Is Anti-Depressant Is Anti-Depressant Medication Always Medication Always

Necessary For Treating Necessary For Treating Major Depression Major Depression

Disorder? Disorder? 

Emily MurrayEmily Murray

100059361100059361

Depression Defined:Depression Defined:

Depression is a normal reaction to grievous Depression is a normal reaction to grievous loss. However, when depression is loss. However, when depression is excessive, disruptive, and recurring, it is excessive, disruptive, and recurring, it is classified as a psychiatric disorder (Pinel, classified as a psychiatric disorder (Pinel, 2003)2003)

Depression as a disorder is sometimes Depression as a disorder is sometimes characterized by symptoms such as characterized by symptoms such as persistent feelings of hopelessness, persistent feelings of hopelessness, dejection, poor concentration, lack of dejection, poor concentration, lack of energy, inability to sleep, and, sometimes, energy, inability to sleep, and, sometimes, suicidal tendencies (Mash & Wolfe, 2005)suicidal tendencies (Mash & Wolfe, 2005)

The Main Features of the DSM-The Main Features of the DSM-IV-TR Diagnostic Criteria for IV-TR Diagnostic Criteria for Major Depressive EpisodeMajor Depressive Episode

Five or more of the following symptoms listed below Five or more of the following symptoms listed below be present during the same 2-week period and be present during the same 2-week period and represent a change from previous functioning; at represent a change from previous functioning; at least one symptom is either (1) depressed mood or least one symptom is either (1) depressed mood or (2) loss of interest or pleasure (Mash & Wolfe, (2) loss of interest or pleasure (Mash & Wolfe, 2005):2005):

(1) Depressed mood most of the day, nearly every day, (1) Depressed mood most of the day, nearly every day, as indicated by subjective account or observations by as indicated by subjective account or observations by otherother

(2) Markedly diminished interest or pleasure in all, or (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as almost all, activities most of the day, nearly every day (as indicated by subjective account or observations by indicated by subjective account or observations by others)others)

(3) Significant weight loss when not dieting or weight (3) Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every daygain, or decrease or increase in appetite nearly every day

(4) Insomnia or hypersomnia nearly every day(4) Insomnia or hypersomnia nearly every day

DSM-IV-TR Criteria Cont’d.DSM-IV-TR Criteria Cont’d. (5) Psychomotor agitation or retardation nearly (5) Psychomotor agitation or retardation nearly

every day (observable by others, not merely every day (observable by others, not merely subjective feelings of restlessness or being slowed subjective feelings of restlessness or being slowed down)down)

(6) Fatigue or loss of energy nearly every day(6) Fatigue or loss of energy nearly every day (7) Feelings of worthlessness or excessive or (7) Feelings of worthlessness or excessive or

inappropriate guilt (which may be delusional) nearly inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about every day (not merely self-reproach or guilt about being sick)being sick)

(8) Diminished ability to think or concentrate, or (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by indecisiveness, nearly every day (either by subjective account or as observed by others)subjective account or as observed by others)

(9) Recurrent thoughts of death (not just fear of (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for plan, or a suicide attempt or a specific plan for committing suicidecommitting suicide

Prevalence of the DisorderPrevalence of the Disorder Depression is now ten times more likely to occur in Depression is now ten times more likely to occur in

individuals than it was in 1960 (Paradise & Kirby, individuals than it was in 1960 (Paradise & Kirby, 2005)2005)

It is estimated that as much as 10% of the It is estimated that as much as 10% of the population may suffer from this disorder and that it population may suffer from this disorder and that it may be the most prevalent problem that is facing may be the most prevalent problem that is facing counselors today (Paradise & Kirby, 2005)counselors today (Paradise & Kirby, 2005)

Research suggests that depression is the most Research suggests that depression is the most common disorder experienced by people who see common disorder experienced by people who see mental health practitioners and that from one third mental health practitioners and that from one third to more than 60% of mental health professions to more than 60% of mental health professions had reported a significant episode of depression had reported a significant episode of depression within the previous year (Paradise & Kirby, 2005)within the previous year (Paradise & Kirby, 2005)

