Major Depressive Disorder: Theories and Therapies Essay

1. Major Depressive Disorder Definition and Symptoms Major Depressive Disorder may be diagnosed as one or more episodes of a Major Depressive Episode. Symptoms of a major depressive episode include depressed mood, diminished interest or pleasure in activities, weight changes, sleep problems, slowing of speech or agitation, fatigue or loss of energy, feelings of worthlessness and/or guilt, difficulties in thinking, concentrating, or indecisiveness, and thoughts of death, suicide, or suicide attempts. These symptoms are not due to another medical or psychological reason, and they cause clinically significant distress or functional impairment. 4th ed. , text rev. ; DSM-IV-TR; American Psychiatric Association, 2000) The cause of depression is not completely understood. It is, most likely, a combination of reasons, which may include chemical imbalances in the brain, psychological, or environmental factors, and genetics. Severe life stressors, such as divorce, or job loss, often contribute to depression. In a twelve month period, 6. 7% of the U. S. population is depressed. Of those that are depressed, 30. 4% are severe, or 2. 0% of the total U. S. population. Lifetime prevalence in the U.  S. is 16. 5% of the population. (National Institute of Mental Health (NIMH), Prevalence) Women are 70% more likely than men to experience depression during their lifetime. (NIMH, Demographics) The National Institute of Mental Health also reports that Blacks are 40% less likely than Whites, to experience depression in their lifetime. The World Health Organization (WHO) estimates the total number of years a person may lose to illness, disability, or death. They have rated Unipolar Depression number one in diseases and disorders, with a loss of 10. years, well above heart disease and cancer. (NIMH, Leading Individual Diseases/Disorders) 2. Cognitive Theory and Symbolic Interaction Theory of Major Depressive Disorder Cognitive Theory (CT) Early negative experiences are overgeneralized and become a part of one’s schema. The theory, developed by Beck, asserts that one’s negative and dysfunctional view of one’s self leads to depression. Thought distortions, such as absolute thinking, selective abstraction, and personalization, set one up for failure, and perpetuate the negative thinking, leading to depression. Maladaptive thinking and behavior may be learned or caused by inexperience. Symbolic Interaction Theory (SIT) A person gives meanings to objects, experiences, and to self. Social interaction with others helps to define those meanings. Symbols and meanings develop and change over time. Self-conception comes from one’s social interactions with other’s, and how one believes the other person perceives them. If a person believes others are looking at them and judging them negatively, self perception is negative. Depression is caused by negative thinking and perceptions. Etiology: Compare and Contrast In both Cognitive Theory and Symbolic Interaction Theory, dysfunctional and negative thinking about self, form the basis for the depression. Both theories involve thoughts and feelings formed from internal and external stimuli. In both theories, beliefs are based on interpretations rather than reality. In CT, the depression is more self centered and self inflicted. It is more internally based and controlled, while SI depends more on negative external stimuli. Symbolic Interaction Theory adds the concept of interaction with others, while Cognitive Theory does not. Cognitive Theory suggests cognition and behavior are learned and built upon, while Symbolic Interaction Theory suggests thoughts and actions taking place in the present and are dynamic, changing according to the present experience. Dynamics: Compare and Contrast Cognitive Theory and Symbolic Interaction Theory both assert that beliefs about self will strongly determine the way the individual behaves. CT and SIT both assert that people process external information and then apply it to themselves. Both involve irrational thinking. In both theories, the epressed person makes thought leaps, assumptions that are not supported. In Cognitive Theory, one may assume that because they had a negative experience in one situation, it will always be experienced the same way. In Symbolic Interaction Theory one may assume that an interaction with a person, or certain types of people will always be the same. CT may involve a situation the person experiences alone or with others, while SIT naturally would include interaction with others. Cognitive Theory of Depression builds and grows stronger with each negative experience, while Symbolic Interaction is more in the present. The negative and distorted thoughts of a depressed person are reactionary. c. Motivation for change: Compare and Contrast In Cognitive Theory and Symbolic Interaction Theory, motivation for change would include the need for love, support, and interaction with others. We are social beings and need that interaction. Depression separates one from others because it becomes mentally and physically difficult to function. With that separation comes confirmation of the distorted, negative self beliefs. Ruminations drag the depressed person further away from truth (cognitive) and people (interaction). Major Depression is not an illness one can pull out of alone. Although it would be possible without professional help, it wouldn’t be possible without other people. There would be no purpose to change. In Cognitive Theory, motivation for change would include a positive self image and the ability to enjoy one’s life. Motivation for change in Symbolic Interaction Theory would include positive self image and enjoying one’s life, as well as rejoining society, and having a positive impact on others. 