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Title: Depression


1
Depression
  • Overview
  • Depression The new epidemic Statistics
  • Depression What is depression? Causes
  • Symptoms of Depression
  • Types of depression DSM-IV Criteria Primary
    types
  • Culture, Age and Gender differences
  • Different models to understand Depression
    Biological/biochemical Cognitive Behavioural
    Cognitive-Behavioural Interpersonal
  • Treatments for Depression Pharmacological
    Therapy Cognitive Therapy Behavioural Therapy
    Interpersonal Psychotherapy Cognitive-Behavioural
    Therapy
  • Typical CBT steps for Depression Management
  • Research findings on relapse rates
  • Other treatments Hypnosis
  • Best treatments for depression future research
  • References

2
Depression The new epidemic
  • It is one of the most common disorders
    encountered by Mental Health Professionals
  • It increases the risk of heart attack, and is a
    frequent and serious complication factor in
    stroke, diabetes, cancer, disability
  • It is widespread, debilitating and costly
  • (Barlow, D., 2001)
  • ? financial costs for treatment and loss of
    productivity due to absenteeism from work
    (Greenberg, Stiglin, Finkelstein, Berndt, 1993
    Wells, et. al., 1989)
  • Depression engenders not only extraordinary
    personal and family suffering, but significant
    societal burdens, i.e., the increased use of
    social and medical services (Johnson, Weissman,
    Klerman, 1992)
  • Depression in its various forms (insomnia,
    fatigue, anxiety, stress, vague aches and pains,
    etc.) is the most common complaint heard in
    doctors offices
  • In the US, the associated costs are more than 30
    billion (National Institute of Mental Health,
    1999)

3
Depression Statistics
  • By 2010, Depression will be the second most
    costly illness worldwide in 1990 it was ranked
    4th (Keller Boland, 1998)
  • More than 19 million adult Americans will
    experience some form of depression each year
    (Barlow, D., 2001)
  • 1 in 4 of a community population will develop
    depression some time in the course of their
    lifetime
  • 86 of depression is labeled primary about 14
    suffer from secondary depression, i.e.,
    depression in individuals who had one or more
    antecedent nonaffective psychiatric disorders
  • (Jackson, Hellar, Ch 22, in King Remenyi,
    1986)
  • Major Depressive Disorder (MDD) is the most
    commonly diagnosed psychiatric disorder among
    adults, with a US lifetime prevalence of 20 to
    25 for women and 9 to 12 for men (American
    Psychiatric Association AMA, 1994 Kessler, et.
    al., 1994 Regier, Kaelber, Roper, Rae
    Santorms, 1994).
  • (In Craighead, Hart, Craighead, Ilardi, Ch. 10
    in Nathan Gorman, 2002)

4
Depression Statistics
  • 1 in 20 Americans currently suffers from a
    depression severe enough to require medical
    attention
  • 1 person in five will have depression at some
    time in their life
  • 2 of all children and 5 of all adolescents
    suffer from depression
  • More than twice as many women are currently being
    treated for depression than men (it is not known
    whether this is because women are more likely to
    be depressed or whether men tend to deny their
    depression)
  • People over 65 are four times likely to suffer
    depression than the rest of the population
  • Depression is the 1 public health problem in
    this country. Depression is an epidemic, an
    epidemic on the rise
  • (www.community.netdoktor.com Depression Part
    1)

5
What is Depression?
  • The term depression refers to what is medically
    known as clinical depression
  • Some believe its a specific illness that
    requires clinical intervention
  • Depression is an illness or condition that robs
    one of the meaning of life
  • The symptom of depression can keep one from
    seeking treatment. It becomes a vicious cycle as
    the untreated depression worsens, the person
    feels that life is less and less worthwhile. As
    the person feels that life is less and less
    worthwhile, he or she is less likely to seek
    treatment
  • A predisposition towards depression can be
    hereditary
  • (www.community.netdoktor.com Depression Part
    1)

6
What causes depression?
  • Depression does not have a single cause. The
    three primary contributing factors are
    biological, social and psychological. Hence, the
    so-called biopsychosocial model predominates
    (Cronkite Moose, 1995 Thase Glick, 1995)
  • Research studies dealing with the onset of
    particular episodes of adult depression has
    concluded that
  • the majority are provoked by life events of
    ongoing difficulties
  • About 66-90 of depressed episodes have a severe
    event occurring within 6 months of onset
  • The majority of these events involve some element
    of loss
  • (Brown, 1996, pp. 151-154)
  • Most people do not receive help (Frank Thase,
    1999 Jarrett, 1995) because
  • Stigma attached to people suffering from
    depression
  • Obtaining the right type of help can be
    inhibiting and overwhelming especially to those
    already impaired
  • The role of events has emerged as one of the more
    important factors

7
Symptoms of Depression
  • The National Institutes of Health (US) has
  • developed the following symptom checklist
  • Persistent sad or empty mood
  • Loss of interest or pleasure in ordinary
    activities, including sex
  • Decreased energy, fatigue, slowed down
  • Sleep disturbances (insomnia, early-morning
    waking, hypersomnia)
  • Eating disturbances (loss of appetite and weight,
    or weight gain)
  • Difficulty concentrating, remembering, making
    decisions
  • Feelings of guilt, worthlessness, helplessness
  • Thoughts of death or suicide, suicide attempts
  • Irritability
  • Excessive crying
  • Chronic aches and pains that dont respond to
    treatment

8
Symptoms of Depression
  • In the workplace, symptoms of depression
  • often may be recognised by
  • Decreased productivity
  • Morale problems
  • Lack of cooperation
  • Safety problems, accidents
  • Absenteeism
  • Frequent complaints of being tired
  • Complaints of unexplained aches/pains
  • Alcohol and drug abuse
  • Symptoms of Mania can include
  • Excessively high mood
  • Irritability
  • Decreased need for sleep
  • Increased energy and activity
  • Increased talking, moving, sexual activity
  • Racing thoughts
  • Disturbed ability to make decisions
  • Grandiose notions

9
Types of Depression DSM-IV Criteria
  • Major Depressive Episode
  • A period of 2 weeks during which there is either
    depressed mood or the loss of interest or please
    in nearly all activities
  • Manic Episode
  • A period of at least one week during which there
    is an abnormally and persistently elevated,
    expansive, or irritable mood
  • Mixed Episode
  • A period of at least 1 week in which the criteria
    are met both for Manic Episode and for a Major
    Depressive Episode nearly every day
  • Hypomanic Episode
  • A Distinct period during which there is an
    abnormally and persistently elevated, expansive,
    or irritable mood that lasts at least four days
  • Major Depressive Disorder
  • A clinical course characterised by one or more
    Major Depressive Episode
  • Dysthymic Disorder
  • A chronically depressed mood that occurs for most
    of the day, more days than not for at least 2
    years

