Depression

by Romeo Vitelli

  All medication needs to be carefully monitored by the prescribing doctor, including regular blood tests and frequent checkups to ensure that the medication is working as prescribed.

  Most importantly, it is essential that people taking antidepressant medication be alert to the possibility of suicidal thinking. Research looking at the effects of SSRIs on depression suggests that people who are already experiencing suicidal thoughts may find this kind of thinking becomes worse while on the medication. This is especially true for children and adolescents on SSRIs who seem particularly vulnerable to increased suicidal thinking and suicide attempts (but not necessarily successful attempts). This is why doctors need to be careful in screening their patients for suicidal thinking or previous attempts before prescribing antidepressant medication. If you or someone you know starts experiencing suicidal thoughts more frequently after starting on a new medication, seek help immediately.

  Ironically, the greatest danger for suicide in people who are dealing with depression isn’t when the symptoms are at their worst, but when they are starting to feel better. Though this sounds like a contradiction, it really isn’t. People dealing with severe depression are usually too despondent and immobilized to make any suicide plans. But when those symptoms ease, whether due to medication or some other treatment, many people may consider suicide out of fear that their condition will eventually get worse. This is another reason why doctors need to screen patients for suicidal thoughts before and after prescribing a new medication.

  There is also some controversy whether certain kinds of antidepressant medication may actually cause suicidal thinking, especially in people who are taking these medications for reasons other than treating depression (such as social anxiety). While this controversy is far from settled, people considering going on medication need to stay alert to new mental health issues that may arise.

  Though newer medications have fewer potential problems, it is still essential that people who have been prescribed an unfamiliar medication do their research and make certain they are aware of all the potential risks. Though the doctor prescribing the medication will be monitoring your condition as well, the symptoms you are experiencing are an important clue to determine how well this medication is working.

  Again, though, medication isn’t necessarily the answer for everyone dealing with depression. We will explore a few alternatives in the next section.

  40. What are some of the alternatives to drug treatment?

  In addition to psychotherapy and treatment with antidepressant medication, there are some alternatives available.

  Among the most well known are as follows:

  Electroconvulsive therapy. One of the controversial alternative treatments for depression is electroconvulsive therapy (ECT), which was first developed in the 1930s. Basically involving the running of small electric currents through the brain, ECT is frequently effective in treating people with severe depression who don’t respond to other forms of treatment. It is still unclear why this treatment works, though research studies have demonstrated its effectiveness in 50 to 70 percent of the cases. While modern ECT is typically conducted under a general anesthetic to avoid trauma, the notoriety resulting from its misuse during the 1940s and 1950s has given ECT a stigma that makes many patients extremely reluctant to try it even if recommended by a doctor. Anyone considering trying ECT needs to be aware of potential side effects including some memory loss, temporary mental confusion, nausea, and other medical complications depending on the patient’s medical history.

  Transcranial electrical stimulation. A more modern variation on ECT, transcranial electrical stimulation (tES) involves the running of minimal electric currents through scalp electrodes applied to different points along the skull. Depending on the polarity of the current, electrical stimulation can either increase or decrease cortical activity in the regions where the current is applied. First used to treat depression in the 1960s, interest in tES declined for many years due to its association with ECT. Since the 1990s, however, numerous research studies have found tES to be as effective as different antidepressant medications with almost no side effects. Along with relieving depressive symptoms, tES has also been used to boost cognitive functioning, including improved memory, concentration, and problem-solving ability. Some studies have also found positive results in treating some kinds of dementia such as Alzheimer’s disease (at least in the early stages). While tES is certainly promising, the negative stigma surrounding ECT still makes it controversial. Also, some companies are offering “do-it-yourself” tES kits to allow people to treat themselves at home despite medical warnings about the dangers involved. As with any other form of treatment for depression, do your research first, and make sure the treatment professional is properly qualified.

  Transcranial magnetic stimulation. As an alternative to the use of direct electric currents, transcranial magnetic stimulation (TMS) involves the use of shifting magnetic fields to induce an electric flow in target regions of the brain. Most forms of TMS involve the use of a magnetic field generator, or “coil,” that can be applied to the head of the patient receiving treatment using a specialized headband. These coils are available in different sizes and configurations to allow very precise placement. Also, depending on how the magnetic fields are applied, it is also possible to stimulate the deeper structures of the brain, which can’t be reached with surface electrodes as with ECT or tES. Along with its value in treating depression, TMS has also been used in treating neuropathic pain and boosting cognitive functioning in dementia cases as well as in diagnosing different types of neurological damage. While most applications of TMS are experimental at this point, it has shown great promise as a therapeutic treatment with few, if any, side effects being found.

  For most people suffering from depression, some combination of psychotherapy and antidepressant medication will probably be all that they may need to help with their symptoms. Still, as newer treatment methods such as TMS and tES become more widely accepted, people needing help will likely benefit from having more options available to them.

