Major depression is the most common condition treated by psychologists. In this book chapter, we first outline the typical symptoms that characterize major depression as well as common risk factors for the development of the disorder. Next, we discuss common diagnostic tools that assist clinicians in the initial recognition of the disorder as well as in further monitoring of the disorder across time. Potential pitfalls and complicating factors related to the diagnosis and monitoring of major depression are also addressed. We then discuss maintaining factors and mechanisms of change associated with major depression, as any psychological intervention has to take these into account when tailoring an appropriate intervention. Finally, we conclude by describing several evidence based treatments available to treat depression and the various outlets available for psychologists who are interested in learning how to apply these treatments in their clinical practice. We conclude by outlining the main competencies required of clinicians interested in working with individuals with major depression. These include: the ability to adequately detect and monitor depression, the ability to make an informed case formulation, the ability to tailor treatment strategies based on existing knowledge concerning maintaining factors and mechanisms of change, and the ability to apply evidence based treatments in the context of evidence based practice.
23.1 1.1 Overview
Major depression is one of the most common mental disorders in adult populations and is the most common illness that psychologists treat. Major depression is considered to be the fourth leading cause of disability in the USA (WHO, 2000). It can affect people at any stage of life, and once a person experiences one episode of major depression, that person is likely to experience at least two to three relapses in his or her lifetime (Parashar et al., 2006). Major depression is also the leading cause of suicide in adults, particularly adults aged 65 and older (Conwell, 2001), and it is associated with increased morbidity and mortality when related to medical illness (WHO).
It is particularly important that all clinical psychologists be familiar with major depression, specifically how to diagnose the disorder and differentiate it from other, similar disorders, how to determine a treatment plan, and how to use evidence-based interventions in treating it. Fortunately, major depression is one of the most widely studied mental disorders, and as such, there are numerous peer-reviewed studies, books, and manuals on the topic. Further, it has been studied widely across adult age groups and in a number of cultural groups. Our aim in this chapter is to synthesize the extant information on major depression and detail the core and expert competencies that clinical psychologists must have when working with this disorder.
23.2 1.2 Recognition of Symptoms and Their Assessment
Major depressive disorder (MDD) is characterized by at least one major depressive episode, with no history of mania (e.g., period of intense energy, euphoria, distorted thinking, and behavioral excesses). To qualify for a major depressive episode, either depressed mood or lack of interest or pleasure in usual activities (anhedonia) must be present most of the day, nearly every day, and the episode must last at least 2 weeks. In addition, at least five out of nine possible symptoms must be present during the same period. The symptoms must be severe enough to interfere with the individual’s social or occupational functioning. MDD is further qualified by its severity, chronicity, and remission status. Severity is generally determined by the degree of disability experienced by the afflicted person. If the person can continue to pursue his or her obligations (work, family, and social activities), the depression is ranked as mild. If the person has trouble getting out of bed and can no longer engage in any obligated activities, the depression will be ranked as moderate. If a person is thinking of death or dying or is so vegetative that she or he has not left his or her bed, eaten, or engaged in any self-management activities or is exhibiting psychotic behavior, then the depression will be ranked as severe. Although rare, a depressed person can exhibit symptoms of Catatonia, which is characterized by immobility, excessive motor activity, extreme negativism or mutism, and bizarre posturing. A person will be diagnosed as having recurrent type MDD, if there has been more than one episode of MDD. Chronic MDD is characterized by symptoms of MDD for as long as 2 years. As research has found MDD to be a recurrent disorder (single episodes are rare), if a person has had an episode of MDD and is no longer experiencing any depressive symptoms, that person is considered to be in remission.
MDD can be further delineated by type. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes the concept of endogenous depression and is subsumed under the category of melancholic depression. This category is characterized by lack of reactivity to pleasurable stimuli, experiencing more severe depression in the morning, and excessive guilt. Some researchers have suggested that this subtype is more typically associated with biological etiology and that it may be more responsive to psychopharmacological intervention (Simons & Thase, 1992). Atypical features of depression include temporary brightening of mood in response to actual or potential positive events, weight gain, hypersomnia, heavy feelings in arms or legs, and interpersonal sensitivity to rejection. These symptoms tend to be interpreted as suggesting a depressive disorder that is more likely to respond to psychosocial interventions rather than medications and may be more stress-related (Angst, Gamma, Sellaro, Zhang, & Merikangas, 2002).
23.2.1 1.2.1 Risk Factors
Most scientists now believe that MDD is multifaceted, with causes resulting from interactions of psychological, social, and biological factors (O’Keane, 2000). We note here that no factor is thought to be exclusively causal of depression; rather, most scientists believe that strength in one area can compensate weakness in another. As an example, someone with a strong genetic loading for developing MDD but over the years has developed effective coping strategies to modulate mood may never develop an episode of MDD. When working with MDD patients, therapists should keep this compensatory model in mind.
23.2.2 1.2.2 Psychological Resilience
In the 1980s and 1990s, there was a considerable amount of interest in the role that coping style or psychological resilience has on the risks for developing MDD. Such interest waned in the mid- to late 1990s, but because of recent interest from institutions such as the National Institute of Mental Health in individualized treatments for mental illness (Zarhouni, 2007), study of factors that prevent MDD from developing in the face of genetic loading for the illness have again become an area of important inquiry. Psychological factors related to prevention or risk of MDD include one’s perception of the world or cognitive set and an active versus passive coping style (Southwick, Vythilingam, & Charney, 2005). Research has found that cognitive set and coping style tend to be a function of one’s experiences with difficult problems. Behaviors develop as a function of either observing others in one’s environment coping with stress or through experience with behaviors that have either successfully or unsuccessfully resulted in problem resolution and positive mood. These experiences also help to shape one’s perspective of the world and one’s ability to function in it. If attempts at solving problems have been largely successful in producing positive mood or in reducing negative mood, then individuals will engage in those successful behaviors in the future and see themselves as being able to successfully manage problems (Haeffel & Grigorenko, 2007; Roy, Sarchiapone, & Carli, 2007; Yi, Vitaliano, Smith, Yi, & Weinger, 2008). Similarly, coping skills have been found to be related to depression. Most researches have found that people who use active forms of coping, such as problems solving, are less likely to become depressed than people who use passive forms of coping, such as avoidance. In fact, one study found that prevalence of major depression was 59.4% in people with avoidant coping styles (Garcia, Valdes, Jodar, Riesco, & de Flores, 1994; Welch & Austin, 2001). Studies show that when faced with a problem to solve, depressed people are more likely to produce less effective solutions than nondepressed people, such as using distraction to cope with a stressor, rather than trying to solve it (Haeffel and Grigorenko).
23.2.3 1.2.3 Life Events
The literature is replete with data indicating that stressful life events contribute to the development of MDD (Hammen, 2005). Although not everyone who is faced with difficult problems becomes depressed, it is evident that prolonged exposure to psychosocial stress can precipitate a depressive episode (Hyde, Mesulis, & Abramson, 2008). Several studies have found that most depressive episodes are preceded by a severe life event or difficulty in the 6 months prior to the onset of the episode (Beck, 2008). In addition, patients with more long-term or chronic depression were more likely to report past abuse, though the causal relationship is unclear (Keita, 2007).
23.2.4 1.2.4 Social Support
Other studies find that the relationship of life events with depression is mediated by social support (Huhman, 2006). Severe life events are significantly more likely to provoke a major depressive episode in individuals without social support (Merry, 2007; Patel, 2007). Support systems give an individual external support when internal coping skills are put to the test. Therefore, while negative life events do influence the occurrence of depressive disorders, the social and psychological resources available to the person facing the stressful life event generally mediate the impact on mood (Robinson & Shahakian, 2008).
23.2.5 1.2.5 Biological and Physical
Much research effort has gone into determining biological determinants of depression. The literature not only shows evidence of the effects from both neurotransmitters and hormones, but also physiological changes arising from stress that can increase susceptibility to depression (Robinson & Shahkian, 2008).
