Are You Blue? What Do You Do?

A Case Study on Treatment Options for Depression

by
Robert Grossman, Psychology Department, Kalamazoo College
Amy Pettigrew, College of Nursing, University of Cincinnati
Linda Walsh, Psychology Department, University of Northern Iowa
Kathleen Boje, School of Pharmacy, University at Buffalo

Read the following scenario.

"You know Peggy, don't you? She's been so down lately," Brenda said as she, Christy,
Bob, Jim, and Jean dropped into chairs at the Student Union lately. "She hasn't been at
volleyball lately! We've missed her killer serve! I just saw her. She was mumbling and
had tears in her eyes. She said she had gotten a couple of D's on her mid-terms and was
worried about losing her scholarship. Seems she hasn't been able to concentrate on
classes the past two or three weeks. But what really upset me was she said she doesn't
enjoy much of anything any more, not even volleyball!"
"Did she complain of feeling tired? Listless?" asked Bob.
"Yes, she did," replied Brenda. "She said she's exhausted but can't seem to get a good
night's sleep. Today she woke up at 4:00 AM and couldn't get back to sleep. She told me
she felt so depressed she could hardly get up. I asked her if anything was going on that
might be related to this and she told me her ex-husband is calling almost every night and
often threatening suicide."
"That's real tough," Jean sighed.
"Yeah, I know," continued Brenda. "She's got two years to finish her degree before the
divorce settlement. I know that she's also worried about her parents' health problems."
"I saw Peggy the other day," Christy interjected. "She was telling me how overwhelmed
she feels trying to taking care of herself and her son. She said she can manage to get his
dinner on the table—just barely—but doesn't have the energy or the appetite to make
anything for herself. She said she thought she may have frightened Joey the other day. He
came back in from playing after dinner and found her sitting in the dark. That shook her
up. She said it reminded her of when her mother would stay in her room for hours on
end."
"Well," said Brenda, "just now when I saw her she told me she had gone to her family
physician, who told her she should see someone about diagnosis and treatment for
depression. Her doctor suggested there might be resources on campus that would be more
affordable than his referral sources. She told me she felt worthless as a mom and a
student, and then ran into the ladies room in tears! I checked to make sure she was OK
and then came here. I don't know what she can do. I'm so worried about her! I know I

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would feel better if I knew what kinds of treatments are available for depression. Do you
guys know?"
"We can't diagnose her or recommend treatments, but we could help you pull together
information on the kinds of treatments available and the kinds of professionals Peggy
might get help from," offered Bob. "My RA told me that the campus health center can
diagnose and prescribe medication for depression. Someone on our dorm floor had
recently gotten help through the health center. This was for an antidepressant medication,
which the health center can write prescriptions for. I'd be willing to follow-up on that and
try to get some information on tricyclic medications (Expert Group A)."
"Come to think of it," said Brenda, "we just learned about Prozac and the other selective
serotonin reuptake inhibitors (Expert Group B) in my psychology class. I have a friend
who saw a psychiatrist at the campus health center and was given a prescription for that. I
can go check my notes on these meds. Christy, you're in that class, didn't we hear about
something called MAO inhibitors (Expert Group C)? Could you look up info on those?"
"Sure," said Christy. "I can do that."
"Some people feel hesitant about taking medication," said Jim. "I know I do! And drugs
usually have side effects that make you feel worse, don't they? I'll check out something
more natural, like St. John's wort (Expert Group D). They can hardly keep it in stock
down at Herbal Health."
"Some people are against taking anything," said Jean. "I think you can get a diagnosis at
the campus counseling center and they offer cognitive psychotherapy (Expert Group E).
I've heard that it's as effective as medication and has almost no side effects. I'll check it
out."
"Great!" said Brenda. "I know I would feel so much better if I knew the pros and cons of
each of these and who one can turn to for help. Let's research these and compare our
notes on them back here later today, OK?"
Vocabulary Help: Efficacy means “Power or capacity to produce a desired effect;
effectiveness1”

NAME:kaleab T. ____________________________

NOTES FROM EXPERT GROUP ON CBT TREATMENT

Clarifying Questions:
side effects: they are no side effect associated with CBT

1 From dictionary.com
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Advantages: no side effects at all
less likely to relapse
more permanent change

Disadvantages:Expensive
can be hard to find time for counselling
higher dropout rate

How sure are we about how this treatment works?

