Current Developments in

Health Psychology
Univ.- Prof. Dr. Heather Foran
Summer semester 2023
Outline
• Definition of depression and epidemiology
• Common treatments and their efficacies
• International and national treatment guidelines
• Public health implications, intersections with
health psychology practice

2
Major Depressive Episode

Nearly every day for at least two weeks

At least 5 of the following:
1. Depressed mood
2. Loss of interest or pleasure
3. Fatigue or loss of energy
4. Insomnia or hypersomnia
5. Weight gain or loss
6. Psychomotor agitation or retardation
7. Feelings of worthlessness or inappropriate guilt
8. Trouble concentrating or making decisions
9. Suicidal thoughts

3
Persistent Depressive Disorder (DSM-5)

• Depressed mood for most of the day, for more days than not, for at
least 2 years
• 2 or more of the following
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty with decisions
6. Feelings of hopelessness

4
Prevalence and Course

• Major Depression Episode (Bromet et al., 2011)

• 6% 12-Month
• 15% Lifetime
• Chronic Depression (Blanco et al. 2010; Jacobi et al. 2004)
• Symptoms for at least 2 years
• 4% Lifetime
• Average Age of Onset (Bromet et al., 2011)
• Mid-20’s, although can occur throughout lifespan
• Reoccurrence (APA, 2000; Kessler & Walters, 1998; Post, 1992)
• 50% for one episode
• 80% for two or more episodes
5
Sociodemographic Risk Factors

• Relationship status
• 3 times as likely if not married
• Gender
• 2 times as likely among women (Bromet et al. 2011)
• Differences emerge during adolescence (Petersen et al.,
1991)
• Postpartum depression affects 16% of women (O’Hara &
McCabe, 2012)
• Income and Employment
• Among poor, 2 times as likely
• Among unemployed in Germany 20% (Jacobi et al. 2004)
6
Detrimental Impacts of Depression

• Leads to Functional Impairment

• Lost days of work, inability to work
• Social Relationships
• Physical health
• Risk factor for Suicide
• 20 times higher rate than general population (Harris & Barraclough, 1997)
• Economic costs (Olesen et al. 2012)
• 92 billion Euros of economic burden in 2010
• 179 Euros per person in Europe in 2010

7
Comorbidities

• Physical health conditions (obesity, diabetes, heart disease,

chronic pain) May be cyclical relationship (e.g., obesity leads
to depression which leads to obesity; Luppino et al. 2010).
• Anxiety, social anxiety is a risk factor for severe depression
(Beesdo et al. 2007 – 30 year prospective study)
• Personality disorders (risk for severity and poor treatment
response, Michels, 2010)

8
Multimorbidities: Depression and Physical
Health
• Multimorbidity is defined as 2 or more chronic conditions
• Depression is associated with increased health problems when
examined for 1, 2, 3 or 4 more physical health conditions (Stubbs et
al. 2017)
• This was found in a recent study of 43 countries.
• The odds ratio across studies was 3.3 for multimorbidity of
depression and physical health conditions in low and middle income
countries.
• Other review found 2 to 3 times more likely to have depression in
people with multimorbidity compared to those with no chronic
physical health condition (Read et al. 2017)
• Also increases health care costs and utilization → recommendation
more integrated care (e.g., primary care and mental health care)
Soley-Bori et al., 2021

9
 Biopsychosocial Model of Depression

Gene-environmental interactions
Neurotransmitter deficits
Impaired regulation of neural systems
Early history of trauma Depression
Certain cognitive styles
Lack of behavioral reinforcers
Impaired interpersonal relationships
Loss
Other mental disorders (e.g., anxiety)
Other psychosocial factors (job loss)
Chronic pain and physical illnesses
10
Prevention of Depression via Reducing
Maltreatment (Li et al. 2016, Psychological Medicine)

 A 10-25% reduction in
maltreatment → 31 to 80
million cases of depression
worldwide

