Combined drugs and therapy most effective for severe nonchronic depression

What do you think of this article released by NIMH?

"The odds that a person who suffers from severe, nonchronic depression will recover are improved by as much as 30 percent if they are treated with a combination of cognitive therapy and antidepressant medicine rather than by antidepressants alone. However, a person with chronic or less severe depression does not receive the same additional benefit from combining the two. That is the result of a major new clinical trial published online by the journal JAMA Psychiatry on Aug. 20. In North America, about one in five women and one in 10 men suffer from major depression in her or his lifetime. "Our results indicate that combining cognitive therapy with antidepressant medicine can make a much bigger difference than we had thought to about one-third of patients suffering from major depressive disorder," said Steven Hollon, the Gertrude Conaway Professor of Psychology at Vanderbilt University, who directed the study. "On the other hand, it does not appear to provide any additional benefit for the other two-thirds." Previous studies have found that about two-thirds of all patients with major depressive disorder will improve on antidepressant medications and about one-third of patients will achieve full remission, but half then relapse before fully recovering. Cognitive therapy has proven to be about as effective as medication alone but its effects tend to be longer lasting. Combining the two has been estimated to improve recovery rates by 6 to 33 percent. "Now, we have to reconsider our general rule of thumb that combining the two treatments keeps the benefits of both," said Hollon. The new study was a randomized clinical trial involving 452 adult outpatients with chronic or recurrent major depressive disorder. Unlike previous studies that followed subjects for a set period of time, this study treated them for as long as it took first to remission (full normalization of symptoms) and then to recovery (six months without relapse), which in some cases took as long as three years. "This provided us with enough data so that we could drill down and see how the combined treatment was working for patients with different types and severity of depression: chronic, recurrent, severe and moderate," Hollon said. According to the psychologist, the results could have a major impact on how major depressive disorder is treated. The most immediate effect is likely to be in the United Kingdom, which, he said, is 10 years ahead of the United States in treatment of depression. The use of combined cognitive therapy and antidepressive medicine is standard for severe cases in the UK, and the English National Health Service is actively training its therapists in cognitive therapy and other empirically supported psychotherapies." ### Collaborators in the study were Robert DeRubeis and Jay Amsterdam from the University of Pennsylvania; Jan Fawcett from the University of New Mexico, Albuquerque; Richard Shelton from the University of Alabama, Birmingham; John Zajecka and Paula Young from Rush University; and Robert Gallop from West Chester University. The study was supported by grants MH60713, MH01697, MH60998 and MH060768 from the National Institute of Mental Health. For more information on mental health and counseling related topics, please visit Counselor CEUs

Study finds family-based exposure therapy effective treatment for young children with OCD

