Counseling Implications

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Trends

One of the most common disorders facing people today is depression. By some estimates, roughly 10% to 25% of the population experiences some form of depression. Accord- ing to Murray and Lopez (1997), depression is the number one cause of disability worldwide. It is clearly the most com- mon disorder experienced by people who see mental health practitioners (Gilroy, Carroll, & Murra, 2002). Also, it may be the most common disorder of mental health workers them- selves (Mahoney, 1997; Pope & Tabachnik, 1994), with re- search suggesting that from one third to more than 60% of mental health professionals had reported a significant epi- sode of depression within the previous year. Depressing? Yes, but there is hope and good news. Depression, by and large, is a problem readily amenable to treatment, and there are many successful approaches, many of which have empirical evi- dence to support their efficacy. The bad news, however, is that depression has been increasing in epidemic proportions. Data reflect that depression is 10 times as prevalent now as it was in 1960! Seligman (2002) provided a provocative paradox on depression. He stated that while every objective indicator of well-being in the U.S. has been increasing, every indicator of subjective well-being is decreasing.

Clearly, the importance of the current knowledge base on depression is obvious. Counselors, from pre-K to adult men- tal health workers, need to be well-versed on the current state of treatment for depression. For counselors, it is quite likely that for many of their clients, whether they present with problems of mood disturbance or not, depression may be involved. For professionals, who are at high risk for mood

disorders by the very nature of their work, the importance of treatment and prevention in self-care is critical. Thus, this topic has considerable value because it is quite likely that counselors will work with clients with depression, and it is quite likely, given the empirical evidence, that counselors are experiencing or will be experiencing some form of de- pression/mood disturbance themselves.

The article “Treatment and Prevention of Depression” (Hollon, Thase, & Markowitz, 2002) reviews the current state of research on various treatment modalities, comparing the effectiveness of the more widely used approaches—psycho- dynamic therapy, interpersonal psychotherapy, cognitive behavior therapy, marital and family therapy—to antidepressant medication therapy. The results of these comparisons are dis- cussed, together with implications for counselors, counseling, and counselor training.

Article Review

In a monograph-length article, Hollon et al. (2002) provided a detailed review of the common treatments for depression, together with a summary of the available empirical support for each. They added to that a brief discussion of marital and family therapy for treating depression, approaches that are only now starting to receive empirical scrutiny. Specific research outcomes were presented for medication treatments, psychodynamic treatments, interpersonal psychotherapy, cognitive behavior approaches, and marital and family ap- proaches. The authors discussed the relative effectiveness of

Louis V. Paradise and Peggy C. Kirby, Department of Educational Leadership, Counseling, and Foundations, University of New Orleans. Correspondence concerning this article should be addressed to Louis V. Paradise, Department of Educational Leadership, Counseling, and Foundations, University of New Orleans, New Orleans, LA 70148 (e-mail: Louis.Paradise@uno.edu).

The Treatment and Prevention of Depression: Implications for Counseling and Counselor Training Louis V. Paradise and Peggy C. Kirby

With depression estimated to exist in as much as 10% of the population, it may be the most prevalent problem facing counselors today. S. D. Hollon, M. E. Thase, and J. C. Markowitz (2002) reviewed the extensive research comparing various psychotherapeutic and pharmaceutical approaches to treating depression. They concluded that certain psychotherapy approaches are as effective as medications, but much remains uncertain about effective treatment. This article reviews the authors’ analyses and presents implications for the counseling profession.

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various combinations of these treatments as well. Although most of the article was concerned with research-based out- comes for adult outpatients with depressive disorders, the authors also presented examples from the growing body of research on the treatment of bipolar disorders.

Hollon et al. (2002) provided a concise primer on the types of mood disorders. The summary should be very help- ful for counselors because most will have clients who ex- hibit some form of mood disorder. The consequences of depression, beyond the disorder itself, are significant. De- pression increases the risk of heart disease and diabetes. Also, mood disorders can increase the risk of substance abuse and vice versa. Thus, sensitivity to the occurrence of depression is a critical diagnostic skill for all counselors.

