Akhil Jay Khanna, M.D.
 https://www.hopkinsmedicine.org/profiles/results/directory/profile/0009137/jay-khanna Cardiac arrhythmias Central nervous system paring patients older than and younger than 65 years old womens health 33511 purchase premarin 0.625mg free shipping, Dementia Pentland et al womens health 022013 order 0.625mg premarin amex. Patients 60 years and older took longer than 7 days ing patients older than and younger than 55 years on average to become responsive to commands compared matched for injury severity and gender pregnancy exercises buy premarin with paypal, Cifu et al women's health big book of exercises results buy premarin now. Additionally, observed that the older patient group had a signicantly the older patients were more likely to have complications longer mean length of rehabilitation stay, higher total such as cardiac arrest, ventriculitis, and sepsis. Thus, rehabilitation charges, and a slower rate of improvement although mild injuries were associated with only slightly on functional measures. Comparing psychosocial outcomes at 1 year group age postinjury in patients of various ages, Rothweiler et al. Author (years) Functional outcome (1998) found that patients ages 60 years and older were Pentland et 65+ vs. Cognitive functioning exerts a substantial inuence on functional independence in all age groups. Severity of injury generally inuences the extent of the inappropriate prescription of a variety of medications, resulting cognitive impairment, though at least one study particularly psychoactive drugs (Zhan et al. However, they also noted similar cognitive impairment in a comparison group of orthopedic inpa Summary tients. In particular, secondary role of medications, particularly polypharmacy, in the el organ failure is much more common and appears to con derly. An additional concern is the concomitant injury, there is a dramatic increase in cholinergic, sero use of psychoactive medications and other drugs that can have an adverse effect on cognition. Cholinergic Systems Neurobiology of Aging Acetylcholine innervation is widely distributed through the human brain achieves full maturity in the second or out the brain. The majority of cholinergic bers originate third decade of life, and age-associated histological in the nucleus basalis of Meynert in the basal forebrain changes develop after age 40 years (Powers 2000). No consistent loss of acetylcho in aging rodents show slowed protein synthesis and line content is found in the brains of healthy elderly axonal transport, indicative of less active metabolism. This atrophy may result from a loss ever, the data in healthy aging humans indicates of neurons, decrease in neuronal volume, and loss of syn minimal reduction or no change at all (Muller et al. On the other hand, cerebrospinal uid levels of the of cortical neurons in many areas may remain stable degradative enzyme acetylcholinesterase are increased through advanced age (Haug and Eggers 1991). The nucleus basalis of Mey growth-associated proteins are considered to be an indi nert begins to atrophy after age 60 years, with neuronal cation of neural plasticity, because they are necessary for loss observed mainly in posterior regions (Finch 1993). Thus, the aging the locus ceruleus is the primary source of noradrenergic brain may be less able to mount an effective regenerative bers innervating the human forebrain (Powers 2000). Age Loss of noradrenergic neurons in the locus ceruleus begins related cerebrovascular changes also lead to a gradual in the fourth decade of life and progresses in a linear fash reduction in cerebral perfusion (Choi et al. This shrinkage adrenergic synthetic enzymes tyrosine hydroxylase and increases the distance between the brain and skull, mak dopamine -hydroxylase also occur in the aging brain ing dural vessels more vulnerable to shearing damage (Powers 2000). Neurochemical changes associated with aging Neurotransmitter Location Change Receptor location Receptor alterations Acetylcholine Nucleus basalis of Meynert v or > Neocortex v M1 and M2 v N Medial septal region In aging patients, decreased density of D2 receptors dopamine and other catecholamines, increasing the risk is associated with cognitive dysfunction that is suggestive of of depression and attentional problems. Experimen tially be less responsive to these treatments because of the tal chemical injury to rat brains produces a more severe reduced density of postsynaptic D1 and D2 receptors in el excitotoxic reaction in the mature animals compared with derly patients (Antonio et al. Neurochemical changes ratio of a suboptimal outcome (fair or unfavorable) was in the aging brain may lead to increased vulnerability to 13. No difference was found on the high prevalence of dementia among former boxers with cognitive measures. This suggests tremor, ataxia, bradykinesia, and cognitive impairment that the apoE 4 allele may interact with cumulative expo (Roberts 1969). Histopathological