PSY360: Abnormal Psychology-2nd week

Depressive and Bipolar Disorders

Dr. Sumaira Khurshid Tahira

Associate Prof

NNU, China

Depressive and Bipolar Disorders

Depression: Low, sad state marked by significant levels of sadness,

lack of energy, low self-worth, guilt, or related symptoms

Mania: State or episode of euphoria or frenzied activity in which

people may have an exaggerated belief that the world is theirs for

the taking

Depressive disorders: Group of disorders marked by unipolar

depression

Unipolar depression: Depression without a history of _mania___

Bipolar disorder: Disorder marked by alternating or intermixed

periods of _mania__ and __depression____

How Common Is Unipolar Depression?

Around 9% of adults in the U.S. suffer from severe unipolar

depression in any given year

–As many as 5% suffer from mild forms

Around 19% of all adults experience unipolar depression at some

time in their lives

The prevalence is similar in Canada, England, France, and many

other countries

 The rate of depression is higher among poor people than

wealthier people

What Are the Symptoms of Depression?

The picture of depression may vary from person to person

Five main areas of functioning may be affected:

Emotional symptoms

Most people who are depressed feel sad and dejected.

They describe themselves as feeling “miserable,” “empty,” and “humiliated.”

They tend to lose their sense of humor, report getting little pleasure from anything, and in some cases display anhedonia, an inability to experience any pleasure at all.

A number also experience anxiety, anger, or agitation.

Continue….

Motivational symptoms (Lacking drive, initiative, spontaneity)

Depressed people typically lose the desire to pursue their usual

activities.

Almost all report a lack of drive, initiative, and spontaneity.

They may have to force themselves to go to work, talk with

friends, eat meals, or have sex. This state has been described as a

“paralysis of will” (Beck, 1967).

–Between 6% and 15% of those with severe depression die by

suicide

Continue

Behavioral symptoms

 Depressed people are usually less active and less productive.

 They spend more time alone and may stay in bed for long periods.

 may also move and even speak more slowly (Behrman, 2014)

Cognitive Symptoms

 Depressed people hold extremely negative views of themselves.

 They consider themselves inadequate, undesirable, inferior, perhaps evil (Lopez Molina et al., 2014; Sowislo & Orth, 2012).

 They also blame themselves for nearly every unfortunate event, even things that have nothing to do with them, and they rarely credit themselves for positive achievements.

Continue….

Another cognitive symptom of depression is pessimism. Sufferers are

usually convinced that nothing will ever improve, and they feel

helpless to change any aspect of their lives. Because they expect the

worst, they are likely to procrastinate. Their sense of hopelessness

and helplessness makes them especially vulnerable to suicidal

thinking (Shiratori et al., 2014; Wilson & Deane, 2010).

People with depression frequently complain that their intellectual

ability is poor.

They feel confused, unable to remember things, easily distracted, and

unable to solve even the smallest problems.

Continue….

Physical Symptoms

• People who are depressed frequently have such physical ailments as

headaches, indigestion, constipation, dizzy spells, and general pain

(Bai et al., 2014; Goldstein et al., 2011).

• Many depressions are misdiagnosed as medical problems at first

(Parker & Hyett, 2010).

• Disturbances in appetite and sleep are particularly common ( Jackson

et al., 2014; Armitage & Arnedt, 2011).

• Most depressed people eat less, sleep less, and feel more fatigued than

they did prior to the disorder. Some, however, eat and sleep

excessively.

Diagnosing Unipolar Depression

Major Depressive Disorder

A severe pattern of depression that is disabling and is not caused

by such factors as drugs or a general medical condition.

Persistent Depressive Disorder

A chronic form of unipolar depression marked by ongoing and

repeated symptoms of either major or mild depression.

Premenstrual Dysphoric Disorder

A disorder marked by repeated episodes of significant depression

and related symptoms during the week before menstruation.

Diagnosing Unipolar Depression

• According to DSM-5, a major depressive episode is a period of 2 or

more weeks marked by at least 5 symptoms of depression, including

sad mood and/or loss of pleasure.

• In extreme cases, the episode may include psychotic symptoms, ones

marked by a loss of contact with reality, such as delusions—bizarre

ideas without foundation—or hallucinations— perceptions of things

that are not actually present.

• A depressed man with psychotic symptoms may imagine that he

cannot eat “because my intestines are deteriorating and will soon

stop working,” or he may believe that he sees his dead wife

Diagnosing Unipolar Depression

DSM-5 lists several types of depressive disorders.

• People who go through a major depressive episode without having any

history of mania receive a diagnosis of major depressive disorder (APA,

2013).

• The disorder may be additionally categorized as

▪ seasonal if it changes with the seasons (e.g, if the depression recurs

each winter)

▪ catatonic if it is marked by either immobility or excessive activity

▪ peripartum if it occurs during pregnancy or within 4 weeks of giving

birth

▪ or melancholic if the person is almost totally unaffected by pleasurable

events.

Continue….

People whose unipolar depression is chronic receive a

diagnosis of persistent depressive disorder (APA,

2013)

Some people with this chronic disorder have repeated

major depressive episodes, a pattern technically called

persistent depressive disorder with major depressive

episodes. Others have less severe and less disabling

symptoms, a pattern technically called persistent

depressive disorder with dysthymic syndrome.

