Research report
An exploratory randomized controlled trial of body psychotherapy for patients with chronic depression

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Abstract

Background

Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. This is the first randomized controlled trial designed to evaluate the effectiveness of Body Psychotherapy (BPT) in patients with chronic depression.

Methods

Patients with chronic depressive syndromes (more than 2 years symptomatic) and a total score of ≥20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. BPT was manualized, delivered in small groups in 20 sessions over a 10 weeks period, and provided in addition to treatment as usual. In an intention to treat analysis, primary outcome were depressive symptoms at the end of treatment adjusted for baseline symptom levels. Secondary outcomes were self-esteem and subjective quality of life.

Results

Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7, 95% confidence interval 1.0–16.7). Secondary outcomes did not show statistically significant differences. When the scores of the waiting group before and after BPT (as offered after the waiting period) were also considered in the analysis, the differences with the initial waiting group remained significant.

Conclusions

The results suggest that BPT may be an effective treatment option for patients with chronic depression. Difficulty recruiting and subsequent attrition was one of the limitations, but the findings merit further trials with larger samples and process studies to identify the precise therapeutic mechanisms.

Introduction

Despite the wide availability of pharmacological and psychological treatments, major depressive disorder and dysthymia remain associated with a high burden. Data from the World Health Organization ranked unipolar major depression fourth among all medical conditions in leading to the loss of disability-adjusted life years (DALYs) with a projected increase to second by the year 2020 (Murray and Lopez, 1997, World Health Organization, 2002). People with depression generate high costs to healthcare services (Nierenberg, 2001). Thomas and Morris (2003) reported that the total cost of depression among adults in the United Kingdom was estimated at over £9 billion.

About 20% of patients do not recover within 2 years (e.g. Scott, 2001) and at least 10% of patients have persistent or chronic depressive syndromes (Kessler et al., 2003) and a high proportion of patients with depression do not sufficiently respond to available treatments (Stimpson et al., 2002). Patients with persistent depression are therefore increasingly a focus of research (e.g. Scott et al., 2003, Schramm et al., 2011) and new therapeutic options are required to reduce the disability associated with depression, improve remission rates and quality of life.

Although considerable research has been conducted on the efficacy of psychotherapy for depression, alone and in addition to medication, relatively few studies have focused on chronic forms of depression. There is substantive empirical support for the use of cognitive therapy in the treatment of mild to moderately severe acute major depression (Scott, 2001). The effectiveness of psychotherapy amongst patients with severe depression has so far been insufficiently addressed in research. Cuipers et al. (2010a) conducted a meta-analysis on the effects of psychotherapy for chronic major depression and dysthymia; they concluded that psychotherapy (including cognitive-behavioural therapy, interpersonal psychotherapy and a mixture of other psychological and behavioural therapies) was generally effective in the treatment of chronic major depression and dysthymia, but was not as effective as pharmacotherapy. The authors emphasized the need for more high-quality studies in order to examine the specific components of psychotherapy that reduce symptoms in chronic depressive disorders.

Physical complaints and body related phenomena have been frequently reported in depressive disorders (e.g. Röhricht et al., 2002, Fuchs, 2005), and somatic symptoms are now regarded as “common presenting features throughout the world” (Bhugra and Mastrogianni, 2003). The link between depressive symptoms and body experience raises the question as to whether a body oriented psychological therapy might be effective in improving depressive symptoms.

Body psychotherapy (BPT) is an umbrella term for all psychotherapies “…that explicitly use body techniques to strengthen the developing dialogue between patient and psychotherapist about what is being experienced and perceived…In most schools of body psychotherapy, the body is considered a means of communication and exploration” (Heller, 2012, p. 1). BPT might impact on depressive symptoms in different ways: movement/exercises may address lack of drive, reduced initiative and psychomotor retardation; sensory awareness techniques – focusing on physical strength and capabilities – aim to improve patients' negative self-evaluation; other interventions focus upon the link between motor systems and emotion regulation as well as on disturbed emotional processing and affect regulation, addressing suppressed negative and aggressive impulses.

There have been positive case reports of Body Psychotherapy (BPT) in the treatment of depression (reviews Röhricht, 2000, Röhricht, 2009). Stewart et al. (2004) conducted a randomized experimental study on movement therapy in a sample of depressed inpatients and found that the therapy had a positive effect on mood. Following a pilot trial, Little et al. (2009) described positive changes in chronic depressive symptoms and well-being measures of patients treated with a “multimodal holistic body/mind group therapy approach”. BPT has been found to improve negative symptoms of schizophrenia in a randomized controlled trial (Röhricht and Priebe, 2006), but so far there has been no randomized trial on the potential effects of BPT in chronic depression.

The aim of this exploratory randomized controlled trial was to test the effectiveness of BPT in the treatment of patients with chronic depression. BPT was manualized, delivered in groups and provided in addition to treatment as usual. It was compared with a waiting group that received treatment as usual only.

Section snippets

Participants (eligibility criteria and sample size)

Patients were identified according to the following selection criteria: Current outpatients in secondary mental health services; aged 18–65 years; a DSM-IV diagnosis of non-bipolar, non-psychotic recurrent major depressive disorder with chronic depressive episode and/or chronic affective disorder (dysthymia); a total score of ≥20 on the 21-item Hamilton Rating Scale for Depression (HAMD; Hamilton, 1960); duration of the current episode of depression of >2 years (DSM-IV criteria for chronic

Statistical analysis

Analyses were conducted on an intention-to-treat basis. We compared outcomes in the immediate BPT group with those in the waiting group. In a subsequent analysis, we also considered pre- and post treatment depression scores in the waiting group when BPT was offered after the 12 weeks waiting period. We added those changes to the changes in the immediate treatment group, and compared changes of depression scores before and after BPT in this combined group with those in the initial waiting group.

Recruitment and description of sample

A total of 61 patients were referred for inclusion in the study, 31 of whom fulfilled the inclusion criteria and consented with subsequent randomisation to the treatment or waiting group conditions. All patients had a diagnosis of chronic major depressive disorder at the point of entering the trial. In total, four groups of 7–8 patients (N=31) were randomised, and 21 of them received the allocated intervention (N=10 did not attend). The detailed flow diagram is shown in Fig. 1.

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Overall findings

In this exploratory trial, we included patients with chronic depression and a substantial level of baseline symptoms. Patients offered immediate BPT showed significantly more favourable changes in their depression scores than the waiting group. Patients in the waiting group hardly changed at all during the waiting period which may reflect the chronic nature of their illness. Patients in the immediate BPT group experienced a significant reduction of their symptoms. On average, the difference

Conclusions

The findings are encouraging. They suggest that BPT is a feasible treatment option for some of the patients with chronic depression who have not responded to any other available treatments, and that it may lead to significant improvements. Larger trials are now required to test the effectiveness of BPT in this patent group. These trials should not only have larger samples, but also include follow up assessments to explore to what extent the improvements are maintained over time and possibly

Role of funding source

The study was conducted without external funding as own account research.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

We would like to thank Layla Smith for her dedicated support as a therapist and Dr. Sajjad Ahmed for his contributions as researcher.

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