Posts tagged CBT
Articles and news from the latest research reports.
![The Search for the Best Depression Treatment
Brain scans, blood samples, and other diagnostic tests could one day direct doctors to the best treatments for depression patients and uncover the biological basis of the condition.
When someone is diagnosed with depression, patient and doctor often begin a long trial-and-error process of testing different treatments. Sometimes they work, sometimes they don’t, so patients may try several options before finding the best one. But in the future, a brain scan, blood test, or some combination could help guide doctors to the best drugs, or lead them to suggest talk therapy.
Recently, Emory University researcher Helen Mayberg reported that a PET scan, a commonly used imaging method, can reveal whether a patient will respond better to an antidepressant or cognitive behavioral therapy. And in May, Medscape reported that David Mischoulon of Massachusetts General Hospital presented findings that the amount of a particular protein in the blood of depression patients could indicate whether a patient would do better by adding a form of folic acid to his or her treatment.
A key goal of such research is to distinguish between causes of depression. “The presence of certain biomarkers might give us a clue whether [a particular patient’s] depression is truly biologically driven, or whether it is depression like sadness over an event,” says Mischoulon. “If we can identify people who have these biological bases, it might suggest these patients might do better with medications, as opposed to psychotherapies or meditation.”
According to the World Health Organization, depression is the leading cause of disability globally. Many people do not seek or do not have access to treatment, and among those who do, fewer than 40 percent of depression patients improve with the first type of treatment they try. The problem is not that treatments like antidepressants and cognitive behavioral therapy don’t work, it’s that no one treatment works for every patient. Researchers from many disciplines, from neuroscience to genomics, are studying this complex disorder, which likely represents many different conditions with unique origins and treatments. Large clinical trials to predict a patient’s response to therapy or drugs based on brain or body biomarkers could improve treatment for future patients and perhaps uncover a clearer understanding of depression’s origins.
“You see now a number of big studies on predictive biomarkers,” says Mayberg, who has pioneered pacemaker-like implants as a treatment for severe cases of depression. She’s also involved in a large study of patients who will be treated with antidepressants or cognitive behavioral therapy based on brain scans. “It’s going to be interesting over the next year or two to see how this plays out,” she says. One question will be whether researchers will be able to identify markers that are both unambiguous but also practical to test. Brain scans may be the best place to start, she says, because they focus on the origin of the condition, but once good biomarkers are identified via brain scan, surrogates found in the blood may provide a simpler and more affordable option.
One challenge for researchers is that depression is probably a conglomeration of many diseases, says Madhukar Trivedi, a University of Texas Southwestern researcher heading a large trial that is trying to distinguish patients who respond better to one type of antidepressant compared to another. “There are a lot of subtypes in depression, so any given marker, whether genetic, protein, imaging, or EEG, ends up accounting for only a small percentage of variance for any group of patients,” says Trivedi.
If these researchers are successful, they could dramatically change how depression is treated and perhaps diagnosed. Doctors in the United States use the Diagnostic and Statistical Manual of Mental Disorders, or DSM, to diagnose depression. The diagnoses are largely based on the collection of symptoms presented or described by patients. In May, the head of the National Institute of Mental Health, Thomas Insel, announced that his institution would focus its research in areas other than the categories presented by the DSM. “Patients with mental disorders deserve better,” he said.
Bruce Cuthbert is heading the NIMH’s project to establish new ways of studying mental illness and potentially to improve future versions of the DSM by more precisely identifying the brain abnormalities in various diseases, including depression. The idea behind the project is to map out the genetic, circuit, and cognitive aspects of mental illness and to focus on individual features of disorders instead of clinical diagnoses. It could provide the information necessary to improve the DSM so that it is based on neuroscience and not just collections of symptoms. “In the future, we might define the disorders differently, or we might not. But this project will provide a framework to look at neural systems and how they operate and how that contributes to disease,” says Cuthbert.
Perhaps more immediately, the NIMH project could help researchers tune clinical trials of drugs to the right patients by focusing on discrete symptoms. For example, anhedonia, the inability to feel pleasure or seek pleasure, is a major symptom of depression, but it is also found in other patients, such as those with schizophrenia. By recruiting patients with measurable anhedonia, drug developers may be more likely to succeed in clinical trials than if they focused only on depression patients, says Cuthbert.
The NIMH project could also help to identify biomarkers of depression. “It could give us a structure to look at the pathology through different markers of the disease,” says Trivedi. “The goal is fantastic, but the proof is going to come in doing it.”](http://40.media.tumblr.com/2cee06d8ba637a69d1ed2f2d29d4c882/tumblr_mr0drrDP3b1rog5d1o1_500.jpg)
The Search for the Best Depression Treatment
Brain scans, blood samples, and other diagnostic tests could one day direct doctors to the best treatments for depression patients and uncover the biological basis of the condition.