 And not just depression…

– Infections
– Cardiovascular diseases
– Diabetes
– Cancer
– Autoimmune diseases

11
Aversive childhood experiences and risk for
Depression
• Child maltreatment increases risk for poor health outcomes
• Including:
• Depression
• Drug and alcohol abuse
• Anxiety
• Eating disorders
• Suicide
• Post-traumatic stress disorder
• Adult Relationship difficulties
• Low health-related quality of life
• The lifetime prevalence of depression is related to the number of
aversive childhood experiences in a dose-dependent manner
• Odds ratio of depression when ACE score is 0 = 1 (no increased risk)
• Odds ratio of depression when ACE score is 3 =3.0 (2.4 – 3.7 CI)
• Odds ratio of depression when ACE score is 2 =1.8 (1.5 – 2.2 CI)

Chapman et al. (2004), Journal of Affective Disorders

12
Li et al. (2016), Psychological Medicine
 Treatments for Depression

Psychological Treatment Control condition

Randomized Controlled Trials

Antidepressant Medication Placebo Pill

13
 Common Antidepressant Medication (ADM)
Types
First generation ADMs Second generation ADMs

Tricyclic Monoamine oxide Selective Serotonin norepinephrine

antidepressants inhibitors serotonin reuptake inhibitors
(TCAs) (MAOIs ) reuptake inhibitors (SNRIs)
(SSRIs)

1950 1960 1970 1980 1990 2000 2010

Bupropion (Atypical
Antidepressant) 14
Antidepressant medications (ADM)

• SSRIs, most prescribed in many countries, and considered a first line

ADM treatment
• Mechanism: Blocking the reuptake of serotonin at the presynaptic
nerve cell
• Takes 2 to 6 weeks to work

Fluoxetin (Fluctin)
Sertralin (Zoloft)
Paroxetin (Seroxat)
Citalopram (Cipramil)

15
ADM common side effects

• Sexual dysfunctions
• Weight gain
• Gastrointestinal symptoms
• Sleep disturbances
• Suicide risk for those under 24
• Largely contraindicated for pregnant women

Noncompliance through premature discontinuation and missed doses

is high – 70%
28% stop in the first month
44% stop by the third month

16
 Treatments for Depression
Randomized Controlled Trials

versus

Antidepressant Medication Placebo Pill

17
Study Design

• Typically Double or Triple Blind

Assigned treatment not known to doctor, assessor, and patient
• Outcome measures:
• Hamilton Depression Rating Scale (clinician rating)
• Beck Depression Inventory (self-report)
• Both have cut-off scores
to define severity.

18
Scoring Severity of Depression on the
Hamilton Rating Scale (HAM-D)
• Normal = 0-7 (Remission status)
• Mild depression = 8-13
• Moderate depression = 14-18
• Severe depression = 19-22
• Very severe depression ≥ 23

Mild - 10%
Moderate - 38%
Severe - 39%
Very Severe -13%

19
Clinical Trial Database

• Food & Drug Administration, National Institute of Health, National

Library of Medicine
• Created based on US laws passed in 1997; 2007

• Publically available since 2000, expanded after 2007 law with more
data available since 2008

• World‘s largest clinical trial database available

20
Other clinical trial databases

• World Health Organization Database:

• https://www.who.int/clinical-trials-registry-platform
• German registry:
• https://www.drks.de/drks_web/navigate.do?navigationId=start&mes
sageDE=Home&messageEN=Home

21
Steps in Clinical Trial Disclosure
Before Study Starts

• Ethics Review and approval

• Initial Registration

During Study

• Updates to registry

After Study Completion

• Reporting of Results

Tse et al., 2012 22

 Clinical Trial Database
• Includes
• Over 370,00
studies
• Data from 219
countries
• Ongoing studies
registered

http://www.clinicaltrials.gov/ct2/results/map/image?term=depression
23
Depression

• Over 7000 studies „depression“

• If search with general term, depression, then find 23967 studies
• Can specically search for studies using a measure like the HAM-D
„hamilton“
• Can search for combination studies on depression and health
conditions.
• For example, heart disease and depression:

24
Clinical Trial Database
• Europe
• 546 studies in DE→ now 1407
• 109 studies in AT→ now 333

• Value
• Research ethics
• Scientific progress

http://www.clinicaltrials.gov/ct2/results/map?term=depression&map=EU 25
Meta-Analyses of RCTs: Antidepressants
versus Placebos
• Studies have analyzed the FDA database of all registered drug trials and re-
analyzed raw data of aggregate studies.
• Turner et al. 2008, New England Journal of Medicine
• N = 12,564 patients in the FDA database, 74 trials
100%