Biological explanations for depression indicate that MDD is caused in part by a disregulation in three major neurotransmitters in the brain: serotonin, norepinephrine, and dopamine. Antidepressants to regulate production and distribution of these neurotransmitters are effective in their ability to increase the availability of receptor sites rather than increasing the production of the neurotransmitters (Celada, Puig, Amargós-Bosch, Adell, & Artigas, 2004). Recent research into neuroendocrinology has added to our understanding of the biological causes of depression. Evidence points to an overabundance of cortisol in the systems of depressed patients as well as abnormalities in the thyroid functions (Bondy, 2005; Krystal, D’Souza, Sanacora, Goddard, & Charney, 2001). Finally, physiological changes in the brain structure of depressed individuals lend to further support for structural changes in the brain with MDD. Some researchers suggest that dysfunction in the mesial temporal lobe may be related to recurrent MDD (Malhi, Parker, & Greenwood, 2005). These physical changes that can occur during stressor illness and are associated so closely with depression give a more comprehensive picture and explanation of the causes of depression.
23.2.6 1.2.6 Genetics
Recent advances in science have led investigators to better understand the role that genetics plays in the development of MDD. Past studies of identical and fraternal twins found that identical twins have greater concordance rates for depressive disorders (r = 0.46) than do fraternal twins (r = 0.20) (Flint, Shifman, Munafo, & Mott, 2008). Furthermore, family studies show that even though having a relative with a mood disorder increases likelihood for developing MDD, rates are not compelling, as having a relative with a mood disorder only confers a 21% risk (Trivedi et al., 2008). Recent research has been able to conduct direct genetic comparisons, where the actual DNA from depressed and nondepressed people is compared. This method is helpful in finding a specific gene that expresses MDD. Early research in this area has been able to uncover differences in the genetic location of dopamine and serotonin receptors between MDD and non-MDD patients (Iga, Ueno, & Ohmori, 2008).
23.2.7 1.2.7 Summary: Knowledge of the Causes of Depression Increases the Competency to Treat
Clinicians who are knowledgeable about how depression is presented and the various risk factors associated with depression are often better at determining an effective course of treatment for patients than those who do not keep abreast of the field. In determining the best course of treatment for patients with MDD, providers should do a thorough assessment of family history, life events, culture, illness, and coping style before determining the treatment needed. As an example, someone with a particularly severe depression who also has a family history for mood disorders may need to consider both psychotherapy and antidepressant medication in the treatment plan. As biological and genetic research proceeds, we may also be seeing a development toward individualized treatment based on genetics, biology, and behavior. As an example of work related to this notion of individualized treatment, Alexopoulus et al. (2008) have recently completed an National Institute of Mental Health (NIMH)-funded study of problem-solving therapy (PST) for depression in older adults with vascular depression. This depression is characterized by increased apathy, trouble with problem solving, planning, and initiation and is also known to be unresponsive to antidepressant medication. This study has found that a targeted intervention, with PST targeting the behavioral deficits associated with vascular depression, is a very successful treatment in case where antidepressant medication is not.
23.3 1.3 Assessment
One of the most critical tools that competent providers who treat depression have is the assessment tool that they use to diagnose MDD and track treatment outcomes. Tools are generally used as guides to help providers make decisions about the severity of the case and whether or not treatment needs to be adjusted along the way. These tools, however, are not the only means by which treatment decisions are made, but rather support and contribute to providers’ clinical judgment. Early in training, providers often rely more heavily on these tools in making treatment decisions, but as they gain more experience, these tools often begin to serve as a means for confirming advanced clinical judgment. Below, we describe the different tools that providers can access in working with their clients with MDD.
23.3.1 1.3.1 Diagnostic Tools
Diagnostic tools were originally developed to help researchers characterize their clinical samples and to conduct large-scale epidemiological studies. The principle behind these tools is consistency from assessor to assessor in deriving a diagnosis. The need for such accuracy and consistency came from research indicating that even experts, when left to their own devices, make considerable mistakes when making diagnosis, and rarely there is a consistent agreement between expert evaluators about how to best diagnose patients. Although the need for diagnostic accuracy and consistency is clear for research, some have argued that this level of accuracy is not as important in clinical work. We beg to differ. Given that the effects of evidence-based treatments are ascertained on groups of patients who were diagnosed in a specific way, it behooves the provider to make similarly accurate diagnosis in order to pick the right treatment for their client.
The most widely known diagnostic tools used in research are the Structured Clinical Interview for DSM-IV (SCID), the Composite International Diagnostic Interview (CIDI), and the Mini-International Neuropsychiatric Interview (MINI). Our focus will only be on the SCID and the MINI. The CIDI was developed for lay interviewers working in epidemiological studies and is neither feasible in clinical practice nor does it allow for clinical judgment in determining a diagnosis. The SCID and MINI are considered semi-structured interviews. Questions or prompts in the tools are meant to help to guide providers toward a diagnosis, but can be answered through clinical observation of the client. Both tools cover all Axis I disorders in the DSM. In both tools, each diagnosis starts with a few gating questions, that if answered positively, guides the clinician to continue to assess for the presence of that disorder. If the gates are answered negatively, the interview, if deemed appropriate by the clinician, moves onto the next diagnosis. There is no particular advantage in selecting one instrument over another. Both are highly accurate in detecting Axis I disorders, and both have been translated into several languages. Both are also in the public domain.
23.3.2 1.3.2 Treatment Tracking Tools
Treatment tracking tools, sometimes referred to as screeners, are self-report/client-completed tools that measure the severity of clients’ symptoms. These tools were originally developed as screening tools, that is, instruments to help identify potentially depressed clients. There are several tools on the market, but the best known are the Beck Depression Inventory (BDI; Beck, 1961), the Geriatric Depression Scale (GDS; Yesavage, 1982), and the Patient Health Questionnaire (PHQ-9; Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000). All of these instruments share in common a solid research base with excellent psychometric properties, brief administration times, easy readability, and translation in several languages. Selecting one tool over another becomes one of convenience and patient population. Our own personal favorite is the PHQ-9 because it is very brief, taking only 2 min to complete, the questions map on directly to the DSM-V symptoms of depression, it assesses for suicide and impact of symptoms on daily functioning, and is the only tool listed that has shown to be sensitive to changes in depression over time, making it an excellent treatment tracking tool. The BDI has several advantages including extensive use in research, and additional mood-related questions that extend beyond the DSM. It also assesses for suicide. The main disadvantage is that the BDI is not in the public domain. Copies must be purchased. The GDS is also an excellent tool, the main advantage being its widespread use in older adults and disabled populations. The main disadvantage is that the items do not map exactly onto DSM criteria, and it does not ask about suicide.
23.3.3 1.3.3 Factors to Consider in Diagnosis
Despite high prevalence of depression in the general population, the well-documented negative consequences associated with untreated depression, and the ample assessment and screening tools available for early detection and recognition of depression, this disorder often goes unrecognized in a variety of clinical settings. For instance, researchers found that only 50% of the depressed individuals who sought assistance in primary care clinics were diagnosed as depressed (Perez-Stable, Miranda, Munoz, & Ying, 1990). Similarly, others found that about half of community-dwelling older adults who suffered from depression were recognized as depressed by a health-care provider (Garrard et al., 1998). Barriers to early detection and recognition of depression may be at the system level, at the provider level, and at the consumer level. In this chapter, we focus on three major barriers to early detection and recognition of depression: health, age, and culture in relation to these three levels.
23.3.4 1.3.4 Health
As already stated in this chapter, there is a strong connection between depression and physical health (Cassem, 1995). This connection goes both ways, as research has shown that higher levels of depression can cause greater medical comorbidity and vice versa. Given this bidirectional relationship (Benton, Staab, & Evans, 2007), it is not surprising that the rates of comorbid depression and medical illness can be over 40% in certain medical populations (Bukberg, Penman, & Holland, 1984; Burg & Abrams, 2001). Hence, physical health is certainly a factor one has to consider when assessing for depression.
A thorough assessment requires attention not only to emotional functioning, but also to physical functioning and medication intake. This is because many medical conditions, including neurological disorders, endocrine disorders, chronic pulmonary disease, and sleep apnea, may cause or worsen depression. Similarly, medications, such as corticosteroids, antihypertensives, and certain cancer chemotherapeutic agents, may also cause or worsen depression.
