Group Therapy for Mood Disorders

Unipolar Depressive Disorders – An Overview of Effectiveness

    •    Evidence for group as primary treatment for Major Depressive
    Disorder (MDD) is “promising to good,” an improvement on “mixed to
    untested” in 2004 (2 meta-analytic studies included 65 studies and 17
    new studies since 2004). A major review of the evidence for mood
    disorders can be found in Burlingame, Strauss & Joyce (2013).

    •    Group Cognitive Behavior Therapy (GCBT) is the primary modality
    studied, with other groups focusing on behavioral activation or
    Mindfulness-based approaches.

    •    Effect sizes (which in this case measured the impact of the treatment)
    range from 1.0-1.1 for depression remission. These are in the large range.

    •    Meta-analyses (McDermut, Miller & Brown, 2001; Oei & Dingle, 2008)
    produced 14 studies that compared individual and group therapy. These
    studies showed, on aggregate, equivalence in treatment outcomes.

    •    “Sudden gains” predict better outcomes. That is, when group
    treatments deliver strong results early in their life (sessions 1-5), they
    tend to predict stronger outcomes at the end. This suggests that groups
    structured for early success may be more potent, which may be a result of
    the common factors in all group therapy rather than the specific
    components of an individual treatment. Third generation group CBT
    focuses on the addition of physical regulation and context in addition to
    addressing the typical cognition-affect link (e.g., Acceptance and
    Commitment Therapy; Crosby, 2012).

    •    Approaches to treating depression in a group format that are on
    NREPP’s (National Registry of Evidence-Based Programs and Practices) list
    of Evidence Based Practices include:

        o    Mindfulness based Cognitive Therapy (MBCT)

        o    Mindfulness Based Stress Reduction (MBSR)

        o    Acceptance and Commitment Therapy (ACT)

        o     Group Interpersonal Therapy (G-IPT), which has also shown some
        early evidence suggesting effectiveness in treating depression.

        o     Short-term Interpretive Group Therapy for Complicated Grief

    •    Most, but not all, of these approaches tend to rely less on group
    process and more on the teaching of skills in a group format.

    •    Meta-analytic research shows that interventions that are culturally
    adapted have a moderately strong effect, suggesting that considerable
    care should be paid to the role of culture. Moreover, targeting a specific
    cultural group was found to be four times more effective than
    interventions targeting a mixed multicultural group. Equally, if an
    intervention was conducted in a client’s native language, it was found to
    be twice as effective (Griner & Smith, 2006).

Group psychodynamic treatments have received little empirical attention due to the methodological challenges embedded within these inherently complex treatment modalities that, by definition, rely on group-level therapeutic processes (Green, 2012). Researchers (e.g., Bhar & Beck, 2009; Blackmore, Tantam, Parry & Chambers, 2012) report that it is impossible to say whether psychodynamic or analytic approaches are proven to be better or worse than other group modalities in ameliorating depression due to the following reasons: difficulty in defining terminology/ensuring fidelity/establishing treatment integrity, varying quality in the research studies, the low number of RCTs, and the variety of different outcome measures. Overall, manualized treatments with greater ability to control internal validity are proving more prevalent in the research literature. The evidence suggests that group approaches to impacting depression are effective and comparable to individual approaches in the aggregate (Burlingame, Strauss & Joyce, 2013).

Etiology-Specific or Population-based Group Treatments for Unipolar Depression

Depression caused by Grief

    •    Complicated grief: set of intensive and prolonged negative reactions to
    the loss of significant others through death.

    •    Patients with complicated grief constitute approximately one-third of
    all psychiatric out-patients.

    •    The efficacy of short-term interpretive group therapy with CG patients
    has been demonstrated through controlled clinical trials.

    •    Statistical and clinical significance have been demonstrated.

    •    Positive findings have been consistently maintained over a six month
    period.

Complicated grief (CG) is defined as a set of negative reactions to the loss of significant others through death. To qualify as complicated grief these negative reactions must be of high intensity and persist over a prolonged period of time. Studies of psychiatric out-patients indicated that as many as one-third of the patients met criteria for CG (Piper et al., 2001; Zisook & Lyons, 1989-90 ). Since 1986, Piper and colleagues have conducted several controlled outpatient clinical trials to study the efficacy of short-term interpretive group therapy with CG patients (Piper, Ogrodniczuk, Joyce, & Weideman, 2011). Treated patients, in comparison to control patients, demonstrated both statistical and clinical significant improvements in a variety of symptoms and behaviours (Piper et al, 2011).  These findings were maintained over a 6 month follow up period. This research is included as an efficacious form of treatment for patients with complicated grief in the National Registry of Evidence-based Programs and Practices (NREPP).

