Transcript Treating Chronic Depression - Digital Commons @ Liberty University

Using Empirically Supported Treatments
that Work
Gary A. Sibcy, II, PhD
Licensed Clinical Psychologist
Professor: School of Behavior Sciences
Center for Counselor Education and Family Development
Liberty University
[email protected]
Treating Depression
 Question: “Don’t we have “effective” medical
treatments for depression?”
 Depends on what you mean by “effective.”
Depression
 Major Depressive Disorder (MDD) is a relatively common
psychiatric disorder, with a lifetime prevalence rate of 7%
to 12% for men and 20% to 25% for women (Kessler et al
2003).
 The annual cost of MDD in the U.S. was estimated at $
83.1 billion (Greenberg et al 2003) and the World Health
Organization predicted it to be the second-leading cause
of functional impairment and disability worldwide by
2020 (Murry and Lopez, 1996).
Depression
 Although a number of effective psychiatric and
psychological treatments have been developed,
 a sizeable portion of patients have a chronic, treatmentresistant course of illness,
 characterized by a failure to reach full-remission and
continuing to exhibit substantial symptomology .
Depression
 In clinical effectiveness studies with representative
treatment samples,
 70% to 89% of patients fail to reach remission after
relatively extend treatment courses of 8 to 12 months (Lin
et al, 1997; Rost et al, 2002; Rush et al, 2004
STAR*D STUDY
 In the largest real-world effectiveness study of MDD ever
conducted, the Sequenced Treatment Alternatives to
Relieve Depression (STAR*D),
 A four-step treatment protocol was designed to treat
patients to remission.
 Each level of treatment lasted up to 12 weeks. All patients
entered level I and if they achieved remission, they
remained at the same level and were followed up to 1
year.
 If they failed to reach remission, they were upgraded to
the next level, offered different augmentation strategies
STAR*D STUDY
 Of the 60% of patients who completed the study, 33%
achieved remission at Level I, 57% at Level 2, and 63%
and 67% achieved remission at Levels 3 and 4,
respectively.
Upshot
 The upshot of this study was that with each
subsequent level of treatment,
 fewer patients achieved remission,
 with only about 10% of treatment resistant patients
(i.e. those who failed to reach remission after levels 1
and 2) achieving remission after level 4.
 Moreover, relapse rates increased with each treatment
step: 40% in step 1, 53% in step 2, 65 % in step 3 and
71% in step 4 and the overall dropout rate was 40%.
Upshot
 Thus a substantial proportion of patients fail to
achieve remission (33% of those who remain in
treatment over the course of 1-year) and
 the majority of treatment-resist patients relapse (65%71%) within 1-year, even when continuing maintenance
medication.
 Consequently these results represent a need to develop
alternative treatments that not only increases the
proportion of patients achieving remission, but also
reduces both relapse rates and dropout rates.
One Such Treatment
 Cognitive Behavioral Analysis System of
Psychotherapy
 Specifically designed for Chronic, Refractory
Depression—especially Early Onset
Characteristics of Chronic
Depression
 Long-standing history of Dysthymic Disorder, now
Persistent Depressive Disorder with multiple,
superimposed Major Depressive Episodes
 Multiple Major Depressive episodes, each lasting
several years
 Some never fully recover and remain in partial remission
 Many have comorbid disorders, including anxiety and
personality disorders
Typical Treatment History
 Long periods of untreated depression before seeking




first treatment
Previously misdiagnosed
Antidepressant only at inadequate doses and/or length
of treat
Those receiving therapy derived little to no benefit
Few will have received combined medication and
psychotherapy
Characteristics of Chronic,
Treatment Resistant Depression
 Highly treatment resistant to nearly all treatment
modes:
 Medication
 Psychotherapy



CBT
IPT
STDP
Normal Mood Variability
Ceiling
Floor
Ceiling
Floor
20 weeks
Ceiling
Floor
2 + year
Ceiling
Floor
childhood
2+ years
Psychosocial Profile
 History of early—sometimes complex-- relationship
trauma//attachment traum
 Relationship Trauma- continuous series of “low
grade” trauma:
 psychological insults, putdowns, interpersonal
rejection/punishment
 Combined with one or more “high grade” traumas:
physical/sexual abuse, actual parental abandonment,
emotional/physical neglect
Psychosocial Profile
 Neurocognitive deficits Pre-operational thinking a

