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Self Management of Depression A Manual for Mental
Health and Primary Care Professionals 1st Edition Albert
Yeung Digital Instant Download
Author(s): Albert Yeung, Greg Feldman, Maurizio Fava
ISBN(s): 9780521710084, 0511642121
Edition: 1
File Details: PDF, 1.37 MB
Year: 2009
Language: english
This page intentionally left blank
Self-Management of Depression
Self-Management of
Depression
A Manual for Mental Health and
Primary Care Professionals

Albert Yeung
Greg Feldman
Maurizio Fava
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore,
São Paulo, Delhi, Dubai, Tokyo

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/9780521710084
© A. Yeung, G. Feldman, M. Fava 2010

This publication is in copyright. Subject to statutory exception and to the

provision of relevant collective licensing agreements, no reproduction of any part
may take place without the written permission of Cambridge University Press.
First published in print format 2009

ISBN-13 978-0-511-64152-7 eBook (NetLibrary)

ISBN-13 978-0-521-71008-4 Paperback

Cambridge University Press has no responsibility for the persistence or accuracy

of urls for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and
up-to-date information which is in accord with accepted standards and practice at
the time of publication. Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this publication. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
To my wife Sharon, and our two daughters, Janet and Alicia,
with love.
–AY
I wish to thank my wife, Amy, and our two sons, Benjamin
and Samuel, for their support and inspiration.
–GF
I could not do what I do without the extraordinary help and
support from my wife Stefania and our son Giovanni.
–MF
Contents

Preface page ix
Acknowledgments x

1 The use of self-management for depression 1

2 Care management of depression: treatment of depression in
primary care and the need for a multidisciplinary approach 24

3 Self-assessment instruments for depression 46

4 Self-help: the role of bibliotherapy and computerized

psychotherapy in self-management for depression 68

5 Physical exercise as a form of self-management for depression 107

6 Self-management of depression using meditation 138

7 Cultivating social support: the role of peer support in

self-management 163
8 Putting it all together: applying self-management for
depression in your practice 190

Index 199

vii
Preface

From the clinician’s perspective, a key component of self-management of

depression is connecting patients with enduring resources to monitor and
manage their symptoms. As such, throughout this book, we provide patient
hand-outs containing information to guide their use of self-management,
including tips for initiating and sustaining an exercise program and select-
ing a peer support group, as well as lists of links to Internet resources where
patients can find self-assessment tools, information about learning medita-
tion, and web-based cognitive behavioral therapy programs. These hand-
outs may be photocopied and distributed by the purchaser of this book
to patients. These hand-outs are also available for download at no cost at
http://www.cambridge.org/9780521710084.

ix
 Acknowledgments

We would like to acknowledge our outstanding colleagues in the Depression

Clinical and Research Program at Massachusetts General Hospital for their
early brainstorming with us about this book when it was in its infancy. In
addition, we are grateful for the expert consultation provided by the following
colleagues at various stages of this book’s development: Jim Cartreine, Ph.D., at
Harvard Medical School and the Beth Israel Deaconess Medical Center; Richard
Bedrosian, Ph.D., of MySelfHelp.com in Northboro, MA; Dennis Tannenbaum,
M.D., at Sentiens in Perth, Australia; Barbara Gentile, Ph.D., at Simmons Col-
lege; and Sheri Johnson, Ph.D., at University of California–Berkeley. We would
also like to thank Katie James and Richard Marley at Cambridge University Press
for their support and knowledgeable assistance with this project at all stages
of its development. We greatly appreciate the following research assistants who
provided invaluable assistance with the preparation of this manuscript: Molly
Kerrigan, Caitlin Novero, Hillary Forbes, and Laurie Low at Simmons College;
and Lily Zhong and Vicky Lepoutre at the Benson Henry Institute for Mind
Body Medicine at Massachusetts General Hospital.
In addition, I (GF) would like to acknowledge that my work on this project
was supported in part by a grant from the President’s Fund for Faculty Excellence
at Simmons College.