In addition to demonstrating RCT-evidence for the efficacy of short-term interpretive group therapy, Piper et al. have investigated the relationship between the personality variable known as “Quality of Object Relations (QOR),” its interaction with different forms of therapy, and the composition of therapy groups. QOR refers to the life-long pattern of interpersonal behavior and ranges on a dimension from primitive to mature. In the former case, QOR was directly related to success in interpretive group therapy and inversely related to success in other forms of therapy (Piper et al., 2001). In the latter case, where composition was defined as the average QOR score across patients, the greater the group level of QOR the greater the success (Piper et al., 2007).

In summary, these results demonstrated the opportunity to investigate a variety of topics that go beyond the classical randomized clinical trial. In so doing, an understanding of the factors affecting success in interpretive group therapy has been increased.

Post-Partum Depression

    •    Post-partum depression is the incidence of depression following child-
    birth. It is the focus of increasing attention due to its prevalence.

    •    Two recent studies (Pesssagno & Hunker, 2013; Reay et al., 2012)
    found empirical support for group Interpersonal Therapy IPT for post-
    partum depression (Weissman, Klerman & Markowitz, 2007).

Adolescent Depression

    •    Treatment of depression in adolescents has its own body of literature.

    •    Group treatment approaches range from skill-building approaches
    such as CBT and DBT that are designed to promote resiliency, to Multi-
    Family Pyschoeducational Psychotherapy that integrates work to
    strengthen and support the family in a group format.

    •    NREPP recommended group treatments for adolescent mood disorders
    include:

        o     Cultural Adaptation of Cognitive Behavioral Therapy (CBT) for
        Puerto Rican Youth (Rosselló, & Bernal, 2007).

        o     Multi-family Psychoeducational Psychotherapy (MF-PEP) (Fristad, &
        Danner, 2011).

        o     Adolescent coping with depression (CWD-A) (Clarke, Lewinsohn,
        Hops, & Grossen, 1990).

        o     CAST: Coping and Support Training curriculum (CAST: Coping And
        Support Training Curriculum, 2007)

        o     Dialectic Behavior Therapy (DBT-A) for adolescent depression
        (Goldstein et al, 2014)

Geriatric Depression

    •    Unlike treatment of adolescent depression, which has received
    considerable empirical attention and has proven efficacious,
    group depression treatments for the geriatric population remain mixed to
    unproven.

    •    In a meta-analysis, Krishna et al. (2013) found that for the sub-clinical
    geriatric population, GCBT’s initial gains failed to be maintained at follow up.
    However, this may have been impacted by the poor quality of studies and
    sub-optimal power issues.

Bipolar disorders

There have been several recent studies exploring the effectiveness of
treating bipolar disorder with group therapies.

    •    The role of psycho-education and building coping skills (including
    interpersonal skills) to manage this disorder seems to be a common
    feature of the approaches that have received empirical validation.

    •    Psychoeducation (PEG) for bipolar disorder has had the strongest
    evidence base, with two RCT designs:

        o    PEG by Colom et al. (2003) showed reduced hospitalizations and
        maintenance of gains after 5 years, although patients with a longer
        history of episodes did not achieve the same gains.

        o     PEG by Simon et al. (2005) showed fewer episodes of mania,
        greater medication compliance and reduction in symptom intensity.

    •    Other recent approaches to group treatment of bipolar disorder that
    have shown early promise, but require further study include:

        o     Group Interpersonal Social Rhythm Therapy (GIPSRT; Bouwkamp,
        et al., 2013)

        o     Dialectic Behavior Therapy (DBT; Van Dijk & Katz, 2013)

        o     Dialectic Behavior Therapy for adolescents with bipolar disorder
        (Goldstein, et al., 2014)

Conclusions

Overall, the evidence for the efficacy of different group psychotherapy treatments for the treatment of depression is highly promising, with some approaches, such as GCBT, now well studied and researched. Treatment for several sub-populations (e.g., adolescent depression) and etiologies (e.g., grief) are well supported by evidence, although some sub-population (e.g. geriatric depression) group treatments have shown mixed findings. Other approaches remain promising, with group treatments for bipolar disorder receiving increasing empirical attention. Overall, there is a continued need for a range of high-quality studies, with Randomized Clinical Trials providing the most direct route to designation as Evidence Based Practice. However, there is also a significant need for high quality mixed-methods and process-outcome studies to better understand the mechanisms of change involved in group therapies.

References

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