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

pre-causal view of worl
Learned helplessness (Low internal locus of control)
Chronic mood dysregulation does not respond to
information/disputation/insight/cognitive restructuring
Behavioral Shut-down
Ineffective, self-defeating patterns of social behavior
Submissive IP Style—pulls therapist into dominant rolerecapitulates previous relationships  helplessness
Self
Learning History
Needs
Wants
Feeling
Opinions
Don’t Speak
Up
Stuff feelings
Others
Rejection
Criticism
Betrayal
Abuse
Feared Outcome
I’m totally flawed
Anxiety
Shame
Guilt
Worthlessness
It’s all my fault
I don’t
matter
I’m bad
Helplessness
Why bother
What’s the
point
No one really cares
Learned Helplessness
I’m tired
Shut-down
Energy
Motivation
Pleasure
I’m
worn
out
Helplessness
Survival Mode
Fight-Flight
On-edge
Irritable/angry
Hypervigilant
Something Bad is
going to happen
I’m going
crazy
I’m dying
I can’t stand this
Emotion Dysregulation
Avoidance Behavior
Dissociation/
Perceptual
Disengagement
Tension Reduction
Behaviors
Avoidance Behavior
--Stop
Mastery
Behavior
--Stop
Pleasure
Reinforces
helplessness/worthlessness
Signals brain, stop
producing
neurochemistry
--Loss of
Energy,
motivation
and pleasure
Emotion Dysregulation
Tension Reduction
Behaviors
Self mutilation
Sexual acting out
Suicide Fantasy
Addictive
Behavior
Psychosocial Profile
 Mood Disorder learned and maintained by chronic and pervasive pattern of
interpersonal avoidance.
 Avoidance is fueled by attachment-based fear (i.e., fear based on history of
interpersonal learning in context of attachment relationships) where
expression of self/attachment (wants, needs, emotions, and intentions) is
repeated associated with attachment injuries and psychological insults
delivered by attachment figures in the form of rejection, criticism, and blame.
 Consequently, the person comes to associate the expression of self (including
all attachment needs) with anxiety, shame, and guilt. A natural response to
these feelings is avoidance behavior (stuffing of feelings).
 This results in chronic feelings of worthlessness (“My feelings don’t matter”)
and helplessness (“Nothing I do works so why try”). The biological
consequence of these perceptions is the deactivation of motivation, energy,
and pleasure (the brain is primarily and conservator of energy, thus when the
perception is that nothing will work or change in turns off activation related
neurotransmitters). It may also activate the brains survival mode, which results
in chronic over-activation of the sympathetic nervous system, resulting in
feelings of anxiety, tension, and irritability.
Neurocognitive Consequences
 The neurobiological consequence of chronic emotion
dysregulation is the disintegration of dendritic connections
between PFC and various subcortical systems in limbic
system, including hippocampus.
 Degeneration of middle frontal areas of the brain and
hippocampus impaired ability to attend to and
contextualizing relationship events
 Consequently, person relates in mindless fashion, repeating
same old patterns of relationship experiences—”Interpersonal
Sameness”
 Confirms feelings of hopelessness and helplessness
 This interferes with the brains ability to form
autobiographical memory and other neurocognitive
deficits
Neurocognitive Deficits
 These neurocognitive deficits are similar to deficits
described in other research, including Theory of Mind,
Mindsight, and Mentalization
 Also similar to Piagetian concept of preoperational
functioning: childlike ego-centric pattern of thinking
where the individual is not influenced by external
environment…
 Failure of Perceptual Engagement—visually disengaged
from social environment, using past experience to interpret
present moment, thus creating the past in the
present…continuous, interpersonal sameness.
Secure vs Insecure Patters
No one
appreciates
what I do…why
do I even help
these people
Thanks for all your help
With the project
Sure, anytime
Self-Defeating Patterns of
Interpersonal Behavior
 Fail to understand how they affect others and actually
“pull” others into behaving exactly the way they expect
others to behavior
 They use the past to interpret the present
 You keep getting the past in the present
 Recapitulation of past in current relationship
experiences
Dominance
H
o
s
t
i
l
e
Dominant
Hostility
Dominant
Friendly
Affiliation
Affiliation
Passive
Hostility
Freindly
Passivity
Passivity
F
r
i
e
n
d
l
y
CBASP Treatment Components
 The Significant Other History
 Transference Hypothesis
 Identification of “Hot Spot”
 Disciplined Personal Involvement
 Interpersonal Discrimination Exercises
 Situation Analysis
Steps in Significant Other History
 Identify Key Players
 For each ask:
 “what was/is it like being around this person?”