100% sure it was found to be as effective as imipramine and IPT in the treatment of
depression

Costs: expensive, for one session on the cheaper side its around 90 dollars
or may be free at college campus

Time to onset of effect: (How long before the person feels better?) 3-7 weeks

What kind of a professional does she need to see to get this treatment?
Therapist

Handout for Expert Group A

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TRICYCLIC ANTIDEPRESSANT MEDICATIONS
[Examples: Amitriptyline (Rx Elavil), Imipramine (Rx Tofranil), and Doxepin (Rx
Sinequan)]
Pharmacologic Mechanism of Action
The mechanism of action of amitriptyline hydrochloride is not definitely known.
However, we know that it does not act primarily by stimulation of the central nervous
system. The clinical effect is hypothesized as being due to potentiation of adrenergic
synapses by blocking reuptake of norepinephrine and serotonin at nerve endings.
The time to onset of effect (i.e., relief of depression) varies from person to person, but
typically takes an average of 1-3 weeks (and sometimes as long as 4-6 weeks) before
mood improvement is noticed.
Indications
For the relief of symptoms of depression. Endogenous depression (i.e., meets DSM-IV
criteria for melancholic features) is more likely to be alleviated than other depressive
states. One to three weeks of treatment may be needed before optimal therapeutic effects
are evident.
Dosage and Administration
Depression—Lower doses are recommended for elderly patients and adolescents. Dosage
should be initiated at a low level and increased gradually, noting carefully the clinical
response and any evidence of intolerance. Following remission, maintenance medication
may be required for a longer period of time at the lowest dose that will maintain
remission.
Usual Adult Oral Dose:
Hospitalized patients—Initially, 100 mg/day in divided doses gradually
increased to 200 mg/day as required. If no response after two weeks, increase
to 250-300 mg/day.
Outpatients—Initially, 75 mg/day increased to 150 mg/day. Dosages over 200
mg/day are not recommended. Maintenance, 50-150 mg/day.

Side Effects
Common—Dry mouth; dizziness, lightheadedness or fainting may occur;
headache; increased appetite and cravings; constipation.
Less common—Anxiety, restlessness, agitation; insomnia and nightmares;
irregular heartbeat; confusional states (especially in the elderly) with
hallucinations, disorientation, delusions.
Symptoms of acute overdose—Confusion, convulsions, enlarged pupils,
irregular heartbeat, vomiting.
Precautions:

● Patients should be warned that amitriptyline hydrochloride might

enhance the CNS depressant effects of alcohol.
● Patients taking amitriptyline hydrochloride should avoid excessive

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 exposure to sunlight, since there have been reports of photosensitization
(severe sunburn).
● Patients may feel drowsy. If this occurs, patients should not drive, use
machines or do anything that could be dangerous if the patient is not
alert.
Cost
Tablets: $3.75 for generic, for a 3-month supply of 100 75mg tablets ($98.17 for Elavil).
The cost can be lower depending on the individual's medical insurance. Available by
prescription only, so one must have an appointment with a physician for diagnosis and
treatment.
Resource: Much of the material on this sheet is quoted directly from
http://www.rxlist.com/cgi/generic/amitrip.htm and is used with permission.

