Đánh giá hiệu quả điều trị rối loạn trầm cảm bằng liệu pháp kích hoạt hành vi kết hợp với amitriptyline tại 4 xã phường, tỉnh khánh hòa tt tiếng anh

1

INTRODUCTION
Major depressive disorder (MDD) occurs from 5 to 10 percents at
primary health care and approximately 50 percents of MDD and dysphoric
disorders weren’t detected on examination. Studies pointed out that the
majority of depressed patients didn’t receive appropriate treatments.
Treatment for dpression current is composed of drug therapy, biological
therapy, and psychotherapy. International researchers, through clinical
trials, stated that behavioral therapy (BA) is effective in reducing and
suppress depressive symptoms (Kanter, 2010; Ritschel, 2011). Studies
showed that BA is simple, teachable, learnable, doesn’t require that
therapists need to have complex skills, easier to accept for population than
with medicines, effective interms of time and cost, designed favourably for
following up patients and for therapists, and easy to generalize in the
community.
In Vietnam, at primary health care level, treatment for depression is
mainly medicines while effective BA for depression hasn’t been applied in
the community yet. The research “Assessing the effectiveness of treating
major depressive disorder by combining behavioral therapy with
amitriptyline at 4 communes/wards of Khanh Hoa province” will illustrate
the benefits of BA, with two objectives:
1. Describe MDD patients features at 4 communes/wards of Khanh Hoa
province in 2011.
2. Assessing the effectiveness of treating major depressive disorder by
combining behavioral therapy with amitriptyline at 4 communes/wards of
Khanh Hoa province from 2012-2015.
New contributions of the dissertation
- Provide description on MDD in the community at four communes/
wards of Khanh Hoa province, through which, provide to policy makers
prevention and management stratergies for currently increasing MDD.

- Initially assess the effectivenes of BA combined with amitriptyline at
4 communes/wards of Khanh Hoa province.
Struture of the dissertation
The dissertation is composed of 144 pages of main contents, 37 tables,
6 figures, 160 references, 10 appendices (patient’s chart sample, patients
list, research tools).


2

Chapter 1
OVERVIEW
1.1. Overview on depression
1.1.1. Concept of depression
Depression is pathologic status of emotion, manifesting by an inhibited
process of all the areas of mental activities (emotion, thought, activities…).
According to the 10th Internation Classification of Diseases, depression
manifests by three characteristic symptoms: depressed mood, loss of interest and
enjoyment, reduced energy leading to increased fatiguability and diminished
activitiy; seven other common symptoms: reduced concentration and attention,
reduced self-esteem and self-confidence, idea of guilt and unworthiness,
pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed
sleep, diminished appetite. The symptoms exist in at least two weeks.
1.1.2. Aetiology of depression
Depression is due to multiple causes, but in general there are three
main causes: psychologic, organic, and endogenous.
1.1.3. Mechanism of depression
Neurotransmitters an receptors play important roles in depression.
Central neurotransmitters biogenic amines (serotonin (5HT), epinephrine,
norepinephrine (NE), dopamine (DA), acetylcholine, histamine), amino

acids (glutamate, gama aminobutiric acid - GABA), and peptides.
Depression is associated with the abnormal functions of neurotransmitters, in
which, the most important are 5HT, NE, DA, and related receptors; and
even the changes in the forms and functions of the brain.
1.1.4. Diagnosis and classification of depression according to ICD-10
1.1.4.1. Diagnostic criteria of depression according to ICD-10
- Three characteristic symptoms: depressed mood, loss of interest and
enjoyment, reduced energy leading to increased fatiguability and diminished
activitiy.


3

- Seven other common symptoms: reduced concentration and attention,
reduced self-esteem and self-confidence, idea of guilt and unworthiness,
pessimistic views of the future, ideas or acts of self-harm or suicide,
disturbed sleep, diminished appetite.
- Somatic symptoms of depression: loss of interest or pleasure in
activities that are normally enjoyable; lack of emotional reactivity to
normally pleasurable surroundings and events; waking in the morning 2
hours or more before the usual time; depression worse in the morning;
psychomotor retardation or agitation; marked loss of appetite; weight loss
(often defined as 5% or more of body weight in the past month); marked
loss of libido.
- Psychotic symptoms such as delusion, hallucination maybe present or
not present in depressed episode.
- Determination of the severity of depression (mild, moderate, severe)
bases on the numbers of characteristic and common symptoms of
depression of patients; the impacts on scopes of social and occupational
activities of patients; the presence of psychotic symptoms; and the duration

of depression episode.
1.1.4.2. Classification of depression
Depresion has 3 types: endogenous, psychologic, and organic.
1.2. BA in depression treatment
1.2.1. Definition of BA
According to Martel (2010), BA is brief, structured therapy aimed at
activating patients by special ways in order to increasing reward
experiences for their lifes; an independent therapy and an important
component of cognitive behavioral therapy in treating depression.
According to Dimidjian (2011), BA is a brief, strutured
psychotherapy aimed at (a) increasing the engagement in appropriate


