Seasonal Affective Disorder (SAD) or Winter Depression can be succesfully treated with bright light therapy. Across studies, 53% of cases of SAD remit with bright light therapy. This involves sitting in front of full-spectrum lights that mimic sunlight on a regular basis — typically for about 30 minutes to 60 minutes each morning. Sometimes one or two weeks is sufficient but some patients will need this for the whole season. This hampers compliance with this therapy, only 41% of patients continued regular light therapy, 59% discontinued light therapy due to ineffectiviness and inconvenience. More important is the prevention of the recurrence of this kind of depressive episodes over subsequent winter seasons.
Cognitive behavioral Therapy could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy
This conclusion was based on a 1 year follow-up study of two pilot studies. The first was an uncontrolled feasability study comparing a novel group CBT, light therapy and the combination of both. The second was the first controlled study comparing CBT, light therapy and the combination of both in 61 patients with SAD compared to a control group of waiting list patients.
The researchers pooled all available data from the naturalistic follow up during the subsequent winter season of participants who had not dropped out of the study.
Both CBT and CBT with light therapy did significantly better at follow up compared to light therapy alone. CBT treated participants &% had another depressive episode in the subsequent winter season, fo CBT and light therapy 5,5%, and for light therapy alone 37%.
Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy
Limitations of this study
It was a naturalistic follow up study, the treatment duing this follow up period varied very much. The participants in the waiting list group from the second trial were not assessed.
A randomized controlled trial with follow up is still needed to confirm these promising results.
Rohan, K., Roecklein, K., Lacy, T., & Vacek, P. (2009). Winter Depression Recurrence One Year After Cognitive-Behavioral Therapy, Light Therapy, or Combination Treatment Behavior Therapy, 40 (3), 225-238 DOI: 10.1016/j.beth.2008.06.004
Online Cognitive Behavioral Psychotherapy for Depression:
Pretrial assessment screening by telephone for in and exclusion criteria
A face to face appointment with one of the researchers to complete a computerized assessment: SCID and Beck Depression Inventory
Online CBT with a therapist online in real time
Patients were allocated to one therapist
Patients made their own appointments online
Sessions were secured by individual passwords
Patienst and therapists typed free text into the computer, with messages sent instantaneously; no other media or means of communication were used
So this is how you do online real time cognitive behavioral therapy. But does it work?
43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months, and 46 (42%) versus 26 (26%) at 8 months
Why is this important?
The use of conventional CBT for depression is declining, the use of antidepressants is increasing, many patients referred for psychotherapy never show up, and 505 of those who attending a first visit drop out by the fourth session. Face to face psychotherapy demands a large amount of time, motivation and is an expensive treatment.
New techniques such as telephone and Internet based therapies are more convenient for patients, better accessible and with lower costs. The level of live therapist contact is the strongest influence on costs. The Internet psychotherapy program mentioned above seems to be a good balance between high and non therapist contact. Between face-to-face contact and self help programs. Drop out is low and the treatment efficacious.
By increasing access and lowering costs, new com munication technologies could provoke some much-needed disruptive innovation in psychotherapy
What do you think?
Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial by David Kessler, Glyn Lewis, Surinder Kaur, Nicola Wiles, Michael King, Scott Weich, Debbie J Sharp, Ricardo Araya, Sandra Hollinghurst, Tim J Peters; The Lancet Vol 374 August 22, 2009. http://www.thelancet.com/
Psychotherapy training in residency has lost much of it’s importance due to the increasing interest for biological psychiatry and biological treatments. Especially those using long term psychotherapy haven’t supplied the answers for the growing demand for evidence based treatment. In the US the residency review committee has reduced the number of psychotherapy schools back to three: supportive-, cognitive-behavioral- and psychodynamic psychotherapy.
Your life before your eyes: What to expect from a past life regression reading. If you’ve tried everything to overcome these challenges and aren’t seeing improvements, you might want to consider past lives regression therapy. There are lots of benefits to this type of therapy. But, it can seem a bit scary to people who are unfamiliar with it. The Y model is based on three publications by two groups. Two reviews by authors from Harvard Medical School and one empirical study by a Dutch group.
This Y Model structure describes the core features, or factors, common to both CBT and psychodynamic psychotherapy and then describes those features that are particular to each school. The core features form the stem of the Y, while particular aspects of psychodynamic and cognitive-behavioral therapies form the branches of the Y.
The authors state that negotiating a therapeutic alliance is common to all therapies. But the way to achieve this is very different for different therapy forms. Nevertheless they encourage their model to teach the skills at the beginning combined with the underlying theoretical underpinnings that explain how a school of therapy works. Residents are also introduced to the differences between the
two major schools in a way that foreshadows the branches of the Y.
