Cognitive Behavioral Therapy (CBT) Interventions for Depression Treatment and Mental Health

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you I'd like to welcome everybody today's presentation on social work and case management issues in the management of depression. I am your host, Dr. Donnelly Snipes. We are going to define depression symptoms and learn how to ask strength based assessment questions. And then we'll identify a range of potential causes for depression and explore activities interventions that can help people address some of the underlying causes of depression. So depression represents a cluster of symptoms, as we well know. And diagnosis with depression only requires people to have a few of those symptoms. So you may have three different clients who have three different relatively different depressant depression presentations. Some may have difficulty with sleep while others don't. Some may have difficulty with appetite while others don't. Some may have more irritability, some may have more lethargy. So we really want to be individualized when we are presenting solutions for clients. And we need to remember and remind clients that depression often indicates the loss of something important. Now this is more situational depression. People who are dealing with chronic, chronic major depressive disorder, there may not be a particular loss. It could be a neurochemical imbalance. Depression itself, just like any other emotion, is not necessarily bad. It can cue us that we've lost something important that we may need to grieve. It also can cue us that there may be something wonky, for lack of a clinical term going on that may be contributing to our body's inability to stabilize the neurotransmitters as well as it normally does. A variety of different things can cause depression. You know, emotions can cause depression. We talked last time about how the fact that most emotions are not singular, we don't just feel depressed, we don't just feel angry. We generally have multiple emotions in there. And the emotion that we are displaying is sort of like the tip of the iceberg. Anger. When we are angry for too long, we tend to get in this negative mindset. And it can when we keep our HPA axis activated because of anger or anxiety, we can start to feel worn down and exhausted and we can start to suffer from the side effects of an elevated HPA axis, including sleep deprivation. So anger and anxiety are two things that can contribute to depression. And we don't want to forget those. We don't want to just help people try to feel happier. You know, that's great, but it is pretty invalidating In a lot of ways, we want to look at what is contributing to the neurochemical imbalance that is causing these symptoms. Grief, guilt and shame are three other feelings that can coincide with depression that we may need to take a look at. Cognitive distortions can contribute to depression. When we see the world, when we think of the world in terms of things are against us, things are negative, we're helpless, we're hopeless, then guess what? We're probably going to feel depressed because one of the key features of depression is helplessness and hopelessness. When we are seeing things in all or nothing terms, we may feel very disempowered. So we're going to talk about how to help people adjust their cognitive thinking styles. Relationships, including self Relationships like poor self esteem can contribute to depression. If people feel hopeless that they're lovable, they don't think they're lovable, they don't think they can change, they don't think they'll ever be lovable. Unhealthy and unsupportive relationships can trigger fears of abandonment and a need for external validation, which often goes back to that. Low self esteem can also contribute to depression. If you don't can't look in the mirror and say I'm good enough and you're relying on other people to do that, then when that doesn't happen, because that's not going to happen all the time, you may start feeling that fear of abandonment, fear of rejection and helplessness and hopelessness to be loved physically. Neurochemical imbalances caused by a variety of things and including poor nutrition, exhaustion, insufficient sleep, medication, side effects, traumatic brain injury. There are a lot of things that can throw our neurotransmitters for a loop and contribute to depressive symptoms and environmentally high stress. Environments that prevent relaxation and rest and increase hopelessness and helplessness also contribute to depression. One of the things we want to do when clients come into our office and this is one of those culturally sensitive responses as well as strengths based, ask them what depression means to them. What caused it? Where did it come from? What do you think is making it worse when you say you're depressed? You know, some people come in and they say, I'm depressed. And okay, you know, you're depressed. I'm glad you're here. Tell me how you know you're depressed. What symptoms do you have that tell you that you're depressed? Which symptoms are most bothersome for you and why? Because sleep disturbances, they may not see that as super bothersome, but excessive guilt may be something that is causing them a lot of problems. Now obviously the apathy and lack of pleasure is going to be an issue for a lot of people. But a lot of clients that I've talked to who come in with self diagnosed depression report that fatigue and the psychomotor retardation or the slowing and heaviness they feel. And sometimes the pain is more problematic than just not being able to feel a sense of happiness or joy. Because that fatigue and that heaviness and lethargy negatively impact so many areas of their life. It's important to understand what's prominent for the client. How is life more pleasurable? Pleasurable, wow. Prior to you getting depressed, if people have had multiple major depressive episodes, then we want to know when you're not depressed, what's different? What's more pleasurable? If they are experiencing situational depression as a result of a loss or a divorce or something, we want