The psychotherapy of a 10-year-old boy is used to demonstrate the usefulness of idealizing and mirroring transferences to help patients move from a state of lack of selfhood and self-differentiation to the development of self-structures that provide strength and self-esteem. Projective identification is presented as a therapeutic technique that can be used to facilitate this process by aiding the internalization of mirroring and idealization functions.
This article discusses the societal implications of substance abuse by pregnant women and women of child-bearing age and reviews their treatment needs as documented in the literature. It then provides a treatment model for pregnant women, using the Southcentral Foundation-Dena A Coy Residential Treatment Program as a model program. It outlines a number of components that are critical to successful substance abuse treatment of these women; specifically, medical interventions, social service provision, educational/vocational services, psychoeducational programs, psychotherapy, substance abuse interventions, and family preservation and involvement. These components are superimposed on a therapeutic community model that stresses gender and cultural relevance, as well as supportive structure and direction.
Depressive disorders cause substantial work impairment that can lead to disability compensation. The authors compared treatment received for depression preceding disability pension between 2 nationally representative samples with a 10-year interval.
The medical statements for 2 random samples drawn from the Finnish national disability pension registers, representing populations granted a disability pension for DSM-III-R major depression during a 12-month period from October 1993 through September 1994 (N = 277) and for ICD-10 depressive disorders (F32-F33) from October 2003 through September 2004 (N = 265) were examined. The proportions of persons receiving weekly psychotherapy, antidepressants, adequate antidepressant dosage, sequential antidepressant trials, lithium augmentation, and electroconvulsive therapy (ECT) were compared.
No significant differences emerged between the 2 samples, except for the adequacy of antidepressant dosage. Few subjects in either of the samples (8.7% for 1993-1994 vs. 10.6% for 2003-2004, p = .45) had received weekly psychotherapy. Most had received antidepressants (87.4% vs. 85.6%, p = .55) with increasingly adequate dosage (75.6% vs. 85.0%, p = .02), but only a minority had received sequential antidepressant trials (39.5% vs. 44.5%, p = .24). Lithium augmentation and ECT were rare (1.1% vs. 1.5%, p = .66 and 4.0% vs. 1.5%, p = .08, respectively). Even in 2003-2004, over half of the subjects were granted a disability pension without sequential antidepressant trials.
This nationally representative study indicates that, despite an increased antidepressant use and improved practice guidelines for depression, a considerable proportion of the people granted long-term compensation for depression seem to be suboptimally treated. Given the enormous costs of the disability, attention to the quality of treatment provided for depression is warranted before long-term disability compensations are granted.
The prevalence, long-term temporal consistency and factors influencing negative attitudes and poor treatment adherence among psychiatric patients with major depressive disorder (MDD) are not well known.
In the Vantaa Depression Study (VDS), a prospective 5-year study of psychiatric patients with DSM-IV MDD, 238 (88.5%) patients' attitudes towards and adherence to both antidepressants and psychotherapeutic treatments at baseline, 6 months, 18 months and 5 years was investigated.
Throughout the follow-up, most patients reported positive attitudes towards pharmacotherapy and psychosocial treatments, and good adherence. While attitudes became more critical over time, adherence to psychosocial treatment improved, but remained unchanged for pharmacotherapy. Employment predicted positive attitude (OR=1.97, 95% CI 1.01-3.83, P=0.046), and larger social network good adherence (OR=1.11, 95% CI 1.00-1.23, P=0.042) to pharmacotherapy at the last follow-up. Cluster B personality disorder symptoms predicted negative attitude (OR=0.82, 95% CI 0.70-0.96, P=0.012) and poor adherence (OR=0.83, 95% CI 0.72-0.95, P=0.007), but cluster C symptoms positive attitude (OR=1.30, 95% CI 1.09-1.54, P=0.003), and living alone good adherence (OR=3.13, 95% CI 1.10-9.09, P=0.032) to psychosocial treatment.
Patients may exaggerate their adherence to treatments. Attrition from follow-up may occur due to undetected negative change in treatment attitude or adherence.
Among psychiatric MDD patients in long-term follow-up, treatment attitudes and adherence to pharmaco- and psychotherapy were and remained mostly positive. They were significantly predicted by personality features and social support. Attention to adherence of those with cluster B personality disorders, or poor social support, may be needed.
Several evidence-based treatment guidelines for major depressive disorder (MDD) have been published. However, little is known about how recommendations for treatment are adhered to by patients in current usual psychiatric practice.
The Vantaa Depression Study is a prospective, naturalistic cohort study of 269 psychiatric patients with a new episode of DSM-IV MDD who were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and Structured Clinical Interview for DSM-III-R Personality Disorders between February 1, 1997, and May 31, 1998, and again at 6 and 18 months. Treatments provided, as well as adherence to and attitudes toward both antidepressants and psychotherapeutic support/psychotherapy, were investigated among the 198 unipolar patients followed for 18 months.
Most depression patients (88%) received antidepressants in the early acute phase, but about half (49%) terminated treatment prematurely. This premature termination was associated with worse outcome of major depressive episodes, and with negative attitudes, mainly explained by fear of dependence on or side effects of antidepressants. Nearly all patients (98%) received some psychosocial treatment in the acute phase; about one fifth (16%) had weekly psychotherapy during the follow-up. About a quarter of patients admitted nonadherence to ongoing treatments.
Problems of psychiatric care seem most related to continuity of treatment. While adequate treatments are provided in the early acute phase, antidepressants are terminated too soon in about half of patients, often following their autonomous decisions. From a secondary and tertiary preventive point of view, improving continuity of treatment would appear a crucial task for improving the outcome of psychiatric patients with MDD.