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SYMPOSIUM 6 | DAY 1: 10.30 AM - 12.00 PM

Schema Therapy for Chronic Depression: What Do We Know and Where Can We Go?

by Jill Lobbestael, Martin Rein, Fritz Renner, David Koppers, and Marcus Huibers

Chair: Jill Lobbestael

   


This symposium is aimed at evaluating the use of schema therapy in recurrent, chronic and comorbid depression, from a scientific perspective. We want to present a rationale as to why Schema Therapy might work for depression as well. The speakers will give an overview of the empirical schema theoretic foundations, shed light on possible modes of action and evaluate the clinical evidence of schema therapy in the treatment of depression. Clinical and research implications will be discussed based on the presented data. 

Segment 1

Title: Schema Therapy for Depression: A systematic review of the empirical foundations and clinical effectiveness

Presenter: Martin Rein

Martin Rein will present the results of a systematic literature search, reviewing the empirical foundations of schema theory in the context of recurrent and chronic depression and evaluating its clinical effectiveness. 

Schema therapy (ST) is constantly extending its clinical use beyond its original focus towards the treatment of Axis-I disorders (Carter et al. 2013; Cockram, Drummond, and Lee 2010; Simpson et al. 2010; Thiel et al. 2016). In contrast to its clinical popularity, supporting empirical foundations and sufficient evidence for the clinical effectiveness of schema therapy have mainly been shown for borderline personality disorder and Cluster-C personality disorders (Bamelis et al., 2014; Farrell, et al., 2009; Giesen-Bloo et al., 2006). 

In order to evaluate the evidence for ST in the treatment of recurrent and chronic depression we conducted a systematic review of the peer-reviewed literature using bibliographic databases, grey literature, hand search and expert consultation (Prospero register: CRD42016039914). 

The presentation addresses the empirical foundations of schema theory by shedding light on the role of early maladaptive schemas in depression etiology and reviews the clinical evidence of schema therapy as a possible treatment option for (chronic) depression: Limited evidence suggests that ST by targeting self-referential cognitive schemas (EMS) which mediate the effects of early life adversity on vulnerability towards and maintenance of depressive disorders in the sense of distal risk factors could be an effective treatment for depression and a feasible alternative to CBT (Brewin et al. 2009; Carter et al. 2013; Malogiannis et al. 2014; Renner et al. 2016).

Segment 2

Title: Schema therapy for chronic depression: effectiveness and mechanisms of change

Presenter: Fritz Renner

For a deeper understanding how schema therapy could work in depressed patients, Fritz Renner presents empirical data exploring the effectiveness and potential mechanisms of symptom change in individual schema therapy of chronically depressed patients, with a special focus on schema modification and therapeutic alliance. 

Chronic depression is often rooted in adverse childhood experiences and comorbid personality pathology is common. Current treatments for chronic depression are only effective for a subset of patients leaving room for improvements and treatment innovation. A better understanding of the mechanisms that contribute to symptom change is the key to treatment innovation. With a focus on childhood experiences and personality pathology, schema therapy might be a promising new treatment approach to chronic depression. 

The first part of the talk will focus on empirical data supporting the effectiveness of schema therapy for chronic depression. In the second part we will present empirical data exploring two potential mechanisms of symptom change in schema therapy for chronic depression: changes in schemas and the therapeutic alliance. 

One challenge in studying mechanisms of change is demonstrating that putative mechanisms precede change in symptoms. To disentangle the temporal relations between the therapeutic alliance, change in schemas and depressive symptoms we drew data from a single-case series of ST for chronic depression. Focusing on repeated assessments within-individuals, we tested whether change in schemas and therapeutic alliance preceded, followed, or occurred concurrently with change in depressive symptoms. 

Contrary to what would be expected based on theory, our findings suggest that change in schemas does not precede change in symptoms. Instead, change in these variables occurs concurrently. Clinical and research implications will be discussed in the symposium. 

Literature 

Renner, F., DeRubeis, R. J., Arntz, A. R., Peeters, F. P. M. L., Lobbestael, J., & Huibers, M. J. H. (2018). Exploring mechanisms of change in schema therapy for chronic depression. Journal of Behavior Therapy and Experimental Psychiatry. https://doi.org/10.1016/j.jbtep.2017.10.002 Renner, F., Arntz, A., Peeters, F. P. M. L., Lobbestael, J., & Huibers, M. J. H. (2016). 