What do you think of this article on kids and OCD? "Bradley Hasbro Children’s Research Center study finds family-based exposure therapy effective treatment for young children with OCD 5/5/2014 • Children five to eight years old with emerging OCD can benefit from therapies used for older children A new study from the Bradley Hasbro Children’s Research Center has found that family-based cognitive behavioral therapy (CBT) is beneficial to young children between the ages of five and eight with Obsessive-Compulsive Disorder (OCD). The study, now published online in JAMA Psychiatry, found developmentally sensitive family-based CBT that included exposure/response prevention (EX/RP) was more effective in reducing OCD symptoms and functional impairment in this age group than a similarly structured relaxation program. Jennifer Freeman, PhD, a staff psychologist at the Bradley Hasbro Children’s Research Center and clinical co-director of the Intensive Program for OCD at Bradley Hospital, led the study. “CBT has been established as an effective form of OCD treatment in older children and adolescents, but its effect on young children has not been thoroughly examined,” said Freeman. “These findings have significant public health implications, as they support the idea that very young children with emerging OCD can benefit from behavioral treatment.” During the 14-week randomized, controlled trial, which was conducted at three academic medical centers over a five-year period, the team studied 127 children between the ages of five and eight with a primary diagnosis of OCD. Each child received either family-based CBT with EX/RP or family-based relaxation therapy. The family-based CBT focused on providing the child and parent “tools” to understand, manage and reduce OCD symptoms. This includes psychoeducation, parenting strategies, and family-based exposure treatment, so children can gradually practice facing feared situations while learning to tolerate anxious feelings. The family-based relaxation therapy focused on learning about feelings and implementing muscle relaxation strategies aimed at lowering the child’s anxiety. At the end of the trial period, 72 percent of children receiving CBT with EX/RP were rated as “much improved” or “very much improved” on the Clinical Global Impression-Improvement scale, versus 41 percent of children receiving the family-based relaxation therapy. According to Freeman, the traditional approach for children this young presenting with OCD symptoms has been to watch and wait. “This study has shown that children with early onset OCD are very much able to benefit from a treatment approach that is uniquely tailored to their developmental needs and family context,” said Freeman. “Family-based EX/RP treatment is effective, tolerable and acceptable to young children and their families.” Freeman hopes that the family-based CBT model will become the first-line choice for young children with OCD in community mental health clinics where they first present for treatment. Earlier intervention may better address the chronic issues many children have with OCD, as well as the impact the debilitating illness can have on their overall development. “We use this family-based CBT model for treating children in this age range in both our Pediatric Anxiety Research Clinic and our Intensive Outpatient Program with much success,” said Freeman. “My hope is that others will utilize this treatment model to the benefit of young children at the onset of their illness.” “The findings from this study support extending downward the age range that can benefit from CBT with EX/RP for pediatric OCD treatment,” said Freeman. “With appropriate parental support, young children with OCD can make significant gains beyond what can be expected from having parents attempt to teach relaxation strategies to their children with OCD.” This study was funded by the National Institute of Mental Health (NIMH) under grant number 1R01MH079217. Freeman’s principal affiliation is the Bradley Hasbro Children’s Research Center, a division of the Lifespan health system in Rhode Island. She is also co-director of the Pediatric Anxiety Research Clinic at the Bradley Hasbro Children’s Research Center and clinical co-director of the Intensive Program for OCD at Bradley Hospital. She is an associate professor (research) at The Warren Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior." For more information on PTSD and other mental health resources, please visit, Aspira Continuing Education Online Courses or our Anxiety Disorders CE Course

Depression Therapy Effective for Poor, Minority Moms

Faced with the dual demands of motherhood and poverty, as many as one fourth of low-income minority mothers struggle with major depression. But the stigma associated with mental illness coupled with limited access to quality treatment prevent the majority of these struggling women from receiving help. Now a new study shows that screening for the disorder and providing short-term, relationship-focused therapy through weekly home visits can relieve depression among minority mothers, even in the face of poverty and personal histories of abuse or violence. Such help can have far reaching benefits not only for mothers, but also for their children, say the authors. "It's amazing, really," says psychologist Sheree Toth, lead author and executive director of the University of Rochester's Mt. Hope Family Center. "This research tracked a 14-week intervention for mothers who are terribly overwhelmed, surrounded by high-crime neighborhoods, lacking social support, and often traumatized—my fear was, 'this is never going to work.'" But to the surprise of Toth and her Rochester team, the series of convenient, one-hour therapy sessions relieved depression in participants much better than standard clinic-based care. The study participants also continued to improve eight-months after the treatment ended, regaining a sense of hope and control over their lives and reporting feeling more connected to and supported by others. For example, on the Beck Depression Inventory (BDI), a widely used questionnaire in which a score of 19 or above indicates major depression, women in the study group saw their depressive symptoms decline from an average of 27 at the beginning of therapy to 9.6 eight months after the program concluded. By contrast, women who received community care remained clinically depressed, with an average BDI score of 21 at the follow-up.

