A2 Depression – Critical Questions On Explanations And Therapies

How we answer the critical questions for each of the sub-topics for Depression depends in part on evidence for other subtopics. It makes sense therefore to put all of the evidence in one place. Please note that there is plenty of material on this blog which did not make it into the resources booklet and which we will not have time to explore specifically in class. Please use Depression category at the bottom of this post and the tags to the left to find material which might interest you.

Biological Explanations Of Depression

What is the evidence that depression is genetic and runs in families? Is this evidence valid? 

We’ll answer this one in class, using the text book resources on pages 13-14 of the resources booklet.

What does evidence from drug therapies tell us about the amine hypothesis?

The text book here represents a pretty good start. It explains the fundamental problem that anti-depressants have an effect straightaway but it takes a while for the symptoms of depression to disappear. This suggests that there is something more to depression than a drop in serotonin or dopamine levels. This recently published article about findings from Gurwitz and Shomron (2013) suggests what that something more might be. See if you can work it out. To understand more about the amine hypothesis, go to this news report from NPR. It gives you an idea about how researchers understand the role of serotonin. If you are not clear about how serotonin works, use this extract from the Deeply Depressed video you watched in class. If you want to know more about how antidepressants working on serotonin were first discovered and developed, listen to the first five minutes of this programme. We’ll come back to it again later.

What does research into the serotonin transporter protein gene tell us about what causes depression? What are the implications of this research for how to treat depression?

Start by watching this video sequence from Deeply Depressed. We have already watched part of this programme in class. The article on pages 14-16 of your resources booklet covers the same material: the reference is Caspi et al (2003). Next, go to the extract from a much longer article by David Dobbs on pages 16-17 of your booklet. This refers to a piece of research by Kaufman et al (2004) which you might find quite surprising. Make sure you can summarise the findings of these studies and the implication for the treatment of depression.

Psychological Explanations Of Depression

What is the evidence for the importance of learned helplessness in the development of depression? Is this evidence valid?

We’ll use text book evidence for this and cover the questions in class.

What do studies into the effectiveness of CBT tell us about the importance of negative thinking in the development of depression? Is this evidence valid?

We’ll use the evidence from Butler and Beck (2000). A very good recent analysis of evidence for CBT comes from this article here: see also pages 21-23 of your resources booklet. The reference is to Cuijpers et al (2013). This is a great resource because it enables you to include some analysis of methodological issues.

Why is it important to take account of both biological and psychological explanations of depression?

To answer this question, go back to the material about the Serotonin Transporter Gene in the section above: Caspi et al (2003), Kaufman et al (2004).

How have psychological explanations of depression been used to explain how people can develop resilience?

“Resilience” can be defined as the ability to overcome setbacks and problems. The starting point for psychologists in this area is to work out what is wrong with the thinking of people with depression and then see how people not affected by depression are different. Resilience is being researched by a team at Manchester University. You can read about them in this article which is also in your resources booklet pages 23-24. An extract from the BBC World Service programme on which they appeared is here. The interesting thing about this research is that resilience may have a genetic basis. That is dealt with in this article on page 25 in your resources booklet and can be found online here. Read and listen to as much as you can and see if you can see the link between the explanations we have worked on in class and the research into resilience.

Biological therapies for depression, including their evaluation in terms of appropriateness and effectiveness

What do outcome studies show about the effectiveness of these therapies? Why is this evidence controversial? Should the fact that we are not sure how these therapies work affect our judgement of their effectiveness? What is the evidence about side effects for these therapies? Why is it hard for doctors to predict whether therapy will be appropriate for any given patient?

The route here is simpler than those above. Download this programme: here’s a link to its webpage. You can use what’s here as a good starting point for all of the evaluation questions alongside the sources in the resources booklet. If you want to know more, follow the Prozac tag on the right of this page. The rest of the Deeply Depressed programme will give you some good insights into the experience of people using these therapies. Try this link, or if it doesn’t work, this one.

Psychological therapies for depression, for example, behavioural, psychodynamic and cognitive-behavioural, including their evaluation in terms of appropriateness and effectiveness

Before you start investigating these questions, please have a look at the comments which I have posted: click on the button at the top of this post. You need to use the ideas we have developed about biological therapies when evaluating psychological therapies.

What do outcome studies show about the effectiveness of these therapies? Why is this evidence controversial? Should the fact that we are not sure how these therapies work affect our judgement of their effectiveness?

Start by reminding yourself about Butler and Beck (2000) in your resources booklet and looking back to the link above to the study by Cuijpers et al (2013). You can add to this by looking at the article referring to Wiles et al (2013): see also resources booklet pages 34-35. The controversy here is about how good CBT really is. It is promoted by many as the treatment of choice but you need to consider whether it is any better than the drugs it often replaces.  A particular issue is that we do not know exactly what CBT does inside the brain nor exactly how drugs and CBT combine to produce an effective treatment for many people. You need to ask yourself how important you think this question is.

