Treatments for Mood Disorders

1. Treatments for Mood Disorders Chapter 9 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

2. 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 Comer, Abnormal Psychology,8e DSM-5 Update

3. 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 Comer, Abnormal Psychology,8e DSM-5 Update

4. Treatments for Unipolar Depression • A variety of treatment approaches are currently in widespread use • These can be divided into psychological, sociocultural, and biological approaches Comer, Abnormal Psychology,8e DSM-5 Update

5. 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 Comer, Abnormal Psychology,8e DSM-5 Update

6. 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 Comer, Abnormal Psychology,8e DSM-5 Update

7. 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 Comer, Abnormal Psychology,8e DSM-5 Update

8. 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 Comer, Abnormal Psychology,8e DSM-5 Update

9. 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 Comer, Abnormal Psychology,8e DSM-5 Update

10. 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 Comer, Abnormal Psychology,8e DSM-5 Update

11. 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 Comer, Abnormal Psychology,8e DSM-5 Update

12. 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 Comer, Abnormal Psychology,8e DSM-5 Update

13. 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 Comer, Abnormal Psychology,8e DSM-5 Update

14. 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 Comer, Abnormal Psychology,8e DSM-5 Update

15. 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 Comer, Abnormal Psychology,8e DSM-5 Update

16. 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 Comer, Abnormal Psychology,8e DSM-5 Update

17. 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 Comer, Abnormal Psychology,8e DSM-5 Update

18. 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 Comer, Abnormal Psychology,8e DSM-5 Update

19. 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 Comer, Abnormal Psychology,8e DSM-5 Update

20. 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 Comer, Abnormal Psychology,8e DSM-5 Update

21. 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 Comer, Abnormal Psychology,8e DSM-5 Update

22. 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 Comer, Abnormal Psychology,8e DSM-5 Update

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24. 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 Comer, Abnormal Psychology,8e DSM-5 Update

25. 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 Comer, Abnormal Psychology,8e DSM-5 Update

26. 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 Comer, Abnormal Psychology,8e DSM-5 Update

27. 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 Comer, Abnormal Psychology,8e DSM-5 Update

28. 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 Comer, Abnormal Psychology,8e DSM-5 Update

29. 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 Comer, Abnormal Psychology,8e DSM-5 Update

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31. 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 Comer, Abnormal Psychology,8e DSM-5 Update

32. 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 • Most of the drugs in this group are labeled selective serotonin reuptake inhibitors (SSRIs) • 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 Comer, Abnormal Psychology,8e DSM-5 Update

33. 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 Comer, Abnormal Psychology,8e DSM-5 Update

34. 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 Comer, Abnormal Psychology,8e DSM-5 Update

35. 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 Comer, Abnormal Psychology,8e DSM-5 Update

36. 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 Comer, Abnormal Psychology,8e DSM-5 Update

37. 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 Comer, Abnormal Psychology,8e DSM-5 Update

38. 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 Comer, Abnormal Psychology,8e DSM-5 Update

39. 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 Comer, Abnormal Psychology,8e DSM-5 Update

40. 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 Comer, Abnormal Psychology,8e DSM-5 Update

41. 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 DSM-5 Update

42. 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 Comer, Abnormal Psychology,8e DSM-5 Update

43. 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 Comer, Abnormal Psychology,8e DSM-5 Update

44. 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 Comer, Abnormal Psychology,8e DSM-5 Update

45. Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers • The use of lithium (a metallic element naturally occurring as mineral salt) and other mood-stabilizers 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 Comer, Abnormal Psychology,8e DSM-5 Update

46. 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 Comer, Abnormal Psychology,8e DSM-5 Update

47. 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 Comer, Abnormal Psychology,8e DSM-5 Update

48. 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 Comer, Abnormal Psychology,8e DSM-5 Update

49. 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 Comer, Abnormal Psychology,8e DSM-5 Update