Women who received home-based interpersonal therapy saw their depression subside by the end of treatment and continue to improve eight months later. Women who received standard care experienced much less relief. The results, says Toth, point to the need for screening high-risk populations. None of these women were seeking treatment, but were identified instead through a questionnaire and an interview at physicians' offices and clinics for the Women, Infants, and Children (WIC) subsidized nutrition program. Says Toth: "When I go to the doctor, they ask me if I use my seatbelt. Why would we not be asking questions about depression when we know the chances of being hit by a car are way less than the chances of being hit by depression? People are suffering needlessly." Published online November 8 in Development and Psychopathology, the findings are good news for mothers and their children alike. "Extensive research has shown that young children whose primary caregivers are depressed often begin life on the wrong foot," explains Toth. "They may fail to develop secure attachments, setting them up for a cascade of difficulties, from behavior problems during childhood and failure in school to involvement in the juvenile justice system and major psychiatric problems down the road." Despite the widespread prevalence of depression among minority mothers, researchers have largely overlooked this vulnerable population. "In fact, studies that formed the empirical base for the American Psychiatric Association guidelines for depression treatment included 3,860 participants, with only 27 identified as African American and none as being of Latina descent," the authors write. To address the imbalance, the researchers tracked 128 low-income mothers of one-year-olds, 60 percent of whom were Black, 20 percent Hispanic, and 20 percent Caucasian. In addition to poverty, the vast majority of these mothers faced extensive life challenges. All but 6 percent had been depressed for more than a year, 87 percent reported histories of child abuse, 30 percent had been raped or sexually assaulted by a relative, and 27 percent suffered from posttraumatic stress disorder. The study tested the effectiveness of interpersonal psychotherapy, a short-term depression treatment that has worked with more advantaged populations. "A big part of this approach is instilling hope," says Robin Sturm, a co-author and one of the family therapists who worked on the study. She and other therapists first help clients recognize that feelings, such as a lack of energy or motivation, are symptoms of depression not signs of laziness or other character flaws. "If they can separate themselves from the symptoms, it helps them see that they can get better," says Sturm. The bulk of the intervention then focuses on identifying and easing one or two key relationship problems in clients' lives. This could be overcoming the loss of a loved one, reconnecting with a family member, or learning how to resolve conflicts with a partner. Using a variety of tools, from role-playing to analyzing arguments, participants practice more effective ways to interact. "The aha moment is when these women realize, 'I have a sense of control,'" says Sturm. "Perhaps there is domestic violence. They can't control what the other person does, but they can control what they do. That stuck feeling is the hallmark of depression." A critical element of the study model was to offer therapy in clients' homes, an option chosen by 85 percent of participants. "It sends a powerful message that I am willing to come to you," explains Sturm, who, if needed, also met with clients in her car or drove them to the clinic for their appointment. "When people are depressed, it may be too hard to have the energy to make it to appointments," she says. The program's flexibility also reduced the need for childcare and transportation, resulting in a compliance rate of 100 percent, the authors report. Therapists were also sensitive to the stigma of mental illness in minority communities. If clients appeared uncomfortable with a diagnosis like depression, therapists used terms like overwhelmed or moody instead and stressed that such feelings were common for parents faced with the demands of childrearing. Instead of therapy, they sometimes describe their appointments as "spending some time talking about how you are feeling." The program involved no anti-depressants or other medication, further distancing the intervention from psychiatric care, says Sturm. To assess the effectiveness of this flexible, problem-solving approach, the study randomly assigned a second group of mothers to standard community care, matched by race, education, age, and other factors. The control group received clinic-based counseling or cognitive behavior therapy, a common short-term treatment for depression, along with a variety of other interventions, including medication, support groups, and marital and family counseling. The comparison was clear: home-based, interpersonal psychotherapy lifted depression much more effectively than standard care. The findings underscore the importance of actively screening and offering culturally sensitive, convenient care for our most vulnerable populations, says co-author Fred Rogosch, associate professor of psychology at the University of Rochester and director of research for Mt. Hope Family Center. In one clinical trial, 83 percent of low-income young minority women referred for treatment for depression did not attend even one session. "Most of these women don't even like to talk about depression. Most of these women would never have asked for treatment," says Rogosch. "When I go to the doctor, they ask me if I use my seatbelt," says Sheree Toth. "Why would we not be asking questions about depression when we know the chances of being hit by a car are way less than the chances of being hit by depression? People are suffering needlessly." "We also are concerned about the children of mothers who feel isolated, helpless, and angry. That is not the ideal emotional environment for infants and toddlers to grow up in. Reaching out to these mothers is critical for their children," says Rogosch. Even with the creative accommodations offered in this study, Rogosch notes that 40 percent of mothers identified as depressed declined all care. The authors suggest that future research should explore ways to make the interview process even more welcoming. Assaf Oshri and Julie Gravener from the University of Rochester and Antonio Alexander Morgan-López from the University of North Carolina at Chapel Hill also contributed to the paper. The research was supported by the National Institutes of Mental Health, grant MH091070 LPC Continuing Education About the University of Rochester The University of Rochester (www.rochester.edu) is one of the nation's leading private universities. Located in Rochester, N.Y., the University gives students exceptional opportunities for interdisciplinary study and close collaboration with faculty through its unique cluster-based curriculum. Its College, School of Arts and Sciences, and Hajim School of Engineering and Applied Sciences are complemented by its Eastman School of Music, Simon School of Business, Warner School of Education, Laboratory for Laser Energetics, School of Medicine and Dentistry, School of Nursing, Eastman Institute for Oral Health, and the Memorial Art Gallery.