What are the costs of these therapies? Why is it hard for doctors to predict whether therapy will be appropriate for any given patient?

To get an idea of the costs involved in therapy, listen to the first part of this programme. It describes some of the experiences of people using CBT as part of the IAPT programme. If you are having problems streaming this, please try this link here and here. There might be many reasons why therapy might be more appropriate for some patients than others. Therapists are increasingly aware of this and are finding ways of making therapy more accessible to a greater range of people. A fascinating example of this comes from New Zealand. Watch this video and read about the study which goes with it here: see also page 37 of your resources booklet. Since that was printed, an article about online therapy has appeared on the BBC which I have linked on a post of the week here.  If you’re feeling brave, the article by James Coyne on the most recent post of the week here is really interesting.

 

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5 comments

  1. Here’s how 13D answered these questions.

    a) What do outcome studies show about the effectiveness of these therapies?
    There is evidence that drug treatments work.
    Thase and Kupfer (1996) report a much higher rate of reduction when medication is used compared to placebos.
    Kirsch et al (2008): only in cases of the most severe depression was there any significant advantage in using SSRIs.
    In cases of moderate depression, beliefs about the effectiveness of depression contributed to the effectiveness of that treatment.
    Cuijpers et al (2013): CBT and drugs work better than drugs alone.
    Geller et al (1992): studies have consistently found no significant advantage of medication over placebo in children and adolescents.
    Studies have found ECT to be effective: sham ECT works less well than real ECT (Gregory et al (1985)).
    Rose (2004): ECT may be more effective than drugs in treating depression in the short term.

    b) Why is this evidence controversial?
    Turner et al (2008) found substantial evidence of publication bias.
    Only positive results published and, if negative results are published, a positive spin is placed on them.
    Attempts to classify and diagnose depression are affected by issues of reliability and validity.
    Self-comparison and the setting of unachievable goals are factors working against valid diagnosis.
    Substantial over-prescription of the drug: people are given it who do not need it, making it hard to assess its effectiveness.
    If they don’t see an improvement, it is because they didn’t need it in the first place.
    If they do, it is placebo.
    The definition of “significant advantage” is controversial: some argue Kirsch has set that too high.
    Number Needing Treatment is a measure designed to give greater clarity.
    Some people need maintenance therapy so are never free of symptoms: measure improvement.

    c) Should the fact that we are not sure how these therapies work affect our judgement of their effectiveness?
    We routinely use medication in other areas even when we do not know how it works.
    People who are given ECT are at risk of suicide and something has to be done: how it works is of secondary importance.
    Depression may be different because people who are severely depressed are not in the right state of mind to give consent.
    Depression may be different because it has no clear footprint in the brain.
    Depression may be different because we now know that the mechanism which the drugs tackle is only a small aspect of the experience of depression.
    Depression may be different because we really have no idea about what drugs or ECT do inside the brain: pigs, dogs, accidents.
    Depression may be different because treatment is invasive and irreversible.

    d) What is the evidence about side effects for these therapies?
    Ferguson et al (2005): SSRIs associated with increased risk of suicide.
    Barbui et al (2008): risk increased in children but not in adults, while SSRIs protected older adults against risk of suicide.
    Devanand et al (1994) report no convincing evidence of memory deficits or structural brain damage as a result of ECT.
    Datto (2000), Rose et al (2003), DOH report (2007) all report negative side effects for ECT.
    Sackeim et al (2000) report fewer side effects with unilateral than bilateral ECT.

    e) Why is it hard for doctors to predict whether therapy will be appropriate for any given patient?
    As a doctor, you have got to do something.
    People in drug trials get regular follow up but people given prescriptions in real life often won’t see a health professional for weeks.
    Treatment may be to help someone to conform to society’s norms more than for their own good.
    Depression may be an umbrella term for a number of different conditions.
    Each drug may treat a different form of depression.
    Treatment is often therefore trial and error.
    Effective therapy requires both a biological and psychological input.
    At the very least, evidence about the placebo effect suggests that patients need to be persuaded that the drugs they are given will work.
    Psychological interventions without drug treatment may be an important first step for many: the rise of online and game based therapy.
    Options for treatment look limited: the question therefore is how to build resilience.

  2. And here are 13B’s ideas. Some of them are the same as those from 13D but others go off in a different direction. This is not the last word.

    What do outcome studies show about the effectiveness of these therapies?
    Everyone agrees that the drugs do something: not just sugar pills or snake oil.
    The debate is whether that “something” leads to a reduction in the symptoms of depression.
    Thase and Kupfer (1996) report a much higher rate of reduction when medication is used compared to placebos.
    Kirsch et al (2008): only in cases of the most severe depression was there any significant advantage in using SSRIs.
    Cuijpers et al (2013): CBT and drugs work better than drugs alone.
    Geller et al (1992): studies have consistently found no significant advantage of medication over placebo in children and adolescents.
    Studies have found ECT to be effective: sham ECT works less well than real ECT (Gregory et al (1985)).
    Rose (2004): ECT may be more effective than drugs in treating depression in the short term.