ndings include neu sure to mild head trauma, leading to cognitive impairment. Thus, the presence of the apoE 4 records of 1,283 patients ages 40 years and older. In this scenario, a patient may present with several weeks or months of progressive cognitive impair ment. Alterations in functional capacity unwitnessed fall or other head trauma that was not over time. Global cerebral perfusion is diminished in normal aging in older individuals because of numerous factors, including (Choi et al. Particularly important is the establishment of a age-related changes may complicate interpretation of results. Frequently, such history must be characterized by a fairly narrow range of impaired perfor obtained from relatives and friends. Moreover, excessive noise and other stimuli that may overwhelm and decreased processing speed in healthy elderly subjects occurs confuse the patient. Caregivers should be trained to only when multiple tasks are involved (Salthouse and Coon approach the patient directly and speak clearly in brief, suc 1993). Reinforcement of communication through pervasive and may thus be distinguished from normal aging. Neuropsychological testing may help identify areas of decit and areas of preserved function. This may assist in the development of environmental and communication Summary modications to enhance function. Obtaining detailed collateral history of the For the patient struggling with adaptation to new cognitive presenting syndrome is critical, as is a history of prior inju and functional impairments, supportive psychotherapy ries and cognitive functioning. Structural as well as func may be helpful in easing distress and obviating the need for tional neuroimaging provide important data regarding the psychotropic medications. Age-related alterations in brain structure and function therapy may be modied readily to accommodate the spe require consideration of these changes when interpreting cic circumstances and needs of elderly patients and may results. These factors that confound the use of formal testing prove quite effective for depressive disorders, particularly and neuroimaging in the elderly accentuate the importance when combined with pharmacotherapy (Miller et al. Caregivers and patients must be helped in the process of grieving lost functioning. As in the dementias, behavioral disturbances are a major cause of caregiver distress and an Pharmacological Treatment obstacle to successful community functioning. Likewise, Pharmacological interventions should take into consider such disturbances may accelerate the need for institutional ation the increased sensitivity of elderly patients to medica placement (Dunkin and Anderson-Hanley 1998). Therefore, work Increases in body fat composition may increase elimination ing with caregivers with supportive and educational inter half-life of lipid-soluble medications, whereas decreased ventions may improve functional outcomes. Neuropsychiatric Syndromes Environmental Interventions Depression Environmental interventions should address age-associ Depression is an independent risk factor for mortality in ated sensory decline. Age-related physiological changes and pharmacokinetic implications Clinical implications in relevant Function Pharmacokinetic effect drugs Absorption v Rate of absorption Delayed onset, incomplete absorption, reduced effect ^ Gastric pH v Gastric emptying v Mesenteric blood ow Distribution ^ Volume of distribution for lipophilic ^ Time until steady-state plasma drugs concentration v Muscle mass ^ Elimination half-life of lipophilic drugs v Duration of effect of single doses v Total body water Slower titration ^ Total body fat Plasma protein binding ^ Free fraction of highly protein-bound ^ Potency and toxicity at lower doses drugs v Albumin Reduced dosage v 1-acid glycoprotein Hepatic metabolism ^ Elimination half-life of hepatically ^ Time till steady-state plasma metabolized drugs concentration v Liver volume ^ Ratio of parent drug to demethylated Reduced dosage derivative v Hepatic blood ow Slower titration v Oxidative metabolism v N-Demethylation > Conjugation Renal clearance ^Elimination half-life of active hydrophilic ^ Time till steady-state plasma drugs concentration v Renal blood ow Reduced dosage v Glomerular ltration rate Slower titration Note. Therefore, stimulants or non by more irritability and apathy, with less overt sadness. Antidepres erbation of a preexisting dementia-related behavioral dis sant therapy may be extremely effective, particularly order.
