Depression: What Is It and What Are My Treatment Options? (Community Lecture)

Depression: What is it & What are my Treatment Options? Presented by:Elizabeth Nikol, LCSW, ACT Dr. Lauren Kaplan-SagalSr. Behavioral Health Clinician Psychiatrist SMG Behavioral Health & Cognitive Therapy Center January 12, 2012

Agenda• What is Depression?• Statistics• Types of Depression• Consequences of Depression• The Neurotransmitter’s Role in Depression• Medication Options• The Role of Our Thoughts in Depression• Cognitive Therapy• Q&A

Statistics – National Institute of Mental Health (NIMH) and the Center for Disease Control (CDC)• In a 12 month period, 9.5% of adults suffer with some form of depression• 45% of these are classified as severe• Only 50% of these people seek treatment• Ages 45 – 64 have the highest incidence, but average age of onset is 30• Women are more likely to suffer from some form of depression• Other risk factors: Less education, those previously married, the unemployed.

Statistics: Robert Leahy, PhD• 1 in 5 people will experience depression in their lifetime• 20% are still depressed two years after onset• 59% of those with depression also suffer with anxiety• 24% have substance abuse disorders• Depressed people are 30 times more likely to commit suicide

What is Depression?According to the American Psychiatric Association:• Depressed mood or extreme sadness• Loss of pleasure or interest in most things that you usually enjoy• Significant weight loss or gain• Difficulty sleeping (too much or too little)• Feeling either restless or slowed down• Being tired all the time• Having feelings of worthlessness or guilt• Difficulty thinking or concentrating• Repeated thoughts of death or dying(Needs to be for at least 2 weeks & nearly every day)

Difference between Sadness and Depression• Sadness lasts for a short period of time, whereas depression can last for weeks or months at a time.• Sadness usually does not impact a person’s ability to function productively, whereas depression can.• Sadness is often times realistic in thought pattern, whereas depressed thoughts can be distorted and unrealistic.• Depression involves feelings of hopelessness and helplessness.• Depression is an illness.

Other Types of Depression• Adjustment Disorder with Depressed Mood• Bipolar I and II• Postpartum Depression• Dysthymia• Cyclothymia• Seasonal Affective Disorder• Pre-menstrual Dysphoric Disorder

Why Does Someone Become Depressed?• Physical (Biochemical/Genetics)• Behavioral• Cognitive• Situational or Environmental

Consequences of DepressionHigher rates of work absences and disabilityIncrease rate of disease and physical symptoms (i.e.headaches, back pain, gastro issues, etc.)Less productivity at work and homePoor lifestyle choicesRelationship difficultiesSuicide

“So, you’re telling me I have a chemical imbalance?”3 Neurotransmitters Likely Involved in Depression• Dopamine• Serotonin• Norepinephrine

Medications• SSRI’s: Celexa, Lexapro,Prozac, Luvox, Paxil, Zoloft• SNRI’s: Effexor (Venlafaxine) , Pristique (also Venlafaxine)• Dopamine-Norepinephrine Reuptake Inhibitors: Wellbutrin (Bupropion):

Medications• Norepinephrine-serotonin modulator: Mirtazapine (Remeron)• MAOI’s: Phenelzine, Tranylcypromine, Moclobemide• Serotonin modulators: Trazadone

Medications• Tricyclic Antidepressants (tertiary amines/secondary amine/tetracyclics): Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine, Desipramine, Nortriptyline, Protriptyline, Amoxapine, Maprotiline• Mood Stabilizers/Major Tranquilizers: Risperdal, Abilify, Seroquel, Zyprexa, Geodon

Electroconvulsive Therapy (ECT)• Used to be called "electroshock" therapy• Electrodes are placed to the head, and a seizure is induced• Causes change the brain chemistry and can relieve severe depression symptoms• Considered for patients with major depressive disorder with a high degree of symptom severity (catatonia, psychotic symptoms, etc) and functional impairment• Also selected for emergence, such as a when someone is refusing to eat, is nutritionally compromised or actively suicidal and not responding to other interventions.

Other interventions• Bright Light Therapy: mostly used for SEASONAL AFFECTIVE DISORDER, but is beginning to be introduced in other forms of depression and for those who are unable to tolerate medication for a variety of reasons.• Other treatments just starting to be used in research settings or in specialty areas – Vagus Nerve stimulation (VNS), approved for intractible epilepsy and refractory depression • Jury still out on how effective it is. • Requires surgery for placement of the device.

