Arguing Cause R.F.

Behavioral-Cognitive vs. Antidepressant Treatment of Depression

Depression is a mental disorder that effects an ever increasing portion of the population of the United States as well as many other countries around the world. People who are effected by Major Depressive Disorder (MDD) can fall anywhere on a spectrum from more moderate to very severe forms of the disorder. MDD can be caused by many biopyschological and psychosocial variables and the symptoms of MDD vary in strength across the spectrum. The main symptoms are generally described as sadness, lack of interest in activities, disturbance of sleep potentially bordering on insomnia and a lack of appetite. Depressed people tend to be pessimistic and mainly focus on the negative aspects of their lives. They may see themselves as utter failures, be overcome with hopelessness about their future, and see almost anything bad or stressful around them as entirely their fault. They tend to have few interactions with other people and a general lack of interest in anything. In the more extreme cases these beliefs of hopelessness, more-so than the other symptoms, may even lead to suicidal thoughts and eventual attempts. Depression is more than just being sad for a few days, it dominates the persons thoughts and their personal beliefs. MDD is generally diagnosed by a psychologist after multiple therapy sessions with an individual. These sessions can consist of many different techniques depending on the doctor and their specialty. After their psychologist diagnoses a patient with MDD they are commonly referred to a psychiatrist who then writes them out a prescription for some form of anti-depression medication, also known as pharmacological therapy.

However use of antidepressants are not the only or even always the most effective form of therapy for depression, it just tends to be the fastest and the easiest. The idea being that all the patient needs to do to drastically change their lives and be “happy” is take a pill once or twice a day and maybe meet with a therapist every few months to make sure the dosage is still effective. The patients insurance company loves this, less expensive therapy sessions for them to cover, especially since the majority of the cost of the drugs themselves come out of the patients pocket not theirs. This has lead to the American Psychological Association (APA) to claim that pharmacological therapy to be the leading/most effective treatment of MDD in their Diagnostic and Statistical Manual of Mental Disorders now on the fifth iteration (DSM-V).This manual is used by psychologists to determine what disorders their patients may have based on their symptoms, then once they diagnose the disorder the DSM lists the most common and effective treatments. The APA generally cites a study performed in the mid ‘90s by the National Institute of Mental Heath (NIMH) on Treatment of Depression Collaborative Research Program (TDCRP). This study claims that it disproves the efficacy of cognitive–behavior therapy (CBT) and interpersonal psychotherapy (IPT) versus antidepressant medication (ADM), in this case imipramine plus clinical management (IMI-CM), and the control group of placebo plus clinical management (PLA-CM). This study claims to prove that IMI-CM shows the fastest, most significant and longest lasting reduction of depressive symptoms in the initially severely depressed population (Elkin et al.). However these pills do not really alter the way a person lives their life, deals with stress, or even their overall perspective, the psychosocial variables of depression. What they do, that we know of, is effect what many researchers and pharmaceutical companies refer to as the chemical imbalances within the patients brain, the biopyschological variables.

These chemicals, also known as neurotransmitters, that are effected by the many variants of antidepressant medications are serotonin and norepinephrine, or noradrenaline. Neurotransmitters are the chemical messengers of the brain, they relay signals from one area to another. Approximately 40 million brain cells receive messages via serotonin and are widely distributed throughout the brain. Including, but not limited to, brain cells related to mood, sleep, appetite, memory, learning, sexual desire, temperature regulation as well as some social behavior. Norepinephrine on the other hand is secreted by the medulla of the adrenal glands, this secretion contains roughly 80 percent epinephrine, also known as adrenaline, and 20 percent norepinephrine. These two chemical compounds are slightly different but have similar effects, usually on the sympathetic nervous system fight or flight responses. Antidepressant medications take many forms, each with their own function and effects. The most commonly known and prescribed form being selective serotonin reuptake inhibitors (SSRIs), Prozac, Paxil, Zoloft and many others are SSRIs. SSRIs do exactly what they claim to do in their name, they block serotonin from being reabsorbed, this means that it spends longer floating around in the synapse increasing its function. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a newer form of medication that does the same thing as SSRIs but also blocking the reuptake of the neurotransmitter norepinephrine. Another common form of medication are tricyclic antidepressants (TCAs) which increase the available amount of serotonin and/or norepinephrine in the brain. Monoamine oxidase inhibitors (MAOIs) have roughly the same effect as TCAs except rather than the and/or the increase the availability of both serotonin and norepinephrine within the synapse and are usually prescribed to individuals who do not have a response to other forms of antidepressants (WebMD).

