4.6: Mood Disorders - Treatment

Learning Objectives

• Describe treatment options for depressive disorders.
• Describe treatment options for bipolar disorders.
• Determine the efficacy of treatment options for depressive disorders.
• Determine the efficacy of treatment options for bipolar disorders.

Depressive Disorders

Given that Major Depressive Disorder is among the most frequent and debilitating psychiatric disorders, it should not be surprising that the research on this disorder is quite extensive. Among its treatment options, the most efficacious ones include antidepressant medications, Cognitive-Behavioral Therapy (CBT; Beck et al., 1979), Behavioral Activation (BA; Jacobson et al., 2001), and Interpersonal Therapy (IPT; Klerman et al., 1984). Although CBT is the most widely known and used treatment for Major Depressive Disorder, there is minimal evidence to support one treatment modality over the other; treatment is generally dictated by therapist competence, availability, and patient preference (Craighhead & Dunlop, 2014).

4.6.1.1. Psychopharmacology – Antidepressant medications. Antidepressants are often the most common first-line attempt at treatment for MDD for a few reasons. Oftentimes an individual will present with symptoms to their primary caregiver (a medical doctor) who will prescribe them some line of antidepressant medication. Medication is often seen as an “easier” treatment for depression as the individual can take the medication at their home, rather than attending weekly therapy sessions; however, this also leaves room for adherence issues as a large percentage of individuals fail to take prescription medication as indicated by their physician. Given the biological functions of neurotransmitters and their involvement in maintaining depressive symptoms, it makes sense that this is an effective type of treatment.

Within antidepressant medications, there are a few different classes, each categorized by their structural or functional relationships. It should be noted that no specific antidepressant medication class or medication have been proven to be more effective in treating MDD than others (APA, 2010). In fact, many patients may try several different types of antidepressant medications until they find one that is effective, with minimal side effects.

4.6.1.2. Psychopharmacology – Selective serotonin reuptake inhibitors(SSRIs). SSRIs are among the most common medications used to treat depression due to their relatively benign side effects. Additionally, the required dose to reach therapeutic levels is low compared to the other medication options. Possible side effects from SSRIs include but are not limited to nausea, insomnia, and reduced sex drive.

SSRIs improve depression symptoms by blocking the reuptake of norepinephrine and/or serotonin in presynaptic neurons, thus allowing more of these neurotransmitters to be available for postsynaptic neurons. While this is the general mechanism through which all SSRI’s work, there are minor biological differences among different types of medications within the SSRI family. These small differences are beneficial to patients in that there are a few treatment options to maximize medication benefits and minimize side effects.

4.6.1.3. Psychopharmacology – Tricyclic antidepressants. Although originally developed to treat schizophrenia, tricyclic antidepressants were adapted to treat depression after failing to manage symptoms of schizophrenia (Kuhn, 1958). The term tricyclic came from the molecular shape of the structure: three rings.

Tricyclic antidepressants are like SSRIs in that they work by affecting brain chemistry, altering the number of neurotransmitters available for neurons. More specifically, they block the absorption or reuptake of serotonin and norepinephrine, thus increasing their availability for postsynaptic neurons. While effective, tricyclic antidepressants have been increasingly replaced by SSRIs due to their reduced side effects. However, tricyclic antidepressants have been shown to be more effective in treating depressive symptoms in individuals who have not been able to achieve symptom reduction via other pharmacological approaches.

While the majority of the side effects are minimal – dry mouth, blurry vision, constipation, others can be serious such as sexual dysfunction, tachycardia, cognitive and/or memory impairment. Due to the potential impact on the heart, tricyclic antidepressants should not be used in cardiac patients as they may exacerbate cardiac arrhythmias (Roose & Spatz, 1999).

4.6.1.4. Psychopharmacology – Monoamine oxidase inhibitors (MAOIs). The use of MAOIs as a treatment for depression began serendipitously as patients in the early 1950s reported reduced depression symptoms while on the medication to treat tuberculosis. Research studies confirmed that MAOIs were effective in treating depression in adults outside the treatment of tuberculosis. Although still prescribed, they are not typically first-line medications due to their safety concerns with hypertensive crises. Because of this, individuals on MAOIs have strict diet restrictions to reduce their risk of hypertensive crises (Shulman, Herrman & Walker, 2013).

How do MAOIs work? In basic terms, monoamine oxidase is released in the brain to remove excess neurotransmitters norepinephrine, serotonin, and dopamine. MAOIs essentially prevent the monoamine oxidase (hence the name monoamine oxidase inhibitors) from removing these neurotransmitters, thus resulting in an increase in these brain chemicals (Shulman, Herman & Walker, 2013). As previously discussed, norepinephrine, serotonin, and dopamine are all involved in the biological mechanisms of maintaining depressive symptoms.

