One of your friends is clinical depressed. She asks you about the effectiveness of drug therapy versus psychotherapy. Using the information obtained from lecture notes and the text, What is your reasoned response? 

please see notes in the attachment

Chapter 7

Depressive and

Bipolar Disorders

How Common Is Unipolar Depression?

• Around 9% of adults in the U.S. suffer from
severe unipolar depression in any given year
– As many as 5% suffer from mild forms

• Around 19% of all adults experience unipolar
depression at some time in their lives

• The prevalence is similar in Canada, England,
France, and many other countries

• The rate of depression is higher among poor
people than wealthier people

What Are the Symptoms of Unipolar
Depression?

• Five main areas of functioning may be
affected:

Emotional
symptoms

• Feeling
“miserable,”
“empty,”
“humiliated”

• Experiencing
little
pleasure

Motivational
symptoms

• Lacking
drive,
initiative,
spontaneity

• Between 6%
and 15% of
those with
severe
depression
die by
suicide

Behavioral
symptoms

• Less active,
less
productive

Cognitive
symptoms

• Hold
negative
views of
themselves

• Blame
themselves
for
unfortunate
events

• Pessimistic

Physical
symptoms

• Headaches,
dizzy spells,
general pain

Symptoms may vary from person to person

Diagnosing Unipolar Depression

• Criteria 1: Major

depressive episode
– Marked by five or

more symptoms
lasting two or more
weeks

• In extreme cases,
symptoms are
psychotic, including

– Hallucinations
– Delusions

• Criteria 2: No
history of mania

Diagnosing Unipolar Depression

• Two diagnoses to consider:
– Major depressive disorder

• Criteria 1 and 2 are met
– Dysthymic disorder

• Symptoms are “mild but chronic”
– Depression is longer lasting but less disabling
– Consistent symptoms for at least two years

– When dysthymic disorder leads to major
depressive disorder, the sequence is called
“double depression”

What Causes Unipolar Depression?

• Stress may be a trigger for depression
– People with depression experience a greater

number of stressful life events during the month
just before the onset of their symptoms

– Some clinicians distinguish reactive (exogenous)
depression from endogenous depression, which
seems to be a response to internal factors

What Causes Unipolar Depression?
The Biological View

Genetic factors
• Family pedigree, twin, adoption, and

molecular biology gene studies suggest that
some people inherit a biological
predisposition
• Researchers have found that as many as

20% of relatives of those with depression
are themselves depressed, compared with
fewer than 10% of the general population

What Causes Unipolar Depression?
The Biological View

Genetic factors
• Twin studies demonstrate a strong genetic

component:
• Concordance rates for identical (MZ) twins = 46%
• Concordance rates for fraternal (DZ) twins = 20%

• Adoption studies also have implicated a genetic factor
in cases of severe unipolar depression

• Using techniques from the field of molecular biology,
researchers have found evidence that unipolar
depression may be tied to specific genes

What Causes Unipolar Depression?
The Biological View

Biochemical factors
• NTs: serotonin and norepinephrine
• In the 1950s, medications for high blood pressure were

found to cause depression
• Some lowered serotonin, others lowered norepinephrine

• The discovery of truly effective antidepressant medications,
which relieved depression by increasing either serotonin or
norepinephrine, confirmed the NT role

• Depression likely involves not just serotonin nor
norepinephrine… a complicated interaction is at work, and
other NTs may be involved

What Causes Unipolar Depression?
The Biological View

Biochemical factors
• Endocrine system / hormone release
• People with depression have been found to have

abnormal levels of cortisol
• Released by the adrenal glands during times of stress

• People with depression have been found to have
abnormal melatonin secretion
• “Dracula hormone”

• Other researchers are investigating deficiencies of
important proteins within neurons as tied to depression

What Causes Unipolar Depression?
The Biological View

Biochemical factors
• Model has produced much enthusiasm but has certain

limitations:
• Relies on analogue studies: depression-like symptoms

created in lab animals
• Do these symptoms correlate with human emotions?

• Measuring brain activity has been difficult and indirect
• Current studies using newer technology are

attempting to address this issue

What Causes Unipolar Depression?
The Biological View

Brain anatomy and brain circuits
• Biological researchers have determined that emotional

reactions of various kinds are tied to brain circuits
• These are networks of brain structures that work together,

triggering each other into action and producing a particular
kind of emotional reaction

• It appears that one circuit is tied to GAD, another to panic
disorder, and yet another to OCD

