Case study

CHAPTER 6

Major Depressive Disorder

Janet called the mental health center to ask if someone could help her 5-year-old son, Adam. He had been having trouble sleeping for the past several weeks, and Janet was becoming concerned about his health. Adam refused to go to sleep at his regular bedtime and also woke up at irregular intervals throughout the night. Whenever he woke up, Adam would come downstairs to be with Janet. Her initial reaction had been sympathetic, but as the cycle came to repeat itself night after night, Janet’s tolerance grew thin, and she became more argumentative. She found herself engaged in repeated battles that usually ended when she agreed to let him sleep in her room. Janet felt guilty about giving in to a 5-year-old’s demands, but it seemed like the only way they would ever get any sleep. The family physician was unable to identify a physical explanation for Adam’s problem; he suggested that Janet contact a psychologist. This advice led Janet to inquire about the mental health center’s series of parent training groups.

Applicants for the groups were routinely screened during an individual intake interview. The therapist began by asking several questions about Janet and her family. Janet was 30 years old and had been divorced from her husband, David, for a little more than 1 year. Adamwas the youngest of Janet’s three children; Jennifer was 10, and Claire was 8. Janet had resumed her college education on a part-time basis when Adam was 2 years old. She had hoped to finish her bachelor’s degree at the end of the next semester and enter law school in the fall. Unfortunately, she had withdrawn from classes 1 month prior to her appointment at the mental health center. Her current plans were indefinite. She spent almost all of her time at home with Adam.

Janet and the children lived in a large, comfortable house that she had received as part of her divorce settlement. Finances were a major concern to Janet, but she managed to make ends meet through the combination of student loans, a grant-in-aid from the university, and child-support payments from David. David lived in a nearby town with a younger woman whom he had married shortly after the divorce. He visited Janet and the children once or twice every month and took the children to spend weekends with him once a month.

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Having collected the necessary background information, the therapist asked for a description of Adam’s sleep difficulties. This discussion covered the sequence of a typical evening’s events. It was clear during this discussion that Janet felt completely overwhelmed. At several points during the interview, Janet was on the verge of tears. Her eyes were watery, and her voice broke as they discussed her response to David’s occasional visits. The therapist, therefore, suggested that they put off a further analysis of Adam’s problems and spend some time discussing Janet’s situation in a broader perspective.

Janet’s mood had been depressed since her husband had asked for a divorce. She felt sad, discouraged, and lonely. This feeling had become even more severe just prior to her withdrawal from classes at the university (1 year after David’s departure). When David left, she remembered feeling “down in the dumps,” but she could usually cheer herself up by playing with the children or going for a walk. Now she was nearing desperation. She cried frequently and for long periods of time. Nothing seemed to cheer her up. She had lost interest in her friends, and the children seemed to be more of a burden than ever. Her depression was somewhat worse in the morning, when it seemed that she would never be able to make it through the day.

Janet was preoccupied by her divorce from David and spent hours each day brooding about the events that led to their separation. These worries interfered considerably with her ability to concentrate and seemed directly related to her withdrawal from the university. She had been totally unable to study assigned readings or concentrate on lectures. Withdrawing from school precipitated fur- ther problems. She was no longer eligible for student aid and would have to begin paying back her loans within a few months. In short, one problem led to another, and her attitude became increasingly pessimistic.

Janet blamed herself for the divorce, although she also harbored considerable resentment toward David and his new wife. She believed that her return to school had placed additional strain on an already problematic relationship, and she won- dered whether she had acted selfishly. The therapist noted that Janet’s reasoning about her marriage often seemed vague and illogical. She argued that she had been a poor marital partner and cited several examples of her own misconduct. These included events and circumstances that struck the therapist as being common and perhaps expected differences between men and women. For example, Janet spent moremoney than he did on clothes, did not share his enthusiasm for sports, and fre- quently tried to engage David in discussions about his personal habits that annoyed her and the imperfections of their relationship. Of course, one could easily argue that David had not been sufficiently concerned about his own appearance (spend- ing too little effort on his own wardrobe), that he had been too preoccupied with sports, and that he had avoided her sincere efforts to work on their marital dif- ficulties. But Janet blamed herself. Rather than viewing these things as simple differences in their interests and personalities, Janet saw them as evidence of her own failures. She blew these matters totally out of proportion until they appeared

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to her to be terrible sins. Janet also generalized from her marriage to other rela- tionships in her life. If her first marriage had failed, how could she ever expect to develop a satisfactory relationship with another man? Furthermore, Janet had begun to question her value as a friend and parent. The collapse of her marriage seemed to affect the manner in which she viewed all of her social relationships.