4

activities (usually related to pleasure or mastery experience), (b) decreasing
engagement in activities that maintain depression or increase depression
risk, and (c) dealing with problems limiting access to reward, or
maintaining, or increasing the control of aversive feelings. BA will focus
directly on those objectives.
1.2.2. Mechanism of BA
According to Martell, the techniques of BA increase the activation,
decrease the avoidance, increase the contact with positive reinforcement for
non-depressive behaviors, and mood increasing behaviors. By the time, this
process will lead to decreasing depression symptoms.
BA activates patients contacting with positive reinforcers,
scheduling to participate in pleasurable events. BA helps patients
engaging more on pleasure activities, provides a clear assessment on
patients’ purpose and present behavioral function in order to determine
the activated objectives to focus on. BA also trains patients social

skills and how to analyse their behavioral function themselves;
encourages the assessment of negative reinforcers for avoidance
behaviors of depression. sự đánh giá các củng cố tiêu cực cho hành vi né
tránh của trầm cảm. As a result, BA activates behaviors decreasing,
supressing symptoms, dosen’t imoact on the causes as well as mechanism of
depression.
1.2.3. Objectives of BA
Decrease the slowness, lack of activity of depressed patients; decrease
avoidance behaviors, activate activities to improve emotion; decrease
negative activities.


5

Chapter 2
STUDY SUBJECTS AND METHODS
2.1. Study subjects
2.1.1. Selection criteria
- Patients from 18 to 65 years old, diagnose of MDD by psychiatrists
following ICD-10, capable of reading, writing, and hearing Vietnamese.
- Patients voluntarily agree participating in the study.
2.1.2. Exclusion criteria
Patients having cognitive impairment, psychotic, manic symptoms,
substance abuse, severe medical illnesses, contraindications with
amitriptyline.
2.2. Locations and period of time of the study
Two Phuoc Tan, Phuoc Hoa wards of Nha Trang city, and two Dien
Son, Dien Phu communes of Dien Khanh distrist of Khanh Hoa province,
from October of 2012 to October of 2015.
2.3. Study methods

2.3.1. Study design
Non-randomized, controled community intervention study. Prospective
study with follow-up for six months.
2.3.2. Sample size
WHO formula:
{Z
n1 = n2 =

1−

α
2

2 P (1 − P − ) + Z1−β

p1 (1 − p1 ) + (1 − p2 ) }

( p1 − p2 ) 2

in which:
n1: Minimum sample size of controlled group, n 2: minimum sample
size of intervention group
p1: Rate of remission patients expected in the controlled group = 50%,
p2: Rate of remission patients expected in the intervention group = 85%
P = (p1 + p2)/2


6

Z(1- α /2): Reliability at 95% level (= 1,96)

1-β: Sample power (= 80%)
The minimum sample size for each group n1 = n2 = 30 patients.
Due to the fact that intervention for depression having high rate of dropout we have to recruit n1= 62 and n2 = 64 to make sure that we have at least 30
patients to follow-up until the end of study which is the week of 30 (T30).
2.3.3. Patients follow-up plan
- Intervetion group: after finishing treatment (6 weeks), patient will be
re-examined and given amitriptyline every two weeks, continuously for
30 weeks.
- Controlled group: after finishing treatment (6 weeks), patient will be
re-examined and given amitriptyline every two weeks, continuously for
30 weeks.
* All the important steps, such as screening at households, interview by
PHQ-9, conducting BA sessions, are implemented by the study group
members who were carefully trained.
2.3.4. Tools used in the study
- PHQ-9 (Appendix 5) – rate the severity of depression and monitor
treatment response. Define mild degree when PHQ-9 score from 10-14,
moderate from 15-19, and severe from 20-27.
- BADS-SF (Appendix 7) – assess behavioral change of depressed
patients after treatment by BA. All the questions of BADS-SF can be
answered by 7 levels as following: 0 – not at all, 1 – very little, 2 – a little,
3 - moderate, 4 – a lot, 5 – very much, 6 - completely. The higher of
BADS-SF is the higher of behavioral activation level. BADS-SF score
negatively correlate with depression severity, avoidance behavior,
automatic depressed thoughts; positively correlate with reinforce
possibility, quality of life, active adapatation.
- Other questions to collect information about related factors:
demography, social-economic conditions…(Appendix 7).