x
 1

The use of self-management for depression

Major depressive disorder – commonly referred to as “depression” – is a preva-

lent, debilitating, costly, often chronic, and potentially fatal condition. As many
as 17% of people will experience major depressive disorder (MDD) in their life-
time (American Psychiatric Association [APA], 2000). The World Health Orga-
nization (2001) predicts that depression will become the second largest cause of
disability worldwide by 2020. The economic burden of depression in the United
States is estimated to be over $83 billion per year, including direct medical costs,
workplace costs, and suicide-related mortality costs (Greenberg et al., 2003).
Despite its high prevalence, many individuals with depression have difficulty
accessing adequate care (Kessler et al., 2003; Hirshfeld et al., 1997). In the United
States and abroad, there are shortages of trained mental health professionals
to address the increasing prevalence of depression. New strategies are needed
for delivering efficient and effective treatment for depression. Self-management
holds promise as a strategy for identifying, treating, and managing depression.

What is self-management?

Self-management can be defined as the methods, skills, and strategies by which

individuals effectively direct their own activities toward the achievement of
specific objectives. It usually includes goal-setting, planning, scheduling, task
tracking, self-evaluation, self-intervention, and self-development. In health
care, self-management typically refers to the training, skill acquisition, and
interventions through which patients who suffer from a disease or a chronic
condition may take care of themselves and manage their illnesses.

Why is self-management relevant for depression?

The principles of self-management have been successfully implemented in

managing many chronic illnesses, including diabetes, congestive heart disease,

1
2 1 The use of self-management for depression

and obesity. Self-management involves a collaborative relationship between the

patient and one or more primary care or mental health clinicians. The patient
is taught and encouraged to (1) view treatment as a collaborative process,
(2) actively self-monitor symptoms, and (3) supplement professionally deliv-
ered interventions (antidepressant medication and psychotherapy) by using
evidence-based, self-administered interventions; for instance, structured phys-
ical exercise programs and interactive computer programs that teach effective
coping strategies. Self-management has the potential to empower individu-
als already receiving treatment and provide them with additional resources. It
can also increase access to treatment for individuals in geographically remote
areas. By shifting more responsibility for symptom management to the patient,
a greater number of patients may access treatment, the efficacy of standard
therapies may be enhanced, risk of relapse may potentially be decreased, and
clinician time may be reduced, thus freeing up clinicians to treat additional
patients. Finally, self-management has the potential to reduce costs associated
with untreated or poorly managed depression, including health care expenses,
disability, and lost workplace productivity.

Overview of this chapter

As previously mentioned, the principles of self-management have been success-

fully implemented in managing many chronic illnesses. In this chapter, we will
present principles and theoretical models describing approaches to manage-
ment of chronic illness based upon reviews of programs or treatments found
to be successful in managing chronic illness through self-management. We will
explain how a collaborative clinician–patient relationship is used to empower
patients and how this can be contrasted with traditional approaches to health
education. Next, we will preview the approaches to self-management for depres-
sion that will be discussed in greater detail in later chapters. From there, we will
discuss why patients’ own attempts at self-management of depression may be
unsuccessful. Finally, we will conclude by discussing six essential components
of self-management and discussing research support for collaborative care and
self-management in treating several chronic illnesses, including depression.

A note on how to read this book

The overall goal of this book is to provide primary care physicians and nurses,
psychiatrists, psychologists, social workers, and other professional caregivers
with the knowledge and tools for making their work with patients with depres-
sion more efficient and effective by integrating self-management treatment
strategies with conventional professionally delivered treatment modalities.
 1 The use of self-management for depression 3

Consistent with the collaborative nature of self-management, this book will

not present a prescription of a rigid sequence of actions a clinician must take in
order to truly use self-management in his/her practice. This book contains no
“one-size-fits all” recommendations. Instead, our goal is to present information
about approaches used across multiple studies that have worked to increase col-
laborative care and self-management. Readers are encouraged to think about
their own clinical setting and the needs of the patients they serve in deciding
how to apply the models and interventions described.

Who needs self-management?