The future looked bleak from her current perspective, but she had not given up all hope. Her interest in solving Adam’s problem, for example, was an encour- aging sign. Although she was not optimistic about the chances of success, she was willing to try to become a more effective parent.

Social History

Janet was reserved socially when she was a child. She tended to have one or two special friendswithwhom she spentmuch of her time outside of school, but she felt awkward and self-conscious in larger groups of children. This friendship pattern persisted throughout high school. She was interested in boys and dated intermit- tently until her junior year in high school, when she began to date one boy on a regular basis. She and her boyfriend spent all of their time together. Unfortunately, she and her boyfriend broke up during Janet’s first year in college.

Janet met David a few weeks afterward, and they were married the following summer. Janet later wondered whether she had rushed into her relationship with David primarily to avoid the vacuum created by her previous boyfriend’s sudden exit. Whatever her motivation might have been, her marriage was followed shortly by her first pregnancy, which precipitated her withdrawal from the university. For the next seven years, Janet was occupied as a full-time mother and housekeeper.

When Adam was 2 years old and able to attend a day-care center, Janet decided to resume her college education. Her relationship with David became increasingly strained. David resented his increased household responsibilities. A more balanced and stable relationship would have been able to withstand the stress associated with these changes, but Janet and David were unable to adjust. Instead of working to improve their communications, they bickered continuously. The final blow came when David met another woman to whom he was attracted and who offered him an alternative to the escalating hostility with Janet. He asked for a divorce and moved to an apartment.

Janet was shaken by David’s departure, despite the fact that they had not been happy together. Fortunately, she did have a few friends to whom she could turn for support. The most important one was a neighbor who had children of approxi- mately the same ages as Janet’s daughters. There were also two couples withwhom she and David had socialized. They were all helpful for the first few weeks, but she quickly lost contact with the couples. It was awkward to get together as a three- some, and Janet had never been close enough with the women to preserve their relationships on an individual basis. That left the neighbor as her sole adviser and

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confidante, the only person with whom Janet felt she could discuss her feelings openly.

As time wore on, Janet found herself brooding more and more about the divorce. She was gaining weight, and the children began to comment on her appearance. To make matters worse, Claire became sick just prior to Janet’s midterm exams. The added worry of Claire’s health and her concern about missed classes and lost studying time contributed substantially to a decline in Janet’s mood. She finally realized that she would have to withdraw from her classes to avoid receiving failing grades.

By this point, 1 month prior to her appointment at the mental health center, she had lost interest in most of her previous activities. Even casual reading had come to be a tedious chore. She did not have any hobbies because she never had enough time. She also found that her best friend, the neighbor, was becoming markedly aloof. When Janet called, she seldom talked for more than a few minutes before finding an excuse to hang up. It seemed that her friend had grown tired of Janet’s company.

This was Janet’s situation when she contacted the mental health center. Her mood was depressed and anxious. She was preoccupied with financial concerns and her lack of social relationships. Adam’s sleeping problem, which had begun about 1 week after she withdrew from her classes, was the last straw. She felt that she could no longer control her difficult situation and recognized that she needed help.

Conceptualization and Treatment

The therapist and Janet discussed her overall situation and agreed that Adam was only a small part of the problem. They decided to work together on an individual basis instead of having Janet join the parent training group.

Janet’s depression was clearly precipitated by her divorce, which had a drastic impact on many areas of her life. Increased financial burdens were clearly part of this picture, but interpersonal relationships were even more meaningful. Although the marriage had been far from ideal in terms of meeting Janet’s needs, her rela- tionship with David had been one important part of the way in which Janet thought about herself. She had lost one of hermost important roles (as awife). The therapist believed that an enduring improvement in her mood would depend on her success in developing new relationships and expanded roles for herself. And she would eventually need to learn parenting skills that would allow her to perform her mater- nal role more successfully. In other words, the therapist adopted a problem-solving approach to Janet’s situation. He was particularly concerned about the passive and ruminative way in which she had begun to respond to the circumstances in her life. The therapist decided to encourage her to engage more actively with her environ- ment while also teaching her to perform specific behaviors more effectively.

