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Treatment for Depression: Psychotherapy and Psychological Treatments





Treatment for Depression: An Introduction

Treatments for depression have come a long way in the last couple of decades with many advancements in psychotherapy and psychological treatments that have been empirically supported by research. Research into cognitive behavioral therapy, behavior therapy and interpersonal therapy have now been conclusively found to be effective. Evidence has also been found to support the use of cognitive therapy and reminiscence therapy among senior adults. A review of each of the main specific therapeutic modalities follows below.

Treatment for Depression: Cognitive Behavioral Therapy

Cognitive behavioral therapy was originally developed by Aaron Beck M.D. in the late 1960’s. It has easily become the most popular treatment modality for depression, anxiety disorders and a multitude of other mental health conditions. Cognitive behavioral therapy focuses on the connection between thoughts, moods and behaviors and utilizes primarily the thoughts as the main intervention point to modify moods and ultimately behaviors. It recognizes the negative bias that many people develop that results in biased information processing and dysfunctional beliefs that lead to and maintain depression. The main goal is to identify and change the dysfunctional or maladaptive thinking which is believed to then consequently change the individual’s affect and behaviors.




Cognitive behavioral therapy is traditionally provided within a structured format that facilitates learning experiences, monitoring thoughts, development of more adaptive coping skills and Socratic questioning of maladaptive thinking. A full course of cognitive behavioral therapy may involve 14 to 16 sessions along with booster sessions whenever necessary. There has been significant evidence over the last several decades recognizing the effectiveness of cognitive behavioral therapy in treating depression. Various outcome studies have found it to be at least as effective as pharmacotherapy and may be more effective than depression medications alone in assisting with preventing relapse of depressive symptoms. A more recent field of cognitive behavioral therapy has also had an increased interest and attention in that it has integrated the concept of mindfulness as well into the traditional cognitive behavioral model, in an attempt to reduce the incidence of relapse.

Behavior Therapy Treatment of Depression:

Behavior therapy focuses on the use of reinforcement and extinction of behaviors that are found to be either positive or negative. Behavior therapies focus on increasing the quality as well as the frequency of pleasant experiences which are then expected to result in improvements in an individual’s mood. A structured treatment program that was developed utilizing this theoretical perspective is the Coping With Depression course. This course uses the format of a psychoeducational group which usually consists of 12 sessions over approximately eight weeks, and then uses skills training to improve social skills. The objective is then to increase activities that are pleasant as well as to teach individuals how to relax. Some recent evidence has found that the use of this Coping With Depression course is at least as effective as antidepressant medications in treating depression in the short-term and possibly even over the long-term.

Interpersonal Therapy for Depression:

An interpersonal therapy model for depression was developed by Klarman, Wiseman and Associates in the 1980’s. The basis for Interpersonal therapy is the Interpersonal model of depression which considers depression to be the result of or to be exacerbated by interpersonal difficulties between people. As a result, interpersonal therapy focuses on remediating these interpersonal problems. Interventions may focus on role transitions, or disputes, interpersonal deficits and skills and even grief issues which have been denied, delayed or may be inadequately completed.

Interpersonal therapy is also provided within a structured format and utilizes a progression through three phases: (1) the diagnosis and identification of specific areas of interpersonal difficulties as well as an explanation of the course of therapy; (2) focus on resolution of the specific problematic areas or difficulties and (3) termination of therapy. This type of therapy has been utilized in a modified format among several specific populations such as adolescents and the elderly and has been used for other mental health disorders as well. Interpersonal therapy has been demonstrated to be effective for both the acute and maintenance phases of depression.

Learned Helplessness Treatment Model for Depression:

Significant research has also recognized the importance of the learned helplessness model for the development and maintenance of depression. Learned helplessness is based upon a model by Martin Seligman Ph.D. in the early 1960’s in which he recognized that there was a connection between an individual’s sense of control over their environment and depression. He found that an individual’s inability to have a sense of control over adverse circumstances in their environment resulted in a sense of helplessness and ultimately depression. He believed this perspective and consequent depressed mood was basically a learned experience. This model recognizes the need for increasing an individual’s sense of control over their environment, reducing feelings of helplessness, hopelessness and depression.

