Psychopharmacological treatment of unipolar depression within the elderly: A discussion paper

Depressive disorders are known to affect all aspects of a person's functioning and are often associated with significant psychosocial impairment. What is unclear is whether these psychosocial issues are consequences or causes of depression; what is known is that these problems do not disappear when the biological symptoms resolve. Existing data on the treatment course and outcome of depression are not generally considered as representative of the older depressed person. Discussion will take place as to whether later life depression should be conceptualized not as a categorical disorder, but as a geriatric syndrome, with multiple aetiologies requiring a combination of treatment interventions. There is general consensus that when intensive psychotherapy is directed towards appropriate patients, geriatric clientele are as able to deal with the viscitudes of intensive therapy as well as any age group. An examination will be undertaken regarding the utilization of psychotherapeutic interventions, namely psychodynamic, interpersonal and cognitive behavioural. Comparative studies have demonstrated all three to be effective, particularly in the treatment of depression. There is a great need for further understanding and research into the appropriateness and efficacy of an integration of psychotherapeutic and pharmacotherapeutic intervention in the treatment of depression, particularly within the elderly. A tantalizing array of research possibilities emerge. If we accept that unipolar depression is a bio-psychosocial phenomena, then we need to understand more about which psychopharmacological treatment paradigms need to be employed, and that perhaps the way forward inclines towards pragmatic integrationism rather than puritanist intervention.     

A Review of Family Therapy in Residential Settings

This article provides an overview of the history of family involvement in residential treatment as well as a synthesis of the research showing family-centered interventions and outcomes for youth in residential settings. There are many methods for engaging families in residential treatment that are discussed in the literature; however, there is a significant gap as the field has not yet identified specific family therapy approaches that demonstrate efficacy in working with youth and their families in this particular setting. A review of the literature over the past 10 years will highlight the emerging family therapy models being utilized in this setting, which include multiple-family group intervention, family-directed structural therapy, and narrative family therapy. The article will also include a discussion of three major, well-established theoretical approaches that have been found to be effective in working with youth with conduct issues and show promise in treating youth and families in the complex setting of residential treatment: brief strategic family therapy, multi systemic therapy, and functional family therapy.     

Cognitive-Behavioral Therapy for Depression in an Older Gay Man: A Clinical Case Study

Although strong evidence supports cognitive-behavioral therapy for late-life depression and depression in racial and ethnic minorities, there are no empirical studies on the treatment of depression in older sexual minorities. Three distinct literatures were tapped to create a depression treatment protocol for an older gay male. Interventions were deduced from the late-life depression literature, culturally adapted CBT protocols for racial minorities, and the emerging social and developmental psychological theories for lesbian, gay, and bisexual populations. Specific treatment interventions, processes, and outcomes are described to illustrate how these literatures may be used to provide more culturally appropriate and effective health care for the growing, older sexual minority population.     

Culturally Adapted Psychosocial Interventions for Schizophrenia: A Review

Recent research examining the potential efficacy of culturally adapted interventions for various mental disorders illustrates increasing interest in the integration of cultural perspectives into mental health systems. Despite recent evidence demonstrating that culturally adapted interventions may be more effective than a one-size-fits-all approach, few psychosocial treatments for schizophrenia consider cultural factors that may enhance their efficacy with diverse populations. The aim of this review is to discuss the empirical evidence examining the potential utility of culturally adapted group interventions for schizophrenia, as a means to encourage further work and expansion in this area. Specifically, this article provides an in-depth review of the empirical literature on culturally adapted psychosocial interventions for individuals with schizophrenia and their family members, with a focus on group-based interventions. This review is followed by a discussion of a few cultural constructs that may impact patient and family member functioning, and therefore may be important to address in psychosocial treatments for schizophrenia. Finally, we end this review with a broad discussion of research limitations and potential areas for additional research, clinical implications for adapting EBTs to better address cultural concerns, and a case vignette to illustrate how cultural considerations can be integrated into a traditional multifamily group therapy approach.     

