Depression and three of its existing treatments
Depression is not only one of the most widespread and prevalent of the major psychiatric disorders but also one of the most excessively researched mental illnesses. It has often fundamentally affects people's well-being and quality of life. While a study discovered that of over 5.000 British residents approximately 5.9% of the males and 4.2% of the females did suffer from depressive illnesses (based on DSM-IV criteria) (Ohayon et al. 1999), the literature suggests that the depression course differs from individual to individual, as does the effect of and the response to a treatment.
As 85% of currently depressed individuals in primary care and 78% in psychiatric settings do endure relapse from depression after treatment (Coyne, Pepper, Flynn, 1999) it becomes self-evident to grasp and comprehend different techniques and methods to treat depression and evaluate their strengths and weakness (Khan-Bourne & Brown, 2003). Consequently this brief aims to review some of the current state of research on three treatments which rely less on medication and exclude pharamcotherapy. The treatments which will be critically evaluated are electro-convulsive therapy, cognitive behaviour therapy, and acupuncture treatment.
According to the DSM-VI, the symptoms of depression fall into four different categories: cognitive (feelings of low self-worth or unbecoming guilt), physical (forms of insomnia or loss of appetite), emotional (enormous sorrowful feelings), and motivational (lack of motivation and aspiration). In other words, everyday feelings of sadness are not as comprehensive, long-lasting and extreme as depression experienced as a mental disorder. Nonetheless, the term depression stands for an ample amount of illnesses that are not comparable in terms of severity and time course since it ranges in severity from mild irregular conditions of natural emotions to disorders of psychotic intensity (Hollon, Thase & Markowitz, 2002).
Murray and Lopez (1997) reported that although depression can be regarded as the top reason for people being disconnected from everyday healthy living worldwide the majority of individuals (approximately 80%) who suffer from depression never seek treatment, according to the National Institute of Mental Health (NIMH). As, however, the amount of people experiencing depression has almost reached an epidemic status, and being mentally ill is not stigmatised to such an extend by society, more and more people inform themselves and seek treatment (Hollon et al., 2002).
The goal of treating depression should be to reach both a thorough symptom and risk of relapse minimisation; and as a consequence, to improve significantly the patients' quality of life. Ellis and collaborators (2003) noted that for a treatment to be generally successful it must include and provide certain essential elements in the treatment plan. Maximising the collaboration and identification between the patient and the treatment in a therapeutic alliance which embraces the patient's social network is, for instance, only one of the necessary pillars of an effective treatment. Gwosdow and Staff (2003) added that tailoring the treatment uniquely to each patient, while paying attention such aspects as the safety, tolerability and efficacy of required medicaments or the treatment are equally important factors which play a role in predicting the success rate of a treatment.
As a matter of fact there are many successful approaches to tackle clinical depression effectively, whereas many are backed up by scientific studies and evidence.
Electro-convulsive Therapy - ECT
Pharamcotherapy is by far not the only way to alleviate or cure depression in people. In fact, the most effective antidepressant modality is electro-convulsive therapy according to Holden (2003). It is often used in acutely depressed patients as antidepressants take usually more than three weeks to impact depression and is chosen over other methods when pharmacotherapy fails to have an effect on a patient. ECT acts in so many ways on individuals that it is hard to disentangle the effects. Blocking effects of stress hormones, increasing serotonin levels or stimulating neurogenesis in the brain are only a few of its positive effects while the induction of seizures and the outbreak of epilepsy and severe personality changes are among some of its weaknesses.
Therefeore, ECT still remains controversial and receives public stigmatisation despite the fact that if a health care specialist administers ECT professionally, it does not bear higher risk factors than surgical treatments that need general anaesthesia of the patient.
