Practitioner’s Guide to Empirically Based Measures of Depression

The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.

STUDY ON THE EFFECT OF MINDFULNESS COGNITIVE BEHAVIOR THERAPY IN THE TREATMENT OF ANXIETY DISORDER -- BASED ON THE PERSPECTIVE OF INDIVIDUAL REHABILITATION

This article highlights the central aims and main methods of Beck's cognitive therapy — a technique readily available to community nurses for use in a wide variety of clinical conditions. While specific methods used in cognitive therapy are multiple and varied, for the purpose of this article and as an introduction to this flexible approach, four key methods are described. The therapeutic use of the client-therapist relationship, providing education and a rationale for using the model, detecting automatic thoughts, and challenging automatic thoughts are regarded as the fundamental methods of cognitive therapy. Recent criticisms of cognitive therapy claim that: 1) its focus is on immediate symptom relief and it disregards personality restructuring; 2) its approach is superficial and mechanistic; 3) the therapeutic relationship is irrelevant; and 4) emotions are of minimal importance. However, careful examination of the methods used in cognitive therapy begin to illuminate misdirection of these criticisms. Indeed, these criticisms represent a misunderstanding of cognitive psychotherapy as a whole. In this paper, during session transcripts, for the purpose of confidentiality and anonymity the client's name and any other identifying information has been changed.

The impact of depression on the treatment of obsessive–compulsive disorder: Results from a 5-year follow-up

BackgroundOnly a minority of dialysis patients with depressive symptoms are diagnosed and receive treatment. Depressive symptoms are highly prevalent in this population and are associated with adverse clinical outcomes. Underlying factors for this undertreatment may be the lack of evidence for the safety and effectivity of antidepressant medication, the reluctance of patients to adhere to antidepressant medication, the lack of mental healthcare provision in somatic healthcare environments and end-stage renal disease (ESRD) related physical limitations that complicate face-to-face psychotherapy. Guided Internet-based self-help treatment has demonstrated to be effective for depressive symptoms in other chronic patient populations and may overcome these barriers. The aim of this study is to investigate the (cost) effectiveness of a guided Internet-based self-help intervention for symptoms of depression in dialysis patients.MethodsThis study is a cluster randomized controlled trial (RCT) that investigates the effectiveness of a 5-week Internet-based self-help Problem Solving Therapy (PST) for depressive symptoms in dialysis patients. Depressive symptoms will be measured using the Beck Depression Inventory – second edition (BDI-II), with a cut-off score of ≥10. We aim to include 206 dialysis patients with depressive symptoms who will be cluster randomized to the intervention or the Care as Usual (CAU) control group. Secondary outcomes will include anxiety symptoms, quality of life, economic costs and clinical outcomes, such as inflammatory factors and hair cortisol levels. Assessments will take place at baseline (T0), 2 weeks after intervention (T1) and 6 months (T2), 12 months (T3) and 18 months (T4) after intervention. The control group will be measured at the same time points. Analysis will be based on the intention-to-treat principle. Mixed models will be used to assess the changes within each condition between pre-treatment and post-treatment.DiscussionIf demonstrated to be (cost) effective, Internet-based PST will offer new possibilities to treat dialysis patients with depressive symptoms and to improve their quality of care.Trial registrationDutch Trial Register: Trial NL6648 (NTR6834) (prospectively registered 13th November 2017).

Deterioration in psychosocial functioning predicts relapse/recurrence after cognitive therapy for depression

Patients with major depressive disorder remain at risk for relapse following remission and often continue to experience subthreshold symptoms. This study compared the rate of relapse of major depressive disorder and the prevalence of residual depressive symptoms during the continuation phase for patients treated with fluoxetine dose increase alone or in combination with cognitive therapy. A total of 132 outpatients with major depressive disorder who achieved remission with 8 weeks of treatment with fluoxetine 20 mg had the dose increased to 40 mg. They were randomized to receive cognitive therapy or medication management alone and were followed for up to 28 weeks for depressive relapse and change in depressive symptoms. A total of 47 (35.6%) out of 132 patients did not complete the 28-week continuation phase. Rates of discontinuation or relapse did not differ significantly between the groups. Change in residual symptoms or wellbeing as measured by Hamilton Depression Scale score or Symptom Questionnaire self-report also did not differ between groups. In this sample of outpatients in continuation phase treatment for major depressive disorder, the combination of cognitive therapy and fluoxetine 40 mg failed to yield any significant benefit in symptoms or relapse rates over fluoxetine 40 mg alone during 28 weeks of follow-up.