In every age group pregnancy predictor discount premarin on line, there is a higher likelihood of a male suffering from a traumatic injury than a female pregnancy zumba dvd cheap premarin 0.625 mg without prescription. Brain and Spinal Cord Injury: 52 Lesson 6 the Rehabilitation Experience Anatomy menopause joint pain natural remedies proven premarin 0.625mg, Careers women's health center in langhorne buy premarin 0.625 mg on-line, and Injury Prevention Student Workbook shepherd. Her room here at the hospital is decorated with cards from everyone and she has the huge poster made by her classmates. As some of you may know, as a result of being hit by the car, Caylee has a brain injury. Once she was stable, we moved to a rehab hospital that specializes in brain injuries. The goal here is to help her relearn as much as she can and to make sure we can take care of her and keep her safe. Her team of therapists are teaching her the steps of all these every day activities like brushing her teeth, eating, grooming, getting dressed and going to the bathroom. She has a communication problem called aphasia, which means she has a hard time understanding what people are saying to her and processing information. Her speech therapist helps her with these issues, but recovery is slow and may take years. Since I have all of your attention, I just want to say that I hope each and every one of you learns from what happened to Caylee. This happened on a quiet street right by our house and the car that hit her was not going very fast at all. He is not aware when he needs to urinate or have a bowel movement, so he wears diapers. She was walking in a crosswalk on a green light and was hit by a driver who was trying to make it through before the light turned red. She has a few fractures and some scrapes, but the real problem is that she has a serious brain injury. She can say a few words, but clearly has a very hard time expressing a whole thought and understanding what others say to her. We have to repeat things a lot and have to be very patient with her with every activity. Maya has been able to stand up, but she has to lean on a walker and it takes a lot of energy just to get up. She might be able to walk on her own again one day, but we know it will be a long time from now and it might always be challenging. She has a very tough time remembering things, but does remember some important things from her life before. When she was fnally conscious and able to communicate, she told her doctor that she wanted to be a doctor. If either one of them had been paying better attention this might not have happened. All I can say is that I hope you learn something from what happened to my beautiful girl. She may not ever be a doctor like she planned, but maybe she can still save some lives by telling her story. The doctors told us that you never know how much better someone will get, but they fgured since I was young and healthy and my diaphragm muscle was working that I would be able to come off the ventilator. I had to practice breathing and I came off the vent for a little bit more time every day. There was a girl down the hall who got hurt in a gymnastics accident and she was on a vent too. Keep praying for me, Kendrick Brain and Spinal Cord Injury: 56 Lesson 6 the Rehabilitation Experience Anatomy, Careers, and Injury Prevention Student Workbook shepherd. About a week after that I was sent to the rehab hospital to start learning how to do things for myself again. The frst thing I had to do in rehab was take an exam, but nothing like what we have in school.
Cardiopulmonary resuscitation is the rst prior ity in initial care of the brain-injured patient womens health magazine careers buy premarin 0.625 mg overnight delivery. Next is control of intracranial pressure to maintain oxygen ow to the brain (Chua et al pregnancy z pack antibiotic buy 0.625 mg premarin. The panel conducted comprehensive electronic database searches of the neurotrauma literature up to April 2006 menstruation gas bloating discount premarin 0.625 mg visa. Two experts independently reviewed each study and clas sied it according to the level of evidence available womens health zinc purchase premarin 0.625 mg with mastercard, which in turn suggests the level of condence with which study ndings can be viewed. The levels of recommendations dened by the panel reect these levels of condence: t Level I recommendations represent principles of patient management that reect a high degree of clinician certainty. Tere is only one Level I recommendation: Steroids should not be used to manage increased intracranial pressure. Rehabilitation involves several domains, including physical, communication and language, vocational, sexual, and cognitive domains (National Guideline Clearing house, 2007). For example, individuals can experience physical complications, such as seizures, neuroendocrine dysfunction, and gastrointestinal complications. They may also have cognitive diculties, such as problems with attention and concentration, rea soning and problem-solving, and/or memory. Various assessment instruments can help track improvements in overall respon siveness. It is also important to conduct a neuropsychological evaluation, which includes measures of general intelligence, attention and concentration, learning and memory, language, visual-spatial abilities, and executive functions. Clinical intuition indicates that correcting