Annotated Abstracts of Journal Articles
2015, 1st Quarter
Annotations by Jane Walker, MBChB, MSc, PhD, MRCPsych
ANNOTATION (Jane Walker)
The Finding: Patients who attended at least three sessions of meaning-centered group psychotherapy had greater improvements in spiritual well-being and quality of life (co-primary outcomes) than those who attended supportive group psychotherapy. Intention-to-treat analyses also found statistically significant differences in quality of life.
Strengths and Weaknesses: The main strength of this study is that randomization was used to allocate treatments. Its main weaknesses are substantial attrition (32% of participants never attended any group sessions) and the lack of a threshold for distress as an entry criterion.
Relevance: This study is relevant to C-L psychiatrists who are considering whether different forms of group therapy might be beneficial for their patients with advanced cancer. The study provides some useful information about uptake of these groups.
Purpose: To test the efficacy of meaning-centered group psychotherapy (MCGP) to reduce psychological distress and improve spiritual well-being in patients with advanced or terminal cancer.
Patients and Methods: Patients with advanced cancer (N=253) were randomly assigned to manualized eight-session interventions of either MCGP or supportive group psychotherapy (SGP). Patients were assessed before and after completing the treatment and 2 months after treatment. The primary outcome measures were spiritual well-being and overall quality of life, with secondary outcome measures assessing depression, hopelessness, desire for hastened death, anxiety, and physical symptom distress.
Results: Hierarchical linear models that included a priori covariates and only participants who attended ≥ three sessions indicated a significant group × time interaction for most outcome variables. Specifically, patients receiving MCGP showed significantly greater improvement in spiritual lwell-being and quality of life and significantly greater reductions in depression, hopelessness, desire for hastened death, and physical symptom distress compared with those receiving SGP. No group differences were observed for changes in anxiety. Analyses that included all patients, regardless of whether they attended any treatment sessions (ie, intent-to-treat analyses), and no covariates still showed significant treatment effects (ie, greater benefit for patients receiving MCGP v SGP) for quality of life, depression, and hopelessness but not for other outcome variables.
Conclusion: This large randomized controlled study provides strong support for the efficacy of MCGP as a treatment for psychological and existential or spiritual distress in patients with advanced cancer.
ANNOTATION (Jane Walker)
The Finding: Single administrations of ketamine were more efficacious than saline or midazolam in reducing depressive symptoms (at 1, 3 and 7 day follow-up) in patients with a major depressive episode (as part of either major depressive disorder or bipolar disorder). Ketamine was accompanied by transient psychotomimetic and dissociative symptoms.
Strengths and Weaknesses: The main strengths of this systematic review are its inclusion of only randomized controlled trials that met basic quality criteria and the analysis of both efficacy and adverse effects. Its main weaknesses are that all trials were small (N<80), the majority used a cross-over design, and none focused on patients at the end of life.
Relevance: Ketamine is sometimes used by C-L psychiatrists working with depressed patients at the end of life. Unfortunately this review failed to find any trials in medically ill populations.
Background: There is growing interest in glutamatergic agents in depression, particularly ketamine, a glutamate N-methyl-d-aspartate (NMDA) receptor antagonist. We aimed to assess the efficacy of ketamine in major depressive episodes.
Method: We searched EMBASE, PsycINFO, CENTRAL, and Medline from 1962 to January 2014 to identify double-blind, randomized controlled trials with allocation concealment evaluating ketamine in major depressive episodes. Clinical remission, response and depressive symptoms were extracted by two independent raters. The primary outcome measure was clinical remission at 24 h, 3 days and 7 days post-treatment. Analyses employed a random-effects model.
Results: Data were synthesized from seven RCTs employing an intravenous infusion and one RCT employing intranasal ketamine, representing 73 subjects in parallel arms and 110 subjects in cross-over designs [n = 34 with bipolar disorder (BD), n = 149 with major depressive disorder (MDD)]. Ketamine was associated with higher rates of clinical remission relative to comparator (saline or midazolam) at 24 h [OR 7.06, number needed to treat (NNT) = 5], 3 days (OR 3.86, NNT = 6), and 7 days (OR 4.00, NNT = 6), as well as higher rates of clinical response at 24 h (OR 9.10, NNT = 3), 3 days (OR 6.77, NNT = 3), and 7 days (OR 4.87, NNT = 4). A standardized mean difference of 0.90 in favor of ketamine was observed at 24 h based on depression rating scale scores, with group comparisons revealing greater efficacy in unipolar depression compared to bipolar depression (1.07 v. 0.68). Ketamine was associated with transient psychotomimetic effects, but no persistent psychosis or affective switches.
Conclusion: Our meta-analysis suggests that single administrations ketamine are efficacious in the rapid treatment of unipolar and bipolar depression. Additional research is required to determine optimal dosing schedules, route, treatment schedules, and the potential efficacy of other glutamatergic agents.