The WHO recommends the following management plan when treating a client with a depressive disorder. It's important to remember that every individual is unique and their needs will differ, however the following provides a general structure typically followed by health care professionals:
1. Conduct a thorough medical and psychiatric assessment, including assessments of an individual's risk of harm.
2. Eliminate depressed mood and depressive features through:
• physical treatments and/or
3. Provide education and support for the clients and family
4. Reduce residual problems using strategies such as:
• structured problem solving
• improving sleep
• increasing activity
• improving eating habits
• relaxation therapy
• improving communication and self-confidence
5. Relapse Prevention
There are many treatment options available for the treatment of depression. Beyond Blue have released an excellent resource called A Guide to What Works for Depression which highlights several of the most supported physical and psychological treatments. This is a short-list of some of those of which we plan to provide more detailed information in future articles.
• Antidepressant medications
• Antipsychotic medications
• Electroconvulsive Therapy (ECT)
• Acceptance and Commitment Therapy (ACT)
• Behavioural Activation
• Cognitive Behavioural Therapy (CBT)
• Interpersonal Therapy (IPT)
• Mindfulness Based Cognitive Therapy
• Psychodynamic psychotherapy
• Reminiscence Therapy
Complimentary and Lifestyle Interventions:
• Alcohol avoidance (remember, alcohol is a depressant)
• Internet interventions (e.g. Mood Gym, Smiling Mind)
• Dietary supplements
• Relaxation training
I've included the Lifestyle Interventions because lifestyle behaviour change is often a key ingredient to successfully overcoming a depressive episode and preventing future recurrence.
When I begin working with a client with depression, the very first step I take is to initiate a behavioural approach called Activity Scheduling. Why do we start with actions? Well, the answer to that question has much to do with brain functioning, to be more precise, the imbalance in activation between the left and right hemispheres of our brain.
As you can see in the diagram above, both hemispheres or sides of our brain, have very different functions. Like most things in our body, systems work in pairs and it's the balance or equilibrium between the pair that creates harmony within the system.
Depression appears to occur when the right side of our brain is more active than the left side and the left hemisphere becomes inhibited.
You can see that if the right side was dominating the show, a person would experience more negative or uncomfortable feelings which might include low mood, anxiety, irritability, stress, to name but a few.
That right hemisphere, let's call it RH for short, also forces a bit more introspection and dwelling on the negative. RH makes us want to withdraw and hide away from the world to think about how EVERYTHING we do will fail and how EVERYONE will let us down - that's the big picture, global focus and feeds right into some fairly problematic automatic thinking styles such as Black & White ("I'm a failure", "I'm hopeless"), Overgeneralisation ("Nothing I do ever succeeds") and Maximisation-Minimisation (where we maximise the strengths of others and minimise our own, and minimise the weaknesses of others while maximising our own).
You'll recall from our first article discussing what depression is and what causes it, that everything we've mentioned so far are features of major depression.
So why does RH make us want to withdraw from our friends and the world? Well, it seems blood flow is restricted to the components of the right hemisphere that read and interpret the facial expressions of other people. As a result, other people become less interesting to us causing us to say no to invitations to hang out as well as feeling like we just can't be bothered picking up the phone to talk to our friends.
Depressive symptoms have this incredible way of feeding each other, perpetuating the sadness and pessimism and social isolation in a cycle that just keeps going around and around. And that's where Activity Scheduling comes in.
We've written before about Activity Scheduling, in fact our very first article was about achieving a balance across our achievement activities, social activities, leisure/pleasure activities and our physical activities. You can read more about it how I use this strategy with clients here.
When someone is depressed, you can bet your bottom dollar that they've stopped investing their time in at least one of those categories, if not three or four of them.
Almost without exception, the socialising has dropped off because of RH urging us to withdraw from our social networks. It just gets too hard to work up the enthusiasm to see our friends and family and so, we don't.
Leisure/pleasure activities also seem to be obviously missing which is not a surprise considering that the busier we get, the more we seem to sacrifice our own self-care.
And exercise - well, let's face it, it's not usually everyone's favourite past-time and many people will look for excuses not to do it. Big mistake. Huge.
Achievement activities either dominate the weekly schedule of someone with depression, or they are completely absent leaving people to feel as though they have no meaning or purpose in their lives.
Hopefully, you're starting to see why I start here. A psychologist's first job, in my opinion, is to get that left hemisphere (LH) to spark up and reactivate to balance out that Negative Nelly, RH.
Essentially, we are scheduling in more of the kinds of activities that we know will activate LH, prescribing those activities as if they were medications, because in actual fact, studies have shown that becoming more active in your life, has the same impact on your brain as some antidepressants. Not only do we encourage our depressed clients to do more of the helpful activities, we also get them to be aware of the impact they have on their mood. Without a doubt, they will experience a lift in their mood, no matter how temporary, but that improvement is what will provide them with motivation to keep on embracing life and engaging in all of the new activities.
