Comer, Abnormal Psychology, 6e – Chapter 1 1 Chapter 9 Treatments for Mood Disorders Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University

Comer, Abnormal Psychology, 6e – Comer, Abnormal Psychology, 6e – Chapter 1Chapter 1

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Chapter 9Chapter 9

Treatments for Mood Treatments for Mood DisordersDisorders

Slides & Handouts by Karen Clay Slides & Handouts by Karen Clay Rhines, Ph.D.Rhines, Ph.D.

Seton Hall UniversitySeton Hall University

2Comer, Abnormal Psychology, 6e – Comer, Abnormal Psychology, 6e –

Chapter 1Chapter 1

Treatments for Mood Treatments for Mood DisordersDisorders

Mood disorders – as extraordinarily Mood disorders – as extraordinarily painful and disabling as they tend to painful and disabling as they tend to be – respond more successfully to be – respond more successfully to more kinds of treatments than do more kinds of treatments than do most other forms of psychological most other forms of psychological dysfunctiondysfunction This diversity of successful treatments This diversity of successful treatments

has affected individuals with depression has affected individuals with depression in both positive and negative waysin both positive and negative ways


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Treatments for Unipolar Treatments for Unipolar DepressionDepression

Approximately one-third of people Approximately one-third of people with unipolar depression (major with unipolar depression (major depressive or dysthymic disorder) depressive or dysthymic disorder) enter treatment in a given yearenter treatment in a given year In addition, many other people in In addition, many other people in

therapy experience depressed feelings therapy experience depressed feelings as part of another disorder – thus, much as part of another disorder – thus, much of the therapy being administered today of the therapy being administered today is for unipolar depressionis for unipolar depression


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Treatments for Unipolar Treatments for Unipolar DepressionDepression

A variety of treatment approaches A variety of treatment approaches are in widespread use are in widespread use These can be divided into psychological, These can be divided into psychological,

sociocultural, and biological approachessociocultural, and biological approaches


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Treatments for Unipolar Treatments for Unipolar Depression: Psychological Depression: Psychological

ApproachesApproaches Psychological approaches to treating Psychological approaches to treating

unipolar depression come from the three unipolar depression come from the three main models:main models: Psychodynamic – Widely used despite no strong Psychodynamic – Widely used despite no strong

research evidence of its effectivenessresearch evidence of its effectiveness

Behavioral – Primarily used for mild or Behavioral – Primarily used for mild or moderate depression but practiced less than in moderate depression but practiced less than in past decadespast decades

Cognitive – Has performed so well in research Cognitive – Has performed so well in research that it has a large and growing clinical followingthat it has a large and growing clinical following


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ApproachesApproaches Psychodynamic therapyPsychodynamic therapy

Believing that unipolar depression results from Believing that unipolar depression results from unconscious grief over real or imagined losses, unconscious grief over real or imagined losses, compounded by excessive dependence on other compounded by excessive dependence on other people, psychodynamic therapists seek to bring people, psychodynamic therapists seek to bring these issues into consciousness and work these issues into consciousness and work through themthrough them

Psychodynamic therapists use the same basic Psychodynamic therapists use the same basic procedures for all psychological disorders:procedures for all psychological disorders:

Free associationFree association

Therapist interpretationTherapist interpretation


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ApproachesApproaches Psychodynamic therapyPsychodynamic therapy

Despite successful case reports, researchers have Despite successful case reports, researchers have found that long-term psychodynamic therapy is found that long-term psychodynamic therapy is only occasionally helpful in cases of unipolar only occasionally helpful in cases of unipolar depressiondepression

Two features may be particularly limiting:Two features may be particularly limiting: Depressed clients may be too passive or weary to fully Depressed clients may be too passive or weary to fully

participate in clinical discussionsparticipate in clinical discussions Depressed clients may become discouraged and end Depressed clients may become discouraged and end

treatment too early when treatment doesn’t provide fast treatment too early when treatment doesn’t provide fast reliefrelief

Short-term approaches have performed better than Short-term approaches have performed better than traditional approachestraditional approaches


