Week 9: Treatment of Depression 1 Flashcards
CBT Model of Depression
Underlying diathesis-stress model
Cognitive processes to target
Behavioral processes to target
Underlying diathesis-stress model
- Personal diatheses interact with stressful life events to disrupt normal mood
- Depression maintained by negative cognitive and behavioral processes
Cognitive processes to target
-Depressogenic thinking
Behavioral processes to target
- Low reinforcement and negative life events
- Skill deficit
Emotional Spirals
Depression may begin,
or deepen, as part of a
DOWNWARD
EMOTIONAL SPIRAL
Negative events may breed negative moods… negative moods, negative behaviors … and negative behaviors, may produce negative thoughts and expectations for the future
But, moods do not have to just go down. We also experience UPWARD EMOTIONAL SPIRALS.
Positive triggers can start a
chain of pleasant feelings,
events, and thoughts
Goal of CBT
To bring reactions in line with reality
Cognitive Techniques in CBT
Goal is to help youths learn how to:
- Observe their thoughts, feelings, and behavior
- Consider alternative explanation
- Solve problems and make rational decisions
Therapy as observation and experiment
- Assess the accuracy and affective consequences of their thinking
- Try correcting your thought and see what happens
- Match developmental level (like adults with adolescents, but not with young kids)
- Use of concrete examples and cartoons
Young kids typically need more behavioral than cognitive
Behavioral Techniques in CBT
Keep track of mood and activity
- How do you feel?
- What are you doing?
Develop list of rewarding activities
- Activities that produce pride
- Activities that produce pleasure
What is a good activity?
All must be negotiated with client
IN DETAIL
if they will ruminate when walking = not good!
If they will listen to a podcast = good
So you have to be specific as to exactly what they will do
It does not have to be big and in fact, probably helps to start small
Behavioral Techniques (2)
Change habits + Obstacles
Change habits Address environmental obstacles -what will get in the way/how can this be overcome -Be specific Address skill deficits -Monitor IMPACT and refine plan
Antidepressant Medication
Developmental differences
- Many efficacious medications for adults
- Some do not work at all in children
- Most do not work as well in adolescents
- May be due to differences in brain development or metabolism
Tricyclic antidepressants
Prevent the reuptake of norepinephrine and serotonin in the synapses or by increasing the responsiveness of receptors to these neurotransmitters
No evidence of efficacy in youth
Monoamine oxidase inhibitors (MAOIs)
MAO is an enzyme that breaks down some neurotransmitters
-MAO inhibitors stop this enzyme thus increasing the level of neurotransmitters in the synapse
-Some mixed evidence of efficacy in teens
-Potentially lethal side effects
-Interacts with foods rich in a particular amino acid (tyramine) and can lead to a potential fatal increase in
blood pressure
Red wine, beer, chocolate, aged/ripened cheese
MUST follow instructions
Not a strong point for adolescents
Selective serotonin reuptake inhibitors (SSRIs)
Inhibit the reuptake of serotonin so that more is available in the synapse
Similar to tricyclics, but more specifially focused on serotonin
Good evidence for fluoxetine (Prozac) in teens
Tend not to be fatal in overdose
Side effects: agitation, jitteriness, anger, hostility, nausea, stomach cramps
Antidepressants for Children and
Adolescents
Some SSRIS show some evidence of efficacy
Suggestion of increased risk of suicide
Black-box warning by the FDA
- Appears on the package insert for medication
- Warns of serious adverse side effects
- Most serious warning the FDA gives
- Named for the black border around the warning
Black-Box Warning
Began with concern about one drug (Paxil)
FDA requested data from all RCTs involving antidepressants
Nine different drugs, 25 trials
Independent team of experts conducted analyses
Found higher levels of suicidality in patients treated with antidepressants compared to placebos
No deaths from suicides were observed in these trials (+4000 patients)
Similar findings in a follow-up study with more patients
Therefore: Black Box Warning
Black Box is a good idea?
Other types of studies have shown that use of antidepressants is
associated with decreased suicidality
Epidemiological data: Prevalence of anti-depressant use and of suicidality
-Indicates that as use of antidepressants goes up, suicidality goes down
Note that adolescent suicide rates in the US increased for the first time in 2004, after many years of decrease
Speculation that this was, in part, due to adolescents not being treated for depression
More Recent Studies
Obtained complete longitudinal data from RCTs for Prozac (fluoxetine) from the drug companies and the Treatment for Adolescents with Depression (TADS) study
Built on previous studies by including additional data
Examined association between treatment group and clinician ratings of suicidal ideation
Did not find higher rates of suicidal ideation in youth treated with Prozac compared to placebo
Study on the effects of black box warning
Investigated whether warnings and media coverage were
associated with decreased use of anti-depressants and
increased suicides
Obtained data from 11 health care organizations in the United States
Identified people who were prescribed an antidepressant
Identified suicide attempts
Psychotropic poisoning
Poisoning by drugs is most common method of suicide attempt leading to hospitalization
As an indicator of suicide, poisoning by psychotropic drugs is highly specific
But, will be an underestimate of suicide attempts
Identified completed suicides