Many medical patients do not present with clear psychological symptoms, such as depression or anhedonia, but instead report considerable somatic symptoms of fatigue, lack of appetite, and poor concentration. Hence, the diagnosis of depression in medically ill populations is often a challenge (Katon, Kleinman, & Rosen, 1982). Four approaches can be used to assess for depression in the medically ill (Cohen-Cole & Stoudemire, 1987). According to the inclusive approach, depressive symptoms are counted regardless of whether they may be related to physical illness (Rifkin et al., 1985). The etiological approach suggests that physical symptoms are counted only if they are not considered to be a result of the physical illness (Rapp & Vrana, 1989). The substitutive approach, on the other hand, suggests that psychological symptoms of depression replace the physical ones (Endicott, 1984). Finally, the exclusive approach suggests removing symptoms from the diagnostic criteria of depression, if they are not found to be more frequent in depressed physically ill individuals compared to nondepressed physically ill (Bukberg et al., 1984).
Nonetheless, there is still considerable debate as to which approach is most appropriate. One study evaluating the effect of using the various approaches in the case of post-stroke depression concluded that modifying the DSM-IV criteria because of the presence of physical illness was unnecessary (Fedoroff, Starkstein, Parikh, Price, & Robinson, 1991). On the other hand, others found that a diagnosis of major depression based on criteria modified for patients with medical illness is a better predictor of mortality than a diagnosis based on the inclusive criteria, arguing that the substitutive approach is preferable (Cavanaugh, Furlanetto, Creech, & Powell, 2001).
Because medically ill individuals usually seek treatment within primary care clinics or other medical settings, the specific setting has to be taken into consideration. Many medical settings may not allow for more than a short visit and in some settings privacy may be compromised (Schappert, 1992). In addition, medical illness often takes the priority and less attention is usually given to psychological conditions. Hence, adequate evaluation of depressive symptoms might be extremely challenging in medical settings.
Another potential barrier for adequate evaluation of depression in the medically ill is a potential bias at the provider level. It is not uncommon for providers to think that depression is justified given the medical situation of the individual. Hence, normalizing depression by the provider may result in underdiagnosis (Goldman, Nielsen, & Champion, 1999).
23.3.5 1.3.5 Age
Old age may pose yet another barrier for accurate diagnosis of depression. Similar to the medically ill, depression often goes unrecognized in older adults. For instance, a recent study has shown that whereas 17% of the nursing home residents suffered from depression, depression was detected in less than half of these individuals (Davison et al., 2007). A different study conducted at hostels for individuals with cognitive impairments found that whereas 39% of participants suffered from depression, less than 50% were diagnosed as depressed (McCabe, 2006).
Because medical illness is a common occurrence in old age, many of the considerations discussed in the previous section also apply here. Yet, older adults have several additional characteristics that may complicate the diagnosis of depression in this population even further. In this section, we discuss the differential symptom pattern of depression in old age, cognitive impairment, and beliefs about depression and old age as important factors that have to be taken into consideration when evaluating depression in older adults.
Differential Symptom Pattern of Depression in Old Age. There is some research suggesting that manifestation of depression is different in older adults versus younger adults. One study of over 6,000 participants found that dysphoria was less likely to be endorsed by older adults (Gallo, Anthony, & Muthen, 1994). This difference between older and younger adults remained even 13 years later at a follow-up study, suggesting that this is not a cohort effect, but potentially an age-related effect (Gallo, Rabins, & Anthony, 1999). Similarly, another study found that relative to younger adults, older adults were less likely to exhibit cognitive-affective symptoms, but the two groups did not differ in relation to report of somatic-performance symptoms (Goldberg, Breckenridge, & Sheikh, 2003).
Cognitive Impairment. Cognitive impairment is common in old age, with as many as 20% of the general population of older adults suffering from mild cognitive impairment (Manly et al., 2008), and about 5% suffering from dementia (Eefsting, Boersma, Van den Brink, & Van Tilburg, 1996). Depression is considered one of many neuropsychiatric symptoms (e.g., agitation, hallucination, apathy) that often co-occur in the presence of dementia, with over 20% of the individuals who suffer from dementia also suffering from depression (Ballard, Bannister, Solis, Oyebode, & Wilcock, 1996). To complicate things even further, in some older adults, depression may present as pseudodementia, characterized by slowness of thought and speech as well as concentration difficulties (Saez-Fonseca, Lee, & Walker, 2007). Unlike dementia, pseudodementia can be reversible; there is clearly an incentive to differentiate the two. Nonetheless, treating depression is obviously an important task also in the case of individuals with cognitive impairment or dementia as depression significantly compromises their quality of life.
A major difficulty associated with the diagnosis of depression in this population of older adults with cognitive impairments is the fact that many older adults at the more severe stages of dementia are unable to express themselves or to provide reliable information about their situation. To address these difficulties, specific depression rating scales that are based on observational data or informant report rather than self-report were developed. One example is the Cornell Scale for Depression in Dementia. A measure that was specifically developed to assess signs and symptoms of major depression in dementia based on informant report (Alexopoulos, Abrams, Young, & Shamoian, 1988).
National Institute of Mental Health Provisional Diagnostic Criteria for Depression of Alzheimer's Disease
Significant depressed mood: sad, hopeless, discouraged, tearful
Decreased positive feelings or reduced pleasure in response to social contacts and usual activities
Social isolation or withdrawal
Disruption in appetite that is not related to other medical conditions
Disruption in sleep
Agitation or slowed behavior
Fatigue or loss of energy
Feelings of worthlessness or hopelessness or inappropriate excessive guilt
Recurrent thoughts of death, suicide plans or suicide attempts
Beliefs About Depression and Old Age. The stigma of mental illness may be yet another barrier for accurate diagnosis of depression in older adults, especially when accompanied by lack of knowledge about depression (Sirey et al., 2001). Both older adults and their physicians may attribute depression to normal aging, grief, or physical illness (Gallo et al., 1994; Uncapher & Arean, 2000). As an example, researchers found that older adults with depression who attributed their depression to old age were less likely to seek professional care or discuss their symptoms (Sarkisian, Lee-Henderson, & Mangione, 2003).
23.3.6 1.3.6 Culture
Culture is considered as the cumulative deposit of knowledge, beliefs, values, and meanings shared by a group of people. There is ample research demonstrating ethnic disparities in the diagnosis of depression (Stockdale, Lagomasino, Siddique, McGuire, & Miranda, 2008). These differences may be partially attributed to variability in symptom report in different ethnic groups. The report of distress among different cultural groups is related to the nature of the stresses presented, the attitudes toward mental illness, the meaning attributed to the symptoms, and the coping mechanisms and resources available to the particular cultural group (Chung & Singer, 1995).
Researchers have argued that level of “Westernization” is associated with variations in self-report of depressive symptoms. People from Western cultures are said to psychologize their depression (i.e., emotional and cognitive report of distress), whereas people from non-Western cultures are said to somatize their depression (i.e., report of distress in the form of bodily complaints and physiological symptoms) (Katon et al., 1982; Kleinman, 1982). Somatization of depressive symptoms has been observed in various cultures such as China (Ryder et al., 2008), United Arab Emirates (Hamdi, Amin, & Abou-Saleh, 1997), and India (Raguram, Weiss, Channabasavanna, & Devins, 1996), whereas psychological report of depression was found among more “Westernized” groups of non-Western societies (Kim, Li, & Kim, 1999). Nonetheless, research suggests that somatic report of depression is common among Western cultures as well (Mattila et al., 2008).
Provider characteristics have also been identified as potential factors that impair the accurate diagnosis of depression in different cultural groups. According to Adebimpe (1981), race of the clinician, social and cultural distance between client and clinician, stereotypes of psychopathology in different cultural group, and biased diagnostic instruments may explain misdiagnosis of ethnic minorities. For instance, whereas epidemiological studies suggest equivalent prevalence rates of depression among Black and White Americans (Zung, MacDonald, & Zung, 1988), in clinical practice, Blacks are more likely to receive a diagnosis of psychotic disorder and less likely to receive a diagnosis of mood disorder relative to Whites (Strakowski et al., 2003).
23.3.7 1.3.7 Genetics
As already noted, depression is at least partially accounted for by genetic makeup. Hence, the inevitable question is whether we could or should screen for genetic susceptibility of depression (Morley, Hall, & Carter, 2004). Apparently, the predictive strength of the various candidate genes is modest at best, suggesting that an individual who has a particular allele that has been found to be associated with depression has around twice the risk of developing a mood disorder relative to an individual who does not. However, because multiple susceptible alleles and environmental factors are considered to increase the risk for depression, information from genetic testing becomes less useful. In addition, to date, there are no clear pharmacological or psychological interventions that could be used for prevention in individuals who have genetic susceptibility to depression in the absence of the condition. It is also unclear what the impact of genetic testing would be on the mental health and social standing of genetically at risk individuals and their family members (Morley et al., 2004).