• Although research is far from complete, a circuit responsible
for unipolar depression has begun to emerge
• Likely brain areas in the circuit include the prefrontal cortex,

hippocampus, amygdala, and Brodmann Area 25

What Causes Unipolar Depression?
The Biological View

Immune System
• This system is the body’s network of activities

and cells that fight off bacteria and other
foreign invaders

• When stressed, the immune system may
become dysregulated, which some believe may
help produce depression
• Support for this explanation is circumstantial

but compelling

What Causes Unipolar Depression?
The Psychological Views

• Three main models:

Psychodynamic

model

• No strong
research
support

Behavioral
model

• Modest
research
support

Cognitive views

• Considerable
research
support

What Causes Unipolar Depression?
The Psychological Views

Psychodynamic view
• Link between depression and grief
• When a loved one dies, an unconscious process begins and the mourner

regresses to the oral stage and experiences introjection – a directing of
feelings for the loved one onto oneself
• For most people, introjection is temporary
• For some, grief worsens over time; if grief is severe and long-lasting,

depression results
• Those with oral stage issues (unmet or excessively met needs) are at

greater risk for developing depression
• Instead of actual loss, some people experience “symbolic” (or imagined) loss

instead
• Newer psychoanalysts (object relations theorists) propose that depression

results when people’s relationships leave them feeling unsafe and insecure

What Causes Unipolar Depression?
The Psychological Views

Psychodynamic view
• Strengths:
• Studies have offered general support for the

psychodynamic idea that depression may be
triggered by a major loss (e.g., anaclitic depression)

• Research supports the theory that early losses set
the stage for later depression

• Research also suggests that people whose childhood
needs were improperly met are more likely to
become depressed after experiencing a loss

What Causes Unipolar Depression?
The Psychological Views

Psychodynamic view
• Limitations:
• Early losses and inadequate parenting

sometimes lead to depression but may not
be typically responsible for development of
the disorder

• Many research findings are inconsistent
• Certain features of the model are nearly

impossible to test

What Causes Unipolar Depression?
The Psychological Views

Behavioral view
• Depression results from changes in rewards and

punishments people receive in their lives
• Lewinsohn suggests that the positive rewards in life

dwindle for some people, leading them to perform
fewer and fewer csonstructive behaviors, and they
spiral toward depression

• Research supports the relationship between the number
of rewards received and the presence or absence of
depression
• Social rewards are especially important

What Causes Unipolar Depression?
The Psychological Views

Behavioral view
• Strengths:
• Researchers have compiled significant data to

support this theory
• Limitations:
• Research has relied heavily on the self-reports of

depressed subjects
• Behavioral studies are largely correlational and do

not establish that decreases in rewards are the initial
cause of depression

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Two main theories:
• Negative thinking
• Learned helplessness

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Negative thinking
• Beck theorizes four interrelated cognitive components

combine to produce unipolar depression:
• Maladaptive attitudes
• Self-defeating attitudes are developed during

childhood
• Beck suggests that upsetting situations later in life

can trigger an extended round of negative thinking

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Negative thinking
• Depressed people also make errors in their thinking,

including:
• Arbitrary inferences
• Minimization of the positive and magnification of the

negative
• Depressed people also experience automatic thoughts
• A steady train of unpleasant thoughts that suggest

inadequacy and hopelessness

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Strengths:
• Many studies have produced evidence in support of Beck’s

explanation:
• High correlation between the level of depression and the

number of maladaptive attitudes held
• Both the cognitive triad and errors in logic are seen in

people with depression
• Automatic thinking has been linked to depression

• Limitations:
• Research fails to show that such cognitive patterns are the

cause and core of unipolar depression

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Learned helplessness
• This theory asserts that people become depressed when

they think that:
• They no longer have control over the reinforcements

(rewards and punishments) in their lives
• They themselves are responsible for this helpless state

• Theory is based on Seligman’s work with laboratory dogs
• There has been significant research support for this

model

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Learned helplessness
• Recent versions of the theory focus on attributions
• Internal attributions that are global and stable lead to greater

feelings of helplessness and possibly depression
• Example: “It’s all my fault” [internal]. “I ruin everything I

touch” [global] “and I always will” [stable].
• If people make other kinds of attributions, this reaction is

unlikely
• Example: “She had a role in this also” [external], “the way I’ve

behaved the past couple weeks blew this relationship”
[specific]. “I don’t know what got into me – I don’t usually
act like that” [unstable].