to look at that. We also want to look at things like maybe they say before I started getting really depressed, I was going out hiking, you know, five times a week or something. That's a lot of hiking. But you get my point. They were outside and then they got caught up with a lot of stuff at work and it's been raining outside so they couldn't go hiking. Oh, well, let's. How long has that been going on? Because we know that lack of sunshine and lack of vitamin D messes up circadian rhythms and is associated with seasonal affective disorder which has symptoms of depression. So this gives us some ideas where we can start looking at what is it that you do when you're not depressed? How is it different now that you are depressed? And how do you expect life to be different when your depression is gone? What things do you want to start doing again? What things do you have hope will bring you joy and that really gets people looking forward to the end goal. What is life going to be like? Why is it worth the effort to make these changes that I need to make or do this hard work that I need to do? Because therapy is hard work. And we come back a lot of times again to neurotransmitters. When the neurotransmitters are out of balance for whatever reason, people are going to have a variety of different symptoms. Your neurotransmitters, dopamine, serotonin, norepinephrine, acetylcholine, gaba, serotonin are all important to have in order to help people feel happy, to help them feel relaxed, to help them get good sleep, to help them Concentrate and learn things to help them have motivation to give them energy. Oh, glutamate is the other neurotransmitter. I knew I was forgetting one. To help modulate their pain, to help prevent irritability and agitation. And neurotransmitters are also really active. When that HPA axis is activated, cortisol is released, which triggers the release of glutamate, norepinephrine to prepare the person to fight or flee. When those neurotransmitters are out of balance for whatever reason, then people are going to have difficulty with some of these very basic life issues or life tasks, if you will. HPA axis hyperactivity. Now remember, HPA axis is just the short term for our body's stress response system. When it is hyperactive, it causes the release of inflammatory cytokines. We've talked about this before. Which are really meant to help you, you know, you think. Why is inflammation ever helpful? Well, generally the HPA axis is activated when there's a threat. And in the immediate, the acute phase of this HPA axis activation, the cortisol actually acts as an anti inflammatory, which is awesome. And then when the threat is passed, the HPA axis causes the body to secrete inflammatory cytokines that are supposed to circulate throughout the body. Find anything that might have been damaged, increase inflammation and help it get better. Bring blood to that area to nourish it and help it heal. Well, when the HPA axis is activated for too long, eventually the body says, well, we got to repair the cortisol. Still saying hi, but I've got to start repairing and keeping the body going even if the stress is going to stay. Think about again, a soldier in a war zone. At a certain point, it's not like they go out, they fight a skirmish, they come back and they just start popping back. Cokes or beers or whatever. They're drinking and everything's relaxed, they are on the go. But their body still has to repair, despite the fact that they can't relax during that time. Because it's not safe to completely relax when those inflammatory cytokines are secreted throughout the body. One of the other interesting things that happens is that it causes symptoms of depression. And we know that there is a strong correlation between depression and inflammation. And one of the reasons is inflammation is the body's way of breaking down tissues and whatever else needs to happen and creating energy to repair whatever has been injured. So the body is diverting any energy from other things like mood in order to help the person repair their body. So they may feel lethargic, they may have reduced locomotor activity or psychomotor retardation, as the DSM calls it. They may have altered food intake and an increased need for sleep. Now, they may not be getting good sleep, but they may have an increased need for sleep. And all of this is because the body is trying to conserve energy. They're saying, you know, we got to find energy somewhere. Even if you can't relax. We got to pull from the energy reserves in order to repair the things that have been broken down. What can we help people do now? We're going to talk about some cognitive interventions in a few minutes, but let's start by just doing some basic lifestyle medicine is what is now being called in PubMed lifestyle medicine interventions to help reduce that HPA axis activation to help the body relax. So it's not using energy, still staying hyper vigilant. And it can use that energy for repairing so it's not having to borrow from a bank account that's already, you know, empty. Get quality sleep. And you see all these hyperlinks in the PowerPoint. These are all the studies that, you know, highlight these different points. And you see there's a lot of blue on this slide because there is a really strong correlation between crappy sleep and crappy mood. People need quality sleep. Sleep deprivation increases the risk for major depression and major depression increases the risk for bad sleep. It's this downward spiral. We need to help people figure out how to break that. Sleep disturbances contribute to inflammation and major depression. Additionally, increased HPA axis activation alters or creates sleep deprivation. And we see that after somebody is sleep deprived, they have an elevated HPA axis. Let's think about why this is somebody sleep deprived. They didn't get enough sleep last night, they wake up, their body says it's daytime, it's time to be alert. And their cortisol levels are kind of out of whack. The HPA axis says, oh, you need energy. I guess I need to ramp up a little bit to help you have energy so that HPA