A third type of depressive disorder is premenstrual

dysphoric disorder, a diagnosis given to certain women

who repeatedly have clinically significant depressive and

related symptoms during the week before menstruation.

Acute illnesses

generally develop

suddenly and last a

short time, often only

a few days or weeks.

Chronic conditions

develop slowly and

may worsen over an

extended period of

time—months to years

Continue…

Yet another kind of depressive disorder, disruptive mood

dysregulation disorder, is characterized by a combination of

persistent depressive symptoms and recurrent outbursts of severe

temper.

This disorder emerges during mid-childhood or adolescence

What Causes Unipolar Depression?

Stress may be a trigger for depression

–People with depression experience a greater number of stressful life

events during the month just before the onset of their symptoms

–Some clinicians distinguish reactive (exogenous) depression from

endogenous depression, which seems to be a response to internal factors

What Causes Unipolar Depression?

Family pedigree, twin, adoption, and molecular biology gene studies

suggest that some people inherit a biological predisposition

 Researchers have found that as many as 20% of relatives of those

with depression are themselves depressed, compared with fewer than

10% of the general population

The Biological View: Genetic factors

What Causes Unipolar Depression?

Twin studies demonstrate a strong genetic

component:

 Concordance rates for identical (MZ) twins = 46%

Concordance rates for fraternal (DZ) twins = 20%

Adoption studies also have implicated a genetic

factor in cases of severe unipolar depression

Using techniques from the field of molecular

biology, researchers have found evidence that

unipolar depression may be tied to specific genes

The Biological View: Genetic factors

Concordance rate: means

the. probability of one twin

having the disorder if the

other already has it

expressed as a percentage.

To form identical or monozygotic twins,

one fertilised egg (ovum) splits and

develops into two babies with exactly the

same genetic information. To form

fraternal or dizygotic twins, two eggs

(ova) are fertilised by two sperm and

produce two genetically unique children.

What Causes Unipolar Depression?

NTs: serotonin and norepinephrine

 In the 1950s, medications for high blood pressure were found to cause depression

 Some lowered serotonin, others lowered norepinephrine

The discovery of truly effective antidepressant medications, which relieved depression by increasing either serotonin or norepinephrine, confirmed the NT role

 Depression likely involves not just serotonin nor norepinephrine… a complicated interaction is at work, and other NTs may be involved

The Biological View: Biochemical factors

What Causes Unipolar Depression?

Endocrine system / hormone release

People with depression have been found to have abnormal

levels of cortisol

Released by the adrenal glands during times of stress

People with depression have been found to have abnormal

melatonin secretion sometimes called the “Dracula hormone”

because it is released only in the dark.

Other researchers are investigating deficiencies of important

proteins within neurons as tied to depression

The Biological View: Biochemical factors

What Causes Unipolar Depression?

Model has produced much enthusiasm but has certain

limitations:

Relies on analogue studies: depression-like symptoms

created in lab animals

Do these symptoms correlate with human emotions?

Measuring brain activity has been difficult and indirect

Current studies using newer technology are attempting

to address this issue

The Biological View Biochemical factors

Analogue study refers to

a study that creates

conditions in the

laboratory meant to

represent conditions in

the real world

What Causes Unipolar Depression?

Biological researchers have determined that emotional reactions of various

kinds are tied to brain circuits

These are networks of brain structures that work together, triggering each

other into action and producing a particular kind of emotional reaction

 It appears that one circuit is tied to GAD, another to panic disorder, and

yet another to OCD

Although research is far from complete, a circuit responsible for unipolar

depression has begun to emerge

Likely brain areas in the circuit include the prefrontal cortex,

hippocampus, amygdala, and Brodmann Area 25

The Biological View :Brain anatomy and brain circuits

What Causes Unipolar Depression?

This system is the body's network of activities and cells that fight

off bacteria and other foreign invaders

 When stressed, the immune system may become dysregulated,

which some believe may help produce depression

 Support for this explanation is circumstantial but compelling

The Biological View Immune System

What Causes Unipolar Depression?

The Psychological Views

Three main models:

Psychodynamic model (No strong research)

Behavioral model (Modest research support)

Cognitive views (Considerable research support)

What Causes Unipolar Depression?

The Psychological Views : Psychodynamic view

Link between depression and grief

When a loved one dies, an unconscious process begins and the mourner

regresses to the oral stage and experiences introjection – a directing of

feelings for the loved one onto oneself

For most people, introjection is temporary

For some, grief worsens over time; if grief is severe and long- lasting,

depression results

What Causes Unipolar Depression?

Those with oral stage issues (unmet or excessively met needs) are

at greater risk for developing depression

 Instead of actual loss, some people experience “symbolic” (or

imagined) loss instead

Newer psychoanalysts (object relations theorists) propose that

depression results when people's relationships leave them feeling

unsafe and insecure

What Causes Unipolar Depression?

Strengths:

Studies have offered general support for the

psychodynamic idea that depression may be triggered

by a major loss (e.g., anaclitic depression)

Research supports the theory that early losses set the

stage for later depression

Research also suggests that people whose childhood

needs were improperly met are more likely to become

depressed after experiencing a loss

The Psychological Views Psychodynamic view

In a famous study of 123

infants who were placed in a

nursery after being separated

from their mothers, René

Spitz (1946, 1945) found that

19 of the infants became very

weepy and sad upon

separation and withdrew from

their surroundings—a pattern

called anaclitic depression.

