The use of the Psychiatric Electroencephalography Evaluation Registry (PEER) to personalize pharmacotherapy.

PURPOSE: This study aims to determine whether Psychiatric Electroencephalography Evaluation Registry (PEER) Interactive (an objective, adjunctive tool based on a comparison of a quantitative electroencephalogram to an existing registry of patient outcomes) is more effective than the current standard of care in treatment of subjects suffering from depression. PATIENTS AND METHODS: This is an interim report of an ongoing, 2-year prospective, randomized, double blind, controlled study to evaluate PEER Interactive in guiding medication selection in subjects with a primary diagnosis of depression vs standard treatment. Subjects in treatment at two military hospitals were blinded as to study group assignment and their self-report symptom ratings were also blinded. Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) depression scores were the primary efficacy endpoint. One hundred and fifty subjects received a quantitative electroencephalography exam and were randomized to either treatment as usual or PEER-informed pharmacotherapy. Subjects in the control group were treated according to Veterans Administration/Department of Defense Guidelines, the current standard of care. In the experimental group, the attending physician received a PEER report ranking the subject's likely clinical response to on-label medications. RESULTS: In this post hoc interim analysis subjects were separated into Report Followed and Report Not Followed groups - based on the concordance between their subsequent treatment and PEER medication guidance. We thus evaluated the predictive validity of PEER recommendations. We found significantly greater improvements in depression scores (QIDS-SR16 P<0.03), reduction in suicidal ideation (Concise Health Risk Tracking Scale-SR7 P<0.002), and post-traumatic stress disorder (PTSD) score improvement (PTSD Checklist Military/Civilian P<0.04) for subjects treated with PEER-recommended medications compared to those who did not follow PEER recommendations. CONCLUSION: This interim analysis suggests that an objective tool such as PEER Interactive can help improve medication selection. Consistent with results of earlier studies, it supports the hypothesis that PEER-guided treatment offers distinct advantages over the current standard of care.

Prediction of attachment status from observation of a clinical intensive psychotherapy interview.

OBJECTIVE: The present study addresses whether it is possible to accurately determine a subject's Adult Attachment Interview (AAI) classification by observing a video-recorded clinical psychotherapy discussion that uses the principles of Intensive Short-Term Dynamic Psychotherapy (ISTDP). METHOD: A random sample of eight of the author's (Robert J. Nebrosky) private practice patients participated in an AAI administered by an experienced interviewer. The authors were blind to the results of the AAI, which were scored and classified by Erik Hesse, PHD (consultant and expert in AAI coding and classification). The authors used the Adult Attachment Clinical Rating Scale (AA-CRS), which is an adapted version of the AAI "states-of-mind scales," in conjunction with the structured ISTDP interview to obtain main classifications and subclassifications. The authors determined the pathway of unconscious anxiety according to the procedures described by Davanloo (1995, 2001) and ten Have-de Labije (2006), beginning with the structured ISTDP interview, then categorized the patient's defenses and quality of the patient's observing and attentive ego, discussed the clinican's knowledge of the patient's attachment history, and from this data drew first the major gateway of attachment using the AA-CRS. Then the authors categorized the subclassifications using the AA-CRS. RESULTS: The authors predicted seven out of eight AAI main classifications correctly, and five out of eight AAI subclassifications correctly, indicating that there was a statistically significant relationship between predicted and expected values for main classifications and subclassifications. CONCLUSIONS: The authors conclude that the systematic ISTDP inquiry at the level of the stimulus (current, past, and therapeutic relationship) and response (defence, anxiety, and impulse/feeling) and combined with the clinician's knowledge of the patient's clinical history can effectively substitute for the AAI interview and therefore, yield an experiential reference from which to explore the patient's state of mind using the Adult Attachment Clinical Rating Scale (AA-CRS). The authors speculate that the differences in subclassification could be accounted for by variations and/or differences in biographical knowledge obtained by the the clinician versus that of the AAI coder (Hesse).

Brain, mind, and dyadic change processes.

For many individuals attachment trauma is at the core of psychoneurosis and personality disorder. Combining theoretical aspects of psychodynamic therapy, developmental neuroscience, and attachment styles provides a useful framework for intensifying emotion and accelerating the course of treatment. A bihemispheric model is considered. The model addresses the challenge in treating the implicit trauma, which resides in the right hemisphere. This is achieved without resorting to interpretation, which is largely a left hemispheric process. The article presents a patient who benefits from a brief emotionally based psychotherapy that was completed after a course of a 20-year psychoanalysis.