axis goes into overdrive. Help people create a sleep routine. Remind them or educate them about the problems with blue light, especially within two hours of bedtime. And that includes not only their digital devices, but their overhead lights. If they've got a lot of the cool or daylight bulbs in their area that they spend their evening hours in, encourage them to think about switching those out to at least softer white bulbs. If not, some bulbs that have a slightly yellow tint to them, reduce stimulants including caffeine and nicotine before bed, encourage people to address pain. We don't sleep well when we're in pain, whether it is a kink in your neck or your bed's not comfortable. My puppy was up on the bed the other night and somehow she managed in king size bed. Little puppy, well, she's like £30 now, but she's still a puppy. Managed to scoot me over to the very, very edge of the bed and I am sleeping in this contorted position and I am very uncomfortable but, but I don't want to go through all the trouble of moving at 2 in the morning or whatever it was. So was I getting good quality sleep at that point? No, because I was uncomfortable and that was just mild discomfort. If you're talking about somebody who has chronic pain, fibromyalgia, something like that, then it may be worse when you have an upset stomach. And I think a lot of us have experienced that. You know, you eat something that's a little different at night and your tummy gets all rumbly tumbly before you go to bed and you have a little bit of a stomach ache that actually can keep you awake or impair your sleep throughout the night. If you have a fitness tracker, you can look at your heart rate throughout the night and you can get an idea about whether you might have been experiencing pain. I know when I'm over trained or if I'm experiencing pain for some reason, my heart rate tends to be fair bit higher. It tends to be about 10 to 15 beats higher per minute throughout the night and that tells me that I probably wasn't getting good restful sleep. Sleep apnea is repeatedly associated with not only increased activation of the HPA axis and increased cortisol levels, but also increases in depression. Continuous positive airway pressure or CPAP machines have been found to be very helpful with with reducing apnea problems. Encourage people to improve their sleep environment. A lot of people don't think about the fact that their snoring spouse may be impairing their sleep. And am I advocating for everybody to sleep in separate bedrooms? No, not necessarily, but I am advocating for considering earplugs. If your spouse snores or significant other snores or your dog snores. It is helpful to encourage deep sleep if you can have a quiet environment. If you live in an area like New York City or somewhere where there's a lot of street noise that your windows can't quite block out, using a white noise machine can be extremely helpful because at Least that's that constant noise, whether it's the. My daughter has chirping crickets that she has going on constantly, and that's her white noise. And that works for her. She habituates to it and goes to sleep. We want to make sure that they get rid of allergens. HEPA filters, really helpful hypoallergenic pillows, anything to help them not wake up in the middle of night coughing. But they've also found an association between allergic rhinosinusitis, you know, stuffy noses and poor sleep and depression. It's important that you can breathe when you're sleeping, even if it's not because of apnea. The light in your sleep environment, your sleep environment should be as dark as possible. And if there has to be light for some reason, a red light, something that doesn't have the blue colors in a yellow light. Even better, in order to preserve your night vision and not make your brain think that it's time to get up. If people have night terrors, or for children who are afraid of the dark, having a tap light by their bed, something that they can easily just reach over and smack. You know, when you have a lamp by your bed and you have to try to reach up and find the little knobby thing, if you're stressed out, if you're freaked out because you had a nightmare, that ain't gonna work. But if you have something that people can just reach over and smack, generally, that is a reasonable compromise to the presenting issues. And temperature. There are beds now that you can get. They're expensive, that can help regulate temperature. I don't know how well they work. There are some that have a tube that goes up under your sheets and blows air. You know, basically circulating air underneath your sheets all night long to keep you from getting hot and sweaty. Whatever you can do to regulate your temperature is also helpful. And what temperature is comfortable for you to sleep is. It's variable between people. I tend to like to sleep on the much cooler side, whereas some people, like 68 to 72 is, I think, what the Sleep foundation recommends. Other factors that can impact sleep shift work. It takes people at least 30 days to adjust to a switch in shifts. And this can only be a switch in shifts of about three hours is not, you know, going from morning shift to midnight shift. It's important that when people are on a shift that they maintain that shift, even on their days off, in order to help stabilize their circadian rhythms. And that is sometimes not realistic for life outside of people's work. And they're not willing to do that. And it is important to encourage them to consider what alterations that they can make or are willing to make while they are in the recovery process in order to help them alleviate their depression. Can they go to day shift? Would be the first thing that we might ask. If people travel between time zones, pilots are a perfect example of this. They are at much higher risk for depression because their circadian rhythms. If they start over on the east coast and they end their day over in California, their circadian rhythms are going to be completely out of whack. And then they fly the next day and they land in Nashville, which is splitting the