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Treating Major Depression


Permission graciously given by the author to reproduce this paper.

Treating Major Depression

D. Cassell
2007

This paper will discuss a psychological intervention that is most effective in bringing about a positive change when confronting Major Depression. However, prior to doing so, this paper will conceptualized a few theoretical frameworks as it will serve as a rationale for the diagnosis and guard treatment recommendations.  

There are several evidences which support the etiology of the biological model of depression. As cited by Comer (2004), evidence from genetic and biochemical studies posits that unipolar depression have biological causes. What this suggests is that some people are susceptible to depression because they have been predisposed to the genes of their parent(s). This explains that depression can be passed on from parents to their offspring. Based on the biological model, people whose parent(s) have such genes and have experienced patterns of unipolar depression are at a higher rate of having similar pattern of unipolar depression as compared to the rest of the population. What this also implies is that people who are predisposed to the genes of unipolar depression could automatically become predisposed to a lower level of serotonin and cortisol activity more often than the rest of the population and especially so during stressful events. 

In addition, biochemical factors also provide supporting evidences of the biological model in explaining the etiology of depression. According to studies, depressed people have an overall imbalance in the activity of the neurotransmitters serotonin, norepinephrine, dopamine, and acetylcholine. Low serotonin activity disrupts the activity of the other neurotransmitter, which leads to depression. Furthermore, it is also suggested that people with unipolar depression have been found to have abnormal levels of cortisol, one of the hormones released by the adrenal glands during times of stress (Comer, 2004). The implication of the biochemical model in explaining the etiology of depression is in two folds. On one hand, this could imply that the abnormal and/or low level of serotonin and cortisol activity in the general population could be mainly due to a person’s perception and response to stressful events resulting from pressures of society. On the other hand, this could imply that people who are predisposed to the genes of unipolar depression could automatically become predisposed to a lower level of serotonin and cortisol activity more often than the rest of the population and especially so during stressful events.

The second theoretical view is the cognitive model: According to the cognitive model, (2004), negative thinking rather than underlying conflicts or a reduction in positive rewards, lies at the heart of depression. The two most influential explanation of depression are the theory of negative thinking and the theory of learned helplessness. The theory of negative thinking is credited to Aaron Beck (2002, 1991, and 1967). According to Beck, maladaptive attitudes, a cognitive triad, errors in thinking and automatic thoughts combine to produce unipolar depression. As such, Beck explains that some people develop maladaptive attitudes based on their perception of their early childhood experiences and this serves as the yardstick by which they judge future experiences. However, problematic situations in the future could result to negative thinking and things of that nature. As this phenomenon sets on, this would lead to a snowball effect which Beck has coined as cognitive triad; in that as these people continue to interpret their past-early childhood experiences, construct of who they are and who they aspire to be-their future in a negative fashion, which makes them hopeless and depressed. Along this line, Beck explains that these people reinforce their depressed behavior by developing an error in their thinking in that they focus and elaborate more on the negative aspects of their experiences and less on the positive one and this practice later becomes an automatic response that reinforces their negative behavior. For example, based on Beck’s point of view, if a person has been constantly abused physically and verbally by their parents during their early childhood as a consequence for misbehaving, that person could interpret their adverse childhood experiences and their self-worth as being negative and this could be carried out into their future life. As such, an abusive relationship in their adult life could trigger a depressive feeling of negative thoughts and perception. This could lead to an automatic response in their thought processes and consequently a painful emotional experience.

The second influential explanation of the cognitive model of depression is the theory of learned helplessness. Martin Seligman (1975) developed the learned helplessness theory of depression. His theory holds that people become depressed when they think (1) that they no longer have control over the reinforcements (the rewards and punishments) in their lives and (2) that they themselves are responsible for this helpless state (Comer, 2004). What Seligman’s theory of learned helplessness explains about the etiology of depression is that there are two folds to this phenomenon. First, the individual must feel completely powerless over the situations or events in their life. And second, the individual must experience self-blame or take on the responsibility for feeling helpless. In other words, what appears to be central and important about the etiology of the learned helplessness theory in explaining depression is its reference to the individual’s internal locust of control. If a student, for example, fails a final math exam and blames himself/herself for failing in the sense of justifying that they have never been good at physics.

