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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Recently several visitors of blog have asked me about this ebook, which is being advertised quite widely across the Internet. So I purchased a copy myself to find out what all the excitement was about.

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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.

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)

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...

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...

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...

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).


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...

The Cognitive Theory Of Depression

The cognitive model of depression helps to explain why the typical complaints of depressed patients relate to their emotional experience and inability to cope with life's demands, because the emotional and behavioral aspects of depression are in some respects the end of the process of depression. The role of the cognitive therapist is to translate the problems of the patient who comes to treatment into a case formulation that explains the core beliefs or schemas that have interacted with life events to eventuate in the process leading to depression (Persons, 1989 Persons & Davidson, 2001 see also Whisman & Weinstock, Chapter 2, this volume). This case formulation then becomes the basis for deciding on strategic targets of change, with the goal of solving problems and reducing depression. Choosing which problems to address first in therapy is a matter of clinical experience and skill, but the case conceptualization guides this process.

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 . The spectrum of psychopathology under the rubric of bipolar disorder has been expanded to include bipolar II (major depression plus hypomania) 21 , bipolar III...

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...

The Typical Course Of Therapy

Although the description of the process of CT sessions is important to learn and to use in treating depression, none of the processes I have discussed really address the content of the treatment of depression, or what I described earlier as the work phase of treatment. Unfortunately, there is no single cookbook or formula for treating depression. Every patient is unique and presents with his her particular history, past efforts to overcome depression, comorbid problems, schemas, and current resources. What is presented below, therefore, is more of an overall guide to typical phases of CT for depression (cf. Beck et al., 1979 J. S. Beck, 1995,2005 Gilbert, 2001 see also Beutler, Clarkin, & Bongar, 2000). Figure 1.2 is an attempt to show how these phases of treatment roughly relate to symptom change in a typical case of depression. Approximately the first one-third of treatment is focused on behavioral change the middle one-third of treatment, on negative automatic thoughts and the...

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...

Alcohol And Mindaltering Drugs

When alcohol is combined with mind-altering (psychotropic) drugs such as those prescribed to fight psychosis and depression, the combined effects of alcohol and the medicine are less predictable than with other drugs. Antipsychotic drugs inhibit the metabolism of alcohol and may thus markedly increase its effects on the CNS in the elderly. Antidepressants increase the response to alcohol and harm one's control over one's mo- tions a significant hazard in the elderly for whom falls often lead to broken bones. Depression of the CNS may range from drowsiness to coma and therefore death, because acute alcohol consumption may increase the CNS effects of antidepressants. Alcohol may also increase the risk of dangerously lowering body temperature in the elderly taking tricyclic antidepressants. Hence the avoidance of alcohol in elderly patients taking any of these drugs is a prudent recommendation (Scott & Mitchell, 1988).

Treatment sideeffects and their psychological impact

Relatively little research has been conducted to examine the relationship between ED and psychological morbidity among men with prostate cancer. Nevertheless, ED has been reported to have a profound effect on a patient's quality of life post-treatment. Nelson et al. 10 examined the relationship between depressive symptoms and erectile function. A group of men, who did not receive any treatment for their prostate cancer, completed self-report questionnaires measuring anxiety and depression symptoms and erectile function approximately 4-years post-diagnosis. Erectile dysfunction was found to be a significant predictor of depression independent of other influential factors of depression, such as anxiety and marital status. This finding suggests that men can experience lasting psychological effects from their disease. Another study by Nelson et al. 11 examined men's responses to ED affecting their sexual function and their adjustment to diminished erections after having undergone a...

Underlying Mechanisms

In considering potential underlying mechanisms of depression, Beck (1983) identified two cognitive-personality styles that are hypothesized to reflect distinct underlying themes associated with major depression sociotropy, or excessive need for approval from others, and autonomy, or excessive concern about independent achievement. Sociotropy and autonomy correspond to the core beliefs of unlovability and worthlessness, respectively, which are the two broad categories of core beliefs associated with psychopathology (J. S. Beck, 1995). Cognitive theory proposes that individuals whose underlying schemas reflect themes of sociotropy develop symptoms of depression in response to rejection or other interpersonal difficulties, whereas individuals whose underlying schemas reflect themes of autonomy may develop depressive symptoms in response to failure events or exposure to obstacles that prevent goal achievement. Research to date has yielded partial and inconsistent support for the...

