ReviewPsychosocial intervention development for the prevention and treatment of depression: promoting innovation and increasing access
Introduction
This workgroup was charged with considering how the National Institute of Mental Health (NIMH) can advance the development of psychosocial interventions for the mood disorders, including unipolar and bipolar disorders, as well as suicide. This goal can be advanced either by developing wholly new psychosocial interventions or by enhancing the efficacy of extant interventions and developing novel applications for their use, including the prevention of onset in people at risk. In a chronic recurrent disorder, prevention may be as important as treatment. One potential advantage of the psychosocial interventions is that many of them involve learning emotion regulation or interpersonal skills that may reduce the risk of onset and minimize the need for ongoing treatment (Hollon et al 1992).
Many psychosocial interventions can be delivered via nontraditional means such as television, telephone, printed materials, and the Internet (Christensen et al 1978). Such nontraditional methods can deliver programmed interventions with fidelity and greatly extend the numbers and types of people who can be reached with services. They also can be used to study the change process because of their suitability for providing selected components of interventions in a highly replicable, controlled fashion. With rapid advances in technology now the norm, such nontraditional methods should be developed and tested; if effective, they can provide opportunities for large numbers of flexible and individually adapted interactions that allow rapid investigation of specific interventions.
The process of innovation is best pursued within a theoretical framework that seeks to determine not just whether an intervention is efficacious, but why, that is, one that determines the mechanisms that mediate and the predictive factors that moderate its effects (Kazdin 2000). A focus on theory facilitates framing questions in terms of mechanisms and provides a basis for moving from basic research to clinical innovation. In so doing, the efficacy of promising interventions may be refined through identifying their active ingredients. Moreover, such a focus provides a framework for identifying moderating factors that influence treatment effects, including patient characteristics (such as ethnicity, comorbidity, or suicide risk) or therapist and setting factors that undermine the effectiveness of interventions when transported into applied clinical settings. Attention to the mechanisms behind these moderating factors can be used to make interventions more effective for a full range of people in real-world settings and may inform about the nature of the underlying disorder.
Section snippets
Nature of mood disorders
Depression is a usually recurrent and potentially chronic disorder that ranks fourth among all medical and psychiatric disorders in disease burden and is the number one cause of disability (Murray and Lopez 1997). Unipolar disorder involves depression only, whereas bipolar disorder also involves mania or hypomania. Unipolar disorder is more common, occurring in about 20% of all women and about 10% of all men, whereas bipolar disorder occurs in only 1% to 2% of the population and affects the
New directions in intervention development
The shortcomings just described will be overcome only by developing innovative treatments and refining existing interventions. The Workgroup recommends that NIMH quicken the pace of innovation by channeling research support along three major lines. First, progress in intervention development can be promoted by strengthening linkages between basic research and clinical science. Second, efforts at developing preventive and maintenance interventions must be increased. Third, access to effective
Acknowledgements
The Workgroup thanks Dr. Karen Babich and Ms. Joan Cole of NIMH for their assistance in many aspects of the preparation of this report.
This manuscript is one of ten prepared by workgroups under the auspices of the National Institute of Mental Health (NIMH) strategic planning initiative for mood disorders research. Each of the workgroups was given the specific charge to 1) review the state of their assigned area; 2) identify gaps and state a vision of where the field should be going and why; and
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