Reduced Contact Cognitive-Behavioral Interventions for Adult Depression: A Review

Depression is a highly prevalent and debilitating mental health condition. Evidence suggests that there is a widening gap between the demand for and availability of effective treatments. As such, there is a vast need for the development and dissemination of accessible and affordable treatments for depression. In the past decade, there has been a proliferation of reduced client-therapist contact protocols for depression. In this article, the authors review and compare the efficacy of reduced contact cognitive-behavioral interventions for adult depression across two degrees of therapist-client contact (i.e., no therapist-client contact versus minimal therapist-client contact interventions). The authors also discuss the methodological and theoretical limitations of this research base. The present review suggests that a) reduced contact interventions for depression can be effective in remediating the symptoms of depression; b) the effect sizes of some reduced contact protocols may approximate those reported in traditional protocols involving significantly greater client-therapist contact; and c) protocols which employ some form of client-therapist contact, on average, generate higher effect sizes than those that are purely self-help in nature. A discussion of the theoretical and applied implications of such findings, as well as areas in need of further research, is provided.     

Involving Family in Psychosocial Interventions for Chronic Illness

ABSTRACT— Interactions with close family members have consequences for the emotional and physical well-being of individuals who are dealing with a chronic physical illness. Therefore, inclusion of a close family member in psychosocial interventions for chronic illnesses is a logical treatment approach that has the potential to boost the effects of intervention on the patient and also benefit the family member. However, randomized, controlled studies indicate that such family-oriented interventions generally have small effects. The efficacy of these treatment approaches might be enhanced by targeting specific interactions that emerging research identifies as promoting or derailing healthy behaviors and by better incorporating strategies from family caregiver interventions. In addition, family-oriented interventions should be more fully evaluated, by assessing the benefits for both patients and family members. Future research in this area can tell us much about how and when to involve family in treatment of specific chronic illnesses and, in turn, may inform conceptual models of the impact of family interactions on health.     

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.     

Systemic family therapy can be manualized: research process and findings

Determining the efficacy of therapeutic interventions is becoming an increasing political and ethical necessity. Comparative therapeutic outcome trials are most powerful when there is a precise specification, or manualization, of the forms that therapies took. Manuals have begun to be developed for structural/behavioural family therapy and couple therapy. The development of these manuals is often reliant on experts' self-report, rather than a systematic analysis of the therapeutic process as it happens. This can limit their validity and applicability to standard clinical practice. In addition, no manuals exist which reflect less structured forms of family therapy aimed at incorporating systemic, postmodern and narrative frameworks. The feasibility of producing a workable manual that reflects the fluidity of such practices has been questioned.
A research project to systematically create and test such a manual is reported. Multiple data sources and research methods, primarily qualitative, were applied to generate a rich specification of the therapy. In reporting these results the contents of various aspects of the final manual are indicated. Procedures to ensure that the prescribed practice is consistent with a widely used approach to systemic family therapy are also described.
The manual will be an important tool for outcome research and therapeutic practice. The account of the research process should be helpful to researchers engaged in constructing a manual for other models of family therapy based on a rigorous analysis of actual practice. The manual itself is available for use by outcome researchers who wish to evaluate this widely used form of systemic family therapy.     

Rediscovering Nagy: What happened to contextual therapy?

Ivan Boszormenyi-Nagy, originator and leading proponent of contextual family therapy, has been addressing relational ethics for more than 40 years. During the 1980s there was a proliferation of contextual publications. Great interest in the approach seemed to peak and then ebb silently. What happened to contextual therapy? Why has contextual therapy not taken its place among the other widely used and recognized therapeutic models? This article addresses these questions through a review of family therapy literature.     