Treatment for Depression: Conclusion

Research and my (Paul Susic Ph.D. Licensed Psychologist) clinical experience has found over the last several decades that optimal treatment for depression may include both psychotherapy and/or psychological treatments along with medications for the most effective treatment of major depressive disorder. Although medications frequently are prescribed as a front-line treatment for depression, this physiological focus is often not ideal. Medications alone have been found to have higher relapse risks of additional episodes than psychotherapy alone. In most cases it seems that the most effective approach may be to attempt to remediate the depression with psychotherapy and then add medication as necessary rather than trying medication and then adding psychotherapy as an adjunct treatment.

By Paul Susic Ph.D. Licensed Psychologist





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Bipolar I Disorder: Current or Most Recent Episode Depressed Diagnosis






Bipolar I Disorder: Current or Most Recent Episode Depressed Diagnosis – General Information

In order to have a Bipolar I Disorder: Current or Most Recent Episode Depressed diagnosis you must have at least one manic episode previous to the current or most recent episode of depression. Nearly every person with bipolar I disorder will have or can have the diagnosis of “current or most recent episode depressed” at some point in time in their mental health history.

A diagnosis of Bipolar I Disorder: Current or Most Recent Episode Depressed obviously requires a depressive episode which includes (as previously mentioned) a manic episode followed by a depressive episode. The depressive episode requires either a depressed mood for at least two weeks or a loss of interest or pleasure in normally pleasurable activities, and at least five of the depression symptoms listed in 1-9 below.

Bipolar I Disorder: Important Information

Bipolar I Disorder: Current or Most Recent Episode Depressed and bipolar I disorder in general, is a very serious mental health condition. Bipolar I disorder has a lifetime prevalence of 0.8%. Obviously, a significant percentage of people suffer from these severe mood episodes. In actuality, contrary to popular belief, bipolar I disorder is not always indicated by rapid mood swings, with some mood episodes going on for weeks or months at a time. They may resolve and then resume with a later mood episode.

Bipolar I disorder in addition to major depressive disorder can be lethal. Some researchers have found that between 25% and 50% of individuals suffering from this disorder may attempt suicide. In addition, individuals experiencing a manic episode may engage in very risky behaviors resulting in severe consequences. The healthcare costs associated with bipolar I disorder are very high because of the frequency of hospitalizations, doctor visits and the usage of expensive medications.


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Bipolar I disorders occur just as frequently among women as in men, although women tend to experience more rapid cycling and more frequent depressive episodes than men. Also, in addition to the bipolar I symptoms, women seem to experience higher rates of comorbid eating disorders and substance use disorders. Unfortunately, individuals who are diagnosed with bipolar I disorders often have a lower socioeconomic status, have much higher rates of disability and a lowered life expectancy.

Bipolar I Disorder: Current or Most Recent Episode Depressed Treatments

Bipolar I Disorder: Current or Most Recent Episode Depressed is most often treated with mood stabilizing medications and antidepressants, along with psychological interventions. These disorders require lifelong management. Many researchers and clinicians agree that the combination of psychotherapy and medications is the most effective treatment for this disorder.

The most effective interventions according to research literature seem to include medications combined with psychoeducation, cognitive behavioral therapy, family-focused therapy, and other types of interpersonal and social rhythm therapy.

The specific symptoms associated with Bipolar I Disorder: Current or Most Recent Episode Depressed follow below.

Basic Bipolar I Disorder Diagnosis Criteria

A. Criteria have been met for at least one manic episode.
B. The occurrence of the manic and major depressive episode or episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum and other psychotic disorders.