Handout for Expert Group B

SELECTIVE SEROTONIN REUPTAKE INHIBITORS
(SSRIs)
[Examples: Fluoxetine (Rx Prozac), Sertraline (Rx Zoloft), and Paroxetine (Rx Paxil)]
Pharmacologic Mechanism of Action
The SSRIs are a well-known group of prescription drugs, which presumably enhance the
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activity of the neurotransmitter serotonin by interfering with its reabsorption back into
axon endings that have released it. There is evidence that depression, in many people,
may be associated with low levels of serotonin activity. By making this chemical more
available, SSRIs may "correct" this deficiency.
Studies at clinically relevant doses in humans have demonstrated that fluoxetine blocks
the uptake of serotonin into platelets. Studies in animals also suggest that fluoxetine is a
much more potent uptake inhibitor of serotonin than of norepinephrine.
SSRIs are no more effective than the older antidepressants (TCAs), but have less
annoying side effects as well as fewer risks in most individuals. Patients are more willing
to take the medication and physicians have fewer concerns about overdose or potentially
dangerous cardiovascular side effects. There has been only a single recorded case of an
SSRI overdose being fatal, which is an important consideration when treating depression.
Patients also like the once-a-day dosing.
Indications (Hint: Efficacy means “Does it work?”)
Depression: Fluoxetine HCl is indicated for the treatment of depression (see web site
listed below for information on other disorders that it is indicated for). The efficacy of
fluoxetine HCl was established in 5- and 6-week trials with depressed outpatients whose
diagnoses corresponded most closely to the DSM-III category of major depressive
disorder.
The antidepressant action of fluoxetine HCl in hospitalized depressed patients has not
been adequately studied.
The efficacy of fluoxetine HCl in maintaining an antidepressant response for up to 38
weeks following 12 weeks of open-label acute treatment (50 weeks total) was
demonstrated in a placebo-controlled trial. The usefulness of the drug in patients
receiving fluoxetine HCl for extended periods should be reevaluated periodically.
Dosage and Administration
Initial Treatment: In controlled trials used to support the efficacy of fluoxetine, patients
were administered morning doses ranging from 20 mg to 80 mg/day. Studies comparing
fluoxetine 20, 40, and 60 mg/day to placebo indicate that 20 mg/day is sufficient to obtain
a satisfactory antidepressant response in most cases. Consequently, a dose of 20 mg/day,
administered in the morning, is recommended as the initial dose.
A dose increase may be considered after several weeks if no clinical improvement is
observed.
Doses above 20 mg/day may be administered on a once a day (morning) or twice a day
schedule and should not exceed a maximum dose of 80 mg/day.
As with other antidepressants, the full antidepressant effect may be delayed until 4 weeks
of treatment or longer.
Side Effects
SSRIs can produce stomach upset, headache, nervousness, dizziness, and insomnia (much
like having had too much caffeine) until you get used to the drug.. SSRIs should not be
used with other medications or herbal remedies without your doctor's approval because
some cause dangerous interactions. This is especially true for other depression remedies.

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Cost
As relatively new drugs, SSRIs are not cheap (no generics available yet). Besides the cost
of visiting your caregiver, a 3-month supply of the 20-mg dose of Prozac averages around
$200. The cost may be lower depending on the individual's medical insurance. This
medication may be prescribed after professional diagnosis at the college health center.
Resource: Much of the material on this sheet is quoted directly from
http://www.rxlist.com/cgi/generic/fluoxetine.htm and is used with permission.

Handout for Expert Group C

MONOAMINE OXIDASE (MAO) INHIBITORS
[Examples: Isocarboxazid (Rx Marplan), Pheneizine (Rx Nardil), and Tranylcypromine
(Rx Parnate)]
Pharmacologic Mechanism of Action
When other antidepressants don't work, some people find relief from an older class of
medications - MAO inhibitors. Monoamine oxidase inhibitors (MAOIs) were the first
type of antidepressant to be used, starting in the 1950s. MAOIs relieve depression by
preventing the enzyme monoamine oxidase from breaking down the neurotransmitters
norepinephrine, serotonin and dopamine in the brain. Higher levels of these chemicals

