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Recent research: CBT, insomnia & depression, GP visits & health anxiety, desensitization & medication, agoraphobia & panic

Manber, R., J. D. Edinger, et al. (2008). "Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia." Sleep 31(4): 489-95.  [PubMed]
                STUDY OBJECTIVE: Insomnia impacts the course of major depressive disorder (MDD), hinders response to treatment, and increases risk for depressive relapse. This study is an initial evaluation of adding cognitive behavioral therapy for insomnia (CBTI) to the antidepressant medication escitalopram (EsCIT) in individuals with both disorders. DESIGN AND SETTING: A randomized, controlled, pilot study in a single academic medical center. PARTICIPANTS: 30 individuals (61% female, mean age 35 +/- 18) with MDD and insomnia. INTERVENTIONS: EsCIT and 7 individual therapy sessions of CBTI or CTRL (quasi-desensitization). Measurements and results: Depression was assessed with the HRSD17 and the depression portion of the SCID, administered by raters masked to treatment assignment, at baseline and after 2, 4, 6, 8, and 12 weeks of treatment. The primary outcome was remission of MDD at study exit, which required both an HRSD17 score < or =7 and absence of the 2 core symptoms of MDD. Sleep was assessed with the insomnia severity index (ISI), daily sleep diaries, and actigraphy. EsCIT + CBTI resulted in a higher rate of remission of depression (61.5%) than EsCIT + CTRL (33.3%). EsCIT + CBTI was also associated with a greater remission from insomnia (50.0%) than EsCIT + CTRL (7.7%) and larger improvement in all diary and actigraphy measures of sleep, except for total sleep time. CONCLUSIONS: This pilot study provides evidence that augmenting an antidepressant medication with a brief, symptom focused, cognitive-behavioral therapy for insomnia is promising for individuals with MDD and comorbid insomnia in terms of alleviating both depression and insomnia.

Mewes, R., W. Rief, et al. (2008). "Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population." Gen Hosp Psychiatry 30(4): 349-55.  [PubMed]  
                OBJECTIVE: Somatization is related to elevated health care utilization (HCU) and high health care costs. However, it is unclear whether HCU in somatizers and nonsomatizers in the general population is determined by existing symptoms or by lower thresholds for doctor visits. METHOD: A representative sample of the German general population (N=2510) was screened for psychopathology and HCU in the prior 12 months. The sample was subdivided into somatizers (n=712) and controls (n=1796), using the Patient Health Questionnaire (PHQ-15). A general tendency to visit doctors even for minor reasons was assessed. Demographic and psychopathological variables were additionally entered into regression analyses to predict HCU for the whole investigated sample and the two subsamples. RESULTS: Higher somatization, unemployment or retirement, a lower decision threshold for doctor visits and higher posttraumatic symptomatology were consistent and unique positive predictors of HCU in the prior 12 months. CONCLUSION: Not only symptoms per se but also a lower decision threshold for doctor visits contribute to increased HCU. Psychopathological and demographic variables can further predict HCU in somatizing persons and controls. Although somatization and reduced thresholds for doctor visits are associated, they have to be distinguished from each other and contribute independently to increased costs.

Powers, M. B., J. A. Smits, et al. (2008). "The effect of attributional processes concerning medication taking on return of fear." J Consult Clin Psychol 76(3): 478-90.  [PubMed
                In this investigation, the authors examined the effect of attributional processes concerning medication taking on return of fear following exposure-based treatment. Participants (87% undergraduate students and 13% community volunteers) displaying marked claustrophobic fear (N = 95) were randomly allocated to a waitlist condition, a psychological placebo condition, a 1-session exposure-based treatment, or the same exposure treatment given in conjunction with an inactive pill. Attributions concerning medication taking were manipulated by further randomly assigning participants in the exposure-based treatment plus pill condition to 1 of 3 instructional sets immediately following treatment completion and posttreatment assessment: (1) The pill was described as a sedating herb that likely made exposure treatment easier; (2) the pill was described as a stimulating herb that likely made exposure treatment more difficult; or (3) the pill was described as a placebo that had no effect on exposure treatment. Return of fear rates for the 3 conditions were 39%, 0%, and 0%, respectively. Moreover, the deleterious effects of the sedation instructions were mediated by reduced self-efficacy. These findings highlight the importance of assessing patient attributions regarding the improvements achieved with combined exposure-based and pharmacological treatments for anxiety disorders.

Wittchen, H. U., A. Nocon, et al. (2008). "Agoraphobia and panic. Prospective-longitudinal relations suggest a rethinking of diagnostic concepts." Psychother Psychosom 77(3): 147-57.  [PubMed]
                BACKGROUND: The relationship of panic attacks (PA), panic disorder (PD) and agoraphobia (AG) is controversial. The aim of the current study is to prospectively examine the 10-year natural course of PA, PD and AG in the first three decades of life, their stability and their reciprocal transitions. METHODS: DSM-IV syndromes were assessed via Composite International Diagnostic Interview - Munich version in a 10-year prospective-longitudinal community study of 3,021 subjects aged 14-24 years at baseline. RESULTS: (1) Incidence patterns for PA (9.4%), PD (with and without AG: 3.4%) and AG (5.3%) revealed differences in age of onset, incidence risk and gender differentiation. (2) Temporally primary PA and PD revealed only a moderately increased risk for subsequent onset of AG, and primary AG had an even lower risk for subsequent PA and PD. (3) In strictly prospective analyses, all baseline groups (PA, PD, AG) had low remission rates (0-23%). Baseline PD with AG or AG with PA were more likely to have follow-up AG, PA and other anxiety disorders and more frequent complications (impairment, disability, help-seeking, comorbidity) as compared to PD without AG and AG without PA. CONCLUSIONS: Differences in incidence patterns, syndrome progression and outcome, and syndrome stability over time indicate that AG exists as a clinically significant phobic condition independent of PD. The majority of agoraphobic subjects in this community sample never experienced PA, calling into question the current pathogenic assumptions underlying the classification of AG as merely a consequence of panic. The findings point to the necessity of rethinking diagnostic concepts and DSM diagnostic hierarchies.

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