Brief approaches to addressing depression and insomnia from screening to interventions.

1. R O L E O F H E A LT H P S Y C H O L O G I S T
DEPRESSION AND
INSOMNIA TREATMENT

2. EPIDEMIOLOGY OF DEPRESSION
• Prevalence: Depression in primary care 10% and 30%
• Global Rates: Globally, more than 350 million people of all ages
suffer from depression.
• Disability: Depression is the leading cause of disability worldwide,
and is a major contributor to the global burden of disease.
Depression is treatable.
• Women: More women are affected by depression than men.
• African American: African American's have lower rates of
depression and higher rates of chronic illness e.g. arthritis, diabetes,
hypertension, stroke, and obesity.
• Highest Rate: Asian American girls have the highest rates of
depressive symptoms of any racial/ethnic or gender group.

3. DEPRESSION SPECTRUM
Major Depression W/ Psychosis
Major Depression
Pervasive Depression Disorder
Complex Grief Reaction
Normal Greif Reaction
Situational Moodiness AKA “the blues”

5. EVIDENCED BASED TREATMENT
• Behavioral Activation: There is now sufficient evidence to conclude that
behavioral activation is an evidence-based therapy.
• CBT: Cognitive behavioral therapy was somewhat superior to
antidepressants in the treatment of adult depression
• ITP: The efficacy of IPT proved to be superior to placebo, similar to
medication and did not increase when combined with medication. Overall,
IPT was more efficacious than CBT.
• ACT: Participants receiving CT and ACT evidenced large, equivalent
improvements in depression, anxiety, functioning difficulties, quality of life,
life satisfaction, and clinician-rated functioning
• MBSR: Results suggest that mindfulness-based therapy is a promising
intervention for treating anxiety and mood problems in clinical populations
• STPP: STPP and CBT/BT seem to be equally effective methods in the
treatment of depression. However, because of the small number of studies
which met the inclusion criteria, this result can only be preliminary.

7. MEDICATION TREATMENT
• Acute Treatment: Starts at dose number 1 and extends
till symptoms are reduced to nearly gone (best case 6-8
weeks – however with multiple drug trials it can take
much longer).
• Continuation Treatment: Best practice for first 2
episodes of depression is to stay on medication for 6
months with a slow taper.
• Maintenance Treatment: Is used to prevent relapse for
those who have had multiple episodes of depression and
includes at times life time use of antidepressant.

8. VEGITATIVE AND PSYCHOLOGICAL
Psychological Sympt.
• Depressed mood
• Excessive guilt
• Loss of pleasure
• Low motivation
• Pessimistic thinking
• Irritability
• Indecision
• Emotional sensitivity
• Suicidal ideation
Vegetative Sympt.
• Sleep disturbances
• Appetite disturbances
• Fatigue
• Decreased sex drive
• Restlessness/agitation
• Psychomotor retardation
• Diurnal variations in mood
(worse in morning)
• Impaired concentration and
forgetfulness
• Anhedonia

9. MEDICAL CONDITIONS AND
DEPRESSION
• Addison’s Disease
• AIDS
• Alzheimer’s Disease
• Anemia
• Apnea
• Asthma
• Chronic Fatigue Syn
• Infections like TB
• Chronic Pain
• Cushing’s Syndrome
• Diabetes
• Hyperthyroidism
• Hypothyroidism
• Flu
• Cancer
• MS
• Menopause
• Parkinson’s
• Rheumatoid Arthritis

10. SOME MEDICATIONS THAT
CAN CAUSE DEPRESSION
• Corticosteroids & Other
Hormones
• Cortisone acetate
• Estrogen
• Progesterone
• Prednisone
• Birth control pills
• Antihypertensive
• Propranolol
• Reserpine
• Hydrochloride
• Methyldopa,
• Drugs and Etoh
• Alcohol
• Pot
• X-tacy and Meth when stopped
• Benzodiazepines
• Valium
• Xanx
• Lorazepam
• Clonazepam
• Antiparkison’s Meds
• Levodopa & Carbidopa
• Levodopa
• Amantadine