Given the conceptualization of the preceding theoretical frameworks, this would than guard the flow of treatment and hopefully bring about change. My initial therapeutic recommendation for a major depressive client would be to conduct an initial assessment of the patient's perceived self-efficacy. Thereafter, the patient would be recommended to individual and possibly group counseling, based on medical necessity. Primarily, cognitive-behavior therapy (CBT) techniques will be recommended and implemented with the use of CBT core principles to help the patient change negative perceptions of themselves. Other therapeutic recommendations would be Rational-emotive Therapy (RET), Physical Exercise and Combination Therapy.

Numerous studies have demonstrated convincingly that cognitive-behavior therapy (CBT) has been used effectively to treat patients with unipolar major depression. In two separate comprehensive meta-analyses studies, findings indicates that cognitive-behavior therapy is as effective as interpersonal or brief psychodynamic therapy in managing depression. It is also indicated that cognitive-behavior therapy is more effective than pharmacotherapy in managing mild to moderate unipolar depression (Journal of Cognitive Psychotherapy, 2006). According to the publication by the Journal of Cognitive Psychotherapy (summer, 2006), Becks's cognitive-behavior therapy (CBT) for depression is one of the most rigorous supported findings of all psychosocial interventions. Beck's cognitive-behavior therapy (CBT) has embraced a great deal of empirical support as an efficacious intervention for the acute treatment of major depressive disorder and the prevention of depressive relapse. Certainly, the concept of cognitive-behavior therapy (CBT) can be used to explain how a depressed person can be helped in realizing normal functioning. Based on the author, the two principal treatment goals of CBT are: (a) teaching patients to modify their dysfunctional thoughts as a means of eradicating depressive symptoms, and (b) helping patients develop set of lasting cognitive skills to reduce their chances of subsequent future relapse. There are a number of foundational principles which serve as the foundation for all CBT interventions. As such, the daughter of Aaron Beck, Judy Beck (1995) identified a set of five CBT principles to compliment in developing treatment plans to suit the need of individual patients.

Establish a Strong Therapeutic Alliance: What this implies base on Beck, is that before a therapist is able to help a client realize change, a therapeutic relationship has to be establish between the patient and the therapist. This is consistent with emerging research evidence which indicates that the therapist-client relationship accounts for a large number of treatment outcome across a wide range of interventions and disorder (Lamber, 1992). For instance, one way of establishing such alliance is to meet the client in their comfort zone. That is, the therapist could engage in an activity or sport that interests the client.  This works well for bonding and creating rapport. 

Focus on Discrete Goals: According to Beck, the implication here is that there are clearly specified set of goals, which than becomes the focus of each session as the therapist work with the depressed client. For example, a goal could be for the client to write in a journal a description of the feelings and emotions, both positives and negatives.   

Focus on the Here-and-Now: Based on Beck, what this implies is that the focus of therapy is to help the client recognize and address their problem in the context of the present. Research evidence suggests that focusing on the present is congruent with many positive psychological approaches; such as "mindfulness meditation," which involves complete attention to the present moment (Langer, 2002) and "optimal flow experience," which involves complete concentration in the present and enjoying the present state based on its intrinsic values (Nakamura & Csikszentmihalyi, 2002).

Cognitive Reappraisal: This is the process of teaching depressed patients ways of identifying excessive negative thought processes and to replace them with more realistic and positive appraisals. For example, based on cognitive reappraisal, instead of a client holding a negative perception of mathematics and say, "I am not good at math and no matter how hard I try I don't get it," which could serve as a trigger for depression after failing a final math exam; the client could reappraise that by saying, " I will work harder at mastering or being good at math."

Patient as Collaborative Partner: In this context, based on Beck, the patient is regarded as partner. In other words, this will create a sense of partnership, and will empower and motivate the client to work harder at achieving their therapy goals. For instance, if a client is involved  and in agreement with a goal of going for a walk once a day, chances are; that person will have a higher chance of adhering to that goal which they helped form as compared to if one was handed down to them.

