Treatments of Unipolar Depression

Due to the frequency with which depression occurs, the suffering it causes, together with the increasing evidence of physiological causes for the disorder has led to the development of a number of treatments such as anti-depressant drugs. #

There have been different ways proposed to treat unipolar depression which are physiological and psychological. Chemotherapy is a physiological treatment and Ellis’ Rational Emotive Behavioural Therapy is a psychological treatment. 

Low levels of both noradrenaline and serotonin have been implicated in unipolar depression so it seems logical to treat it with drugs which increase the availability of these neurotransmitters.

Most antidepressants can be given just once per day and usually become effective after 10-14 days. A drug was used in 1952 as a treatment for TB and alleviated the patient’s mood but did not treat the actual disease.

This drug and other similar drugs inhibited the enzyme monoamine oxidase and gradually increased the level of activity of neurons that utilise noradrenaline and serotonin. Monoamine Oxidase Inhibitors (MAOIs) are however less effective than tricyclics when used to treat depression and have serious side effects e.g. cerebral haemorrhage and dangerous reactions with food stuffs and other drugs.  

Tricyclics have three carbon rings in their molecular structure and appear to work by blocking the reuptake of dopamine and noradrenaline, and in some cases serotonin. This leads to increased synaptic activity in neurons which utilise these neurotransmitters.

They are effective in treating of both mild and severe depression and are the first choice of drug for the latter form.

(-) However, there are many side effects including toxic effects on the cardiovascular system, so as a result they are gradually being replaced by modified tricyclics which cause fewer side effects (Gelder et al 1999). 

Selective Serotonin Reuptake Inhibitors (SSRIs) are second generation drugs that selectively inhibit the reuptake of serotonin into presynaptic neurons to make serotonin more available and reduce the symptoms of depression. An example is Prozac.

(+) They seem to be as effective as tricyclics in treating mild depression and they are safer for patients with glaucoma and in overdose. Prozac has become the most rapidly prescribed antidepressant (Costello et al 1995), having been taken by more than 38 million people since its introduction in 1988.

(-) However Prozac has had some controversy as being used as a ‘designer drug’. Kramer says everyone could benefit from taking it as it makes people more assertive and improves relationships, and he believes in the near future we could change our ‘self’ as easily as we change our clothes.

About 250,000 people worldwide taking this drug have attempted suicide however, so it can produce disturbing accounts of violence and suicide if taken. 

Drug treatments are relatively inexpensive when compared to psychological treatments as they require much less contact time between doctors and patient, and they are quite effective at preventing relapse and maintaining a good quality of life for the patient.

However a major problem with drug treatment is that it does not cure mental illness even though it does relieve and control symptoms, as some patients’ symptoms return immediately after they stop taking the drugs or eventually relapse and require the medication again.

It has been found though that the success rate for drug therapy is about 60% but will vary from one individual to another, as will the impact of side effects e.g. drowsiness, blurred vision, withdrawal symptoms or increased risk of self-harm. There are many types of each drug and each have different success rates as some are more effective than others.

Trivedi et al found 80% of patients treated with an SSRI improved, and if the condition is partly due to biological factors (neurotransmitters) it would be sensible to treat them physically

Despite their role in the treatment of adults, antidepressants appear less useful when given to children and adolescents (Hammen). Double blind studies have consistently failed to demonstrate the superiority of antidepressant medications over placebo conditions. Ryan suggests this may have something to do with developmental differences in brain neurochemistry. 

Fisher and Greenberg discussed the methodology of drug trials, specifically double-blind studies where neither doctor nor patient knows whether the drugs are placebos or real antidepressants.

When inactive placebos don’t produce as many bodily sensations as the drugs, participants soon learn to discriminate between them, so active placebos are sometimes used which do produce side effects.

In one review Fisher and Greenberg cited that when 68 studies using inert placebos were compared with 7 studies using an active placebo, the antidepressants were superior to the placebo in 59% of the former and only 14% of the latter, suggesting the placebo effect was at work improving mood and not the antidepressants themselves.

