Depression Tool Kit
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Lesson 7 | Teacher's Guide

Neurons and Neurotransmitters

"Teachers: Nikki neuron reminds you to check the standards tables in the front of the toolkit to see which ones apply for this lesson and your subject area."


Overview1

An assessment of the person’s physical and psychological status is the fi rst step in providing appropriate professional treatment for depression. Mental health professionals who are trained in diagnosing and treating depression include psychiatrists, psychologists, psychiatric nurses, social workers, and counselors. In some cases, a family physician or other medical doctor may initially suspect depression in a patient and prescribe antidepressant medication to treat the problem.

The most widely used treatments are “talk” therapy (psychotherapy or counseling), antidepressant medication, or a combination of the two. The right treatment is the one that works best for a particular individual. However, research has found that, at least with adults, a combination of medicine and psychotherapy work better than either treatment alone.2,3 Less commonly, some severe cases of depression respond well to electro-convulsive therapy (ECT).

Although most cases are improved by either medication or psychotherapy, research has found that the more severe the depression is, the more likely medication will be necessary. Some studies suggest that improvement may be slower for the patient relying solely on psychotherapy, but the long-term outcome is about the same as for medication alone. On the other hand, some individuals who rely solely on medication are more likely to experience a relapse (return of symptoms), if the medication is discontinued. The benefit of psychotherapy is that a patient learns new ways of thinking that can be integrated into everyday life, so that positive changes are more likely to be lasting.

Psychotherapies

Mild to moderate depression can improve with “talk therapy” (psychotherapy) alone or in combination with medication. New research is also showing that psychotherapy alone may help even severe depression in some cases.4 Psychotherapy works by providing the “tools” by which a person can modify thinking patterns that perpetuate a depressed state of mind.
There are several types of psychotherapy: cognitivebehavioral therapy (CBT), interpersonal therapy (IPT), as well as group, marriage and family therapies, to name a few. Research has found that for mild depression, either CBT or IPT are effective even when used without medication. 2,5,6 However, for severe or recurrent depression, psychotherapy alone is usually less effective. While CBT can help to relieve symptoms, in such cases antidepressant medication is often also required.7

Cognitive-behavioral therapy helps a depressed person recognize and change negative styles of thinking and behaving that are often associated with depression. For example, someone who is depressed is more inclined to take one upsetting incident and from that, make sweeping, pessimistic generalizations about his or her self worth or future. A depressed person is also more likely to attribute disappointments in life to his or her own internal shortcomings, but on the other hand, attribute the successes to external factors, such as “a lucky break” rather than one’s own positive qualities. In all, depressed persons are more likely to feel powerless and see life’s circumstances as unchanging and beyond their control. These pessimistic ways of thinking about oneself, others, the future and the world are referred to as “cognitive distortions.” Learning how to cultivate more positive and realistic ways of thinking about life can be a significant step in overcoming depression.

Interpersonal therapy helps a depressed person improve dysfunctional personal relationships that may be contributing to the depression or are being impaired by the depression. Recent research with depressed adults has shown promise with this type of intervention.6 A history of difficult relationships or poor social skills can be an additional stressor that sometimes contributes to the development of depression in vulnerable persons.

Medications8

The Food and Drug Administration (FDA) has approved dozens of medications to treat depression. They are grouped according to chemical structure and effect on brain chemistry. It is important to remember that all FDA-approved medications for depression as a group can be effective – they just don’t work the same for everyone. Antidepressant medications take several weeks to be clinically effective, even though they begin to alter brain chemistry with the very first dose. Studies on the mechanisms by which these drugs work comprise an important area of research on depression.

Untreated depression often has an accelerating course, in which episodes become more frequent and severe over time. Researchers are now studying early intervention with medications and maintenance treatment during well periods as a way to prevent recurrence of episodes of depression. A medical doctor (MD) such as a psychiatrist, general practitioner or other physician must be consulted for medication treatment of depression, since other mental health professionals do not have the training or license to prescribe medication.

The two most common types of antidepressants are tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). However, there are other medications available for depression, and research to develop new medication for depression continues. Below are some of the more common types of medications currently used to treat depression:

Selective serotonin reuptake inhibitors (SSRIs): These newer medications have fewer side effects than the older drugs, making it easier for patients to adhere to treatment. They are thought to work by decreasing reuptake of serotonin by nerve cells, thus making more serotonin available for transmission. Examples of SSRIs are Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine).

