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Background: The return of depressive symptoms during maintenance antidepressant treatment is a common phenomenon, but has attracted very limited research attention. The aims of this investigation were to explore the feasibility of a family intervention approach to loss of clinical effect during long-term antidepressant therapy and to compare this approach with dose increase. Method: Twenty outpatients with recurrent major depressive disorder (diagnosed using Research Diagnostic Criteria, i.e., patients were at their third or greater episode of major depressive disorder, with the immediately preceding episode being no more than 2.5 years before the onset of the episode which led to antidepressant treatment) who lived with a partner and relapsed while taking antidepressant drugs were randomly assigned to (1) family intervention approach according to the McMaster Model and maintenance of the antidepressant drug at the same dosage or (2) dose increase and clinical management. A 1-year follow-up was performed. The study was conducted from January 2002 to December 2004. Results: Seven of 10 patients responded to an increased dosage; all but 1 relapsed again on that dosage during follow-up. Seven of 10 patients responded to family intervention, but only 1 relapsed during follow-up. The difference in relapse was significant (p

Objective: Administration of treatments in a sequential order is a common practice in clinical medicine, but has received insufficient attention in psychiatry. The aim of this review was to survey the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood and anxiety disturbances. Data sources and study selection: A review of the clinical trials in which treatment components were used in a sequential order (i.e., pharmacotherapy followed by psychotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another, or one psychotherapeutic technique following another) was performed. Studies were identified by using MEDLINE (English language articles published from 1967 to March 2005; keywords: sequential treatment, drugs and psychotherapy, combined treatment related to depressive disorder, bipolar disorder, depression, mania, anxiety disorders, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder) and a manual search of the literature and Index Medicus for the years 1960 to 2005. Data synthesis: In unipolar recurrent depression, the sequential use of pharmacotherapy was found to reduce relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already undergoing treatment with mood stabilizers was also found to yield clinical benefits. In anxiety disorders, the sequential use of pharmacotherapy and psychotherapy was not found to improve long-term outcome. Conclusion: The sequential treatment of mood and anxiety disorders does not fall within the realm of maintenance strategies. It is an intensive, 2-stage approach, which is based on the fact that one course of treatment with a specific treatment (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the complex array of symptoms of patients with mood and anxiety disorders. The sequential model introduces a conceptual shift in current assessment methods.

Objective The aim of this study was to assess the presence of demoralization and major depression in the setting of medical disease. Method 807 consecutive outpatients recruited from different medical settings (gastroenterology, cardiology, endocrinology, and oncology) were assessed according to DSM-IV criteria and Diagnostic Criteria for Psychosomatic Research, using semistructured research interviews. Results Demoralization was identified in 245 patients (30.4%), while major depression was present in 135 patients (16.7%). Even though there was a considerable overlap between the 2 diagnoses, 59 patients (43.7%) with major depression were not classified as demoralized, and 169 patients (69.0%) with demoralization did not satisfy the criteria for major depression. Conclusions The findings suggest a high prevalence of demoralization in the medically ill and the feasibility of a differentiation between demoralization and depression. Further research may determine whether demoralization, alone or in association with major depression, entails prognostic and clinical implications.

Background: The application of cognitive-behavioral treatment (CBT) to patients with bipolar disorder who had an affective episode while on lithium prophylaxis has received little research attention. The aim of this preliminary study was to test whether reduction of residual symptomatology by cognitive-behavioral methods could yield long-term beneficial effects in patients with bipolar disorder, as was found to be the case in recurrent unipolar depression. Method: Fifteen patients with RDC bipolar disorder, type I, who relapsed while on lithium prophylaxis despite initial response and adequate compliance were treated by cognitive-behavioral methods in an open trial. A 2- to 9-year follow-up was performed. Results: Five of the 15 patients had a new affective episode during follow-up. CBT was associated with a significant reduction of residual symptomatology. Conclusion: These preliminary results suggest that a trial of CBT may enhance lithium prophylaxis and improve long-term outcome of bipolar disorder.