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This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care.
Methods
We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted.
Results
Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3–4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3–4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions.
Conclusions
When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.
The Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory (BDI-II) and the Generalised Anxiety Disorder Assessment (GAD-7) are widely used in the evaluation of interventions for depression and anxiety. The smallest reduction in depressive symptoms that matter to patients is known as the Minimum Clinically Important Difference (MCID). Little empirical study of the MCID for these scales exists.
Methods
A prospective cohort of 400 patients in UK primary care were interviewed on four occasions, 2 weeks apart. At each time point, participants completed all three questionnaires and a ‘global rating of change’ scale (GRS). MCID estimation relied on estimated changes in symptoms according to reported improvement on the GRS scale, stratified by baseline severity on the Clinical Interview Schedule (CIS-R).
Results
For moderate baseline severity, those who reported improvement on the GRS had a reduction of 21% (95% confidence interval (CI) −26.7 to −14.9) on the PHQ-9; 23% (95% CI −27.8 to −18.0) on the BDI-II and 26.8% (95% CI −33.5 to −20.1) on the GAD-7. The corresponding threshold scores below which participants were more likely to report improvement were −1.7, −3.5 and −1.5 points on the PHQ-9, BDI-II and GAD-7, respectively. Patients with milder symptoms require much larger reductions as percentage of their baseline to endorse improvement.
Conclusions
An MCID representing 20% reduction of scores in these scales, is a useful guide for patients with moderately severe symptoms. If treatment had the same effect on patients irrespective of baseline severity, those with low symptoms are unlikely to notice a benefit.
This chapter is organized around Diderot, who gave much attention to the craft of acting, and remains the best-known eighteenth-century theorist of acting. In two essays of the 1750s, Diderot conjured up a vision of twentieth-century naturalism, echoing Saint-Albine’s fashionable emphasis on feeling, while in his later Paradox on the Actor he argued that the best actors reproduce emotion on stage through cold analysis. Diderot invoked numerous contemporary actors, and this chapter establishes how the point of view of these actors differed profoundly from that attributed to them by Diderot. Antoine-François Riccoboni: who emphasized core technique for the benefit of amateurs. Marie-Jeanne Riccoboni: patronizingly dismissed by Diderot, who went on to adopt her arguments. Marie-Madeleine Jodin: a rebellious protégée who rejected his advice. Michel ‘Kelly’ Sticotti: a jobbing actor whose ideas had a complex genesis. Hyppolite Clairon: a remarkable actress and teacher whose published account of the acting process offers a more subtle analysis than Diderot. François-Joseph Talma: an articulate actor who challenged Diderot’s attack on Sticotti. Coda: theatre and oratory: two modes that remained closely related, despite claims that theatre somehow ‘liberated’ itself from oratory.
The term ‘declamation’ shifted its meaning from a training and display exercise undertaken by orators to a mode of speech used by tragic actors. By the end of the seventeenth century, the logic of grammar had suppressed the vagaries of orality, and the term ‘declamation’ served to define that which separated dramatic speech from the speech of everyday life. Because speech is driven by the breath and produced by the body, the thought or idea expressed by the actor could not be dissociated from their feeling or passion. In the sixteenth century and for much of the seventeenth century the dramatic text was conceived as sonorous matter, a visual sign of corporeal actions. The second phase follows from words becoming the arbitrary signs of ideas. From the perspective of a modern taste for self-expression, the earlier conception of the text as a score places unwelcome constraints upon the actor’s freedom.
This chapter sets out the rationale for the European focus, and examines the surprisingly small amount of scholarship that addresses the field covered by this book. I explain the rationale for the structure of the book, and examine some of the historiographical issues that are at stake.
Can you teach someone to be an actor? Paradoxically, the French cultural context while constraining the remit of the actor allowed acting to emerge as an autonomous science. The conservatoire training model that flourished in France in the nineteenth century was vigorously resisted by the nineteenth-century English actor-manager. Training or talent: the classical debate: Cicero and Quintilian resisted Aristotle’s claim that acting was merely ‘natural’. Early modern apprenticeship in the science of acting: our best evidence comes from Paris in the Shakespearean era, where Hardy’s classical dramaturgy demanded new skills. Multiple skills served the craft of acting. Early modern schooling: the example of Marston’s boy actors: how boys with a rhetorical education challenged the older generation of professionals. Hamlet: fencing as a foundation for acting: Hamlet learns to ‘act’ by learning to fence, and I trace the enduring place of fencing in actor training, distinguishing Italian and English methods. The pedagogy of Charles Macklin: a case study in how eighteenth-century acting was taught. The birth of the conservatoire: first championed by Lekain and his contemporaries.
