Examine biomedical, individual and group approaches to treatment
Biomedical treatment of depression
The biomedical approach to treatment is based on the assumption that if a mental problem is caused by biological malfunctioning, the cure is to restore the biological system with drugs. For example, the serotonin hypothesis of depression suggests that depression is linked to low levels of the neurotransmitter serotonin Antidepressant treatment should therefore aim to regulate serotonin levels.
Anti-depressants are often used in the treatment of bulimia nervosa because some patients also suffer other disorders such as depression (co-morbidity).
Anti-depressants are also used to treat minor depressive symptoms but the American Food and Drug Administration (FDA, 2004) warned that use of anti-depressants for children and adolescents could perhaps lead to an increased risk of suicide.
Selective serotonin re-uptake inhibitors (SSRI)
Drugs that interfere with serotonin re-uptake (SSRI) are used in the treatment of depression. They interfere with serotonin levels and affect mood and emotional responses positively in most people. Anti-depressants normally take seven to 14 days to relieve depressive symptoms.
Currently the most widely used drugs are SSRI. They all increase the level of available serotonin by blocking the reuptake process for serotonin. This results in an increased amount of serotonin in the synaptic gap. The theory is that this increases serotonergic nerve activity leading to improvement in mood in depressive patients.
SSRI are popular because they have fewer side effects than previous drugs such as the tricyclic antidepressants but not everyone can use SSRI. The most common side effects are headache, nausea, sleeplessness, agitation, and sexual problems.
Neale et al. (2011) conducted a meta-analysis of published studies on the outcome of anti-depressants versus placebo. The study focused on: (1) patients who started with antidepressants and then changed to placebo, (2) patients who only received a placebo, and (3) patients who only took anti-depressants.
The study found that patients who do not take antidepressants have a 25% risk of relapse, compared to 42% or higher for those who have been on medication and then stopped it.
According to the researchers, anti-depressants may interfere with the brain’s natural self-regulation. They argue that drugs affecting serotonin or other neurotransmitters may increase the risk of relapse. The drugs reduce symptoms in the short term but, when people stop taking the drug, depression may return because the brain’s natural self-regulation is disturbed.
In individual therapy, the therapist works one-on-one with a client. One of the most widely used individual therapies is cognitive behavioral therapy (CBT).
The therapy is linked to Beck’s explanation of depression where automatic negative thinking is assumed to cause depression. CBT aims to change negative thinking patterns (cognitive restructuring).
CBT includes around 12 to 20 weekly sessions combined with daily practice exercises, with a focus on helping people with major depression to identify automatic negative thinking patterns and change them.
How CBT works....
Step 1: Identify and correct faulty cognitions and unhealthy behavior (cognitive triad)
The therapist encourages the client to identify thinking patterns associated with depressive feelings. These false beliefs are challenged (reality testing) to give the client the possibility to correct them (cognitive restructuring).
Step 2: Increase activity and learn alternative problem solving strategies
The therapist encourages the client to gradually increase activities that could be rewarding such as sport, going to concerts, or meeting other people (behavioral activation).
Paykel et al. (1999) conducted a controlled trial of 158 patients who had experienced one episode of major depression. The patients received antidepressant medication but some of them also received cognitive therapy. The CBT group had a relapse rate of 29% compared to those who only had medication. Paykel argues that cognitive therapy appears to be effective to prevent relapse, particularly in combination with medication.
How CBT works in treating bulimia (Fairburn, 1997)
CBT is considered the best psychological treatment for bulimia. The treatment involves:
· replacing binge eating with a pattern of regular eating (three planned meals and two planned snacks) and trying to avoid vomiting or other compensatory behaviors
· therapy sessions with the client and later with important friends and relatives who will support behavioral change
· therapy sessions that address both behavior (e.g. food that provokes anxiety or desire to binge and purse) and cognitive distortions (e.g. concerns about weight and body shape)
· maintenance of the program and considerations of strategies to prevent relapse.
Does it work?
Hay et al. (2004) studied the effectiveness of CBT in the treatment of bulimia and binge eating. The aim of this metaanalysis was to evaluate the effectiveness of CBT, and a specific form of CBT developed for the treatment of bulimia (CBT-BN). The study showed that CBT was an effective treatment for eating disorders. CBT was effective in group settings. CBT-BN was particularly effective in the treatment of bulimia but also other eating disorders that involve bingeing.
Wilson (1996) reported that 55% of participants in CBT programs no longer purged at the end of therapy, and those who continued to purge did so much less (86% reduction in purging).
Fairburn et al. (1995) found that after nearly six years, 63% of the participants in their study had not relapsed.
Interpersonal psychotherapy (IPT)
· Klerman et al. (1984) developed IPT as a short-term, structured psychotherapy for depression, but it has been adapted for bulimia nervosa by Fairburn et al. (1993).
· The aim of the therapy is to help clients identify and modify current interpersonal problems as these problems are assumed to maintain the eating disorder. The therapy does not focus directly on eating disorder symptoms.
· Elkin et al. (1989) found that IPT was effective in relieving major depression and to prevent relapse when treatment was continued after recovery.
· Fairburn et al. (1993) compared IPT with CBT and found that IPT was less effective than CBT at post-treatment, but follow-up studies after one and six years found that the two treatments were equally effective.
In group therapy, the therapist meets with a group of people (e.g. a family or a group of individuals suffering form the same disorder). Group therapy is generally less expensive than individual therapy. Group therapy based on mindfulness is becoming increasingly popular and studies indicate that it may be a useful approach.
An example of group therapy is.....
Mindfulness-based cognitive therapy (MBCT)
MBCT to treat depression
MBCT is based on Kabat-Zinn’s mindfulness-based stress reduction program. The MBCT is developed by Segal, Williams and Teasdale (2001).
The aim of this psychosocial group-based therapy is to prevent people becoming depressed again (relapsing) after successful treatment for major depression.
How MBCT works....
· MBCT is based on Buddhist meditation and relaxation techniques. These help people to direct their focus and concentrate so they are able to observe intrusive thoughts and gradually become more able to prevent the escalation of negative thoughts.
· The goal of MBCT is to teach people to recognize the signs of depression and adopt a “decentered” perspective, where people see their thoughts as “mental events” rather than something central to their self-concept or as accurate reflections of reality.
Kuyken et al. (2008) Randomized controlled trial of MBCT and anti-depressive medication
· The study investigated the effectiveness of MBCT in a randomized controlled study with 123 participants with a history of three or more episodes of depression. All participants received anti-depressive medication.
· Participants were randomly allocated to two groups. Over the 15-month study, the control group continued their medication and the experimental group participated in an MBCT course and gradually diminished their medication.
· People in the control group who received anti-depressive medication had a relapse rate of 60% compared to the experimental group of 47%. Participants in the MBCT group overall reported a higher quality of life, in terms of enjoyment of daily living and physical well-being. Antidepressive medication was significantly reduced in the MBCT group and 75% of the patients stopped taking the medication.
MBCT for bulimia....
Mindfulness-based treatment of bulimia Proulx (2008) used an eight-week mindfulness-based intervention to treat six college-age women suffering from bulimia. Participants were interviewed individually before and after treatment. They all reported that they could control emotional and behavioral extremes better after the treatment and had reached a greater self-acceptance. Generally, they felt less emotional stress and were more able to manage stress and the symptoms of bulimia.