Search

Background. There is increasing literature on the unsatisfactory degree of remission that current therapeutic strategies yield in unipolar depression. The aims of this review were to survey the available literature on residual symptoms of depression, to introduce new targets for therapy and to outline a more stringent definition of recovery.Method. Studies were identified by using MEDLINE (English language articles published from 1967 to June 2006; keywords: recovery, remission, residual symptoms, sequential treatment, drugs and psychotherapy, related to depressive disorder and depression) and a manual search of the literature and Index Medicus for the years 1960-2006.Results. Most patients report residual symptoms despite apparently successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology. The concept of recovery should involve psychological well-being.Conclusions. Appraisal of subclinical symptomatology in depression has important implications for pathophysiological models of disease and relapse prevention. New therapeutic strategies for improving the level of remission, such as treatment on residual symptoms that progress to become prodromes of relapse, may yield more lasting benefits. [ABSTRACT FROM AUTHOR]

Background: The clinical value of the identification of mood disorders in patients with acute coronary syndrome (ACS) is well established. However, assessment based on DSM criteria presents some limitations. This study aimed to provide an innovative strategy for evaluating the spectrum of mood disturbances in ACS., Methods: A total of 288 patients with a first episode of ACS underwent interviews based on DSM-IV-TR criteria (major depressive disorder, minor depression, and dysthymia), Diagnostic Criteria for Psychosomatic Research-DCPR (demoralization and type A behavior), and the Clinical Interview for Depression-CID. Additional self-report inventories (psychological well-being and distress) were administered. A total of 100 consecutive patients who satisfied criteria for DSM-IV-TR depression or DCPR demoralization were enrolled in a randomized controlled trial on a sequential combination of cognitive-behavioral and well-being therapy (CBT/WBT) vs clinical management (CM) and reassessed up to 30-month post-intervention., Results: A total of 29.9% of patients showed a DSM-IV-TR depressive syndrome. Inclusion of demoralization and type A identified psychological distress in 58% of the sample. According to CID, reactivity to social environment, fatigue, depressed mood, and somatic anxiety were the most common symptoms. Somatic symptoms were significantly associated with DSM-IV-TR depression (fatigue and changes of appetite), whereas environmental reactivity with demoralization. Both depression and demoralization were associated with higher distress and lower well-being. Unlike CM, CBT/WBT was significantly associated with decrease of guilt, pessimism, fatigue, and early insomnia (CID)., Conclusions: The findings indicate that standard psychiatric approach identifies only a narrow part of mood disturbances affecting ACS patients. A more articulated assessment unravels specific clinical configurations that may entail prognostic and therapeutic implications.

Staging has been increasingly used in unipolar depression since its introduction in the nineties. Several models are available, but their differential features and implications are not completely clear. We systematically reviewed: (a) staging models of longitudinal development of unipolar depression; (b) staging models of treatment-resistant unipolar depression; (c) their applications. MEDLINE, PsycINFO, EMBASE, and Web of Science were examined according to PRISMA guidelines from inception to December 2021. Search terms were: 'stage/staging', combined using the Boolean 'AND' operator with 'psychiatric disorder/mental disorder/depressive/mood disorder'. A total of 169 studies were identified for inclusion: 18 described staging models or applications, 151 described treatment-resistant staging models or applications. Staging models of longitudinal development were found to play a key role in formulating sequential treatment, with particular reference to the use of psychotherapy after pharmacotherapy. Staging methods based on treatment resistance played a crucial role in setting entry criteria for randomized clinical trials and neurobiological investigations. Staging is part of clinimetrics, the science of clinical measurements, and its role can be enhanced by its association with other clinimetric strategies, such as repeated assessments, organization of problematic areas, and evaluation of phenomena that may affect responsiveness. In research, it may allow to identify more homogeneous populations in terms of treatment history that may diminish the likelihood of spurious results in comparisons. In clinical practice, the use of staging in a clinimetric perspective allows clinicians to make full use of the information that is available for an individual patient at a specific time.

Summary: We propose that discussions of benzodiazepines in the current psychiatric literature have become negatively biased and have strayed from the scientific evidence base. We advocate returning to the evidence in discussing benzodiazepines and adhering to clear definitions and conceptual rigour in commentary about them.