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As an initial step, the therapist asked Janet to list all the activities that she enjoyed. He wanted to shift attention away from the unpleasant factors with which Janet was currently preoccupied. Most of the activities Janet mentioned were things that she had not done for several months or years. For example, prior to her return to school, her favorite pastime had been riding horses. She said that she would like to begin riding again, but she felt that it was prohibitively expensive and time consuming. With considerable prodding from the therapist, Janet also listed a few other activities. These included talking with a friend over a cup of coffee, listening to music late at night after the children were asleep, and going for walks in the woods behind her home. In some cases, Janet indicated that these activities used to be pleasant, but she did not think that they would be enjoyable at the present time.

Despite Janet’s ambivalence, the therapist encouraged her to pick one activity that she would try at least twice before their next meeting. A short walk in the woods seemed like the most practical alternative, considering that Adam might interrupt listening to music and she did not want to call Susan. The therapist also asked Janet to call the campus riding club to inquire about their activities.

At the same time that the therapist encouraged Janet to increase her activity level, he also began to concentrate on an assessment of her interactions with other people. For several sessions, they covered topics such as selecting situations in which Janet might be likely to meet people with whom she would be interested in developing a friendship, initiating a conversation, maintaining a conversation by asking the other person a series of consecutive questions, and other elemen- tary issues. Having identified areas that were problematic for Janet, they discussed solutions and actually practiced, or role-played, various social interactions.

During the first fewweeks of treatment, Janet’smood seemed to be improving. Perhaps, most important was her luck in finding a part-time job at a local riding stable. She learned of the opening when she called to ask about the campus riding club. They were looking for someone who would feed and exercise the horses every morning. The wages were low, but she was allowed to ride as long as she wanted each day without charge. Furthermore, the schedule allowed her to finish before the girls returned from school. The money also helped her return Adam to the day-care center on a part-time basis. Janet still felt depressed when she was at home, but she loved to ride, and it helped to know that she would go to work in the morning.

An unfortunate sequence of events led to a serious setback shortly after it seemed that Janet’s mood was beginning to improve. Her financial aid had been discontinued, and she could no longer cover her monthly mortgage payments. Within several weeks, she received a notice from the bank threatening to fore- close her mortgage and sell her house. Her appearance was noticeably changed when she arrived for her next appointment. She was apathetic and lethargic. She cried through most of the session, and her outlook had grown distinctly more pes- simistic. The therapist was particularly alarmed by an incident that Janet described as happening the previous day. She had been filling her car with gas when a

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mechanic at the service station mentioned that her muffler sounded like it was cracked. He told her that she should get it fixed right away because of the danger- ous exhaust fumes. In his words, “that’s a good way to kill yourself.” The thought of suicide had not occurred to Janet prior to this comment, but she found that she could not get it out of her mind. She was frightened by the idea and tried to distract herself by watching television. The thoughts continued to intrude despite these efforts.

The therapist immediately discussed several changes in the treatment plan with Janet. He arranged for her to consult a psychiatrist, who prescribed fluoxe- tine (Prozac), an antidepressant drug. She also agreed to increase the frequency of her appointments at the clinic to three times a week. These changes were pri- marily motivated by the onset of suicidal ideation. More drastic action, such as hospitalization or calling relatives for additional support, did not seem to be nec- essary because her thoughts were not particularly lethal. For example, she said that she did not want to die, even though she was thinking quite a lot about death. The idea frightened her, and she did not have a specific plan arranged by which she would accomplish her own death. Nevertheless, the obvious deterioration in her condition warranted a more intense treatment program.

