Treatment Recommendations for Moderate Depression: Psychological and Biological Perspectives

question
Discuss treatment recommendations that are supported by the literature for a client facing moderate depression. Be sure to include suggestions from both psychological and biological perspectives. For which would you advocate most strongly, and why?
Answer
1. Psychological Treatment Recommendations
Recent meta-analyses and reviews have found that the effects of CBT for depression are large and that it is a highly effective treatment, particularly for outpatients. Beck’s original cognitive therapy (CT) model has been modified over the years, and there are now several manual-based therapies which are informed by CBT principles.
CBT also involves behavioral strategies, regular activity, and routine scheduling. It assesses the patient’s current level of activity and routine compared to what it was prior to the onset of depression or to a previously non-depressed person of the same age. It is suggested that a lack of positive activities or the adoption of avoidant behaviors may serve to maintain or further lower an individual’s mood. In these instances, activity scheduling will be used to plan and implement activities which are aimed to increase positive mood, a sense of achievement, or pleasure.
The most well-known cognitive-behavioral intervention for depression is the ABC model. This suggests that an individual’s thoughts (B) about an event or problem directly cause their emotional and behavioral responses (C). This is a result of the activating event (A). Often in depression, negative thoughts about self, the world, and the future are triggered by a negative event or situation. The ABC model is useful in discovering the relationship between thoughts and mood, which in turn can be used to test the validity of the particular thoughts. If the thoughts are found to be unrealistic or unhelpful, it is likely that there is a significant improvement in mood by changing them to a more realistic or helpful alternative. This method is usually used in conjunction with monitoring an individual’s mood and thought diary.
Cognitive Behavioral Therapy (CBT) is the most well-established evidence-based psychological treatment for depression in children, adolescents, adults, and older adults. It is designed to be a short-term, problem-specific approach which typically takes 12-16 weeks to complete. CBT is a highly directive therapy, which is based on the cognitive model: that depression is caused by a particular pattern of negative thinking which, in turn, leads to changes in behavior and mood. Treatment is focused on the present and is goal-oriented.
1.1. Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is a widely used method for moderating depression (Gloaguen et al., 1998; Veale, 2008). Its effect has been demonstrated in numerous controlled trials and a variety of patient groups (Dobson, 1989; Hollon et al., 2002). CBT focuses on helping the patient to overcome a range of psychological difficulties. The concept of the therapy is that how we feel and what we do is determined by the way we think. This can be seen in Figure 1 when the patient has automatic negative thoughts about a specific situation. This will lead to a negative mood and no longer enjoying the activities that are usually found pleasurable. This can then spark a vicious cycle, making the patient become more and more depressed. The role of the therapist is to identify the negative thoughts and bring them to the attention of the patient. This can be achieved by collaboration with the patient using guided discovery. The automatic thoughts can be identified during the session or the therapist can assign the patient homework to monitor their moods at set times during the week and record the thought that coincided with the mood when it was lowered (Beck, 1995). Once the thought has been identified, the next step is to assess whether the thought is rational and if there is an alternative explanation. This is done by examining the evidence that the thought exists and creating a ‘thought record’. This thought record compares the positive and negative evidence for the thought and then looks for alternative explanations and if they are believed to be true. If the negative thought is deemed to be true, the third step is to try and decatastrophize and reduce the belief in the thoughts. This method of analysis also applies to the core beliefs of the patient and the way they view themselves in the world. The goal of this is to relieve the distress by resolving the psychological difficulties and disturbing thoughts which in turn will change the patient’s feelings and behavior (Beck, 1976). This can be contrasted to other therapies that focus on the past of the patient with the aim of bringing an understanding as to why the patient may be depressed. CBT only looks at the past in terms of identifying the cause of a psychological difficulty and does not dwell on historical issues. Beck’s model has been known to exhaust cognitive therapy and to try and define specific similarities that exist among patients with the same psychological difficulties, e.g. depression (Dobson, 1989). This has led to recent attempts of a more precise treatment based on an individual formulation. Step prologue CBT has also been proven to be an effective relapse prevention tool for recurrent depression and in many cases has a higher rate of improvement than various antidepressants (Bockting et al., 2009).
1.2. Interpersonal Therapy (IPT)
This IPT theory was developed in 1984 by Klerman and his colleagues in a medication treatment study at the University of North Carolina at Chapel Hill. Klerman’s group and an NIMH convened team subsequently refined, further developed and tested the psychotherapy over the next decade. IPT is a manual-based treatment with efficacy in the treatment of a range of psychiatric illnesses. It was first tested in major depressive disorder and then adapted for use in a variety of other mood and non-mood disorders. IPT has been most extensively tested in major depressive disorder where it is a monotherapy of equal potency to medication treatment and there is a wealth of converging evidence supporting its use. IPT theorizes that psychiatric illness can be termed a medical state with psychological symptoms. It posits that there are sometimes events which precipitate the onset of a psychiatric disorder, whether it be major events or a more insidious slow change. Once an episode is established, this will have effects on the interpersonal life situation of the sufferer. A depressive episode can have a profound effect on a person’s identity and character, and they may become this aggregated illness self. IPT understands the illness as separate from the patient and works via the management of specific symptoms and the prevention of future episodes to relieve the illness’s effect on the person’s identity. This effect is achieved through an effect on one of the patient’s four Interpersonal Problem Areas.
