DEPRESSION AND ANXIETY 27 : 27–34 (2010)

Research Article
AN ADJUNCTIVE MANAGEMENT OF DEPRESSION
PROGRAM FOR DIFFICULT-TO-TREAT DEPRESSED
PATIENTS AND THEIR FAMILIES
Christine E. Ryan, Ph.D., G.I. Keitner, M.D., and S. Bishop, Ph.D.

Background: The goal of this open-label feasibility trial was to test a short-
term, adjunctive intervention, the Management of Depression (MoD) Program,
to determine if patients with difficult-to-treat forms of depression and their
family members could learn to cope more effectively with their illness. Methods:
Nineteen patients meeting The Diagnostic and Statistical Manual IV criteria
for major depressive disorder, dysthymia, or chronic/recurrent depression and
their family members participated in an open-label study testing the efficacy of
the MoD Program. The intervention consisted of nine sessions over 16 weeks,
followed by an 8-month maintenance phase. Outcome measures focused on
quality of life, psychological and family functioning, and level of depression.
Results: Fourteen patients and their family members improved significantly in
psychosocial and family functioning, and depression severity (all P-values o.05)
by the end of the 16-week intervention. There was also significant improvement
in quality of life, psychosocial and family functioning, and depression scores
(all P-valueso.05) for the 10 patients who completed the maintenance phase.
Conclusion: The MoD Program is a useful adjunctive intervention that helped
patients and their family members deal more effectively with their persisting
depression. The disease management approach improved the patient’s perceived
quality of life and functioning, reduced depressive symptoms, and improved
perception of their family’s functioning. Depression and Anxiety 27:27–34,
2010. r 2009 Wiley-Liss, Inc.

Key words: depression; mood disorders; family functioning; psychosocial

functioning; quality of life

reported in several studies of combination treatments

INTRODUCTION
The effectiveness of treatments for difficult-to-treat
depression is suboptimal. Despite repeated treatment
trials, a substantial proportion of depressed patients
respond poorly to antidepressant medication, meet
criteria for chronicity, do not remit from their
depressive episode, and report residual depressive
symptoms, including impaired quality of life and poor
psychosocial and family functioning.[1–3] Though the
degree of residual symptoms varies, their presence
indicates an active illness state and are strongly
associated with recurrence.[4–7] Although combining
antidepressant medication with brief, structured psy-
chotherapy may improve short-term outcome for some
patients with chronic depression, remission rates
also remain low.[8–11]
Department of Psychiatry and Human Behavior, The Warren
Alpert School of Medicine at Brown University and Rhode
Island Hospital, Providence, Rhode Island
No conflict of interest was declared.
Correspondence to: Gabor I Keitner, MD, Mood Disorders
Program, Rhode Island Hospital, Potter 3, 593 Eddy Street,
Providence, RI 02903. E-mail: gkeitner@lifespan.org
Received for publication 8 July 2009; Revised 15 October 2009;
Accepted 21 October 2009
DOI 10.1002/da.20640
Published online 10 December 2009 in Wiley InterScience
(www.interscience.wiley.com).

r 2009 Wiley-Liss, Inc.