7

- Assess the effectiveness of treatment on depression degree
The study assess the effectiveness of treatment on depression degree
bases on the changes of PHQ-9 score. The more decrease the PHQ-9 score
is the more effectiveness the treatment is, and vice versa.
- Assess the effectiveness of treatment on depression behavior: bases on
the changes of BADS-SF score. The more increase the BADS-SF score is
the more increase the level of activation behavior is, and vice versa.
- Assess the effectiveness of treatment on remission, recovery, relapse,
recurrence, bases on PHQ-9 score.
- Remission – a short period of time having no depression symptoms:
PHQ-9 < 5 since the point of T6 on.
- Recovery – a period of remission lasting at least 6 months: PHQ-9 < 5
at the point of T30.
- Relapse – the return of depressed symptoms, occuring in the
remission period, before recovery period: PHQ-9 > 9 again among 6
months after having had PHQ-9 <5 at the point of T6.
- Recurrence – the return of depressed symptoms in the period of
recovery: PHQ-9 at T6, T12 and T24 < 5, PHQ-9 at T30 > 9.
2.4. Data entry and analysis
Data were entered and analyzed using EpiData 3.1 and STATA 12.0.


8

Chapter 3
STUDY RESULTS
3.1. Individual characteristics of study subjects
Table 3.1. Individual characteristics of study subjects

Individual factors

Age

Gender

Education

Marriage

Occupation

18 - <35
35 - <45
45 - <55
55 - <65
Meanh
SD
Male
Female
Primary
Secondary
High school
College, university
Missing
Single
Marriaged
Separation, divorce
Widowed
Missing

Official
Worker
Farmer
Small business
Housewife
Free laboror

n (126)

(%)

10
28
44
44

8,0
22,2
34,9
34,9
49,7
9,8

31
95
53
42
22
3
6

10
107
2
5
2
3
6
33
14
20
50

24,6
75,4
42,1
33,3
17,5
2,4
4,7
7,9
84,9
1,6
4,0
1,6
2,4
4,8
26,1
11,1
15,9
39,7

9

3.2. MDD characteristics
Table 3.2. Rate of patients having depression symptoms
Symptoms
n (126)
(%)
Cognitive symptoms
Reduced concentration, attention
98
77,8
Reduced self-esteem, self-confidence
102
81,0
Ideation of guilty, unworthiness
78
61,9
Suicidal idea
38
30,2
Emotional symptoms
Depressed mood
118
93,7
Pessimism about future
107
84,9
Somatic symptoms

Loss of interest and enioyment
109
86,5
Fatiguablity
126
100
Disturbance of sleep
125
99,2
Disturnamce of appetite
103
81,8
Table 3.6. Mean of illness duration before study (week)
n
Mean
SD
min - max
125
83,8
116,0
2-520
Table 3.7. Depression degree according to ICD-10 before intervention
Degree
n (126)
(%)
Mild
63
50,0
Moderate
40

31,8
Severe
23
18,2


10

3.3. Effectiveness of BA combined with amitriptyline in the treatment
of depression
3.3.1. Effectiveness in depression symptoms
Table 3.11. Differences of score changes of depressed mood symptoms at study times
Controll group
Intervention group Ranksum test
Median
Median
Time
n
of
R1
n
of
R2
z
p
change
change
T6-T0 30
-1,5
1.166 37

-2
1.112 1,9
0,06
T12-T0 28
-1
976 35
-2
1.040 1,1
0,25
T24-T0 21
-1
667,5 31
-2
710.5 2,2
0,03
T30-T0 31
-1
1.321,5 37
-2
1.024.5 3,2
0,01
Table 3.12. Differences of score changes of loss of enterest/enjoyment
symptoms at study times
Control group
Intervention group
Ranksum test
Tim
Median
Median
n

of
R1
n
of
R2
z
p
e
change
change
T6-T0 30
-1
1.234 37
-2
1.044
2,8
0,01
T12-T0 28
-1,5
954,5 33
-2
936,5
1,3
0,20
T24-T0 21
-1
663
30
-2
663

2,3
0,02
T30-T0 31
-1
1.209,5 37
-2
1.136,5 1,8
0,08
Table 3.16. Differences of score changes guilty and unworthy ideas
symptoms at study times
Control group
Intervention group Ranksum test
Median
Media
Time
n
of
R1
n
n of
R2
z
p
change
change
T6-T0 30
0
1.189,5 36
-1
1.021,5 2,5

0,01
T12-T0 28
0
1.040 34
-1
913
2,4
0,02
T24-T0 21
0
662,5 30
-1
663,5
2,4
0,02
T30-T0 31
0
1.308 31
-1
970
3,3
0,01
Table 3.23. Effectiveness of intervention on depression of the two group by
study times Thay đổi tỉ lệ tc


11

Group
Time

Control group

Intervention group

χ2

p

T0
31 (100)
37 (100)
T6
5/30 (16,7)
3/37 (8,1)
1,2
0,28
T12
3/28 (10,7)
6/33 (18,2)
0,7
0,41
T24
3/21 (14,3)
2/30 (6,7)
0,8
0,37
T30
5/31 (16,1)
3/37 (8,1)

