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Treatment of Depression and Mood Disorders

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Depression is treatable. Research has consistently shown that individuals with depression or mood disorders benefit from treatment. Psychotherapy has been found to be a very helpful intervention for those suffering from depression. In addition, there is extensive research supporting the combination of psychotherapy and medication in the treatment of depression and mood disorders (ref. 1 & ref. 2). This article discusses the treatment of Major Depressive Episodes and Dysthymia, and then considers what is known about the treatment of Bipolar Disorders, SAD, Postpartum Depression, and Adjustment Disorders with Depressed Mood.

Psychotherapy plus Medication: the recommended treatment approach for Major Depression and Dysthymia

The combination of psychotherapy and medication is thought to be the most effective approach for the treatment of depression. There is a consistent body of research
supporting the effectiveness of both psychotherapy and medication. Based on this research most experts have concluded that the most effective treatment approach is the combination of medication and psychotherapy.

We recommend that you read the well written summary of this issue,
by John Grohl, Ph.D., at www.psychcentral.com/Depression treatment Psychotherapy, Medication or Both? In this article Grohl summarizes the research on the treatment of depression and notes the following conclusions:

  1. That psychotherapy is a valuable part of the treatment of depression.
  2. That people who receive psychotherapy and medication get better faster than people who receive only one or the other treatment.
  3. That studies show that psychotherapy (primarily Cognitive Behavioral Therapy) is more effective than medication in head to head comparisons.
  4. That people are more likely to drop out of treatment when receiving medication only.
  5. That when the research on medication is carefully analyzed, the benefits are not as great as touted by pharmaceutical companies, particularly over the long term.

Given these findings we strongly recommend the combination of psychotherapy and medication. However, we agree with Grohl that the second best option is psychotherapy alone. In fact (see below) some scientists are beginning to re-evaluate the research on the benefits of medication, and are suggesting that medication’s benefits may have been over-stated.

Cognitive Behavioral Therapy (CBT)

CBT is touted as the most effective treatment for depression. First, there is a good amount of research that supports CBT’s efficacy in treating depression (ref. 1 & 2, 9). Second, CBT is theoretically a good fit for the treatment of depression because it focuses on the negative and self-critical thinking that often accompanies depression. Third, CBT is an active treatment which helps mobilize people to fight their depression, and thus instills hope and reinforces activity.

Do other therapies work? Clearly there is evidence to suggest that psychotherapy in general is helpful in the treatment of depression. Research has found that Interpersonal therapy is a useful treatment approach (ref. 1 & 10). Interpersonal therapy involves a focus on the here and now, what is going on in your life that is affecting you, and what steps and actions you can take to resolve problems, improve relationships, and improve your daily life.

Insight Oriented Psychotherapy

As noted previously, depression is influenced by many factors. In instances where past losses and traumas have had a significant impact on an individual, therapy approaches which focus on increased insight and self-awareness would appear to be particularly useful. In addition, much research on the benefits of psychotherapy has found that the alliance (the working relationship between therapist and client) are a key ingredient in the success of therapy (ref. 11).

Marital/Family Therapy. There is growing support for the use of marital and family therapy in the treatment of depression. First, marital or relationship conflicts, family stresses, and other life stresses may underlie, significantly contribute to, or exacerbate depression. Therefore, it is important to address and resolve these problems. Second, when one family member or spouse is experiencing a significant depressive disorder, this may disrupt family functioning. Moreover, family members’ reactions to depressive symptoms may inadvertently reinforce or exacerbate symptoms. Thus, family or marital/couples therapy may be a needed component in the treatment of depression. Third, research has supported the benefits of family therapy in the treatment of depression (ref. 12, 13 & 14).

Medication

Medication is widely used in treating depression. While there are many studies supporting the use of anti-depressant medication in treating depression there are a number of caveats which should be noted about medication.

First, compliance with medication treatment is a key factor. Anti-depressant medications can take 3-6 weeks to reach a therapeutic level. In addition, dosages may need to be adjusted. Thus, to obtain the maximum benefit from medication one has to be persistent and stick with medication treatment. This challenge is made even greater by the fact that some people have to try several medications before they find the one that works best for them.