Adapting the Emphasis or Focus of CT for Depression

For example, using the therapeutic relationship as a testing ground for modifying cognitions might be particularly helpful for people with chronic or persistent depression, or for people with personality disorders or dysfunctional personality traits (Beck et al., 2003 Young, Klosko, & Weishaar, 2003).

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...

Water Soluble Vitamins

Folic acid is transported into brain as methylenete-trahydrofolic acid, the major form of folic acid in the circulation. It is then transported rapidly into neurons and glia from the CSF extracellular fluid. Once inside cells, folates are polyglutamated. Methylenetetrahydrofolate is used by neurons and glia in reactions involving single carbon groups, such as in the conversion of serine to glycine or homocysteine to methionine. Once methylenetetra-hydrofolate is consumed in these reactions, folic acid is transported out of the brain into the circulation. Folate has become an issue of neurologic concern because of a link between folate deficiency and abnormal CNS development. The incidence of spina bifida, a serious spinal cord abnormality, rises above the population mean in the children of women who are folate-deficient during pregnancy. Moreover, the incidence of spina bifida can be reduced by folic acid supplementation during pregnancy, beginning prior to conception. Initiating...

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.

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...

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...

Have had a problem with binge eating Does this mean I am not a candidate for bariatric surgery

It is important to point out that people with BED often have underlying depression. Sometimes treating the underlying condition with antidepressants dramatically improves BED. If depression is diagnosed, treatment should begin before undergoing surgery. Other beneficial therapies for BED include cognitive therapy and bariatric surgery.

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...

Phase 2 Treatment of Vulnerability to Depression

In the middle phase of treatment, the therapist focuses on helping the patient understand his or her particular vulnerability to depressive symptoms (Table 3-2). The patient's individual version of core depressive dynamics is explored and understood from as many vantage points as possible, as the patient has experienced these dynamics internally and in fantasy, in rela-

Psychometric Measures

Focus on a specific, recent time period (e.g., the last week), but the therapist should ascertain whether the chosen time period is reasonably representative of the patient's usual experience of depressive symptoms. It is also helpful to assess the severity of the patient's overall symptomatology and standard measures such as the Beck Depression Inventory-II (BDI-II Steer & Brown, 1996) have a useful role. However, we provide a note of caution. Given that a proportion of patients with chronic depression are reluctant to acknowledge and discuss depressive symptoms, they may underrate their symptoms when completing standard measures. Therefore, as a rule of thumb, such measures should always be supplemented by more detailed questioning about each symptom, with some subjective measure of frequency, intensity, and duration.

Behavioral health disorders in the medical setting

The frequency with which common psychiatric disorders are encountered in general medical outpatients is even greater than has been reported in community samples 13-20 , especially when patients present with chronic medical conditions 15,21-23 . Furthermore, some medical diseases are associated with a higher incidence of specific psychiatric syndromes than are others. For instance, patients who have respiratory and gastrointestinal illness have a higher rate of anxiety disorders, whereas patients who have back pain, multiple sclerosis, Parkinson's disease, cancer, and stroke are more likely to have depressive disorders. Patients who have some conditions, such as cardiac disease and diabetes mellitus, have a high incidence of both.

Dealing with depression

Many primary-care physicians recognize and treat depression, although they may refer the patient to a psychiatrist, a specialist in treating emotional disorders. Treating depression with medication or therapy Depressive disorders are usually treated with antidepressants and therapy. Doctors have many different types of antidepressant medications to choose from. If a drug from one category doesn't work, another medication may be effective.

Canada Drug And Alcohol

The 1996 survey found that 4.5 percent of adults used sleeping pills, 4.3 percent used tranquilizers such as Valium, .9 percent used diet pills or stimulants, 3 percent used antidepressants, and 13 percent used narcotic painkillers such as De-merol, morphine, or codeine. (In Canada, codeine of less than 8 milligrams per tablet is an over-the-counter drug.)

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...