Different Therapies for Treating Different Therapies for Treating the Disorderthe Disorder

Paradise & Kirby (2005) identified the Paradise & Kirby (2005) identified the most widely used approaches to most widely used approaches to treating depression:treating depression: Psychodynamic therapyPsychodynamic therapy Interpersonal psychotherapyInterpersonal psychotherapy Cognitive behavior therapyCognitive behavior therapy Marital and family therapyMarital and family therapy Antidepressant medication therapyAntidepressant medication therapy

The Current DebateThe Current Debate

Is anti-depressant medication always Is anti-depressant medication always necessary when treating individuals necessary when treating individuals who are suffering from major who are suffering from major depression disorder?depression disorder?

Background History to the Background History to the DebateDebate

The complexities of the debate between The complexities of the debate between psychotherapy and psychopharmacology psychotherapy and psychopharmacology stem from a historical conflict between stem from a historical conflict between the advocates of the two approaches. the advocates of the two approaches. The earliest advances in biological The earliest advances in biological psychiatry challenged the unquestioned psychiatry challenged the unquestioned dominance of psychoanalysis, which dominance of psychoanalysis, which provoked the both sides of the debate to provoked the both sides of the debate to trivialize, if not demonize each other. trivialize, if not demonize each other. (Winston, Been, & Serby, 2005)(Winston, Been, & Serby, 2005)

How Antidepressants Work:How Antidepressants Work: The serotonin transporter is the molecular The serotonin transporter is the molecular

target of many antidepressants, and the target of many antidepressants, and the gene (SLC6A4) encoding this protein has gene (SLC6A4) encoding this protein has been associated with response to selective been associated with response to selective serotonin reuptake inhibitors (SSRIs) (Kraft, serotonin reuptake inhibitors (SSRIs) (Kraft, Slager, McGrath, & Hamilton, 2005)Slager, McGrath, & Hamilton, 2005)

There are four types of antidepressant drugs:There are four types of antidepressant drugs: Monoamine Oxidase InhibitorsMonoamine Oxidase Inhibitors

• Monoamine agonist that increases the levels of amines Monoamine agonist that increases the levels of amines by inhibiting the activity of monoamine oxidase (MAO), by inhibiting the activity of monoamine oxidase (MAO), the enzyme that has been found to break down the enzyme that has been found to break down monoamine neurotransmitters in the cytoplasm of the monoamine neurotransmitters in the cytoplasm of the neuron (Pinel, 2003)neuron (Pinel, 2003)

Tricyclic antidepressantsTricyclic antidepressants• Block the reuptake of both serotonin and nor Block the reuptake of both serotonin and nor

epinephrine, thus increasing their levels in the brain epinephrine, thus increasing their levels in the brain (Pinel, 2003)(Pinel, 2003)

How Antidepressants WorkHow Antidepressants Work

LithiumLithium• Therapeutic effects are thought to be Therapeutic effects are thought to be

mediated by its agonistic effects on mediated by its agonistic effects on serotonin function (Pinel, 2003)serotonin function (Pinel, 2003)

Selective monoamine-reuptake Selective monoamine-reuptake inhibitorsinhibitors• Exert agonistic effects on serotonergic Exert agonistic effects on serotonergic

transmission by blocking the reuptake of transmission by blocking the reuptake of serotonin from synapses (Pinel, 2003)serotonin from synapses (Pinel, 2003)

Those For Antidepressant Those For Antidepressant Medication TherapyMedication Therapy

Biological cause: That depression is due to Biological cause: That depression is due to biological factors biological factors Mainly that there is an insufficient Mainly that there is an insufficient

amount of serotonin in the individual’s amount of serotonin in the individual’s synapses which decreases the nor synapses which decreases the nor epinephrine levels, which results in epinephrine levels, which results in depression.depression.