28 Ryan et al.
It may be that there are subtypes of depressions that
are not responsive to currently available treatments.[1]
For some persistent and chronic depressions, it may be
helpful to shift from an acute treatment paradigm to an
illness management model.[12] Disease management
models, emphasizing health education, coping skills,
and empowering the patient to manage their illness,
have been used successfully in the treatment of chronic
medical conditions (e.g. asthma, diabetes, chronic pain,
arthritis), and have shown some promise in treating and
managing depression.[13–16]
We developed an adjunctive Management of Depres-
sion (MoD) Program for patients with difficult-to-treat
depression, by integrating features of disease manage-
ment and coping with depression models into a short-
term intervention that augments other treatments
patients receive. The MoD Program: (1) applies a
paradigm shift from treating the acute episode to
teaching patients how to self-manage their illness over
time, including setting realistic expectations about
illness course; (2) focuses on patient action and
responsibility in the decision-making process; (3)
targets quality-of-life and psychosocial domains rather
than depressive symptomatology; (4) includes family
members and adapts a multipath plan to promote
effectiveness in living with the illness. The MoD
Program differs from other models in that it targets a
patient population with chronic/recurrent depression;
focuses on a wide range of outcomes, particularly
psychosocial, family functioning, and quality of life;
involves patients and family members; teaches patients
how to self-manage their depression; includes a format
that allows for flexibility and shared decision-making;
includes a variety of strategies that provide alternative
options; provides for the practice of in-session learning
techniques; and works from the strengths of patients
and family members. The MoD Program is designed to
be used as an adjunctive program to ongoing pharma-
cological and psychotherapeutic treatment. The em-
phasis is on teaching a patient to reframe their illness in
a more realistic way that is consistent with their
experience.[17]
The goal of this pilot study was to test the MoD
Program to determine the feasibility of the intervention
in helping patients and their family members self-
manage their illness and function better in spite of their
depression. This exploratory study is a first step in
developing a new paradigm for managing resistant forms
of depression.[11,18–21]
METHODS
The adjunctive MoD Program includes an assembly of simplified
interventions explained in a series of individual and family sessions
designed to give depressed patients and their families a set of skills to
help them cope better with the nonremitting course of their
depression and improve their quality of life. The individual session
content for the MoD Program is listed in Table 1. Throughout the
intervention, the therapist helps the patient set realistic expectations
Depression and Anxiety
TABLE 1. Management of depression program content
Session 1: Orientation to the program. Establish patient–therapist
alliance; review patient’s illness characteristics, knowledge of
depression, attitude toward treatment, practice recoping
behaviors. Begin psychoeducation about difficult-to-treat and
treatment resistant depression
Session 2: Build positive physical health habits. Assess the patient’s
knowledge, attitude, and practice with respect to the role of sleep,
exercise, diet, and relaxation as they relate to depression.
Therapist works in collaboration with patient to tailor action plan
to maintain, change, or initiate positive physical health habits
based on his/her individual needs
Session 3: Orient the family—with the patient’s help—to the MoD
program. Assess the family’s knowledge of depression, attitude
toward treatment, and practice recoping behaviors. Focus on
family roles and how a family and social support can help the
patient deal with the illness
Session 4: Build positive mental health habits. Review patient’s
knowledge, attitude, and practice when dealing with a difficult
situation. Focus on patient’s insight, social skills, and self-
awareness; identify situational triggers and coping difficulties
Session 5: Review progress and course corrections. Discuss how to build on
skills training to achieve a cumulative effect. Stress that the tools,
techniques, and knowledge gained are for use over the long-term,
not just for the length of the program
Session 6: Keep the family on track. Introduce communication and
problem-solving skills to patients and families. Practice ‘‘active
listening’’ and ‘‘crossover techniques’’
Session 7: Find or rediscover meaning and purpose. Keep an appreciation
journal. Revisit periods in life when there was a purpose in life.
Discuss ways life could be meaningful again
Session 8: Keep the family on track with affective involvement. Build on
the communication techniques learned to improve patient–family
interaction. Let patients and family members share how the
depression affects the patient and the family. Discuss what they can
do (maintain, change, initiate) to help each other
Session 9: Summarize patient– family progress and prepare follow-up.
Discuss how knowledge of the illness, attitude toward treatment,
and practice of coping behaviors changed for both patients and
families during the program. Correct any misconceptions or
misinformation. Prepare patient and family members for follow-
up period by summarizing the knowledge gained, and motivating
them to continue with their program
of outcome, focus on his/her well-being in spite of the illness, become
aware of the importance of medical management, learn to maintain,
change, or create meaningful behaviors or roles, deal with the
emotional sequelae of having a chronic condition, and focus less on
depressive symptoms and more on functioning and quality of life.
The therapist was a clinical psychologist with experience in
administering cognitive-behavioral therapies.
There were two phases to the program. Phase I included the MoD
5 individual and 4 family sessions delivered over 16 weeks. Phase II,
the maintenance phase, included 4 individual and 2 family sessions
over 8 months. A trained research assistant telephoned patients
monthly to ask how they were doing and to monitor the depression
over time. No clinical support was offered during the telephone calls.
Each session was individualized to incorporate patient and family
needs, as well as their previous experiences. For example, after
