Analyzing Qualitative Research Paper

¶ … 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.

Psychiatrists have recognized the relationship between anxiety and depression; detailed studies into the phenomenon have just begun. According to various researches and data, both conditions have been known to occur collectively more often than as singular clinical illnesses. Many researchers believe that both or either of these conditions occur when a prolonged illness has persisted, for example, chronic anxiety can transform into depression over time. In short, anxiety can be considered a prodrome for depression. Having these two conditions present in a single patient can greatly damage his/her clinical outcome as a combination is lethal and slows down the effect of drugs and/or clinical treatment. Luckily, the new variety of antidepressants are doing a good job of targeting both mood and anxiety issues.

There are so many diagnostic overlaps that the reoccurrence or prevalence of these conditions as a duo in a single individual are hard to monitor, and to what extent the population is affected by the combination of depression and anxiety. From acquired data, it is clear that as many as 10% patients have exhibited comorbid anxiety and depression in primary care settings. However, almost 60% MDD patients exhibited moderate levels of anxiety, 20-25%; the rest, on the other hand, exhibited severe anxiety. There is no set criterion here (Ballenger 2000)

Under primary care settings, it is difficult to diagnose patients with comorbid anxiety and depression because they don't really fall in a specific criterion for either issue fully. Therefore, this condition has been named "Mixed anxiety-depressive disorder." To better identify diagnostic basis for such patients, the APA has integrated the condition in the DSM-IV under a provisional category. The symptoms of this disorder are incomplete forms or low intensity symptoms of both anxiety and depression. Usually this disorder can be recognized by:

Difficulty in concentration

Memory loss

Lack of sleep

Reoccurring dysphoric moods

Fatigue

Irritability

Low energy and prone to worrying

While these symptoms are congruent with both anxiety and depression, the evidence is limited and not enough for a full diagnosis of either an anxiety disorder or depression. However, even while coexisting, one condition will be more dominant than the other. For example, if the coexisting depression is dominant, the patient will show hopelessness and the absence of positivity while dominant anxiety will most likely show motor tension and/or hyperactivity (Ballenger 2000)

Even if the diagnosis is not easy to make, the resolution process should always initiate with controlling the anxiety issues of such a patient. Once one aspect is managed, the other can be controlled with a regime of antidepressants. Medication and therapy is required for a full remission of depression. One such combination of drugs that is highly recommended for comorbid anxiety and depression is BZD or buspirone with an antidepressant. Since traditional anxiolytics will have little to no effect on depression, it is essential that treatment be coupled with antidepressants to manage this disorder (Koons et al., 2001). However, doctors have to be very careful with this particular combination of drugs and taper off the patient steadily and carefully. The withdrawal effects, especially from drugs like BZD, are not to be taken lightly.

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).

Drawbacks of the "systematic review approach" are repeatedly brought to light in this paper. They are as follows:

Long time scale

Narrow focus

Lack of cost-effectiveness

Wasteful approach to data retrieval

No actual clinical relevance (Leitner et al., 2006).

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 (Farrell, Shaw & Webber, 2009). 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. Summary of the Collected Data

The review recognized a variety of methodological problems pertinent to the current research evidence, which must to be dealt with if future researches are to work successfully and be based around an "evidence-based practice." The review also pointed out a number of issues with respect to the limitations, outreach and focus of the existing evidence bank. Due to the "Scatter gun" approach that has been adopted towards the study, research and treatment of comorbid anxiety and depression, neither doctors nor policy makers have been able to benefit from this poor evidence base collected from small studies addressing a much larger issue (Campbell, 2000). In the intervention paper, the people that face the worst fate are the patients of comorbid anxiety and depression. These people exist throughout the age spectrum and the lack of an actual address to the society, especially cultural and ethnic minorities that literature tends to ignore. Even the Socioeconomic status has been given little value in literature.

On the whole, the quality of the research at hand compares favorably to other larger studies that are conducting researches on anxiety and depressions separately (Leitner et al., 2006). Being favorable, however, does not account for its various failings as a methodology. These drawbacks are usually the fault of actual and/or perceived ethical and practical restrictions on research into suicidal conduct. For example, the researchers have failed to randomize the participants. A standard treatment or controlled conditions cannot be set. 'Blind' investigations are not possible and other outside stimulus can also not be controlled. Furthermore, the participant dropout rate is frequently high and accurate summations are made more difficult because of that.