10
Types of Depression DSM-IV Criteria
  • Bipolar I Disorder
  • A clinical course characterised by the occurrence
    of one or more Manic Episodes or Mixed Episodes
  • Bipolar II Disorder
  • A clinical course characterised by the occurrence
    of one or more Major Depressive Episodes
    accompanied by at least one Hypomanic Episode
  • Cyclothymic Disorder
  • A chronic, fluctuating mood disturbance involving
    numerous periods of hypmanic symptoms and
    numerous periods of depressive symptoms
  • Seasonal Affective Disorder
  • The onset and remission of Major Depressive
    Episodes at characteristic times of the year
  • Post Natal Depression
  • The current or most recent Major Depressive,
    Manioc, or Mixed Episode of Major Depressive
    Disorder, Bipolar I Disorder or Bipolar II
    Disorder if onset is within 4 weeks after
    delivery of a child
  • Reactive vs Endogenous Depression
  • External factors compared with internal
    biochemical makeup

11
Types of Depression DSM-IV Criteria
  • Criteria for Major Depressive Episode
  • A. Five (or more) of the following symptoms
    have been present during the same 2-week period
    and represent a change from previous functioning
    at least one of the symptoms is either (1)
    depressed mood or (2) loss of interest or
    pleasure
  • (1) Depressed mood most of the day, nearly every
    day, as indicated by either subjective report
    (e.g., feels sad or empty) or observation made by
    others (e.g., appears tearful). Note In
    children and adolescents, can be irritable mood
  • (2) Markedly diminished interest or pleasure in
    all, or almost all, activities most of the day,
    nearly every day (as indicated by either
    subjective account or observation made by others)
  • (3) Significant weight loss when not dieting,
    or, weight gain (e.g., a change of more than 5 o
    body weight in a month), or decrease or increase
    in appetite nearly every day. Note In children,
    consider failure to make expected weight gains
  • (4) Insomnia or hypersomnia nearly every day
  • (5) Psychomotor agitation or retardation nearly
    every day (observable by others, not merely
    subjective feelings of restlessness or being
    slowed down)
  • (6) Fatigue or loss of energy nearly every day

12
Types of Depression DSM-IV Criteria
  • Criteria for Major Depressive Episode cont
  • (7) Feelings of worthlessness or excessive or
    inappropriate guilt (which may be delusional)
    nearly every day (not merely self-reproach or
    guilt about being sick)
  • (8) Diminished ability to think or concentrate,
    or indecisiveness, nearly every day (either by
    subjective account or as observed by others)
  • (9) Recurrent thoughts of death (not just fear
    of dying), recurrent suicidal ideation without a
    specific plan, or a suicide attempt or a specific
    plan for committing suicide
  • B. The symptoms do not meet criteria for Mixed
    Episode
  • C. The symptoms cause clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning
  • D. The symptoms are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition (e.g., hypthyroidism)
  • E. The symptoms are not better accounted for
    by Bereavement, i.e., after the loss of a loved
    one the symptoms persist for longer than 2
    months or are characterised by marked functional
    impairment, morbid preoccupation with
    worthlessness, suicidal ideation, psychotic
    symptoms, or psychomotor retardation

13
Types of Depression DSM-IV Criteria
  • Criteria for Manic Episode
  • A. A distinct period of abnormally and
    persistently elevated, expansive, or irritable
    mood, lasting at least 1 week (or any duration if
    hospitalisation is necessary)
  • B. During the period of mood disturbance,
    three (or more) of the following symptoms have
    persisted (four if the mood is only irritable)
    and have been present to a significant degree
  • (1) Inflated self-esteem or grandiosity
  • (2) Decreased need for sleep (e.g., feels rested
    after only 3 hours of sleep)
  • (3) More talkative than usual or pressure to
    keep talking
  • (4) Flight of ideas or subjective experience
    that thoughts are racing
  • (5) Distractibility (i.e., attention too easily
    drawn to unimportant or irrelevant external
    stimuli)
  • (6) Increase in goal-directed activity (either
    socially, at work or school, or sexually) or
    psychomotor agitation
  • (7) Excessive involvement in pleasurable
    activities that have a high potential for painful
    consequences (e.g., engaging in unrestrained
    sprees, sexual indiscretions, or foolish business
    investments)

14
Types of Depression DSM-IV Criteria
  • Criteria for Manic Episode cont
  • C. The symptoms do not meet criteria for Mixed
    Episode
  • D. The mood disturbance is sufficiently severe to
    cause marked impairment in occupational
    functioning or in usual social activities or
    relationships with others, or to necessitate
    hospitalisation to prevent harm to self or
    others, or there are psychotic features
  • E The symptoms are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication, or other treatment)
    or a general medical condition (e.g.,
    hyperthyroidism)
  • Note Manic-like episodes that are clearly
    caused by somatic antidepressant treatment (e.g.,
    medication, electroconvulsive therapy, light
    therapy) should not count toward a diagnosis of
    Bipolar Disorder

15
Types of Depression DSM-IV Criteria
  • Criteria for Mixed Episode
  • A. The Criteria are met both for Manic Episode
    and for a Major Depressive Episode (except for
    duration) nearly every day during at least a
    1-week period
  • B. The mood disturbance is sufficiently severe to
    cause marked impairment in occupational
    functioning or in usual social activities or
    relationships with others, or to necessitate
    hospitalisation to prevent harm to self or
    others, or there are psychotic features
  • C. The symptoms are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication, or other treatment)
    or a general medical condition (e.g.,
    hyperthyroidism)
  • Note Mixed-like episodes that are clearly
    caused by somatic antidepressant treatment (e.g.,
    medication, electroconvulsive therapy, light
    therapy) should not count toward a diagnosis of
    Bipolar Disorder

16
Types of Depression DSM-IV Criteria
  • Criteria for Hypomanic Episode
  • A. A distinct period of persistently elevated,
    expansive, or irritable mood, lasting throughout
    at least 4 days, that is clearly different from
    the usual non-depressed mood
  • B. During the period of mood disturbance, three
    (or more) of the following symptoms have
    persisted (four if the mood is only irritable)
    and have been present to a significant degree
  • (1) Inflated self-esteem or grandiosity
  • (2) Decreased need for sleep (e.g., feels rested
    after only 3 hours of sleep)
  • (3) More talkative than usual or pressure to
    keep talking
  • (4) Flight of ideas or subjective experience
    that thoughts are racing
  • (5) Distractibility (i.e., attention too easily
    drawn to unimportant or irrelevant external
    stimuli
  • (6) Increase in goal-directed activity (either
    socially, at work or school or sexually) or
    psychomotor agitation
  • (7) Excessive involvement in pleasurable
    activities that have a high potential for painful
    consequences (e.g., the person engages in
    unrestrained buying sprees, sexual indiscretions,
    or foolish business investments)