difference. Helping them understand the importance or the impact of regularly switching time zones on their circadian rhythms and advocating and encouraging them to figure out how they want to handle it. Like I said, not everybody is going to be able to change something. A pilot's not going to be able to say we, well, I can only fly on the east coast, but what can they do and empower them to be creative? Safety and ptsd, I kind of put those together. When people go to sleep, they want to be able to relax. In order to relax, they need to feel safe. People who have a history of PTSD often have difficulty feeling safe, difficulty not being hypervigilant, or which negatively impacts their sleep quality and can contribute to concurrent depression. Helping people figure out what they need. Now, emotional support animals are super helpful with this. There are a variety of other interventions that can be helpful, but it comes down to asking the person, what would help you feel safe when you close your eyes? Interestingly enough, antidepressants can also cause depression. Really? Yes. We know that antidepressants are not the panacea that, you know, some of the pharmaceutical companies might want us to think they are. They work for 20 to 30% of the population. But for the other 60 to 80%, 70 to 80%, the antidepressants may not be super effective. Additionally, many antidepressants with activating effects, like Prozac, is one that is known for its activating effects. It's supposed to help people who have depression and fatigue have some more energy that can disrupt sleep. They found that people who take those may have less deep sleep because they are hyperactivated. The antidepressants that have sedative properties, some of those antidepressants like Paxil that tend to make people sleepy may improve sleep initially, which is really awesome. But it may cause problems in the long term due to over sedation. Talking with clients, encouraging them to advocate for Themselves with their doctor about what's working, what's not. If they're taking this drug and it helps them sleep, but they just can't wake up throughout the rest of the next day and they're pounding back coffee, that's defeating the purpose. They're actually probably causing more problems. Encouraging them to advocate for themselves. Sometimes doctors will start with changing the dosing time. My stepfather used to take Paxil in the evening before he would go to bed because it would help him get sleepy. But he would take it early in the evening. So when he woke up 12 hours later, it wasn't still as prominent in his system and didn't have overly sedating effects. So sometimes that can work. Other times, people may have to consider trying a different antidepressant. There are dozens of them out there. And encouraging patients not to give up if the first antidepressant doesn't work for them, but they really feel like they need one. Relaxation is another non pharmacological way to reduce HPA axis activation. Biofeedback has been shown repeatedly to be really helpful. And it can be as simple as getting a fitness tracker or a chest strap that monitors your heart rate and encouraging people to spend a little bit of time each day focusing on trying to reduce their heart rate, you know, deep breathing and seeing how when they breathe deeply and slowly, it actually slows their heart rate. They start feeling a sense of empowerment because they realize that they can control some of these symptoms. Then when they start feeling anxious, they have this sense of personal efficacy that, okay, I'm hyperventilating here, I need to belly breathe and I need to focus on slowing my breathing down because that will make my heart rate go down. That sense of personal control over your body goes a long way towards reducing feelings of helplessness and hopelessness. It also helps reduce any HPA axis activation sooner. You know, if somebody gets anxious, we don't want them to stay anxious for four hours because that's going to contribute to depression. We want to help them, you know, recognize that, okay, I feel angry, I feel anxious, Feelings are normal. That HPA axis kicked off just like the fire alarm goes off and says, check to see if there's a threat. But with biofeedback, that allows them to check and then relax afterwards. Progressive muscular relaxation, meditation and yoga have all been shown to help with reducing HPA axis activation and reducing symptoms of depression. Recreation therapy, and that is broad, everything from art therapy to playing ball to checkers, Anything that's recreation oriented, that can be kind of fun that helps people divert their attention or from a stressor to something that might be at least mildly enjoyable. Has been shown to reduce HPA axis activation and reduce symptoms of depression. Forest and ecotherapy have also both been shown to be very helpful at reducing depressive symptoms in adults. I didn't see any studies on children, but basically this is encouraging people to be exposed to nature, to get away from the, you know, digital things, to get away from the tv, to get out in nature. Because nature tends to go more slowly and people tend to be more relaxed when they are out in, out in nature, out in the forest, hiking, you know, or even just going through a park where there's a lot of greenery. They found that there's a pretty positive correlation between the amount of greenery and nature and people's moods. So it's kind of an interesting little side effect with that. People can arrange their home environments to be a little bit more eco friendly, if you will, have a place in your house. Most people have a place where they can have a couple of plants or a window that looks out onto a landscape, little area. It doesn't have to be this huge landscape, but looks out onto this little garden area that they can appreciate. We also want to look at other medication side effects and we often forget to consider these things when we are doing our assessments with people. We already talked about psychotropics and there's a lot of other psychotropics out there. The atypical antidepressant, not