Holistic Treatment to Overcome Depression

Destroy Depression

Destroy Depression is written by James Gordon, a former sufferer of depression from the United Kingdom who was unhappy with the treatment he was being given by medical personnell to fight his illness. Apparently, he stopped All of his medication one day and began to search for answers on how to cure himself of depression in a 100% natural way. He spent every waking hour researching all he could on the subject, making notes and changing things along the way until he had totally cured his depression. Three years later, he put all of his findings into an eBook and the Destroy Depression System was born. The Destroy Depression System is a comprehensive system that will guide you to overcome your depression and to prevent it from injuring you mentally and physically. More here...

Destroy Depression Summary

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Bipolar Depressive Phase And Mixed States Depressive Phase

Like mania, bipolar depression may manifest psychotic symptoms of usually mood-congruent nature 16 . However, delusional and hallucinatory experiences are less common. Stupor, uncommonly observed today, represents the most severe expression of the depressive phase of bipolar disorder. In the elderly, bipolar depression may present as a pseudodementia. Neur-astheniform symptoms 32 with reverse vegetative signs (i.e., atypical depression in the sense of DSM-IV) are more characteristic of juvenile bipolar depressives, particularly adolescents and young adult women. Psychomotor retardation, with or without hypersomnia, is generally considered the hallmark of the uncomplicated depressive phase of bipolar disorder 136 . Onset and offset are often abrupt, though gradual onset over several weeks can also occur. Patients may recover into a free interval or switch directly into mania 137, 138 switching into an excited phase is not infrequently associated with somatotherapy (e.g., ECT, sleep...

Parental Perceptions of Depressed Patients

To test the suggestions of many theorists that problematic parental behavior may contribute to the development of depression, some researchers have explored patients' perceptions of parents by use of systematic assessment instruments. Using the parental bonding instrument, Parker (1983) found that depressed patients viewed their parents as having less emotional warmth and as being more protective than did a control group without depressive disorders. In a study by Perris et al. (1986), patients with depressive disorders were compared with healthy controls by using the EMBU, a Swedish instrument for assessing parental perceptions. The authors found that depressed patients experienced less emotional warmth from their parents, but they did not find prominent experiences of overprotection. The authors concluded that rearing practices which deprived the child of love might be an important risk factor predisposing to depression (p. 174). MacKinnon et al. (1993) also found that the...

Barriers to Engagement in Depressed Patients

Some depressed patients are initially quite resistant to treatment because of their exquisite susceptibility to shame and their difficulty tolerating an exposure to the therapist of a shameful vulnerability (Kilborne 2002). Managing this difficulty is important from the start, and a sensitive acknowledgement of its existence, paired with an understanding of its role in actually contributing to depression, can be useful in establishing a good initial alliance.

Fighting Fibromyalgia with Antidepressants

Many people with fibromyalgia take one or more antidepressant medications. These medications include Two common antidepressant medications used by people with FMS are Elavil and Desyrel. In addition, a newer antidepressant, Cymbalta (generic name duloxetine), approved by the FDA in 2004 to treat depression, also provides significant pain relief to many people with FMS. Cymbalta increases the levels of both serotonin and norepinephrine, important neurochemicals that can improve mood as well as decrease chronic pain. (For this reason, it is called a serotonin norepinephrine reuptake inhibitor, or SNRI see the nearby sidebar.) This medication may cause weight loss in some individuals.

Other Antidepressants

Venlafaxine (Effexor, Effexor XR) is a serotonin and noradrenergic reuptake inhibitor with a better side effect profile than TCAs or MAOIs. A May 2002 meta-analysis of prior antidepressant trials suggested that venlafaxine and TCAs may have a greater remission rate than SSRIs. Further study is needed including more head-to-head comparison trials. Nefazodone (Serzone) and trazodone (Desyrel) are serotonin-modulating antidepressants. Trazodone is prescribed rarely as a sole antidepressant but is often prescribed as an adjunct to an SSRI for sleep because it has strong sedative properties (at higher doses it serves as an antidepressant). In addition to sedation, trazodone can on rare occasions induce priapism (prolonged, painful penile erection) that can cause permanent damage. Patients must be instructed to seek emergency treatment should such an erection occur. Nefazodone is similar to trazodone but is less sedating at therapeutic doses. It appears to have a low rate of sexual...

Impact Of Bpd On Outcomes Of Depressive Disorders

BPD enter treatment for relief from depressive symptoms, yet patients with BPD have poorer outcomes for depression than those without BPD (Mulder, 2002). Surprisingly, we could locate no reports on the influence of BPD on effects of psychotherapy for depression in a controlled treatment study, only in naturalistic studies. Meyer, Pilkonis, Proietti, Heape, and Egan (2001) reported that BPD features predicted less improvement in depressive symptoms and overall level of functioning over 1 year of treatment (95 received psychotherapy, 65 received medications), whereas other Cluster B and Cluster C disorder features did not. Grilo et al. (2005) found that, among 302 patients with major depression, those with BPD had a lower remission rate (60 vs. 89 ) and a longer interval until remission than those without BPD, even when controlling for many parameters of depression course and history. McGlashan (1987) reported that depressed patients with BPD were more likely over a 15-year follow-up to...

Antidepressants Elavil and Relatives

These drugs date from 1958, when the parent compound, imip-ramine (Tofranil), was invented. It is still in wide use today, along with a close relative, amitriptyline (Elavil), and a number of other similar drugs. Some depressed patients respond very well to these medications but not until after at least two weeks of regular use. On the other hand, the toxic effects begin right away sedation, dry mouth, blurred vision, constipation, difficulty in urinating. Normal people are likely to notice only these side effects without any positive mood changes. A newer antidepressant drug is fluoxetine (Prozac), unrelated to the older members of this group. It is currently very popular in psychiatric medicine. Fluoxetine is an effective antidepressant, but some patients cannot tolerate it, because it makes them very anxious. Like the major tranquilizers, the antidepressants do not lend themselves to recreational use because no one likes their effects. Often, even depressed patients who are helped...

Table 118 Practical Things You Can Do to Improve Your Mood

As you think about your own situation, recognize that you need to be good to yourself. Excessively worrying about your mood is counterproductive. Instead, step out of the situation for a moment and look at yourself as though you were a loved one. What would you advise that loved one to do Would you encourage him or her to get professional help, knowing that it might aid with physical as well as emotional recovery Whether or not you decide to seek assistance for your emotional health, remember that there are many things that you can do other than psychological counseling or taking an antidepressant medication. Just as you carefully considered the options for treating your cancer, I encourage you to consider your emotional health and how it can impact your recovery.

Major Depression Is Associated with Poor Family Functioning

Epidemiological research suggests that marital distress is associated with significantly increased levels of major depression in men and women (Whisman & Bruce, 1999). Poorer general family functioning also characterizes depressed adults relative to nondepressed control subjects (Friedman et al., 1997). Approximately 69 of the depressed individuals in this study reported significant family problems. Furthermore, poorer marital or family functioning is associated with depression symptoms in different ethnic or racial groups, including Mexican Americans (Vega, Kolody, & Valle, 1988) and African Americans (Brown, Brody, & Stoneman, 2000).

Family Problems Predict Onset Delayed Recovery and Relapse of Major Depression

Using a nationally representative sample, Whisman and Bruce (1999) found that people with marital distress were nearly three times more likely to develop a new major depressive episode in the next year than those who did not report marital distress. Humiliating events, such as infidelity or threats of divorce, may leave people particularly vulnerable to major depression (Cano & O'Leary, 2000). These data are supported by retrospective studies in which large portions of depressed individuals reported that marital problems occurred before the onset of their depression (e.g., Kendler, Karkowski, & Prescott, 1999), and that they believed marital problems had a causal role in the onset of the depression (O'Leary, Riso, & Beach, 1990). Family problems are also associated with a decreased likelihood of recovery from depression (Keitner, Ryan, Miller, & Zlotnick, 1997). Expressed emotion, which refers to the tendency of family members to be critical, hostile, and overinvolved with a family...