If we use a broad definition of self-management, it can be argued that everyone

needs and performs some form of self-management. Every day, we are faced
with stress and challenges in life that frequently lead to distress and emotional
problems. To maintain a sense of well-being, people usually have their own ways
to obtain a sense of emotional well-being. When people suffer from an illness,
they may need specific knowledge or skills to respond so that they can recover
from the illness, avoid its worsening, or prevent recurrences. There is extensive
literature on how environmental factors, emotions, and lifestyles affect health.
We make decisions every day on the type of food we eat, how often and how
much we eat, how much physical exercise we do, how much time we spend
working and resting, the type of activities we do for recreation, the people with
whom we interact, and the way in which we interact with them. All of these can
be considered as some forms of self-management. We know that what we eat
affects our body chemistry. A diet rich in saturated fat could increase our blood
cholesterol; elevated cholesterol level is a known risk factor for atherosclerosis,
heart disease, and stroke; high caloric intake may lead to becoming overweight
and obese; and consuming too many sweets and carbohydrates among people
who are predisposed to diabetes may lead to elevated levels of blood glucose.
Patients with chronic medical conditions, in particular, live with and self-
manage their illnesses continuously. Each day, they decide what they eat,
whether they will exercise, and in some conditions like diabetes and asthma,
the dosages of medications to use. For successful management of their diseases,
it is important that patients have an in-depth understanding of their illnesses
so that they are able to meticulously monitor their symptoms, adopt healthy
lifestyles, and implement treatment plans for their illnesses. Depression can
be considered a recurrent and/or chronic disorder in that episodes of depres-
sion may recur and/or last for many years. Furthermore, even for patients who
recover from an episode, the majority will relapse (APA, 2000). In fact, at least
60% of patients with one episode of depression will experience a second. Sev-
enty percent of those with two episodes experience a third, and 90% of those
with three episodes will have a fourth. This book explores what people can do
4 1 The use of self-management for depression

to manage their symptoms of depression through behavioral change, such as

lifestyle modification, and how health care providers can encourage and guide
patients’ use of these self-management strategies.

Self-management of chronic medical conditions

Epidemiology of chronic disease

The population of the United States has a demographic profile that is rapidly
aging. As a result, the prevalence of chronic medical conditions associated with
aging is increasing at a fast pace. Today, chronic disease is the main reason
why people in the United States seek health care, and they consume 70% or
more of health care spending (Holman & Lorig, 2000). In most industrialized
nations and in many developing countries, chronic diseases are the main causes
of disability and death. According to data published by the World Bank, 5 of the
10 leading causes of burdens of diseases (projected years living in disability due
to the condition) were chronic diseases, including ischemic heart disease, cere-
brovascular disease, HIV/AIDS, unipolar depression, and chronic obstructive
pulmonary disease (Lopez et al., 2006).

Goals of treating chronic diseases

The goals in the treatment of chronic disease are very different from those in
the treatment of acute illnesses. For acute diseases, the goal of treatment is to
eradicate the causes of the disease so that the patients can return to normal.
Chronic diseases are irreversible or relapsing conditions that are either persistent
or run a wax-and-wane course. They typically interact with environmental
factors, recur and remit throughout the lives of the patients, and tend to require
continuous and complex management. The goal of chronic diseases treatment is
not cure, but to support patients in managing their own diseases so that they can
maintain satisfying, pleasurable, and independent lifestyles. There is increasing
evidence that self-management educational and supportive interventions are
effective in helping patients with chronic diseases change their risky behaviors
or become better self-managers, and in improving outcomes across a range of
chronic illnesses.

Management of chronic illnesses: is the current US health

care system adequate?
With the rising prevalence of chronic illnesses and the increasing attention
they have received in recent years, effective treatment has been devised for
many of the chronic diseases, such as hypertension, depression, diabetes, and
 1 The use of self-management for depression 5

asthma. Yet, less than half of patients with hypertension, depression, diabetes,
and asthma are receiving appropriate treatment, according to a recent Institute
of Medicine report (Wagner et al., 2001a). This lack of adequate care was partly
attributed to the high demands on medical care due to the rapid increase in the
prevalence of chronic diseases and partly to the US health care system, which
was designed to manage acute illnesses or injuries and not chronic diseases.
“The focus of the current health care system is on the immediate problem, its
rapid recognition and exclusion of more serious alternative diagnoses, and the
initiation of professional treatment. Under such a system, the patient’s role was
largely passive” (Wagner et al., 2001a).
The current primary care health delivery system provides little support to
handle the needed lifestyle changes, such as changes in diet, exercise, and
stress management, required by people with chronic medical conditions. It
also does not provide patients with assistance in creating and maintaining new
meaningful life-roles regarding jobs, family, and friends, nor does it provide
guidance in ways to cope with the anger, fear, frustration, and sadness that
can be part of the experience of a chronic condition. People with chronic
conditions have to successfully overcome all these challenges before they can
effectively manage their chronic conditions (Corbin & Strauss, 1988). Wagner
(2000) concluded that there was a need to redesign the current health care
delivery system in order to provide better care to patients with chronic medical
conditions and diseases.