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ApproachesApproaches Behavioral therapyBehavioral therapy

Lewinsohn, whose theory tied a person’s Lewinsohn, whose theory tied a person’s mood to his/her life rewards, developed a mood to his/her life rewards, developed a behavioral therapy for unipolar depression behavioral therapy for unipolar depression in the 1970s:in the 1970s:

Reintroduce clients to pleasurable activities Reintroduce clients to pleasurable activities and events, often using a weekly scheduleand events, often using a weekly schedule

Appropriately reinforce their depressive and Appropriately reinforce their depressive and nondepressive behaviorsnondepressive behaviors

Use a contingency management approachUse a contingency management approach

Help them improve their social skillsHelp them improve their social skills


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ApproachesApproaches Behavioral therapyBehavioral therapy

The behavioral techniques seem to be of The behavioral techniques seem to be of only limited help when just one of them only limited help when just one of them is appliedis applied When treatment programs combine two or When treatment programs combine two or

three of the techniques, as Lewinsohn had three of the techniques, as Lewinsohn had envisioned, depressive symptoms envisioned, depressive symptoms (especially mild symptoms) seem to be (especially mild symptoms) seem to be reduced reduced


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ApproachesApproaches Cognitive therapyCognitive therapy

Beck views unipolar depression as Beck views unipolar depression as resulting from a pattern of negative resulting from a pattern of negative thinking that may be triggered by current thinking that may be triggered by current upsetting situationsupsetting situations

Maladaptive attitudes lead people to the Maladaptive attitudes lead people to the “cognitive triad”“cognitive triad”

Negatively viewing oneself, the world, and the futureNegatively viewing oneself, the world, and the future

These biased views combine with illogical These biased views combine with illogical thinking to produce automatic thoughtsthinking to produce automatic thoughts


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Beck’s cognitive therapy – the leading Beck’s cognitive therapy – the leading cognitive treatment for unipolar depression – cognitive treatment for unipolar depression – is designed to help clients recognize and is designed to help clients recognize and change their negative cognitive processeschange their negative cognitive processes

This approach follows four phases and This approach follows four phases and usually lasts fewer than 20 sessionsusually lasts fewer than 20 sessions

Phases:Phases:1.1. Increasing activities and elevate moodIncreasing activities and elevate mood

2.2. Challenging automatic thoughtsChallenging automatic thoughts

3.3. Identifying negative thinking and biasesIdentifying negative thinking and biases

4.4. Changing primary attitudesChanging primary attitudes


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Over the past three decades, hundreds Over the past three decades, hundreds of studies have shown that cognitive of studies have shown that cognitive therapy helps unipolar depressiontherapy helps unipolar depression

Around 50%Around 50%––60% of clients show a 60% of clients show a near-total elimination of symptomsnear-total elimination of symptoms

This treatment has also been used in a This treatment has also been used in a group therapy formatgroup therapy format


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Treatments for Unipolar Treatments for Unipolar Depression: Sociocultural Depression: Sociocultural

ApproachesApproaches Theorists trace the causes of unipolar Theorists trace the causes of unipolar

depression to the broader social depression to the broader social structure in which people live, and the structure in which people live, and the roles they are required to playroles they are required to play

The most effective sociocultural The most effective sociocultural approaches to treating unipolar approaches to treating unipolar depression are interpersonal depression are interpersonal psychotherapy and couple therapypsychotherapy and couple therapy The techniques used in these approaches The techniques used in these approaches

borrow from other modelsborrow from other models


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ApproachesApproaches Interpersonal therapy (IPT)Interpersonal therapy (IPT)

This model holds that four interpersonal This model holds that four interpersonal problems may lead to depression and must problems may lead to depression and must be addressed:be addressed:

Interpersonal lossInterpersonal loss Interpersonal role disputeInterpersonal role dispute Interpersonal role transitionInterpersonal role transition Interpersonal deficitsInterpersonal deficits