Balancing the pluses and minuses of antidepressants

The good news about using antidepressants to treat fibromyalgia pain is that many antidepressants are relatively inexpensive, and most doctors will not hesitate to prescribe these medications for the treatment of chronic-pain problems. However, Cymbalta and some other antidepressants can be costly if you don't have medication coverage. In other words, you generally don't need to see a psychiatrist in order to receive a prescription for an antidepressant. As with all medications, antidepressants have potential side effects

Antidepressant Medications

It was once thought that antidepressants (medications commonly prescribed to treat depressive disorders and anxiety) were necessary to treat bipolar depression. Research now shows that mood stabilizers alone can help with both mania and depression, so taking an antidepressant might not be necessary (Sachs, Sylvia, and Kund 2009 Altshuler et al. 2009). For many people with bipolar disorder, taking an antidepressant without a mood stabilizer can cause a manic episode (Ghaemi, Lenox, and Baldessarini 2001). This risk is lower if antidepressants are taken in combination with other mood stabilizing medications (Sachs et al. 2007). That said, if your mood is stable, don't be alarmed if you're taking antidepres-sants without a mood stabilizer. This means that the antidepressant you're taking seems to be working, so it isn't necessary to switch medications. Since finding the right medication takes time, it's best not to change a medication if it is working for you. If you do have concerns, be...

Major Depressive Disorder

There is strong evidence that major depression is associated with FM, although the nature of the association has remained controversial. For example, some clinicians still hold that psychosomatic illness plays a large role in chronic pain conditions, including FM. In the past, clinicians endorsed a theory of Tension Myositis Syndrome (TMS). Practitioners who treat TMS consider that when pain cannot be relieved by standard medical treatments, psychosomatic illness is the likely cause, especially chronic pain in the back, neck, and limbs. The theory is that untreatable pain functions as an unconscious distraction from dangerous emotions, and when patients recognize this is the situation and confront their emotions, their symptoms no longer serve a useful purpose and go away. TMS treatment involves attitude change, education, and psychotherapy. Emerging objective evidence in pain processing in FM has led most researchers and clinicians away from TMS as an explanation for FM. Further,...

Table 114 Antidepressant Medications

Noradrenergic Specific Serotonergic Antidepressants (NaSSAs) Action Enhance norepinephrine and serotonin activity in the brain. Drug Remeron (mirtazapine). Tricyclic Antidepressants Action Increase serotonin and norepinephrine levels in the brain. Drugs Anafranil (clomipramine), Elavil (amitryptiline), Norpramin (desipramine), Pamelor (nortryptiline), Sinequan (doxepin), Tofranil (imipramine). some cancer survivors, but there are also other options to help stabilize or improve your mood.

Defense Mechanisms in Depressed Patients

A s discussed in Chapter 2, patients prone to depression use a number of defense mechanisms that can be usefully recognized for therapeutic work as habitual ways of protecting themselves from conscious comprehension of warded-off affects and fantasies (Bloch et al. 1993). Although these defenses may temporarily ease painful feelings, in the long term they can worsen depressive symptoms. As described in Chapter 9 ( Idealization and Devaluation ), for example, idealization employed in an effort to bolster self-esteem or protect others from aggression may lead to disappointment and devaluation when self and others cannot meet the inflated expectations. Therefore, it is important to help patients become aware of characteristic defenses and more directly access underlying, threatening fantasies. As long as patients avoid awareness of their anger, for example, it is difficult to help them view anger as less toxic or to help them keep from turning the anger against themselves. Defense...

How do you treat depression pharmacologically

Are there any other antidepressants Yes, there are other antidepressants also considered as first-line treatment with different mechanism of action options (see Table 13.2). Table 13.2 Other Antidepressants Indicated for the Treatment of Depression Table 13.2 Other Antidepressants Indicated for the Treatment of Depression (Continued)

Antidepressants

Another less frequently used group of medications are the antidepressants which are also believed to work by acting on the neurotransmitters dopamine and norepinephrine in the brain (CHADD, 2003). These are used in the treatment of children with ADHD as a second-line choice. This class of medications is often prescribed for a child who is not responding to a stimulant medication or cannot tolerate the side effects (U.S. Public Health Service, 1999). This category includes the tricyclic antidepressant medications Antidepressants that only affect the serotonin system (Prozac , Zoloft , Celexa ) have not been shown to be effective for treating primary symptoms of ADHD but may be effective against co-existing conditions (CHADD, 2003). The tricyclic antidepressants take some time to build up in the bloodstream and reach a therapeutic level. Their benefits include reduction in the symptoms of hyperactivity and impulsivity. In addition, they may also help with mood swings, emotionality,...

Depressive Episodes

The words depression and depressed are often used in the media and in everyday conversations. However, psychologists and physicians define a depressive episode as the presence of five or more symptoms of depression (described below) experienced most of the day nearly every day for at least two weeks. At least one of the five symptoms must be depressed mood or loss of interest or The depressive symptoms of bipolar disorder are the same as those seen among people who experience depression without manic symptoms. When depressive symptoms occur in a person who has never experienced manic or hypomanic symptoms, it is called major depressive disorder or unipolar depression. However, when people with bipolar disorder experience depression, it usually occurs more often, arises more quickly, and is felt more intensely than unipolar depression. Therefore, it's important to educate yourself on how to recognize not only the highs of mania, but also the lows of depression. Depression is defined by...

Mood swings

Adjusting to being pregnant and preparing for new responsibilities may leave you feeling up one day and down the next. Your emotions may range from exhilaration to exhaustion, delight to depression. Your moods can also change considerably over the course of a single day. Some of these mood swings may result from the physical stresses your growing baby is placing on your body. Some may be the result of fatigue, pure and simple. Mood changes may also be caused by the release of certain hormones and changes in your metabolism. contribute to mood swings during pregnancy. Sudden fluctuations in progesterone, estrogen and other hormones likely play some role in mood swings. The effects of hormones from the thyroid and adrenal glands also are receiving considerable scientific attention. Your moods are likely to be strongly influenced by the nurturing and support you receive from your partner and family. Perhaps now as never before, you need understanding, support and encouragement as you...

Introduction The New Bipolar

After relative neglect in the age of melancholy during the 1970s and 1980s, there has been a renaissance of bipolar disorder during the last decade of the 20th century. Major monographs which cover the psychopathology of the illness have been published, beginning with the Goodwin-Jamison encyclopaedic coverage of Manic Depressive Illness 1 , the Marneros and Angst's book on Bipolar Disorders 100 Years After Manic Depressive Insanity 2 and the present author's monograph entitled Bipolarity Beyond Classic Mania 3 . Several volumes deal primarily with biological aspects 4-6 . Two poignant autobiographical accounts 7, 8 have helped in the cause of destigmatizing the illness. Other books have been written to address the needs of patients and their families, while at the same time maintaining a scholarly base 7, 9 . unmistakable. However, the illness may begin insidiously with manifestations of a subthreshold or disturbances of a temperamental nature buried in early childhood or adolescence...

General Characteristics Of Cognitive Therapy Therapeutic Relationship

The therapeutic relationship has long been recognized as an important aspect of CT (Beck et al., 1979 J. S. Beck, 1995). CT is not something that is done to patients it is a treatment that is done with them. Thus, CT emphasizes the development of a good working alliance between therapist and patient, and a collaborative partnership as the ideal way of working together. There are several ways in which the CT therapist tries to develop this type of relationship. First, the therapist enters the treatment process with an attitude of empathy and respect. Cognitive therapists recognize that depressed patients often come to treatment with a sense of personal failure and a need for help. The therapist conveys concern and caring, and an optimism that derives from both a general conviction that CT for depression is effective and competence with the approach. At the same time, another common perspective in CT is that the patient is the expert on his her own life. Thus, though the cognitive...

US vs International Concepts

The extension of the boundaries of bipolarity is reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in its 4th edition (DSM-IV) 28 . In this manual, bipolar disorders include bipolar disorder proper (also known as bipolar I), followed by bipolar II, cyclothymia, and bipolar not otherwise specified. This is implicit acceptance of the concept of some sort of a bipolar severity spectrum, contrasted with a depressive disorder spectrum consisting of major depressive disorder, dys-thymia, and depression not otherwise specified. The rubric unipolar disorder'', however, is wisely avoided because of the risk for bipolar transformation of major depressive disorder even after many episodes 2934 , The World Health Organization Classification in its 10th revision (ICD-10) 35 is less committed to the concept of spectrum. Depressive disorders are extensively documented, but again, the term unipolar is avoided. While bipolar disorder is...