1,0
0,31
3.3.5. Effectiness on depression degree
Table 3.25. Change of PHQ-9 mean of each study group at study times
relative to T0
Signed-rank test
Control group
Intervention group
Time Effectiveness
n
R
z
p
n
R
z
p
Effectiveness 29 457
36 702
T0-T6
Opposite
1
8
4,6 0,00 0
0 5,3 0,00
No change
0
0
1
1

Effectiveness 27 405
30 555
T0-T12
Opposite
0
0
4,6 0,00 2
5 4,9 0,00
No change
1
1
1
1
Effectiveness 19 226,5
30 465
T0-T24
Opposite
2
4,5 3,9 0,00 0
0 4,8 0,00
No change
0
0
0
0
Effectiveness 28 490
37 703
T0-T30
Opposite
1

3
4,8 0,00 0
0 5,3 0,00
No change
2
3
0
0


12

Table 3.26. Differences of changes of PHQ-9 mean between groups at
treatment times
Control group
Time
n
T6-T0
T12-T0
T24-T0
T30-T0

30
28
21
31

Median
of
R1

change
-9,5
1.185
-11,5
906,5
-11
659,5
-9
1.284,5

Intervention group
n
37
33
30
37

Median
of
R2
change
-12
1.093
-12
984,5
-13
666,5
-13
1.061,5

Ranksum
test
z

p

2,1
0,6
2,2
2,7

0,04
0,58
0,03
0,01

Table 3.27. Remission rate of each study group by treatment times
BN
Control group
Intervention group
χ2
p
n
%
n
%
Time
T6
15/30
50,0

24/37
64,9
1,51
0,22
T12
20/28
71,4
21/33
63,6
0,42
0,52
T24
14/21
66,7
24/30
80,0
1,16
0,28
T30
16/31
51,6
27/37
73,0
3,31
0,07
Table 3.28. Recovery rate by study time of two groups
BN
Control group
Intervention group
χ2

n
%
n
%
Time
T24
7/21
33,3
14/30
46,7
0,91
T30
10/31
32,3
14/37
37,8
0,23

p
0,34
0,63

Table 3.29. Relapse rate by study time of two groups
BN
Control group
Intervention group
χ2
p
n
%

n
%
Time
T12
2/27
7,4
4/33
12,1 0,37
0,55
T24
2/21
9,5
1/30
3,3
0,86
0,36
T30
4/31
12,9
2/37
5,4
1,18
0,28
Table 3.30. Recurrent rate by study time of two groups
BN
Control group
Intervention group
χ2
p
n

%
n
%
Time


13

BN
TimeT30

Control group
1/31
3,2

Intervention group
2/37
5,4

χ2
0,19

p
0,66

Table 3.32. Change of BADS-SF mean of each study group at study times
relative to T0
Signed-rank test
Control group
Intervention group

Time
Effectiveness
n
R
z
p
n
R
z
p
Effectiveness 21 382,5
32 672,5
T0-T6
Opposite
7 107,5 2,7 0,01 4
29,5 4,9 0,00
No change
3
6
1
1
Effectiveness 23 353,5
30 580,5
T0-T12
Opposite
4
51,5 3,4 0,00 2
11,5 4,9 0,00
No change
1

1
2
3
Effectiveness 13 100
26 469
T0-T24
Opposite
1
5
3,0 0,00 4
26 4,3 0,00
4,3
No change
0
0
1
1
Effectiveness 23 375.5
31 663
T0-T30
Opposite
6
88,5 3,0 0,00 4
37 4,7 0,00
No change
1
1
2
3
Table 3.33. Differences of changes of BADS-SF mean between groups at

treatment times
Control group
Intervention group
Median
Median
Time
z
p
n
of
R1
n
of
R2
change
change
T6-T0
31
5
862,5 37
9
1.483,5 -2,6 0,01
T12-T0 28
7,5
795
34
9
1.158 -1,2 0,22
T24-T0 14
12

343,5 31
10
691,5
0,5 0,60
T30-T0 30
7,5
953
37
7
1.325 -0,8 0,40
Table 3.36. Differences of changes of Avoidance subschale mean
between groups at treatment times
Control group
Intervention group
Median
Median
Time
z
p
n
of
R1
n
of
R2
change
change


14

Time
T6-T0
T12-T0
T24-T0
T30-T0

31
28
14
30

Control group
1
1.067,5
2
928,5
2
341,5
3
999,5

Intervention group
z
p
37
1
1.278,5 -0,03 0,98
34
2

1.024,5 0,7 0,51
31
3
693,5
0,5 0,63
37
2
1.278,5 -0,3 0,80

Table 3.37. Diffences of average dose of amitriptyline between groups in
the treatment (mg/day)
Ranksum test
Group
n Mean SD Median
R
z
p
Control group
31 56,0 22,5
55,5
1.492
5,7
0,00
Intervention group
37 27,6
8,2
25
854