Studies suggest that IPT is as effective as Studies suggest that IPT is as effective as cognitive therapy for treating depressioncognitive therapy for treating depression


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ApproachesApproaches Couple therapyCouple therapy

The main type of couple therapy is The main type of couple therapy is behavioral marital therapy (BMT)behavioral marital therapy (BMT) Focus is on developing specific Focus is on developing specific

communication and problem-solving skillscommunication and problem-solving skills

If marriage is conflictual, BMT is as If marriage is conflictual, BMT is as effective as other therapies for reducing effective as other therapies for reducing depressiondepression


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Treatments for Unipolar Treatments for Unipolar Depression: Biological Depression: Biological

ApproachesApproaches Biological treatments can bring great Biological treatments can bring great

relief to people with unipolar relief to people with unipolar depressiondepression

Usually biological treatment means Usually biological treatment means antidepressant drugs, but for severely antidepressant drugs, but for severely depressed persons who do not depressed persons who do not respond to other forms of treatment, respond to other forms of treatment, it sometimes includes it sometimes includes electroconvulsive therapyelectroconvulsive therapy


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ApproachesApproaches Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT)

The use of ECT was -- and is -- controversialThe use of ECT was -- and is -- controversial It is now used frequently but only in severe casesIt is now used frequently but only in severe cases

The procedure consists of targeted electrical The procedure consists of targeted electrical stimulation to cause a brain seizurestimulation to cause a brain seizure

The usual course of treatment is 6The usual course of treatment is 6 to to 12 sessions 12 sessions spaced over two to four weeksspaced over two to four weeks

Treatment may be bilateral or unilateralTreatment may be bilateral or unilateral


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The discovery of the effectiveness of ECT was The discovery of the effectiveness of ECT was accidental and based on a fallacious link accidental and based on a fallacious link between psychosis and epilepsybetween psychosis and epilepsy

The procedure has been modified in recent The procedure has been modified in recent years to reduce some of the negative effectsyears to reduce some of the negative effects For example, patients are given muscle relaxants For example, patients are given muscle relaxants

and anesthetics before and during the procedureand anesthetics before and during the procedure

Patients generally report some memory lossPatients generally report some memory loss


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ECT is clearly effective in treating unipolar ECT is clearly effective in treating unipolar depressiondepression

Studies find improvement in 60%Studies find improvement in 60%––70% of patients 70% of patients

The procedure seems particularly effective in cases The procedure seems particularly effective in cases of severe depression with delusions, but it has of severe depression with delusions, but it has been difficult to determine why ECT works so wellbeen difficult to determine why ECT works so well

Although effective, the use of ECT has declined Although effective, the use of ECT has declined since the 1950s, because of the memory loss since the 1950s, because of the memory loss caused by the procedure and the emergence of caused by the procedure and the emergence of effective antidepressant drugseffective antidepressant drugs


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ApproachesApproaches Antidepressant drugsAntidepressant drugs

In the 1950s, two kinds of drugs were In the 1950s, two kinds of drugs were found to be effective:found to be effective: Monoamine oxidase inhibitors (MAO Monoamine oxidase inhibitors (MAO

inhibitors)inhibitors)

TricyclicsTricyclics

These drugs have been joined in recent These drugs have been joined in recent years by a third group, the second-years by a third group, the second-generation antidepressantsgeneration antidepressants


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ApproachesApproaches Antidepressant drugs: MAO inhibitorsAntidepressant drugs: MAO inhibitors

Originally used to treat TB, doctors noticed that Originally used to treat TB, doctors noticed that the medication seemed to make patients happierthe medication seemed to make patients happier

The drug works biochemically by slowing down The drug works biochemically by slowing down the body’s production of MAOthe body’s production of MAO

MAO breaks down norepinephrineMAO breaks down norepinephrine

MAO inhibitors stop this breakdown from occurringMAO inhibitors stop this breakdown from occurring

This leads to a rise in norepinephrine activity and a This leads to a rise in norepinephrine activity and a reduction in depressive symptoms reduction in depressive symptoms

About half of patients who take these drugs are helped by About half of patients who take these drugs are helped by themthem


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ApproachesApproaches Antidepressant drugs: MAO inhibitorsAntidepressant drugs: MAO inhibitors

MAO inhibitors potentially pose a serious MAO inhibitors potentially pose a serious danger!danger!