Initial Evaluation and Determining the Appropriateness of Psychodynamic Psychotherapy

The initial evaluation of the depressed patient should include both an assessment of depressive symptoms and of the patient's capacity to benefit from psychodynamic treatment. The clinician reviews the patient's developmental history, relationships, stressors, and conflicts. The clinician employs a semistructured interview and should follow up on topics that trigger a depressed mood or defensiveness. At all times, the clinician is sensitive to linkages, word usage, repetitions, and omissions that stamp the delivery of the narrative. Important topics to explore in the evaluation are summarized in Table 1 1. Depressive symptoms as delineated in DSM-IV-TR (American Psychiatric Association 2000a) Prior depressive episodes and the circumstances surrounding them, such as precipitating events and stressors, with a focus on eliciting accompanying feelings and fantasies Childhood depressive symptoms Family history of depressive disorders family attitudes toward this history

The Structure Of A Typical Session

Although the content of CT for depression varies dramatically from patient to patient, the process of therapy is relatively similar. Sessions typically last 50 minutes and are scheduled on a weekly basis, although it is not uncommon at the beginning of the treatment process (i.e., the first 3 or 4 weeks) to schedule two sessions a week for more severely depressed patients. Session scheduling and session time frames can be used flexibly, though. With more depressed patients, it may be more productive to have relatively shorter sessions more frequently at the beginning of treatment, then move toward a weekly schedule of sessions as the depression begins to lift. Also, it is fairly common for the assignments between one session and the next to become somewhat more elaborate and to need time for implementation as the treatment develops. In such a case, it may be that scheduling sessions too frequently does not permit the patient enough time to complete homework, and may be somewhat...

Aging And Altered Drug Response

Another mechanism of age-related changes in the response to some medicines is an apparent change in how sensitive the nerve cells are to the presence of the drug and how well they take the drug inside the nerve cell through tiny pipe-like structures called receptors which are found in the cell wall. In general, drugs acting on the central nervous system produce a stronger effect in older patients. Any drug that affects alertness, coordination, and balance will likely cause more falls and other accidents in elderly persons than in younger ones. Thus, hangover effects of sedative-hypnotic drugs and other mind-altering medicines such as ANTIPSYCHOTICS, ANTIDEPRESSANTS, and anxiolytics) are common and often more serious in the elderly. The dangerous consequences of the hangover effects, such as falls which cause broken hips, suggest, in part, that the receptors in the nerve cells in the elderly are more sensitive, even supersensitive, to the presence of these medicines. In contrast to...

The Place of CT as an Empirically Supported Therapy for Depression

The treatment X severity interaction effect discussed earlier was subjected to a further mega-analysis (DeRubeis, Gelfand, Tang, & Simons, 1999). This study combined the raw data from four independent comparative trials of CT and pharmacotherapy (including the NIMH TDCRP data), and despite several ways of examining the data, failed to find the interaction effect. DeRubeis et al.'s argument, based on their analyses with more statistical power and more sophisticated data methods, was that the treatment X severity interaction did not in fact exist, and that these treatments were equally efficacious in both less and more severely depressed patients. These predictions have subsequently been borne out in two recent studies. One of these studies was completed at two sites and only employed more severely depressed patients (DeRubeis et al., 2005 Hollon et al., 2005). Results indicated roughly equivalent outcomes between CT and selective serotonin reuptake inhibitor (SSRI) medications in the...

Understanding Bipolar Disorder

Bipolar disorder is a biological illness that affects your ability to regulate your mood and leads to feelings of extreme happiness, intense sadness, or heightened irritability. It is considered an illness because, like other medical disorders such as heart disease or diabetes, it occurs after a biological change in your body, has well-described symptoms, and causes distress to people who have it. Certain symptoms tend to occur together, and when they do, mental health providers call this experience a mood episode. Symptoms that occur while feeling high, euphoric, or irritable are called manic or hypomanic episodes. Symptoms that occur when feeling down, blue, or emotionally empty are called depressive episodes. In the next section, we'll walk you through what experiences and symptoms form the criteria for a mood episode.

Conceptualization Of Severe Depression

The severity of a major depressive disorder is generally defined according to the number of symptoms present, the severity of the symptoms, and the associated functional impairment or distress (American Psychiatric Association, 1994). According to criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), mild depression is indicated by the presence of five or six symptoms, mild functional impairment, or the ability to function normally with significant effort. Severe depression is indicated by the presence of most of the symptoms of a major depressive episode and clear functional impairment. Up to 15 of severely depressed individuals also die by suicide (American Psychiatric Association, 1994) readers are strongly encouraged to consult specific guidelines regarding the assessment and management of suicidality (e.g., Ghahramanlou-Holloway, Brown, & Beck, Chapter 7, this volume). Moreover, severe depression may also be accompanied by psychotic...

Assessment Of Severe Depression

For patients who have been diagnosed with major depressive disorder according to DSM-IV criteria, both interview- and self-report based measures are available for the assessment of depressive severity. The Beck Depression Inventory Second Edition (BDI-II Beck, Steer, & Brown, 1996) is perhaps the most widely used self-report measure. Beck et al. report the following ranges for depressive symptom severity minimal (0-13), mild (14-19), moderate (20-28), and severe (29-63). Among the most widely used interview-based measures is the Hamilton Rating Scale for Depression (HRSD Hamilton, 1960) scores on the 17-item version range in increasing severity from 0 to 69. In many clinical studies, scores of 20 or greater indicate moderate to severely depressed patients, and scores of 14 to 19 indicate less severely depressed patients. Other studies have used cutoffs of 25 or 28 to demarcate purely high-severity subgroups using the HRSD.

Behavioral Strategies

The seminal formulation of CT suggested a strong emphasis on the use of behavioral strategies with more severely depressed patients (Beck, Rush, Shaw, & Emery, 1979). As Beck and colleagues (1979) noted The behavioral techniques are clearly indicated with severely depressed patients. An individual with severe depression commonly has considerable difficulty focusing on more abstract conceptualizations. His attention span may be limited to well-defined concrete suggestions. Research findings in the area suggest success experiences on concrete behavioral tasks are most effective in breaking the vicious cycle of demoralization, passivity and avoidance, and self-disparagement. (p. 140) And, as discussed in greater detail below, research by our group has suggested that purely behavioral treatments demonstrate comparable or possibly superior outcomes to CT among more severely depressed patients (Dimidjian et al., 2006 Jacobson et al., 1996). When working with severely depressed patients,...

The Experience Of Bipolar Disorder Over Time

Bipolar disorder is an episodic, recurrent illness. This means that throughout your life, you might experience symptoms of mania or depression, and then these symptoms will clear and you will experience periods of wellness. Often, this pattern tends to repeat itself. Relapse refers to a new episode after your first episode of mania or depression. Remission or euthymia refers to periods without manic or depressive symptoms. Even if you do everything you can to take care of yourself, you may have relapses. However, they will be less frequent if you take good care of yourself by doing things such as taking your medications, working with your treatment providers, getting enough sleep, and identifying changes in your mood. The goal of treatment is for you to learn how to minimize the chances of having another episode. While there currently is no cure for bipolar disorder, many effective treatments exist (discussed in chapters 3 and 4). Thanks to these treatments, many people who in the...

Toward an Expansion of Bipolar Disorders in DSMV

The second area has to do with treatment-induced hypomania. Currently patients who are depressed and become hypomanic in response to treatment are classified as major depression with (antidepressant) induced hypo-mania. This classification ignores the fact that many patients with bipolar disorder go through phasic cycles with mania or hypomania preceded by depressive states. Thus, the natural history of their disorder is to have a switch from depression to an elevated mood state. Why such patients were not considered bipolar in the DSM-IV ICD-10 is unclear. However, data to clarify this point would seem to be an important contribution to the planners for the next nomenclature.

Collaborative Presentation of the Treatment Model and Ongoing Attention to the Therapeutic Relationship

Attention to patient reactions to the cognitive model may be particularly important when therapists work with severely depressed patients. Among the patients who received CT in our recent trial, those who did poorly were more likely to be severely depressed and to have significant problems with their primary support group when they began treatment (in addition to having greater functional impairment Coffman et al., 2007). The specific support group problems that were common to these patients included death Moreover, breaches in the alliance may be particularly likely when therapist and patient explore cognitions about interpersonal problems (Hayes, Castonguay, & Goldfried, 1996). These findings suggest that particular skill may be needed to address interpersonal problems such that the therapist empathizes with the patient's experience, yet does not validate irrational beliefs and faulty attributions. The importance of the therapeutic relationship has been stressed in CT generally and...

Concurrent Use of Pharmacotherapy

Finally, it is recommended that therapists consider and discuss with their patients the option of concurrent pharmacotherapy. Although not all patients wish to take medication and many cannot tolerate the accompanying side effects, studies to date suggest a modest advantage of combined pharmacotherapy and psychotherapy. Although these studies have not focused specifically on severely depressed patients, they have included sizable numbers of such patients in their samples. In general, studies of combined treatments suggest an increase in response rates of approximately 10-15 (Hollon, Thase, & Markowitz, 2002).

