Making a Difference in Overcoming Depression: The Case for Psychoeducation as a Treatment Enhancement
By: Robert Dyer, Ph.D.
Published exclusively for guests of Allied Behavioral Technologies.
Introduction
Over seven per cent of the population experiences the phenomenon of depression at any given time. The range is from transitory coping with loss, to pervasive feelings of helplessness and hopelessness.
All of us experience the “blues” from time to time. All of us grieve at the loss of a loved one or a major change in our way of life (as in a move or divorce) or the loss of use of a function we had (as in our diminishing capabilities with aging or accidents). What separates the normal coping with the negatives which life forces on us and clinical depression is the pervasiveness and invasiveness of the feelings.
Society pays a large bill for depression. The recognition that depression can be a crippling brain disorder is best exemplified by the World Health Organization finding that depression is the second leading cause of disability (National Institute of Mental Health, 1999). Job absenteeism, diminished energy, sleep disturbances, appetite disturbances, apathy, suicidal ideation all create a cluster of obstacles to a satisfactory, fulfilling life. Depression can profoundly and adversely impact an individual and their relationships.
The impact of depression is further accelerated when it co-occurs with other physical disorders:
- People with heart disease have a four times as great of chance of heart attack if they are also depressed. Some 20-40% of people experiencing myocardial infarctions are depressed within six months following the event. (N.I.H., 1999).
- When depression co-occurs with diabetes increased symptomatology occurs and the patient quality of life suffers. Cost of care received is over sixty per cent greater. Incidence of depression is thirty per cent of people suffering diabetes (American Diabetes Association, 1999).
- 40% people experiencing Parkinson’s disease are depressed. This and the following from Goldman et.al. 1999.
- 50% people experiencing Huntington’s disease are clinically depressed.
- 25-50% people experience depression within year after stroke.
- 30-35% people with Alzheimer’s experience depression.
- 60% people suffering chronic pain experience depression.
- 37% people suffering spinal cord injury experience depression.
Recognizing Clinical Depression
The various forms of clinical depression are defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Version IV (known as DSM-IV).
Clinical depression significantly invades people’s lives: The following are often found in people experiencing depression:
- Appetite changes (significant weight loss or gain).
- Sleep disturbance (insomnia- difficulty going to sleep or early morning wakening-or sleeping too much).
- Changes in activity level (most often slowing down, but sometimes being restless).
- Loss of interest or pleasure in usual activities.
- Loss of energy, fatigue.
- Difficulties in concentration.
- Feelings of hopelessness or helplessness to impact own life.
- In a percent of people with recurrent thoughts of death or suicide.
Since three quarters of people suffering depression first seek help from primary care physicians (as opposed to mental health professionals) screening becomes a major issue. The Symptom-Driven Diagnostic System for Primary Care and the Primary Care Evaluation of mental Disorders represent patient administered diagnostic screening tools that can quickly aid primary care recognition of depression.
Typical Treatment
The most common treatment episode involves seeing the primary care physician and receiving an antidepressant medication.
The medications received for the treatment of depression are well known to many people. For example, over 20 million people take Prozac alone annually. Fifty per cent of people successfully taking medication show improvement within six months.
There has long been an issue of the preferred mode of care. Research has shown psychotherapy to achieve equal outcomes to medication. The issues involved in psychotherapy have been related to access to care (i.e. 75% of people first go to their family doctor for treatment) and cost (psychotherapy costs more than medication alone). The research literature indicates that people improve more when they receive expert assistance in addition to medication. Wells (2000) has shown that when people receive medication and additional care provided by a mental health professional they improve their outcomes over twenty per cent. (Wells, 2000). The issue for society revolves around cost effectiveness. The Agency for Health Care Policy and Research, through its Depression Guideline Panel, has recommended primary care physicians try two courses of medication before referral for psychotherapy (AHCPR Publication 93-0550,1993).
What seems to be needed to improve outcomes is an inexpensive, practice based way to provide education and support to patients receiving medication to augment their medication-taking compliance as well as to stimulate energy and purpose.
Psychoeducation
The notion that skill training can assist traditional treatment is not new. There is a considerable body of research to attest to the impact that learning basic skills and when to apply them may make on quality of life (Marder et.al., 1996, Liberman et.al, 1986, Liberman et. al., 1998).
