Different Treatments for Different Depressions

By: Garry Cooper, LCSW

Reprinted with permission from Psychotherapy Networker magazine. Copyright, Psychotherapy Networker, Inc.

 

Diagnoses originally formulated to sharply delineate a mental disorder often grow fuzzy over time. Nevertheless, therapists can become so accustomed to them that we fail to recognize their imprecision and lack of clinical usefulness. Depression is a good example. Evolving research indicates that even the current DSM breakdown of depression into major, dysthymic, recurrent, single episode, and not otherwise specified doesn’t adequately describe the condition, and that a clearer conceptual map of depression is needed to help therapists make better treatment decisions, tailored to each individual client.

Using brain imaging to study the brains if depressed persons, Emory University neurologist Helen Mayberg has found at least three different neural pathways for depression. Mayberg says that diagnosing depression is like diagnosing a weak arm for someone. “A lot of things can give you a weak arm,” she says, “but you’d never suggest the same treatment for everyone with a weak arm. You have to understand what’s causing it.” Many new depression researchers believe that the key to more sharply diagnosing and treating depression may lie in better history-taking, a more precise neurological roadmap, or both.

Mayberg has used brain scans to find out how antidepressants and cognitive behavior therapy (CBT) affected the brains of people who responded positively to their treatments. Published in the January, 2004, Archives of General Psychiatry, the study results indicate that people who undergo 15 to 20 sessions of successful CBT show decreasing brain activity in the frontal cortex—the “higher” level of the brain linked to how we think about ourselves. This decrease in higher-brain activity translates into less brooding and less likelihood of responding to negative circumstances with self-critical thinking, which are the kinds of changes that CBT promotes. Mayberg’s brain scans reveal that the dampening down of these brain regions then leads to increased activity in the more primitive limbic system, where emotions are brewed and memories formed. As these brain changes occur, people are more likely to take action, to respond with emotional energy, and to learn new ways of responding to negative situations. The brain scans of successful CBT clients thus reveal a top-down action—a decrease in higher-level negative thoughts and an increase in lower-level emotional energy.

In contrast, the brains of people whose depression improved with paroxetine show decreased activity in the more primitive brain regions, followed by an increase in the higher, cognitive levels. These may be the people who, before treatment, respond to negative situations more viscerally than cognitively. This visceral reaction may flood the higher brain levels with negative affect and fuel negative thoughts. By decreasing activity in the primitive, limbic brain centers, antidepressants may shut off the negative emotional ignition and free the cognitive levels to make more accurate appraisals of events.

The different actions of medications and CBT, says Mayberg, may explain why some depressed people do worse on antidepressants: if you give antidepressants to someone whose depression is triggered by higher-level negative thinking, the medication may actually increase the depressed or anxious thoughts, while suppressing the emotional energy of the limbic brain areas.