Astrocytes identified as target for new depression therapy

Tufts neuroscientists find that starry brain cells can be used to mimic sleep deprivation BOSTON (January 23, 2013) — Neuroscience researchers from Tufts University have found that our star-shaped brain cells, called astrocytes, may be responsible for the rapid improvement in mood in depressed patients after acute sleep deprivation. This in vivo study, published in the current issue of Translational Psychiatry, identified how astrocytes regulate a neurotransmitter involved in sleep. The researchers report that the findings may help lead to the development of effective and fast-acting drugs to treat depression, particularly in psychiatric emergencies. Drugs are widely used to treat depression, but often take weeks to work effectively. Sleep deprivation, however, has been shown to be effective immediately in approximately 60% of patients with major depressive disorders. Although widely-recognized as helpful, it is not always ideal because it can be uncomfortable for patients, and the effects are not long-lasting Marriage and Family Therapist Continuing Education During the 1970s, research verified the effectiveness of acute sleep deprivation for treating depression, particularly deprivation of rapid eye movement sleep, but the underlying brain mechanisms were not known. Most of what we understand of the brain has come from research on neurons, but another type of largely-ignored cell, called glia, are their partners. Although historically thought of as a support cell for neurons, the Phil Haydon group at Tufts University School of Medicine has shown in animal models that a type of glia, called astrocytes, affect behavior. Haydon's team had established previously that astrocytes regulate responses to sleep deprivation by releasing neurotransmitters that regulate neurons. This regulation of neuronal activity affects the sleep-wake cycle. Specifically, astrocytes act on adenosine receptors on neurons. Adenosine is a chemical known to have sleep-inducing effects. During our waking hours, adenosine accumulates and increases the urge to sleep, known as sleep pressure. Chemicals, such as caffeine, are adenosine receptor antagonists and promote wakefulness. In contrast, an adenosine receptor agonist creates sleepiness. "In this study, we administered three doses of an adenosine receptor agonist to mice over the course of a night that caused the equivalent of sleep deprivation. The mice slept as normal, but the sleep did not reduce adenosine levels sufficiently, mimicking the effects of sleep deprivation. After only 12 hours, we observed that mice had decreased depressive-like symptoms and increased levels of adenosine in the brain, and these results were sustained for 48 hours," said first author Dustin Hines, Ph.D., a post-doctoral fellow in the department of neuroscience at Tufts University School of Medicine (TUSM). "By manipulating astrocytes we were able to mimic the effects of sleep deprivation on depressive-like symptoms, causing a rapid and sustained improvement in behavior," continued Hines. "Further understanding of astrocytic signaling and the role of adenosine is important for research and development of anti-depressant drugs. Potentially, new drugs that target this mechanism may provide rapid relief for psychiatric emergencies, as well as long-term alleviation of chronic depressive symptoms," said Naomi Rosenberg, Ph.D., dean of the Sackler School of Graduate Biomedical Sciences and vice dean for research at Tufts University School of Medicine. "The team's next step is to further understand the other receptors in this system and see if they, too, can be affected." ### Senior author, Phillip G. Haydon, Ph.D., is the Annetta and Gustav Grisard professor and chair of the department of neuroscience at Tufts University School of Medicine (TUSM). Haydon is also a member of the neuroscience program faculty at the Sackler School of Graduate Biomedical Sciences at Tufts. Additional authors are Luke I. Schmitt, B.S., a Ph.D. candidate in neuroscience at the Sackler School; Rochelle M. Hines, Ph.D., a post-doctoral fellow in the department of neuroscience at TUSM; and Stephen J. Moss, Ph.D., a professor of neuroscience at Tufts University School of Medicine and a member of the neuroscience program faculty at the Sackler School. Hines DJ, Schmitt LI, Hines RM, Moss SJ, Haydon PG. Translational Psychiatry. "Antidepressant effects of sleep deprivation require astrocyte-dependent adenosine mediated signaling." (2013) 3, e212; doi:10.1038/tp.2012.136. Published online 15 January 2013. This research was supported by award number R01MH095385 from the National Institute of Mental Health, part of the National Institutes of Health, as well as by award number R01NS037585 from the National Institute of Neurological Disorders and Stroke, both of the National Institutes of Health. Dustin Hines was partially funded by the Heart and Stroke Foundation of Canada. Haydon is co-founder and president of GliaCure Inc., which has licensed a pending patent application filed by Tufts University claiming compounds that modulate the signaling cascades, and related methods of use, described in this paper. About Tufts University School of Medicine and the Sackler School of Graduate Biomedical Sciences Tufts University School of Medicine and the Sackler School of Graduate Biomedical Sciences at Tufts University are international leaders in innovative medical education and advanced research. The School of Medicine and the Sackler School are renowned for excellence in education in general medicine, biomedical sciences, special combined degree programs in business, health management, public health, bioengineering and international relations, as well as basic and clinical research at the cellular and molecular level. Ranked among the top in the nation, the School of Medicine is affiliated with six major teaching hospitals and more than 30 health care facilities. Tufts University School of Medicine and the Sackler School undertake research that is consistently rated among the highest in the nation for its effect on the advancement of medical science. If you are a member of the media interested in learning more about this topic, or speaking with a faculty member at the Tufts University School of Medicine or another Tufts health sciences researcher, please contact Siobhan Gallagher.

