9. Examine biomedical, individual and group approaches to treatment
10. Evaluate biomedical, individual and group approaches in the treatment of depression
The biomedical approach is based on the assumption that a neurotransmitter imbalance is implicated in disorders such as depression. The serotonin hypothesis suggests that there is an lack of serotonin in the synaptic gaps for effective transmission. Most medications aim to increase the amount of serotonin available by preventing the reuptake of serotonin, making it stay in the synaptic gap longer, and thereby increasing the efficiency of the serotonin already present. The most common SSRI is fluoxetine, more commonly known by its brand name Prozac.
The two main criticisms of fluoxetine are that it treats the only the symptoms but does not cure, thus making people dependent on it. Such drugs often have significant side effects including sexual problems, insomnia and even an increase in suicidal thoughts. For many people the side effects outweigh the benefits.
Evaluation Generally antidepressants such as Prozac are an effective way to treat depression. However a well known study by Elkin et al (1989) conducted by the NIMH randomly assigned patients to drug therapy or cognitive therapies. The control group was given a placebo pill. All patients were assessed at the start, after 16 weeks and after 18 months of treatment. Results showed the drug group showed the fastest results, but no other difference in the effectiveness of treatment between drug therapy and cognitive therapies such as CBT. Such a study does raise ethical issues, in that lying to patients about the kind of treatment they receive is not only deceptive, but also possibly dangerous if the patient is having frequent suicidal thoughts ( and put in a placebo condition). A meta analysis of 19 studies by Kirsch & Sapirstein (1998) found that anti-depressants were only 25% more effective than placebos. The debate over the effectiveness of drugs is also a political one. Drug manufacturing and marketing is multi-million dollar industry. Negative press for drugs would lead to a massive loss of income for a number of pharmaceutical companies
2.Individual approaches – Cognitive therapy
The rationale behind cognitive therapy is to identify faulty patterns of thinking, and to replace them with more positive ways of thinking. Cognitive Behavioral Therapy is based on the idea that how we think (cognition),how we feel (emotion) and how we act (behavior) all interact together. Specifically, our thoughts determine our feelings and our behavior. CBT then aims to identify these negative thoughts, challenge them and replace them with positive thoughts. The emphasis is on client meta-awareness – that is, the ability to think about their own thoughts. Thoughts and feelings are seen as mental events that can be examined objectively and changed if necessary. Cognitive-behavioural therapy for depression
Although a variety of different models and interventions have been developed under the rubric of cognitive- behavioral therapy, all share certain features that are common to CB; 1.Cognitive restructuring
Cognitive restructuring involves teaching clients to become aware of their automatic negative thoughts, to evaluate the extent to which these thoughts are accurate or rational, and to replace irrational thoughts with more reasonable interpretations, evaluations, and assumptions. Some cognitive distortions that clients learn to identify are; all-or-nothing thinking; magnifying or minimizing the importance of an event; overgeneralization (drawing extensive conclusions from a single event); personalization (taking things too personally); selective abstraction(giving disproportionate weight to negative events); arbitrary inference (drawing illogical conclusions from an event); Once negative ways of thinking have been identified, the therapist helps the client work on replacing them with more adaptive/positive ones. This process involves a repertoire of techniques, including self-evaluation, positive self-talk, control of negative thoughts and feelings, and accurate assessment of both external situations and of the client's own emotional state. Clients practice these techniques alone, with the therapist, and also, wherever possible, in the actual settings in which stressful situations occur (in vivo), gradually building up confidence in theirto cope with difficult situations successfully by breaking out of dysfunctional patterns of response. 2.Behavioural activation
Cognitive-behavioral therapies require clients to behave in new ways in order to alter maladaptive patterns of interpreting and interacting with their environments. Novel interventions and activities are developed and performed by the client both in session and beyond in an attempt to address and eventually modify dysfunctional distortions, behaviors, and beliefs
Homework is an important component of cognitive-behavioral treatments. Homework may include such activities as practicing specific techniques (e.g., relaxation or breathing), conducting personal experiments, rehearsing behavioral skills, or completing cognitive journals and assessments
We have already seen in the previously mentioned study by Elkin (1998) that CBT is as effective as drug treatment. They are also quite cost-effective as they do not involve prolonged treatment. However CBT focuses only on symptoms and strategies and does address the causes of depression.
Group psychotherapy is a special form of therapy in which a small number of people meet together under the guidance of a professionally trained therapist to help themselves and one another.
Interpersonal group therapy for depression
Although developed as an individual model for therapy IP naturally lends itself to group sessions. IPT examines the person’s past and current social roles and assumes that mental illnesses such as depression
occurs within a social system and that one’s social (interpersonal) roles are of the keys to recover – in other wordscan be treated by improving the communication patterns and how people relate to others.
An advantage of IP group therapy is that it serves as an ‘interpersonal laboratory’ in which interpersonal functioning can be observed and new ways of relating tried out through role playing. Participants can join one another in applying various therapeutic techniques. It can provide practical and empathetic interactions between group members.
Trials of interpersonal therapy in Uganda, a country ravaged by war, poverty and AIDS, have shown the approach to be remarkably effective, especially among women. Specifically, Uganda has had notable success in reducing the incidence of AIDS. Health workers there feel that combating depression is an important aspect of this success, since depressed people often engage in risky behavior.
Bolton et al ( 2003 ) conducted a randomised controlled trial comparing group interpersonal psychotherapy with treatment as usual among rural Ugandans meeting the criteria for major depression.
Therapy was conducted in single-gender groups of five to eight participants, with one group per participating village. Groups met for approximately 90 min once a week for 16 weeks. Each group was led by a local Ugandan of the same gender with no previous mental health or counselling experience other than training in group interpersonal psychotherapy by members of the study team
Results showed that interpersonal group therapy proved highly effective in reducing depression: after therapy only 6 percent of the treated group met the criteria for major depression, compared with more than half of the untreated control group
Group therapy has numerous advantages over individual therapy. The therapist's knowledge about the clients offers an added dimension through the opportunity of observing them interact with each other. Clients are helped by listening to others discuss their problems (including problems more severe than theirs) and by realizing that they are not alone. They also gain hope by watching the progress of other members and experience the satisfaction of being helpful to others. Groups give the individual client the chance to model positive behavior they observe in others. Besides learning from each other, the trust and cohesiveness developed within the group can bolster each member's self-confidence and interpersonal skills. Group therapy gives clients an opportunity to test these new skills in a safe environment. In addition, the group experience may be therapeutic by offering the clients a chance to reenact or revise the way in which they relate to their primary families. Finally, group therapy is cost-effective, reducing the use of the therapist's total time.
Nevertheless, there are also some possible disadvantages to group therapy. Some clients may be less comfortable speaking openly in a group setting than in individual therapy, and some group feedback may actually be harmful to members. In addition, the process of group interaction itself may become a focal point of discussion, consuming a disproportionate amount of time compared with that spent on the actual presenting problem. This can especially be a problem with interpersonal therapy.
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