1.3. Mindfulness-Based Cognitive Therapy (MBCT)
Cognitive therapy provides a cognitive framework, which is treated as a simulation of the problems or a hypothesis (Beck, Rush, Shaw & Emery, 1979). This model is used to test the validity of the assumptions to identify areas of conflict in the brain and revise the assumptions (Teasdale, 1988). Although effective, it is difficult for the depressed patient to understand how this process can affect change, cognitive insight into one’s problems does not suffice to produce recovery from mood disorders. Instead, patients need to learn to disengage from the unconstructive modes of processing the facilitative of depressive relapse and learn a mode of processing that is more adaptive when recognizing early signs of progression into mood disturbance (Teasdale, Segal & Williams, 1995). Mindfulness is a mode of processing that is the opposite of autopilot, it enables cognitive reappraisal concerning the habit of a certain automatic process (i.e. becoming lost in rumination) and is seen as an alternative or precursor to CBT regarding cognitive change strategies (Teasdale, 1999). It is this principle that is the focus of Mindfulness-Based Cognitive Therapy (MBCT) for the prevention of major depressive relapse. MBCT was developed by Segal, Williams, and Teasdale (2002) as a psychological intervention designed to prevent the relapse of depression by teaching people with a history of depression to recognize the early signs of warning that a depressive relapse may occur and to disengage from the mode of mind that can draw them back into depression. This is achieved by cultivating mindfulness, an awareness that is in the present moment and adopting an accepting orientation to what is (Kabat-Zinn, 1990). The rationale of MBCT is in its understanding that a current episode of depression is characterized by automatic disengagement from the present moment into a rumination concerning the self and automatic assimilation of mood with its solutions being to attempt to fix the mood state by thinking and acting reactively to it, therefore avoidance of recurrence is best achieved by teaching patients to foster a mode of being that is detached, focused, and non-judgmental.
1.4. Behavioral Activation Therapy
Behavioral activation (BA), a component within the third wave of behavior therapy, constitutes a simple, yet elegant approach to treating depression. Its basis on the reinforcement contingency model and its use of functional assessment has allowed for vast developments within the treatment of depression and more importantly in the experimental and applied psychological field. From its theoretical roots to its current standing, BA has far-reaching implications in our understanding and treatment of depression. Simple, yet elegant, the reinforcement contingency model for depression states that depression is a disorder of low response-contingent positive reinforcement. In more understandable language, depression is a disorder occurring when positive outcomes in life no longer reinforce positive behaviors necessary for healthy living. With less activity and fewer chances for positive reinforcement from the environment, a person becomes subtly withdrawn or inactive. This state is self-perpetuating – continued inactivity leads to fewer experiences of reward or pleasure, resulting in depression that becomes more severe. The final result is always an increase in avoidance behaviors and generally low response-contingent positive reinforcement. This simple theory proposed by Lewinsohn represents a powerful explanation of the nature of depressive disorders and suggests an easy place to begin for treatment. Lewinsohn states that “a person who is depressed can be helped to recover if the positive reinforcement contingencies can be increased in the person’s life”. By targeting the issue of positive reinforcement, the hallmark of BA is its idiographic methodology which continues to influence assessment and experimental research.
2. Biological Treatment Recommendations
2.1. Selective Serotonin Reuptake Inhibitors (SSRIs)
2.2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
2.3. Tricyclic Antidepressants (TCAs)
2.4. Monoamine Oxidase Inhibitors (MAOIs)
3. Combined Psychological and Biological Treatment Approaches
3.1. Cognitive Behavioral Therapy with Medication
3.2. Interpersonal Therapy with Medication
3.3. Mindfulness-Based Cognitive Therapy with Medication
3.4. Behavioral Activation Therapy with Medication
4. Factors to Consider in Treatment Selection
4.1. Severity of Symptoms
4.2. Treatment History
4.3. Potential Side Effects
4.4. Patient Preferences and Values
5. Advocacy for Psychological Treatment
5.1. Efficacy of Psychological Approaches in Research
5.2. Focus on Long-Term Coping Skills
5.3. Potential for Personal Growth and Insight
6. Advocacy for Biological Treatment
6.1. Effectiveness of Medication in Symptom Reduction
6.2. Quick Onset of Action
6.3. Potential for Relief from Physical Symptoms