Целесообразность потенцирования атипичными антипсихотиками при депрессии

For the study, researchers reviewed 14 previous randomized clinical trials in which the combined use of an antidepressant and an antipsychotic medication were compared to the use of an antidepressant with a placebo.

The medications investigated in the studies were aripiprazole (Abilify), olanzapine/fluoxetine (Symbyax), quetiapine (Seroquel) and risperidone (Risperdal).

The results showed a small benefit with antipsychotic use on relieving the symptoms of depression. But when the researchers looked for a more meaningful outcome — whether the patients’ quality of life had improved — no benefit was found.

...

Antipsychotic medications were associated, however, with more negative side effects, including weight gain, akathisia (a feeling of restlessness), sleepiness and abnormal results from cholesterol and other metabolic-related laboratory tests.

In another study, British researchers found strong evidence that engaging in talk therapy was an effective add-on to antidepressants.

The findings showed that antidepressant-resistant patients who received cognitive behavioral therapy in addition to an antidepressant experienced both a significant reduction in their depression and a significant improvement in their quality of life.

Adding Antipsychotic Meds to Antidepressants Shows Risk, Little Benefit

Ранняя диагностика шизофрении

The study of the preventive potential of pre-onset or psychosis-risk intervention requires a common and reliable diagnosis of a risk syndrome with which to construct samples that we can track and treat and that can be replicated by independent clinical investigators. Yung and McGorry10 created the Comprehensive Assessment of At-Risk Mental States (CAARMS), a structured interview for diagnosing the psychosis-risk syndrome. Our team at Yale developed the Structured Interview for Psychosis-Risk Syndromes (SIPS); this tool is used to rate the severity/frequency of key prodromal symptoms and can be used to determine the presence or absence of several psychosis-risk syndromes. It can also be used to estimate the severity of these symptoms and syndromes, including the boundary of transition from the prodrome to psychosis, called “conversion.”
The interrater reliability of the SIPS is satisfactory. Moreover, the SIPS has proved to be a valid predictor of psychosis insofar as psychosis developed over the next 2.5 years in approximately 33% of a large sample of treatment-seeking persons meeting SIPS criteria. In essence, approximately 1 of 3 persons who met an SIPS prodromal diagnosis became psychotic, which amounts to a risk for psychosis that is more than 400 times the risk for the average individual. Some of the remaining two-thirds of the sample who met an SIPS prodromal diagnosis and in whom psychosis did not develop remained prodromally symptomatic and eventually met criteria for schizotypal personality disorder; in others, Axis I disorders, such as depression, developed; and in many, prodromal symptoms remitted with time without sequelae (J. Addington et al, unpublished data, 2010).

Treatment research in psychosis risk has just begun, and initial findings show promise. Combined antipsychotic (risperidone) and individual psychotherapy, antipsychotic therapy alone (olanzapine), and psychotherapy (cognitive-behavioral therapy) alone all show that onset of psychosis in prodromal samples can be delayed, but often with substantial adverse effects (eg, weight gain with olanzapine). Most recently, a randomized trial of v-3 fatty acids delayed onset of psychosis with virtually no adverse effects. In this study, the risk to benefit ratio is remarkably good, and if the results can be replicated, they should essentially eliminate concerns about untoward adverse effects in false-positive cases. Overall, however, many more treatment studies are needed before integrated guidelines can be formulated.

Early Antecedents and Detection of Schizophrenia

Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence

Поддерживающая терапия в комбинации с психосоциальным вмешательством

Xiaofeng Guo, M.D., and Jinguo Zhai, M.D., and colleagues evaluated this combination of therapies in 1,268 patients with early-stage schizophrenia treated from 2005 to 2007. A total of 633 were randomly assigned to receive schizophrenia drugs plus a psychosocial intervention involving 48 one-hour group sessions.

The psychosocial intervention included four evidence-based practices: psychoeducation (instruction for families and caregivers about mental illness), family intervention (teaching coping and socializing skills), skills training and cognitive behavioral therapy.

