Hi Team, I wanted to start off this week by reflecting back on a couple of things that we talked about last week. If you recall, Katie asked about what was the preferred treatment modality for Narcissitic Personality disorder. And while it is true the CBT can be effective with this personality disorder, the actual preferred treatment is the psycho-dynamic model. It makes sense for a couple of reasons, one of them being that the ideal treatment time frame is 16 weeks and and since the manifestation of NPD has a huge amount to do with Freud's EGO development, it would make sense for a modality to go back early child hood development and require a much longer length of treatment. Although the ecclectic modality of drawing from different theories is often criticized for it being to generalized in nature, the beauty of social work is that we draw from the strengths of all these theories. It is also very important as a clinician not to fall in love with any one theory and always keep and open mind. Katie mentioned last week almost apprehensively that she still wants to examine freud's modality and I think we should as so many good things and understanding of early development and defense mechanisms are so important to the development of other modalities and the treatment of our patients. My guess is the reason why she was apprehensive is because the behavior science world currently is in love with the CBT model. Insurance companies love it because of it's tangibility and there is and end to treatment.
Last week, I hand you out an article on Brief therapy. Will touch base on this further. I did it as a continuum of the Crisis Intervention Model as far as time because after the CIM model it is another short term therapy that averages 4 to 6 weeks. This will most likely be on the test as a recall question. What will help you to rember it is many insurance companies will only allow the employee this amount of therapy. Team, always consider all of the financial factors when you are examining these theories because they have such a huge impact.
Okay, On to Depression. For the LICSW test, you all need to know the difference between Endogenous and Exogenous Depression. Endogenous is essentially the biochemical depression coming frome within and Exogenous is enviromental.
There are so many different angles we can go with depression. But for now, I will keep it basic. Two huge things that the test looks for in screening for depression is Appetite and sleeping Patterns, Over sleep and under sleep( usually less than 4 hours) Of course, you are always exploring suicidality, mood, affect, energy level, activity level family history, med compliance, eye contact, appearance and a multitude of other variables.
I also think depression comes in many shapes and sizes and it is a word that is unfortunately getting played out but I think it is hugely important as clinicians for us to tease out what kind of depression are we looking at. Are we looking at Major Depression Disorder, MDD, situational depression, Depression c psychotic features, bipolar disorder, dysthimia. I am actually glad that we are starting off very general with this topic because it is typically how it is presented to us and we need to become skilled at specifying and educating.
In General CBT works very well with depression. Essentially, one of the main premises of this model is that Perceptions and Cognitions determine the effects of sitiuations and emotions and behavior. The two major compenents behind people with depression tend to be Negative Automatic thoughts, images and memories, for instance, "those people don't like me or I am going to screw up this test. The other component is having cognitive distortions basically what CBT refers to as thinking errors because of thes Negative Automatic Thoughts. And some of the "Defense Mechanisms" that people c depression use are All or nothing type thinking, Catastrophising and Mind reading. Of course all of this negativity can lead to a terrible cycle of anxiety producing, hopelessness. CBT is problem focused and anxiety relieving. CBT tends to have alot of face validity c clients because of it's quick ability to relieve anxiety and it tends to be highly effective c Generalized Anxiety disorder , Panic Disorder and Agoraphobia.
I want to spend some time in depth on CBT but some of it's general goals are to Recognize Thinking Distortions, Evidence to support and disprove the distortion and and learn about alternative perspectives and to de-cotastrophize
Does anyone want to talk about some of the medications for depression, three categories that I am looking for and the test is looking for
See you guys, D
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The three different types of drugs that I know of that that are used to treat depression are Monoamine Oxidase Inhibitors (MAOIs), Tricyclic antidepressants (TCA's), and Selective Serotonin Reuptake Inhibitors (SSRIs). There is a fourth group Serotonin-Norepinephrine reuptake inhibitors (SNRIs). I think this is a pretty new group. Most antidepressants have a delayed onset of action (2-6)weeks and can be taken for months to years.
ReplyDeleteThansk for your posting it was helpful. I have never heard of Endogenous and Exogenous Depression. It is strange I have never heard of the difference, but I haven't....grad school doesn't teach everything I guess.
ReplyDeleteI never really heard of the two types of depression either. Very interesting reading
ReplyDeleteMonica, Excellent answers. Exactly what I was looking for. I am glad you took a risk a spoke of the fourth group. Team, don't let this fourth group scare you about the test. Remember the aim of this test is to make sure that as a clinician you are proficient in the skills you offer to the public you serve, not to see if you are up to speed on all the latest cutting edge treatment. That being said, it is important to always keep an element of curiosity to your practice. It just keeps you humble. Monica, I wondering if TCA's would be a good choice of medications at high risk for suicidality? And which group would patients who had heart problems use? Kasie, can you elaborate more on what is interesting to you? Katie, I am wondering if you could touch on the working c clients c depression in which you are recommending Psychiatry for medication stabalization and other recommendations you make in conjunction and walk this tight rope of the antidepressant not having a major impact for two weeks to 6 weeks; while family members and other clinicians are focused on the pt's acuity level, not considering this time line. The biggest run on sentence of all time.
ReplyDeleteghgh
ReplyDeleteThere are a ton of great thought provoking things in your post Derek... Where to start?.. Hmm... the half life of the SSRI's can be concerning as they do take about 2-6 weeks to kick in. During the initial phase, the anxiety or depression can actually worsen/heighten before finding some relief. In the ER.... if this is the case and a pt is going to begin an ati-depressant, I make sure that there is a lot of support, either with family, friends or community. If they are tiered in the community, I make sure they have an appointment, or have an appt with their PCP, or psychiatrist or therapist. If they are presenting w/depression that is so debilitating (i.e suicidal, psychosis)then I would go the route of inpt psych for med management and mood stabilization. Depression sucks...... and there is no pill that will take it allaway. I am a firm believer in adding cog behavioral therapy in conjunction with the meds. The SSRI's are usually (on average) needed for a year (DISCLAIMER... some people have to be on them their whole life). This meaning that within a year, the brain chemcials, neurotransmitter and synapses that are responsible for depression are typically stablized within a year. Some people need itlonger from a chemcial standpoint, others may be afraid to discontinue to meds for fear that the sxs will return.
ReplyDeleteBecause CBT is problem focused and anxiety relieving, this seems to be the most appealing for tx effectiveness. Psycho-analytic is needed (I think) because we have to get to the root of the depression, anxiety issues. Looking at childhood experiences (i.e trauma, neglect, abandonment (emotional or physical)) can help us understand why certain core beliefs (CBT) exist and how this contributes to our current beliefs about ourself and our world view. Tx plans are different for everyone, depending on what type of depression/anxiety they are suffering from and the route of the issue. Another huge factor to take in to consideration is drug/etoh use as a contributing factor.