While the excess of the database is collected from the U.S. or Canada, the literature has a focus on international audience, with the current evidence being contributed by 21 countries in total. As opposed to other public health literatures, the UK is active here, accounting for almost 19% empirical studies in this field. However, even here there were only five independent studies on the comorbid anxiety and depression. The studies were performed using data from the Scottish population (Leitner et al., 2006).

Other apprehensions regarding the 'coverage' of the accessible research material relates to the different people and locations in the researches being conducted. There is a prominent trend in the literature, more often than not; it associates depression and comorbid anxiety with mental illness. Almost half (46%), of the existing research material, points out interventions for the psychiatric population. The research particularly pinpoints patients with depression and/or borderline personality disorders. This association is a gross exaggeration, mental illness plays a part and has been linked with this condition as a vital risk factor, but it is in no way a compulsion (Chapman, 2006). The researches done do not focus on localities like schools, colleges and places like prison. Emergency situations have poor to no study and interventions, which are left to the sufferer's ingenuity.

2.4. 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

Dialectical behavior therapy (DBT) is a comprehensive interference, initially established for the management of suicidal conduct and borderline personality disorders (BPD). As a management system, DBT comprises of the following:

Integration of behavioral therapy approaches designed for change.

Validation strategies focused on acceptance.

These tactics are used in weekly "outpatient group skills training" and psychotherapy sessions. There are four behavioral basics to stand by that are both taught, instilled ad reinforced by therapy and they are as follows:

Mindfulness

Emotion regulation

Interpersonal effectiveness

Distress tolerance (Matusiewicz et al., 2010).

Since Mindfulness is the point of discussion in the current chapter, it is considered a pivotal skill in DBT because it is assimilated in other skill elements and regarded as an integral part of a successful treatment regime.

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. In DBT, several interventions and skills are geared toward conveying acceptance of the patient and helping the patient accept him or herself, others, and the world. One such intervention is mindfulness. In DBT, a talent for mindfulness aids a patient in facing their present. Some exercises require involvement, attending to and being unbiased towards the whole experience, stating the facts of an experience while being fully aware of the present and being there as well (Koons et al., 2001). A goal of this exercise is to focus on skills and good behavior.

Another aspect of the DBT that is taught and accepted in congruence with the distress module is the "Radical Acceptance." This exercise allows the patient to come face-to-face with their issues and deal with the present. There should be no struggle, or willful resistance in accepting the truth of the matter and not through the looking glass of the patient, but the truth of their feelings, events and emotions involved (Ballenger, 2000). The skill of a psychiatrist or a therapist lies with their ability to push them towards acceptance and more acceptance oriented realities.

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). Dialectical philosophy has been the energy that commands the distinctiveness of DBT in contrast to additional cognitive-behavioral therapies. Moreover, Dialectical philosophy is most frequently related to the ideology of Hegel or Marx and has been around for millennia. Inside a dialectical structure, reality comprises of divergent, polar forces, which are in strain. For example, the encouragement to utilize change-inclined management tactics creates a tension by augmenting a patient's need to be agreed upon instead of being changed. Obviously, there is a constant need to balance these forces (Ballenger, 2000). However, concentrating entirely on change-inclined struggles was an unfinished strategy; what it lacked was acceptance. However, this can be counterproductive, especially when dealing with a suicidal individual.

Dialectical thought affects many facets of a therapist's style and approach. The therapist effectively assimilates change and acceptance strategies to balance the treatment. The therapist tries to achieve a delicate frame where validation of the problems and their acceptance becomes possible. In proposing resolutions, he/she frequently proposes not only acceptance-centered (e.g., tolerating pain, radical recognition, being cautious of events as well as emotions) but also change-centered (e.g., varying conducts, solving problems, altering environments as well as reinforcement possibilities, changing cognitions) results. When the therapist and patient discuss specific problems, the dialectical mode of thinking allows the therapist to abandon being "right" and focus on methods to try and synthesize their approach with the patient's (Chapman, 2006). Lastly, in DBT, there happens to be a prominence of movement, natural flow and speed inside the confines of a therapy session. Therapists use varying techniques, change their style, as well as play with their intensity and care to keep the polar balance in a session.

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 a reduction in depressive symptoms, though the difference was not much greater than that of the comparison group that was receiving CBT treatment. Anxiety Symptoms: 3 studies investigated anxiety symptoms. In two of the studies, symptoms were reduced and improvements maintained for more than a month (Valentine et al., 2015; Kvarstein et al., 2015).