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Biomedical subjects

R H Howland

Publications and source records attributed to R H Howland.

At least 19 recordsLinked to original sources
PubMed1998

Workplace performance effects from chronic depression and its treatment.

Utilizing data from a clinical trial and an econometric model incorporating the impact of a medical intervention and regression to the mean, we present evidence supporting the hypotheses that for chronically depressed individuals: (i) the level of perceived at-work performance is negatively related to the severity of depressive status; and (ii) a reduction in depressive severity improves the patient's perceived work performance. Improvement in work performance is rapid, with about two-thirds of the change occurring already by week 4. Those patients having the greatest work improvement are those with both relatively low baseline work performance and the least severity of baseline depression.

Chronic Disease↗
PubMed1998

Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine.

BACKGROUND: The literature on predictors of response to treatment of nonchronic major depression has identified shorter duration of illness, acute onset, and less severity of illness as positive predictors. Unfortunately, there are almost no data on predictors of response to treatment for chronic depression. This study examined predictors of response to pharmacotherapy (sertraline or imipramine) in the treatment of outpatients who had DSM-III-R-defined chronic major or double depression. METHOD: The acute phase of the Chronic Major Depression and Double Depression Study is a double-blind, randomized, parallel-group 12-week comparison of sertraline and imipramine. Analyses are based on 623 patients who comprised the intent-to-treat sample, of whom 299 were nonresponders and 324 were responders, defined by a priori criteria as either remission or satisfactory therapeutic response. A stepwise logistic multiple regression analysis was performed on candidate clinical, psychosocial, and demographic variables previously identified as statistically significant in an attempt to develop a predictive model of positive antidepressant response. RESULTS: The sociodemographic variables that were predictive of positive response included living with spouse or partner or being at least a high school graduate. With regard to symptomatology and clinical history, responders had significantly lower baseline depression severity scores. In general, comorbid anxiety, substance abuse, and personality disorders did not influence rates of response. However, the presence of depressive personality traits was associated with a higher nonresponse rate. Among psychosocial variables, longer duration of personal relationships as well as higher baseline quality of life were associated with positive response. A stepwise logistic multiple regression identified 5 variables-living with spouse or partner, higher educational level, passive-aggressive personality, lower introverted-tense personality traits, and higher quality of life--that significantly and independently contributed to the predictive model. This model correctly classified 67% of patients. CONCLUSION: A higher baseline quality of life, living with spouse or partner, and having more education were the strongest predictors of response to acute pharmacotherapy among chronically depressed patients. Clinical variables and comorbidity were not identified as independent predictors, although personality traits did appear to influence treatment response. Overall, the predictive value of these baseline measures was modest, and therefore of limited clinical utility.

Adult↗
PubMed1998

Treating antidepressant nonresponders with augmentation strategies: an overview.

This paper provides an overview of antidepressant nonresponse and the role of augmentation strategies in the management of treatment-resistant depression. When effective, the more widely used augmentation strategies, including lithium salts, thyroid hormones, pindolol, buspirone, and psychostimulants, share two important advantages when compared with "switching" strategies: avoidance of ill effects associated with discontinuing the initial antidepressant and rapidity of onset of action. Ideally, advances in the understanding of the neurobiology of mood disorders and mechanisms of antidepressant response will permit a more efficient and specific matching between patient, initial antidepressant, and subsequent strategy for enhancing response to treatment.

Antidepressive Agents↗
PubMed1997

A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy.

The definitions that are commonly employed to describe the outcome of the depressive disorders are often used in inconsistent ways and remain largely untested. The lack of a standard and valid set of outcome definitions hinders the study of the naturalistic course and treatment of depressive disorders. In the present study, we operationalized definitions for response, remission, relapse, recovery, and recurrence and examined their validity in a sample of depressed patients treated with cognitive behavior therapy. Validity was evaluated by the ability of the definitions to predict subsequent outcome in acute treatment and during a 3 year follow-up period. All five definitions demonstrated moderate to excellent validity. Moreover, we were able to empirically distinguish response from remission, and relapse from recurrence, despite the frequent confusion of these terms in the literature. Several of the findings suggest that continued refinement of the outcome definitions may enhance validity even further.

Adult↗
PubMed1997

Pharmacotherapy of inpatients with bipolar depression.

The pharmacotherapy of bipolar depression has not been well studied. Controlled studies support the efficacy of some antimanic and antidepressant drugs, but these studies usually exclude patients typically seen in nonresearch settings. The purpose of this study was to examine the pharmacotherapy of 69 inpatients with bipolar depression. More than 90% of the patients received at least one antimanic drug, and lithium was used most frequently. Only one-half of the patients received antidepressants. Three-quarters of antidepressant-treated patients received serotonin reuptake inhibitors or other nontricyclic drugs. There were few differences between antidepressant- and non-antidepressant-treated patients. Psychotic patients were more likely to receive lithium, neuroleptics, and anticholinergics, whereas nonpsychotic patients tended to receive anticonvulsants more often. Psychotic patients were also more likely to receive polypharmacy. These results suggest that polypharmacy of inpatients with bipolar depression is common, and that psychosis is an important variable in the choice of pharmacotherapy.