What Causes Unipolar Depression?

Limitations:

Early losses and inadequate parenting sometimes lead to

depression but may not be typically responsible for development

of the disorder

Many research findings are inconsistent

Certain features of the model are nearly impossible to test

The Psychological Views Psychodynamic view

What Causes Unipolar Depression?

Depression results from changes in rewards and punishments

people receive in their lives

Lewinsohn suggests that the positive rewards in life dwindle for

some people, leading them to perform fewer and fewer

constructive behaviors, and they spiral toward depression

Research supports the relationship between the number of

rewards received and the presence or absence of depression

Social rewards are especially important

The Psychological Views Behavioral view

What Causes Unipolar Depression?

Strengths:

Researchers have compiled significant data to support this theory

Limitations:

Research has relied heavily on the self- reports of depressed subjects

Behavioral studies are largely correlational and do not establish that

decreases in rewards are the initial cause of depression

The Psychological Views: Behavioral view

What Causes Unipolar Depression?

Cognitive views

 Two main theories:

 Negative thinking

Learned helplessness

The Psychological Views

Learned helplessness is a state that

occurs after a person has experienced a

stressful situation repeatedly. They come

to believe that they are unable to control

or change the situation, so they do not

try — even when opportunities for

change become available.

What Causes Unipolar Depression?

Beck theorizes four interrelated cognitive components combine

to produce unipolar depression:

Maladaptive attitudes

Self-defeating attitudes are developed during childhood

Beck suggests that upsetting situations later in life can trigger

an extended round of negative thinking

The Psychological Views Cognitive views

What Causes Unipolar Depression? The

Psychological Views Cognitive views

Negative thinking

Depressed people also make errors in their thinking,

including:

Arbitrary inferences

Minimization of the positive and magnification of the

negative

Depressed people also experience automatic thoughts

A steady train of unpleasant thoughts that suggest

inadequacy and hopelessness

Arbitrary inference a

cognitive distortion in

which a person draws a

conclusion that is unrelated

to or contradicted by the

evidence.

What Causes Unipolar Depression?

Strengths:

Many studies have produced evidence in support of Beck's

explanation:

High correlation between the level of depression and the

number of maladaptive attitudes held

Both the cognitive triad and errors in logic are seen in people

with depression



The Psychological Views Cognitive views

Cognitive triad: the

individuals repeatedly

interpret (1) their

experiences, (2)

themselves, and (3) their

futures in negative ways

that lead them to feel

depressed. The cognitive

triad is at work in the

thinking of this depressed

person:

What Causes Unipolar Depression?

Automatic thinking has been linked to depression

Limitations:

 Research fails to show that such cognitive patterns are

the cause and core of unipolar depression

Automatic Thughts

Numerous unpleasant

thoughts that help to

cause or maintain

depression, anxiety, or

other forms of

psychological

dysfunction.

What Causes Unipolar Depression?

Learned helplessness

This theory asserts that people become depressed when they think

that:

They no longer have control over the reinforcements (rewards and

punishments) in their lives

They themselves are responsible for this helpless state

 Theory is based on Seligman's work with laboratory dogs

There has been significant research support for this model

The Psychological Views Cognitive views

What Causes Unipolar Depression?

Learned helplessness

Recent versions of the theory focus on attributions

Internal attributions that are global and stable lead to greater feelings of

helplessness and possibly depression

 Example: “It's all my fault” [internal]. “I ruin everything I touch”

[global] “and I always will” [stable].

If people make other kinds of attributions, this reaction is unlikely

Example: “She had a role in this also” [external], “the way I've behaved

the past couple weeks blew this relationship” [specific]. “I don't know

what got into me – I don't usually act like that” [unstable].

The Psychological Views Cognitive views

What Causes Unipolar Depression?

Sociocultural theorists propose that unipolar depression is greatly

influenced by the social context that surrounds people

–This belief is supported by the finding that depression is often

triggered by outside stressors

–There are two kinds of sociocultural views:

• The family-social perspective

• The multicultural perspective

The Sociocultural View

What Causes Unipolar Depression?

The Family-Social Perspective

The connection between declining social rewards and depression

Depressed people often display social deficits that make other

people uncomfortable and may cause them to avoid the depressed

individuals

This leads to decreased social contact and a further deterioration of

social skills

The Sociocultural View

What Causes Unipolar Depression?

The Family-Social Perspective

 Consistent with these findings, depression has been tied repeatedly to the

unavailability of social support such as that found in a happy marriage

 People who are separated or divorced display three times the depression rate of

married or widowed persons and double the rate of people who have never been

married

 There also is a high correlation between level of marital conflict and degree of

sadness that is particularly strong among those who are clinically depressed

 It also appears that people who are isolated and without intimacy are particularly

likely to become depressed in times of stress

The Sociocultural View

What Causes Unipolar Depression?

The Multicultural Perspective

Two kinds of relationships have captured the interest of multicultural

theorists:

Gender and depression

A strong link exists between gender and depression

 Women cross-culturally are twice as likely as men to receive a

diagnosis of unipolar depression

Women also appear to be younger, have more frequent and longer-

lasting bouts, and to respond less successfully to treatment

The Sociocultural View

What Causes Unipolar Depression?

