Depression: Scott J

Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, Matthews K, McAllister-Williams RH, Peveler RC, Scott J, Tylee A. · Senior Lecturer and Honorary Consultant Psychiatrist, Neuroscience and Psychiatry Unit, University of Manchester, UK. · J Psychopharmacol. · Pubmed #18413657 No free full text.

Abstract: A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Scott J. · No affiliation provided · BMJ. · Pubmed #16644810 links to  free full text

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Scott J, Dickey B. · No affiliation provided · Br J Psychiatry. · Pubmed #12893658 links to  free full text

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Scott J. · No affiliation provided · N Engl J Med. · Pubmed #10816192 No free full text.

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Scott J, McNeill Y, Cavanagh J, Cannon M, Murray R. · PO 96, Department of Psychological Medicine, Institute of Psychiatry, London SE5 8AF, UK. · Br J Psychiatry. · Pubmed #16816299 links to  free full text

Abstract: BACKGROUND: Research has suggested an association between obstetric complications and bipolar disorder. However, no quantitative evaluation has been made of the pooled data from existing studies. AIMS: To systematically review studies comparing exposure to obstetric complications in cases of bipolar disorder v. non-psychiatric controls, and in cases of bipolar disorder v. cases of other mental disorders. METHOD: Publications were identified by computer searches of seven databases, by hand searches of reference lists and from raw data received from researchers. RESULTS: Forty-six studies were identified, of which 22 met the inclusion criteria. The pooled odds ratio for exposure to obstetric complications and subsequent development of bipolar disorder was 1.01 (95% CI 0.76-1.35) compared with healthy controls, 1.13 (95% CI 0.64-1.99) compared with cases of unipolar disorder and 0.61 (95% CI 0.39-0.95) compared with those who developed schizophrenia. CONCLUSIONS: There is no robust evidence that exposure to obstetric complications increases the risk of developing bipolar disorder. However, the range of events regarded as obstetric complications and methodological inadequacies make definitive conclusions difficult.

Scott J. · Institute of Psychiatry, London, UK. · J Psychopharmacol. · Pubmed #16551672 No free full text.

Abstract: This paper explores the development of psychological treatments as an adjunct to medication in bipolar disorders. Randomized controlled treatment trials of specific therapy models, such as cognitive therapy, that tackle a spectrum of complex psychological and social problems associated with bipolar disorders are reviewed. A systematic review of the most recent treatment outcome studies suggest that adjunctive psychological therapies reduce overall rates of relapse, but are more effective for depression than for mania. There is no evidence that any particular therapy has a unique mechanism of action or any specific advantages over any other approach. Finally, it is suggested that gaps in the theory and available evidence for effectiveness need to be addressed if we are to enable clinicians to target psychological therapies towards those individuals with bipolar disorder who are most likely to benefit.

Mansell W, Colom F, Scott J. · Psychological Treatments PO96, Department of Psychological Medicine, Institute of Psychiatry, London SE5 8AF, UK. · Clin Psychol Rev. · Pubmed #16140444 No free full text.

Abstract: Bipolar depression is poorly understood and researched, yet it is has a huge impact on functioning in bipolar disorder. This review explores the current status of research regarding the phenomenology, natural history, neuropsychology, psychosocial predictors and cognitive style of bipolar depression. The current status of pharmacotherapy and psychological treatment of bipolar depression is also described. In particular, the manner in which cognitive behaviour therapy for bipolar depression has been adapted from CBT for unipolar depression is critically evaluated. It is concluded that there appears to be a considerable overlap between the features of unipolar and bipolar depression, yet there is also emerging evidence for specific elements. The ability of current psychological theories of bipolar disorder to account for the findings are compared, and as a consequence, a new preliminary integrative model is proposed to direct future hypothesis-led research, which will need to incorporate more suitable populations and utilise more objective methods of assessment.

Doy R, Burroughs D, Scott J. · School of Nursing and Midwifery, University of East Anglia, UK. · Emerg Med J. · Pubmed #15788835 links to  free full text

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Gutierrez MJ, Scott J. · Psychological Treatments Research, Institute of Psychiatry, Denmark Hill, 96, London, SE5 8AF, UK. · Eur Arch Psychiatry Clin Neurosci. · Pubmed #15146338 No free full text.