While these drugs are effective, they come with serious side effects. In addition to the hypertensive episodes, they can also cause nausea, headaches, drowsiness, involuntary muscle jerks, reduced sexual desire, weight gain, etc. (APA, 2010). Despite these side effects, studies have shown that individuals prescribed MAOIs for depression have a treatment response rate of 50-70% (Krishnan, 2007). Overall, despite their effectiveness, MAOIs are likely the best treatment for late-stage, treatment-resistant depression patients who have exhausted other treatment options (Krishnan, 2007).

It should be noted that occasionally, antipsychotic medications are used for individuals with MDD; however, these are limited to individuals presenting with psychotic features.

4.6.1.5. Psychotherapy – Cognitive behavioral therapy (CBT). CBT was founded by Aaron Beck in the 1960s and is a widely practiced therapeutic tool used to treat depression (and other disorders as well). The basics of CBT involve what Beck called the cognitive triangle— cognitions (thoughts), behaviors, and emotions. Beck believed that these three components are interconnected, and therefore, affect one another. It is believed that CBT can improve emotions in depressed patients by changing both cognitions (thoughts) and behaviors, which in return enhances mood. Common cognitive interventions with CBT include thought monitoring and recording, identifying cognitive errors, examining evidence supporting/negating cognitions, and creating rational alternatives to maladaptive thought patterns. Behavioral interventions of CBT include activity planning, pleasant event scheduling, task assignments, and coping-skills training.

CBT generally follows four phases of treatment:

• Phase 1: Increasing pleasurable activities. Similar to behavioral activation (see below), the clinician encourages the patient to identify and engage in activities that are pleasurable to the individual. The clinician can help the patient to select the activity, as well as help them plan when they will engage in that activity.
• Phase 2: Challenging automatic thoughts. During this stage, the clinician provides psychoeducation about the negative automatic thoughts that can maintain depressive symptoms. The patient will learn to identify these thoughts on their own during the week and maintain a thought journal of these cognitions to review with the clinician in session.
• Phase 3: Identifying negative thoughts. Once the individual is consistently able to identify these negative thoughts on a daily basis, the clinician can help the patient identify how these thoughts are maintaining their depressive symptoms. It is at this point that the patient begins to have direct insight as to how their cognitions contribute to their disorder.
• Phase 4: Changing thoughts. The final stage of treatment involves challenging the negative thoughts the patient has been identifying in the last two phases of treatment and replacing them with positive thoughts.

4.6.1.6. Psychotherapy – Behavioral activation (BA). BA is similar to the behavioral component of CBT in that the goal of treatment is to alleviate depression and prevent future relapse by changing an individual’s behavior. Founded by Ferster (1973), as well as Lewinsohn and colleagues (Lewinsohn, 1974; Lewinsohn, Biglan, & Zeiss, 1976), the goal of BA is to increase the frequency of behaviors so that individuals have opportunities to experience greater contact with sources of reward in their lives. To do this, the clinician assists the patient by developing a list of pleasurable activities that they can engage in outside of treatment (i.e., going for a walk, going shopping, having dinner with a friend). Additionally, the clinician assists the patient in identifying their negative behaviors—crying, sleeping in, avoiding friends—and monitoring them so that they do not impact the outcome of their pleasurable activities. Finally, the clinician works with the patient on effective social skills. By minimizing negative behaviors and maximizing pleasurable activities, the individual will receive more positive reward and reinforcement from others and their environment, thus improving their overall mood.

4.6.1.7. Psychotherapy – Interpersonal therapy (IPT). IPT was developed by Klerman, Weissman, and colleagues in the 1970s as a treatment arm for a pharmacotherapy study of depression (Weissman, 1995). The treatment was created based on data from post-World War II individuals who expressed a substantial impact on their psychosocial life events. Klerman and colleagues noticed a significant relationship between the development of depression and complicated bereavement, role disputes, role transitions, and interpersonal deficits in these individuals (Weissman, 1995). The idea behind IPT is that depressive episodes compromise interpersonal functioning, which makes it difficult to manage stressful life events. The basic mechanism of IPT is to establish effective strategies to manage interpersonal issues, which in return, will ameliorate depressive symptoms.

There are two main principles of IPT. First, depression is a common medical illness with a complex and multi-determined etiology. Since depression is a medical illness, it is also treatable and not the patient’s fault. Second, depression is connected to a current or recent life event. The goal of IPT is to identify the interpersonal problem that is related to the depressive symptoms and solve this crisis so the patient can improve their life situation while relieving depressive symptoms.