The Multicultural Perspective

A variety of theories has been offered:

The artifact theory holds that women and men are equally prone

to depression, but that clinicians often fail to detect depression in

men

The hormone explanation holds that hormone changes trigger

depression in many women

The life stress theory suggests that women in our society

experience more stress than men

The Sociocultural View

What Causes Unipolar Depression?

The Multicultural Perspective

Two kinds of relationships have captured the interest of multicultural

theorists:

 Cultural background and depression

Depression is a worldwide phenomenon, and certain symptoms seem to

be constant across all countries, including sadness, joylessness, anxiety,

tension, lack of energy, loss of interest, and thoughts of suicide

Beyond such core symptoms, research suggests that the precise picture

of depression varies from country to country

The Sociocultural View

What Causes Unipolar Depression? The

Sociocultural View

The Multicultural Perspective

In addition, although overall depression rates are similar,

differences exist in specific populations living under oppressive

circumstances

n a study of one Native American village, lifetime risk was 37%

among women, 19% among men, and 28% overall

These findings are thought to be the result of economic and social

pressures

Bipolar Disorders

People with a bipolar disorder experience both the lows of

depression and the highs of mania

–Many describe their lives as an emotional roller coaster

Hypomania is a milder version of mania that

lasts for a short period (usually a few days) ·

Mania is a more severe form that lasts for a

longer period (a week or more​).

Hypomania is a milder form of mania.

energy level is higher than normal, but it's

not as extreme as in mania. It causes

problems in your life, but not to the extent

that mania can.

Bipolar I disorder is diagnosed when a person

experiences a manic episode. During a manic

episode, people with bipolar I disorder experience

an extreme increase in energy and may feel on top

of the world or uncomfortably irritable in mood.

Bipolar I disorder involves periods of severe mood

episodes from mania to depression.

Bipolar II disorder is a milder form of mood

elevation, involving milder episodes of hypomania

that alternate with periods of severe depression.

What Are the Symptoms of Mania?

Unlike those experiencing depression, people in a state of mania typically

experience dramatic and inappropriate rises in mood

Five main areas of functioning may be affected:

Emotional symptoms

Active, powerful emotions in search of outlet

Motivational symptoms

Need for constant excitement, involvement, companionship

What Are the Symptoms of Mania?

Behavioral symptoms

Very active – move quickly; talk loudly or rapidly

Cognitive symptoms

Show poor judgment or planning

May have trouble remaining coherent or in touch with reality

Physical symptom

 High energy level – often in the presence of little or no rest

Diagnosing Bipolar Disorders

 Criteria 1: Manic episode

–Three or more symptoms of mania lasting one week or more

 In extreme cases, symptoms are psychotic

 Criteria 2: History of mania

–If currently experiencing hypomania or depression

Diagnosing Bipolar Disorders

 DSM-5 distinguishes two kinds of bipolar disorder:

– Bipolar I disorder

 Full manic and major depressive episodes

–Some experience an alternation of episodes

–Others have mixed episodes

–Bipolar II disorder

 Hypomanic episodes alternate with major depressive episodes

Diagnosing Bipolar Disorders

 Without treatment, the mood episodes tend to recur for people with either type of bipolar

disorder

–If people experience four or more episodes within a one-year period, their disorder is further

classified as rapid cycling

Diagnosing Bipolar Disorders

 Regardless of particular pattern, individuals with bipolar disorder tend to experience

depression more than mania over the years

–In most cases, depressive episodes occur three times as often as manic ones, and last longer

Diagnosing Bipolar Disorders

 Between 1% and 2.6% of all adults in the world suffer from a bipolar disorder at any given

time, and as many as 4% over the course of their lives –Bipolar I seems to be a bit more

common than Bipolar II

 The disorders are equally common in women and men

–Women may experience more depressive episodes and fewer manic episodes than men and

rapid cycling is more common in women

 The disorders are more common among people with low incomes than those with high

income

Diagnosing Bipolar Disorders

 A final diagnostic option:

– When a person experiences numerous episodes of hypomania and mild depressive

symptoms, a diagnosis of cyclothymic disorder is assigned

 Mild symptoms for two or more years, interrupted by periods of normal mood

 Affects at least 0.4% of the population

 May eventually blossom into bipolar I or II disorder

What Causes Bipolar Disorders?

Throughout the first half of the 20th century, the search for the

cause of bipolar disorders made little progress

 More recently, biological research has produced some promising

clues

–These insights have come from research into NT activity, ion

activity, brain structure, and genetic factors

What Causes Bipolar Disorders?

Neurotransmitters

–After finding a relationship between low norepinephrine and

unipolar depression, early researchers expected to find a link

between high norepinephrine levels and mania

This theory is supported by some research studies; bipolar

disorders may be related to overactivity of norepinephrine

What Causes Bipolar Disorders?

Neurotransmitters

–Because serotonin activity often parallels norepinephrine activity

in unipolar depression, theorists expected that mania would also

be related to high serotonin activity

 Although no relationship with high serotonin has been found,

bipolar disorder may be linked to low serotonin activity, which

seems contradictory…

What Causes Bipolar Disorders?

