Depression most effectiveness in the treatment of people

  

Depression
is a broad and heterogeneous?diagnosis?12-?Appendix1?

Worldwide,
depression is?the predominant mental health problem.?In any year
the?percentage?of people who suffer from depression range between 8%?and
12%?12??? Prevalence rates have consistently been found to be between 1.5 and
2.5 times higher in women than men and have also been fairly stable in the age
range of 18 to 64 years 11? Depression tends to recur, with over
three-quarters?of all people who recover from  
one episode going on to have at least one?more8. It has been recognized
that effectively treating depression when it first presents is important to
avoid?recurrence?as many cases become chronic, lasting over two years in one
third of individuals?without?treatment16.?

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In
England mental health expenditure including depression are projected to rise by
17% to 1.45 million by 2026 compared to 1.24 in 200713-APPENDIX?4?.?These
figures are an estimation of the total costs of depression included NHS
services, supported?accommodation, impatient care, social services, prescribed
drugs and lost employment in terms of?absenteeism13??

The
annual service costs to treat people with depression in 2007 were estimated to
be £1.7 billion,?while lost employment increased this total?to?7.5?billion?13.?

These figures were estimated to?be?3 billion?and??12.2?billion respectively by?2026.13?Certainly, this illness imposes a
significant cost not only on a societal level but also on a personal ones, as
it is a burden on people and their?carers?and family?members.?Depressed people have
the?perception (usually mistakenly) of being alone in the world and not having
anyone who really cares about them,?feeling?like a?burden on others and that it?would
be better if they were dead,?leading?to?suicide?which?is the?main cause of
death, both in the UK and?worldwide.??

Northern
Ireland?shows?higher suicide rates than other UK nations?18-APPENDIX?1 The?suicide
rate in?Northern Ireland?has increased dramatically over the last 30 years –
the male rate has increased by 82% in this time.?18-APPENDIX 2 

Psychological
treatments for depressive illnesses currently claiming most effectiveness in
the treatment of people are CBT and Antidepressant medication. Both are
recommended by the National Institute for Health and Care Excellence.12

Antidepressant
medication is considered the standard treatment for depression and it is the
most common used especially for major depression. In the decade 1989-1999
antidepressant prescribing in?Northern?Ireland?has increased over
five-fold.?As?C.B.Kelly?showed, increased antidepressant prescribing was
associated with a reduction in suicide rate in the?30+?yo,?so it appears to be
an effective strategy for reducing?suicide.4?However, antidepressant
medication is not the?preferred treatment for many individual who consider the
side effects that often accompany their use and relapsed risk on ADM
discontinuation and cognitive therapy is the most widely studied with positive
outcomes documenting its efficacy.?9?

Cognitive
therapy can be defined as a set of operation’s? focused on a patient’s
cognitions (verbal or pictorial) and on the premises, assumptions and attitudes
underlying these cognitions. Idiosyncratic cognition are also
called,?because?they are peculiar of a given individual or a psychological
state and they reflect a faulty appraisal, going from mild distortion to?a
complete misinterpretation. The idiosyncratic?cognition?contains an elaborate
idea compressed into a very short period of time and may be very rapid: they
are experienced as if they are automatic; they also seem to have an involuntary
quality. Training the client to recognize these cognitions or “automatic
thoughts” is one of the main cognitive?techniques,?making?a distinction
between thought and external reality, between hypothesis and fact, because
patient even after have identified idiosyncratic ideas might find difficult
examining these ideas objectively.?Simply a patient needs to be reminded that
thoughts are not equivalent to external reality because even though a
patient?think?something it doesn’t mean that is true. Once they have learnt to
objectify reality testing is the next stage?and?to make appropriate?corrections.1

However,
CBT is a complex therapy with high requirement, and a psychological alternative
for depression is Behavioral Activation.

Behavioral?Activation?is?a
short term structured treatment for depression that serve the ultimate goal of
activating patients in specific ways that will rice rewarding experiences in
their lives. All of the techniques used in BA aim to increase activation and
engagement in one’s world.??

