Psychological treatments

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Acute treatment of unipolar disorder

The psychological management of acute depression ranges from basic clinical management, supportive psychotherapy, psychoeducation sessions for the individual with their partner or family present, through to formal psychotherapy. Clinical management and family psychoeducation sessions will involve education about the nature of the disorder (including polarity, course, and prognosis), treatment options (including the advantages and disadvantages of psychotherapy, or in the use of drugs, the delay in benefits, and probable side-effects) and an early discussion about the planned length of treatment. These basic sessions can help build a strong alliance between the clinician and the patient, overcome misconceptions about the diagnosis and treatment (such as fears of addiction to antidepressants), reduce tension in interpersonal relationships and significantly reduce barriers to medication compliance.

For some individuals the reduction in symptoms that occurs after the introduction of medication restores them to their previous level of functioning and they are once again able to use their own coping skills to resolve personal problems. However, for others, the disorder is only partially resolved or the nature of problems is such that additional input is required over a longer period of time. Such cases may benefit from longer-term supportive psychotherapy. This may be provided in an outpatient clinic, but might also be provided through day services or visits by a community psychiatric nurse.

Formal psychotherapy may be offered as the only treatment to individuals with milder depressions or in combination with medication in those with moderate and severe disorders. More than 20 per cent of couples report marital discord in association with depressive disorders and so marital or family approaches should always be considered as an alternative to individual therapy. Individual treatments, such as cognitive therapy, may particularly benefit milder depressions. There are a number of features that identify potentially effective psychological approaches to depression. (56) The therapy should be highly structured and based on a coherent model. It should provide the patient with a clear rationale for the interventions made and the therapy should promote independent use of the skills learned. Change should be attributed to the individual's rather than the therapist's skillfulness and the therapy should enhance the individual's sense of self-efficacy. Clearly cognitive therapy, behavioural therapy, and interpersonal therapy conform to this description. The choice of which of these models to use is less dependent on the patient's presentation than on the availability of a trained and experienced therapist. Adherence to the therapy model, therapists' level of expertise and skill and the provision of regular and adequate supervision to the practitioner are important determinants of outcome and may account for some 30 per cent of the variance in patient's improvement.(57) Furthermore, the more severe or complex the case, the more important therapist factors become.(5,57) It is also likely that more severe or chronic disorders will require a more prolonged course of therapy. Scott and DeRubeis (106) reviewed studies using cognitive therapy plus drugs in patients with non-responsive depression and found that the average response rate (about 44 per cent) was about the same as that achieved with lithium augmentation, but tended to increase with expertise of the therapist and overall duration of treatment.

Acute treatment of mania

Psychotherapy has not been tested in manic patients, but it is important to use clinical management, supportive therapy, and psychoeducational sessions as described previously. Clarkin et al.'(i07) have demonstrated that the use of inpatient family interventions (about six sessions) with patients who have been stabilized in hospital can have beneficial effects extending beyond discharge.

Longer-term treatment

In day-to-day practice, supportive therapy or other forms of psychological input may extend over considerable periods of time. In addition, people with affective disorders form about 15 to 20 per cent of the long-stay patient populations of mental hospitals in the United Kingdom and the United States. Rehabilitation techniques as applied to schizophrenia and other severe mental disorders are important for instilling hope and developing day-to-day living skills in people with chronic or recurrent affective disorders. Lastly, all individuals with chronic health problems are at high risk (about 50 per cent) of non-compliance with medication. (!08) Jamison et al.(!°.9) have identified the potentially critical role of psychotherapy in enhancing medication compliance in bipolar disorder and outlined an intervention programme. (47)

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