When someone is diagnosed with depression, patient and doctor often begin a long trial-and-error process of testing different treatments. Sometimes they work, sometimes they don’t, so patients may try several options before finding the best one. But in the future, a brain scan, blood test, or some combination could help guide doctors to the best drugs, or lead them to suggest talk therapy.
Recently, Emory University researcher Helen Mayberg reported that a PET scan, a commonly used imaging method, can reveal whether a patient will respond better to an antidepressant or cognitive behavioral therapy. And in May, Medscape reported that David Mischoulon of Massachusetts General Hospital presented findings that the amount of a particular protein in the blood of depression patients could indicate whether a patient would do better by adding a form of folic acid to his or her treatment.
A key goal of such research is to distinguish between causes of depression. “The presence of certain biomarkers might give us a clue whether [a particular patient’s] depression is truly biologically driven, or whether it is depression like sadness over an event,” says Mischoulon. “If we can identify people who have these biological bases, it might suggest these patients might do better with medications, as opposed to psychotherapies or meditation.”
According to the World Health Organization, depression is the leading cause of disability globally. Many people do not seek or do not have access to treatment, and among those who do, fewer than 40 percent of depression patients improve with the first type of treatment they try. The problem is not that treatments like antidepressants and cognitive behavioral therapy don’t work, it’s that no one treatment works for every patient. Researchers from many disciplines, from neuroscience to genomics, are studying this complex disorder, which likely represents many different conditions with unique origins and treatments. Large clinical trials to predict a patient’s response to therapy or drugs based on brain or body biomarkers could improve treatment for future patients and perhaps uncover a clearer understanding of depression’s origins.
“You see now a number of big studies on predictive biomarkers,” says Mayberg, who has pioneered pacemaker-like implants as a treatment for severe cases of depression. She’s also involved in a large study of patients who will be treated with antidepressants or cognitive behavioral therapy based on brain scans. “It’s going to be interesting over the next year or two to see how this plays out,” she says. One question will be whether researchers will be able to identify markers that are both unambiguous but also practical to test. Brain scans may be the best place to start, she says, because they focus on the origin of the condition, but once good biomarkers are identified via brain scan, surrogates found in the blood may provide a simpler and more affordable option.
One challenge for researchers is that depression is probably a conglomeration of many diseases, says Madhukar Trivedi, a University of Texas Southwestern researcher heading a large trial that is trying to distinguish patients who respond better to one type of antidepressant compared to another. “There are a lot of subtypes in depression, so any given marker, whether genetic, protein, imaging, or EEG, ends up accounting for only a small percentage of variance for any group of patients,” says Trivedi.
If these researchers are successful, they could dramatically change how depression is treated and perhaps diagnosed. Doctors in the United States use the Diagnostic and Statistical Manual of Mental Disorders, or DSM, to diagnose depression. The diagnoses are largely based on the collection of symptoms presented or described by patients. In May, the head of the National Institute of Mental Health, Thomas Insel, announced that his institution would focus its research in areas other than the categories presented by the DSM. “Patients with mental disorders deserve better,” he said.
Bruce Cuthbert is heading the NIMH’s project to establish new ways of studying mental illness and potentially to improve future versions of the DSM by more precisely identifying the brain abnormalities in various diseases, including depression. The idea behind the project is to map out the genetic, circuit, and cognitive aspects of mental illness and to focus on individual features of disorders instead of clinical diagnoses. It could provide the information necessary to improve the DSM so that it is based on neuroscience and not just collections of symptoms. “In the future, we might define the disorders differently, or we might not. But this project will provide a framework to look at neural systems and how they operate and how that contributes to disease,” says Cuthbert.
Perhaps more immediately, the NIMH project could help researchers tune clinical trials of drugs to the right patients by focusing on discrete symptoms. For example, anhedonia, the inability to feel pleasure or seek pleasure, is a major symptom of depression, but it is also found in other patients, such as those with schizophrenia. By recruiting patients with measurable anhedonia, drug developers may be more likely to succeed in clinical trials than if they focused only on depression patients, says Cuthbert.
The NIMH project could also help to identify biomarkers of depression. “It could give us a structure to look at the pathology through different markers of the disease,” says Trivedi. “The goal is fantastic, but the proof is going to come in doing it.”
Helping SAD Sufferers Sleep Soundly
Lying awake in bed plagues everyone occasionally, but for those with seasonal affective disorder, sleeplessness is routine.University of Pittsburgh researchers report in the Journal of Affective Disorders that individuals with seasonal affective disorder (SAD)—a winter depression that leads to loss of motivation and interest in daily activities—have misconceptions about their sleep habits similar to those of insomniacs. These findings open the door for treating seasonal affective disorder similar to the way doctors treat insomnia.
