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Recent research: two papers on mindfulness, two on insomnia & two on antidepressants in pregnancy

Here are six recently published research papers.  Barnhofer and colleagues report on encouraging results using mindfulness-based cognitive therapy (MBCT) for sufferers from chronic-recurrent depression while they are still depressed.  The three major studies published already have used MBCT for recurrent depression while the sufferers are reasonably well.  The next step will clearly be a fuller randomized controlled trial.  Heeren and colleagues report on the how MBCT acts to reduce overgeneral autobiographical memoriy in formerly depressed patients. 

Archer and colleagues describe the successful development and assessment of a group-based cognitive behavioural intervention for sleep problems.  Participants' satisfaction ratings with the training were very high and there were very encouraging reductions in their sleep problems and depressive symptoms.  Morin and coworkers also report on CBT for sleep problems, this time singly or combined with sleep medication.  They concluded that "In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT."

Wisner and colleagues report on an important prospective observational study of the adverse effects on mother and child of either not treating depression during pregnancy or of treating with SSRI antidepressants.  The message is that both continuous untreated depression over the course of the pregnancy and the use of SSRI's throughout the pregnancy both led to similarly increased preterm birth rates.  The freely downloadable full text accompanying editorial by Parry discusses these and related findings and comes down on the side of using antidepressants rather than letting a pregnant woman go right through her pregancy with untreated depression. This obviously begs the question as to why non-pharmacological approaches like psychotherapy, exercise and phototherapy weren't tried instead.

Barnhofer, T., C. Crane, et al. (2009). "Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study." Behaviour Research and Therapy 47(5): 366-373. [Abstract/Full Text]
This pilot study investigated the effectiveness of Mindfulness-Based Cognitive Therapy (MBCT), a treatment combining mindfulness meditation and interventions taken from cognitive therapy, in patients suffering from chronic-recurrent depression. Currently symptomatic patients with at least three previous episodes of depression and a history of suicidal ideation were randomly allocated to receive either MBCT delivered in addition to treatment-as-usual (TAU; N = 14 completers) or TAU alone (N = 14 completers). Depressive symptoms and diagnostic status were assessed before and after treatment phase. Self-reported symptoms of depression decreased from severe to mild levels in the MBCT group while there was no significant change in the TAU group. Similarly, numbers of patients meeting full criteria for depression decreased significantly more in the MBCT group than in the TAU group. Results are consistent with previous uncontrolled studies. Although based on a small sample and, therefore, limited in their generalizability, they provide further preliminary evidence that MBCT can be used to successfully reduce current symptoms in patients suffering from a protracted course of the disorder.

Heeren, A., N. Van Broeck, et al. (2009). "The effects of mindfulness on executive processes and autobiographical memory specificity." Behaviour Research and Therapy 47(5): 403-409. [Abstract/Full Text]
Previous studies have found that mindfulness training reduces overgeneral memories and increases autobiographical memory specificity (e.g., [Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Soulsby, J. (2000). Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology, 109, 150-155]). However, little work has investigated the mechanisms underlying this effect. The present study explored the role of executive processes as a mediator of MBCT effects in an unselected sample. An autobiographical memory task, a cognitive inhibition task, a motor inhibition task, a cognitive flexibility task and a motor flexibility task were administered before and after intervention. Compared to matched controls, MBCT participants showed increased autobiographical memory specificity, decreased overgenerality, and improved cognitive flexibility capacity and capacity to inhibit cognitive prepotent responses. Mediational analyses indicated that changes in cognitive flexibility partially mediate the impact of MBCT on overgeneral memories. Results are discussed in terms of Conway's [2005. Memory and the self. Journal of Memory and Language, 53, 594-628] autobiographical memory model.

Archer, M., J. S. L. Brown, et al. (2009). "The Development and Evaluation of a Large-Scale Self-Referral CBT-I Intervention for Men Who Have Insomnia: An Exploratory Study." Behavioural and Cognitive Psychotherapy 37(03): 239-248.  [Abstract/Full Text]
Background: Whilst effective psychological treatments such as CBT-I have been developed for insomnia, few services provide CBT-I and awareness of CBT-I is low among referrers. In addition, men tend to seek help less frequently for their insomnia than women. This paper describes the development and evaluation of psycho-educational CBT-I workshops, each for up to 25 people, and designed to be acceptable to men. Method: The CBT-I programme was based on Morin and Espie (2003), and adapted into a self-referral one-day workshop format designed specifically to improve access. Workshops were held on Saturdays in leisure centres. A one group pretest-posttest design was used and assessments were collected before and 6 weeks after each workshop. Over a 6-month period, 74 men self-referred, and attended the Introductory Talks preceding the workshops. Of these, 49.3% had never sought help from their GP, 66.2% suffered from clinical insomnia (ISI) and 61.6% were experiencing elevated depression symptoms (BDI over 10). Results: At follow-up, the workshops were found to be effective in reducing insomnia and depression. Satisfaction ratings with the workshops were very high. Conclusions: Given these promising results, further work is now proposed for a larger controlled study with a longer-term follow-up.