Blood pressure may rise to a potentially fatal level Blood pressure may rise to a potentially fatal level if one eats foods with tyramine (cheese, bananas, if one eats foods with tyramine (cheese, bananas, wine) while taking MAOIswine) while taking MAOIs

In recent years, a new MAO inhibitor in the In recent years, a new MAO inhibitor in the form of a skin patch has become availableform of a skin patch has become available

Dangerous food interactions do not appear to be as Dangerous food interactions do not appear to be as common a problem with this kind of MAO inhibitorcommon a problem with this kind of MAO inhibitor


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ApproachesApproaches Antidepressant drugs: TricyclicsAntidepressant drugs: Tricyclics

In searching for medications for In searching for medications for schizophrenia, researchers discovered schizophrenia, researchers discovered that imipramine lessened depressive that imipramine lessened depressive symptomssymptoms Imipramine and related drugs are known as Imipramine and related drugs are known as

tricyclics because they share a three-ring tricyclics because they share a three-ring molecular structuremolecular structure


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ApproachesApproaches Antidepressant drugs: Tricyclics Antidepressant drugs: Tricyclics

Hundreds of studies have found that Hundreds of studies have found that depressed patients taking tricyclics depressed patients taking tricyclics have improved much more than similar have improved much more than similar patients taking placebospatients taking placebos Drugs must be taken for at least 10 days Drugs must be taken for at least 10 days

before such improvement is seenbefore such improvement is seen

About 60%About 60%––65% of patients find symptom 65% of patients find symptom improvementimprovement


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Most patients who immediately stop Most patients who immediately stop taking tricyclics upon relief of symptoms taking tricyclics upon relief of symptoms relapse within one yearrelapse within one year Patients who take tricyclics for five additional Patients who take tricyclics for five additional

months (“continuation therapy”) have a months (“continuation therapy”) have a significantly decreased risk of relapsesignificantly decreased risk of relapse

Patients who take antidepressant drugs for Patients who take antidepressant drugs for three or more years after initial improvement three or more years after initial improvement (“maintenance therapy”) may reduce the risk (“maintenance therapy”) may reduce the risk of relapse even moreof relapse even more


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ApproachesApproaches Antidepressant drugs: TricyclicsAntidepressant drugs: Tricyclics

Tricyclics are believed to reduce depression by Tricyclics are believed to reduce depression by affecting neurotransmitter (NT) reuptakeaffecting neurotransmitter (NT) reuptake

To prevent an NT from remaining in the synapse too To prevent an NT from remaining in the synapse too long, a pumplike mechanism recaptures the NT and long, a pumplike mechanism recaptures the NT and draws it back into the presynaptic neurondraws it back into the presynaptic neuron

The reuptake process appears to be too effective in The reuptake process appears to be too effective in some people, drawing in too much of the NT from the some people, drawing in too much of the NT from the synapsesynapse

This reduction in NT activity in the synapse is thought This reduction in NT activity in the synapse is thought to result in clinical depressionto result in clinical depression

Tricyclics block the reuptake process, thus increasing Tricyclics block the reuptake process, thus increasing NT activity in the synapse NT activity in the synapse


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There is growing evidence that when tricyclics There is growing evidence that when tricyclics are ingested, they initially slow down the activity are ingested, they initially slow down the activity of the neurons that use norepinephrine and of the neurons that use norepinephrine and serotoninserotonin

After a week or two, the neurons adapt to the After a week or two, the neurons adapt to the drugs and go back to releasing normal amounts drugs and go back to releasing normal amounts of the NTsof the NTs

Today tricyclics are prescribed more often than Today tricyclics are prescribed more often than MAO inhibitorsMAO inhibitors

They do not require dietary restrictionsThey do not require dietary restrictions Some patients show higher rates of improvementSome patients show higher rates of improvement


