In This Issue
The risk of relapse in children and adolescents with depression after a successful response to antidepressant medication is decreased by adding cognitive-behavioral therapy (CBT) during continuation pharmacotherapy. The rates of relapse in the 30-week continuation treatment period reported by Kennard et al. (p. Original article: 1083) were 9% for fluoxetine plus CBT versus 27% for fluoxetine alone (figure). The time to remission did not differ between groups, however. Applying CBT along with successful antidepressant treatment reduces the number of sessions needed, and thereby cost, but as noted by Birmaher in an editorial (p. Original article: 1031), youths who have already improved with an antidepressant may not be interested in starting psychotherapy.
Mood stabilizers protect against an antidepressant-induced switch to mania in depressed patients with bipolar I disorder, according to an analysis of a Swedish national database. Viktorin et al. (CME, p. Original article: 1067) calculated the risks of mania before and after the start of antidepressant treatment. In patients who began antidepressant-only treatment, manic episodes increased, but they decreased in patients starting antidepressant treatment while also taking a mood stabilizer. The editorial by Vieta (p. Original article: 1023) raises the related question of antidepressant efficacy for bipolar depression, citing the weak evidence base.
Tapered discontinuation or dosage reduction is the first-line treatment for severe glucocorticoid-induced psychological, behavioral, or cognitive disorders—such as mania, depression, panic disorder, suicidal behavior, or delirium or confusion. Patients should be monitored for depression and cognitive problems during the taper, caution Judd et al. (p. Original article: 1045). In addition, glucocorticoid-induced mania and depression can be treated with lithium and SSRI antidepressants, respectively. Glucocorticoid-induced delirium appears to respond to haloperidol or atypical antipsychotics. Prophylactic lamotrigine can reduce memory problems, and prophylactic treatment should also be considered for patients with neurological disorders involving mood or cognitive disturbance. Greater risk of glucocorticoid-induced neuropsychiatric problems is associated with higher dosage, long-term treatment, greater patient age, and past history of a neuropsychiatric disorder during glucocorticoid treatment.
Exploring the patient-therapist relationship in psychodynamic psychotherapy appears to be most helpful for female patients with difficult interpersonal relationships or severe personality pathology. Studies reviewed by Høglend (p. Original article: 1056) indicate that transference work is an active therapeutic ingredient and that transference-based treatments have more benefit than other treatments for personality functioning. Transference interventions may have negative effects if used too frequently or with patients having more mature relationships.
Long-term results of cognitive-behavioral therapy (CBT) and psychodynamic therapy are similar in patients with social anxiety disorder. Leichsenring et al. (CME, p. Original article: 1074) found no differences at 6, 12, or 24 months after the end of treatment. The remission rate for CBT was higher immediately after treatment (Am J Psychiatry 2013; 170:759–767), but patients in the dynamic therapy group continued to improve after the intervention. In an editorial, Clarkin (p. Original article: 1027) describes how the two therapies approach the same pathology, e.g., negative self-image, in different ways, and the review by Høglend (p. Original article: 1056) explores the patient-therapist relationship.