Objective: Assessment of mood in eating disorders (EDs) has important clinical implications, but the current standard psychiatric classification (DSM-5) has limitations. The aim of the current study is to broaden the evaluation of depressive symptomatology by providing a comprehensive and innovative assessment approach in EDs through instruments that capture clinical phenomena of demoralization, subclinical distress, and psychological well-being., Methods: Seventy-nine patients who met diagnostic criteria for EDs of the Diagnostic and Statistical Manual of Mental Disorders - Fifth edition (DSM-5) were evaluated for depressive symptoms through Paykel's Clinical Interview for Depression, the Structured Clinical Interview for DSM-5 for major depressive episode and persistent depressive disorder, and the Diagnostic Criteria for Psychosomatic Research (DCPR) interview for demoralization. Further, self-report inventories encompassing psychological well-being and distress were used., Results: Guilt, abnormal reactivity to social environment, and depressed mood were the most common depressive symptoms in the sample. DSM-defined depressive disorders were found in 55.7% of patients. The DCPR-demoralization criteria identified an additional 20.3% of the sample that would have been undetected with DSM criteria. Both DSM and DCPR diagnostic categories were associated with compromised psychological well-being and distress. Demoralization, unlike depression, was not associated with the severity of ED symptomatology., Conclusion: The findings indicate that a standard psychiatric approach, DSM-5-based, captures only a narrow part of the spectrum of mood disturbances affecting patients with EDs. A broadened clinimetric assessment unravels the presence of demoralization and yields clinical distinctions that may entail prognostic and therapeutic differences among patients who would be otherwise simply labeled as depressed.

The Diagnostic and Statistical of Mental Disorders, Fifth Edition (DSM-5) somatic symptom and related disorders chapter has a limited clinical utility. In addition to the problems that the single diagnostic rubrics and the deletion of the diagnosis of hypochondriasis entail, there are 2 major ambiguities: (1) the use of the term "somatic symptoms" reflects an ill-defined concept of somatization and (2) abnormal illness behavior is included in all diagnostic rubrics, but it is never conceptually defined. In the present review of the literature, we will attempt to approach the clinical issue from a different angle, by introducing the trans-diagnostic viewpoint of illness behavior and propose an alternative clinimetric classification system, based on the Diagnostic Criteria for Psychosomatic Research.

Background: Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope., Methods: We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected., Results: Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes., Conclusions: Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.

Background: The classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill., Method: A cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate., Results: Three clusters were identified: non-specific psychological distress, irritability and affective disturbances with somatization., Conclusions: Two-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR.

Background: Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD., Method: Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis., Results: Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659-0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674-1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463-0.912)., Conclusions: We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.

The clinical value of the current Diagnostic and Statistical Manual of Mental Disorders diagnosis of adjustment disorder is controversial. The aim of this article is to review the literature on adjustment disorder and to present suggestions for the improvement of this diagnostic category in future classification systems. The literature utilized for this review was retrieved by MEDLINE (1967 until May 2009) and was supplemented by a manual search of the literature. The analysis of the literature indicates that the diagnosis of adjustment disorder is not characterized by consistent clinical description and prognosis, adequate differentiation from other disorders, or specific psychometric and neurobiologic features. The spectrum of affective disturbances entailed by the diagnosis of adjustment disorder appears to be too broad. A major problem seems to lie in the fact that it is an exclusion diagnosis that overlaps with subthreshold manifestations of mood and anxiety disorders. More precise characterizations of stress-related disturbances are available.

Background: There is a paucity of long-term outcome studies of panic disorder that exceed a 2-year follow-up. The aim of the study was to evaluate the long-term follow-up of patients with panic disorder with agoraphobia treated according to a standardized protocol., Methods: A consecutive series of 200 patients satisfying the DSM-IV criteria for panic disorder with agoraphobia was treated in an out-patient clinic with behavioural methods based on exposure homework. One hundred and thirty-six patients became panic free after 12 sessions of psychotherapy and 132 were available for follow-up. A 2- to 14-year (median = 8 years) follow-up was performed. Survival analysis was employed to characterize the clinical course of patients., Results: Thirty-one of the 132 patients (23%) had a relapse of panic disorder at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 93.1 after 2 years, 82.4 after 5 years, 78.8 after 7 years and 62.1 after 10 years. Such probabilities increased with younger age, and in the absence of a personality disorder, of high pre-treatment levels of depressed mood, of residual agoraphobic avoidance after exposure, and of concurrent use of benzodiazepines and antidepressant drugs., Conclusions: The findings suggest that exposure treatment can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.