In Search for a Definition for Bipolar Disorder

Depression is responsible for much of the suffering associated with bipolar disorder 1 . Its role in the illness, however, is still not well understood, and many of the unresolved problems in diagnosis involve depression. Akiskal emphasizes these the existence of mixed depressions as well as mixed manias, the prominent role of depression in bipolar II (and the higher bipolar numbers) 2 , the identification of patients with bipolar disorder who have experienced depressive episodes but have not yet been manic or hypomanic. These questions have large practical treatment implications, since antidepressant treatments may have deleterious effects in at least some patients with bipolar disorder. major depressive disorder or individuals without a psychiatric illness 3 . Akiskal has addressed this by emphasizing the role of temperament 4 , As pointed out earlier by Kraepelin, temperament shades gradually into normal variation. It may provide, however, the physiological substrate on which other...

How To Minimize And Manage The Different Types Of Fatigue

What you eat fuels your body with energy stores. It is important for you to eat a well-balanced diet to minimize fatigue and maximize function. Good nutrition will also contribute to your skin integrity, your mood, and elimination patterns. (Nutrition is discussed in detail in Chapter 15, The Role of Nutrition in Multiple Sclerosis. ) Depression. Your feelings of fatigue may be worsened by underlying depression. Depression is recognized as a symptom of MS and can also occur if life becomes very difficult when you are dealing with the day-to-day challenges of the disease. If so, feelings of overwhelming tiredness or lassitude may be unrelated to your level of activity and more to your mood. In addition, depression can affect sleep, appetite, motivation, and participation in activities. Such feelings can occur in the morning, afternoon, or evening. They do not appear to occur at any particular time of day in fact, when you are depressed, you may wake up feeling tired....

Phase 1 Forming a Therapeutic Alliance and a Frame for Treatment

As seen in Table 3-1, phase 1 of this treatment is characterized by an initial examination of the depressive symptoms and the context in which they have occurred. The therapist works collaboratively with the patient to uncover a developmental understanding of the depressed feelings and the fantasies that accompany them within the patient's history, to identify particular areas of conflict that seem to trigger the depressed feelings currently, and to begin understanding the meanings of each of the patient's particular depressive ideas. Within this collaboration, the therapist and patient form an alliance, ideally with the therapist perceived as both a sympathetic and nonjudgmental collaborator in understanding, and as an authoritative voice with knowledge about and experience in treating the patient's illness. In this phase, the initial explorations of the patient's symptoms become linked in a dynamic formulation that specifically integrates the patient's experiences and perceptions...

Cultivating the Therapists Mind Set to Work Effectively with Chronic Depression

McCullough (2000) observed that fundamentally, in therapy, chronically depressed patients need to have an experience of engaging with a decent, caring, human being. This is a position we also endorse. Chronically depressed patients can present considerable obstacles to the therapist conveying warmth and care, and there is the potential for supposedly therapeutic encounters to be damaging, unless the therapist has some capacity to recognize and manage his her own contribution to interpersonal encounters in therapy. The therapist also needs to be consistent and reliable, and have the tenacity to stick with the therapy process and structure, and remain proactive, often in the face of extreme hopelessness, helplessness, and negativity.

Establishing a Therapeutic Frame

As the recommendation for dynamic psychotherapy is made, it is important to introduce its basic format and to connect each aspect explicitly with how it will help the patient's depressive symptoms. The therapist can review and describe the patient's depressive symptoms and provide education about the potential neurobiological and psychological contributions to depression. The psychological attitudes about self and others and the ways in which the patient understands and manages painful affects are identified as the focus for exploration.

Adaptations to Standard CT When Working with Chronic Depression

Many aspects of how chronically depressed patients present indicate that unless there is active management of a structured process, therapy can disintegrate into a diffuse entity that lacks focus and direction. This can lead to hopelessness and despondence in both patient and therapist. It is in this area that, if the therapist can accept the idea that everything is grist for the mill and not become exasperated at him herself or the patient, therapy can be its most productive and rewarding. Homework is a central mechanism of change in CT (Burns & Spangle, 2000 Garland & Scott, 2000), and there is some evidence that the extent to which patients engage in homework predicts outcome in CT (Kazantzis, Dean, & Roman, 2000). In chronically depressed patients, a number of factors are likely to interfere with the completion of homework assignments. Behavioral and cognitive avoidance work directly against the patient's engagement with any task that has the potential to require effort or to...

Cocaine And Other Stimulants

Amphetamine and cocaine are both potent PSYCHOMOTOR stimulants. They produce increased alertness and energy and lower ANXIETY and social inhibitions. The acute reinforcing actions of the stimulants are primarily determined by their augmentation of DA systems. With prolonged consumption (1) acute TOLERANCE becomes substantial, and (2) the individual starts to regularly consume higher and many more doses if the resources are available. Over time, in high-dose regimens, the behavioral pattern of use becomes stereotyped and restricted. In settings of low availability, the individual focuses on the acquisition and consumption of the drug. These effects of stimulants occur within weeks or months of continued use. The individual may also start bingeing during this period. A binge is characterized by the readministration of the drug approximately every ten to twenty minutes, resulting in frequent mood swings (i.e., alternations of highs and lows). Cocaine binges typically last twelve hours,...

Receiving a Diagnosis and Finding Help

Receiving a diagnosis of bipolar disorder, or any other illness for that matter, is often challenging and may bring up many different emotions. You may feel scared because bipolar disorder is a lifelong illness, or you may feel relieved because you've struggled with symptoms for a long time and now your experiences have a name. A diagnosis is the first step in receiving treatment that will help you take control of your mood and maintain longer periods of wellness. In this chapter, we'll help you prepare to take that first step. We'll provide you with resources to help you find treatment

No treatment and treatment delay

Several studies have reported that two thirds of patients who have behavioral health difficulties receive no treatment for their mental illness or substance abuse problems (Fig. 1) 8,9,20,30,41,42 . Nontreatment of mental illness and substance abuse is consistent throughout the world, with even fewer persons receiving treatment in the underdeveloped countries 12,43 . Of those who receive treatment, the average delay between onset of illness and treatment is 10 years although this varies based on the illness category 44,45 . For instance, the average delay between onset of illness and treatment of depressive disorders is 6 to 8 years, whereas that for anxiety disorders is 9 to 23 years 45 . Hansen and colleagues 25 reported that 39 of medical inpatients had active psychiatric illness in their hospital. Only 12 of these were referred for psychiatric evaluation and only 6 were being treated despite free care in the national health system of Denmark. Treatment delay is distressingly...

Do I Really Need to Take Medications

Many individuals have mixed feelings about taking medications, and, in an ideal world, most people would choose not to do so. However, numerous studies have shown the benefit of medications for treating episodes of depression and mania and helping to prevent these episodes. Medications, such as mood stabilizers and antidepressants,

What Types of Medications are Used to Treat Bipolar Disorder

The following sections describe the four major types of medications used to treat bipolar disorder mood stabilizers, antidepressants, antipsychotics, and antianxiety (anxiolytics). These medications are the main tools for controlling bipolar disorder. Used individually or in combination, these medications provide a way for you to manage your bipolar disorder. Other medication tools also may be used to treat additional symptoms. Drugs often are classified according to the purpose for which they first got approval for use in the United States. Although many drugs are found to have a variety of uses in addition to this first use, the original name sticks. Because of this, doctors often use drugs classified as antidepressants to treat anxiety and drugs called anxiolytics to treat insomnia. For this reason, it is extremely important for you to know the purpose of a medication, not just its name. It helps to try to have a sense of humor with the well-meaning people who may question your...

Bipolar II is Bipolar

In psychiatry and, in particular, in the field of affective disorders, the cross-sectional clinical picture is hardly sufficient for making a precise clinical diagnosis. As demonstrated in Akiskal's review, not only depressed patients with past hypomania, but also those with premorbid cyclothymia or hyperthymia can correctly receive a diagnoses of bipolar II rather than unipolar depression.

Review of Efficacy Research

There is little literature on CT approaches to drug-resistant depression. Fen-nell and Teasdale (1982) failed to detect a significant effect of CT in five chronic, drug-refractory, depressed outpatients. Antonuccio et al. (1984) applied a psychoeducational group treatment (including relaxation, increasing pleasant activities, cognitive strategies, and social skills) to 10 outpatients with unipolar depression who had not responded to antidepressant medication. All patients continued drug treatment. One patient dropped out of group treatment, four were no longer depressed, two showed some improvement, and three patients were still depressed after psychoeducational group treatment. Improvements were maintained at 9-month follow-up. Miller, Bishop, Norman, and Keitner (1985) examined the effectiveness of a treatment program comprising CT, pharmacotherapy, and short-term hospitalization in six chronic, drug-resistant, depressed females. The approach produced a substantial improvement in...

Pain thresholdpsychological factors

These observations led to the concept of altered visceral receptor sensitivity. When such individuals are given standard psychological tests many are found to have greater anxiety, depression, somatisation, neuroticism, or even panic disorder scores than control subjects, and some studies have shown improvement in pain with the use of antidepressants or anxiolytics.