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,

Review Of Efficacy Research

The approach to CT for chronic depression described briefly here (and elaborated in Moore & Garland, 2003) was first developed for use in a rigorous, randomized controlled trial of CT for chronic depression, known as the Cambridge-Newcastle Depression Study (Paykel et al., 1999 Scott et al., 2000). This study (the results of which are described in detail in Moore & Garland, 2003) indicated that CT, as outlined here, produced a significant but modest additional improvement in remission rates, overall symptom functioning, and social functioning when added to good clinical management and medication. CT also resulted in significant improvement in the key symptoms of hopelessness and low self-esteem. Most importantly, it achieved a worthwhile reduction in the rate of relapse into full major depression, over and above the effects of continued medication. Analysis of the mechanism of change by which CT prevented relapse found little evidence to support the idea that this occurs by...

Pharmacological Management Of Chronic Pain

Other medications used in the treatment of chronic pain include antidepressants and anticon-vulsants. Nerve blocks, injection of anesthetics into trigger points, or injection of steroids into the epi-dural space of the spinal cord may also be utilized. Implantable methods are utilized as treatments of last resort. These methods involve implanting drug delivery systems or electrodes into specific areas of the spinal cord.

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...

Depression Epidemiology

In a community-based study, the prevalence of depressive symptomatology in PD patients was six times that of healthy age- and sex-matched controls (2). In a registry-based study of 211,245 patients, Nilsson et al. (65) compared the incidence of depression in PD patients (n 11,698) with non-PD patients with diabetes (n 91,318) and non-PD patients with osteoarthritis (n 10,822) who were matched for degree of disability. An increased probability of developing a depressive episode was found for patients with PD when compared with the diabetes and osteoarthritis groups. Nilsson et al. (66) also showed that patients with an affective disorder (depression or mania) had an increased risk of being diagnosed with PD (odds ratio 2.2) when compared to patients with osteoarthritis or diabetes. In an analysis of 10 studies that used DSM-III criteria to define depression, an aggregate prevalence of 42 was reported for depressive disorders in PD (67). The prevalence rates...

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.

Assessment of Efficacy

Overall, based on clinical experience and the available scientific data, SSRIs and TCAs may be considered useful for the treatment of depression in PD, and the agent that provides the best overall clinical benefit-to-risk profile should be selected (168). Amoxapine and lithium should be avoided, given the propensity of these agents to worsen motor symptoms and the availability of safer agents (169,170). Additionally, the nonselective MAO inhibitors (e.g., isocarboxazid, phenelzine, and tranylcypromine) should be avoided in levodopa-treated patients due to the risk of hypertensive crisis. Several antidepressants, such as bupropion, fluoxetine, fluvoxamine, nefa-zodone, and paroxetine, are potent in vivo inhibitors of various cytochrome P450 (CYP450) drug-metabolizing isoenzymes (171,172). These antidepressants may increase the risk for drug interactions. The first step in treating a patient who fails to respond to treatment is to increase the dosage of the antidepressant. If a patient...

Relationship of general medical to behavioral health disorders

Abbreviations CV, cardiovascular disease DM, diabetes mellitus HT, hypertension. Data from Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major U.S. corporation. Am J Psychiatry 2000 157(8) 1274 8. Abbreviations CV, cardiovascular disease DM, diabetes mellitus HT, hypertension. Data from Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major U.S. corporation. Am J Psychiatry 2000 157(8) 1274 8. Depression, the most common comorbid psychiatric disorder with medical illness, gets worse as medical illness severity increases but it also may contribute independently to worse medical outcomes. This association is not explained totally by poor adherence. For example, the severity of depression, ie, subsyndromal to major depression, in those who have diabetes 48 , is related to worse glycemic control and hemoglobin A1c 81 levels as depressive symptoms increase 47,48 . Anxiety also has been linked with poor...

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, months...

Incidence Prevalence and Risk Factors

Incidence rates for PD dementia range from 4 to 11 per year, with a relative risk for the development of dementia in PD of 2 to 6 (12,129,131-133). Age and severity of extrapyramidal symptoms were associated with an overall risk of developing dementia. One study demonstrated that age and severity of disease by themselves were not associated with a greater risk of dementia, but the combination of these two features resulted in an almost 10-fold greater risk (134), suggesting a combined effect. Later age of onset of PD, longer duration of PD symptoms, the presence of hallucinations, depressive symptoms, and a family history of dementia have also been reported to be risk factors for dementia, although less consistently.

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.

