Depression is a serious mental illness that saps your energy and reduces your quality of life. Living with depression can cause other illnesses, and it can lead to unhealthy lifestyle choices, including drug or alcohol abuse. According to the Anxiety and Depression Association of America, 20 percent of American adults who suffer from depression also have a substance abuse disorder, and 20 percent of people with a substance abuse disorder are addicted to drugs or alcohol.
Depression can be effectively treated with both medication and psychotherapy, although the National Institute of Mental Health notes that psychotherapy is typically the best option for mild to moderate depression in adults.
Psychotherapy can be administered one-on-one or in a group setting. Group therapy is less expensive than individual therapy, and numerous studies, including one meta-analytic study published by the American Psychological Association, show that there is no difference in outcomes between group and individual therapy.
How Group Therapy Works
Therapy groups typically have between 5 and 15 members, along with a professionally trained therapist who facilitates the group meetings. Some groups meet for the short-term, usually between 8 and 12 weeks, while others are ongoing and may last for years. Groups meet once or twice a week for one to two hours, and they may be focused on one issue – such as depression – or they may have members who are working on a wide variety of issues.
Some groups limit members to a certain demographic, such as gender-specific groups or those made up of a certain age group. Regardless of the demographic makeup of the members, group therapy offers a number of benefits over individual therapy.
Benefits of Group Therapy
The fundamental benefit of group therapy is the realization that while different people have different issues and a variety of coping mechanisms, humans share some very basic struggles that define our species. This revelation is a very comforting concept that can help reduce feelings of isolation, particularly for those who suffer from depression, which is, by nature, an isolating condition.
The benefits don’t stop there, though. Group therapy can bring about profound experiences and important epiphanies for those suffering from a variety of conditions, including depression and substance abuse disorders.
Support and Acceptance
Groups offer support and acceptance. Group therapy is uniquely suited for forming strong bonds with other people from all walks of life. Therapy group members enjoy intense feelings of trust toward one another, promoting an honesty and openness that can lead members to share – and question – very deeply held beliefs without worrying about being judged. Groups are extremely supportive and accepting of both superficial and fundamental differences among members.
Advice and Comfort
Groups provide the opportunity to help others. Sometimes, we’re so mired in our own problems that it’s hard to imagine that we might be able to help someone else through their struggles.
But with group therapy comes the unique opportunity to share your perspectives to help bring comfort or clarity to others, which feels good and helps divert attention from your own struggles for a while. And sometimes, the advice we give others is the advice that we, too, need to take.
Seeing Perspectives
Groups offer a variety of perspectives. Hearing different perspectives on an issue can help you sort through and synthesize your own feelings, and it offers ways of looking at a problem that you may not have considered. This helps you learn to think through issues more objectively.
Groups can increase momentum. Learning how others grapple with their issues and overcome certain problems can be very encouraging for those who are currently working through similar situations. It’s easier to push yourself harder when you see what others have done and how they have fared.
Groups help us see ourselves more clearly. Each member of a therapy group has different experiences, and they draw on those experiences when addressing others’ issues. This enables you to see yourself from many perspectives and uncover truths about yourself that may not otherwise have been revealed.
Participants
The present study draws from a project that evaluated the effectiveness of a treatment for depression given at the group therapy unit at the Psychiatric Centre of the Helgeland Hospital Trust in Mo i Rana in Norway. The center is a secondary care setting located in a rural area near the polar circle that serves a population of approximately 33,000 individuals. Patients are referred to the clinic primarily by their general practitioner, but other specialized health services can also refer patients to the outpatient clinic.
Using the hospital’s electronic record system, the records of patients who were registered as having received cognitive behavioral group therapy for depression between 2002 and 2013 were reviewed. A total of 143 patients (71% female, mean age =41.6 years, range =20 to 69 years) were identified; the patients had participated in 26 different treatment groups. The dropout rate was 17.5% (25 patients). We defined dropouts broadly as patients who attended the first group session but discontinued the treatment at a later time point. Treatment completers could miss single sessions. For 88 patients (62% of the total sample), 73% female with a mean age of 41.8 years (SD =11.3, range =20 – 68), a pre-treatment and post-treatment or follow-up scores on the BDI were available; these patients were included in the outcome analyses. Further demographic and clinical characteristics of this sample are displayed in Table 1. Until 2006, the patients’ diagnoses were established using the Structured Psychiatric Interview for General Practice SPIFA; [32]. Since 2006, the MINI [33] has been routinely used for diagnoses at the group treatment unit.