Often
reported events occurred in life such as changes, on-going daily?hassles,
financial?losses?or burdens,?losses?of relationship or jobs, and when people’s
lives are low in positive reinforcement or high in punishment, depression is
more likely. People can learn to pull back from life, stop engaging to avoid a
punishing environment to minimize the impact of emotional disruption which can
keep this person stuck in depression. Under such conditions it make sense that
the?individual?engage in?passive?behaviors?such as excessive sleeping or
watching television or drinking or being caught in endless ruminative thinking
on?distress,?escape?and avoidance?not testing out coping strategies which may
keep people stuck over time, feeling down pulling away from one’s world, doing
less and as a consequence feeling more down.?

Both
client and therapist develop a comprehensive?conceptualization of the
case?through the? understanding of behaviors that have been reinforced in the
past and those that were not reinforced or were punished,?thus?recognizing behavior
patterns?linked?to?depression.?BA concentrates on processes that inhibit
activation such us avoidance and escape,?establishing?regularized?routines and behavioral
strategies for targeting rumination with a focus on the function of ruminative
thoughts toward direct, immediate experience.?

BA
therapist uses?activity?monitoring?charts to understand?clients’?behavior and
the link between?behaviors?and mood. A core part of BA is to begin to act even
when mood and motivation are?low?acting?from the outside to experiment with
acting according to a?goal,?rather?than waiting for one’s mood to improve prior
to getting engaged,?basically?from the outside-in instead of the inside-in. The
focus is to increase the likelihood of finding opportunities that serve
as?an?antidepressant so as they can be naturally?reinforced, before deciding if
a?behavior is worth continuing,?where?the empirical problem-solving approach of
the?therapist?acting as a coach?should?encourage the client to test out behavior
and observe the result more than once just like a laboratory?experiment?Making
and keeping records is?an essential part of?care?.It?is expected that all
members of BABCP approach their work with the aim of resolving problems and
promoting the well-being of service users and will endeavour to use their
ability and skills to service users’ best advantage???Those?strategies can
be?accomplished?by creating detailed schedule with task broken down into its
extremely small elements, or component? behaviors. ?A BA therapist has to
be?mindful?and?notice?when?the?client is doing?too much, too soon which can
cause discouragement and?despair?and in case plans and activities do not
provide the desired outcome?it is important that the therapist maintain a
hopeful and a positive attitude in front of client’s discouragement,?suggesting?a
different approach and remaining curious.??Many depressed clients might
undervalue their capabilities to face problems, looking at them as if they are
out of?their? control?so the therapist should guide the process of change and
make?suggestions?when necessary, give directions and plan
strategies,?maintaining the right distance to allow client to become
more?confident??and?independent?instead of solving the problem for them. To
make the most out of the 45/50 minutes session therapy it is essential to?structure?therapy
session so that the treatment stays on track setting an agenda during the first
5/10 minutes Since it is?important? to?assess?the client’s problem and present
a treatment plan to the client since the beginning of the?therapy,??the
therapist might need to control the agenda more than the client, and to be as
effective as possible a good?therapist? will?continuously encourage client’s
activation asking to add any important activity to the agenda.????

The
heart of the BA approach is activity, so homework which can be called
“between –session?assignment” to avoid that the word
homework?which?could be associated with something?aversive.?With?depressed
clients engage in activity in between session is not easy to do,?there?is why
activities have to be planned in collaboration with the client and to maximize
success the task must be kept realistic and be as detailed as possible. A
potential pitfall for a therapist is failing to review the assignments between
session?extinguishing?homework?compliance?if?it is?not rewarded, especially
because?homework?offer?a great opportunity to discuss?raising?the intensity and
frequency of the activity for the?following?week in case of success.??Vice
versa?in case of failures in completing the?assignments,?both clients and
therapist should conduct an analysis of the problems that hindered
the?accomplishment?of the task. Of course, BA requires creativity
and?persistence?troubleshooting actual hinders when they will arise. In order
to minimize the likelihood of failures or that the same problem will?occur?in
the future,?therapist should anticipate barriers to client’s completing
activity when promoting?activation.4?Cognitive?therapy and?behavioral?activation?have
much in?common, although,?CT is rooted more in cognitive theory?and??BA?is
primarily based on learning theory.??

The?overt
symptom or?behavior?problem?is the?main target?of?both BA and
CT?therapists’?techniques.?