The next month proved to be a difficult one for Janet, but she was able to persevere. Three weeks after she began taking the medication, her mood seemed to brighten. The suicidal ideation disappeared, she became more talkative, and she resumed most of her normal activities. The people who owned the riding stable were understanding and held Janet’s new job for her until she was able to return. The financial crisis was solved, at least temporarily, when her father agreed to provide her with substantial assistance. In fact, he expressed surprise and some dismay that she had never asked him for help in the past or even told him that she was in financial trouble. The problem-solving and social skills program progressed well after Janet began taking medication. Within several weeks, she was able to reestablish her friendship with Susan. She was able to meet a few people at the riding stable, and her social network seemed to be widening.

After Janet’s mood had improved, the issue of Adam’s sleeping problem was addressed. The therapist explained that Janet needed to set firm limits on Adam’s manipulative behavior. Her inconsistency in dealing with his demands, coupled with the attention that he received during the bedtime scene, could be thought of as leading to intermittent reinforcement of his inappropriate behavior. Janet and the therapist worked out a simple set of responses that she would follow whenever he got up and came downstairs. She would offer him a drink, take him back to his room, tuck him in bed, and leave immediately. Ten days after the procedure was implemented, Adam began sleeping through the night without interruption. This rapid success enhanced Janet’s sense of control over her situation. Her enthusi- asm led her to enroll in the parent training program for which she had originally applied. She continued to improve her relationship with her children.

Janet’s individual therapy sessions were discontinued 9 months after her first appointment. At that point, she was planning to return to school, was still working

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part time at the riding stable, and had started to date one of the men she met at work. Her children were all healthy, and she had managed to keep their house. She continued to take antidepressant medication.

Discussion

A sad or dysphoric mood is obviously the most prominent feature of clinical depression. Depressed patients describe themselves as feeling discouraged, hope- less, and apathetic. This dejected emotional state is usually accompanied by a variety of unpleasant thoughts that may include suicidal ideation. These cogni- tive features of depression are sometimes called the depressive triad: a negative view of the self, the world, and the future. Depressed people see themselves as inadequate and unworthy. They are often filled with guilt and remorse over appar- ently ordinary and trivial events. These patients hold a similarly dim view of their environment. Everyday experiences and social interactions are interpreted in the most critical fashion. The future seems bleak and empty. In fact, some extremely depressed patients find it impossible to imagine any future at all.

Clinical depression is identified by changes in several important areas in the person’s life. DSM-5 (APA, 2013) lists several features for major depressive episodes. At least five out of nine symptoms must have been present nearly every day for at least 2 weeks if the person is to meet the criteria for this diagnostic category. Briefly, they are depressed mood, loss of interest in activities that are usually pleasurable, an important change in weight, marked trouble sleeping, obvious problems involving motor behavior (such as agitation), loss of energy, feelings of worthlessness or guilt, trouble concentrating, and suicidal thinking.

Janet clearly fit these criteria. Her mood had been markedly depressed since her separation from David. She had gained considerable weight—25 pounds in 9 months. Her concentration was severely impaired, as evidenced by her inability to study and her loss of interest in almost everything. Excessive and inappropriate guilt was clearly a prominent feature of her constant brooding about the divorce. Although she did not actually attempt to harm herself, she experienced a distress- ing period of ruminative suicidal ideation. Sleep impairment may also have been a problem, but it was difficult to evaluate in the context of Adam’s behavior. Prior to her first visit at the clinic, Janet had been sleeping less than her usual number of hours per night, and she reported considerable fatigue. It was difficult to know whether she would have been able to sleep if Adam had not been so demanding of her attention throughout the night.

Most therapists agree that it is important to recognize the difference between clinical depression and other states of unhappiness and disappointment. Is this a qualitative or a quantitative distinction? Are patients who might be considered clinically depressed simply more unhappy than their peers, or are these phenom- ena completely distinct? This is one of the most interesting and difficult ques- tions facing investigators in the field of mood disorders. The present diagnostic

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system handles the problem by including an intermediate category, dysthymia, that lies between major depressive disorder and normal mood. This category includes patients who exhibit chronic depressed symptoms that are not of sufficient severity to meet the criteria for major mood disorder.

Etiological Considerations

Several psychological models have been proposed to account for the develop- ment of major depression. Each model focuses on somewhat different features of depressive disorders (e.g., interpersonal relations, inactivity, or self-deprecating thoughts), but most share an interest in the role of negative or stressful events in the precipitation of major depression.

