Depression: A Primer for Practitioners

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Steven Richards & Michael G. Perri

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  • Dedication

    To Carol

    S.R.

    To Kathy, Katie, and Matthew

    M.G.P

    Copyright

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    Preface

    This book is written primarily for practitioners. We believe that a readable, scholarly, applied, and up-to-date book on depression should help the numerous practitioners who work with depressed patients. We understand that it is virtually impossible for most practitioners to keep up with the literature on depression: There have been over 60,000 empirical publications on depression since 1980 (Seligman & Csikszentmihalyi, 2000). Even ambitious depression experts find it challenging to keep up with this literature. Therefore, we wrote Depression: A Primer for Practitioners. One of our goals for this book is helping practitioners to stay abreast of the empirical literature on depression.

    This book is organized as a primer. Therefore, we provide brief coverage of many of the topics that are central to working with depressed patients. We cannot, of course, cover all of the relevant topics. Moreover, even the topics that we do cover must be discussed briefly. We purposely and strategically include a modest amount of redundancy, particularly regarding therapy issues and clinical guidelines. We appreciate that busy practitioners will sometimes consult certain sections of the book, for context-sensitive information, when using the book as a resource for a particular patient. For example, a psychotherapist who typically works with adult patients may consult the chapter on depression in adolescence when working with an older-adolescent patient who is depressed. Thus, we include some context-sensitive information about therapy and suicide in the adolescence chapter because the practitioner may not reread the three chapters on psychotherapy, pharmacotherapy, and suicide.

    The empirical literature and our own clinical experience support the merit of cooperative, interdisciplinary interventions. In addition, a wide array or practitioners work with depressed patients and clients: psychotherapists of all backgrounds and persuasions; clinical, counseling, and school psychologists; social workers; marital and family counselors; general practice physicians; psychiatrists; nurses; ambulance and emergency room staff; physical therapists; occupational therapists; pastors; crisis hotline workers; teachers; school counselors; police officers; and so on. Furthermore, significant others and family members of the depressed individual often want accessible, empirically based information regarding depression. Hence, we have written Depression: A Primer for Practitioners for this broad range of practitioners and significant others. For instance, our case studies, which are composites of dozens of cases with all of the identifying information changed, include many types of participants, reflecting our interdisciplinary readership.

    The chapters in this book usually have the following organizational scheme within each chapter: overview, case study, discussion of the case study, symptoms, prevalence, risk factors, assessment, treatment, special topics, clinical guidelines, chapter summary, and suggested readings. In a few chapters, however, we have deviated slightly from this organizational scheme to accommodate the relevant topics and to provide more how-to examples.

    This book is divided into four parts:

    • Part 1: Depression: Symptoms and Theories About Therapies
    • Part 2: Depression Across the Life Span
    • Part 3: Comorbid Conditions and Other Symptoms, Signs, and Problems Associated With Depression
    • Part 4: Treatment of Depression

    Part 1, “Symptoms and Theories About Therapies,” contains chapters on the symptoms, signs, and diagnosis of depression (Chapter 1) and theories about therapies for depression (Chapter 2). In Chapter 1, we focus on the most common type of serious depression, which is Major Depressive Disorder (American Psychiatric Association, 2000a). This focus dovetails with the goals of our brief volume. It would be far beyond the scope of this book to attempt a thorough discussion of all mood disorders and the many intricacies of differential diagnosis among these mood disorders; hence, we focus on the central topic of this book—depression or Major Depressive Disorder. In Chapter 2, we overview the theoretical literature regarding treatments for depression. We do not discuss the large number of theories regarding the development and course of depression, as this would be impossible in a short primer and is not central to the mission of our book. Rather, we believe that in a primer for practitioners, a discussion of theories about therapies will be the most helpful approach to theory exposition.