Background: There is very little information on long-term follow-up of social phobia., Methods: A consecutive series of 70 patients satisfying the DSM-IV criteria for social phobia was treated in an out-patient clinic with behavioural methods based on exposure homework. Forty-five patients were judged to be remitted after eight individual sessions of psychotherapy. A 2 to 12 year (median = 6 years) follow-up was performed. Survival analysis was selected to characterize the clinical course of patients. Assessments were performed before treatment, at the end of therapy, after 1 year, and subsequently on a yearly basis, and utilized selected items of Paykel's Clinical Interview for Depression., Results: Six of the 45 patients (13%) had a relapse of social phobia at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 98 after 2 years, 85 after 5 years and 85 after 10 years. Such probabilities increased in the absence of a personality disorder, of residual social phobic avoidance after exposure, and of concurrent use of benzodiazepines., Conclusions: The findings suggest that, even though one patient out of three is unable to complete treatment or does not benefit sufficiently from it, exposure treatment can provide lasting effects to the majority of patients with social phobia. Disappearance of residual, subclinical social phobic avoidance appears to be the target of treatment.

Background: Little is known about the interaction of life events with prodromal symptoms in bulimia nervosa., Methods: A semistructured research interview based on Paykel's Interview for Recent Life Events and on the Clinical Interview for Depression for eliciting prodromal symptoms was administered to 30 patients with bulimia nervosa and 30 healthy control subjects matched for sociodemographic variables., Results: Patients reported significantly more stressful life events than controls. Most of the patients reported prodromal symptoms. Anorexia, low self-esteem, depressed mood, anhedonia, generalized anxiety and irritability were the most common prodromal symptoms., Conclusions: The prodromal phase of bulimia nervosa was found to be characterized by a combination of prodromal symptoms of affective type and stressful life events. Their joint occurrence may increase vulnerability to bulimia nervosa.

Background: The aim of this review was to survey the available literature on prodromal and residual symptoms of unipolar major depression and bipolar disorder., Methods: Both a computerized (Medline) and a manual search of the literature were performed., Results: In a substantial proportion of patients with affective disorders a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon)., Conclusions: Appraisal of subclinical symptomatology in mood disorders has important implications for pathophysiological models of disease and relapse prevention. In depression, specific treatment of residual symptoms may improve long-term outcome, by acting on those residual symptoms that progress to become prodromes of relapse. In bipolar disorder, decrease of subclinical fluctuations and improvement of level of functioning by specific therapeutic strategies may add to the benefits provided by lithium prophylaxis.

Background: There is increasing awareness of the prognostic value of residual symptomatology in affective disorders and of the need for specific therapeutic strategies in this phase of illness. The aims of the study were to apply a novel, short-term psychotherapeutic approach for increasing well-being, based on Ryff's conceptual model, to remitted patients with affective disorders and to compare the results with those obtained with symptom-oriented cognitive behavioural strategies., Methods: Twenty patients with affective disorders (major depression, panic disorder with agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder) who had been successfully treated by behavioural or pharmacological methods were randomly assigned to a well-being enhancing therapeutic strategy (well-being therapy) or cognitive-behavioural treatment of residual symptoms., Results: Both well-being and cognitive-behavioural therapies were associated with a significant reduction of residual symptoms. However, a significant advantage of well-being therapy over cognitive-behavioural strategies was observed with observer-rated methods., Discussion: These preliminary results suggest the feasibility of well-being therapy in the residual stage of affective disorders. Further research should determine its value as a relapse-preventive strategy in specific mood and anxiety disorders.

Background: There are few long-term follow-up studies of panic disorder treatments, particularly when patients have been treated by behavioural methods only and have recovered., Method: 110 consecutive patients satisfying the DSM-III-R criteria for panic disorder with agoraphobia were treated in an out-patient clinic with behavioural methods based on exposure. After 12 sessions of psychotherapy, 81 patients became panic-free. A 2-9 year follow-up was available. Survival analysis was employed to characterise the clinical course of patients. Regular assessments by a clinical psychologist were based on the Clinical Interview for Depression., Results: The estimated cumulative percentage of patients remaining in remission was 96.1% for at least two years, 77.6% for at least five years, and 67.4% for at least seven years. These outcomes greatly improved in the absence of a personality disorder or residual agoraphobia after treatment., Conclusions: The findings suggest that, even though one patient in four is unable to complete treatment or does not benefit sufficiently from it, exposure treatment can provide lasting relief for the majority of patients. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.