Psychology Essay 代写:Psychotherapies In The Treatment Of Depression

The model of Beck (Beck, Rush, & Shaw, 1979) is the most searched in cognitive psychotherapy. Depressed patients would express "negative automatic thoughts" about themselves, their world and their future. Beck noted that these negative cognitions were maintained by means of an ambiguous model of how the information is processed, thus creating a vicious circle, in which the "depressed affection" increased the intensity of the negative thoughts that, by their turn, increased the affective disorders, cognitive and behavioural. The negative cognitions would arise from the activation of the underlying dysfunctional beliefs, learned, created and maintained, unconsciously, from childhood. The essential feature of this therapy is the use of a collaborative approach, to "test" the patient's distorted hypotheses. The acute symptoms of the depression are challenged by using verbal and behavioural techniques (identification, opposition and challenging of the negative cognitions). Later on, the target of the interventions is to challenge the dysfunctional beliefs more entrenched and consequently try to reduce the vulnerability of the patient to future episodes. The addition of behavioural techniques to the cognitive strategies often causes the association of both models which is known by cognitive-behavioural psychotherapy (CBT) for depression.

Psychology Essay 代写:Psychotherapies In The Treatment Of Depression

传统的Â简短的心理动力学心理治疗（西佛尼奥斯，1972）（马兰，1976）（Luborsky，原则的精神分析心理治疗：手动表达支持治疗，2004）（她和粘结剂，2004）共有抑郁症的概念作为一种自适应的失败从心灵内部的冲突造成的，而最近，社会关系失调。Â代替聚焦到抑郁症状，自己，这些方法旨在利用治疗关系的探讨和澄清这些早熟的冲突问题，主要是那些剥夺相关，情感亲近和亲密。Â这些心理治疗的份额至少以下一个或多个特征的各种格式：围绕他们ES的损失和分离，积极性高的患者选择，相对强调移情的解释和治疗的总是即将终止的愤怒和后悔的阐述。

The traditional brief psychodynamic psychotherapies (Sifneos, 1972) (Malan, 1976) (Luborsky, Principles of psychoanalytic psychotherapy: a manual for supportive-expressive treatment, 2004) (Strupp & Binder, 2004) have in common the concept of depression as an adaptive failure resulting from intra-psychic conflicts, and more recently, social-relational disorders. Instead of focus into the depressive symptoms, themselves, these methodologies aim to use the therapeutic relationship to investigate and clarify these precocious conflicts, mainly those related to problems of deprivation, emotional closeness and intimacy. The various formats of these psychotherapies share at least one or more of the following characteristics: centred on themes of loss and separation, selection of highly motivated patients, relative emphasis on the transferential interpretations and the elaboration of anger and regret by the always imminent termination of the therapy.

最近，一个手册描述表达支持（SE）的心理发展（卢博斯基，马克，孔，抑郁症的心理治疗：支持表现动态的时间限制版，2005），明显不同于传统心理治疗常见的图像。Â除了简短的（16至20节），治疗师似乎一个更积极的角色，移情的关注更多的是有限的，它更是集中在患者的人际关系的不适应的过程。Â根据Mary Beth Connolly的话（康诺利，击克里斯托夫，与shappel，1998）”虽然精神分析是治疗关系中的不良主题转移系统解释，硒治疗的重点是探索转移的患者的治疗以外的关系。

More recently, a manual describing the Supportive-Expressive (SE) psychotherapy was developed (Luborsky, Mark, & Hole, Supportive-expressive dynamic psychotherapy for depression: a time limited version, 2005) which differs considerably from the common image of traditional psychotherapy. Besides being brief (16 to 20 sessions), the therapist seems to have a more active role, the transferential focus is more limited, and it is more centred in the maladaptive process of the patient's interpersonal relationships. According to the words of Mary Beth Connolly (Connoly, Crits-Christoph, & Shappel, 1998) "Although psychoanalysis involves a systematic interpretation of the transference of maladaptive themes in the therapeutic relationship, SE treatment focuses on the exploration of transference in patients' relationships outside of therapy."