Abstract: The increased acceptance of stress-vulnerability models of severe mental disorders and of brief evidence-based psychological treatments in their treatment has finally led to increased interest in the role of psychotherapies in bipolar disorders. This paper reviews the results from randomised controlled trials of psychological therapies as an adjunct to standard medications. The evidence suggests that the addition of a psychological therapy may significantly reduce symptoms, enhance social adjustment and functioning, and reduce relapses and hospitalisations in patients with bipolar disorder. However, the methodological problems in the published randomised controlled trials and the heterogeneity in the outcomes achieved (some therapies reduce manic but not depressive relapses, others have the opposite effect) suggests that further studies are required to fully establish the place of these approaches in day to day practice.

Choi PT, Bhandari M, Scott J, Douketis J. · Departments of Anaesthesia and Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, Room HSC-2U5, Hamilton, Ontario, Canada, L8N 3Z5. · Cochrane Database Syst Rev. · Pubmed #12917945 No free full text.

Abstract: BACKGROUND: Hip and knee replacement are common operative procedures to improve mobility and quality of life. Adequate pain relief is essential in the postoperative period to enable ambulation and initiation of physiotherapy. Lumbar epidural analgesia is a common modality for pain relief following these procedures. However, there is no systematic review of the evidence comparing the efficacy of epidural analgesia with other postoperative analgesic modalities. As the use of epidural analgesia may delay the initiation of anticoagulant thromboprophylaxis due to the potential risk of epidural hematoma, a synthesis of the evidence is necessary to determine whether or not alternative analgesic modalities are worse, equivalent, or better than epidural analgesia. OBJECTIVES: Our objective is to answer the question: "Is lumbar epidural analgesia more efficacious than systemic analgesia or long-acting spinal analgesia for postoperative pain relief in patients after elective hip or knee replacement?" SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, LILACS, and the Cochrane Controlled Trials Register were searched from their inception to June 2001. Reference lists of review articles and included studies were also reviewed for additional citations. SELECTION CRITERIA: A study was included if it was a randomized or pseudo randomized controlled clinical trial of patients undergoing hip or knee replacement, in which postoperative lumbar epidural analgesia was compared to other methods for pain relief. Study selection was performed unblinded in duplicate. DATA COLLECTION AND ANALYSIS: Data were collected unblinded in duplicate. Information on the patients, methods, interventions, outcomes (pain relief, postoperative function, length of stay) and adverse events were recorded. Methodological quality was assessed using a validated 5-point scale. Meta-analysis was conducted when sufficient data existed from two or more studies. Heterogeneity testing was performed using the Breslow-Day method. The fixed effects model was used unless heterogeneity was present, in which case, a random effects model was used. Continuous data were summarized as weighted mean differences (WMD) or standardized mean differences (SMD) with 95% confidence intervals (CI). Dichotomous data were summarized as odds ratios (OR) and numbers-needed-to-treat (NNT) or numbers-needed-to-harm (NNH) with their respective 95% CI. Graphical representation of continuous data used the MetaView program. MAIN RESULTS: In the first four to six hours after surgery, patients receiving epidural analgesia had less pain at rest, based on visual analog scores (VAS), than patients receiving systemic analgesia (SMD -0.77; 95% CI -1.24 to -0.31). This effect was not statistically significant by 18 to 24 hours (SMD -0.29; 95% CI -0.73 to 0.16). These observations were based only on studies evaluating populations consisting of total knee replacements alone or mixed populations of total hip or total knee replacements. For pain relief with movement after surgery, patients receiving epidural analgesia reported lower pain scores than patients receiving systemic analgesia in all four studies examining these outcomes. The choice of epidural agents may also influence the extent to which epidural analgesia differs from systemic analgesia. The differences between epidural analgesia and systemic analgesia in the frequency of nausea and vomiting (OR 0.95; 95% CI 0.60 to 1.49) or depression of breathing (OR 1.07; 95% CI 0.45 to 2.54) were not statistically significant. Sedation occurred less frequently with epidural analgesia (OR 0.30; 95% CI 0.09 to 0.97) with a number-needed-to-harm of 7.7 (95% CI 3.5 to 42.0) patients for the systemic analgesia group. Retention of urine (OR 3.50, 95% CI 1.63 to 7.51; NNH 4.5, 95% CI 2.3 to 12.2), itching (OR 4.74, 95% CI 1.76 to 12.78; NNH 6.8, 95% CI 4.4 to 15.8), and low blood pressure (OR 2.78, 95% CI 1.15 to 6.72; NNH 6.7, 95% CI 3.5 to 103) were more frequent with epidural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the edural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the effect of epidural analgesia on serious postoperative complications, functional outcomes, or length of hospital stay. REVIEWER'S CONCLUSIONS: Epidural analgesia may be useful for postoperative pain relief following major lower limb joint replacements. However, the benefits may be limited to the early (four to six hours) postoperative period. An epidural infusion of local anesthetic or local anesthetic-narcotic mixture may be better than epidural narcotic alone. The magnitude of pain relief must be weighed against the frequency of adverse events. The current evidence is insufficient to draw conclusions on the frequency of rare complications from epidural analgesia, postoperative morbidity or mortality, functional outcomes, or length of hospital stay.