90%

80%

70%

60%

50% Positive Result

Negative Result
40%

30%

20%

10%

0%
Published literature Total FDA databasae
26
Effect Size Measurement
• Cohen’s d
• .2 considered small effect
• .5 considered medium effect
• .8 considered large effect

27
 Fournier et al. 2010, JAMA

Medium Effect Sizes for Antidepressant Medication

0,5
Effect
0,45

0,4

0,35

0,3

0,25
Small 0,2
Effect
0,15

0,1

0,05

0
Mild to Moderate Severe Very Severe

28
Severity of Depression

Mild - 10%

Moderate - 38%

Severe - 39%

Very Severe -13%

29
New Study just Published 2018….
„Antidepressant drugs do work, review on almost 120,000 patients concludes
Effectiveness of 21 drugs varies widely, but all were more effective than placebo“

Thomson Reuters · Posted: Feb 22, 2018 10:58 AM ET | Last Updated: Feb. 22

http://www.cbc.ca/news/health/antidepressants-meta-analysis-
1.4546709
30
Cipriani et al. 2018; Lancet

• Review study of Antidepressant effectiveness

• Sample – 28 552 citations, 522 trials, 116 477 participants
• They found overall that antidepressants were more effective than
placebos (Odds ratios ranged from 2.13 and 1.37, favoring
medication over placebo).

• However, how confident can we be in these results?

• The authors conclude:
• “All antidepressants were more efficacious than placebo in adults with major
depressive disorder.”
• “46 (9%) of 522 trials were rated as high risk of bias, 380 (73%) trials as
moderate, and 96 (18%) as low; and the certainty of evidence was moderate
to very low.”

31
Searching process, some examples

• “The electronic database searches were supplemented with manual

searches for published, unpublished, and ongoing RCTs in
international trial registers, websites of drug approval agencies, and
key scientific journals in the field.8 For example, we searched
ClinicalTrials.gov using the search term “major depressive disorder”
combined with a list of all included antidepressants. We contacted all
the pharmaceutical companies marketing antidepressants and asked
for supplemental unpublished information about both premarketing
and post-marketing studies, with a specific focus on second-
generation antidepressants. We also contacted study authors and
drug manufacturers to supplement incomplete reports of the original
papers or provide data for unpublished studies.”

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889788/

32
Conflict of Interest Statement for this Paper

• Declaration of interests
• ACi is supported by the National Institute for Health Research (NIHR)
Oxford Cognitive Health Clinical Research Facility. TAF has received
lecture fees from Eli Lilly, Janssen, Meiji, Mitsubishi-Tanabe, Merck
Sharp & Dohme, and Pfizer; consultancy fees from Takeda Science
Foundation; and research support from Mochida and Mitsubishi-
Tanabe. SL has received honoraria for consulting from LB Pharma,
Lundbeck, Otsuka, TEVA, Geodon Richter, Recordati, LTS Lohmann,
and Boehringer Ingelheim; and for lectures from Janssen, Lilly,
Lundbeck, Otsuka, SanofiAventis, and Servier. NT has received lecture
fees from Otsuka and Meiji. YH has received lecture fees from
Yoshitomi. JRG is an NIHR Senior Investigator. All other authors
declare no competing interests.

33
Strengths

• Largest study to date

• Includes data that was previously included in other reviews
• They published their study protocol BEFORE the study
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947714/

• Data is made publically available through Mendeley Data, a secure

online repository for data. DOI:10.17632/83rthbp8ys.2
• Limitations are well documented in the manuscript

34
Study Limitations

• “Additionally, because of the paucity of information reported in the

original studies, we were not able to quantify some outcomes, such
as global functioning. It should also be noted that some of the
adverse effects of antidepressants occur over a prolonged period,
meaning that positive results need to be taken with great caution,
because the trials in this network meta-analysis were of short
duration. The current report summarises evidence of differences
between antidepressants when prescribed as an initial treatment.
Given the modest effect sizes, non-response to antidepressants will
occur. Our information unfortunately cannot guide next-step choices
after failure of such a first step (ie, they do not apply to treatment-
resistant depression), for which well performed trials are scarce.29”

• 29. Furukawa TA, Akechi T, Shimodera S. Strategic use of new

generation antidepressants for depression: SUN(^_^)D study
protocol. Trials. 2011;12:116.