Other interventions (con’t)• Transcranial Magnetic Stimulation (TMS) – Uses transcranial pulsed magnetic fields – No siezure, but molecular changes are suspected to occur – Jury is still out on this as well, but some people are doing it – Does not require surgery

Other Medical Conditions ThatMimic Depression – Need to Rule Out• Thyroid condition• Cardiac condition• Certain Pancreatic conditions• Anemia• B12 or Folic Acid deficiency (certain vitamin deficiency)• Viral infections (eg. Lyme disease, Influenza post- viral infection)

Criteria used to determine when medication is needed• Mild vs. Moderate vs. Severe Depression• Psychosocial or interpersonal issues• Previous response to medication (combination necessary?)• Effectiveness• Side effects• Risk of suicide

Most optimal• The medications used and found to be most optimal for most patients: • SSRI’s (Prozac, Zoloft, Lexapro, Paxil) • Buproprion (Wellbutrin) • SNRI’s: Venlefaxine (Effexor, Pristique) or Cymbalta• Monoamine Oxidase Inhibitors (MAOI’s) are most often restricted to patients who do not respond to other treatments because of their potential for serious side effects and the necessity for dietary restrictions

Possible Side Effects• Cardiovascular• Anticholinergic: (mostly from Tricyclics): Dry mouth, constipation, urinary Hesitancy, visual changes, confusion, sedation, weight gain, GI (nausea, vomiting, diarrhea), insomnia• Neurological: Myoclonus, Extrapyramidal (joint stiffness) and TARDIVE DYSKINESIA— irreversible involuntary muscle movement, seizures (Wellbutrin, amoxapine), headaches• Sexual side effects: arousal, erectile dysfunction, orgasm dysfunction, Priapism (TRAZADONE)• SEROTONIN SYNDROME: often dose related

Length of time for treatment• After 4-8 weeks a patient should begin to notice moderate improvement• Once a patient is feeling the symptom that brought the patient in for treatment, one counts 9-12 months from that day of treatment relief for the possibility of tapering off the medication.• If a person has more than one episode of Major Depression, the recommendation is for that individual to remain on medication to prevent relapse and recurrence.

Risk Factors for Recurrence of Major Depressive Disorder • Prior History of multiple episodes of MDD • Persistence of depression symptoms after recovery of the episode • Presence of additional psychiatric issues (substance abuse, panic or anxiety disorders…) • Presence of a chronic general medical condition

Other Conditions Requiring Psychiatric Evaluation and Intervention • Post-Partum Depression (and Peri-Partum Depression) o A patient with a known diagnosis of depression should, whenever possible, have a planned pregnancy and in consultation with a Psychiatrist understand the risks of being on medication while pregnant. o If one can be off all medication prior to conception, that should be done in consultation and with careful monitoring throughout pregnancy. o However, there are times when a woman may need to be on medication while pregnant and all the risks and fetal effects should be reviewed.

Therapeutic Interventions: Cognitive Behavioral Therapy (CBT)• Pioneers: Aaron Beck and Albert Ellis• Negative thinking encourages and continues depression and anxiety• These thought processes help to engage self defeating behaviors• Together the therapist and patient work to evaluate thinking, make changes where necessary and problems solve• New behaviors are created• Effectiveness confirmed in numerous studies• Short-term treatment

Negative Cognitions• Self• Others• The future

Cognitive Distortions• Emotional Reasoning• Overgeneralization• Arbitrary Inference• All or Nothing Thinking• Should statements• Mind reading• Fortune Telling• Selective negative focus• Disqualifying the Positive• Catastrophizing• Personalizing• Labeling

Thought Record & Socratic Questions• What evidence/facts do I have that supports mythought?• What evidence/facts do I have that counters mythought?• Alternative explanations?• What are the advantages of thinking this way?• What are the disadvantages of thinkingthis way?

Thought Record & Socratic Questions• What is the worst that could happen? Could I live through it?• What would I tell a friend with the same thought?• Is this thought a cognitive distortion?• What would I like to think instead?

Behavioral Activation• Depressed people act depressed• Few activities that are pleasurable or achievement oriented• Track activities for one week• Score 1 – 10 for pleasure (P), achievement (A) and depression (D)• As pleasure and achievement go up, depression goes down• Activity scheduling

Mindfulness• A way of experiencing the world based in Buddhisttradition• Fully aware• Staying in the present moment• Observing thoughts without judging them• Actively change relationship to the thoughts• Watch them come about and then actively move away• Move away from doing and focus on being• Experiential Exercise

Resources• Mind Over Mood – Dennis Greenberger & Christine Padesky• The New Feeling Good – David Burns, MD• Beat the Blues Before They Beat You – Robert L. Leahy• Overcoming Depression Once Step at a Time – Michael Addis & Christopher Martell• The Mindful Way Through Depression – Zindel Segal, Mark Williams, John Teasdale & Jon Kabat-Zinn• SMG Behavioral Health and Cognitive Therapy Center: http://www.summitmedicalgroup.com/service/Behavioral-Health-and- Cognitive-Therapy-Center/• Academy of Cognitive Therapy website: http://www.academyofct.org• Mindfulness Center of NJ: http://www.mindfulnessnj.com

For more information• Visit http://www.summitmedicalgroup.com• Call (908) 508-8909

Depression: What Is It and What Are My Treatment Options? (Community Lecture)

by Summit Medical Group

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