    In Part 2, “Depression Across the Life Span,” there are chapters on children (Chapter 3), adolescents (Chapter 4), adults (Chapter 5), and older adults (Chapter 6). These four chapters follow the organizational scheme within chapters that we noted previously. For example, the chapter on depression in children includes the following topics: overview, case study, discussion of the case study, prevalence, symptoms, assessment, treatment, special topics relevant to children, clinical guidelines, chapter summary, and suggested readings. All of the information in the chapter on children is context sensitive—we discuss issues in the context of depressed children. In alignment with this strategy of supplying context-sensitive information, the chapter on depression in adolescents includes both the standard topics and information on gender differences, close relationships, substance abuse, family interventions, and suicide because these topics are very germane to depressed adolescents. Similarly, the chapter on depression in adults includes both the standard topics and context-sensitive information on interview outlines, coping without professional treatment, electroconvulsive therapy, chronic depression, and a range of ethical, practical, and training issues that are relevant to depressed adults. The chapter on depression in older adults also includes both the standard topics and context-sensitive information regarding assessment, treatment, and special topics relevant to depressed older adults.

    Part 3, “Comorbid Conditions and Other Symptoms, Signs, and Problems Associated With Depression,” contains chapters on additional psychiatric disorders and severely distressed close relationships associated with depression (Chapter 7), chronic health problems associated with depression (Chapter 8), and suicide and depression (Chapter 9). Here again, the standard chapter organization is often followed, but some modifications are included to provide context-sensitive information, more how-to examples, special topics, and clearer chapter organization. For example, in Chapter 7, we discuss two of the additional psychiatric disorders that are frequently associated with depression: anxiety disorders and alcohol abuse. We also discuss the common association of severely distressed close relationships and depression. In Chapter 8, we discuss three of the chronic health problems that are often associated with depression: cardiovascular disease, cancer, and dementia. In addition, we provide context-sensitive clinical guidelines for each of these chronic health problems. We do not attempt to discuss all of the psychiatric disorders and chronic health problems that are associated with depression, however, because that would take us far beyond the scope of a brief primer. In Chapter 9 on suicide, we again include both the standard chapter topics and some context-sensitive topics such as risk factors, crisis intervention, and ethical issues regarding suicide.

    Part 4, “Treatment,” contains chapters on psychotherapy (Chapter 10), pharmacotherapy (Chapter 11), and relapse prevention (Chapter 12). The psychotherapy chapter focuses on the two psychotherapies with the most empirical support for treating depression: cognitive behavior therapy and interpersonal psychotherapy. These two psychotherapies enjoy strong empirical support from randomized controlled trials (DeRubeis & Crits-Christoph, 1998; Hollon & Shelton, 2001). Case examples are given in the context of these two treatment approaches. We also acknowledge, of course, that psychotherapists and other practitioners need thorough training in these complex treatments to use them effectively. Furthermore, no primer can come close to supplying all of the necessary information and training. Some additional psychotherapy interventions are discussed very briefly, within the confines of a primer. The pharmacotherapy chapter provides a brief overview of the major Food and Drug Administration (FDA)-approved antidepressant medications, while staying in close alignment with numerous well-regarded reviews and practice guidelines on this topic (e.g., American Psychiatric Association, 2000b; Halbreich & Montgomery, 2000). We also note that we are not physicians and that pharmacotherapy for depression should be prescribed and carefully supervised by qualified physicians. We discuss combinations of pharmacotherapy and psychotherapy, and we provide clinical guidelines for psychotherapists whose patients are receiving these combined treatments. The chapter on relapse prevention includes some of the standard chapter topics, such as a case study and discussion, along with context-sensitive discussions about risk factors, models of relapse, people coping on their own, practical issues, and booster sessions to prevent relapse. The relapse problem has been around for a long time (Richards & Perri, 1978), it is far from completely solved (e.g., Paykel et al., 1999; Reynolds et al., 1999), and it remains one of the more important challenges for practitioners working with depressed patients (e.g., Jarrett et al., 2001; Katon et al., 2001).

    Our primer text concludes with a brief epilogue. This epilogue includes a case study, some highlights of the difficult therapeutic challenges for practitioners who are working with depressed patients, and an overview of the prominent clinical guidelines that pervade many of the chapters. We also discuss certain therapeutic themes that arise from these clinical guidelines. As befits an epilogue, there is a short list of suggested readings on depression, which are relatively broad in their coverage, in contrast to the more specific readings that are suggested at the end of each chapter.

    At the end of this book there is a complete list of references, an index, and a brief statement about the authors.

