The New Trend in Psychotherapy

1
The New Trend in Psychotherapy

• Lena Verdeli, Ph.D.,
• Teachers College
• New York State Psychiatric Institute
• Columbia University

2
The Good News

• The empirical basis of psychotherapy is
  broadening and deepening
• Even disorders with a heavy genetic loading, such
  as bipolar disorder, have been shown to respond
  favorably to psychotherapy combined with
  medication1
• In a national survey of training programs in
  psychiatry, psychology and social work,
  psychiatry required coursework and clinical
  supervision in a largest of EBTs2
• 1. Miklowitz DJ, Otto MW, Frank E, et al.
  Arch Gen Psychiatry. 200764(4)419-26.
• 2. Weissman M, Verdeli H, Gameroff MJ, et
  al. Arch Gen Psychiatry. 200663925-934.

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The Bad News

• The practice of psychotherapy among
  psychiatrists is declining
• The of office visits to psychiatrists involving
  psychotherapy declined from 44.4 in 1996-97 to
  28.9 in 2004-05
• Number of psychiatrists who provided
  psychotherapy to all their patients declined from
  19.1 in 1996-97 to 10.8 in 2004-05
• The decline in psychotherapy provision was
  mediated by changes in payment source and
  increased medication prescription3
• 3. Mojtabai R, Olfson M. Arch Gen Psychiatry.
  200865(8)962-970.

4
The Paradox4

• There is an overwhelming demand for training
  and testing of evidence-based psychotherapies by
  NGOs and academic centers in other areas of the
  world
• 4. Weissman MM. Commentary on Psychotherapy
  for Depression in Adults A Review of Recent
  Developments by Thase M. In Herrman H, (Ed.)
  Depressive Disorders 3rd Edition (2008). UK
  Wiley-Blackwell

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In Western Countries

• In the UK The government has made available
  funds to implement the National Institute for
  Health and Clinical Excellence (NICE) guidelines
  for depressed patients
• In Canada In the province of British Columbia
  IPT-A has been disseminated in all community
  mental health centers.

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In Developing Countries

• In the last seven years, our IPT team has had
  numerous requests to adapt and test IPT for
  resource-poor areas in sub-Saharan Africa, India,
  Iraq, etc.

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Study 1 (2002-2003)Group IPT with Depressed
Adults in Southern Uganda

• Johns Hopkins Bloomberg School of Public Health
• Paul Bolton (PI), Judy Bass
• NY State Psychiatric Institute, Columbia
  University
• Myrna Weissman, Lena Verdeli, Kathleen F.
  Clougherty, Priya Wickramaratne, Richard
  Neugebauer
• World Vision Uganda Lincoln Ndogoni, Liesbeth
  Speelman

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The request

• Qualitative mental health study by Boltons team
  (2002)1 found high prevalence of depression
  symptoms (21) among adults in the southwest
  region of Uganda
• Team in search of a psychotherapy which had shown
  efficacy, would have to be adapted for the local
  setting, and tested in a randomized controlled
  trial
• 5Wilk CM, Bolton P. (2002)Local perceptions of
  the mental health effects of the Uganda acquired
  immunodeficiency syndrome epidemic. J Nerv Ment
  Dis,190394-7

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Initial reactions

• Why label human suffering depression?
• Why intervene?
• Is psychotherapy a luxury in these communities?
• Should we use western-based psychotherapy
  concepts and techniques in these communities?
• Would a rigorous clinical trial in such a
  resource-poor setting be possible?
• Even if the intervention proved to be
  efficacious, would it be sustainable?

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Local Syndromes of Depression

• Yokwekyawa (self-loathing)
• - Feeling lonely
• - Feeling no interest in things
• - Worrying too much about things
• - Feeling hopeless about the future
• - Hating the world
• - Thoughts of killing self
• - Irritability
• - Bad, criminal or reckless behavior
• - Feeling sad
• - Feeling worthless
• - Not responding when greeted/withdrawn
• - Crying easily
• - Poor appetite
• - Feeling of severe suffering/pain

• Okwekubagiza (self-pity)
• - Feeling sad
• - Feeling lonely
• - Worry too much about things
• - Feeling worthless
• - Low energy, feeling slowed down
• - Crying easily
• - Feeling fidgety
• - Feeling no interest in things
• - Feeling everything is an effort
• - Irritability
• - Unappreciative of assistance

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Assessment of Depressive Symptoms Hopkins
Symptom Checklist (HSCL) 6 Ethnographic methods
were used to validate the HSCL Assessment of
Functioning Development of a Local Measure
7 Ethnographic methods derived gender-specific
tasks viewed as essential elements of functioning
(caring for self, family, community) 6Bolton P.
(2001) Cross-cultural validity and reliability
testing of a standard psychiatric assessment
instrument. Nerv Ment Dis. 189238-242. 7
BoltonP, Tang AM. (2003). An alternative approach
to cross-cultural function assessment. Soc
Psychiatry Psychiatr Epidemiol. 37537-543.
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Function Assessment Graphic
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Rationale for using psychotherapy

• Depression was a major source of disability and
  needed to be addressed
• Local traditional healers felt unable to treat
  depressive syndromes effectively.
• Medication not feasible, e.g., cost too high, few
  MDs

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Selecting IPT

• CBT and IPT were considered
• Cultural attitude in Uganda people see
  themselves as part of a family or group
• IPT seemed compatible with the Ugandan culture

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The group leaders
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How the IPT Manual was Adapted

• Sources of information trainees, and
  ethnographic study (interactive process)
• Modifications of manual
• General adaptations
• Simple language,
• More structure

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How the IPT Manual was Adapted

• Specific adaptations
• Pre-group meeting
• Local definition of depression (emphasize that it
  is not madness)
• Role of leader will not provide material goods
• Confidentiality (how much to disclose to the
  community)
• Treatment contract (flexibility, schedule around
  community events)

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Modifications of manual Specific Adaptations
(cont) Evidence for 3 Problem Areas

• 1) Grief death of a loved one multiple deaths
  - reconstruct the relationship while not being
  disrespectful to the dead loved one.
• 2) Role Disputes disagreements - respect and
  work within the cultural code regarding power and
  intimacy.
• 3) Role Transitions life changes - when
  dealing with devastating life changes (AIDS,
  famine), focus on the elements under the
  individuals control.

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Results for Intent-to-Treat Sample (N248)
Depression Scores (HSCL)
Plt .001
Plt .001
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Results for Intent-to-Treat Sample
Functional impairment Scores
Plt .001
Plt .001
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Conclusion

• There is international demand for feasible,
  effective and sustainable psychotherapy
• Emphasis on functionality, not cure
• How does one understand this paradox that what
  is too expensive in the US is sustainable in
  poorer countries and is of interest in wealthier
  countries?4