Depression Research Program Psychotherapy for treatmentresistant depression: What makes it complex? Brin Grenyer grenyer@uow.edu.au Wollongong Team Brin F.S. Grenyer Karin Sandquist Kate Lewis Marianne Bourke Kye McCarthy Andreas Comninos Trevor Crowe Samantha Reis Frank Deane Peter Caputi Collaborators Jacques Barber (University of Pennsylvania) Robert DeRubeis (University of Pennsylvania) Robert King (University of Queensland) David Kavanagh (Queensland University of Technology) Robert Schweitzer (Queensland University of Technology) Roger Mulder (University of Otago) Some remarkable Psychotherapists involved in depression trials Jane Martin Tania Cartmill Carla Walton Michelle Greene Lisa Parker Trevor Crowe David StQuintin Keiren Hynes Merryn Tendys Suzy Green Victoria Bel Gina Parker Wollongong approach High quality psychotherapy not working for some patients Patients struggle to change Process-Outcome studies needed What can be done to help treatments? Focus on change across time Trajectories of change Patient factors Patient-therapist interactional patterns 1
Wollongong Chronic Depression Studies Samples collected from multiple on-going studies at Northfields Clinic What patients look like an example N=70 sample Age 45.14 (21-70) 43 females (61%) Chronicity of depression 14.1 years (1-50), median 10 years 80% previous psychotherapy 75% previous psychiatric medication, 91% current medications 93% Axis IV current psychosocial problems GAF = 50 (31-65) Education, mean ±SD, y 14.1 ±4 Employed % 35.0 Current relationship > 6 months, % 57.5 History of psychiatric hospitalization % 37.2 Concurrent antidepressant use % (% SSRI) 74.4 (57) Antidepressant treatment resistant % 61.9 Comorbid dysthymia % 71.8 Comorbid anxiety disorders % 51.2 Comorbid nicotine abuse % 25.5 Cluster A personality disorder % 9.2 Cluster B personality disorder % 22.1 Cluster C personality disorder % 42.1 Wollongong Chronic Depression Studies Patients characterised as chronic, with high rates of treatment-resistance to anti-depressant medications (current/previous medications) Chronic course, long history of depression, comorbid problems in interpersonal and personality functioning All were enrolled into 4 months of a manualised interpersonal-dynamic psychotherapy (Luborsky, 1984) 10 doctoral level clinical psychologists Treatment Outcomes Average rating of improvement 7/10 (5-10) Average rating of success 7/10 (3-9) Average rating of satisfaction 7/10 (3-10) 17% drop-out HRSD intake = 23.24 (S.D. = 4.54) HRSD termination = 10.85 (S.D. = 6.36) ES = 2.73 Remitted (7 or less on HRSD) = 32% 2
How they improved Certain patients responded suddenly (or early) to psychotherapy Results in more positive outcomes, including higher rates of recovery. Is not a placebo effect Adults (22 Studies) Adolescents (2 Studies) Across range of therapies (23 Studies) Clinical trials (20 Studies) Routine community settings (3 Studies) Depression (20 Studies) Across range of disorders (6 Studies) Sudden gains: Reduction of 7 BDI points in a between-session interval (Tang & DeRubeis, 1999) Can occur anytime across treatment Note the larger improvement than in later sessions Measuring rapid responders. Early Rapid Responders Early rapid response (ERR) = reduction of at least 50% of intake BDI score by the Session 6. 37% had a rapid response The mean BDI magnitude of the symptom reductions achieved by ERR patients at Session 6 was 18.61 (SD = 7.60), which accounted for an average 96.13% (18.61/19.48) of their entire symptom reduction By comparison, non-err patients had achieved an average symptom reduction of only 4.59 BDI points, or 18% (4.59/25.85), by this session. The relative benefit that accrued to ERR patients by the sixth session was maintained through to the end of treatment. 3