Predicting how patients respond to therapy

Brain scans could help doctors choose treatments for people with social anxiety disorder CAMBRIDGE, MA -- A new study led by MIT neuroscientists has found that brain scans of patients with social anxiety disorder can help predict whether they will benefit from cognitive behavioral therapy. Social anxiety is usually treated with either cognitive behavioral therapy or medications. However, it is currently impossible to predict which treatment will work best for a particular patient. The team of researchers from MIT, Boston University (BU) and Massachusetts General Hospital (MGH) found that the effectiveness of therapy could be predicted by measuring patients' brain activity as they looked at photos of faces, before the therapy sessions began. The findings, published this week in the Archives of General Psychiatry, may help doctors choose more effective treatments for social anxiety disorder, which is estimated to affect around 15 million people in the United States. "Our vision is that some of these measures might direct individuals to treatments that are more likely to work for them," says John Gabrieli, the Grover M. Hermann Professor of Brain and Cognitive Sciences at MIT, a member of the McGovern Institute for Brain Research and senior author of the paper. Lead authors of the paper are MIT postdoc Oliver Doehrmann and Satrajit Ghosh, a research scientist in the McGovern Institute. Choosing treatments Sufferers of social anxiety disorder experience intense fear in social situations that interferes with their ability to function in daily life. Cognitive behavioral therapy aims to change the thought and behavior patterns that lead to anxiety. For social anxiety disorder patients, that might include learning to reverse the belief that others are watching or judging them. The new paper is part of a larger study that MGH and BU ran recently on cognitive behavioral therapy for social anxiety, led by Mark Pollack, director of the Center for Anxiety and Traumatic Stress Disorders at MGH, and Stefan Hofmann, director of the Social Anxiety Program at BU. "This was a chance to ask if these brain measures, taken before treatment, would be informative in ways above and beyond what physicians can measure now, and determine who would be responsive to this treatment," Gabrieli says. Currently doctors might choose a treatment based on factors such as ease of taking pills versus going to therapy, the possibility of drug side effects, or what the patient's insurance will cover. "From a science perspective there's very little evidence about which treatment is optimal for a person," Gabrieli says. The researchers used functional magnetic resonance imaging (fMRI) to image the brains of patients before and after treatment. There have been many imaging studies showing brain differences between healthy people and patients with neuropsychiatric disorders, but so far imaging has not been established as a way to predict patients' responses to particular treatments CADC I & II Continuing Education Measuring brain activity In the new study, the researchers measured differences in brain activity as patients looked at images of angry or neutral faces. After 12 weeks of cognitive behavioral therapy, patients' social anxiety levels were tested. The researchers found that patients who had shown a greater difference in activity in high-level visual processing areas during the face-response task showed the most improvement after therapy. Gabrieli says it's unclear why activity in brain regions involved with visual processing would be a good predictor of treatment outcome. One possibility is that patients who benefited more were those whose brains were already adept at segregating different types of experiences, Gabrieli says. The researchers are now planning a follow-up study to investigate whether brain scans can predict differences in response between cognitive behavioral therapy and drug treatment. "Right now, all by itself, we're just giving somebody encouraging or discouraging news about the likely outcome" of therapy, Gabrieli says. "The really valuable thing would be if it turns out to be differentially sensitive to different treatment choices." ### The research was funded by the Poitras Center for Affective Disorders Research and the National Institute of Mental Health. Written by Anne Trafton, MIT News Office