23.3.8 1.3.8 Family
Although familial screening for depression is not the norm, the one instance in which familial screening has been recommended is the case of mothers bringing their children for the treatment of depression. Reportedly, a substantial number of mothers who bring their children for depression treatment are also depressed, yet their depression often goes unrecognized and untreated (Ferro, Verdeli, Pierre, & Weissman, 2000). It also is recommended to screen for depression in family caregivers of individuals with severe medical illness, psychiatric impairments, or cognitive impairments, as caregiving is a highly taxing role associated with high levels of depression (Carol, 2003; Ratnakar et al., 2008).
23.3.9 1.3.9 Placebo Effects
The placebo effect in depression is considered to be of great magnitude. One factor that has shown to increase the placebo effect is the therapeutic effect of assessment contacts. A recent meta-analysis found that follow-up assessments in antidepressant treatment trials account for 40% of the therapeutic effect for participants on placebo. Moreover, these researchers have argued that the therapeutic effect of the initial evaluation meeting is even larger (Posternak & Zimmerman, 2007). Hence, clinicians should be aware of the fact that attention and care exhibited during standard assessment procedures are of great impact and often account for improvement in depressive symptoms.
Provider Competencies: Understanding Factors Related to Diagnosis. Clinicians facing the diagnosis of major depression have to conduct a thorough assessment not only of the mental health functioning of the individual, but also of his or her medical and cognitive functioning. In this chapter, we outline some of the potential barriers for accurate diagnosis of depression. These barriers may be at the consumer, provider, or setting level.
23.4 1.4 Maintenance Factors of the Disorder
As already noted, depression is more often a recurrent or chronic condition than a single episode (Kessler et al., 2003). Relative to acute depression, chronic depression is characterized by greater medical comorbidity, impaired functioning, and increased health-care utilization (Crown et al., 2002; Weissman, Leaf, Bruce, & Florio, 1988). One major problem associated with the understanding of chronic depression is a lack of consistent definition. According to the DSM-IV, the specifier “chronicity” can be applied to major depression, if it has lasted for over 2 years. The specifier “incomplete inter-episode recovery” is applied, if symptoms no longer meet criteria for major depression, but residual symptoms are still present. Dysthymia (i.e., as episode of less severe depressive symptoms that lasts at least 2 years) is also characterized by a chronic course. Furthermore, although not listed in the DSM-IV, the term “double depression,” which refers to depression superimposed on dysthymia also characterizes a chronic course of depression (Keller & Lavori, 1984). In addition, the DSM-IV proposed a classification of depressive personality as a category for further research. To date, there have been several attempts to differentiate between these various classifications of chronicity, but the majority of the studies did not yield consistent differences (McCullough et al., 2000; Remick, Sadovnick, Lam, Zis, & Yee, 1996). To complicate issues even further, there is the term “treatment-resistant depression,” which is characterized by failure of at least two consecutive antidepressant trails. Although treatment-resistant depression is not synonymous with chronic depression, it often results in a more chronic course of depressive illness.
Here, we will discuss several factors responsible for the maintenance of depression, including inadequate diagnosis and treatment, genetic/familial predisposition, early childhood experiences, comorbid medical and psychiatric illnesses, and personality style/disorder.
Inadequate Diagnosis and Treatment. As we have already noted, there is ample research demonstrating inadequate detection of depression in a variety of settings. Moreover, even when depression is detected, it often is poorly managed. According to results from the National Comorbidity Survey Replication, 57% of depressed individuals receive some type of treatment, but only 21% receive treatment that is considered adequate (Kessler et al., 2003).
Although the course of untreated or poorly treated depression has not been extensively studied due to ethical reasons, a meta-analysis of randomized controled trials, in which one group was a wait-list control, found that about 20% experience a spontaneous remission in their depressive symptoms without any treatment. Although impressive, compared to a 50–60% response rate to pharmacological and nonpharmacological interventions, this finding reemphasizes the importance of early detection and adequate treatment of depression (Posternak & Miller, 2001). Similarly, research has shown that a longer interval between the onset of depression and the receipt of treatment is associated with a poor prognosis (Scott, Eccleston, & Boys, 1992).
Genetic/Familial Predisposition. There is some research suggesting that individuals who have a family history of dysthymia or personality disorder are more likely to suffer from chronic depression (Klein et al., 1995). Chronic depression was also found to be familially aggregated especially in the early onset cases (Mondimore et al., 2006). Others found that having a co-twin with a history of depression predicted a slower recovery from major depression (Kendler, Walters, & Kessler, 1997).
Early Childhood Experiences. The finding that early onset depression is associated with a more chronic course of depression has led to hypotheses about early childhood experiences as predictors of chronic depression. There is considerable research demonstrating that early childhood adversities are associated with a more chronic course of depression (Riso, Miyatake, & Thase, 2002). Although, both childhood trauma, loss of object relations, and early separations have been examined as potential predictors of chronic depression, childhood trauma has received the strongest support (Akiskal, King, Rosenthal, Robinson, & Scott-Strauss, 1981; Durbin, Klein, & Schwartz, 2000; Kendler et al., 1997; Weissman & Klerman, 1977; Zlotnick, Warshaw, Shea, & Keller, 1997).
Comorbid Medical and Psychiatric Illnesses. Comorbid medical illness and psychiatric illness have shown to be associated with a chronic course of depression. In a 5-year follow-up study of the outcomes of dysthymic disorder, researchers found that comorbid anxiety disorder was associated with a lower probability of recovery (Hayden & Klein, 2001). Comorbid substance abuse disorders and suicidality were also found to predict a more chronic course of depression (Mondimore et al., 2007). Others have used the term “chronic secondary depression” (Akiskal et al., 1981) to refer to individuals with chronic medical conditions, such as dementia, stroke, and arthritis who suffer from chronic depression.
Personality Style/Disorder. The term depressive personality proposed by DSM-IV as a research category implies that some aspects of chronic depression are thought to share characteristics with personality disorders. Indeed, personality disorders are more commonly found in individuals who suffer from chronic depression, such as dysthymia relative to individuals who have acute depression (Hayden & Klein, 2001; Pepper et al., 1995). In addition, there is considerable research demonstrating that neuroticism (i.e., emotional instability characterized by vulnerability to stress and anxiety) is a strong predictor of chronic depression (Duggan, Sham, Lee, Minne, & Murray, 1995; Weissman, Prusoff, & Klerman, 1978). However, it has been argued that it is hard to tell whether personality disorders are a precursor of chronic depression or whether the two share a common etiology (Riso et al., 2002).
23.4.1 1.4.1 Provider Competencies: Understanding Maintenance Factors
In this section, we outline several mechanisms responsible for the maintenance of depression. Because these are largely nonmodifiable, clinicians may use this information as “red flags” indicating that further attention is necessary. Particularly in cases where clients are not responding to treatment, providers may need to reassess for family and genetic contributions to depression that may point in a different treatment direction, or providers may need to assess for potential comorbid substance abuse or personality disorder. Having an understanding of the factors that contribute to persistence of depression will help in better treatment decisions for those clients who fail to respond.
23.5 1.5 Mechanisms of Change Underlying the Intervention
As one would expect, there is a considerable interest in the mechanisms responsible for change and reduction in depressive symptoms. Gaining a better understanding into these mechanisms can assist in the development and refinement of theories about the etiology of depression as well as assist in the development of specific therapeutic interventions for depression. Given the magnitude of research on the topic, this section is focused on some of the more prominent mechanisms.
Illness Characteristics. Ample research has demonstrated that a more severe level of depressive illness (Lam, Green, Power, & Checkley, 1994; Trivedi, Morris, Pan, Grannemann, & Rush, 2005), a greater number of past depressive episodes, a family history of depression (Trivedi et al., 2005), a longer depressive course, and an early onset of depression are all associated with poorer prognosis. Hence, those individuals who suffer from milder depression are more likely to experience change either following therapy or spontaneously.