Substance Abuse And Mood Disorders

Nearly all substances of abuse have the potential to alter mood symptoms. Classically, Psychostimulants, such as Amphetamines and COCAINE, may induce an appearance of elevated mood, racing thoughts, increased energy, and sense of well-being. Individuals who have developed tolerance to stimulants will experience, upon their discontinuation, withdrawal. These withdrawal symptoms will overlap characteristic depressive symptoms, including severe dysphoria, insomnia followed by hypersomnia, irritability, and fatigue. OPIATES induce a sense of elevated mood, and increased self-esteem. A sense of decreased anxiety is also frequently reported. Upon withdrawal, depressive symptoms are accompanied by characteristic physical symptoms such as muscle aches, drug CRAVING, lacrimation (secretion of tears), and piloerection (goose flesh).

Antisocial Personality and Alcoholism A

In a carefully designed study, Rounsaville and coworkers (1987) evaluated 266 alcoholics one year after treatment. Multiple-outcome measures were utilized in this study and over 84 percent of the original cohort were reevaluated. In this study, it was found that in males, an additional diagnosis of major depression, antisocial personality disorder, or drug abuse were associated with poor prognosis at one year. Further analysis in this study also supported the conclusion that the diagnosis was the factor that conveyed the poor prognosis, not general severity of psychopathology or degree of alcohol dependence.

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.

Posttraumatic Stress Disorder

Few studies exist that examined the effectiveness of SH interventions for people with a diagnosis of PTSD. One recent study (Ehlers et al, 2003) compared an SH booklet, cognitive therapy, and repeated assessments in people with PTSD after a motor vehicle accident. Comparisons based on self-report measures as well as clinician-rating scales were made at 12-weeks posttreatment and 6 months after the conclusion of treatment. Although the SH treatment reduced some symptoms, the therapist-directed cognitive therapy was clearly superior to the SH booklet. In addition, treatment using the SH booklet was only slightly more effective than the assessment group at posttreatment and slightly less effective than the assessment group at follow-up. In contrast to these relatively small therapeutic effects, Hirai and Clum (2005) reported significant improvement on symptoms produced by an online SH treatment. These authors developed an 8-week online SH program for trauma victims that consisted of four...

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...

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

Psychiatric Treatment

Despite the common use of antidepressants, several double-blind trials have been inconclusive or only slightly favorable. Patients with clear manifestations of depression and the more severe cases seem to benefit more from these medications. Tricyclic antidepressants tend to increase appetite and are more suited for patients with pure anorexia nervosa. Selective serotonin reuptake inhibitors may help decrease binging in patients with associated bulimia. Olanzapine, an atypical antipsychotic medication associated with weight gain, has been shown to be useful in some patients with anorexia nervosa in uncontrolled studies.

Trisha M Karr Heather Simonich and Stephen A Wonderlich

And histrionic personality disorder (HPD), as well as anxious, fearful personality disorders, including obsessive compulsive personality disorder (OCPD) and avoidant personality disorder (AVPD), appear to be the most prevalent personality diagnoses among individuals with BED. Indeed, Wilfley et al. (2000) found that the rates of OCPD and AVPD were twice as high among the BED group than a general psychiatric group. Furthermore, people with BED and OCPD or AVPD have reported higher rates of major depressive disorder (MDD), social phobia, post-traumatic stress disorder (PTSD), and generalized anxiety disorder (GAD) than participants without personality disorders (Becker et al. 2010 Wilfley et al. 2000). Therefore, comorbid psychiatric conditions appear to be typical characteristics of the majority of people with BED. Given that there is evidence that trauma is related to a wide range of psychiatric problems (Johnson et al. 1999 Lobbestael et al. 2010), it may be that traumatized people...

A lifecourse approach

Accumulation of risk is another concept that plays a pivotal role in the life-course model of chronic diseases. More than 80 years ago Selye 22 recognized that the physiologic systems activated by stress can protect and restore but also can damage the body. To understand this paradox, the concept of allostasis has been introduced 23 . Allostasis is defined as the ability to achieve stability through change. The price of this accommodation to stress has been defined as the allostatic load 23 . It follows that acute stress (eg, the fright, flight or fight'' response or major life events) and chronic stress (the cumulative load of minor, day-to-day stresses) can add to the allostatic load and have long-term consequences. Subacute stress is defined as an accumulation of stressful life events over a duration of months and includes emotional factors such as hostility and anger as well as affective disorders such as major depression and anxiety disorders. Chronic stressors include factors...

