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"The best-titled book in the psychotherapy field returns for a triumphant second edition. The original authors have updated their analysis of the literature using an approach that is calm in tone, liberal in outlook, and judicious in evaluation. They are passionate about evidence-based practice and the proper use of clinical judgment, and they anticipate an evolution of existing psychotherapies in ways that respect necessary complexity and creativity. As experienced researchers and clinicians, they clearly describe the limitations as well as the strengths of the different research methodologies and are opposed to privileging one strategy over another. Without doubt, this book is essential reading for all psychotherapy researchers, trainers, practitioners, and students."--Mark Aveline, MD, FRCPsych, Institute of Lifelong Learning, University of Leicester, UK: and President (2003-2004), Society for Psychotherapy Research
"In this era of evidence-based treatment, researchers are proud of their 'significant differences,' and clinicians often find research based on the mean score to be wanting in the individual case. The Roth and Fonagy volume, now in its updated second edition, provides a clinically sophisticated guide to utilizing the existing research with judicious sensitivity to the client who does not fit neatly into oversimplified categories of diagnosis and treatment brands. Simply put, this is the best book on the topic. Researchers will find their work put into a broader context, and clinicians will relish a thoughtful guide through the complicated tasks of assessment and treatment planning."--John F. Clarkin, PhD, Department of Psychiatry, Weill-Cornell Medical College
"Given that 'What works for whom?' is the perennial question asked by psychotherapy trainees, this superb book should be required reading in any psychotherapy course or seminar. Roth and Fonagy underscore not only the importance of understanding the answer to this question, but also the importance of asking the question in the first place."--Wendy K. Silverman, PhD, Department of Psychology, Florida International University
"A worthy successor and expansion of the first edition. Readers will find comprehensive reviews of empirical outcome studies on psychosocial treatments and selected medications found helpful in working with clients with specific disorders. In addition, the book discusses methodological considerations in designing and evaluating psychotherapy outcome studies, offering a masterful exposition of this complex topic. This is a clinically useful resource that would make an excellent text for graduate students in the mental health fields. I highly recommend it."--Bruce A. Thyer, PhD, LCSW, School of Social Work, Florida State University
DSM-IV-TR describes a number of subcategories of depression; those particularly relevant to research studies are defined as follows (adapted from Wells, 1985).
Major Depressive Disorder
Major depressive disorder (MDD) is characterized by one or more major depressive episodes and the absence of manic episodes. A major depressive episode is defined by depressive mood or loss of interest or pleasure in almost all usual activities, accompanied by other depressive symptoms. These include disturbances in appetite, weight, and sleep; psychomotor agitation or retardation; decreased energy; feelings of worthlessness or guilt; difficulty concentrating or thinking; and thoughts of death or suicide, or suicidal attempts. DSM-IV-TR specifies that at least five of nine specific depressive symptoms must be present nearly every day for at least 2 weeks to make a diagnosis of MDD, and that the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Depressive episodes are distinguished from normal bereavement reactions.
This disorder is characterized bydepressed mood or loss of interest in nearly all usual activities, though symptom severity is not sufficient to meet the criteria for MDD. The disorder is, by definition, chronic. Symptoms should be present for at least 2 years, and a diagnosis cannot be made if patients are symptom-free for more than 2 months in any 2-year period. It is characterized by depressed mood for most of the day, together with at least two of the following six symptoms: poor appetite, insomnia or hypersomnia, low energy, low self-esteem, poor concentration, and feelings of hopelessness. For diagnostic purposes, these symptoms should be severe enough to cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
Patients with dysthymic disorder frequently present with a superimposed MDD; this is usually referred to as "double depression."
PREVALENCE AND NATURAL HISTORY
Only a portion of individuals with mental health problems present to family physicians or mental health professionals (e.g., Bebbington et al., 2000a; Goldberg & Huxley, 1980). Because of this, estimating treatment need is better done through community-based surveys rather than relying on data from clinical services. Two large-scale community surveys provide data on the prevalence of psychiatric disorders in the United States. The National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) program was a five-site project sampling approximately 20,000 adults (Robins & Regier, 1991). The National Comorbidity Survey (NCS; Blazer et al., 1994) had a slightly more restricted age range, and interviewed approximately 8,000 adults between ages 15 and 54. The prevalence rates derived from these surveys need to be interpreted cautiously; for example, there is a risk that they are inflated by individuals whose distress is transient. Deriving a "correct" prevalence rate that accounts for the clinical significance of symptoms is difficult and controversial. Narrow et al. (2002) have recomputed prevalence rates from the ECA and NCS surveys, taking into account the degree to which symptoms resulted in help-seeking behavior and led to significant levels of distress (see Table 4.1). In addition, they attempted to reconcile differences in prevalence rates between the surveys, some of which relate to methodological differences. Their approach has been criticized as inappropriately robust (Wakefield & Spitzer, 2002), and it is clear, that while presentation to services appears to be linked to the severity of symptoms (Bebbington et al., 2000b), lack of help seeking cannot be assumed to indicate that distress is unimportant. Nonetheless, the revised rates are cited here (and in Appendix III), since they probably yield a more accurate indicator of service need.