17
Types of DepressionDSM-IV Criteria
  • Criteria for Hypomanic Episode cont
  • C. The episode is associated with an unequivocal
    change in functioning that is uncharacteristic of
    the person when not symptomatic
  • D. The disturbance in mood and the change in
    functioning are observable by others
  • E. The episode is not severe enough to cause
    marked impairment in social or occupational
    functioning, or to necessitate hospitalisation,
    and there are no psychotic features
  • F. The symptoms are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication, or other treatment)
    or a general medication condition (i.e.,
    hyperthyroidism)
  • NOTE Hypomanic-like episodes that are clearly
    caused by somatic antidepressant treatment (e.g.,
    medication, electroconvulsive therapy, light
    therapy) should not count toward a diagnosis of
    Bipolar II Disorder

18
Types of Depression DSM-IV Criteria
  • Criteria for Major Depressive Disorder
  • (Note There are two listings for Major
    Depressive Disorder, Single Episode and
    Recurrent. Wont be listed separately.
    Recurrent information is in parenthesis)
  • A. Presence of a single (two or more) Major
    Depressive Episode
  • B. The Major Depressive Episode (Episodes) is not
    better accounted for by Schizoaffective Disorder
    and is not superimposed on Schizophrenia,
    Schizophreniform Disorder, Delusional Disorder,
    or Psychotic Disorder Not Otherwise Specified
  • C. There has never been a Manic Episode, a Mixed
    Episode, or a Hypomanic Episode. NOTE This
    exclusion does not apply if all of the
    manic-like, mixed-like, or hypomanic-like
    episodes are substance or treatment induced or
    are due to the direct physiological effects of a
    general medical condition

19
Types of Depression DSM-IV Criteria
  • Criteria for Dysthymic Disorder
  • A. Depressed mood for most of the day, for more
    days than not, as indicated either by subjective
    account or observation by others, for at least 2
    years. NOTE In children and adolescents, mood
    can be irritable and duration must be at least 1
    year
  • B. Presence, while depressed, of two (or more) of
    the following
  • (1) Poor appetite or overeating
  • (2) Insomnia or hypersomnia
  • (3) Low energy or fatigue
  • (4) Low self-esteem
  • (5) Poor concentration or difficulty making
    decisions
  • (6) Feelings of hopelessness
  • C. During the 2-year period (1 year for children
    or adolescents) of the disturbance, the person
    has never been without the symptoms in Criteria A
    and B for more than 2 months at a time
  • D. No Major Depressive Episode has been present
    during the first 2 years of the disturbance (1
    year for children and adolescents) i.e., the
    disturbance is not better accounted for by
    chronic Major Depressive Disorder, or Major
    Depressive Disorder, In Partial Remission
  • E. There has never been a Manic Episode, a Mixed
    Episode, or a Hypomanic Episode, and criteria
    have never been met for Cyclothymic Disorder

20
Types of Depression DSM-IV Criteria
  • Criteria for Dysthymic Disorder cont
  • F. The disturbance does not occur exclusively
    during the course of a chronic Psychotic
    Disorder, such as Schizophrenia or Delusional
    Disorder
  • G. The symptoms are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition (e.g., hypothyroidism)
  • H. The symptoms cause clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning

21
Types of Depression DSM-IV Criteria
  • Criteria for Bipolar I Disorder (Most Recent
    Episode Unspecified)
  • A. Criteria, except for duration, are currently
    (or most recently) met for a Manic, a Hypomanic,
    a Mixed, or a Major Depressive Episode
  • B. There has previously been at least one Manic
    Episode or Mixed Episode
  • C. The mood symptoms cause clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning
  • D. The mood symptoms in Criteria A and B are not
    better accounted for by Schizoaffective Disorder
    and are not superimposed on Schizophrenia,
    Schizophreniform Disorder, Delusional Disorder,
    or Psychotic Disorder Not Otherwise Specified
  • E. The mood symptoms in Criteria A and B are not
    due to the direct physiological effects of a
    substance (e.g., drug of abuse, a medication, or
    other treatment) or a general medical condition
    (e.g., hyperthyroidism)

22
Types of Depression DSM-IV Criteria
  • Criteria for Bipolar II Disorder
  • A. Presence (or history) of one or more Major
    Depressive Episodes
  • B. Presence (or history) of at least one
    Hypomanic Episode
  • C. There has never been a Manic Episode or a
    Mixed Episode
  • D. The mood symptoms in Criteria A and B are not
    better accounted for by Schizoaffectve Disorder
    and are not superimposed on Schizophrenia,
    Schizophreniform Disorder, Delusional Disorder,
    or Psychotic Disorder Not Otherwise Specified
  • E. The symptoms cause clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning

23
Types of Depression DSM-IV Criteria
  • Criteria for Cyclothymic Disorder
  • A. For least 2 years, the presence of numerous
    periods with hypomanic symptoms and numerous
    periods with depressive symptoms that do not meet
    criteria for a Major Depressive Episode. NOTE
    In children and adolescents, the duration must be
    at least 1 year
  • B. During the above 2-year period (1 year in
    children and adolescents), the person has not
    been without the symptoms in Criteria A for more
    than 2 months at a time
  • C. No Major Depressive Episode, Manic Episode, or
    Mixed Episode has been present during the first 2
    years of the disturbance
  • D. The symptoms in Criterion A are not better
    accounted for by Schizoaffectve Disorder and are
    not superimposed on Schizophrenia,
    Schizophreniform Disorder, Delusional Disorder,
    or Psychotic Disorder Not Otherwise Specified
  • E. The symptoms are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition (e.g., hypothyroidism)
  • F. The symptoms cause clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning
  • (Diagnostic and Statistical Manual of Mental
    Disorders 4th Ed, 1994)