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.

Neurological Effects

Depression The balance between n-6 and n-3 fatty acids influences the metabolism of biogenic amines, an interaction that may be relevant to changes in mood and behaviour (Bruinsma & Taren 2000). In several observational studies, low concentrations of n 3 PUFAs predicted impulsive behaviours and greater severity of depression. Additionally early research by Horrobin et al (1999) revealed that almost all studies on depression have found increased PG2 series or related thromboxanes and there is evidence that the older antidepressants (i.e. MAOIs and TCAs) either inhibit PFG synthesis or are powerful antagonists of their actions. Going one step further are the findings of a number of studies showing a correlation between low erythrocyte n-3 EFAs and suicide attempts one of these demonstrated an eightfold difference in suicide attempt risk between the lowest and highest RBC EPA level quartiles (Huan et al 2004). Researchers from Belgium have also speculated about a seasonal variation in...

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...

Pathophysiologic mechanisms

The most accepted and unifying hypothesis to describe the pathophysi-ology of the metabolic syndrome is insulin resistance, although quantification of insulin action in vivo is not always strongly related to the presence of the syndrome 26 . Alterations that are not included in the diagnostic criteria for the metabolic syndrome but have been reported in association with insulin resistance are depicted in Box 1. Several studies have reported an association between insulin resistance and depressive disorder, although the association is not seen universally 27-30 . Insulin resistance and major depression share several disturbances in the aforementioned physiologic systems that include the HPA axis, the auto-nomic nervous system, the immune system, platelets, and endothelial function.

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...

What Happens When There Is a Lapse vs a Relapse during CCT

It is important to teach patients to discriminate a full relapse (a syndrome with impairment that lasts 2 weeks or more) from a blip or lapse (transient symptoms that may resolve with intensified use of critical skills). Attention to the temporal aspects of the diagnosis and the effect of symptoms on functioning helps with this discrimination. Furthermore, it can be helpful to teach patients to use self-rating scales (e.g., BDI or IDS-SR) to detect depressive symptoms and to learn when to intensify the use of critical skills, to call the therapist for extra help, or to request an appointment. A lapse can cue therapist and patient to design specialized homework over the telephone to address the symptoms and to determine whether a session should be scheduled soon or out of sequence. The therapist's aim is to promote a sense of mastery and self-efficacy and to help the patient learn that he she can use compensatory strategies successfully and independently to reduce depressive symptoms....

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.

Clinical Vignettes

Note that there have been psychotic symptoms without affective symptoms present, but now also meets criteria for a depressive episode. A 76-year-old man presents with 1 year of worsening depressive symptoms. He has trouble falling asleep, feels worthless, cannot concentrate, and has thoughts of death. Over 3 years ago his wife passed away from cancer. For 6 months now he has adamantly stated that the cancer was his fault and that he was the one that killed his wife, despite all evidence to the contrary. He also often hears her voice scolding him when no one is around. What is the most likely diagnosis

Clinical Considerations

Several studies of self-help for depression have examined variables that may moderate treatment outcome. In a study conducted by Landreville and Bissonnette (1997), cognitive bibliotherapy was administered to older adults with a disability. Although the other studies of bibliotherapy with older adults indicated significant treatment gains over wait-list control, improvements for depressed older adults using bibliotherapy in this study were only slightly greater than for individuals in the wait-list control group. Landreville and Bissonnette speculate that this may be due to chronic disabilities and related limitations in daily living that create a more resistant, harder to treat depression.

Autonomic nervous system imbalance

Abnormalities in autonomic nervous system activity are consistent findings in depression, insulin resistance, and, more recently, the metabolic syndrome. Impaired autonomic function previously has been associated with elevated concentrations of serum insulin and decreased insulin sensitivity (markers of insulin resistance), independent of glucose levels 35,36 . Depressed patients commonly manifest higher resting heart rates than healthy controls and exhibit autonomic nervous system dysfunction, including diminished heart rate variability (HRV), baroreflex dysfunction, and increased QT variability, all of which have been linked to increased cardiac mortality, including sudden death 37 .