The ECA and NCS estimate 1-year prevalence for MDD at 5.4% and 8.9%; corrected for clinical significance, these figures lower to 4.6% and 5.4%, respectively. Narrow et al.'s (2002) estimate, which combines data from both surveys, is 4.5%. For dysthymic disorder, the ECA and NCS estimates are 5.7% and 2.5%, respectively; with correction for clinical significance, these reduce to 1.7% and 1.8%, respectively; the combined estimate is 1.6%. Other reviews derive somewhat different (uncorrected) rates. Angst (1992), reviewing 17 studies, suggests that 1-year prevalence rates for MDD lie between 2.6 and 6.2%, and for dysthymic disorder, between 2.3 and 3.7%. Lifetime prevalence rates vary between 4.4 and 19.5%. Angst also reports data from a Swiss prospective community survey carried out (to date) over 10 years. This was based on multiple interviews and hence avoided problems of estimating prevalence based on recall. Lifetime prevalence to age 30 of MDD was 14.5%, with around half of affected individuals seeking treatment.
The prevalence of depression varies by gender and age; prevalence of MDD in the ECA and NCS was almost twice as high in women as men, and greater in younger adults. In part, this may reflect the greater willingness of younger adults to admit to mental health problems (Taube & Barrett, 1985; Weissman et al., 1988), or problems of recall when older respondents are interviewed in cross-sectional surveys (Fombonne, 1994). However, there is evidence that prevalence within younger age groups is increasing (Burke et al., 1991), though the degree to which this is associated with comorbid substance abuse is unclear. Furthermore, there is some agreement that overall rates of depression are increasing (Fombonne, 1998b; Klerman & Weissman, 1989).
Most studies of "natural" history monitor longitudinal outcomes for patients offered "treatment as usual" (TAU). Over a 2-year period, Wells et al. (1992) followed up 626 outpatients; the sample included patients diagnosed with MDD, dysthymic disorder, and double depression, and also contained clients with subthreshold depressive symptoms. Patients with MDD had a 42% probability of remission in the first year, and a 60% probability of remission in the second year, if none had occurred in the first year. Clients with double depression had a rather different course, depending on the severity of their symptoms. Those with more severe symptoms had a 37% likelihood of remission in the first year; if no remission occurred by this point, there was only a 16% probability of remission in the second year. Both dysthymic patients and those with subthreshold symptoms of depression were at considerable risk of suffering an episode of MDD over the study period. Half the patients with an initial diagnosis of dysthymic disorder and 25% of patients with subthreshold symptoms of depression (with or without a prior history of depression) experienced an episode of MDD over the 2-year period. Data from patient samples in field trials for DSM-IV-TR confirm this pattern; 79% of patients with dysthymic disorder eventually developed MDD (McCullough et al., 1992). The poorest clinical outcomes were found in patients with double depression; there was a particularly low rate of remission in patients with both double depression and high initial symptom severity. Patients with dysthymic disorder (even in the absence of MDD) had higher levels of depressive symptoms over the 2-year period of the study than patients with MDD alone, despite the fact that dysthymic disorder is defined by the presence of less severe (if persistent) depressive symptoms. In addition, patients with dysthymic disorder were rated as having poorer social and emotional functioning than those with MDD.
Keller and Shapiro (1982) and Keller et al. (1983) suggest that patients with double depression tend to have a shorter episode of MDD but are also likely to relapse more quickly than those with MDD alone. Double depressives appear to have a faster "cycle time"; over a 2-year period, 62% of them had completed a cycle of recovery and relapse, compared to 33% of the MDD group.
Long-term monitoring confirms a pattern of vulnerability to relapse for people with MDD. Piccinelli and Wilkinson (1994) reviewed 50 naturalistic follow-up studies of in- and outpatients with unipolar depression, carried out between 1970 and 1993. Although recovery rates increase over time (on average, 53% of patients will recover at least briefly by 6 months), one-fourth of the patients will have suffered a recurrence of the index episode within 1 year. Seventy-five percent of patients followed up for 10 years suffered a further episode of depression, and 10% of patients suffered persistent depression. Mueller et al. (1999) followed up patients over 15 years; all were in receipt of TAU. Of 380 patients who had recovered from an index episode of MDD, a cumulative proportion of 85% relapsed over this period. Of a further 105 patients who had recovered and remained well over 5 years, a cumulative proportion of 58% relapsed. Though there were indications that TAU included suboptimal delivery of medication, there was little information available regarding the use of psychosocial interventions. Demographic or clinical characteristics did not predict relapse, though there were indications that individuals who had recovered but continued to experience subthreshold symptoms were particularly vulnerable, a pattern found in other studies (e.g., Judd et al., 1998b).