exacerbation of the symptoms and often, to the situation. Stoppard further argues that the cognitive/ behavioural therapies are androcentric because they emphasize male-valued skills such as rationality, while implicity devaluing nurturance or other relationship skills. This is an entirely specious argument, implying that all nurturance and relationship skills are healthy and desirable, and that they are incompatible with being reasonable, forthright, and accurate in appraising and dealing with problem situations. Beck's cognitive therapy of depression seems well-suited to help women and men identify maladaptive beliefs about relationships and about nurturance that can help avert unrealistic expectations and disappointment, or avoidance and conflict. It can help individuals to learn to be selfnurturing as well as nurturant of others. In short, the cognitive therapy of depression is equipped, and is often called upon, to facilitate effective relationship skills for both sexes. And, while it promotes realistic appraisals of the self and circumstances, it is not rationalistic or devaluing of all emotional experiences. Rather, it helps clients to learn more about their emotions and their meaning, by learning about the link between thoughts and negative emotional states. It almost seems as if Stoppard misperceives cognitive therapies as producing highly intellectualized, rational, detached machines, but such a view is a gross misstatement of the reality of the therapeutic goals and processes. Finally, Stoppard argues that cognitive/behavioural therapies do not extend beyond the alleviation of current depression, and offer little to prevent future episodes. This charge is unfounded, for the therapies explicitly attempt to teach strategies for avoiding depression, with research evidence based on Beck's cognitive therapy indicating that they have been successful over extended follow-up periods (reviewed in Sacco & Beck, 1985). Institutional changes that improve employment opportunities, educational advancement, family cohesion, and the like would doubtless contribute to reductions in rates of depression in women (and men), and cognitive/behavioural therapists recognize this as well as anyone else. That cognitive/behavioural theorists have not led the fight for such political and social changes does not, however, invalidate the theories or their relevance for treatment of depression in women. In the final analysis, cognitive/behavioural theories continue to evolve and to respond to reasonable criticisms of their limitations. Given the incomplete state of our knowledge about biological and psychosocial vulnerabilities to depression, they have nonetheless made two major contributions. One is to help improve our understanding of when and why some individuals get depressed in certain circumstances and others do not, by promoting an integration of environmental events and cognitive appraisals. The second is the development of important therapeutic interventions that have helped reduce current depression and empowered individuals to prevent future depressions. These are major achievements serving both women and men.

Because evidence-based psychotherapies of 12 to 20 sessions can be perceived as too lengthy and time intensive for the treatment of depression in primary care, a number of studies have examined abbreviated psychotherapy protocols. The purpose of this study was to conduct a systematic review and meta-analysis to determine the efficacy of brief psychotherapy (i.e., < or =8 sessions) for depression. We used combined literature searches in PubMed, EMBASE, PsycINFO, and an Internet-accessible database of clinical trials of psychotherapy to conduct two systematic searches: one for existing systematic reviews and another for randomized controlled trials (RCTs). Included studies examined evidence-based psychotherapy(s) of eight or fewer sessions, focused on adults with depression, contained an acceptable control condition, were published in English, and used validated measures of depressive symptoms. We retained 2 systematic reviews and 15 RCTs evaluating cognitive behavioral therapy, problem-solving therapy, and mindfulness-based cognitive therapy. The systematic reviews found brief psychotherapies to be more efficacious than control, with effect sizes ranging from -0.33 to -0.25. Our meta-analysis found six to eight sessions of cognitive behavioral therapy to be more efficacious than control (ES -0.42, 95% CI -0.74 to -0.10, 12 = 56%). A sensitivity analysis controlled for statistical heterogeneity but showed smaller treatment effects (ES -0.24, 95% CI -0.42 to -0.06, 12 = 0%). Depression can be efficaciously treated with six to eight sessions of psychotherapy, particularly cognitive behavioral therapy and problem-solving therapy. Access to non-pharmacologic treatments for depression could be improved by training healthcare providers to deliver brief psychotherapies.