hypotension and hypoxemia improves outcomes; however, clinical studies have not provided supporting data (Brain Trauma Foundation et al. There is no evidence to recommend repeated, deterioration not attributable to extracranial causes. Current evidence is not sufcient to make recommendations on use, concentration, and method of administration of hypertonic saline for the treatment of traumatic intracranial hypertension. Infection prophylaxis There is no support for use of prolonged antibiotics for systemic Level I: There are insufcient data to support a Level I recommendation. A single study supports the use of a short course to reduce the incidence of pneumonia. However, they do not change of antibiotics at the time of intubation to reduce the incidence of length of stay or mortality. Early extubation in qualied patients can be done without increased risk of pneumonia. Low molecular weight heparin or low-dose unfractionated heparin should be used in combination with mechanical prophylaxis. Intracranial pressure thresholds Level I: There are insufcient data to support a Level I recommendation. Brain oxygen monitoring and thresholds Level I: There are insufcient data to support a Level I recommendation. Jugular venous saturation or brain tissue oxygen monitoring measures cerebral oxygenation. Anesthetics, analgesics, and sedatives Analgesics and sedatives are a common management strategy for Level I: There are insufcient data to support a Level I recommendation. Nutrition Data indicate that feeding should occur by the end of the rst Level I: There are insufcient data to support a Level I recommendation. Hyperventilation Hyperventilation is not recommended in the rst 24 hours after Level I: There are insufcient data to support a Level I recommendation. Hyperventilation should be avoided during the rst 24 hours after injury, when cerebral blood ow is often critically reduced. If hyperventilation is used, jugular venous oxygen saturation or brain tissue oxygen tension measurements are recommended to monitor oxygen delivery. Steroids Routine use of steroids is not recommended (Roberts, 2000; Whyte Level I: the use of steroids is not recommended for improving or reducing et al. Systems of Care: Challenges and Opportunities to Improve Access to High-Quality Care 383 that guide behavior). Terapies for addressing these problems include cognitive-behavioral interventions, such as self monitoring, relaxation techniques, and anger management; supportive therapies that address issues of poor self-esteem; family or marital therapy; spiritual guidance; and education (Veterans Health Initiative, 2004). Turner-Stokes and Wade (2004) provide summary guidelines for assessment, treatment, and referral to rehabilitation (see Figure 7. Pharmacologic interventions can be used to treat specic symptoms, such as head ache and sleep disorder. Typically, post-traumatic headache is treated with nonsteroidal anti-inammatory drugs. Individuals who experience headaches and problems with depression, anger, irri tability etc. Nonpharmacologic interventions include providing individuals with educational materials regarding such symptoms as fatigue, irritability, and mood swings. Such services are best provided in an established inter disciplinary brain-injury program. The goal in the early rehabilitation phase is to help the individual restore maximal functional independence. Comprehensive, integrated post-acute programs are designed to serve clients with impaired awareness and other cognitive and behavioral diculties (Sander et al. Patients who participate in these types of programs tend to show positive changes and improved functioning in independent living, productivity, and social functioning at both discharge (Prigatano et al. In addition, long-term services may help prevent decline in indi vidual cases (Sander et al. When patients are in pain, the drug of choice is the one that controls the pain most eectively with the fewest central nervous system eects and drug-drug interac tions. Acetaminophen is often used because it is safe, inexpensive, and has very little central nervous system interaction. Many hospitals automatically order it to be given on an as-needed basis so that nurses do not have to call doctors; at home, people can buy it over the counter. Acetaminophen is administered using a dosing schedule rather than on-demand dosing (Veterans Health Initiative, 2004). Inpatient interdisciplinary programs generally provide three hours or more of formal therapy (physical, occupational, speech, recreational, neuropsychological) per day. Because co-occurring problems may impede the rehabilitation process, they should be assessed and managed. Common co-occurring problems include, but are not limited to , wound care; pressure sores; spasticity; post-traumatic epilepsy; asso ciated orthopedic injuries. Trudel, Nidier, and Barth (2007) provide a framework for community integrated rehabilitation that is based on work by Malec and