Medication Treatments

The most useful single piece of information presented by Hollon et al. (2002) was a chart of commonly used medica- tions. The various types of medications were presented to- gether with their brand names, common dosage levels, and prominent side effects. The chart was written for nonmedical readers, and it could serve as a useful guide to antidepres- sant drugs. Overall, the authors concluded that antidepres- sant medications were clearly effective in the treatment of depression and that the drugs provided some measure of protection from relapse as long as the person continues to take the medication.

Noncompliance with medication regimen, over time, is a very common problem. Motivation, bad side effects, cost, and so on, all contribute to negative outcomes over time. Side effects for these medications include insomnia, nausea, vom- iting, tremors, and memory impairment, to name just a few. Hollon et al. (2002) concluded that the various types of drug treatments are generally comparable in efficacy but differ in terms of side effects, which do vary considerably among people and can be substantial. Although the empirical evi- dence presented is clear, in that most individuals will respond to one or more of the medications, there is no evidence that any medications will reduce the risk of future depression once they are discontinued. Furthermore, because of the wide vari- ability in the effects of antidepressant medications, it may take some time for the drugs to take effect or for the correct medication or dosage level to be determined. All these issues directly affect compliance and outcomes.

To support their assertions on the efficacy of antidepres- sant medications, Hollon et al. (2002) presented overall sum- mary research data from a meta-analysis of treatment out- comes conducted for the Agency for Health Care and Policy Research (Depression Guideline Panel, 1993) and from an update of that review by Mulrow et al. (1999). It is interest- ing that placebo conditions, in general, produced about a 30% response compared with medications at slightly more than 50% response. These data support the long-held notion

of the powerful effects of placebos in general. Nonetheless, the medications typically are effective and relatively fast- acting as a treatment for depression. The authors explained that the 50% response from medication is reasonable when one realizes that individuals may need to try several drugs or combinations of drugs before an effective medication is found.

Therapy Treatments

The authors described the various psychotherapy approaches: psychodynamic, interpersonal, cognitive-behavioral, and marital and family. A substantial number of empirical out- come studies were presented, several of which were meta- analyses quantitatively summarizing collections of other studies. The findings suggested that psychodynamic therapy, although having a long history, lacks adequate empirical evidence of its efficacy. Based on available data, its results are just slightly better than placebo medications. The au- thors lamented this finding given the depth and longevity of the approach and the number of individuals who receive this form of treatment.

Interpersonal psychotherapy has demonstrated its effec- tiveness as a treatment for major depression. Its efficacy, in comparison studies, shows it is as effective as medication ap- proaches. The authors concluded that for severe depression, it seems to produce better outcomes than other psychotherapy/ counseling approaches and may be the treatment of choice. It is noted that this approach is recommended in practice guide- lines by the American Psychiatric Association.

Hollon et al. (2002) differentiated the findings from cog- nitive therapy from those for behavior therapy. However, they recognized clearly that the most current approaches are by and large a combination of cognitive and behavioral strategies. In fact, their conclusions and many of the research summaries cited by Hollon et al. treated the two approaches as one, cognitive behavior therapy. As for purely cognitive approaches, the authors noted that although they often match or exceed medication results, the level of expertise of the therapist/counselor makes a greater difference in results the more severe the depression is to treat. Most important, the effects of cognitive therapy seem to show enduring ef- fects beyond the end of treatment, whether the individuals were on medication or not. The authors reported that behav- ior therapy interventions have never been as popular as cog- nitive approaches for treating depression; however, in re- cent years there has been greater interest in behavioral inter- ventions. Several studies were cited that reported positive outcomes for pure behavior interventions. However, there was greater overall support and more outcomes studies, as well as wider use by practitioners of cognitive approaches or cognitive with behavioral intervention than of behavior therapy alone.

What about combining therapies? The current evidence sug- gests, according to the authors, that combining cognitive

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therapy or related cognitive behavioral interventions with medi- cation appears to provide only modest increments in improve- ment. Cognitive approaches with medications appear to be useful for severe/chronic cases of depression. There is also em- pirical evidence to support the use of cognitive approaches with medication for the treatment of bipolar depression.

