Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

Abstract

BackgroundDepression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence.Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression.DesignA therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions).MethodParticipants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used.DiscussionWe expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression.Trial registrationISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Self-narrative reconstruction after dilemma-focused therapy for depression: A comparison of good and poor outcome cases

“…Ten participants were selected from a pool of 22 clients seen as part of the dilemma-focused intervention arm of an ongoing study of Feixas et al (2013. This is a randomized controlled clinical trial of psychotherapy for adults with depressive disorders that explore the relative efficacy of a dilemma-focused module intervention over standardized CBT.…”

“…In particular, a series of studies found that IDs were significantly more prevalent in depressive participants than in controls and that such cognitive conflicts were associated with the severity of patients' clinical complaints Feixas, Montesano, Erazo-Caicedo, Compañg, & Pucurull, 2014;. Consequently, a dilemma-focused intervention was devised to target IDs ) and is currently being tested for the treatment of depression in combination with standard CBT (Feixas et al, 2013). Preliminary analyses showed promising results for dilemma-focused therapy, which proved to be at least as effective as standard CBT in improving depressive symptoms and more suitable for helping clients resolving their IDs.…”

Cognitive conflicts in major depression: Between desired change and personal coherence

“…For instance, psychological interventions could specifically target dilemmas insofar as they could constitute a focus of therapeutic work and allow individualizing the design of the treatment to fit patient subjective experience. It is noteworthy that although the concept of ID arose from a particular theoretical framework (personal construct theory), a dilemma-focused intervention could constitute an 'add-on' for a broad range of therapeutic models as it is being tested out in combination with CBT (Feixas et al, 2013). Thirdly, IDs can be detected by means of the RGT.…”

Cognitive conflicts and symptom severity in dysthymia: “I’d rather be good than happy”

“…40 In addition, the efficacy of a dilemma-focused intervention in combination with cognitive behavioural therapy is being tested out for unipolar depression. 41 While the results of this study have clarified the role of implicative dilemmas and their content for dysthymic patients, there are some limitations that need to be considered. First of all, the lack of a matched control group restricted the generalizability of the results; likewise, the current comparison group was formed of a convenience sample with no control for undiagnosed disorders.…”