Beyond-Blue-A-guide-to-what-works-for-anxiety (PDF)

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A guide to what works for anxiety 1300 22 4636 Nicola Reavley, Nick Allen, Anthony Jorm, Amy Morgan, Siobhan Ryan, Rosemary Purcell Contents What is anxiety? 2 What causes anxiety? 3 Types of anxiety, their signs and symptoms 4 Who can assist? 8 How to use this booklet 11 A summary of what works for anxiety 14 Psychological interventions Acceptance and commitment therapy (ACT) 17 Applied muscle tension 19 Art therapy 20 Behaviour therapy (exposure therapy) 21 Biofeedback 23 Cognitive behaviour therapy (CBT) 24 Computer-aided psychological therapy 25 Dance and movement therapy (DMT) 27 Eye movement desensitisation and reprocessing (EMDR) 28 Family therapy 29 Flooding (aka ‘implosion therapy’) 30 Hypnosis 31 Interpersonal therapy (IPT) 32 In vivo exposure 33 Mindfulness-based therapies 34 Narrative exposure therapy (NET) 36 Neurolinguistic programming (NLP) 37 Psychoanalysis 38 Psychodynamic psychotherapy 39 Rational emotive therapy (RET) 41 Relationship therapy 42 Social skills training 43 Supportive therapy 44 Systematic desensitisation 45 Virtual reality exposure therapy 46 Medical interventions Anti-convulsant drugs 48 Antidepressant drugs 50 Anti-glucocorticoid (AGC) drugs 52 Antihistamine drugs 53 Antipsychotic drugs 54 Azapirone drugs 56 Benzodiazepines 57 Beta-blockers 59 D-Cycloserine (DCS) with exposure therapy 61 Deep brain stimulation (DBS) 63 Electroconvulsive therapy (ECT) 64 Glucocorticoid drugs 65 Lithium 66 Psychosurgery (aka ‘neurosurgery’) 67 Stimulant drugs 68 Transcranial magnetic stimulation (TMS) 69 Vagus nerve stimulation (VNS) 70 Complementary and lifestyle interventions Complementary and lifestyle interventions 71 Acupuncture 71 Alcohol 73 Aromatherapy 74 Ashwagandha 75 Autogenic training 75 Ayurveda 77 Bach flower remedies 77 Bibliotherapy 78 Black cohosh 80 Breathing training 81 Caffeine consumption 82 Caffeine reduction or avoidance 83 Chamomile 84 Energy psychology (aka meridian tapping) 85 Exercise 86 Foods rich in tryptophan 88 Ginkgo 89 Glycine 90 Golden Root 91 Gotu kola 92 Holy basil 92 Homeopathy 93 Inositol 94 Juggling therapy 95 Kampo 95 Kava 96 Lavender 97 Massage 98 Meditation 99 Milk thistle 100 N-acetylcysteine (NAC) 101 Omega-3 fatty acids (fish oil) 102 Painkillers 103 Passionflower 104 Relaxation training 105 Smoking cigarettes 106 St John’s wort 107 Sympathyl 109 Valerian 110 Vitamin supplements 111 Water-based treatments 112 Yoga 113 New interventions that are not routinely available Borage 114 Cannabidiol 115 Galphimia glauca 115 Sweet flag 116 Interventions reviewed but where no 117 evidence was found References 119 ISBN: 978-0-9807463-1-0 Copyright: Beyond Blue Ltd, Reavley, Allen, Jorm, Morgan, Ryan, Purcell. Suggested citation: Reavley NJ, Allen NB, Jorm AF, Morgan AJ, Ryan S, Purcell R. A guide to what works for anxiety: 2nd Edition. beyondblue: Melbourne, 2013. About the Authors The authors of this guide are researchers at the Melbourne School of Population and Global Health, the Centre for Youth Mental Health and the Melbourne School of Psychological Sciences, The University of Melbourne, Victoria. Acknowledgements The authors wish to thank the focus group members who provided valuable feedback on revising this booklet, including the rating system used throughout. What is anxiety? Anxiety is more than just feeling stressed or worried. While stress and anxious feelings are a common response to a situation where a person feels under pressure, it usually passes once the stressful situation has passed, or ‘stressor’ is removed. Anxiety is when these anxious feelings don’t subside. Anxiety is when they are ongoing and exist without any particular reason or cause. It’s a serious condition that makes it hard for a person to cope with daily life. We all feel anxious from time to time, but for a person experiencing anxiety, these feelings cannot be easily controlled. The symptoms of anxiety can often develop gradually over time. Given that we all experience some anxiety, it can be hard to know how much is too much. In order to be diagnosed with anxiety, the condition must have a disabling impact on the person’s life. There are many types of anxiety. While the symptoms for each type are different, some general signs and symptoms include: • feeling very worried or anxious most of the time • finding it difficult to calm down • feeling overwhelmed or frightened by sudden feelings of intense panic/ anxiety • experiencing recurring thoughts that cause anxiety, but may seem silly to others • avoiding situations or things which cause anxiety (e.g. social events or crowded places) • experiencing ongoing difficulties (e.g. nightmares/ flashbacks) after a traumatic event. For more information about symptoms of anxiety, see ‘Types of anxiety, their signs and symptoms’ overleaf, or visit 2 What causes anxiety? It’s often a combination of factors that can lead to a person developing anxiety. Family history of mental health problems People who experience anxiety may have a history of mental health problems in their family. However, this doesn’t mean that a person will automatically develop anxiety if a parent or close relative has had a mental health condition. Stressful life events Stressful events can also