However,
the target differs somewhat. The?behavior?therapist focuses more on the
evident?behavior?for example the maladaptive avoidance responses. The cognitive
therapist focuses more on the ideational content involved in the symptom, the
irrational inferences and premises. Within a theoretical framework borrowed
from concepts of classical and operant conditioning and from the
field?of?psychological?learning theory behavior therapist conceptualized
disorders of behavior and procedures for their amelioration. The attention is
on observable?behavior, in fact,?the majority of the published writings?tend?to
eschew inferred or hypothesized psychological states that cannot be directly
measured and observed.?”Cognitive therapist?are?more willing to use these
inferred psychological states, collectively called?” cognitions” as
clinical data”?1?

IN
CT?behavioral?techniques aim to change how people think as belief change is
considered to be?fundamental?for long term improvement in emotional and behavioral
problems but, in?BA?activity is recommended to bring the client into contact
with positive reinforcement that will increase antidepressant activity. CT and
BA both encourage patients to engage in?behavioural?experiments, but, in BA the
patient is requested?to engage in experiments?to evaluate?the results on?mood
and the impact on?goals. In CT clients are?requested?to engage
in?experiments?to test their depressive?expectations?and?assumptions,??in?spite
of the differences, the development of CT?serves?as a foundation for the
development of the current model of BA. In addition to the similarities
mentioned above, BA adopts an emphasis on structuring sessions that
is?characteristic?on?CT.4?

Autonomous?and?accountable?practitioners??need?to
make informed and reasonable decision?to?meet?the?BABCP?standards.?This?might?include?getting?advice?and
support from?education?providers,?employers,?clinical?supervisor,?colleagues?and?other?people?to?

protect?the?wellbeing?of
service users at all times. BABCP recognize the valuable role professional
bodies play in representing and promoting the interests of their members. This
often includes advises and guidance about good practice, which include not
allowing personal views or beliefs about a service users’ sex,?age,?color,
race,?disability,?sexuality, social or?economic?status,?lifestyle, culture,
religion to affect the way?of?treating?or?advising?them. Also, therapists with
due recognition of the value and dignity of every human being, do not do
anything or fail  to do anything, or
allow someone else to do anything that will put the health or safety of a
service user or others in danger. This includes both therapist actions and
those of other people. Therapists are responsible for conduct of practice, care
or advice and any failure to act. Protecting the rights of children and
vulnerable adults at risk following national and local policies. 17

The?university
of Washington conducted a?clinical trial?to rigorously test the contemporary
model of BA?by focusing on?2 groups of interest: the less and more severely
depressed patients.?The aim was?to?address?the earlier component analysis study
major’s limitations.

BA?was
compared to CBT and to antidepressant medication.??Past?research?showed
that?moderate?to severe major depression was not treated
effectively?with?CT.?Treatment?guidelines suggested that,
even?though?less?severely depressed patients?could?benefit
from?psychotherapy,?moderately to severely depressed?patients?to be
successfully treated?need? medication?(American Psychiatric Association
Workgroup on Major Depressive Disorder 2000).Thus, the study compared?BA?to CT
and?medication?(paroxetine).??

The?analysis?focused
on how the?treatments?compared?between?the less and more?severely depressed
patients.??

The
results of those?who received BA were comparable to those who received
medication, even the severely depressed patients.?Moreover, BA retained a
greater percentage in treatment than those assigned to pharmacotherapy?and
it?might?offer?higher?protection against relapse compared to antidepressant
medication?treatment?completed, with no medical risk of psychotropic medication.??Also,?BA?was
more efficacious than CT in the acute treatment of more severely depressed
patients.?Over a 2 year follow up was evidenced that the benefits of BA were as
enduring as those of CT?in?preventing relapse or future episode of depression.
Participants relapsed at?greater rates?when withdrawn from their medication
than participants who had prior BA or?CT.9?

Although
CBT is known to be effective, access is often restricted, with long
waiting?lists. Yet, until now, the UK’s National Institute for Health and
Clinical Excellence?12?has said there is insufficient evidence to recommend Behavioral
Activation as a first-line treatment in clinical guidelines, and has called for
more robust research to investigate the benefits. The Cost and Outcome of Behavioral
Activation versus Cognitive Behavioral Therapy for Depression (COBRA) trial,
one of the largest of its kind in the world, was designed to meet this need.?

