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Relapse of Depression and a role for Mindfulness.

28/5/2011

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A recent post on the PsychCentral Blog reports on a study by Norman Farb, a PhD psychology student from the University of Toronto published in Biological Psychiatry.  

"When previously depressed individuals enter mild states of sadness, their brain’s response can predict if they will sink into depression again, say researchers at the University of Toronto.

“Part of what makes depression such a devastating disease is the high rate of relapse,” says Norman Farb, a PhD psychology student and lead author of the study.

“However, the fact that some patients are able to fully maintain their recovery suggests the possibility that different responses to the type of emotional challenges encountered in everyday life could reduce the chance of relapse.”

For the study, researchers used functional magnetic resonance imaging (fMRI) to track the brain activity of 16 formerly depressed patients as they watched sad movie clips. Sixteen months later, after nine of the 16 patients had relapsed into depression, th
e team compared the brain activity of the relapsed patients against those who remained healthy as well as a control group who had never been depressed". .....


Click here to read the full PsychCentral post 

This has some interesting implications for psychological treatment of depression.  

The article suggests that the neurological difference is related to rumination about sadness. This is where we get sad or worried about our own sadness, which of course keeps the cycle of depression going.  Mindfulness Cognitive Behavioural Therapy (MBCT) teaches patients to develop what might be called an "observer self".  This is where we develop the skill of "meta cognition" where we look at, rather than respond to our thoughts.  We notice that they are thoughts which may or may not be helpful, rather than facts that must be followed as truth.  Patients with depression are specifically taught in MBCT to be aware of their thoughts about sadness and to let them pass, rather than act on them.  


For example, "It's awful that I'm sad, I think I am getting depressed again.  Why is this happening to me. This is awful" could be noticed, rather than ruminated on.  Rumination is likely to focus your mind on all things negative, which begin to create a self fulfilling prophecy about becoming depressed.

The UK National Institute of Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse in Depre. Research has shown that people who have been clinically depressed 3 or more times (sometimes for twenty years or more) find that taking the program and learning these skills helps to reduce considerably their chances that depression will return. The evidence from two randomized clinical trials of MBCT indicates that it reduces rates of relapse by 50% among patients who suffer from recurrent depression.

Comments welcome on the facebook page. 
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First Post!

6/5/2011

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What just happened. I went to bed before the budget knowing that I could do my best to treat patients with eating disorders in line with the guidelines that we know to be scientifically valid.  Under the original "Better Access" Scheme, patients could typically receive 18 sessions of treatment subsidised by Medicare.  When I woke up after the budget this rebate had been cut to 10 sessions.  Now the government had based this figure in part on data produced by my professional body the Australian Psychological Society.  This data indicated that most patients were receiving about 6 - 8 sessions of therapy before the completion of their treatment. Only about one percent of therapists were using upto 18 sessions with their patients.  I think that 1% may have been me.  The other 99% must have not been seeing patients with eating disorders.

Lets look a little at the treatment of people suffering from eating disorders and why we have a problem.

The eating disorders are amongst the most serious psychiatric disorders.  Eating Disorders effect up to 10% of Australian women.  Anorexia Nervosa is the third most common chronic illness effecting adolescent women.  It has the highest mortality rate of ANY psychiatric illness, with 20% of patients dying from the illness after a prolonged history.  Matched for age, patients with anorexia nervosa have a death rate five times higher than the general population.  Death from suicide is relatively common, being 32 times higher than expected than in the general population (for comparison, patients diagnosed with major depression are 20 times more likely to die from suicide).

The Eating Disorders are often chronic and debilitating illness. On average, patients with Anorexia Nervosa have a similar level of disability to those suffering from Schizophrenia and Borderline Personality Disorder. In a systematic review of the literature eating disorders are shown to have one of the highest impacts on health related quality of life of all psychiatric disorders.  Cost of treatment per year for Anorexia Nervosa is as expensive as that required for schizophrenia.  Data from the private hospital system indicates patients with eating disorders are the most expensive patients to treat in a hospital setting. This is due to the complex psychiatric and physical comorbidity, the protracted length of treatment, and the requirement of specialist care. 

We know that patients who have access to the empirically supported evidence based approaches provided by specialist services have a significantly improved outcome.  This is particularly so for those who are able to access these treatments early in the course of their illness.

There are two well validated outpatient treatments for patients with the eating disorders, Family Based Therapy for Anorexia Nervosa, and Cognitive Behaviour Therapy for Bulimia Nervosa. 

The treatment of the eating disorders is complex and often protracted. The treatment manuals for both FBT and CBT indicate that the number of sessions recommended for treatment 20 treatment session over a 6 - 12 month period.  This is of course the problem.  We had 18 sessions, which almost fitted in with what works.  Now we have 10 session.  This is half the recommended course of treatment. (Actually, I'm not sure 18 was ever really enough but that is an argument for another time {I suspect now in the distant past}. I'm not going to mention the problems of FBT under the current legislation).

The government’s recent reduction of this figure to 10 sessions is woefully inadequate for my patients needs.  The reduction will result in fewer patients accessing appropriate treatment within an adequate time frame.  Outcomes from the eating disorders will deteriorate and the personal, social and economic burden from the eating disorders will increase.  

So, what to do ......
 I am a great advocate of accept what you can't change AND trying to change something that you can do something about.  There was a move to remove Social Workers from the Medicare Scheme which was reversed die to public pressure.  I am hopeful that the same can happen here.

Lift what you want from what I have written above and send an email to the Minister for Health and Ageing Nicola Roxon and Minister for Mental Health Mark Butler

Lets not forget the Greens (whom I've heard are supportive of my position)
bob.brown@aph.gov.au                      
and the independants
senator.xenophon@aph.gov.au            

senator.fielding@aph.gov.au                

Peter.Dutton.MP@aph.gov.au             

Mark.Butler.MP@aph.gov.au             

Tony.Windsor.MP@aph.gov.au

robert.oakeshott.mp@aph.gov.au

Lets get active to support the effective and affordable treatment of eating disorders.  I know I have.


Chris Thornton
Clinical Director 
The Redleaf Practice.

 


 


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    Author

    Chris Thornton is a Clinical Psychologist and the Clinical Director of The Redleaf Practice, a specialist outpatient clinic for the treatment of eating disorders.  He is interested in bringing elements of positive psychology, Cognitive Behavioural Therapy and Acceptance and Mindfulness approaches to the treatment of eating disorders.   

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