Wednesday, March 21, 2012

Therapies for Depression

Depression is a broad term to describe a psychiatric state of literally, unhappiness.  So called Clinical Depression refers to some such state that persists for at least a couple of weeks. It's associated with a depressed mood, most of day, most every day.  Sleep and motivation and cognitive function can all be affected.  There have been a wide variety of terms over the year to describe this state.  It's been called dysthymia, major affective disorder, mood disorder, major mood disorder, and at it's most extreme melancholia.  It's differentiated from the blahs by being a bit more severe and lasting a bit longer. It's differentiated from Grief or Bereavement, the natural state of loss when a loved one is lost, by lasting much longer.
At the turn of the century a study in Pennsylvania at a farm when Quakers kept people who came with mental illness treating them with tender loving care but not much else, the length of 'untreated major depression' was approximately 9 months.  Adjustment disorders, a reaction to a negative event in one's life such as the loss of a job or the break up of a dating realationship was considered to be about 6 months. The depth of suffering with an adjustment disorder could be as great as major mood disorder but if the disorder laster longer or was greater then the term major mood disorder or major affective disorder was used to describe the experience.  There have been some who wrongly defined adjustment disorders as 'minor' depressions but adjustment referred to the presence of an identifiable stressor. In Major Mood Disorder alone a person might have a stressor or not.
Indeed there is a tendency in the pharmacological industry associated psychiatric diagnosis to described disorders independent of the causation. Hence the 'antidepressants' medication is likened to 'fever' medication, like Aspirin and Acetomenophen.  People can have pain for a variety of reasons but aspirin or tylenol tend to treat the 'pain' regardless. There's this kind of non specific benefit noted with the antidepressant medications so that in association the term "major mood disorder' has by convention been likened to the condition a psychiatrist would use an antidepressant with.
That said depression and moods in general can be altered by a variety of factors in terms of the individual, their relationship or environment.  A large number of physical medica conditions give rise to depression. Often the first presentation of an underlying major medical physical illness is depression. Cancer, Diabetes, Heart Disease, Chronic low grade infections, Anemia, Metabolic Diseases, all commonly present with depression as the first sympton of the disorder.  For this reason people with persisting depression often benefit from seeing their family doctor who can readily rule out the major and more likely conditions that may present as depression.
Many of my patients have come to me after months of psychological treatments or counselling when they had an undiagnosed physical disease which was causing the person to have low mood, loss of energy and sleep problems and cognitive difficulties. The diagnosis of depression was correct. It's just that the cause and treatment had been wrong.  I saw one poor gentleman after a year of weekly psychotherapy and all manner of discussion of his sex life when he had an anemic condition. When the anemia was treated his mood improved and he no longer had need for psychological treatment and certainly was disheartened by the year of therapy, the $10,000 of dollars cost and the loss of work and relationship which had occurred. In several cases depression was the way my patients breast cancer presented. I did an appropriate medical screening history and found that they had other symptons of concern.  Hundreds of cases that have come to me for depression, even those who have seen family physicians before me have turned out to have a physical illness which when treated caused the patient to no longer need antidepressants or depression therapy.
The message there is 'screening'.  Give a boy a hammer and everything is a nail. That's the problem with counsellors.  They over diagnosis psychological depression and miss the other often common causes.
Psychosocial reasons for depression abound.  Often people become depressed by lack of exercise.  Scientific studies have shown that 1 half hour of aerobic exercise daily has the equivalent benefit on mood as taking prozac 10 mg daily has.
Often people who have eating disorders are depressed. Both obesity and anorexia are associated with depression.
All the addictions are associated with depressions.  Alcohol is a 'depressive'.  Cocaine is a 'stimulant' but it quickly depletes the bodies stimulant neurotransmitters and causes a depression as a result.  Addictions are generally associated with a dramatic high followed by a low. Sex addicts get this and eventually the flogging of the dead horse phenomena in addiction leads to chronic depression and dysthymia.  Bipolar II in the diagnosis associated with addiction until proven otherwise.
Chronic anxiety states lead to depression. Indeed the Seligman 'learned helplessness' studies suggest that depression is a chronic anxiety state.  There's work with neuro implants that suggest that chronic anxiety may set up a derailed neurotransmitter pathway that requires a 'brain pacemaker' to disrupt and restore a person to having normal neurotransmitter release.