15

Chapter 4
DISCUSSION
4.1. Characteristic individuals of study subjects
The majority of depression ages are from 35 – 64, with the rate of 92%
(Table 3.1). Mean age of the whole group is 49,7 ± 9,8. Our results are
similar to the results of Tran Huu Binh (2007) in which the ages from 30 69 are predominant, with the rate of 89,41%.
Predominant gender in this study is female and the ratio of female/male
is (Table 3.1). This result is also similar to the result of Tran Viet Nghi
(female/male=3/1), more higher than the result of Kessler 1,7/1, Sadeghirad
1,95/1, Sadock 2/1, Dimidjian 2/1, Pham Tu Duong 2,1/1. In explaining for
this phenomena Loewenthal (1995) hypothesize that: 1) Women are at a
less powerful position than men leading them to have an adaptation style
that make to be easier to develop depression like compliance, passitivity,
and imppotence. 2) The burden of housework and the care are all on
women, in the mean time, men benefits from the marriage like the support,
status, and the comfort. 3) Men and women react differently with stress and
psychological sufferring. Women can be more rumination than men. Men
can be more reluctant than women in seeking the help when depressed. As a
result, the rate of depression in men is lower than in female.
The common level of education in this study is primary, and decrease by
the increase of education level. Not high school graduation take the
majority (65,4%) (Table 3.1). High school graduation is low (19,9%). This
study results are similar to the results of some researchers such as Tran
Quynh Anh (2017), Amin, Akhtar-Danesh.
The majority of marital status in this study is marriaged, currently living
with their spouses (84,9%). Single, separation/divorce groups are the
minorities in the study (Table 3.1). Our results are aso similar to the results
of Tran Huu Binh (2007) in that depressed patients have high rate of

marriage (82,35%).
The common occupation in the study is free laborer (39,7%) and farmer
(26,1%) (Table 3.1). Similar to the result of Tran Quynh Anh when finding
84,2% depressed ptients are farmers.


16

4.2. MDD characteristics
4.2.1. Rate of patients having depression symptoms
Results of Table 3.2 show that the most common symptoms are
fatiguability (100%), disturbed sleep (99,2%), depressed mood (93,7%),
loss of interest and enjoyment (86,5%), pessimistic views of the future
(84,9%), reduced appetite (81,8%), reduced self-esteem and self-confidence
(81,0%). Three characteristic symptoms of depression which are
fatiguability, depressed mood, loss of interest and enjoyment belong to this
group. In the group of common symptoms of depression, disturbed sleep
occurs almost in all depressed patients (99,2%). The study results are
similar to the results of Tran Huu Binh in that most of depression symptoms
fatiguability 95,29%, loss of enjoyment 88,82%, reduced mood 85,88%,
disturbed sleep 89,44%, low self-esteem 80%. High rate of disturbed sleep,
fatiguability show that when being depressed the patients in our study focus
more on somatic symptoms than emotional and cognitive symptoms
(reduced concentration, pessimism, reduced self-confidence). This may
allow to propose a hypothesis that the depressed patients in our study pay
less attention on the impact of the cognition by depression. This result is
similar the the statement of Simon (1999) that the complaints on somatic
symptoms is common in many countries.
In the study, the most concerned issue is that the suicidal ideations are
pretty high (30,2%). Results of Weissman and Amin also found that the rate

of depressed patients having death ideas or suicidal trend in the community
are high.
4.2.2. Cognitive symptoms and related factors
In the Table 3.2, two symptoms that are high are reduce self-esteem/selfcofidence (81,0%), reduced concentration and attention (77,8%). Table 3.2
showed that the rate of cognitive symptoms weren’t as high as other
symptoms. These results are reasonable as in the ICD-10 cognitive
symptoms aren’t classified as characteristic symptoms of depression. There
maybe also another possibility that patients usually don’t pay attention to
their depreesion, and especially they don’t even pay attention to their
cognitive symptoms of depression.
4.2.3. Emotional symptoms and related factors