The Chronic Care Model

To improve care for chronic disease, Wagner studied successful quality improve-
ment programs for many chronic diseases, including diabetes, congestive heart
failure, asthma, hyperlipidemia, and depression. Wagner (1998) found that what
these successful programs had in common was that they used a multifaceted
approach and all included one or more of the following provider-oriented com-
ponents: continuing education to physicians, organizational changes in person-
nel to facilitate patients’ visits and follow-up, information systems changes, and
patient-oriented interventions. Based on these observations, Wagner (1998)
designed the Chronic Care Model for the management of chronic diseases.
The Chronic Care Model typically includes setting up a clinical informa-
tion system registry, delivery system design, decision support, self-management
support, and community resources and policies. The development of comput-
erized disease registries facilitates systematic tracking of patients with a spe-
cific condition, sending reminders to patients regarding their follow-up visits
to avoid delayed treatment, monitoring treatment outcomes, and providing
feedback to practitioners. The designing of the delivery system involves defin-
ing roles in the patient treatment team to delegate responsibilities among the
6 1 The use of self-management for depression

multidisciplinary team members. The goal is to ensure continuity of care by the

treatment team and to ensure regular follow-up. Decision support involves the
development and implementation of evidence-based guidelines using provider
education, reminders, and increased interactions among generalists and
specialists.
Of particular relevance to this book, self-management support is considered
a key element in the Chronic Care Model. Self-management support empha-
sizes the patients’ central role in managing their illness and provides effective
behavior change interventions and ongoing support with peers or professionals.
Establishment of community resources and policies involves setting up part-
nerships with community organizations to develop evidence-based programs
and identifying effective programs in the community in which patients may
participate. The Chronic Care Model has been found to be successful in over
300 diverse health care systems in the context of quality-improvement efforts
for asthma, congestive heart failure, depression, diabetes, prevention of frailty
in the elderly, and provision of an extremely helpful organizing framework for
these diverse quality improvement efforts (Wagner et al., 2001b; Glasgow et al.,
2001).
In the Chronic Care Model, optimal chronic care is achieved when a pre-
pared, proactive practice team interacts with an informed, activated patient.
It embraces two major components: collaborative care and self-management
education. Collaborative care is established on a new form of patient-physician
relationship in which physicians and patients form a partnership relationship.
Together, they make health care decisions and implement the treatment plan. In
the following sections, we will discuss the principles of self-management with
a focus on how the collaborative clinician–patient relationship can promote
self-management.

The principles of self-management

In this section, we describe some of the key principles for self-management,

including the importance of empowering patients and promoting their self-
efficacy through the use of collaborative care and self-management education.

Empowering patients through shared decision making

To live the best quality of life, patients with chronic conditions need to be expert
in managing their own conditions and to understand how to avoid intensifying
or having relapses of their conditions. Patients are no longer passive recipients
of medical care. They need to be partners in the process and to play a key role
in making decisions about the choice of treatment, interpreting and managing
changes in their conditions, coping with emotional reactions, implementing
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Important: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Problem-solving strategies and techniques
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 47: Theoretical framework and methodology
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Theoretical framework and methodology
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Theoretical framework and methodology
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Review 6: Historical development and evolution
Note: Assessment criteria and rubrics
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Fundamental concepts and principles
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Best practices and recommendations
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Assessment criteria and rubrics
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 54: Key terms and definitions
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Critical analysis and evaluation
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Best practices and recommendations
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 57: Research findings and conclusions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Practice Problem 58: Comparative analysis and synthesis
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 59: Current trends and future directions
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Quiz 7: Research findings and conclusions
Key Concept: Case studies and real-world applications
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Ethical considerations and implications
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 62: Current trends and future directions
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 63: Diagram/Chart/Graph]
Note: Assessment criteria and rubrics
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Theoretical framework and methodology
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 65: Key terms and definitions
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
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