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First High Quality Study of Cognitive Behaviour Therapy in Depression

MD-FM Thursday February 7, 2013




GENERIQUE
Carillon
 
Sarah:
MD FM — Medical News from around the world with Peter Goodwin.

P1

PETER:
Hello, and with me is Sarah Maxwell. To begin with: for patients with severe depression in whom anti-depressants aren’t working, adding cognitive behavioral therapy — or CBT —  can be twice as effective as pressing on with anti-depressants alone:
 
SARAH:
Yes, these results — published in The Lancet — are from the first high quality study looking at CBT for severe depression. Nearly 500 patients who’d had at least six weeks of antidepressant treatment — without any improvement — were randomized to either: continue on antidepressants alone for 12 months or, have up to 18 sessions of CBT in addition to antidepressant therapy:

Bob-Lewis-1: “Those who did receive CBT had a much greater rate of improvement: At about 6 months, 46% of those who received CBT in addition to usual care improved against about 22% of those who just had the usual care --so that was quite a substantial improvement, which we could attribute to cognitive behavior therapy.”
 
SARAH:
That was senior study author Glyn Lewis, from the University of Bristol in the UK, who added that until now, there was little evidence available to help clinicians choose a follow-on option for patients whose symptoms didn’t respond to standard drug therapies. And he told MDFM, that the CBT approach is gaining ground at every level of treatment:
 
Bob-Lewis-2: “I think there’s a lot of interest in CBT because there is now a lot of evidence for previously untreated depression that it is an effective treatment, more so than many of the other psychotherapies.”  

SARAH:
Professor Glyn Lewis, from Bristol.

P2

PETER:  
And in another study — published in JAMA Psychiatry — for patients with major depressive disorder, combining trans-cranial direct-current stimulation with sertraline hydrochloride was more effective than having either separately. A change in score at six weeks using the “Montgomery-Asberg depression rating scale” was the primary outcome measure in the trial and the difference found of three points was considered to be clinically relevant.

VIRGULE MUSICALE

P3

PETER:
Levels of Lipoprotein-A are associated with aortic calcification and stenosis, according to results published this week in the New England Journal of Medicine…
 
SARAH:
Yes, a study from Scandinavia showed that having a genetic variation in the coding of the LPA gene, increased the risk of developing aortic calcification and stenosis by about 60% over a 10 to 15 year period. Lead study author George Thanassoulis:
 
Bob-Thanassoulis-1: “I think there’s increasing evidence that LPA is an important cardiovascular risk factor. We definitely screen for common forms of cholesterol: LDL, HDL, triglycerides... Definitely we are going to be seeing more people measuring lipoprotein A, which can be measured clinically. We know now that LPA increases the risk of having myocardial infarction and now our data adds to that and says ‘well it also seems to be an important risk factor for aortic stenosis.’ So basically two of the most common cardiovascular diseases have been linked with LPA.”
 
SARAH:
Doctor George Thanassoulis from McGill University in Canada and his team performed a genome wide association study with about 7,000 people.
 
PETER:
Except for valve replacement, there aren’t really any drugs available to treat people for the effects of this unusual form of dislipidemia are there?
 
SARAH:
Well, your right there’s not too much, but there is hope for the future:
 
Bob-Thanassoulis-2: “Although we don’t have that many drugs that reduce lipoprotein A there is a very old medication known as niacin, which does lower LPA by about 20 to 30%. So an interesting next step would be to consider performing a randomized trial of individuals who have early valve disease and seeing whether LPA lowering with niacin for example could eventually slow the progression of valve disease.”
 
SARAH:
That was George Thanassoulis from McGill University.

VIRGULE MUSICALE
 
P4

PETER:
For protecting babies against tuberculosis infection, an alternative vaccine candidate was no better than the current BCG according to findings reported in The Lancet...
 
SARAH:
Yes, the candidate vaccine had shown promise in earlier investigations but was only 17% effective in this trial. 3,000 babies — previously vaccinated with BCG — were randomized to have either a placebo jab or the new vaccine — MVA85A. We asked Paul Fine — who wasn’t an author of the study, to comment on the results:

Bob-Fine-1: “17 percent is so small, it is not statistically significant, and even if it were, it’s so small that one would not want to deliver such a vaccine in a population. On the other hand, it may be an indicator of some very low level of protection induced by these antigens and perhaps after exploring the samples, the various immunological samples that they’ve collected, they will look at responsiveness, for example, of cell types to different antigens. It may give them indicators of the sorts of immune response which they need to generate in order to provide protection --let us hope.”
 
SARAH:
Paul Fine, from the London School of Hygiene and Tropical Medicine added that this doesn’t signal the end of the line for the new vaccine…

Bob-Fine-2: Now we don’t know --maybe this vaccine would provide protection in another population, which hadn’t received BCG. It may be that the protection imparted by BCG had masked any effect that could be imparted by this particular vaccine.”
 
SARAH:
Professor Paul Fine in the UK — who pointed out that there are another ten TB vaccines currently in development.


VIRGULE MUSICALE


P5

PETER:
For patients with tennis elbow, having physiotherapy after corticosteroid injection doesn’t improve long-term outcomes…

SARAH:
Yes, in a study published in JAMA, all patients were first given an injection of either steroids or placebo then half of each group had physiotherapy. Bill Vicenzino, from the University of Queensland in Australia:

BOB-Vicenzino: “What everyone says is that the reason why patients get recurrences is because they feel good for a while and then they go off and hurt themselves by doing too much too soon, and the remedy that’s always been recommended, and it still is, is that people should have physiotherapy soon after the injection to insure that they get rehabilitation so they don’t get a recurrence”

SARAH:
That was lead author Bill Vicenzino, who also said steroids were associated with poorer outcomes and higher recurrence rates at one-year compared with placebo, and physiotherapy did nothing to recurrence rates or long-term delaying and protective recovery. So, instead of steroids, what does he recommend?

BOB-Vicenzino: “First thing is education of the patient, second thing: it’s reasonably well established that a pain-free graduated progressive exercise program for the muscles of about 6 to 8 weeks will help recovery of the muscle system and help reduce pain. We’ve also shown in some studies and previous clinical trials that if you add a manual therapy technique you can actually reduce the pain quite considerably sooner and allow exercise to occur better, and patients can learn how to do that themselves.”

SARAH:
Professor Bill Vicenzino from Australia.


BREVE 1 Sur fond musical
 
PETER:
Finally, in brief:

For patients with musculoskeletal problems, phoning a physiotherapist for advice and initial assessment without waiting for a face-to-face appointment, seems to be as clinically effective and safe as actually seeing her or him. And — according to a study in the British Medical Journal — the approach — based on the PhysioDirect system  — provided faster access to advice and treatment. But patient satisfaction was still an issue.

And...
 
BREVE 2

In men with and without a history of cardiovascular disease, the risk of death and future heart disease increased with the severity of erectile dysfunction. That’s according to findings published in PLOS Medicine that say, ED could serve as a useful marker to identify men who should get further testing to assess their risk of cardiovascular diseases.

That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then, from me Peter Goodwin, goodbye.
 
JINGLE FIN     
 

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