Psychology Essay 代写:Psychotherapies In The Treatment Of Depression

Interpersonal Psychotherapy (IPT)

The interpersonal psychotherapy (IPT) is also time-limited treatment, designed specifically to treat the acute phase of major depression, unipolar, non-psychotic, which was developed and tested through randomized clinical trials by Gerald Klerman and colleagues, who published his manual in 1984 (Klerman GL, Weissman MM, Rousanville BJ, & Chevron E, 1984). Based mainly on the ideas of interpersonal school of psychoanalysis of Sullivan (Sullivan, 1956), studies on bereavement of Freud (Freud, 1914-1916), and Bowlby's Attachment Theory (Bowlby, 1969), IPT does not consider the interpersonal factors as a cause of depression. It conceptualizes depression as a complex and multi-determined phenomenon, which should be the object of scientific research in various fields of knowledge (Weismann, 2006) (Weissman MM & Markowitz JC, 1998).  However, IPT assumes that the depression occurs in a social and interpersonal context and its onset, treatment's response and prognosis are influenced by the interpersonal relationships of the depressed patient with his/her social environment. IPT uses the connection between the current interpersonal phenomena and the depressive symptoms as a treatment focus, and deals, generally, with most current interpersonal relationships rather than the past ones, helping the patient to more adequately handle the interpersonal problems that are associated with the onset or maintenance of the depressive episode, whatever be its duration or nature (Markowitz JC, 1998) (Weissman, 1994).

The objective of the IPT is to concentrate the focus of the treatment in the source of the stress. There are four sources of stress often found in depressed patients, well defined by IPT: 1. mourning (bereavement), 2. Interpersonal disputes (with partner, children, other family members, friends, co-workers), 3. Role changes (new job, leaving home, completion of studies, moving house, divorce, economic changes or other changing situation) and 4. Interpersonal deficits (loneliness, social isolation).

These areas may be combined, but preferably one, or at most two, should be chosen as the focus, prioritizing those most directly related to the onset of the current depressive episode. The IPT is structured to generally be held in 16 sessions, with weekly frequency.

Interpersonal Therapy Maintenance (IPT-M)

Depression is a disease that tends to be recurrent. As a result, maintenance treatments are intended to prevent recurrences, currently have grown greatly in importance. The maintenance psychotherapeutic treatment is important as an alternative to pharmacotherapy in patients to whom medication is not indicated (e.g. during pregnancy), in patients who do not tolerate it (10-15%), in patients which responds only partially (15 - 25%) or those who do not accept take it (5-10%) (Weissman, 1994) (Frank, Kupfer, & Wagner, 1991). Moreover, many patients shows a symptomatically improvement of the depression, but the social and interpersonal problems associated may persist between episodes, which can trigger recurrences (Keller, Lavori, & Mueller, 1992).

The IPT-M is a type of maintenance treatment that stems from the idea that the depressed patient, in addition to biological vulnerability and personality, has a psychosocial and interpersonal context which predisposes to recurrence. The IPT-M was designed to sustain the recovery and to reduce the vulnerability to future episodes. While IPT is concerned with modifying the psychosocial context associated with depressive episode, IPT-M seeks to enhance the psychosocial context of remission status, working with the same presupposition of "preventive medicine" to help the patient or to deal with the issues that persisted after recovery, or more often in the resolution of those issues who came up with the recovery (Frank, Kupfer, & Perel, Early recurrence in unipolar depression, 1989). Thus, the therapist who performs IPT-M should be alert to the early signs of interpersonal problems that are similar to those identified as having contributed to previous depressive episodes.

The IPT-M has been applied in a frequency of once a month, although the optimal frequency for the psychotherapy of maintenance is not yet completely defined.Â

Results of individual studies on the effectiveness of psychotherapy

There are four major studies conducted in order to test the effectiveness of psychotherapy, of which I will make a brief summary of the first experiment, once it is beyond the scope of this work to discuss in depth the findings of all the experiments, and the first is enough for us to draw conclusions regarding the efficacy of IPT when compared to other therapies. Three of the studies examined primarily the treatments in the acute phases of depression (follow up for 12 to 18 months), and the remaining one, followed 230 patients for 3 to 5 years, with maintenance treatments. The first three are: a) the Program for Research on the NIMH Treatment of Depression (Elkin, Shea, & W., 1989) (Elkin, The NIMH treatment of depression collaborative program: where we began and where we are, 1994); b) Study of the University of Minnesota for Cognitive Psychotherapy and Pharmacotherapy (Hollon, Du Rubels, & Evans, 1992), c) the second project of psychotherapy of Sheffield (Shapiro, Barkham, & Ress, 1994). The fourth study is the Long-Term Maintenance's Psychotherapy of the University of Pittsburgh (Frank, Kupfer, & Perel, 1990), (Frank, Kupfer, & Wagner, Efficacy of Interpersonal psychotherapy as a maintenance treatment of recurrent depression: contributing factors, 1991), (Kupfer, Frank, & Perel, 1992).