Second, medications have side effects. The side effects associated with antidepressant medications include: nausea; dizziness; feelings of sedation; agitation; impairment of sexual functioning. Some people cannot or are not willing to tolerate these side-effects.

Third, some scientists and consumer advocates point to recent studies that suggest that the benefits of medication be over stated (ref. 7, 8). For example, a recent article in the New England Journal of Medicine (ref. 7) suggested that the research on antidepressant medications has been published selectively, with those studies that were not supportive of the benefits of medication being far less likely to be published than those that supported the benefits of medication.

In conclusion, we want to stress that we are not opposed to the medication based treatment of depression. In fact, many of our clients have reported significant benefits from medication. Rather, we want to present information that provides a balanced (and scientifically fair) view of the data regarding the treatment of depression. It is our view that the combination of medication and therapy is still the most effective approach for the treatment of Major Depressive Episodes and Dysthymia, but that the option of utilizing psychotherapy alone is also a reasonable and effective approach.

Treatment of Bipolar Disorder

Overview of treatment. There has been far less research on the treatment of bipolar disorder than on depression (Major Depression or Dysthymia). The general consensus has been that medication treatment is the key component of treatment, supported by psychotherapy.

Recent research on the treatment of bipolar disorder. Recently, NIMH funded a large study which examined the treatment of Bipolar Disorder, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Although, data from this study has just begun to be analyzed, the first results support the use of medication and psychotherapy in the treatment of bipolar disorder. Specifically research found that those participants who were treated with medication and intensive psychotherapy (30 sessions over nine months of either CBT, interpersonal and social rhythm therapy, or family-focused therapy) had fewer relapses, lower hospitalization rates, and were better able to stick with their treatment plan than a group that received a less intensive treatment program. (ref. 15). Additional findings from the STEP-BD study should be forthcoming on which types of psychotherapy and medication interventions seem most effective for different types of bipolar disorders.

Benefits of psychotherapy in addition to medication. Early findings from the STEP-BD study also support the use of psychotherapy in the treatment of bipolar disorders (for patients taking medication). Specifically, patients receiving intensive therapy programs had a better outcome than those who received only supportive treatment. All patients were receiving medication treatment as well as therapy. The study concluded that psychotherapy is an important component in the treatment of bipolar disorders (ref. 15,16).

Medication. Multiple medications are used for treating bipolar disorders. There are a number of medications specifically approved by the FDA for the treatment of bipolar disorder. These range from Lithium, the earliest medication used to help stabilize mood, to newer drugs such as Abilify, Lamictal, Respirdal, Seroquel, and Geodon. Often physicians start patients on a mood stabilizing medication, and then add additional medications in an effort to effectively control and alleviate symptoms. There is widespread consensus among mental health professionals that medication is an essential part of the treatment of bipolar disorders.

The website of the Depression Bipolar Support Alliance offers an extensive list of medications that are commonly used in treating bipolar disorders, including their side effects (see www.dbsalliance.org, the section: Finding Peace of Mind: Treatment Strategies for Depression and Bipolar Disorder).

Treatment of Postpartum Depression

Treatment recommendations for Postpartum Depression are generally very similar to those for Dysthymia and Major Depression. Specifically, a combination of therapy and medication based treatment (antidepressant medication) is recommended.

Treatment of Seasonal Affective Disorders

Treatment for SAD has emphasized the use of light therapy. Light therapy involves increased exposure to light that mimics or is as similar as possible to the sun’s rays. There is a body of research that supports the use of light therapy (ref. 17 & 18) and continued studies are underway to determine which types of light therapies are most effective. In addition to light therapy, medication and therapy have also been utilized in the treatment of SAD.

Treatment of Adjustment Disorder with Depressed Mood

The focus of treatment of Adjustment Disorders tends be less on depressive symptoms and more on how the individual is coping with the specific stress or stressors in their lives. Therapists may use Cognitive Behavioral, Problem Focused, and Insight Oriented therapies to help clients find more effective ways to manage the stresses they are facing, and develop more effective coping strategies.

