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Depression: Not just a Bad Mood
MDD: Not Just Another Bad Mood
The term "Prozac Nation" says a lot. This catch-phrase had begun to describe the current state in the U.S. when cases of clinical depression began blooming and treatment turned to medication as a first response. According to the National Institute of Mental Health, over fourteen million of the adult U.S. population suffers from Major Depressive Disorder. Major Depressive Disorder, or MDD, is the leading cause of disability in people ages 15-44. The average age of onset is 32 (U.S. Department of, 2011.) It is often also found co-occurring with other mental disorders, such as anxiety and substance abuse. Perhaps it is worth taking a closer look at a case example in order to better understand this often debilitating disorder in our times.
Taylor is a 24-year-old single, Jewish female presenting with symptoms of depression. She reports that for the last 6 months she has struggled with feelings of emptiness, loneliness, chronic sadness and fatigue. She also states that she has not enjoyed activities she used to engage in recreationally such as playing the piano and painting. Taylor sleeps fitfully and subsequently tends to nod off in her college classes during the day. Lately, she has been attempting to drink more alcohol at night to help her fall asleep and quell her anxious thoughts, but does not feel that it helps consistently. Her appetite is also lacking and she has to date lost 15 pounds without trying to. Taylor reports that she constantly has negative nagging thoughts in her head, and feels bad about herself in general. She feels worthless. Though she would not actually hurt herself, Taylor reports thinking "suicidal thoughts" and wishing she just wouldn't wake up in the morning. She passively hopes to die and wants to do anything to "make the pain stop."
Taylor had been living with her boyfriend, Ted, for the last two years in Ted's apartment in the city. She would describe their relationship as "on and off," but claims that she loves him. One day, Taylor came home to find that she was locked out and her things were packed up, and that Ted had decided he wanted to end the relationship for unspecified reasons. He refused to talk to her and just stated that he "needs his space" and "wants to move on." Since that fateful day, Taylor had begun experiencing all the above-mentioned symptoms. Though it started as normal sadness, grieving and pain over the rejection, it steadily worsened into the debilitating state of depression she currently experiences. She finds it hard to get out of bed in the mornings, and though feels the weight of depression making her sluggish, still attempts to attend her classes.
Though Taylor reports that she is Jewish, a minority population in the state where she lives, she is not observant and considers herself very secular. Taylor was raised in a traditional family, one in which the Jewish identity was acknowledged and identified with. However, as Taylor moved away from her home at age 17 to go to college, she also left their ideals behind and stopped identifying herself with her Jewish roots. She later fell in love with Ted, a devout Christian, and though her parents did not approve, she did not see this as an issue in their relationship. Now along with all the self-doubt Taylor is plagued with, she questions whether this was, in fact, an underlying issue for Ted, along with a myriad of other unanswered questions she has for him. She has since moved back in with her parents, where the "you are better off without him" attitude is prevalent, and not in the least supportive of how she is coping with this loss. Taylor's symptoms qualify for the clinical diagnosis of Major Depressive Disorder according to the DSM-IV TR. She reports experiencing seven out of the nine criteria, and as it has lasted for six months, has passed the diagnosable time table for Adjustment Disorder with Depressed Mood (Quick reference to, 2000.) Taking her symptoms into account, as well as her goal to return to pre-breakup functioning, several psychotherapeutic approaches may prove helpful.
Taylor has never been in treatment before, but comes in now because she can no longer bear how the symptoms of depression are interfering with her quality of life and feels that she needs someone supportive to sort out her issues with. She is motivated for change, and as a therapist, I would discuss the various approaches of treatment that Taylor may benefit from. For starters, medication treatment can prove very helpful for a case like Taylor's, which is not a long-term depression, but seems to be reactive to a specific loss. Any one of the several antidepressant medication options such as SSRI's, MAOI's or SNRI's, would target the biochemical aspect of the depression and may prove helpful in taking the edge off of Taylor's depressed mood (Martin, 2010.) This could then allow her to think more clearly about her goals and help her engage in therapy to learn how to more effectively cope better with her situation. Research on the effectiveness of medication treatment combined with psychotherapy shows more effectiveness on decreasing symptoms of adult depression than psychotherapy alone (Cuijpers, van Straten, Hollon, & Andersson, 2010). I would then embark on explaining the way psychotherapy can help her particular situation.
Cognitive Behavioral Therapy has been empirically proven to help people who suffer from Major Depression. It is widely accepted that symptom reduction can be expected after engaging in a course of CBT treatment. The mechanism by which this works is by teaching a client the premise that they can be in control of altering their mood by changing their thoughts and behaviors (Rupke, Blecke, & Renfrow, 2006.) On the cognitive end, several handouts can be effectively used during sessions to encourage client motivation and collaboration in the therapeutic work. These include a "Daily Mood Log," which is used to track negative thoughts and encourage thought-restructuring, as well symptom rating scales, which can help both patient and therapist gauge progress more objectively (Burns, 1989.) Taylor may find CBT particularly helpful in addressing negative thought patterns which affect her feelings of self- worth related to the breakup, and quelling gnawing self-doubts.
Furthermore, the behavioral aspect of CBT can also address the actions that Taylor has begun taking in order to self-soothe which may have long-term negative effects, such as drinking alcohol every night. Behavioral therapy may begin to address her sleep habits in a more effective way, such as working on developing a structured sleep routine and engaging in relaxation techniques prior to going to bed. Positive reinforcement of functional behavior and small successes along the way are also useful in rebuilding self-confidence and a sense of competence in coping (Rupke, Blecke, & Renfrow, 2006). Tracking how her thoughts and feelings are connected can prove useful to Taylor in empowering her to take control over her moods and grow from the experience. Throughout the treatment, it would be important to show support and empathy, validating Taylor's perception of the loss and allowing her to grieve appropriately.
Another approach that has been proven useful and was developed specifically for people suffering from depression is Interpersonal Psychotherapy, or IPT, an interpersonal approach combining aspects from supportive and psychodynamic psychotherapy. This approach can be particularly helpful for someone like Taylor who is struggling with the impact of attachment and social disruption following her breakup. This form of therapy would encourage Taylor to focus on what her goals of therapy are, what the specific symptoms of depression that she struggles with are, and how this all relates to her interpersonal functioning (Corns, & Frank, 1994.)
Treatment planning is an essential part of any treatment approach. The goal of this initial stage in treatment would be to engage the client in contracting for treatment, enabling her to understand her goals and the method by which the therapeutic process can be helpful, and empowering her to be an active participant by encouraging her questions and concerns. The initial sessions of our work would include a detailed assessment and history of her symptoms and related experiences, as well as beginning to address which symptoms she would most like to work on alleviating first (Jongsma, & Peterson, 2006.) Breaking down the ultimate goal of alleviating depression and prioritizing our work can be empowering and decrease any feelings of overwhelm she may be entering treatment with.
Furthermore, during this phase I would discuss the benefits of obtaining a psychiatric evaluation in order to get antidepressant medication, and would empathically explore any concerns she may have. Treatment planning would also include practical aspects of the treatment such as how often we would meet and for how long, as well as the fee. In order to begin engaging in our work right from the start, I would show Taylor a Mood Log and encourage her to fill one out for homework, to begin learning how…[continue]
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