goodmedicine

This is the 7^th blog post in a series reviewing the recent Scottish Intercollegiate Guideline Network's (SIGN) draft guideline for "Non-pharmacological management of depression".  I gave more background details in the first post of the series.  This post covers the third session of the guideline presentation seminar.  The session was entitled "Effectiveness of psychological therapies in depression 2" and there were three speakers.  Professor Kevin Power, Area Head of Psychological Therapies, NHS Tayside, talked about "Counselling, marital, family and reminiscence therapy".  Kevin said there were comparatively few good randomized controlled trials on counselling interventions specifically for patients diagnosed with major depressive disorder.  SIGN gave a Grade B recommendation that "Counselling may be considered as a treatment option for patients with mild to moderate depression."  This limited evidence base applies, it seems, even more strongly to Family Therapy, Marital Therapy, and Reminiscence Therapy.  See the draft guideline for fuller comments on these approaches (and for an explanation of what is meant by the different recommendation Grades).

Dr Lorna Champion, Consultant Clinical Psychologist at the Royal Edinburgh Hospital, then spoke about "Interpersonal Psychotherapy".  In a whole series of well-performed research trials, IPT has been shown to be equivalent in effectiveness to antidepressants or CBT.  Possibly CBT (or Behavioural Activation) may be somewhat better than IPT for those suffering from severe depression.  SIGN gave a grade A recommendation that "IPT is recommended as a treatment option for patients with mild to moderate depression."  Dr Margaret Maxwell, Reader in Sociology at the University of Stirling, gave the third presentation of this session on "Psychodynamic psychotherapy".  The supporting evidence for this group of linked approaches is less robust than for CBT or IPT, and SIGN gave a grade B recommendation that "Psychodynamic psychotherapy may be considered as a treatment option for patients with mild to moderate depression."

I have already mentioned the more limited evidence base for Family, Marital and Reminiscence Therapies.  Hypnosis and Music Therapies are further examples of methods with limited supporting research - but not enough to allow any firm recommendation to be made.

I think SIGN should add Emotion-Focused Therapy (EFT) to this list of therapies with some, though limited, evidence to support them as treatments for depression.  EFT has been shown, in one study, to produce rather broader benefits than counselling in depression treatment (Greenberg and Watson 1998), and in another randomized controlled trial EFT was found to be as effective as CBT (Watson, Gordon et al. 2003).  There is a good treatment manual too (Greenberg and Watson 2006).  I suspect EFT is the only form of psychotherapy for depression that boasts one of its originators as working in Scotland - Professor Robert Elliot teaches EFT courses at Strathclyde University (see below).  Robert has also recently produced a meta-analysis comparing counselling with CBT in the general treatment of psychological disorders suggesting equivalent results (Cooper, Elliott et al. 2008).  This meta-analysis has not yet, I believe, been published in a peer-reviewed journal, so the jury is still out on the quality of this paper. 

A number of other approaches were also touched on in this third session of the day, primarily to say that there is currently no good quality evidence identified supporting their use for people suffering from major depression.  These unsupported methods included Art Therapy, Emotional Freedom Technique, Eye Movement Desensitisation and Reprocessing (EMDR), Neurolinguistic Programming (NLP), and Thought Field Therapy.

Cooper, M., R. Elliott, et al. (2008). CBT superiority is a myth: the four professors joint statement. PCE Conference. University of East Anglia, Norwich, UK.  [Abstract]
Elliott, R.  (2008)  Biographical page at University of Strathclyde.  http://www.strath.ac.uk/Departments/counsunit/staff/robert.html  Accessed September 27.
Greenberg, L. and J. Watson (1998). "Experiential Therapy of Depression: Differential Effects of Client-Centered Relationship Conditions and Process Experiential Interventions." Psychotherapy Research 8(2): 210 - 224.  [Abstract/Full Text]
Greenberg, L. and J. Watson (2006).  "Emotion-focused therapy for depression."  Washington, DC: American Psychological Association.  [AbeBooks]  [Amazon UK]
Watson, J. C., L. B. Gordon, et al. (2003). "Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression." J Consult Clin Psychol 71(4): 773-81.  [PubMed]