Basford (1996). Community rehabilitation should include neurobehavioral programs, residential programs, comprehensive holistic day-treatment programs, and home-based programs. Briey, neurobehavioral programs focus on treat ing mood, behavior, and executive functions in a safe residential, nonhospital setting. Tese programs, which typically have interdisciplinary teams, emphasize development of functional skills (Wood et al. Residential programs were initially developed for individuals who required extended rehabilitation and 24-hour supervision but did not have access to adequate outpatient services. More recently, the lines have been blurred between neurobehavioral and community programs (Trudel, Nidier, and 386 Invisible Wounds of War Barth, 2007). Comprehensive holistic day-treatment programs target awareness, cogni tive functions, social skills, and vocational preparation through individual, group, and family interventions delivered by an interdisciplinary team (Ben-Yishay et al. Finally, home-based programs involve a variety of services and supports so that the individual can live at home. Tere is usually no identied treatment team, although a number of health and social-service systems may be collaborating to provide treat ment (Vander Laan et al. Cicerone and colleagues (2000) reviewed 655 articles on standards, guidelines, and options for cognitive rehabilitation. Of the 29 randomized controlled studies they found, 20 provided clear evidence that cognitive rehabilitation is eective.
It is not possible to cover all syndromes in one antibiotic prophylaxis may be necessary women's health center university blvd order premarin mastercard. Adrenal article pregnancy 23 weeks order premarin from india, but a Google search on the Internet provides an invaluable suppression can occur due to use of powerful topical steroids resource for the paediatric anaesthetist faced with a child with a rare or oral steroids necessitating perioperative steroid congenital syndrome pregnancy 7 weeks spotting buy 0.625mg premarin with mastercard. Airway management may be antenatal diagnoses in England and Wales from 1989 to 2008: analysis difcult as a result of oral lesions breast cancer metastasis order premarin online pills, limited mouth opening, adhesion of data from the National Down Syndrome Cytogenetic Register. Anaesthetic considerations dressings such Mepiform or Mepitel, which are silicone based. Oropharyngeal secretions can be cleared with lubricated soft suction catheters under low pressure, 8. Anaesthesia for this group of patients can be extremely challenging but with meticulous attention 9. Safety of neck rotation for ear surgery in children: pathophysiology, anaesthesia and pain management. It is a multisystem disease which affects approximately 4 million people worldwide. The basic Haemoglobin S (HbS) occurs as a result of a single principles of oxygenation, nature, rather than its insolubility. Tese patients such as thalaessaemia and haemoglobin C and have no normal adult haemoglobin (HbA) and only haemoglobin D. This is because polymerisation of have HbS, HbA2 and HbF, with approximately 95% HbS is afected by the presence of other haemoglobins, haemoglobin as HbS. It is thought thalassaemia with HbS result in disease ranging in that these parallel microfbrils cause red cell membrane severity depending on the nature of the thalassaemia damage and result in the classical sickle cell deformity mutation. In Equatorial Africa the sickle cell trait Specialist Registrar 15 days in homozygous sickle cell disease) with the occurs in up to 30% of the population. Heterozygotes for sickle cell anaemia show a Christie Locke (the lining of the vessel wall) due to the efects of marked resistance to malaria. The anaemia is usually well tolerated, In North America approximately 8% of the black population has sickle and adequate tissue oxygenation is maintained due to a compensatory cell trait, and up to 1. Abdominal pain occurs in older that causes HbS to precipitate in a hyperosmolar phosphate bufer children and can be caused by bowel dysfunction, organ infarction solution to produce a cloudy suspension. Tese abdominal crises can be difcult to distinguish from other common acute surgical disorders. Precipitants levels of HbS and high levels of HbF (with normal solubility) may for acute painful crises include infection, dehydration, cold, hypoxia result in false negative results. Electrophoresis of umbilical cord chest pain and the appearance of new lung lobar infltration on chest blood can be used for diagnosis in the newborn. Hypoxia is common and ventilatory support is occasionally needed in severe sickle chest crisis. The majority of patients are managed with oxygen therapy, hydration and blood transfusion. The incidence of acute chest syndrome in the postoperative child may be as high as 10% in those with severe disease undergoing major surgery. Risk factors for sickle chest crisis are age between 2-4 years and a