    We attempted to write a book that is a combination of “scholarly book” plus “how-to book.” Our goals included writing chapters that are accessible, research-based, and practical. Moreover, our goals included writing a book with a clear style, broad coverage, extensive documentation, clinical guidelines, and up-to-date citations. We followed the format and strategy of a primer; this should be useful for practitioners who are working with depressed patients. Indeed, most mental health professionals and health care providers, along with practitioners in many other disciplines, have frequent contact with depressed patients and clients. One of our goals was to develop an up-to-date primer that would be a helpful resource for practitioners in this very diverse array of disciplines and settings. In addition, certain family members and significant others of depressed individuals may want clear, empirically based information about depression, and this brief primer may be a useful resource for some of them. First and foremost, however, this is a book for practitioners who are working with depressed patients.

    Acknowledgments

    In the kind of job that we have, a book gets written on weekends. Thus, our first acknowledgment goes to the Richards family and the Perri family for tolerating our frequent absences on weekends. Thanks go to Carol, Dawn, and Jill Richards, and Kathy, Katie, and Matthew Perri. Our families are wonderfully supportive, empathic, and good-natured. We love them!

    Our second acknowledgment goes to university colleagues and staff members who helped us. Susan Hendrick provided thoughtful, supportive, and gracious comments on the early drafts of several of our chapters. Clyde Hendrick, James Rodrigue, and Ronald Rozensky gave us helpful advice about publication strategy. The staff members in our respective departments are always efficient in their efforts to help us. The same goes for the staff members in our respective university libraries: With the publication of over 60,000 empirical articles on depression since 1980, a book like this would be impossible to write without the resources of excellent libraries.

    Our third and final acknowledgment goes to the editors, staff members, and reviewers for Sage Publications. These individuals are great to work with. The editor for this book is Jim Brace-Thompson. Jim is a marvelous source of encouragement, expertise, and tact. The staff members at Sage are consistently helpful, and we would particularly like to thank Jim's staff colleague, Karen Ehrmann, and the copy-editor for this book, Elisabeth Magnus. In addition, eight anonymous reviewers for Sage provided thoughtful comments on our book—some in the beginning and some toward the end of our writing efforts.

    All of the individuals noted in this acknowledgment have helped us, and we are very grateful for their help.

    StevenRichards, Texas Tech University, Lubbock, Texas
    Michael G.Perri, University of Florida, Gainesville, Florida
  • Epilogue

    Overview

    We begin this brief epilogue with a letter from one of our former patients. The letter describes what therapy was like for the patient and how he has coped since therapy ended. After discussing key facets of the letter, we highlight some of the difficult therapeutic challenges for practitioners who are working with depressed patients. Next, we provide an overview of some of the prominent clinical guidelines for practitioners. These clinical guidelines pervade many of the chapters in our primer. We also discuss certain therapeutic themes that arise from these clinical guidelines. Finally, we provide a short list of suggested readings on depression that should be helpful for practitioners. These readings are relatively broad in their coverage, in contrast to some of the more specific readings that are suggested at the end of each chapter.

    Case Study

    The following letter was written by one of our former patients some months after therapy had ended. A number of personal details and phrases in the letter have been changed to protect the identity of the patient.

    Dear Doctor,

    I'm writing to let you know how I'm doing and to say a special “thanks” for your help. It's been nearly 5 months since our last session, and I'm actually doing pretty well right now. When I look back to where I was when I first saw you about a year ago, I realize that I've made a lot of progress since then. In fact, back then I wasn't sure that I was going to make it. I was so terribly depressed that life truly did not seem worth living. Looking back, it's hard to believe how dark and scary those days were and how close I was to “checking out.”

    You were a big part of my continuing the struggle and not giving up, even when I was facing my darkest hours. As you know, at times therapy itself was a struggle for me. One of the things that made a difference for me was knowing that you cared—that you really cared about me as a person. I think back to that night when I called and told you I was suicidal. I probably would not be here today if you had not been there for me. I know how resistant I was to the idea of going to the hospital, but your going with me to the emergency room that Saturday night made the difference. I would not have gone on my own, and God only knows what would have happened if I hadn't been able to reach you! It seems like such a long time ago, but it was less than a year.