orienting the patient to the goals of the study in the initial session, the
therapist assessed the patient’s knowledge of and attitude toward his/
her depression and previous coping strategies (successful and
unsuccessful). The therapist educated the patient about the course,
 Research Article: Management of Depression
symptoms, treatment options, and biopsychosocial aspects of treating
depression, and reframed unrealistic expectations about their illness.
The second session built on positive physical habits already used by
the patient—or the therapist helped initiate a new set of positive
physical habits (Table 1). The therapist first assessed the knowledge
the patient had of positive physical habits in relation to their effect on
depression, explored the patient’s attitude toward physical habits, and
worked with the patient to come up with an activity to practice
through the following session. The patient chose the task/action from
several possibilities, with the guidance of the therapist, to ensure that
the goal was feasible and realistic, so that the outcome would likely be
positive.
INCLUSION/EXCLUSION CRITERIA
Inclusion criteria for this study were (1) patients in treatment with
a psychiatrist or physician and who met The Diagnostic and Statistical
Manual (DSM-IV) criteria for major depressive disorder, dysthymia,
or chronic depression; (2) patients who received or were currently
receiving, but failed or responded poorly to several trials of adequate
antidepressant medication; (3) a Montgomery–Asberg Depression
Rating Scale[22] score of 12 or more at baseline screening; (4) a Beck
Depression Inventory[23] score of 18 or more at baseline; (5) a family
member available to participate; (6) ability to read and write English
and provide written, informed consent.
Exclusion criteria included: (1) a diagnosis of bipolar I or bipolar II
disorder; (2) acute suicidality; (3) psychotic features; (4) substance
abuse or dependence in the previous 3 months; (5) currently receiving
ECT.
An adequate trial of an antidepressant medication was defined a
priori as a minimum of 5 weeks of treatment with an adequate dose
for at least 3 weeks. Adequate doses of antidepressants were adapted
from previously published reports[24,25] and updated for more recent
antidepressant medications. Patients reported any change in the dose
or antidepressant medication during the study. Patients receiving
psychotherapy were eligible for the study, but were asked not to make
a change in their psychotherapy schedule without informing the
study staff. Institutional Review Board (IRB) procedures were
adhered to and patients and family members enrolled only after
providing written, informed consent.
ASSESSMENTS
Instruments used to measure quality of life, psychosocial and
family functioning, and depression ratings included (1) Quality of
Life and Enjoyment Questionnaire,[26] assesses enjoyment and
satisfaction experienced by subjects in areas of daily functioning; (2)
Scales for Psychological Well-Being,[27] an inventory of well-being
including autonomy, environmental mastery, personal growth,
positive relations with others, purpose in life, and self-acceptance;
(3) Family Assessment Device,[28,29] an assessment given to families to
rate their family’s functioning in problem-solving, communication,
roles, affective responsiveness, affective involvement, behavioral
control, and overall functioning.
Instruments used to diagnose and evaluate symptoms and severity
of depression included: (1) a DSM-IV Checklist; (2) the Montgomer-
y–Asberg Depression Rating Scale (MADRS), an interviewer based
measure of symptoms of depression; and (3) the Beck Depression
Inventory (BDI), a subjective scale that evaluates depressive
symptoms. In this study, all but two of the patients were referred
by clinicians within the department of psychiatry at Rhode Island
Hospital.
29
ANALYSES
Primary outcomes focused on quality of life and psychosocial and
family functioning; secondary outcomes included symptoms of
depression. We examined changes in scores from baseline through
the end of the intervention (16 weeks) and end of the study (48 weeks)
on quality-of-life, psychosocial and family functioning, and level of
depression. We used the last-observation-carried-forward (LOCF)
method for one patient who completed week 8 of the intervention,
but did not complete the week 16 in-person assessment. Paired t-tests
and repeated measures ANOVAs were used to determine changes in
patient scores and family scores. We also conducted post hoc analyses
on completers and those who dropped from the study. Statistical tests
were two-tailed and the level of significance was set at the 0.05 level.
RESULTS—END OF
INTERVENTION—16 WEEKS
PATIENT CHARACTERISTICS
Of 19 patients and family members who signed
informed consents, 5 dropped from the study, 2 missed
numerous appointments, 1 had a scheduling problem, 1
family member declined, and 1 patient was lost to
follow-up. The average age of the 14 patients who
completed the intervention phase (Phase I) was 47
years. Patients reported an average of 9.8 previous
episodes of depression with a median of 5.5. When
asked how long they had been depressed in their life,
on average, patients reported that they were depressed
for 23 years (SD 5 16.4, range 5 2–53 years) with one/
third reporting being depressed for 6 years or less and
two/third reporting being depressed for 20 or more
years. Almost all the patients had previously received
psychotherapy, and a majority of the patients were
enrolled in psychotherapy at entry into the study and
continued to receive psychotherapy while on study
protocol (Table 2).
Pharmacologic treatment on entering the study
included: 4/14 (29%) on only one SSRI; 1/14 (7%)
on only one SNRI; 1 (7%) on only one atypical
antidepressant; 1(7%) on only one atypical antipsycho-
tic. The remaining seven patients (7/14, 50%) were on
combinations of SSRI, SNRI, TCA, mood stabilizers,
atypical antipsychotic medications, and atypical anti-
depressants. Six of 14 patients (6/14, 43%) were on
antidepressant medication for at least 5 weeks, whereas
8 of 14 patients (57%) were on antidepressant
medication for at least 8 weeks (mode 5 12 weeks).
Four patients had previous trials with two antidepres-
sant medications and 10 patients had multiple trials of
different psychotropic medications.
QUALITY OF LIFE
Quality-of-life ratings showed improvement from
baseline (18.0776.75) to week 8 (25.00712.13) and
reached significance when examined from baseline to
week 16 (24.8678.99, paired-t 5 3.16, P 5.008).
Depression and Anxiety
30 Ryan et al.