Schema therapy for chronic depression: Results of a multiple single case series. Journal of Behavior Therapy and Experimental Psychiatry, 51, 66–73. https://doi.org/10.1016/j.jbtep.2015.12.001 Renner, F., Arntz, A., Leeuw, I., & Huibers, M. (2013). 

Treatment for chronic depression using schema therapy. Clinical Psychology: Science and Practice, 20(2), 166–180. https://doi.org/10.1111/cpsp.12032

Segment 3

Title: Impact of comorbid depression on personality disorders after schema-group therapy

Presenter: David Koppers

David Koppers will complement the symposium with clinical data from group therapy: He will present the results of a cohort study investigating the effectiveness of short term group schema therapy in a mixed personality disorder sample with or without comorbid depression.

Introduction


Several studies demonstrated the efficacy of schema focused therapy for borderline patients. However, in clinical practice most personality pathology presents itself in mixed forms of both cluster B and cluster C symptoms and the evidence of schema therapy in these types is rather scarce. In addition, most studies address individual therapy while schema group therapy might be an (cost) efficious alternative.


Methods


In a cohort study short term schema cognitive behavioural therapy in groups were investigated on (follow-up) effectiveness and drop-out. The total sample, consisted of 247 referred patients, had at least one cluster B and/or cluster C personality disorder with a comorbid depression (PD-MDD) or without (PD). The aim of this study was to determine the impact of co-morbid depression on recovery from personality disorders after schema group therapy, measured by a symptom checklist (SCL-90) and the Young Schema Questionnaire (YSQ).


Results


The drop-out rate among personality disorders with comorbid depression was 41% and without 30%. This difference was not significant. Symptom reduction after schema group therapy for personality disorders alone and with comorbid depression were significant, with medium effect sizes (resp.ES= 0.48 and ES= 0.53). Difference in outcome between the two patient groups were not significant. Reduction of dysfunctional schema’s were significant, with medium effect sizes for both patient groups, respectively ES=0.59 and ES=0.53. At treatment termination there was a significant difference in outcome between the two patient groups, this disappears at follow up. On symptom and schema reduction both patient groups remain stable during follow-up.


Conclusion 


Effect sizes of short term schema group therapy were medium and significant. This indicates that schema therapy can be successfully offered in groups for a broad group of patients with personality disorders with comorbidity and may be a cost-effective alternative. 

Segment 4

Title: Schema therapy for (complex) depression: where do we go from here?

Presenter: Marcus Huibers

Marcus Huibers will synthesize the findings presented in the previous three talks and present a wrap up of theory, associated research data and treatment selection issues with regard to the clinical practices in the Netherlands.

Abstract Schema therapy appears to be an effective treatment for more complex forms of depression. This final presentation will synthesize the findings presented in the previous three talks, and will be a wrap up of theory, recent research data, treatment selection issues (when is ST called for?), and current clinical practices in the Netherlands (such as individual therapy versus group therapy). Future avenues and research recommendations are discussed, with the ultimate goal to advance our knowledge of schema therapy for depression.

About the Presenters:

Jill Lobbestael 

Jill is an assistant professor in clinical psychology, studying personality disorders and aggression. She also teaches about these topics and partly work as a schematherapist in an outpatient setting.

Fritz Renner

Fritz Renner is a Marie-Curie Fellow working at the Emotional Disorders and Mental Imagery group at the MRC Cognition and Brain Sciences Unit, University of Cambridge, UK (Programme Leader: Prof Emily Holmes). He is an experimental psychologist and his research is on the impact of mental imagery on behaviour with a focus on developing experimental interventions that target behavioural aspects of depression.

Before joining the MRC Cognition and Brain Sciences Unit he was based at Maastricht University, the Netherlands, Department of Clinical Psychological Science where he completed his PhD (2014) ‘Chronic Depression: An integrative approach to the study of underlying vulnerability factors and psychological treatment’ under supervision of Prof Marcus Huibers and Prof Arnoud Arntz.

His recent work is supported by the German Academic Exchange Service (DAAD) and a Marie Skłodowska-Curie Individual Fellowship from the European Union. His current research investigates the relationship between mental imagery and behaviour. Understanding how mental imagery can impact behaviour can help inform the development of new interventions, for example for depression by targeting behavioural aspects of depression. Since 2017 he is a CBT trainee at the FAVT, Freiburg, Germany.

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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