Targeted Behavioral Therapy Can Effectively Control Tics in Adults with Tourette Syndrome

A comprehensive behavioral intervention is more effective than supportive therapy and education in helping adults control the tics associated with Tourette syndrome, according to an NIMH-funded study published in the August 2012 issue of the Archives of General Psychiatry. The study follows a previous study involving children with the disorder, which showed similar results. Background Tourette syndrome (TS) is a chronic neurological disorder associated with motor or vocal tics that can be disruptive and difficult to control. Tics begin in childhood, typically peak in early adolescence and often decrease by adulthood. For some adults, the tics persist and can be difficult to control. Many individuals with TS describe an unwanted urge or sensation prior to the tic that is relieved by performing the tic. TS is commonly treated with an antipsychotic medication such as pimozide or risperidone. But these medications rarely eliminate tics entirely and can cause troubling side effects such as weight gain and sedation. Because of these adverse side effects, many patients decline or discontinue use of these medications. Until now, few large-scale studies have examined the effectiveness of behavioral interventions for TS. A team of investigators from Massachusetts General Hospital/Harvard Medical School; Yale University; University of Texas Health Science Center at San Antonio; University of California, Los Angeles; the University of Wisconsin-Milwaukee; Johns Hopkins Medical Institutions; and the Tourette Syndrome Association tested the effectiveness of a Comprehensive Behavioral Intervention for Tics (CBIT), a therapy based on habit reversal training that includes two concepts: Tic-awareness training, which teaches how to recognize early signs that a tic is about to occur, and Competing-response training, which teaches how to engage in a voluntary behavior that is physically incompatible with the impending tic. For example, a person feeling an urge to jerk his or her shoulder may be taught to tense arm muscles while pushing the elbow against the torso (a competing response). This combination of awareness training and competing response training is intended to disrupt the cycle of premonitory urge and performance of the tic. The researchers randomized 122 adults at three research centers to either CBIT or a control treatment that included supportive therapy and education about TS. Each group received eight sessions over a 10-week period. Those who responded to therapy were assessed three months and six months after the end of the study period to determine if the therapy’s benefits persisted. Results of the Study Overall, 38 percent of patients receiving CBIT showed significant symptom improvement compared to 6 percent receiving the control treatment. The results complement the earlier CBIT study in children, which found that 52 percent of the children who received CBIT showed significant symptom improvement compared to 18.5 percent receiving the control treatment.

