Depression, Suicide, ECT

CBT for Depression

Cognitive behavioral therapy (CBT) is an effective treatment for depression.

Generally speaking, persons with mild or moderate depression can benefit from CBT, even without taking medication.

Studies have demonstrated that CBT can be as effective as antidepressants in treating mild and moderate depression.

Studies have also demonstrated that a combination therapy of antidepressants and CBT can be effective in treating Major Depressive Disorder (MDD).

CBT theory supports that a person's mood is directly related to their thought patterns. Negative thoughts affect a person's mood, sense of self, behavior, and even physical state.

The goal of cognitive behavioral therapy is to help a person learn to recognize their negative thought patterns, assess how true they really are, and replace them with healthier ways of thinking.

In addition, therapists also help their patients change behavior patterns that are directly linked to their negative thinking. Negative thoughts and behaviors make a vulnerable person more susceptible to depression.

CBT seeks to change patterns of thought and behavior and thus impact mood.

CBT for depression focuses on: Cognitive restructuring (therapist and patient work together to change thinking

patterns) and behavioral activation( patients learn to overcome obstacles to participating in enjoyable activities).

The immediate present- what and how a person thinks more than why a person thinks that way.

Specific problems- problem behaviors and problem thinking are identified, prioritized, and specifically addressed.

Goal setting behavior-patients are asked to define goals for each session and long-term goals too.

Education- the use of structured learning experiences teach patients to monitor and write down their negative thoughts and images. The goal is to recognize how those thoughts and images affect their mood, behavior, and physical condition. Therapists also teach important coping skills, such as problem solving and scheduling pleasurable experiences.

Homework assignments- patients must take an active role in learning, both in the session and between sessions. Homework is assigned at every session, can be graded in the beginning, and the HW is reviewed reviewed at the start of the next session.

Using many different techniques, including Socratic questioning, role playing, imagery, guided discovery, and behavioral experiments. 

Cognitive Restructuring

Cognitive restructuring refers to the process of identifying and changing inaccurate negative thoughts that contribute to the development of depression.

This is done collaboratively between the patient and therapist, often in the form of a dialogue. EXAMPLE: a college student fails a math quiz and responds "That just proves I'm stupid.” The therapist might ask if that's really what the test means. In order to help the student recognize the inaccuracy of the response, the therapist could ask what the student's overall grade is in math. If the student answers, "It's a B," the therapist can then point out that his answer shows he's not stupid because he couldn't be stupid and get a B. Then together they can explore ways to reframe what the performance on the quiz actually says.

"I'm stupid” is an example of an automatic thought. Patients with depression may have automatic thoughts in response to certain situations. They're automatic in that they're spontaneous, negatively evaluative, and don't come out of deliberate thinking or logic. These are often underpinned by a negative or dysfunctional assumption that is guiding the way patients view themselves, the situation, or the world around them.

More examples of automatic thinking: Always thinking the worst is going to happen.

Someone can convince themselves that they are about to lose a job because the boss didn't talk to them that morning or heard an unsubstantiated rumor that his department was going to cut back.

Always putting the blame on oneself even when there is no involvement in something bad that happened. When someone does not return your call, you might blame it on the fact that you are not liked.

Exaggerating the negative aspects of something rather than the positive.

The goal in CBT is for the patient to recognize the negative thoughts and find a healthier way to view the situation.

The ultimate goal is to discover the underlying assumptions out of which those thoughts arise and evaluate them. Once the inaccuracy of the assumption becomes evident, the patient can replace that perspective with a more accurate one.

Between sessions, the patient should be asked to monitor and write down the negative thoughts in a journal and to evaluate the situations that bring the negative thoughts up. Eventually the patient learns how to do this on their own.

Behavioral Activation

Behavioral activation seeks to help patients engage more often in enjoyable activities and develop or improve problem-solving skills.

Inertia is a major problem for people with depression. One major symptom of depression is loss of interest in things that were once found enjoyable. A person with depression stops doing things because he or she thinks it's not worth the effort. But this only deepens the depression.

In CBT, the therapist helps the patient schedule enjoyable experiences, often with other people who can reinforce the enjoyment. Part of the process is looking at obstacles to taking part in that experience and deciding how to get past those obstacles by breaking the process down into smaller steps.

Patients are encouraged to keep a record of the experience, noting how they felt and what the specific circumstances were. If it didn't go as planned, the patient is encouraged to explore why and what might be done to change it. By taking action that moves toward a positive solution and goal, the patient moves farther from the inactivity that keeps them in the depression.

Format for sessions (about 50 minutes)

The session begins with a check on the patient's mood and symptoms.

Then the patient and therapist set an agenda for the meeting.

Next they revisit the previous session so they can link it to the new one.