Jackson A, Cavanagh J, Scott J. · Department of Psychological Medicine, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK. · J Affect Disord. · Pubmed #12738039 No free full text.

Abstract: BACKGROUND: This paper explores whether individuals with a mood disorder can identify the nature and duration of depressive and manic prodromes. METHODS: Seventy-three publications of prodromal symptoms in bipolar and unipolar disorders were identified by computer searches of seven databases (including MEDLINE and PsycLIT) supplemented by hand searches of journals. Seventeen studies (total sample=1191 subjects) met criteria for inclusion in a systematic review. RESULTS: At least 80% of individuals with a mood disorder can identify one or more prodromal symptoms. There are limited data about unipolar disorders. In bipolar disorders, early symptoms of mania are identified more frequently than early symptoms of depression. The most robust early symptom of mania is sleep disturbance (median prevalence 77%). Early symptoms of depression are inconsistent. The mean length of manic prodromes (>20 days) was consistently reported to be longer than depressive prodromes (<19 days). However, depressive prodromes showed greater inter-individual variation (ranging from 2 to 365 days) in duration than manic prodromes (1-120 days). LIMITATIONS: Few prospective studies of bipolar, and particularly unipolar disorders have been reported. CONCLUSIONS: Early symptoms of relapse in affective disorders can be identified. Explanations of the apparent differences in the recognition and length of prodromes between mania and bipolar depression are explored. Further research on duration, sequence of symptom appearance and characteristics of prodromes is warranted to clarify the clinical usefulness of early symptom monitoring.

Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G. · Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OXON, UK, OX3 7JX. · Cochrane Database Syst Rev. · Pubmed #12535506 No free full text.

