Chapter 9

1. Chapter 9 Treatments for Mood Disorders Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University

2. Treatments for Mood Disorders • Mood disorders – as extraordinarily 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 diversity is in some ways puzzling for researchers and clinicians, but it is also a source of reassurance for those with a disorder • Between one-third and one-half of people with mood disorders enter treatment in a given year • Many find they improve as a result

3. Treatments for Unipolar Depression • Ten percent of clients seeking psychological help suffer primarily from unipolar depression • Additionally, many other people in therapy report depressive symptoms and feelings • A variety of treatment approaches are in widespread use • These can be divided into psychological and biological approaches

4. Treatments for Unipolar Depression: Psychological Approaches • Psychological approaches to treating unipolar depression come from the three main models: • Psychodynamic – No strong research evidence for effectiveness • Behavioral – Effective for mild and moderate depression • Cognitive – Excellent research support

5. 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

6. 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 fatigued to fully participate in clinical discussions • Depressed clients may become discouraged and end treatment too early when treatment doesn’t provide fast relief • Short-term approaches have performed better than traditional approaches

7. Treatments for Unipolar Depression: Psychological Approaches • Behavioral therapy • Lewinsohn, whose theory tied a person’s mood to his/her life rewards, developed a behavioral therapy for unipolar depression: • Reintroduce clients to pleasurable activities and events • Use a Pleasant Events Schedule and Activities Schedule • Appropriately reinforce their depressive and nondepressive behaviors • Use a contingency management approach • Help them improve their social skills

8. Treatments for Unipolar Depression: Psychological Approaches • Behavioral therapy • The behavioral techniques seem to be of only limited help when just one of them is used • When treatment programs combine two or three of the techniques, as Lewinsohn had envisioned, depressive symptoms (especially mild symptoms) seem to be reduced

9. Treatments for Unipolar Depression: Psychological Approaches • Cognitive therapy • Beck views 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”: • Negatively viewing themselves, the world, and the future • These biased views combine with illogical thinking to produce automatic thoughts

10. Treatments for Unipolar Depression: Psychological Approaches • Cognitive therapy • Beck’s cognitive therapy – the leading cognitive treatment for unipolar depression – 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: • Increase activities and elevate mood • Challenge automatic thoughts • Identify negative thinking and biases • Change primary attitudes

11. Treatments for Unipolar Depression: Psychological Approaches • Cognitive therapy • Over the past three decades, hundreds of studies have shown that cognitive therapy helps unipolar depression • Around 50–60% of clients show near elimination of symptoms • This treatment has also been used in a group therapy format

12. Treatments for Unipolar Depression: Sociocultural Approaches • Theorists propose that unipolar depression is greatly influenced by the social structure in which people live • The most effective sociocultural approaches to treating unipolar depression are interpersonal psychotherapy and couple therapy • The techniques used in these approaches borrow from other models

13. 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

14. Treatments for Unipolar Depression: Sociocultural Approaches • 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 conflictual, BMT is as effective as other therapies for reducing depression

15. 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 persons who do not respond to other forms of treatment, it sometimes includes electroconvulsive therapy

16. Treatments for Unipolar Depression: Biological Approaches • Electroconvulsive therapy (ECT) • The use of ECT was and is controversial • It is now used frequently but only in severe cases • The procedure consists of targeted electrical stimulation to cause a brain seizure • The usual course of treatment is 6 to 12 sessions spaced over two to four weeks • Treatment may be bilateral or unilateral

17. Treatments for Unipolar Depression: Biological Approaches • Electroconvulsive therapy (ECT) • The discovery of ECT’s effectiveness was accidental and based on a fallacious link between psychosis and epilepsy • First major form of treatment • 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

18. Treatments for Unipolar Depression: Biological Approaches • Electroconvulsive therapy (ECT) • ECT is clearly effective in treating unipolar depression • Studies find improvement in 60–70% of patients • The procedure seems particularly effective in cases of severe depression with delusions • Although effective, the use of ECT has declined since the 1950s, due to the memory loss caused by the procedure and the emergence of effective antidepressant drugs

19. Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs • In the 1950s, two kinds of drugs were found to be effective: • Monoamine oxidase inhibitors (MAOIs) • Tricyclics • In the 1980s, “second-generation” drugs were developed

21. Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Monoamine oxidase inhibitors (MAOIs) • Originally used to treat TB, doctors noticed that the medication seemed to make patients happier • The drug works by slowing down the body’s production of MAO • MAO breaks down norepinephrine • MAOIs stop this breakdown from occurring

22. Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: MAOIs • MAOIs potentially pose a serious danger! • Blood pressure may rise to a potentially fatal level if one eats foods with tyramine (cheese, bananas, wine) while taking MAOIs • Newer drugs, called reversible selective MAOIs, pose fewer of these dangers

23. Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Tricyclics • In searching for medications for schizophrenia, researchers discovered that imipramine lessened depressive symptoms • Imipramine and related drugs are known as “tricyclics” because they share a three-ring molecular structure

24. 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

25. 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

26. Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Tricyclics • Tricyclics are believed to reduce depression by affecting NT “reuptake” • In order 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 effective 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

28. 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 • Today tricyclics are prescribed more often than MAOIs • They do not require dietary restrictions • Some patients show higher rates of improvement than on MAOIs

29. Treatments for Unipolar Depression: Biological Approaches • Second-generation antidepressant drugs • A third group of effective antidepressant drugs is structurally different from the MAOIs and tricyclics • Most of the drugs in this third group are selective serotonin reuptake inhibitors (SSRIs) • These drugs act only on serotonin (no other NTs are affected) • This class includes fluoxetine (Prozac) and sertraline (Zoloft) • Selective norepinephrine reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the newer second-generation antidepressants

30. Treatments for Unipolar Depression: Biological Approaches • Second-generation antidepressant drugs • The effectiveness of these drugs is on par with the tricyclics yet they boast ENORMOUS sales • 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 MAOIs • There have fewer side effects than the tricyclics • These drugs may cause some undesired effects of their own, including a reduction in sex drive

31. 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 successful • Unipolar depression seems to be the exception, responding to any of several approaches

32. How Do the Treatments for Unipolar Depression Compare? • Findings from a number of research studies suggest that: • Cognitive, interpersonal, and biological therapies are all highly effective treatments for mild to severe unipolar depression • Although cognitive and interpersonal therapies may lower the likelihood of relapse, they are hardly relapse-proof

33. How Do the Treatments for Unipolar Depression Compare? • Findings from a number of research studies suggest that: • When persons 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, interpersonal, or biological therapy

34. How Do the Treatments for Unipolar Depression Compare? • Findings from a number of research studies suggest that: • 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

35. How Do the Treatments for Unipolar Depression Compare? • Findings from a number of research studies suggest that: • Among the biological treatments, antidepressant drugs and ECT appear to be equally effective for reducing depression, although ECT seems to act more quickly

36. Treatments for Bipolar Disorders • Until the past three decades, 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

37. Treatments for Bipolar Disorders: Lithium Therapy • Discovered in 1949, lithium is a metallic element occurring as mineral salt • It is extraordinarily effective in treating bipolar disorders and mania • Determining the correct dosage for a given patient is a difficult process • Too low = no effect • Too high = lithium intoxication (poisoning)

38. Treatments for Bipolar Disorder: Lithium Therapy • Lithium provides improvement for 60% of manic patients • Most patients also experience fewer new episodes while on the drug • Lithium may be a prophylactic drug, one that actually prevents symptoms from developing • Lithium also helps those with bipolar disorder overcome their depressive episodes

39. Treatments for Bipolar Disorder: Lithium Therapy • Researchers do not fully understand how lithium operates • They suspect that it changes synaptic activity in neurons, but in a different way than antidepressant drugs • While antidepressant drugs affect a neuron’s initial reception on NTs, lithium seems to affect a neuron’s second messengers • Another theory is that lithium corrects bipolar functioning by directly changing sodium and potassium ion activity in neurons

40. Treatments for Bipolar Disorder: Adjunctive Psychotherapy • Psychotherapy alone is rarely helpful for persons with bipolar disorder • Lithium therapy is also not always effective alone • 30% of patients don’t respond, may not receive the correct dose, or may relapse while taking it • As a result, clinicians often use psychotherapy to supplement lithium (or other medication-based) therapy

41. Treatments for Bipolar Disorder: Adjunctive Psychotherapy • Therapy focuses on medication management, social skills, and relationship issues • Few controlled studies have tested the effectiveness of psychotherapy as an adjunct to drug therapy for severe bipolar disorders • Growing research suggests that it helps reduce hospitalization, improves social functioning, and increases clients’ ability to obtain and hold a job