Homework is reviewed and any problems and/or successes are discussed.

Now they turn to the agenda for the session- all issues may or may not be addressed.

New homework is set.The session ends with the therapist summarizing the

session and getting feedback from the patient.

Suicide

CBT is effective at helping suicidal patients reduce the risk of future ideation and intent.

Family therapy has also been shown to help improve outcomes for suicidal patients.

Family Therapy for Depression/suicide

Family and couples therapy approaches have been used for some time and have proved to be effective with patients suffering from depression. Many RCTs of marital and family therapy as a treatment for depression exist.

The main systemic approaches are: Structural Strategic Milan systemic Narrative Psychoeducational Behavioral

The Structural (Minuchin, 1974) approach states that families function particularly well when certain family structures prevail. These include hierarchies between the generations within a family, with semi-permeable boundaries permitting a sufficient flow of information up and down, for example between parents and their children. Structural family therapists intervene with the aim of making the family as stated above. Techniques include challenging directly absent or rigid boundaries, unbalancing the family equilibrium by temporarily joining with one member of the family against others or setting homework tasks designed to restore hierarchies. Family members are at times asked to enact problems in the session so that the stuck or pathological communications and interactions can be observed. This allows for the development of concrete interventions by the therapist.

Strategic systemic therapy (Haley, 1963; Watzlawick et al, 1974) is based on the hypothesis that the symptom is being maintained by behaviors that seek to suppress it. For example, a woman with depression and low self-esteem may elicit her partner's over-protectiveness, a solution that perpetuates the presenting problem. A strategic systemic therapist may reframe the woman's depression as being an unselfish act designed to protect her partner from his own depression and prescribe a ritual where for a week, on uneven days, the partner needs to experiment with talking about his own worries. Strategic therapists argue that once some changes are achieved in relation to the presenting symptom, a domino effect sets in, affecting other interactions and behaviors in the whole family and the larger system. The patient's perceived problem(s) are put into a different meaning that provides new perspectives and makes new behaviors possible.

The Milan systemic approach (Selvini Palazzoli et al, 1978) has been modified over the years, from its original paradoxical prescriptions to a great emphasis on a particular style of interviewing – circular and reflexive questioning (Selvini Palazzoli et al, 1980). This technique focuses on questioning the various family members' beliefs and perceptions regarding relationships. Asking each to comment and reflect on the answers given by the various family members creates feedback that changes the fabric of family interactions. The Milan team's commitment to positive connotation produced a non-blaming approach: the actions of all family members are in no way seen as negative but always as the best everyone can do under the circumstances – with the intentions being positive even if the outcome is not.

The social constructionist approach is based on the awareness that the reality that the therapist observes is invented, with perceptions being shaped by the therapist's own cultures and his/her implicit assumptions and beliefs. This approach is influencing many systemic therapists and has led to an examination of how language shapes problem perceptions and definitions. If the narratives in which clients story their experience – or have their experience storied by psychiatrists – do not fit these experiences, then significant aspects of their lived experience will contradict the dominant narrative and be experienced as problematic.

Systemic narrative therapists attempt to help families to generate and evolve new stories and ways of interpreting events to make sense of their experiences. Family and therapist together co-evolve or co-construct new ways of describing the individual and related family issues so that they no longer need to be viewed or experienced as problematic.

Brief solution-focused therapy ignores the problem saturated ways of talking, with the focus instead on the patterns of previous attempted solutions. The approach is based on the observation that symptoms and problems have a tendency to fluctuate. Concentrating on those times when a symptom, such as an anxiety state, is less or not present, allows the therapist to design therapeutic strategies around the exceptions, as they form the basis of the solution. The theory has it that by encouraging families to amplify the solution patterns of their lives, the problem patterns can be driven into the background.

Psychoeducational approaches combine behavioral interventions with structural techniques. Relatives are educated about the causes and course of their family member's psychiatric illness, as well as being taught about helpful and less helpful ways in which relatives can respond. The general aim of therapy is to reduce the emotional intensity in the family as well as the degree of physical proximity. The other important ingredients of this approach are regular relatives' groups – to share experiences and solutions – and family sessions.

Behavioral family and couple therapy views the family as a major health enhancing resource, with each member doing his/her very best to maximize pleasant events in the family unit and the immediate social environment. Specific behavioral change strategies, such as contingency contracting or operant conditioning, may be used. Concrete goals for change are targeted by both family and therapist, following an analysis of the observed or recounted family and couple interactions. The link between assessment and intervention tends to create a focus on readily observable behaviors. Communication training, is a behavioral intervention strategy with an initial emphasis on clear and direct expression of positive feelings, ideas and plans. Once some progress has been made, the focus shifts to the expression of negative feelings in a constructive manner so that problem resolution can be facilitated. The therapist may then adopt a structured problem-solving stance to encouraging family members to agree on the problems and goals; to brainstorm and list various possible solutions; to highlight advantages and disadvantages of each proposed solution and then to agree on choosing the optimal solution; to formulate a detailed implementation plan; and to review the efforts and results.