    Why is this evidence controversial?
    Turner et al (2008) found substantial evidence of publication bias.
    Only positive results published and, if negative results are published, a positive spin is placed on them.
    A clear benchmark has to be established: we need to be able to say how much better people are when treated with drugs compared to alternatives.
    Lots of ways of measuring depression but no commonly agreed scale.
    The definition of “significant advantage” is controversial: some argue Kirsch has set that too high.
    Number Needing Treatment is a measure designed to give greater clarity.
    Some people need maintenance therapy so are never free of symptoms.
    So we cannot talk about these therapies as curing depression, only as helping people to manage their condition.
    Everybody accepts that placebo plays a part: believing that the drugs work and that you will get better is part of the process.
    This should alert us to the importance of psychological factors: how well the drugs work depends on how well people are cared for.
    That is why CBT plus pharmacotherapy is effective.

    Should the fact that we are not sure how these therapies work affect our judgement of their effectiveness?
    In general, if someone tells me that a device or a product is effective, I want to know why it works.
    We routinely use medication in other areas even when we do not know how it works.
    People who are given ECT are at risk of suicide and something has to be done: how it works is of secondary importance.
    We might want to make not being sure about how these drugs work and appropriateness issue.

    What is the evidence about side effects for these therapies?
    Ferguson et al (2005): SSRIs associated with increased risk of suicide.
    Barbui et al (2008): risk increased in children but not in adults, while SSRIs protected older adults against risk of suicide.
    Devanand et al (1994) report no convincing evidence of memory deficits or structural brain damage as a result of ECT.
    Datto (2000), Rose et al (2003), DOH report (2007) all report negative side effects for ECT.
    Sackeim et al (2000) report fewer side effects with unilateral than bilateral ECT.

    Why is it hard for doctors to predict whether therapy will be appropriate for any given patient?
    Classification and diagnosis are unreliable: the doctor has to be clear whether the patient is actually depressed.
    The doctor has to decide whether to use a biological therapy at all: using a psychological therapy may be more appropriate.
    The doctor has to match the symptoms being presented to her/him with a range of possible medications: leads to trial and error prescribing.
    There are costs involved in getting it wrong: risk of suicide.
    There is now no clear consensus about the defining features of a depressed brain nor a clear consensus about the effects of antidepressants within the brain.
    The same applies to ECT.

  3. Here is a summary for 13D Psychological Therapies.

    What do outcome studies show about the effectiveness of these therapies?
    Cuijpers et al (2013): CBT and drugs work better than drugs alone.
    Cuijpers et al (2013): CBT is better than treatment as usual, placebo, waiting list, other .
    There is no significant difference in effectiveness between drugs and CBT.
    Butler and Beck (2000): 14 meta analyses suggest that 80% of adults benefit from therapy compared to controls who had no treatment.
    “At six months, 46 per cent of those who received CBT in addition to usual care had improved, reporting at least a 50 per cent reduction in symptoms of depression, compared to 22 per cent of those who continued with usual care alone. This beneficial effect was maintained over 12 months.” Wiles et al (2013)
    Elkin et al (1989) found that IPT was as effective as CBT or drugs.

    Why is this evidence controversial?
    You need to come to a view about how effective these therapies are: 50% improvement in 46% of cases in Wiles et al (2013)
    The idea of placebo is deeply obscure: you cannot have a placebo psychological therapy which you think is real but is in fact doing nothing.
    We know that a combination of drug therapy and CBT works best
    We can’t answer the question of how much is due to the drugs and how much to the CBT.
    The effectiveness of the therapy depends on so many factors: therapist competence, client motivation and willingness, home environment.
    Even if all of these are in place, it does not work for everyone.
    Some clinical psychologists dispute the value of showing effectiveness through a randomised control trial.
    They dispute the medical model of depression as an illness with a clearly defined set of symptoms which can be cured or reduced through a structured therapeutic process.
    Formulation of a problem in conjunction with a client, not diagnosis given by a health professional.

    Should the fact that we are not sure how these therapies work affect our judgement of their effectiveness?
    Evidence of effectiveness is an excuse for not looking at how a therapy works and whether it is appropriate.
    We do not know about the long term effectiveness of CBT or IPT.
    In order to understand this, we might need to know more about what it is doing in the brain.
    Some clinical psychologists suggest that it is the therapeutic relationship rather than the structure of CBT which makes it work.
    So we cannot judge the effectiveness of something that will be different case by case.

