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Depression Research and Treatment

Volume 2013, Article ID 408983, 5 pages

Research Article
Short-Term Psychodynamic Psychotherapy in
Patients with Male Depression Syndrome,
Hopelessness, and Suicide Risk: A Pilot Study

1 2 2 1
Gloria Angeletti, Maurizio Pompili, Marco Innamorati, Chiara Santucci, Valeria
1 3, 4 1, 2, 5
Savoja, Mark Goldblatt, and Paolo Girardi
Department of Neurosciences, Mental Health and Sensory Functions and Department of Psychiatry,
SantAndrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
2Department of Neurosciences, Mental Health and Sensory Functions and Department of Psychiatry, Suicide Prevention
Center, SantAndrea Hospital, Sapienza University of Rome, 1035 Via di Grottarossa, 00189 Rome, Italy
3McLean Hospital, Belmont, MA, USA
4Department of Psychiatry, Harvard Medical School, Cambridge, MA 02138, USA
Villa Rosa Medical Research Centre, Viterbo, Italy
Correspondence should be addressed to Maurizio Pompili; Received 20 October 2012; Revised 23 December

2012; Accepted 23 December 2012 Academic Editor: H. Grunze

Copyright 2013 Gloria Angeletti et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objectives and Methods. is was an observational study of the ecacy of short-term psychodynamic psychotherapy
(STPP) in
GSMD score changes (Pearsons ; ( ) = 9.082.74; = 0.50

a sample of 35 (30 women and 5 men) patients with moderate-to-severe male depression (Gotland Scale for Male Depression
; ( ) = 0.921 .55; = 0.03

(GSMD) 13) comorbid with unipolar mood disorder (dysthymia and major depression) or anxiety disorder. Outcome measures
was only marginally reduced by

were GSMD and BHS (Beck Hopelessness Scale) score changes from baseline. Results. Patients had a strong response to STPP on
GSMD (estimated mean score change
SE ; partial eta squared ), but not on the BHS (estimated

mean score change SE ; partial eta squared ). BHS score changes were signicantly associated with
), even when controlling for the severity of hopelessness at the baseline (partial
). Conclusions. STPP proved to be eective in patients suering from male depression although hopelessness
this treatment which points to the need to better understand how STPP can be involved in the
reduction of suicide risk.

% %
1. Introduction Catchment Area (ECA) Study indicated a one-month preva-
lence between 1.7 and 3.4 [7], and more recently, the a 12-month
e term depression encompasses a wide range of condi- National Comorbidity Survey Replication (NCS-R) estimated
tions that may occur along a continuum, ranging from milder prevalence of 6.6 [8]. Nevertheless, prevalence
forms of discomfort to more severe and persistent form, as of moderate-to-severe depressive symptoms could be
in the case of major depression. Depression is the leading much higher [911].
cause of disability and the 4th leading contributor to the In 2010, the British National Institute for Health and
global burden of disease [1, 2] and by the year 2020, it is Clinical Excellence (NICE) commissioned the development
projected to become the 2nd leading contributor to the of an updated version of the guideline on the treatment and
global burden of disease in all ages and both sexes [1]. management of depression in adults [12]. e NICE guideline
Major depression is the most frequent mental illness in pointed out that people who suer from depres-sion usually
the world [36]. For example, in the US, the Epidemiological prefer psychological treatments to medication
2 Depression Research and Treatment

