CBT for depression.

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     1  Dr Christine MIRABEL SARRON CMME Service du Professeur ROUILLON Université Paris V 100 rue de la Santé 75014 PARIS
     2  Martine, 39 years old « Everything is now very difficult for me. I lie down on my bed all day long. I can’t concentrate on books, or anything else. Everything is e problem. I don’t want people to see me in such a bad state. I am exhausted. My whole body hurts. I try to make efforts, but it does’nt work »
     3  A few figures about depression (1) In France, at least 4% of the population suffers from depression. A problem of public health : depression-disease ranks in 3rd position in Europe. 1st in the world ($2020??$) as far as women are concerned, 2nd for men, right after the cardio-vascular pathologies.
     4  A few figures about depression (2) People are concerned, whatever their age, social-professional environnement and culture. To be noted : women are twice as vulnerable as men, as well as people between 18 to 45.
     5  A few figures about depression (3) 80% of the people with a major depression are cured with an anti-depressive treatment. 50% of the depressed people are not properly treated, or not treated at all.
     6  Description Depression is predictable when : You notice some change in your beahaviour You become sad and pessimistic Any type of activity is difficult Tiredness, disturbed sleep cause disturbances in your daily-life Each has his own depression There is no minor depression
     7  Why am i depressed ? The brain-chemistry is involved. As well as genetic inheritability. Environnemental impact. Schemas of thoughts.
     8  Treatment Medication and psychotherapy : formely used separatly, nowadays combined. Treatment based on the prescription of anti-depressors. It has to be continued for a period long enough and carefully supervised. Prevention of relapse : medication and psychotherapy.
     9  Evolution with treatment (1) The improvement is not linear, but in stages. That makes you think that it has been interrupted. A few weeks later, an improvment of the physical and psychological troubles linked to the depression enables you to return to activities you were familiar with. Most of the symptoms of depression have disappeared. You get back to a normal relationship with family and collegues. You feel well, but the situation remains risky. It still takes time for brain-biological process to get back to normal. You must carry on with the treatment, as prescribed by the terapist. The depressive episode is considered to be over by the therapist who proposes a lighter treatment and, then, the end of the treatment.
     10  Evolution with treatment When the therapist proposes a lighter treatment, then, the end of the treatment, your depressive period is considered to be over. If that depressive episode is not the first one, the therapist proposes a type of medication which reduces the risk of relapse. It is known as « mood-regulators ». Keep in touch with your doctor, with a good relationship. Don’t be afraid to ask questions about your depression, now over. When you feel again calm and relaxed, think about the reasons why you had a depression. That might be a difficult exercise. That investigation has to be lead by your doctor, or even by your therapist. Remain in touch with the doctor who treated your depression. He knows you well, he knows exactly what type of depression you had and how you react to medication.
     11  Evolution Because of the relapse, the recovery periods get shorter and more and more difficult. Relapse-rate : 50% after the first depressive episode. 70% after the second one. 90% after the third one (schwenk et all. 2004).
     12  Evolution The goal of the treatment is to prevent relapse. The period of maintenance treatment is extended. The duration of maintenance treatment gets longer example : In case of relapse during the therapy as usual, WSFPP advises : to assess observance, investigate addiction – explore cormobidities – qualities of stress
     13  What is psychotherapy ? It is a psychological help with verbal interviews. Whatever the psychotheray : self-eploration, self-understanding, problem-solving The prescription of a psychotherapy is individual. Every human being is unique – There is no universal psychotherapy.
     14  What is cognitive therapy ? The patients are influenced by the perception they have of events, and not by the events themselves. Effects of cogntive therapy The patient is aware of his depressive thoughts, is able to face them with a critical mind. Gets a representation of the world more rational than emotional. Our wrong evaluations and cognitive distorsions cause an emotional, anxious and depressive suffering.
     15  Specificities A strong, participating and cooperative alliance. Use of specific interview-modalities : open questions, reformulation, prescription of home-tasks. The goal of this specific interview is to improve the learning of TCC interventions and the memorisation of the exchanges. Before and after the treatment : chimical and psychological assessment measuring the changes. When the therapy is over, the TCC strategies can be used by the patient, at home and by himself.
     16  Present indications
     17  Different stages in cognitive therapy Presentation of the cognitive model : I observe the link between thoughts, emotions and behaviour. I identify my depressive thoughts. I fight against my pessimistic depressive thoughts. I schedule my activities : initiation to the graduated home-tasks. I identity bias thoughts. I identity my cognitive schemas – training of strategies modifying the schemas.
