Introduction

Low mood is a universal experience. It is most often a temporary emotional response to losses, disappointments or conflicts, which are an inevitable part of human experience. Fortunately for most of us the transitory nature of ordinary mood changes means that periods of lower mood impose only a passing additional burden. With time or a change of fortune the emotional temperature changes and so mood adapts. The point at which low mood becomes characterised as clinically depressed mood is difficult to determine and rests somewhere along a spectrum of emotional experiences from sadness to desolate emptiness. The overlap with associated emotional states such as hopelessness and grief further add to difficulties of clear definition.

It has been argued that depressed mood can be a functional response, preventing dangerous or futile actions in unfavourable circumstances (Nesse, 2000) or facilitating mourning necessary to accommodate loss (Freud, 1917). Depression, however, is also used to refer to a persistent and intense alteration in mood, associated with concomitant cognitive, behavioural and physiological changes resulting in functional impairment. In such cases depression is no longer a relatively isolated, contained and transitory emotional state but describes a more pervasive change in status. It demands a high cost from those living with it both directly and indirectly. In such cases depression is a collective term used to refer to a clinical disorder and may be anticipated to have further implications both personally and interpersonally.

Both DSM-IV and ICD-10 describe a cluster of physical, cognitive and emotional symptoms that, when presented together over a period of at least two weeks, are regarded as consistent with a diagnosis of major depression. DSM-IV presents a threshold of five out of nine symptoms, including low mood, loss of interest, weight loss or gain, sleep difficulties, agitation or slowing down, feelings of worthlessness or inappropriate guilt, difficulty thinking and concentrating and thoughts of death or self-harm. Both diagnostic systems agreeing that persistent low mood and loss of interest are core and necessary for diagnosis. ICD-10 additionally specifies reduced self-esteem and self-confidence and a bleak and pessimistic view of the future with an increasing number of the additional symptoms anticipated as the

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

severity of the episode increases. Although not included in either diagnostic system, indicators of social dysfunction including social withdrawal and isolation and sexual dysfunction are common features of a depressive state.

Current classification systems focus on the commonality of experience between depressed individuals, drawing lines of demarcation along subtypes, severity, patterns of recurrence and, to a limited extent, co-morbidity. However such systems do not similarly accommodate the differences between depressed individuals, which may be of significant bearing on their response to treatment and interaction with different treatment formats, such as personality, gender and the impact of historical and current relationship and socio-economic factors. Such factors continue to rely on the skill and wisdom of the clinician to integrate and accommodate into any treatment plan.

Depression is a very common disorder, most commonly emerging in early adult life, but potentially having onset from childhood to late life. Large-scale community prevalence studies have shown lifetime prevalence rates of approximately 17 %, and 6 % to 10 % in the last year (Kessler et al., 1994; Kessler et al., 2003). Rates show significant interactions with social and economic status (Brown & Harris, 1978; NICE, 2004) especially for women who are at greater risk during early and mid-adult life but less so in later life when the gender pattern reverses. The majority of identified community cases are rated as moderate severity or above, with almost 13 % having very severe symptoms (Kessler et al., 2003) although it is uncertain how valid a symptom count definition of severity is in practical terms. The impact of moderate to severe depression is reflected in over 59 % of individuals who have suffered from depression in the last year reporting severely or very severely impaired role functioning, with particular difficulties noted in the social domain (Kessler et al., 2003). The fortune of those suffering with depression is further hampered by the fact that depression rarely presents in isolation. Co-morbidity has been identified in 72 % of those with a lifetime diagnosis and in 78 % with a diagnosis in the last 12 months. The most common presentation is co-morbidity with an anxiety disorder (Kessler et al., 1998, 2003). The impact of this diagnosis is reflected in it being one of the major causes of social, physical and occupational impairment, and associated with increased mortality risk, with two-thirds of suicides completed in the midst of an episode of depression (Sartorius, 2001).

Depression is often described as an episodic disorder, with widely varying estimates of mean duration, ranging from 3-12 months, while 10-30 % experience more than 12 months of symptoms (Keller etal., 1982,1992; Spijker etal., 2002). Thus the delineation among and between episodes is not always clear and, for many, the disorder can run on for months or years in a chronic or repeatedly relapsing course. The World Health Organisation found that one year after diagnosis with depression 66 % continue to meet criteria for a mental health disorder, 50 % of those being depressed (NICE, 2004). It is also known that once depressed the risk of becoming depressed again increases. This is important in understanding what it means to someone's life to become depressed - whether it is a temporary difficulty or lifelong challenge. Kupfer (1991) reports a 50 % risk of recurrence following first episode, higher if onset is before 20 (Giles et al., 1989). The odds of future episodes further increase with each subsequent episode, rising to 70 % and 90 % after second and third episodes (Kupfer, 1991).

A persuasive body of theoretical argument and evidence has developed since the 1960s supporting the use of psychological interventions in the treatment of this disorder. This is further promoted by the demonstration of patient preference for such talking therapy as treatment approach of choice (Ward et al, 2000). The goals of psychotherapy reflect those of pharmacotherapy in reducing depressive symptoms, improving social and occupational functioning and preventing a recurrence of the symptomatic and functional difficulties in the future. In addition psychotherapies provide a framework for understanding, addressing and correcting cognitive, behavioural, social and interpersonal factors hypothesised to play a precipitating, exacerbating or maintaining role in the spectrum of depressive symptoms.

A number of models of therapy have been examined in relation to relieving the symptoms of depression, and these have undergone varying degrees of evaluation with respect to their clinical value. Numerous meta-analyses have been conducted and clinical guidelines produced to review the wealth of research that has been published on psychological interventions for depression (De Rubeis & Crits-Christoph, 1998; Frank et al., 1993; Jorgensen, Dam & Bolwig, 1998; NICE, 2004; Robinson et al., 1990) and to help clinicians and researchers alike to determine whether all that shines is in fact gold. Empirical evidence points to cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT) and problem solving therapy (PST) as primary treatment options for depression, with more limited evidence supporting the use of behaviour therapy, couples therapy, and forms of brief psychodynamic therapy.

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