    Things are going better now. I'm not 100%, but I'm doing pretty well. I'm still on an antidepressant and that seems to help, but I do want to let you know that the work we did in therapy is something that helped back then and is still helping now. I've been through some stressful times in the past few months. I didn't get the promotion at work that you know I'd been hoping for. But I didn't get depressed.

    You'll be proud to know that I've been real careful to examine my thinking for those “hot” thoughts—you know the ones that tend to trigger my feeling down and depressed. When I didn't get the promotion, I was disappointed and down for a while. But then I asked myself, “What's so terrible about not getting the promotion?” One of the important things I learned in therapy was not to judge my self-worth based on the need to have approval from my boss for everything I do. I also looked at the flip side of the situation and realized that there were some good things associated with not getting the promotion—like less stress on the job and more time for myself and for my family. The more I thought about it from that perspective the better I felt.

    Anyway, I don't mean to ramble on, but I did want to let you know that I'm doing well. I also want to tell you that I really appreciate all that you have done to help me. Right now I seem to be doing pretty well. But I also realize that if I hit a bump in the road, then I know that I can count on you to help me get back on track. I want to say thank you for your concern and helpful therapy!

    Sincerely, George
    Discussion of the Case

    Working with depressed patients can be rewarding as well as challenging. It is particularly gratifying when patients respond to treatment and their lives are improved as a result of our interventions. George initially came into treatment at the urging of his wife, who saw him as getting “stressed out” from work-related problems. Our assessment indicated that George was experiencing a Major Depressive Episode, which was triggered in part by his perception that he was a “failure” in his professional life. Like many high-achieving individuals, George's standards for judging his performance at work were unrealistically high. In fact, by any objective indication, his work performance was fully satisfactory and he was in no danger of losing his job. Our evaluation and detailed history taking also indicated that although this was probably not the most severe episode of depression that George had experienced it was part of a pattern of recurrent depression. Yet he had never been treated previously by a mental health professional, in large part due to his fears about the stigma associated with having a psychiatric disorder.

    One month into treatment, George's depression worsened and he became suicidal. Fortunately, he contacted his therapist. After some crisis counseling, he trusted his therapist enough to allow himself to be hospitalized. He was in the hospital less than 2 weeks and was started on an antidepressant medication. Following his discharge, he resumed outpatient treatment that focused heavily on cognitive behavior therapy.

    George responded well to the combination of cognitive behavior therapy and pharmacotherapy (an SSRI antidepressant). His letter highlights several important aspects about the treatment of depression. First, the development of a close working relationship appears to have been instrumental to successful treatment. George trusted the therapist enough to contact him when he was suicidal and to allow himself to be hospitalized when the therapist indicated it was necessary. Second, George appears to recognize the value of both antidepressant medication and cognitive behavior therapy. Indeed, he appears to be effectively implementing some key strategies in cognitive behavior therapy, such as his coping strategies when he did not get the promotion he wanted at work. Finally, George also appears aware that at some point in the future he may again need the therapist's assistance, and he seems receptive to getting additional treatment if needed.

    Difficult Therapeutic Challenges

    Depression is a horrible experience for many patients. Therefore, it can be challenging for the sensitive and concerned practitioner to avoid distress. Cultivating a strong professional identity, a resilient perspective, and a good sense of humor are helpful. Consultation with trusted colleagues is also beneficial. In addition, substantial knowledge of the empirical literature on depression is very helpful.

    Depressed patients are sometimes difficult to work with. Therefore, it can be challenging for the goal-oriented and ambitious practitioner to avoid disappointment. A structured and organized approach to psychotherapy is helpful. A calm and empathic therapeutic style makes a positive impact. Furthermore, some reality testing is helpful: Psychotherapy is hard work, and it is not always effective.

    Awful traumas are sometimes part of the depressed patient's life. Therefore, the practitioner may get traumatized too. Patient suicide is an obvious example. Patients who have experienced child abuse or rape are additional examples (from a potentially long list). Practitioners should not hesitate to get help for themselves if their patients' traumas are intensely upsetting them. Moreover, this is an issue where consulting with experts, collaborating with trusted colleagues, and working with an interdisciplinary team can be very beneficial.

