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Remote collaborative care for depression

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A study published in the American Journal of Psychiatry looks at the remote provision of mental health care in rural health centres. These centres cannot support a practice-based mental health team and so depressed patients usually depend upon the local doctor and nurse to deliver evidence-based treatment. This compares to larger centres, where on-site mental health practitioners can provide collaborative care.

In this study 364 patients who screened positive for depression were allocated to either solely centre-based care or to receiving additional collaborative care delivered remotely by an off-site team. Follow up at 6, 12 and 18 months showed that the latter group experienced significantly better outcomes.

Medscape carries a short discussion of the study.

Successful and Schizophrenic

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A moving account by Elyn R. Saks of building a successful and creative life while experiencing schizophrenia. After a hospitalisation at the age of 28 she was advised that because of her diagnosis she would never lead an independent life. She has since become Associate Dean and Orrin B. Evans Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California Gould Law School.

No impact on crime by alcohol arrest referral schemes

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Disappointing results have been obtained from pilot alcohol arrest referral schemes in the UK. The projects provided brief counselling to arrested individuals who the police believed were under the influence of alcohol. It was hoped that these interventions would lead to a reduction in offending behaviour. If successful, such schemes could form an important tool in tackling the public disorder associated with the night time economy.

The schemes delivered nearly 7,000 interventions, mainly to young white men. Nearly half of the individuals were drinking at hazardous/harmful levels, while more than a third were dependent drinkers. Just over a third of those arrested were suspected of violent offences and a sixth of being drunk and disorderly.

Disappointingly, there was no clear evidence that the interventions led to a reduction in offending behaviour. In fact, in some schemes individuals in a control group showed a greater decrease in offending behaviour than in the group receiving counselling.

The authors believe that one cause for this disappointing result lay in the fact that many of the participants were not prolific offenders. For these individuals there was not much offending to reduce, a situation very different from drug referral schemes. Schemes that might be appropriate in the context of illegal drugs cannot simply be transposed over to problematic alcohol use.

The schemes did identify many dependent drinkers and may be an effective way to signpost those individuals into alcohol treatment. However, it is questionable that interventions aimed at offenders are the best way to tackle the disorder associated with the night time economy.

Findings has a report on this research here.

Depressed parents and their children

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Medscape has recently carried two reports on studies that looked at the effects of parental depression.

One report looked at a study published in Pediatrics, which looked at links between depression in fathers and their parenting behaviour. The study was particularly interested in parenting behaviour that could negatively affect the child’s development, including the physical punishment of young children or the absence of shared activities, such as reading to the child.

The study looked at 1,746 fathers drawn form the Fragile Families and Child Wellbeing Study (FFCWS), an ongoing study that looks at a representative cohort of children born in the United States between 1998 and 2000. Families were recruited at the child’s birth and the fathers were interviewed when the child was one year old. Seven percent of the fathers reported a major depressive episode in the previous 12 months; many of these men were unemployed or also reported substance misuse.

Fathers identified as experiencing depression were:

  • More likely to have hit their child (41% of depressed fathers had spanked their child in the previous month, compared to 13% of non-depressed fathers),
  • Less likely to have read to their child (41% of depressed fathers had read to their child at least three times in the previous week, compared to 58% of non-depressed fathers).

Some points made by the study include:

  • That while some may argue for the use of corporal punishment in older children, its use in children under one year is very problematic.
  • That the increased likelihood of spanking by these fathers may be linked to some of the symptoms of depression, such as irritability and anger.
  • That around half of all fathers interviewed in the FFCWS thought that discipline was one of their key roles, even with younger children.
  • That over three quarters of all fathers had spoken to a pediatrician about their child in the previous year, presenting opportunities for screening for depression and for a discussion about parenting behaviour.

The study authors pointed to several limitations of their study, including the possibility that children with a difficult temperament might result in both negative parental behaviour and parental depression.

The second report in Medscape describes a study of 80 mothers and their children who participated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. The study looked at mothers who were experiencing major depression and whose children also experienced psychiatric symptoms and problem behaviours.

The study showed improvements in the children of mothers whose depression improved in treatment. This was not the case for the children of mothers whose depression did not improve, in fact there was an increase in the problematic behaviour of children whose mothers did not get better.

(Questions have been raised about the overall STAR*D programme, which was intended to test the effectiveness of anti-depressants. There are claims that the methodology used in the trial and the way that the trail was reported both overestimated the evidence for the effectiveness of drug treatments for depression. For example, see this article in Psychology Today.)

These two reports remind us of the crucial need to provide support for parents to avoid later problems for the children. Both mothers and fathers can experience depression following the birth of a child and those early months are so important for the baby’s emotional and intellectual development. Often today that support is not available from an extended family and other help needs to be available.

via Medscape (free registration required)

Record of an online analysis

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Interesting description by Carole Rosen of an analysis that she conducted online using Skype. The analysis was conducted in Chinese with a patient in China, while Rosen was, I assume, located in New York and is not a native speaker of Chinese.