While pharmacological therapy may effectively treat some of the biopyschological variables of depression, what about the psychosocial aspects? Just because there are now more “feel good” chemicals floating around in their neural synapses than there were before the person may still think, act and live the lifestyle of a depressed individual because that is how they have learned to behave through the majority of their life experience. Just because they do not necessarily have a biological reason why they are no longer depressed all the time this does not magically grant them social behaviors they rarely used before, or change their lifestyle from one of sheer laziness to one of prosocial activity overnight. These behaviors become so ingrained in what makes the person who they are that they do not change without significant effort and thought on their part. That is where behavioral and cognitive therapies should be utilized to achieve the most effective treatment of the overall variables of depression. The most common types or branches of behavioral cognitive therapy are known as Behavioral Activation (BA), Cognitive Therapy (CT) and the various combinations of the two known collectively as Cognitive-Behavioral Therapy (CBT or sometimes confusingly just lumped into the CT package). Behavioral activation is based on the matching law, similar to the law of effect, that suggests that behavior is maintained by its consequences (Lejuez et al.). Depressive behavior, which usually consists of a lack of activity, is slowly and systematically replaced with prosocial behaviors. The therapist will ask the participant to make some goals for themselves to achieve over the course of the week, month or year to come. These goals are ranked on a 1-5 scale based on the perceived difficulty according to the patient through functional behavior assessment (FBA). The rank 1 goals are relatively easily attainable, things like getting out of bed, taking a shower or doing the dishes. Throughout the treatment these goals are slowly replaced with more difficult tasks such as interacting with strangers, exercising daily, eating better, joining a book club and on and on. The idea being that the person can not possibly ruminate on sad, depressing and potentially self-destructive thoughts as much when they are doing something productive rather than escaping, avoiding or withdrawing from life by just laying in bed. While this may not completely treat the more extreme forms of depression it works very well for some. BA helps people begin to access sources of positive reinforcement in their lives and can vastly reduce relapse.

Behavioral activation was originally developed as a stand alone treatment to help people reengage but was eventually integrated into the CT (or CBT) package developed by Beck, Rush, Shaw and Emery. The CT package was designed to produce change in negative attitudes by analyzing and altering thoughts (Jacobson, Martell, Dimidjian). The idea being that repetitive negative thinking, associated with increased limbic activity and decreased activity in the prefrontal cortex, is a causal role in depression. If the maladaptive thinking were to be corrected the individuals depression would be corrected. The data of one study that compared these two forms of therapy with various antidepressants showed CT to be far more effective and less prone to extinction than antidepressant medications on their own (DeRubeis, Siegle & Hollon). While the data of another study by a couple of the same researchers (DeRubeis et al. “Cognitive Therapy vs Medications in the Treatment of Moderate to Severe Depression”) showed CT to be at least an equally effective treatment when compared to medication. This study had a much larger population than the first, 250 participants, randomly placed into one of three groups, these consisted of either CT, ADM or control/placebo. The placebo/control group is added to potentially eliminate the third variable problem since these participants are not receiving treatment at all, they are in fact only being given sugar pills, but are lead to believe that they are being treated with antidepressants.

In closing there is still much research to be done to determine exactly which therapy or combination of therapies are the most effective for each individual suffering through life with depression. However just because antidepressant medication seems to be the easiest and most cost effective way, at least according to the APA and insurance companies, that does not mean it is the only or the longest lasting method. The more traditional forms of behavior and cognitive therapy may take more time to grant results when compared to medication but it is only because the patient is receiving the cognitive and behavioral tools to cope with and possibly eventually treat their depression without the reliance on psychotropic, brain-altering pharmaceuticals. They are slowly changing the fundamental ways in which they view and interact with the world around them organically. Since the patient is not reliant on a drug to maintain happiness and fend off the darkness of depression, if/when they achieve said happiness it is truly their achievement. They can not just run out of pills and fall back down into the pit of despair, instead they will have built a powerful system, tailor made for them with their help. So if they start to feel themselves slipping back into the shadows they know exactly what target behaviors to focus on and how to address their darker thoughts. Because of their behavioral training and understanding of their cognizance the person truly has mastery over their own entirely unique form of depression, something that no drug can provide.

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