Transcript Comer, Abnormal Psychology, 8th edition

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
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
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:

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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 problemsolving 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
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


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
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 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

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
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