Because there was no equivalent in Renaissance England to the Roman Forum and Senate, the stage actor was free to inherit the mantle of Cicero and Quintilian. I shall ask in this chapter how far stage actors did in practice follow a path mapped out by the ancient orators. Italian accounts of the actor’s art: De Sommi, Cecchini and Scala were Italian stage directors who contested appropriation of the rhetorical tradition by intellectuals, and the improvisatory tradition placed them as makers of embodied speech. Erasmus and the act of speaking: although Erasmus fostered a culture of the book, his sense of language was grounded in orality. Vives offers a vivid account of the fleshiness of the spoken word. A case study from ‘Merchant of Venice’ illustrates how Shakespeare wrote for different rhetorical registers. Sacred rhetoric: Erasmus straddled a tension between the Catholic tradition that emphasized form and the nascent Protestant tradition that required the preacher to be driven by the spirit. Donne and Alleyn: I focus on the relationship between England’s greatest preacher in the early seventeenth century and his son-in-law, who had been England’s greatest stage actor, bringing out the different conceptions of rhetoric.
The ancient concept of ‘gesture’ had no place in the brave new world of Stanislavskian naturalism. Rhetorical gesture was understood as an adjunct of speech, hardwired to speech in the idiom of modern brain science. Classical gesture: refused to separate the physical person of the orator from his moral and intellectual capacities. The gestures of a Ciceronian speech were deemed to be implicit in the words. Renaissance gesture: raising the question of whether gesture is teachable. Shakespearean gesture: I focus on Bertram Joseph’s controversial research into gesture, and examine his work with Shakespearean actors presenting Macbeth at the Mermaid. Baroque gesture: contrasting Le Faucheur’s practice in the pulpit with the new approaches of Descartes and Le Brun. Enlightenment France: F. Riccoboni’s argument for an intelligent actor in control of his movements. Enlightenment Germany: Lessing’s desire for ‘individualizing’ gestures was not well received by actors. Engel followed Lessing in quest of detail, but Goethe return to tradition in order to find a language of the body that would support the delivery of verse.
The tradition that Hamlet is Shakespeare’s mouthpiece: almost universally accepted for reasons of tradition and prejudice towards the class and education of the princely speaker. The Player’s speech: a successful exercise in using Virgil to express emotion, as recommended by Quintilian. Hamlet’s advice: drawing essentially from Quintilian. The play-within-a-play: risibly poor dramaturgy, a display of dialectic rather than rhetoric, well suited to ensuring that Claudius is moved by the facts rather than by the fiction of the play. The pay-off: Hamlet as clown. In this chapter, I map a tension between two ideals of performance: moving the emotions of an audience versus an accurate mimesis of reality.
In this chapter I show how the job of the Baroque actor was to embellish the dramatic poem, and as it were to colour in the outline provided by the text. Actor and writer: Racine coached young actresses in exactly how to deliver his lines, but experienced actors wanted more autonomy. ‘Action’ in sacred oratory: Louis de Crésolles’ Jesuit treatise on acting atomized the body, and allowed Christians to think in a technical way about their performance methods, but Le Faucheur’s Protestant manual placed more emphasis on authenticity of feeling. Mondory and Corneille: A reading of Le Cid reveals the physicality and emotionalism expected of the celebrity lead actor, in a balance of power between actor and writer that would subsequently be eroded. The first manuals dedicated to stage acting: Perrucci and Gildon look back to seventeenth-century practice, as does Jean Poisson, the first professional actor to offer advice about performance to non-actors in a printed manual of 1717. Another actor, Luigi Riccoboni, in 1728 published a manifesto for novice Italian actors, warning them against French formalism and arguing for the primacy of feeling. He is less interested in the work of the voice, and more concerned with the way feeling operates on the body.
Pre-modern acting theory was framed around emotion, not character, and in this chapter I explore what ‘emotion’ is. There is growing recognition today that emotions have a history, and neurology has suggested new ways of thinking about the mind–body connection. The assumption that humankind has distinct fundamental emotions remains a widely held position today. Passions and emotions: the question of terminology: in addition to the distinction between passions and emotions, I interrogate notions of mind and soul, complicated by questions of translation. Early Modern England: Hamlet seen through the lens of the contemporary Jesuit Thomas Wright, who negotiated competing theories of emotion. The Cartesian turn: I consider Mondory as a pre-Cartesian actor, and the fundamental influence of Charles Le Brun on acting as well as paining. David Hume and English acting theory in the Enlightenment: the multiplication and refinement of emotions as reflected in the theories of Aaron Hill. Two examples of playing the passions: Lekain’s Herod and Nossiter’s Juliet: I draw on Lekain’s manuscript notes and on Morgan’s account of Nossiter’s performance. Rousseau and the ideal of emotional authenticity: Rousseau’s Pygmalion attempted to reconcile the needs of rhetorical delivery with a new sense of emotional truth.