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Applying ACT to Cases of Complex Depression: New Clinical And ApplyingApplying ACTACT toto CasesCases ofof ComplexComplex Depression:Depression: NewNew ClinicalClinical andand ResearchResearch PerspectivesPerspectives PartPart I:I: DepressionDepression withwith PsychosisPsychosis andand SuicidalitySuicidality Brandon Gaudiano, Ph.D. Assistant Professor of Psychiatry Grant Support: NIH K23 MH076937 OutlineOutline ¾¾ ClinicalClinical FeaturesFeatures ofof PsychoticPsychotic DepressionDepression ¾¾ ACTACT forfor PsychosisPsychosis ResearchResearch ¾¾ TreatmentTreatment DevelopmentDevelopment ProjectProject ¾¾ ClinicalClinical ConsiderationsConsiderations ¾¾ CaseCase ExampleExample DepressionDepression withwith hallucinationshallucinations and/orand/or delusionsdelusions PsychoticPsychotic DepressionDepression ¾ PrevalencePrevalence ratesrates z 15-19% of individuals with depression have hallucinations or delusions (Ohayon and Schatzberg, 2002) z Up to 25% of depressed hospitalized patients (Coryell et al., 1984) ¾ PsychoticPsychotic depressiondepression cancan bebe difficultdifficult toto diagnosediagnose andand treat:treat: z psychotic features in mood disorders can be more subtle than those found in patients with primary psychotic disorders ¾ PsychoticPsychotic depressiondepression cancan bebe difficultdifficult toto diagnosediagnose andand treat:treat: z psychotic features in mood disorders can be more subtle than those found in patients with primary psychotic disorders z patients often underreport psychotic symptoms due to embarrassment or paranoia ¾ PsychoticPsychotic depressiondepression cancan bebe difficultdifficult toto diagnosediagnose andand treat:treat: z psychotic features in mood disorders can be more subtle than those found in patients with primary psychotic disorders z patients often underreport psychotic symptoms due to embarrassment or paranoia z clinicians frequently fail to fully assess for the presence of psychotic symptoms in patients with mood disorders HowHow doesdoes depressiondepression withwith versusversus withoutwithout psychoticpsychotic featuresfeatures differdiffer clinically?clinically? PsychoticPsychotic vs.vs. NonpsychoticNonpsychotic DepressionDepression ¾ More likely to be non-white ¾ More time out of work ¾ Less education ¾ More chronic depression (> 2 ¾ Earlier age of depression years) onset ¾ More severe current suicidal ¾ More severe current ideation depression severity ¾ More past hospitalizations and ¾ More current social impairment suicide attempts ¾ More insomnia, concentration ¾ More anxiety disorders and problems, psychomotor personality dysfunction disturbance ¾ More childhood trauma Gaudiano BA, et al. Depress Anxiety 2009, 26, 54-64. Gaudiano BA et al. Comprehensive Psychiatry 2008;49:421-429 PatientsPatients withwith psychoticpsychotic depressiondepression showshow aa poorerpoorer responseresponse toto conventionalconventional treatmenttreatment withwith medicationsmedications andand psychotherapypsychotherapy Combined Pharmacotherapy and Psychotherapy Depression Severity in Psychotic versus Nonpsychotic Depression 30 25 20 Nonpsychotic 15 Psychotic 10 5 0 Admission Discharge Post- Follow-Up Treatment Gaudiano, BA et al. J Nervous Mental Disease 2005;193:625-628. Post-Treatment High Suicidal Ideation and Depression Severity in Psychotic versus Nonpsychotic Depression 30 25 % 20 15 Nonpsychotic Psychotic 10 5 0 Post-Treatment Follow-Up Gaudiano, B.A. et al. J Nervous Mental Disease 2005;193:625-628. CurrentCurrent SomaticSomatic TreatmentsTreatments forfor PsychoticPsychotic DepressionDepression ¾ Medications and electroconvulsive therapy z Antidepressant plus antidepressant may be more effective than either drug alone z ECT also effective for short term treatment (maybe more than medications) ¾ Limitations z Treatment adherence z Side effects z Acceptability issues z Treatment preferences z Continued residual or chronic symptoms after treatment z High relapse rates after treatment discontinuation z Don’t fully address problems of complex patients z Treatment resistance z Polypharmacy issues ACTACT forfor PsychosisPsychosis WhyWhy ACTACT forfor Psychosis?Psychosis? ¾ SymptomsSymptoms ofof psychosispsychosis oftenoften areare notnot permanentlypermanently oror completelycompletely eliminatedeliminated withwith currentcurrent treatmentstreatments ¾ ManyMany patientspatients whowho remainremain outout ofof thethe hospitalhospital despitedespite theirtheir symptomssymptoms reportreport usingusing moremore acceptanceacceptance--basedbased copingcoping strategiesstrategies ¾ NewerNewer approachesapproaches forfor psychosispsychosis placeplace moremore emphasisemphasis onon acceptanceacceptance andand improvedimproved functioningfunctioning ratherrather thanthan