35
New ADM for Postpartum Depression?

https://www.vox.com/science-and-health/2019/3/20/18274133/postpartum-
depression-sage-therapeutics-brexanolone
36
FDA approved this “Zulresso”

• Approval granted to Sage Therapeutics, Inc.

• First approval by FDA for postpartum depression specificially
• Intravenous (IV) use
• Continuous IV infusion over 60 hours
• Risk for loss of consciousness
• Must be monitored when interacting with their children
• Available late June 2019

• https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm633919.htm?utm_campaign=FDA%20approves%20first%2
0treatment%20for%20post-partum%20depression-%20Drug%20Information&utm_medium=email&utm_source=Eloqua

37
What is the evidence?

• Three trials
• Trial one (21 women with severe postpartum depression, HAM-D >=
26)
• Randomized to placebo or drug (Brexanolone)
• Follow up at 30 days

Treatment (n = 10) Placebo (n =11)

HAM-D score pre = 28 HAM-D score pre = 29
HAM-D score post = 7 HAM-D score post = 20

https://www.uptodate.com/contents/severe-postpartum-unipolar-major-depression-treatment/abstract/43

38
What is the evidence?

• Next studies:
• N = 138 and N = 108 and N =21 (3 trials, N = 267 in total; Zheng et al.
2019)
• https://clinicaltrials.gov/ct2/show/NCT02942004
• https://clinicaltrials.gov/ct2/show/NCT02942017

• Keep in mind this is only approved for severe cases.

• More replications and follow-ups are needed.

• Attachment to the child not considered in the outcomes

39
Effectiveness Trial – STAR*D

• In clinical practice, if a patient doesn’t respond to

one antidepressant a second may be prescribed or
substituted
• Sequenced Treatment Alternatives to Relieve
Depression –STAR*D
• Largest and longest study of antidepressants
• 41 sites and over 4,000 patients

40
Effectiveness Trial – STAR*D
• Did not find a lot of differences in responsiveness to one ADM versus
another
• In ADM trials, remission rates are typically 35% to 45%, so remission
after 1 trial was lower than expected

STAR*D Trial Percent of Sample

Remitted
Over 1,000 participants 80
70
stopped early due to 60
50
medication intolerance 40
30
20
10 STAR*D Trial Percent of
0 Sample Remitted

41
Antidepressant Medications

•Long-term Effects
• In STAR*D trial, relapse was over 40% of those
who stayed in
• Patients may be on medications indefinitely
• Evidence that antidepressants lose their
effectiveness with increased exposure to ADMs
(Amsterdam et al. 2009; Leykin et al. 2007)

42
Another meta-analysis (Maslej et al. 2020)…

• They examined 87 randomized clinical trials

• One main finding was that there was more variability in the response
to anti-depressants than placebo.
• Suggests that may be individual differences that are important for
this variability in response.

43
Summary: Antidepressant Medications

•Do they work?

• New evidence that they work compared to placebo
• Strong evidence for severe forms of depression
• Less side effects with some newer medications, but still a concern
• Long-term effectiveness also a concern

44
 Treatments for Depression

Control Condition

versus

Psychological Treatment 1

Psychological Treatment 2
45
Common Brief Empirically-based
Psychological Treatments

• List is not exhaustive!

• Cognitive Therapy (CT)

• Interpersonal Therapy (IPT)
• Behavioral Activation (BA)

• Specialized Treatments
• Cognitive Behavioral Analysis System of Psychotherapy for Chronic
Depression
• Mindfulness-based Cognitive Behavioral Therapy for Recurrent Depression
• Couple therapy for Depression

46
Development of Psychological Treatments of
Depression

IPT

Cognitive Therapy CBASP for chronic Behavioral

depression Activation

1980 1990 2000 2010

Couple Therapy Mindfulness –

based CBT
for relapse
prevention
47
Cognitive Therapy (Beck et al. 1979)

• Therapeutic Focus
• Changing irrational thought patterns and related behaviors
• Connecting thoughts, feelings and behaviors
• Types of therapeutic activities
• Testing depressogenic beliefs empirically
• Homework assignments such as thought logs to increase awareness of
contingencies

Event Belief Consequence Counter-belief

Meeting new people with “No one will be Feel sad, anxious “I have some good
a physical illness interested in me because Avoid others qualities that some
of my illness.” people will appreciate. I
am more than just my
illness.”