Rational-Emotive Therapy (RET) was developed by Ellis (1962) as a form of cognitive restructuring that helps individuals identify and alter irrational beliefs and statements. RET is based on the premise that every emotional problems and behaviors arise from irrational self-statements that we tell ourselves when we experience predicaments in our lives and/or things do not proceed as planned (i.e. awfulizing, demandingness, damnation, always and never thinking). As such, its therapeutic approach is to teach people to counteract irrational beliefs with more positive and realistic statements (Journal of Cognitive Psychotherapy, summer 2006). The ideas of Ellis' rational-emotive model can definitely help us develop effective therapeutic intervention in working with depressed patients. As we look at a depressed person’s situation, based on Ellis', it seems very likely that the dilemma they are experiencing is mainly due to their irrational beliefs and statements about themselve. In therapy-individual, the goal would be to replace old negative thoughts and belief systems. For example, based on Ellis suggestions, instead of a "husband thinking that his wife purposely gained weight after their second child to get him angry and turn him off,” which is characteristic of maladaptive behavior; the husband could replace his thought to believing that "his wife has put on some extra pounds because physiological changes of her body following their second child and not because of him." In other words, the rationale here is to replace the former negative beliefs and thinking with new and positive ones.

The psychological benefits of relaxation training as an outlet to elevating an individual's well-being have been well documented (Blumenthal, 1985) and several different methods of inducing relaxation, such as imagery exercises, progressive muscle relaxation, meditation, and yoga have been employed as effective treatment for a variety of psychological disorders. Evidence suggests that relaxation training is usually provided in cognitive-behavior training as an optional technique that may be used as a modality to decrease state of anxiety, which is frequently associated with depression (Beck, 1995). Given this view, relaxation training can certainly be used as a therapeutic intervention, along with therapy and in extreme cases combination therapy to restore normal mood and functioning in depressed patients.

Accumulating evidence suggests that physical exercise may be a potent and efficacious intervention for depression. In addition, participating in physical exercise is documented to correlate to increase in psychological well-being (Blumenthal & Gullette, 2002). Based on this view, physical exercise such as regular aerobics exercises may be introduced as an array of possible intervention in treating depressed patients. However, the exact point and motivational strategies will be contingent on the outcome of the client's initial assessment.

On one hand, some evidence suggests that cognitive-behavior therapy is an effective alternative to antidepressants for patients with mild to moderate depression and do significantly reduce the risk of relapse as compared with discontinuation of antidepressants. On the other hand, evidence states that clients with severe depression continue to benefit from the combination of psychotherapy and pharmacotherapy. However, in terms of long-term outcome, studies indicates that clients have greatly benefited from combined CBT and antidepressant therapy than either CBT or antidepressants individually (Journal of Cognitive Psychotherapy, summer 2006). Given this point, referral would be made to a psychiatrist who would make a determination for antidepressants. Based on both psychiatric and psychological evaluations, combination therapy-psychotherapy and pharmacotherapy or psychotherapy or pharmacotherapy would be provided.

Reference

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Blumenthal, J. A., & Gullette, E. C. D. (2002). Exercise interventions and       aging: Psychological and physical health behavior in older adults.        Societal impact on aging (pp. 157-177). New York: Springer             Publishing. Retrieved on Aug. 5, 2006, from Proquest database:       http://proquest.umi.com/pqdweb?did=1060347341&Fmt=3&clientld=5            2110&R QT=309&VName=PQD

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Langer, E. (2002). Well-being: Mindfulness versus positive psychology. In C.R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp.   214-230). New York: Oxford University Press. Karwoski, L. Garratt, G. M., IIardi, S. S. (2006). On the integration of Cognitive Behavioral therapy           for Depression and Positive Psychology. Journal of Cognitive             Psychotherapy (2), 159-170. Retrieved on Aug. 5, 2006, from Proquest database:             http://proquest.umi.com/pqdweb?did=1060347341&Fmt=3&clientld=5           2110&R QT=309&VName=PQD

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