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Chapter 8 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Treatment for Depressive and Bipolar Disorders Treatments for Unipolar Depression – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Around half of persons with unipolar depression (major depressive or dysthymic disorder) receive treatment from a mental health professional each year Treatments for Unipolar Depression • A variety of treatment approaches are currently in widespread use Copyright © 2015 by Worth Publishers. All rights reserved – These can be divided into psychological, sociocultural, and biological approaches Abnormal Psychology | Ronald J. Comer | Ninth Edition Treatments for Unipolar Depression: Psychological Approaches – ___________ – Widely used despite no strong research evidence of its effectiveness – ___________ – Primarily used for mild or moderate depression but practiced less than in past decades – ___________ – Has performed so well in research that it has a large and growing clinical following Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Psychological treatments used most often to combat unipolar depression come from three main schools of thought: Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Psychodynamic therapy Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Psychodynamic therapy Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Behavioral therapy Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Behavioral therapy Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Cognitive therapy Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Cognitive therapy Treatments for Unipolar Depression: Psychological Approaches • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Cognitive therapy • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Treatments for Unipolar Depression: Sociocultural Approaches • Cognitive-behavioral and other therapists who work with depressed clients often instruct the clients to keep track of their mood changes— hour by hour, day by day—and to also note the situations and thoughts that cause their moods to change • Mood tracking apps for smartphones are gaining in popularity • Can you think of other uses, advantages, and disadvantages that might result from the growing use of mood-tracking apps? Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Mood Tracking Treatments for Unipolar Depression: Sociocultural Approaches – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • ___________ treatments Treatments for Unipolar Depression: Sociocultural Approaches • _____________ Treatments – Interpersonal therapy (IPT) – – – – Interpersonal loss Interpersonal role dispute Interpersonal role transition Interpersonal deficits • Studies suggest that IPT is as effective as cognitive therapy for treating depression Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • This model holds that four interpersonal problems may lead to depression and must be addressed: Treatments for Unipolar Depression: Sociocultural Approaches • Family-Social Treatments – Couple therapy – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • The main type of couple therapy is behavioral marital therapy (BMT) • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Treatments for Unipolar Depression: Biological Approaches Treatments for Unipolar Depression: Biological Approaches • ______________ therapy (ECT) – One of the most controversial forms of treatment – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • It is used frequently because it is an effective and fast-acting intervention Treatments for Unipolar Depression: Biological Approaches – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Electroconvulsive therapy (ECT) Treatments for Unipolar Depression: Biological Approaches • Electroconvulsive therapy (ECT) – ECT is clearly effective in treating unipolar depression – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Studies find improvement in 60%–80% of patients Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs – In the 1950s, two kinds of drugs were found to reduce the symptoms of depression: – These drugs have been joined in recent years by a third group, the second-generation antidepressants Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Monoamine oxidase inhibitors (MAO inhibitors) • Tricyclics Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: MAO inhibitors • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – 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 Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: MAO inhibitors – MAO inhibitors pose a potential danger – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • People who take MAOIs experience a dangerous rise in blood pressure if they eat foods containing tyramine (cheese, bananas, wine) Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Tricyclics • Imipramine and related drugs are known as tricyclics because they share a three-ring molecular structure Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – In searching for medications for schizophrenia, researchers discovered that imipramine relieved depressive symptoms Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Tricyclics • Drugs must be taken for at least 10 days before such improvement is seen • About 60%–65% of patients find symptom improvement Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Hundreds of studies have found that depressed patients taking tricyclics have improved much more than similar patients taking placebos Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Tricyclics • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Most patients who immediately stop taking tricyclics upon relief of symptoms relapse within one year Treatments for Unipolar Depression: Biological Approaches • Antidepressant drugs: Tricyclics • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Tricyclics are believed to reduce depression by affecting neurotransmitter (NT) reuptake mechanisms Treatments for Unipolar Depression: Biological Approaches – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Antidepressant drugs: Tricyclics 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) • This class includes fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro) – Selective norepinephrine reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are also now available Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Most of the drugs in this group are labeled selective serotonin reuptake inhibitors (SSRIs) Treatments for Unipolar Depression: Biological Approaches • Second-generation antidepressant drugs • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – In effectiveness and speed of action of these drugs are on a par with the tricyclics, yet their sales have skyrocketed Treatments for Unipolar Depression: Biological Approaches • As effective as antidepressant drugs are, it is important to recognize that they do not work for everyone Copyright © 2015 by Worth Publishers. All rights reserved – Even the most successful of them fails to help at least 35 percent of clients with depression Abnormal Psychology | Ronald J. Comer | Ninth Edition Treatments for Unipolar Depression: Biological Approaches • Brain stimulation • Vagus nerve stimulation • Transcranial magnetic stimulation • Deep brain stimulation Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – In recent years, three additional biological approaches have been developed: Treatments for Unipolar Depression: Biological Approaches – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • __________ stimulation Treatments for Unipolar Depression: Biological Approaches • ______________________ • ______________________ – Theorizing a “depression switch” located deep within the brain, researchers have successfully experimented with electrode implantation in the brain's Brodman Area 25 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – 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 Treatments for Unipolar Depression: Biological Approaches – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • ______________ 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 Copyright © 2015 by Worth Publishers. All rights reserved – Unipolar depression seems to be an exception, responding to any of several approaches Abnormal Psychology | Ronald J. Comer | Ninth Edition How Do the Treatments for Unipolar Depression Compare? – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Findings from a number of treatment outcome studies suggest that: How Do the Treatments for Unipolar Depression Compare? – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Findings from a number of treatment outcome studies suggest that: How Do the Treatments for Unipolar Depression Compare? – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Findings from a number of treatment outcome studies suggest that: How Do the Treatments for Unipolar Depression Compare? – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Findings from a number of treatment outcome studies suggest that: Treatments for Bipolar Disorder – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Until the latter part of the 20th century, people with bipolar disorders were destined to spend their lives on an emotional roller coaster Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • The use of lithium (a metallic element naturally occurring as mineral salt) and other mood-stabilizers has dramatically changed this picture Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • All manner of research has attested to the effectiveness of lithium and other mood stabilizers in treating manic episodes Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers • Researchers do not fully understand how mood stabilizing drugs operate • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – They suspect that the drugs change synaptic activity in neurons, but in a different way from that of antidepressant drugs Treatments for Bipolar Disorder: Adjunctive Psychotherapy – 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 medicationbased) therapy Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Psychotherapy alone is rarely helpful for persons with bipolar disorder • Mood stabilizing drugs alone are also not always sufficient Treatments for Bipolar Disorder: Adjunctive Psychotherapy – Growing research suggests that it helps reduce hospitalization, improves social functioning, and increases clients' ability to obtain and hold a job Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Therapy focuses on medication management, social skills, and relationship issues • Few controlled studies have tested the effectiveness of such adjunctive therapy