Studies of the prevalence and natural history of depression have a number of implications for research. Although precise estimation is complicated, it is clear that depression is a relatively common syndrome affecting at least 4.5% of the population, with prevalence among women about double that among men. The course of depression appears to differ according to subtype (MDD, dysthymic disorder, or double depression). It is likely that 80% of patients with dysthymic disorder will eventually develop an MDD, suggesting that dysthymic disorder and acute depression are variants of a similar condition. Relapse is a serious challenge: 85% of patients followed up over 15 years, and 75% of patients followed up over 10 years will have suffered a further episode of MDD, and 10% of these will have endured persistent depression. The probability of relapse is increased in patients with more than three previous episodes of MDD but is greatest in patients with a diagnosis of dysthymic disorder; these patients show a faster cycle of recovery and relapse than those with MDD alone. Even among those patients who have "recovered," subthreshold symptoms are common and are associated with an increased likelihood of relapse.
The risk-indeed, the probability-of relapse has obvious implications for treatment trials. The effectiveness of a treatment needs to be judged not only by its capacity to manage an index episode but also by its ability to maintain remission. This poses a challenge, in part, because on the basis of figures given above, long-term follow-up of at least 2 years would be necessary to provide a conclusive result that is not confounded with the natural history of this disorder. It is also likely that outcome in clinical trials will be influenced by case mix, and particularly by the presence of patients with double depression or a history of recurrent MDD. Because of the exclusion criteria applied in at least some research trials, it is possible that the clinical population will contain comparatively more patients with chronic depression and dysthymic disorder. This may lead to overestimation of treatment effects; poorer outcomes might be expected in clinical practice than in trials. However, as an increasing number of studies concern themselves with "treatment resistant" patients, this may be a less pertinent issue than before.
LANDMARK STUDIES OF EFFICACY
Subsequent chapters review individual studies in the context of meta-analyses and qualitative reviews. This chapter adopts a different strategy, describing in some detail a small number of high-quality individual studies that help to contextualize the broader body of evidence. These trials give indications of the acute and longer term efficacy of the major treatment approaches in this area (cognitive-behavioral therapy, interpersonal psychotherapy, short-term psychodynamic therapy, and medication), and of the challenge posed by relapse.
Cognitive-Behavioral Therapy and Interpersonal Psychotherapy: NIMH Treatment of Depression Collaborative Research Program
This major and widely cited research program (summarized in Elkin, 1994) set a standard against which other studies can be judged. Patients were randomized to receive one of four interventions: cognitive-behavioral therapy (CBT; Beck et al., 1979), interpersonal psychotherapy (IPT; Klerman et al., 1984), imipramine plus clinical management (IMI-CM), or placebo plus clinical management (PLA-CM). Clinical management consisted of a weekly meeting of 20-30 minutes to discuss medication, side effects, and the patient's clinical status. In addition, and where necessary, support, encouragement, and direct advice were also offered. On this basis, it is worth noting that both medication conditions contained psychotherapeutic elements. This research design has been misinterpreted as a test of therapy against medication (Elkin, 1994); more accurately, the intention was to use medication condition as a "benchmark" against which to compare the psychological therapies.
The study was carried out at three research sites in the United States. Five hundred sixty outpatients were initially screened, essentially ensuring that patients met criteria for a DSM-III-R diagnosis of unipolar depression. Two hundred fifty patients, all moderately to severely depressed, were selected for the trial; 239 actually entered it. Of these, 60% had been depressed for more than 6 months; for only 36% was this a first episode of depression.
Treatments were carried out by experienced therapists (10 each in IPT and pharmacotherapy, eight in CBT) chosen for their expertise in applying their respective therapy and supervised regularly throughout the clinical trial. To ensure that therapies were conducted as intended, sessions were taped, and the process of therapy was checked against measures of therapy adherence. Though there were some differences in attrition from each condition, these were not statistically significant. Rates of dropout across treatment modalities were as follows: 23% (n = 14) for IPT, 32% (n = 19) for CBT, 33% (n = 19) for IMI-CM, and 40% (n = 25) for PLA-CM.
Excerpted from What Works for Whom? by Anthony Roth Peter Fonagy Copyright © 2005 by The Guilford Press. Excerpted by permission.
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