atypical. Atypical antipsychotics tend to be extremely sedating to people. Some people will experience rebound anxiety when they take benzodiazepines, which can contribute to their depression. People are the best judge of what medications are working best for them and which ones make them feel worse. And we need to listen. However, other things that are not even, you know, identified as mood altering drugs have been associated with increasing people's risk of depression. Beta blockers, which are used for high blood pressure, statins, which are used for high cholesterol, anticholinergic drugs. Well, you're like, what are those? Those are the ones. They're used pretty ubiquitously actually for bladder problems, Parkinson's disease, copd, asthma and motion sickness, to name a few. They can also be used some for allergies. But it's important to recognize that some of these physical conditions people may be getting medicated for. We need to understand the impact that those medications are having on their mood. They may not be able to stop, stop taking that medication, but we need to help them identify if. Okay, When I started taking this statin, my mood went into the toilet. I know with motion sickness medication. Oh, that's a doozy on my mood. I can tell you what, I can't take it because it's just, I would rather be motion sick than feel the way I feel after I take the. Whatever it is. Dramamine. Not everybody may be as sensitive, but it's important for people to understand what causes it and talk with their doctor about how to address it. Opioids depress the system. They tend to slow respiration. They make pain go away. But they have a lot of other side effects. When we are not breathing enough, when we have shallow breathing, we tend to feel more lethargic and tired, which is one of those symptoms of depression. Corticosteroids like prednisone increase people's risk for depression as well as certain antibiotics. Who knew Levofloxacin and ciprofloxacin. Ciprofloxacin is also known as Cipro. Most of us have taken it or are familiar with it. Both of those are uniquely associated with potentially triggering or exacerbating depression most of the time. There are other antibiotic alternatives if your clients are sensitive to that. And then birth control or hormone replacement therapy, and this is specifically for women, they haven't found depressive side effects of testosterone therapy. They do have seen people with low testosterone experiencing symptoms of depression. But people who take birth control, including the implanted progesterone birth control, do have higher rates of depression. Some people are more sensitive than others. Encourage people to improve their nutrition. Remember, the neurotransmitters that help us feel happy and focused and energetic are made from the foods that we eat. If you're not eating, your brain's not getting or your body's not getting what it needs to make those neurotransmitters. Well, what might be preventing clients, except for just apathy, they may not have good access to nutrition if they can't drive, because they've lost their license, because the nearest store is 15 miles away, because they are elderly and are afraid to drive from whatever reason. If they can't get to it, they can't ingest it. There are a lot of places that will deliver fresh groceries as well as places like Meals on Wheels that can deliver to homebound people. Affordability is another thing that prevents access to good nutrition. Your healthiest foods tend to be the most expensive. Unfortunately, we need to help people figure out, where am I going to spend my. My nutrition dollars? Where I'M going to. I can spend my grocery budget and encourage them to learn about growing their own vegetables. We can grow a lot of things hydroponically now using the Kratky method. It's K R A T K Y I believe, which doesn't require anything but like a kitty litter bucket, some styrofoam, some water and some seeds. I mean it's really easy. You can do it without, you know, having to break the bank. And people can grow things. I grow a lot of my green leafy vegetables hydroponically and you can do that in a, in an apartment. So there's no excuse for. Well, I don't have a backyard. You don't need a backyard. And even a little bit. And sprouts. Your broccoli sprouts and other kinds of sprouts. Your microgreens have 200 to 400 times the some of the cancer fighting and health benefiting chemicals in them. If they're willing to sprout, then that is something else they can consider. I don't really like the taste of sprouts myself. They tend to taste too radishy to me. But some people love them and if they're willing to sprout and eat them, anybody can do that. It takes one ball jar and a little bit of time every day. Some people don't have access to good nutrition because they don't know how to cook. And yes, you can buy some frozen frozen dinners and things like that that are somewhat, you know, they have, they're colorful. But people may get bored with that. And frozen dinners tend to be more expensive. We can help them learn how to cook rice and beans. We can help them learn how to cook affordable healthy meals. They are not that hard to do. Encourage people to be. And yes, planning ahead also helps with eating more economically and healthier. Great point, Barrett. When we are hungry, we tend to want something that is really, we can do fast. And rice and beans is not something you can cook quickly unless you already pre cooked the rice and pre cooked the beans, which is what I do on Sunday. On Sundays I pre cook pasta, rice, beans and lentils. I'm vegetarian so I don't have any meats in there. And then throughout the rest of the week I can put things together to make different types of dishes and casseroles and things like that. So pre planning definitely helps. Getting people excited about cooking is also helpful and group activities. This is a great activity for recreation therapists to help people learn different dishes that they can make, different casseroles, you know, focus on one dish meals if you want to, so there's less to clean up. Encourage people to be aware of nutritional principles. Their macros, your proteins, carbohydrates, fats, you know, those are the big things that you're considered considering. Most of our neurotransmitters are made from proteins. They break down different proteins, but in order to break those proteins down, they need vitamins and minerals like calcium and iron and zinc and selenium from the other foods. You can't just eat protein alone. People need to eat colorfully, try to have three colors on their plate at every meal. Hydration with as little as 2% dehydration and you're not even really feeling super thirsty when you're 2% dehydrated. 