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ApproachesApproaches Second-generation antidepressant drugsSecond-generation antidepressant drugs

A third group of effective antidepressant drugs is A third group of effective antidepressant drugs is structurally different from the MAO inhibitors and structurally different from the MAO inhibitors and tricyclicstricyclics

Most of the drugs in this group are labeled selective serotonin Most of the drugs in this group are labeled selective serotonin reuptake inhibitors (SSRIs)reuptake inhibitors (SSRIs)

These drugs act only on serotonin (no other NTs are These drugs act only on serotonin (no other NTs are affected)affected)

This class includes fluoxetine (Prozac) and sertraline (Zoloft)This class includes fluoxetine (Prozac) and sertraline (Zoloft)

Selective norepinephrine reuptake inhibitors and Selective norepinephrine reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are also serotonin-norepinephrine reuptake inhibitors are also now availablenow available


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ApproachesApproaches Second-generation antidepressant drugsSecond-generation antidepressant drugs

The effectiveness and speed of action of these The effectiveness and speed of action of these drugs is on par with the tricyclics yet they boast drugs is on par with the tricyclics yet they boast enormous salesenormous sales

Clinicians often prefer these drugs because it is harder to Clinicians often prefer these drugs because it is harder to overdose on them than on other kinds of antidepressantsoverdose on them than on other kinds of antidepressants

There are no dietary restrictions like there are with MAO There are no dietary restrictions like there are with MAO inhibitorsinhibitors

There have fewer side effects than the tricyclicsThere have fewer side effects than the tricyclics

These drugs may cause some undesired effects of These drugs may cause some undesired effects of their own, including a reduction in sex drivetheir own, including a reduction in sex drive


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How Do the Treatments How Do the Treatments for Unipolar Depression for Unipolar Depression

Compare?Compare? For most kinds of psychological For most kinds of psychological

disorders, no more than one or two disorders, no more than one or two treatments, if any, emerge as treatments, if any, emerge as successfulsuccessful Unipolar depression seems to be the Unipolar depression seems to be the

exception, responding to any of several exception, responding to any of several approachesapproaches


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Compare?Compare? Findings from a number of research Findings from a number of research

studies suggest that:studies suggest that: Cognitive, interpersonal, and biological Cognitive, interpersonal, and biological

therapies are all highly effective therapies are all highly effective treatments for mild to severe unipolar treatments for mild to severe unipolar depressiondepression

Although cognitive and interpersonal Although cognitive and interpersonal therapies may lower the likelihood of therapies may lower the likelihood of relapse, they are hardly relapse-proofrelapse, they are hardly relapse-proof


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studies suggest that:studies suggest that: When persons with unipolar depression When persons with unipolar depression

experience significant marital discord, experience significant marital discord, couple therapy tends to be very helpfulcouple therapy tends to be very helpful

Depressed people who receive strictly Depressed people who receive strictly behavioral therapy have shown less behavioral therapy have shown less improvement than those who receive improvement than those who receive cognitive, interpersonal, or biological cognitive, interpersonal, or biological therapytherapy


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studies suggest that:studies suggest that: Psychodynamic therapies are less Psychodynamic therapies are less

effective than other therapies in effective than other therapies in treating all levels of unipolar depressiontreating all levels of unipolar depression

A combination of psychotherapy and A combination of psychotherapy and drug therapy is modestly more helpful drug therapy is modestly more helpful to depressed people than either to depressed people than either treatment alonetreatment alone


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studies suggest that:studies suggest that: Among biological treatments, Among biological treatments,

antidepressant drugs and ECT appear antidepressant drugs and ECT appear to be equally effective for reducing to be equally effective for reducing depression, although ECT seems to act depression, although ECT seems to act more quicklymore quickly


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Treatments for Bipolar Treatments for Bipolar DisordersDisorders