  41. Do herbal and dietary remedies work in treating depression?

  While most people dealing with depression are going to rely on conventional antidepressant medication, we are seeing a greater push in recent years toward more “natural alternatives,” including the use of complementary and alternative medicine, as well as herbal remedies for mood problems. Though over 70 percent of the world’s population continues to rely on these herbal remedies, most health care professionals remain skeptical about how effective they actually are.

  Among the reasons for the popularity of herbal remedies is the belief that they are healthier than prescription medications since they contain all “natural” ingredients. Unfortunately, because many of these remedies aren’t monitored by regulating agencies such as the U.S. Food and Drug Administration (FDA), it’s hard to tell how the remedies have been prepared and whether they contain potentially harmful ingredients. Though side effects resulting from use of these herbal remedies and their interactions with other drugs are relatively rare, problems have been known to develop. This is why anyone considering herbal remedies to treat their depression should seek medical advice first.

  Some of the most popular herbal remedies currently available are as follows:

  St. John’s Wort (Hypericum perforatum): Extracted from the flower of the St. John’s Wort plant native to different parts of Europe and Asia, Hypericum has been used for centuries by medical doctors and apothecaries for treating mild to moderate depression. One of the active components of Hypericum, hypericin, appears to reduce serotonin receptor density and may also dampen the production of cortisol by acting on the body’s hormonal system. Another active ingredient, hyperforin, seems to inhibit the reuptake of serotonin, norepinephrine, and acetylcholine, though researchers are still not clear about the mechanisms involved.

  While most commercial compounds of Hypericum are high in either hypericin or hyperforin, the actual amo
unt of active ingredients can vary widely since herbal medications aren’t standardized in the way that prescription medications are. Also, no research data is currently available showing the actual clinical benefits of the different brands on the market.

  Research studies comparing Hypericum to placebos tend to show that it is reasonably effective in treating some symptoms of depression. Still, the results of many of these studies have been inconsistent, possibly due to the lack of a standardized form of Hypericum. At present, there is no clear evidence that Hypericum is as effective as prescription antidepressant medications.

  People who wish to take Hypericum need to be aware of possible side effects, including a greater sensitivity to ultraviolet radiation and possible interaction with certain kinds of medication. Do not take Hypericum without medical advice.

  Omega-3 Fatty Acids: An active ingredient in certain types of food, fish, nuts, and seeds, omega-3 fatty acids have become popular as a natural treatment for depression in recent years. This is largely based on research suggesting that the modern Western diet is deficient in these nutrients. On the other hand, people from countries where fish is more widely eaten tend to have a healthier plasma ratio of omega-6 compared to omega-3. These healthier eating habits, coupled with experiencing less stress than is found in Western societies, may lead to fewer problems with inflammation, including cardiovascular disease and mood disorders.

  Though the exact mechanism linking omega-3 fatty acids to reduced depression hasn’t been identified, researchers have identified potential explanations. For example, administration of omega-3 supplements such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) can lower plasma norepinephrine levels and may also affect the release of hormones linked to higher stress.

  Randomized, placebo-controlled trials using EPA and/or DHA suggests that high doses of omega-3 supplements may have antidepressant effects, though, typically, the dosages required are around fifteen times the current daily levels found in most Western diets. Omega-3 supplements may also help treat postpartum depression and bipolar disorder as well as other conditions such as obsessive-compulsive disorder. Still, most of these studies have small sample sizes, and more research needs to be done.

  While omega-3 supplements such as EPA and DHA have few side effects, they should still not be taken without medical advice, especially for people with other medical problems or who are taking medications such as blood thinners.

  SAMe: Also known as adenosylmethionine, SAMe is a molecule that forms naturally in the body and which plays a role in the synthesis of key proteins, hormones, and neurotransmitters. This includes norepinephrine, dopamine, and serotonin. Available by prescription in many parts of Europe for decades as an extremely popular treatment for depression, SAMe is mainly sold as a dietary supplement in North America. This has been changing in recent years, however, and it has become increasingly popular as a natural remedy for depression. Despite reports that SAMe may work even more rapidly than conventional antidepressants, medical researchers have identified potential side effects. These include gastric problems, dry mouth, and sweating. While many people take SAMe along with regular antidepressant treatment, it is important to get medical clearance first. This is particularly true for people who have additional medical problems or who are on different types of medication.

  As you can see, there are a number of alternative treatments for depression, and many people who have difficulty trusting conventional medicine may prefer to give them a try. Still, being “natural” doesn’t necessarily mean that they are safe to take. Anyone considering one of these alternative remedies should consult with a medical doctor to avoid problems. It is also important to remember that herbal supplements and alternative remedies aren’t monitored as carefully as prescription medications are, so potential users should do their homework about which brands are best before trying them.

