A South Australian Study of Depressed Adolescents: Therapy

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A South Australian Study of Depressed
AdolescentsTherapy

• There was no difference between those who had
  Cognitive Behavioural Therapy compared with those
  who did not

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Therapy

• No apparent or statistical difference between the
  psychotherapy subgroup compared with the
  psychotherapy medication subgroup

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Prefrontal Cortex

• Attention span
• Perseverance
• Judgment
• Impulse Control
• Organisation
• Problem Solving
• Emotions
• Empathy
• Compassion

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Family Therapy Alliance

• that aspect of the relationship between the
  therapist system and the patient system that
  pertains to their capacity to mutually invest in,
  and collaborate on, the therapy
• Pinsof and Catherall, 1986

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Therapeutic Alliance

• Building the Therapeutic Alliance is a creative
  process, a central issue for all age groups,
  since in its absence, there can be no therapy.
• Dorothy M Marcus, 1998

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Therapeutic Alliance

• Set of Tasks
• Relationship Bond
• Toward a defined Goal
• Bordin 1979

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Joining as an Issue

• If you dont join with all members of the system
  early then therapy is doomed. The relationship
  between therapist and family can become so
  tenuous that early termination results.

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Level of Alliance

• Level at the start of therapy predicts Outcome
• Ryan and Cichetti, 1985
• Positive patient statements correlate with rated
  benefits
• Luborsky et al, 1983
• Therapists personal qualities correlate highly
  with Outcome
• Luborsky et al, 1985

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In a Nutshell

• You have to like them!

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Therapist Qualities

• Better Outcomes from
• Engagement
• High Credibility
• Warm, empathic approach
• Accepting stance
• Liking the patient or family

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Ps

• Predisposing Factors
• Precipitating Events
• Perpetuating Features
• Prognostic Indicators
• Preventive Opportunities

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Socratic Questioning(Journalism)

• Who?
• What?
• Where?
• When?
• How?
• How much?
• Why?

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Why?

• Why this young person?
• From this context?
• With these features?
• At this time?
• And, where do we start?

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Is it the Young Persons problem?

• Is the young person causing the problem for the
  parents, or in the family?
• Is the young person the symptom of the family?
• Is the young person accepting anothers
  projection?
• (cf Munchausen by Proxy)

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The Family Context
Father
Sig. other
Mother
Self
Sibling
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PARAMETERS OF FAMILY FUNCTIONINGafter Epstein
Bishop (MCMASTER)

• Roles
• Problem Solving
• Communication
• Affective Involvement
• Affective Responsiveness
• Behaviour Control
• General Functioning

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Cognitive Behavioural Therapy (CBT)
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Psychoeducation

• from RCT, educational materials play a
  significant role in improvement in depression
• Robinson, Katon, Von Korff et al., 1997

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Cognitive Behaviour Therapy

• Dispute about unique effect
• Murphy, Carney et al., 1995
• May reduce relapse
• Fava, Grandi, Zielezny et al., 1996
• Therapist competency is vital
• Scott, Tacchi, Jones Scott, 1997
• Meta-analysis suggests effect size post-treatment
• Reinecke, Ryan DuBois, 1998

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CBT Assumptions

• Cognitive activity affects behaviour
• Cognitive contents processes can be monitored
  changed
• Behavioural ( emotional) change may be affected
  through cognitive change
• Dobson and Dozois, 2001

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Other assumptions

• Processing of information is active adaptive
• Individuals derive meaning from their experiences
  using information processing
• Belief systems are idiosyncratic
• New information is assimilated into existing
  belief systems

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Automatic Thoughts

• Specific, discrete essential words
• Shorthand distilled format
• Not a result of deliberation, reasoning, or
  reflection - Just happen
• Not sequential as in goal directed thinking or
  problem solving
• Autonomous patient does not need to make any
  effort to generate can have difficulty
  switching off
• Beck

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Core Beliefs

• Learned through childhood experiences
• 2 broad categories helplessness and
  unlovability
• Core dysfunctional beliefs latent during low
  stress periods
• Reactivated by negative experiences that resemble
  conditions under which original beliefs were
  formed

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Cognitive Distortions

• Overgeneralisation
• Dichotomous thinking
• Magnification
• Personalisation
• Disqualifying positives
• Jumping to conclusions
• Catastrophising
• Emotional Reasoning
• Shoulds Oughts
• Labels

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Cognitive Triad

• Negative view of self, the world, and the future
  central to maintenance of depression
• Beck (1983)subsequently proposed that individuals
  were particularly likely to experience depression
  if there is a congruence between negative life
  events depresso-genic schemata

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Research

• Presence of high levels of depressive
  symptomatology in children with negativistic
  attributional styles and presence of internal,
  stable, global negative style
• increases risks of further depression in
  adolescence
• suggests causal role of attributional style in
  development of depression
• pessimistic attribution style predicts future
  increases in depressive symptoms among
  adolescents irrespective of negative life events
• Spence et al., 2002

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Research

• 40 of adolescents who responded to CBT relapsed
  within 6 months
• Significant number of adolescents discontinue
  treatment prematurely, do not comply or remain
  depressed at end of intervention (approx 33)
• Younger children seem to better
• Need to investigate involvement of family
• Spence Reinecke, 2004

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Major CBT strategies

• Behavioural activation
• Getting the person to do something
• Monitoring activities, pleasure, mastery
• Scheduling activities
• Graded task assignment
• Cognitive activities
• Distraction techniques
• Time set aside for thinking

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Major CBT strategies

• C-B strategies
• Identifying negative thoughts
• Questioning negative thoughts
• Behavioural experiments
• Preventative strategies
• Identifying assumptions
• Challenging assumptions
• Use of set-backs
• Preparing for future