17

Table 3.2 showed that the two emotional symptoms occurred with very
high rate which are depressed mood (93,7%) and pessimistic views of the
future (84,9%). These two symptoms were mainly detected by medical staff
but not the reasons for patients to go for examination.
4.2.4. Somatic symptoms and related factors
The results of Table 3.2 showed that depression usually had four
symptoms as follows: fatiguability (100%), disturbed sleep (99,2%), loss of
interest and enjoyment (86,5%) and reduced appetite (81,8%). This results
are similar to the results of some researchers such as Pham Tu Duong
(2000), Nambi (2002). Simon (1999) conducted a study from 1991 to 1992,
having screened 25.916 patients in 15 primary health care centers of 14
countries in 5 continentals and found 5.447 depressed patients in which
there were from 45% to 95% of cases who complait only somatic symptoms
on examination. Half of depressed patients complaint about unexplained
somatic symptoms, and 11% denied to have psychological symptoms of

depression when directly asked.
4.2.5. Mean of illness duration before the study (week)
The results of the Table Bảng 3.6 showed that the mean duration of
depression of the study group was 83,8 weeks (± 116). The mean duration
of depression in this study is relative shorter than the one of Tran Huu
Binh’s research. In his study, the illness durations ranged from 6 months to
15 years, 4 years on average. The explanation for this result is that the
subjects of our study live in the community and more important thing is the
majority of them didn’t know that they had depression.
4.2.6. Depression degree of the study group before intervention
Table 3.7 showed that mild degree was highest (50,0%), and the lowest
was severe degree (18,2%). Our results are similar to the resuts of Tran Viet
Nghi and Tran Huu Binh. In Tran Viet Nghi’s study (2002), severe
depression without psychotic symptoms was 20,75%, severe depression
with psychotic symptoms was 19,40%. And the corresponding results of
Tran Huu Binh (2007) are 19,41%, and 16,47%. These results showed that
there are cases with depression in the community but patients didn’t
recognize that they had depression, or they just focused on somatic
symptoms and pay less attention on emotional and cognitive symptoms and
as a result they didn’t come to psychiatric hospita to seek appropriate
treatments but just stayed home, therefore the illness became severe.


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4.3. Effectiveness of BA combined with amitriptyline in the treatment
of depression
4.3.2. Effectiveness on depression symptoms
The results of the Tables 3.11, 3.12, 3.16 showed that the differences in
the change of depressed mood, loss of interest and enjoyment, guilty and

unworthy ideas symptoms between the two groups were statistically
significance at some points (p <0,05). These results showed that the
combination of BA and amitriptyline method was more effective than
amitriptyline monotherapy in the treatment of those symptoms at the
corresponding times.
4.3.3. Effectiveness on depression of the two groups by study times
The results of the Table 3.22 showed that in the controlled group the rate
of depression at T6, T12, T24, T30 are 16,7%, 10,7%, 14,3%, 16,1%,
correspondingly. The corresponding results of the intervention group are
8,1%, 18,2%, 6,7%, 8,1%. The above results showed that the rate of
depression of the two group at the study times relative to T0. At almost
after-intervention time, the rates of depression in the intervention group are
lower than the rates of the controlled group, apart from at T12. Although
the differences aren’t statistically significant (Table 3.23) but the
intervention group showed a tendency of a decrease in depression more
than in the controlled group.
4.3.4. Effectiveness on depression degree
Table 3.25 showed that depression degree by PHQ-9 score all decreased
at T6, T12, T24 and T30 with statistic significance (p <0,01). This showed
that amitriptyline, with or without the combination with BA, are effective in
the treatment of depression in the community.
When comparing the two group, Table 3.26 showed that the treatment of
the intervention group was more effective than the treatment of the
controlled group in decreasing depression degree at almost all the times of
T6, T24, T30 (all p < 0,05), apart from at T12 which the difference was no
statistically significant between the two groups.
This result is similar to the result of Beck (1985) when comparing the
effectiveness in the treatmet of depression between the two group:
monotherapy by cognitive therapy and combination of cognitive therapy
amitriptyline.

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Our research was conducted at commune health stations. This result
shows that BA can be effectively applied at outside hospital environments.
This result is also similar to the results of all the above researchers and of
other researchers in the world and shows BA is effective for depreesion at
outpatient facilities.
4.3.5. Remission rate of each study group at treatment times
Table 3.27 shows that the remission rates in the controlled group at T6,
T12, T24, T30 are 50,0%, 71,4%, 66,7%, 51,6%. The corresponding results
of the intervention group are 64,9%, 63,6%, 80,0%, 73%. This statistically
insignificant differences are similar to the results of DeRubeis when
comparing effectiveness of cognitive therapy and paroxetine in the
treatment of depression (during 16 weeks) in 2005. In which, remission rate
when treated by paroxetine was 46%, and remission rate when treated by
cognitive therapy was 40%. If comapring the remission rates at T12 and
T24 with DeRubeis’s results the remission rates in both groups of our study
are all higher than the ones of DeRubeis (71,4% and 66,7% of amitriptyline
vs 46% of paroxetine; 63,6% and 80,0% of amitriptyline combined with BA
VS 40% of cognitive therapy). However, our results are contrary to the
results of Dimidjian (2006) in which the remission rate of BA was higher
than the one of paroxetine (52% vs 42%).
4.3.6. Recovery rate of each study group by treatment times
According to the results of Table 3.28, the treatment method of the
intervention group result in the recovery rate higher than the one of the
controlled group at all the study times but these differences aren’t
statistically significant. The recovery rate at T24 is 43,75%, and at T30 is
37,84%. BA factor hasn’t proved yet the advantage impact on the recovery