trigger symptoms of anxiety. Common triggers include: • job stress or changing jobs • change in living arrangements • pregnancy and giving birth • family and relationship problems • experiencing a major emotional shock following a stressful or traumatic event • experiencing verbal, sexual, physical or emotional abuse or trauma • death or loss of a loved one. Physical health problems Continuing physical illness can also trigger anxiety or complicate the treatment of the anxiety or the physical illness itself. Common conditions that can do this include: • hormonal problems (e.g. overactive thyroid) • diabetes • asthma • heart disease. If there is concern about any of these conditions, ask a doctor for medical tests to rule out a medical cause for the feelings of anxiety. Substance use Heavy or long-term use of substances such as alcohol, cannabis, amphetamines or sedatives (such as benzodiazepines) can actually cause people to develop anxiety, particularly as the effects of the substance wear off. People with anxiety may find themselves using more of the substance to cope with withdrawal-related anxiety, which can lead to them feeling worse. 3 Types of anxiety, their signs and symptoms There are many types of anxiety, with a range of signs and symptoms. It’s important to note that the following are only guides to recognising different types of anxiety. They will not provide a diagnosis – for that you need to see a health professional. Generalised anxiety disorder (GAD) A person feels anxious on most days, worrying about lots of different things, over a period of six months or more. For six months or more, on more days than not, have you: • felt very worried • found it hard to stop worrying • found that your anxiety made it difficult to carry out everyday activities (e.g. work, study, seeing friends and family)? If you answered ‘yes’ to all of these questions have you also experienced three or more of the following: • felt restless or on edge • felt tired easily • had difficulty concentrating • felt irritable • had muscle pain (e.g. sore jaw or back) • had trouble sleeping (e.g. difficulty falling or staying asleep or restless sleep)? For more information see beyondblue’s Generalised anxiety disorder fact sheet at Social phobia (or social anxiety disorder) A person with social phobia has an intense fear of criticism, being embarrassed or humiliated, even just in everyday situations, for example, public speaking, eating in public, being assertive at work or making small talk. Have you: • felt fear of one or more social or performance situations where you may be criticised • avoided a situation or endured with anxiety and distress • felt that the anxiety interferes with normal routine, working life, social functioning, or you are distressed about the problem • felt that the fear is identified as unreasonable? For more information see beyondblue’s Social phobia fact sheet at Specific phobias A person feels very fearful about a particular object or situation and may go to great lengths to avoid the object or situation, for example, having an injection or travelling on a plane. There are many different types of phobias. Have you: • felt very nervous when faced with a specific object or situation e.g.: − flying on an aeroplane − going near an animal − receiving an injection • avoided a situation that might cause you to face the specific phobia e.g.: − needed to change work patterns − not getting health check-ups • found it hard to go about daily life (e.g. working, studying or seeing friends and family) because you are trying to avoid such situations? For more information see beyondblue’s Specific phobias fact sheet at 4 Panic disorder A person has panic attacks, which are intense, overwhelming and often uncontrollable feelings of anxiety combined with a range of physical symptoms. Within a 10 minute period have you felt four or more of the following: • sweaty • shaky • increased heart rate • short of breath • choked • nauseous or pain in the stomach • dizzy, lightheaded or faint • numb or tingly • derealisation (feelings of unreality) or depersonalisation (feeling detached from yourself or your surroundings) • hot or cold flushes • scared of going crazy • scared of dying? If you answered ‘yes’ to all of these questions, have you also: • felt scared, for one month or more, of experiencing these feelings again? Having a panic attack does not always mean that a person will develop panic disorder. Some people may develop panic disorder after only a few panic attacks. Others may have many panic attacks without developing a panic disorder. Some people who have panic attacks develop agoraphobia. They avoid situations because they worry about having a panic attack. They worry that it will be difficult or embarrassing to get away or that there will be no one to help them. Some people avoid situations like crowds, enclosed places such as shopping malls, or driving. Others may avoid leaving their homes altogether. For more information see beyondblue’s Panic disorder fact sheet at Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) PTSD and ASD can happen after a person experiences a distressing and traumatic event (e.g. war, assault, accident, disaster). They may have experienced the event or seen it happen to someone else. They also react with intense