The Bipolar Spectrum

A critical example is that of a clinician observing a patient whose most evident symptoms are the manic and depressive ones. Presumably, he will not feel the need to go further in gathering the subtler clinical phenomenology, which would make his choice of therapeutic approach a wiser one. These considerations arise very clearly from recent research and clinical data supporting a broader bipolar concept. A major problem is the difficulty of recognizing subthreshold clinical expressions of this complex clinical entity. This is not a new issue. For long have several authors, like Weitbrecht 1 , emphasized the need to search and evaluate hypomanic oscillations in the past history of the endogenous depressive patients . Also Storring 2 described an uncomplete manic syndrome , pointing out the difficulties in establishing a clear-cut separation from the depressive clinical picture. According to this author, some clinically relevant aspects of bipolarity might already be present weeks,...

General Treatment of Dementia

And medications with CNS effects (sedatives, narcotics, antidepressants, anxiolytics, and antihistamines) should be discontinued, or used sparingly. The clinician should also be aware that other commonly prescribed medications, including antiemetics, antispasmodics for the bladder, H2 receptor antagonists, antiarrhythmic agents, antihypertensive agents, and nonsteroidal anti-inflammatory agents, may also cause cognitive impairment.

Working With the Central Themes

Tendencies toward idealization and devaluation, and characteristic defenses in depressed patients. In this chapter, we review the basic techniques used in this treatment. These techniques are used in every phase of treatment but constitute the primary work of the important middle phase.

During The Appointment

As mentioned, there are no medical tests (such as brain scans or blood tests) that can confirm a diagnosis of bipolar disorder. Instead, treatment providers will ask you lots of questions about your experiences and the length of time you've had symptoms to determine whether the frequency, severity, and timing of your mood symptoms meet the diagnostic criteria for bipolar disorder. You may also be referred to a physician for a physical exam and thorough medical history in order to rule out other illnesses that might be causing your symptoms for example, thyroid problems can cause mood swings. To help you prepare for your appointment, we'll list some of the questions that mental health professionals will ask to learn more about your mood, symptoms of mania and depression, and other symptoms or concerns. While some of these questions may seem invasive or embarrassing, it's important to answer openly and honestly so the care provider has an accurate picture of your experiences and can...

Using Levels of Residual Symptoms to Decide

To demonstrate the ability of depressive symptoms at the last A-CT session (residual symptoms) to predict relapse recurrence among responders to ACT (Jarrett et al., 2005), we operationalized depressive symptoms as the common factor score we mentioned earlier and examined the data in two different ways. First, we examined 8 points on the survival function (the probability of remaining well over time), and found that higher depressive symptom factor scores at the last A-CT session predicted quicker relapse recurrence as a main effect and also interacted with assignment to C-CT versus assessment only. Specifically, C-CT does not reduce the probability of relapse recurrence for patients with no or low residual symptoms, but As a further illustration, we then divided these same patients (from the clinical trial reported by Jarrett et al., 2001) into lower versus higher residual symptoms, assignment to C-CT or to assessment only, and relapse recurrence within 24 months. Residual symptoms...

Finding a Reliable Way to Take Your Medications

Finally, remember to keep track of the amount of pills that you have left in your bottle. This way you can ask your doctor for refills or you can pick up your refills before you run out of medication. Remember that medications are a useful tool to help you maintain your mood within the range you want so that you can best pursue your life goals. These tools are only useful if you use them the right way.

NMHA Depression Checklist

Every year more than 19 million Americans experience clinical depression. It affects men, women, and children of all races and socioeconomic groups, causing them to lose motivation, energy, and the pleasure of everyday life. Clinical depression often goes untreated because people don't recognize many of its symptoms. The good news is that almost everyone who gets treated can soon feel better. Here is a checklist of ten symptoms of clinical depression

Consistent Use of Your Medication

For many individuals, a combination of medications may be used to enhance mood stability. Once your mood stabilizes, there is often the temptation to discontinue medication and to believe that the disorder has been cured. Unfortunately, bipolar disorder is a lifelong condition, one that requires ongoing treatment. We use the analogy of a seatbelt to help underscore the importance of this point. As you know, a seatbelt is a protective device designed to prevent injury in

Clinical Manifestations

Patients who have attempted suicide deserve thorough psychiatric evaluation. Psychiatric history and mental status examination should explicitly address depressive symptoms, such as suicidal thoughts, intent, and plans. The details of the suicide attempt are critical to understanding the risk of a future suicide. Patients who carefully plan the attempt, use particularly violent means, and isolate themselves so as not to be found alive are at particularly high risk of future suicide completion.

Myroslava Romach Karen Parker

When a dysphoric mood becomes more severe, is persistent, and impairs functioning, a major depression as a clinical syndrome has developed. Concurrent clinical features include a loss of interest or pleasure in usual activities, a sense of hopelessness, poor or alternatively increased sleep, loss of appetite or overeating with resultant changes in weight, fatigue, anxiety, restlessness, obsessive thinking, difficulty concentrating, irritability, feelings of worthlessness, recurring thoughts of death, and suicidal ideation or an actual attempt to end one's life. Suicidal disturbances are of serious concern approximately 66 percent of depressed patients contemplate suicide, and it is estimated that 10 to 15 percent succeed. In some cases, psychotic features such as hallucinations and delusions may develop. Depression is one of the most common psychiatric disorders seen in adults. The lifetime prevalence of major depressive disorder (using DSM-III-R criteria) in the United States is...

Analysing Course of Illness in Bipolar Disorder

Typically, for bipolar disorder, the outcome of interest includes recurrence of mania and major depression, and recovery from these mood episodes. Older studies treated recurrence and recovery as a dichotomous variable the study patient had a recurrence or did not, and likewise, recovered from a mood episode or did not. Problems arise with this approach when subjects drop out of the study or ultimately when the study ends. Taking recurrence as an example, if subjects withdraw prior to recurrence, the rate of recurrence may be underestimated. Similarly, termination of the study may lead to underestimating the rate of recurrence simply because the length of follow-up was inadequate.

Road Map within CCT

Patients start and progress through C-CT with different levels of skills development, durations of symptom remission, and composites of risks. Behavioral assessment of patients' skills aids therapists in knowing when to modify the focus or content ofthe therapy, its homework, or its schedule. To determine where to focus C-CT, therapists consider (1) syndromal status (i.e., the presence or absence of a mood and other psychiatric disorder, noting that all patients begin C-CT without MDD) (2) severity of residual depressive symptoms (3) the degree to which patients have mastered, are using, and can generalize compensatory skills and (4) the continuation or emergence of risk factors that might necessitate a change in the treatment schedule or homework recommended. Below we describe some typical combinations and describe the associated therapeutic focus or goal.

Fewer Symptoms and Skills Acquired Goal Prevent Relapse and Generalize Gains over Time and Environments Promote

When the HRSD has often been below 5 and patients know how to use one or more skills to produce symptomatic relief, the focus of C-CT moves to relapse prevention, stress inoculation, and promotion of sustained remission and a full recovery. Stress inoculation comprises constructing an individualized model of depression onsets, offsets, and prevention. Patient and therapist work together to make the model of depression and prevention practical and usable in daily life. They examine common themes associated with prior onsets of depression or with increases in negative affect. They examine the cognitive and behavioral patterns associated with offsets in prior depressions or negative affect. For example, if onsets of prior depressions were associated with the end of romantic relationships and offsets were correlated with starting a new romantic relationship, the therapist would attempt to elicit an underlying belief, such as I am only worthwhile and happy if I have a partner. Patient and...

Self Help Therapies for Depression

This chapter focuses on the extant research on self-administered treatments for depression including their effectiveness when integrated with therapist contact, antidepressants, or implemented alone. One application of self-administered treatments is as a first line in a stepped-care model of depression intervention (Scogin, Hanson, & Welsh, 2003). In such a model, the first line of intervention should be the least intrusive, most Self-administered treatments can be considered a possible first step in mild to moderate cases of depression. Using self-administered treatments first may save some individuals the money and time usually spent on more rigorous treatment courses. In more complex or severe cases, bibliotherapy could still be applied as an adjunct to more traditional treatment in an effort to maximize treatment gains. Bibliotherapy is one form of self-administered treatment that has been researched as both the first step in intervention and as a stand-alone treatment for...