3. Major Depressive Disorder Interventions  According to the American Psychiatric Association (APA) practice guidelines, acute phase treatment for patients with major depressive disorder may include pharmacotherapy, depression-focused psychotherapy, the combination of medications and psychotherapy, or other somatic therapies such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or light therapy. The treatment chosen should depend on the severity of symptoms, other illnesses or stressors present, patient and doctor preference, and past treatment outcomes. In their study of depressed patients, Budd, James, & Hughes (2008) found that patients felt Cognitive Behavioral Therapy helped them more than any other therapy. Pharmacotherapy Antidepressant medication is generally the first treatment recommended for depression. Some of the first drugs used to treat depression were tricyclic antidepressants (TCAs), such as Elavil. They affect the neurotransmitters norepinephrine and serotonin. They are used less often because of side effects. Monoamine oxidase inhibitors (MAOIs), such as Narwal, were also used in early treatments for patients with treatment resistant depression. Because of food interactions and the need for dietary restrictions, these medications are also used less often. Selective serotonin reuptake inhibitors (SSRIs), such as Prozac, work by increasing the amount of the neurotransmitter serotonin available to the brain. Seratonin and Norepinephrin reuptake inhibitors (SNRIs), such as Effexor, increase the amount of serotonin and norepinephrine neurotransmitters that can be used by the brain. Mirtazapine, a brand name is Remora, is a non-adrenegic and specific serotonergic antidepressant. Buproprion, found in the brand Wellbutrin, is a norepinephrine-dopamine reuptake inhibitor. All of these drugs may be used in the treatment of depression. (NIMH) Psychotherapy Psychotherapy, sometimes referred to as talk therapy, educates a patient about mental illness and provides tools, or strategies, to improve the patient’s mental health, as well as social functioning. There are several different types of psychotherapy. Psychotherapy for Major Depression is usually used in conjunction with medication. Cognitive Behavioral Therapy (CBT) Developed by Aaron Beck in the 1960’s, CBT helps the patient understand how thoughts can influence behavior. CBT helps a person focus on his or her current problems and how to solve them. The patient learns how to identify distorted or unhelpful thinking patterns, recognize and change inaccurate beliefs, relate to others in more positive ways, and change behaviors accordingly. (NIMH) Interpersonal Psychotherapy (IPT) Interpersonal Psychotherapy was developed in the 1980’s, by Gerald Kerman and Myrna Weissman, to treat depression. (Markowitz & Weissman, 2012) Mood, and it’s relation to social circumstances, is examined, and the patient learns how to react positively to negative circumstances. It is time limited and has been proven to be an effective treatment for depression. (Markowitz & Weitzman, 2012) Rational Emotive Behavioral Therapy (REBT) Similar to CBT, Rational Emotive Behavioral Therapy focuses on changing cognitive, emotional, and behavioral problems. The therapy was developed by Albert Ellis, Ph. D. , in 1955. Ellis asserts, â€Å"It is largely our thinking about events that leads to emotional and behavioral upset. Working with the present in mind, the patient is encouraged to look at the negative thinking that leads to negative emotions and behaviors†. Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-Based Cognitive Therapy was developed by Drs. Zindel Segal, Mark Williams, and John Teasdale. It is an eight-session program based on eastern spirituality. Developed for use in preventing depression relapse, it focuses on the patient’s awareness of personal thought patterns and emotions. Knowing the ruminations and self-critical thinking that precedes depression, the patient is taught how to divert the depression. (American Psychological Association) Somatic Therapies Deep Brain Stimulation (DBS) Electrodes are placed on specific areas of the brain that stimulate the brain continuously through a pulse generator implanted under the skin. A long term follow up study by Kennedy and his colleagues (2011), found social functioning and physical health continued to improve for up to six years after the treatment. The response rate was high at 60%, and the remission rate was 30%, based on the Hamilton Depression Rating Scale. (Kennedy et al. , 2011) Repetitive Transcranial Magnetic Stimulation (rTMS) Repetitive Transcranial Magnetic Stimulation was first used in a study for treatment of depression in 1993, and approved by the FDA in 2008. The neural pathway, from the frontal cortex of the brain to the limbic area, is stimulated. This pathway is believed to be deficient in depressed patients. A pulsating, alternating magnetic field above the scalp sends an electric current through the brain. The electrical current flows to the cortex, depolarizing neurons, and sends signals to the limbic region. This procedure is preformed while the patient is awake. It produces minor twitches, has few side effects, and is non-invasive. The study I read showed a 65% improvement in symptoms. (George & Post, 2011) Electroconvulsive Therapy (ECT) Electroconvulsive therapy (ECT), or shock therapy, is usually used on treatment-resistant depression. A seizure is produced by an electrical shock to the brain. This shock changes the chemical balance in the brain. A patient generally has several procedures a week at first. Procedures are reduced to once a week and then once a month. The amount of ECT needed varies with each person. Memory loss and other cognitive effects sometimes occur, but usually diminish with time. (National Institute of Mental Health) It is important that a skilled Psychiatrist perform the procedure because the effectiveness of the treatment depends on the accuracy of the physician’s skills. (Lisanby, 2007) Vagus Nerve Stimulation (VNS) Vagus nerve stimulation sends electrical pulses from a surgically implanted generator in the chest to the vagus nerve. Every few seconds a pulse runs through the nerve to the part of the brain that is thought to effect mood. (NIMH) Complimentary and Alternative Therapies The National Institute of Mental Health also lists St. John’s wort, S-adenosyl methionine (sometimes called SAMe), omega-3 fatty acids, light therapy, and acupuncture as complimentary and alternative therapies. Botox has also been studied as a treatment for depression, with the theory that suppressing frowning in a depressed person can decrease the depression. (Kruger, T. H. C. , et al. , 2012) 4. Theory and Treatment Links Cognitive Theory and Cognitive Behavioral Therapy a) Etiology Maintenance of depression by negative, automatic thoughts, and withdrawing from others, is the basis for Cognitive Theory. In Cognitive Behavioral Therapy (CBT) for depression, the client is taught to replace negative cognitive thoughts and behaviors with positive ones. Sterling Moorey (2010) developed a maintenance model of depression with six cycles depicted as a â€Å"vicious flower†. It is a tool to help clients understand depression: what causes it, and how it is maintained, as well as cognitive and behavioral changes to ameliorate it. The links between Cognitive Theory and Cognitive Behavioral Therapy can be seen clearly in the model as described below. b) Dynamics Testing negative thoughts and beliefs replaces automatic negative thinking. Problem solving and developing compassion replaces ruminating and self-attacks. Mood recognition replaces mood/emotions. Becoming physically active, and taking one step at a time, replaces withdrawal and avoidance. Experimenting with helpful behaviors replaces unhelpful behaviors. Motivation and physical symptoms are replaced by taking care of oneself and exercising. (Moorey, 2010) A link between Cognitive Theory and Cognitive Behavioral Therapy, is demonstrated when exercise is used as a treatment for depression. Exercise engages the patient mentally and physically. It changes behavior, increases health, and encourages interaction with others. It is positive change that can be used for intervention and prevention. (Martinson, 2008) c) Motivation for Change Cognitive Theory of Depression asserts that dysfunctional and negative beliefs about self causes and maintains depression. Gaining a positive self image based on cognitive behavioral changes will enable a depressed person to participate in, and enjoy life. Looking at difficulties and life events from a positive perspective, allows one to believe success is possible, and behave accordingly. Symbolic Interaction Theory and Interpersonal Therapy a. Etiology Looking at events from a dysfunctional and negative view, based on our interactions with others, perpetuates negative thoughts and feelings, according to the Symbolic Theory of Major Depressive Disorder. This was demonstrated in a study by Vranceanu, Gallo, and Bogart (2009). They found that women with depressed symptomatology reported more negative personal interactions and less positive support, than women who were not depressed. The negative reactions the depressed women received, may serve as reinforcers for dysfunctional beliefs. (p. 468) Interpersonal Therapy (IPT) links mood to the clients circumstances, helping the client to understand what triggers the depression. Often, negative circumstances involve a relationship, or some event that involves the client’s interpersonal functioning. (Markowitz and Weissman, 2012) Liverant, Kamholz, Sloan, & Brown (2011), showed there is a correlation between rumination and other forms of emotional suppression, such as avoidance and withdrawal. They found the more often emotional suppression was used, particularly rumination, the greater the intensity of sadness. b. Dynamics The negative thoughts and feelings the client has perceived from interactions with others, as well as personal relationship problems, are evaluated by the therapist. IPT is time-limited, and solution based. The therapist is understanding, supportive, and encouraging. Emotional acceptance of negative experiences may serve as a tool to reduce rumination, thus decreasing the symptoms of depression. (Liverant, et al. 2011) Interpersonal skills are taught so clients can learn to interact with others in more positive ways. c. Motivation for Change Motivation for change in both Symbolic Interaction Theory and Interpersonal Therapy is a return to a positive mood, the ability to enjoy life, and to interact with others in a positive way. Negative, dysfunctional beliefs attained through interaction with others, as demonstrated in Symbolic Interaction Theory, can b e changed by learning person skills to interact more positively with others, thus providing positive response and reducing depression.