Transcript Depression in Young People - Suicide Prevention Studies

Working with
Adolescents
Professor Graham Martin
Working with Adolescents (3)
• Therapeutic Alliance
• On doing therapy
• On prescribing
A South Australian Study
of Depressed Adolescents:
Therapy
There was no difference between those
who had Cognitive Behavioural
Therapy compared with those who
did not
Therapy
• No apparent or statistical
difference between the
psychotherapy subgroup
compared with the
psychotherapy + medication
subgroup
Prefrontal Cortex
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Attention span
Perseverance
Judgment
Impulse Control
Organisation
Problem Solving
Emotions
Empathy
Compassion
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
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
Therapeutic Alliance
• Set of Tasks
• Relationship Bond
• Toward a defined Goal
Bordin 1979
Joining as an Issue
If you don’t 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.
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
• Therapist’s personal qualities correlate highly with
Outcome
Luborsky et al, 1985
In a Nutshell
 You
have to like them!
Therapist Qualities
Better Outcomes from
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Engagement
High Credibility
Warm, empathic approach
Accepting stance
Liking the patient or family
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Predisposing Factors
Precipitating Events
Perpetuating Features
Prognostic Indicators
Preventive Opportunities
‘Socratic’ Questioning
(Journalism)
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Who?
What?
Where?
When?
How?
How much?
Why?
Why?
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Why this young person?
From this context?
With these features?
At this time?
• And, where do we start?
Is it the Young Person’s 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 another’s
projection?
– (cf Munchausen by Proxy)
The Family Context
Father
Sig. other
Mother
Self
Sibling
PARAMETERS OF FAMILY
FUNCTIONING
after Epstein & Bishop (MCMASTER)
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Roles
Problem Solving
Communication
Affective Involvement
Affective Responsiveness
Behaviour Control
General Functioning
Cognitive Behavioural Therapy
(CBT)
Psychoeducation
 from
RCT, educational materials play a
significant role in improvement in
depression
Robinson, Katon, Von Korff et al., 1997
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
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
Other assumptions
 Processing
of information is active & adaptive
 Individuals derive
meaning from their experiences
using information processing
 Belief
 New
systems are idiosyncratic
information is assimilated into existing belief
systems
Automatic Thoughts
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Specific, discrete essential words
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Shorthand distilled format
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Not a result of deliberation, reasoning, or reflection - “Just
happen”
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Not sequential as in goal directed thinking or problem solving
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Autonomous – patient does not need to make any effort to
generate & can have difficulty “switching off”
Beck
Core Beliefs
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Learned through childhood experiences
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2 broad categories – helplessness and ‘unlovability’
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Core dysfunctional beliefs latent during low stress periods
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Reactivated by negative experiences that resemble
conditions under which original beliefs were formed
Cognitive Distortions
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Overgeneralisation
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Dichotomous thinking
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Magnification
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Personalisation
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Disqualifying positives
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Jumping to conclusions
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Catastrophising
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Emotional Reasoning
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Shoulds & Oughts
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Labels
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
Research
Presence of high levels of depressive symptomatology in
children with negativistic attributional styles and presence
of internal, stable, global negative style:
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increases risks of further depression in adolescence
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suggests causal role of attributional style in development
of depression
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pessimistic attribution style predicts future increases in
depressive symptoms among adolescents irrespective of
negative life events
Spence et al., 2002
Research
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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
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
Major CBT strategies
• C-B strategies
– Identifying negative thoughts
– Questioning negative thoughts
– Behavioural experiments
• Preventative strategies
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Identifying assumptions
Challenging assumptions
Use of set-backs
Preparing for future
Initial Interview
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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
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
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:
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Establish rapport
Elicit hope
Give pt preliminary understanding of model
Get working agreement to test it in practice
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?
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
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 can’t do anything, a no lose
situation will learn something regardless
– Predicted difficulties
• Feedback from client
– Understanding ( summarise main points
– Reactions to session
On Prescribing
When to prescribe?
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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 child’s problem
When you don’t have the therapy skills
Alongside therapy
The Synapse
Electrical
pulse
Target
nerve
cell
Neurotransmitter
receptor
Electrica
l pulse
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
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
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
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
Tourette’s Syndrome
Hauser & Zesiewicz, 1995
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
SSRIs - Concurrent Use
 SSRIs
may substantially increase
TCA plasma levels, leading to
adverse effects.
 Scant literature to support
concurrent use.
Taylor, 1995
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
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
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
De Shazer
• Solution focused
• Very task focused
• Demands ‘Customer’ Status over ‘Visitor’
or ‘Complainant’
• Seeks ‘Exceptions’
Group Therapies
 Review
notes that treatments lack
specificity and focus on narrow range
of deficits
Beeferman & Orvaschel, 1994
 Dropouts participate
less
Oei & Kazmierczak, 1997
The Spectrum of Prevention
Mental Health Promotion
Rehabilitation
Maintenance
Standard treatment
Case identification
Indicated
Selective
Universal
after Patricia Mrazek and Robert Haggerty, 1994
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
Auseinet.com
Commonwealth documents
Research reports
Online Journal - AeJAMH