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result, and mood is boosted. These drugs are used much less frequently now, because they
can have dangerous side-effects.
For the small number of people for whom MAOIs are the best treatment, it is necessary
to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines,
and pickles, as well as medications such as decongestants. The interaction of tyramine
with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that
can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the
patient should carry at all times. Other forms of antidepressants require no food
restrictions.
Some people do find these medications to be lifesaving. For these people MAOIs can be
the best treatment. As long as they are vigilant about their diet they can get real relief
from their depression. http://mentalhealth.about.com/cs/psychopharmacology/a/mao.htm
Indications
Marplan is indicated for the treatment of depression. Because of its potentially serious
side effects, Marplan is not an antidepressant of first choice in the treatment of newly
diagnosed depressed patients.
The efficacy of Marplan in the treatment of depression was established in 6-week
controlled trials of depressed outpatients. These patients had symptoms that corresponded
to the DSM-IV category of major depressive disorder; however, they often also had signs
and symptoms of anxiety (anxious mood, panic, and or phobic symptoms).
The antidepressant effectiveness of Marplan in hospitalized depressed patients, or in
delusionally depressed patients, has not been adequately studied.
Dosage and Administration
For maximum therapeutic effect, the dosage of Marplan must be individually adjusted on
the basis of careful observation of the patient. Dosage should be started with one tablet
(10 mg) twice daily. If tolerated, dosage may be increased by increments of one tablet (10
mg) every 2 to 4 days to achieve a dosage of four tablets daily (40 mg) by the end of the
first week of treatment. Dosage can then be increased by increments of up to 20
mg/week, if needed and tolerated, to a maximum recommended dosage of 60 mg/day.
After maximum clinical response is achieved, an attempt should be made to reduce the
dosage slowly over a period of several weeks without jeopardizing the therapeutic
response.
Beneficial effects may not be seen in some patients for 3 to 6 weeks. If no response is
obtained by then, continued administration is unlikely to help.
Side Effects
The commonly observed adverse events that occurred in Marplan patients with an
incidence of 5% or greater and at least twice the incidence in placebo patients were
nausea, dry mouth, and dizziness.
Marplan can cause serious side effects. It is not recommended as initial therapy but
should be reserved for patients who have not responded satisfactorily to other
antidepressants.
The most important reaction associated with MAO inhibitors is the occurrence of
hypertensive crises, which have sometimes been fatal, resulting from the co-

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administration of MAOIs and certain drugs and foods. Hypertensive crises have
sometimes occurred during Marplan therapy after ingestion of foods with a high tyramine
content. In particular, patients should be instructed not to take foods such as cheese
(particularly strong or aged varieties), sour cream, Chianti wine, sherry, beer (including
non-alcoholic beer), liqueurs, pickled herring, anchovies, caviar, liver, canned figs,
raisins, bananas or avocados (particularly if overripe), chocolate, soy sauce, sauerkraut,
broad beans (fava beans), yeast extracts, yogurt, meat extracts, meat prepared with
tenderizers, or dry sausage.
Cost
Marplan 10 mg 120 tablets cost $69.48. The cost can be lower depending on the
individual's medical insurance. It is available by prescription only, so one must have an
appointment with a physician or nurse practitioner for diagnosis and treatment.
(Appointments may be available for a minimum cost at the college health center.)
Resource: Much of the material on this sheet is quoted directly from
http://www.rxlist.com/cgi/generic/isocarbo_cp.htm and is used with permission.

Group D
A NATURAL REMEDY FOR DEPRESSION
St. John's Wort
St. John's wort is the most commonly used and most thoroughly researched natural
product for the treatment of depression. St. John's wort is a bushy shrub native to Europe
but now found throughout the world. The flowering tops are used for medicinal purposes,
and use has been documented for thousands of years (Kuhn 1999). The active ingredients
in St. John's wort include 10 or more chemical compounds. The most likely active
ingredient in affecting depression is Hypericum perforatum.
A total of 1,592 patients have been studied in 25 double-blind controlled studies (Murray
and Pizzomo 1998). In the studies, St. John's wort extract produced improvements in
many symptoms of depression and has been found to be as effective in the treatment of
depression as antidepressants (Philipp, Kohnen, and Hiller 1999).