To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians. Randomized controlled trial. Department of Veterans Affairs healthcare system. Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159). Nonclinician "sleep coaches" delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education. Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)). Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (-23.4, -15.8, and -17.3 minutes, respectively), TWT-D (-68.4, -37.0, and -30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (-3.4, -2.4, and -2.1 in total score, respectively), and ISI (-4.5, -3.9, and -2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2. Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.

A insônia é uma das perturbações do sono mais comuns, sendo uma das principais queixas dos pacientes que recorrem aos cuidados médicos. A perturbação de insônia está associada a aumento da morbimortalidade por doenças cardiovasculares, psiquiátricas e acidentes, estando igualmente associada a maior absentismo laboral e maiores custos em saúde. Foram pesquisadas normas de orientação clínica, revisões sistemáticas, meta-análises e estudos originais, publicados entre 2010 e 15 de maio de 2015, relacionados com o tratamento da insônia. O tratamento da insônia pode iniciar-se por terapia cognitivo-comportamental, tratamento farmacológico ou associação dos dois. A terapia cognitivo-comportamental é considerada por várias sociedades médicas como tratamento padrão, sendo que os estudos comprovam a sua eficácia no tratamento da insônia sem ou com comorbilidades e com manutenção a longo prazo dos seus efeitos. Esta compreende múltiplas estratégias, como controle de estímulo, restrição do sono, relaxamento, terapia cognitiva e intenção paradoxal. A farmacoterapia deve ser considerada em situações agudas com necessidade de redução imediata dos sintomas. Os fármacos hipnóticos têm indicação no tratamento da insônia quando os sintomas assumem caráter patológico. Os antidepressivos sedativos, apesar de comumente utilizados, não reúnem evidência da sua eficácia, com exceção da insônia associada a sintomas depressivos ou de ansiedade ou em pacientes com abuso de substâncias. Assim, dada a prevalência de queixas de insônia em atenção primária à saúde, o médico de família deve conhecer a melhor abordagem para o seu tratamento, quer seja farmacológico ou não farmacológico, e os critérios de referenciação.

The tendency to experience shame or guilt is associated differentially with anxiety and depression, with shame being associated with greater psychopathology. Correlational studies have shown self-compassion to be related to lower shame and rumination, and mindfulness-based interventions increase self-compassion. Therefore, mindfulness-based interventions may decrease shame. This pilot study aimed to assess the association of shame, rumination, self-compassion, and psychological distress and the effects of a mindfulness-based intervention on these measures in a clinical sample. Single-group design with pre-test and post-test measures. Thirty-two service users who experienced clinically diagnosed depressive or anxiety disorders in a mindfulness-based cognitive therapy programme were assessed before and twenty-two after therapy with measures of shame-proneness, external shame, rumination, self-compassion, and psychological distress. Shame-proneness and external shame were positively correlated with self-coldness, and external shame was positively correlated with stress and depressive symptoms. Self-compassion increased and self-coldness decreased, while shame-proneness, rumination, anxiety, and stress symptoms decreased from pre- to post-treatment. There was no significant reduction in depressive symptoms, guilt-proneness, or external shame. Our preliminary findings suggest that mindfulness-based approaches may be helpful in increasing self-compassion and reducing shame-proneness in mixed groups of anxious and depressed patients. Controlled studies of the effects of mindfulness-based interventions on shame in clinical populations are warranted. Shame-proneness and external shame showed different patterns of relationship with depressive and stress symptoms and with self-compassion. Shame-proneness decreased to a greater extent than external shame decreased following participation in an MBCT group. Mindfulness-based interventions may benefit shame-proneness to a greater extent than external shame.