Pre-existing Interpersonal Factors appear to decelerate response to treatment (Comninos & Grenyer, 2007) Non-ERRs - Greater Social Isolation (Mastery Scale; Grenyer, 2002 ) - Greater Fear of Intimacy (RQ; Bartholomew & Horowitz, 1991) - A more domineering Interpersonal Style (IIP; Alden et al., 1990) Gender, age, pre-existing diagnostic or symptom severity, Session 3 and 16 working alliance (WAI; Horvath & Greenberg, 1989) an overall Therapist effect failed to differentiate So why does this phenomenon occur? Hostility & withdrawal reduces therapy effectiveness (Binder & Strupp, 1997; Safran et al., 2000, 2002; Samstag et al., 2002, 2004) Adult Attachment Bartholomew & Horowitz (1991) Attachment styles in adulthood Working Models Enduring cognitive representations of relationship experiences Positive or negative Self and other 4 adult attachment styles... Attachment models of self and other + OTHER _ + SELF _ Secure Preoccupied + + - + Dismissive Fearful + - - - Attachment classification in Chronic Depression Sample 86% of the sample were insecurely attached Largest proportion had both a negative view of self and a negative view of others 4
Mean attachment scores for Remitted Vs Depressed Clients Mean attachment classification for remitted and non-remitted participants Secure Fearful Preoccupied Dismissive Remitted (< =7 on HRSD) 42.50 48.89 30.94 28.11 Depressed (> 7 on HRSD) 37.60 67.87** 52.28** 27.73 ** p <.01 80 60 40 20 Remitted Depressed 0 Secure Fearful Preoccupied Dismissing Attachment Style Attachment and IIP Fearful attachment and Depression Blatt (1976, 1995) model of depressive experiences Anaclitic depression = interpersonal dependency Introjective depression = self-criticism Measured using the Depressive Experiences Questionnaire 5
What does fearful attachment mean? Sandquist and Grenyer 2009 N=370 Sample N=245 Reis and Grenyer 2002 Self-Criticism 6 key items 1) Often I find that I do not live according to my standards or ideals Effect of self-criticism on treatment outcome 2) There is a significant gap between who I am today and who I would like to be 3) I tend not to be content with what I have 4) I find it hard to accept my weaknesses 5) I have a tendency to be very self-critical 6) I compare myself often to standards or goals 6
Further work investigating the in-session process in the Wollongong chronic depressed Patients N = 20 (10 ERRs / 10 nerrs) Gender: equal across ERRs and nerrs AGE: No sig. differences BDI: sig from week 6 (incl. 12 mth Follow up) RQ: nerrs sig. more fearful & less secure Mastery: ERRs sig. higher in mastery The Psychotherapy Process Q-Set (PQS; Jones, 1985; 1990) E.g. The P's behaviour during the hour is reformulated by the T in a way not explicitly recognized previously PQS Results: What we know about these patients past: Origin of self-criticism: early parent-child interactions. Blatt and Homann (1992) proposed that self-criticism is related to parental control, intrusion, and inconsistent expressions of affection. Parental expression of low warmth (or care) and high control (or overprotection) appears to be important in the development of a self-critical style (Amitay, Mongrain, & Fazaa, 2008; Koestner, Zuroff, & Powers, 1991; McCranie & Bass, 1984. 7
How these patients present in psychotherapy Do not respond rapidly to dose of psychotherapy no change by session 6 or 16 Fearful, insecure attachment problems - negative model of others and self, uncomfortable with intimacy Interpersonally cold, avoidant and vindictive Provocative, domineering, negative, ambivalent (about dependence) and hostile towards therapist High shame, highly introjective and self-critical What do psychotherapists need to work with this client group? To go to Robert DeRubeis workshop on Wednesday Time more sessions 6 months not enough Patience and counter-transference management Understand and work with ambivalence and hostility in relationship, understand shame and guilt Focus on key narratives, particularly with parents Look to build positive interpersonal experiences inside and outside therapy Paradox, humour and dialogue to undo self-critical cognition triggers and toxic inter- and intra-personal fears and core conflictual relationships 8