Group CT May Reduce Relapse and Recurrence

For example, Teasdale et al. (2000) randomized patients with recurrent MDD who were in recovery remission (i.e., who did not meet MDE criteria) for 12 or more weeks after discontinuing antidepressant medication, to treatment as usual (TAU i.e., patients sought help on their own, as needed) or to TAU plus mindfulness-based cognitive therapy (MBCT). CT included eight weekly group sessions followed by four monthly group sessions lasting 2 hours. Over 60 weeks, for 105 patients with a history of more than three depressive episodes, CT reduced relapse (40 defined as meeting MDE criteria) compared to TAU (67 ) alone. For a smaller subset of 32 patients with two depressive episodes, relapse recurrence rates did not differ significantly (56 CT, 31 TAU). Very similar results were found in a replication study (Ma & Teasdale, 2004). Over 60 weeks, MBCT reduced relapse (defined as meeting MDE criteria) compared to TAU for patients with more than three episodes (36 vs. 78 N 55), but the effect...

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 is...

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...

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.

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.

Endothelial dysfunction

Depression is associated with a heightened incidence of endothelial dysfunction (ie, impaired flow-mediated vasodilation) among various cohorts, including young and otherwise healthy depressed patients 40 . Impaired en-dothelial function is a putative mechanism that links insulin resistance and cardiovascular disease, including hypertension 41-43 . It comes as no surprise that endothelial function is found to be impaired in the metabolic syndrome as well 44 .

Approach To Neuropathic Pain

Pharmacologic interventions include tricyclic antidepressants, anticonvulsants, and anesthetic agents. Sequential single drug trials are recommended, with the drug dose escalated to the maximal allowable dose, before proceeding to the next agent. Various algorithms have been proposed. One general approach includes the use of opioids for severe pain, anticonvulsants for spontaneous or lancinating pains, and tramadol, tricyclic antidepressants Lamotrigine, carbamazepine, venlafaxine, bupropion, At least one RCT (Ib) tricyclic antidepressants or gabapentin for other features of neuropathic pain such as burning, dysesthesias, or allodynia.29 Reviews of older trials provide estimates for the number needed to treat (NNT) for tricyclic antidepressants (NNT 2-3), opioids (NNT 2.5), and anticonvulsants such as gabapentin (NNT 3.8). Based upon this, one might consider topical lidocaine patches for patients with post-herpetic neuralgia, and then alternate trials of tricyclic antidepressants or...

Marjan Ghahramanlou Holloway Gregory K Brown Aaron T Beck

Suicide among individuals with depression is a major public health problem. The lifetime risk of suicide for individuals with major depressive disorder (MDD) has been estimated to be 15 among psychiatric inpatients (Guze & Robins, 1970). Recent epidemiological data have suggested that the risk of suicide for individuals with MDD is approximately 3.4 , with males having a 7 risk and females having a 1 risk (Blair-West, Cantor, Mellsop, & Eyeson-Annan, 1999). An overall 6 risk of completed suicide Most individuals with MDD are at the highest risk for suicide during the early years within the course of illness (Vieta, Nieto, Gasto, & Cirera, 1992) those who attempt suicide often do so in the first 3 months of a depressive episode and within 5 years of the onset of their depression (Malone, Haas, Sweeney, & Mann, 1995). Anxiety increases the risk of early suicide in the course of major depression, whereas stable levels of hopelessness increase long-term risk (Placidi et al.,...

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 .

Putative Treatments For Bipolar Disorder

Many drugs are proposed conceptually, or presented in print as effective, in some aspect of treatment of bipolar disorder. Rarely is it possible to assess adequately a drug for bipolar disorder in other than a placebo-controlled, randomized, parallel-group study, enrolling patients who have common illness characteristics at the start of the study. The inherently changing symptomatology of bipolar disorder probably contributes to a greater likelihood of positive open reports in bipolar disorder than most other mental disorders, but ones wherein the improvement reflects inherent changes in symptomatology, rather than an effect of drug. The following drugs have case reports that suggest efficacy in some patients, but have not been tested in the above paradigms, or have had largely negative studies conducted that may have methodological constraints that reduced capacity to identify drug efficacy. Topiramate is a fructopyranose that has been reported as beneficial principally as add-on to...

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