48
Beck‘s Cognitive Model of Depression

https://www.google.at/search?q=beck%27s+cognitive+model&client=firefox-b-
ab&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj2lPL14v3SAhVEsxQKHVX6AwMQ_AUICCg
49
B&biw=1920&bih=914#imgrc=BiKsH23c4fonGM:
 Behavioral Activation (Jacobson et al. 1991)
• An elaboration of a component of Cognitive Therapy
• Therapeutic Focus: Doing is what is most important for change
• Identifying behavioral chains related to depression
• Changing avoidant behaviors and increasing reinforcing behaviors
• Avoidance may make physical illness and pain worse

Avoidance

Behavior → Punishment → Reduction of the Behavior in the Future

Asking someone out → Rejection → Stop asking women out,

Loneliness, depression

Positive Reinforcement

Asking someone out → Success → Companionship

50
Interpersonal Therapy (Klerman et al. 1984)
• 12-20 Sessions
• Therapeutic Focus
• Interpersonal problems that may play a role in onset and maintenance of
depression
• (Will discuss this in relation to chronic pain later in the semester)
• Themes focus on
• Unresolved grief
• Interpersonal disputes
• Role transitions
• Interpersonal deficits

51
Developers

• Gerald Klerman, Psychiatrist (Pittsburgh)

• Myrna Weissman, Psychologist (1984)

• German replication: Elisabeth Schramm, Freiburg (1996 German

version)

52
Evidence for Psychological Treatments based on
Meta-Analyses
(Butler et al., 2006; Cuijipers et al. 2010; Cuijipers et al. 2011; Cuijipers et al. 2008)

Effect Sizes (Cohen's d)

Large 0,9

Effect 0,8

0,7

0,6
Medium
Effect 0,5

0,4

0,3

Small 0,2
Effect 0,1

0
CT v. Control BA v. Control IPT v. Control CT v IPT CT v BA
-0,1

-0,2

53
CBT versus IPT
Jakobsen et al. 2012; meta-analysis of 6 trials comparing CBT versus IPT
Found no significant difference in outcome for two treatments, although
tendency to favor CBT.

2
IPT Mean difference in BDI
0
Total scores
-2

CBT -4

-6

-8

-10

-12

54
 Psychological Treatments
• In studies of Cognitive Therapy and Behavioral Activation, but not
Interpersonal Therapy, publication bias was found
(Cuijipers et al. 2010 British J Psychiatry; Cuijipers et al. 2011; American J Psychiatry)

0,8

0,7

Medium 0,6

Effect 0,5
Effect size
0,4

0,3 Effect size accounting for

Small 0,2
publication bias

Effect 0,1

0
Cognitive Therapy Behavioral Interpersonal
Activation Therapy

55
 Treatments for Depression

versus
or in combination
with
Psychological Treatment Antidepressant Medication

56
Comparison studies
Elkin et al. 1989 ADM CT IPT Placebo

DeRuebis et al. 2005 ADM CT Placebo

Dimidijian et al. 2006 ADM CT BA Placebo

57
Comparison studies: Results
Elkin et al. 1989 ADM CT IPT Placebo

DeRuebis et al. 2005 ADM CT Placebo

Dimidijian et al. 2006 ADM CT BA Placebo

Conclusion from these studies: ADM and psychological

treatments are equally effective and better than placebo

Two stars indicate equally effective but better

than placebo.

58
Combined Studies

Lesperance et al. 2007 ADM ADM + IPT Placebo + IPT Placebo

Blom et al. 2007 ADM IPT ADM + IPT Placebo + IPT

Schramm et al. 2007 ADM ADM + IPT

ADM Better than placebo. No significant

differences found for other groups.

ADM + IPT better than ADM. IPT, ADM + IPT or Placebo +

IPT no significant differences 59
Combined Studies: Conclusion

• Cuijipers et al. 2009 Meta-analysis

• Combined ADM + psychological treatment is better than

psychological treatment alone.

