Depression: biolo&psych

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  • Created by: alex
  • Created on: 30-01-14 13:03

Biological therapies for Depression:

  • The main form of treatment prescribed for depression is the use of antidepressant medication which are typically taken for at least 4-6 months.
  • Depression is thought to be due to insufficient amounts of neurotransmitters (e.g. serotonin and noradrenaline)
  • so tricyclics block the reuptake of these neurotransmitters so they exist in the synapse for longer, prolonging their activity and making transmission of the next impulse easier.
  • SSRIs (e.g. Prozac) work in a similar way but mainly block serotonin so increase the quantity available to excite neighbouring brain cells, thus reducing the symptoms of depression.
  • Antidepressants have been found to be effective in releiving the symptons of depression in about 70% of patients compared to just 33% for placebos.
  • However, Kirch reviewed the clinical trials of SSRIs and concluded that there was only a significant advantage of using these antidepressants in the most severe cases. However, they found that there was only a significant difference in SSRIs and placebos in severely depressed individuals. This shows that even the placebo appeared to benefit moderately depressed individuals because it offered hope, however, it probably didn't benefit the severely depressed so much because their hope of anything working was lessened, therefore diminishing the placebo effect and increasing the apparent difference between the two groups.
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Biological therapies for Depression:

  • The appropriateness of antidepressants has also been questioned. Despite their role in the treatment of adults, Hammen found that they appear less useful for children and adolescents, and Barbui found that although the risk of suicide decreased with the use of SSRIs in adults, they increased the risk of suicide among adolescents.
  • Turner claimed that there is evidence for publication bias towards studies which show a positive outcome of antidepressant treatment, exaggerating the benefits. The authors found that, not only were positive results more likely to be published, but studies that were not so positive were conveyed in a positive way. This selective publication can lead doctors to make inappropriate treatment decisions that may not be in the best interest of their patients.
  • ECT is an option for severely depressed patients or those who have not responded to drug treatment. The patient is first injected with a short-term general anaesthetic and given a nerve-blocking agent. An electrode is then placed on the patient's head and a current of about 100V is sent through the brain lasting about half a second which produces a seizure lasting up to a minute. ECT is usually given 3 times a week  for 3-15 treatments.
  • There is evidence for the effectiveness of ECT such as that of Gregory who found that when comparing ECT with sham ECT found a significant difference in favour of the real ECT. Richards found that about two-thirds of patients with severe depression improved after ECT.
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Biological therapies for Depression:

  • However, Sackeim found that a significant proportion of these relapsed within a year of receiving ECT.
  • A review of 18 studies with 1100 patients comparing the two showed that ECT was more effective than antidepressants.
  • However, there have been side effects reported including impaired memory, cardiovascular changes and headaches. Rose concluded that at least one-third of patients complained of persistent memory loss after ECT and The Department of Health report found that among those receiving ECT, 30% reported a resulting permanent fear and anxiety. 
  • Benek-Higgins claimed that depression in elderly people is often misdiagnosed because its symptoms are masked by natural changes in these individuals and their lifestyles. As a result, antidepressant medication and ECT is less likely to be prescribed even though ECT seems to be very effective amongst the elderly with an improvement of about 80%.
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Psychological therapies for Depression:

  • Cognitive Behavioural Therapy (CBT) developed by Beck aims to identify and alter maladaptive conditions and dysfunctional behaviours that might be contributing to depression.
  • It includes thought catching in which individuals record any emotion-arousing events and the automatic negative thoughts associated with these events and then their rational thoughts that challenge these negative thoughts. By challenging these dysfunctional thoughts, and replacing them with more constructive ones, new ways of behaving can be learned.
  • Also, during CBT, the therapist and the client identify pleasurable activities and anticipate and deal with any cognitive obsticles so the client can learn to enjoy the activities they once enjoyed.
  • A meta-analysis by Robinson found that CBT was superior to non-treatment groups, however, when a placebo group was included, CBT was found to not be significantly more effective than the placebo condition at reducing depressive symptoms.
  • CBT has been successfully applied to many different client groups, including elderly populations, children and adolescents but Elkin found that it appears to be less suitable for people who have high levels of dysfunctional beliefs that are resistant to change.
  • The cognitive aspect of CBT has also been administered by computer and shown to be as effective as other forms of psychotherapy treatment.
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Psychological therapies for Depression:

  • A particular advantage of computer-based and phone-based psychotherapy is the relatively low drop-out rate compared to face-to-face. In fact, Mohr found that only 8% of patients dropped out of phone psychotherapy whereas 47% dropped out of face-to-face psychotherapy.
  • The fear that some antidepressant drugs might increase the risk of suicide has led to researchers to explore the possibility of combining it with CBT to reduce this risk. March enrolled 330 adolescents who were diagnosed with major depression who were randomly assigned either a SSRI antidepressant, CBT or a combination of both and found that a 60% positive response to antidepressants, 50% to CBT and 70% to the combination. However, March's further analysis showed that CBT significantly reduced suicidal thoughts and behaviour.
  • The belief that changing behaviour can go some way to alleviating depression is supported by a study on the beneficial effects of exercise. Babyak studied 160 adult volunteers diagnosed with major depressive disorder who were randomly assigned to a 4-month course of anaerobic exercise, drug treatment or a combination of the two. All three groups had significant improvement but found that those in the exercise group had significantly lower relapse rates.
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Psychological therapies for Depression:

  • PIT, first developed by Hobson, focuses on the idea that symptoms of depression arise from disturbances can only be explored and modified effectively from disturbances in interpersonal relationships - the quality of the relationship is therefore crucial. The model has 7 components such as exploratory rationale in which interpersonal difficulties in the individual's life are identified and the therapist tries to find a rationale to link their current symptoms with these difficulties. Another component is focus on difficult feelings such as the individual's emotion (e.g. anger) of which they are unaware or may not display an appropriate emotion e.g. appear calm when discussing something of great emotional significance. Shared understanding is another important component in which the therapist tries to understand what the individual is really experiencing or feelingby asking for exaplme: "This is what I am hearing you say, is this right?".
  • Paley investigated the effectiveness of PIT in a routine clinical practice setting. 60 patients received a course of PIT over a 50-month period. The outcomes were assessed using Beck's depression Inventory and found that there was a significant change in the pre and post treatment phases and this improvement was achieved by 35% of clients. This shows that PIT can be an effective treatment for depression in routineclinical settings.
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Psychological therapies for Depression:

  • Paley have shown that as a treatment for depression, outcomes for PIT are at least equivalent to those achieved with CBT. However, they acknowledge that changes in significant life-events were not monitored during the study, therefore, any observed clinical gains could not be attributed solely to the therapeutic intervention.
  • Guthrie argues that explanations that concentrate solely on cognitive processes in the development of depression, neglects the important role of interpersonal relationships. This makes PIT particularly important in the treatment of cases of depression that result from dysfunctional relationships. As a result, research has consistenly showed that the quality of the relationship between therapist and client is a central determinant of the outcomes of therapy.
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