    What is the evidence about the costs of these therapies?
    Time both in therapy and on homework.
    There is clear evidence of therapist variation: Kuyken’s comments in Wiles et al (2013), Kuyken and Tsvirikos (2009).
    A weaker therapist brings higher costs and less appropriate treatment.
    For people who are rigid or resistant to change, it may do more harm than good.
    It is costly when someone is asked to think positively about something which isn’t positive or to change a behaviour which cannot be changed.
    “The therapist often asks for background information about the past to throw some light on current circumstances.”
    So it’s not just dealing with the here and now.
    True of IPT as well: cannot divorce itself from its psychoanalytic roots.

    Why is it hard for doctors to predict whether therapy will be appropriate for any given patient?
    The therapy is time limited: not enough time to get to know the client.
    The therapy requires cognitive flexibility and the ability to acknowledge the positive.
    There’s no test for this.
    Nobody can explain why therapy works for some clients and not others: Wiles et al (2013).
    A GP may refer someone diagnosed with depression to a CBT practitioner.
    That practitioner will then formulate a set of problems with the help of the client.
    So the appropriateness of the intervention depends to some extent on the input of the client.
    The development of online therapy suggests that for some clients, particularly young people, therapy will not be appropriate.
    It also shows that the CBT framework is flexible enough to be adapted effectively to an online environment.

  4. Here are the answers from 13B on psychological therapies.

    What do outcome studies show about the effectiveness of these therapies?
    Cuijpers et al (2013): CBT and drugs work better than drugs alone.
    Cuijpers et al (2013): CBT is better than treatment as usual, placebo, waiting list, other .
    There is no significant difference in effectiveness between drugs and CBT.
    Butler and Beck (2000): 14 meta analyses suggest that 80% of adults benefit from therapy compared to controls who had no treatment.
    Butler and Beck (2000): CBT more successful than drug therapy and had a lower relapse rate.
    “At six months, 46 per cent of those who received CBT in addition to usual care had improved, reporting at least a 50 per cent reduction in symptoms of depression, compared to 22 per cent of those who continued with usual care alone. This beneficial effect was maintained over 12 months.” Wiles et al (2013)
    Elkin et al (1989) found that IPT was as effective as CBT or drugs.

    Why is this evidence controversial?
    You need to come to a view about how effective these therapies are: 50% improvement in 46% of cases in Wiles et al (2013).
    The idea of placebo is deeply obscure: you cannot have a placebo psychological therapy which you think is real but is in fact doing nothing.
    Some of the positive effect in Wiles et al (2013) may be due to the fact that the experimental group know they are getting therapy.
    We know that a combination of drug therapy and CBT works best
    We can’t answer the question of how much is due to the drugs and how much to the CBT.
    The effectiveness of the therapy depends on so many factors: therapist competence, client motivation and willingness, home environment.
    It also depends on the therapeutic relationship.
    Even if the therapist is not particularly competent in the procedures of CBT, establishing a relationship with the client may be an important aspect of the client’s recovery.
    Even if all of these are in place, it does not work for everyone.

    Should the fact that we are not sure how these therapies work affect our judgement of their effectiveness?
    Evidence of effectiveness is an excuse for not looking at how a therapy works and whether it is appropriate.
    We do not know about the long term effectiveness of CBT or IPT: studies are limited to six or twelve months.
    In order to understand this, we might need to know more about what it is doing in the brain.
    We cannot judge the effectiveness of something that will be different case by case.
    So many factors contribute to the success of the therapy: competence, relationship, client’s beliefs about the power of therapy.

    What is the evidence about the costs of these therapies?
    Time both in therapy and on homework.
    There is clear evidence of therapist variation: Kuyken’s comments in Wiles et al (2013), Kuyken and Tsvirikos (2009).
    A weaker therapist brings higher costs and less appropriate treatment.
    For people who are rigid or resistant to change, it may do more harm than good.
    It is costly when someone is asked to think positively about something which isn’t positive or to change a behaviour which cannot be changed.
    “The therapist often asks for background information about the past to throw some light on current circumstances.”
    So it’s not just dealing with the here and now.
    True of IPT as well: cannot divorce itself from its psychoanalytic roots.

    Why is it hard for doctors to predict whether therapy will be appropriate for any given patient?
    The therapy is time limited: not enough time to get to know the client.
    The therapy requires cognitive flexibility and the ability to acknowledge the positive.
    There’s no test for this.
    Nobody can explain why therapy works for some clients and not others: Wiles et al (2013).
    The range of therapies available is quite limited: people get whatever is available.
    The development of online therapy suggests that for some clients, particularly young people, therapy will not be appropriate.
    It also shows that the CBT framework is flexible enough to be adapted effectively to an online environment.

  5. […] of CBT which can be applied to its use as an intervention for addiction. Look back to the posts about depression on this blog from earlier in the year to remind yourself what those issues are. […]

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