Imagery rescripting for depression: protocol development and a pilot open trial

BACKGROUND: Depression is often associated with distressing life events. Studies showed that people with depression reported frequent intrusive memories of past negative events. Yet, existing treatments for depression seldom directly address such problem. Current treatments for depression have been criticized as too generic without considering the heterogeneity of presenting symptoms and underlying cognitive processes. In the past decade, Imagery Rescripting (ImRs) has emerged as an alternative approach which targets at alleviating distress associated with intrusive imagery. It had demonstrated large effects in reducing clinical symptoms in a wide range of emotional disorders. Application of ImRs on depression is still in its infancy. Initial data showed that ImRs effectively reduced depression symptoms, ruminations and intrusive memories in individuals with depression.OBJECTIVES: This pilot study employed an open, uncontrolled trial design with four major objectives: (1) To develop a Chinese treatment protocol of ImRs for depression; (2) To understand the acceptability and feasibility of the treatment protocol; (3) To evaluate its efficacy in reducing intrusive memories and depression; and (4) To explore possible mechanism of change for the treatment outcome.METHOD: Participants diagnosed with Major Depressive Disorder (MDD) and suffered from intrusive memories of past negative events were recruited from a local psychiatric outpatient clinic. Eligible participants were offered a minimum of 4 and a maximum of 12 sessions of Imagery Rescripting for depression, with the number of sessions contingent to the amount of intrusive memories reported. Outcome measures which tracked changes in depression, anxiety symptoms as well as process variables including Intrusion, Rumination and Self-compassion were administered at pre-treatment, during treatment, post-treatment and at 3-months follow-up.RESULTS: A total of 19 participants were enrolled to the current study among which 17 participants completed the treatment. They attended an average of 7.29 sessions, with a range of 4 to 12 sessions. Content of intrusive memories revolved around themes of interpersonal events happened in childhood or adulthood. Recruitment, retention, completion and satisfaction rates reflected that the treatment protocol was feasible to deliver and acceptable to participants. Significant improvement in clinical measures: depression and anxiety, as well as process measures: Intrusion, Rumination and Self-compassion were obtained from pre- to post-treatment with large effect sizes (d = 1.64-3.65). These positive effects were maintained at 3-months follow-up. Further analyses exploring potential mediators for the treatment outcomes were conducted. Results showed that, the mediation effect of Intrusion was significant for depression symptoms; while the mediation effect of Rumination was marginally significant for depression but significant for anxiety symptoms with the presence of all process variables. Whereas, the mediating effect of Self-compassion was non-significant among all process variables.CONCLUSION: This pilot open trial demonstrated the efficacy of ImRs as a standalone treatment for depression. Further analyses suggested that the treatment effect was mediated by changes in the target cognitive processes. Large-scale outcome studies were warranted to establish evidence base for the technique and to understand the specific effect of each treatment components involved.背景：抑鬱症常被認為與困擾的生活經驗有關。研究指出抑鬱症患者常會經歷到與過往事件有關的侵擾回憶 (Intrusive Memory) 。可是，現有的心理治療甚少直接處理此現象。現有的心理治療常被批評為內容過於籠統，未能針對抑鬱症表癥的多樣性及背後相關的認知因素。過去十年間，意象重組治療 (Imagery Rescripting) 被用於處理侵擾回憶相關的困擾。研究顯示它對於改善各項情緒病的病癥有顯著效果。意象重組治療用於抑鬱症的治療尚處於起步階段。一些初步研究指出其對減低抑鬱症癥狀、侵擾回憶及反芻思考 (Rumination) 有顯著效果。目標：本研究有四大目標: (1) 設計適用於本土的「抑鬱症意象重組治療」手冊、(2)了解治療手冊的可行性 (Feasibility) 及可接受程度 (Acceptability) 、(3) 評估治療成效及(4)了解治療成效的相關因素。方法：本研究採用開放式單臂研究設計，並以精神科專科門診為招募地點。研究對象為確診患有抑鬱症，並且過去一個月曾出現侵擾回憶的成年人。合乎條件的人士會按其侵擾回憶的數量參與最少4節至最多12節的意象重組治療。參加者於治療的前、中、後期及完成治療3個月後接受評估，以了解參加者的抑鬱癥狀、焦慮癥狀、回憶侵擾度、反芻思考及自我關懷 (Self-compassion) 程度。本研究以重複測量變異數分析及多層次結構方程式模型進行分析。結果：本研究共招募了19名參加者，其中17位完成整個療程。他們平均的治療節數為7.29節。侵擾回憶主要環繞童年以至成年後的人際關係問題。研究的招募率、保持率、完成度及滿意度都顯示治療是可行及為參加者所接受的。治療後，參加者的抑鬱癥狀、焦慮癥狀、回憶侵擾度、反芻思考及自我關懷程度均有顯著改善，而效應值在1.64-3.65之間。治療成效亦維持至治療後3個月。為了解治療成效的中介因素 (mediators)，本研究亦進一步進行了中介分析。結果顯示回憶侵擾度於抑鬱癥狀有顯著的中介作用 (mediating effect) 。相對於其他過程因素 (process variables)，反芻思考於抑鬱癥狀有近乎顯著 (marginally significant) 的中介作用，而其於焦慮癥狀的中介作用則為顯著;自我關懷的中介作用則不顯著。結論: 本研究結果進一步支持「意象重組治療」於抑鬱症治療中的成效。中介分析亦顯示治療成效是與目標的認知因素有關。此治療技巧是值得進行大型研究以建立其實証基礎及了解各治療成份的效能。Lee, Sze Wai.Psy.D. Chinese University of Hong Kong 2020.Includes bibliographical references (leaves 112-132).Abstracts also in Chinese, appendix I,II,IV in ChineseTitle from PDF title page (viewed on September 13, 2022)