancer. Women with breast symptoms were referred by physicians to the Kuopio University Hospital (Finland) and were asked to participate in this study. PATIENTS AND METHODS: The women (n=115) were interviewed and all study variables were obtained before any diagnostic procedures were done, so neither the investigator nor the subject knew the final diagnosis of breast symptoms at the time of the interview. The research method used was the semistructured in-depth interview method. The investigator used the Montgomery-Asberg Depression rating scale (MADRS) to evaluate the depression of the study subjects. All study subjects were also asked to complete standardised questionnaires (Beck Depression Inventory and Spielberger Trait Inventory). The investigator used the modified coping and defence inventory made by Haan. This inventory is divided into ten scales, and each scale has subscales from grade 0 to grade 3. In addition, the researcher estimated the patients ability to cope (scale 1 to 5), the amount of defensiveness (scale 1 to 5) and fragmentation (scale 1 to 5). RESULTS: Clinical examination and biopsy showed breast cancer (BC) in 34 patients, benign breast disease (BBD) in 53 patients, while 28 study subjects were healthy (HSS). The results indicated that breast cancer patients used more defending mechanisms; denial, intellectualising, rationalisation and reaction formation than the BBD and HSS groups. The defensive mechanisms were significantly associated with increased breast cancer risk (RR=1.7, CI=1.1-2.6). In addition, the breast cancer patients used less coping mechanisms; concentration, intellectuality, logical analysis, empathy, ambiguity tolerance, regression-ego, sublimation and substitution. CONCLUSION: The results of this study support a moderate association between unsatisfactory coping and defending mechanisms and increased breast cancer risk. The biological explanation of the association might be that coping and defending processes impact directly on the hormonal, immune and nervous systems, or indirectly by affecting behaviour such as diet, exercise or sleep.