Adult↗
PubMed1997

Sleep-onset rapid eye movement periods in neuropsychiatric disorders: implications for the pathophysiology of psychosis.

This paper reviews the literature describing the occurrence of sleep-onset rapid eye movement periods in narcolepsy, schizophrenia, psychotic depression, and delirium tremens; the association of narcolepsy with psychotic disorders; the neuropathology of the brainstem in narcolepsy and schizophrenia; and other behavioral disorders resulting from probable brainstem pathology. These findings suggest that some forms of psychosis are a manifestation of pathophysiological changes in the brainstem. Some implications of this hypothesis for the treatment of psychoses are discussed. Future research should investigate psychoses and the psychobiological correlates of such biological markers as sleep-onset rapid eye movement periods across diagnostic categories.

Alcohol Withdrawal Delirium↗
PubMed1996

Induction of mania with serotonin reuptake inhibitors.

Serotonin reuptake inhibitors (SRIs) are now considered the first-line treatment for depression, but they have not been well studied in bipolar disorder. Recently, some authors have recommended that patients at risk for antidepressant-induced mania be treated with SRIs rather than tricyclic antidepressants (TCAs). Clinical information about 11 patients who developed mania during treatment with SRIs is described. These patients were found to have personal or family histories of hypomania or mania, but these disorders were not usually recognized at the time of the patients' initial treatment for depression. The SRI-induced manic episodes were also quite severe, having psychotic features or requiring patients to be secluded for extreme agitation, but patients responded completely to antimanic treatment. The risk of treatment-emergent mania with SRIs is not trivial, especially among patients at risk for bipolar disorder. Additional research is needed to compare the actual rate of drug-induced mania with SRIs and TCAs in patients with different bipolar subtypes, while controlling for concurrent antimanic drug use.

Adult↗
PubMed1996

Hypothalamic-pituitary-adrenocortical activity and response to cognitive behavior therapy in unmedicated, hospitalized depressed patients.

OBJECTIVE: Surprisingly little research supports the hypothesis that depressions characterized by objective measures of neurobiological dysregulation respond poorly to psychotherapy. Moreover, relevant studies testing this hypothesis have been compromised by low rates of neurobiological abnormality in outpatient samples. The authors therefore investigated response to cognitive behavior therapy in relation to pretreatment measures of hypothalamic-pituitary-adrenocortical (HPA) activity in hospitalized, yet unmedicated, patients. METHOD: The subjects were 29 unmedicated, hospitalized patients with major depression (DSM-III-R and Schedule for Affective Disorders and Schizophrenia/Research Diagnostic Criteria), nonpsychotic/nonbipolar subtype. After a 7- to 14-day evaluation, urinary free cortisol levels and dexamethasone suppression tests (DSTs) were obtained. Patients were treated for an average of 3 weeks with intensive individual cognitive behavior therapy. Response was assessed in relation to clinical severity of illness and pretreatment HPA parameters. RESULTS: Response to inpatient cognitive behavior therapy was inversely associated with pretreatment urinary free cortisol concentrations, although not strongly correlated with DST results. Overall, 12 (92%) of 13 cortisol suppressors on the DST who had normal urinary free cortisol concentrations responded to treatment, compared with only seven (44%) of the 16 patients characterized by nonsuppression of cortisol and/or elevated urinary free cortisol excretion. The relation between response to cognitive behavior therapy and HPA activity was not explained by clinical measures of symptom severity. CONCLUSIONS: Results are consistent with the hypothesis that patients with increased HPA function are less responsive to psychotherapy and, hence, might require somatic interventions. It is proposed that the negative impact of hypercortisolism on neurocognitive function mediates this relationship.

Adolescent↗
PubMed1995

The treatment of persons with dual diagnoses in a rural community.

Persons with dual diagnoses of psychiatric illness and substance abuse represent a large subpopulation within the mental health system, but mental health service delivery systems typically do not adequately address their special needs. The literature on dual diagnoses is marked by the paucity of information on such persons in rural settings. This paper describes the characteristics of a rural community mental health system, which illustrate the difficulties in treating persons with dual diagnoses in rural communities. These problems include a fragmented system of services, centralized services in a large geographic area, overly restrictive regulations, conceptual differences in treatment approaches, confidentiality and stigma in a rural culture, and the academic and professional isolation of mental health workers, leading to high turnover and a shortage of staff having sufficient training and experience to work with persons with dual diagnoses. Some recommendations to address these problems and to improve the delivery of services to persons with dual diagnoses are suggested.

Community Mental Health Services↗