Psychotherapy: two trials and an evaluation of access to treatment
Two papers in the Journal this month present the results of randomised controlled trials of psychotherapeutic interventions – cognitive analytic therapy (CAT) for personality disorder and internet-delivered cognitive–behavioural therapy (CBT) for bulimia nervosa. Clarke et al (pp. ) found that CAT was effective for individuals with a range of personality disorders when compared with treatment as usual. In this service-based trial, benefits were seen in diagnostic threshold status, measures of interpersonal functioning, and levels of symptomatic distress. Many of those receiving treatment as usual were noted by the authors to have demonstrated signs of deterioration during the trial period, while deterioration was not seen in any of the individuals randomised to receive CAT. In a linked editorial, Mulder & Chanen (pp. ) comment that in addition to emerging evidence of effectiveness, the practical nature and relatively short intervention period of CAT may make it particularly suitable for clinical services, although they note the lengthy time commitment required for training clinicians.
For adults with bulimia nervosa, CBT is the treatment of choice and both guided and unguided self-help formats of CBT can be as effective as face-to-face treatment. On the basis that internet-delivered guided self-help would have advantages over conventional guided bibliotherapy, Wagner et al (pp. ) conducted a randomised controlled trial over 7 months and followed participants up over 18 months. The authors found no difference in outcomes between the two groups, with improvements seen in eating disorder symptomatology in both groups and benefits sustained across the sample at 18 months. The authors comment that on the basis that more than two-thirds of participants had experienced psychotherapy previously, guided self-help, in either form, might be effective not only as a first-line treatment but also in various stages of treatment.
Jokela et al (pp. ) examined socioeconomic status in relation to common mental disorder and psychotherapy treatment in the UK between 1991 and 2009 using data from annual waves of the longitudinal British Household Panel Survey. Higher socioeconomic status was associated with lower odds of common mental disorder and of receiving publicly provided psychotherapy but higher odds of receiving private psychotherapy. Public provision of psychotherapy to those at greatest risk of common mental disorder based on socioeconomic disadvantage improved during the period of observation. In a linked editorial, Meadows & Tylee (pp. ) comment that beyond equity of access to public psychotherapy, socioeconomic disadvantage might still have an impact on proportionality of response, and cite evidence from Australia to support their argument.
Depression: role of vitamin D and costs of treatment in dementia
Anglin et al (pp. ) conducted a systematic review and meta-analysis of observational studies and randomised controlled trials focused on the relationship between vitamin D and depression. One case–control, ten cross-sectional and three cohort studies were included. Overall, evidence was found to support the hypothesis that low vitamin D levels are associated with depression. The authors call on researchers to undertake randomised controlled trials of vitamin D in order to clarify the causal status of the association and determine whether vitamin D administration might potentially play a role in the prevention and treatment of depression.
Depression is common among those diagnosed with dementia and is a risk factor for poor outcomes, having a negative impact on costs. Romeo et al (pp. ) report on cost-effectiveness findings from a randomised controlled trial of sertraline and mirtazapine, compared with placebo, for the treatment of depression in dementia. In relation to the primary outcome, decrease in depression, antidepressant treatment was not cost-effective compared with placebo. However, mirtazapine did appear to be cost-effective when costing included unpaid carer time and quality of life was considered in the assessment of outcome. The authors comment on the possibility that the effect of mirtazapine may be mediated by improvements in sleep and reduction in anxiety rather than reduction in depressive symptoms.
Intergenerational transmission of risk for psychopathology
Offspring of mothers with depression are well known to be at increased risk of developing psychopathology but outcomes are variable and little is known about the determinants of such variability. Sellers et al (pp. ) undertook a longitudinal investigation of mothers with recurrent depression and their adolescent offspring. Co-occurring problems such as anxiety, antisocial behaviour and problem drinking were found in 40% of mothers. Rates of new-onset disorder in offspring were found to be associated with the number of such co-occurring maternal mental health problems, even after account was taken of the severity of maternal depression. In a linked editorial, Ramchandani & Murphy (pp. ) highlight the complexity of likely mechanisms underpinning the association between parental depression and offspring risk of psychopathology, and warn against assumptions of causality. They do, however, call on clinicians and clinical services to consider the impact of parental mental disorder on offspring and implement supportive interventions for affected children.
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