Asymptomatic Recovered with Skills Goal Maintain Gains Initiate MCT

When patients' symptoms have not met criteria for major depression, the HRSD (or other symptom severity measure) score has been below 5 (or the measure's equivalent) more weeks than not during the past 8 or more consecutive months, and psychosocial functioning is fully restored, then patients can be declared recovered from an episode of MDD. When patients also have acquired the basic CT compensatory skills and have learned to generalize the so-called critical skills to new target problems and situations, they are ready to graduate from C-CT to maintenance-phase CT (M-CT). The aims of M-CT are to maintain recovery and to prevent recurrence or new depressive episodes. During M-CT some patients move from habitually using compensatory skills to achieving a fundamental and meaningful change in their lifestyle and perceptions of the world, self, and future. The few data that exist on M-CT suggest that (1) the preventive effects of C-CT are finite for most patients (Jarrett et al., 2001),...

Dropouts And Substance

In the meantime, the broad range of unfortunate effects of dropping out of school makes it important to sustain and increase the vigor of stay-in-school programs as well as outreach programs for youths who are chronically absent from school or who actually have dropped out before graduation. These programs may help the individual youths, their families, and society in many ways they may not only confer benefits in relation to schooling and better preparation for adult life, but also reduce the amount of substance use in the teenage years, prevent the occurrence of alcohol and drug problems in adulthood, and possibly prevent other psychiatric disorders such as major DEPRESSION.

Recording Information Reality Scramblers on Thought Trackers

Tracking your thoughts and looking for distortions in them helps clear your thinking, which in turn starts improving your mood. Before you get to work on your own Thought Tracker, see what Bradford (see Worksheet 5-2) and Sheila (see Worksheet 5-3) discover when they track their thoughts and analyze them for reality scramblers.

The Role of Seasonal Changes in the Course of Bipolar Disorder

In addition to the various diagnostic subtypes described, there are a number of longitudinal course specifiers listed in DSM-IV which can influence prognosis. Of particular interest to me is the seasonal pattern specifier which can be applied to bipolar I, bipolar II or major depressive disorder. This relates to the onset of depressive episodes occurring at characteristic times of the year, typically in autumn or winter, with remission in spring summer. Although not given the status of a diagnostic category in DSM-IV, this pattern of illness has been widely regarded as if it were a discrete condition, usually referred to as seasonal affective disorder (SAD). Here too, a number of variants have been described winter SAD , which is the most common and the one first described 7 summer SAD , a worsening of mood occurring mainly in summer rather than winter sub-syndromal SAD, applying to less severe depressive mood swings which do not reach diagnostic criteria for depressive disorder. It...

Benefits of MCT Have Been Identified

Fewer data are available for M-CT than for C-CT. Blackburn and Moore (1997) found that 2-year relapse recurrence rates (HRSD 15) did not differ significantly among depressed patients randomized to acute-phase followed by maintenance-phase pharmacotherapy (31 ), A-CT followed by M-CT (24 ), and acute-phase pharmacotherapy followed by M-CT (36 ). This study suggested that M-CT is as effective as maintenance-phase pharmacotherapy but lacked a no- or minimal-treatment condition to establish firmly the benefits of M-phase CT. Helping to fill this gap, Klein et al. (2004) randomized patients with chronic depression who responded (reduction in baseline 24-item HRSD score by 50 to a total score 15) to cognitive-behavioral analysis system of psychotherapy (CBASP) as an acute-phase treatment (either alone or after failed pharmacotherapy), and who maintained response for 16 weeks with continuation CBASP, to monthly maintenance CBASP or assessment only. After 1 year, maintenance CBASP reduced...

Administration of Self Help Programs

Mental health practitioners recommending self-administered treatments to their depressed patients are encouraged to explain the reasoning behind their recommendations the self-administered treatment is being used because of its cost-effectiveness, convenience, and empirical support. Regarding the last point, caution should be exercised when implementing a self-administered treatment that has not been researched. Prior to recommending self-administered treatment, mental health professionals are encouraged to engage in an active discussion with their clients regarding treatment options. experience relapses or reemergence of depressive symptoms and that part of the appeal of self-help materials is that the client can reaccess them at will during such times.

Exercise And Mental Health Benefits

On her website, Sheri Colberg-Ochs writes about exercise and the benefits to emotional health. She says, A good reason to try to enhance and uplift your mood is the very well documented, but poorly understood, mind-body connection. Physical health and mental health are undeniably interrelated, and each affects the other accordingly, your physical well-being often can't be improved if your psychological problems haven't been adequately addressed. Depression is an illness affecting both your mind and your body. When in a depressed state, you may feel sluggish, lethargic, apathetic toward your self-care, or downright uninterested in everything. Is it any wonder that it's difficult to manage your diabetes and stay healthy when you're depressed 3

Primary and Adjunctive Drugs

An additional useful distinction is between medications that have primary roles in treatment of, bipolar disorder, vs. those with roles that are per se adjunctive. Primary medications include mood stabilizers, but also include medications that are effective in the manic or depressive phase of the illness. Antipsychotic medications are effectively antimanic. Antidepressant drugs that are approved for major depression are probably effective in alleviating acute bipolar depression, although few have been systematically studied in even one adequate clinical trial. These drugs would qualify as primary treatments.

Envy or blame of others increasing feelings of being bad unlovable

In this chapter, we illustrate how to explore and identify areas of narcissistic vulnerability common for depressed patients and offer case examples showing how to link these to earlier life experiences. Then we discuss how to work with these realizations in treatment by 1) exploring the negative fantasies patients hold about themselves as a result of these areas of vulnerability, 2) connecting these fantasies to patients' sensitivity to rejection and disappointment to help them recognize their often distorted perceptions about others' response or about their own value, and 3) examining defensive responses to the vulnerabilities in patients' characteristic behavior that actually perpetuate their frustration and disappointment in relationships.

Methodological Issues

The case with antidepressants was complicated by the fact that the DSM essentially utilized the criteria for major depression to define bipolar depression, despite evidence, dating back prior to introduction of the DSM system, that symptom pattern and other illness course features, while overlapping, allowed substantial differentiation 22, 31, 32 . Pivotal trials for currently approved antidepressants have included few bipolar depressed patients, and no drug is specifically approved for bipolar depression 24 .

Drugs Primarily Alleviating Mania Lithium

However, on other indices of prophylaxis, especially time to relapse to depression, lithium was either ineffective or only modestly effective 9 . An 18-month study of bipolar patients who had experienced a recent manic episode reported that lithium extended time to relapse for any affective episode or to use of additional pharmacotherapy, and was generally equivalent to lamotrigine. Lithium significantly extended time to a manic episode, but not time to a depressive episode (level I) 65, 66 . These data are consistent with the randomized, crossover, one-year study by Denicoff et al. 67 , showing that lithium reduced time spent in mania from 26 of the year to 9 . However, lithium did not change time spent in depression 67 . Similarly, a randomized, parallel-group maintenance study found that lithium reduced the number of manic episodes in both non-rapid cycling and rapid-cycling bipolar patients. In contrast, the number of depressive episodes was greater with lithium treatment than...

Case Example 1 Understanding the Residues of Painful Childhood Separations

P presented with major depression and severe daily panic attacks during her final year in graduate school, when at age 30 she faced making decisions about where she would live in the future and about whether to continue a relationship with her boyfriend on whom she felt shamefully dependent. Her therapist noted that Ms. P tended to minimize any description of suffering or vulnerability and to feel deeply ashamed of her psychiatric illness, going to great lengths to hide it from anyone other than her therapist, parents, and boyfriend.

How do you diagnose Bipolar I Disorder

A 1-week or longer period in which criteria for both manic and major depressive episodes are met. The patient has one or more manic or mixed episodes. Usually there is also a depressive episode, but this is not required for the diagnosis. The patient has one or more major depressive episodes, plus one or more hypomanic episodes (but never any manic episodes). Previously undiagnosed bipolar patients who have only been treated for a major depression may have their manic episodes precipitated by treatment with antidepressants.

Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are safer in overdose than tricyclic antidepressants and have a better side-effect profile. However, as with all of the drugs other than lamotrigine in this section, there has been limited systematic study in bipolar depression. Cohn et a reported a higher response with fluoxetine treatment than with imipramine or placebo 112 . Nemeroff et a found paroxetine or imipramine plus standard lithium no different overall from lithium plus placebo (level I) 113 . Paroxetine plus lithium and imipramine plus lithium were superior to lithium alone in the subset of patients with serum levels of lithium below 0.8 mEq l. Retrospective studies of fluoxetine, venlafaxine, and paroxetine suggest response rates above 50 (level III) 114-116 . Rates of mania hypomania during treatment appear lower with SSRIs than with TCAs 112,117 .

