Nonpharmacologic

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Cognitive behavior therapy (CBT) is based on the construct that depressed people hold distorted cognitions. The aim of CBT is to provide a structured approach to help people to identify maladaptive thoughts contributing to emotional discomfort and to replace them with more enabling alternatives. Some evidence suggests that CBT is effective for reducing depressive symptoms in people with chronic neurological conditions (175). The use of CBT in the PD population has been described in a few case reports and small studies (176-178).

In a pilot study, 12 PD patients with either major depressive disorder or dys-thymia received 10 sessions of modified individual CBT, and their caregivers attended four psychoeducational sessions (176). All patients had a history of poor tolerance or lack of efficacy to antidepressants. Results indicated that patients' depression, negative inferences, and perception of social support significantly improved over the course of the study. Additionally, caregivers' knowledge and provision of appropriate types of support and subjective feelings of caregiver burden were improved. In another study of nine young PD patients, CBT was associated with improvement in some psychological indices (178). However, in the study, CBT was not specifically targeted for depression. In a case series report, home-based CBT resulted in a clinically meaningful reduction of depressive symptoms (177). These preliminary results indicate that individual CBT in patients with PD, along with psychoeducational support to caregivers, is effective for reducing depressive symptoms and caregiver burden. Additionally, reports in elderly patients without PD suggest that a multimodal treatment approach (i.e., psychotherapy and antidepressant treatment) may be more effective than a single treatment approach (179).

In cases of severe pharmacologically refractory major depression, serial elec-troconvulsive therapy (ECT) may be effective for improving depressive symptoms and may also provide transient improvement in motor symptoms (180). However, common adverse effects of ECT include delirium and cognitive impairment, and its long-term utility is limited. Preliminary data suggest that repetitive transcranial magnetic stimulation (rTMS), a less invasive physical intervention than ECT, may improve depressive symptoms as well as cognitive and motor symptoms in PD patients (122,181,182). The role of rTMS in management of depression in PD warrants further evaluation.

Lastly, application of a structured physical therapy program may also improve depressive symptomatology in patients with PD (183).

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