Major Depressive Episode:

A. At least five of the following symptoms have been present during the same two week period and represent a significant change from previous functioning; At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure in normal activities.
Note: Never include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either an individual’s subjective report, such as feelings of sadness, emptiness or hopelessness, or observation by others such as that they appear tearful or sad. (Note: In children and adolescents it can be an irritable mood.)
2. A significantly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day as indicated by either an individual’s subjective account or observation by others.
3. A significant weight loss when not dieting or a weight gain such as a change of more than 5% of body weight in a month, or a decrease or an increase in appetite nearly every day. (Note: in children, consider a significant failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor retardation or agitation nearly every day which may be observable by others and cannot be merely subjective feelings of restlessness or being slowed down.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or inappropriate or excessive guilt (which may be delusional) nearly every day.
8. Diminished ability to concentrate, to think or be decisive, nearly every day, either by subjective account or be observable by others.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a plan or suicide attempt or a specific plan for committing suicide.

B. The symptoms above cause significant distress or impairment in an individual’s social, occupational, educational or other important areas of functioning.

C. The episode above is not attributable to the physiological effects of a medication, substance, or to another medical condition.

Note: Criteria A-C, see above to indicate a major depressive episode. Major depressive episodes are common in individuals with Bipolar I disorder but are not absolutely required for the diagnosis of the disorder.

Note: Responses to a significant loss such as bereavement, financial ruin, losses from a natural disaster, serious medical illness or disability may include the feelings of intense sadness, ruminating about the loss, insomnia, poor appetite, and weight loss noted in criterion A above, which may resemble a depressive episode. Although such symptoms may be understandable or even appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be considered very carefully. This decision obviously requires the exercise of clinical judgment based upon the individual’s history and cultural norms for the expression of the distress in the context of the loss.

Coding for Bipolar I Disorder: Current or Most Recent Episode Depressed and other bipolar one disorders:

The diagnostic code for bipolar I disorder is 296._ _ (F31._ _). The actual specific coding defines either the current or most recent episode only. Also, psychologists, psychiatrists and other mental health clinicians need to specify the severity, whether psychotic features are present and finally if the patient is in partial or full remission.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic And Statistical Manual of Mental Disorders Fifth Edition DSM-5



Unspecified Depressive Disorder Symptoms and Related DSM–5 Diagnosis





Unspecified Depressive Disorder 311 (F32.9)

Information related to Unspecified Depressive Disorder as well as the specific symptoms follow below. While some of these Unspecified Depressive Disorder symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Unspecified Depressive Disorder 311 (F32.9) Diagnostic criteria:

This category applies to presentations in which symptoms characteristic of a depressive disorder that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The Unspecified Depressive Disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific depressive disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis such as in an emergency room setting.

Adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5: American Psychiatric Association




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Major Depressive Disorder Diagnosis and Symptoms




Major Depressive Disorder Diagnosis

Major depressive disorder is diagnosed as major disorder, single episode or having recurrent episodes and is also rated in terms of severity such as mild, moderate or severe. It has been part of the DSM diagnostic system used by mental health professionals for many years. It is probably the most often diagnosed disorder by mental health clinicians. The National Institute of Mental Health estimates that 6.7% of the population in the United States suffer from major depressive disorder in any given year. Unfortunately, as reported by the Substance Abuse and Mental Health Services Administration in 2008 only about 64.5% of individuals experiencing major depressive disorder seek treatment.

In order to receive a major depressive disorder diagnosis, you must experience nearly every day (usually all day) either a low mood or lack of interest in your daily activities and interests or both. Additionally, you may experience a loss of appetite, fatigue, problems with sleeping, suicidal ideation, agitation, trouble concentrating, and feelings of excessive guilt. Major depressive disorder can lead to a variety of physical and emotional problems and can be a chronic illness requiring long-term psychotherapy, and/or medical and biological treatments.

Major Depressive Disorder Diagnosis and the Bereavement Exclusion:

An exclusion for bereavement was removed from the DSM-5. Previous editions of the DSM had an exclusion for individuals who experience depression for up to two months after the death of someone of significance. Some individuals criticized the removal of the exclusion stating that the existence of bereavement could pathologize the normal grieving process. However, the American Psychiatric Association concluded that normal grieving frequently occurs without a diagnosis of major depressive disorder.