Tricyclic antidepressants (TCAs): Once widely used, but much less so now with the emergence of newer medications, these medications affect the activity of the monoamine neurotransmitters serotonin and norepinephrine simultaneously, but primarily norepinephrine. Their disadvantage is that they can be difficult to tolerate due to side effects. Examples of tricyclic antidepressants are Elavil (amitriptyline), Tofranil (imipramine), and Norpramin (desipramine).

Other medications: Other medications for depression also affect various neurotransmitters including serotonin, norepinephrine, dopamine and monoamine oxidase. Many of these medications can be very effective for treating depression and, in some cases, are well tolerated by individuals taking them. However, some of them cause side effects or interact with food or other medication making them difficult to tolerate. Examples of other medications include Serzone (nefazone), Effexor (venlafaxine), Wellbutrin (bupropion), and Parnate (tranylcypromine).

Each type of medication is effective in relieving depression, although some people will respond well to one type of drug, but not another. To date, there is no evidence of any adverse effects of long-term antidepressant use by adults. However, to date, there is still little known about the effects of long-term use of antidepressants by adolescents. All medications for depression should be prescribed by a medical doctor, and any adolescent or child on these medications should have regular follow-up by that doctor to assess a medication’s effectiveness and monitor potential side effects.9

Some people experience short-term side effects when they take antidepressants. However, in most cases these problems will decrease or go away completely with continued use. Common side effects include:

■ Dry mouth
■ Constipation
■ Nausea, vomiting or diarrhea
■ Drowsiness
■ Wakefulness
■ Feeling “wound up”
■ Blurred vision
■ Dizziness
■ Headache

Herbal or Natural Treatments

Dietary supplements and other alternative treatments for depression regularly enter the marketplace. Among the more popular products are Omega-3, St. John’s Wort, and SAM-e. Research into the safety and effectiveness of these remedies is still relatively new, and findings vary. Some clinical trials have found St. John’s Wort did help patients with mild to moderate depression. Conversely, a study sponsored by the National Institutes of Health concluded that St. John’s Wort was no more effective in treating moderate depression than was a placebo.10

One potential problem with the use of herbal treatments is that the concentration of ingredients is not standardized, which means that one company’s preparation may be different than another company’s preparation, even though both would say they contain the same herbal substance. It should also be noted that some herbal treatments could cause problems when combined with other kinds of medication. For instance, recent studies have suggested that herbal treatments, such as St. John’s Wort, may interfere with the beneficial effects of some medications. A doctor or pharmacist should always be consulted before beginning to use these preparations.

Electroconvulsive Therapy (ECT)11
Electroconvulsive therapy (also known as shock therapy) is generally prescribed for severe depression and some cases of mania. Although some distorted movie and media portrayals of ECT have led to its undeserved reputation as an inhumane treatment, ECT is considered an appropriate treatment option in some cases. When medications and psychotherapy fail to adequately lessen symptoms of depression, or when a quick improvement in symptoms is sought as in the suididal patient, ECT can be a safe and effective alternative. Mild electrical stimulation to the brain causes brief seizures, which, in turn, relieve the depression. An average of six to 12 treatments over three to four weeks is usually required. After a successful course of treatment, antidepressants or occasional doses of ECT may be all that is needed to reduce subsequent depressive episodes.

Like all therapies, ECT has potential side effects, with some patients reporting confusion or memory impairment. However, in most instances these problems cease within a few weeks after treatment concludes, and most patients report that the positive effects far outweigh the alternative – suffering from long-term, severe depression.11 Electroconvulsive therapy has special benefi t for suicidal patients, who may otherwise have carried out their self-harming impulses while waiting for medication therapy to take effect.

Other Therapeutic Interventions

Research into the treatment of depression and other mental disorders continues. Controversial drugs and therapies and their potential merits are sometimes slow to receive recognition from mental health professionals, who as scientists have stringent standards by which to evaluate a treatment’s effectiveness. However, these high standards also help to ensure that ineffective or harmful treatments are not endorsed for widespread use.

