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Allison Kearney

on 23 August 2015

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Transcript of Depression

A Pill For Your Ill
Client Preferences
Growing proportion of clients present to their mental healthcare professional with a preference for one treatment relative to another
Patterns of treatment utilisation do not reflect client preferences

Might suggest that clients are not engaged in decision-making processes about their mental healthcare
Shared Decision Making
Shared decision making: Incorporating client's informed preferences and values into goal setting, treatment planning and decision-making.
What informs client preference: perceptions of efficacy, stigma and convenience?

Important role for psychoeducation to facilitate informed decision-making
Effects of Client Preference
Growing body of evidence suggests better clinical outcomes when clients receive treatment that is consistent with their personal preference: influences uptake, adherence, and satisfaction
The efficacy of various psychotherapies have been established over many individual clinical trials and meta-analyses

Meta-analysis by Driessen et al. (2010)
Short-term psychodynamic psychotherapy (STPP) shown effective in reducing depressive symptoms with effects maintained at 3 months, 6 months, and 1 year

Meta-analysis by Cuijipers, van Straten, van Oppen, & Andersson (2011)
Interpersonal psychotherapy (IPT) effective in treating depression as compared to controls.
Pharmacotherapy potentially more efficacious in treating patients with dysthymia, clinically insignificant differences between the two treatments for major depression.
Equivalency of psychotherapy to pharmacotherapy replicated across a number of studies
Meta-analysis by Spielmans, Berman & Usitalo (2011) compared the efficacy of psychotherapy to modern antidepressant medications.
Concluded that both treatments produced similar reductions in depressive symptoms over short-term
Psychotherapy found to produce superior results at follow-up

Cognitive Behavioural Therapy (CBT) found to be highly efficacious treating depression, but no more or less efficacious than pharmacotherapy or other standard psychotherapies
Antidepressant medication is typically the first and most widely used treatment for depression

Recent meta-analysis by Linde et al. (2015)
Reviewed 66 studies, more than 15,000 patients
Diagnoses ranged from major depression, mixed/unclear or minor depression/dysthymia
Large number of antidepressants proved effective in treating acute depression
Drop out rates due to side effects varied across medications
Results demonstrating the efficacy of antidepressant medications have been replicated over thousands of trials

Meta-analyses have concluded that around 65% of cases will achieve symptom reduction with pharmacotherapy, of which 30-40% will achieve complete remission

Studies have also found however that many patients taking pharmacotherapy do not receive adequate ongoing monitoring and that provided care is not designed to reduce the burden of the disorder, or the likelihood of relapse
Combination Therapy
Research is now suggesting that pharmacological and psychological interventions may work via different mechanisms, and thus relieve symptoms differently

Studies have indicated support for the superior efficacy of combined treatment
Combination Therapy
Combined treatment has been associated with:
Higher remission rates
Higher response rates
Stronger reductions & faster improvement of symptoms

Increased medication compliance
Reduced drop out rates for longer therapies

Lower rates of relapse

Significant improvements in depressive symptoms compared to pharmacotherapy treatments alone
Combination Therapy
Some studies have however found no additional benefit to combination therapy:
Combined CBT/Pharmacotherapy demonstrated no additional benefit above individual treatments in reducing subjective, cognitive, and behavioural measures of depression

Interpret with caution however as many combination studies do not examine additional factors such as potential self-selection bias by participants, client preferences for treatment, or differing client expectation biases
Severity of Depression
The Australian and New Zealand clinical practice guidelines for psychiatrists (2004), advises practitioners to treat the acute stages of severe depression with pharmacotherapy

These recommendations are largely based on the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP).

Elkin et al. found that for severely depressed participants, the combined treatment of the antidepressant 'imipramine' and clinical management achieved significantly greater reduction in symptoms, compared with both IPT and CBT.
Limitations within Current Research
(Corrigan & Salzer, 2003; Dunlop et al., 2012; Kwan, Dimidjian, & Rizvi, 2010; Lindheim et al., 2014; Mergl et al., 2011; Moradveisi, Huibers, Renner, & Arntz, 2014).
(Barry & Edgman-Levitan, 2012; Charles, Gafni, & Whelan, 1997).
(Lindhiem, Bennett, Trentacosta, & McLear, 2014).
Recent meta-analysis revealed 75% of clients voiced a preference or psychological treatment (e.g. psychotherapy), compared to client preferences for pharmacological treatment.
(McHugh, Whitton, Peckham, Welge, & Otto, 2013).
Conflicting results exist within the severe depression research
Siddique et al. (2012) found that psychotherapy may be more successful in cases of severe depression 12 months post treatment.

Need to control confounding variables:
Psychotherapist experience and comorbidities

Do the different forms of both psychotherapy and antidepressants result in different outcomes?

Participants receiving antidepressants still typically receive constant contact hours with physicians, limiting the validity of the findings
(Craighead & Dunlop, 2014; Iftene, Predescu, Stefan, & David, 2015)
Psychotherapy, pharmacotherapy, and combination therapy can all be effective forms of treatment for depression
(Cuijpers et al., 2011; Cuijpers et al., 2013; Linde et al., 2015)
A significant role exists for client preferences and psychoeducation in treatment practices

Important to take an unbiased and multidisciplinary approach

The therapeutic alliance is the strongest predictor of treatment success

Clinicians have an ethical responsibility to adhere to the APS Code of Ethics, and to work within professional boundaries and scope of practice
(Cuijpers et al., 2013)
(Cuijpers et al., 2011; Spielmans, Berman, & Usitalo, 2011)
(Craighead & Dunlop, 2014)
(Cuijpers et al., 2011)
(Kohler et al., 2013)
(de Mello, Myczcowisk, & Menzes, 2001)
(Cuijpers et al., 2011)
(Pampallona, 2004)
(Iftene, Predescu, Stefan, & David, 2015)

(Craighead & Dunlop, 2014)
Consultation Time with Dr Georgie
"[Depression is] ... a slower way of being dead."
- Andrew Solomon
"And I thought... 'Is it a chemical problem, or a psychological problem, and does it need a chemical cure or a philosophical cure?'...and I couldn't figure out which it was, but then I understood. We aren't advanced enough in either area to explain things fully. The chemical cure and the psychological cure both have a role to play."
- Andrew Solomon
(DeRubeis et al., 2005)
(Dimidjian et al., 2006)
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