Placebo. As already noted, the placebo effect is particularly strong in individuals with depression. According to a meta-analysis comparing the placebo effect to pharmacological treatment of depression, the mean proportion of patients who respond in the placebo group is about 30%, whereas the greatest response in patients receiving medication is 50%. In fact, there is some research suggesting that as the attributed effect of psychotropic medications of the new generation had increased so did the placebo effect (Walsh, Seidman, Sysko, & Gould, 2002). Given the strong effect placebo has on the course of depression, clinicians should utilize the placebo effect for their benefit by instilling in patients beliefs in the ability to change. Importance of beliefs in the successful treatment of depression is demonstrated by a study that found that at the end of successful treatment, individuals assigned to the medication arm were less likely to believe in psychotherapy as an effective treatment for depression, whereas those assigned to the psychotherapy arm were less likely to believe in the effectiveness of medication (Leykin, DeRubeis, Shelton, & Amsterdam, 2007).
Motivation. Research suggests that depression is often associated with a deficit in motivation (Cohen, Weingartner, Smallberg, Pickar, & Murphy, 1982; Layne, 1980). Instilling motivation in patients is important because higher motivation for change has been associated with better treatment outcomes. Although not specific to depression, the technique of motivational interviewing designed to prepare and activate individuals in the direction of change has gained considerable popularity in treating a variety of disorders, including depression (Westra, 2004).
Adherence to Treatment. Despite the many innovations in the field of psychotherapy and pharmacotherapy, rates of treatment nonresponse are still significant. This is at least partially due to nonadherence or inadequate adherence to treatment. There is ample research demonstrating that those individuals who adhere more closely to their treatment regime are more likely to benefit from their medication treatment (Melfi et al., 1998). It is also true for psychotherapy trials that have consistently shown that those individuals who complete their homework assignments are more likely to benefit from therapy (Cowan et al., 2008). In fact, one hypothesis suggests that the combination of psychopharmacology and psychotherapy in the treatment of depression is more effective than psychopharmacology alone because the psychotherapy component encourages adherence to psychopharmacological treatments (Basco, 1995).
Cognitive Changes. The study of cognitive changes as mediators of change in depressive symptoms is largely attributed to the cognitive theories of depression. According to these theories, depression is a result of maladaptive schemas or core beliefs (Beck, Rush, Shaw, & Emery, 1979). Hence, one would expect that changes in these maladaptive schemas would result in lower levels of depression. Research has largely supported this assumption and shown that changes in dysfunctional thoughts and attributions mediate the effect of depression treatment (Barber & DeRubeis, 2001; Quilty, McBride, & Bagby, 2008).
In many cases, however, the effects of certain cognitive changes as a result of therapy were not specific to cognitive-behavioral therapy, but were instead observed in patients undergoing behavioral therapy or medication therapy as well (Garratt, Ingram, Rand, & Sawalani, 2007; Jacobson et al., 1996). Furthermore, acquisition of adaptive skills is considered common to both cognitive-behavioral and psychodynamic approaches despite the fact that the two use different terminology and radically different approaches (Badgio, Halperin, & Barber, 1999). Hence, it appears that unrelated to the therapeutic modality employed, those individuals who are able to adapt a more adaptive form of thinking are more likely to recover from their depression.
Social Support. The beneficial effects of social support are well documented and include higher rates of quality of life and lower medical and psychiatric illness (Bell, LeRoy, & Stephenson, 1982). Furthermore, there is a strong body of evidence demonstrating that individuals of greater social support and those married or living with a partner are more likely to benefit from therapy and overcome adverse life events (Brown, Adler, & Bifulco, 1988; Paykel, 1994; Trivedi et al., 2005). Interestingly, even expected social support plays a role in recovery from depression. Specifically, those individuals who expressed higher levels of ideal social support were less likely to recover from their depression (Lam et al., 1994).
Religiosity. Similar to social support, the beneficial effects of religiosity are also well documented. Religious individuals have shown to enjoy a longer life span as well as better physical and psychological health (Clark, Friedman, & Martin, 1999). A recent study has shown that religiosity also plays a role in recovery from depression. A retrospective study followed 94 medically ill older adults, diagnosed with depression. The study found that those individuals who reported intrinsic religiosity, but not those who reported more frequent church visits, had a shorter time to recovery from their depression (Koenig, George, & Peterson, 1998).
Provider Competencies: Understanding the Factors Related to Change. This section has outlined several mechanisms thought to be responsible for change. Whereas some, such as illness characteristics, are nonmodifiable, others such as the placebo effect, motivation, and adherence to treatment may be utilized by the therapist to enhance the effects of therapy. A great advantage of the majority of these mechanisms is that they have not shown to be specific to a certain therapeutic modality, but instead affect change across a variety of treatment options.
23.6 1.6 Evidence-Based Treatment Approaches
It is important to distinguish between what is meant by evidence-based practice (EBP) and evidence-based treatment (EBT). EBP is a concept that was derived from medicine in the 1970s (McKibbon, 1998). The concept was developed to help clinicians move beyond clinical lore in making treatment decisions, by ensuring that clinicians and clients have sufficient information about the efficacy and safety of a treatment before deciding to employ it. In order to improve health care, physicians must be aware of the state-of-the-art treatment and assessment and select those treatments based on clinical judgment and client input. EBP has been conceptualized as a three-legged stool, with clinical judgment, evidence-based treatment, and client preference all equal in developing effective treatment plans (McKibbon). EBT, on the other hand, is one of the legs on the three-legged stool that is EBP. EBT is the actual intervention selected by the clinician and client to address an illness, and is an intervention that has been researched sufficiently to determine its efficacy and safety in treating the disorder. For MDD, a number of effective interventions are available. Interventions with an evidence base include antidepressant medication, electroshock therapy, and psychotherapy. A whole book, let alone a chapter, could be dedicated to the array of evidence-based treatments available to people with major depression. We dedicate our discussion here to evidence-based psychotherapies for adult populations with major depression.
How an Intervention Becomes an EBT. There are several guidelines for determining whether interventions can be an EBT, and the most reliable guidelines evaluate the quality of the research and the degree to which there is an agreement between the studies that the intervention is effective. The most notable guidelines include the Kaufman Best Practice Approach, which specifies that an EBT should be based in sound theory, have treatment guidelines, have been studied in at least one randomized clinical trial, and is safe (Kaufman Best Practice Project, 2004); The Center for Reviews and Dissemination (Khan, 2001) considers treatments to be EBTs, if there are more than two randomized clinical trials that ensure true randomization and concealment about treatment condition, thorough description of the intervention, and the use of intent-to-treat analyses only; the National Registry of Evidence-Based Programs and Practices (NREPP, 2008) specifies that interventions are evaluated on the quality of the research supporting it and readiness for dissemination. Quality of the research is judged on a 0–4 scale on several quality criteria that include reliability of the measures used, validity of the measures, intervention fidelity, management of missing data, potential alternative explanations for outcomes based on the data, and the appropriateness of the data analysis and interpretation. Readiness for dissemination is determined by the same 0–4 quality scale regarding how available implementation materials are, if there are training and support services, and if any quality improvement materials exist; and finally, the American Psychological Association Guidelines focuses primarily on the rigor to which an intervention has been studied, existence of a manual, and the degree of agreement between studies regarding treatment effects (Chambless & Hollon, 1998).
In considering these methods for determining EBT, we compiled our own list of chatacteristics defining EBT: there are two or more randomized trials demonstrating positive outcomes, the research is of high quality with regard to methods, measures, implementation, and data analyses, and finally there is a mechanism by which others can replicate the treatment in their settings. Using these criteria, the following psychotherapies have been found to be EBTs for MDD: cognitive-behavioral therapy (CBT), behavioral activation (BA), interpersonal psychotherapy (IPT), and problem-solving treatment (PST). We discuss each intervention in terms of the theory, practice, evidence base, and safety.
Cognitive-Behavioral Therapy (CBT). CBT has become an umbrella term for a series of interventions that share commonalities with regard to how depression is viewed and treated. Cognitive-behavioral treatments share in common a focus on cognitions, assumptions, beliefs, and reactions that are a function of, or contribute to, major depression symptoms, with the aim of changing appraisals to affect emotional change.
