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

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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)

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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