Saturday, December 08, 2007

'Top-down' vs. 'Bottom-up' Depression Treatments

Judy, RN commented on my recent antidepressant post that she was surprised that I didn't mention exercise and other therapeutic lifestyle changes (TLC) to improve my patient's mood disorder. I certainly do include those things in my initial meeting with depressed patients, and this particular lady and I had already discussed that. In fact, she is the poster girl for using TLC on her depression, and she was dismayed that despite her efforts, her depression was no better.

Top-down therapy involves the use of TLC or behavior that counteracts negative thinking through action. This favorably alters mood states through cognitive processes controlled by the cortical surface of the brain. Anti-depressants, on the other hand, target brain neurochemistry to work from the bottom-up to change mood and behavior.

The guru of the top-down approach using Cognitive Behavioral Therapy (CBT) is Dr. David Burns. I often recommend his book Feeling Good: The New Mood Therapy Revised as a good self-help resource to my patients. A good web-site for people so overwhelmed with life that they can't even manage their personal space is Fly Lady. She starts the inert and unmotivated with the baby step of nightly cleaning of their kitchen sink.

Researchers have demonstrated that either approach to the treatment of depression favorably alters brain activity, although in different ways. They performed positron emission tomography (PET) scans which shows those areas of the brain that are activated and currently consuming sugar. While both CBT and antidepressants were equally successful in correcting depression, the new, improved brain activity was quite different in the two sets of patients.

Study author Dr. Helen Mayberg concluded: "When treating clinical depression we know that one type of treatment doesn't fit all. Our imaging study shows that you can correct the depression network along a variety of pathways" She went on to note, "The challenge continues to be how to figure out 'how to best treat' for what the brain needs."


dorsey said...

"baby step of nightly cleaning kitchen sink" made me laugh. I'm so tired, so suddenly, I can barely manage to turn off the light. (I do clean it the next morning). After mild depression for years, finally finding mostly joy, (and then having both smacked out of me), I'm very interested in the discussion. I've always thought people should find a good therapist when things are going well so they have a contact if they're in crisis, but for some reason people rarely take my advice. So a relationship with a good PCP is essential, especially if therapist can't access meds. Both top and bottom approach helped me. Now I'm looking to jelly fish as happiness returns. in spurts. Thanks for being there, Judy, and for humor. (cleaning the sink, ha!) (and did you notice I used PCP in a sentence?)

Mauigirl said...

If not cleaning the kitchen sink at night is a sign of depression, hubby and I are deeply depressed! :-)

My dad definitely had clinical depression, the kind that needs meds. I think the combination of meds and cognitive therapy, excercise and other activities is the best thing for people with severe depression. He did benefit from cognitive therapy but ironically his cognitive therapist couldn't prescribe meds, and his insurance wouldn't pay for both a psychiatrist and the cognitive psychologist so he had to give up the one that was actually helping reprogram his thought processes. The psychiatrist really wasn't helpful in that regard. I think insurance needs to get more open to the idea of paying for both types of therapy.