References cited in our discussion of Depression & Mood Disorders

Ref. 1. Antonuccio, David O., Danton, William G., & DeNelsky, Garland Y. Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom With Data Professional Psychology: Research and Practice. December 1995 Vol. 26, No. 6, 574-585.

Ref. 2. Jacobson, Neil S. Cognitive-Behavior Therapy Versus Pharmacotherapy: Now That the Jury's Returned Its Verdict, It's Time to Present the Rest of the Evidence. Journal of Consulting and Clinical Psychology February 1996 Vol. 64, No. 1, 74-80.

Ref. 3. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication, Archives General Psychiatry. 2005;62:593-602.

Ref. 4. Kessler, R.C., Chiu, W.T., Demler, O., Walters, E.E. Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives General Psychiatry. 2005;62:617-627.

Ref. 5. Gibbons, R.D., Hur, K., Bhaumik, D.K., Mann, J.J. The Relationship Between Antidepressant Medication Use and Rate of Suicide. Archives General Psychiatry. 2005;62:165-172.

Ref. 6. Oquendo, M.A., Malone, K.M., Ellis, S.P., Sackeim, H.A., Mann, J.J. Inadequacy of Antidepressant Treatment for Patients With Major Depression Who Are at Risk for Suicidal Behavior. American Journal of Psychiatry 156:190-194, February 1999.

Ref. 7. Turner E., Matthews, A., Linardtos, E., et al. Selective publication of antidepressant trials and its influence on apparent efficacy. New England Journal of Medicine, 358, January 2008, pp 252-260.

Ref. 8. Kirsch, I., Deacon, B., Huedo-Medina, T., et al. Initial severity and antidepressant benefits: A meta analysis of data submitted to the food and drug Administration. PLoS Medicine, February 2008, 5 (2), e45.

Ref. 9. Barlow, D. H. Psychological interventions in the era of managed competition. Clinical Psychology: Science and Practice, 1994, 1, 109–122.

Ref. 10. Elkin I., Shea M.T., Watkins J.T., et al: National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Archives of General Psychiatry. 1989; 46:971-982.

Ref. 11. Psychotherapy Relationships that work, (ed) Norcross, John. Oxford University Press, 2002.

Ref. 12 Lemmens, G.M.D., Eisler, I., Buysse, A., Heene, E.,  Demyttenaere, K.  The Effects on Mood of Adjunctive Single-Family and Multi-Family Group Therapy in the Treatment of Hospitalized Patients with Major Depression. Psychotherapy and Psychosomatics,  2009;78:98-105 

Ref. 13. Jacobson, N.S., Fruzzetti,K., Dobson, M., & Whisman, H. Couples therapy as a treatment for depression: II. The effects of relationship quality and therapy on depression. Journal of consulting and Clinical Psychology, 1996, 61, 516-519.

Ref. 14. Johnson, S.M, & Lebow J. The coming of age of couple therapy: A decade review. Journal of Marital and Family Therapy, 2000, 26, 9-24.

Ref. 15. Miklowitz D.J., Otto M.W., Frank E., Reilly-Harrington N.A., Wisniewski S.R., Kogan J.N., Nierenberg A.A., Calabrese J.R., Marangell L.B., Gyulai L., Araga M., Gonzalez J.M., Shirley E.R., Thase M.E., Sachs G.S. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program (STEP). Archives General Psychiatry. 2007 Apr;64(4):419-426.

Ref. 16. Miklowitz D.J. A review of evidence-based psychosocial interventions for bipolar disorder. Journal of Consulting and Clinical Psychology, 2006 67(Suppl 11):28-33.

Ref. 17. Terman, J.S., Terman, F.M., Quitkin, P.J., McGrath, J.W. Light therapy for seasonal affective disorder. A review of efficacy. Neuropsychopharmacology. 1989 Mar;2(1):1-22.

Ref. 18. Golden R.N., et al. (2005). The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 162(4): 656–662.


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