Acute treatment

Collaborative study for the treatment of depression NIMH

The National Institute of Mental Health (NIMH) conducted a collaborative research program within three different centres, it represented the broadest and well-conducted methodological evaluation of two different techniques to treat depression (Elkin, The NIMH treatment of depression collaborative program: where we began and where we are, 1994) (Elkin, Shea, & W., National Institute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments, 1989), and that become a benchmark for all other studies that followed. It was selected 250 patients, of which 239 entered the study, and randomly assigned to four treatment conditions for 16 weeks: interpersonal psychotherapy, cognitive-behavioural therapy, imipramine (a tricyclic antidepressant) plus clinical management (IMI+CM) (average 185 mg/day IMI after the second week of treatment) and placebo plus clinical management (CM+PLA).

There were a consistent order of responses, with IMI + MC having the best result, PLA + MC the worst, and the two forms of psychotherapy an intermediate result, but closer to the results obtained by IMI + MC. When the analysis was performed with the universe of patients, regardless of the initial severity of illness, there was no evidence of greater effectiveness of one over the other psychotherapies, and even the standard treatment (IMI+MC) in relation to the psychotherapies. When compared with PLA+MC, there was limited evidence of improved performance of IPT and no evidence to the CBT. A secondary analysis was then performed, dividing the total sample by the severity of depressive symptoms and the functioning impairment (Elkin, The NIMH treatment of depression collaborative program: where we began and where we are, 1994). This analysis helped to understand the absence of significant differences in the original analysis. Significant differences between the types of therapies were obtained only for the subgroup of patients more severely depressed and with greater impairment of social functioning. With these patients, there was some evidence of the effectiveness of IPT and strong evidence of the effectiveness of IMI+MC.

In contrast, there were no differences between the mean scores of different treatments, including PLA+MC, for patients less depressed and with less functional impairment. The interpretation of the latter finding was interesting: it was, apparently, not due to poor performance of the IPT, the CBT or imipramine, but the good results of the patients in the PLA+MC (at least in the subsample of moderately depressed patients). One must remember that the MC included nonspecific elements of reassurance, clarification about the symptoms and instillation of the hope to improve, which would qualify as a form of minimal supportive psychotherapy  (Elkin, The NIMH treatment of depression collaborative program: where we began and where we are, 1994).

It is important to point out that the research did not intend to test the efficacy of imipramine, already exhaustively tested. It was only used exactly for this reason, as a standard reference treatment. Therefore, the results obtained with the tested psychotherapies should be properly valued, because they were not only compared with a combined treatment, (IMI+MC = IMI+ Minimum supportive psychotherapy), but also with one of the strictest controls (placebo + minimum psychotherapeutic support). In a sense, one might even consider that the differences observed between PLA+MC and the two psychotherapies might reflect, in fact, differences between the nonspecific elements of the control condition and more specific the technical interventions of IPT and the CBT, only more apparent in the more severe depressions (Roth & Fonagy, 1996).

Conclusion

What can be said about the treatment of depression through psychotherapy today is that there is already strong evidence about its effectiveness, something that 10 years ago seemed to depend solely on intuitive experience that psychotherapists and psychiatrists derived from the day- to-day experience with their patients.

There are currently no clear answers about what makes psychotherapy effective in depression. Maybe it's more what they have in common rather than what sets them apart: in all it offers the patient an understandable model of his/her depression, each therapy has a well-designed and logical arguments, and are highly structured. The schedules for changes are made ​​ in logical sequences; they encourage the patients the autonomous and independent to use of their capacities and reinforce to the patient, the feeling that the changes that occurred were of their responsibility (Scott, 1995).

There is also the idea that the relational or interactional aspects involved in these psychotherapies are the most important (Alberniz & Holmes, 1996), their ability to provide hope, to offer a reliable and trustworthy relationship, and provide an emotional space where the patient can feel his/her depressive anxieties understood and safeguarded - aside of these cognitive-rational models, or conceptual schemes, which allow the patient to organize the suffering.

We focused on the interpersonal psychotherapy, not because it has any superiority over others, but because it is the most flexible and integrative model of psychotherapy for depression: it can be administered in their 'pure' form whenever it is possible, it can be enriched by the psychodynamic comprehension in cases involving intense anxieties of loss, grief and separation, it can transform and extend itself into a long-term dynamic psychotherapy when is needed to deal with associated personality disorders, it can adopt cognitive-behavioural techniques to address social skills deficits in cases of social isolation, or join a spouse in a marital therapy, if it is needed. It is also the model that less competes with the medication when it is indicated (in bipolar depression, melancholic or psychotic (Klerman GL, Weissman MM, Rousanville BJ, & Chevron E, 1984).

Either way, it is possible to treat depression with a broader and richer approach, suggesting that the relationship between "mind" and "brain" in this phenomenological area of depression is one of the most exciting developments of the turn of the century, and very promising for the new century.