HIV and depression--a systematic review of interventions

HIV-positive individuals are more likely to be diagnosed with major depressive disorder than HIV-negative individuals. Depression can precede diagnosis and be associated with risk factors for infection. The experience of illness can also exacerbate depressive episodes and depression can be a side effect to treatment. A systematic understanding of which interventions have been tested in and are effective with HIV-seropositive individuals is needed. This review aims to provide a comprehensive understanding of evaluated interventions related to HIV and depression and provide some insight on questions of prevalence and measurement. Standard systematic research methods were used to gather quality published papers on HIV and depression. From the search, 1015 articles were generated and hand searched resulting in 90 studies meeting adequacy inclusion criteria for analysis. Of these, 67 (74.4%) were implemented in North America (the US and Canada) and 14 (15.5%) in Europe, with little representation from Africa, Asia and South America. Sixty-five (65.5%) studies recruited only men or mostly men, of which 31 (35%) recruited gay or bisexual men. Prevalence rates of depression ranged from 0 to 80%; measures were diverse and rarely adopted the same cut-off points. Twenty-one standardized instruments were used to measure depression. Ninety-nine interventions were investigated. The interventions were diverse and could broadly be categorized into psychological, psychotropic, psychosocial, physical, HIV-specific health psychology interventions and HIV treatment-related interventions. Psychological interventions were particularly effective and in particular interventions that incorporated a cognitive-behavioural component. Psychotropic and HIV-specific health psychology interventions were generally effective. Evidence is not clear-cut regarding the effectiveness of physical therapies and psychosocial interventions were generally ineffective. Interventions that investigated the effects of treatments for HIV and HIV-associated conditions on depression generally found that these treatments did not increase but often decreased depression. Interventions are both effective and available, although further research into enhancing efficacy would be valuable. Depression needs to be routinely logged in those with HIV infection during the course of their disease. Specific data on women, young people, heterosexual men, drug users and those indiverse geographic areas are needed. Measurement of depression needs to be harmonized and management into care protocols incorporated.     

Family therapy with delinquents: a critical review of the literature

A critical review of the theoretical and outcome studies on family therapy with delinquents is presented. Assessment of the theoretical developments reveals that families of delinquents may be distinguishable from other families by their interactional sequences and processes. The available outcome studies within the field indicate that family therapy is viable for interventions with this population, with behavioral, structural, strategic, and communication approaches receiving the most support, but more specific and robust evidence is still needed. Trends in the research and critical issues are identified and used to provide suggestions for future research and practice.     

Evidence-based psychological treatments for distress in family caregivers of older adults

This review identifies evidence-based psychological treatments (EBTs) for reducing distress, and improving well-being, of family members caring for an older relative with significant cognitive and/or physical impairment. Three categories of psychologically derived treatments met EBT criteria: psychoeducational programs (N = 14 studies), psychotherapy (N = 3 studies), and multicomponent interventions (N = 2 studies). Specifically, support within the psychoeducational category was found for skill-training programs focused on behavior management, depression management, and anger management and for the progressively lowered threshold model. Within the psychotherapy category, cognitive-behavioral therapy enjoys strong empirical support. Within the multicomponent category, programs using a combination of at least 2 distinct theoretical approaches (e.g., individual counseling and support group attendance) were also found to be effective. Suggestions for future research include the development of more well-integrated multicomponent approaches, greater inclusion of ethnically diverse family caregivers in research protocols, and greater incorporation of new technologies for treatment delivery.     

The treatment of depression in older adults in the primary care setting: an evidence-based review.

The objective of this study was to conduct an evidence-based review of treatments for depression in older adults in the primary care setting. A literature search was conducted using PsycINFO and Medline to identify relevant, English language studies published from January 1994 to April 2004 with samples aged 55 and older. Studies were required to be randomized controlled trials that compared psychosocial interventions conducted within the primary care setting with "usual care" conditions. Eight studies with older adult samples met inclusion criteria and were included in the review. Two treatment models were evident: Geriatric Evaluation Management (GEM) clinics and an approach labeled integrated health care models. Support was found for each model, with improvement in depressive symptoms and better outcomes than usual care; however, findings varied by depression severity, and interventions were difficult to compare. Further efforts to improve research and clinical care of depression in the primary care setting for older adults are needed. The authors recommend the use of interdisciplinary teams and more implementation of psychosocial treatments shown to be effective for older adults.     