It?was
found that for reducing depressive symptoms BA was not inferior to CBT and was
more cost-effective and affordable.?BA might offer higher protection against
relapse compared to antidepressant medication?treatment?completed, with no
medical risk of psychotropic?medication.16????

BA
has four significant advantages over CBT.?

 

In
fact CBT is limited by the?high?cost?of training as it is a
complex?therapy??that?need highly qualified practitioners that have to meet
BABCP standards to be able to practice CBT effectively and safely where their
skills determine the therapy effectiveness and?also?high?level skills need to
be learnt by?patients?whereas?BA??is relatively simple, meaning it can be
delivered by more junior staff with less?training?as the skills required
are?relatively?straightforward and?highly?structured?which may mean that can be
easier to disseminate thus creating a larger?workforce, making it a
cost-effective option. It is around 20 per cent cheaper than CBT, meaning it
could help ease current difficulties in accessing therapy, and could make it
more realistic to deliver for a wider range of countries worldwide. BA
encourages people to focus on meaningful activities driven by their own
personal values as a way of overcoming depression.?

Thirdly,
BA may?suits?specific individuals who do not?respond?to CBT?eg. The number of
populations who are not psychologically minded” ,?those with poor verbal
skills or do not respond to cognitive or other therapies.?studies?of BA have
included?people difficult to treat for
depression,?eg.?with?substance?dependence?and depression, depressed cancer
patients, dementia and depression thus applicable to a range of populations
commonly experienced in clinical practice.?14?

Whether?therapists?practice?BA
or CBT?it?is?essential?to?maintain?high?standards?of personal?conduct?and do
not do anything which might affect the public’s confidence in BABCP body.
Therapists?must act?within?the?limits?of?their?knowledge, skills
and?experience?and,?if?necessary,?refer?the?matter?to?other?therapists?at the
request of either party if the goals are not being met after a reasonable
period of time or if they later appear to be?inappropriate.??being always
responsible for the appropriateness of a decision to delegate a task and to be
able to justify any decision taken if asked to. For?referring?a service to
another practitioner, it is essential that the referral is appropriate in case
of question asked regarding the decision made, or if a referral is accepted
from another practitioner it is essential to fully understand the request, only
providing the appropriate treatment.  If
this is not the case, the referral must be discussed with the practitioner who
made the referral, and also the service user, before you begin any treatment or
provide any advice. Communication must be appropriate and effective with
service users co-operating, sharing your knowledge and expertise with other
practitioners. In the following assignment I will discuss how CBT might be
eclipsed by BA due to its complex cognitive techniques, which may be too cognitively
challenging for chronic substance users with cognitive?deficit.  Behavioural Activation Treatment for Depression
(BATD-R) is?an empirically supported treatment for depression that has shown
some efficacy among substance users of a residential rehabilitation in the context
of a controlled trials.  Among
the?depressed?groups with?substance?dependence,?who received the
BATD-R?intervention had significantly greater improvements in depression at
post-treatment.?A?subsequent trial compared the ?BATD-R with a time matched
control treatment (supportive counseling), and found that while both groups
showed a significant reduction in depressive symptoms on completion of
treatment, retention in drug treatment was significantly greater in the behavioral
activation?group.10?

In
conclusion I believe that ?the practical nature of BA and the relative
simplicity of delivery might be an attractive  
option for NHS services as?a?front line?treatment?for depression?and?my
findings?suggest?that?the access to psychological?therapy,?the?need for
costly?professional?training and?the?waiting times?could be reduced for health
services?despite the many obstacles.?? The acute treatment
of?depression?shouldn’t rely on new?psychotherapies?to reduce the burden of the
disease. Although,?the?need for a further reduction of this
disease?burden?is?very?high, so it is more important to?develop simpler and
more efficient way methods for?applying psychological?treatments.  This is vital as psychotherapies have not
been scaled up so much so to help?reduce the disease burden of mental disorders?less?than
half of?people,?with depressive disorders?in high- income?countries?receive?treatment,?in??middle?and?in
low-income?countries?this is much lower,?but?also??people?from ethnic
minorities.?people with lower socioeconomic status,?and older adults.?15?