Neurotransmitters

–This apparent contradiction is addressed by the “permissive

theory” about mood disorders:

Low serotonin may “open the door” to a mood disorder and

permit norepinephrine activity to define the particular form the

disorder will take:

 –Low serotonin + Low norepinephrine = Depression

–Low serotonin + High norepinephrine = Mania

What Causes Bipolar Disorders?

Ion activity

–Ions, which are needed to send incoming messages to nerve

endings, may be improperly transported through the cells of

individuals with bipolar disorder

 –Some theorists believe that irregularities in the transport of

these ions may cause neurons to fire too easily (mania) or to

stubbornly resist firing (depression)

There is some research support for this theory

What Causes Bipolar Disorders?

Ion Activity

 Neurotransmitters play a significant role in the communication between neurons, ions seem to play a critical role in relaying messages within a neuron.

 Ions help transmit messages down the neuron’s axon to the nerve endings. Positively charged sodium ions (Na1) sit on both sides of a neuron’s cell membrane. When the neuron is at rest, more sodium ions sit outside the membrane.

 When the neuron receives an incoming message at its receptor sites, pores in the cell membrane open, allowing the sodium ions to flow to the inside of the membrane, thus increasing the positive charge inside the neuron. This starts a wave of electrical activity that travels down the length of the neuron and results in its “firing.”

What Causes Bipolar Disorders?

Ion Activity

After the neuron “fires,” potassium ions (K1) flow from the inside

of the neuron across the cell membrane to the outside, helping to

return the neuron to its original resting state (see Figure).

If messages are to be relayed effectively down the axon, the ions

must be able to travel easily between the outside and the inside of

the neural membrane.

Some theorists believe that irregularities in the transport of these

ions may cause neurons to fire too easily (resulting in mania) or to

stubbornly resist firing (resulting in depression) (Manji & Zarate,

2011; Li & El-Mallakh, 2004)

figure

Ions and the firing of neurons Neurons relay messages in the form of electrical impulses that travel down the axon toward the

nerve endings. As an impulse travels along the axon, sodium ions (Na1), on the outside of the neuron’s membrane, flow inside,

causing the impulse to continue down the axon. Once sodium ions flow in, potassium ions (K1) flow out, returning the

membrane’s electrical balance to its resting state, ready for the arrival of a new impulse.

What Causes Bipolar Disorders?

Brain structure

 –Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorder (Eker et al., 2014; Chen et al., 2011; Savitz & Drevets, 2011).

 E.g, the basal ganglia and cerebellum of these people tend to be smaller than those of other people, they have lower volumes of gray matter in the brain, and their dorsal raphe nucleus, striatum, amygdala, hippocampus, and prefrontal cortex have some structural abnormalities

 The dorsal raphe nucleus, for example, is one of the brain sites where serotonin is produced.

 It is not clear what role such structural abnormalities play.

What Causes Bipolar Disorders?

Genetic factors

 –Many theorists believe that people inherit a biological

predisposition to develop bipolar disorders

 Family pedigree studies support this theory:

–Identical (MZ) twins = 40% likelihood

–Fraternal (DZ) twins and siblings = 5% to 10% likelihood

–General population = 1 to 2.6% likelihood

What Causes Bipolar Disorders?

Genetic factors

–Researchers have conducted genetic linkage studies to

identify possible patterns of inheritance

–Other researchers are using techniques from molecular

biology to further examine genetic patterns in large families

–Such wide-ranging findings suggest that a number of genetic

abnormalities probably combine to help bring about bipolar

disorders

Treatment for Depressive and Bipolar

Disorders

Treatments for Unipolar Depression

Around half of persons with unipolar depression (major

depressive or dysthymic disorder) receive treatment from a

mental health professional each year

In addition, many other people in therapy experience depressed

feelings as part of another disorder – thus, much of the therapy

being done today is for unipolar depression

Treatments for Unipolar Depression

A variety of treatment approaches are currently in

widespread use

These can be divided into psychological, sociocultural,

and biological approaches

Treatments for Unipolar Depression:

Psychological Approaches

Psychological treatments used most often to combat unipolar

depression come from three main schools of thought:

 – Widely used despite no strong research evidence of its

effectiveness

 – Primarily used for mild or moderate depression but

practiced less than in past decades

 – Has performed so well in research that it has a large and

growing clinical following

Treatments for Unipolar Depression:

Psychological Approaches

Psychodynamic therapy

• Believing that unipolar depression results from unconscious grief over real or imagined losses, compounded by excessive dependence on other people, psychodynamic therapists seek to bring these issues into consciousness and work through them

• Psychodynamic therapists use the same basic procedures for all psychological disorders:

• Free association

• Therapist interpretation

• Review of past events and feelings

Treatments for Unipolar Depression:

Psychological Approaches

Psychodynamic therapy

• Despite successful case reports, researchers have found that long- term psychodynamic therapy is only occasionally helpful in cases of unipolar depression

• Two features may be particularly limiting:

• Depressed clients may be too passive or weary to fully participate in subtle therapy discussions

• Depressed clients may become discouraged and end treatment too early when treatment is unable to provide quick relief

• Short-term approaches have performed better than traditional approaches

Treatments for Unipolar Depression:

Psychological Approaches

Behavioral therapy

• Most behavioral treatment for unipolar depression is modeled after the interventions proposed by Lewinsohn:

• Reintroduce clients to pleasurable activities and events, often using a weekly schedule

• Appropriately reinforce their depressive and non-depressive behaviors

• Use a contingency management approach

• Help them improve their social skills

Contingency management refers to a

type of behavioural therapy in which

individuals are 'reinforced', or

rewarded, for evidence of positive

behavioural change.