The other 635 patients received medication alone.

Rates of treatment discontinuation or change were 32.8 percent in the combined treatment group, compared with 46.8 percent in the medication-only group. The risk of relapse was lower among patients in the combination group, occurring in 14.6 percent of patients in that group and 22.5 percent of patients in the medication-only group.

The combined treatment group also exhibited greater improvements in insight, social functioning, activities of daily living and on four domains of quality of life, and a significantly higher proportion of them were employed or received education. There were no significant differences in either frequency or type of adverse events between the groups.

Early Meds, Counseling Aid Schizophrenia

Когнитивно-поведенческая терапия психозов

Beyond Antipsychotics: Using Cognitive Behavioral Therapy for Psychosis

Нелекарственные методы лечения инсомнии

Stimulus control therapy. Bootzin et al5 first evaluated stimulus control therapy for conditioned insomnia (subsequently identified as primary insomnia). This therapy’s goal is to interrupt the conditioned activation that occurs at bedtime. Patients are instructed to:

*

go to bed when sleepy
*

remain in bed for no more than 10 minutes (20 minutes if elderly) without sleeping
*

if unable to sleep, get up, do something boring, and return to bed only when sleepy
*

repeat getting up and returning as frequently as necessary until sleep onset.

For the first 2 weeks of stimulus control therapy, patients are required to self-monitor their sleep behaviors using a sleep diary. Stimulus control therapy is beneficial for primary insomnia and insomnia related to anxious preoccupation. About 70% of patients with conditioned insomnia will improve using stimulus control therapy,4 but it is not clear whether the primary effective intervention is:

*

patients dissociating conditioned responses at bedtime, or
*

the inevitable sleep restriction caused by getting out of bed.

Relaxation training. Progressive muscle relaxation is a common behavioral treatment of insomnia. Patients learn to tense and then relax individual muscles, beginning at the feet or head and working their way up or down the body. Patients are taught the difference between tension and relaxation to facilitate a relaxation response at bedtime. Another method is the body scanning technique, in which the patient “talks” to each body part, telling it to “relax… relax… relax.”

Relaxation training is predicated on the belief that insomnia is caused by somatized tension and psychophysiologic arousal. The greatest challenge to effective relaxation training is that patients need extensive daytime practice before they can bring the method to the bedroom.

Remind patients that “practice makes perfect.” Therapists often instruct patients to start practicing their relaxation method during the day while self-monitoring by sleep diary and restricting time in bed at night.2

CBTi is the most extensively investigated nonpharmacologic therapy for insomnia.6 It has been used to effectively manage comorbid insomnia in patients with psychiatric disorders,7,8 such as depression,9 generalized anxiety,10 and alcohol dependence,11 as well as those with breast cancer,12 traumatic brain injury,13 and fibromyalgia.14 Age does not appear to be a limitation; research trials show the technique is effective in elderly patients.15

CBTi incorporates cognitive strategies and behavioral interventions to improve sleep quality. Patient self-monitoring with sleep diaries and worksheets is essential.

CBTi commonly is provided in 5 to 8 sessions over 8 to 12 weeks, although studies have described abbreviated practices that used 2 sessions16 and CBTi delivered over the Internet.17 Highly trained clinical psychologists are at the forefront of therapy, but counselors and nurses in primary care settings have administered CBTi.18 For primary insomnia, CBTi is superior in efficacy to pharmacotherapy:

*

as initial treatment19
*

for long-term management4
*

in assisting discontinuation of hypnotic medication.20

Put your patients to sleep: Useful nondrug strategies for chronic insomnia

Рекомендации по лечению инсомнии и других расстройств сна

Recommendations for Diagnosis and Treatment

Specific evidence-based recommendations for diagnosis and treatment of insomnia and other sleep disorders, and their accompanying level of evidence rating, are as follows:

* The diagnosis of insomnia is primarily based on complaints provided in the clinical interview by the patient, family, and/or caregiver, ideally corroborated by a patient diary (level of evidence, A).
* Referral to a specialist sleep center may be indicated for other tests in some cases, such as actigraphy for differential diagnosis of circadian rhythm disorder (level of evidence, A), polysomnography for suspected parasomnia or other primary sleep disorder (level of evidence, A), or in the case of treatment failure (level of evidence, D).
* Insomnia should be treated because it impairs quality of life and many areas of functioning and is associated with an increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A). Treatment goals are to reduce distress and to improve daytime function. Choice of treatment modality is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
* For chronic insomnia, cognitive behavioral therapy (CBT)-based treatment packages are effective and should be offered to patients as a first-line treatment (level of evidence, A). CBT, which may include sleep restriction and stimulus control, should be made available in more settings.
* When prescribing hypnotic drug treatment, clinicians need to consider efficacy, safety, and duration of action (level of evidence, A). Other issues to consider may include previous efficacy or adverse effects of the drug and history of substance abuse or dependence (level of evidence, D).
* Recommendations for long-term hypnotic drug treatment are to use it as clinically indicated (level of evidence, A). To discontinue long-term hypnotic drug therapy, intermittent use should first be attempted if feasible. Depending on ongoing life circumstances and patient consent, discontinuation should be attempted every 3 to 6 months or at regular intervals (level of evidence, D). During taper of long-term hypnotic drug treatment, CBT improves outcome (level of evidence, A).
* When using antidepressants, clinicians should apply their knowledge of pharmacology (level of evidence, A). When there is a comorbid mood disorder, antidepressants should be used at therapeutic doses (level of evidence, A). However, clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
* Because of frequent adverse effects of antipsychotic drugs, as well as a few reports of abuse, there is no indication for use as first-line treatment of insomnia or other sleep disorders (level of evidence, D).
* Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia (level of evidence, D).

New Guidelines Issued for Insomnia and Other Sleep Disorders

Фенелзин и когнитивно-поведенческая терапия в лечении социофобий

Patients with social phobia respond well to phenelzine, especially when combined with psychotherapy.

Concerns about drug and food interactions and the ease of use of newer antidepressants have so decreased the popularity of monoamine oxidase inhibitors (MAOIs) that psychiatrists can complete residency without ever using them. This study, completed almost 10 years ago, examined the effectiveness of the prototypical MAOI phenelzine, alone or combined with group cognitive-behavioral therapy (GCBT), in treating 128 patients with social anxiety disorder meeting DSM-IV criteria.

In the acute phase, patients were randomized to phenelzine (mean, 66 mg/day), weekly GCBT, phenelzine in a similar dose (mean, 62 mg/day) combined with GCBT, or pill placebo for 12 weeks. Combined treatment and phenelzine alone (but not GCBT alone) produced significantly more improvement at 12 weeks than placebo by several measures. Effect sizes varied with the measure but generally ranged between 0.28 and 1.05 for combined treatment, 0.07 to 0.60 for phenelzine, and 0.06 to 0.36 for GCBT.

In the continuation phase, patients who improved continued their treatments at a decreased frequency through week 24. Response rates were 78% for combined treatment, 53% for GCBT, 49% for phenelzine, and 33% for placebo (remission rates, 53%, 24%, 26%, and 15%, respectively). Results from a 28-week maintenance phase and a 12-month naturalistic follow-up were not reported.

Comment: By several measures, combination treatment outperformed either MAOI or psychotherapy alone. The most likely explanation for the additive effect is that the antidepressant facilitated exposure by reducing anxiety and arousal in social and performance situations, while CBT helped patients to integrate the gains promoted by the antidepressant. The latest generation of psychiatrists should bear in mind that even MAOIs that were available 10 years ago are still effective for social anxiety and atypical depression. Insurers should pay attention to the synergistic effects of medications and psychotherapy in this and other disorders.

— Steven Dubovsky, MD
Published in Journal Watch Psychiatry April 5, 201