One important consideration involves the observation that the onset of depression is often preceded by a dependent personality style and then precipi- tated by the loss of an important relationship. Personality factors and relational distress may help to explain the fact that women are twice as likely as men to develop major depression. Dependent people base their self-esteem on acceptance and approval by others. Some authors have suggested that, throughout their social development, women are frequently taught to think this way about themselves (Crick & Zahn-Waxler, 2003; Gilligan, 1982). Stereotypes of female roles include descriptions of personality traits such as being passive, dependent, and emotional (whereas men are presumably more often encouraged to be aggressive, autonomous, and rational). An extension of this hypothesis holds that women are more likely than men to define themselves in terms of their relationships with other people. Women would then presumably be more distressed by marital difficulties and divorce. In Janet’s case, the loss of her relationship with David was certainly an important consideration in the onset of her depression. Her sense of self-worth was severely threatened by the divorce, despite the fact that her marriage had been far from ideal.

Stressful life events play a causal role in the etiology of depression (Hark- ness et al., 2010; Monroe & Harkness, 2005). One classic study has received considerable attention because it led to the development of a model that begins to explain the relationship between environmental conditions and the onset of depres- sion. Brown and Harris (1978) found an increased incidence of stressful events in the lives of depressed women, but only with regard to a particular subset of such events—those that were severe and involved long-term consequences for the woman’s well-being. Divorce and marital separation were prominent among these events, which also included events such as illness, loss of a job, and many other types of personal adversity. The impact of a stressful event apparently depends on the meaning that the event has for the person. Severe events that occur in the con- text of ongoing difficulties (such as a chronically distressed marriage) and events that occur in areas of a woman’s life to which she is particularly committed (such as a child’s health or the development of a career) are most likely to lead to the onset of depression (Brown, 2002).

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The association between stressful life events and depression is apparently bidirectional. Stress may cause depression, but depression also causes stress. In comparison to women who are not depressed and women with medical disorders, depressed women generate higher levels of stress, especially in interpersonal rela- tionships such as marriage (Hammen, 2005). This result indicates the operation of a dynamic process. Stressors that are not related to the person’s own behavior may precipitate the onset of a depressed mood. The depressed person may then engage in maladaptive ways of coping with the immediate situation, and these dysfunctional behaviors may lead to even higher levels of stress.

Several of these concepts are consistent with Janet’s situation. She had clearly experienced a high level of stress in the months before she entered therapy. The divorce from David is one obvious example. Her difficulties with the children may be another instance. When Claire’s illness eventually forced her to withdraw from the university, there were important long-term consequences for her graduation and subsequent plans to enter law school.

Stressful life events are likely to precipitate depression, particularly in the absence of adequate social support. The manner in which these experiences com- bine to take their effect, however, is currently a matter of dispute and speculation. It is important to remember that most people experience stressful events at one time or another, but most people do not become seriously depressed. What factors make some people more psychologically vulnerable? Do people who are prone to depression respond differently than others to the problems of everyday life? Are they less likely than other people to establish or maintain a protective social sup- port network? These questions have been addressed by other etiological models.

Social learning theorists (Joiner, Coyne, & Blalock, 1999) also emphasize the importance of interpersonal relationships and social skills (cf. narcissism and dependence) in the onset and maintenance of depression. This model provides an interesting account of the way in which depressed people respond to stress- ful life events and the effect that these responses have on other people. Others respond empathically and are initially attentive when the depressed person talks about depressing experiences; yet, the long-range result of this process is usually negative. The depressed person’s few remaining friends eventually become tired of this behavior and begin to avoid further interactions. Whatever sources of social support may have been available are eventually driven away. One important fac- tor in this regard is a deficit in social skills. Depressed people may be ineffective in their interactions with other people. An important aspect of treatment would, therefore, be to identify specific skills in which the person is deficient and to teach the person more effective ways of interacting with others.

Several aspects of this model are consistent with the present case. After her separation from David, Janet had become isolated. Her long discussions with her neighbor had eventually soured their relationship and eliminated one of her last sources of social support. When Janet and her therapist discussed things that she might do tomeet new friends, she seemed lost. The few attempts that she hadmade, such as her blind dates, had gone badly, and she did not know where else to begin.

