Targeting dissociation in treatment-resistant patients with depressive or anxiety disorders may improve the effectiveness of overall treatment response, suggests a new study in the journal Neuropsychiatric Disease and Treatment.
“Lower treatment efficacy in reduction of anxiety and depression symptoms was associated with higher rates of dissociation at the beginning of the treatment, and reduction of dissociation during the treatment correlated with decrease in severity of the disorder and also with reduction of symptoms of depression and anxiety,” wrote Jan Prasko, MD, PhD, of the Palacky University Hospital Olomouc in Czech Republic and his colleagues. “This result could pave way for developing innovative treatment strategies for resistant patients with anxiety or depressive symptomatology in future.”
The authors also noted that “the responses of patients with panic disorder and agoraphobia were significantly greater than those of patients in OCD or dissociative/conversion diagnostic groups,” although no other diagnostic groups showed significant differences in therapy response.
Overall, “the improvement and remission rate are encouraging in the light of the fact that these patients had been resistant to the previous outpatient pharmacological treatment,” the authors wrote.
Dr Prasko’s team analyzed 606 inpatients with anxiety or depressive spectrum disorders, including depressive disorder, panic disorder, generalized anxiety disorder, mixed anxiety-depressive disorder, agoraphobia, social phobia, obsessive compulsive disorder, post-traumatic stress disorder, adjustment disorders, dissociative/conversion disorders, somatoform disorder, or another anxiety/neurotic spectrum disorder.
Each patient completed the Beck Depression Inventory, Beck Anxiety Inventory, a subjective version of Clinical Global Impression-Severity, the Sheehan Patient-Related Anxiety Scale and the Dissociative Experience Scale.
The patients had all been resistant to pharmacological treatment and referred to a 6-week inpatient therapeutic program involving cognitive behavioral therapy or brief psychodynamic therapy with individual and group sessions, along with antidepressants, anxiolytics and/or antipsychotics. Community sessions included drama therapy, progressive muscle relaxation, art therapy, mental imagery, occupational therapy, and physical activities.
During treatment, average scores on all assessments decreased (fewer symptoms), with 67.5% reaching at least minimal improvement. The researchers defined treatment response for both depressive and anxiety symptoms as at least a 30% improvement on their BDI-II or BAI scores, respectively. Overall, 45.7% experienced improvement in depressive symptoms, and 39.5% experienced improvement in anxiety symptoms. Just over a third of the patients (35.3%) experienced remission, and 42.4% showed moderate improvement or better.
Although patients with a comorbid personality disorder did not experience as much significant improvement with depression symptoms as those without that comorbidity, patients both with and without a personality disorder had similar changes in anxiety symptoms and severity.
“Comparison of the efficacy between patients with and without personality disorders showed that this reduction in depressive symptoms did not influence the reduction in overall severity of the disorder,” the authors reported.
Those with a higher degree of dissociation at baseline experienced minor improvement in depressive and anxiety symptoms, as hypothesized, but did not experience changes in overall disorder severity.
“These findings are equivocal and show that changes in concrete symptoms cannot reflect the subjective meaning of the overall severity of the disorder,” the authors wrote. They also reported that a greater response to therapy resulted in a bigger drop in dissociation level.
Despite hypothesizing that treatment responses would differ according to marital status, heredity and employment status, the researchers found no differences associated with employment status.
Marital status only appeared to be a mediating factor with anxiety symptoms, not with depressive symptoms or overall clinical severity. And only the severity of the disorder differed in patients with and without a family history of the illness, based on CGI-S scores.
“It remains unclear whether a positive family history of depression or anxiety disorder affects the effectiveness of treatment for major depressive or anxiety/neurotic spectrum disorders,” the authors wrote.
Prasko J, Grambal A, Kasalova P, et al. Impact of dissociation on treatment of depressive and anxiety spectrum disorders with and without personality disorders. Neuropsychiatr Dis Treat. 2016 Oct 17;12:2659-2676. doi:10.2147/NDT.S118058.