November 2010  << Back  

  Can't open the PDF? Click here for help.



Self-Management of Depression: A Manual for Mental Health and Primary Care Professionals

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Albert Yeung, Greg Feldman, and Maurizio Fava. New York, NY; Cambridge University Press; 2009; ISBN 978-0-521-71008-4; pp 206; $55.00 (paperback).

Chronic diseases, such as diabetes, obesity, some cardiovascular diseases, and depression, often are irreversible or relapsing conditions that are either persistent or run a wax-and-wane course (p 4). The goal of chronic disease treatment is not cure—as we do not have a cure, in most cases—but “to support patients in managing their own disease so they can maintain satisfying, pleasurable, and independent lifestyles” (p 4). Thus, the modern approach to comprehensive management of various chronic illnesses includes self-management.

According to the authors of this book, “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” (p 1). They wrote this book 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 depression more efficient and effective by integrating self-management treatment strategies with conventional professionally delivered treatment modalities” (p 2).

The book consists of 8 chapters that explain the use of self-management in depression in various settings and discuss key elements in its use. The first chapter, “The use of self-management for depression,” explains what self-management is and how it is relevant for depression and other chronic conditions, and then discusses the principles of self-management, such as empowering patients and promoting their self-efficacy. The text then turns to the specifics of self-management of depression and the key resources and tools of self-management, such as individualized assessment, collaborative goal-setting, skills enhancement, follow-up and support, access to resources of daily life, and continuity of quality clinical care.

The second chapter, “Care management of depression,” focuses on treatment of depression in primary care and the need for a multidisciplinary approach. It discusses the role of care managers in the management of depression in primary care (eg, facilitating depression screening or providing depression education). The final part of this chapter reviews barriers in the implementation of collaborative care for depression in primary care, such as technical difficulties, practice orientation of primary care physicians, and reimbursement policies of insurers. One important piece of information found in this chapter: most screening questionnaires, such as Center for Epidemiological Studies Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), and Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) are free, but there is a fee for using the Beck Depression Inventory II (BDI-II).

The third chapter, “Self assessment instruments for depression,” is a detailed review of properties of self-assessment instruments for monitoring the severity of depression (CES-D, PHQ-9, Inventory of Depressive Symptomatology Self Report, QIDS, and BDI, BDI-IA, and BDI-II), Internet-based self-instruments for depression, and the application of all these instruments. The authors point out (p 47) that, compared with clinician-rated instruments, self-rated instruments are less time consuming, less expensive to administer, and don’t require trained personnel for administration. This chapter also covers the limitations of depression screening using self-assessment instruments and the clinician’s role in the use of these instruments.

The following chapter, “Self-help,” addresses the role of bibliotherapy and computerized psychotherapy in self-management of depression. Bibliotherapy is defined as the use of written texts as a means of personal development or alleviating distress, whereas computerized psychotherapy is a standardized, automated intervention delivered by a computer program to a user who accesses the program through software on a personal computer or from a distance via the Internet or telephone (p 69). The authors discuss several books they consider very useful books (eg, Feeling good, Control your depression, and Mind over mood), and they list self-help resources for patients. They also summarize computerized cognitive-behavioral therapy programs.

The chapter concludes with practical challenges to implementing bibliotherapy and computerized psychotherapy (eg, cost, resistance from psychotherapists) and practical recommendations for incorporating these modalities into a treatment plan. There are 4 possible models for integrating self-help into practice: 1) Self-help is offered to the patient before or instead of therapy, or, in some cases, medication; 2) Self-help is presented as a “therapist extender;” 3) Self-help is presented as a complement to standard psychotherapy; and 4) Self-help is integrated into a comprehensive e-health system.

The fifth chapter, “Physical exercise as a form of self-management for depression,” is a solid review of the evidence of the value of exercise in depression management, challenges in implementing exercise as a treatment for depression, and practical recommendations for incorporating exercise into depression management. This chapter includes 4 appendices: A. Weekly exercise log; B. Tips for deciding on type, schedule, and intensity of exercise; C. Frequently asked questions about exercise and depression treatment; and D. The pros and cons of beginning an exercise program.

The sixth chapter, “Self-management of depression using meditation,” is a thorough review of meditation use in depression (including mindfulness training), its challenges and limitations, and finally, some practical considerations (which patients would be appropriate candidates for meditation, how should it be introduced, etc.). This chapter includes an appendix on resources for learning about meditation.

The seventh chapter, “Cultivating social support,” focuses on the role of peer support in self-management. The peer who provides the support usually is an individual who has previously had first-hand experience with the patient’s condition (p 163). This chapter again discusses challenges and limitations of peer support and provides some practical advice in this area. The chapter is accompanied by 4 appendices: A. Tips for finding a peer support group; B. Tips for selecting a peer support group; C. How can family and friends help when a loved one is depressed? (very useful, eg, recognizing and understanding the symptoms of depression, approaching the person with depression, encouraging treatment, etc.); and D. Six interpersonal habits that can make depression worse.

The last chapter, “Putting it all together,” is the usual summary of the previous chapters—in this case, advising how to apply self-management for depression in your practice.

Although this book addresses an important area of management of depression and parts of the book are interesting, I had mixed feelings about it. It is wordy and repetitive at times. I think it provides too much information about issues busy clinicians would not care much for—or have much time for—such as a detailed discussion of the various versions of the BDI. The first half of the book is not very practical, and the authors only slowly get into practical, clinically oriented advice later.

I would appreciate much more concise and direct advice-oriented summaries of each chapter, perhaps in the form of bullets. One would also appreciate an appendix with all the screening assessment tools (at least the free ones) printed and ready to be copied. I also cannot envision many practitioners having enough time to implement most of the advice, which is not a criticism of the book but rather a complaint about the current state of affairs in the practice of psychiatry.

In summary, this is a book about self-management of depression, not really for introducing self-management of depression to one’s practice; so although it contains a lot of useful information, it is not very practical for that purpose.