Abstract: BACKGROUND: Bipolar disorder is a common debilitating illness, characterised by acute affective episodes with full or partial inter-episode remission. Effective and acceptable treatment of acute episodes is required. Valproate has become a leading adjunctive and alternative mood stabilising treatment to lithium in bipolar disorder. OBJECTIVES: To determine the efficacy and acceptability of valproate in the treatment of acute episodes of bipolar disorder. SEARCH STRATEGY: The search included the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registrar (CCDANCTR), the Cochrane Controlled Clinical Trials Register (CCTR), reference lists of relevant papers and books, and contact with authors of trials, experts and pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials comparing valproate with placebo, other mood stabilisers and antipsychotic medication in the treatment of any bipolar affective episode. Participants were of both sexes, of all ages, with a diagnosis of bipolar affective disorder approximating to ICD 10 Code F31 and DSM IV 296. DATA COLLECTION AND ANALYSIS: Methodological quality was assessed independently by two reviewers blind to the authorship and source of papers. Ten randomised controlled trials were found comparing valproate with other interventions in mania. None was found examining its use in depression or mixed affective episodes. Data were extracted on the main outcome 'failure to respond by the end of the study' assessed by a less than 50% reduction in the Young Mania Rating Scale or the SADS-S mania scale. Three trials (316 participants) compared valproate with placebo. Three trials (158 participants) compared valproate with lithium. Two trials (363 participants) compared valproate with olanzapine. One trial (36 participants) compared valproate with haloperidol. Two trials (59 patients) compared valproate with carbamazepine. Acceptability of treatment was estimated using the outcome measure 'total number of subjects withdrawing from the study'. Three trials (321 patients) contributed to the comparison between valproate and placebo, two studies (144 patients) contributed to the comparison with lithium. One study (30 patients) provided data on this outcome in the comparison between valproate and carbamazepine. Pooled relative risks (with 95% confidence intervals) were calculated using fixed effect approaches. MAIN RESULTS: Valproate was more efficacious than placebo (RRR 38%; RR 0.62; 95% C.I. 0.51 to 0.77) in the treatment of mania. There was no significant difference between valproate and lithium (RRI 5%; RR 1.05; 95% C.I. 0.74-1.50) or between valproate and carbamazepine (RRR 34%; RR 0.66; 95% C.I. 0.38 to 1.16). Valproate was less effective than olanzapine (failure to achieve clinical response; RRI 25%; RR 1.25, 95% C.I. 1.01 to 1.54; average of 2.8 point less change on the Mania Rating Scale (95% CI 0.83 to 4.79). There were no significant differences in acceptability as measured by total number of subjects withdrawing from the study. There were significant differences in the side effect profiles of valproate and olanzapine, with more sedation and weight gain on olanzapine. REVIEWER'S CONCLUSIONS: There is consistent, if limited, evidence to suggest that valproate is an efficacious treatment for acute mania. Valproate may be less effective than olanzapine but may cause less sedation and weight gain. More well designed, randomised controlled trials investigating the relative efficacy and acceptability of valproate in the treatment of the full range of acute affective episodes occurring in bipolar disorder are required.

Garland A, Scott J. · Nottinghamshire Healthcare NHS Trust, United Kingdom. · J Clin Psychol. · Pubmed #11967875 No free full text.

Abstract: There is a growing body of research evidence that demonstrates that completion of homework assignments is significantly correlated with outcome in cognitive therapy. The cognitive model of depression sees homework as an intrinsic aspect of the therapy process. Homework serves a number of purposes, including generalizing learning from the session into everyday life and fostering the independent practice of skills acquired during treatment. We review a number of commonly occurring problems that arise when seeking to engage the client in homework. The negotiation and implementation of homework assignments is a core clinical skill, and we present a range of strategies the clinician can use to optimize its effectiveness. It is vital that practitioners have an awareness of their own role and expectations in developing homework assignments.

Lingam R, Scott J. · Department of Psychiatry and Psychotherapy, Claremont House, Royal Victoria Infirmary, Newcastle upon Tyne, UK. · Acta Psychiatr Scand. · Pubmed #11939969 No free full text.

Abstract: OBJECTIVE: The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders. METHOD: Studies were identified through Medline and PsycLit searches of English language publications between 1976 and 2001. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice. RESULTS: Estimates of medication non-adherence for unipolar and bipolar disorders range from 10 to 60% (median 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side-effects in predicting adherence. The limited number of empirical studies of how to reduce non-adherence offer encouraging evidence that, if recognized, the problem can be overcome. CONCLUSION: Only 1-2% of all publications on the treatment of affective disorders explore factors associated with medication non-adherence. This is disappointing as research and clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of affective disorders.

Paton J, Jenkins R, Scott J. · WHO Collaborating Centre for Research and Training for Mental Health, Institute of Psychiatry, London, UK. · Soc Psychiatry Psychiatr Epidemiol. · Pubmed #11766973 No free full text.