TABLE 2. Patient characteristics at baseline (n 5 14)

Age (years) Age of depression onset (years)
Mean (SD) 46.9 (9.92) Mean (SD) 22.8 (10.85)
Range 29.0–60.0 Range 7.0–39.0
Education (years) Number of depressive episodes
Mean (SD) 14.3 (2.61) Mean (SD) 9.8 (7.91)
Range 9.0–18.0 Range 4.0–20.0
Gender n (%) In psychotherapy at enrollment n (%)
Female 10 (71.4) Yes 10 (71.4)
Male 4 (28.6) No 4 (28.6)
Employment n (%) Previously enrolled in psychotherapy n (%)
Employed 3 (23.1) Yes 12 (92.3)
Not employed 10 (76.9) No 1 (7.7)
Marital status n (%) Family member living with patient n (%)
Married 7 (50.0) Yes 8 (57.1)
Not married 7 (50.0) No 6 (42.9)

TABLE 3. Perception of family functioninga by family members without the patient and patient ratings at baseline and
week 16 (n 5 14)

Cut-off Baseline Week 16

Score Mean (SD) Mean (SD) t-score P

Family members without patient

Problem solving 2.20 2.33 (0.44) 2.11 (0.50) 2.329 .045
Communication 2.20 2.31 (0.43) 2.16 (0.63) 1.242 .246
Roles 2.30 2.25 (0.41) 2.24 (0.49) 0.600 .565
Affective responsiveness 2.20 2.31 (0.63) 2.24 (0.62) 0.748 .474
Affective involvement 2.10 2.06 (0.62) 2.00 (0.39) 0.028 .978
Behavior control 1.90 1.97 (0.41) 1.85 (0.46) 3.356 .010
General functioning 2.00 2.18 (0.50) 1.99 (0.53) 2.442 .037
Patient ratings
Problem solving 2.28 (0.49) 2.27 (0.66) 0.271 .791
Communication 2.48 (0.55) 2.30 (0.59) 1.467 .170
Roles 2.35 (0.49) 2.30 (0.42) 0.510 .620
Affective responsiveness 2.34 (0.70) 2.29 (0.74) 0.343 .738
Affective involvement 2.21 (0.46) 2.15 (0.53) 0.102 .921
Behavior control 1.95 (0.46) 1.87 (0.39) 0.244 .812
General functioning 2.33 (0.54) 2.15 (0.71) 1.433 .180
a
Based on the Family Assessment Device (27, 28). Higher score 5 worse perceived functioning.
Po.05; underline 5 score reached cut-off of unhealthy family functioning.