symptomsymptom reductionreduction ¾ TreatmentsTreatments areare neededneeded forfor patientspatients inin acuteacute phasesphases ofof illnessillness whenwhen theythey areare moremore difficultdifficult toto engageengage inin psychotherapypsychotherapy ACTACT vsvs TraditionalTraditional CBTCBT forfor PsychosisPsychosis ¾¾ TraditionalTraditional cognitivecognitive therapytherapy z UseUse rationalrational deliberation,deliberation, logicallogical reasoning,reasoning, andand SocraticSocratic questioningquestioning andand behavioralbehavioral experimentsexperiments toto changechange patientpatient’’ss beliefsbeliefs aboutabout hallucinationshallucinations andand delusionsdelusions ¾¾ ACTACT z EncourageEncourage patientpatient toto bebe nonjudgmentallynonjudgmentally awareaware ofof psychoticpsychotic symptomssymptoms inin thethe momentmoment whilewhile simultaneouslysimultaneously workingworking towardtoward valuedvalued goalsgoals BachBach && HayesHayes (2002)(2002) ¾¾ 8080 inpatientsinpatients withwith psychoticpsychotic disorderdisorder randomlyrandomly assignedassigned toto TAUTAU oror TAU+ACTTAU+ACT (4(4 sessions)sessions) ¾¾ AssessmentsAssessments atat baselinebaseline andand 44 monthsmonths postpost--hospitalizationhospitalization z SelfSelf--ratingsratings ofof psychoticpsychotic symptomssymptoms frequency,frequency, believability,believability, andand distressdistress z RehospitalizationRehospitalization ratesrates PsychoticPsychotic SymptomSymptom BelievabilityBelievability Change in Believability Rating 100 80 ACT 60 Rating Control 40 Believability SUDS 20 Baseline vs Follow-up RehospitalizationRehospitalization RatesRates Survival Curve: Days to Hospitalization 35 30 TAU 25 ACT 20 # Subjects Surviving 15 1 21416181101 Days GaudianoGaudiano && HerbertHerbert (2006)(2006) ¾ Randomized psychiatric inpatients with psychotic symptoms (schizophrenia, schizoaffective disorder, delusional disorder, psychotic depression, bipolar disorder with psychosis) to treatment as usual with versus without ACT (3 sessions) ¾ Assessments admission and discharge z Brief Psychiatric Rating Scale z Sheehan Disability Scale z Self-ratings of psychotic symptom: frequency, believability, and associated distress z Insurance records of psychiatric rehospitalizations (4 month follow-up) Gaudiano, B. A., & Herbert, J. D. (2006).(2006). Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: Pilot results. Behaviour Research and Therapy, 44, 415-437. SampleSample DescriptionDescription ¾ NN == 4040 (TAU(TAU == 1919 andand ACTACT == 21)21) ¾ MeanMean ageage == 4040 ¾ MostlyMostly male:male: 64%64% ¾ 88%88% AfricanAfrican--AmericanAmerican ¾ 35%35% notnot graduatinggraduating HSHS ¾ 86%86% receivingreceiving disabilitydisability compensationcompensation ¾ 29%29% homelesshomeless ¾ 12%12% marriedmarried ¾ DropDrop outs:outs: TAUTAU == 11 andand ACTACT == 11 BriefBrief ACTACT forfor PsychoticPsychotic InpatientsInpatients PatientsPatients werewere taught:taught: 1. ToTo acceptaccept unavoidableunavoidable psychologicalpsychological distressdistress 2. ToTo simplysimply noticenotice psychoticpsychotic symptomssymptoms withoutwithout treatingtreating themthem asas eithereither truetrue oror falsefalse 3. ToTo identifyidentify andand workwork towardtoward valuedvalued goalsgoals despitedespite theirtheir symptoms.symptoms. Bach, P., Gaudiano, B., Pankey, J., Herbert, J. D., & Hayes, S. C. (2006). Acceptance, mindfulness, values, and psychosis: Applying Acceptance and Commitment Therapy (ACT) to the chronically mentally ill. In R. A. Baer (Ed.), Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications (pp. 93-116). San Diego: Academic Press. Change in Distress Related to Hallucinations 8 7.5 7 TAU 6.5 ACT 6 5.5 5 Pre Post Change in Perceived Disability Related to Illness 8.5 8 7.5 7 TAU 6.5 ACT 6 5.5 5 Pre Post ClinicallyClinically SignificantSignificant ChangeChange inin SymptomsSymptoms PrePre--PostPost (>(> 22 SD)SD) 80 71 70 60 50 % 40 TAU ACT 30 27 20 14 10 7 0 Mood Symptoms Psychotic Symptoms RehospitalizationRehospitalization RatesRates atat 44 MonthMonth FollowFollow--upup 50 45 45 40 40 35 28 % 30 25 TAU 20 20 ACT 15 10 5 0 Gaudiano & Herbert (2006) Bach & Hayes (2002) ACTACT--ConsistentConsistent MediationMediation ofof TreatmentTreatment EffectsEffects Decreased Change in believability of Believability of hallucinations led Hallucinations to decreased distress in the ACT (Cognitive Defusion) group only Treatment Change in Distress Group Related to Hallucinations (TAU vs ACT) ACT produced greater reductions in hallucination- related distress compared with TAU alone ClinicallyClinically SignificantSignificant ImprovementImprovement inin SubgroupSubgroup withwith PsychoticPsychotic DepressionDepression ¾ ACT group showed ACT group showed
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