What Causes Unipolar Depression?
The Psychological Views

Cognitive views
• Learned helplessness
• Strengths:
• Hundreds of studies have supported the relationship

between styles of attribution, helplessness, and depression
• Limitations:
• Laboratory helplessness does not parallel depression in

every way
• Much of the research relies on animal subjects
• The attributional component of the theory raises particularly

difficult questions in terms of animal models of depression

What Causes Unipolar Depression?
The Sociocultural View

• Sociocultural theorists propose that unipolar
depression is greatly influenced by the social
context that surrounds people
– This belief is supported by the finding that

depression is often triggered by outside stressors
– There are two kinds of sociocultural views:

• The family-social perspective
• The multicultural perspective

What Causes Unipolar Depression?
The Sociocultural View

The Family-Social Perspective
• The connection between declining social rewards

and depression (as discussed by the behaviorists)
is a two-way street
• Depressed people often display social deficits

that make other people uncomfortable and may
cause them to avoid the depressed individuals

• This leads to decreased social contact and a
further deterioration of social skills

What Causes Unipolar Depression?
The Sociocultural View

The Family-Social Perspective
• Consistent with these findings, depression has been tied repeatedly

to the unavailability of social support such as that found in a happy
marriage
• People who are separated or divorced display three times the

depression rate of married or widowed persons and double the
rate of people who have never been married

• There also is a high correlation between level of marital conflict
and degree of sadness that is particularly strong among those
who are clinically depressed

• It also appears that people who are isolated and without intimacy
are particularly likely to become depressed in times of stress

What Causes Unipolar Depression?
The Sociocultural View

The Multicultural Perspective
• Two kinds of relationships have captured the interest

of multicultural theorists:
• Gender and depression
• A strong link exists between gender and depression
• Women cross-culturally are twice as likely as men

to receive a diagnosis of unipolar depression
• Women also appear to be younger, have more

frequent and longer-lasting bouts, and to respond
less successfully to treatment

What Causes Unipolar Depression?
The Sociocultural View

The Multicultural Perspective
• A variety of theories has been offered:
• The artifact theory holds that women and men

are equally prone to depression, but that
clinicians often fail to detect depression in men

• The hormone explanation holds that hormone
changes trigger depression in many women

• The life stress theory suggests that women in
our society experience more stress than men

What Causes Unipolar Depression?
The Sociocultural View

The Multicultural Perspective
• Two kinds of relationships have captured the interest of

multicultural theorists:
• Cultural background and depression
• Depression is a worldwide phenomenon, and certain

symptoms seem to be constant across all countries,
including sadness, joylessness, anxiety, tension, lack
of energy, loss of interest, and thoughts of suicide

• Beyond such core symptoms, research suggests that
the precise picture of depression varies from country
to country

What Causes Unipolar Depression?
The Sociocultural View

The Multicultural Perspective
• In addition, although overall depression rates are

similar, differences exist in specific populations
living under oppressive circumstances
• In a study of one Native American village,

lifetime risk was 37% among women, 19%
among men, and 28% overall

• These findings are thought to be the result of
economic and social pressures

Bipolar Disorders

• People with a bipolar disorder experience
both the lows of depression and the highs of
mania
– Many describe their lives as an emotional roller

coaster

What Are the Symptoms of Mania?

• Unlike those experiencing depression, people in a
state of mania typically experience dramatic and
inappropriate rises in mood

• Five main areas of functioning may be affected:

Emotional
symptoms

•Active,
powerful
emotions in
search of outlet

Motivational
symptoms

•Need for
constant
excitement,
involvement,
companionship

Behavioral
symptoms

•Very active –
move quickly;
talk loudly or
rapidly
•Flamboyance

is not
uncommon

Cognitive
symptoms

•Show poor
judgment or
planning
•May have

trouble
remaining
coherent or in
touch with
reality

Physical
symptoms

•High energy
level – often in
the presence of
little or no rest

Diagnosing Bipolar Disorders

• Criteria 1: Manic episode
– Three or more symptoms of mania lasting one

week or more
• In extreme cases, symptoms are psychotic

• Criteria 2: History of mania
– If currently experiencing hypomania or depression

Diagnosing Bipolar Disorders

• DSM-5 distinguishes two kinds of bipolar
disorder:
– Bipolar I disorder

• Full manic and major depressive

episodes

– Some experience an alternation of episodes
– Others have mixed episodes

– Bipolar II disorder
• Hypomanic episodes alternate with major depressive

episodes

Diagnosing Bipolar Disorders

• Without treatment, the mood episodes tend
to recur for people with either type of bipolar
disorder
– If people experience four or more episodes within

a one-year period, their disorder is further
classified as rapid cycling

Diagnosing Bipolar Disorders

• Regardless of particular pattern, individuals
with bipolar disorder tend to experience
depression more than mania over the years
– In most cases, depressive episodes occur three

times as often as manic ones, and last longer

Diagnosing Bipolar Disorders

• Between 1% and 2.6% of all adults in the world suffer
from a bipolar disorder at any given time, and as many
as 4% over the course of their lives
– Bipolar I seems to be a bit more common than Bipolar II

• The disorders are equally common in women and men
– Women may experience more depressive episodes and

fewer manic episodes than men and rapid cycling is more
common in women

• The disorders are more common among people with
low incomes than those with high incomes

Diagnosing Bipolar Disorders

• A final diagnostic option:
– When a person experiences numerous episodes of

hypomania and mild depressive symptoms, a
diagnosis of cyclothymic disorder is assigned

• Mild symptoms for two or more years, interrupted by
periods of normal mood

• Affects at least 0.4% of the population
• May eventually blossom into bipolar I or II disorder

What Causes Bipolar Disorders?

