This document discusses depression, including its definition, statistics, types, causes, consequences, role of neurotransmitters, treatment options like medication and cognitive behavioral therapy. It defines depression and differentiates it from normal sadness. It covers diagnostic criteria, risk factors, and treatments including antidepressant medications, electroconvulsive therapy, light therapy, and cognitive behavioral therapy. Relapse prevention and the importance of continued treatment are also discussed.

1. Depression:
What is it & What are my
Treatment Options?
Presented by:
Elizabeth Nikol, LCSW, ACT Dr. Lauren Kaplan-Sagal
Sr. Behavioral Health Clinician Psychiatrist
SMG Behavioral Health & Cognitive Therapy Center
January 12, 2012

2. Agenda
• What is Depression?
• Statistics
• Types of Depression
• Consequences of Depression
• The Neurotransmitter’s Role in Depression
• Medication Options
• The Role of Our Thoughts in Depression
• Cognitive Therapy
• Q&A

3. Statistics – National Institute of Mental Health
(NIMH) and the Center for Disease Control
(CDC)
• In a 12 month period, 9.5% of adults suffer with some form
of depression
• 45% of these are classified as severe
• Only 50% of these people seek treatment
• Ages 45 – 64 have the highest incidence, but average age of
onset is 30
• Women are more likely to suffer from some form of
depression
• Other risk factors: Less education, those previously
married, the unemployed.

4. Statistics: Robert Leahy, PhD
• 1 in 5 people will experience depression in their
lifetime
• 20% are still depressed two years after onset
• 59% of those with depression also suffer with
anxiety
• 24% have substance abuse disorders
• Depressed people are 30 times more likely to
commit suicide

5. What is Depression?
According to the American Psychiatric Association:
• Depressed mood or extreme sadness
• Loss of pleasure or interest in most things that you usually enjoy
• Significant weight loss or gain
• Difficulty sleeping (too much or too little)
• Feeling either restless or slowed down
• Being tired all the time
• Having feelings of worthlessness or guilt
• Difficulty thinking or concentrating
• Repeated thoughts of death or dying
(Needs to be for at least 2 weeks & nearly every day)

6. Difference between Sadness and
Depression
• Sadness lasts for a short period of time, whereas
depression can last for weeks or months at a time.
• Sadness usually does not impact a person’s ability to
function productively, whereas depression can.
• Sadness is often times realistic in thought pattern,
whereas depressed thoughts can be distorted and
unrealistic.
• Depression involves feelings of hopelessness and
helplessness.
• Depression is an illness.

7. Other Types of Depression
• Adjustment Disorder with Depressed Mood
• Bipolar I and II
• Postpartum Depression
• Dysthymia
• Cyclothymia
• Seasonal Affective Disorder
• Pre-menstrual Dysphoric Disorder

8. Why Does Someone Become
Depressed?
• Physical (Biochemical/Genetics)
• Behavioral
• Cognitive
• Situational or Environmental

9. Consequences of Depression
Higher rates of work absences and disability
Increase rate of disease and physical symptoms (i.e.
headaches, back pain, gastro issues, etc.)
Less productivity at work and home
Poor lifestyle choices
Relationship difficulties
Suicide

10. “So, you’re telling me I have a
chemical imbalance?”
3 Neurotransmitters Likely Involved in Depression
• Dopamine
• Serotonin
• Norepinephrine

12. Medications
• SSRI’s: Celexa, Lexapro,Prozac, Luvox, Paxil,
Zoloft
• SNRI’s: Effexor (Venlafaxine) , Pristique (also
Venlafaxine)
• Dopamine-Norepinephrine Reuptake Inhibitors:
Wellbutrin (Bupropion):

13. Medications
• Norepinephrine-serotonin modulator:
Mirtazapine (Remeron)
• MAOI’s: Phenelzine, Tranylcypromine,
Moclobemide
• Serotonin modulators: Trazadone

14. Medications
• Tricyclic Antidepressants (tertiary
amines/secondary amine/tetracyclics):
Amitriptyline, Clomipramine, Doxepin,
Imipramine, Trimipramine, Desipramine,
Nortriptyline, Protriptyline, Amoxapine,
Maprotiline
• Mood Stabilizers/Major Tranquilizers:
Risperdal, Abilify, Seroquel, Zyprexa,
Geodon

15. Electroconvulsive Therapy (ECT)
• Used to be called "electroshock" therapy
• Electrodes are placed to the head, and a seizure is
induced
• Causes change the brain chemistry and can relieve severe
depression symptoms
• Considered for patients with major depressive disorder
with a high degree of symptom severity (catatonia,
psychotic symptoms, etc) and functional impairment
• Also selected for emergence, such as a when someone is
refusing to eat, is nutritionally compromised or actively
suicidal and not responding to other
interventions.

16. Other interventions
• Bright Light Therapy: mostly used for SEASONAL
AFFECTIVE DISORDER, but is beginning to be
introduced in other forms of depression and for
those who are unable to tolerate medication for a
variety of reasons.
• Other treatments just starting to be used in research
settings or in specialty areas
– Vagus Nerve stimulation (VNS), approved for
intractible epilepsy and refractory depression
• Jury still out on how effective it is.
• Requires surgery for placement of the
device.