Table 1 Demographic and clinical characteristics of the sample
Full size table
Therapists and treatment
The groups were led by a therapist and co-therapist. The therapists were mainly psychiatric nurses, but other mental health professionals (e.g., psychologists) were also group leaders. During the period studied, all therapists had received formal training in CBT. Prior to treatment and baseline assessment with the BDI-II and the BAI, a member of the group therapy unit met the client for a clinical assessment (if the client had not been diagnosed before), to provide information about the group treatment, to discuss with the patient whether the treatment was suitable for him or her and to determine the patients’ motivation. This clinical assessment period typically lasted approximately 4-5 sessions. Group sessions were closed and comprised 5-7 patients when they started. The treatment initially consisted of 12 weekly sessions, but was later extended to 15 sessions. Each session lasted 120 minutes, including a 15-minute break. The content of the group sessions was based on manuals for the cognitive behavioral treatment of depression that were available in Norwegian [34]. As no single manual was used during the study period, there was some variation in the treatment received by groups. However, the core elements of CBT for depression, such as psychoeducation, behavioral activation, and cognitive restructuring, were central to all treatments. In its current form, the group CBT treatment given at the center is guided by the manual written by Hagen and Gråwe [34], and the elements are psychoeducation about depression (two sessions), self-assertion, interpersonal relationships, and social network (three sessions), resources and pleasurable activities (one session), the cognitive model of depression and cognitive restructuring (eight sessions), and relapse prevention and evaluation of treatment (one session). A patient workbook is used during treatment. Each session has the following structure: 1) review of homework; 2) presentation of topic A; 3) exercise related to topic A – conducted individually, in pairs, or in groups; 4) break; 5) presentation of topic B; 6) exercise related to topic B – conducted individually, in pairs, or in groups; and 7) presentation of homework. (A parts and timing plot detailing the current treatment timeline can be found in the online appendix). Approximately three months after the last treatment session, patients receive a follow-up group session that focuses on treatment evaluation and relapse prevention.
Measures
The BDI is the main outcome variable in the present study. The BDI [30] and its successor, the BDI-II [31], are widely used, 21-item, self-report inventories designed to assess depression severity. Items are answered on a four-point scale ranging from 0 to 3. The BDI was used at the group therapy unit until the spring of 2009, at which point use of the BDI-II began. Due to the differences between the two versions of the inventory, all BDI scores were converted to BDI-II scores using the adjustment table in the BDI-II manual [31] for comparability. According to the BDI-II manual, the adjustment table is based on a study of psychiatric outpatients and an equipercentile equating method [31]. The Norwegian version of the BDI-II has been shown to have a high internal consistency (Cronbach’s alpha = .91) and an acceptable test-retest reliability (.77) over a three week period [35].
The Beck Anxiety Inventory (BAI) [36] consists of 21 items assessing the severity of anxiety symptoms on a four-point scale ranging from 0 to 3. The Cronbach’s alpha for the Norwegian version of the BAI is .88, and its test-retest reliability over three weeks is .69 [37].
The BDI/BDI-II and BAI were administered to patients at the start of group treatment, at approximately mid-treatment (week 7), at the end of the group treatment, and at 3-months follow-up (Additional file 1).
According to the Norwegian Health Research Act, approval from the Research Ethics Committee is not required for the evaluation of routine service delivery (http://www.regjeringen.no/upload/HOD/HRA/Helseforskning/Helseforskningsloven%20-%20ENGELSK%20endelig%2029%2006%2009.pdf and http://www.regjeringen.no/upload/HOD/HRA/Veileder%20til%20helseforskningsloven.pdf). The Data Protection Official for Research for the Helgeland Hospital Trust was notified of the study.
Statistical analyses
Differences between subgroups of patients were investigated using χ2 tests for categorical data and ANOVA for quantitative variables. The overall effect of the treatment was examined using multilevel modeling. This approach was considered particularly suited for the current investigation, as the analyses did not require complete data for every subject [38,39]. In the analyses, time was defined as fixed factor, and the BDI-II and BAI scores were the dependent variables. Group membership was defined as a level 2 variable. Random intercepts and slopes were specified. Finally, an autoregressive covariance structure with heterogeneous variances was assumed. Unfortunately, as almost no data were available for patients who dropped out of treatment, intent-to-treat analyses could not be performed. Effect sizes (d) between two time points were calculated by dividing the mean differences in outcome variables by the standard deviations of the differences. Uncontrolled effect sizes were calculated for available data pairs and for a data set in which missing data were imputed. The handling of missing data followed the recommendations of Schlomer, Bauman, and Card [40] and Sterne et al. [41]. To evaluate the pattern of missing data, Little’s [42] MCAR test was used. Missing BDI-II and BAI values were imputed by means of a multiple imputation procedure [43] using the automatic method in SPSS 21.0. The number of imputations was specified as 20, and the range of imputed values was constrained to a minimum of 0 and a maximum of 63. The automatic method uses linear regression as model for scale variables [44]. All available BDI-II and BAI scores were included in the imputation procedure.
To further evaluate treatment success and to categorize patients as recovered, improved, unchanged, or deteriorated, the Jacobson and Truax [45] approach as recommended by Bauer, Lambert, and Nielsen [46] was used. For the BDI, cut-off values for reliable change and recovery have been developed [47]. However, as a the BDI and the BDI-II are not entirely identical instruments, it was decided to calculate cut-off scores for the BDI-II and BAI based on the characteristics of the present sample and existing data from the Norwegian general population [35,37]. Patients who showed no reliable change in their BDI-II scores were classified as “unchanged”. If there was a reliable change in negative direction, the patient was classified as “deteriorated”. Patients showing reliable change in positive direction were classified as “improved”, and if patients’ BDI-II scores were below the cut-off for the normal range in addition, the patients were classified as “recovered”.