Treatments for Unipolar Depression:

Psychological Approaches

Behavioral Therapy

• The behavioral techniques seem to be of only limited help when just one of them is applied

• When two or more of the techniques are combined, behavioral treatment does seem to reduce depressive symptoms, particularly if mild

• It is worth noting that Lewinsohn himself has combined behavioral techniques with cognitive strategies in recent years

Treatments for Unipolar Depression:

Psychological Approaches

Cognitive therapy

• Beck viewed unipolar depression as resulting from a pattern of negative thinking that may be triggered by current upsetting situations

• Maladaptive attitudes lead people to the “cognitive triad”

• Repeatedly viewing oneself, the world, and the future in negative ways

• These biased views combine with illogical thinking to produce automatic thoughts

Treatments for Unipolar Depression:

Psychological Approaches

Cognitive Therapy

• Beck's cognitive therapy – which includes a number of behavioral techniques – is designed to help clients recognize and change their negative cognitive processes

• This approach follows four phases and usually lasts fewer than 20 sessions

• Phases:

• Increasing activities and elevating mood

• Challenging automatic thoughts

• Identifying negative thinking and biases

• Changing primary attitudes

Treatments for Unipolar Depression:

Psychological Approaches

Cognitive Therapy

• Over the past several decades, hundreds of studies have shown that cognitive therapy helps unipolar depression

• Around 50%–60% of clients show a near-total elimination of symptoms

• It is worth noting that a growing number of today's cognitive- behavior therapists disagree with Beck's proposition that individuals must fully disregard negative cognitions

• These therapists guide clients to recognize and accept their negative cognitions

Treatments for Unipolar Depression:

Sociocultural Approaches

Theorists trace the causes of unipolar depression to the broader

social structure in which people live and to the roles they are

required to play

Two groups of sociocultural treatments are now widely applied

 – multicultural approaches and family

-social approaches

Mood Tracking

Cognitive-behavioral and other therapists who work with

depressed clients often instruct the clients to keep track of their

mood changes—hour by hour, day by day—and to also note the

situations and thoughts that cause their moods to change

Mood tracking apps for smartphones are gaining in popularity

Treatments for Unipolar Depression:

Sociocultural Approaches

Culture-sensitive approaches increasingly are being

combined with traditional forms of psychotherapy to help

maximize the likelihood of minority clients overcoming

their disorders

It also appears that the medication needs of many depressed

minority clients are inadequately addressed

Treatments for Unipolar Depression:

Sociocultural Approaches

Interpersonal therapy (IPT)

This model holds that four interpersonal problems may lead to

depression and must be addressed:

Interpersonal loss

Interpersonal role dispute

Interpersonal role transition

Interpersonal deficits

Studies suggest that IPT is as effective as cognitive therapy

for treating depression

Treatments for Unipolar Depression:

Sociocultural Approaches

Family-Social Treatments

Couple therapy

The main type of couple therapy is behavioral marital

therapy (BMT)

Focus is on developing specific communication and

problem-solving skills

If marriage is filled with conflict, BMT is as effective as

other therapies for reducing depression

Treatments for Unipolar Depression:

Biological Approaches

Biological treatments can bring great relief to people with unipolar

depression

Usually biological treatment means antidepressant drugs, but for

severely depressed individuals who do not respond to other forms

of treatment, it sometimes includes electroconvulsive therapy or

brain stimulation

Treatments for Unipolar Depression:

Biological Approaches

Electroconvulsive therapy(ECT)

One of the most controversial forms of treatment

It is used frequently because it is an effective and

fast-acting intervention

The procedure consists of targeted electrical

stimulation to cause a brain seizure

The usual course of treatment is 6 to 12 sessions

spaced over 2 to 4 weeks

Treatment may be bilateral or unilateral

In bilateral ECT, one

electrode is placed on the

left side of the head, the

other on the right side. In

unilateral ECT, one

electrode is placed at the top

(vertex) of the head and the

other typically on the right

side.

Treatments for Unipolar Depression:

Biological Approaches

Electroconvulsive therapy (ECT)

The discovery of the effectiveness of ECT was accidental and

based on a fallacious link between psychosis and epilepsy

The procedure has been modified in recent years to reduce some

of the negative effects

For example, patients are given muscle relaxants and anesthetics

before and during the procedure

Patients generally report some memory loss

Treatments for Unipolar Depression:

Biological Approaches

Electroconvulsive therapy (ECT)

ECT is clearly effective in treating unipolar depression

Studies find improvement in 60%–80% of patients

The procedure seems particularly effective in cases of severe depression with delusions, but it has been difficult to determine why ECT works so well

Although effective, the use of ECT has declined since the 1950s because of the memory loss caused by the procedure, the frightening nature of the procedure, and the emergence of effective antidepressant drugs

Treatments for Unipolar Depression:

Biological Approaches

Antidepressant drugs

In the 1950s, two kinds of drugs were found to reduce the

symptoms of depression:

Monoamine oxidase inhibitors (MAO inhibitors)