Kathryn Roecklein, primary investigator and assistant professor in Pitt’s Department of Psychology within the Kenneth P. Dietrich School of Arts and Sciences, along with a team of researchers from Pitt’s School of Medicine and Reyerson University, investigated why, according to a previously published sleep study by the University of California, Berkeley, individuals with seasonal affective disorder incorrectly reported that they slept four more hours a night in the winter.
“We wondered if this misreporting was a result of depression symptoms like fatigue and low motivation, prompting people to spend more time in bed,” said Roecklein. “And people with seasonal affective disorder have depression approximately five months a year, most years. This puts a significant strain on a person’s work life and home life.”
Roecklein and her team interviewed 147 adults between the ages of 18 and 65 living in the Pittsburgh metropolitan area during the winters of 2011 and 2012. Data was collected through self-reported questionnaires and structured clinical interviews in which participants were asked such questions as: “In the past month, have you been sleeping more than usual?” and “How many hours, on average, have you been sleeping in the past month? How does that compare to your normal sleep duration during the summer?”
In order to understand participants’ ideas about sleep, Roecklein’s team asked them to respond to questions such as “I need at least 8 hours of sleep to function the next day” and “Insomnia is dangerous for health” on a scale from 0 to 7, where 7 means “strongly agree” and 0 means “disagree completely.”
Roecklein and her team found that SAD participants’ misconceptions about sleep were similar to the “unhelpful beliefs” or personal misconceptions about sleep that insomniacs often hold. Due to depression, individuals with SAD, like those with insomnia, may spend more time resting in bed, but not actually sleeping—leading to misconceptions about how much they sleep. These misconceptions, said Roecklein, play a significant role in sleep cognition for those with seasonal affective disorder.
“We predict that about 750,000 people in the Pittsburgh metro area suffer from seasonal affective disorder, making this an important issue for our community and the economic strength and vitality of our city,” said Roecklein. “If we can properly treat this disorder, we can significantly lower the number of sufferers in our city.”
Roecklein’s research data suggests that addressing, understanding, and managing these “unhelpful beliefs” about sleep by way of psychotherapy could lead to improved treatments for seasonal affective disorder. One of the most effective treatment options for insomnia, said Roecklein, is cognitive behavioral therapy for insomnia (known as CBT-I), which aims to help people take control of their thinking to improve their sleep habits as well as mood, behavior, and emotions.
Roecklein’s next research project aims to improve treatment for seasonal affective disorder by studying light perception and biological clock synchronization. Light from the environment synchronizes internal biological rhythms with the timing of dawn and dusk, which naturally changes with the seasons. This synchronization allows people to be awake and alert during the day and to sleep at night. Roecklein will examine whether people with seasonal affective disorder perceive this light from the environment differently because of changes in the function of neurological pathways from the eye to the brain. This could help uncover reasons why people suffer from seasonal affective disorder and could suggest new treatment options.
(Image: Shutterstock)
'Out-of-body' virtual experience could help social anxiety
New virtual imaging technology could be used as part of therapy to help people get over social anxiety according to new research from the University of East Anglia (UEA).
Research published today investigated for the first time whether people with social anxiety could benefit from seeing themselves interacting in social situations via video capture.
The experiment gave participants the chance to experience social interaction in the safety of a virtual environment by seeing their own life-size image projected into specially scripted real-time video scenes.
UEA researchers, led by Dr Lina Gega from UEA’s Norwich Medical School and MHCO’s Northumberland Talking Therapies, worked with Xenodu Virtual Environments to create more than 100 different social scenarios – such as using public transport, buying a drink at a bar, socialising at a party, shopping, and talking to a stranger in an art gallery.
The researchers tested whether this sort of experience could become a valuable part of Cognitive Behavioural Therapy (CBT) by including an hour-long session midway through a 12-week CBT course.
Dr Gega said: “People with social anxiety are afraid that they will draw attention to themselves and be negatively judged by others in social situations. Many will either avoid public places and social gatherings altogether, or use safety behaviours to cope – such as not making eye contact and being guarded or hyper-vigilant towards others.
“Paradoxically, this sort of behaviour draws attention to people with social anxiety and feeds into their beliefs that they don’t fit in.
“We wanted to see whether practising social situations in a virtual environment could help.”
Paul Strickland from Xenodu, the company behind the virtual environment system, said: “Our system uses video capture to project a user’s life-size image on screen so that they can watch themselves interacting with custom-scripted and digitally edited video clips.
“It isn’t a head-mounted display – which anxious people may find uncomfortable,” he added. “Instead, the user observes from an out-of-body perspective. They can then simultaneously view themselves and interact with the characters of the film.”