    Some depressed patients do not get better, and many patients relapse after they do improve. Therefore, the practitioner may get discouraged. Psychotherapy can be tough, disappointing work. Most patients treated with empirically supported therapies do get better, however, and that helps a lot. Furthermore, we are making progress on developing efficacious relapse prevention strategies, which is also encouraging.

    Even the strongest practitioners may occasionally make a therapeutic or professional mistake with their depressed patients. Therefore, the practitioner may feel vulnerable. A subtle mistake about “crossing the lines of competence” or “a lapse in confidentiality” is an obvious example of this concern. Following professional ethics codes and laws of the jurisdiction will be very helpful. Keeping careful records will be beneficial. Moreover, staying in alignment with a cautious and prudent treatment plan, using empirically supported treatments, and consulting frequently with experts are effective therapeutic strategies, as well as reliable ways to reduce vulnerability.

    Prominent Clinical Guidelines

    Conduct careful interviews. Among the prominent clinical guidelines that run through most of the chapters is the theme that practitioners should conduct careful interviews of their depressed patients. This will afford the practitioner an opportunity to observe signs, discuss symptoms, clarify issues, and corroborate information. These interviews, of course, also allow the practitioner and the patient to begin developing their therapeutic relationship and collaborative working style. Furthermore, these interviews provide the patient with a chance to self-disclose and express emotion, while providing the practitioner with a chance to be empathic and understanding. Finally, practitioners should routinely assess for suicidal risk factors during their first interview of the patient.

    Be empathic. Practitioners should evidence empathy with their depressed patients. This clinical guideline is apparent in most of the chapters, and research supports the association of effective empathy and effective psychotherapy. Moreover, being empathic with all patients—including those who are suffering from the horrible effects of severe depression—seems to be the decent and gracious thing to do. In addition, the empirical literature indicates that effective therapeutic alliances and positive treatment outcomes are related to clear empathy from the practitioner.

    Assess and treat the symptoms, signs, problems, and comorbid conditions that are frequently associated with depression. There are many symptoms, signs, and problems associated with depression. Examples include severely distressed close relationships, employment problems, economic difficulties, and recent personal traumas. Furthermore, additional psychiatric disorders, such as anxiety disorders and alcohol abuse, frequently occur as comorbid conditions with depression. Chronic health problems, such as cardiovascular disease, cancer, and dementia, are often associated with depression. Finally, increased suicidal risk is common in cases of severe and chronic depression. Our clinical guidelines have repeatedly suggested that practitioners look for these associated problems and comorbid conditions, and that they aggressively treat them within the context of cooperative, interdisciplinary interventions.

    Use empirically supported treatments. Certainly a very prominent clinical guideline, mentioned repeatedly throughout this primer, is that practitioners should study and use empirically supported treatments for their depressed patients. We need treatments that work. Empirical studies, particularly the more systematic studies such as randomized controlled trials, tell us what will work. Cognitive behavior therapy, interpersonal psychotherapy, and pharmacotherapy enjoy considerable empirical support as treatments for depression. Practitioners should use these empirically supported treatments. Moreover, both practitioners and patients benefit from education about the current state of these treatment interventions.

    Pursue cognitive change. Depressed patients need to change their dysfunctional thinking. This point is evident in much of the empirical literature, and it is reflected in many of our clinical guidelines.

    Pursue behavior change. Depressed patients need to change their ineffective behaviors. These patients need behavior change and skill enhancement that will yield the following improvements: more efficacious communication styles, interpersonal skills, social support, problem-solving strategies, coping skills, emotional regulation, and reinforcing activities. This conclusion is prominent in much of the empirical literature and in many of our clinical guidelines.

    Consider the ethical, legal, and professional issues. Depressed patients sometimes present the practitioner with a complex array of ethical, legal, and professional issues. For example, there may be limits to confidentiality when a suicidal patient presents a clear and immediate danger to him- or herself. The professional challenges for practitioners in these cases include staying calm, being prepared to take immediate action, and protecting themselves. Ethical and legal issues include the legal standard of care, which is typically defined as care that is “average, reasonable, and prudent.” Our clinical guidelines have repeatedly argued for getting expert consultation and for working in a cooperative, interdisciplinary manner. A crisis intervention case, such as a severely depressed and suicidal patient, is a good context for reviewing these clinical guidelines. Finally, pharmacotherapy for depression should be prescribed and carefully supervised by a qualified physician.