Tricyclics

These drugs have been joined in recent years by a third group,

the second-generation antidepressants

Treatments for Unipolar Depression:

Biological Approaches Antidepressant drugs: MAO inhibitors

Originally used to treat tuberculosis , doctors noticed that the

medication seemed to make patients happier

The drug works biochemically by slowing down the body's production

of enzyme monoamine oxidase(MAO)

MAO breaks down norepinephrine

MAO inhibitors stop this breakdown from occurring

This leads to a rise in norepinephrine activity and a reduction in

depressive symptoms

Approximately half of patients who take these drugs are helped by

them

Treatments for Unipolar Depression:

Biological Approaches

Antidepressant drugs: MAO inhibitors

MAO inhibitors pose a potential danger

People who take MAOIs experience a dangerous rise in blood

pressure if they eat foods containing tyramine (cheese, bananas,

wine)

In recent years, a new MAO inhibitor in the form of a skin

patch has become available

Dangerous food interactions do not appear to be as common a

problem with this kind of MAO inhibitor

Treatments for Unipolar Depression:

Biological Approaches

Antidepressant drugs: Tricyclics

In searching for medications for schizophrenia, researchers

discovered that imipramine relieved depressive symptoms

Imipramine and related drugs are known as tricyclics because they

share a three-ring molecular structure

Treatments for Unipolar Depression:

Biological Approaches

Antidepressant drugs: Tricyclics

Hundreds of studies have found that depressed patients taking

tricyclics have improved much more than similar patients taking

placebos

Drugs must be taken for at least 10 days before such improvement

is seen

About 60%–65% of patients find symptom improvement

Treatments for Unipolar Depression:

Biological Approaches

Antidepressant drugs: Tricyclics

Most patients who immediately stop taking tricyclics upon relief

of symptoms relapse within one year

Patients who take tricyclics for five additional months (“continuation therapy”) have a significantly decreased risk of

relapse

Patients who take antidepressant drugs for three or more years after initial improvement (“maintenance therapy”) may reduce the

risk of relapse even more

Treatments for Unipolar Depression:

Biological Approaches Antidepressant drugs: Tricyclics

Tricyclics are believed to reduce depression by affecting

neurotransmitter (NT) reuptake mechanisms

To prevent an NT from remaining in the synapse too

long, a pump like mechanism recaptures the NT and

draws it back into the presynaptic neuron

The reuptake process appears to be too efficient in some

people, drawing in too much of the NT from the synapse

Reuptake:

The process by

which

neurotransmitter

molecules that have

been released at a

synapse are

reabsorbed by the

presynaptic neuron

that released them.

Treatments for Unipolar Depression: Biological

Approaches

This reduction in NT activity in the synapse is thought to result in

clinical depression

Tricyclics block the reuptake process, thus increasing NT activity

in the synapse

Treatments for Unipolar Depression:

Biological Approaches Antidepressant drugs: Tricyclics

There is growing evidence that when tricyclics are ingested, they

initially slow down the activity of the neurons that use norepinephrine

and serotonin

After a week or two, the neurons adapt to the drugs and go back to

releasing normal amounts of the NTs, and the reuptake mechanism

begins to have the desired effect

Today, tricyclics are prescribed more often than MAO inhibitors

They do not require dietary restrictions

Some patients show higher rates of improvement

Treatments for Unipolar Depression:

Biological Approaches

Second-generation antidepressants

A third group of effective antidepressant drugs is structurally different

from the MAO inhibitors and tricyclics

Most of the drugs in this group are labeled selective serotonin

reuptake inhibitors (SSRIs)

These drugs increase serotonin activity specifically (no other NTs are

affected)

Treatments for Unipolar Depression: Biological

Approaches

This class includes fluoxetine (Prozac), sertraline (Zoloft), and

escitalopram (Lexapro)

Selective norepinephrine reuptake inhibitors and serotonin-

norepinephrine reuptake inhibitors are also now available

Treatments for Unipolar Depression:

Biological Approaches

Second-generation antidepressant drugs

In effectiveness and speed of action of these drugs are on a par with the

tricyclics, yet their sales have skyrocketed

Clinicians often prefer these drugs because it is harder to overdose

on them than on other kinds of antidepressants

There are no dietary restrictions like there are with MAO inhibitors

They have fewer side effects than the tricyclics

These drugs may cause some undesired effects of their own,

including a reduction in sex drive

Treatments for Unipolar Depression:

Biological Approaches

As effective as antidepressant drugs are, it is important to

recognize that they do not work for everyone

Even the most successful of them fails to help at least 35 percent

of clients with depression

Treatments for Unipolar Depression:

Biological Approaches

Brain stimulation

In recent years, three additional biological approaches have been

developed:

Vagus nerve stimulation

Transcranial magnetic stimulation

Deep brain stimulation

Treatments for Unipolar Depression:

Biological Approaches

Depression researchers surmised they might be able to stimulate the

brain by electrically stimulating the vagus nerve through the use of

a pulse generator implanted under the skin of the chest

Research has found that the procedure brings significant relief to as

many as 40% of those with treatment-resistant depression

As with ECT, researchers do not yet know precisely why this

technique reduces depression

Treatments for Unipolar Depression:

Biological Approaches

Brain stimulation

Another technique designed to stimulate the brain without the

undesired effects of ECT, TMS has been found to reduce

depression when administered daily for 2 to 4 weeks

Theorizing a “depression switch” located deep within the brain,

researchers have successfully experimented with electrode

implantation in the brain's Brodman Area 25

Treatments for Unipolar Depression:

Biological Approaches

While such positive initial findings have

produced considerable enthusiasm in the

clinical field, it is important to recognize

and remember that, in the past, certain

promising interventions (e.g., lobotomies)

later proved problematic and even

dangerous upon closer inspection

A lobotomy, or leucotomy, is a

form of psychosurgery, a

neurosurgical treatment of a mental

disorder that involves severing

connections in the brain's

prefrontal cortex. Most of the

connections to and from the

prefrontal cortex, the anterior part

of the frontal lobes of the brain, are

severed.