persistently raised white cell count. Multiple episodes of acute chest syndrome in children are likely to result in pulmonary fbrosis and chronic lung disease as the child gets older. Tese are typically caused by vascular lesions in the cerebral vessels and may present as watershed infarctions during a sickle crisis (infarction occurring at the more vulnerable regions between major cerebral arterial zones). Transcranial Doppler ultrasonography can identify children at risk of cerebral infarction, by detecting reduced blood fow in cerebral vessels. It has been shown that treating patients at risk with regular transfusion programmes signifcantly reduces the incidence of stroke. Patients should be encouraged to drink free clear fuids until two hours before surgery. The pathophysiology of the disease is better understood and priapism many of the precipitating factors for sickle crisis in the perioperative Attacks start as young as the age of eight and are reported by up to period can be avoided (see below). Treatment includes hydration, exchange transfusion and intra evaluate whether blood transfusion should be given to patients with cavernous injections of an alpha-adrenergic agent. Although the recruitment target was 400 patients, the trial was ended early (after 70 patients) avascular necrosis as a review of patient safety identifed that there were more serious Intravascular sickling of the red blood cells in the microcirculation of complications in patients who did not receive pre-operative blood the bone results in intramedullary sludging, stasis, thrombosis, and 6 transfusion (unpublished data). However, aggressive transfusion regimens are associated with a high incidence of long-term complications of Scd in adults transfusion-associated complications. Recurrent sickle cell crises may cause many complications including gall stones, sickle retinopathy, leg ulcers, chronic renal failure due to In resource poor areas where screening for infection and highly specifc renal parenchymal scarring, pulmonary hypertension, chronic lung blood cross matching is limited, the balance of the risks versus the disease, and neurological impairment. Chronic bone damage may benefts of blood transfusion needs to be carefully considered. All children in a high-risk population or those with a positive family Guidelines may vary between hospitals and between regions. Transfusion may be used to increase the haemoglobin level; repeated pre-operative assessment and preparation top-up transfusion will also reduce the percentage of HbS in the Patients with a history of chest crisis, stroke, frequent painful crises, blood. It is important to surgery such as tonsillectomy or laparotomy: top-up transfusion to Hb 9-11g. All cases should be Oxygen saturation should be monitored continuously and discussed with a haematologist if possible supplemental oxygen should be given to maintain saturations >92%. Fluid management intraoperatiVe manaGement Continue intravenous maintenance fuids until the child is tolerating oxygenation oral fuids. The primary goal is to maintain good oxygenation during the postoperative analgesia perioperative period. Perioperative pulse oximetry monitoring is Management of post-operative pain is challenging. Patients may essential as patients may have impaired oxygen delivery resulting from have very high perioperative analgesic requirements, and may have chronic anaemia or chronic lung damage, and may have a limited developed tolerance to opioids. A multimodal approach should be ability to maintain tissue perfusion and oxygenation during hypoxic used with a combination of opioids where indicated, paracetamol and episodes. Dehydration may lead to increased nasopharyngeal airway tissue viscosity, poor perfusion, acidosis and increased sickling. The patient should be encouraged to drink clear paid to these patients postoperatively to avoid airway obstruction, fuids up until 2 hours before surgery, or if this is not possible, to have hypoventilation or hypoxia. A nasopharyngeal airway may be used intravenous fuids during the preoperative fasting period. Intravenous after tonsillectomy or in those with severe obstructive sleep apnoea to fuids should be used during surgery, and postoperative intravenous prevent post-operative airway obstruction and hypoxia. Acidosis causes increased sickling, with subsequent as serious post-operative complications usually occur within 48hrs of increased blood viscosity and impaired tissue perfusion. Tese include: the tissues to become more acidotic, causing further sickling, which may result in a sickle crisis. Tese should be avoided if there is evidence of of establishing intravenous fuids, oxygen therapy, analgesia, and peripheral vascular occlusive disease. Buy premarin once a day. New Children's Psychiatric Treatment Center in Wichita Kansas.