• Effect size d = .35.

60
 Bidirectional cortico-limbic interaction in depression

Prefrontal cortex: important for planning complex

cognitive behaviors, decision making and social
behaviors
Amygdala: important for emotions and motivation
DeRubeis et al. Nat.Rev.Neurosci. 2008 61
Long-term Outcome

• Do treatments differ in risk for relapse?

• Patients treated with CT were half as likely to relapse at 1
year (26%) as those treated with antidepressants (64%)
and no different than those kept on medications (Hollon
et al. 2005; DeRubeis & Crits-Christoph, 1998)
• Similar findings for BA and IPT
• However, without some type of follow-up treatment, risk
for relapse within 2 years, is still high – 54% for CT
(Vittengl et al. 2007)

62
Depression among Cancer Patients (will discuss
more about cancer later in the course)
• Depression treatments need to be tested in patient groups with
specific health issues.
• Depression is common among cancer patients, for example
• Evidence that group-based cognitive behavioral interventions for
breast cancer survivors can reduce depressive symptoms compared
to control group over 1 year follow-up period.
• Randomized controlled trial of 10 week group intervention compared
to 1 day psychoeducational training.
• Followed over 5 years
• N = 240
• Found significant differences in depressive symptoms at 5 year follow-up,
supporting evidence that the intervention is effective.

Stagl, Jamie M.,Antoni, Michael H.,Lechner, Suzanne C.,Bouchard, Laura C.,Blomberg, Bonnie B.,Glück,
Stefan,Derhagopian, Robert P.,Carver, Charles S. Health Psychology, Vol 34(2), Feb 2015, 176-180

63
Why Consider CBT for the Treatment of
Major Depression?

• Acceptable
• Recent meta-analysis indicates that psychotherapy is preferred
3:1 to pharmacotherapy for depression (McHugh et al., 2013, J
Clin Psychiatry)
• Efficacious and Cost-Effective
• CBT is more cost-effective than pharmacotherapy over follow-
up periods) (Dobson et al. 2009)
• Long-term Maintenance of Gains
• CBT has enduring effect over time (Cuijpers et al., 2013, BMJ
open)
Cognitive Behavioral Analysis System of
Psychotherapy (CBASP) for chronic depression
(McCullough et al., 2000)

• A combination of cognitive-behavioral and interpersonal

techniques
• Therapeutic Focus
• Patient-therapist relationship
• Interpersonal relationships
• Modification of ineffective social behavior

65
CBASP v ADM Studies

Keller et al. 2000 ADM CBASP CBASP + ADM

CBASP
Chronic Depression
N = 681

Kocsis et al. 2009 ADM ADM + supportive CBASP + ADM

therapy
(REVAMP)

CBASP + ADM better

No significant differences in the Kocsis et al. 2009 study.

Possibly due to sample bias.
66
Differential Effect of Antidepressants (blue below) and
Psychotherapy (green below) for chronic depression
(with or without trauma).

Without Trauma With Trauma

Average Improvement in Symptoms

Nemeroff et al., 2003

Mindfulness-based cognitive therapy for
relapse prevention (Segal, Williams, & Teasdale, 2002)

• 8 session Group therapy with 8 to 15 participants

• Therapeutic Focus
• Training in mindfulness-based meditation
• Combined with cognitive-behavioral techniques
• Targets rumination and emotional avoidance by teaching skills for managing
emotions in the moment

68
 Mindfulness-based cognitive therapy for
relapse prevention (Segal, Williams, & Teasdale, 2002)

Piet et al. 2011 ADM Mindfulness CBT Treatment as Usual or

Meta-analysis continued Placebo

• Both better than placebo or treatment as usual

• Will come back to this type of therapy when discuss chronic pain

69
Couple Therapy for Depression?
• There is a .4 correlation between relationship distress and
depression (Hahlweg, 2003; Whisman, 2001).
• 50% of suicide attempts are preceded by relationship conflicts
• Relationship distress is a moderator for treatment outcome in
depression (Denton et al., 2010)
• Relationship conflict predicts relapse
(Hooley & Teasdale, 1989)