Dr Gega’s project focused on six socially anxious young men recovering from psychosis who also have debilitating social anxiety. The participants engaged with a range of scenarios, some of which were designed to feature rude and hostile people. The virtual environments encouraged participants to practice small-talk, maintain eye contact, test beliefs that they wouldn’t know what to say, and resist safety behaviour such as looking at the floor or being hyper-vigilant.
The main benefits of using these virtual environments in therapy was that it helped participants notice and change anxious behaviours in a safe, controlled environment which could be rehearsed over and over again. Participants were found to drop safety behaviours and take greater social risks. And while realistic to an extent, the ‘fake’ feeling of staged scenarios in itself proved to be a virtue.
“It helped the participants question their interpretation of social cues,” said Dr Gega. “For example, if they thought that one of the characters was looking at them ‘funny’ they could immediately see that there must be an alternative explanation because the scenarios were artificial.
“Another useful aspect of the system is that it can be tailored to address specific fears in social situations - for example a fear of performance, intimacy, or crowds,” she added.
“Two of the patients said that the system felt “weird and surreal”, so the element of having an out-of-body experience is something to study further in future – particularly because psychosis itself is defined by a distorted perception of reality.
“This research explored the feasibility and potential added value of using virtual environments as part of CBT. The next stage would be to carry out a randomised, controlled comparison of CBT with and without the virtual environment system to test whether using the system as a therapy tool leads to greater or quicker symptom improvement.”
Mr Strickland added: “I hope our technology can help make a difference to the lives of people experiencing social anxiety and other specific anxiety conditions for which controlled exposure to feared situations is part of therapy. It is particularly versatile because it doesn’t need technical expertise to set up and use. And the library of scenarios can be built on to capture different types of exposure environments needed in day-to-day clinical practice.”
‘Virtual Environments Using Video Capture for Social Phobia with Psychosis’ is published by the journal Cyberpsychology, Behaviour and Social Networking.
In a National Institutes of Health (NIH) funded clinical trial, researchers at Emory have discovered that specific patterns of brain activity may indicate whether a depressed patient will or will not respond to treatment with medication or psychotherapy. The study was published June 12, 2013, in JAMA Psychiatry Online First.
The choice of medication versus psychotherapy is often based on the preference of the patient or clinician, rather than objective factors. On average, only 35-40 percent of patients get well with whatever treatment they start with.
"To be ill with depression any longer than necessary can be perilous," says Helen Mayberg,md principal investigator for the study and professor of psychiatry, neurology and radiology at Emory University School of Medicine. "This is a serious illness and the prolonged suffering resulting from an ineffective treatment can have serious medical, personal and social consequences. Our goal is not just to get patients well, but to get them well as fast as possible, using the treatment that is best for each individual."
Mayberg’s positron emission tomography (PET) studies over the years have given clues about what may be going on in the brain when people are depressed, and how different treatments affect brain activity.
These studies have also suggested that scan patterns prior to treatment might provide important clues as to which treatment to choose. In this study, the investigators used PET scans to measure brain glucose metabolism, an important index of brain functioning to test this hypothesis.
Participants in the trial were randomly assigned to receive a 12-week course of either the SSRI medication escitalopram or cognitive behavior therapy (CBT) after first undergoing a pretreatment PET scan.
The team found that activity in one particular region of the brain, the anterior insula, could discriminate patients who recovered from those who were non-responders to the treatment assigned. Specifically, patients with low activity in the insula showed remission with CBT, but poor response to medication; patients with high activity in the insula did well with medication, and poorly with CBT.
"These data suggest that if you treat based on a patient’s brain type, you increase the chance of getting them into remission," says Mayberg.
Mayberg is quick to add that this approach needs to be replicated before it would be appropriate for routine treatment selection decisions for individual depressed patients. It is, however, a first step to better define different types of depression that can be used to select a specific treatment for a patient.
A treatment stratification approach is done routinely in the management of other medical conditions such as infections, cancer, and heart disease, notes Mayberg. “The study reported here provides important first results towards the development of brain-based treatment algorithms that match a patient to the treatment with the highest likelihood of success, while also avoiding those treatments that will be ineffective.”
A new study led by MIT neuroscientists has found that brain scans of patients with social anxiety disorder can help predict whether they will benefit from cognitive behavioral therapy.
Social anxiety is usually treated with either cognitive behavioral therapy or medications. However, it is currently impossible to predict which treatment will work best for a particular patient. The team of researchers from MIT, Boston University (BU) and Massachusetts General Hospital (MGH) found that the effectiveness of therapy could be predicted by measuring patients’ brain activity as they looked at photos of faces, before the therapy sessions began.
The findings, published this week in the Archives of General Psychiatry, may help doctors choose more effective treatments for social anxiety disorder, which is estimated to affect around 15 million people in the United States.