Attachment-bases family therapy for depressed adolescents (Diamond)

Attachment – Based Family Therapy for Depressed Adolescents” (Diamond, Siqueland, & Diamond, 2003)- The objective of ABFT is to create in the parents the notion that it is important for parents to have a strong and solid emotional connection with their teens to help them deal with their feelings of sadness.

Although many factors such as biology, cognitions, social skills, stressors, and parental psychopathology may contribute to the onset and maintenance of childhood depression, ABFT focuses on the interpersonal risks associated with depression. For example, parental depression, marital conflict, ineffective parenting practices, unmet attachment needs, loss, and negative parent-child interaction have repeatedly been associated with the etiology and reinforcement of depression (Asarnow et al., 1993; Harris et al., 1986; Cummings & Davis, 1994). One interpersonal view on depression proposes that adolescent depression may be associated with an adolescent’s failure to negotiate autonomy from parents while maintaining closeness and intimacy (Allen & Land, 1999; Powers & Welsh,1999). Attachment theory provides both a theoretical understanding of the attachment/autonomy task and provides direction for clinical intervention.

Having secure attachment during adolescence depends on three factors: 1) Maintaining open communication between parents and their children 2) Parents being accessible to their children 3) Parents providing protection and help if needed. Insecurely attached adolescents perceive the expression of negative feelings as unwelcome and unsafe,

which reinforces the negative schema of self and others, and thus makes them vulnerable to depression. Rather than appropriately seeking redress from interpersonal injustices, they act out destructively towards self and others. Consequently, adolescents express anger about these core attachment failures and restricted psychological autonomy indirectly through irritability and conflicts over day-to-day behavioral problems (e.g., chores, curfew, etc.).

Repairing Attachment Given the adolescent’s emerging cognitive capacity, conversation increasingly becomes the mechanism

through which attachment security is experienced and negotiated. ABFT model uses conversations directly about relational failures as the key mechanism for earning security. To repair attachments in the relationship between parent and child

Discussion of relational failures, helping adolescent discuss past and present family conflict with parent. Rather than avoiding assertions of psychological autonomy, adolescents are encouraged and coached to appropriately express core concerns and conflicts. For parents, these conversations help them differentiate between adolescents’ irritability and legitimate claims of injustice. In Hispanic families, parents might feel threatened as they might perceive open conversation with adolescents about legitimate claims of injustice as an attempt to challenge their authority as head of the family. Family therapists have to be attentive during session as to how parents interpret this kind of exchange with the intention of validating their feelings and making a reframe that allows parents to be more open and tolerant with their child. Parents must know that listening to what makes their youth feel frustrated about their relationship does not undermine their role as an authority or head of the family but for the contrary it allows the parents to gain a role of leader as they show that they are able to understand and calm their youth, helping to repair the attachment.

Repairing trust and reestablishing fairness between family members, promote the child’s autonomy. In family therapy, adolescents resolve interpersonal problems directly with parents rather than through the relationship with the therapist. A profound corrective experience with one’s caretakers may have the potency to alter interpersonal schemas about self and other.

The specific intervention around working on re-attachment should be implemented only after: Therapist has established rapport with adolescent Therapist has established an alliance with the parents Therapist has worked on some minimal level of teaching basic communication skills (e.g., listening skills) and

affective parenting skills (e.g., accepting strong emotions, empathic listening, validating, and labeling feelings). These skills help parents listen to their adolescent’s complaints, ask questions, be curious, and not become defensive or try ‘to fix’ things.

Re-Attachment Task With this foundation, the therapist initiates a conversation between family

members about the core relational failures. If the foundation is unstable, the therapist may postpone the enactment of this conversation. Alternatively, the conversation itself may solidify the foundation.

Therapist initiates a conversation between family members about core relational failures.

Therapist or parents encourages adolescent to express his or her grievances. If adolescents can maturely express claims of injustice, many parents

experience remorse and empathy. As adolescent feels acknowledged, feelings of anger and vengeance often

give way to sadness, fear, and disappointment. Parents may tell their side of the story, to create a moment of mutual

intimacy, not to defend parent or burden adolescent. Resolution of these conflicts may not directly reduce depression, but it

dissipates the tension and hostility that inhibits trust and communication and gives the family a positive experience of adolescent psychological autonomy.

Promoting Competency Task- Primary goals of this task include: increase quantity and quality of competency experiences decrease social isolation help parents become an effective resource for the adolescent

Therapist focuses his attention on behavioral changes inside and outside the home. Focusing on the resolution of current behavioral problems provides a context for using the newly found trust and mutual respect experienced in earlier sessions.