About 62.5 percent of those who responded to CBIT in the trial returned for follow-up assessments at three and six months. About 80 percent of the returning participants continued to show a positive response to CBIT, indicating the treatment has enduring benefits for a significant group. In comparison, about 50 percent of those who responded to the control treatment returned for post-treatment assessment, and only about 25 percent of those continued to show benefits after six months. Significance Given the limited medication options for treating TS and the adverse effects associated with the antipsychotic medications, CBIT provides an alternative treatment to manage tics in children and adults. However, the positive response among adults was lower than among the children. The researchers suggest that people with tics that persist into adulthood may have a more chronic form of the disorder that is more difficult to treat. What’s Next Future research focused on CBIT may uncover the role of behavioral learning in reducing the involuntary movements and tics associated with TS. In the meantime, the researchers are working with the Tourette Syndrome Association and the Centers for Disease Control and Prevention to disseminate this intervention by offering training workshops to clinicians around the country social worker ceus Reference Wilhelm S, Peterson AL, Piacentini J, Woods DW, Deckersbach T, Sukhodolsky DG, Chang S, Liu H, Dziura J, Walkup JT, Scahill L. Randomized trial of behavior therapy for adults with Tourette syndrome. Archives of General Psychiatry. 2012 August.

Therapists phone it in and keep more patients

Telephone therapy retains more patients than face-to-face sessions and improves depression CHICAGO --- Phoning it in is more effective than the therapist's couch when it comes to keeping patients in psychotherapy. New Northwestern Medicine research shows patients who had therapy sessions provided over the phone were more likely to complete 18 weeks of treatment than those who had face-to-face sessions. The study, published in the June 6 issue of the Journal of the American Medical Association, is the first large trial to compare the benefits of face-to-face and telephone therapy. Phone therapy is a rapidly growing trend among therapists. About 85 percent of psychologists now deliver some of their services over the phone because competing demands, transportation time and other problems make it difficult for many patients to get to their offices social worker continuing education "Now therapists can make house calls," said David Mohr, the lead author and a professor of preventive medicine at Northwestern University Feinberg School of Medicine. "Our study found psychotherapy conveniently provided by telephone to patients wherever they are is effective and reduces dropout. This suggests these services now should be covered by insurance." While telephone therapy was as effective as face-to-face sessions in reducing depression during treatment, the improvement ebbed slightly six months after treatment ended compared to face-to-face therapy. The randomized control trial included 325 primary care patients with major depressive disorder. The results showed 20.9 percent of patients who had cognitive behavioral therapy over the phone dropped out compared to 32.7 percent for face-to-face therapy. Patients in both therapies showed equally good improvement in their depression when treatment ended. Six months after treatment ended, all patients remained much improved. However, patients who had the telephone therapy scored three points higher on a depression scale than those who had face-to-face sessions. "The three point difference is of questionable clinical significance but it raises the question whether some individuals are at risk of worsening after treatment with telephone therapy compared to face-to-face," Mohr said. It may be that the slight worsening seen in the telephone therapy after the end of treatment was because patients who had more mental health difficulties and who would have dropped out of face-to-face sessions were retained in telephone therapy, Mohr noted. Thus, this may not be a real finding. "But we can't rule out the possibility that it may be true and there is something about face-to-face treatment that creates better results for some people," Mohr said. "The physical presence of the therapist may be therapeutic in a way that helps some patients maintain their improvement in mood. There may be a unique quality about the human contact that increases resilience and maintains the skills learned to manage depression after treatment has ended." Mohr said he hopes the study results will encourage insurance providers including Medicare to reimburse telephone therapy sessions, which many companies currently don't cover. "There is good reason to reimburse these sessions," Mohr said. "Many people can't get to a therapist's office, but they want to talk to someone. Telephone therapy is highly effective and offers a solution to people with depression who otherwise would be left out." This is particularly true for disabled people or those who live where care is unavailable, such as in rural areas, he noted. Research shows people prefer talk therapy to antidepressant medication, but many quickly drop out of treatment or don't follow up on a referral from their primary care physicians, likely the result of obstacles that prevent them from getting to the therapist's office. ### Other Northwestern authors include: Joyce Ho, Jenna Duffecy, Michelle Nicole Burns, Ling Jin and Juned Siddique. This study was funded by the National Institute of Mental Health of the National Institutes of Health research grant NIMH R01-MH059708.