  42. What is cognitive behavioral therapy?

  Cognitive behavioral therapy (CBT) is an overall term describing a range of problem-oriented psychotherapy techniques focusing on identifying and changing harmful thoughts and behaviors. Unlike more traditional forms of psychotherapy, CBT clients and their therapists work together in an active partnership to explore the negative thoughts, feelings, and behaviors that can underlie negative thinking and depression.

  How these negative beliefs develop often depends on the social and cultural experiences people have growing up and whether there are other accompanying health problems such as chronic pain, social anxiety, or substance abuse. Though CBT tends to focus on current thought patterns and behaviors, people dealing with other mental health issues or early abuse may also explore how these issues may be sabotaging their recovery.

  Part of the appeal of CBT is its flexibility. Not only can it be administered either individually or in treatment groups but CBT can also be adapted for use in couples or family therapy or in dealing with clients with special needs. Along with CBT programs for children and adolescents, there are also treatment programs aimed at adults dealing with childhood sexual or physical abuse, domestic violence, or other issues that might trigger chronic depression.

  Typically, individual or group CBT sessions can range from forty-five minutes to over an hour per week. Despite having a strong educational component, clients and therapists can also use CBT sessions to exchange information and ideas about how the treatment is going. In a real sense, clients and therapists are working together as part of the therapy process to find real solutions to mental health issues such as depression.

  Along with the treatment sessions, clients receive homework assignments with exercises to apply what they learn in treatment. The lessons covered in these assignments can include learning to identify negative thoughts and behaviors that might increase the risk of relapsing, learning coping strategies to deal with potential sources of stress, and learning effective ways of coping with self-defeating thoughts.

  While there are different forms of CBT, including dialectic behavior therapy, rational living therapy, rational emotive behavior therapy, cognitive therapy, and rational behavior therapy, they all focus on a series of core principles including functional analysis, behavior modification, and skill training.

  Functional analysis involves clients and their therapists working together to explore the clients’ own thoughts and beliefs and how they can shape their behavior. Clients are encouraged to talk openly and honestly about their depression and explore the way that their mood issues have impacted their lives. Using techniques such as the Socratic method, clients learn to identify destructive beliefs and thinking patterns by questioning many of the assumptions they have always taken for granted in the past.

  In the early stages of treatment, clients use functional analysis to understand the kind of triggers that can lead to problem behaviors and negative thinking. They also gain insights into their self-doubts and the kind of situations that reinforce these negative beliefs. To help this process along, people in therapy are encouraged to keep a cognitive diary in which they record any thoughts or challenges they may have when not in treatment. Diaries are also useful in monitoring their behavior when they are in social situations or when they encounter problems that might lead to backsliding.

  Along with functional analysis, clients also receive skill training to unlearn destructive habits and thought patterns and develop healthier alternatives. Using techniques such as cognitive restructuring, substance abusers learn to examine and change the addictive beliefs and automatic thinking patterns that can lead to problem behaviors. Destructive beliefs or automatic thinking patterns can include, “I am not attractive/popular enough to socialize with other people,” “They are laughing at me,” or “Nobody cares about me.”

  While reinforcing negative thinking, these automatic beliefs may also reflect how users view themselves or the world in general. Having a poor opinion of their own self-worth, their current circumstances, or their family situation can also feed into intensive brooding, not to mention sabotage
any attempt at helping themselves. These beliefs also grow and change over time as users become increasingly pessimistic about the possibility of making a real change.

  Automatic beliefs are often based on cognitive distortions or errors in thinking people often make. These include all or nothing thinking, (seeing situations in black or white terms), overgeneralizations (viewing any setback as a sign that change is impossible), mental filtering to focus only on the negative, or jumping to conclusions about the way they view the world.

  As part of their skill training, clients are taught how to incorporate these positive thought patterns into their daily life and to develop positive behavior patterns that can defeat the old patterns that encourage self-doubt and negative thinking. Over the course of treatment, clients can also engage in role-play and behavioral rehearsal to learn more positive ways of thinking and behaving in situations that might help them to be more self-assertive. This also allows them to practice their new skills and become more comfortable in making them a part of their daily routine.

  Other skills that can be learned during CBT sessions include relaxation training, problem-solving training, stress inoculation, guided imagery, assertiveness training, and mindfulness training (more on that in Question 43).

  Behavior modification (also known as contingency management) focuses on making positive changes in how a client behaves on a daily basis. This is often based on principles of operant conditioning by using specific rewards to reinforce positive behavior (such as avoiding brooding behavior or isolation). There are different kinds of rewards that can be used including gift vouchers, spending time with friends or family, or some other form of recognition that reinforce the gains being made. This allows clients attending treatment to make real changes to their daily routines that can continue long after the treatment program has ended.