These interventions include cognitive therapy (CT; Beck, 1993) and mindfulness-based cognitive therapy (MBCT; Segal, Teasdale, & Williams, 2002). Although these two interventions are similar in theory and focus, they vary in how emotion and change in behavior are addressed. We note here that some authors have also included problem-solving therapy (PST; Nezu, Nezu, & Perri, 1998; Mynors-Wallis, Gath, Day, & Baker, 2000) under this category of EBT, but because of its unique process, its relatively recent designation as an EBT, and its growing popularity in non-mental-health settings, we discuss that treatment in a separate section. Similarly, authors will often include behavioral activation under the CBT category of treatments, but because of its unique process and its minimal focus on cognition and appraisals, we will give this intervention its own section.
Cognitive Therapy. CT was developed by a psychiatrist, Aaron T. Beck, who conceptualized his theory of affective disorders after concluding from his clinical practice that clients who improved from treatment did so through a process of changing their interpretation of events in their current lives and their belief in themselves as effective change agents. In his earlier work, Beck focused primarily on helping clients overcome common “errors in thinking” that he found to be related to depressive emotion and behavior. Errors in thinking included making arbitrary and negative inferences of events in clients’ lives, overgeneralizing negative events and minimizing positive events, and selective attention to the negative things in life. These errors in thinking are considered to be just below clients’ level of awareness, and in the process of helping become more aware of those thoughts; the correlation between those thoughts and moods and subsequently, how they interact with other people and solve problems are the paramount aims of treatment (Beck, 1993). Beck has since amended his theory to also include the concept of “schemas,” which are the lens by which clients process information about themselves and the world. Errors in thinking arise from these schemata, and the ultimate way to treat depression is to better understand the schema underlying the errors in thinking and change that lens to a more objective, realistic perspective. Once the schema changes, errors in thinking change creating more positive affect.
The evidence base for CT as a depression intervention is very strong, and highly positive (Whitfield & Williams, 2003). In a recent review of the CBT literature, Kuyken, Galgliesh, and Holden (2007) found that CT was as effective as antidepressant medication for treating acute depression and for preventing relapse of depression as well. However, there are clients with chronic recurrent depression, where cognitive schemas are so ingrained that they are resistant to change. Additionally, there has been little evidence that when compared directly to other interventions, such as behavioral activation and brief dynamic therapy, the intervention has any added advantage in treating this type of major depression (Whitefield & Williams). One review found that investigator allegiance to CT seemed to result in better outcomes than when CT was studied by an independent group (Gaffan, Tsaousis, & Kemp-Wheeler, 1995). However, most experts in depression treatment consider CT to be an efficacious treatment alternative that has ample support for adults in all age groups (Mackin & Arean, 2005) and ethnic minority populations (Miranda et al., 2003).
Mindfullness-Based Cogntive Therapy (MBCT). MCBT (Segal et al., 2002) is a combination of CT and mindfulness-based stress reduction intervention developed by Jon-Kabat-Zin in the 1980s. Segal et al. took the MBSR model and adapted it for use in patients who have chronic recurring depression. It is an 8-week, often group-based course, that has been studied primarily as a relapse prevention intervention. Mindfulness has its roots in Buddhism, in which people are taught to focus on the present, acknowledge thoughts from moment to moment without passing, one way or another, and instead respond to the situation, rather than react to it. Instead of challenging errors in thinking, as is done in traditional CT, clients are taught to just be aware of their thoughts and subsequent impulses to act on those thoughts and are then taught how to reshift their focus from the thoughts to the situation in front of them. The main principle taught to clients is that no amount of meditation or therapy can make clients’ lives pain-free; however, the way to cope with pain is to be continually shifting one’s focus from reacting emotionally to a situation, and then respond to the situation, without passing judgment.
Treatment consists of a combination of CT techniques and mindfulness exercises. Using experiential exercises, such as object focus techniques and thought journaling, clients learn to recognize patterns in their thinking early on, and then how to respond to thoughts as ideas, rather than facts. Additionally, clients learn to see patterns in how they react to situations, with the aim of helping them choose a different way to respond to negative situations, rather than being on automatic pilot.
MBCT has largely been studied as an intervention to recurrence of major depressive episode: and thus, most of the research has focused on prevention effects. The research has largely been positive. One study found that in 145 participants with chronic recurrent depression who were successfully treated with medication, only 35% of those receiving MBCT as a prevention measure relapsed 1 year after treatment compared to 66% of those who did not receive MBCT (Teasdale et al., 2000). The UK National Institute for Health and Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse. However, it should be pointed out here that there has been no independent replication of MBCT as a prevention intervention; a majority of the research on MBCT is done by the MBCT group in Ottawa.
23.6.1 1.6.1 Behavioral Activation
Behavioral activation (BA) is a third-generation behavioral therapy for depression. BA was originally one component of Beck’s original incarnation of CBT. It became a stand-alone intervention when Jacobson et al. (1996) conducted a dismantling study, comparing CT, BA, and CBT as treatments for depression and found that the CT component added little to the treatment effects of CBT. This finding has been supported several times, most recently by Dobson et al. (2008) who found that CT did not add any benefit, and in more severe depression, BA was superior to CT as a treatment for depression and as effective as an antidepressant medication.
Operant theory of behavior is the main theoretical underpinning of BA. According to this theory, depression is a function of punishment and negative reinforcement and too little positive events. Take for instance a client who moves to a new city and is looking for a new group of friends. The client may initially feel optimistic about his or her chances of finding new friends because of past successes in acquiring friends in his or her hometown. However, as months go by and the client unsuccessfully makes new friends, his or her attempts at friendship become punished by the feeling of rejection. Over time, the client stops trying to make new friends and avoids social situations all together. This avoidance results in a decrease in the negative consequences of engaging socially, and so, the act of avoidance is reinforced. Eventually, because of the social isolation, the client eventually begins to have too few positive social events. As a result, the client becomes lonely, isolated, and eventually depressed.
Based on the above theory, BA attempts to change the clients’ behavior by increasing the likelihood that they will experience positive consequences to behavior they have given up, or, in cases where the behavior itself may be the cause of the negative consequences, teach clients new behaviors that will produce more positive consequences. Using our relocated client as an example, the BA therapist works with the client to create a list of social activities that are ordered from most likely to pursue to least likely to pursue. Starting with the easiest task, the client creates a plan to engage in that positive situation between sessions and measures his or her mood before and after engaging in the activity. In the case of our client, he or she may feel more comfortable starting a conversation with someone at work before joining an activity with people the client does not know. The task would be small and doable, perhaps to ask the co-worker if they want to step out for coffee. If the therapist and client determine that part of the problem is a lack of social skills, then together, the client and therapist will practice new skills to ensure the client has a positive interaction. Over the course of therapy, the client works through this list of activities until their depression remits and they feel comfortable pursuing more complex activities on their own.
As stated above, the evidence for BA is growing strong. In the 1990s, Jacobsen et al. studied the relative merits of BA compared to CT and found consistently that BA was an effective, stand-alone intervention. More recently, researchers found that BA was particularly good for patients with severe depression (Coffman, Martell, Dimidjian, Gallop, & Hollon, 2007). In a recent meta-analysis by Cuijpers, van Straten, and Warmerdam (2007), BA was found to have very large effect sizes, although the differences in effect sizes of BA compared to CT were not statistically significant. In addition to having positive effects as a depression treatment, BA is particularly attractive because it is a cost-efficient intervention, requiring very little additional skill learning for the therapist and client, and could be delivered by people with varying levels of expertise.
23.6.2 1.6.2 Interpersonal Therapy
Interpersonal therapy (IPT) is a brief supportive therapy for depression that was originally developed as a psychotherapy control condition for the Collaborative Treatment for Depression Study, a large randomized trial comparing CBT to antidepressant therapy for treating major depression. The intervention was developed by Gerald Klerman and Myrna Weissman, after reviewing hundreds of hours of therapy tapes and identifying the commonalities between all therapies (Klerman, Weissman, Rounsaville, & Chevron, 1984). In the collaborative study, IPT was found to be as effective as CBT in treating depression, and because of its supportive nature and similarities to psychodynamic therapies, IPT became a popular depression intervention.
