FOR TREATMENTS MOOD DISORDERS
I. BIOLOGICAL TREATMENTS FOR MOOD DISORDERS II. PSYCHOTHERAPY FOR MOOD DISORDERS
I.
BIOLOGICAL TREATMENTS FOR MOOD DISORDERS
ECT (Electroconvulsive Therapy)
* * * Overuse in the 1940's-mid 1960's Today mostly for severe depression not responding to medication Modern ECT is like a surgical procedure: anesthesia and muscle relaxants oxygen to reduce memory loss heart monitor, EEG monitoring, etc. Shock levels lower (12-65 volts vs. 150) and briefer (< sec.) Shocks sometimes applied unilaterally (although this doesn't always work) Convulsions last several minutes At least 6-10 treatments High relapse rate (60%) Not understood why/how it works Side effects: - Common: Severe headaches; memory loss for events surrounding ECT - Less common: Irretrievable loss of long-term memories
* * * * * * *
TRANSCRANIAL MAGNETIC STIMULATION (TMS)
* * for treatment-resistant depression mostly; (also being researched for OCD patients) electromagnetic coil is held against patient's scalp that emits powerful magnetic pulses to alter brain activity
VAGUS NERVE STIMULATION (VNS)
* * * for treatment-resistant depression (FDA approved in 2005) surgical implantation of a pulse generator in left upper chest; wires go from there into the neck and send mild pulses (every 5 minutes) to the neck's left vagus nerve, and from there to brain areas involved in the regulation of mood, motivation, sleep, appetite, etc. adverse effects: voice alteration or hoarseness
LIGHT THERAPY
* * for SAD (Seasonal Affective Disorder) light boxes, requiring at least 10,000 lux
MEDICATIONS FOR MOOD DISORDERS
1.
1.1
* * * *
ANTIDEPRESSANTS
Tricyclics
Available since mid 1950's E.g., Tofranil (Imipramine), Amitryptiline (Elavil) They are mostly norepinephrine reuptake inhibitors Side effects of Tricyclics weight gain sedation constipation dry mouth
1.2
* * * *
SSRI's (Serotonin Selective Reuptake Inhibitors)
Available since 1989 in U.S., first one was Prozac E.g.: Prozac, Zoloft, Paxil, Celexa, Lexapro Work by blocking serotonin reuptake Advantages of SSRI's over Tricyclics: generally fewer side effects, hence better compliance less dangerous in overdose less interaction with alcohol faster action than tricyclics (2-3 weeks vs. 5-6 weeks) more effective for OCD features more effective for sensitivity to rejection
*
Side effects/problems specific to SSRI's sexual side effects (delayed orgasm, decreased desire or arousal) headaches and gastrointestinal problems sometimes a zombie-like feeling (esp. Paxil) elevated suicide risk in that they are very activating increased energy before mood and negative thoughts improve
1.3
* * * * * *
MAO Inhibitors (Monoamine Oxidase Inhibitors)
Available since 1960's E.g., Nardil (phenelzine) Block enzymes at synapses that degrade excess NT at synapses Increase norepinephrine, serotonin, and dopamine Prior to SSRI's: for rejection sensitivity and atypical depression Problems: They also block same enzymes in liver and intestines, causing tyramine build up Danger of "hypertensive crisis" (stroke, heart attack) Food (with tyramine) restrictions Dangerous interactions with most other medications New MAO Inhibitor: ENSAM (transdermal selegiline) available since 2006 maximizes delivery to brain, not gut
*
1.4
* * *
SNRI's (Serotonin-Norepinephrine Reuptake Inhibitors)
block reuptake of both norepinephrine and serotonin Effexor, first designer SNRI, in 1993 e.g., Effexor (venlafaxine); Cymbalta (duloxetine)
1.5
* * * * * * * * *
NDRI's (Norepinephrine-Dopamine Reuptake Inhibitors)
Wellbutrin (Bupropion) since 1984 blocks reuptake of mostly dopamine and also norepinephrine also is a nicotine antagonist (Zyban) risks include lowered seizure threshold no weight gain, no decrease in sexual functioning, very activating helpful with attention deficit/hyperactivity disorder helpful with former stimulant abusers less effective for anxiety or may even cause anxiety of no use for panic & OCD
2.