[13] and value outcomes beyond symptom reduction [14]. e All the patients participated voluntarily in the study
NICE guideline indicated that it was not possible to and gave their informed consent. e study was
demonstrate a consistent picture of any clinically important approved by the local IRB.
benet for short-term psychodynamic psychotherapy
(STPP) in depression. While cognitive-behavioral therapy
and inter-personal therapy continue to have the most 2.2. Measures. At intake the participants were assessed
evidence for ecacy [15], however, some randomized trials for psychopathology by expert clinical psychologists
and meta-analyses indicated that STPP could be eective through a clinical interview based on the DSM-IV-TR
in reducing symptoms and in improving functional ability of [27]. e patients were also administered the GSMD and
patients with mild or moderate depression [1620]. the Beck Hopelessness Scale (BHS: [28]).
Based on the experiences of the Gotland Study, Wlinder e GSMD [21, 22, 29] is a screening instrument for male
and Rutz [21] identied a male depressive syndrome includ- depression, consisting of 13 items which are rated on a 4-
ing low stress tolerance, acting-out behavior, poor impulse >point Likert scale from 0 (not present) to 3 (present to a high
control, substance abuse and family history of depression, degree). A score of 12 or lower indicates no depression, scores
alcoholism, and suicidality. e authors also devised an in the 1326 range indicate moderate depression, and scores
instrument to measure such syndrome, the Gotland Scale for 26 indicate severe depression [22]. e GMDS has
Male Depression [22]. Despite its name, male depression is good validity [3032].
common in women; for example, female students showed a e BHS is a 20-item scale for measuring the cognitive
greater risk of male depression than their male counterparts in component of the syndrome of depression. is scale
one study [23]. Male depression was found to be equally severe assesses three major aspects of hopelessness: feelings
in men and women who had made a nonviolent suicide attempt about the future, loss of motivation, and expectations.
[24]. Both men and women with substance abuse have a higher Responding to the 20 true or false items on the Beck
probability of having male depression and higher suicide risk Hopelessness Scale, individuals have to either endorse a
than those without substance abuse [25]. pessimistic statement or deny an optimistic statement.
To date, no psychological therapies have been assessed Research consistently supports a positive relationship
for their ecacy in the treatment of male depression. us, the between BHS scores and measures of depression, suicidal
aim of this study was to assess the ecacy of STPP in intent, and current suicidal ideation. In addition, Beck et al.
reducing male depression symptoms comorbid with mood [33] carried%out a prospective study of 1,958 outpatients
disorders or anxiety disorders in an outpatient setting. Our and found that BHS scores were related signicantly to
hypothesis is that STPP can be eective in reducing male eventual completed suicide. A cuto score of 9 or above
depression. Furthermore, we hypothesize that the reduction in identied 16 (94 ) of the 17 patients who eventually
male depression will be signicantly associated with a committed suicide. e high-risk group identied by this
reduction of hopelessness, a proxy of suicide risk. cuto score was 11 times more likely to commit suicide than
the rest of the outpatients. e BHS may, therefore, be used
as an indicator of suicide potential. An Italian version of the
2. Materials and Methods BHS has validated by the authors of the present study [34,
2.1. Participants. is was an observational study of the
ecacy of STPP in a sample of 35 consecutive (30 women
and 5 men) outpatients with moderate to severe male 2.3. Interventions. Our intervention was derived from
depression (Gotland Scale for Male Depression (GSMD) Mala-ns focused short-term technique [36, 37].
13) comorbid with an unipolar mood disorder (dysthymia and e treatment was administered in individual 45-minute
major depression) or an anxiety disorder. Patients were sessions per week for no longer than 40 sessions. STPP
admitted between January and June 2009 at the Department of explores those aspects of self not fully known, especially as
Psychiatry of the SantAndrea Hospital, Rome, Italy. Inclusion they are manifested and potentially inuenced in the
criteria were the presence of moderate-to-severe male therapy relationship [38]. It requires the psychological work
depression syndrome as assessed by the GSMD, ages to be organized around a focus (i.e., a specic, strategic
between 18 and 64 years old, and a diagnosis of a mood conictual area to reach an understanding of the
disorder or anxiety disorder. Exclusion criteria were the psychopathological picture manifesting as a crisis), and that
presence of lifetime diagnosis of delirium, dementia, amnesic or the therapist takes an active role working through the
other cognitive disorders, schizophrenia or other psychotic central conictual area in the psychic life of the patient.
disorders, anorexia nervosa and bulimia nervosa, comorbid e psychotherapists were psychologists or psychiatrists
cluster B personality disorder, current presence of severe certied as psychotherapists from the Italian Board with a
suicide intent, a score on the Hamilton Depression Rating previous training in STPP. Group supervision sessions were
Scale [26] of 28 or higher, and the inability to complete the carried out weekly allowing psychotherapists to discuss their
assessment for illiteracy or the denial of informed consent. cases with senior psychotherapists/supervisor.
As concomitant psychotropic medication, only
benzodi-azepines at a maximum of 3 mg lorazepam
equivalent per day were allowed. 2.4. Analysis. e primary outcome measure was the mean
GSMD score changes from baseline. e secondary outcome
Depression Research and Treatment 3
T1: Outcomes.