Dialectical Behavior Therapy Skills for Families of Individuals With Behavioral Disorders: Initial Feasibility and Outcomes

Family members of individuals with behavioral disorders are a valuable source of logistical and emotional support for patients. Family members may take on tremendous financial and/or psychological responsibility to care for their loved ones, which can result in poor psychological outcomes for the family and, in turn, impede the recovery of the patient. Dialectical Behavior Therapy (DBT) skills training is an effective treatment that has been utilized with numerous populations, including family members of individuals with behavioral problems, and has shown efficacy in improving various interpersonal outcomes; however, no study has examined feasibility and outcomes of delivering all four unabridged DBT skills modules to this population. Twenty participants attended weekly DBT skills classes for 6 months, where they acquired skills in mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. There were significant pre-post improvements for emotion dysregulation, stress reactivity, and various interpersonal outcomes; there were no significant changes in depression or anxiety. These results suggest that DBT skills may be effective at improving broad clinical domains in a sample of family members of individuals with behavioral problems. This research is the first step in demonstrating that DBT skills might benefit family members of patients with heterogeneous mental health problems and, therefore, fits in to the field’s growing interest in cost-effective transdiagnostic interventions.     

Cognitive-Behavioral Treatment of Depression, Part IX: Confronting Predisposing Factors

Cognitive-behavioral therapy can help many depressed clients learn more effective ways of coping with problems in their lives. However, for many clients with chronic or recurrent depression, it can be helpful to examine the biological, psychological, and social/cultural factors that may predispose a person toward depressive episodes. In order to address possible biological predispositions, it is important to assess for a positive family history of depression, evaluate family members' response to previous treatments, and refer for medications when needed. In order to address possible psychological predispositions, it is useful to evaluate long-standing personality styles, identify negative events from childhood, examine the client's relationship with his or her parents, evaluate the history of abuse, and identify early loss experiences. Cultural factors may play an influential role in the etiology of depression, and can be useful to incorporate into a broad treatment plan. However, cultural factors are difficult to modify through individual psychotherapy. Hence, they are unlikely to play a central role in cognitive-behavioral therapy for depression. Overall, therapists working with depressed clients should be prepared to confront a broad range of biological, psychological, and environmental factors that can create or perpetuate a client's risk for depression.     

Toward optimal treatments for major depression

The treatment of major depression remains problematic for several reasons. In particular, the therapeutic response to medications usually does not manifest itself until a week after administration has begun, and more than half the patients will not experience a full recovery with the first antidepressant drug administration. There are, however, some pharmacologic strategies that can accelerate antidepressant response. When facing a treatment-resistant depression, combination therapy offers a more time-efficient approach to achieve remission than drug substitution. These interventions have been devised on a better understanding of the basis for the therapeutic response obtained with the first- and second-generation antidepressants, and evidence derived from controlled clinical trials of their superior effectiveness is growing. The rationale for such approaches will be described in this article, as well as their advantages and potential inconveniences. Ongoing research in this field continues to fuel the development of novel, better-tolerated, and more effective pharmacotherapies for depression.     

Marital interventions for depression: Empirical foundation and future prospects

There is a robust association between marital adjustment and depressive symptoms, and many scholars identify marital discord as a cause of depression. Outcome research shows that marital interventions are effective for increasing marital adjustment and that they may have considerable potential both in the treatment of episodes of depression and in the prevention of depressive symptomatology. To encourage further development of marital interventions for depression, a model is offered that incorporates individual difference and development perspectives.