11. CULTURAL IMPACTING
DEPRESSION TREATMENT
• A small met analysis indicated that
cultural adaptation in depression
management improved care.
• Giving priority to culturally competent
practices in assessment, diagnosis and
treatment appears to help reduce health
disparities in early studies.
• Spanish language explanation of care and
health believes in Latino(a)s impact health
choices about care e.g. medication or
therapy.
• Current data suggest that the mental
health of Black Americans is negatively
impacted by exposure to racism an can
mirror symptoms of PTSD.
• ACT studies do not currently
accurately report cultural factors.
The improved methodology is
needed.
• A pilot randomized controlled trial
integrating type 2 DM tx and
depression improved outcomes
among older African Americans.
• Older adults and children both
report more irritability when
depressed.
• Generational factors can impact
depression treatment.
• African American older adults
showed increased internalize
stigma and less MH Tx seeking

13. FUNCTIONAL ASSESSMENT OF
DEPRESSION
• On Set
• Duration
• Intensity
• Successful coping
• Unsuccessful coping
• Substance Use
• Medications
• Medical Conditions
• Protective factors
• Hx of Tx
• Grief
• Big T-Traumas
• Changes in work
• Changes in relations
• Changes in sex drive
• Changes in
meaningful activities
• Exercise

15. CBT FORMULATION

16. DEVELOPING INTERVENTIONS

17. DAILY MOOD RECORD
M T W TR F S SU
Mood
M T W TR F S SU
Mood

18. TRACK PROGRESS
DAY OF
WEEK
MON TUES WED THURS FRI SAT SUN
MOOD 4 4 6 7 8 6 3
ACTIVITY Talked
to friend
on
phone
Pain Work Stayed
at home
with cats
Went for
walk
MOOD
AFTER
ACTIVITY
4 7 5 5 6 6 4
The goal is to learn if changing these behaviors have affected the patient’s
mood eg. Patient’s mood increased on Tuesday when she was able to talk on
the phone with a friend

19. INSOMNIA AND SLEEP EPIDEMIOLOGY
• Sleep Loss Disorders: Australians demonstrates that disrupted sleep,
inadequate sleep duration, daytime fatigue, excessive sleepiness and
irritability are highly prevalent (20%–35%).
• Obstructive Sleep Apnea: (INSERT DATA)
• Shift Work Impacts: Health, performance and safety are often
degraded in shift workers due to the combined effects of circadian
rhythm
• Restless Legs Syndrome: As many as 10 percent of the U.S.
population may have RLS. Several studies have shown that moderate
to severe RLS affects approximately 2-3 percent of adults (more than 5
million individuals).
• Insomnia: Insomnia is an independent risk factor for diabetes, and is
associated with anxiety disorders, depression, and increased risk of
falls in the elderly Insomnia rivals diabetes in terms of annual direct
$147.2 billion in 2006 dollars.

22. SLEEP AND ENDOCRINE FXN
• Endocrine system: Most hormone secretion is controlled by the
circadian clock or in response to physical events.
• Release of growth hormone may facilitate repair processes that occur during
sleep.
• Follicle stimulating hormone and luteinizing hormone, which are involved in
maturational and reproductive processes, are among the hormones released
during sleep.
• Thyroid-stimulating hormone is released prior to sleep.
• Renal system: Kidney filtration, plasma flow, and the excretion of
sodium, chloride, potassium, and calcium all are reduced during both
NREM and REM sleep. These changes cause urine to be more
concentrated during sleep.
• Alimentary activity: In a person with normal digestive function, gastric
acid secretion is reduced during sleep. In those with an active ulcer,
gastric acid secretion is actually increased and swallowing occurs less
frequently.

23. SLEEP CYCLES

24. EEG STUDY SLEEP

25. DIURNAL CORTISOL

26. INSOMNIA TREATMENT
• Sleep Hygiene: Sound, Light, Temp., Computers/TV, Sleep Ritual.
• Skills to Fall Asleep: Relaxation training, Worry Journals, Thought
Skills, MBSR, Exercise during daylight, Exposure to light in morning,
reduced light at night, safe touch, self touch.
• Skills to Stay Asleep: Temp control, substance reduction (Etoh and
caf.).
• Reduce Sleep Latency: Relaxation training, Thought skills,
sleeping when tired.
• Stimulus Control: Reduce stimulus from inside the mind/body and
outside = state of rest.
• Sleep Restriction: Restrict napping during the day.
• Food Timing and Quality: Better food helps good sleep. Eating
small amounts of the right foods help people stay asleep.