Transcript Comer, Abnormal Psychology, 8th edition

Chapter 8
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatment for Depressive and Bipolar
Disorders
Treatments for Unipolar Depression
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Around half of persons with unipolar depression
(major depressive or dysthymic disorder) receive
treatment from a mental health professional
each year
Treatments for Unipolar Depression
• A variety of treatment approaches are currently
in widespread use
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– These can be divided into psychological,
sociocultural, and biological approaches
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Treatments for Unipolar Depression:
Psychological Approaches
– ___________ – 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Psychological treatments used most often to
combat unipolar depression come from three
main schools of thought:
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Psychodynamic therapy
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Psychodynamic therapy
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Behavioral therapy
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Behavioral therapy
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Cognitive therapy
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Cognitive therapy
Treatments for Unipolar Depression:
Psychological Approaches
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Cognitive therapy
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatments for Unipolar Depression:
Sociocultural Approaches
• 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?
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Mood Tracking
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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• ___________ treatments
Treatments for Unipolar Depression:
Sociocultural Approaches
• _____________ Treatments
– Interpersonal therapy (IPT)
–
–
–
–
Interpersonal loss
Interpersonal role dispute
Interpersonal role transition
Interpersonal deficits
• Studies suggest that IPT is as effective as cognitive therapy
for treating depression
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• This model holds that four interpersonal problems may lead
to depression and must be addressed:
Treatments for Unipolar Depression:
Sociocultural Approaches
• Family-Social Treatments
– Couple therapy
– Focus is on developing specific communication and problemsolving skills
• If marriage is filled with conflict, BMT is as effective as other
therapies for reducing depression
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The main type of couple therapy is behavioral marital therapy
(BMT)
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatments for Unipolar Depression:
Biological Approaches
Treatments for Unipolar Depression:
Biological Approaches
• ______________ therapy (ECT)
– One of the most controversial forms of treatment
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• It is used frequently because it is an effective and fast-acting
intervention
Treatments for Unipolar Depression:
Biological Approaches
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Electroconvulsive therapy (ECT)
Treatments for Unipolar Depression:
Biological Approaches
• Electroconvulsive therapy (ECT)
– ECT is clearly effective in treating unipolar depression
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Studies find improvement in 60%–80% of patients
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs
– In the 1950s, two kinds of drugs were found to reduce
the symptoms of depression:
– These drugs have been joined in recent years by a
third group, the second-generation antidepressants
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Monoamine oxidase inhibitors (MAO inhibitors)
• Tricyclics
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs: MAO inhibitors
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– 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
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs: MAO inhibitors
– MAO inhibitors pose a potential danger
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• People who take MAOIs experience a dangerous rise in
blood pressure if they eat foods containing tyramine (cheese,
bananas, wine)
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs: Tricyclics
• Imipramine and related drugs are known as tricyclics
because they share a three-ring molecular structure
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– In searching for medications for schizophrenia,
researchers discovered that imipramine relieved
depressive symptoms
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs: Tricyclics
• Drugs must be taken for at least 10 days before such
improvement is seen
• About 60%–65% of patients find symptom improvement
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Hundreds of studies have found that depressed
patients taking tricyclics have improved much more
than similar patients taking placebos
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs: Tricyclics
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Most patients who immediately stop taking tricyclics
upon relief of symptoms relapse within one year
Treatments for Unipolar Depression:
Biological Approaches
• Antidepressant drugs: Tricyclics
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Tricyclics are believed to reduce depression by
affecting neurotransmitter (NT) reuptake mechanisms
Treatments for Unipolar Depression:
Biological Approaches
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Antidepressant drugs: Tricyclics
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
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Most of the drugs in this group are labeled selective serotonin
reuptake inhibitors (SSRIs)
Treatments for Unipolar Depression:
Biological Approaches
• Second-generation antidepressant drugs
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– In effectiveness and speed of action of these drugs
are on a par with the tricyclics, yet their sales have
skyrocketed
Treatments for Unipolar Depression:
Biological Approaches
• As effective as antidepressant drugs are, it is
important to recognize that they do not work for
everyone
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– Even the most successful of them fails to help at least
35 percent of clients with depression
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Treatments for Unipolar Depression:
Biological Approaches
• Brain stimulation
• Vagus nerve stimulation
• Transcranial magnetic stimulation
• Deep brain stimulation
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– In recent years, three additional biological
approaches have been developed:
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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• __________ stimulation
Treatments for Unipolar Depression:
Biological Approaches
• ______________________
• ______________________
– Theorizing a “depression switch” located deep within
the brain, researchers have successfully
experimented with electrode implantation in the
brain's Brodman Area 25
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
– 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
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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• ______________
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
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– Unipolar depression seems to be an exception,
responding to any of several approaches
Abnormal Psychology | Ronald J. Comer | Ninth Edition
How Do the Treatments for Unipolar
Depression Compare?
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Findings from a number of treatment outcome
studies suggest that:
How Do the Treatments for Unipolar
Depression Compare?
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Findings from a number of treatment outcome
studies suggest that:
How Do the Treatments for Unipolar
Depression Compare?
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Findings from a number of treatment outcome
studies suggest that:
How Do the Treatments for Unipolar
Depression Compare?
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Findings from a number of treatment outcome
studies suggest that:
Treatments for Bipolar Disorder
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Until the latter part of the 20th century, people
with bipolar disorders were destined to spend
their lives on an emotional roller coaster
Treatments for Bipolar Disorder: Lithium and
Other Mood Stabilizers
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• The use of lithium (a metallic element naturally
occurring as mineral salt) and other mood-stabilizers
has dramatically changed this picture
Treatments for Bipolar Disorder: Lithium and
Other Mood Stabilizers
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• All manner of research has attested to the
effectiveness of lithium and other mood stabilizers in
treating manic episodes
Treatments for Bipolar Disorder: Lithium and
Other Mood Stabilizers
• Researchers do not fully understand how mood
stabilizing drugs operate
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
– They suspect that the drugs change synaptic activity in
neurons, but in a different way from that of antidepressant
drugs
Treatments for Bipolar Disorder: Adjunctive
Psychotherapy
– 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 medicationbased) therapy
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Psychotherapy alone is rarely helpful for
persons with bipolar disorder
• Mood stabilizing drugs alone are also not always
sufficient
Treatments for Bipolar Disorder: Adjunctive
Psychotherapy
– Growing research suggests that it helps reduce
hospitalization, improves social functioning, and
increases clients' ability to obtain and hold a job
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Therapy focuses on medication management,
social skills, and relationship issues
• Few controlled studies have tested the
effectiveness of such adjunctive therapy