fear, helplessness or horror. PTSD is diagnosed when a person has symptoms for at least a month. Have you: • experienced or seen something that involved death, injury, torture or abuse and felt very frightened or helpless • had upsetting memories or dreams of the event for at least one month • found it hard to go about daily life (e.g. difficulty working, studying or getting along with family and friends)? If you answered ‘yes’ to all of these questions have you also experienced at least three of the following: • avoided activities that are a reminder of the event • had trouble remembering parts of the event • felt less interested in doing things you used to enjoy • had trouble feeling intensely positive emotions (e.g. love or excitement) • thought less about the future (e.g. about career or family goals)? and have you experienced at least two of the following: 5 • had difficulty sleeping (e.g. had bad dreams or found it hard to fall or stay asleep) • become angry or irritated easily • had trouble concentrating • felt on guard • been easily startled? For more information see beyondblue’s Post-traumatic stress disorder fact sheet at Obsessive compulsive disorder (OCD) A person has ongoing unwanted/intrusive thoughts and fears that cause anxiety. Although the person may acknowledge these thoughts as silly, the person often finds him or herself trying to relieve their anxiety by carrying out certain behaviours or rituals. For example, a fear of germs and contamination can lead to constant washing of hands and clothes. Have you: • had repetitive thoughts or concerns that are not about real life problems (e.g. thoughts that you or people close to you will be harmed) • performed the same activity repeatedly and in a very ordered, precise and similar way each time e.g.: − constantly washing hands or clothes, showering or brushing teeth − constantly cleaning, tidying or rearranging in a particular way things at home, at work or in the car − constantly checking that doors and windows are locked and/or appliances are turned off • felt relieved in the short term by doing these things, but soon felt the need to repeat them • recognised that these feelings, thoughts and behaviour patterns are unreasonable • found that these thoughts or behaviour patterns take up more than one hour a day and/or interfered with your normal routine (e.g. working, studying or seeing friends and family)? For more information see beyondblue’s Obsessive compulsive disorder fact sheet at The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook published by the American Psychiatric Association and is used by health professionals in many countries around the world as a guide to the diagnosis of mental disorders. The DSM is periodically reviewed and in May 2013, DSM-5 (an update on DSM-IV) was released. The DSM-5 chapter on anxiety disorders no longer includes obsessive compulsive disorder (which is included with the obsessive compulsive and related disorders) or post-traumatic stress disorder and acute stress disorder (which is included with the trauma and stressor-related disorders). However, the DSM-5 does reflect the close relationships among anxiety, OCD and PTSD. Mixed anxiety, depression and substance abuse Many people have symptoms of more than one type of anxiety. In addition, it is not uncommon for depression and anxiety to occur together – over half of those who experience depression also experience symptoms of anxiety – and in some cases, one can lead to the onset of the other. Substance abuse also frequently occurs with anxiety. People may use alcohol or other drugs to try to help them cope. However, alcohol and other drug use can lead to increased anxiety. 6 Anxiety is common, but often untreated Anxiety is the most common mental health condition in Australia. On average, one in four people – one in three women and one in five men – will experience an anxiety disorder at some stage in their life.1 A national survey of the mental health of Australians was carried out in 2007. This survey asked people about a range of symptoms of anxiety disorders and other mental health problems. A special computer program was used to make a diagnosis based on the answers provided. Shown below are the percentages of people found to be affected by particular types of anxiety in any given year. Specific phobias were not asked about. Percentage of Australians aged 16 years or over affected by anxiety1 Although anxiety is common, many people affected do not get treatment. In the national survey, many of those who had anxiety in the previous 12 months did not receive any professional help. Type of disorder Percentage affected in previous 12 months Percentage affected at any time in their life Post-traumatic stress disorder 6.4% 12.2% Social phobia 4.7% 10.6% Agoraphobia 2.8% 6.0% Generalised anxiety disorder 2.7% 5.9% Panic disorder 2.6% 5.2% Obsessive compulsive disorder 1.9% 2.8% 7 Who can assist? Different health professionals (such as GPs, psychologists and psychiatrists) offer different types of services and treatments for anxiety. Below is a guide to the range of practitioners available and what kind of treatment they provide. General Practitioners (GPs) GPs are the best starting point for someone seeking professional help. A good GP can: • make a diagnosis • check for any physical