Treatments for Mood Disorders

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Chapter 9

• Treatments for Mood Disorders

Slides Handouts by Karen Clay Rhines,
Ph.D. Seton Hall University
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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

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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

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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

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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

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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 fatigued
  to fully participate in clinical discussions
• Depressed clients may become discouraged and end
  treatment too early when treatment doesnt
  provide fast relief
• Short-term approaches have performed better than
  traditional approaches

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Treatments for Unipolar Depression Psychological
Approaches

• Behavioral therapy
• Lewinsohn, whose theory tied a persons 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

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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 used
• When treatment programs combine two or three of
  the techniques, as Lewinsohn had envisioned,
  depressive symptoms (especially mild symptoms)
  seem to be reduced

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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

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Treatments for Unipolar Depression Psychological
Approaches

• Cognitive therapy
• Becks 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

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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 5060 of clients show near elimination of
  symptoms
• This treatment has also been used in a group
  therapy format

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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

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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

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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

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

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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

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Treatments for Unipolar Depression Biological
Approaches

• Electroconvulsive therapy (ECT)
• The discovery of ECTs 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

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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 6070 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

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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

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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 bodys
  production of MAO
• MAO breaks down norepinephrine
• MAOIs stop this breakdown from occurring

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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

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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

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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 6065 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 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

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

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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

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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

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

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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

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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

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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

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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

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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

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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)

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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

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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 neurons
  initial reception on NTs, lithium seems to affect
  a neurons second messengers
• Another theory is that lithium corrects 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
• Lithium therapy is also not always effective
  alone
• 30 of patients dont 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

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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 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