In This Issue

Psychotherapy in Depression

According to an analysis by Thase et al. (p. Original article: 739 ) from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, outcomes for cognitive therapy as a second-step treatment, as augmentation or as an alternative to medication, were equivalent to those for medication. Patients who discontinued citalopram in the first treatment phase were randomly assigned to a different treatment or to citalopram plus an additional treatment. Cognitive therapy was received by 100 patients, either alone or combined with citalopram. Although cognitive therapy produced remission more slowly than medication, side effects were fewer. Random assignment in this STAR*D level was based on each patient’s treatment preferences, and only 26% of the patients accepted cognitive therapy as an option. Wisniewski et al. (p. Original article: 753 ) found that acceptance increased with greater education and with a family history of a mood disorder. Patients with panic disorder were less likely to accept cognitive therapy. Finding the minimum frequency of interpersonal psychotherapy needed to maintain remission in women with recurrent depression was the goal of Frank et al. (p. Original article: 761 ). Surprisingly, one session per month was just as effective for maintenance treatment as weekly or twice-monthly sessions. A difference in recurrence was found, however, between women who had received only psychotherapy before remission (26%) and those who had required addition of an antidepressant (50%). For patients hospitalized with severe depression, adding intensive psychotherapy to drug treatment produced a 70% response rate, compared to 51% for a group treated with medication plus intensive clinical management. In addition, Schramm et al. (p. Original article: 768 ) found that the rates of sustained response 12 months later were 67% and 36%, respectively. The higher rates were achieved with interpersonal psychotherapy, which focuses on interpersonal life events and social roles. These findings are reviewed in an editorial by Dr. Myrna Weissman on p. Original article: 693 .

Antidepressant vs. Psychotherapy: Effects on Brain Metabolism

Depressed patients who responded to venlafaxine and those who responded to cognitive behavior therapy showed both similarities and differences in their changes in brain metabolism. Kennedy et al. (CME, p. Original article: 778 ) report that over 16 weeks, responders to both treatments had reductions in several prefrontal regions. However, the two groups differed in other brain areas. Increases in the anterior cingulate with cognitive therapy and decreases in subgenual cingulate with velafaxine replicate an earlier report that compared cognitive therapy with paroxetine. Dr. Mary Phillips discusses these findings in an editorial on p. Original article: 697 .

Stepped Care With Buprenorphine Equals Standard Methadone Maintenance

Buprenorphine’s advantages over methadone for treating heroin dependence include both its lower risk of overdose and its approval for office-based use. It is not effective for all patients, however. Kakko et al. (CME, p. Original article: 797 ) describe a flexible program that began with a standard dose of a buprenorphine/naloxone combination and allowed dose increases and, if necessary, a switch to methadone. Of 37 patients, 17 took buprenorphine throughout and 20 required a switch to methadone. The 6-month completion rate was 77%, compared to 79% for a group receiving conventional methadone maintenance. Proportions of drug-free urine samples were also similar. Dr. Kathleen Brady comments in an editorial on p. Original article: 702 .

Inherited Deficits in Schizophrenia

Two studies identified the heritability of neurophysiological and neurocognitive deficits with schizophrenia as potential endophenotypes for future genetic studies. A twin study by Hall et al. (p. Original article: 804 ) identified two aspects of EEG evoked responses—P50 inhibition and P300 amplitude—that share substantial genetic influences with schizophrenia. The effects of environment were not significant. In a multigenerational study of families with multiple cases of schizophrenia, Gur et al. (p. Original article: 813 ) found several measures of memory, mental processing, and attention that were genetically linked to schizophrenia. For some measures, patients could perform the mental tasks, but they required substantially more time to do so. Dr. David Braff et al. discuss these findings in an editorial on p. Original article: 705 .