* * *
MOOD STABILIZERS
Preventive medications, mostly to prevent mania Require weeks to build up to therapeutic blood levels May be combined with antidepressants or antipsychotics
2.1
* * * * * * * *
Lithium (Lithium Carbonate, Li2CO3)
Available since 1950's Lithium affects the flow of sodium through nerve & muscle cells - interferes with relay and amplification of neuronal messages Levels affected by dehydration & excessive water intake Requires build up in system Narrow therapeutic range Regular blood draws required Danger of kidney toxicity Side effects from Lithium: fine hand tremors short-term memory impairment weight gain possible sedation toxicity: flu-like symptoms, lack of coordination, confusion
2.2
* *
Anticonvulsants * (anti-seizure medication)
Preferred for rapid crying or mixed episodes Preferred if Hx of head injury or drug use Different side effect profile than Lithium ((See next page for the various anticonvulsants that are used these days)
*
Depakote (Valporic Acid) - requires blood draws - side effects include: sedation, weight gain, danger of liver damage; diabetes Tegretol (Carbamazepine) - requires blood draws - good for explosive anger problems - side effects include: tremor, sedation, increased liver enzymes, etc. Trileptal (Oxcarbazine) - no blood draws required - milder side effect profile, some sedation Lamictal (Lamotrigine) no blood draws required milder side effect profile, no weight gain or sedation need at low dose and titrate up because otherwise skin rash medication of choice for bipolar depression and rapid cycling less helpful to prevent severe mania by itself
*
*
*
3.
* * * * * *
NEWER ANTIPSYCHOTICS
E.g., Abilify, Zyprexa, Risperdal, Seroquel To treat psychosis in both manic and depressive episodes To bring down mania quickly Also have some mood-stabilizing properties As an "augmentation strategy" (together with antidepressant) for treating depression Side effects to be discussed later (with schizophrenia)
Summary:
Three medication groups for mood disorders: 1. Antidepressants 2. Mood Stabilizers 3. Newer Antipsychotics Medications may be combined from within a single group and/or across groups.
II
PSYCHOTHERAPY FOR MOOD DISORDERS
PSYCHOTHERAPY FOR DEPRESSION
Psychodynamic Therapy
* * * * * * repressed conflicts (e.g., ambivalence, guilt) "anger turned inward" with potential suicidality childhood attachment and loss issues connection between early and present relationships/ losses identification with the lost person or lost relationship loss of self with loss of relationship
Humanistic-Existential Therapy
* * * focus on finding meaning and purpose in life discover one's strengths and talents overcome alienation and develop true self
Behavioral Therapy
* * * change behaviors to change feelings change reward structure in everyday life chart progress
Cognitive Therapy
* * * change maladaptive, irrational thoughts to change negative feelings most common form of psychotherapy for depression today Aaron Beck's cognitive therapy of depression Cognitive triad of depression. - Negative about: (1) Self, (2) World, (3) Future Maladaptive cognitive schemas & errors in logic - e.g., magnification, minimization, overgeneralization
Group Therapy Support Groups Family Therapy
PSYCHOTHERAPY FOR BIPOLAR DISORDER (Mania)
* * * As an adjunct to pharmacological treatment Help clients to function and thrive in spite of having bipolar disorder Both individual and family therapy are helpful
Risk Factors/Triggers for Bipolar Episode
Lack of sleep * * * * Irregular wake-sleep hours Working irregular shifts Travel to different time zones Caffeine and other stimulant drugs
Caffeine (and other stimulants inc. diet pills) * Interferes with sleep and triggers manic states * Most psychotropics slow down caffeine metabolism Antidepressants * "Manic switch" on antidepressants without mood stabilizers Anesthesia * Anesthesia can trigger mania * Probably by throwing off the internal clock Life events * Major life event--both negative and positive * Anything interfering with sleep, increasing stress & excitement * Sad events (like family death) often trigger mania, not depression Medication side effects * Side effects put client at risk for non-compliance
Individual Therapy for Bipolar Disorder
Initially: * * * * * * accept diagnosis and work through denial accept is life-long disorder, requiring medication work through grief over lost life opportunities help client accept new "slower" self deal with embarrassment about mania help "clean up the aftermath" of mania
Throughout therapy: * * * * * monitor moods, provide feedback identify risk factors and triggers stay in touch with family emphasize medication compliance help with decision making
Family counseling for Bipolar Disorder
* * * * * Mania is an illness Recognize signs and triggers for mood changes Help family deal with consequences of mania Help solve power struggle about medication compliance Develop action plan to intervene early
Individuals with Bipolar I Disorder do well when ....
* * * * * * * * Medications are effective (true for 60-70% of bipolars) Good judgment and insight No comorbid psychological disorders No comorbid substance abuse (including caffeine) Supportive friends and family Keep regular sleep-wake cycle Suitable job or meaningful volunteer work Manage time well and avoid stress