Effects of Religious Versus Conventional Cognitive-Behavioral Therapy on Gratitude in Major Depression and Chronic Medical Illness: A Randomized Clinical Trial

Gratitude and Religiosity in Psychiatric Inpatients with Depression

Background

Gratitude and religiousness/spirituality are increasingly recognized resources that have potential influence on psychological states such as depression. However, only few studies have investigated this relationship in psychiatric patients.

Objective

The present study examined gratitude in psychiatric inpatients with depression, exploring its relevance, course, and interaction with psychopathological and religious measures. Both general and religious gratitude will be evaluated.

Methods

A total of 212 inpatients with depression completed a questionnaire both at the beginning and the end of treatment. Gratitude was measured with a general gratitude scale using the Gratitude Questionnaire and a religion-specific measure assessing gratitude to God as part of the Structure of Religiosity Test. The Beck Depression Inventory was used to evaluate depressive symptoms. General religiosity was assessed using the Centrality of Religiosity Scale.

Results

Scores on the general and religious gratitude measures were in the upper range of these scales at baseline and demonstrated a significant increase during the hospital stay. Negative associations were found between general gratitude and depressive symptoms both on admission and at discharge (r = -0.505 and r = -0.478, respectively). General as well as religious gratitude was associated with the centrality of religiosity (r = 0.384 and r = 0.546, respectively). Religiosity accounted for approximately 10% of the variance in general gratitude on admission.

Conclusions

Gratitude is highly prevalent in psychiatric patients with depression, and that may serve as a resource for these individuals. Both general and religious gratitude are associated with religiosity, which may also serve as a resource to these patients.

Without Your Therapist: Contemplative Prayer During Treatment as a Religious Exposure Intervention to Reduce Religious Struggle and Anxious God Representation

This case study focuses on the treatment of a 44-year-old Dutch man presenting with an anxious God representation and religious struggles according to DSM-5 criteria. Having received prior treatment for a panic disorder and alcohol use disorder, the patient was given a 60-day treatment in which the Jesus Prayer intervention was used to address his religious and spiritual problems. To our knowledge, this is the first case study involving the Jesus Prayer in the treatment of a patient. The intervention had positive effects on the patient’s religious and spiritual problems concerning an anxious God representation, religious struggles, stress levels and surrender to God. The intervention may also play a supporting role in decreasing symptoms of depression and anxiety and in promoting global mental health, as reliable change index analyses revealed symptom reduction between baseline levels and at post-assessment levels for all measured symptoms, with a semi-gradual decrease over the course of treatment. These improvements were continued in a 3-month follow-up assessment, suggesting promise for the Jesus Prayer as an effective treatment method for religious and spiritual problems. Recommendations regarding the importance of assessing the religious life of patients and implementing spiritual interventions are discussed, as well as the relevance of the therapist’s own assumptions when treating a religious or spiritual problem.

Use of Spirituality in the Treatment of Depression: Systematic Literature Review

Spirituality has been gaining recognition as a potential treatment modality. Our paper aimed to provide a systematic overview of existing research examining the use of spirituality as a treatment method for depression. All articles published between 2000 and 2018 that scientifically evaluated therapeutic interventions with elements of spirituality were included in the review. Ten studies met the inclusion criteria. Their analysis showed that there were elements of spirituality-based treatments that were repeatedly mentioned, including gratitude, forgiveness, self-acceptance, and compassion. Most often, spirituality was used together with psychotherapy. The review also noted the emergence of digital interventions.

A controlled trial of Cognitive Behavioural Therapy-based strategies for insomnia among in-school adolescents in southern Nigeria

BACKGROUND

Sleep difficulties are highly prevalent among adolescents, and are associated with significant impairments. The effectiveness and acceptability of Cognitive Behavioural Therapy-based (CBT-based) treatment for insomnia in adolescents is established for High Income Countries, but unknown for African settings. Thus, the aim of this study was to assess the effect of CBT-based intervention among in-school adolescents with sleep difficulties in Southern Nigeria.

METHODS

This was a pilot controlled trial involving 50 adolescents with highest ranked scores on the Insomnia Severity Index (ISI) recruited from four schools (two government and two privately owned). Balloting was used to assign two schools (public and private) with 25 participants to the intervention group, and the other two schools (public and private) with 25 participants as waiting-list controls. The two groups were dyad-matched for baseline ISI scores, gender, and type of school to reduce baseline differences. The treatment group received weekly group-based manualised CBT-based intervention over 5 weeks. Primary outcome was ISI score at 6th week. Secondary outcomes were sleep onset latency (SOL), Total sleep duration (TSD), depressive symptoms, sleep hygiene, and knowledge about sleep.

RESULTS

Participants were aged 13-17 years (M = 14.9, SD = 1.16) and consisted of 18 males and 32 females. Controlling for baseline scores, the intervention group showed significantly lower post-intervention insomnia scores compared with the control group {F (1, 34) = 1.10, p = 0.0001, (ηp² = 0.59}, shorter SOL {F (1, 33) = 1.41, p = 0.0001, ηp² = 0.39}, longer TSD {F (1, 33) = 1.03, p = 0.0001, ηp² = 0.47}, lower depressive symptoms {F (1, 31) = 1.32, p = 0.002 (ηp² = 0.34}, higher knowledge of sleep {F (1, 34) = 1.02, p = 0.001, ηp² = 0.36}, but no significant change in sleep hygiene {F (1, 32) = 1.08, p = 0.08, ηp² = 0.15}. All participants in the intervention group rated the programme as good or excellent.

CONCLUSION

This pilot CBT-based intervention for adolescents with insomnia was feasible, well received and showed promising efficacy in this setting. Larger controlled trials are recommended to establish the generalisability of these findings in this region. Trial registration Pan African Clinical Trial Registry (Registration Number PACTR202001710494962).

Exploration of a Biblical Counseling Program for Depression

Millions of Americans experience sadness, fatigue, and sleeping difficulty. These symptoms are consistent with a diagnosis of depression, which the American Psychiatric Association (APA) categorizes as a serious medical illness. Treatments include pharmacotherapy and/or counseling, with varying outcomes. Anecdotally, positive outcomes are seen in adults with depressive symptoms seeking Biblical counseling (BC) that uses the Judeo-Christian Bible as its foundation; so, this project explored such a program. The project included a retrospective chart review and a pilot study introducing the use of the Center for Epidemiologic Studies Depression Scale Revised (CESD-R) to identify and track depressive symptoms. Findings support further investigation into BC as a viable option.

Psychological therapies for treatment-resistant depression in adults

BACKGROUND

Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.

OBJECTIVES

To assess the effectiveness of psychotherapies for adults with TRD.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).

DATA COLLECTION AND ANALYSIS

We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs).

MAIN RESULTS

We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.

AUTHORS' CONCLUSIONS

Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.