Advances in biological and psychosocial treatments for mood disorders
LOUISVILLE Kentucky healthcare professionals are fortunate to have one of the nation’s top depression centers right here at the University of Louisville. The UofL Health Depression Center Conference, November 16–17, 2023, drew nationally recognized researchers focused on advanced methods for challenging clinical problems.
What are some of the most promising developments in mental health treatment?
Evaluate and Manage Difficultto-Treat Depression.
It starts with removing any connotation of blame attached to the diagnosis, suggested Michael Thase, MD. That’s why it’s no longer called treatment resistant depression. Difficult-to-treat depression (DTD) is not a diagnosis; it’s more of a description of the patient’s prognosis and course of treatment.
Behavioral Activation for Treating Depression and Anxiety.
Behavioral activation (BA) is a third-generation behavior therapy for treating depression and anxiety. The emphasis is on engaging in positive and enjoyable activities to enhance one’s mood.
This does not just mean encouraging your patients to “get out there” and schedule enjoyable activities, get more exercise, and socialize more, says Thase. BA focuses on connecting the dots between actions and emotional consequences. The goal is to identify “depression loops,” coping behaviors that provide temporary relief but come with high-cost consequences.
Whether it’s avoidance, escape, rumination, alcohol, or other drugs, the idea is to replace less effective coping patterns with more adaptive behaviors. For the process to work, new behaviors need to feel better in the moment, not just like delayed gratification.
The acronym “TRAP” (trigger, response, avoidance pattern) is a clever way to identify the depression loop behavior, which is then replaced with a “TRAC” (trigger, response, alternate coping) response.
The general program is described with the acronym “ACTION” (assess behavior/mood, choose alternate responses, try out those alternate responses, integrate these alternatives, observe results, and (now) evaluate).
Here’s how BA can help reduce rumination, a particularly common avoidance behavior that worsens mood:
- Trigger: What gets the rumination started?
- Response: Describe the rumination mental behavior. What does the patient tell themself?
- Avoidance Pattern: What does the patient get from rumination? How does it temporarily help them?
- Evaluate the effectiveness of rumination as a coping strategy: Did it improve the situation they were ruminating about? How they feel after ruminating?
- Identify and experiment with alternate coping responses that might work better and make the patient feel better. For example, ask them to substitute a different behavior (e.g. watching a comedy). Try reducing the amount of rumination by giving themself a time limit to their rumination. If it’s too late and they’re already in the TRAP, advise them to not fight or resist the rumination. Instead, simply notice (without judgment) the felt experience of ruminating. Ask, What’s it like to ruminate? Does it feel expansive or contracted? Are there any specific sensations or areas of the body that activate when they are ruminating? How do they feel after ruminating?
- Finally, tap into the part of their brain that is designed to compare relative rewards. Evaluate all the results of any alternative behaviors compared to rumination behavior. Compare results from each behavior (positive, negative, or neutral) in the moment, versus later.
Is Estrogen to Blame?
The hormonal fluctuations in women during the teenage and perimenopausal years are a major, but not the only, influence in mood disorders. While estrogen has been the main focus of research and is strongly associated with mood, it’s more complicated than that, according to Jennifer Wood, MD.
Here’s what we do know: About one-third of gynecologists do not ask their patients about depression.
Here’s why that needs to change: Until puberty, there’s no difference in depression rates between boys and girls. Starting at puberty, female rates of depression increase to twice that of males.
Make a Safety Plan
Patients who contemplate or attempt suicide say that implementing a safety plan was the thing that made the most difference in their treatment outcome and recovery.
Stephen O’Connor, PhD, shared recent research on suicide risk and key findings that can improve how we evaluate and treat patients with risk for suicide, including action steps for helping someone in emotional pain.
How Can You Help Someone in Emotional Pain?
- Ask: Are you thinking of killing yourself?
- Keep them safe: Reduce access to lethal items, means, and places.
- Be there: Listen carefully and acknowledge feelings.
- Help them connect: Call 988 (Suicide and Crisis lifeline. A person doesn’t have to be suicidal to call, and there is a substance abuse option.
- Stay connected: Follow up.
The Suicide Assessment Five-Step Evaluation and Triage (SAFE-T)
- Identify risk factors: Note those that can be modified to reduce risk.
- Identify protective factors: Note those that can be enhanced.
- Conduct suicide inquiry: Ask them about their suicidal thoughts, plans, behavior, and intent.
- Determine risk level/intervention: Determine risk. Choose the appropriate intervention to address and reduce risk.
- Document your assessment of the risk, rationale, intervention, and follow-up. More information is at https://store.samhsa. gov/sites/default/files/sma09-4432.pdf
Other breakout sessions covered the most promising developments in these areas of mental health treatment:
- Core methods for assessing and treating cognitive impairment in mood disorders and mood disturbances in dementia.
- Evidence-based treatment strategies for depression related to trauma.
- Mood symptoms and evidenced-based interventions for improving coping and promoting well-being in patients with life-limiting illnesses.
- Core principals of interpersonal psychotherapy, evidence for its effectiveness, and examples of the diverse and widespread applications of this treatment method.