Individualizing Psychotherapies for Women with Depression

By Ellen Frank, Ph.D., Jill Cyranowski, Ph.D, Holly Swartz, M.D. and M. Katherine Shear, M.D.

Despite enormous progress in depression treatment, we still have clear challenges. We have long considered the goal of treatment to be full remission of symptoms and full return to functioning, not just improvement of symptoms. Yet, in recent studies, only 60% to 70% of patients responded to an initial trial of an antidepressant medication and only 25% to 50% achieved full remission. Additionally, an initial trial of Interpersonal Psychotherapy (IPT) provided by expert therapists was associated with less than a 50% remission rate in recent studies.

At the Western Psychiatric Institute and Clinic, we are currently developing modifications of standard psychotherapies for patients who have depression co-existing with other conditions and for patients who are less able to tend to their own psychological needs because of the needs of their families. We are attempting to identify patients who are unlikely to respond to standard psychotherapies before beginning a standard treatment and offering treatments tailored to their specific needs.

The Depression-Panic Combination
Our work is based on the conviction that milder manifestations of co-existing psychiatric disorders (such as anxiety) are important to understanding why standard treatments for depression don’t work as they should for some. For example, we found that while only 12% of a group of women with depression met criteria for panic disorder, fully one-third reported high levels of lifetime panic-like symptoms that did not meet criteria for the disorder. Chances of achieving remission with a course of standard IPT were 25% lower for women with panic-like symptoms. Full remission for these women took a full eight weeks longer than for women without panic symptoms.

In light of these findings, we began developing a modified form of IPT that addresses panic and anxiety symptoms. We found that patients with depression and some level of panic symptoms were particularly likely to 1) demonstrate more fears than other patients; 2) avoid conflict, strong emotions, interpersonal interactions and any tasks that seemed threatening or challenging; 3) have long-standing (rather than recent, depressive episode-related) interpersonal problems; and 4) have trouble keeping the therapy focused on their current interpersonal problems. We realized this kind of anxiety would interfere with the ordinary work we do in IPT, which depends on patients’ ability to identify their emotions, acknowledge or “name” their feelings and focus on their current interpersonal problems.

In order to try to be more helpful to these patients, we 1) worked on teaching them to identify and correctly name their unacknowledged emotions; 2) addressed the adult separation anxiety from which many of them suffer; 3) worked specifically on increasing their interpersonal assertiveness and decreasing their avoidance of conflict; and 4) taught them strategies for decreasing their tendency to avoid challenging or seemingly overwhelming day-to-day tasks.

By making these changes, we found that remission rates for patients with depression and panic symptoms rose from about 43% with standard IPT to nearly 78%, a very respectable remission rate. When we assessed these patients again three months after the end of treatment, we found that these gains had been fully maintained. In fact, their depression and anxiety symptoms had actually decreased a bit more and their functioning remained at a high level.

Engaging Challenging Patients
Another series of our studies identified the mothers of children with mental disorders as a particularly important focus of treatment development. We found that more than 60% of the mothers of children receiving mental health treatment met criteria for a current disorder, usually a depression or anxiety disorder, but more than 2/3 of these women were not receiving any treatment. This is not surprising when one considers the multiple barriers to treatment for these mothers, including stigma, fear, limited resources and the conviction that all their time and money must be directed toward their children and family.

We thought that if we could help these mothers to see how their depression was limiting their ability to best care for their families and offer a treatment that was very brief and focused, we might be able to engage them in treatment. We are now testing an eight-session version of IPT that builds on the woman’s existing strengths, focuses on resolvable problems one-by-one and makes use of between-session homework assignments. The mothers we have treated with this brief form of IPT have typically remained engaged in the treatment and accomplished remarkable changes in a very brief time frame. At the end of eight weeks, most showed a remission of depression. The remaining women were much improved, if not fully in remission. They also had experienced sizable reductions in levels of anxiety. These gains were maintained six months after the end of treatment.

Conclusion
All too often, patients seeking depression-specific psychotherapy receive a “one size fits all” approach. The new techniques we are testing take into account the individual differences and needs of patients with specific co-existing conditions and environmental issues. So far, our results have been very encouraging, with greatly increased remission rates and good prognoses for lasting remission.

Dr. Frank is Professor of Psychiatry and Psychology at the Western Psychiatric Institute and Clinic at University of Pittsburgh School of Medicine, and a member of DBSA’s Scientific Advisory Board. Drs. Frank, Cyranowski, Swartz and Shear are conducting studies under the auspices of the National Institute of Mental Health-sponsored Intervention Research Center at Western Psychiatric Institute and Clinic.