Gender Differences in Psychopathology

Eysenck (1995) suggested that the dispositional trait underlying schizophrenia is an important ingredient of creativity and noted that the incidence of schizophrenia is higher in men than women. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994) stated, however, that although men tend to be institutionalized at a greater rate, community-based studies have suggested an equal gender ratio between the men and women who have schizophrenia. As I mention in the chapter on neurotransmitters (chapter 8), enhanced creativity appears to be associated with affective disorders. According to the dSm-IV, bipolar disorders are also equally distributed between men and women. Major depressive disorders, however, are reported more frequently with women. Although the higher incidence of depression in women might be related to an ascertainment-reporting bias (e.g., men are less likely to go for professional help), the incidence of mood...

Special Situations Sleep

Disturbed sleep is a common, and pathophysiologically important component of bipolar disorder. Persons with bipolar disorder often escalate their interest, elation and energy levels in the evening hours, into the early hours of the next day. It is important to counsel patients regarding this diurnal phase disturbance, but medications are often needed. No systematic studies have been conducted regarding comparative benefits of various strategies. Benzodiazepines are most commonly employed. Benzodiazepines vary along dimensions of speed of onset and half-life. It is best to tailor the drug in a trial-and-error fashion to the patient's unique sleep problems. Some patients may have side effects from benzodiazepines, principally carryover sedation, or less frequently disinhibition of affect and action. In such instances, alternative medications can be used. Despite lack of direct testing for insomnia, gabapentin, at doses of 100 to 400 mg, is often helpful for sleep induction. Although...

Understanding Counterproductive Reactions to Narcissistic Vulnerability

Persistent early fantasies and the feelings that become connected to them are often characteristically resisted or expressed in ways that become embedded in a patient's repertoire of responses to relationships and to attempts at self-expression. For example, Arieti and Bemporad (1978) wrote of a tendency they found in their depressed patients to continually attempt to gain security from parents who had unrealistically high expectations of them. To avoid the sadness and sense of inadequacy their parents' unrealistic expectations engendered, these patients would characteristically come to conform to their parents' wishes and try to please them, even by substantially inhibiting their own desires. The need to do this in order to maintain a close connection to the parents, and the need to bury guilt-inducing, frightening reactive anger, became a way of life. In adulthood, these depressed patients would continue to search for connection with dominant others, from whom they would again seek...

Treatment as Guided by the Dim Light of Evidence

Acceptance of lithium as a therapeutic agent required the invention of the randomized controlled trial. The evidentiary illumination provided by this new technology was sufficient to demonstrate that psychiatric illness was amenable to medical treatment. The science of clinical research also necessitated increased diagnostic rigour. While advancing the entire field of psychiatry, this trend has fostered the paradoxical evolution of manic-depressive illness from an imprecise but narrowly defined condition into operationally defined but more inclusive unipolar and bipolar mood disorders 1 . As the 21st century opens, this nosological paradox is paralleled by a clinical paradox even as clinical efficacy studies expand our armamentarium of evidence-based treatments, the population of bipolar patients with inadequate response to these treatments seems to grow ever larger.

Description Of Group

This particular group is open ended, having continued for over fifteen years with patients entering and leaving based on their own growth and particular needs. It is a geriatric group, with an age range of seventy to ninety-six years. All participants have had serious psychiatric illness such as major depression and bipolar disorder. There are no schizophrenics in the group. Most have been hospitalized for depression and about 25 percent have been treated with ECT. All are on psychotherapeutic medications.

Addressing a Lack of Awareness of Anger

Sometimes patients with depression are unaware of experiencing any anger toward others. As noted previously, they may avoid the knowledge or experience of anger through a variety of defense mechanisms, including denial and repression, projection of angry feelings externally, reaction formation, or passive aggression. Depressive symptoms in and of themselves can lead to avoidance of the experience of anger, as feelings of hopelessness or sadness predominate. Additionally, because of their low self-esteem, depressed patients may feel they don't have a right to be angry.

Clinical and Epidemiological Studies

Epidemiological and clinical studies support a strong association between depression and GAD, OCD, and PTSD. The National Comorbidity Survey (NCS) demonstrated that 58 of primarily depressed patients also experienced an anxiety disorder, estimating the rate of comorbidity between depression and GAD to be 17.2 (Kessler et al., 1996). The NCS found that of those individuals with a primary diagnosis of current GAD, 39 had current major depression and 22 had current dysthymia (Judd et al., 1998). Studies also suggest comorbidity rates of 21-54 between depression and OCD (Abramowitz, 2004). Epidemiological and clinical studies also indicate that up to 56 of individuals have concurrent PTSD and depression, and that as many as 95 of individuals with PTSD have a lifetime history of major depression (Bleich, Koslowsky, Dolev, & Lerer, 1997). In clinical studies, an association between depression and anxiety is also supported. Brown and Barlow (1992), for example, found that 55 of patients with...

Other Medications Used in FM

Cyclobenzaprine (sigh-clo-BEN-zah-preen) is often thought to be a muscle relaxant, but chemically it is more aligned with tricyclic antidepressants. Used at night, cyclobenzaprine may help people with mildly disordered sleep. Unfortunately, when used during the day, it can contribute to fatigue or fibro-fog. Dopamine agonists (compounds that mimic the effect of the neurotransmitter dopamine) are increasingly used in FM. At low doses they are helpful for Restless Legs Syndrome (RLS). At higher doses they can treat many of the symptoms of FM. Stimulants such as Ritalin that are commonly used in attention deficit disorder (ADD) are sometimes prescribed for daytime fatigue and fibro-fog, though currently there is scant evidence to support the use of these agents.

Interpersonal and Social Rhythm Therapy

Another approach to staying healthy is to decrease behaviors or experiences that may make symptoms more likely to occur. Interpersonal and social rhythm therapy (IPSRT) focuses on reducing risk factors that could contribute to relapse. For example, there is strong evidence that sleep deprivation can trigger manic symptoms (Colombo et al. 1999). There is also good evidence that stress and interpersonal conflict can trigger depressive symptoms for a person with bipolar disorder (Johnson 2005a). In IPSRT, you learn strategies for reducing these risk factors. Research shows that when IPSRT is combined with medication, it is helpful for decreasing symptoms of depression and preventing future depressive episodes (Miklowitz et al. 2003 Frank et al. 2005).

Identifying Specific Angry Fantasies

As noted in the opening of this chapter, the anger of depressed patients is typically a response to their feelings of narcissistic injury. These angry reactions can include bitterness about feeling unloved, vengeful feelings toward parents or siblings who were abusive, jealousy of those who are better off, and envying others their success, happier families, better health, better looks, or confidence. Despite the specificity of their angry reactions, depressed patients are often vague about the content of their aggressive feelings and fantasies. Angry fantasies are typically unique and meaningful for each patient. Therefore, it is of value for the therapist to elicit their specific content. Because patients are often guilty about, ashamed of, or fearful of their angry fantasies, they may be reluctant to be forthcoming. Nevertheless, with ongoing exploration, and in the context of a therapeutic alliance, patients usually reveal the specific contents of their feelings.

Treatment Of Depression Comorbid With Gad Ocd And Ptsd

In the treatment of comorbidity, the clinician has to choose whether to treat the disorders simultaneously or sequentially. Few guidelines exist for the treatment of comorbidity between depression and GAD, OCD, and PTSD, although it has been suggested that depression should be treated prior to treatment of OCD (Abramowitz, 2004). In addition, results from treatment outcome research suggest that if the primary anxiety disorder is treated, depressive symptoms do improve (i.e., Ehlers et al., 2005).

Bipolar Disorder Pharmacological Treatment Where are We

First, a rational, commonly accepted approach to the pharmacological treatment of bipolar disorder is based much more on expert opinion and clinical experience than on evidence derived from rigorous clinical trials. Studies of treatment of all phases of bipolar disorder are woefully inadequate in both quality and quantity as compared with the large dossiers of clinical trial data supporting the efficacy of currently used antidepressants and antipsychotics. While the database on randomized controlled trials of treatments for acute mania now approaches respectability, the database for acute treatment of bipolar depression and particularly the longer term prophylactic treatment of all phases of bipolar illness are substantially limited. It makes a review such as Bowden's, I have no doubt, a challenge to write and more particularly difficult to evaluate. In the end, one is struck not so much by the difference in evidence for efficacy of various acute antidepressants or long-term...

Directions For The Future

In terms of interventions, there are several areas with potential. First, given the relative scarcity of psychologists and psychiatrists in community oncology settings, interventions utilizing oncology nurses to identify and treat depression have shown promise.77 Second, caregiver depression has recently become a focus,78 and a number of emerging programs have proposed to treat caregiver depression in the hopes of improving quality of life for the entire cancer-affected family. Third, prospective trials continue to explore the role of support groups in mediating depression, and the functional components of these groups (see Goodwin,79 for a review). Finally, the role of exercise in remediating depression has shown notable promise,80 although some studies have found no beneficial psychological impact of exercise.81Coping style continues to be an active area of research interest in cancer survivors. It is clear that coping style and dispositional traits may play a large role in risk of...