2% dehydration has negative effects on your feelings of vigor, your mood, your short term memory and your attention span. Drink water, preferably clear water with a little bit of lemon if you want to encourage people to brainstorm ways they can start ingesting more fluid, especially non, non sugar, non caffeinated and ideally non carbonated fluids. Aspartame has been associated, and we know that as NutraSweet has been associated with increases in headaches and irritability in certain aspects of the certain segments of the population. Not everybody is going to experience it, but some may. So if people have been eating, drinking a lot of aspartame, it's important for them to be aware. And if you look on the side of the drinks like crystal light and things like that, a lot of them unfortunately still do have NutraSweet in it. And it's going to be important for clients to recognize how that NutraSweet impacts them, their mood, their energy, and whether it gives them headaches. People who quit drinking it, they were drinking it, you know, they had a weekend that they were out at their in laws or whatever, they drank a bunch of it and then they came home and switched back over to a different no calorie sweetener. They also may start having headaches and feeling lethargic while their body detoxes that aspartame out of their system. Again, not everybody's going to experience this, but it is one of those triggers that is worth noting because it does affect enough of the population. Addictive behaviors, altered dopamine, serotonin and norepinephrine levels and different addictions alter different neurotransmitters. Stimulants are going to ramp up that dopamine and your norepinephrine and your glutamate it's going to get you excited and then you're going to crash. Depressants tend to increase levels of GABA and dopamine in our systems. Alcohol is kind of interesting because initially it serves as a depressant and a relaxant, but then as it exits the body, it, it actually causes anxiety. The body can't keep up. It leaves the body faster than the body can secrete GABA to balance it out. So we do see people experiencing anxiety on this detox end, on the sobering up end of drinking alcohol, gaming and gambling produces pleasure. It produces excitement. Excitement means increased HPA activation, increased cortisol levels. You know you're trying to win that game, whatever it is, which can also result in sort of a dopamine hangover the next day, if you want to think about it that way. Same thing with sex and pornography in an addictive fashion. When it's used addictively, when it's used too much, it can alter the levels of neurochemicals in the brain, which can contribute to mood disorders. Thyroids also impact mood, libido and energy levels as well as estrogen and testosterone. It's not hard for people to go to the doctor and get a test for their sex hormones and their thyroid hormones to see if they are in balance. Even if they are in balance and in normal range, not everybody feels great when they're hormones. Whatever hormone it is is in normal range, especially if it's like at the low end of the normal range. Well, low end of normal may be fine for some people, but that may be too low for others. Having clients learn the numbers and learn where they feel good and where they don't feel good can be important. And having them work with an endocrinologist that understands that, you know, those, that normal range is just a guideline and not everybody feels great there. A lot of your newer physicians are starting to understand that those ranges are simply guidelines. Cortisol is that hormone that's released by the adrenal glands and during the fight or flight situation when the HPA axis is activated. It helps the body adapt to stress by increasing heart rate, respiration and blood pressure, and by impacting serotonin and norepinephrine levels. Cortisol alters the norepinephrine levels. It alters our serotonin levels. Norepinephrine and serotonin are two of the primary neurochemicals involved in depression. What are our antidepressants? SSRIs, selective serotonin reuptake inhibitors and, and SNRIs, selective norepinephrine reuptake inhibitors. So if we're monkeying with either one of those, it's likely that we are going to affect our mood. Normally, cortisol levels increase early in the morning to prepare us to meet the demands of the day and gradually decrease throughout the day. This is our circadian rhythm. Not only does cortisol do this, but our circadian rhythms influence our feeding hormones, our sleeping hormones, our stress hormones, everything. We want to make sure that we pay attention to that. DHEA can also impact our mood. DHEA naturally declines in people as they age. It doesn't mean that everybody needs to take a DHEA supplement. And the supplements that they sell over the counter are like 100 to 500 times stronger than what your body actually needs in 99.99% of the cases. This is another one I would not recommend people trying to self medicate, they really need to see an endocrinologist. But that aside, if DHEA levels are low, then their libido and sexual arousal may be low, they may be low in motivation, they may not have a great sense of well being, they may experience more pain, not sleep as well, and have difficulty with memory and immune system functioning. So there's a lot of symptoms of depression that are related to DHEA levels. So we're seeing how depression itself is not something that is so simple to treat. Have