Get examples of key words
 “What has been the stamp this person has left on your
life?
 At the end Ask:
 “Looking back on all these relationships, what is the
affect you think they have had on who you are today.”
Transference Hypothesis
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Four Content Domains
Relational intimacy
Disclosure of private material
Mistakes
Feeling or expressing negative emotion
Formulate TH as highly probable interpersonal event
(hot spots) which will trigger patient’s internal
working model
 Basic Model:
 If I do x…Sibcy will…..
Disciplined Personal Involvement/
Conditioned personal responsivity
 Designed to penetrate patients interpersonal sameness
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
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through perceptual engagement
Confronting interpersonal behavior
Increasing Mentalization, understanding how his
behavior effects others
Not using past to interpret the present
Usually will activate “Transference Hot Spot”
Interpersonal Discrimination
Exercises
 Hot spot activated
 Draw attention to it
 Ask how others would react to it
 Ask how “you” reacted to it with them in session
 Compare and contrast to past/others
 Ask about implication for therapy
 Ask about generalization to future
CBASP Situational Analysis
 Uses Coping Survey Questionnaire
 Two phases
 Elicitation – SA used as an interpersonal, cognitive
behavioral diagnostic tool
 Remediation – Problematic behaviors are targeted for
change and revised until new behaviors bring a desirable
conclusion
 Confronts avoidance and directs the patient’s
attention to the interpersonal environment
CBASP Situational Analysis
 Step 1: Describe what happened. (A brief “slice of time” with a beginning,
an end, and a short story in between.)
 Step 2: Describe your interpretation of what happened (how did you “read” the
situation?). (A description of the process of the situation.)
 Step 3: Describe what you did during the situation (what you said/how you said
it). (What someone else would have observed if they had been able to see
you during this situation.)
 Step 4: Describe how the event came out for you (actual outcome). (Goes back
to the end of the situation in Step 1)
 Step 5: Describe how you wanted the event to come out for you (desired
outcome). (Looking at the end point of this situation, what is the best
you could do at that point? Remember, goals must be realistic and
attainable.)
 Step 6: Was the desired outcome achieved? YES ___ NO ____
 Step 7: Why?
Situation Analysis
 Situation Interpretations Behaviors-
 Actual Outcome Desired Outcome Did you get DO
 Why?
Early Sample Narrative
 My husband doesn’t appreciate me.
 Nothing I do interests him. He cares more about his
video games than me.
 He’s always had sort of an addictive personality…he
gets totally absorbed in things…he doesn’t care about
anyone but himself…I guess it’s just me.
 If I try to say something to him about how I feel he just
goes off and starts putting me down.
 It’s useless for me to say anything to him about my
feelings. They don’t matter to him.
Situation Analysis (session 6)
 Situation:
 At home eating dinner.
 As soon as husband and I finished dinner, he got up




from the table and took his plate to sink.
Then he started to head down stairs. I asked him
where he was going.
He said, “I think I’ll go play some war of aircraft.”
I didn’t say anything but just nodded my head.
He turned and walked off downstairs.
SA (continue)
 Interpretations:
 He doesn’t love me
 I must be such a bore
 What’s the point…no one cares about what I need
 Behavior:
 I just nodded my head up and down and stared past
him. Then I dropped it
SA continued
 Actual Outcome:
 I dropped it
 Desired Outcome:
 I want him to give up these stupid games
 I want him to love me and care about me
SA
 Revised DO:
 To tell him: I really want to spend some time with you
this evening…can we do that later?
 Did you get DO?
 No
 Why?
 I didn’t say anything to him
SA continued
 Revise interpretations:
 He doesn’t love me
 I must be such a bore
 What’s the point…no one cares about what I need
 Revised Action Read:
 Ask him to spend time; speak up
 Be nice
Case Example:
 Bill
 48 year-old accountant with chronic depression
 Depressed his whole life
 Numerous medications
 Numerous therapists
 Nothing helps
Sample Narrative
 The other evening I decided to tell my husband my
feelings about him spending so much time playing the
video game. I told him that I felt he was addicted to
the game and even told him there is research on how
these games work like addictions. I also told him it was
like he had a mistress and I couldn’t stand it anymore.
He told me I was overreacting and that I blow
everything out of proportion. He told me I needed to
get a life. I just turned away and walked off.
What is the evidence
 An FDA approved medication must demonstrate at
least 2 large scale Randomized Controlled Treatment
studies
 Using clinically depressed patients who meet strict
inclusion and exclusion criteria
 Qualified patients were randomly assigned to one of
two group:
 Medication group
 Placebo control group
Evidence
 Depression is measured using standardized
instruments– self report vs clinician rated
 These are administered repeatedly over course of
treatment to endpoint (usually 8-12 weeks)
 Usually use of fixed dose methods (e.g., 20 mg
Prozac).
 Statistical Outcome:
 Treatment group is compared to placebo to see if there
was a “statistically significant difference” between
treatment and control group (P<.05)
The Problem
 Statistical Significance does not equal Real Life Benefit
 SS is affected by two factors
 Number of people in the study
 Everyone in the study is alike
An Integrative Model of Depression
Behavioral
Disturbances
•Role Transitions
•Loss/grief
•Relationship
disturbances
•Loneliness
•Type I
•Type II
Self
Other/
world
Genetics/biology
X
Early
Relationship
Experiences
Negative
Bias
Insecure Working
Models of Attachment
X
Social-Neuro-cognitive
Skill Deficits
Chronic Mood
Dysregulation
Future
Focus Intervention