¶ … Successful Are Clinicians in the Treatment of Comorbid Depression and Anxiety in Adult Patients, With DBT Skills Application? Depression and anxiety are two of the most common mental health problems in the United States. These two conditions affect a significant percentage of the United States population, meaning that billions of dollars are spent every year to care for the conditions and related problems. Additionally, depression and anxiety are behind the significant declines in patient social functioning and well-being. The two disorders have also been found to cause great suffering and pain to both patients and their close friends and family. In spite of the fact that proven treatments exist, both conditions remain undertreated (Rizvi, 2011 -- ). The diagnosis and subsequent treatment of the disorders are made even more difficult by the fact that the two disorders share many signs and symptoms. For instance, data from the National Comorbidity Survey shows that at least 58% of individuals who were found to have lifetime depression have a minimum of one anxiety disorder. Patients with comorbid anxiety and depression were also found to have significantly lower levels of productivity and use of healthcare resources (Ballenger, 2000).

Depression and anxiety have been found to frequently co-occur, both sequentially and concurrently, in both children and adults. It has also been found that the presence of one of the disorders increases the risk of getting the other, as time goes by. The most prevalent anxiety disorder among adults is GAD (Generalized Anxiety Disorder), while the most prevalent depression disorder is MDD (Major Depressive Disorder). GAD and MDD frequently appear together in many patients, through family lines (Garber & Weersing, 2010). One of the most frequently used type of psychotherapy today, is CBT (Cognitive Behavioral Therapy). The focus of this therapy is to help individuals learn their thought process so that they can eventually change how they feel and behave, at the end of therapy. The majority of American psychotherapists who practice CBT use a version of it that is more goal-oriented and time-limited (Garber & Weersing, 2010). A version of CBT that is gaining prominence among therapists is DBT (Dialectical Behavioral Therapy). DBT is based on the principles of CBT, which it uses to increase the effectiveness of treatment and focus on specific issues. The founder of dialectical behavioral therapy, Dr. Marsha Linehan, came up with this version of CBT after seeing the deficits in Cognitive Behavioral Therapy (Matusiewicz, Hopwood, Banducci & Lejuez, 2010). This study would therefore help in the understanding and delivery of best practices in psychological therapy.

2. Method

2.1. Data Sources

The purpose of this review is to evaluate evidence of the efficacy of various psychological interventions used in the treatment or management of comorbid anxiety and depression.

Three databases were used in conducting this literature review and they include: MEDLINE -- A database of the United States Library of Medicine (www.nlm.nih.gov/); PsycINFO -- A database for storing psychology articles, reports and other literature (www.apa.org/psycinfo); and the Cochrane Library - an evidence-based database for health care literature (www.cochrane.org).

As the search was being conducted in each of these databases, only literature published between 2011 and 2014 were considered. Considering the little time and money available for the review, only literature published in English were considered. Previous reviews done show that this kind of restriction has little impact on the outcome. Given the specifications of this study, the search was also restricted by the age i.e. only adults were considered. Further restrictions were made based on study design, intervention settings and ways in which the interventions were evaluated. To get only the most relevant data, the following criteria was used to "fine tune" the search process, and only empirical studies were considered (Valentine et al., 2015).

2.2. Sample Unit Description

In the search done on the three databases, the following keywords were used "depress*" OR "depression" OR "dysthymic disorder" OR "depressive disorder" OR "intent*" OR "Depression and anxiety" OR "DBT compared with CBT" OR "DBT Effectiveness" OR "Success" (The asterisk indicates a wildcard search, which retrieves all data that include the phrase preceded by the asterisk). By removing all duplicated searches and then applying the restriction criteria highlighted above, the number of individual texts found was thirty-six. The intervention restriction criteria further reduced this number to 18 texts. Random selection searches on the excluded texts revealed that the majority of those texts were purely discursive. However, it was also clear that there was an imbalance in the texts with many of them focusing on risk rather than intervention...

The abstracts of the remaining texts were each individually read so as to further exclude any that did not meet the review criteria. Those which were ambiguous or did not have enough information were read by other reviewers. At the end of the process, only 12 papers out of the initial 36 were found to be potentially worth reading, and were purchased in full-text format. Each of these was then read to the end, after which a final decision was made to consider all of them for the review (Valentine et al., 2015; Kvarstein et al., 2015).
2.3. Data Analysis Approach

The data analysis approach utilized for this review was inductive. This is because I believe that this kind of analysis better meets the rational and practical needs of research on clinical matters. Inductive data analysis allows iterative exploration of outcomes by following the empirical approaches utilized in primary research. An added benefit of utilizing this approach for psychological research is that it allows any grouping/clustering of texts around key themes to be data-driven. Apart from this, inductive data analysis also allows the analysis of data from different kinds of study designs and evaluates not only the outcome, but also the participants as a variable. It is my opinion that this approach gives the proper flexibility required to address clinical issues in complex studies (Matusiewicz et al., 2010; Rizvi, 2011).

3. Findings

Content analysis was clustered based on the results and descriptions provided in the published literature. Data used from the material was analyzed at least three times and reviewed against other studies that contained similar variables or results. Where discrepancies were found, they were resolved through careful and repeated reading of the pertinent literature and discussion of the content. At first, data was gathered from each paper using the characteristics of the population receiving Dialectical Behavioral Therapy (sex, race and gender) and a comparison of the sample against other studies with similar demographics and how the therapy was implemented. All the measures of outcome utilized and any follow-up results were also captured in the present study. The second step entailed the collection of any other data related to CBT as a treatment therapy. Comparisons were also made in this step. To assess the risk of bias, in studies, different methodological factors were looked into for each study using PRISMA standards (Liberati et al., 2009; Matusiewicz et al., 2010).

Thematic Area 1: DBT Implementation

Since there is no one standard way of conducting inpatient DBT, the treatment packages described in the different texts varied greatly. However, there exists a standard framework for outpatient DBT and many of the authors reported to have operated from it. Researchers Lynch, Trost, Salsman & Linehan (2007) offer information about treatment stages, but they didn't go further to describe the treatment strategies utilized. Treatment Duration: Most of the treatment periods ranged from 2 weeks to 3 months. This was also the model period of treatment. Individual Therapy: Standard outpatient Dialectical Behavioral Therapy entails weekly therapy sessions, lasting approximately 1 hour. Of the 8 studies that did describe their treatment strategies, only 1 didn't cover individual therapy (Valentine et al., 2015). Group Skills Training: Standard outpatient therapy reported in the studies was approximately 2.5 hours weekly. These weekly sessions included training in four main areas; interpersonal effectiveness, emotional regulation, distress tolerance and mindfulness. All the studies had some variation of a skills training activity. Consultation: In standard Dialectical Behavioral Therapy, the therapist engaged their clients on phone so as to help improve the ability of the clients to call for help. However, none of the articles that were reviewed described any phone conversation taking place (Valentine et al., 2015). Therapist Consultation Groups: Standard outpatient DBT generally includes weekly consultation meetings. Six of the studies had either once or twice per week meetings in their treatment plans. Comparison Groups: Of the twelve studies used, nine of them conducted comparison analyses between one group that received DBT and another group that received either CBT or some other type of depression/anxiety intervention.

Thematic Area 2: Treatment Outcomes

Across all the 12 studies, the group that received DBT treatment reported improvements in either a symptom or a problematic behavior. Some individuals reported behavior changes in more than one point of a problematic behavior. Depressive Symptoms: Out of 8 studies that looked into depressive symptoms, 6 of them reported a considerable reduction in these symptoms after DBT treatment. Many of the behavioral improvements were maintained for up to 21 months post-discharge. One study also reported…