Research Findings Supporting Research Findings Supporting the Use of Antidepressant the Use of Antidepressant

Medication TherapyMedication Therapy• As noted by Paradise & Kirby (2005), reasons to use As noted by Paradise & Kirby (2005), reasons to use

antidepressant medication as a form of therapy for antidepressant medication as a form of therapy for depression include:depression include:

• their clear effectiveness to treat the disordertheir clear effectiveness to treat the disorder• how the drugs provide a measure of protection against relapse how the drugs provide a measure of protection against relapse

as long as the user continues to take the medication as was as long as the user continues to take the medication as was prescribedprescribed

• An approximate fifty percent response rate to the medicationAn approximate fifty percent response rate to the medication• Psychodynamic therapy lacks the adequate empirical evidence Psychodynamic therapy lacks the adequate empirical evidence

of its efficacyof its efficacy• Its results are just slightly better than those of placebo medicationsIts results are just slightly better than those of placebo medications

According to Kraft, Slager, McGrath, & Hamilton (2005) According to Kraft, Slager, McGrath, & Hamilton (2005) selective serotonin reuptake inhibitors (SSRIs) are effective selective serotonin reuptake inhibitors (SSRIs) are effective medications for MDD and are the most widely prescribed medications for MDD and are the most widely prescribed antidepressants worldwideantidepressants worldwide

Those Against Antidepressant Those Against Antidepressant Medication TherapyMedication Therapy

Believe that there are other ways to treat depression Believe that there are other ways to treat depression and that depression is not always caused by biological and that depression is not always caused by biological factorsfactors

Past research has found that:Past research has found that: Interpersonal psychotherapy has demonstrated its Interpersonal psychotherapy has demonstrated its

effectiveness as a treatment for major depression. In effectiveness as a treatment for major depression. In comparison studies it has shown it is as effective as comparison studies it has shown it is as effective as medication approaches (Paradise & Kirby, 2005).medication approaches (Paradise & Kirby, 2005).

The overall effectiveness of psychotherapy with The overall effectiveness of psychotherapy with depressed children and adolescents has been depressed children and adolescents has been supported in at least three recent meta-analytic supported in at least three recent meta-analytic reviews (Michael, Huelsman, & Crowley, 2005)reviews (Michael, Huelsman, & Crowley, 2005)

Winston, Been & Serby (2005) attested that all Winston, Been & Serby (2005) attested that all practitioners need to recognize and acknowledge practitioners need to recognize and acknowledge those cases that do not progress in therapy and may those cases that do not progress in therapy and may respond well to drugs as well as those patients who respond well to drugs as well as those patients who may improve through a “talking cure” without the may improve through a “talking cure” without the use of psychotropicsuse of psychotropics

Those Against, cont’d.Those Against, cont’d. Most clinicians recognize that many Most clinicians recognize that many

patients require both drug treatment and patients require both drug treatment and psychotherapy as in the studies reviewed psychotherapy as in the studies reviewed by Winston, Been & Serby (2005) where it by Winston, Been & Serby (2005) where it appears to indicate that a combined appears to indicate that a combined approach of medication and approach of medication and psychotherapy is most advantageous for psychotherapy is most advantageous for severe, recurrent depression; chronic severe, recurrent depression; chronic depression; and depression in the elderly. depression; and depression in the elderly. For other types of depression, For other types of depression, combination treatment may not be better combination treatment may not be better at reducing depressive symptoms but at reducing depressive symptoms but may have a broader effect, particularly on may have a broader effect, particularly on social adjustmentsocial adjustment

Those Against, cont’d.Those Against, cont’d. Ethical issueEthical issue The downside to medication:The downside to medication:

Discontinued use does not protect one against relapse Discontinued use does not protect one against relapse (Paradise & Kirby, 2005)(Paradise & Kirby, 2005)

Motivation, bad side effects, cost, and so on, all Motivation, bad side effects, cost, and so on, all contribute to negative outcomes over time (Paradise & contribute to negative outcomes over time (Paradise & Kirby, 2005)Kirby, 2005)• Side effects for these medications include insomnia, Side effects for these medications include insomnia,

nausea, vomiting, tremors, and memory impairment, nausea, vomiting, tremors, and memory impairment, to name just a few (Paradise & Kirby, 2005)to name just a few (Paradise & Kirby, 2005)