Abstract: OBJECTIVE: This paper addresses the prevention and treatment of depression in the general population. It argues that the public health burden of depression cannot be effectively tackled solely at the level of the treatment of individuals; in addition, coherent strategies by national governments are required. It summarises some of the public health interventions that were undertaken in England by the government to reduce the risk factors associated with depression in increase detection and treatment and to destigmatise this disorder. Lessons learned from this experience are described. METHODS: To assess the scope for collective public interventions, a national psychiatric morbidity study was commissioned. The Government set targets for reducing psychiatric morbidity and suicide. Research related to depression was commissioned. A public information strategy was launched to increase understanding and reduce stigma, including a five year 'Defeat Depression' Campaign. Particular attention was paid to updating General Practitioners in the recognition, detection and management of depression. Government departments worked with employers and trade union organisations to attempt to reduce work-induced stress. Universal and selective prevention measures aimed to reduce factors associated with depression, such as unemployment. Measures to reduce suicide include education of health and social care professionals, supporting high-risk groups and restricting access to means of suicide. The impact of these strategies is difficult to assess and will not be apparent until the national psychiatric morbidity study is repeated in 2001. The overall suicide rate fell by 11.7% in five years.

Macritchie KA, Geddes JR, Scott J, Haslam DR, Goodwin GM. · Department of Psychiatry, University of Oxford, Oxford, UK, OX3 7JX. · Cochrane Database Syst Rev. · Pubmed #11687047 No free full text.

Abstract: BACKGROUND: Although lithium has been the most commonly used maintenance treatment in bipolar disorder for several decades, valproate is being used increasingly - especially in the United States of America. There is a need to clarify whether the increasingly prominent prophylactic role of valproate in bipolar disorder is justified. OBJECTIVES: To review the effectiveness of valproate, relative to placebo, other mood stabilisers and antipsychotics, in the prevention and/or attenuation of acute episodes of bipolar disorder. The effectiveness of valproate was considered in terms of mood symptoms, mortality, general health, social functioning, adverse effects and overall acceptability to patients. SEARCH STRATEGY: The CCDAN group search strategy was used. The following databases were searched: The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), The Cochrane Controlled Clinical Trials Register (CCCTR), EMBASE, MEDLINE, LILACS, PsycLIT and Psyndex. Reference lists of relevant papers and major textbooks of mood disorder were examined. Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable published or unpublished trials. SELECTION CRITERIA: Randomised controlled trials which compared valproate with placebo, alternative mood stabilisers (including lithium and carbamazepine) or neuroleptics, where the stated intent of intervention was the maintenance treatment of bipolar disorder. Participants were males and females of all ages with a diagnosis of bipolar disorder however diagnosed, approximating to ICD 10 Code F31 and DSM IV 296, but including patients diagnosed as ICD-9 manic depressive psychosis and DSM-III and DSM-IIIR bipolar disorder. DATA COLLECTION AND ANALYSIS: Data were extracted from the original reports individually by two reviewers. The main outcomes to be assessed were: 1.The effectiveness of valproate treatment in preventing or attenuating further episodes of bipolar disorder, including its effectiveness in rapid cycling disorder. 2.The acceptability of valproate treatment to patients. 3.The prevalence of side-effects. 4.Mortality on valproate treatment. Outcomes concerning relapse/recurrence were analysed excluding data from discontinuation studies, which were to be analysed separately. Sub-group analyses were to be performed to examine the effects of valproate treatment in rapid cycling bipolar disorder and previous mood stabiliser non-responders. Data were analysed using Review Manager version 4.1. MAIN RESULTS: One trial of 12 months duration with 372 participants was identified comparing lithium, divalproex and placebo. It had several methodological limitations. The primary analysis of time to occurrence of mood episode described in the main trial report found no reliable difference between the treatments, although there was a trend for divalproex to be more effective than lithium. In the analysis in this review, patients taking divalproex who left the study because of the occurrence of an mood episode were significantly less in number than those on placebo (RRR 37%; RR 0.63; 95% CI 0.44 to 0.90). There was no significant difference in the numbers of patients in receipt of divalproex compared with those in receipt of lithium who left the study because they suffered any mood episode. (RRR 22%; RR 0.78; 95% C.I. 0.52 to 1.17). There was insufficient information to allow sub-group analyses of rapid-cycling disorder. The divalproex group had significantly more patients suffering tremor (RRI 223%; RR 3.23; 95% C.I. 1.85 to 5.62), weight gain (RRI 187%; RR 2.87; 95% C.I. 1.34 to 6.17) and alopecia (RRI 143%; RR 2.43; 95% C.I. 1.05 to 5.65) than the placebo group. In comparison with the lithium, divalproex was associated with more frequent sedation (RRI 58%; RR 1.58; 95% C.I. 1.08 to 2.32) and infection (RRI 107%; RR 2.07; 95% C.I. 1.16 to 3.68), but less suffered thirst (RRR 62%; RR 0.38; 95% C.I. 0.18 to 0.81) and polyuria (RRR 57%; RR 0.43; 95% C.I. 0.22 to 0.82). REVIEWER'S CONCLUSIONS: In view of the equivocal findings of this review, conclusions about the efficacy and acceptability of valproate compared to placebo and lithium cannot be made with any degree of confidence. With current evidence, patients and clinicians would probably wish to use lithium before valproate for maintenance treatment. At present, the observed shift of prescribing practice to valproate is not based on reliable evidence of efficacy