70
Couple Therapy

• Couple therapy is as effective as ADM or individual therapy

(CT) in reducing depressive symptoms and more effective in
reducing relationship distress
• (Bodenmann et al. 2008; O’Leary & Beach 1990; 1992;
Cohen, O’Leary, & Foran, 2010)

71
Guidelines
Severity England U.S. Germany
Of Depression (NICE, 2009; updated (APA 2010) (DGPPN, 2012)
2018)

Mild Low intensity Psychotherapy and/or Psychosocial intervention

Psychosocial intervention Medication or Psychotherapy

(physical activity
programs, too)

Moderate Psychotherapy and/or Psychotherapy and/or Psychotherapy

Medication Medication or Medication
(including behavioral
couples therapy, CBT or
IPT)

Severe Psychotherapy and Medication or combined Psychotherapy and

Medication with psychotherapy Medication

72
Effectiveness Research

• Hans & Hiller, 2013

• Meta-analysis of 34 nonrandomized effectiveness studies of CBT
• Effect sizes for completers: d = 1.13
• Effect size for intent-to-treat sample: d = 1.06
• Average dropout rate = 25%

• Conclusion:
• CBT is effective for depression in practice, but less effective than is
found in RCTs.
• Generalizability from RCTs is a problem
• e.g., as much as 76% of patients in clinical practice would be excluded from
RCTs

73
Dissemination Issues
• Less than 25% get treatment world-wide
• Even in high income countries, major public health gaps (e.g. 21% in
U.S. get “minimally” recommended treatment)
• Issues
• Costs
• Stigma
• Availability and training

74
Dissemination Issues
• More than half in need of treatment are undetected in primary
care.

• Often they may report physical symptoms.

• Approximately 15% of patients in primary care are suffering from

depression.

75
Public Health Implications

• Prevention and address risk factors from a socioeconomic

perspective
• Relationship distress and social support
• Prevention of risk factors such as child maltreatment
• Social skill deficits
• Occupational risk factors
• Including other caregivers (e.g., to increase adherence, address
relapse predictors)
• Improve screening
• Scaling up (see assigned reading by Chisholm et al. 2016). The
economic benefit of scaling up treatment options is enormous.

76
Next Steps

• What can be done to improve outcome?

• Better understanding of etiologies
• More transparency in randomized controlled trials
• Better understanding of long-term outcomes
• Better consideration of medical comorbidities and social environment
• More attention to matching trials to the “real world”
• Prevention
• Dissemination studies
• Effectiveness studies
• More integrated care, e.g., via primary care, health psychologist and
psychotherapists in medical settings

77
What works?

• There isn’t one psychological treatment that is significantly better

• Both ADM and psychological treatments work for severe depression
• Continued medication or psychological treatment reduces relapse

• However….research is constantly evolving.

• Recommended to also look at the way in which people may recover without
treatments (which don’t help for that person, but have negative side effects)
• Examples are exercise, time in nature, and community activities….
• More work is also needed with children and youth.
• See also Cuijpers et al. 2020

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 Other treatments

• St. John’s Wort (Johanniskraut)

May be equal to antidepressants for non-severe depression, but
findings vary for country studied
• Exercise (small to moderate effect over placebo; see also Hu et al.
2020)
• Yoga (19 studies reviewed, more yoga per week, less depressive
symptoms; Brinsley et al. 2020)

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Psychodynamic Therapies

• Studies also show effectiveness of short-term psychodynamic

therapies (meta-analysis, Driessen et al. 2010)

• Driessen et al. 2013; American Journal of Psychiatry

• 341 outpatients
• Compared CBT to short-term psychodynamic therapy
• No difference in effectiveness detected

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Assigned readings

• Lui, R. T. et al. (2017). Child adversities and depression in adulthood:

Current findings and future directions. Clinical Psychology Science
and Practice, doi: 10.1111/cpsp.12190
• Chisholm, D. et al. (2016). Scaling-up treatment of depression and
anxiety: a global return on investment analysis. Lancet Psychiatry, 3,
415-424. http://ac.els-cdn.com/S2215036616300244/1-s2.0-S2215036616300244-
main.pdf?_tid=7085f46c-1523-11e7-8493-
00000aab0f6c&acdnat=1490862941_0f24678b1be70eba9ca11d6c6822467c

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