people get a physical to address what may be causing any imbalances. Encourage them to talk with their doctor about eating a low glycemic diet so their blood sugar is not going up and down all the time, which can make you feel fatigued and remember, the less sleep you get, the higher your cortisol will be, the more sleep you get, within reason, the lower your cortisol will be. Deep sleep tends to reduce cortisol levels, your rapid eye movement sleep, not so much. So we want to make sure people are getting quality sleep. Hormone imbalances affect millions of people and symptoms of hormone imbalances are very similar to depression and include feeling anxious, tired, irritable, weight changes, not sleeping well, changes in sex drive, focus and appetite. Causes for hormonal imbalances include poor gut health, inflammation, high amounts of stress, genetic susceptibility, we know that that exists, and toxicity from heavy metals and other chemicals. If people are trying to eat relatively healthfully and if they're drinking enough water, they can minimize some of those things. Natural treatments include eating an anti inflammatory diet, consuming enough omega 3s, getting good sleep, exercising and controlling stress. So these Are some of our lifestyle factors that may help. People who experience pain need to help control that. And they can do that with exercise, guided imagery, progressive muscular relaxation. We already talked about that one. Alternate focus. When we're in pain, if we focus on what hurts, we're just going to exacerbate that. If we try to focus on something else, then it can help divert our attention. I always grab towards my ear when I, when I do this demonstration because when I get an earache that is like one of the worst pains I think that exists in the world. And if I can focus on something else, it helps me tolerate the pain a little bit more. TENS therapy, physical therapy, hydrotherapy, which is, you know, water baths or hot tubs, ice or heat and hypnosis and EMDR have all also been effectively used with pain. We may not be able to help our clients eliminate their pain, but we can help them identify problem solving strategies to mitigate their pain and help them address their cognition surrounding pain. If they're having cognitive distortions like I will always be in pain, I can never feel pain free or, you know, any of the all or nothing or exaggeration things, I can't tolerate this. We can help them work on their distress tolerance skills and their distress tolerance verbiage and change what they're telling themselves. You know, this is agonizing. I'm going to die. That's not going to help you feel any better. Thinking of it on a scale of 1 to 5 and how much better it feels today than it felt yesterday can help you get through it. That's what I do a lot of times when I, when I've had surgeries. I had foot surgery one time and instead of focusing on how much it hurt that day, I was just focusing on, focusing on how much better I felt each successive day. And you know, I rapidly actually did feel a lot better. But I had a good surgeon too. Anger, resentment, jealousy, envy, guilt, that whole family of anger emotions pushes people away and asserts dominance or control. But excessive anger can exhaust our stress response system, contribute to negative thoughts. We start seeing everybody is against us and impair our relationships, which could help buffer our depression. And it can even actually cause physical harm like hypertension and metabolic disorder. We want to help people identify what is causing their depression if they are feeling depressed. My grandfather, I would say had concurrent depression and anger issues. You know, he just, he was angry at the world and he felt hopeless and helpless and he was in pain all the time, bless his heart. You know, if we would have known then what we know now, but he just. He had a hard time seeing the good in anything because he was in so much pain and he was so. He felt so powerless. Helping people change their cognitions and focus on what they do have control over in order to address their anger. Anger is a natural emotion. And if there is a threat, people need to figure out, what am I going to do to address it to improve the next moment. If there's something worthy of being angry about, in terms of something that may prevent you from achieving your rich and meaningful life, then what are you going to do about it? I'm not saying suppress the anger. I'm saying accept it, embrace it, say, okay, I feel like there's a threat right now. I'm angry. What do I need to do that's going to help me achieve my goals? And is staying angry going to do anything to help me achieve my goals? Encourage people to pay attention when they're angry. What do they notice? You know, and a lot of we have angry days. When you have an angry day, think about, you know, what did you notice that day? Did you notice the clouds? Did you notice the birds chirping? Did you notice whatever? For me, I notice the dust on the baseboards. I notice the dishes in the sink. I notice the fingerprints on the window. I can be a little bit obsessive compulsive sometimes, but I notice the things that irritate me when I am in a bad mood. Unless I make a conscious choice to say, you know what, I am going to spend 10 or 20 minutes focusing on the good and trying to get myself out of that negativity spiral. Help people identify what their anger triggers are so they can prevent them or minimize them, and develop a plan to address triggers to feel safer and more empowered. For example, if being on Facebook and having somebody put something nasty or on Instagram, put something nasty on your. On your wall or on your. Whatever they call it on Instagram, if that triggers your anger, well, one of the things you can do is make your profile private and only allow your trusted people to post on those. Because generally your friends are not going to be hateful. And if they are, you can block them. But there are strategies that you can use to keep yourself feeling safer. Since you can't control other people, you've got to control yourself and