PSYCHOSOCIAL FUNCTIONING dimensions. Only the general functioning score showed

Patients reported improvement in four areas of
psychosocial functioning (environmental mastery, per-
sonal growth, purpose in life, and self-acceptance) from
baseline to week 8. Environmental mastery (base-
line 5 2.5670.85, week 16 5 3.0770.80, paired-t 5
2.82, P 5.015) and self-acceptance (baseline 5 2.247
0.78, week 16 5 2.9671.15, paired-t 5 2.72, P 5.019)
showed significant improvement from baseline to
week 16.
FAMILY FUNCTIONING
Patients and family members rated their family
functioning as unhealthy at baseline in most family
significant improvement from baseline (2.21.70.50) to
week 16 (2.0370.59, paired-t 5 2.44, P 5.037). We
compared family scores (without the patient) and patient
scores only to examine the changes in perceived
functioning. Family scores without patient ratings showed
significant improvement in problem-solving, behavior
control, and general functioning (Table 3). Patient ratings
of family functioning showed some improvement, but
none reached statistical significance. By the end of the
intervention, family members rated only one dimension
(affective responsiveness) as unhealthy. In contrast, and
with the exception of behavior control, patients continued
to see their family’s functioning as unhealthy despite gains
made during the program.

Depression and Anxiety

 Research Article: Management of Depression 31

DEPRESSION RATINGS TABLE 4. Clinical characteristics of patients who

completed the intervention and maintenance phase
Both objective (MADRS) and subjective (BDI)
(n 5 10)
depression scores improved significantly from baseline
to week 16. The mean MADRS score at baseline was Baseline Week 16a Week 48b
30.86 (75.95) and decreased to 22.36 (79.82, paired-
t 5 2.62, P 5.021) by week 16. The mean BDI score at Mean (SD) Mean (SD) Mean (SD)
baseline was 29.79 (78.41) and decreased to 19.43
Q-LES-Qc 17.4 (7.71) 26.4 (10.20)d 31.5 (11.76)e
(79.80, paired-t 5 3.49, P 5.004) by week 16.
SPWBc
Although most of the patients received psychotherapy Autonomy 4.1 (0.62) 4.6 (0.76)d 4.4 (0.82)
(independent from the MoD intervention) in addition Environmental 2.5 (0.78) 3.2 (0.80)d 3.7 (0.75)e
to their pharmacotherapy, there was no difference in mastery
improvement based on whether or not patients were Personal growth 4.0 (0.67) 4.7 (0.69)d 4.8 (0.79)e
currently in psychotherapy. Positive relations 3.3 (0.97) 4.0 (1.03)d 4.3 (1.01)e
Purpose in life 2.9 (0.66) 3.6 (0.82) 3.8 (1.00)
Self-acceptance 2.2 (0.84) 3.1 (1.29)d 3.3 (1.23)e
MADRSf 31.6 (6.87) 22.2 (11.15) 15.0 (12.17)e
RESULTS—END OF STUDY—48 BDIf 31.4 (8.72) 16.5 (9.35)d 12.7 (16.22)e
WEEKS (COMPLETERS) a
Week 16 5 end of intervention.
b
QUALITY OF LIFE Week 48 5 end of study.
c
Higher score 5 better.
Ten of the 14 patients who completed the MoD d 5 Significant difference from baseline to end of intervention (week
intervention also completed the 32-week maintenance 16): Q-LES-Q: F(1,9) 5 12.1, P 5.01; SPWB (autonomy):
phase. These 10 completers reported significant gains F(1,8) 5 11.2, P 5.01; SPWB (environmental mastery): F(1,8) 5 13.7,
from baseline through the end of the intervention and P 5.01; SPWB (personal growth): F(1,8) 5 10.3, P 5.01; SPWB
the end of the study (overall F(2,18) 5 7.91, P 5.003). (positive relations): F(1,8) 5 6.0, P 5.04; SPWB (self-acceptance):
Although these patients continued to improve during F(1,8) 5 8.69, P 5.02; BDI: F(1,9) 5 23.2, P 5.001.
the maintenance phase, the most significant gains were e 5 Significant difference from baseline to end of study (week 48):
Q-LES-Q: F(1,9) 5 10.2, P 5.01; SPWB (environmental mastery):
made during phase I.
F(1,8) 5 12.0, P 5.009; SPWB (personal growth): F(1,8) 5 14.3,
P 5.006; SPWB (positive relations): F(1,8) 5 8.52, P 5.02; SPWB
(self-acceptance): F(1,8) 5 8.21, P 5.02; MADRS: F(1,9) 5 8.87,
PSYCHOSOCIAL FUNCTIONING P 5.02; BDI: F(1,9) 5 11.64, P 5.01.
f
By the end of the study, patients reported significant Higher score 5 worse.
improvement in most areas of psychological function-
ing (Table 4). Significant improvement made by the DEPRESSION RATINGS
end of phase I was maintained in personal growth Objectively rated depression scores (MADRS)
(overall F(2,16) 5 9.88, P 5.002), positive relations showed significant improvement throughout the study
(overall F(2,16) 5 6.1, P 5.01), self-acceptance (overall (overall F(2,18) 5 6.48, P 5.008). Although change in
F(2,16) 5 5.96, P 5.01), and environmental mastery depression levels approached significance by the end of