     18  Martine’s negative thoughts
     19  Martine’s schemas I want to give a good image of myself. When someone above me oversteps his power, I feel revolted and humiliated. I can’t stand it when people fulfill their aims without any consideration towards the others.
     20  Conclusion Very frequent clinical case. A bad medication - observance. A double vulnerability : External with stress over reactivity Internal with cognitive impairments
     21  First studies
     22  Partial recovery Maintenance study
     23  TCC and booster sessions Paybel and al’study includes 158 patients with recent depressive episode receiving anti-depressing treatment, but remaining partially distressed. Randomised in 2 groups : the first one receiving only clinical treatment, the second one clinical treatment combined with cognitive therapy (Beck’s method) including 16 sessions for 20 weeks, with 2 extra-sessions (boosters). Follow-up : 1 year. The relapse-rate after a 68 week treatment is 47% in the control group, and 29%, in the group with cognitive therapy.
     24  A maintenance period Thase & al (1992) worked on the link between the residual symptoms of depression and the depressive relapses. 48 patients EDM following Beck’s therapy for 16 weeks. Patients followed up for a year. Regular reevaluations, 1, 3, 6, 9 and 12 months after treatment. 16 patients (32%) had a relapse during the following-up year. It has been noted that there was less risk of relapse (9% versus 52%) for patients completly cured with cognitive therapy than for patients partly cured. They recommend a long-term cognitive therapy for depressed patients with residual symptoms, even after treatment of acute state.
     25  Consolidation period Jarret and al (2001) compare the efficacy of cognitive therapy with and without maintainance period. 156 patients EDM participate to a cognitive therapy for 20 weeks. 84 patients (responders) were randomised in 2 groups : both with a 24 month treatment : a control-group, and a second group with the 10 maintainance sessions. The maintainance period of the therapy reduces significantly the relapse-risk (10 versus 31). For patients who remain sicky after the first period of cognitive therapy, the maintainance session improves their mood significantly. The maintainance period (30 sessions) reduces relapse and recurrence-risk.
     26  TCC and well being combined Fava & al’s study – 1998 – includes 48 depressed patients randomised in 2 groups : Therapy as usual Beck’s therapy combined with well being, with respectively 6 and 4 fifty minute sessions A 20 week therapy (10 sessions). The 2 year follow-up shows : 80% relapse in the group with therapy as usual 25% relapse in the group with combined therapy
     27  Ryff’s TCC Well being therapy – 8 sessions – a session per week. In the first 2 sessions, moments of well being are identified and experimented. The aim of the next 3 sessions using rational emotive therapy (Ellis and Harper 1961) and cognitive therapy (Beck al 1979) teaches the patient how to identify the believes linked to the end of the well being period.
     28  Mindfulness based cognitive therapy From the Kabat Zinn’s program of stress-reduction, based on the mindfulness theory (Mindfulness based stress reduction (MBSR). Teaching the recurrent depressive patients how to be aware of their thoughts, emotions and physical sensations during the remaining period. That program enables the patients $to distanciate$ Their automatic thoughts and particularly the ruminations linked to the depression. It also reduces the risk of depression-relapse.
     29  MBCT procedure After an initial assessment, an instructor leads an 8 session-program, with a 2 hour-session per week. Besides the compliance of home-tasks, an effective participation is required from the group of 12 patients. This procedure includes exercices, guided or not guided which lead the patient to an increasing consciousness of thoughts, emotions and physical sensations, and helps him how to use MBCT technics in daily-life.
     30  Effetcs of TCC Improvement of the residual symptoms. Fava and al : the residual symptoms could trend towards the evolution of previous symptoms of depression-relapse. According to them, tighting against tho residual symptoms might reduce the rate of depressive and recurrent episodes, thanks to the cognitive therapy. Improvement of the interpersonal and social functionning. Vitteng’ and al (2004, 156 patients with recurrent depression. 20 sessions with Beck’s cognitive therapy. 84 responders were followed-up for a 2 year period, including an 8 month comparative test, between a group with long-term therapy, and a control group. According to the results, the interpersonal and social functionning is improving and maintained for responders during 2 years.
     31  Conclusions Interest (importance) of psychotherapy for the recurrent relapsed patient with residual symptoms. The indication is individual. Any depression is special. To prevent from relapse, TCC recommand : A longer period for therapy (30 sessions) with consolidating sessions. A combined TCC with well being therapy, or also with MBCT, which would maintain the prophylactic effect of a long-term therapy.
     32  I thank you for your attention