Although it was originally a control condition for research, it has since been indicated that IPT is based in Sullivanian Theory of social behavior. Harry Stack Sullivan was an analyst who felt that traditional psychodynamic theory did not capture the current state of society well, and that main issues driving psychopathology and neurosis were interpersonal needs and interactions. People who are depressed are unaware of their effect on others, and only pay attention to certain aspects of their social interactions. He felt that for analysis to be effective, therapists must elicit specific details about interpersonal interactions, so that facts about behavior become conscious, and the client is more aware of his/her impact on others and their role in interpersonal problems. IPT takes this conceptualization of human behavior and further refines it. According to IPT, depression is a function of interpersonal difficulties and the goal is to help clients realize what they can do to change maladaptive relationships. Depression is considered a function of four main conflict areas: grief, role dispute, role transition, and interpersonal deficits.
The evidence for IPT is quite strong and largely positive. IPT has been found to be quite effective for treating depression in younger adult populations and young Latina mothers, in particular. However, its efficacy in older or geriatric populations is not promising. Most research on IPT in treating geriatric depression has found it to be relatively ineffective, and in some cases, worse than placebo (Reynolds et al., 2006).
23.6.3 1.6.3 Problem-Solving Treatment
Problem-solving treatment (PST) is a relatively new EBT for treating major depression. Although it was originally conceptualized by Nezu and D’Zurilla in the 1980s, it has not been until recently that this intervention has received any recognition as an effective depression treatment. There are two forms of PST, the original developed by Nezu et al. (1998) called social problem-solving therapy (SPST), and the one developed by Mynors-Wallis as a depression intervention for primary care medicine (PST-PC; Mynors-Wallis et al., 2000). Although developed independently and in two different countries, the two models are nearly identical in theory and practice, differing only in how problem-solving process is taught to clients. In SPST, each step of the process is taught sequentially; the first session involves explaining the whole problem-solving process, the first week details the first step, the second week the second steps, and so forth. Further, SPST includes a step called problem orientation, an explicit exercise to help clients overcome negative perceptions about their ability to solve problems. PST-PC teaches the process in one session, as one cohesive tool to help clients solve problems, and refinement in the execution of each step is done over each subsequent session and application of the tool. Because PST-PC was meant to be an intervention for non-mental-health providers, problem orientation is not taught explicitly, as the creators found that non-mental-health providers had a difficult time grasping and teaching this concept effectively. The theory behind both interventions is identical. Depression is a function of either poor problem-solving skills or learned helplessness, a concept originally posited by Seligman, Weiss, Weinraub, and Schulman (1980). People with poor problem-solving skills are vulnerable to become depressed because of a lack of effective skills in proactively developing solutions for day-to-day problems. In other cases, people who where originally effective problem solvers stop using these skills when they are faced with repeated failed attempts to solve problems. The goal of PST therefore is to either teach an effective method for solving social problems or help reinforce existing problem-solving skills that may have fallen by the wayside because of depressed mood.
The evidence for PST is quite positive as a treatment for major depression. According to a recent meta-analysis by Cuijpers et al. (2007), PST is effective in treating depression, but it is an effective intervention for some groups of patients and not for others. For instance, the effects of PST on geriatric depression, even in older adults with mild cognitive impairments, physical disability, or severe illness are very strong (Arean et al., 1993; Arean, Hegel, Vannoy, Fan, & Unuzter, 2008); however, clients with milder depression do not appear to do quite as well (Williams et al., 2000).
23.6.4 1.6.4 EBTs for Special Populations: Older Adults, Ethnic Minorities, Disabled Populations, and Co-occurring Disorders
One of the limitations of psychotherapy research in general is that most of the research is focused on physically healthy volunteers. Further, to study efficacy of these treatments on depression, the samples have often excluded older adults, physically ill, and adults with co-occurring illnesses. Thus, the generalizability of the research has been called into question by providers who work in community-based settings where clients are not similar to the participants in research. In the last 15 years, however, there is a growing evidence base that the EBTs discussed above can be effective for special populations.
With regard to ethnic minorities, a number of studies have found that CBT (Miranda et al., 2003), IPT (Rossello & Bernal, 1999), and PST (Arean et al., 2008) can be effective in these populations, and each intervention has been translated into several languages. Older adults also respond well to CBT (Gallagher-Thompson & Thompson, 1996) and PST (Arean et al., 1993), but not to IPT (Reynolds et al., 2006). Those with chronic illnesses also respond to CBT and PST. For instance, CBT has been found to be effective for patients with multiple sclerosis (Mohr, Hart, & Vella, 2007). CBT is also useful for disabled populations, in that it has been adapted for telephonic delivery, with highly positive results. Unfortunately, there has been very little research on the effects of these interventions in dually diagnosed populations.
23.6.5 1.6.5 Training Competencies in EBTs
Each EBT discussed below has training programs that any provider can participate in, for a cost. These trainings have many similarities, which include an introductory workshop, followed by provider application of the intervention, under the guidance of a trained expert. Below, we describe the process for each intervention reviewed above.
CT. Training in CT can be acquired in a number of ways, but the first place to go if providers are interested in training in this model is the Beck Institute for Cognitive Therapy (www.beckinstitute.org-training). Interested providers must hold at least a master’s degree in a mental health or health profession. Providers apply to participate in the training, which can be online or in person. Providers first participate in a 2-day workshop, either at a national conference, the Beck Institute, or one arranged by the provider in training. The workshop provides an overview of CT. Providers can elect a 6-month or 1-year training, which involves audiotape or videotape review of CT sessions and weekly individual telephone supervision. Once a provider becomes competent in CT, he or she is eligible to become a trainer. This requires weekly telephone review of supervision cases. As of this writing, tuition for the 1-year program is US$8,075 and US$4,550 for the 6-month program.
PST. Providers interested in learning PST can find trainers from the University of Washington IMPACT Web site (www.impact-uw.edu). This Web site is funded by the Hartford Foundation and provides a free introduction to PST, and access to a PST trainer. Feedback is not free, although the cost of training is reasonable. PST experts can be found throughout the USA, but if there is no expert in your location, the training can be done over videoconferencing, telephone, or Skype. As of this writing, training is approximately US$2,500 for the workshop and supervision. If the workshop is online, then the cost is US$1,500.
Providers do not need to have a prior working knowledge of major depression or experience in mental health, although Hegel et al. (2004) found that people with a mental health background, particularly in CT, tend to need less training than those who are mental health novices. Training consists of a 1-day overview workshop, which can be done online for free, and two to three supervised training cases. Training cases are audio taped, and the first, middle, and last session for each case is sent to the expert for review. Reviewers rate each tape on the provider’s ability to cover each of the problem-solving steps, as well as basic clinical functions, such as structuring the therapy hour, working collaboratively with the client, demonstrating warmth and empathy, and ability to handle difficult or crisis situations. The difficulty level of the client is also considered in the ratings; however, providers in training are encouraged to find mildly depressed patients for their very first PST case. Once the provider in training has demonstrated proficiency in PST, he or she is then certified and is eligible to participate in a monthly, toll-free call to discuss new or complicated cases. In our experience, most providers are basically competent by the end of the training period, but usually appreciate the opportunity to discuss difficult cases after certification. Providers are eligible to become expert trainers after having used PST for 1 year on at least 20–30 cases.
BA. We were unable to locate any formal training program in BA. Based on our review of the research standards for BA research therapists, the training criteria is similar to that of PST. Providers interested in BA participate in a workshop on the principles of BA. Once they complete the workshop, providers participate in audio taped or videotaped supervision of at least three cases, which are rated for fidelity to the model by an expert in BA. Providers receive feedback on their cases, and are certified once they have successfully completed cases.
IPT. We report here the guidelines for IPT training that are listed on the International Society for Interpersonal Therapy (ISIPT) Web site (http://www.interpersonalpsychotherapy.org). Providers interested in learning IPT should have a good understanding of major depression and experience in mental health before beginning training (contrary to PST and BA). Training can be obtained by contacting the ISIPT Web site for locations of workshops and official trainers.
ISIPT delineates training into four levels: level A provides general information on IPT to curious providers, level B involves basic IPT training, level C involves more intensive supervised training, and level D is training to become a trainer. Level A training is a 2-day introductory training course that is offered at professional conferences or occasionally as continuing education units. Those who complete level A and wish to learn how to provide IPT participate in level B. (Only those who have participated in an ISIPT-approved level A workshop can move onto level B training.) Providers must have the IPT manual for major depression and identify at least two cases that are willing to be videotaped or audio taped for training. All 16 sessions of IPT are sent to a certified IPT trainer, who reviews a random sample of 12 tapes. Providers receive a minimum of 4 h of supervision on their cases, either in individual or group format. Level C training occurs when the provider has been carrying at least two cases in IPT for a year. These providers still receive monthly supervision during the year and are encouraged to attend IPT-focused conferences. Level D training can only happen once level C training is completed. The provider must have a minimum of ten supervised cases in IPT. Providers wishing to be trainers must join a regional group of trainers, and if none exists, they must create one. They must also attend the Trainers’ Workshop and two conferences a year in IPT.