(overall F(2,16) 5 9.95, P 5.002). Patients continued the intervention (week 16), the difference did not reach
to improve in self-mastery from the end of the significance until the end of the study (week 48),
intervention to the end of the study (P 5.07). There suggesting continued improvement during the main-
was no significant change in purpose in life at the end tenance phase. Improvement in subjective depre-
of phase I, but improvement approached significance ssion ratings (BDI) was evident by week 16 (overall
(F(1,8) 5 4.65, P 5.06) by the end of the study. F(2,18) 5 10.44, P 5.001) and continued to improve
during the maintenance phase. In spite of significant
improvement in level of depression, patients continued
FAMILY FUNCTIONING to experience moderate levels of depressive symptoms
Patients who rated their family functioning as good at the end of the study (Table 4).
or poor at baseline did not differ in their level of
depression severity. Patient perspectives of their
family’s functioning showed no improvement from COMPLETERS VERSUS
baseline through the end of the study. Three patients
whose rating of their family’s functioning was in the
NONCOMPLETERS
healthy range at baseline were significantly more likely We conducted post hoc analyses to examine differ-
to respond (50% drop in depression scores) by the end ences between patients who completed the study
of the intervention than patients whose rating of their (n 5 10) versus those who dropped at any point after
family’s functioning was unhealthy (6 of 10) (w2 5 6.43, enrollment (n 5 9). There were no differences between
df 5 1, P 5.011). the two groups by gender, marital status, age, baseline
Depression and Anxiety
32
quality of life, psychological functioning, severity of
depression, age of depression onset, or number of
depressive episodes or hospitalizations. In comparison
to those who dropped, patients who completed the
study rated their family’s functioning as significantly
better at baseline in two areas of family functioning:
problem-solving (2.1170.43 versus 2.5770.34,
t 5 2.28, df 5 16, P 5.025) and behavior control
(1.8270.48 versus 2.2970.21, t 5 2.42, df 5 15,
P 5.028). Differences in the general functioning
ratings (2.2170.56 versus 2.6570.34, t 5 1.97,
P 5.067) tended toward significance.
DISCUSSION
Patients participating in the MoD Program reported
significant improvement in their quality of life,
psychosocial and family functioning, and levels of
depression. The largest and most significant changes in
life satisfaction, psychosocial functioning, and self-
reported depression scores occurred during the inter-
vention phase. With one exception (the autonomy
subscale), patients continued their improvement
throughout the maintenance phase. Patients who rated
their family functioning as good at baseline were
significantly more likely to improve than patients who
reported poor family functioning. Although depression
levels improved throughout the study, patients still
reported moderate levels of depression at the end of the
maintenance phase.
Although there is a generally accepted antidepressant
dose range for determining an adequate treatment trial,
there is no consensus on what constitutes an adequate
duration of a treatment trial.[30,31] We followed
Keller’s[24] and Sackheim’s[25] recommendations re-
garding adequacy of dose and duration of treatment
for an episode of depression. Results of the STARD
study suggest that a 12-week course for each medica-
tion trial of a unipolar depression may be more
appropriate.[30] Others believe that an 8-week[32] or a
6-week[33] trial is sufficient. Stimpson et al.[34] reviewed
clinical trials in which a 4-week course constituted the
trial duration for treatment-refractory depression.
Patients with difficult-to-treat depression may need a
longer medication trial; alternatively, if these patients
show no response after only a few weeks, it may
indicate that a change in medication is warranted
sooner rather than later. Fourteen of 19 (74%) patients
with difficult-to-treat depression completed the
4-month intervention. Of those, 10/14 completed the
8-month follow-up phase. It is not clear if patients
with difficult-to-treat depression have a harder time
in organizing themselves and maintaining comp-
liance with treatment, or if the depression becomes
difficult-to-treat because patients do not follow
treatment recommendations. Reasons for dropping
from this study varied as noted earlier. The drop-out
rate is comparable to that in other treatment trials.
Adherence to treatments may need to be a particular
Depression and Anxiety
Ryan et al.
