New Modalities of Assessment and Treatment Planning in Depression

Abstract

The sequential model of treatment for depression, i.e. the use of psychotherapy in patients who have remitted from a major depressive disorder after a course of pharmacotherapy, is an intensive two-stage approach that derives from the awareness that one course of treatment is unlikely to provide a solution to all the symptoms of patients. The aim of the sequential approach is to provide different types of treatment for as long as considered necessary in different phases of illness as determined by repeated assessments. The treatment strategies are chosen on the basis of the symptoms identified and not as predefined options. The sequential model emphasizes consideration of subclinical and residual symptomatology according to the organizing principles of macro-analysis (a relationship between co-occurring symptoms and problems is established on the basis of where treatment should commence in the first place). Diagnostic endpoints (i.e. DSM diagnoses), the customary guidance of treatment planning, are replaced by conceptualization of disorders as 'transfer stations', which are amenable to longitudinal verification and modification. The aim of this systematic review was to survey the literature concerned with the sequential approach to the treatment of depression. Randomized controlled trials were identified using MEDLINE and a manual search of the literature. In seven of the eight studies that were identified, the sequential use of pharmacotherapy and psychotherapy was found to improve long-term outcome after termination of treatment compared with clinical management and treatment as usual. Nevertheless, data on this approach are limited and more studies are necessary for detailing the various clinical steps associated with it. The sequential approach calls for a re-assessment of the design of comparative clinical trials. It allows randomization of patients who are already in treatment and assignment of them to treatment alternatives according to stages of development of their illness and not simply to disease classification. The model is thus more in line with the chronicity of mood disorders compared to the standard randomized controlled trial, which is based on the acute disease model.

The Sequential Combination of Cognitive Behavioral Treatment and Well-Being Therapy in Cyclothymic Disorder

“…Psychological well-being [13,41] and related constructs [60] are also object, by use of the diary, of the second half of therapy. Second, clinical decision making is addressed to attainment of individual goals and identification and treatment of all modifiable factors, rather than solely to the concept of disease [37,61]. As in previous studies on unipolar depression [14,15,16,23], treatment concerned both depressive and anxiety symptoms.…”

“…As in previous studies on unipolar depression [14,15,16,23], treatment concerned both depressive and anxiety symptoms. By use of macro- and microanalysis, targets are not predetermined, but depend on the response and modifications of illness during treatment [61]. Finally, psychotherapy has much more ambitious goals than the customary key themes of the literature on bipolar disorder (psychoeducation, medication adherence, lifestyle regularity and relapse prevention [1]): a positive evaluation of one’s self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage effectively one’s life and a sense of self-determination [13,39].…”

Efficacy versus Effectiveness: A Direct Comparison of the Outcome of Treatment for Mild to Moderate Depression in Randomized Controlled Trials and Daily Practice

“…Evidence-based treatment guidelines are based on the results of randomized controlled trials (RCTs) [1]. Adherence to these treatment guidelines is expected to improve effectiveness of treatment in daily practice [2].…”

Clinical judgment in psychiatry. Requiem or reveille?

“…These stations are a pause for verifi cation, or change to another direction (87). The use of diagnostic transfer stations has been suggested by the sequential treatment model (29,88), an intensive, two-stage approach, which includes the use of one treatment (e.g. psychotherapy) after remission has been achieved with another (e.g.…”