24
Some other forms of Depression
  • Post Natal Depression
  • Occurs in 80 of women after child birth
  • Occurs within first 12 months of having a baby,
    within the first few weeks or months
  • Common symptoms lowered self esteem and a lack
    of confidence, guilt, inadequacy, negative
    thoughts, pessimism, irritability, tearfulness,
    difficulties in remembering or concentrating,
    sleeping problems, lowered libido
  • Contributing factors Physical changes (hormone
    levels), emotional change, social changes
  • Endogenous vs Reactive Depression
  • The theory that depression is either reactive or
    endogenous in origin is losing support.
  • Common belief now Environment genetic history
  • Reactive depression caused by a specific
    event or circumstance
  • Endogenous depression no obvious cause

25
Some other forms of Depression
  • Seasonal Affective Disorder tends to affect most
    people throughout their life
  • Moods change depending on the amount of sunlight
    or rain most common during winter
  • Common symptoms become a vegetable depressive,
    eat more, sleep more, experience chronic fatigue
    and gain weight, and in some cases social
    withdrawal
  • (See www.community.netdoktor.com Depression
    Pt1)

26
Three Primary Types of Depression
  • Major Depression
  • Major depression has a beginning, a middle and an
    end, and often lasts for months. Left untreated,
    it can reoccur. Each reoccurrence tends to last
    longer and is more debilitating than the one
    before
  • Chronic Depression
  • Is a low-grade, long-term depression that can go
    on for years. Some people have had it most of
    their lives. Long-term, low-grade depression is
    also known as dysthymia, a disorder of ones mood
  • Manic-Depression
  • The lows of depression can alternate with days or
    weeks of mania-extreme elation, unreasonable
    grandiose thoughts, and inappropriate, sometimes
    destructive actions. Also known as Bipolar
    depression, because it fluctuates from one
    emotional pole (down) to the opposite pole (up)
    in unpredictable, rapid swings. (major
    depression is unipolar down)
  • (See www.community.netdoktor.com Depression
    Pt1)

27
Culture, Age, and Gender Features of Major
Depression
  • Culture
  • Culture can influence the experience and
    communication of symptoms of depression
  • In some cultures, depression may be experienced
    in somatic terms, rather than with sadness or
    guilt
  • Latino and Mediterranean cultures Complaints of
    nerves and headaches
  • Chinese and Asian cultures Complaints of
    weakness, tiredness, or imbalance
  • Cultures may differ in judgments about the
    seriousness of experiencing or expressing
    dysphoria (e.g., irritability may provoke greater
    concern than sadness or withdrawal)

28
Culture, Age, and Gender Features of Major
Depression cont
  • Also, culturally distinctive experiences fear of
    being hexed or bewitched feelings of heat in
    head crawling sensations of worms or ants vivid
    feelings of being visited by those who have died
    must be distinguished from actual hallucinations
    or delusions
  • Age
  • Age of first episode of MDD has been decreasing
    (Burke, Burke, Regier, Rae, 1990 Lewinsohn,
    Clarke, Seeley, Rhode, 1994)peak years for
    first onset are now between 15 and 29 years of
    age (Burke, et. al., 1990 Hankin, et. al., 1998)
  • Common symptoms in children Somatic complaints,
    irritability, and social withdrawal
  • In prepubertal children MDEs usually occur in
    conjunction with other mental disorders, i.e.,
    Disruptive Behaviour Disorders, Attention-Deficit
    Disorders, and Anxiety Disorders

29
Culture, Age, and Gender Features of Major
Depression cont
  • In Adolescents MDEs associated with Disruptive
    Behaviour Disorders, Attention-Deficit Disorders,
    Anxiety Disorders, Substance-Related Disorders,
    and Eating Disorders
  • In elderly adults, cognitive symptoms (e.g.,
    disorientation, memory loss, and distractibility)
    may be particularly prominent
  • Gender
  • Studies indicate that depressive episodes occur
    twice as frequently in women as in men
  • A significant portion of women report a worsening
    of the symptoms of a Major Depressive Episode
    several days before the onset of menses
  • (Diagnostic and Statistical Manual of Mental
    Disorders 4th Ed, 1994)

30
Different Models of Depression
  • Biological/Biochemical Model
  • Depression has often been called a disease by
    mental health professionals
  • Assumes that depression is caused by a chemical
    imbalance in the brain
  • When a person responds well to antidepressant
    medication, it is taken as confirming evidence
  • (Yapko, M., 1997)

31
Different Models of Depression
  • Cognitive Model
  • According to Beck (1967), the depressed person
    has an unrealistically negative view of self,
    future and world (Jackson Heller, Ch 22 in King
    Remenyi, 1986)
  • Assumes that cognition, behaviour and
    biochemistry are all components of depressive
    disorders
  • Not reviewed as competing theories, but rather as
    different levels of analysis
  • The cognitive therapist intervenes at the
    cognitive, affective, and behavioural levels

32
Different Models of Depression
  • Experience suggests that when people change
    depressive cognitions, they simultaneously change
    the characteristic mood, the behaviour, and as
    some evidence suggests (Free, Oei, Appleton,
    1998 Joffe, Segal, Singer, 1996) the
    biochemistry of depression
  • Although the exact mechanism of change remains a
    target of considerable investigation, speculation
    and debate (Barber DeRubeis, 1989 Castonguay,
    Goldfried, Wiser, Raue, Hayes, 1996 Crews
    Harrison, 1995 DeRubeis, et. al., 1990 DeRubeis
    Feeley, 1990 Hayes Strauss, 1998 Oei
    Free, 1995 Oei Shuttlewood, 1996 Shea
    Elkin, 1996 Sullivan Conway, 1991 Whisman,
    1993)

33
Different Models of Depression
  • Behavioural Model
  • First behavioural program of significance
    developed by Lewinshon, who built previous
    formulations of depression (Ferster, 1973
    Skinner, 1953)
  • Assumes that Major Depressive Disorder (MDD) is
    related to a decrease of behaviours that produce
    positive reinforcement
  • (Craighead, Hart, Craighead, Ilardi, Ch 10, in
  • Nathan Gorman, 2002)

34
Different Models of Depression
  • Cognitive-behavioural Model
  • The cognitive component of CBT can take different
    forms (e.g., paradoxical intention, stress
    inoculation training, rational emotive behaviour
    therapy). It focuses on the correction of
    catastrophic misinterpretation of life events
    (leading to early maladaptive schemas) bodily and
    emotional changes. The behavioural component of
    CBT focuses on techniques such as exposure
    therapy, relaxation methods, and coping skills
    training