17. Other interventions (con’t)
• Transcranial Magnetic Stimulation (TMS)
– Uses transcranial pulsed magnetic fields
– No siezure, but molecular changes are suspected
to occur
– Jury is still out on this as well, but some people
are doing it
– Does not require surgery

18. Other Medical Conditions That
Mimic Depression – Need to Rule Out
• Thyroid condition
• Cardiac condition
• Certain Pancreatic conditions
• Anemia
• B12 or Folic Acid deficiency (certain vitamin
deficiency)
• Viral infections (eg. Lyme disease, Influenza post-
viral infection)

19. Criteria used to determine when
medication is needed
• Mild vs. Moderate vs. Severe Depression
• Psychosocial or interpersonal issues
• Previous response to medication (combination
necessary?)
• Effectiveness
• Side effects
• Risk of suicide

20. Most optimal
• The medications used and found to be most optimal for
most patients:
• SSRI’s (Prozac, Zoloft, Lexapro, Paxil)
• Buproprion (Wellbutrin)
• SNRI’s: Venlefaxine (Effexor, Pristique) or
Cymbalta
• Monoamine Oxidase Inhibitors (MAOI’s) are most
often restricted to patients who do not respond to other
treatments because of their potential for serious side
effects and the necessity for dietary restrictions

21. Possible Side Effects
• Cardiovascular
• Anticholinergic: (mostly from Tricyclics): Dry mouth,
constipation, urinary Hesitancy, visual changes, confusion,
sedation, weight gain, GI (nausea, vomiting, diarrhea),
insomnia
• Neurological: Myoclonus, Extrapyramidal (joint stiffness)
and TARDIVE DYSKINESIA— irreversible involuntary
muscle movement, seizures (Wellbutrin, amoxapine),
headaches
• Sexual side effects: arousal, erectile dysfunction, orgasm
dysfunction, Priapism (TRAZADONE)
• SEROTONIN SYNDROME: often dose related

22. Length of time for treatment
• After 4-8 weeks a patient should begin to notice
moderate improvement
• Once a patient is feeling the symptom that brought
the patient in for treatment, one counts 9-12
months from that day of treatment relief for the
possibility of tapering off the medication.
• If a person has more than one episode of Major
Depression, the recommendation is for that
individual to remain on medication to prevent
relapse and recurrence.

23. Risk Factors for Recurrence of Major
Depressive Disorder
• Prior History of multiple episodes of MDD
• Persistence of depression symptoms after
recovery of the episode
• Presence of additional psychiatric issues
(substance abuse, panic or anxiety disorders…)
• Presence of a chronic general medical condition

24. Other Conditions Requiring Psychiatric
Evaluation and Intervention
• Post-Partum Depression (and Peri-Partum Depression)
o A patient with a known diagnosis of depression
should, whenever possible, have a planned pregnancy
and in consultation with a Psychiatrist understand the
risks of being on medication while pregnant.
o If one can be off all medication prior to conception,
that should be done in consultation and with careful
monitoring throughout pregnancy.
o However, there are times when a woman may need to
be on medication while pregnant and all the
risks and fetal effects should be reviewed.

25. Therapeutic Interventions:
Cognitive Behavioral Therapy (CBT)
• Pioneers: Aaron Beck and Albert Ellis
• Negative thinking encourages and continues depression
and anxiety
• These thought processes help to engage self defeating
behaviors
• Together the therapist and patient work to evaluate
thinking, make changes where necessary and problems
solve
• New behaviors are created
• Effectiveness confirmed in numerous studies
• Short-term treatment

26. Negative Cognitions
• Self
• Others
• The future

27. Cognitive Distortions
• Emotional Reasoning
• Overgeneralization
• Arbitrary Inference
• All or Nothing Thinking
• Should statements
• Mind reading
• Fortune Telling
• Selective negative focus
• Disqualifying the Positive
• Catastrophizing
• Personalizing
• Labeling

28. Thought Record & Socratic Questions
• What evidence/facts do I have that supports my
thought?
• What evidence/facts do I have that counters my
thought?
• Alternative explanations?
• What are the advantages of thinking this way?
• What are the disadvantages of thinking
this way?

29. Thought Record & Socratic Questions
• What is the worst that could happen? Could I live
through it?
• What would I tell a friend with the same thought?
• Is this thought a cognitive distortion?
• What would I like to think instead?

30. Behavioral Activation
• Depressed people act depressed
• Few activities that are pleasurable or achievement
oriented
• Track activities for one week
• Score 1 – 10 for pleasure (P), achievement (A) and
depression (D)
• As pleasure and achievement go up, depression goes
down
• Activity scheduling

31. Mindfulness
• A way of experiencing the world based in Buddhist
tradition
• Fully aware
• Staying in the present moment
• Observing thoughts without judging them
• Actively change relationship to the thoughts
• Watch them come about and then actively move away
• Move away from doing and focus on being
• Experiential Exercise

32. Resources
• Mind Over Mood – Dennis Greenberger & Christine Padesky
• The New Feeling Good – David Burns, MD
• Beat the Blues Before They Beat You – Robert L. Leahy
• Overcoming Depression Once Step at a Time – Michael Addis &
Christopher Martell
• The Mindful Way Through Depression – Zindel Segal, Mark Williams,
John Teasdale & Jon Kabat-Zinn
• SMG Behavioral Health and Cognitive Therapy Center:
http://www.summitmedicalgroup.com/service/Behavioral-Health-and-
Cognitive-Therapy-Center/
• Academy of Cognitive Therapy website: http://www.academyofct.org
• Mindfulness Center of NJ: http://www.mindfulnessnj.com

33. For more information
• Visit http://www.summitmedicalgroup.com
• Call (908) 508-8909