Cognitive psychologists believe mental processes (memory, attention, perception etc.) should be studied to understand human behaviour, so therefore believe that mental health problems like depression are due to problems with mental processes.

A psychological treatment is Ellis’ Rational Emotive Behavioural Therapy; a cognitive therapy which attempts to directly and actively get clients to dispute their irrational and unscientific beliefs and replace them with rational beliefs which are less likely to be associated with negative emotional states or maladaptive behaviour.

Although Ellis believed that people have a biological tendency to think irrationally, REBT is an optimistic approach which can be effective if people work at it to replace self-defeating beliefs (negative thoughts) with adaptive beliefs (positive and optimistic).

The aim of cognitive therapies is to change incorrect thinking patterns, usually negative ones, into positive ones, normally resulting in a change of behaviour. Cognitive therapies are often used alongside behavioural therapies, combining techniques from the two approaches.

REBT uses the ABC model, where ‘A’ is the activating event e.g. a student being given a B grade in an essay, ‘B’ is the belief system (how the person interprets the event) e.g. anything less than an A grade is a failure, and ‘C’ is the consequences (emotional response) e.g. I am worthless and stupid. REBT aims to develop a ‘D’ aspect, the dispute system, to replace ‘B’ with an adaptive belief, e.g. what I do does not have to be perfect to be good work. 

The therapist would expect the client to test their belief systems with actions (hypothesis testing), challenging the conditioning that is maintaining their irrational beliefs by asking clients to provide evidence that they should feel the way they do.

This allows the clients to decide for themselves whether they are right to think negatively about themselves, the world around them and their future. The therapist would be blunt in communicating the inappropriate thinking to the client and not show sympathy as it may reinforce the problem; however the method of challenging the negative thinking is gentle towards the client.

REBT uses the ABC model, where ‘A’ is the activating event e.g. a student being given a B grade in an essay, ‘B’ is the belief system (how the person interprets the event) e.g. anything less than an A grade is a failure, and ‘C’ is the consequences (emotional response) e.g. I am worthless and stupid. REBT aims to develop a ‘D’ aspect, the dispute system, to replace ‘B’ with an adaptive belief, e.g. what I do does not have to be perfect to be good work. 

The therapist would expect the client to test their belief systems with actions (hypothesis testing), challenging the conditioning that is maintaining their irrational beliefs by asking clients to provide evidence that they should feel the way they do. This allows the clients to decide for themselves whether they are right to think negatively about themselves, the world around them and their future.

The therapist would be blunt in communicating the inappropriate thinking to the client and not show sympathy as it may reinforce the problem; however the method of challenging the negative thinking is gentle towards the client. 

Elkin et al carried out a large scale study where they compared four groups of people suffering from unipolar depression.

Half of participants that received medication and half of participants that received interpersonal therapy got better.

Only 29% of the controls who were given a placebo got better, showing that the treatments are quite effective however the placebo effect is still having a considerable influence.

More than half of the patients that received cognitive therapy recovered, which is a very good result considering the size of the study and could provide a useful alternative to drug therapy. 

REBT is useful for people who do not want to go into their past as it is based on present experiences.

If clients wanted to go into their past, the psychodynamic therapy would be more appropriate if childhood experiences are relevant to their depression.

(-) This could become a criticism of the therapy, as it fails to address underlying problems; however this is refuted by REBT theorists who have pointed out that it is actually humanistic, philosophically deep and works on the basis of the client’s point of reference. 

Cognitive therapy is widely used on the NHS as it is measurable and time limited, making it very economical considering the current financial climate in the UK.

(-) However, those who value empathy in therapy argue cognitive approaches are too argumentative and that which may appear irrational to the therapist may be very reasonable to the client, considering their experiences, as reason and logic are subjective properties which cannot be objectively determined.

If one believes the diathesis stress model is a likely explanation for unipolar depression, it may be appropriate that a combination of both drug treatment and cognitive therapy is the most effective for clients.