Longterm Prophylactic Efficacy The Most Important Feature of Mood Normalizers

For the treatment of bipolar depression, there is an increasing tendency to use new generation antidepressants with lesser propensity to induce manic switch. However, a consensus exists that in bipolar I patients they should be combined with mood normalizers. On the other hand, it has been suggested to use new generation antidepressants as a monotherapy in treating depression in bipolar II patients 5, 6 . How long the antidepressant alone should be safely given in such conditions remains unclear. Moreover, whether continuing the antidepressant into the hypomanic phase without a mood normalizer may precipitate subsequent depressive recurrence or rapid cycling remains to be established. In most of such patients, a mood normal-izer would be indicated especially as an augmenter in case of non-optimal antidepressant response. Our experience with lithium augmentation shows that this effect is more robust in bipolar than in unipolar depression 7 . Furthermore, in another study, we found that...

Electroconvulsive Therapy ECT

ECT (formerly known as electric shock therapy) is one of the oldest and most effective treatments for major depression. ECT also has some efficacy in refractory mania and in psychoses with prominent mood components or catatonia. ECr appears to work via the induction of generalized seizure activity in the brain. The peripheral manifestations of seizuie activity aie blocked by the use of paralytics, and memory for the event is blocked by the use of anesthetics and by seizure activity. Modern ECT produces short-term memory loss and confusion. Bilateral ECT is more effective than unilateral ECT but produces more cognitive side effects. 1. Antidepressants have multiple indications including various forms of depression, anxiety disorders, bulimia, and OCD, among others. 2. Antidepressants act on serotonergic and noradrenergic receptor systems. 3. Some antidepressants have been shown to be efficacious for particular disorders for major depression, all approved antidepressants reduce symptoms...

Identifying Guilty Reactions to Anger

Guilt stimulated by aggressive reactions to narcissistic injury is discussed at greater length in Chapter 8 ( The Severe Superego and Guilt ). Here, case examples are offered that illustrate the value of identifying patients' angry reactions that stimulate guilt. Helping patients to acknowledge the difference between aggressive thoughts and fantasies and actual aggressive actions is of great importance here, in that the guilt associated with such thoughts is often as intense for depressed patients as if they had actually committed the imagined actions.

Choosing Among Antimanic Treatments Can the Clinician be Guided by the Evidence from Randomized Controlled Trials

Besides limitations in generalizability, the available industry driven RCTs designed for drug approval have other limitations. A drug-placebo difference of 25 in response rates (defined as a 50 or more reduction in a mania rating scale) has been observed for valproate and olanzapine. This implies that four patients have to be treated in order to achieve a modest benefit in one patient, which may not be convincing for the clinician. Hopefully, remission rates will be more commonly reported in future trials. Furthermore, follow-up data on responding and non-responding patients would be very helpful for the clinician, considering the fluctuation of manic and depressive symptoms within each single episode. Given the very high drop-out rates of around 50 , partly due to high requirements for protocol adherence in RCTs conducted for drug approvals, follow-up data of drop outs are also needed.

Box 2 Mood disorders in the medically ill future research clinical and public policy agenda

One-year prevalence of depressive disorders among adults 18 and over in the US NIMH ECA prospective data. National Institute of Mental Health 1998. 6 Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003 289(23) 3095-105. 18 Egede LE, Zheng D. Independent factors associated with major depressive disorder in a national sample of individuals with diabetes. Diabetes Care 2003 26(1) 104-11. 22 Egede LE. Diabetes, major depression, and functional disability among US adults. Diabetes Care 2004 27(2) 421-8. 25 Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000 160(21) 3278-85. 26 Finkelstein EA, Bray JW, Chen H, et al. Prevalence and costs of major depression among elderly claimants with diabetes. Diabetes Care 2003 26(2) 415-20. 42 Zhang X, Norris SL, Gregg EW, et al....

Case Illustration Referral Route and Presenting Problems

Mary, a 45-year-old, unemployed European American woman, was referred to an outpatient service by her psychiatrist for CT for depression. At the time of the initial assessment, Mary tended to make vague statements that lacked emotional details, although she appeared visibly upset and tearful. She reported feeling depressed and hopeless for the last 3 years. She requested therapy for her depression. Based on the results from a SCID-I interview, Mary met MDD criteria (depressed mood, lack of motivation, appetite disturbance, difficulty concentrating, and feelings of worthlessness). She denied having suicidal ideation. She also met the criteria for PTSD (e.g., recurrent thoughts, avoidance of thoughts and people, diminished range of affect, irritability, and sleep disturbance) in response to a hostage taking that had taken place 3 years earlier. Her score on the PTSD Checklist (PCL Weathers, Litz, Huska, & Keane, 1991) indicated that she met the criteria for PTSD. A score of 33 on the...

Challenges for the Experimental Therapeutics of Bipolar Disorder

In his thoughtful overview of contemporary pharmacological treatments for bipolar manic-depressive illness, Charles Bowden raises points calling for further emphasis. First, reasonable criteria for mood stabilization'' should include more than the short-term antimanic effects for which several agents are FDA-approved with research support. Even lithium, the standard mood stabilizer, is FDA-approved only for mania and its recurrences 1 . Evidence of long-term protection, even against mania, remains strikingly limited for agents other than lithium and perhaps carbamazepine 1 . For mood stabilization, controlled trials lasting more than one year are required, particularly in view of the natural average spontaneous recurrence rate in untreated bipolar disorder of about one new episode year 2, 3 . A central problem in experimental therapeutics for bipolar disorder is prevention of recurrences of depression. For most proposed alternatives to lithium, evidence for long-term protection...

Abused Prescription Drugs

In 1954, the Ciba Pharmaceutical Company (later called Novartis) introduced a drug called Ritalin (methylfenidate) that was originally used to treat depression, chronic fatigue, and narcolepsy. Beginning in the 1960s, it was used to treat children with attention deficit hyperactivity disorder (ADHD), known at the time as hyperactivity or minimal brain dysfunction (MBD). Investigators Joanna Fowler, Nora Volkov and their colleagues of Brookhaven National Laboratory showed that methylphenidate is a dop-amine reuptake inhibitor, which increases the concentration of synaptic dopamine in the brain by blocking the transporters that remove it from synapses. Positron emission tomography (PET) showed that administering therapeutic doses of methylphenidate to healthy adult men increased synaptic dopamine levels.

Mechanism of Action

Lithium is indicated as a first-line treatment for regular cycling bipolar disorder in individuals with normal renal function. Lithium also is used to augment other antidepressants in unipolar depression. Lithium is renally cleared and can easily reach toxic levels in persons with altered renal function (e.g., especially the elderly). It is less effective in the treatment of the rapid cycling variant of bipolar disorder.

Early Warning Signs and Triggers

Noticing changes in your mood or behaviors can help protect you from future mood episodes. For example, you may notice that you don't want to spend time with family or friends or that you're getting into arguments with strangers for no reason. Events like these may indicate that your mood is beginning to get too low or too high. The earlier you notice these changes, the more time you have to protect yourself from experiencing additional or more intense symptoms in the future. In this chapter, we'll review changes in your emotions, behaviors, and thoughts that may

Pharmacological Treatment of Bipolar Disorder The State of the

Bipolar affective disorder has been described for most of recorded history and ranked high amongst psychiatric disorders in the global burden of disease study 1 . However, it is arguably still under-recognized. Classical epidemiological studies indicate a lifetime prevalence rate of approximately 1 for bipolar I disorder. However, a wider bipolar spectrum'' also exists. This includes bipolar II disorder or major depression with a history of hypomanic episodes and less commonly recognized subsyndromes combining hypomania and minor depression or manic symptoms alone. Jules Angst's longitudinal studies in Zurich recorded high lifetime prevalence rates of this bipolar spectrum 2 . Although the dangers of widening the concept of the bipolar spectrum are clear, it is likely that many cases of bipolar disorder are not recognized as such but may well be diagnosed as unipolar depressive disorder. Many psychiatric researchers have argued for a continuum approach to unipolar major depression and...

Natural Depression Cures

Natural Depression Cures

Are You Depressed? Heard the horror stories about anti-depressants and how they can just make things worse? Are you sick of being over medicated, glazed over and too fat from taking too many happy pills? Do you hate the dry mouth, the mania and mood swings and sleep disturbances that can come with taking a prescribed mood elevator?

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