Until the latter part of the 20Until the latter part of the 20thth century, century, people with bipolar disorders were people with bipolar disorders were destined to spend their lives on an destined to spend their lives on an emotional roller coasteremotional roller coaster Psychotherapists reported almost no successPsychotherapists reported almost no success Antidepressant drugs were of limited helpAntidepressant drugs were of limited help

These drugs sometimes triggered manic episodesThese drugs sometimes triggered manic episodes

ECT only occasionally relieved either the ECT only occasionally relieved either the depressive or the manic episodes of bipolar depressive or the manic episodes of bipolar disorderdisorder


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Treatments for Bipolar Treatments for Bipolar Disorders: Lithium TherapyDisorders: Lithium Therapy

The use of lithium, a metallic element The use of lithium, a metallic element occurring as mineral salt, has occurring as mineral salt, has dramatically changed this picturedramatically changed this picture It is extraordinarily effective in treating It is extraordinarily effective in treating

bipolar disorders and maniabipolar disorders and mania Determining the correct dosage for a Determining the correct dosage for a

given patient is a delicate processgiven patient is a delicate process Too low = no effectToo low = no effect Too high = lithium intoxication (poisoning)Too high = lithium intoxication (poisoning)


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Treatments for Bipolar Treatments for Bipolar Disorder: Lithium TherapyDisorder: Lithium Therapy

Lithium provides improvement for more Lithium provides improvement for more than 60% of manic patientsthan 60% of manic patients Most patients also experience fewer new Most patients also experience fewer new

episodes while on the drugepisodes while on the drug

Lithium also is a prophylactic drug, one that Lithium also is a prophylactic drug, one that actually prevents symptoms from developingactually prevents symptoms from developing

Lithium also helps those with bipolar Lithium also helps those with bipolar disorder overcome their depressive disorder overcome their depressive episodesepisodes


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Treatments for Bipolar Treatments for Bipolar Disorder: Lithium TherapyDisorder: Lithium Therapy

Researchers do not fully understand how Researchers do not fully understand how lithium operateslithium operates They suspect that it changes synaptic activity They suspect that it changes synaptic activity

in neurons, but in a different way from that of in neurons, but in a different way from that of antidepressant drugsantidepressant drugs

Although antidepressant drugs affect a neuron’s Although antidepressant drugs affect a neuron’s initial reception on NTs, lithium seems to affect a initial reception on NTs, lithium seems to affect a neuron’s second messengersneuron’s second messengers

Another theory is that lithium corrects bipolar Another theory is that lithium corrects bipolar functioning by directly changing sodium and functioning by directly changing sodium and potassium ion activity in neuronspotassium ion activity in neurons


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Treatments for Bipolar Treatments for Bipolar Disorder: Adjunctive Disorder: Adjunctive

PsychotherapyPsychotherapy Psychotherapy alone is rarely helpful for Psychotherapy alone is rarely helpful for

persons with bipolar disorderpersons with bipolar disorder

Lithium therapy alone is also not always Lithium therapy alone is also not always sufficient, eithersufficient, either 30% or more of patients don’t respond, may not 30% or more of patients don’t respond, may not

receive the correct dose, or may relapse while receive the correct dose, or may relapse while taking ittaking it

As a result, clinicians often use As a result, clinicians often use psychotherapy as an adjunct to lithium (or psychotherapy as an adjunct to lithium (or other medication-based) therapyother medication-based) therapy


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Treatments for Bipolar Treatments for Bipolar Disorder: Adjunctive Disorder: Adjunctive

PsychotherapyPsychotherapy Therapy focuses on medication Therapy focuses on medication

management, social skills, and management, social skills, and relationship issuesrelationship issues

Few controlled studies have tested the Few controlled studies have tested the effectiveness of such adjunctive therapyeffectiveness of such adjunctive therapy Growing research suggests that it helps Growing research suggests that it helps

reduce hospitalization, improves social reduce hospitalization, improves social functioning, and increases clients’ ability to functioning, and increases clients’ ability to obtain and hold a jobobtain and hold a job

Documents

Comer, Abnormal Psychology, 6e – Chapter 1 1 Chapter 9 Treatments for Mood Disorders Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University