Cornwall PL, Scott J. · University Department of Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne. · Br J Gen Pract. · Pubmed #11141878 links to  free full text

Abstract: BACKGROUND: Many policy and research documents on the treatment of depression in primary care suggest that general practitioners (GPs) should make use of clinical guidelines. AIM: To describe the content of peer-reviewed guidelines for the detection and treatment of depression in primary care and help GPs identify the one most useful to their own needs. METHOD: Guidelines were evaluated by an explicit method using the Institute of Medicine assessment instrument and according to six key clinical management questions identified as important by GPs and psychiatrists. RESULTS: Only five (30%) of the published guidelines identified met all the pre-defined inclusion criteria. Total scores for development process and content ranged from 54% to 82%. Validity scores ranged from 52% to 88%. No guideline answered all the key questions identified by clinicians. CONCLUSIONS: Only two guidelines conform to the quality standard of a clinical practice guideline. One covers all aspects of detection and management of depression in primary care but gives no advice on first-line choice of antidepressant, while the other focuses only on medication and fails to explore problems of case detection or to consider non-pharmacological treatments. However, taken together they do cover most of the key clinical issues in a reliable and valid manner. The identified guidelines vary considerably in both utility and clinical applicability.

Watkins E, Scott J, Wingrove J, Rimes K, Bathurst N, Steiner H, Kennell-Webb S, Moulds M, Malliaris Y. · Mood Disorders Centre, School of Psychology, University of Exeter, Exeter EX4 4QG, UK. · Behav Res Ther. · Pubmed #17367751 No free full text.

Abstract: The treatment of chronic and recurrent depression is a priority for the development of new interventions. The maintenance of residual symptoms following acute treatment for depression is a risk factor for both chronic depression and further relapse/recurrence. This open case series provides the first data on a cognitive-behavioural treatment for residual depression that explicitly targets depressive rumination. Rumination has been identified as a key factor in the onset and maintenance of depression, which is found to remain elevated following remission from depression. Fourteen consecutively recruited participants meeting criteria for medication--refractory residual depression [Paykel, E.S., Scott, J., Teasdale, J.D., Johnson, A.L., Garland, A., Moore, R. et al., 1999. Prevention of relapse in residual depression by cognitive therapy--a controlled trial. Archives of General Psychiatry 56, 829-835] were treated individually for up to 12 weekly 60-min sessions. Treatment specifically focused on switching patients from less helpful to more helpful styles of thinking through the use of functional analysis, experiential/imagery exercises and behavioural experiments. Treatment produced significant improvements in depressive symptoms, rumination and co-morbid disorders: 71% responded (50% reduction on Hamilton Depression Rating Scale) and 50% achieved full remission. Treating depressive rumination appears to yield generalised improvement in depression and co-morbidity. This study provides preliminary evidence that rumination-focused CBT may be an efficacious treatment for medication--refractory residual depression.

Davidson K, Scott J, Schmidt U, Tata P, Thornton S, Tyrer P. · Psychological Medicine, Gartnavel Royal Hospital, Glasgow, UK. · Psychol Med. · Pubmed #15500306 No free full text.