35
Different Models of Depression
  • Interpersonal Model
  • IPT derived in large part from Sullivans
    interpersonal theory (1953) and the
    psychobiological theory of Meyer (1957), with its
    emphasis on the reciprocal relationship between
    biological and psychosocial facets of
    psychopathology
  • IPT suggests that patients interpersonal
    relations may play a significant role in both the
    onset and maintenance of an MDD
  • IPT focuses on identifying and modifying those
    intrapersonal problems that are thought to be
    responsible for episodes of depression. A major
    focus is on specific difficulties that
    individuals have in forming or maintaining
    relationships and that lead to symptoms of
    anxiety or depression
  • (Craighead, Hart, Craighead, Ilardi, Ch 10, in
  • Nathan Gorman, 2002)

36
Treatments for Depression
  • Pharmacological treatments
  • The efficacy of antidepressant medication has
    been well established in a substantial number of
    controlled clinical trials
  • In general, the response of patients with
    unipolar depression is comparable to the success
    rate of treatment of major medical disorders such
    as coronary artery disease (by angioplasty) and
    hypertension
  • A drug is defined as effective/responsive if
    there is a 50 decline in a dimensional measure
    of depression severity, such as the Hamilton
    Depression Rating Scale (HDRS) or the
    Montgomery-Ashberg Depression Rating Scale
    (MADRS)
  • New antidepressants must be shown to be
    statistically superior to a placebo pill, and as
    efficacious as an already approved
    antidepressant, usually a TCA (tricyclic
    antidepressant) in order to receive FDA (Food and
    Drug Adminstration) approval
  • Antidepressant medications require 3 to 4 weeks
    before their therapeutic response is clinically
    evident.
  • (Nemeroff Schatzberg, Ch 9, in Nathan
    Gorman, 2002)

37
Treatments for Depression
  • Different types of antidepressants
  • Tricyclic antidepressants (TCAs)
  • Potent inhibitors of the reuptake of
    norepinephrine into pre-synaptic neurons. They
    exert fewer effects on serotonin
  • Imiprimine (Tofranil), Amitryptiline (Elavil),
    Desiprimine (Norpramin), Nortriptyline (Pamelor,
    Aventyl), Doxepin (Sinequan), Amoxapin (Asendin),
    Clomipramine (Anafranil), Trimipramine
    (Surmontil)
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Prevent the degradation of monoamines,
    particularly serotonin, norepinephrine, and
    dopamine, all posited to be reduced in
    availability in patients with unipolar depression
  • Phenelzine (Nardil), Tranylcypromine (Parnate),
    Isocarboxizid (Marplan)
  • (Nemeroff Schatzberg, Ch 9, in Nathan
    Gorman, 2002)

38
Treatments for Depression
  • Selected Serotonin Reuptake Inhibitors (SSRIs)
  • Block the reuptake of serotonin into presynaptic
    neurons
  • Has become the treatment of choice
  • Fluoxetine (Prozac), Paroxetine (Paxil),
    Sertraline (Zoloft), Citalopram (Celexa),
    Fluvoxamine
  • Venlafaxine (Efexor)
  • Dual serotonin/norepinephrine (5HT/NE) reuptake
    inhibitor approved for treatment of depression
  • (Nemeroff Schatzberg, Ch 9, in Nathan
    Gorman, 2002)

39
Treatments for Depression
  • Critique
  • Antonuccio et. al., (1995, p. 581) concluded
    that
  • there is much evidence that antidepressant
    medications are not benign treatments
  • many antidepressants are cardiotoxic, have
    dangerous side effects, and are often used in
    suicide attempts
  • they also result in relatively poorer compliance
    than psychotherapy, have a higher drop-out rate,
    and result in as much as a 60 non response rate
    with some patient populations
  • Medication as the treatment of choice
  • Antonuccio, et. al., 1995, concludes that despite
    the findings cited on other forms of treatment,
    drugs are still the initial and most frequently
    prescribed form of treatment for unipolar
    depression
  • In the US Although psychotropic medications
    clearly provide enormous benefit and relief to a
    substantial portion of depressed patients,
    research does not support this unilateral bias
    toward medication
  • (Nemeroff Schatzberg, Ch 9, in Nathan
    Gorman, 2002)

40
Treatments for Depression
  • Cognitive Therapy
  • Therapy is time limited and may involve both
    verbal and behavioural methods to help the
    depressed person correct the distorted beliefs
    that form the basis for the depressogenic
    cognitions (Beck, et. al., 1979)
  • Some behavioural techniques (for example,
    activity scheduling, mastery and pleasure
    monitoring, graded task assignments, behavioural
    experiments and behaviour rehearsal) are
    sometimes used in the early part of therapy,
    where a person experiences apathy, anhedonia
    (loss of the capacity to experience pleasure) and
    immobility
  • As treatment progresses, the client is encouraged
    to record unpleasant, dysfunctional thoughts and
    feelings, and situations in which the ideation
    and feelings emerge
  • The therapist eventually helps client to
    challenge thought processes, which is done by
    acquiring alternative rational statements

41
Treatments for Depression
  • Empirical Evidence
  • It has been consistently found in outcome
    research, that cognitive therapy is at least as
    effective as tricyclic antidepressants (TCAs) in
    the treatment of outpatients with nonbipolar
    depression at termination of treatment (Beck, et.
    al., 1979 Blackburn Bishop, 1979, 1980
    McClean Hakstian, 1979 Rush, Beck, Kovacs,
    Hollon, 1977)
  • In one group of studies, the mean percentage
    changes in the level of depression for such
    outpatients immediately after treatment were as
    follows
  • 66 for those receiving cognitive therapy alone
  • 63 for those treated with TCAs alone and
  • 72 for patients receiving some combination of
    the two (Williams, 1997)

42
Treatments for Depression
  • Behaviour Therapy
  • Behavioural-therapies have focused largely on
  • Monitoring and increasing positive daily
    activities
  • Improving social and communication skills
  • Increasing adaptive behaviour as such as positive
    and negative assertion
  • Increasing response-contingent positive
    reinforcement for adaptive behaviours
  • Decreasing negative experience
  • (Craighead, Hart, Craighead, Ilardi, Ch 10, in
    Nathan Gorman, 2002)
  • Empirical Evidence
  • Behaviour Therapy (BT) increased pleasant
    experiences and decreased aversive experiences,
    which produced simultaneous decreases in
    depression severity (Lewinsohn Gotlib, 1995)

43
Treatments for Depression
  • Jacobson Colleagues (1996) tested the
    hypothesised theory of change of Becks cognitive
    therapy for depression by comparing full CBT
    package to its component parts Behavioural
    Activation (BA) and behavioural activation plus
    modification of Automatic dysfunctional Thoughts
    (AT)
  • Major finding BA was equally effective to AT and
    to the full CBT package, both immediately after
    the 20-session treatment trial and at 6-month
    follow-up
  • BA performed equally well over a 2-year follow-up
    period, with patients across the three treatments
    having equivalent rates of relapse, time to
    relapse, and number of well weeks (Gortner,
    Gollan, Dobson, Jacobson, 1998)