focus of interventions in patients with difficult-to-treat
depressions.
Patients and their family members lived with varying
degrees of depressive illness and its negative impact on
themselves and their family/social relationships for many
years. Including family members was an important
component of the intervention. Patients were consis-
tently given the message that the goal was to improve
quality of life and functioning, learn what coping
strategies worked and did not work, facilitate new ways
of reframing their illness, and address the multidimen-
sional aspects of managing their illness despite persisting
depressive symptoms. The MoD Program did not teach
passive acceptance and did not focus on symptoms, but
took a proactive approach to develop a greater sense of
effectiveness in managing the illness.
Although Engel[35] and others[36,37] advocated a
biopsychosocial approach to treating patients, reducing
depressive symptomatology has long been the over-
riding focus in the field. Both Epstein and Ryff
highlighted positive aspects of family functioning and
psychological well-being. Others[12] have called for a
broader definition of treatment outcome by moving
beyond a summary of depressive symptoms to a more
real-world, meaningful reflection of patients lives.
The fact that there was a difference between patients
and family members on their perception of family
functioning over time is not surprising. It may be due
to the patient’s continued depressed mood. Alterna-
tively, cognitive aspects of a patient’s well-being may
respond before behavioral or interpersonal compo-
nents. Improvement seen for the families may be due to
the educational component of better understanding the
effect of depression on family functioning and the
support they may have experienced by being included
in the treatment process.
Although the philosophy and approach of the MoD
Program showed promise, the study was unable to
address key questions relating to its active components.
Without a control group, it is not clear whether the
specific components of the program were instrumental
in bringing about changes. It is possible that the
additional time spent with patients and their families
could have produced similar improvements. Additional
time by itself, however, is not likely to have led to
improvements found in this study, as most patients
already had extensive pharmacotherapy and psy-
chotherapy. Only a randomized control study can
confirm that assumption.
It is not possible to rule out individual therapist
effects as opposed to program content effects, as one
therapist delivered the intervention to all patients.
A controlled study with multiple therapists needs to be
undertaken to further test the extent of the program’s
generalizability and transportability. It is of interest
that the 10 patients, who completed both the inter-
vention and the maintenance phases, had small but
significant differences in their family functioning at
baseline, despite having no difference in quality of life,
 Research Article: Management of Depression
psychological functioning, depression levels, and other
clinical variables. Positive relations can help bolster a
patient’s ability to reframe their depression and
encourage a patient to learn new ways of coping.
Finally, although patients were administered a DSM-
IV checklist to confirm a diagnosis of depression, we
were unable to distinguish specific subtypes of depres-
sion (e.g. recurrent/chronic/dysthymia) over the long
time-span that patients were ill.
CONCLUSION
Due to the small sample size, these results are
noteworthy, but only suggestive. It was encouraging,
nonetheless, to see that patients who had multiple
episodes of depression and multiple treatment trials
were still able to develop a sense of mastery, personal
growth, self-acceptance, and purpose in life as well as
improved family functioning, even in the face of
persistent depressive symptoms. An approach that sets
realistic expectations about illness outcome and focuses
on coping, functioning, and interpersonal support,
rather than symptom reduction, was acceptable to
depressed patients and their family members. The
MoD Program complemented the pharmacotherapy
and psychotherapy that patients were receiving, by
emphasizing ways in which patients and family
members could actively manage certain aspects of their
lives even while recognizing that they could not control
their depressed mood. A randomly designed controlled
trial is underway to see if the positive results can be
replicated in a more rigorous study.
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