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The main advantage of St. John's wort was found to be not a difference in treatment
outcome but rather an advantage in terms of reduced incidence and severity of side
effects, costs, and increased patient satisfaction.
It is not clear how Hypericum perforatum works in its ability to treat some kinds of
depression but there are several theories being investigated. Evidence indicates that the
inhibition of norepinephrine and serotonin reuptake may underlie the antidepressant
activity.
Dosage
St. John's wort is available as a tea, powder, oil, liquid, capsule, and tablet. Dosage: 300
mg of St. John's Wort (9.3% hypercium) three times a day. It should be taken with food to
prevent stomach upset.
It takes four to six weeks to be effective.
Side Effects
The major side effect with St. John's wort is mild stomach irritation. It is considered a
safe herb and incidents of adverse reactions are rare; however, it is not recommended for
allergic or photosensitive individuals. Safety for use in pregnancy has not been
established, therefore do not use if pregnant. Drug interactions include: intensifies action
of caffeine and cough and cold remedies; should not be used with other antidepressants;
decreases effectiveness of birth control pills; does NOT increase alcohol effects; and does
NOT combine well with other sleep aids.
Regulation:
The Food and Drug Administration does not classify herbal medications as drugs. St.
John's wort is considered a "nutritional supplement," and as such is not subject to quality
control regulations as are standard pharmaceuticals. Products are therefore largely
unregulated, and therefore label claims of hypericum content may or may not be reliable
(Gaster and Holroyd 2000).
Cost
The retail cost of St. John's wort varies depending upon the vendor. It is readily available
in drug stores, groceries, and health food stores. The prices are generally lower than the
cost of standard antidepressant therapy. A typical cost for 90 300-mg tablets is $8.10. This
is approximately a one-month's supply. No medical appointment is needed, so careful
diagnosis by a professional is not required—this can result in taking a substance that may
be inappropriate for the problems the person is experiencing.
Resources: Much of the material on this sheet is quoted directly from
http://www.rxlist.com/cgi/alt/stjohn.htm and is used with permission. A good second
source is http://www.hypericum.com.

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 Handout for Expert Group E
COGNITIVE BEHAVIORAL THERAPY
Psychological Mechanism of Action
Cognitive behavior therapy (CBT) is a structured form of psychotherapy in which the
client is taught to recognize and change thought processes that cause or contribute to the
deepening of symptoms of depression. For example, in this case, when Peggy felt
worthless as a mother and a student her symptoms of depression intensified (she ran off
to the restroom in tears). In cognitive therapy she would be taught to recognize this as "all
or nothing thinking" or an "overgeneralization." She would be encouraged in therapy to
challenge this distortion with more realistic thoughts like, "Just because I'm having
problems coping at this time, doesn't mean I'm 'totally worthless.' In fact I am able to help
my son get food and I am attending classes and doing some homework." Most patients
experience some lifting of the intensity of their depression when they are able to do this
type of challenging. This often leads to being able to cope more effectively, which can lift
the depression even further. Clients are also taught skills for dealing with things like poor
concentration and procrastination that also help relieve dysphoric feelings.
CBT was developed and studied by Aaron Beck and his group of therapist-researchers at
the University of Pennsylvania. It was compared with interpersonal psychotherapy (IPT)
and imipramine (the main tricyclic antidepressant drug in use at the time) in a major
study conducted by the National Institute of Mental Health in 1977.

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Indications
CBT was found to be as effective as imipramine and IPT in the treatment of depression.
All three treatments were equivalent in the degree of success and for the most part
superior to the placebo control group. Imipramine was somewhat faster in reducing
symptoms, but by the end of the 16 weeks of treatments, the three groups were
equivalent.
On average it may take 3-7 weeks or more for the person to gain enough symptom relief
to make a positive difference with CBT.
Some analyses of the data showed that the drug was more effective with severely
depressed individuals. Several later studies have disputed this finding. Some studies have
shown that patients receiving CBT have been less likely to relapse though there is not
clear agreement on this finding. A few studies have shown that cognitive therapy helps
make standard antidepressants more effective (probably by reducing the drop-out rate in
the antidepressant groups) but most of these studies have failed to show an advantage for
combined treatment.
Side Effects
Though there are no obvious side effects with CBT, there are some risks and difficulties.
First one needs to be in therapy from 16 to 20 weeks. Finding an hour or more a week
and locating a therapist in reasonable driving distance also can be complicating factors.
Some research has shown that compatibility with the therapist is a factor in treatment
success. It may take some trial and error to find the right therapist and if the therapy is
disrupted the client may experience this as a significant "loss" and thus have to deal with
a deepened depression.
Cost
Sometimes, especially in the beginning, the person needs to go for two therapy sessions a
week. Since most therapists now charge between $90 and $120 per session, the cost can
be a concern. Over a one-month period, the cost can be between $360 and $480. Some
health insurance programs cover costs for therapy but few of them cover the full cost and
almost none allow an unlimited number of visits. College and university counseling
centers often offers diagnosis and this type of therapy free for a limited number of
sessions if it is deemed appropriate.
Resource: http://www.apa.org/journals/anton.html

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