Morin, C. M., A. Vallieres, et al. (2009). "Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent Insomnia: A Randomized Controlled Trial." JAMA 301(19): 2005-2015.  [Abstract/Full Text]
Context Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome. Objectives To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome. Design, Setting, and Patients Prospective, randomized controlled trial involving 2-stage therapy for 160 adults with persistent insomnia treated at a university hospital sleep center in Canada between January 2002 and April 2005. Interventions Participants received CBT alone or CBT plus 10 mg/d (taken at bedtime) of zolpidem for an initial 6-week therapy, followed by extended 6-month therapy. Patients initially treated with CBT attended monthly maintenance CBT for 6 months or received no additional treatment and those initially treated with combined therapy (CBT plus 10 mg/d of zolpidem) continued with CBT plus intermittent use of zolpidem or CBT only. Main Outcome Measures Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary outcomes); treatment response and remission rates derived from the Insomnia Severity Index (secondary outcomes). Results Cognitive behavioral therapy used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P<.001); a larger increase of sleep time was obtained with the combined approach (P = .04). Both CBT alone and CBT plus zolpidem produced similar rates of treatment responders (60% [45/75] vs 61% [45/74], respectively; P = .84) and treatment remissions (39% [29/75] vs 44% [33/74], respectively; P = .52) with the 6-week acute treatment, but combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P = .05). The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the 6-month follow-up compared with patients who continued to take zolpidem during extended therapy (68% [20/30] vs 42% [12/29]; P = .04). Conclusion In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT.

Wisner, K. L., D. K. Y. Sit, et al. (2009). "Major Depression and Antidepressant Treatment: Impact on Pregnancy and Neonatal Outcomes." Am J Psychiatry 166(5): 557-566.  [Abstract/Full Text]
OBJECTIVE: Selective serotonin reuptake inhibitor (SSRI) use during pregnancy incurs a low absolute risk for major malformations; however, other adverse outcomes have been reported. Major depression also affects reproductive outcomes. This study examined whether 1) minor physical anomalies, 2) maternal weight gain and infant birth weight, 3) preterm birth, and 4) neonatal adaptation are affected by SSRI or depression exposure. METHOD: This prospective observational investigation included maternal assessments at 20, 30, and 36 weeks of gestation. Neonatal outcomes were obtained by blinded review of delivery records and infant examinations. Pregnant women (N=238) were categorized into three mutually exclusive exposure groups: 1) no SSRI, no depression (N=131); 2) SSRI exposure (N=71), either continuous (N=48) or partial (N=23); and 3) major depressive disorder (N=36), either continuous (N=14) or partial (N=22). The mean depressive symptom level of the group with continuous depression and no SSRI exposure was significantly greater than for all other groups, demonstrating the expected treatment effect of SSRIs. Main outcomes were minor physical anomalies, maternal weight gain, infant birth weight, pregnancy duration, and neonatal characteristics. RESULTS: Infants exposed to either SSRIs or depression continuously across gestation were more likely to be born preterm than infants with partial or no exposure. Neither SSRI nor depression exposure increased risk for minor physical anomalies or reduced maternal weight gain. Mean infant birth weights were equivalent. Other neonatal outcomes were similar, except 5-minute Apgar scores. CONCLUSIONS: For depressed pregnant women, both continuous SSRI exposure and continuous untreated depression were associated with preterm birth rates exceeding 20%.

Parry, B. L. (2009). "Assessing Risk and Benefit: To Treat or Not to Treat Major Depression During Pregnancy With Antidepressant Medication." Am J Psychiatry 166(5): 512-514.  [Free Full Text]
To treat or not to treat major depression during pregnancy with antidepressant medication is a critical question to clinicians concerned with the welfare of the mother, on the one hand, and the healthy development of the infant, on the other. The patient and her psychiatrist face a dilemma: untreated depression in the mother can impair the neurocognitive development of the infant and result in preterm birth; medication use during pregnancy also can impact the fetus and has been associated with an increased risk of preterm birth ... all things considered, on the basis of the findings from the methodologically sound and rigorous study of Wisner et al. and the evidence available from long-term studies, this author thinks that the risk of untreated major depression outweighs the risk of effects of SSRI treatment on neonatal outcomes. We need to consider not just short-term, but also long-term, consequences of our decisions. In addition to focusing on the child, the clinician needs to consider the risk of untreated major depression in the mother. These risks include exacerbation or recurrence of her underlying psychiatric illness, which can have adverse effects on her morbidity and mortality and can impair not only her functioning, but that of her family and other children under her care (Freely downloadable in full text).


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