44
Treatments for Depression
  • Study by Keller Colleagues (2000)
  • randomly assigned 681 adults with chronic major
    depression (MDD of at least 2 years duration,
    current MDD superimposed on a pre-existing
    dysthymic disorder, or recurrent MDD with
    incomplete remission between episodes and a total
    duration of continuous illness of at least 2
    years) to 12 weeks of treatment with either the
    Cognitive Behavioural Analysis System of
    Psychotherapy (CBASP), the antidepressant
    nefazodone groups, or the combination of CBASP
    and nefazodone
  • The overall rate of response was equivalent in
    the CBASP and nefazodone groups, though patients
    receiving nefazodone had a more rapid reduction
    in symptoms during the first 4 weeks of treatment
  • Immediately post treatment, the combination of
    CBASP and nefazodone was superior to either
    treatment on its own

45
Treatments for Depression
  • Conclusions
  • Although consistent findings support the efficacy
    of BT for depression, they have been overshadowed
    by subsequent outcome studies that have focused
    on cognitive behaviour therapy and interpersonal
    psychotherapy interventions for MDD
  • (Craighead, Hart, Craighead, Ilardi, Ch 10, in
    Nathan Gorman, 2002)

46
Treatments for Depression
  • Interpersonal Therapy
  • Focuses on identifying and resolving the
    individuals difficulties in interpersonal
    functioning related to the current MDD. Common
    problem areas include unresolved grief,
    interpersonal disputes, role transitions, and
    interpersonal deficits (e.g., social isolation)
  • Developed as a time-limited (approximately 12 to
    16 weeks), weekly-based intervention for
    unipolar, nonpsychotic depression (Klerman,
    Weissman, Rainsaville, Chevron, 1984)

47
Treatments for Depression
  • Empirical Evidence
  • A study was conducted by Weissman and Klerman and
    their colleagues (DiMascio et. al., 1979
    Weissman, et. al., 1979), on the use of IPT for
    the acute treatment of MDD.
  • Involved randomly assigning 81 patients to
    treatment with 16 weeks of IPT, AMI
    (antidepressant), combined IPT and AMI, or non
    scheduled (i.e., therapy on request, up to one
    session per month) supportive psychotherapy
    control
  • All three treatments were superior to the
    non-scheduled control condition combination of
    IPT and AMI was slightly more effective than
    either condition alone (this last finding was
    only marginally significant, with plt.10)

48
Treatments for Depression
  • The TDCRP (Treatment of Depression Collaborative
    Research Program) (Elkin, et. al., 1989),
    measured by the HRSD (Hamilton Rating Depression
    Scale)
  • HRSD pretreatment mean 19 for all groups, i.e.,
    IPT, IMI-CM (Imipramine Clinical Management),
    PLA-CM (Placebo clinical Management)
  • Post-test depression score of 6 or less showed
    both IPT (43) and IMI-CM (42) had a
    significantly greater proportion of patients who
    achieved the recovery criterion than was achieved
    in the PLA-CM (21) condition
  • Secondary data analysis (Elkin, et. al., 1995)
    Showed IPT and IMI-CM to be of comparable
    efficacy among the subset of patients who were
    severely depressed (defined as a pre-treatment
    HRSD score of 20 or greater)

49
Treatments for Depression
  • It was highlighted that because of the presence
    of either a strong trend or a significant
    treatment-by-site-by-severity interaction
    (depending on the analysis) no definitive
    conclusions can be drawn from this finding
    (Elkin, et. al., 1996 Jacobson Hollon, 1996b)
  • (Craighead, Hart, Craighead, Ilardi, Ch 10, in
    Nathan Gorman, 2002)
  • Conclusions
  • IPT is a very favourable treatment for MDD,
    either on its own or in combination with
    antidepressants
  • IPT seems to be an effective, efficacious
    treatment for (1) acute treatment of an MDD and
    (2) as a maintenance treatment when compared with
    antidepressant medication for chronic and
    treatment resistant depression
  • (Craighead, Hart, Craighead, Ilardi, Ch 10. In
    Nathan Gorman, 2002)

50
Treatments for Depression
  • Cognitive-Behavioural Therapy
  • It is a short-term (16 to 20 sessions over a
    period of 12 to 16 weeks) directive therapy
    designed to change the depressed patients
    negative view of the self, world, and future
  • Therapy begins with the presentation of the
    rationale, which is designed to inform the client
    of the therapy model and the process of
    therapeutic change

51
Treatments for Depression
  • Early CBT sessions implement strategies designed
    to increase active behavioural performance
  • The purpose of an increase is to allow the
    monitoring of behaviours and their associated
    thoughts and feelings behavioural changes are
    not posited to be directly responsible for the
    desired changes in depression
  • During the third week, expanded self-monitoring
    techniques are introduced in order to demonstrate
    the relationship between thoughts and feelings
  • Patients are taught to evaluate their thoughts
    for selective abstraction, which include
    arbitrary inference, selective abstraction,
    overgeneralisation, magnification and
    minimisation, personalisation, and dichotomous
    thinking

52
Treatments for Depression
  • In the middle of therapy (around sessions 8 or 9)
    the concept of schema, or beliefs underlying
    negative and positive thoughts, is introduced,
    and therapy begins to focus on changing those
    negative schemas that are posited to have been
    activated, thus precipitating MDD
  • Toward the end of sessions (sessions 14-16), the
    focus shifts to termination and the use of
    cognitive strategies to prevent relapse or a
    future recurrence of depression
  • (Beck, 1979)

53
Treatments for Depression
  • Empirical Evidence
  • A number of studies that have compared the
    effectiveness of CBT to several tricyclic
    antidepressant medications (Elkin, et. al., 1989
    Hollon, et. al., 1992 Rush, Beck, Kovacs
    Hollon, 1977 Simons, Murphy, Levine, Wetzel,
    1986).
  • With the possible exception of the NIMH
    Treatment of Depression Collaborative Research
    Program (TDCRP Elkin, et. al., 1989), these
    studies have found that CBT is equally effective
    to tricyclic antidepressant medication in
    alleviating MDD among outpatients
  • CBT is as effective as monoamine oxidase
    inhibitor (phenelzine), and more effective than
    pill placebo in the treatment of atypical
    depression (Jarret, et. Al., 1999)

