Transcript Comer, Abnormal Psychology, 8th edition

Treatments for
Mood Disorders
Chapter 9
Slides & Handouts by Karen Clay Rhines, Ph.D.
American Public University System
Comer, Abnormal Psychology, 8e
DSM-5 Update
Treatments for Mood Disorders

Disorders of mood – as painful and disabling as
they tend to be – respond more successfully to
more kinds of treatments than do most other
forms of psychological dysfunction

This range of treatment options has been a source of
reassurance and hope for the millions of people who
desire to regain some measure of control over their
moods
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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


Access differs among ethnic and racial groups
In addition, many people in therapy
experience depressed feelings as part of
another disorder – thus, much of the therapy
being done today is for unipolar depression
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Treatments for
Unipolar Depression

A variety of treatment approaches are
currently in widespread use

These can be divided into psychological,
sociocultural, and biological approaches
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Treatments for Unipolar Depression:
Sociocultural Approaches

Multicultural treatments

Culture-sensitive therapies 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
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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 has a success rate similar to
cognitive and cognitive-behavior therapies for treating
depression
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Treatments for Unipolar Depression:
Sociocultural Approaches

Family-Social Treatments

Couple therapy

Since depression can result from marital discord, it
is not surprising that many cases of depression have
been treated by couple therapy

Behavioral marital therapy focuses on developing specific
communication and problem-solving skills

When the depressed person’s marriage is filled with
conflict, this approach is as effective as other therapies for
reducing depression
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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
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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 fastacting 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
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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
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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
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Treatments for Unipolar Depression:
Biological Approaches

Electroconvulsive therapy (ECT)

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
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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
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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
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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
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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
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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
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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
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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
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Comer, Abnormal Psychology,8e
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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
Patients typically show higher rates of improvement
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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)


Most of the drugs in this group are labeled selective serotonin
reuptake inhibitors (SSRIs)
This class includes fluoxetine (Prozac), sertraline (Zoloft), and
escitalopram (Lexapro)
Selective norepinephrine reuptake inhibitors and serotoninnorepinephrine reuptake inhibitors are also now available
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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
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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
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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
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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
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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 Brodmann Area 25
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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
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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
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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
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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 helpful

Depressed people who receive strictly behavioral
therapy have shown less improvement than those
who receive cognitive, cognitive-behavioral,
interpersonal, or biological therapy
Comer, Abnormal Psychology,8e
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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
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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
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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
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Treatments for Bipolar Disorder:
Lithium and Other Mood Stabilizers

The use of lithium (a metallic element naturally
occurring as mineral salt) and other moodstabilizers 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
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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
they continue taking the medications
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
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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 reduce bipolar symptoms
Another theory is that mood stabilizers correct bipolar
functioning by directly changing sodium and potassium ion
activity in neurons
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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 medicationbased) therapy
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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
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