One promising experimental technique for treating depression is transcranial magnetic stimulation (TMS). This approach has been proposed as a new way to treat depression. TMS uses a high-intensity magnetic field briefly applied to the scalp to alter neuronal function in the area of the brain beneath. Although it is too early to fully establish its effectiveness as a treatment for depression, some early research has shown promise.12 Evidence that TMS is an effective treatment for depression would be a significant advance in the treatment of depression. Because TMS is less invasive than electroconvulsive therapy, and it has fewer side effects than ECT, it may be a good substitute for ECT for patients that do not respond to other interventions.
Other interventions often used in the treatment or prevention of depression include:

Exercise. Many recent research studies have shown that vigorous and regular exercise can significantly reduce depressive symptoms. Even moderate exercise can help, especially if symptoms are not severe.13

Social support. A primary symptom of depression is social withdrawal; a depressed person’s first instinct is to withdraw from others.14,15 Therefore, family, friends, and other social supports can make a big difference by helping buffer the depression-prone person from worse symptoms.

Involving those close to the depressed person. Better understanding and support for the depressed individual – and a better treatment outcome – will result if the person’s family and school are involved in the treatment process.

Changing negative thinking. A positive, optimistic outlook can help one become emotionally resilient in the face of disappointments and in many cases can help prevent the development of depression.

How Family and Friends Can Help

■ Encourage the depressed person to get help, even to the point that you make the appointment and accompany the person to the doctor or therapist.

■ Support the person emotionally. Don’t discount their feelings even if you think they are distorting reality. It is OK to point out the realities of the situation, while being sympathetic.

■ Listen rather than provide advice as much as possible.

■ Encourage the depressed individual to be around people and to be active, even inviting them along with you.

■ If the person brings up suicide or death, ask direct questions to find out more, or tell the person’s therapist, doctor, or family member right away. Don’t avoid talking about it because you find it difficult to discuss. Get the person to promise to not attempt suicide or if tempted to do so, to contact someone immediately.

■ Don’t push a depressed person too much beyond what they can accomplish. That can lead to more discouragement.

■ Don’t accuse a person with depression of being weak or tell them to just “snap out of it.” It doesn’t work that way, and they aren’t depressed because they aren’t trying hard enough.
■ Find help from professionals and ask their advice on how you can help.

How to Help a Friend: Advice for Young People5,16

■ Don’t assume that someone else is taking care of the problem if a friend or family member is depressed. Negative thinking, inappropriate behavior, or physical changes need to be reversed as quickly as possible. Early treatment may lessen the severity of depression, shorten the length of the illness, or reduce the risk of future reoccurrences.

■ If a friend shows signs of depression, listen and encourage him or her to ask a parent or teacher about treatment. If the friend doesn’t seek help quickly, talk to a trusted adult – especially if death or suicide is mentioned.

■ There are many places in the community where people with depressive disorders can be diagnosed and treated: a family medical clinic, or a private or community mental health center with mental health specialists or other health professionals.

If You are Depressed: Words of Wisdom5,17

■ Set realistic goals and don’t assume too much responsibility. Get help with some tasks until recovery is imminent.

■ Break down large tasks into smaller ones. Set priorities, concentrating on those things that need to be done the most.

■ Try to be around other people. Social withdrawal tends to worsen depression.

■ Participate in activities. Staying active can prevent a worsening of mood.

■ Do things that are fun, even if it does not seem as much fun as it used to. (Diminished capacity to experience pleasure, called anhedonia, is a common symptom of depression.) But don’t “fi x” bad moods with alcohol, drugs, or sex.

■ Exercise regularly. Research shows exercise can help reduce and prevent depression.
■ Be patient. Healing happens gradually over time.

■ Avoid important decisions while acutely depressed. Pessimism and negativity accompany depression, so one takes the chance of making a decision that could be regretted later.

■ Think positively. Be alert to overly negative thought patterns and put a stop to them. Try to substitute positive, realistic thoughts in their place.

■ Remember that depression can make one feel exhausted, worthless, helpless, and hopeless. Negative thoughts and feelings make some people feel like giving up. It is important to realize that these attitudes are caused by the depression and are not a true reflection of one’s actual circumstances. Negative thinking fades as treatment begins to take effect.

■ Avoid substance abuse: Abuse of substances such as alcohol, prescription medications, or illegal drugs can prevent recovery from depression or even worsen it.

■ Do relaxation exercises: Stress can lead to or aggravate depression so learning to relax is important for overall mental and physical health.

■ Identify organic and physiological causes of depression: Be aware that food allergies, heavy metals (lead, mercury, cadmium, arsenic, nickel, and aluminum), medical illnesses, or hormonal changes can cause depression, as well as certain prescription drugs, over-the-counter drugs, sleep deprivation and poor adrenal functioning.

■ Get help: If you suspect that you are suffering from depression, get help from a physician, a psychiatrist, or other mental health professional. Professional counseling can be very helpful in treating depression.