Therapist encourages parents to appropriately challenge and support the adolescent to become motivated and accountable. At the same time, therapist encourages adolescent to stop blaming their parents and accept greater responsibility. This task requires that therapist be attentive to interpersonal processes (e.g., how family members talk to each other) and behavioral goals (e.g., returning to school).

Therapist encourages discussion about normative activities (e.g., chores, curfews, dating, as well as problems related to school, drugs, and relationships).

Another important step in promoting competency is increasing social supports or resources.

Desired Outcome: Parents to become a safe and secure base to which the adolescent can turn for comfort, support, and guidance.

Group therapy for depression

Group therapy is useful in encouraging those suffering from depression to share their feelings with others, and learn from others new ways of coping with depression. Group therapy helps individual realize that they are not alone with their illness.

Group therapy goes beyond the benefits of individual therapy in that it fosters bonding between those suffering from depression. This may allow someone who is overly cautious in individual therapy to share more and to make more progress in treatment. A patient might not be able to open up to a therapist, but may be more ready to speak in the presence of others who have had the same experience. Many people who suffer from depression pursue group therapy in conjunction, or instead of, individual therapy.

Group therapy as a follow-up after inpatient treatment for depression is essential for the patient's feeling of normalcy and his or her ability to readjust to the world. Group therapy can also work well for mild and moderate forms of depression.

Yalom group therapy tenants

Yalom (1995) defined therapeutic factors as "the actual mechanisms of effecting change in the patient" (p. xi).

Yalom identified 11 factors that influence the

processes of change and recovery among group therapy clients.

11 Therapeutic Factors

Universality - feeling of having problems similar to others, not alone

Altruism - helping and supporting othersInstillation of hope - encouragement that

recovery is possibleGuidance - nurturing support & assistanceImparting information - teaching about problem

and recoveryDeveloping social skills - learning new ways to talk

about feelings, observations and concernsInterpersonal learning - finding out about

themselves & others from the group

Cohesion - feeling of belonging to the group, valuing the group

Catharsis – release of emotional tensionExistential factors – life & death are realitiesImitative behavior – modeling another’s

manners & recovery skillsCorrective recapitulation of family of origin

issues – identifying & changing the dysfunctional patterns or roles one played in primary family

Existential Factors - loneliness, death, meaning of human existence are issues common to all. Learn to accept responsibility, and provide their own direction

The Group Contract Goals and purpose of the group Location, time, and frequency Statement regarding addition of new members Attendance expectations Roles and responsibilities of group members Fee Confidentiality

Stages of group development

Orientation- Trust issues, superficial communication, getting to know one another, observe each other, need to feel safe

Working Phase- Active involvement and participation in working toward group’s goals, heart and soul of group treatment, understanding of themselves

Termination-Prepare for separation, review accomplishments, help each other prepare for the future

The group leader role:Self vs Group FocusHere & Now Focus VS There & ThenTrust VS Mistrust= self disclosureModeling w Co leader & GroupIncrease TrustAttend & listen

Nonverbal Empathy self disclosure respect

Specific groups for depression that can be used CBT group IPT group

Electroconvulsive therapy (ECT) is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure. Electroconvulsive therapy seems to cause changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful.

Much of the stigma attached to electroconvulsive therapy is based on early treatments in which high doses of electricity were administered without anesthesia, leading to memory loss, fractured bones and other serious side effects.

Electroconvulsive therapy is much safer today. Although electroconvulsive therapy still causes some side effects, it now uses electrical currents given in a controlled setting to achieve the most benefit with the fewest possible risks.

Electroconvulsive therapy (ECT) can provide rapid, significant improvements in severe symptoms of a number of mental health conditions. It may be an effective treatment in someone who is suicidal, for instance, or end an episode of severe mania.

ECT is used to treat: Severe depression, particularly when accompanied by detachment from reality

(psychosis), a desire to commit suicide or refusal to eat. Treatment-resistant depression, long-term depression that doesn't improve

with medications or other treatments. Schizophrenia, particularly when accompanied by psychosis, a desire to

commit suicide or hurt someone else, or refusal to eat. Severe mania, a state of intense euphoria, agitation or hyperactivity that

occurs as part of bipolar disorder. Other signs of mania include impaired decision making, impulsive or risky behavior, substance abuse and psychosis.

Catatonia, characterized by lack of movement, fast or strange movements, lack of speech, and other symptoms. It's associated with schizophrenia and some other psychiatric disorders. In some cases, catatonia is caused by a medical illness.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. They do not consciously feel the electrical impulse administered in ECT.

On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.

ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment.