1、1,The New Trend in Psychotherapy,Lena Verdeli, Ph.D., Teachers College New York State Psychiatric Institute Columbia University,2,The Good News:,The empirical basis of psychotherapy is broadening and deepening Even disorders with a heavy genetic loading, such as bipolar disorder, have been shown to

2、respond favorably to psychotherapy combined with medication1 In a national survey of training programs in psychiatry, psychology and social work, psychiatry required coursework and clinical supervision in a largest % of EBTs2 1. Miklowitz DJ, Otto MW, Frank E, et al. Arch Gen Psychiatry. 2007;64(4):

3、419-26. 2. Weissman M, Verdeli H, Gameroff MJ, et al. Arch Gen Psychiatry. 2006;63:925-934.,3,The Bad News:,The practice of psychotherapy among psychiatrists is declining The % of office visits to psychiatrists involving psychotherapy declined from 44.4% in 1996-97 to 28.9% in 2004-05 Number of psyc

4、hiatrists who provided psychotherapy to all their patients declined from 19.1% in 1996-97 to 10.8% in 2004-05 The decline in psychotherapy provision was mediated by changes in payment source and increased medication prescription3 3. Mojtabai R, Olfson M. Arch Gen Psychiatry. 2008;65(8):962-970.,4,Th

5、e Paradox:4,There is an overwhelming demand for training and testing of evidence-based psychotherapies by NGOs and academic centers in other areas of the world 4. Weissman MM. Commentary on Psychotherapy for Depression in Adults: A Review of Recent Developments by Thase M. In Herrman H, (Ed.) Depres

6、sive Disorders 3rd Edition (2008). UK: Wiley-Blackwell,5,In Western Countries:,In the UK: The government has made available funds to implement the National Institute for Health and Clinical Excellence (NICE) guidelines for depressed patients In Canada: In the province of British Columbia IPT-A has b

7、een disseminated in all community mental health centers.,6,In Developing Countries:,In the last seven years, our IPT team has had numerous requests to adapt and test IPT for resource-poor areas in sub-Saharan Africa, India, Iraq, etc.,7,8,Study #1 (2002-2003)Group IPT with Depressed Adults in Southe

8、rn Uganda,Johns Hopkins Bloomberg School of Public Health: Paul Bolton (PI), Judy Bass NY State Psychiatric Institute, Columbia University: Myrna Weissman, Lena Verdeli, Kathleen F. Clougherty, Priya Wickramaratne, Richard Neugebauer World Vision Uganda: Lincoln Ndogoni, Liesbeth Speelman,9,The requ

9、est,Qualitative mental health study by Boltons team (2002)1 found high prevalence of depression symptoms (21%) among adults in the southwest region of Uganda Team in search of a psychotherapy which had shown efficacy, would have to be adapted for the local setting, and tested in a randomized control

10、led trial 5Wilk CM, Bolton P. (2002)Local perceptions of the mental health effects of the Uganda acquired immunodeficiency syndrome epidemic. J Nerv Ment Dis,190:394-7,10,Initial reactions,Why label human suffering “depression”? Why intervene? Is psychotherapy a luxury in these communities? Should w

11、e use western-based psychotherapy concepts and techniques in these communities? Would a rigorous clinical trial in such a resource-poor setting be possible? Even if the intervention proved to be efficacious, would it be sustainable?,11,Local Syndromes of Depression,Yokwekyawa (self-loathing) - Feeli

12、ng lonely - Feeling no interest in things - Worrying too much about things - Feeling hopeless about the future - Hating the world - Thoughts of killing self - Irritability - Bad, criminal or reckless behavior - Feeling sad - Feeling worthless - Not responding when greeted/withdrawn - Crying easily -

13、 Poor appetite - Feeling of severe suffering/pain,Okwekubagiza (self-pity) - Feeling sad - Feeling lonely - Worry too much about things - Feeling worthless - Low energy, feeling slowed down - Crying easily - Feeling fidgety - Feeling no interest in things - Feeling everything is an effort - Irritabi

14、lity - Unappreciative of assistance,12,Assessment of Depressive Symptoms: Hopkins Symptom Checklist (HSCL) 6 Ethnographic methods were used to validate the HSCL Assessment of Functioning: Development of a Local Measure 7 Ethnographic methods derived gender-specific tasks viewed as essential elements

15、 of functioning (caring for self, family, community) 6Bolton P. (2001) Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument. Nerv Ment Dis. 189:238-242. 7 BoltonP, Tang AM. (2003). An alternative approach to cross-cultural function assessment. Soc Psychiatr

16、y Psychiatr Epidemiol. 37:537-543.,13,Function Assessment Graphic,14,Rationale for using psychotherapy,Depression was a major source of disability and needed to be addressed Local traditional healers felt unable to treat depressive syndromes effectively. Medication not feasible, e.g., cost too high,

17、 few MDs,15,Selecting IPT,CBT and IPT were considered Cultural attitude in Uganda: people see themselves as part of a family or group IPT seemed compatible with the Ugandan culture,16,The group leaders,17,How the IPT Manual was Adapted,Sources of information: trainees, and ethnographic study (intera

18、ctive process) Modifications of manual : General adaptations: Simple language, More structure,18,How the IPT Manual was Adapted,Specific adaptations : Pre-group meeting: Local definition of depression (emphasize that it is not madness) Role of leader: will not provide material goods Confidentiality

19、(how much to disclose to the community) Treatment contract (flexibility, schedule around community events),19,Modifications of manual Specific Adaptations (cont)Evidence for 3 Problem Areas,1) Grief: death of a loved one multiple deaths - reconstruct the relationship while not being disrespectful to the dead loved one. 2) Role Disputes: disagreements - respect and work within the cultur