Electroshock therapy served to 'reset' this distrurbed neurotransmitter system.  Serotonin deficiency was disagnosed in the cerebral spinal fluid of suicidals and the general pharmacalogical explanation for depression was a low serotonin or noradrenaline state.  It's now recognised that there's more likely an imbalance between varying neuro pathways serving to maintain equilibrium.
All manner of therapies have therefore been scientifically shown to be beneficial in the treatment depression.  Prevalence studies of depression show as much as 30% of a population base may have some form of depression at any time.
Talking therapies - counselling - psychotherapy -have all been shown to be beneficall. The is much competition between the various 'schools' of thought and the 'latest' brand of therapy but one very interesting study some years ago showed that psychiatrists with 10 years of clinical therapy experience regardless of their theoretical basis had the same general benefit.
The 'convention' is to use a 'cognitive behavioural therapy' today, mostly because it's so easy to train a person in and therefore costs less. Psychodynamic therapies have equal if not greater success in the treatment of depressive disorders but require more training and are more difficult to learn than 'cognitive behavioural therapy'.
Generally speaking 'relationship therapies' have been good with most depressions.  Garden variety depressions were what we always gave the new residents as they tended to respond to any form of positive hopeful encounter.
Having branched out in to other areas of study I've seen that "pastoral counselling' has been effectively treating depression quietly for centuries because it combines cognitive behavioural therapies idea, with relationship therapy and even has the 'lending the ego' elements which were beneficial in psychoanalytic therapies.
The advantage of psychotherapies over doing nothing was the generally speaking it's been shown that therapy shortens the length of the dysfunction associated with depression and the risk of suicide.  Considering untreated depression can last 9 months, most counselling therapies result in a depressive episode getting better in 6 to 10 weeks.
Indeed prozac the antidepressant was considered a success because it was shown to have relatively equivalent benefit to 10 weeks of psychotherapy.  Combined psychotherapy and psychopharmacology, the person improved symptomatically but the potential for recurrence was also reduced.
Individual therapy is expensive as any labour intensive therapy is. Therefore there have been studies on group therapy especially with cognitive behaviour therapy which really lends itself to the class room. Indeed I  might argue that individual therapy of the CBT nature should only be considered when group therapy had failed.
Misery loves company. A significant success of the self help movement has been it's ability to counteract the tendency to isolation.
Spiritual people as evidenced by a measurable variable such as church attendance have less likelihood of depression and respond to treatment better with greater success.
Seligman at his Authentic Happiness site has been doing research on improving the various traits that counteract depression, two specifically being hope and reslience.
While a lot of people think that depression should be a reason to not be working, not working can actually make depression worse. Clearly a pilot who has depression may present a risk for his passengers but if he is sent home 'to rest' , the isolation might indeed make the depression worse. A very effective therapeutic strategy employed by the British Columbia worksafe program was to have depressed patients attend a daily coffee house thereby ensuring that they had the occupation benefits associated with group therapy and socialization.  People who isolate worsen their depression.
However depressives can run in 'packs'. Individually I've treated dozens of patients by encouraging them to reduce the contact with 'sick' people in their social network. It's the 'dosage' of the relationship that is sickening. One women became physically ill if she talked to her deeply mentally ill mother for more than a half hour a week. The mother was dependent and clinging and literallly what caloquially we'd call a soul sucker. In contrast one of my male patients had only to talk to his father for an hour and his father was constantly demeaning to him causing him to be literally suicidal.  Again by limitting the dose of the relationship to 15 minute contacts the man was able to get better. I routinely ask depressed patients to avoid the news in whatever form since it's commonly old and depressing.
Music therapy has been shown to be a treatment for depression. It's especially beneificall if people are themselves participating in making the music.
Given the wide range of successful treatments available it's usually beneficial to consider the efficiency and cost effectiveness of a therapy.
Magnetic therapies have been shown to be very effective for therapy and equivalent in some patients as medication therapy however right now the cost is higher than electroconvulsive therapies.
Hypno therapy is an effective therapy for depression as is neurotherapy.
Often the therapy that is used is the one most available in the community.  It's also is affected by what experience the therapists have. In eastern Canada it's common that there are a psychotherapeutically trained psychiatrist with extensive experience in a variety of non pharmacological treatments as well as pharmacalogical treatments and physical treatments. In western canada it's most common that the psychiatrists are only trained in psychopharmacology or if trained in other forms of therapy these are supported by the community financially or professionally.