• Throughout the first half of the 20th century,
the search for the cause of bipolar disorders
made little progress

• More recently, biological research has
produced some promising clues
– These insights have come from research into NT

activity, ion activity, brain structure, and genetic
factors

What Causes Bipolar Disorders?

• Neurotransmitters
– After finding a relationship between low

norepinephrine and unipolar depression, early
researchers expected to find a link between high
norepinephrine levels and mania

• This theory is supported by some research studies;
bipolar disorders may be related to overactivity of
norepinephrine

What Causes Bipolar Disorders?

• Neurotransmitters
– Because serotonin activity often parallels

norepinephrine activity in unipolar depression,
theorists expected that mania would also be
related to high serotonin activity

• Although no relationship with high serotonin has been
found, bipolar disorder may be linked to low serotonin
activity, which seems contradictory…

What Causes Bipolar Disorders?

• Neurotransmitters
– This apparent contradiction is addressed by the

“permissive theory” about mood disorders:
• Low serotonin may “open the door” to a mood

disorder and permit norepinephrine activity to define
the particular form the disorder will take:

– Low serotonin + Low norepinephrine = Depression
– Low serotonin + High norepinephrine = Mania

What Causes Bipolar Disorders?

• Ion activity
– Ions, which are needed to send incoming

messages to nerve endings, may be improperly
transported through the cells of individuals with
bipolar disorder

– Some theorists believe that irregularities in the
transport of these ions may cause neurons to fire
too easily (mania) or to stubbornly resist firing
(depression)

• There is some research support for this theory

What Causes Bipolar Disorders?

• Brain structure
– Brain imaging and postmortem studies have

identified a number of abnormal brain structures
in people with bipolar disorder; in particular, the
basal ganglia and cerebellum among others

• It is not clear what role such structural abnormalities
play

What Causes Bipolar Disorders?

• Genetic factors
– Many theorists believe that people inherit a

biological predisposition to develop bipolar
disorders

• Family pedigree studies support this theory:
– Identical (MZ) twins = 40% likelihood
– Fraternal (DZ) twins and siblings = 5% to 10% likelihood
– General population = 1 to 2.6% likelihood

What Causes Bipolar Disorders?

• Genetic factors
– Researchers have conducted genetic linkage

studies to identify possible patterns of inheritance
– Other researchers are using techniques from

molecular biology to further examine genetic
patterns in large families

– Such wide-ranging findings suggest that a number
of genetic abnormalities probably combine to help
bring about bipolar disorders

Chapter 7
How Common Is Unipolar Depression?
• What Are the Symptoms of Unipolar Depression?

Diagnosing Unipolar Depression
Diagnosing Unipolar Depression
What Causes Unipolar Depression?

• What Causes Unipolar Depression? The Biological View

What Causes Unipolar Depression? The Biological View
What Causes Unipolar Depression? The Biological View
What Causes Unipolar Depression? The Biological View
What Causes Unipolar Depression? The Biological View
What Causes Unipolar Depression? The Biological View
What Causes Unipolar Depression? The Biological View

• What Causes Unipolar Depression? The Psychological Views

What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views
What Causes Unipolar Depression? The Psychological Views

• What Causes Unipolar Depression? The Sociocultural View

What Causes Unipolar Depression? The Sociocultural View
What Causes Unipolar Depression? The Sociocultural View
What Causes Unipolar Depression? The Sociocultural View
What Causes Unipolar Depression? The Sociocultural View
What Causes Unipolar Depression? The Sociocultural View
What Causes Unipolar Depression? The Sociocultural View
Bipolar Disorders
What Are the Symptoms of Mania?
Diagnosing Bipolar Disorders

• Slide Number 37

Diagnosing Bipolar Disorders
Diagnosing Bipolar Disorders
Diagnosing Bipolar Disorders
Diagnosing Bipolar Disorders
Diagnosing Bipolar Disorders
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?
What Causes Bipolar Disorders?

Treatmentsfor Unipolar
Depression
• Around half of persons with unipolar depression (major

depressive or dysthymic disorder) receive treatment from a
mental health professional each year
• In addition, many other people in therapy experience depressed

feelings as part of another disorder – thus, much of the therapy
being done today is for unipolar depression

Treatments for Unipolar
Depression
• A variety of treatment approaches are currently in widespread

use
• These can be divided into psychological, sociocultural, and

biological approaches

Treatments for Unipolar
Depression: Psychological
Approaches
• Psychological treatments used most often to combat unipolar

depression come from three main schools of thought:
• Psychodynamic – Widely used despite no strong research

evidence of its effectiveness
• Behavioral – Primarily used for mild or moderate depression but

practiced less than in past decades
• Cognitive – Has performed so well in research that it has a large

and growing clinical following

Treatments for Unipolar Depression

:
Psychological Approaches

Psychodynamic therapy
• Believing that unipolar depression results from

unconscious grief over real or imagined losses,
compounded by excessive dependence on other people,
psychodynamic therapists seek to bring these issues into
consciousness and work through them

• Psychodynamic therapists use the same basic procedures
for all psychological disorders:
• Free association
• Therapist interpretation
• Review of past events and feelings

Treatments for Unipolar Depression:
Psychological Approaches
Psychodynamic therapy
• Despite successful case reports, researchers have found that

long-term psychodynamic therapy is only occasionally helpful
in cases of unipolar depression

• Two features may be particularly limiting:
• Depressed clients may be too passive or weary to fully

participate in subtle therapy discussions
• Depressed clients may become discouraged and end

treatment too early when treatment is unable to provide
quick relief

• Short-term approaches have performed better than
traditional approaches

Treatments for Unipolar Depression:
Psychological Approaches

Behavioral therapy
• Most behavioral treatment for unipolar depression is

modeled after the interventions proposed by
Lewinsohn:
• Reintroduce clients to pleasurable activities and

events, often using a weekly schedule
• Appropriately reinforce their depressive and

nondepressive behaviors
• Use a contingency management approach

• Help them improve their social skills

Treatments for Unipolar Depression:
Psychological Approaches

Behavioral therapy
• The behavioral techniques seem to be of only

limited help when just one of them is applied
• When two or more of the techniques are

combined, behavioral treatment does seem to
reduce depressive symptoms, particularly if mild

• It is worth noting that Lewinsohn himself has
combined behavioral techniques with cognitive
strategies in recent years

Treatments for Unipolar Depression:
Psychological Approaches

Cognitive therapy
• Beck viewed unipolar depression as resulting from a

pattern of negative thinking that may be triggered
by current upsetting situations
• Maladaptive attitudes lead people to the

“cognitive triad”
• Repeatedly viewing oneself, the world, and the

future in negative ways
• These biased views combine with illogical thinking

to produce automatic thoughts

Treatments for Unipolar Depression:
Psychological Approaches

Cognitive therapy
• Beck’s cognitive therapy – which includes a number of

behavioral techniques – is designed to help clients
recognize and change their negative cognitive processes

• This approach follows four phases and usually lasts fewer
than 20 sessions

• Phases:
• Increasing activities and elevating mood
• Challenging automatic thoughts
• Identifying negative thinking and biases
• Changing primary attitudes

Treatments for Unipolar Depression:
Psychological Approaches

Cognitive therapy
• Over the past several decades, hundreds of studies have

shown that cognitive therapy helps unipolar depression
• Around 50%–60% of clients show a near-total

elimination of symptoms
• It is worth noting that a growing number of today’s

cognitive-behavior therapists disagree with Beck’s
proposition that individuals must fully disregard negative
cognitions
• These therapists guide clients to recognize and accept

their negative cognitions

Treatments for Unipolar Depression:
Sociocultural Approaches
• Theorists trace the causes of unipolar depression to the

broader social structure in which people live and to the roles
they are required to play

• Two groups of sociocultural treatments are now widely
applied – multicultural approaches and family-social
approaches

Mood Tracking
• Cognitive-behavioral and other therapists who work with

depressed clients often instruct the clients to keep track of
their mood changes—hour by hour, day by day—and to also
note the situations and thoughts that cause their moods to
change

• Mood tracking apps for smartphones are gaining in popularity
• Can you think of other uses, advantages, and disadvantages

that might result from the growing use of mood-tracking
apps?

Treatments for Unipolar Depression:
Sociocultural Approaches
• Multicultural treatments

• Culture-sensitive approaches increasingly are being combined
with traditional forms of psychotherapy to help maximize the
likelihood of minority clients overcoming their disorders

• It also appears that the medication needs of many depressed
minority clients are inadequately addressed

Treatments for Unipolar Depression:
Sociocultural Approaches
• Family-Social Treatments

• Interpersonal therapy (IPT)
• This model holds that four interpersonal problems may lead to

depression and must be addressed:
• Interpersonal loss
• Interpersonal role dispute
• Interpersonal role transition
• Interpersonal deficits

• Studies suggest that IPT is as effective as cognitive therapy for
treating depression

Treatments for Unipolar Depression:
Sociocultural Approaches
• Family-Social Treatments

• Couple therapy
• The main type of couple therapy is behavioral marital therapy (BMT)

• Focus is on developing specific communication and problem-solving skills
• If marriage is filled with conflict, BMT is as effective as other

therapies for reducing depression

Treatments for Unipolar
Depression: Biological Approaches
• Biological treatments can bring great relief to people with

unipolar depression
• Usually biological treatment means antidepressant drugs, but

for severely depressed individuals who do not respond to
other forms of treatment, it sometimes includes
electroconvulsive therapy or brain stimulation

Treatments for Unipolar
Depression: Biological Approaches
• Electroconvulsive therapy (ECT)

• One of the most controversial forms of treatment
• It is used frequently because it is an effective and fast-acting

intervention
• The procedure consists of targeted electrical stimulation to cause

a brain seizure
• The usual course of treatment is 6 to 12 sessions spaced over 2 to 4

weeks
• Treatment may be bilateral or unilateral

Treatments for Unipolar
Depression: Biological Approaches
• Electroconvulsive therapy (ECT)

• The discovery of the effectiveness of ECT was accidental and
based on a fallacious link between psychosis and epilepsy

• The procedure has been modified in recent years to reduce some
of the negative effects

• For example, patients are given muscle relaxants and anesthetics
before and during the procedure

• Patients generally report some memory loss

Treatments for Unipolar
Depression: Biological Approaches
• Electroconvulsive therapy (ECT)

• ECT is clearly effective in treating unipolar depression
• Studies find improvement in 60%–80% of patients

• The procedure seems particularly effective in cases of severe
depression with delusions, but it has been difficult to determine
why ECT works so well

• Although effective, the use of ECT has declined since the 1950s
because of the memory loss caused by the procedure, the
frightening nature of the procedure, and the emergence of
effective antidepressant drugs

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs

• In the 1950s, two kinds of drugs were found to reduce the
symptoms of depression:

• Monoamine oxidase inhibitors (MAO inhibitors)
• Tricyclics

• These drugs have been joined in recent years by a third group,
the second-generation antidepressants

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: MAO inhibitors

• Originally used to treat TB, doctors noticed that the medication
seemed to make patients happier

• The drug works biochemically by slowing down the body’s
production of MAO

• MAO breaks down norepinephrine
• MAO inhibitors stop this breakdown from occurring
• This leads to a rise in norepinephrine activity and a reduction in

depressive symptoms
• Approximately half of patients who take these drugs are helped by them

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: MAO inhibitors

• MAO inhibitors pose a potential danger
• People who take MAOIs experience a dangerous rise in blood

pressure if they eat foods containing tyramine (cheese, bananas,
wine)

• In recent years, a new MAO inhibitor in the form of a skin patch
has become available

• Dangerous food interactions do not appear to be as common a
problem with this kind of MAO inhibitor

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: Tricyclics

• In searching for medications for schizophrenia, researchers
discovered that imipramine relieved depressive symptoms

• Imipramine and related drugs are known as tricyclics because they
share a three-ring molecular structure

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: Tricyclics

• Hundreds of studies have found that depressed patients taking
tricyclics have improved much more than similar patients taking
placebos

• Drugs must be taken for at least 10 days before such improvement is
seen

• About 60%–65% of patients find symptom improvement

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: Tricyclics

• Most patients who immediately stop taking tricyclics upon relief
of symptoms relapse within one year

• Patients who take tricyclics for five additional months
(“continuation therapy”) have a significantly decreased risk of
relapse

• Patients who take antidepressant drugs for three or more years after
initial improvement (“maintenance therapy”) may reduce the risk
of relapse even more

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: Tricyclics

• Tricyclics are believed to reduce depression by affecting
neurotransmitter (NT) reuptake mechanisms

• To prevent an NT from remaining in the synapse too long, a pumplike
mechanism recaptures the NT and draws it back into the presynaptic
neuron

• The reuptake process appears to be too efficient in some people,
drawing in too much of the NT from the synapse

• This reduction in NT activity in the synapse is thought to result in
clinical depression

• Tricyclics block the reuptake process, thus increasing NT activity in
the synapse

Reuptake and Antidepressants

(Left) Soon after a neuron releases neurotransmitters such as norepinephrine or serotonin into
its synaptic space, it activates a pumplike reuptake mechanism to reabsorb excess
neurotransmitters. In depression, however, this reuptake process is too active, removing too
many neurotransmitters before they can bind to a
receiving neuron. (Right) Tricyclic and most second-generation antidepressant drugs block
this reuptake process, enabling norepinephrine or serotonin to remain in the synapse longer
and bind to the receiving neuron.

Treatments for Unipolar
Depression: Biological Approaches
• Antidepressant drugs: Tricyclics

• There is growing evidence that when tricyclics are ingested, they
initially slow down the activity of the neurons that use
norepinephrine and serotonin

• After a week or two, the neurons adapt to the drugs and go back
to releasing normal amounts of the NTs, and the reuptake
mechanism begins to have the desired effect

• Today, tricyclics are prescribed more often than MAO inhibitors
• They do not require dietary restrictions
• Some patients show higher rates of improvement

Treatments for Unipolar
Depression: Biological Approaches
• Second-generation antidepressants

• A third group of effective antidepressant drugs is structurally
different from the MAO inhibitors and tricyclics

• Most of the drugs in this group are labeled selective serotonin
reuptake inhibitors (SSRIs)

• These drugs increase serotonin activity specifically (no other NTs
are affected)

• This class includes fluoxetine (Prozac), sertraline (Zoloft), and
escitalopram (Lexapro)

• Selective norepinephrine reuptake inhibitors and serotonin-
norepinephrine reuptake inhibitors are also now available

Treatments for Unipolar
Depression: Biological Approaches
• Second-generation antidepressant drugs

• In effectiveness and speed of action of these drugs are on a par
with the tricyclics, yet their sales have skyrocketed

• Clinicians often prefer these drugs because it is harder to overdose
on them than on other kinds of antidepressants

• There are no dietary restrictions like there are with MAO inhibitors
• They have fewer side effects than the tricyclics

• These drugs may cause some undesired effects of their own,
including a reduction in sex drive

Treatments for Unipolar
Depression: Biological Approaches
• As effective as antidepressant drugs are, it is important to

recognize that they do not work for everyone
• Even the most successful of them fails to help at least 35 percent

of clients with depression

Treatments for Unipolar
Depression: Biological Approaches
• Brain stimulation

• In recent years, three additional biological approaches have been
developed:

• Vagus nerve stimulation
• Transcranial magnetic stimulation
• Deep brain stimulation

Treatments for Unipolar
Depression: Biological Approaches
• Vagus nerve stimulation

• Depression researchers surmised they might be able to stimulate
the brain by electrically stimulating the vagus nerve through the
use of a pulse generator implanted under the skin of the chest

• Research has found that the procedure brings significant relief to
as many as 40% of those with treatment-resistant depression

• As with ECT, researchers do not yet know precisely why this
technique reduces depression

Vagus Nerve Stimulation

Treatments for Unipolar
Depression: Biological Approaches
• Transcranial magnetic stimulation

• Another technique designed to stimulate the brain without the
undesired effects of ECT, TMS has been found to reduce
depression when administered daily for 2 to 4 weeks

• Deep brain stimulation
• Theorizing a “depression switch” located deep within the

brain, researchers have successfully experimented with electrode
implantation in the brain’s Brodman Area 25

Treatments for Unipolar
Depression: Biological Approaches
• Brain stimulation

• While such positive initial findings have produced considerable
enthusiasm in the clinical field, it is important to recognize and
remember that, in the past, certain promising interventions (e.g.,
lobotomies) later proved problematic and even dangerous upon
closer inspection

How Do the Treatments for
Unipolar Depression Compare?
• For most kinds of psychological disorders, no more than one

or two treatments, if any, emerge as highly successful
• Unipolar depression seems to be an exception, responding to any

of several approaches

How Do the Treatments for
Unipolar Depression Compare?
• Findings from a number of treatment outcome studies suggest

that:
• Cognitive, cognitive-behavioral, interpersonal, and biological

therapies are all highly effective treatments for mild to severe
unipolar depression

• Although cognitive, cognitive-behavioral, and interpersonal
therapies may lower the likelihood of relapse, they are hardly
relapse-proof

How Do the Treatments for
Unipolar Depression Compare?
• Findings from a number of treatment outcome studies suggest

that:
• When people with unipolar depression experience significant

marital discord, couple therapy tends to be very helpful
• Depressed people who receive strictly behavioral therapy have

shown less improvement than those who receive cognitive,
cognitive-behavioral, interpersonal, or biological therapy

How Do the Treatments for
Unipolar Depression Compare?
• Findings from a number of treatment outcome studies suggest

that:
• Traditional psychodynamic therapies are less effective than other

therapies in treating all levels of unipolar depression
• A combination of psychotherapy and drug therapy is modestly

more helpful to depressed people than either treatment alone

How Do the Treatments for
Unipolar Depression Compare?
• Findings from a number of treatment outcome studies suggest

that:
• These various trends do not always carry over to the treatment of

depressed children and adolescents
• Among biological treatments, ECT appears to be somewhat more

effective than antidepressant drugs and ECT seems to act more
quickly

• In addition, the newly developed brain stimulation treatments
seem helpful for some severely depressed individuals who have
been repeatedly unresponsive to drug therapy, ECT, or
psychotherapy