Graduate WorkGraduate Work

Dr. Peter HorvathDr. Peter Horvath Acadia UniversityAcadia University Personality and DepressionPersonality and Depression

Dr. Kate L. HarknessDr. Kate L. Harkness Queen’s UniversityQueen’s University Etiology and pathology of major depression in adolescents Etiology and pathology of major depression in adolescents

and adults. and adults. Dr. Peter McleodDr. Peter Mcleod

Acadia UniversityAcadia University Depression, Anxiety, Stress, & Coping; The Psychology of Depression, Anxiety, Stress, & Coping; The Psychology of

ControlControl Dr. David ZuroffDr. David Zuroff

McGill UniversityMcGill University Relations between personality, especially dependency and Relations between personality, especially dependency and

self-criticism, and psychopathology, especially depression.self-criticism, and psychopathology, especially depression.

QuestionQuestion

Do you believe that medication Do you believe that medication should be used to treat individuals should be used to treat individuals with depression?with depression?

ReferencesReferencesKraft, J.B., Slager, S.L., McGrath, P.J., & Hamilton, S.P. (2005). Kraft, J.B., Slager, S.L., McGrath, P.J., & Hamilton, S.P. (2005).

Sequence analysis of the serotonin transporter and Sequence analysis of the serotonin transporter and associations with antidepressant response.associations with antidepressant response. Biol Psychiatry, 58, Biol Psychiatry, 58, 374-381.374-381.

Mash, E.J., & Wolfe, D.A. (2005). Mood Disorders. In E.J. Mash & Mash, E.J., & Wolfe, D.A. (2005). Mood Disorders. In E.J. Mash & D.A. Wolfe, D.A. Wolfe, Abnormal Child Psychology Abnormal Child Psychology (3(3rdrd ed., pp. 224-225). ed., pp. 224-225). Toronto: Thomson Wadsworth.Toronto: Thomson Wadsworth.

Michael, K.D., Heulsman, T.J., & Crowley, S.L. (2005). Michael, K.D., Heulsman, T.J., & Crowley, S.L. (2005). Interventions for child and adolescent depression: do Interventions for child and adolescent depression: do professional therapists produce better results? professional therapists produce better results? Journal of Child Journal of Child and Family Studies, 14and Family Studies, 14(2), 223-236.(2), 223-236.

Pinel, J.P.J. (2003). Affective Disorders: Depression and Mania. In Pinel, J.P.J. (2003). Affective Disorders: Depression and Mania. In J.P.J. Pinel, J.P.J. Pinel, BiopsychologyBiopsychology (5 (5thth ed., pp. 468-469). The United ed., pp. 468-469). The United States of America: Allyn and Bacon.States of America: Allyn and Bacon.

Paradise, L.V., & Kirby, P.C. (2005). The Treatment andParadise, L.V., & Kirby, P.C. (2005). The Treatment andPrevention of Depression: Implications for Counseling and Prevention of Depression: Implications for Counseling and Counselor Training. Counselor Training. Journal of Counseling and Development, Journal of Counseling and Development, 8383, 116-119. , 116-119.

Winston, A., Been, H., & Serby, M. (2005). Psychotherapy and Winston, A., Been, H., & Serby, M. (2005). Psychotherapy and psychopharmacology: different universes or an integrated psychopharmacology: different universes or an integrated future? future? Journal of Psychology Integration, 15Journal of Psychology Integration, 15(2), 213-223. (2), 213-223.

http://hawthorne.mfriends.org/faculty/Biology/cmb-2000/cmb-http://hawthorne.mfriends.org/faculty/Biology/cmb-2000/cmb-kd/Biochemical Causes.htm (Retrieved on October 15, 2005).kd/Biochemical Causes.htm (Retrieved on October 15, 2005).