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What is Depression? Therapies
What are the most common therapies and treatments for depression? Get to know your ECT from your EBT with our analysis here.
Anti-depressants are widely prescribed as a treatment for depression. This is because they work fairly quickly (approx. 3-4 weeks) and are seen to be effective at reducing symptoms of depression. They come in 3 different forms: Tricyclics (TCIs), Monoamine oxidase inhibitors (MAOIs), and more recently Selective serotonin reuptake inhibitors (SSRIs). They all work in a similar fashion, by increasing the availability of neurotransmitters in the synapses of the brain, and making messages more easily passed from neuron to neuron. TCIs focus on preventing the reuptake of serotonin and noradrenaline and similarly SSRIs inhibit reuptake but focus only on serotonin. MAOIs increase the levels of serotonin, dopamine and noradrenaline by reducing the production of monoamine oxidase (MAO). This is an enzyme present in the synapse that breaks down any excess neurotransmitters. Thus, if there are fewer enzymes present then there will be less breakdown of neurotransmitters and an increase in their availability.
Anti-depressants (TCAs and SSRIs) have been shown to be more effective than placebos at reducing the symptoms of depression (Arroll et al., 2005); however, they may only be suitable as an initial treatment and not a long term solution to depression due to side effects and issues of dependency. It has also been argued that drug therapy does not treat the cause of depression- it merely treats the symptoms and thus, is not getting to the root of why people become depressed in the first place. Anti-depressants are more effective at preventing relapse when they are combined with other therapy e.g. cognitive behavioural therapy rather than being used on their own.
Electro-convulsive therapy (ECT)
ECT is used to treat depression in its most severe form, usually when the patient has not responded to drug treatment and the depression they are experiencing is life-threatening, due to an increased suicide risk. The treatment involves an electric current being administered through the brain to trigger a seizure. Electrodes are attached to the temples and an electric shock, lasting less than a second is given, causing the patient to experience a seizure, like that of an epileptic fit. The patient will typically undergo 6-12 treatments with two sessions a week.
ECT can administered bi-laterally, applied to both hemispheres of the brain or unilaterally, applied to only one side. Unilateral ECT is more common as it has the least side effects, especially if administered to the right side of the brain because it will not affect language, which is predominately controlled by the left hemisphere. The patient will also be given a general anaesthetic, muscle relaxants and a rubber gumshield in their mouth, in order to reduce injuries to the body when they convulse.
It is not fully understood why ECT works as a treatment for depression. Some theorists argue that the seizure causes alterations of neurotransmitters in the brain and this is what alleviates the symptoms. Others argue that it adjusts hormone regulation consequently affecting energy, sleep and mood. Despite this uncertainty on how it works, research has shown it can provide relief from severe depressive symptoms in about 70% of patients (Rey and Walter, 1997).
However, the main issue with ECT are the side effects of short-term memory loss with at least one third of patients complaining of persistent memory loss after ECT (Rose et al., 2003). There are also ethical concerns with using ECT as it can be a particularly distressing experience for people, sometimes leading to permanent fear and anxiety (Department of Health report, 2007) and it is also questionable whether people suffering from severe depression are in an appropriate frame of mind to give fully informed consent for treatment.
Cognitive Behavioural Therapy (CBT)
CBT aims to change the way that people think by changing negative, pessimistic and irrational thoughts into more positive and helpful ones. It addresses the underlying beliefs that are at the root of abnormal emotions and behaviour seen in sufferers of depression. The therapy combines a cognitive element which targets the negative thoughts and a behavioural element which focuses on taking action e.g. using role play to challenge negative beliefs. There are a range of CBT techniques, including Beck’s cognitive therapy and Ellis’ rational emotional-behavioural therapy (REBT). Beck’s therapy involves the patient engaging in a schedule of activities, whilst keeping a record of negative thoughts, which are later challenged by the therapist to assess the reality of these thoughts. The key aim of the therapy is to recognise the illogical thinking processes, test these in real life and adapt them to be more positive.
Similarly, REBT is based on the idea that dysfunctional behaviour and unhappiness seen in people with depression is the consequence of irrational thoughts. This therapy uses the ABC model; A is the activating event, B are the beliefs (about event A) and C are the consequences (of B). If an individual’s beliefs about an event are irrational then this will lead to undesirable emotions and undesirable behaviours but if these beliefs can be made rational then this will lead to desirable emotions and behaviour.
Research has shown CBT to be a very successful treatment for moderate and severe depression (Butler, 2006) and is recommended as being the most effective psychological treatment by the Royal college of Psychiatrists and NICE. CBT has many benefits over drug treatment, for example, it has no side effects or issues of dependency and is focused on treating the cause of the depression, as opposed to just treating the symptoms. However, is it not as cost-effective and is not as fast acting as drug treatment. It also requires time and motivation from the patient, which unfortunately reduces it appropriateness as a treatment because sufferers of depression often lack these drives. CBT becomes most beneficial when it is administered sequentially after drug therapy. Fava et al. (1998) found a relapse rate (over 2 years) of only 25% when patients had drug therapy followed by CBT compared to 80% for patients who only had drug therapy.
Freud believed that depression is caused by traumatic experiences in childhood and repressed thoughts and memories. Thus, psychodynamic therapy entails exploring the patient’s past, particularly the loss of a parent, and linking this to their current emotional state, whilst also bringing unconscious memories into the patient’s conscious awareness.
This is done in a number of ways, through dream analysis, free association and transference. Dream analysis involves the therapist interpreting the content of the client’s dreams to find the underlying, true meaning of the dream, which is often hidden by the literal events that occurred. The process of free association allows the patient to discuss their thoughts freely and thus allowing unconscious thoughts to emerge, which would normally have been concealed. Transference is used to facilitate insight into repressed feelings that a patient has towards a certain individual, usually a parent. In this procedure a patient will project their unconscious feelings about this person onto the therapist and after repeating this process it helps the patient to understand their unknown feelings towards this individual. The whole process aims to help the patient understand the cause of their depression and in doing so enables them to cope better with their inner emotional state, ending the client’s depression.
Psychoanalytic therapy can be praised for its approach to treating depression as it focuses on the underlying causes of behaviour and allows the patient autonomy during the treatment process, rather than just treating the observable symptoms. However, there is inconsistent support for the effectiveness of the treatment. Research by Eysenck (1952), demonstrated that receiving psychoanalysis was no more effective than being on a waiting list and not receiving any treatment, and was not as effective as behavioural therapies. But, Eysenck’s research was then refuted for its poor analysis and selective nature and when the data was re-examined psychoanalysis was found to be twice as effective as no treatment (Bergin, 1971). More recent research has also found a positive impact of new versions of treatment, showing that short-term psychodynamic psychotherapy (STPP) is equally as effective as CBT for treating depression.
The main criticism of this treatment method is the fact that it takes a number of years to complete and can be an expensive and an emotionally demanding therapy option. Similarly, it has been argued that someone suffering from depression who may be lacking in motivation and experiencing feelings of hopelessness is not likely to be able to engage fully in the treatment process and might withdraw before therapeutic effect is seen. The process itself could also exacerbate symptoms in patients as they are guided to relive traumatic childhood experiences and this could be particularly emotionally distressing, perhaps greater than the original distress.