This study aimed to test reliability and validity of the Japanese-version Cognitive Therapy Awareness Scale, a self-rating scale that measures basic knowledge of cognitive behavioral therapy (CBT) concepts and methodology. Furthermore, we explored optimal cutoff score to demonstrate required standard of CBT competency. The reliability and validity of the scale was tested among 252 mental health professionals. The participants' number of readings relevant to CBT, as well as their experience in training and practice in CBT were used as external standards of competency. The scale has good internal consistency (the Kuder-Richardson formula 20=0.76). The total score of the scale was significantly correlated with experience in training and practice in cognitive behavioral therapy, and the number of relevant readings (Spearman's rho =0.27, 0.28 and 0.44, respectively, P<0.001). No significant correlation was found between the total score of the scale and experience in general psychosocial care (Spearman's rho = -0.02, P=0.76). The receiver operating characteristics curve analysis produced the area under curve (AUC) of 0.77 (SD=0.05, P<0.001), and a cutoff score of 31/32 produced sensitivity of 0.81 and specificity of 0.64 to discriminate trainees who have experience of 40 h or more of CBT training and five or more of relevant readings, from those who do not meet this standard. The Japanese-version Cognitive Therapy Awareness Scale was successfully validated. It has been demonstrated that the scale specifically assess knowledge in cognitive behavioral therapy. This scale would serve as a rough guide to assess competencies among beginner cognitive behavior therapists.

Psychiatric clinicians frequently prescribe biologic treatments such as antidepressant medication in combination with psychologic treatments such as psychotherapy. In the present article we propose a model integrating antidepressant treatment with Beck's cognitive therapy, a form of psychotherapy with established efficacy in the acute treatment of depression. We argue for adding cognitive therapy following successful pharmacological treatment, i.e., for spending cognitive therapy resources in the continuation phase of treatment, where they are most likely to make a unique and separate contribution to patient well-being, particularly in the areas of relapse prevention and treating residual symptoms. We encourage researchers to compare this treatment strategy to other approaches in terms of its ability to (1) prevent relapses and recurrences of depressive episodes, and (2) to impact positively on the overall quality of life in recovered depressed patients.

BackgroundIn Turkey, there are serious deficiencies in mental health care. Although depression is highly prevalent, only a small number of people seek professional help. Innovative solutions are needed to overcome this treatment gap. Web-based problem-solving therapy (PST) is an intervention proven to be effective in the treatment of depression, although little is known about its clinical effects in Turkey.ObjectiveThis study aims to test the clinical effects of a Web and mobile app of an adapted PST for depressive symptoms among the general population in Turkey.MethodsParticipants will be recruited through announcements in social media and the Middle East Technical University. Adults (18-55 years) with mild to moderate depressive symptoms (Beck Depression Inventory-II [BDI-II] score between 10-29) will be included in the study. Participants with a medium-to-high suicidal risk (according to the Mini-International Neuropsychiatric Interview) will be excluded. A 3-armed randomized controlled trial with a waiting control group will be utilized. A sample size of 444 participants will be randomized across 3 groups. The first experimental group will receive direct access to the Web version of the intervention; the second experimental group will receive direct access to the mobile app of the intervention as well as automated supportive short message service text messages based on PST. The control group consists of a wait-list and will gain access to the intervention 4 months after the baseline. The intervention is based on an existing PST for the Turkish population, Her Şey Kontrol Altında (HŞKA), consisting of 5 modules each with a duration of 1 week and is guided by a clinical psychologist. The primary outcome is change in depressive symptoms measured by the BDI-II. Secondary outcomes include symptoms of anxiety, stress, worry, self-efficacy, and quality of life. Furthermore, satisfaction with, usability and acceptability of the intervention are important features that will be evaluated. All outcomes will take place online through self-assessment at posttest (6-8 weeks after baseline) and at follow-up (4 months after baseline).ResultsWe will recruit a total of 444 participants with mild to moderate depressive symptoms from March 2018 to February 2019 or until the recruitment is complete. We expect the final trial results to be available by the end of May 2019. This trial is funded by the Scientific and Technological Research Council of Turkey (National Postdoctoral Research Fellowship Programme 2016/1).ConclusionsResults from this study will reveal more information about the clinical effects of HŞKA as well as its applicability in a Turkish setting through the Web and mobile platforms. On the basis of the results, a guided Web- and mobile-based PST intervention might become an appropriate alternative for treating mild to moderate depressive symptoms.Trial RegistrationClinicalTrials.gov NCT03754829; https://clinicaltrials.gov/ct2/show/NCT03754829 (Archived by WebCite at http://www.webcitation.org/74HugwLo7).International Registered Report Identifier (IRRID)DERR1-10.2196/13239