Abstract: BACKGROUND: Therapist competence may be an important factor in determining clinical outcome in psychological therapies. However, there are few published studies of therapist competence v. patient outcome from randomized controlled trials. We tested the hypothesis that higher levels of therapist competence would lead to better clinical outcomes in both patient- and observer-rated measures at 6- and 12-month follow-up. METHOD: A random sample of 49 audiotapes of manual assisted cognitive therapy sessions delivered by 21 therapists involved in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial was rated to assess the level of therapist competence. Patient outcome was assessed using self and observer ratings of depressive and anxiety symptoms, social functioning, global functioning and number of episodes of deliberate self-harm. RESULTS: At 6-month follow-up, there was a statistically significant association between therapist level of competence and observer-rated depression only. At 12-month follow-up, significant associations were noted between therapist competence and all observer-rated clinical outcomes but not for self-rated outcome measures. However, there was no association between therapist competence and the number of self-harm episodes during follow-up. CONCLUSIONS: When treated by therapists rated as more competent than other therapists who received equivalent brief training, patients with recurrent self-harm show significant clinical improvements. However, this benefit is not identified across all outcome measures and is not fully apparent until 12-month follow-up.

Tyrer P, Thompson S, Schmidt U, Jones V, Knapp M, Davidson K, Catalan J, Airlie J, Baxter S, Byford S, Byrne G, Cameron S, Caplan R, Cooper S, Ferguson B, Freeman C, Frost S, Godley J, Greenshields J, Henderson J, Holden N, Keech P, Kim L, Logan K, Manley C, MacLeod A, Murphy R, Patience L, Ramsay L, De Munroz S, Scott J, Seivewright H, Sivakumar K, Tata P, Thornton S, Ukoumunne OC, Wessely S. · Department of Psychological Medicine, Imperial College, King's College and Maudsley Hospitals, Center for the Economics of Mental Health, Institute of Psychiatry, London. · Psychol Med. · Pubmed #12946081 No free full text.

Abstract: BACKGROUND: We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm. METHOD: Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months. RESULTS: Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20). CONCLUSION: Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Paykel ES, Scott J, Teasdale JD, Johnson AL, Garland A, Moore R, Jenaway A, Cornwall PL, Hayhurst H, Abbott R, Pope M. · Department of Psychiatry, University of Cambridge, Cambridge, England. · Arch Gen Psychiatry. · Pubmed #12884889 links to  free full text

Abstract: BACKGROUND: Previous studies indicate that depressed patients with partial remission and residual symptoms following antidepressant treatment are common and have high rates of relapse. There is evidence that cognitive therapy may reduce relapse rates in depression. METHODS: One hundred fifty-eight patients with recent major depression, partially remitted with antidepressant treatment (mean daily doses equivalent to 185 mg of amitriptyline or 33 mg of fluoxetine) but with residual symptoms of 2 to 18 months' duration, were included in a controlled trial. Subjects were randomized to receive clinical management alone or clinical management plus cognitive therapy for 16 sessions during 20 weeks, with 2 subsequent booster sessions. Subjects were assessed regularly throughout the 20 weeks' treatment and for a further year. They received continuation and maintenance antidepressants at the same dose throughout. RESULTS: Cognitive therapy reduced relapse rates for acute major depression and persistent severe residual symptoms, in both intention to treat and treated per protocol samples. The cumulative relapse rate at 68 weeks was reduced significantly, from 47% in the clinical management control group to 29% with cognitive therapy (hazard ratio 0.54; 95% confidence interval, 0.32-0.93; intention to treat analysis). Cognitive therapy also increased full remission rates at 20 weeks but did not significantly improve symptom ratings. CONCLUSION: In this difficult-to-treat group of patients with residual depression who showed only partial response despite antidepressant treatment, cognitive therapy produced worthwhile benefit.

Scott J, Palmer S, Paykel E, Teasdale J, Hayhurst H. · Institute of Psychiatry, London, UK. · Br J Psychiatry. · Pubmed #12611785 links to  free full text

Abstract: BACKGROUND: There is a lack of data on the cost-effectiveness of relapse prevention in depression. METHOD: A total of 158 subjects with partially remitted major depression despite adequate clinical treatment were randomly allocated to cognitive therapy in addition to antidepressants and clinical management v. antidepressants and clinical management alone. Relapse rates and health care resource utilisation were measured prospectively over 17 months. RESULTS: Cumulative relapse rates in the cognitive therapy group were significantly lower than in the control group (29% v. 47%). The incremental cost incurred in subjects receiving cognitive therapy over 17 months (pound sterling 779; 95% CI pound sterling 387- pound sterling 1170) was significantly lower than the overall mean costs of cognitive therapy (pound sterling 1164; 95% CI pound sterling 1084- pound sterling 1244). The incremental cost-effectiveness ratio ranged from pound sterling 4328 to pound sterling 5027 per additional relapse prevented. CONCLUSIONS: In individuals with depressive symptoms that are resistant to standard treatment, adjunctive cognitive therapy is more costly but more effective than intensive clinical treatment alone.