    Include relapse prevention strategies. Most depressed patients relapse, even following successful treatment. Thus, relapse prevention strategies should be incorporated into the treatment programs for depressed patients. Booster sessions of psychotherapy, following the completion of the initial treatment program, seem to be a particularly promising relapse prevention strategy. This has been demonstrated in several randomized controlled trials that included large samples of severely depressed patients. Booster sessions of cognitive behavior therapy or interpersonal psychotherapy enjoy the strongest empirical support as psychotherapeutic relapse prevention strategies. Long-term maintenance pharmacotherapy is another well-supported strategy for relapse prevention. Planning for relapse prevention is a theme that pervades many of our clinical guidelines. Practitioners should prepare their depressed patients for the possibility of relapse, they should discuss coping and help-seeking strategies that patients can pursue if they do relapse, and they should emphasize that it is okay to pursue treatment again. Solving the relapse problem is one of the remaining frontiers for depression treatment.

    Suggested Readings

    These suggested readings are expository and relatively broad in scope, as befits an Epilogue. In contrast, the suggested readings at the end of each chapter are typically more focused and include both expository and empirical publications. We kept this list of suggested readings short-10 of the most helpful references for practitioners.

    • The DSM-IV-TR (American Psychiatric Association, 2000a) is an indispensable resource for empirically based information on the symptoms, signs, course, and diagnosis of depression (and other psychiatric disorders). Practitioners who work with seriously depressed patients will find it helpful to have this manual on their bookshelves and to consult it regularly.
    • Panels of experts representing the American Psychiatric Association (2000b) have provided a compendium of practice guidelines for numerous psychiatric disorders, including Major Depressive Disorder. The practice guidelines regarding pharmacotherapy for depression are empirically based, thorough, and helpful. The practice guidelines regarding psychosocial interventions for depression are also helpful. Some experts argue, however, that cognitive behavior therapy and interpersonal psychotherapy do not receive the full credit that these psychotherapies have earned through many randomized controlled trials (see Hollon & Shelton, 2001).
    • The cognitive behavior therapy of depression, developed by Beck, Rush, Shaw, and Emery, and their numerous colleagues, is clearly described in their classic treatment manual (Beck et al., 1979). This influential book includes case examples, discussion of practical issues, and clinical guidelines.
    • Gilbert (2000) provided a clear overview of psychotherapy for depression. This book includes brief literature reviews, how-to examples, and clinical guidelines. The therapeutic emphasis is an eclectic blend of cognitive behavior therapy, interpersonal psychotherapy, and biological/evolutionary perspectives.
    • Jacobs (1999) presented a series of reviews on evaluating and treating suicidal patients. This edited book includes helpful literature reviews, clinical examples, and how-to advice.
    • Jamison (1999) provided a well-written overview of what is currently known about suicide. This book is appropriate for both practitioners and laypersons.
    • The interpersonal psychotherapy of depression, developed by Klerman, Weissman, Rounsaville, and Chevron, and their numerous colleagues, is clearly described in their classic treatment manual (Klerman et al., 1984). This influential book includes case examples, how-to suggestions, and clinical guidelines.
    • Koocher and Keith-Spiegel (1998) provided a well-written review of the ethical issues in psychotherapy (and related instructional and research settings). This book includes helpful case examples, literature reviews, and summary guidelines.
    • Markowitz (1998) provided a contemporary treatment manual for interpersonal psychotherapy of chronic depression (Dysthymic Disorder; see also McCullough, 2000). The numerous how-to suggestions and clinical guidelines in this book may be generalized to other serious forms of depression, such as Major Depressive Disorder.
    • Persons et al. (2001) provided a contemporary discussion of cognitive behavior therapy for depression, with many case examples, how-to suggestions, and clinical guidelines (see also Persons, 1989). In addition, this book includes a very detailed case study in Chapter 7 that illustrates an insightful perspective on the dysfunctional thoughts and ineffective behaviors that are evidenced by many depressed patients.

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    Author Index