Rosen’s description of the clinical material is engaging and moving, but I was particularly interested in two aspects of her paper.

The first was the careful way in which she thought about the cultural framework of her Chinese patient. She describes both some general aspects of Chinese culture and also some specific issues faced by the generation that grew up during the Cultural Revolution. This understanding of her patient’s cultural and historical context was important in making sense of her patient’s inner world and in giving him the experience of being held in mind. It was also interesting to see how familiar themes, such as Oedipal relationships, were expressed within this cultural framework.

The second aspect of the paper that interested me was its description of communication across languages and across continents. Rosen was wary both of conducting the analysis in Chinese and of carrying it out over Skype. In both cases she seems to have established a good way of working with her patient, checking with him the meaning of unclear words and his preferred way of working at distance. She’s alert to the ways in which these issues are present within the transference and in themselves can provide useful avenues through which her patient’s phantasies can be explored.

Although I work solely in English, I’ve worked with many people who have English as a second language or who come from a very different culture to mine. In this work it’s been important to check our shared understanding of words. Even when working with someone whose first language is English, we can’t assume that we both mean the same thing by the same word. Being aware of and exploring different meanings is part of developing a shared understanding of each other and of building our relationship.

I’ve also worked via Skype and I agree that a therapeutic relationship can be developed in that way. It’s not the same as being in the room together, but a relationship can be built and change helped along.

via the website International Psychoanalysis

Psychoanalysis and research

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An editorial piece for the December 2010 edition of the journal Psychoanalytic Psychotherapy makes for challenging reading. The authors strenuously criticise the indifference and resistance towards research that they see amongst many psychoanalysts.

Given the time, cost, and intensity of the demands placed on patients and therapists who enter into psychoanalysis, the fact that the field has neglected to perform appropriate assessments of whether or not the treatments we routinely recommend and deliver actually work is shocking.

The authors are not anti-psychoanalysis, both are staff members of the Columbia University Center for Psychoanalytic Training and Research. Part of their concern is for the diminishing prevalence and influence of psychoanalytic treatment, which they relate to the absence of sound evidence for its effectiveness. They dismiss those forms of evidence that are most often used by psychoanalysts and psychodynamic psychotherapists.

…clinical lore, collegial interaction, and direct observations by sole practitioners can appear superficially rational as a basis for determining the effectiveness of a treatment….
Psychoanalysts pride themselves on their awareness of the impact of fantasy and wishful thinking during their treatments, but minimize the impact of such factors on their subjective assessment of their own clinical outcomes.

In place of such subjectivity, the effectiveness of these treatments should be evaluated using randomised controlled trials based upon treatment manuals, so that the practitioner’s adherence to the treatment protocol can be assessed. Although some effectiveness studies have been published, it is claimed that many are flawed.

As I say, a challenging article, and one that leaves me with contradictory thoughts.

On the one hand I do feel the lack of a widely-accepted evidence base for the effectiveness of psychoanalytic psychotherapy. I do think that such a body of evidence is growing and I appreciate those studies that I see that add to this evidence.

However, I’m uneasy about the the insistence that randomised controlled trials provide the only trustworthy evidence of effectiveness. The work of John Ioannidis, for example, brings the reliability of such trials into question. In a study of 49 of the most highly regarded and frequently cited medical papers published in the last 13 years, his team found that 11 had not received independent verification, while of those that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. Two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance. (see my earlier post)

I’m also sceptical about the prospect of manualised treatment. For me psychotherapy is about an encounter between two people, with an attempt by the therapist to leave behind preconceptions and to see what use of him or her the patient or client wishes to make. Can a manual allow me to enter into that encounter without memory or desire? Although, I have to admit my ignorance of such manuals and how they are utilised.

And so I’m left with dilemmas that for now I cannot resolve. I want, for myself and for our profession, proof that this practice is effective, both for ethical reasons and to secure our place amongst recommended treatments. But I’m also not sure that the concept of treatment is the best way to describe this journey that I take with my patients. Certainly they come to me in distress and hoping for change. And, given the investment noted above, they deserve to find that our encounter is worthwhile and helps to bring about change. But I have doubts that this is best described in terms of a DSM diagnosis or the relief of a symptom.

Mother-infant psychoanalysis

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A Swedish study, involving mothers with troubled infants, showed improvements in mother’s depression and her relationship with her baby following a two-month course of two or three times a week psychoanalytic treatment for both mother and infant.