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Initial Interview

• Assessment of current difficulties
• Symptoms
• Life problems, e.g., interpersonal, medical,
  practical
• Associated negative thoughts
• Onset/development/context of depression
• Hopelessness/suicidal thoughts/lack of energy
• Agreed problem list

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Initial Interview

• Goal definition may change later but helps
  correct unrealistic expectations, provides a
  standard against which to monitor progress,
  focuses attention on the future.
• Presentation/acceptance of treatment rationale
• Practical details what is involved e.g.,
  homework, between session tasks, frequency

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Initial Interview

• Introduction to basic relationship between
  negative thoughts depression
• Possibility of change
• Beginning intervention
• Specific
• Select first target
• Agree appropriate homework, monitoring/reading
• General
• Give Client experience of CBT style (focus on
  specific issues, active collaboration, homework)
• Overall aims
• Establish rapport
• Elicit hope
• Give pt preliminary understanding of model
• Get working agreement to test it in practice

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Subsequent sessions

• Set agenda
• Weekly items
• Review events from last session
• Feedback from client on last session
• Homework review (emphasises self-help,
  independent functioning)
• Outcome?
• Difficulties?
• What has been learned?

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Subsequent sessions

• Major topic for session
• Specific strategies (e.g., relaxation, learning
  evaluate automatic thoughts
• Specific problems (e.g., difficulties that have
  arisen during week)
• Long term problems
• List in order of priority

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Subsequent sessions

• Homework assignments
• Task
• Should follow logically from session content
• Needs to be clearly defined
• Rationale
• explicit e.g., to test the idea that I cant do
  anything, a no lose situation will learn
  something regardless
• Predicted difficulties
• Feedback from client
• Understanding ( summarise main points
• Reactions to session

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On Prescribing
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When to prescribe?

• When a rapid response is needed
• When danger may be an issue
• With an older rather than a younger child
• Where the diagnosis is more clear
• Where it is clearly the childs problem
• When you dont have the therapy skills
• Alongside therapy

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The Synapse
Target nerve cell
Electrical pulse
Electrical pulse
Neurotransmitter receptor

• Drugs such as SSRIs (?) block the return of
  serotonin (?) to its release site. More of the
  neurotransmitter reaches the target nerve cell,
  enhancing synaptic transmission

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Selective Serotonin Reuptake Inhibitors (SSRIs)

• 1996 review found 3 double blind, placebo
  controlled trials (65), 16 open label trials
  (322) and 23 case reports (41).
• DeVane Sallee
• 1997 (10yr) revue of metabolism noted paucity of
  pharmacokinetic data on young people
• Leonard, March, Rickler Allen

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SSRIs - complications

• Meta-analysis on 62 RCTs - 10 lower
  discontinuation rate than TCAs
• Fabre, Abuzzahab, Amin, Cleghorn et al., 1995
• Extrapyramidal Reactions
• Arya, Mckenzie Worrall, 1995
• Sexual Dysfunction
• Montejo-Gonzalez, Llorca, Izquiero, Ledesma et
  al., 1997
• No cardiac conduction abnormalities
• Feighner, 1995

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SSRIs - complications (contd.)

• Manic switching
• Jain, Birmaher, Garcia, Al-Shabbout et al., 1992
• Behavioural activation
• Guile, 1996
• Aggression not confirmed
• Constantino, Liberman Kincaid, 1997
• ? Exacerbation of tics in Tourettes Syndrome
• Hauser Zesiewicz, 1995

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SSRIs - Toxicity

• 34 of 52 cases experienced no symptoms from up to
  1400mgms
• all but 3 of 38 adolescents/adults treated in
  hospital 10 of 14 children treated at home
• lavage in 37, no other therapy
• mild CNS, CVS, GI symptoms only
• Klein-Schwartz Anderson, 1996

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SSRIs - Concurrent Use

• SSRIs may substantially increase TCA plasma
  levels, leading to adverse effects.
• Scant literature to support concurrent use.
• Taylor, 1995

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The Current Debate

• There have been deaths, but causality is hard to
  prove
• The recommended drug (Fluoxetine) was said to
  cause deaths 10 years go
• Probably a media beat-up

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Social Skills Training

• Structured Learning Therapy reliable better in
  males
• Reed, 1994
• Problem Solving Treatment effective for major
  depression
• Mynors-Wallis, 1996
• Interpersonal Therapy recovery maintained to 1
  year
• Mufson Fairbanks, 1996

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Family Therapy

• Differences between families of
  depressed/non-depressed.
• Cumsville Epstein, 1994
• Nilzon Palmerus, 1997
• CBT better in controlled study
• Brent, Holder, Kolko, Birmaher et al., 1997
• Home based family therapy better
• Harrington, Kerfoot, Dyer et al., 1998

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De Shazer

• Solution focused
• Very task focused
• Demands Customer Status over Visitor or
  Complainant
• Seeks Exceptions

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Group Therapies

• Review notes that treatments lack specificity and
  focus on narrow range of deficits
• Beeferman Orvaschel, 1994
• Dropouts participate less
• Oei Kazmierczak, 1997

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The Spectrum of Prevention
Rehabilitation
Maintenance
Standard treatment
Case identification
Indicated
Selective
Universal
after Patricia Mrazek and Robert Haggerty, 1994
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Prevention of Depression

• Protective Factors Resilience
• Temperament building
• Resilience building in school
• Learned Optimism programs
• Options and Choices personal judgment
• Developing sense of self through sport, games,
  drama
• Developing supportive relationships at peer level
• and with adults
• Stress inoculation
• Developing national pride

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Auseinet.com

• Commonwealth documents
• Research reports
• Online Journal - AeJAMH