Specific to the treatment of depression, Antonuccio et. al. (1995) reviews outcome studies on the treatment of depression, distilling the results of various modes of care. One of the earliest, well-controlled studies compared insight-oriented psychotherapy, behavioral skill treatment and the use of tri-cyclic medications (McLean and Hakstian, 1079). They found the skill training superior on nine of ten outcome measures. They found it significantly superior on follow-up. They found significantly fewer treatment drop-outs (5% vs. 26 & 36% respectively). Additionally on long term follow up the effects endured superior to all types of care received (McLean and Hakstian, 1990)
Antonuccio et. al. reports the significant effect of specific psychoeducational approaches. They call out the significant impact psychoeducation adds to results in the Brown and Lewinsohn (1984) study. Brown and Lewinsohn demonstrate significantly that psychoeducation is safe; time- efficient; has lower dropout rates; long lasting effects and is cost-effective. They note the reluctance for use seems rooted in treatment funding issues rather than effect. Medication has historically been reimbursed by insurers at a level of at least 80 per cent of charges. Traditional psychotherapy has historically been reimbursed at a level of 50 per cent of charges. Group activities often are reimbursed at a lower level. Capitation, the use of physician extending personnel in practices and the pressure of competition among practices for patients seem to be encouraging the use of powerful techniques such as psychoeducation to be reinstated.
One of the more thorny issues in psychoeducation is the replicability of impact. Can assessment, training and application generalize across the trainers and outside the setting in which it was learned? Wallace et.al. (1992) investigated common social skills training in twenty- eight facilities. Materials for five domains of social skills were created. Interventions involved:
- Patient education,
- Videotape demonstration,
- Role- playing practice,
- Solving environmental resource problems (i.e. housing, money, etc.),
- Solving outcome problems (i.e. anticipating future symptoms),
- In vivo exercises, and
- Homework
Facilitators from seven organizations received a two-day training on materials including a trainer’s manual and a participant’s workbook. The manual specified scripts for the trainers. The modules contained nearly forty sessions. The trained facilitators were of varied backgrounds; nurses, residential aides, recreation therapists and master’s level mental health professionals. Experience was varied from less than one month to over a decade.
The training effect was measured. Adherence to instructional techniques was measured by observations. The percent of trainer behavior that matched those specified in the manuals was measured. A learning effect was deemed present in all but one location.
Reviewing the discrete aspects of psychoeducation to determine their respective contributory effect has led to understanding more about the elements of the process. Barton (1999) investigated skill training, peer support and community system development (among others). Skill training was found to make the greatest single impact. In this study, skill training reduced the total cost of care over fifty per cent.
Methodology on the Meta messages of the scripts facilitators use is also an area of investigation. Clark and Dodge (1999) explored adherence to interventions in 570 women receiving training for diet, exercise or stress management. They learned that participant’s beliefs that they would change at the beginning of the intervention were most strongly correlated with the results, (i.e. those believing they would improve- did, those unsure had less impact in results). Rothman and Salovey (1997) sought to directly influence this concept of self-efficacy that is the belief that one can carry out new behavior to reach a personal goal. Their review indicated the following:
- Presentations displaying only positive change as a result of participation resulted in low adherence. (The authors reasoned people are conservative when contemplating personal change and they will not participate if only the upside is presented.)
- Arguments to change “or you will experience dire consequences” had little effect.
- Programs presenting a certain percent of negative outcomes for participants had low levels of accommodating behavior.
- The odds of positive change were greatest when participants were told that some percent of participants will improve (i.e. at outset all are told that 2/3 of participants will experience improvement as a result of this training).
An Example of Treatment Enhancement
One example of a treatment enhancement program is Brio! This
psycho-educational program is designed to provide a cost-effective practical
learning and skill-building experience for adults coping with depressive
thoughts and feelings. The Brio! Program provides a productive, supportive
enhancement of traditional behavioral health services for adults who are high
utilizers of services. In the Brio! Program, participants have an opportunity to
develop life skills that may enable them to benefit more effectively from
therapy in the present or the future.
Brio! provides a structured approach to supporting change in areas of high
frequency need for psychotherapy patients. The six modules include:
· Definition of Depression
· Internal Environment
· External Environment
· Communication
· Health
· Coping Over the Long Haul
Brio! uses adult learning technologies and selects most frequently needed
content areas from high use psychotherapy patients. Each session is designed for
ninety minutes of instruction, interaction, skill application and skill building
practice. Participants’ families are also attended to in the program.
Facilitators may utilize the company’s (Navik Solutions) web site to build
additional sessions or additional content modules. Participants in the program
can use the web site to keep a personal journal, set goals, and get additional
assistance from other participants and behavioral health professionals.
Each Brio! session is set up to present the materials using the following model:
· Presentation of new material
· Determining application of new skills
· Practicing the new skills in a supportive environment
· Implementing the new skills between sessions
· Reporting and discussing the implementation in the following session
Summary
It is well known that depression affects a major portion of the population at some time. And, that a tremendous price, not only financially, but also emotionally and socially from this disorder. We have made tremendous strides in the treatment of depression with medication and psychotherapy. This is an effective regime, but all too often is expensive beyond the person’s capabilities to participate. Psycho-educational programs when well designed and executed can be very effective in extending and enhancing medication and psychotherapy programs. These programs, such as Brio! are cost-effective and provide a well-rounded intervention which empowers the depressed person to fully utilize all of the options available.
Resources
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