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PSYCHOTHERAPY IN DEPRESSION

Teaching psychotherapy

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PSYCHOTHERAPY IN DEPRESSION

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  1. PSYCHOTHERAPY IN DEPRESSION DR KELVIN SOO MB BCh BAO (Ire) ‘19 MEDICAL OFFICERDEPARTMENT OF PSYCHIATRYRIPAS HOSPITALMINISTRY OF HEALTH BRUNEI

  2. LEARNING OBJECTIVES By the end of this session, students should be able to: • Apply knowledge of the biopsychosocial model of depression with particular focus on psychological factors • Recognise indications for psychotherapy in the treatment of depression • Identify suitability factors in which patients would likely benefit from psychotherapy • Awareness of various psychotherapeutic interventions & techniques in the treatment of depression

  3. DEPRESSION CRITERIA

  4. BIOPSYCHOSOCIAL MODEL OF MENTAL ILLNESS

  5. DIAGNOSTIC FORMULATION: THE 4Ps Predisposing: Factors that make a patient susceptible to mental illnessPrecipitating: Factors that trigger current presentation of mental illnessPerpetuating: Factors that prolong course of mental illnessProtective: Factors that reduce severity of mental illness

  6. CLINICAL CASE VIGNETTE Nuraidah is a 35 year old female referred to Psychiatric services by GP for 4 year history of low mood. Upon further query, she stated that her frequent marital conflicts due to financial difficulties resulted in persistent low mood and inability to enjoy her favourite pastime which is painting. She has lost 3kg in past 1 year due to eating one meal a day and difficulty falling asleep. She revealed that she has polycystic ovarian syndrome and has been trying to conceive for 6 years without success having 3 early miscarriages leading her to feelings of chronic guilt and thoughts of suicide. She denies ever hearing voices. Nuraidah was tearful recounting husband’s physical and emotional abuse. Her husband who is unemployed takes shabu (methylamphetamine) to which she was coerced into taking at times with her husband in fear of retaliation from husband. She admitted that as a child, she felt neglected by her mother who suffered from depression after giving birth to her following a complicated delivery. She is the 4th of 7 siblings and suspects that her youngest brother may be attending Psychiatric services. Growing up, patient suffered from bullying in school due to her large weight and engaged in self-harm by cutting wrist until her late teens. She attained Form 5 (Year 11) education and worked as a government clerk shortly after. She has been taking unpaid leave for the past 6 months on the advice of her superiors. She is currently living with her parents, 2 siblings and abusive husband and not on talking terms with her family due to household disputes. She described herself as reserved and does not talk about her problems to others due to her low self-esteem and lack of confiding relationships. She cited her spirituality as the main reason for not attempting suicide thus far.

  7. CLINICAL CASE FORMULATION

  8. CLINICAL CASE FORMULATION (EXAMPLE)

  9. INDICATIONS FOR PSYCHOTHERAPY • NICE Guidelines for Depression revised in 2022 outlined changes in which psychotherapy is incorporated in the treatment of depression from previous version 2010 • Previously, psychotherapy is indicated in the treatment of mild to moderate depression often in conjunction with pharmacotherapy in the latter. Individuals with severe depression were deemed as unsuitable for psychotherapy • Revision was made such that treatment plan for depression are all-inclusive and patient-oriented • For the purposes of delivering psychotherapy, depression is stratified to “less severe depression” (subthreshold & mild depression) & “more severe depression” (moderate & severe depression) • Notable difference is that “more severe depression” requires higher number of psychotherapy sessions (e.g. Individual CBT: 12-16 sessions vs 8 sessions in “less severe depression”)

  10. SUITABILITY FOR PSYCHOTHERAPY • Assessment of suitability for psychotherapy allows mental health professionals to identify which patients would most likely benefit from psychotherapy. Key considerations include:

  11. HOMEWORK TIME

  12. BEHAVIOURAL ACTIVATION (BA)

  13. COGNITIVE BEHAVIOURAL THERAPY (CBT)

  14. INTERPERSONAL THERAPY (IPT)

  15. SHORT-TERM PSYCHODYNAMIC THERAPY (STPP)

  16. GROUP ACTIVITIES (EXERCISE)

  17. GROUP ACTIVITIES (MINDFULNESS)

  18. COUNSELLING

  19. GUIDED SELF-HELP

  20. INDIVIDUAL PROBLEM-SOLVING

  21. TAKE HOME POINTS • Practise formulation and devising management plans for psychiatric cases (needed to pass Psych OSCE & medical school!) • Determine the severity of depression (mild, moderate, severe), degree of impairment and presence of psychotic symptoms • Treatment options should be discussed with patient including pharmacological and psychological interventions • Determine if patient is suitable for psychotherapy; this often requires more than one consultation with the patient • Choice of psychotherapy should be tailored based on patient’s needs

  22. THANK YOU CHERISH YOUR TIME IN MEDICAL SCHOOL REFERENCES Recommendations | Depression in adults: treatment and management | Guidance | NICE https://www.nice.org.uk/guidance/ng222/chapter/Recommendations Free CBT Worksheets | Cognitive Behavioural Therapy Exercises | the Think CBT Workbook https://www.thinkcbt.com/think-cbt-worksheets Assessment of Suitability for Psychotherapy (psychiatryonline.org) https://www.psychotherapy.psychiatryonline.org/doi/epdf/10.1176/appi.psychotherapy.1999.53.1.17

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