Five Hundred Hours of Psychotherapy

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Five Hundred Hours of Psychotherapy

• By
• Dr. G .M. Tarrant, MD, CCFP, FCFP

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DSM-IV Criteria

• Depressed mood or markedly diminished interest or
  pleasure in almost all activities
• Duration greater than or equal to 2 weeks
• Every day or nearly every day

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And at least 5 of the following

• S leep decreased
• I nterest decreased
• G uilt or worthlessness (not major criteria)
• E nergy decreased
• C oncentration difficulties
• A ppetite disturbance/weight loss
• P sychomotor retardation or agitation
• S uicidal thoughts

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Remember!

• The symptoms cause significant stress or
  psychosocial impairment
• Not due to bereavement, gmc or drugs
• No manic or hypomanic episode
• Not superimposed upon psychotic disorders and not
  better accounted for by a schizoaffective disorder

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Epidemiology

• Lifetime risk 7-12 men and 20-25 women
• Between 5-10 of primary care patients typically
  meet the criteria for MDD
• Less than 50 of MDD patients receive treatment
  for their condition
• Of those treated 57 received all care from
  non-psychiatric physicians

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More!

• In U.S., 70 billion estimated to related to MDD
  per year (500 million in Ontario)
• 15 of severely depressed patients eventually
  commit suicide
• This excludes dysthymia 4 prevalence rate (71
  femalemale ratio) and minor depressive disorder
  10 prevalence rate

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Beck Depression Inventory

• 21 items scored 0-4
• Under 9 normal, 10-19 mild, 20-29 moderate, 30
  and up severe
• Over 35, consider personality disorder
• 2 and 9 are helpful re suicide
• Validated tool to detect depression and very
  helpful in monitoring

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Hamilton Rating Scale

• 17-21 item scale
• 15 to 30 minutes to administer
• Administered and scored by examiner
• More valid than Becks
• Gold standard of rating scales

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The MADRAS

• Montgomery-Asberg Depression Rating Scale
• Therapist rated
• More sensitive to results from pharmaco- therapy
• Used by drug companies in their research

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Medications

• Get familiar with two or three
• Forewarn patients of the side-effects
• See patient in one week and allow means for
  patient to call you in the meantime
• Allow for 3 weeks for some change in symptoms
  on the basis of this either change or increase

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Medications

• Augmentation strategies not as good as they are
  cracked up to be combination may be better
• Keep on medication for 9 months and during the
  winter months supervise discontinuation and
  contract with patient not to stop except with
  consultation (good luck!!)

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Medications and Psychotherapy

• In a number patients, medications work the best
  for vegetative and function symptoms
• Education important in explaining biopsychosocial
  role in causing depression
• The medical model important

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When to refer!!!

• Suicidal risk
• Psychotic
• Pregnant or plans to be pregnant
• Little or no social support
• Disabled by depression
• Co-morbid conditions
• Response failure

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Before you refer!!!

• Good psych history
• R/O medical condition
• Becks or Ham-D score (if possible)
• If admitted, follow-up on disposition

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Psychotherapy and Depression

• General Principles and Techniques

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Therapeutic Stance

• Warm, caring and genuine curiosity
• Non-judgmental
• Therapeutic alliance is the single most important
  factor in mainstream therapies
• Limited availability

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Empathy

• What is it?
• Absence is easier to detect than its presence
• Those who think they are empathic generally are
  less empathic
• Within 17msecs we mirror a smile or frown of
  another person

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Empathy

• Engendering empathy in a patient is a powerful
  technique
• This is done by modeling empathy for the patient
• And helping the patient to consider others
  empathically

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Hope

• Depressed patients are typically feeling
  hopeless, overwhelmed and empty
• Instill positive expectancy and hope
• The bad news is that you have depression, the
  good news is that I think I can help

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Agency

• By giving the patient agency in session, it
  helps them to exert more agency outside of the
  session (this helps the development of
  assertiveness which is generally poor in patients
  with depression)
• Silence
• Allowing the patient to generate options

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Kieslers Circumplex
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Kieslers Circumplex

• Need for control/agency
• power/dominance/status/influence
• Need for affiliation love/friendliness/proximity/c
  loseness
• We continually negotiate these two
  interpersonal forces
• Hook patient and then draw them to the middle
  of the circle

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Statement Response Reaction

• Important theme in all mainstream therapies
• If you are a hammer all you tend to see is
  nails ie. You tend to find what you expect to
  find
• Engender reflection and not reaction

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Transference, etc

• Beware of it
• The feelings that the patient elicits in you can
  be the same feelings they elicit in other people
• Dont take patients too personally
• Define boundaries

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Affect

• Sometimes it is better to bear the affect eg.
  Grief
• Note change of affect in session (also change of
  subject or change of position)
• Ask what the patient is in touch with

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Termination

• Recognize it
• Inform patient about it
• Recognize the effect on you