Treatment provisions for depression in psychological therapy services
Necessarily, the treatments offered by any given service will depend upon local, as well as more general, factors. These will have to take into account the high- and low-intensity treatments approved by the revised NICE depression guideline, as well as the potential value of coordination with IAPT services, which, in turn, depends upon their state, level of functioning, and the attitude of the personnel involved.
Many of the treatment modalities described in detail in previous chapters can offer value for patients with depression. The following kind of provisions should form part of any service aiming to offer a good provision for depressed patients. However, as well as precisely what is on offer, how well it is done matters as much.
- • An invaluable first step remains getting a sense of a person and his or her life and illness, current and past, plus the very considerable therapeutic benefits for the individual patient associated with doing so. Although belonging to a bygone era, Karl Menninger’s brief paper The Psychiatric Diagnosis continues to give an exemplary account of how to go about this.
- • Psychodynamic and psychoanalytic approaches are distinguished by the emphasis they give to the role of subjectivity, interiority, intentionality, and personal meaning in affective states. There
is an increasingly strong evidence base for the efficacy of such treatments in depressive disorder for both short-term therapies, such as DIT, and longer-term therapies. For example, the Tavistock Adult Depression Study is producing evidence about the effectiveness of 60 sessions of psychoanalytic psychotherapy with chronically depressed patients. A German trial used the same manual to compare the effects of longer psychoanalytic treatments with those of an augmented form of CBT, also with chronically depressed patients. The Tavistock treatment approach authorizes psychoanalytically trained clinicians to use their skills to ‘follow the patient’, rather than to apply a simplifying structure or predetermined focus, as is the case in most manualized approaches to psychodynamic or psychoanalytic forms of therapy (see E oanalytic psychotherapy in Chapter 2, pp. 20-30, and in Chapter 5, pp. 163-72; Dynamic interpersonal therapy in Chapter 2, pp. 6l—63, and in Chapter 5, pp. 215-20).
- • Whilst psychoanalytic or psychodynamic approaches match the preferences of many patients, they are by no means wanted or liked by all. Many patients prefer and value a cognitive behavioural approach, and may gain more benefit from it (see Cognitive behavioural therapy in Chapter 2, pp. 30—4, and in Chapter 5, pp. 172—84).
- • Group therapy: in NHS settings, individual treatments currently are time-limited. In this context, psychodynamic group therapy following on individual treatments offers the advantage of therapy continuing for longer than otherwise could be the case. It also provides a chance for the patient to work with the anxieties involved in moving from the shelter of illusory, exclusive one-to-one relationships (such as may be sought through individual treatments) to a social world involving the benefits, as well as the difficulties, of identification with peers. The ability to feel personal in the company of others has often presented difficulties for many depressed people. Groups offer an opportunity to transfer into the social sphere what was initiated in a one-to-one setting (see E Group therapy and group analysis in Chapter 2,
pp. 42—7, and in Chapter 5, pp. 188—94).
- • Family and/or couple therapies: the designated patient’s depression is sometimes sustained by an interpersonal systemic situation operating either in a family or a couple setting. Moreover, one individual’s depression often has—or, in the case of suicide, will have—long-term effects on spouses, parents, children, and others. In these situations, family or couple therapy may be indicated (see E Systemic family and couple therapy in Chapter 2, pp. 34—42, and in Chapter 5, pp. 184—8).
- • Medication: results from studies of combined drug and psychological therapy are mixed, but there is evidence of ‘extra value’ from adding psychodynamic or cognitive treatments to medication. Also, adding medication to psychotherapy, especially where vegetative symptoms are pronounced, should not be forgotten (see Psychotherapy and medication in Chapter 7, pp. 322-4).