Remember in depression, the right hemisphere is more activated than the left. The left hemisphere is more positive, more planful and it can talk. The right hemisphere is more negative, global and silent.
Now I don't want to weigh you down with neuroscientific jargon but there are a couple of other things you should understand before I talk about the cognitive (thinking) therapies.
We've mentioned our two friends LH and RH - they form the Top Elements of our brain.
We also have to introduce you to the Bottom Elements - for this conversation, the hippocampus and our old friend, the amygdala. The amygdala is activated by both positive and negative emotions, but is more active when it detects negative and fearful experiences and reduces in activity when it assesses a situation to not be threatening.
In depression, high levels of the stress hormone cortisol can cause the hippocampus can shrink which lets the amygdala take over. You'll remember from previous articles on anxiety that the amygdala can be a real panic merchant and without the hippocampus to balance it out, the amygdala just gets carried away sending all of its Dooms Day messages to RH, stirring the pot.
Stuck in between the Top and Bottom Elements is a little guy called the Anterior Cingulate Cortex (ACC) who surrounds the corpus callosum - the part that connects LH and RH. The ACC is involved in some fairly sophisticated cognitive functions including: anticipating rewards, decision making, empathy, subjective emotional experiences, error detection, anticipation of tasks, motivation and modulating emotional responses. It's also involved in understanding the responses of others.
In depression, the ACC becomes less active, interfering with all of those tasks. The other symptoms of depression that become prevalent as a result of exposure to cortisol include impairments in cognitive functioning including working memory deficits and a reduction in problem-solving and decision making abilities.
In my clinic, lack of motivation, difficulty making decisions, initiating activities and controlling emotional responses are all commonly presented issues for my clients with depression.
The ACC is sort of the go-between guy and in depression, is constantly getting negative messages from the top and the bottom. This is why it becomes hard for the depressed person to pay attention to any new experiences coming in, instead being forced us to focus on thoughts and feeling similar to their current feelings.
So, when someone is depressed, they are more likely to remember sad things, their failures and to dwell on them, forgetting the joy.
This is where the cognitive therapies come in.
You can review our articles discussing the ABC model and some brief thinking strategies in our recent article.
Remember that LH is our language guy. He adds the story - the narrative - to our experiences and helps to process the meaning and structure of language. He's very analytical and focuses on the finer details in order to provide us with accurate interpretations of our experiences. LH is interested in people and the world and wants to engage with it, analyse it and figure it all out. He's a friendly, social kind of guy.
RH however is the opposite. Not one for words, more the shy silent type, he can get the general gist of what's going on but would much rather stay oblivious to all the details thank you very much. Hello avoidance. RH doesn't has terrible self-esteem and he'd rather we just keep to ourselves.
We know from the ABC Model that the language we use to talk to ourselves, to interpret our situations, to perceive things in our environment, greatly influences how we feel. We also know after our review of LH and RH that in depression, our ability to use language, much less helpful, positive, joyful language is diminished.
Activity Scheduling works to reduce stress and activate LH, improving mood and self-confidence along the way. It's at this point that I typically introduce the thinking strategies to target any unhelpful 'global' thinking and to further activate the language focussed expertise of LH.
Therapies such as cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT) are widely used in my clinic and I will write more specifically about both in further articles.
For today though, it's enough to know that we aim to bring our clients' observations regarding their thoughts, beliefs, feelings and actions into their consciousness.
CBT for example, emphasises turning clients into neutral observers of their own behaviour with a willingness to collect data to test hypotheses about themselves and the world. Again, this engages LH which may be as important as anything relating to the conscious content of the hypothesis testing. CBT encourages clients to reintegrate both sides of their brain through thinking, feeling and behaving.
If clients are able to develop the habit of bringing thoughts and feelings out of their working memory into longer term storage for conscious analysis, it allows both sides of the brain, to do a better job regulating moods and emotions.
We challenge unhelpful thinking styles and core beliefs by searching for evidence for the belief - there's rarely any. We also explore whether the belief is a possibility or a probability. People often take a possibility and act as though it's a foregone conclusion that it will occur. We aim to label the thinking errors and the emotions which in itself can lead to enhancing activation of LH, increasing the client's awareness of which thoughts deserve further attention and which just cause discomfort and more problems.
In the beginning, it isn't easy to become more active, more social, more conscious of our thoughts, but sometimes we have to just go through the motions and 'fake it till we make it' because every time we do, we are turning a new task into a new habit, priming the key areas in our brains so that they will be more easily activated in the future, requiring less effort, and more importantly, preventing us from future relapses of depression.
Arden, John. B., & Linford, Loyd. (2009). Brain-Based Therapy with Adults: Evidence-Based Treatment for Everyday Practice. John Wiley & Sons, Inc.
Jorm, Anthony., Allen, Nick., Morgan, Amy., & Purcell, Rosemary. (2009). A Guide to What Works for Depression. A Beyond Blue Publication.
World Health Organisation. (2004). Management of Mental Disorders, Volume 1, Fourth Edition.