23.7 1.7 Basic Competencies of the Clinician
After each section detailed above, we provided a summary of how the information in each section represents an important competency for providers working with MDD clients. In this section, we discuss how providers can acquire these basic competencies. To reiterate, the basic competencies for treating major depression are:
How to use assessment, research, and client history to make an informed case formulation
Ability to apply what we know about maintenance factors and mechanisms of change in MDD to amending treatments
Ability to apply evidence-based treatment in the context of evidence-based practice
All new providers should begin the process of developing competencies by working with an expert in major depression, particularly an expert in at least one EBT. This expert can help new providers fine-tune their assessment, formulation, and treatment skills, and provide information on the latest developments in the depression field. To illustrate how novice providers can acquire these skills, we describe the process we have used to train psychology interns, psychiatry residents, research therapists, and community providers at the University of California, San Francisco, Over-60 research and training program.
23.7.1 1.7.1 Detecting and Monitoring Major Depression
Our typical approach to training providers in the assessment of major depression involves a combination of in-services reviewing of the information discussed in the sections on assessment and risk factors for major depression, participant observation of assessment, and guided, in vivo training opportunities. After novice providers have completed the didactic part of our training, they then watch videos of clients with different presentations of major depression, and while watching the videos complete a SCID on the videotaped client. Afterwards, novice providers and assessment experts discuss the cases and the results of the SCID. Once the expert and novice feel that the novice provider is ready, the provider then watches the expert conduct two to three clinical interviews with clients. This is followed by expert observation of the novice provider conducting two to three interviews. The novices are then ready to conduct interviews on their own, some of which are videotaped for continued training opportunities. Depending on the providers’ backgrounds and experience with mental health issues, novice providers generally become competent assessors of major depression within 6 months of training.
23.7.2 1.7.2 Case Formulation
As detailed in the excellent article by Sim, Gwee, and Bateman (2005), case formulation is the working hypothesis that guides treatment decisions, without which the process of therapy would become haphazard. Case formulations involve combining information from assessment tools, client history, knowledge of the common causes of depression, and a treatment theory. Information detailed in a case formulation varies by the theory from which the case is being conceptualized. As an example, Persons’ case formulation model for CT indicates that to make a CT formulation, seven components must be in place, including the clients’ problem list, schema, triggers, client problem history, a hypothesis, treatment plan, and barriers to treatment. Whereas an interpersonal formulation includes a summarizing statement, assessment of the primary area of conflict, self-psychology model, prognosis, and prescription. Sim et al. (2005) indicate that while the content of a formulation may theoretically vary, the quality of case formulation can be measured across all theoretical types from these five aspects of a competent case formulation: integrative, explanatory, prescriptive, predictive, and therapist.
An integrative case formulation is one that succinctly combines all the information on a case and identifies the key issues to be worked on clearly. A competent formulation also provides a theoretical explanation for presenting problem and is supported by evidence collected in the initial assessment, client’s history, and over the course of treatment. Competent formulations are also prescriptive, in that a clear treatment plan evolves logically from the explanation of the factors contributing to the presenting problem.
At UCSF, we train novice providers in case formulation in the following way. As stated in the section on assessment, our providers are given in-services on the latest information about risk factors, causes, and correlates of major depression, and the factors that are likely to contribute to relapse. We provide a comprehensive overview of biological, genetic, psychosocial, cross-cultural, and developmental research on major depression. Trainees are required to make case presentations of initial formulations based on one of the EBTs they are learning during the course of treatment; the trainer periodically asks the trainee to make adjustments in their formulation based on the course of treatment. At the end of treatment, the formulation is again reviewed and refined.
23.7.3 1.7.3 Application of Evidence-Based Treatment
Competent application is more than knowing how to do an EBT and how to apply it in the context of evidence-based practice. Under the section on EBTs, we discussed how one can become accredited in each psychotherapy. Here, we describe the process involved in applying those treatments competently.
In order to be an effective psychotherapist in treating major depression, providers must have the following set of competencies. First, they must be well trained in at least one evidence-based practice, ideally two. The advantage of knowing two EBTs allows the provider to be flexible for clients who may have a preference for a certain type of therapy. Second, providers should know how to formulate a treatment plan based on the EBT being used. Third, providers should not apply EBTs in a vacuum. As described in the section under evidence-based practice, clinical judgment and client preferences should be part of the decision regarding which treatment to use. Fourth, providers must learn to be flexible within the EBT they are using, not applying the specifics of a manual in a cookbook fashion, but adjusting the pacing and specifics of the intervention to be most effective. Fifth, providers must be aware of the limits of the research and keep abreast of new developments in treatment development; in other words, good psychotherapists do not form firm allegiances to theories, but keep an open and objective mind when new information is available about existing interventions, modifications of these interventions, and new theories and treatments for major depression. No one intervention is appropriate for all client populations.
23.8 1.8 Expert Competencies of the Clinician
A definition of an expert in any field is someone who possesses the latest information about the field and can apply and teach that information flexibly and innovatively. In MDD, that amounts to having ample exposure to working with clients who are suffering from MDD and learning the latest developments in MDD. The main difference between being competent and being an expert is in the depth of understanding. Competent MDD providers typically are trained to conduct state-of-the-art assessment and treatment and can create useful treatment plans based on case formulation. Competent therapists sometimes have trouble in working with clients suffering from MDD that is complicated by other comorbidities, or who are not making improvements to treatment as expected.
In training providers in PST, providers who are newly certified tend to still need guidance on how to use PST in situations where the client does not understand the model or who behave differently in treatment than the clients in the certification phase. Expert opinion and advice are often needed in the first 6 months post certification to help the competent PST provider work with the model in a flexible way and tailor the intervention to the unique characteristics of the client or help the PST provider decide whether or not PST will be effective for the client. In our experience, after 6 months of such expert consultation, most competent PST providers no longer need expert guidance, and can often offer advice to others who are just learning the ropes. Thus, competent PST providers understand the PST model and provide the intervention under the best situations; expert PST providers can not only use PST in more complex cases, but also have enough judgment and flexibility to know when PST may not be the best treatment for a client.
23.9 1.9 Transition from Basic Competence to Expert Competence
How one becomes an expert in MDD is a bit more difficult to describe. Based on our personal experiences and in pooling MDD experts around the USA about when and how one becomes a depression expert, we were able to delineate the process by which one moves from being simply competent in MDD to being an expert. First, the most important factor in becoming an expert is the working time with MDD patients. The more you assess and treat, the better you become as an MDD provider. A second and important addition to time is working and communicating with other MDD experts. It is not enough to simply treat clients with MDD. One must also confer with colleagues and consider fresh perspectives on the illness. An advantage in being a researcher in MDD is that through academic activities, one routinely works and interacts with other experts, reading their work, engaging in discussion about MDD, and having others comment on their work related to MDD. Clinicians can emulate this practice by attending meetings, joining groups of MDD clinicians, and routinely reading the literature. Another avenue toward being an expert is training others in how to assess, understand, and treat MDD. Many experts in MDD are often educators who work with professionals and students wanting to learn the state-of-the-art assessment and treatment. Finally, although no one was willing to put a timeline to when one can be considered an expert, most felt that if a provider worked primarily with clients suffering from MDD and routinely interacted with other experts in the area, expertise could be reached on an average after 2 years of this exposure. Everyone conceded that this timeline would vary from person to person.
23.10 1.10 Summary
MDD is one of the best-studied mental health illnesses. We have considerable information about how MDD presents, factors that put people at risk for MDD, factors that complicate treatment, what assessment tools work best, and which treatments are most effective for most people with MDD. Although more research is needed to understand how to best treat specific clients with more complex presentations of MDD, providers do have enough information available to effectively assess and treat a majority of the clients they will see with MDD. Becoming competent as an MDD therapist requires learning all one can about the illness and the different treatments available and becoming skilled at delivering evidence-based treatment within the context of evidence-based practice.