Teaching these common characteristics to residents first may help to decrease the confusion that often arises when residents are taught multiple therapeutic approaches as if each one requires very different basic assumptions.
Combining psychotherapy with medication and brief psychotherapy is also incorporated in the stem of the Y, since it is assumed that any school of therapy can modify its techniques and goals in relation to a limitation of time. The basics of supportive psychotherapy, one of the most difficult forms of psychotherapy is also educated during the stem of the Y but will be broadened during the teaching of the two branches: Cognitive behavioral therapy and psychodynamic therapy.
The authors next describe the discussions in the Commission on Psychotherapy by Psychiatrists (COPP). These discussions had to result in the differences between the psychodynamic and cognitive behavioral therapy as the heuristic elements located on the branches of the Y. These differences were based on the 7 core features of psychodynamic psychotherapy that differentiated it from CBT as described by the Harvard Medical school group. Members of the committee couldn’t decide whether the finding of repeating patterns in a patient’s life was considered a feature of psychodynamic therapy or CBT. The solution was to name it a core feature for both therapies, leaving 6 differences to be defined.
The therapies differed in:
Psychodynamic therapy focus more on affect and expression of emotion, they encourage the expression of feelings to expose unconscious issues. CBT uses these affects as an opportunity to identify automatic thoughts
Psychodynamic therapists explore the patient’s avoidance of topics and behaviors while in CBT it is a maladaptive coping style needed to be modified.
Psychodynamic therapy places more emphasis on past experiences than CBT, looking for unresolved past conflicts. CBT focusses on patients’ future experiences, patients are taught skills to use with future problems
Psychodynamic psychotherapists place more emphasis on the therapeutic relationship and the notion of transference in sessions than cognitive-behavioral therapists. In CBT the relationships is one of collaborators.
Psychodynamic therapists explore the patient’s wishes, dreams, and fantasies, which are seen as central opportunities for accessing the unconscious, while these are de-emphasized in CBT.
In CBT there is a focus on how the emotions and behavior of the patient is influenced by beliefs or thoughts about the world. In psychodynamic therapy the focus is on impulses, affects, conflicts, wishes and fantasies
CBT is more likely to assign homework as part of the treatment
Sessions during CBT are structured and use active guidance, discussions with the patient
CBT teaches skills to cope with symptoms much more than in psychodynamic psychotherapy.
CBT provides information about their ailment, therapy and symptoms more often than psychodynamic therapy
You can see a narrated PowerPoint presentation suitable for teaching an overview of the Y Model without charge on line at www.austenriggs.org in the Continuing Education section on the left margin of the home page. You will have to register first but that’s simple and easy.
I think this model is a deterioration of teaching psychotherapy to residents.
These differences between psychodynamic therapy and cognitive behavioral therapy. I don’t think that residents are often confused when they are taught multiple therapeutic approaches. I think we can improve the education of psychotherapy for residents when using modern insights of the different schools, loosing a lot of old theoretical education and using more active learning methods.
What I mean is that reading most of Freud’s work although very interesting does not contribute much to the understanding of psychodynamic psychotherapy. Active learning means e.g. the use of camera recordings.
The Y model is to simplistic obscuring the different frame works for different kind of therapies. Interpersonal therapy is lumped together with psychodynamic psychotherapy and family therapy is completely absent. For psychiatrists it is important to learn the differences between therapies, learn the indications for the different therapies. Psychiatrists are the ones to assign patients to suited forms of therapy and they should focus on the difficult forms of psychotherapy with the difficult to treat patients, for complex mental disorders. Our focus on teaching residents psychotherapy should be directed to learning them to indicate the right form of therapy and teach them the more difficult forms such as long term supportive psychodynamic psychotherapy for complex mental disorders.
Nevertheless I think the authors and those in the committees did a great job, it will improve the education of psychotherapy to psychiatric residents in the US but in The Netherlands the situation is different. The critique has not yet resulted in an almost disappearing education of psychotherapy to residents. Most patients are insured for most forms of psychotherapy. But we will have to come up with improvements for educating psychotherapy before it’s to late and we will also have to cope with faculty programs educating only 2 forms of psychotherapy.
Plakun, E., Sudak, D., & Goldberg, D. (2009). The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies Journal of Psychiatric Practice, 15 (1), 5-11 DOI: 10.1097/01.pra.0000344914.54082.eb
For depression several self help treatment options are available. In short mutual self help groups, cognitive behavioral therapy and problem solving therapy are the most important Mutual help groups provide limited but promising evidence that mutual help groups benefit people with three types of problems: chronic mental illness, depression/anxiety, and bereavement.
Cognitive behavioral therapy is very efficient as self help treatment, its structured format makes it very suitable for self-help purposes and it can be very efficacious for the treatment of depression. Problem solving therapy (PST) is another option for self help in depression. Recently, a new, generic, PST-based intervention for multiple mental health problems that could be applied through the Internet was developed.