you've got to control your environment. So your space online, so your space at home, so your space at work feels safe and you feel empowered in those areas. Anxiety is the other half of fight or flight. Chronic anxiety, worry, or just Good old fashioned stress will exhaust the stress response system causing neurochemical hormonal imbalances and increasing muscle tension and pain. When our HPA axis is elevated, our body's going, now's not the time to reproduce. When it says that because you know it's time to fight or flee, then it alters our levels of sex hormones. And we already saw that that altered levels of sex hormones can contribute to depression. The body under chronic anxiety adapts to excessive stress by often shutting down a lot of the receptors for the cortisol because it says I cannot be this revved up all the time, I can't run this hot all the time or I'm just, I'm going to break. And that causes glucocorticoid resistance or hypocortisolism, which is a bad thing. Anxiety also makes it harder to sleep, which contributes to exhaustion, hormonal imbalances and ultimately depression. Grief is another one of those feelings that doesn't fall nicely anywhere. It is sadness and depression experienced as a result of loss. I'm not saying that grief is bad. People grief, you know, that's okay. We want to help them grieve in a healthy way and move through that process towards acceptance. Happiness. You can't be happy and depressed at exactly the same moment. You can have things going on in your life that make you happy and things that are going on in your life that make you depressed. But at one exact moment, I don't think it's possible to be happy and depressed at the exact same time. So if we want to increase those happy chemicals and increase feelings of happiness and increase the serotonin and the norepinephrine, then do things that make you happy. Listen to comedians, watch your kids, watch stupid cat videos. I do that. You know, it's whatever will help you feel happier. Negative thinking styles contribute to exhaustion and highlight what's out of your control, which heightens a sense of helplessness and hopelessness. Encourage people to try to look. Put on those rose colored glasses and try to look at the positive. Try to see the silver lining in whatever's happening. And it will feel fake at first sometimes, but if you, if we can encourage them to embrace the good with the bad, they will be able to notice more than just the negative in life. Poor self esteem contributes to self loathing, shame and a feeling of unlovability. It negatively impacts relationships which creates that self fulfilling prophecy of loneliness and rejection. And it often causes a person to seek external validation. We want to, there are tons of books out there. On improving self esteem Encouraging people to examine their self esteem. One of my favorite activities is to have people write down all the characteristics that they look for in a best friend and then when they're finished doing that, have them examine that list and figure out which characteristics they have in themselves. You know, that's an easy way to do it where people don't feel like they're boasting because they're talking about a best friend, and then all of a sudden I turn it back on them. Negative relationships can also take a toll on self esteem, contributing to fears of abandonment, which maintains high levels of stress and feelings of helplessness. If you feel like you have no control in your relationship and you never know if this person is just going to leave, you know, that contributes to a lot of anxiety. When we are unable to develop supportive, healthy relationships, then we don't have that social buffer. And we know from adult attachment theory that while we don't have the same type of attachment that we do to our primary caregiver, when we're a child in adult attachment, we do form attachment bonds with multiple other adults who fulfill similar functions. They help us feel safe, they help us rejuvenate in our life. High stress environments prevent relaxation and rest, increase hopelessness, increase stress hormones and decreased relaxation hormones. Encourage people to design a low stress area in their home and at their workplace or at school. It's not the easiest to do at work or at school, but if they can, it's great. There may be a park bench somewhere that they can go sit on or something. Identify ways to reduce the stress in the environment in both places by adding positive sounds, reducing negative noise, avoiding interruptions, having good lighting that's positive, uplifting and eliminating anything that might trigger thoughts or feelings of a negativity, and adding things that will add positivity, whether it's pictures or smells or colors or a favorite soft, fluffy blanket. Whatever it is. Depression is the cluster of symptoms created when there is a neurochemical imbalance in the brain. That's what it is. What causes the imbalance can be emotional, it can be cognitive, it can be physical, interpersonal, environmental, or some combination of the above. And we want to help people recognize that depression is a symptom of an underlying problem with their neurotransmitter balance. And we need to figure out what's causing those neurotransmitters to be out of whack. Part of the strengths based approach means helping people see what they're already doing to prevent or deal with the symptoms. And examining all of the causative factors, recognizing the reciprocal nature between things like sleep and environment and mood. Are there any questions? Alrighty everybody. That gives you a fair number of probably unique ways to think about approaching depression treatment plans with clients and I will see you now. Remember, next week we're doing Monday and Tuesday again because I've got to go to Chicago again. I'm almost finished with that contract, but so Monday and Tuesday for next week, everybody. Have a great weekend and try to stay warm. It's supposed to get to 16 here tonight. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. 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