Arts for the blues – a new creative psychological therapy for depression

ABSTRACT

Routinely prescribed psychological therapies for depression are not always effective. Arts therapies, particularly Dance Movement Psychotherapy, may offer additional therapeutic mechanisms for depression. Therefore, client-reported helpful factors from various therapy types, along with client preferences, are key in devising new therapeutic interventions. We present a framework for a new pluralistic “meta-approach” of therapy for depression, based on an interdisciplinary thematic synthesis (Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8[1], 45) of active ingredients from both talking therapies and creative approaches. Lastly, we offer an illustrative group therapy workshop based on this approach, to be piloted with clients and practitioners within an NHS mental health service. Further research is required to evaluate this pilot and to devise a full treatment for trialling within the service.     

Relational-developmental therapy group for postnatal depression

Postnatal depression has been estimated to affect as many as 30% of childbearing women. Emerging evidence offers reason to believe that psychoanalytically-oriented group treatment may be beneficial for some women with postnatal depression. This study was designed to evaluate the effectiveness of one model of analytic group therapy for this clinical population. Our findings suggest that the women had a positive response to the group treatment. The particulars of the psychoanalytic group approach, here referred to as relational-developmental, are described in detail and an analysis is offered about why this approach may be beneficial. Also discussed are limitations of the research design and suggestions for studying a relational-developmental group-centered prevention program for children at-risk from postnatal depression.     

Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression

Internet-delivered psychological treatment of major depression has been investigated in several trials, but the role of personalized treatment is less investigated. Studies suggest that guidance is important and that automated computerized programmes without therapist support are less effective. Individualized e-mail therapy for depression has not been studied in a controlled trial. Eighty-eight individuals with major depression were randomized to two different forms of Internet-delivered cognitive behaviour therapy (CBT), or to a waiting-list control group. One form of Internet treatment consisted of guided self-help, with weekly modules and homework assignments. Standard CBT components were presented and brief support was provided during the treatment. The other group received e-mail therapy, which was tailored and did not use the self-help texts i.e., all e-mails were written for the unique patient. Both treatments lasted for 8 weeks. In the guided self-help 93% completed (27/29) and in the e-mail therapy 96% (29/30) completed the posttreatment assessment. Results showed significant symptom reductions in both treatment groups with moderate to large effect sizes. At posttreatment 34.5% of the guided self-help group and 30% of the e-mail therapy group reached the criteria of high-end-state functioning (Beck Depression Inventory score below 9). At six-month follow-up the corresponding figures were 47.4% and 43.3%. Overall, the difference between guided self-help and e-mail therapy was small, but in favour of the latter. These findings indicate that both guided self-help and individualized e-mail therapy can be effective.     

Client Report of Delivery of Common Elements in Usual Care and the Association to Satisfaction

Recently, scholars have advocated for the use of a new flexible approach to evidence-based practice through the use of “common elements”, which are treatment procedures that are utilized in a variety of evidence-based mental health interventions. The objective of this study was to describe the extent to which clinicians are using common elements of evidence-based treatment (EBT) in routine mental health care for children and if they are utilizing more of the elements associated with their client’s diagnosis. A second objective was to determine whether use of these elements was associated with client satisfaction. The Youth Services Survey was administered to a diverse sample of youth and their caregivers (total sample = 1075) to measure satisfaction with services and use of both talk-based and skill-based common elements. More than 74 % of caregivers indicated that their child’s clinician utilized the talk-based common elements frequently or almost always. Additionally, at least 69 % of youth agreed with this finding. Youth and caregivers reported that the common elements related to skill building were utilized less frequently. A Generalized Estimating Equation approach was used to examine the relationship between use of common elements and client diagnosis and satisfaction. The results for diagnosis were mixed and varied by parent and youth report. Finally, the more clinicians discussed and practiced common elements of EBT with their clients, both youth and caregivers were more likely to be satisfied. Due to clients’ reporting that on average clinicians utilized skill building common elements less often, targeted clinician training may be important, since practicing skill-building therapeutic elements is key to adopting new methods of managing behavior and emotions. Further, if families are more satisfied with a common elements approach, then clinicians may be more likely to utilize it.     

The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

The effect of contingent reinforcement on target variables in outpatient psychotherapy for depression: a successful and unsuccessful case using functional analytic psychotherapy

The current study investigated a behavior-analytic treatment, functional analytic psychotherapy (FAP), for outpatient depression utilizing two single-subject A/A+B designs. The baseline condition was cognitive behavioral therapy. Results demonstrated treatment success in 1 client after the addition of FAP and treatment failure in the 2nd. This study highlights the challenges in measuring treatment progress and outcome idiographically in this population.     