How Do the Treatments for Unipolar

Depression Compare?

For most kinds of psychological disorders, no more than one or two

treatments, if any, emerge as highly successful

Unipolar depression seems to be an exception, responding to any of

several approaches

How Do the Treatments for Unipolar

Depression Compare?

Findings from a number of treatment outcome studies

suggest that:

Cognitive, cognitive-behavioral, interpersonal, and

biological therapies are all highly effective treatments for

mild to severe unipolar depression

Although cognitive, cognitive-behavioral, and

interpersonal therapies may lower the likelihood of

relapse, they are hardly relapse-proof

Relapse is the worsening of a

medical condition that had

previously improved. A relapse to

addiction is when the person with the

past addiction starts doing his or her

addictive behavior again after a

period of not doing it, known as

abstinence.

How Do the Treatments for Unipolar

Depression Compare?

Findings from a number of treatment outcome studies suggest

that:

When people with unipolar depression experience

significant marital discord, couple therapy tends to be very

helpful

Depressed people who receive strictly behavioral therapy

have shown less improvement than those who receive

cognitive, cognitive-behavioral, interpersonal, or biological

therapy

How Do the Treatments for Unipolar Depression

Compare?

Findings from a number of treatment outcome studies suggest that:

Traditional psychodynamic therapies are less effective than other

therapies in treating all levels of unipolar depression

A combination of psychotherapy and drug therapy is modestly

more helpful to depressed people than either treatment alone

How Do the Treatments for Unipolar

Depression Compare?

Findings from a number of treatment outcome studies suggest that:

These various trends do not always carry over to the treatment of

depressed children and adolescents

Among biological treatments, ECT appears to be somewhat more

effective than antidepressant drugs and ECT seems to act more quickly

In addition, the newly developed brain stimulation treatments seem

helpful for some severely depressed individuals who have been

repeatedly unresponsive to drug therapy, ECT, or psychotherapy

Treatments for Bipolar Disorder

Until the latter part of the 20th century, people with bipolar

disorders were destined to spend their lives on an emotional

roller coaster

Psychotherapists reported almost no success

Antidepressant drugs were of limited help

These drugs sometimes triggered manic episodes

ECT only occasionally relieved either the depressive or the

manic episodes of bipolar disorder

Treatments for Bipolar Disorder: Lithium

and Other Mood Stabilizers The use of lithium (a metallic element naturally occurring as mineral salt)

and other mood-stabilizers has dramatically changed this picture

Lithium is extraordinarily effective in treating bipolar disorders and mania

Determining the correct dosage for a given patient is a delicate process

Too low = no effect

Too high = lithium intoxication (poisoning)

Given the effectiveness, around one-third of all persons with bipolar

disorder seek treatment in a given year; another 15% are monitored by

family physicians

Treatments for Bipolar Disorder: Lithium

and Other Mood Stabilizers

All manner of research has attested to the effectiveness of lithium and

other mood stabilizers in treating manic episodes

More than 60% of patients with mania improve on these medications

Most individuals experience fewer new episodes while on the drug

Findings suggest that the mood stabilizers are also prophylactic

drugs, ones that actually help prevent symptoms from developing

Mood stabilizers also help those with bipolar disorder overcome their

depressive episodes to a lesser degree

Treatments for Bipolar Disorder: Lithium

and Other Mood Stabilizers

Researchers do not fully understand how mood stabilizing drugs operate

They suspect that the drugs change synaptic activity in neurons, but in a

different way from that of antidepressant drugs

Although antidepressant drugs affect a neuron's initial reception on

NTs, mood stabilizers seem to affect a neuron's second messengers

These drugs also increase the production of neuroprotective proteins,

which may decrease bipolar symptoms

Another theory is that mood stabilizers correct bipolar functioning by

directly changing sodium and potassium ion activity in neurons

Treatments for Bipolar Disorder:

Adjunctive Psychotherapy

Psychotherapy alone is rarely helpful for persons with bipolar

disorder

Mood stabilizing drugs alone are also not always sufficient

30% or more of patients don't respond, may not receive the correct

dose, and/or may relapse while taking it

As a result, clinicians often use psychotherapy as an adjunct to

lithium (or other medication-based) therapy

Treatments for Bipolar Disorder:

Adjunctive Psychotherapy

Therapy focuses on medication management, social skills, and

relationship issues

Few controlled studies have tested the effectiveness of such

adjunctive therapy

Growing research suggests that it helps reduce hospitalization,

improves social functioning, and increases clients' ability to

obtain and hold a job