health problem or medication that may be contributing to the anxiety • discuss available treatments • work with the person to draw up a Mental Health Treatment Plan so he or she can get a Medicare rebate for psychological treatment • provide brief counselling or, in some cases, talking therapy • prescribe medication if appropriate • refer a person to a mental health specialist such as a psychologist or psychiatrist. Before consulting a GP about anxiety, it’s important to ask the receptionist to book a longer or double appointment, so there is plenty of time to discuss the situation without feeling rushed. It is also a good idea to raise the issue of anxiety early in the consultation. Some GPs are better at dealing with mental health conditions than others. The GP will discuss various treatment options and take the person’s treatment preferences into account. It is recommended that people consult their regular GP or another GP in the same clinic, as medical information is shared within a practice. For those without a regular GP or clinic, there is a list of GPs with expertise in treating common mental health problems available from or by calling 1300 22 4636. Psychologists Psychologists are health professionals who provide psychological therapies (talking therapies) such as cognitive behaviour therapy (CBT) and interpersonal therapy (IPT). Clinical psychologists specialise in the assessment, diagnosis and treatment of mental health conditions. Psychologists and clinical psychologists are not doctors and cannot prescribe medication in Australia. It is not necessary to have a referral from a GP or psychiatrist to see a psychologist. However, a Mental Health Treatment Plan from a GP is needed to claim rebates through Medicare. If you have private health insurance and extras cover, you may be able to claim part of a psychologist’s fee. Contact your health fund to check. Psychiatrists Psychiatrists are doctors who have undergone further training to specialise in mental health. They also specialise in the assessment, diagnosis and treatment of mental health conditions. They can make medical and psychiatric assessments, conduct medical tests, provide therapy and prescribe medication. Psychiatrists often use psychological treatments such as cognitive behaviour therapy (CBT), interpersonal therapy (IPT) and/or medication. If the anxiety is severe and hospital admission is required, a psychiatrist will be in charge of the person’s treatment. A referral from a GP is needed to see a psychiatrist. Rebates can also be claimed through Medicare. A GP may suggest the person sees a psychiatrist if: • the nature of the anxiety is unclear • the anxiety is severe • the anxiety lasts for a long time, or comes back • the anxiety is associated with a high risk of self-harm • the anxiety has failed to respond to treatment • the GP thinks that he or she doesn’t have the appropriate skills required to treat the person effectively. 8 Mental health nurses Mental health nurses are specially trained to care for people with mental health conditions. They work with psychiatrists and GPs to review the state of a person’s mental health and monitor their medication. They also provide people with information about mental health conditions and treatment. Some have training in psychological therapies. For a referral to a mental health nurse who works in a general practice, ask your GP. Accredited Mental Health Social Workers Accredited Mental Health Social Workers specialise in working with and treating mental health conditions, such as depression and anxiety. Many Accredited Mental Health Social Workers are registered with Medicare to provide focused psychological strategies, such as CBT, IPT, relaxation training, psycho- education and interpersonal skills training. Occupational therapists in mental health Occupational therapists in mental health help people who have difficulty functioning because of a mental health condition (such as anxiety or depression) to participate in normal, everyday activities. They can also provide focused psychological strategies. Medicare rebates are also available for individual or group sessions with social workers and occupational therapists in mental health. Aboriginal and Torres Strait Islander health workers Aboriginal and Torres Strait Islander health workers are health workers who understand the health issues of Indigenous people and what is needed to provide culturally-safe and accessible services. Some workers may have undertaken training in mental health and psychological therapies. Support provided by Aboriginal and Torres Strait Islander health workers might include, but not be limited to, case management, screening, assessment, referrals, transport to and attendance at specialist appointments, education, improving access to mainstream services, advocacy, counselling, support for family and acute distress response. Counsellors ‘Counsellor’ is a generic term used to describe various professionals who offer some type of talking therapy. A counsellor may be a psychologist, nurse, social worker, occupational therapist, or they may have a specific counselling qualification such as a Bachelor or Master of Counselling degree. Counsellors can work in a variety of settings, including private practices, community health centres, schools and