ability of depressed patients in this study at the time of 24 weeks and 30
weeks since being treated. The recovery rates in our study are lower than
the ones of Jacobson (1996). In which, the recovery rate when treated by
BA was 46,4% and by cognitive therapy was 56%.
4.3.7. Relapse rate at each study times among the two groups
The relapse rates are relative low in both groups at study times, from
7,4% to 12,9% in the controlled group and from 3,3% to 12,1% in the
intervention group (Table 3.29). However, the relapse rates were gradually
increasing by the time in the controlled group, and was just slightly


20

increasing T30 in the intervention group althouh still much lower than the
rate of the controlled group. Perhaps BA has contributed in this decreasing
tendency. However, the relapse rates aren’t statistically significant between
the two groups at study times.
In the study of Blackburn (1986), the drug group (amitriptyline or
clomiprapine) had relapse rate of 30%, cognitive therapy of 6%, and
cognitive therapy combined with drug of 0% after 6 months. In this study,
both cognitive therapy groups have low relapse rates. Blackburn’s drug
group had relapse rate much higher than the one of our study. However, the
relapse rate in the study of Jaconson (1996) was higher than the one in our
study. In which, the relapse rate after 6 months of BA treatment were from
15,0% to 20,8%, of cognitive therapy were from 18,9% to 28,0%.
So, although cognitive therapy has been considered as the best
psychotherapy in many researches but the relapse rates also rang from 6%
to 39%%, depending on reasearches. This means that the relapse rates in the
intervention group of our study (from 3,3% to 12,1%) are acceptable.
4.3.8. Recurrent rates of each study group at treatment times

The results of Table 3.30 shows that the recurrent rates in the controlled
group is 3,2% and in the intervention group is 5,4%. Our recurrent rates are
lower than the ones of Blackburn (1986). In which, after two years, the drug
group (amitriptyline or clomiprapine) had the recurrent rate of 78%,
cognitive therapy of 23%, and cognitive therapy combine with drug group
of 21%.
The recurrent rate after two year in the study of Dobson (2008) was 52%
for antidepressant group, 26% for BA group, and 24% for cognitive therapy
group.
The recurrent rates in our study which are lower than the ones of
Blackburn and Dobson due to the duration for re-assessment of those two
researchers were two years, longer than the re-assessment duration of our
study which is 6 months.
4.3.9. Effectiveness of treatment methods on the increase of activation
behavior in depression
Table 3.31 shows that both treatment methods of the controlled group
(amitriptyline monotherapy) and of the intervention group (amitriptyline
combined with BA) were effective in the increase the degree of activation


21

behaviors through the increase of BADS-SF’s scores at T6, T12, T24, and
T30. These results show that amitriptyline, with or without the combination
with BA, were effective in the treatment of depression in the community.
The above results show that although not being trained on BA but depressed
patients in the controlled group also had the increase in the degree of
activation behaviors at all the assessment times. This may allow to propose
a hypothesis that when depression decreases the activation behaviors will
automatically increase at some extent. The question is will it increase the

degree of activation behaviors more than the amitriptyline monotherapy
when combined with BA? In order to answering to this question we analyze
the results in the Table 3.33. Table 3.33 shows that the treatment method in
the intervention group was more significantly effective relative to the
treatment method in the controlled group in increasing the degree of
activation behaviors at T6 (all p < 0,01), 6 weeks since starting treatment.
From T12 to T30 this avantage in the increase of the degree of activation
behaviors didn’t exist any longer. The results of Table Bảng 3.26 show that
the effectivenes in the intervention in decreasing the scores of depression
degree is more favourable than the controlled group at all study times (apart
from T12), in the mean time, the advantage of the intervention group over
the controlled group on increasing the degree of activation behaviors is just
clear at only T6. This results prove that the effectiveness of BA on the
degree of activation behaviors exist in the short duration.
4.3.10. Effectiveness of treatment methods on avoidace behavior in
depression
The results of Table 3.35 show that after 6 weeks of treatment, both
treatment methods in the controlled group and treatment group decreased
avoidance behavior but these differences aren’t statistically significant.
From T12 to T30 both treatment methods decreased the avoidance
behaviors statistically significantly. The decrease in avoidace behaviors
occurred more slowly than the decrease of depression degree and the
increase of activation behaviors. When comparing the results of the two
groups at Table 3.36 we found that the decrease in avoidance behaviors in
the two groups aren’t statistically significant. In this study, BA didn’t
produce any advantages over amitriptyline monotherapy in the decrease of
avoidance behavior at all study times. This results haven’t got the