54
Treatments for Depression
  • Typically, 50 to 70 of MDD patients who
    complete a course of CBT, no longer meet criteria
    for MDD at post treatment
  • with pre-post changes from the high 20s to single
    digits for the Beck Depression Inventory (BDI)
    scores and
  • changes from the high teens/low 20s to single
    digits for Hamilton Rating Scale of Depression
    (HRSD) scores
  • (Craighead, Hart, Craighead, Ilardi, Ch. 10 in
    Nathan Gorman, 2002)

55
Treatments for Depression
  • Among the samples studied, CBT appeared to confer
    some enduring prophylactic effects (i.e., tending
    to prevent further disease)
  • Only 20 to 30 of those successfully treated
    with CBT relapsed during the first year following
    treatment
  • Sixteen weeks of CBT produced a 1-year follow-up
    success rate that equaled or slightly exceeded
    that achieved by a full year of antidepressants
    (Evans, et. al., 1992)
  • CBTs maintenance effects were clearly superior
    to short-term (16 weeks) antidepressant treatment
    (16 weeks is not preferred but it is,
    unfortunately longer than the actual average
    length of completed medication treatment in
    clinical practice Hirschfeld, et. al., 1997)

56
Treatments for Depression
  • TDCRP study (Elkin, et. al., 1989)
  • This study has played a significant role in the
    development of guidelines (not standards) for
    treatment of outpatients suffering from MDD
    (Agency for Health Care Policy Research
    AHCPR, 1993 APA, 1993)
  • 250 patients randomly assigned to one of four
    16-week treatment conditions CBT, IPT,
    imiprimine hydrochloride plus clinical management
    (IMP-CM), or pill-placebo plus clinical
    management (PLA-CM)
  • Both IMP-CM PLA-CM conditions included a
    clinical management component (20 minutes per
    week talking with an experienced psychiatrist)

57
Treatments for Depression
  • Results At post treatment, as measured by a
    Hamilton Depression Rating Scale of 6 or less
  • CBT 36 IPT 43 and IMP-CM 42
  • Only IPT and IMP-CM produced significantly
    greater reductions in depression than PLA-CM
    (21) over course of treatment
  • At 18 months follow-up, percentages of patients
    that were not depressed and not receiving
    treatment were quite low (CBT 30 IPT 26
    IMP-CM 19 and PLA-CM 20). In this study
  • In this study, the three active treatment groups
    were not superior to the PLA-CM conditions at 18
    months follow-up (Shea, Elkin, et. Al., 1992)

58
Treatments for Depression
  • TDCRP study is the only clinical trial of CBT in
    which a pill placebo was employed
  • One of the major problems described in the
    original report of the TDCRP was consistent
    significant treatment-by-site-by-severity
    interactions for more severely depressed and
    functionally impaired patients (Elkin, et. al.,
    1989, p. 980)
  • The general treatment-by-site-by-severity
    interaction is still acknowledged, and the
    authors concluded, In regard to the general
    efficacy of CBT in the treatment of severely
    depressed (and functionally impaired)
    outpatientswe believethat the answer is not yet
    in (Elkin, et. al., 1996, p. 101)

59
Treatments for Depression
  • Conclusions
  • Given the substantial number of studies
    supporting the effectiveness and efficacy of CBT
    with patients diagnosed with an MDD, CBT appears
    to be a viable treatment of choice for patients
    with MDD
  • Whether or not CBT must be combined with
    antidepressants in order to be effective with
    severely depressed outpatients, is yet to be
    determined
  • It is particularly important that therapists
    delivering CBT be well trained before they
    undertake the therapy with patients
  • (Craighead, Hart, Craighead Ilardi, Ch. 10 in
    Nathan Gorman, 2002)

60
Typical CBT steps for Depression Management
  • Overall and in first session
  • Assessment
  • By questionnaires
  • By interview elicit automatic thoughts
  • Case-formulation data
  • Symptom relief by problem definition Ascertain
  • Symptomatology
  • Client perceptions of hope and hopelessness
  • Prioritise problems

61
Typical CBT steps for Depression Management
  • Formulate relationships between thoughts,
    situations, emotions and behaviour
  • Problem-formulation by utilising biopsychosocial
    model
  • Labeling negative thoughts and errors in thinking
  • Drawing connections between these and emotions
    and behaviour
  • Set homework tasks
  • E.g., Daily record of dysfunctional thoughts
    other self-monitoring

62
Typical CBT steps for Depression Management
  • In early sessions
  • Set an agenda dependent upon
  • Clients experiences since last session
  • Homework completed
  • Focus on one or two problems agreed on
  • Clarify the nature of these (e.g., negative
    automatic thoughts)
  • Formulate the cognitive-behavioural
    concept-ualisation of why the client is having
    difficulty in the area concerned. Determine the
    thoughts, images, schemas or behaviours involved
  • Clients are in this way taught to evaluate their
    thoughts (dichotomous thinking, catastrophising,
    personalising, minimising, overgeneralising)

63
Typical CBT steps for Depression Management
  • Choose the cognitive or behavioural techniques to
    apply and to teach client their rationale
  • Re-attribution
  • Testing automatic thoughts
  • Generalising alternatives
  • Scheduling activities and homework
  • Cognitive rehearsal and role-playing
  • Draw conclusions
  • Reactions
  • Implications
  • Homework assignments
  • E.g., Self-monitoring

64
Typical CBT steps for Depression Management
  • In later sessions
  • To prevent relapse, identify and change the
    clients underlying schemas. These are long-term
    patterns, problems, and themes (Early Maladaptive
    Schemas) that could predispose the client to
    future episodes of depression
  • History and presenting problems assessment
    using Youngs Schema Questionnaire
  • Link past experiences to current problems
    education
  • Confront client with the logic and illogically
    their current schema, and with concrete evidence
    for and against it
  • Use behavioural and other techniques to modify
    destructive schemas, e.g., role-playing, hypnosis

65
Other treatments Hypnosis
  • It can be viewed as a vehicle or tool for
    delivering information
  • Hypnosis amplifies client responsiveness, and
    facilitates learning on experiential
    (multidimensional) levels
  • (Yapko, 1992)
  • It is considered to be more than a mere catalyst
    for other therapies
  • To date, there have been no therapeutic efficacy
    research studies involving hypnosis, specifically
    for depression
  • It was widely believed that depression was a
    specific contraindication for the use of hypnosis
    (Crasilneck Hall, 1985 Spiegel Spiegel,
    1987). No research has either validated or
    invalidated this notion
  • (Yapko, D., 2001)