I recently came across a link to this interesting study, reported in Science Daily last year. The study followed 80 mothers who had sought help at Child Health Centres, nursing centres or  parenting internet sites. All of the mother-infant pairs received support from the centres, but half were also assigned to joint psychoanalytic treatment at the Mother-Infant Psychoanalytic Project of Stockholm. The treatment lasted about two months, with two to three sessions a week.

The treatment provided a safe environment in which the mother and her baby could  express how they felt. With the help of the analyst the mother could come to understand her baby’s ‘difficult’ behaviour as a form of communication, rather than as an attack upon her or a result of her failure. In this safe place the mother and baby could finally find each other.

In follow-ups six months later, mothers who had received the psychoanalytic treatment showed improvements in their depression, better relationships with their babies and a greater sensitivity to their baby’s signals, as compared to mothers who had only received the support of the Child Health Centres.
See http://www.sciencedaily.com/releases/2010/04/100413072042.htm

Analysing the effectiveness of long-term therapy

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I’ve just caught up with a 2008 article in the Journal of the American Medical Association reviewing a meta-analysis of studies looking at the effectiveness of long-term psychodynamic psychotherapy. The meta-analysis looked at 23 studies, including 11 randomised controlled trials and involving 1,053 patients. The meta-analysis concluded that long-term psychodynamic psychotherapy led to significantly better outcomes than shorter forms of psychotherapy, especially for individuals who were experiencing more complex mental disorders. Thanks to Mike Langlois who pointed out this article to me.

The meta-analysis looked at studies, published over the past 50 years, of individual psychodynamic psychotherapies that lasted for at least one year. Studies were only included if they had reliable outcome data and had a prospective design, that is, they included before and after assessments of the patient. Patients treated in the studies had a range of mental disorders including ‘personality disorders, chronic mental disorders (defined as mental disorders lasting ≥1 year), multiple mental disorders (defined as 2 or more diagnoses of mental disorders), and complex depressive or anxiety disorders’.

The two authors independently rated the reported treatment outcomes in terms of overall effectiveness, the presenting problems, general psychiatric symptoms, personality functioning and social functioning. The studies were then analysed to compare the outcomes achieved by long-term psychodynamic psychotherapy, with those of other forms of therapy, including ‘CBT, cognitive-analytic therapy, dialectical-behavioral therapy, family therapy, supportive therapy, short-term psychodynamic therapy, and psychiatric treatment’.

The article describes the detailed statistical analysis that was carried out on these 23 studies. This analysis came to the following conclusion:

In this meta-analysis, (long-term psychodynamic psychotherapy) was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning. Long-term psychodynamic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders, and chronic mental disorders. The effect sizes for overall outcome increased significantly between end of therapy and follow-up.

Interestingly, the number of therapy sessions seemed more significant in these positive outcomes, than the number of weeks that the therapy lasted.

There are growing pressures, at least within the UK, for psychotherapy to be offered in its shorter, and therefore less costly forms. It’s certainly correct for a range of help to be available to people in distress. It is also true that many individuals may only need, or be prepared to contemplate, a relatively brief therapy. However, the studies looked at in this analysis suggest that more complex or chronic problems are best helped by longer-term work.

As a society and as individuals we face difficult economic realities. In both cases we need to decide how much we want to invest in our mental wellbeing.

The effectiveness of brief interventions in A&E

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A recent study suggests that brief alcohol interventions in A&E may not be as effective as other studies have indicated. However, within this overall disappointing result, variations in counsellor skills may have a positive effect upon outcomes.

The Swiss research, reported in Findings, used a sample of 987 heavy drinkers to explore the effectiveness of brief motivational interventions in A&E. The disappointing headline result was that in this study, at least, receiving a brief intervention did not seem to lead to any greater level of improved outcomes in drinking one year later. About two-thirds of the participants were still drinking heavily after one year, regardless of whether or not they had received a brief intervention. This does contradict other studies, which have shown some positive effects from this form of intervention. For example, another study mentioned in Findings found that brief motivational interventions did seem to lead to a reduction in harmful drinking for dependent drinkers who were admitted to A&E with an injury.

However, the Swiss researchers also looked in more detail at these brief interventions and at the performance of individual counsellors. They found that although the overall results were disappointing, some patient and counsellor characteristics did predict a more positive outcome. The analysis was based upon a sample of only five counsellors and so should be treated with great caution. What it did find was that counsellors tended to produce more positive results to the degree that they delivered the interventions in a motivational style. The article describes this style in terms of demonstrating acceptance of the patient, having a collaborative approach and emphasising the individual’s control over their behaviour.

People who are approached with a brief alcohol intervention in A&E are generally there for some other reason and are not expecting an intervention regarding their alcohol use. The background notes to the article in Findings suggest that in this case, especially, a collaborative and non-confrontational approach is more likely to be successful.