Basic Features of a Major Depressive Disorder Diagnosis:

A major depressive disorder diagnosis can be given at any age although the prevalence seems to increase often after an individual gets to the age of puberty. First episodes can occur in middle age or even for senior citizens although it seems to peak when individuals are in their early twenties. As previously stated, major depressive disorder can be diagnosed to consist of either a single or recurrent episode. It must consist of at least five of the nine criteria below. It is also important to recognize that these criteria must define a change from the individual’s previously normal level of functioning. The symptoms must continue for at least a two-week period of time. Mental health clinicians need to be very considerate that they do not include symptoms related to another medical condition when diagnosing major depressive disorder.

There are very high mortality rates associated with major depressive disorder. Some estimates have found that as many as 40.3% individuals diagnosed with major depressive disorder have suicidal ideation within a given year and approximate 10.4% actually make an attempt.

Psychologists and mental health clinicians frequently use depression screening and suicide assessment instruments to closely monitor clients with moderate to severe depression symptoms. Occasionally, an individual may require a higher level of care such as hospitalization.

Major Depressive Disorder Diagnosis: Cultural Considerations

It is also very important to understand that there are cultural considerations related to major depressive disorder. It has been found that Latinos may be more susceptible to major depressive disorder especially if they are recent immigrants or they have had trouble acclimating to the new culture. Native Americans seem to have relatively the highest risk of prevalence for major depressive disorder over their entire lifetime. Some studies have found rates as high as 19.17%. The second highest cultural group of individuals with diagnosed major depressive disorder are Caucasian Americans with a rate of approximately 14.58% followed by Latinos at 9.64%, African-Americans at 8.93% and Asian Americans and Pacific Islanders at 8.77%.

It is important to understand that culture affects not only the prevalence rates of the different ethnic groups but also influences their experience of the symptoms, the language that they use to report the symptoms as well as influences their decision whether to seek treatment or not. It may affect every aspect of their diagnosis and care.

Treatment for Major Depressive Disorder:

Most of treatments for major depressive disorder fall within the categories of either psychotherapy or depression medication or in many cases both. Clinical experience seems to indicate that in many cases the optimum treatment may require both psychotherapy and medication management of depression symptoms.

Coding for Major Depressive Disorder:

Major depressive disorder is diagnosed as having either single or recurrent episodes. Also, the severity level such as mild, moderate, severe and with psychotic features are also specified to note the unique aspects of the course of the disorder. Major depressive disorder specific codes can be found on the previous page.
Please see below for specific symptoms for major depressive disorder.




Major Depressive Disorder diagnostic criteria:

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.
Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) 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).
3. Significant weight loss when not dieting or weight gain (e.g., A change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
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.
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 dying), recurrent suicidal ideation without a specific plan, or suicide attempt or specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in criteria a, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of major depressive episode in addition to normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on individual’s history and cultural norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by seasonal affective disorder, schizophrenia, schizophrenic form disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or hypomanic episode.

Note: This exclusion does not apply if all the manic -like or hypomanic-like episodes are substance -induced or are attributable to the physiological effects of another medical condition.

Severity/Course Specifier, Single Episode, Recurrent Episode

Mild 296. 21 (F32.0) 296. 31 (F33.0)
Moderate 296. 22 (F32.1) 296. 32 (F33.1)
Severe 296. 23 (F32.2) 296. 33 (F33.2)
With psychotic features 296. 24 (F32.3) 296. 34 (F 33.3)
In partial remission 296. 25 (F 32.4) 296. 35 (F 33.41)
In full remission 296. 26 (F32.5) 296. 36 (F 33.42)
Unspecified 296.20 (F 32.9) 296.30 (F 33.9)

Specify:

With anxious distress
With mixed features
With melancholic features
With atypical features
With mood congruent psychotic features
With mood-incongruent psychotic features
With catatonia Coding note: Use additional code 293.89 (F06.1).
With peripartum onset
With seasonal pattern

Diagnostic Criterion for Major Depressive Disorder from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association