Phobia's effect on perception of feared object allows fear to persist

COLUMBUS, Ohio – The more afraid a person is of a spider, the bigger that individual perceives the spider to be, new research suggests. In the context of a fear of spiders, this warped perception doesn't necessarily interfere with daily living. But for individuals who are afraid of needles, for example, the conviction that needles are larger than they really are could lead people who fear injections to avoid getting the health care they need. A better understanding of how a phobia affects the perception of feared objects can help clinicians design more effective treatments for people who seek to overcome their fears, according to the researchers. In this study, participants who feared spiders were asked to undergo five encounters with live spiders – tarantulas, in fact – and then provide size estimates of the spiders after those encounters ended. The more afraid the participants said they were of the spiders, the larger they estimated the spiders had been. "If one is afraid of spiders, and by virtue of being afraid of spiders one tends to perceive spiders as bigger than they really are, that may feed the fear, foster that fear, and make it difficult to overcome," said Michael Vasey, professor of psychology at Ohio State University and lead author of the study. "When it comes to phobias, it's all about avoidance as a primary means of keeping oneself safe. As long as you avoid, you can't discover that you're wrong. And you're stuck. So to the extent that perceiving spiders as bigger than they really are fosters fear and avoidance, it then potentially is part of this cycle that feeds the phobia that leads to its persistence continuing education for social workers "We're trying to understand why phobias persist so we can better target treatments to change those reasons they persist." The study is published in a recent issue of the Journal of Anxiety Disorders. The researchers recruited 57 people who self-identified as having a spider phobia. Each participant then interacted at specific time points over a period of eight weeks with five different varieties of tarantulas varying in size from about 1 to 6 inches long. The spiders were contained in an uncovered glass tank. Participants began their encounters 12 feet from the tank and were asked to approach the spider. Once they were standing next to the tank, they were asked to guide the spider around the tank by touching it with an 8-inch probe, and later with a shorter probe. Throughout these encounters, researchers asked participants to report how afraid they were feeling on a scale of 0-100 according to an index of subjective units of distress. After the encounters, participants completed additional self-report measures of their specific fear of spiders, any panic symptoms they experienced during the encounters with the spiders, and thoughts about fear reduction and future spider encounters. Finally, the research participants estimated the size of the spiders – while no longer being able to see them – by drawing a single line on an index card indicating the length of the spider from the tips of its front legs to the tips of its back legs. An analysis of the results showed that higher average peak ratings of distress during the spider encounters were associated with estimates that the spiders were larger than they really were. Similar positive associations were seen between over-estimates of spider size and participants' higher average peak levels of anxiety, higher average numbers of panic symptoms and overall spider fear. These findings have been supported in later studies with broader samples of people with varying levels of fear of spiders. "It would appear from that result that fear is driving or altering the perception of the feared object, in this case a spider," said Vasey, also the director of research for the psychology department's Anxiety and Stress Disorders Clinic. "We already knew fear and anxiety alter thoughts about the feared thing. For example, the feared outcome is interpreted as being more likely than it really is. But this study shows that even perception is altered by fear. In this case, the feared spider is seen as being bigger. And that may serve as a maintaining factor for the fear." The approach tasks with the spiders are a classic example of exposure therapy, a common treatment for people with phobias. Though this therapy is known to be effective, scientists still do not fully understand why it works. And for some, the effects don't last – but it is difficult to predict who will have a relapse of fear, Vasey said. He and colleagues are studying these biased perceptions as well as attitudes with hopes that the new knowledge will enhance treatment for people with various phobias. The work suggests that fear not only alters one's perception of the feared thing, but also can influence a person's automatic attitude toward an object. Those who have developed an automatic negative attitude toward a feared object might have a harder time overcoming their fear. Though individuals with arachnophobia are unlikely to seek treatment, the use of spiders in this research was a convenient way to study the complex effects of fear on visual perception and how those effects might cause fear to persist, Vasey noted. "Ultimately, we are interested in identifying predictors of relapse so we can better measure when a person is done with treatment," he said. This work is supported by the National Institute of Mental Health. Co-authors include Michael Vilensky, Jacqueline Heath, Casaundra Harbaugh, Adam Buffington and Vasey's principal collaborator, Russell Fazio, all of Ohio State's Department of Psychology.