Depression: Not Just a Bad Mood Mdd:

¶ … 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 she can control her thinking process and subsequently her moods. Finally, I would validate Taylor's challenge in coping with depressive symptoms while being expected to function normally in her parents' house and in this unsupportive environment. I would explain that therapy is a safe place for us to explore her interpersonal challenges and all related feelings, and that I will do my best to be a positive support figure for her. It would be critical to empathize with the client's perception of her experience and synthesize strengths and supports in order to boost her emotional functioning. The core of empathic attunement, that is, seeing the world from the client's perspective, can have a powerful effect on the therapeutic process and outcomes (Mahrer.)

The treatment planning phase must include the beginning, middle and end stage goals for treatment. One way to frame these goals can be as follows: In phase one, the goal would be to build therapeutic alliance, and explore a detailed history of Taylor's symptoms as well as relationship with her boyfriend. We would also have to formulate how we are going to work on her goals of symptom reduction and increased functioning. In the middle phase of therapy, the details will unfold and we will work more directly on cognitive restructuring, as well as behavioral modification. At the same time, as a therapist I would depict a compassionate and empathic stance, in order to facilitate positive transference which can then be utilized in-vivo interpersonal work (Lichtmacher, 2008.) Role playing and assertiveness training may be beneficial at this stage, both in order to heal from her breakup, and empower Taylor to interact more effectively with her family members. Exploration of any of Taylor's negative thoughts and self-doubts would be encouraged, including how the issue of her religion may have been a factor in her breakup and her beliefs about that now.

In the final phase of treatment, we will discuss relapse prevention and synthesize her support system, including her internal resources for coping with setbacks. The termination phase will also have to include specific feelings that come up for Taylor regarding terminating therapy, which may or may not relate to similar feelings of grieving her loss of her boyfriend. Often termination can be of the more challenging aspects of treatment, especially for those clients with prior relationship issues and interpersonal loss. However, if handled appropriately and sensitively by the therapist, it can be a healing process in and of itself. Part of termination would be to explore what feelings arise in Taylor at saying goodbye, and exploring any lingering concerns, so as not to recreate another loss for her. Finally, we would review the progress she has made and schedule a follow up session in the future if she would like.

First Therapy Session:

T (Therapist): So, what brings you here today?

C (Client): Well, I have been having a really hard time getting over a difficult breakup. I mean, it did happen six months ago, and everyone keeps telling me it's about time I move on but I can't seem to.

T: It sounds like there is outside pressure on you to suppress your feelings, is that right?

C: Yes, and on top of that, my mom just doesn't understand what the big deal was in the first place. It's like she doesn't even care that I was dumped like a ton of bricks by my boyfriend of five years! It's really hard to talk to her…and I hate feeling this way!

T: There may be several issues that you will want to address in treatment, and hopefully you will find that this will be a safe place to explore your feelings- but firstly, let's talk about your symptoms and what concerns you the most right now.

C: I guess the biggest problem is that I don't feel like doing anything and it takes enormous amounts of energy to get out of bed in the morning and attend my classes. I really want to do well in school but it's so hard to concentrate when all I can think about is how it ended. I just keep replaying the scene in my head and feel like crying all the time. I don't feel like eating, and I'm just exhausted! What's the point?

T: I sense your despair. It seems that the breakup has really affected your functioning.

C: Yeah! And I'm just so mad at Ted for wrecking my life like this! How can I ever move on when it haunts me like this?

T: The breakup has really been difficult for you! I can sense the pain you are suffering on a daily basis. And it doesn't help that you can't stop thinking about the painful past while trying to live your life and move on.

C: Yeah, that's right.

T: Well, the good news is that you came here today. That must have taken a lot of courage to come to a total stranger and be willing to open up about your struggles. I'd like to tell you a bit about what to expect from the process of therapy and explore your goals a bit further.

C: Okay.

T: In my experience, I have seen that techniques from Cognitive Behavioral Therapy have proven helpful for others who come in with symptoms like those you describe. Depression comes in many forms, especially in ways that affect our thinking. Do you find that you have a lot of negative thoughts during the day?

C: Totally. I feel rotten when all I can think about is how much I hate the world and myself for getting into this in the first place.

T: I'm hearing you blame yourself. What do you think that is about?

C: Maybe I should've listened to my parents when they told me to date a "nice Jewish boy!" Why can't I just forget about him already?

T: Well, that's tough to say…people take time to grieve. You suffered the loss of a lengthy relationship. I mean, you knew him for five years! That is a long time to just be expected to "get over."

C: I guess you are right. Thanks for understanding!

T: This is actually a perfect example of how CBT can help. You see, the thoughts we have and the actions we do are all connected to the feelings we have also. Does that make sense?

C: I guess so.

T: So by learning how to control our thinking and alter our negative thoughts, we can also improve our mood. We can do this by exploring the thoughts that interfere more specifically throughout our time together, and work on changing them to more neutral thoughts. How does that sound?

C: I guess it sounds good if it works! But it's not just my thoughts that are the problem. It's other things