Blunted amygdala activity is associated with depression severity in treatment-resistant depression

Up to 50% of individuals with major depressive disorder (MDD) do not recover after two antidepressant medication trials, and therefore meet the criteria for treatment-resistant depression (TRD). Mindfulness-based cognitive therapy (MBCT) is one promising treatment; however, the extent to which MBCT influences clinical outcomes relative to baseline neural activation remains unknown. In the present study we investigated baseline differences in amygdala activation between TRD patients and healthy controls (HCs), related amygdala activation to depression symptoms, and examined the impacts of MBCT and amygdala activation on longitudinal depression outcomes. At baseline, TRD patients (n = 80) and HCs (n = 37) participated in a functional magnetic resonance imaging task in which they identified either the emotion (affect labeling) or the gender (gender labeling) of faces, or passively viewed faces (observing). The TRD participants then completed eight weeks of MBCT or a health enhancement program (HEP). Relative to HCs, the TRD patients demonstrated less amygdala activation during affect labeling, and marginally less during gender labeling. Blunted amygdala activation in TRD patients during affect labeling was associated with greater depression severity. MBCT was associated with greater depression reductions than was HEP directly following treatment; however, at 52 weeks the treatment effect was not significant, and baseline amygdala activation across the task conditions predicted depression severity in both groups. TRD patients have blunted amygdala responses during affect labeling that are associated with greater concurrent depression. Furthermore, although MBCT produced greater short-term improvements in depression than did HEP, overall baseline amygdala reactivity was predictive of long-term clinical outcomes in both groups.     

The behavioral activation for depression scale-short form: development and validation

Following a landmark component analysis of cognitive therapy by Jacobson and colleagues (1996), there has been renewed interest in behavioral activation (BA) treatments for depression. The Behavioral Activation for Depression Scale (BADS) was developed to measure when and how clients become activated over the course of BA treatment. Multiple studies have provided initial support for the BADS but have also identified several potential problems. Four studies were conducted in order to develop and provide initial evaluation of a short form of the BADS that addresses these concerns. In Study 1, an exploratory factor analysis was conducted on existing data using the original BADS in order to identify items to retain for the short form. In Study 2, these items were administered to a new sample of college students with elevated depressive symptoms and were analyzed with exploratory and confirmatory factor analyses. Study 3 examined the predictive validity of the BADS-SF by examining the BADS-SF and depression scores in relation to activity tracking and reward-value ratings over the course of 1 week. Study 4 examined BADS-SF data over the course of BA treatment for two clients using cross-lagged panel correlations. With one client, changes in BADS-SF scores led changes in depression scores by 1 week, whereas with the other client changes in BADS-SF and depression scores occurred concurrently. These studies resulted in a nine-item scale that demonstrated good item characteristics as well as acceptable internal consistency reliability, construct validity, and predictive validity.     

Outcome studies of family therapy in child and adolescent depression

There is surprisingly little good-quality evidence for the effectiveness of family systemic interventions with child and adolescent depression given the prevalence of depression and the demonstrated association with a range of family factors. What studies there are suggest the possibility of family therapy being an effective intervention but more research is needed before firm conclusions may be drawn. Family interventions may be more effective in children than in adolescents and where other family members are depressed. It is possible that family interventions continue to bring about improvement in symptoms after cessation of treatment. What research there is evaluates older structural models of therapy: there is a real need for more evaluation of newer models of practice.     

Predicting Response to Therapist-Assisted Internet-Delivered Cognitive Behavior Therapy for Depression or Anxiety Within an Open Dissemination Trial

Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) is efficacious for treating anxiety and depression, but predictors of response to treatment when delivered in clinical practice are not well understood. In this study, we explored demographic, clinical, and program variables that predicted modules started and symptom improvement (i.e., Generalized Anxiety Disorder-7 or Patient Health Questionnaire-9 total scores over pre-, mid-, and posttreatment) within a previously published open dissemination trial (Hadjistavropoulos et al., 2014). The sample consisted of 195 patients offered 12 modules of therapist-assisted ICBT for depression or generalized anxiety; ICBT was delivered by therapists working in six geographically dispersed clinics. Consistent across ICBT for depression or generalized anxiety, starting fewer modules was associated with more phone calls from therapists reflecting that therapists tended to call patients who did not start modules as scheduled. Also consistent for both ICBT programs, greater pretreatment condition severity and completion of more modules was associated with superior ICBT-derived benefit. Other predictors of response to treatment varied across the two programs. Younger age, lower education, taking psychotropic medication, being in receipt of psychiatric care and lower comfort with written communication were associated with either fewer program starts or lower symptom improvement in one of the two programs. It is concluded that monitoring response to ICBT may be particularly important in patients with these characteristics. Research directions for identifying patients who are less likely to benefit from ICBT are discussed.     