22

expectations as with previous studies which contributed to the formuation
of BA of Dimidjian, Martell which is BA focuses on and decreases
avoidance behaviors through treatment process. This problem may have
three reasons: 1) BA therapists of our study were less experienced and as a
result the effectiveness was limited; 2) Patients didn’t comply with
homeworks as guided in the therapy; 3) BA isn’t really specific in
decreasing avoidance behaviors.
Summarizing all the results of the Parts 4.3.4, 4.3.9 and 4.3.10, we found
that BA in this study help increasing clearly the effectiveness of decreasing
depression at almost the study times; is more effective in the increase of
activation behaviors degree at 6 weeks since the beginning of treatment,
that is a short time after finishing therapy sessions; and not different with
drug monotherapy in decreasing avoidance behaviors.
4.3.11. Impact of treatment methods on amitriptyline dosage in the
treatment of depression
The results of Table 3.37 show that the median of amitriptyline average
dose of 25 mg/day in the intervention group was statistically significantly
lower than the median of amitriptyline average dose of 55,5 mg/day in the
controlled group. This result points out that when combining BA with
amitriptyline will decrease the dosage of amitriptyline in the treatment of
depression. When comparing this dosage of amitriptyline with guided
amitriptyline dosages in the textbook (150 – 300 mg) we found that the
average dosage of amitriptyline in this study is very low. However, the
results in the Part Mục 3.3.4 showed that the above low dosages of
amitriptyline were still effective to treating depression in the community.
Perhaps depression in the community need to have lower dosage of
amitriptyline relative to the dosage of amitriptyline at inpatient facilities.

23

CONCLUSIONS
1. Major depressive disorder characteristics of depressed patients at 4
communes/wards of Khanh Hoa province in 2011
- Female/male ratio of depression was 3,1/1.
- Not high school graduation was predominant (65,4%).
- Marriaged group was very high (84,9%).
- The two highest groups were free laborer (39,7%), and farmer (26,1%).
- Fatiguability and disturbed sleep were highest among depression
symptoms.
- No factors related to cognitive, emotional, and somatic symptoms
after analysis. It is clear that depression in this study didn’t depend on
individual factors but on depression degree itself.
- Mild depression was highest (50%).
2. Effectiveness of the treatment of major depressive disorder by
behavioral activation combined with amitriptyline at 4 communes/
wards of Khanh Hoa province during 2012-2015.
- Both methods of treating depression by BA combined with
amitriptyline and amitriptyline alone decrease the rates of depression at all
times, beginning at T6.
- The treatment method of BA combined with amitriptyline was more
effective than amitriptyline monotherapy in decreasing depression degree at
almost the study times of T6, T24, T30, apart from T12.
- Remission rates were high but not significantly different between the
two groups
- Recovery rates were high but not significantly different between the
two groups
- Relapse and recurrent rates weren’t statistically significantly different
between the two groups.

- The treatment method of BA combined with amitriptyline was more
effective than amitriptyline monotherapy in the increase of activation
behavior degree at T6, since T12 on, the differences didn’t exist any longer.
- The treatment method of BA combined with amitriptyline was as
effective as amitriptyline monotherapy in the decrease of avoidance
behaviors at all study times.
- When combined with BA in the treatment of depression, the dosage of
amitriptyline was more decreased than amitriptyline monotherapy.


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RECOMMENDATIONS
From the results of the study, we propose several recommendations:
- Depressed patients manifested somatic symptoms with high rate in the
community. Therefore, it is necessary to organize education, training for
primary care staff, family doctors, general doctors, and all related
specializations, the knowledges and skills of detecting, assessing and
treating depression so as they could manage and provide treatment properly
for depressed patients.
- Behavioral activation is effective, economic for patients, easy to train
for primary care medical staff, easy to appply and generalize in the
community and other areas, various ethnicities, as a result, it can be brought
into National Targer Programme.
- This study showed that behavioral therapy, implemented in five
sesions, is effective in the treatment for depression in the community.
However, the sample size is limit. We propose that there should be a
research with bigger sample size to evaluate all the strenths and weaknesses
of behavioral activation in the treatment for depression. Based on study
results we think that the future studies on depression shouldn’t focus on

individual related factors with depression because there wasn’t relations, but
rather shoud focus on depression measuring scales, supervision on the loss
of study subjects because not being able to follow-up them all during the
study period, especially with studies on outpatients or in the community. It
is important that there should be hân ngoại trú hoặc là ở cộng đồng. Điều
quan trọng là new researches should study the effectiveness of behavioral
therapy monotherapy in the treatment for depression.