What is Internet problem solving therapy?
The general idea of self-examination therapy is that subjects learn to regain control over their problems and lives by
determining what really matters to them
investing energy only in those problems that are related to what matters
thinking less negatively about the problems that are unrelated
accepting those situations that cannot be changed.
Self-examination therapy was exclusively designed to be a self-administered treatment and has been found to be effective in several studies in the United States [11-14]. In these studies, self-examination therapy was offered in book format, and it is not known whether it also works when given via the Internet.
How was this study done?
PST has a short duration of 5 weeks. CBT is an 8-week intervention, both can be administered on the Internet. These two forms of self help for depression were compared in a 3-arm randomized controlled trial to compare CBT, PST, and a waiting list group (WL). Patients had to have depressive symptoms (≥ 16 on the Center for Epidemiological Studies Depression scale). CBT and PST consisted of eight and five weekly lessons respectively. Participants were supported by email. Self-report measures of depression, anxiety, and quality of life were completed at pretest and after 5, 8, and 12 weeks.
Internet-based CBT and Internet-based PST are both effective in reducing depressive symptoms in comparison to a waiting list control group. These results were visible directly after treatment and 12 weeks after baseline. There is no indication that one is more effective than the other, although the effects are realized faster by PST than by CBT.
Mind you we’re talking about depressive symptoms not depressive disorder, this might also explain the high drop out rate.Overall the percentage of completers in this study was 38%. This is relatively low in comparison to other trials about Internet-based self-help for depression.
Of those participants assigned to CBT and PST, 8 (9.1%) versus 14 (15.9%) completed no lesson at all. Of those assigned to CBT, 63 (71.6%) participants completed at least four lessons and 34 (38.6%) completed all eight. Of those assigned to PST, 49 (55.7%) participants completed three or more sessions and 33 (37.5%) finished the whole course.
The advantage of this kind of therapies is the short duration until efficacy, low costs, prevents fear of stigmatization.
Lisanne Warmerdam, Annemieke van Straten, Jos Twisk, Heleen Riper, Pim Cuijpers (2008). Internet-Based Treatment for Adults with Depressive Symptoms: Randomized Controlled Trial Journal of Medical Internet Research, 10 (4) DOI: 10.2196/jmir.1094
An increasing number of randomized controlled studies have clearly demonstrated that psychological interventions are effective in the treatment of depression.
This can also be seen from the above figure: number of studies from 1970 to 2005 in the world (red line), and in the United States (blue line).
The data on the 149 included studies are presented in order to give other researchers access to the studies we collected, and to give background information about the meta-analyses we have published using this dataset. The number of studies examining the effects of psychological treatments of depression has increased considerably in the past decades, and this will continue in the future. The database we have presented in this paper can help to integrate the results of these studies in future meta-analyses and systematic reviews on psychological treatments for depression.
This group performed systematic reviews and meta-analysis on different subjects within psychotherapy for depression.
Activity scheduling is an attractive treatment for depression, not only because it is relatively uncomplicated, time-efficient and does not require complex skills from patients or therapist, but also because a meta-analysis found clear indications that it is effective. Activity scheduling is a therapy in which patients learn techniques to monitor their mood and daily activities, and to see the connection between these. Then the patients learn how to develop a plan to increase number of pleasant activities and to increase positive interactions with their environment. In this approach, specific attention is paid to social skills and interactions with other people.
In this paper, they present the methods they have used to build this database, and an overview of the characteristics of the studies that have been included in the database.There objectives with providing free access to this database are:
The database can give other researcher access to the studies they have collected and facilitate replications and independent analyses of selections of studies.
The database can provide background information about their own (published, in press, and currently written) meta-analyses.
They hope the database might help researchers to plan new studies and hence either encourage or discourage replications without “reinventing the wheel”.
Cuijpers, P., van Straten, A., Warmerdam, L., Andersson, G. (2008). Psychological treatment of depression: A meta-analytic database of randomized studies. BMC Psychiatry, 8(1), 36. DOI: 10.1186/1471-244X-8-36
CUIJPERS, P., VANSTRATEN, A., WARMERDAM, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27(3), 318-326. DOI: 10.1016/j.cpr.2006.11.001
Cuijpers, P., BrÃ¤nnmark, J.G., van Straten, A. (2007). Psychological treatment of postpartum depression: a meta-analysis. Journal of Clinical Psychology, 64(1), 103-118. DOI: 10.1002/jclp.20432
Cuijpers, P., van Straten, A., Smit, F. (2006). Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials. International Journal of Geriatric Psychiatry, 21(12), 1139-1149. DOI: 10.1002/gps.1620