Treatments for Bipolar
Disorder
• Until the latter part of the 20th century, people with bipolar

disorders were destined to spend their lives on an emotional
roller coaster
• Psychotherapists reported almost no success
• Antidepressant drugs were of limited help

• These drugs sometimes triggered manic episodes
• ECT only occasionally relieved either the depressive or the manic

episodes of bipolar disorder

Treatments for Bipolar Disorder

:
Lithium and Other Mood Stabilizers
• The use of lithium (a metallic element naturally occurring as

mineral salt) and other mood-stabilizers has dramatically
changed this picture
• Lithium is extraordinarily effective in treating bipolar disorders

and mania
• Determining the correct dosage for a given patient is a delicate

process
• Too low = no effect
• Too high = lithium intoxication (poisoning)

• Given the effectiveness, around one-third of all persons with
bipolar disorder seek treatment in a given year; another 15% are
monitored by family physicians

Treatments for Bipolar Disorder:
Lithium and Other Mood Stabilizers
• All manner of research has attested to the effectiveness of

lithium and other mood stabilizers in treating manic episodes
• More than 60% of patients with mania improve on these

medications
• Most individuals experience fewer new episodes while on the

drug
• Findings suggest that the mood stabilizers are also prophylactic

drugs, ones that actually help prevent symptoms from developing
• Mood stabilizers also help those with bipolar disorder overcome

their depressive episodes to a lesser degree

Treatments for Bipolar Disorder:
Lithium and Other Mood Stabilizers
• Researchers do not fully understand how mood stabilizing

drugs operate
• They suspect that the drugs change synaptic activity in neurons,

but in a different way from that of antidepressant drugs
• Although antidepressant drugs affect a neuron’s initial reception on

NTs, mood stabilizers seem to affect a neuron’s second messengers
• These drugs also increase the production of neuroprotective

proteins, which may decrease bipolar symptoms
• Another theory is that mood stabilizers correct bipolar

functioning by directly changing sodium and potassium ion
activity in neurons

Treatments for Bipolar Disorder:
Adjunctive Psychotherapy
• Psychotherapy alone is rarely helpful for persons with bipolar

disorder
• Mood stabilizing drugs alone are also not always sufficient

• 30% or more of patients don’t respond, may not receive the
correct dose, and/or may relapse while taking it

• As a result, clinicians often use psychotherapy as an adjunct to
lithium (or other medication-based) therapy

Treatments for Bipolar Disorder:
Adjunctive Psychotherapy
• Therapy focuses on medication management, social skills, and

relationship issues
• Few controlled studies have tested the effectiveness of such

adjunctive therapy
• Growing research suggests that it helps reduce hospitalization,

improves social functioning, and increases clients’ ability to
obtain and hold a job

Treatments for Unipolar Depression
Treatments for Unipolar Depression
• Treatments for Unipolar Depression: Psychological Approaches

Treatments for Unipolar Depression: Psychological Approaches
Treatments for Unipolar Depression: Psychological Approaches
Treatments for Unipolar Depression: Psychological Approaches
Treatments for Unipolar Depression: Psychological Approaches
Treatments for Unipolar Depression: Psychological Approaches
Treatments for Unipolar Depression: Psychological Approaches
Treatments for Unipolar Depression: Psychological Approaches

• Treatments for Unipolar Depression: Sociocultural Approaches
• Mood Tracking

Treatments for Unipolar Depression: Sociocultural Approaches
Treatments for Unipolar Depression: Sociocultural Approaches
Treatments for Unipolar Depression: Sociocultural Approaches

• Treatments for Unipolar Depression: Biological Approaches

Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Reuptake and Antidepressants
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches
Vagus Nerve Stimulation
Treatments for Unipolar Depression: Biological Approaches
Treatments for Unipolar Depression: Biological Approaches

• How Do the Treatments for Unipolar Depression Compare?

How Do the Treatments for Unipolar Depression Compare?
How Do the Treatments for Unipolar Depression Compare?
How Do the Treatments for Unipolar Depression Compare?
How Do the Treatments for Unipolar Depression Compare?
Treatments for Bipolar Disorder

• Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers

Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers
Treatments for Bipolar Disorder: Lithium and Other Mood Stabilizers

• Treatments for Bipolar Disorder: Adjunctive Psychotherapy

Treatments for Bipolar Disorder: Adjunctive Psychotherapy