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Another consideration regarding causes of depression involves the way in which people respond to the onset of a depressed mood. Some people try to dis- tract themselves from negative emotions by becoming involved in some activity. Others respond in a more passive fashion and tend to ruminate about the sources of their distress. Nolen-Hoeksema (2002) proposed that people who respond in a pas- sive, ruminative way experience longer andmore severe periods of depression. She also suggested that this factor may account for gender differences in the prevalence of depression because women are more likely than men to employ this response style. Janet’s behavior following her divorce fits nicely with Nolen-Hoeksema’s conceptual framework. Although Janet initially tried to cope actively with her var- ious problems, she soon relinquished most of her efforts to find new friends or to keep up with her studies. She frequently found herself brooding about the divorce and the hopeless nature of her circumstances. Her therapist encouraged Janet to engage more frequently in pleasant activities in an effort to break this cycle of passive, ruminative behavior.

In addition to the social and behavioral aspects of depression, it is also impor- tant to consider the way in which depressed people perceive or interpret events in their environment. What do they think about themselves and things that happen in their world? More specifically, how do they explain the experience of negative events? Cognitive perspectives suggest that patterns of thinking and perception play a prominent role in the development of depression (Gotlib & Joormann, 2010; Mathews & MacLeod, 2005). According to one influential theory, the occurrence of negative life events may lead to the development of hopelessness, which in turn causes the onset of symptoms of depression (Alloy, Abramson, Walshaw, & Neeren, 2006). Two cognitive elements define the state of hopelessness: (a) the expectation that highly desired outcomes will not occur or that highly aversive out- comes will occur, and (b) the belief that the person cannot do anything (is helpless) to change the likelihood that these events will occur.

Depressed people do express an inordinately high proportion of negative state- ments about themselves and how they relate to the world. Janet’s interpretation of the events leading up to and surrounding her divorce fit nicely with the hopeless- ness theory. She believed that the disintegration of her marriage was her own fault rather than David’s; she argued that her failure in that relationship was character- istic of her interactions with all other men rather than specific to one person; and she maintained that she would never be able to change this pattern of behavior.

Treatment

Janet’s treatment involved a combination of psychotherapy and antidepressant medication. Following the social learning/interpersonal model, her therapist focused on increasing Janet’s activity level and helping her learn new social skills. By encouraging activities such as riding, the therapist hoped to interrupt and reverse the ongoing, interactive process in which social isolation, rumination, and inactivity led to increased depression, depression led to further withdrawal,

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and so on. Through the development of new response patterns, particularly those involving interpersonal communication and parenting skills, he hoped to enable Janet to deal more effectively with future stressful events. Increased social activity and more effective communication would also lead to a more supportive social network that might help reduce the impact of stressful events. Recent evidence suggests that behavioral activation—increasing pleasant activities and positive interactions with others—is one effective approach to the treatment of depression (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011; Mazzucchelli, Kane, & Rees, 2009).

The therapy that Janet received was, in many respects, quite similar to another psychological approach to treating depression that is known as interpersonal psy- chotherapy, or IPT (Mufson et al., 2004; Weissman, 2007). The focus of IPT is the connection between depressive symptoms and current interpersonal prob- lems. Relatively little attention is paid to long-standing personality problems or developmental issues. The treatment takes a practical, problem-solving approach to resolving the sorts of daily conflicts in close relationships that can exacerbate and maintain depression. Deficits in social skills are addressed in an active and supportive fashion. The depressed person is also encouraged to pursue new activ- ities that might take the place of relationships or occupational roles that have been lost. Therapy sessions often include nondirective discussions of social difficulties and unexpressed or unacknowledged negative emotions as well as role-playing to practice specific social skills.

Antidepressant medication was introduced when the risk of suicide became apparent. Janet’s suicidal ideation was not extremely lethal. She had not planned a particular method by which she might end her life, and she reported that the idea of harming herself was frightening. The risk would have been much greater if she did have more specific plans and if she had really wanted to die. Never- theless, her morbid ruminations marked a clear deterioration in her condition that called for more intensive treatment. Three general classes of drugs are useful in the treatment of depression: selective serotonin reuptake inhibitors (SSRIs), tri- cyclics (TCAs), and monoamine oxidase (MAO) inhibitors. Improvements in the patient’s mood and other specific affective symptoms are typically evident after 2 to 4 weeks of drug treatment. Their continued administration also reduces the probability of symptomatic relapse.

Janet was given fluoxetine (Prozac), which is an SSRI. SSRIs were developed in the 1980s and now account for most prescriptions written for antidepressant medication (Hameed, Schwartz, Malhotra, West, & Bertone, 2005; Hirschfeld, 2001). Additional examples of SSRIs include fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil). The SSRIs inhibit the reuptake of serotonin into the presynaptic nerve ending and, therefore, increase the amount of serotonin available in the synaptic cleft. SSRIs have fewer side effects (such as weight gain, constipation, and drowsiness) than TCAs or MAO inhibitors; they are easier to take (one pill a day instead of experimenting for weeks to find the proper dosage); and they are less dangerous if the patient takes an overdose. This does

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not mean that they are without side effects of their own. Some patients experience nausea, headaches, fatigue, restlessness, and sexual side effects such as difficulty in reaching orgasm. Controlled outcome studies indicate that Prozac and other SSRIs are at least as effective as traditional forms of antidepressant medication (Kroenke et al., 2001). Medication and psychotherapy are both effective forms of treatment for people who suffer from major depression (Hollon, Thase, & Markowitz, 2002).

One obvious disadvantage associated with both medication and psychother- apy is the extended delay involved in achieving therapeutic effects. In the face of a serious suicidal threat, for example, the therapist may not be able to wait several weeks for a change in the patient’s adjustment. There are also many patients who do not respond positively to medication or psychosocial treatment approaches. Another form of intervention that may be tried with depressed patients, particu- larly if they exhibit profound motor retardation and have failed to respond pos- itively to antidepressant medication, is electroconvulsive therapy (ECT). In the standard ECT procedure, a brief seizure is induced by passing an electrical cur- rent between two electrodes that have been placed over the patient’s temples. A full course of treatment generally involves the induction of six to eight seizures spaced at 48-hour intervals. The procedure was first introduced as a treatment for schizophrenia, but it soon became apparent that it was most effective with depressed patients. Many studies have supported this conclusion (Husain, Kevan, Linnell, & Scott, 2004).

Much of the controversy surrounding ECT is based on misconceptions con- cerning the procedure and its effects. Although it is often referred to as shock therapy, ECT does not involve the perception of an electrical current. In fact, a short-acting anesthetic is administered prior to the seizure so that the patient is not conscious when the current is applied. Many of the deleterious side effects of ECT have been eliminated by modifications in the treatment procedure, such as the use of muscle relaxants to avoid bone fractures during the seizure (Abrams, 2002). The extent and severity of memory loss can be greatly reduced by the use of uni- lateral electrode placement. If both electrodes are placed over the nondominant hemisphere of the patient’s brain, the patient can experience less verbal memory impairment, but the treatment may be less effective in terms of its antidepressant results. There is, of course, the serious question of permanent changes in brain structure and function. Some critics of ECT have argued that it produces irre- versible neurological impairment. Proponents of ECT maintain that the evidence for this conclusion is inadequate (Abrams, 2002). Although most of the objec- tions to the use of ECT are based on misconceptions, the evidence supporting its therapeutic efficacy seems to justify the continued use of ECT with some severely depressed patients who have not responded to less-intrusive forms of treatment.

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Discussion Questions

1. Patients who are experiencing serious suicidal thoughts are frequently hospi- talized involuntarily. What are the advantages and disadvantages of forcing a person to be hospitalized against her or his will?

2. Janet had experienced a series of stressful events and circumstances. Would anyone have become depressed if they were in the same situation? If not, what other factors might have combined with these stressful events to lead to her depression?

3. From the beginning of therapy, the psychologist encouraged Janet to become more actively involved in various pleasant activities. Do you think treatment would have been even more effective if they had initially spent more time discussing at length the sources of her distress (such as her feelings about her divorce)?

4. Imagine that one of your close relatives has been depressed for several years. The person has not responded to previous forms of treatment (bothmedication and psychotherapy) and is now talking about committing suicide. Would you be willing to authorize a series of electroconvulsive therapy for him or her? Why or why not?