universities and youth services. A counsellor can talk through different problems you may be experiencing and look for possible solutions. However, it is important to note that not all counsellors have specific training in treating mental health conditions like depression and anxiety. While there are many qualified counsellors who work across different settings, unfortunately, anyone can call themselves a ‘counsellor’, even if they don’t have training or experience. For this reason, it’s important to ask for information about the counsellor’s qualifications and whether they are registered with a state board or a professional society. It is also important to note that only psychologists, social workers or occupational therapists are eligible to be registered with Medicare to provide services that attract a Medicare rebate. 9 Complementary health practitioners There are many alternative and complementary treatment approaches for anxiety. However, many of these services are not covered by Medicare. Some services may be covered by private health insurance. If you don’t have private health insurance, you may have to pay for these treatments. When seeking a complementary treatment, it is best to check whether the practitioner is registered by a state Registration Board or a professional society. It is a good idea to make sure the practitioner uses treatments which are supported by evidence that shows they are effective. Do you live in a rural or remote area? People living in rural and remote communities may find it difficult to access the mental health professionals listed here. If a General Practitioner or other mental health professional is not readily available, there are a number of help and information lines that may be able to assist and provide information or advice. For people with internet access, it may also be beneficial in some cases to try online e-therapies. The cost of getting treatment for anxiety from a health professional varies. However, in the same way that people can get a Medicare rebate when they see a doctor, they can also get part or all of the consultation fee subsidised when they see a mental health professional for treatment of depression. It’s a good idea to find out the cost of the service and the available rebate before making an appointment. The receptionist should be able to provide this information. How family and friends can help Family members and friends play an important role in a person’s recovery. They can offer support, understanding and help, and can assist the person to get appropriate professional help. When someone you care about is experiencing anxiety, it can be hard to know what the right thing is to do. Sometimes, it can be overwhelming and can cause worry and stress. It is very important that you take the time to look after yourself and monitor your own feelings if you’re supporting a friend or family member who is experiencing anxiety. Information about anxiety and practical advice on how to help someone you are worried about is available at The beyondblue Guide for carers booklet gives information on supporting and caring for a person with anxiety or depression. beyondblue also has a range of helpful resources, including fact sheets, booklets, wallet cards and DVDs about anxiety and depression, available treatments and where to get help – go to 10 How to use this booklet There are many different approaches to treating anxiety. These include medical treatments (such as medications or medical procedures), psychological therapies (including ‘talking therapies’) and self-help (such as complementary and alternative therapies or lifestyle approaches). All of the approaches included in this booklet have been investigated as possible ‘treatments’ for anxiety – see ‘How this booklet was developed’ on page 12. However, the amount of evidence supporting the effectiveness of different interventions can vary greatly. In addition, some of the approaches listed are not available or used as treatments – for example, kava is not readily available in Australia but it has been used in research studies to see if it reduces anxiety. This booklet provides a summary of what the scientific evidence says about each approach. Even when an intervention is shown to have some effect in research this does not mean it is available, used in clinical practice, or will be recommended or work equally well for every person. There is no substitute for the advice of a mental health practitioner, who can advise on the best available treatment options. We have rated the evidence for the effectiveness of each intervention covered in this booklet using a ‘thumbs up’ scale: There are a lot of good quality studies showing that the approach works. There are a number of studies showing that the intervention works, but the evidence is not as strong as for the best approaches. There are at least two good studies showing that the approach works. The evidence shows that the intervention does not work. There is not enough evidence to say whether or not the approach works. The intervention has potential risks, mainly in terms of side-effects. 