Massage therapy is very attractive to patients. I once asked my heroin addicts if they had the choice of going to detox or massage therapy which would they choose.  They'd naturally choose massage therapy.  Unfortunately there's no evidence that massage therapy is an effective treatment for heroin addiction.  Abstinence is and detox is not nearly as pleasant as doing heroin and getting a government funded massage.
No one ever questions what individuals do to treat their own depressions. This is in fact the 'right' to 'pursuit of happiness'.  I personally find riding my Harley Davidson Electraglide an antidepressant but it's most unfortunate I can't convince an insurance body to pay for my motorcycle. Similiarly i personly think that if I were depressed I'd benefit from a year of high paid tropical therapy on a beach. I suspect I could devise a scientific study to show that this did work but the cost would be prohibitive for any insurance company.
Much of the failure in treatment of depression has been due to the failure of patients to follow medical regimens, such simple suggestions as don't drink alcohol or exercise a half hour a day, or get out of bed.
Dance therapy is an effective therapy for depression.  I used dance and psychodrama to effectively treat depressed patients. There's just no support in the very conservative medical system for me to do these therapies. I'd need a larger office or space where I could do dance. I have a group therapy that helps depression but even to have a group therapy in my office I have to pay the higher overhead costs for the office that can hold 10 people at a time.  Further the medical service plan discourages me from having group therapy because it's more time and effort for my staff to arrange and bill and yet there's no commiserate increase in the therapy cost.
So there's lots of therapies and lots work. The choice of therapy and indeed the choices available are numerous. People don't need to be depressed. Talk about it and get help.
When I started in psychiatry I commonly talked with patients and rather quickly they got better. Often just listening to people who had otherwise well established lives served to result in their mood improving.  Later I would see more complex problems with less and less resources and more and more demands on my services.  As a result I tended to use medications more often. Commonly I have the pleasure and benefit of working with a psychologist or occupational therapist who does the lions share of talk therapy.  I'm a consultant and diagnostician and the the psychopharmacologist in these arrangements.  The psychologists and counsellors and occupation therapists can't prescribe medications and aren't aware of the whole medical and neurological aspects of depression which can be an important part.  A number of the psychologists I work with a specifically trained in a subset of patients and their experience and training makes them especially good with this group of patients. My experience and training is really broad based with some subspecialty areas so it's refreshing to work with psychologists who are subspecialists themselves. Increasingly family physicians are working psychologically with patients so that makes things easier all round.
I still come across alot of depressed negative people in my daily walk in life.  It's like the number of addicts who actually access treatment. Very few. So commonly I'm treating an addict in the office but there are a dozen or so more who deny they have addiction and attribute their regular social and occupational problems to the 'other guy'.  Similiarly depressive people often are the last to seek help which is unfortunate too.
When I consider psychiatric illness I often think it was akin to physical illness in the 30's. All manner of people had physical illness like heart disease or treatable infections or cancers but they never sought help for them. As a result the morbidity and mortality rate only one or two generations ago was so much higher.  Today people have much more 'quantity' of life in general but the 'quality 'is still an issue.
Ironically alot of people think that they'd be happy if they were rich but wealth is not a cure for depression and not a guarantee against it.  I used to think if I lived on a tropical island I d not see depression becuase I'd associated it more with the dreary winter months but when I worked on a tropical island I saw just as much depression.  I have been thankful for the wide range of therapies that I've learned, the excellent psychopharmacologies and elegant psychotherapies.


Anonymous said...

are you familar with a study many years ago where graduate medical students were put in psyc wards

the result was that none got better in the opinion of their doctors

in fact they all got worse was the opinion of their drs.

makes you wonder

haykind said...

Yes, I loved that research. I believe Goffman quotes this in his book Asylums, a study of totalitarian institutions. The students didn`t change but the doctors refused to accept they were better while the other patients knew they were well. Yes it does make you wonder.
What was concerning ethically in hospitals in the US was that there was an association between the `length òf `committal`and the quality of insurance coverage. Those who didn`t want to be kept a long time in hospital were wise not to get good health care coverage. Alot of health care insurance private in the states doesn`t cover mental illness as well. Thanks for your comment