Brief Treatment Strategies for Major Depressive Disorder: Advice for the Primary Care Clinician

Ivan Valdivia, PhD Candidate; Nadine Rossy, BAC, PhD Candidate

Disclosures

Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Role of Advanced Practice Nurses

Advanced practice nurses play an important role in the assessment and treatment of depression,[53] and they are becoming more important as new collaborative treatment programs are created.[54] Given the limitations placed on modern mental healthcare (ie, time, training, access, and cost limitations), 3 specific techniques taken mainly from cognitive-behavioral strategies will be presented. Advanced practice nurses should be able to effectively carry out these interventions in a relatively short period of time.

In order for the techniques to be effective, the practicing clinician must be knowledgeable about the cornerstones of psychotherapy. These include: the development and maintenance of a strong and positive therapeutic alliance, accurate empathetic understanding, positive regard, genuineness, and a collaborative, problem-solving-based (ie, vs advice-based) orientation.

Emery[55] noted that MDD can often be effectively controlled in 10 sessions of CBT, but described how it could be pared down to 6 sessions. More recent evidence has suggested that therapy can be effective at reducing depressive symptomatology in just 3 sessions: 2 meetings 1 week apart followed by a third session 3 months later.[56] The cognitive-based brief treatment showed sustained improvement over 1 year. Bloom[57] noted that while brief therapy may be effective, the chronicity of the disorder might be better treated with multiple periodic brief treatments and "tune-up" sessions. The efficacy and sustainability of most such brief treatments has thus far not been compared with complete treatment regimens.

Behavioral activation. Lejuez and colleagues[58] described a course of therapy that isolates some of the active ingredients of CBT in an effort to minimize treatment time. Although the authors recommend 10-12 sessions in total, later sessions can last 15 to 30 minutes or less and can be conducted over the telephone if desired.

The behavioral component is a vital part of most CBT regimens. As mentioned, MDD has several negative cognitive sets that contribute to the maintenance of the disorder. Inherent in these cognitive sets is the idea that one is powerless to change one's life and that one cannot accomplish or control what is desired. In addition, a patient's loss of pleasure in things previously enjoyed can result in the cessation of pleasurable activities. Thus, Lejuez and colleagues'[58] brief therapy has as its goal to identify environmental factors that are maintaining the depression and the factors that limit pleasurable activity, and then gradually increase that positive activity to not only increase one's pleasure, but one's sense of control as well.

It has been proposed that people who suffer from MDD become stuck in patterns where they behave in a depressed way because those behaviors are perceived to be more reinforced than alternative behaviors.[59] The goal of this therapy is to increase the likelihood of positive behaviors through reinforcement. The program proceeds as follows:

  1. Introduction of treatment rationale;

  2. Monitoring of baseline activity/depressive severity, identification of reinforcers;

  3. Selection of activities to be added and arrangement on a hierarchy; and

  4. Planning and introducing behaviors, monitoring mood and activities.

This program requires very little training and can be implemented easily by most clinicians familiar with the fundamentals of psychotherapy. Further, a manual can be given to patients, ensuring that they are directly responsible for their own behavior change. The clinician can monitor and reinforce their progress, while troubleshooting along the way. (The full manual can be found in Lejuez, Hopko, and Hopko.[60])

Guided self-management: psychoeducation and bibliotherapy. Another vital part of CBT is psychoeducation, where the clinician educates the patient about MDD. For example, psychoeducation has been used effectively with groups of women with postpartum depression,[61] and nurses have been able to successfully reduce depression in caregivers of persons with dementia through psychoeducation.[53]

Information that should be given to patients includes statistics regarding prevalence rates, psychological and biological theories of depression (ie, the nature of the illness), treatment options, risk factors, medication side effects, and prognosis.[62] The educator's role is not simply to hand out pamphlets, but to discuss, explain, and teach patients about their illness so that they can make informed decisions about their treatment, and in so doing, experience a sense of accomplishment and mastery. Ideally, by assimilating the information, patients will realize that they are not the only person experiencing MDD, myths concerning MDD will be dispelled, and the stigma associated with mental disorders will be reduced. Table 2 includes sources of information that can be provided to patients.

In addition to psychoeducation, nurses can guide patients in a self-help form of treatment. Using bibliotherapy, a form of treatment where patients are provided a manual to work on nearly autonomously, nurses can provide the support and direction that the patient may need to maintain focus. For example, research conducted using the "Feeling Good" handbook[63] has shown it to be effective at reducing mild-to-moderate forms of depression.[64]

If the patient's primary clinician is another healthcare provider, a nurse can still play an important role in treatment. Both pharmacologic and psychotherapeutic treatments contain elements of unpleasantness. For example, medications often have side effects that the patient may feel are out of proportion to the benefits. Thus, they may be motivated to either discontinue treatment or take the medications inappropriately (eg, take less because they think they will do just as well or to reduce side effects). Likewise, some of the tasks required of patients in psychotherapy are sometimes seen as tedious at best, and terrifying at worst.

Tasks that encourage patients to proactively seek social interaction, monitor behaviors, and engage in activities when they do not think they have the energy to do so can be anxiety provoking. Having a clinician monitor their prescribed treatments and answer questions about those treatments can help patients to remain adherent. In this way, it is important for nurses to have knowledge about psychological and pharmacologic treatments in general, and their patient's treatment plan in particular, so they can help the individual to remain on course. Research has shown that nurses play a useful role in this capacity,[54,65] and that psychoeducation can precipitate adherence.[66]

In addition to the above interventions, nurses are uniquely positioned to intervene and treat those with MDD. First, they likely have the greatest amount of direct patient contact, which has as its benefit the potential development of a strong and consistent therapeutic relationship. Second, as a result of this extensive contact, they are exposed to a greater sampling of a patient's behavior that can lead to faster detection of disorders, which is important for case conceptualization, especially on an inpatient ward. Finally, primary care nurses are in a position that would likely allow them to coordinate services and service providers in order to assure the best care for individual patients.

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