11 When a treatment is shown to work scientifically, this does not mean it will work equally well for every person. While it might work for the average person, some people will have complications, side-effects or incompatibilities with their lifestyle. The best strategy is to try an approach that works for most people and that you are comfortable with. If you do not recover quickly enough, or experience problems with the treatment, then try another. Another factor to consider is beliefs about treatment. A treatment is more likely to work if a person believes in it and is willing to commit to it.2, 3, 4 Even the most effective treatments will not work if they are used sometimes or half-heartedly. Some people have strong beliefs about particular types of treatment. For example, some do not like taking medications in general, whereas others have great faith in medical treatments. However, strong beliefs in a particular treatment may not be enough, especially if there is no good evidence that the treatment works. This booklet provides a summary of what the scientific evidence says about different approaches that have been studied to see if they reduce depression. The reviews in this booklet are divided into the following sections: Psychological interventions These therapies can be provided by a range of health practitioners, but particularly psychologists, clinical psychologists and psychiatrists. Medical interventions These interventions are generally provided by a doctor (usually a GP or a psychiatrist). Complementary and lifestyle interventions These approaches can be provided by a range of health practitioners, including complementary health practitioners. Some of them can be used as self-help. Interventions that are not routinely available Approaches that are not currently available or used as a treatment for anxiety, but have been used in research studies. Within each of these areas, we review the scientific evidence for each intervention to determine whether or not they are supported as being effective. We recommend that people seek treatments that they believe in and are also supported by evidence. Whatever treatments are used, they are best done under the supervision of a GP or mental health professional. This is particularly important where more than one treatment is used. Often combining treatments that work is the best approach. However, sometimes there can be side-effects from combinations, particularly prescribed or complementary medications. How this booklet was developed Searching the literature To produce these reviews, the scientific literature was searched systematically on the following online databases: the Cochrane Library, PubMed, PsycINFO and Web of Science. For many of the searches we relied on work that had been done for a recent review article by two of the authors: Morgan AJ, Jorm AF (2009). Outcomes of self-help efforts in anxiety disorders. Expert Reviews in Pharmacoeconomic Outcomes Research, 9:445–459. 12 Evaluating the evidence Studies were excluded if they involved people who had not been diagnosed with an anxiety disorder or sought help. Where there was an existing recent systematic review or meta-analysis, this was used as the basis for drawing conclusions. Where a systematic review did not exist, individual studies were read and evaluated. A study was considered adequate if it had an appropriate control group and participants were randomised. For the complementary, lifestyle and psychological interventions, we included studies that tested the effects of adding treatments to commonly-used medical treatments e.g. a lifestyle intervention was evaluated in people already taking prescribed medication. This was not done for the medical interventions section so that the medical reviews were as clear and easy to understand as possible. Writing the reviews The reviews were written to be at the 8th grade reading level or less. Each review was written by one of the authors and checked for readability and clarity by a second author. All authors discussed and reached consensus on the ‘thumbs up’ rating for each treatment. If a treatment gets the ‘thumbs up’ does that mean it will work for me? When a treatment is shown to work in research studies, this does not mean it will work equally well for every person. While it might work for the average person, some people will have complications, side-effects, or the treatment may not fit well with their lifestyle. If you have any concerns about a treatment that has received a ‘thumbs down’ rating, you should discuss the pros and cons of it with a GP or mental health professional to decide whether the treatment is suitable for you. It is not recommended that you stop using your current treatments until you have consulted a professional. 1 Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: Summary of Results,2007 (4326.0). Canberra: Australian Bureau of Statistics. 2 Sotsky SM, Glass DR, Shea MT, Pilkonis PA, Collins JF, Elkin I, et al. Patient predictors of response to psychotherapy and pharmacotherapy: findings in the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry. 1991; 148:997–1008. 3 Krell HV, Leuchter AF, Morgan M, Cook IA, Abrams M. Subject expectations of treatment effectiveness and outcome of treatment with an experimental antidepressant. Journal of Clinical Psychiatry. 2004;65:1174–1179. 4 Priebe S, Gruyters T. The importance of the first three days: predictors of treatment outcome in depressed in-patients. British Journal of Clinical Psychology. 1995;34:229–236. 13