Studies breast cancer survival rates order genuine premarin on line, or findings within studies women's health clinic unionville purchase premarin 0.625mg overnight delivery, were also excluded if psychodynamic psychotherapy was initiated at the same time as other treatments menstruation 100 years ago buy premarin pills in toronto. Papers in which findings pertinent to this review were duplicated from other publications included in the review were excluded pregnancy quiz before missed period 0.625 mg premarin free shipping. Study Selection and Data Extraction the author performed the eligibility assessment of the studies in an unblinded, standardised manner. The following data were extracted from papers that met the eligibility criteria: study authors, year of publication, study design, intervention name, intervention duration, intervention characteristics, number of participants, participant characteristics, outcome measures, comparison conditions, intervention effectiveness, intervention effectiveness relative to comparison conditions, follow up length of time, number of participants at follow up, intervention effectiveness at follow up, intervention effectiveness relative to comparison conditions at follow up. In studies with more than one follow up point, the statistics for the final follow up point have been reported. Effect sizes for the differences between treatments 2 and differences between time points are reported. When these statistics were not reported in the original papers, they were calculated using the statistics available. Given that researchers rarely report these correlations, however, an acceptable alternative is to use means and standard deviations provided to estimate effect sizes. In the social sciences, guidelines for small, medium, and large effect 2 sizes for d are 0. Whenever possible, levels of statistical significance were also extracted from the papers. Findings the findings from the reviews of recent and Australian literature are presented separately. Review of Recent Literature Of the 1,343 records retrieved from the two databases, 59 papers met the eligibility criteria to be included in this review (see Figure 1). Systematic reviews and meta-analyses During the search, four combined systematic reviews and meta-analyses, nine meta analyses, and eight systematic reviews were found. Summaries of the papers with meta analyses are presented separately (see Table 1) from those in which only systematic reviews are reported (see Table 2). Collectively, the findings from these reviews demonstrate that psychodynamic psychotherapy, in various forms, is effective in the treatment of mood disorders (mainly depressive disorders), some anxiety disorders (mainly generalised anxiety disorder), somatic symptoms and somatoform disorders, and some personality disorders (mainly borderline and Cluster C personality disorders). Cluster C includes obsessive compulsive, avoidant, and dependent personality disorders (American Psychiatric Association, 2000). There is also evidence from a limited number of studies that psychodynamic psychotherapy can be effective in the treatment of eating disorders, post traumatic stress disorder, and some substance-related disorders (alcohol dependence, opiate dependence). Longer forms of psychodynamic psychotherapy may be more effective than short forms for the treatment of depression, anxiety, and general psychiatric symptoms. The evidence suggests that the effects of psychodynamic psychotherapy may endure after the termination of treatment. When follow up measurements have been included in studies, 4 there have generally been minimal changes in depression, mood, general psychopathy, and interpersonal functioning scores between the conclusion of treatment and follow up. In 17 of these studies, the efficacy of individual psychodynamic psychotherapy was investigated, with group therapy evaluated in the remaining study (Sandahl et al. Collectively, these studies included 1,845 participants in treatment and comparison conditions. Over half the studies (n = 11) included participants with anxiety or depressive disorders, with the findings suggesting that psychodynamic psychotherapy is effective in reducing the symptoms related to these conditions. A small number of studies have demonstrated that psychodynamic psychotherapy is beneficial in the treatment of hypochondriasis, borderline and other personality disorders, and alcohol-related disorders. The effects of psychodynamic psychotherapy beyond the termination of treatment are equivocal. The findings of most studies suggest that the effects are at least maintained at follow up. The evidence for the effectiveness of psychodynamic psychotherapy in comparison with other treatments is equivocal. Quasi-experimental studies During the search of recent literature, 18 papers on 17 quasi-experimental studies were found (see Tables 5 and 6). These designs used in these studies were: non-randomised controlled trials (n = 4), non-equivalent groups controlled trials (n = 3), a time series design (n = 1), and single condition, pre-treatment/post-treatment (n = 9). Most of the studies (n = 13) included participants with broad ranges of disorders or psychosocial issues. In general, psychodynamic psychotherapy appeared effective in the treatment of the problems presented in therapy. For those studies in which people with specific disorders were treated, psychodynamic psychotherapy was associated with the reduction of symptoms relating to depressive disorders, anxiety disorders, and borderline personality disorder. Systematic reviews and meta-analyses No systematic reviews or meta-analyses of Australian literature were found. The participants in this study were 60 patients (the number of patients differed slightly between some of the papers) with borderline personality disorder. Between post-treatment and five year follow up, there were significant reductions in time off work (p =. Discussion the reviewed evidence suggests that psychodynamic psychotherapy is effective in treating a broad range of mental health conditions, particularly depressive disorders, some anxiety disorders (especially generalised anxiety disorder), somatic symptoms and some somatoform disorders. In a limited number of studies, psychodynamic psychotherapy has also been effective in the treatment of eating disorders, post traumatic stress disorder, and some substance-related disorders (alcohol dependence, opiate dependence). In reviews and studies on the effectiveness of psychodynamic psychotherapy, meta-analysts and researchers have routinely reported medium, large, and very large (exceeding two standard deviations) effect sizes for improvement on primary outcome measures. In this review, psychodynamic psychotherapy was found to be superior to inactive comparators. Psychodynamic psychotherapy was also found to be equivalent to active treatments. Although these results are sufficient to consider psychodynamic psychotherapy to be empirically validated (as per American Psychological Association Division 12 standards), more research needs to be conducted to replicate and extend these findings to specific disorders (Gerber et al. The collective findings from the present review should encourage researchers to conduct head-to-head trials to compare various therapies for specific disorders, which would enable more definitive conclusions to be drawn about the relative effectiveness of different psychotherapies for the treatment of specific conditions. Higher quality trials of long-term versus short-term psychodynamic psychotherapy need to be conducted before firmer conclusions can be drawn. This review has highlighted the substantial work that has occurred to evaluate the effectiveness of psychodynamic psychotherapy, especially in adults with depressive disorders and some anxiety disorders. More research is clearly needed in areas where initial studies have yielded positive findings, such as somatoform disorders, eating disorders, substance-related disorders, and other anxiety disorders. In addition, more work is needed to investigate the efficacy of psychodynamic therapy with children and adolescents. One meta-analysis on children and adolescents who had been sexually abused, for example, produced mixed findings on the effectiveness of psychodynamic psychotherapy (Sanchez Meca, Rosa-Alcazar, & Lopez-Soler, 2011). Clearly, a stronger evidence base for the use of psychodynamic psychotherapy in the treatment of some issues needs to be developed. The findings of this review suggest that Australian researchers have not been particularly active in publishing the results of research on the effectiveness of psychodynamic 7 psychotherapy, except at the level of case studies. Only four papers (representing one study) were sourced during the search for Australian literature. The limited work in this area highlights a possible avenue for research to support clinicians in Australia. Conclusion the conclusion reached in this review is that there is strong support for the use of psychodynamic psychotherapy in the treatment of a broad range of psychological conditions. Moreover, the improvements gained through psychodynamic psychotherapy are typically maintained beyond the termination of treatment. Psychodynamic psychotherapy appears to be as effective as other psychotherapies, but more comparative trials are needed before firmer conclusions can be drawn. A naturalistic study of intensive short term dynamic psychotherapy trial therapy. Short-term psychodynamic psychotherapy for somatic disorders: Systematic review of meta-analysis of clinical trials. The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Intensive short-term dynamic psychotherapy: A systematic review and meta-analysis of outcome research. Interim report to Department of Health on initial mapping project for psychotherapy and counselling. Supervised team management, with or without structured psychotherapy, in heavy users of a mental health service with borderline personality disorder: A two-year follow-up preliminary randomized study. |
