Week 3 Treating Depression

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: • Psychodynamic – Widely used despite no strong research

evidence of its effectiveness • Behavioral – Primarily used for mild or moderate depression but

practiced less than in past decades • Cognitive – 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

nondepressive behaviors • Use a contingency management approach

• Help them improve their social skills

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 • Can you think of other uses, advantages, and disadvantages

that might result from the growing use of mood-tracking apps?

Treatments for Unipolar Depression: Sociocultural Approaches • Multicultural treatments

• 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 • Family-Social Treatments

• 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

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 TB, doctors noticed that the medication seemed to make patients happier

• The drug works biochemically by slowing down the body's production of 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 pumplike 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

• 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

Reuptake and Antidepressants

(Left) Soon after a neuron releases neurotransmitters such as norepinephrine or serotonin into its synaptic space, it activates a pumplike reuptake mechanism to reabsorb excess neurotransmitters. In depression, however, this reuptake process is too active, removing too many neurotransmitters before they can bind to a receiving neuron. (Right) Tricyclic and most second-generation antidepressant drugs block this reuptake process, enabling norepinephrine or serotonin to remain in the synapse longer and bind to the receiving neuron.

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)

• 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 • Vagus nerve stimulation

• 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

Vagus Nerve Stimulation

Treatments for Unipolar Depression: Biological Approaches • Transcranial magnetic 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

• Deep brain stimulation • 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 • Brain stimulation

• 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

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

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