Good Nutrition is Important18,19

■ Avoid sugar: Sugar’s boost of energy can be quickly followed by fatigue and lower mood.

■ Avoid caffeine: Caffeine’s energy boost is short-lived with a negative aftermath similar to sugar.

■ Avoid alcohol: Alcohol interferes with the workings of the brain and actually is a depressive drug, disrupts sleep, and can lead to hypoglycemia, all of which increase the risk and the severity of depression.

■ Eat a low-fat diet: Fatty foods interfere with blood flow by blocking the arteries and blood vessels, which results in poor circulation of blood to the brain and throughout the body. This causes sluggishness, slow thinking, and feelings of fatigue even after having rested.

■ Eat fruits and veggies: Most fruits and vegetables are high in complex carbohydrates and bioflavonoids, both essential for maintenance of healthy levels of serotonin and other neurotransmitters, which are required for optimal brain functioning, which in turn helps ward off depression. Complex carbohydrates also help the body relax, reducing body stress.

■ Get plenty of protein: Protein meals that are high in essential fatty acids such as salmon and white fish increase alertness. Foods such as turkey and salmon, which contain both protein and tryptophan, are good for lifting the spirits.

References

1. Depression: National Institutes of Health Publication No. 00-3561. Available at: http://www.nimh.nih.gov. Accessed May 13, 2000.

2. Frank E, Karp JF, Rush AJ. Efficacy of treatments for major depression. Psychopharmacology Bulletin. 1993;29:457-75.

3. McCusker J, Cole M, Keller E, Bellavance F, Berard A. Effectiveness of treatments of depression in older ambulatory patients. Archives of Internal Medicine. 1998;158:705-12.

4. DeRubeis RJ, Amsterdam JD. Cognitive therapy vs. medications for severe depression: acute response and relapse prevention. Paper presented at: Annual meeting of the Association of the American Psychiatric Association; May, 2002.

5. DEPRESSION/Awareness, Recognition, and Treatment (D/ART). National Institute of Mental Health Public Inquiries website. Available at:www.nimh.nim.gov.org.

6. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Archives of General Psychiatry. 1989;46:971-982.

7. Evans MD, Hollon SD, DeRubeis RJ, et al. Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry, 1992;49:802–808.
8. Potter WZ, Rudorfer MV, Manji H. The pharmacologic treatment of depression. New England Journal of Medicine. 1991;325:633-642.

9. Vitiello B, Jensen P. Medication development and testing in children and adolescents. Archives of General Psychiatry. 1997;54:871-6.

10. Hypericum Depression Trial Study Group. Hypericum depression trial study group. Effect of Hypericum perforatum (St. John’s Wort) in major depressive disorder: a randomized, controlled trial. JAMA. 2002;287:1807-1814.

11. Potter WZ, Rudorfer MV. Electroconvulsive therapy: a modern medical procedure [editorial]. New England Journal of Medicine. 1993;328:882-883.

12. Berman RM, Narasimhan M, Sanacora G, et al. A randomized clinical trial of repetitive transcranial magnetic stimulation in the treatment of major depression. Biological Psychiatry. 2000:47:332-337.

13. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Archives of Internal Medicine. 1999;159(19):2349-56.

14. Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life: consensus statement update. Journal of the American Medical Association. 1997;278:1186-90.

15. Heller T, Roccoforte JA, Hsieh K, Cook JA, Pickett SA. Benefi ts of support groups for families of adults with severe mental illness. American Journal of Orthopsychiatry. 1997(suppl B67):187–198.

16. Jaycox L, Reivich K, Gillham J, Seligman ME. Prevention of depressive symptoms in school children. Behaviour Research and Therapy. 1994;32: 801–816.

17. Depression. Available at http://www.mayoclinic.com/invoke.cfm?id=DS00175.
Accessed September 13, 2003.

18. Depression and Nutrition. Available att:http://www.healingwell.com/library/depression/beardsley1.asp Accessed September 8, 2003.

19. What you need to know about depression. Available at: http://depression.about.com/cs/diet/. Accessed September 8, 2003.

Sponsored by the UAMS College of Medicine, Department of Psychiatry’s Partners in Behavioral Health Sciences program which is made possible by support from a Science Education Partnership Award (R25 RR15976) from the National Center for Research Resources at the National Institutes of Health. University of Arkansas, Board of Trustees © 2002. All rights reserved.