The treatment usually starts with the process of 6 to 12 electrically induced seizures spaced several days apart. ECT treatments are spread over several days while the electrical current is utilised across the less dominant brain hemisphere (both uni- and bilaterally). ECT excites the compensatory central nervous system mechanisms which moderate the neurotransmitter systems that are also affected by pharamcotherapeutic medications. Confusion, which is the most natural first response to ECT is generally followed by transient amnesia after and for several months. Although research could not demonstrate permanent memory loss many patients complain and lament about this negative side of ECT. However as it is very expensive and as it has possible impacts on cognition, memory and personality this method is only applied in severe cases of depression. Despite this fact only every second patient who did not benefit from medication will benefit from ECT, according to Prudic and collaborators 1996. A high relapse risk rate is another weakness of successful ECT while those who proved to be resistant against antidepressant are also more prone to suffer from relapse. Therefore, the ECT treatment is often extended and involves nowadays follow-up medication therapy that combines antidepressants and mood stabilizers (Sackeim et al., 2001). Individuals who suffer from depression post-recurrence despite having undergone this newly developed strategy may are asked to continue ECT treatment using a less powerful current and more distanced treatment days (Hollon et al., 2002).
Cognitive Behavioural Therapy - CBT
Beck (1991) can be regarded as the pioneer and innovator of cognitive the therapy who developed this kind of therapy in the early 1960s. It is theorized that individuals' sentiments and interpretations about certain life events have a fundamental impact on the individuals' response to those events. In other words, depressed patients are regarded as possessing inappropriate negative attitudes and notions towards life events and their illness is thought to be due to the utilisation improper and incorrect information processing strategies. Therefore, the aim of cognitive therapy is to allow patients to identify, assess and most importantly modify their maladaptive notions and to hinder the occurrence of negative automatic thoughts (NATs). Given that behavioural strategies are additionally used to enhance depressed patients' conditions the treatment is termed cognitive behavioural therapy (CBT). Unlike what one might guess, CBT does not involve instilling unrealistic optimism into suffering individuals but seeks to help patients to assess themselves, their opportunities and abilities with more realistic measures. Previously held notions and sentiments have to be, as a consequence, constantly and continuously independently questioned by the depressed person so that he or she acquires a higher sense of mastery which gives him or her, in turn, more control and confidence over future life-events. This approach seems quite effective as some studies have discovered that the relapse rate of mentally depressed people treated by this method is twice as low as the relapse rate of individuals treated with medications, according to Levine and Wetzel (1986). Hollon and colleagues (2001) demonstrated this more remarkable superiority of CBT over medication more recently and discovered that within a year after treatment 81% of individuals receiving medication relapsed whereas only 25% of patients treated by CBT relapsed. Unfortunately, there are not many studies that have extended the scope beyond relapse risk rate but Fava and colleagues (1998) maintained that CBT diminishes the risk of recurrence. Weaknesses of CBT include the fact that it is thought of having low cost-effectiveness compared to pharmacotherapy although Hollon (2002) interjects that this might be incorrect for long-term treatments where CBT is at least as cost-effective as pharmacotherapy.
CBT has additionally been extended to other cognitive therapies which include the so-called Mindfulness-based cognitive therapy which utilises and includes strategies acceptance and meditation techniques (dialectic behaviour therapy) which facilitates patients keeping a safe mental distance form any depressive ruminations while targeting less the content than the process of pondering (Teasdale, Segal, & Williams,
1995). Teasdale and collaborators succeeded in finding support for this method and estimated that due to its low relapse rate, increasing popularity and possibility to enjoy treatment in groups, this kind of treatment will play an even bigger role in the near future.
In sum, cognitive based therapies seem to be successful in both minimising severe depression during treatment and diminishing its come-back risk after treatment. Additionally patients rarely suffer from any kinds of side-effects and feel more enabled to control their illnesses themselves. Recently developed interventions which are based on cognitive therapy appear, in addition to that, quite promising like the mindfulness-based cognitive therapy. The implications which seem especially encouraging are ideas theorising that the interventions which effectively tackle relapse and recurrence could also diminish the worrying risk for initial onset in children and youths who have never encountered depression.
