How would you treat an intelligent 15-year-old boy with moderate depression but no suicidal thoughts?
A. NICE guidelines recommend referral to CAMHS tier 2 or 3. The fi rst step in the management is to offer one of the following specifi c psychological therapies (for at least 3 months) as a fi rst-line treatment:
If the depression is unresponsive to the above therapies in four to six sessions a multidisciplinary review should follow. Further psychological assessment for comorbidity and further psychological and social treatments that address these should be considered. Only after these steps, is medication considered as an addition.
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The therapeutic work of interpersonal psychotherapy is organized around central interpersonal problem areas in the patient’s life.
Which of the following situations are possible problem areas in a case of acute depression?
E. In acute treatment for depression with IPT, the problem areas can be classified as role transitions (associated with stressful life events), grief, role disputes (e.g. in marriage), or interpersonal deficits (lack of social support). Although specific stressful experiences are relevant to other IPT problem areas in the broadest sense, adjusting to stress and change in the social context requires a role transition. This might be the case in depression following the birth of a child, retirement, medical illness, divorce, etc. According to IPT, bereavement is thought to be a potential precursor of clinical depression. Development of clinical depression following a death is evidence that the normal grief process did not take place and that the individual has had an abnormal grief reaction. In such cases the work of IPT is to help the patient experience the normal grief process. A role dispute can occur in any important relationship especially the patient’s relationship with his or her spouse or significant other. In interpersonal deficits, the patient’s primary problem is seen as a paucity of social connections. Relationships buffer the individual against stressful life events and are essential to psychological well-being. As such, the primary goal is to enhance the level of social connection through concrete positive changes in the patient’s social activities (e.g. joining a club, taking a class). Attention to social support and a positive social network is also a component of work in the other IPT problem areas.
Which of the following is NOT a step in interpersonal psychotherapy for depression?
C. Because guilt and low self-esteem are characteristic of depression, patients frequently blame themselves and think of themselves as ‘bad’ when problems arise. Although many depressed patients report these negative cognitions, the therapist does not systematically question and evaluate the automatic negative thoughts. Unlike cognitive therapists, interpersonal therapists neither employ thought records nor weigh the evidence to help patients re-evaluate negative cognitions. Instead, therapists shift blame to the illness, which often provides patients with an immediate feeling of relief. Therapists then capitalize on this transient mood improvement by encouraging patients to take positive steps towards resolving interpersonal problems.
In the landmark National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program, which of the following psychotherapies was found to be equivalent to imipramine in severe depression?
B. A landmark trial in the history of antidepressant psychotherapy was the multisite NIMH Treatment of Depression Collaborative Research Program. Investigators randomly assigned 250 outpatients with major depression to receive 16 weeks of IPT, CBT, imipramine plus clinical management, or placebo pills plus clinical management. This study was the first comparison of IPT and CBT, each of which had demonstrated efficacy in separate trials, and the first trial to use treatment manuals and monitor the psychotherapeutic input of pharmacotherapists. Most patients completed at least 12 once-weekly treatment sessions or 15 weeks of therapy. Those with milder depression (defined as a score of <20 on the 17-item Hamilton Rating Scale for Depression) improved equally regardless of which treatment was used. For more severely depressed patients (those with a Ham-D score of 20), imipramine worked fastest and was most consistently superior to placebo. IPT and imipramine had comparable effects on Ham-D scores and several other outcome measures, and were superior to placebo for more severely depressed patients. CBT was not superior to placebo among the more depressed patients.
Which of the following is the first step involved in crisis intervention?
D. Crisis intervention originated from the work of Lindemann and Caplan. It is based on Caplan’s description of four stages of coping, including emotional arousal, disorganization of behaviour, trials of alternative coping and finally exhaustion and decompensation. Crisis intervention aims primarily to deal with the first stage, so that further stages can be prevented. Hence the first step is to reduce arousal, both physiological and emotional. The approach is collaborative with family and friends. Very often this stage includes the use of medications that prevent or help reduce arousal. Along with the reduction in arousal, the patient is encouraged to focus on the current problems and encourage self-help. The second stage of crisis intervention resembles problem-solving counselling and includes the assessment of patients’ problems and assets, their ability to come up with solutions and test them, and finally to consider coping mechanisms for the future if similar problems arise.
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