Estimated Eect size

Variables dierences
(M SE) (partial eta squared)
14.3 85.7

% SD 40.00 12.57
erapy durationmonths
7.21 2.03

Baseline BHSM
Follow-up BHSM
SD SD 9.03
4.90 5.17
0.92 1.55 0.57 0.03

Baseline GMDSM SD
9.08 2.74 0.01 0.50
Follow-up GMDSM 15.54

Multivariate test of within subject e ect: Wilks ; = 5.11;

. 3: no hopelessness; BHS between 4 and
moderate depression; GMDS 26: severe depression. BHS
GMDS 13: no depression; GMDS between 13 and 26: 2;10
8: mild hopelessness; BHS 9 moderate-to- severe hopelessness. =0 .5 1

was mean score changes from baseline on the BHS. Response 4. Discussion
to treatment was assessed with a general linear model e results of this pilot study of short-term psychodynamic
for repeated measures. Dierences between baseline and
followup are calculated on the estimated marginal means psychotherapy for male depression are mixed. We found
( ). Partial eta squared ( ) are reported as measures of that self-ratings of depressive symptoms were signicantly
eect size. Associations between response on the GSMD and improved, suggesting that this therapy is eective for depres-
and partial sive symptoms in these patients.
on the BHS were assessed through Pearsons

Self-ratings associated with increased suicide risk were

indices of correlations. All the analyses were performed with
for Windows not signicantly aected over the course of treatment. Even
the statistical package for social sciences SPSS those patients who reported a signicant response on the
19.0. MINI-based suicidal risk a er treatment showed no improve-
ment on the BHS. is result is consistent with other studies,
3. Results such as that of Linehan et al. [39], which showed a reduction
in the risk of suicide a er a psychotherapeutic intervention,
e mean age of the patients was 40.0 years (SD ; but no signicant changes between baseline and posttreat-
ment in BHS scores. However, cognitive behavioural therapy
Min./Max.: 20/62), years for men and proved to be superior in the reduction of hopelessness

years for women. Sixty percent of the patients had a diagnosis

= 12. 6 (a proxy of suicide risk) compared to other therapeutic

40. 3 19. 6
(mostly, generalized anxiety, panic attack
40.0 12. 1
interventions [40].
of anxiety disorders

disorder, and anxiety disorder not otherwise specied), 26

were diagnosed with dysthymia, and 14 were diagnosed Although suicide risk has most o en been studied in
with a major depressive disorder. % Psychotherapy sessions were carried out for a mean of 7.2
the context of depressive symptoms, it remains unclear what
distinguishes those depressions with lethal outcome from

% those in which the patients do not attack themselves.

months (SD ; range, 510) (see Table 1). At baseline,
It should also be noted that these treatments took place
mean GSMD scores were 23.6 (SD ; range, 1437). Six-
ty-three percent of patients scored 9 or more on the BHS at in a public psychiatric setting where their sessions are part of
= 2.0
baseline ( ). = 6. 1 the government supported public health system, and patients
Patients had a signicant strong response to the psycho- paid a small additional fee. While there are dierences
psychotherapy on the GSMD ( SE between sessions taking place in a therapists oce and those
in the rooms of an outpatient clinic (due to changes in the set-
dynamic 10.5 4.9

; ; 2 ), but not on the BHS ( = SE

=0 9.0 8 ting from time to time, hospital furniture, white coats around,
2. 74 ; ;.50 ). Mean changes on outcome =
etc.), every eort was made to maintain standard procedures
2 and provide a good test of STPP. Nevertheless, we must admit
treatments (Pearsons from 0.06 to 0.16), nor with the that discussion over the delivery of such psychotherapy in
measures were neither associated with the length of the

0.9 2 1.55 =0 .0 3 public environment was o en raised nationwide, pointing to

baseline severity of male depression (Pearsons between 0.05
hopelessness (Pearsons ). Only mean caution in the generalization of our results.
and 0.07), or
BHS score change was moderately associated with baseline Such important considerations may explain decits in
severity of hopelessness ( ; ). outcomes as compared with modalities in which STPP is
Furthermore, mean GSMD score change was signicantly currently practiced. that our original model was
score change (Pearsons ; It should also be noted
associated with BHS derived from Malans technique; our approach shared prin-
), even when controlling for the severity of hopelessness
at the baseline (partial ; ). ciples with Davanloos method [41, 42]. Although it is
0.00 1
4 Depression Research and Treatment

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