Alternative Medicine - Acupuncture
Especially the UK has experienced a significant boom of complementary and alternative medicine (CAM) treatments of mental disorders like depression. The statistics are speaking in favour of CAMs and are indicating extreme present and future potential of CAMs. As a matter of fact, only 20% of the patients who received CAMs were dissatisfied with the received treatment while in total a quarter of the British population have stated to have already benefited from CAMs and over 90% of GPs (general practitioners) have already suggested the referral of a patient to CAMs (Hagelskamp et al. 2003).
Nevertheless, many limitations exist that has not allowed CAMs yet to become more integrated into standard medical interventions and practices. One of the major downsides of CAMs is that most of them lack clinical and scientific evidence and support which demonstrates their validated positive effects on disorders such as depression. However, therapists who are in favour of treatments like acupuncture which is used for alleviating pain and depressive symptoms in patients seek to gain higher clinical acceptance in the near future by conducting more scientific studies. In acupuncture treatment, the physiological functioning of the human body is sought to be altered and the energy balance is sought to be restored by inserting extremely fine needles alongside the energy meridians on the surface of the body.
Acupuncture has the benefit of lacking limitations of both counselling and medication as it does neither need oral administration nor motivation to self-reflect language, and as it, additionally, excludes frequently appearing side effects or potential dependency. On the other hand, one of the weaknesses of this particular treatment is that the there is no consent about the influence of the needles on body and mind, and while Chinese therapists regard the effect of acupuncture based on de-stagnation of unresolved stress and emotional conflicts, Western therapists regard acupuncture as actively changing the neuropsychology of patients. Ernst and colleagues (1998) were among the first and few who sought to establish sound clinical evidence for acupuncture treatment. Although their studies implicated that acupuncture significantly changed depressive patients conditions to the better, their research only utilised case studies and thus the reliability and validity of their study was questioned. Yang (1998) discovered that in contrast to medication acupuncture did reduce anxiety in patients and gave them more confidence in dealing with their disorder. More recently, Roeschke and collaborators (2000) investigated whether different types of acupuncture (e.g. sham, venum acupuncture) have different effects and discovered that there were no observable differences between different acupuncture treatments although all had significant effects on the patients well-being compared to a control group whose members did not receive acupuncture sessions. This study led Roeschke and colleagues to imply that needling in general may be an effective countermeasure against depression. In sum, acupuncture does seem to successfully tackle depression and may possess both administrative and clinical advantages over pharmacological treatments. Nevertheless, as it is not yet sufficiently supported by research institutions, central government or health professionals it has not established and integrated itself among the mainstream health treatments of depression (Hagelskamp et al. 2003).
Not one but several types of treatments exist which seem to be effectively intervening against depression. Each single one has both strengths and weaknesses - advantages and disadvantages; thus none is universally accepted or successful. Usually, antidepressant medication based treatments have the most ample scientific support although on the downside they involve the risk of detrimental and negative side effects. Additionally, there relapse and recurrence risk after treatment is remarkably high so the treatment has to be steadily continued. ECT on the other hand represents the single most promising intervention for the most acute depressions, but since it impacts memory and cognition irrecoverably its advantages and disadvantages are well balanced and need to be considered before treatment. CBT seems to be a more appropriate counter-measure against depression for more mild types of depression (e.g. unipolar depression). Although it does neither bear negative side-effect nor involve high relapse risk factors its degree of success relies heavily on the competence of the responsible clinician. Nevertheless, one fact which has to be considered is that despite the overwhelming amount of scientific studies assessing existing depression treatments over 50% of patients do not respond to any type of treatment yet and researchers and medical professionals have to date been unsuccessful in decreasing this staggering statistic. In conclusion no guide exists telling one what to do if acupuncture, CBT, ECT or pharmacology fails to have an impact on depressed individuals (Hollon et al. 2002).