4.6.1.8. Multimodal treatment. While both pharmacological and psychological treatment alone is very effective in treating depression, a combination of the two treatments may offer additional benefits, particularly in the maintenance of wellness. Additionally, multimodal treatment options may be helpful for individuals who have not achieved wellness in a single modality.

Multimodal treatments can be offered in three different ways: concurrently, sequentially, or within a stepped manner (McGorry et al., 2010). With a stepped manner treatment, pharmacological therapy is often used initially to treat depressive symptoms. Once the patient reports some relief in symptoms, the psychosocial treatment is added to address the remaining symptoms. While all three methods are effective in managing depressive symptoms, matching patients to their treatment preferences may produce better outcomes than clinician-driven treatment decisions.

Bipolar Disorder

4.6.2.1. Psychopharmacology. Unlike treatment for MDD, there is some controversy regarding effective treatment of bipolar disorder. One suggestion is to treat bipolar disorder aggressively with mood stabilizers such as Lithium or Depakote as these medications do not induce pharmacological mania/hypomania. These mood stabilizers are occasionally combined with antidepressants later in treatment only if absolutely necessary (Ghaemi, Hsu, Soldani & Goodwin, 2003). Research has shown that mood stabilizers are less potent in treating depressive symptoms, and therefore, the combination approach is believed to help manage both the manic and depressive episodes (Nivoli et al., 2011).

The other treatment option is to forgo the mood stabilizer and treat symptoms with newer antidepressants early in treatment. Unfortunately, large scale research studies have not shown great support for this method (Gijsman, Geddes, Rendell, Nolen, & Goodwin, 2004; Moller, Grunze & Broich, 2006). Antidepressants often trigger a manic or hypomanic episode in bipolar patients. Because of this, the first-line treatment option for bipolar disorder is mood stabilizers, particularly Lithium.

4.6.2.2. Psychological treatment. Although psychopharmacology is the first and most widely used treatment for bipolar disorders, occasionally psychological interventions are also paired with medication as psychotherapy alone is not a sufficient treatment option. Majority of psychological interventions are aimed at medication adherence, as many bipolar patients stop taking their mood stabilizers when they “feel better” (Advokat et al., 2014). Social skills training and problem-solving skills are also helpful techniques to address in the therapeutic setting as individuals with bipolar disorder often struggle in this area.

Outcome of Treatment

4.6.3.1. Depressive treatment. As we have discussed, major depressive disorder has a variety of treatment options, all found to be efficacious. However, research suggests that while psychopharmacological interventions are more effective in rapidly reducing symptoms, psychotherapy, or even a combined treatment approach, are more effective in establishing long-term relief of symptoms.

Rates of relapse for major depressive disorder are often associated with individuals whose onset was at a younger age (particularly adolescents), those who have already experienced multiple major depressive episodes, and those with more severe symptomology, especially those presenting with severe suicidal ideation and psychotic features (APA, 2022).

4.6.3.2. Bipolar treatment. Lithium and other mood stabilizers are very effective in managing symptoms of patients with bipolar disorder. Unfortunately, it is the adherence to the medication regimen that is often the issue with these patients. Bipolar patients often desire the euphoric highs that are associated with manic and hypomanic episodes, leading them to forgo their medication. A combination of psychopharmacology and psychotherapy aimed at increasing the rate of adherence to medical treatment may be the most effective treatment option for bipolar I and II disorder.

Key Takeaways

You should have learned the following in this section:

• Treatment of depressive disorders include psychopharmacological options such as anti-depressant mediations, SSRIs, tricyclic antidepressants, and MAOIs and/or psychotherapy options to include CBT, behavioral activation (BA), and interpersonal therapy (IPT). A combination of the two main approaches often works best, especially in relation to maintenance of wellness.
• Treatment of bipolar disorder involves mood stabilizers such as Lithium and psychological interventions with the goal of medication adherence, as well as social skills training and problem-solving skills.
• Regarding depression, psychopharmacological interventions are more effective in rapidly reducing symptoms, while psychotherapy, or even a combined treatment approach, is more effective in establishing long-term relief of symptoms.
• A combination of psychopharmacology and psychotherapy aimed at increasing the rate of adherence to medical treatment may be the most effective treatment option for bipolar I and II disorder.

Review Questions

1. Discuss the effectiveness of the different pharmacological treatments for mood disorders.
2. What are the four phases of CBT? How do they address symptoms of mood disorder?
3. What is ITP and what are its main treatment strategies?
4. What are the effective treatment options for bipolar disorder?

Module Recap

That concludes our discussion of mood disorders. You should now have a good understanding of the two major types of mood disorders – depressive and bipolar disorders. Be sure you are clear on what makes them different from one another in terms of their clinical presentation, epidemiology, comorbidity, and etiology. This will help you with understanding treatment options and their efficacy.