Prenatal depression effects and interventions: A review

This review covers research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity and low birthweight. Although prenatal depression and cortisol were typically measured at around 20 weeks gestation, other research suggests the stability of depression and cortisol levels across pregnancy. Women with Dysthymia as compared to Major Depression Disorder had higher cortisol levels, and their newborns had lower gestational age and birthweight. The cortisol effects in these studies were unfortunately confounded by low serotonin and low dopamine levels which in themselves could contribute to non-optimal pregnancy outcomes. The negative effects of depression and cortisol were also potentially confounded by comorbid anxiety, by demographic factors including younger age, less education and lower SES of the mothers and by the absence of a partner or a partner who was unhappy about the pregnancy or a partner who was depressed. Substance use (especially caffeine use) was still another risk factor. All of these problems including prenatal depression, elevated cortisol, prematurity and low birthweight and even postpartum depression have been reduced by prenatal massage therapy provided by the women's partners. Massage therapy combined with group interpersonal psychotherapy was also effective for reducing depression and cortisol levels. Several limitations of these studies were noted and suggestions for future research included exploring other predictor variables like progesterone/estriol ratios, immune factors and genetic determinants. Further research is needed both on the potential use of cortisol as a screening measure and the use of other therapies that might reduce prenatal depression and cortisol in the women and prematurity and low birthweight in their infants.     

Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study

This pilot study investigated the effectiveness of Mindfulness-Based Cognitive Therapy (MBCT), a treatment combining mindfulness meditation and interventions taken from cognitive therapy, in patients suffering from chronic-recurrent depression. Currently symptomatic patients with at least three previous episodes of depression and a history of suicidal ideation were randomly allocated to receive either MBCT delivered in addition to treatment-as-usual (TAU; N = 14 completers) or TAU alone (N = 14 completers). Depressive symptoms and diagnostic status were assessed before and after treatment phase. Self-reported symptoms of depression decreased from severe to mild levels in the MBCT group while there was no significant change in the TAU group. Similarly, numbers of patients meeting full criteria for depression decreased significantly more in the MBCT group than in the TAU group. Results are consistent with previous uncontrolled studies. Although based on a small sample and, therefore, limited in their generalizability, they provide further preliminary evidence that MBCT can be used to successfully reduce current symptoms in patients suffering from a protracted course of the disorder.     

Managing resistance in cognitive behavioural therapy: the application of motivational interviewing in mixed anxiety and depression

While cognitive behavioural therapy is highly effective in the treatment of anxiety and depression, a substantive number of individuals either refuse treatment, fail to respond to treatment or respond only partially. Arguably, ambivalence about change or about engaging in treatment tasks may in part be related to incomplete recovery rates in cognitive behavioural therapy. Motivational interviewing is a client-centred, directive treatment originally developed in the addictions domain whose goal is to enhance motivation for change by understanding and resolving ambivalence. This method has consistently received support for enhancing outcomes in the addictions domain, particularly when used as an adjunct to further treatment. As yet, motivational methods have not been generalized to the treatment of prevalent mental health problems, such as anxiety and depression. The present paper presents the application of a treatment targeting motivation (motivational interviewing adapted for anxiety and depression) to the management of resistance in cognitive behavioural therapy for 3 clients with mixed anxiety and depression. Motivational interviewing is conceived as an adjunct to highly effective traditional cognitive behavioural therapy methods, which is indicated for use with clients resistant to and significantly ambivalent about change-based techniques for managing anxiety or alleviating depression.     

Effect of dichotomous thinking on the association of depression with BMI and weight change among obese females

This study tested whether a dichotomous thinking style moderates the association of depression with body mass, and investigated the effect of dichotomous thinking and depression on weight loss during a cognitive behavioural therapy (CBT) intervention.Overweight and obese females (n = 76) participated in CBT for weight management for 12 weeks. Before treatment, dichotomous thinking moderated the association of depression with BMI, such that depression was positively associated with BMI among those with low dichotomous thinking, but was not associated among those with high dichotomous thinking. Weight loss was negatively associated with pre-treatment depression and frequency of treatment attendance, but not with dichotomous thinking. Females who regard their weight as unacceptably high and who think dichotomously may experience high levels of depression irrespective of their actual weight, while depression may be proportionate to the degree of obesity among those who do not think dichotomously. Depression, but not dichotomous thinking, is likely to interfere with the ability to adhere to short-term weight loss strategies.     

A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries

This paper describes the Common Elements Treatment Approach (CETA) for adults presenting with mood or anxiety problems developed specifically for use with lay counselors in low- and middle-income countries (LMIC). Details of the intervention development, training, supervision, and decision-making process are presented. Case vignettes are used as examples throughout. Preliminary findings are presented on counselor/supervisor performance and client outcomes from practice cases completed prior to randomized controlled trials (RCT) conducted at two sites for adult survivors of torture and/or systematic violence in (a) southern Iraq and (b) Thailand-Burma border.Data suggest that local supervisors and lay counselors with little prior mental health training or experience maintained fidelity to the model. The majority of pilot clients were retained in treatment, suggesting acceptability. Using the Reliable Change Index (RCI) for each individual we examined the number of clients above a minimal threshold (z > 1.96) for each outcome. In Iraq 100% of clients had RCIs above the threshold for depression and posttraumatic stress, and 81.8% for impaired function. In Thailand, 81.3% of clients had RCIs above minimum threshold for depression, 68.8% for posttraumatic stress, and 37.5% for impaired function.Implementation of CETA is discussed in relation to cultural issues within LMIC. These findings, combined with US-based evidence, suggest that a common elements approach warrants further development and testing as a means for addressing the treatment gap for mental health problems in LMIC.