Some contributions on the experience and therapy of depression published in the Italian journal Psicoterapia e Scienze Umane («Psychotherapy and the Human Sciences»)

Abstract

The author reflects about a psychoanalytic interpretation of The Tale of Genji (Genji monogatari), considered by many to be the greatest novel of the ancient Japanese literature. It was composed by Murasaki Shikibu (about 1.000 A.D.), a lady-in-waiting for the Empress Akiko at the imperial court in Heian, now Kyoto. The tale is mostly full of poetical explorations about themes of love, affection, friendship, loyalty, into the social political Heian’s world and in conformity with Buddhist conviction in the vanity of the world. A comprehensive reading of the text including Murasaki’s life and her background, gives us the possibility to catch the human attempt to cure depression through narration. Kirsch et al. in 2002 studied all 47 randomized clinical trials (RCT) submitted by pharmaceutical companies to the U.S. Food and Drug Administration (FDA) for approval of the six most prescribed Selective Serotonin Reuptake Inhibitors (SSRI) antidepressants. The mean difference between drug and placebo was less than 2 points on the 21-item (62-point) Hamilton Depression Scale (which is the version used in many of the these RTCs). This superiority to placebo, although statistically significant, was not clinically significant. Furthermore, 57% of the trials funded by the pharmaceutical industry failed to show a significant difference between drug and placebo. Most of these negative data were not published and were accessible only by gaining access, thanks to the Freedom of Information Act, to FDA documents. This research is discussed in light of the wider problem of the roles of medications and interpersonal relationship in psychiatric practice. The polarity of relatedness and self-definition («anaclitic» and «introjective»), fundamental to the development of psychoanalytic theory and consistent with a number of other approaches to personality theory, provides the basis for articulating aspects of personality development, variations in normal personality organization, the explanation of a wide-range of psychopathology, and aspects of the therapeutic process in both short and long-term treatments. The contributions of this fundamental polarity to these aspects of personality theory speak to the validity of this theoretical model and the importance of the fundamental polarity of relatedness and self-definition. The formulations and findings discussed in this paper indicate that there is much to be gained by going beyond the symptom focus of contemporary diagnostic nosology presented in DSM-III and DSM-IV, and seeking instead to identify underlying principles of personality organization. Empirical evidence shows that empirically supported treatments are helpful for many mental disorders. However, in most countries the great majority of people do not have access to psychological therapies. The English Improving Access to Psychological Therapies (IAPT) program aims to improve the access to psychological therapies by training over 10,500 new therapists in empirically supported treatments and deploying them for the treatment of depression and anxiety disorders. IAPT treats over 560,000 patients per year, obtains clinical outcome data on 98.5% of them, and this information is in the public domain. Around half of these patients recover and about two thirds of them show benefits. The clinical and economic arguments on which IAPT is based are presented, along with details on the service model, how the program is implemented, and findings updated to July 2017. Limitations and future directions are discussed.