For counselors, many of whom use cognitive behavior ap- proaches, the news is good. These approaches in the absence of medication fare well as a depression treatment for all but the most severe cases. Also, the effects seem to last after treatment. Because the prime effort behind these approaches is usually to teach new ways of behaving, relating, and thinking, it makes sense that the skills learned in treatment can carry forward. Even for the most severe cases of depression, it seems that cognitive behavior therapy can be a useful adjunct to medica- tion treatment regardless of the severity.

Marital and family approaches were briefly discussed by Hollon et al. (2002). They indicated that although these approaches are often used to reduce family conflict and to relieve distress, they are rarely studied in the treatment of depression. The few studies available suggested that there may be some value in these approaches, especially from an educational and family relationship perspective.

In summary, Hollon et al. (2002) concluded that the medi- cation approaches have the most extensive empirical support and generally are effective as long as they are continued, but they do produce troublesome side effects. Treatments such as interpersonal psychotherapy and cognitive behavior therapy also are successful in the treatment of depression. Although they produce effects that are often similar to medication approaches, they seem to have the added benefit of endur- ing effects after treatment. The authors did note that depres- sion is an eminently treatable problem. Furthermore, they indicated that while considerable progress in treatment has been made over the years, far too many people go untreated or do not have access to tested interventions. The authors’ last comment in the article has substantial implications for all coun- selors and mental health practitioners: “Most important of all, the field needs to emphasize efforts at prevention that build on existing indications that people can learn strategies to reduce future risk” (Hollon et al., 2002, p. 70).

Implications for the Counseling Profession

With depression being a widespread and growing problem, it is important for counseling professionals to recognize the prevalence of the disorder and to be able to provide assis- tance not only to the clients they serve but to themselves when necessary. Whereas the Hollon et al. (2002) article only dealt with outcomes research on clinical depression, the overall number of individuals with lesser forms of de- pression is substantial. The profession can play a significant role in the treatment of this problem. There is ample evi- dence that interventions for depression are successful and

can benefit individuals with mood disorders. The interven- tions reviewed by Hollon et al.—interpersonal psycho- therapy, cognitive behavior therapy, and marital and family therapy—all prove to be beneficial either with or without medications. If we counselors extrapolate downward to the large number of individuals with serious but less severe depres- sion (nonclinical)—the type most often seen by counselors—we are faced with a compelling argument that there is much work to be done. Given that Seligman (2002) believed there is an epi- demic of depression in America, the counseling profession needs to provide greater focus on training, research, and practice for mood disorders in both clinical and nonclinical populations.

For counselors engaged in marital and family counseling, the evidence is supportive. Hollon et al. (2002) are encour- aged by the potential of this treatment, and others (Beach, 2003; Gollan, Friedman, & Miller, 2002) provide similar conclusions. However, much more needs to be done in re- search and training, especially on documenting the outcomes of this approach and its unique and added value for treating depression in the individual with the disorder and for the other members of that family.

Counselor Implications

Staying current in the field, although important for any pro- fessional, is critical for practicing counselors. Reviews of treatment outcomes provide a useful mechanism to inform the practitioner about which techniques work and under what conditions they work. Synthesizing years of disparate re- search findings into a set of omnibus empirically based con- clusions greatly facilitates counselors’ task of practicing under state-of-the-art conditions.

On a personal level for the counselor, given the demand- ing nature of the task, susceptibility to depressive symptoms is high. Thus, personal issues of self-awareness and self-care need constant attention. Carroll, Gilroy, and Murra (2003) dis- cussed the need for counselors to engage in self-care behaviors for this very reason. Although personal counseling is often recommended for counselor trainees, practicing counselors often resist this self-care option.

Counseling Implications

The findings of Hollon et al. (2002) provide validation in that commonly used approaches in counseling can have signifi- cant outcomes, even for clinical cases of depression. Using the many techniques of cognitive behavior therapy—helping people learn skills to change the way they think, interact, feel, and so on—can produce positive outcomes with or without medications for inpatients or outpatients. Counseling’s role in the treatment of major depression may become more promi- nent. A study by Chilvers et al. (2001) comparing generic counseling with the use of antidepressant drugs found es- sentially no difference in positive outcomes other than