Led by Thomas Lynch, Professor of Clinical Psychology at the University of Southampton, the approach is based on Dialectical Behaviour Therapy (DBT), a treatment with a proven track record in overcoming other serious mental health problems.
Refractory Depression is a common and chronic condition which severely disrupts the family, social and working lives of sufferers. Patients are often rigid and self-critical, exert unnecessary control over their emotions, and show little mental flexibility. At its most extreme, this pattern of behavior constitutes a maladaptive personality style known as emotional over-control. Particularly when under stress, such people prefer order to novelty and are relatively sensitive to threat, but insensitive to reward, for example, in a rose garden, they see the thorns but miss the flowers.
The REFRAMED (REFRActory Depression: Mechanisms and Efficacy of Dialectical Behaviour Therapy) study is the first large clinical trial to extend the principles of DBT to refractory depression. Professor Lynch’s key insight is the idea that pre-existing personality characteristics—rooted in brain processes that emerge in childhood—are central to understanding why some individuals are prone to the disorder.
Professor Lynch comments: “Self-control, the ability to manage competing urges, impulses, behaviours, or desires, is highly valued in society. In fact, a lack of self-control characterizes many of the personal and social problems that afflict modern civilisation. But too much self-control can be equally damaging. People who are emotionally closed-off may find it difficult to get on with others or to recruit help when they encounter difficulties. This social isolation may lead to the development of severe and difficult-to-treat mental health problems—such as refractory depression.”
To assess the impact of the new therapy, the REFRAMED study will recruit up to 276 patients in Dorset, Hampshire, and North Wales. Over six months, half will receive 24 individual sessions and 24 group sessions of DBT from specially trained clinicians, while the remaining patients will receive standard NHS care for depression (usually anti-depressant medication). Patients will be assessed before and after the treatment to gauge its benefits, but researchers will additionally focus on mood changes during treatment through telephone messages that assess patients’ moods, ways of coping, and their self-compassion. The study has been deliberately designed to recruit the most difficult-to-treat patients. Previous studies into treatment-resistant or chronic depression have excluded patients with other psychological problems, such as suicidal behaviour or personality disorders; unlike other studies, REFRAMED wants to include these patients.
“There is one fundamental difference between DBT and other evidence-based treatments for depression,” says Professor Lynch. “REFRAMED is based on the idea that depression is not the primary problem for many hard-to-help patients. Rather, their over-controlled personality style limits opportunities to interact flexibly with others and to learn new skills. So, when these people experience a depression-triggering life event, they find it hard to get help and their depression becomes more entrenched, resistant to change, and chronic in nature. Our therapy assumes that depressed, emotionally over-controlled patients lack the skills needed to be flexible, express vulnerable emotions, or establish close relationships; thus, we focus on teaching a range of skills that target these specific difficulties.”
The £1.9million study, which is independent research funded by the Medical Research Council (MRC) and managed by the National Institute of Health Research (NIHR) on behalf of the MRC-NIHR partnership, is set to run for five years. It is a multi-centre randomised controlled trial and a collaboration between researchers from the Universities of Southampton, Plymouth, Swansea, Bournemouth, Bristol, King’s College London, and Exeter.