Teasdale JD, Scott J, Moore RG, Hayhurst H, Pope M, Paykel ES. · Cognition and Brain Sciences Unit, Medical Research Council, Cambridge, United Kingdom. · J Consult Clin Psychol. · Pubmed #11495165 No free full text.

Abstract: This study examined the cognitive mediation of relapse prevention by cognitive therapy (CT) in a trial of 158 patients with residual depression. Scores based on agreement with item content of 5 questionnaires of depression-related cognition provided no evidence for cognitive mediation. A measure of the form of response to those questionnaires, the number of times patients used extreme response categories ("totally agree" and "totally disagree"), showed significant and substantial prediction of relapse, differential response to CT. and conformity to mediational criteria. CT reduced relapse through reductions in absolutist, dichotomous thinking style. CT may prevent relapse by training patients to change the way that they process depression-related material rather than by changing belief in depressive thought content.

Scott J, Garland A, Moorhead S. · Department of Psychological Medicine, University of Glasgow, Gartnavel Royal Hospital. · Psychol Med. · Pubmed #11305854 No free full text.

Abstract: BACKGROUND: The efficacy and effectiveness of cognitive therapy (CT) is well established for unipolar disorders, but little is known about its utility in bipolar disorders. This study aimed to explore the feasibility and efficacy of using CT as an adjunct to usual psychiatric treatment in this patient population. METHOD: Subjects referred by general adult psychiatrists were assessed by and independent rater and then randomly allocated to immediate CT (N = 21) or 6-month waiting-list control, which was then followed by CT (N = 21). Observer and self-ratings of symptoms and functioning were undertaken immediately prior to CT, after a 6-month course of CT and a further 6-months later. Data on relapse and hospitalization rates in the 18 months before and after commencing CT were also collected. RESULTS: At 6-month follow-up, subjects allocated to CT showed statistically significantly greater improvements in symptoms and functioning as measured on the Beck Depression Inventory, the Internal State Scale, and the Global Assessment of Functioning than those in the waiting-list control group. In the 29 patients who eventually received CT, relapse rates in the 1 8 months after commencing CT showed a 60 % reduction in comparison with the 18 months prior to commencing CT. Seventy per cent of subjects who commenced therapy viewed CT as highly acceptable. CONCLUSION: Although the results of this study are encouraging, the use of CT in subjects with bipolar disorders is more complex than in unipolar disorders and requires a high level of therapist expertise. The therapy may prove to be particularly useful in the treatment of bipolar depression.

Scott J, Teasdale JD, Paykel ES, Johnson AL, Abbott R, Hayhurst H, Moore R, Garland A. · Gartnavel Royal Hospital, Glasgow. · Br J Psychiatry. · Pubmed #11059998 links to  free full text

Abstract: BACKGROUND: About 30% of psychiatric out-patients with major depression demonstrate partial remission. AIMS: To explore whether the addition of cognitive therapy (CT) had any differential effect on residual symptoms or social adjustment. METHOD: Patients with residual symptoms of major depression (n=158) were randomised to receive clinical management (CM) alone, or CM plus 18 sessions of CT. Subjects' depressive symptoms and social functioning were assessed regularly over 16 months. RESULTS: The addition of CT produced statistically significant differential effects on: two out of four measures of overall severity of depression; specific psychological symptoms (guilt, self-esteem and hopelessness); and social functioning (including dependency, interpersonal behaviour and friction). CONCLUSIONS: In patients showing only partial response to antidepressants, the addition of CT produced modest improvements in social and psychological functioning. The implications for research on the mechanisms of action of CT are discussed.