66
Other treatments Hypnosis
  • Hypnosis is a procedure during which a health
    professional or researcher suggests that a
    client, patient, or subject experience changes in
    sensations, perceptions, thoughts, or behaviour
    (Formal definition from the American
    Psychological Associations Division of
    Psychological Hypnosis, 1985)
  • Hypnosis involves
  • Identifying and building on human strengths
  • Teaching coping and problem-solving skills
  • The efficacy data affirms that when people are
    empowered, and when they learn the skills for
    better living, they are likely to recover
    (Lewinsohn, Munos, Youngren, Zeiss, 1986
    Schulberg Rush, 1994)

67
Other treatments Hypnosis
  • The following are some of the skills needed to be
    an effective clinician, as opposed to the skills
    needed to merely perform an induction
  • A broad range of knowledge of current clinical
    literature
  • An ability to relate to the client and form a
    therapeutic alliance
  • An ability to organise and direct a well
    structured intervention
  • (Yapko, 2001)
  • Using Hypnosis with Depression sufferers
  • Some clinicians claim one should have a strong
    rapport and therapeutic alliance before doing
    hypnosis early in the treatment process (Frauman,
    Lynn, Brentar, 1993)
  • However, Yapko (2001) suggests that one can often
    use the hypnosis itself as a means to build the
    necessary rapport and therapeutic alliance with a
    client

68
Other treatments Hypnosis
  • Hypnosis has the ability to reduce anxiety and
    agitation, and to reduce ruminations. Therefore,
    hypnosis may be used early on in treatment as a
    was of demonstrating to the client that his/her
    symptoms are malleable
  • Getting started
  • Because of therapy mortality (i.e., clients
    termination of sessions), it is critical in the
    first session to facilitate hope and meet the
    need for at least some relief as quickly as
    possible
  • A clinician then interviews the client to
    ascertain the following information
  • Symptom description, history, medical history,
    psychosocial factors operating in the persons
    life
  • Clinician uses the above information to formulate
    a meaningful hypnotic intervention

69
Other treatments Hypnosis
  • Introducing hypnosis to the client
  • One can interview an client and then twenty
  • or thirty minutes into the session say
  • something such as the following as a lead-in
  • to hypnosis
  • Ive been listening to you now for the last
    half hour or so, describing your symptoms and
    problems, and how absorbed you have been in just
    trying to manage. Ive been impressed by your
    suffering and despair, and its obvious to me
    that you want things to change. Having been so
    focused on and absorbed in all the most hurtful
    thoughts and feelings, it seems obvious to me how
    valuable it would be to you to start to consider
    and get absorbed in different thoughts and
    feelings that can help you feel better. You came
    here knowing it would be important to get
    absorbed in a different way of looking at things,
    and to help you start to get absorbed in a
    different way of thinking and feeling you can
    just let your eyes close and focus yourself on
    some of the possibilities I want to describe to
    you
  • And thus the hypnosis session begins
  • (Yapko, D., 2001)

70
Other treatments Hypnosis
  • Clinical Applications
  • Ambiguity
  • An individuals lack of clear meaning associated
    with different life experiences. The therapist
    challenges and changes a persons distorted
    and/or maladaptive perceptions
  • Flexibility
  • An individuals strong attitudes and beliefs can
    often be the basis of pain and depression. The
    therapist teaches a person (i) how to let go of
    or self-correct specific dysfunctional attitudes
    or beliefs, and (ii) how to recognise changes in
    a situation that requires a person to modify
    their attitudes/beliefs, and having the
    flexibility to do that
  • Discrimination strategies
  • An individuals belief that events are
    absolute, and do not change according to
    context. The therapist teaches a person that in
    one context its this, but in another context
    its that

71
Other treatments Hypnosis
  • Hopefulness and solution orientation
  • An individual who does not have hope (i.e., the
    belief that things can change), loses motivation
    to try. The therapist sets a goal orientation in
    therapy builds therapeutic hopefulness in a
    depressed person
  • Expectancy
  • This is used to establish a positive expectancy
    for treatment
  • Discriminating controllability
  • An individual cannot distinguish between what is
    and is not controllable in a given context. The
    therapist uses discrimination to distinguish
    what is from what is not controllable in a
    given situation
  • (Yapko, 2001)

72
Other treatments Hypnosis
  • External versus internal aversive, uncontrollable
    stimuli
  • An individual adopts a perception of
    uncontrollability, or learned helplessness
    the internal, uncontrollable stimulus is in the
    persons head. The therapist encourages the
    client to focus on and relate to their subjective
    world
  • Perfectionism
  • It is an internally generated aversive,
    uncontrollable stimulus. It is reflection of
    dichotomous or all or nothing thinking. The
    therapist teaches a person how to be accepting
    and compassionate through compartmentalisation
  • (Yapko, D., 2001)

73
Other treatments Hypnosis
  • Self-criticism
  • When a person attends to and believes their
    self-criticisms or internal critic, without
    critically analysing its truth. The therapist
    teaches a client to between what is useful
    feedback from ones self and others and what they
    can disregard as nonsense or simply malicious
  • (Yapko, D., 2001)

74
Other treatments Hypnosis
  • Expectations and victimisation
  • When a persons unrealistic expectation are not
    fulfilled, the person becomes disappointed and
    externalises their anger, i.e., blaming others,
    taking no personal responsibilities for their own
    inappropriate expectations. The therapist teaches
    a person how to
  • (a) Discriminate what is and is not realistic in
    terms of ones expectations,
  • (b) Develop impulse control to allow sufficient
    time time to critically examine ones
    expectations
  • (c) Recognise anger in in degrees
  • (d) When and how to express anger appropriately,
    (i,.e., without intimidation or physical/verbal
    abuse
  • (e) To tolerate others making decisions that are
    personally disappointing but within their right
  • (f) To compartmentalise anger so it can be
    handled and resolved appropriately
  • (Yapko, D., 2001)

75
Research findings on relapse rates in treating
depression
  • Recurrence/relapse is a major problem for
    depression sufferers
  • At least 50 of individuals who suffer from one
    depressive episode will have another episode
    within 10 years
  • Individuals who experience 2 episodes have 90
    chance of suffering a third episode
  • Individuals with 3 or more life time episodes
    have relapse rates of 40 within 15 weeks of
    recovery from an episodes
  • (Kupfer, Frank, Wamhoff, 1996, p. 293)
  • Other investigators have estimated that 85 of
    patients with unipolar depression are likely to
    experience recurrences (Keller Boland, 1998, p.
    350)

76
Research findings on relapse rates in treating
depression cont
  • Antidepressants
  • Treatment of depression by pharmacological means
    is likely to leave a substantial amount of
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