TIC TACS or TREATMENT

Anti-depressants vs Placebo

Joan R. Shepherd, FNP

Objectives

• Estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression

• Recognize current standard of care/medications for selected mood disorders

Objectives

• Consider alternative tools for use in primary or acute care setting • ACT--Acceptance and Commitment

Therapy• Thought Work--Byron Katie• Self-Coaching Model--Brooke Castillo• Change Cycle-- Martha Beck, PhD.

•Higher standard of living than ever before

•Medical treatment

•Food

•Housing

•Sanitation

•Money

•Welfare

•Access to education

•Justice

•Travel

•Entertainment

•Career opportunities

Depression

• 13.1 to 14.2 million American adults in any given year

• 1/10th of the adult population/week

• 32 million (one in five)at some point in their life

Harris, R. 2008. The Happiness Trap, Exisle Pub.Ltd

World Health Organization

• 4th biggest, costliest most debilitating disease in the world

• By 2020, 2nd biggest

Harris, R. 2008. The Happiness Trap. Exisle Pub. Ltd.

• only 50% of depressed people seek and receive adequate treatment

•Mostly treated by PCP

•Fitzgerald Health Education Assoc. 2007

DSM IV Criteria at least 5 symptoms in the

same 2-week period

• Sleep: insomnia or hypersomnia, staying asleep problematic

• Interest: depressed mood, loss of interest or pleasure

• Guilt; feelings of worthlessness

• Energy: fatigue

• Concentration: diminished ability to think or make decisions

• Appetite: weight change, loss of food enjoyment

• Psychomotor: agitation or retardation

• Suicide: recurrent thoughts of death; passive, without plan

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

PCPs will not use a screening tool that’s more than 4 questions long!

Sally Miller, PhD. NCNP Conference 2007

PHQ-2• In the last 2 weeks, have you felt down,

depressed, or hopeless?• In the last 2 weeks, have you felt little

interest or pleasure in doing things?• 96% Sensitivity, less Specificity

• Positive response should lead to PHQ-9:download at www.depression-primarycare.org,

accessed 9.17.10

Kirsch et al 1998

• 1998 analysis of 38 manufacturer-sponsored studies of 3000 depressed patients

• Patients did improve• This formed the basis for the claim

that anti-depressants work

Studies Impact?

• The number of Americans taking anti-depressants doubled in a decade

• 13.3 million in 1996 • 27 million in 2005

National Patterns in Antidepressant Medication Treatment.Marcus and Olfson, Archives of General Psychiatry, 2005.

hmmmmmm…

• Comparing improvement in patients on ADM and placebo…

• Placebo improved about 75% as much as those on ADM

or• 3/4 of benefit from ADM is placebo

•Clinical trials of antidepressants are difficult to design and conduct. •more than half of all recent clinical trials of commonly used antidepressants failed to show statistical superiority for the drug over placebo. •This is not necessarily because of the ineffectiveness of the antidepressant, but rather because of an increased response to placebo.

Kahn et al 2005

Symptom Severity

• Estimate the relative benefit of medication vs placebo across a wide range of initial symptom range of initial symptom severityseverity in patients diagnosed with depression

What affects outcome?

• Fournier et al 2010• Examined Kirsch and Kahn’s meta-

analyses• Looked at Baseline symptom

severity• Hamilton Depression Rating Scale

Hamilton Depression Rating Scale (HDRS)

• Most widely used clinician-administered depression assessment scale.

• 17- items pertaining to symptoms experienced over the past week

• Originally developed for hospital patients

• Many variations since then

HDRS Scoring

• 0-7 normal or remission• 8-13 mild depression• 14-18 moderate depression• 19-22 severe depression• > 23 very severe depression

Placebo Washout• Most trials testing the effectiveness of

psychotropic drugs begin with a placebo washout phase.

• Pill placebo administered in single blind fashion

• Improvement > 20% excluded from the trial prior to randomization

Kahn et al• Hypothetically this technique rids

studies of placebo responders before randomization of subjects to drug and placebo groups.

• In theory, this lowers the level of response to placebo in the study and magnifies the superiority of the response to medication.

Kahn et al• An analysis of 10 years of research: the

washout technique does not do what it was designed to do in antidepressant studies.

• Within placebo or drug groups neither measures of depression nor dropouts were affected by including a preliminary washout in the design.

Size Matters

• Kirsch: Only 1 of 35 studies comprised samples with mean baseline HDRS scores lower than 23 (very severe depression)

• Kahn: Minimum entry score 20 (severe or very severe)

• 71% of 503 depressed, treatment-seeking out patients had HDRS scores less than 22

Zimmerman, Posternak, Chelminski. 2002

Conclusion “The magnitude of benefit of antidepressant

medication compared with placebo increases with severity of depression symptoms and may be minimal or non-existent, on average, in patients with mild or moderate symptoms.”

Founier et al. Antidepressant Drug Effects and Depression Severity. 2010

Numbers, please

• The minimum baseline HDRS score needed to achieve a clinically meaningful ADM/placebo difference is approximately 28

• Differences are negligible for lower baseline HDRS scores

Current Guidelines• Provide information and support• Build a trusting relationship• Explore treatment options• Information appropriate to their level of

understanding and range of treatments• Comprehensive written info available• Audio available

National Guideline Clearinghouse. Depression: the treatment and management of depression in adults. Accessed 9/17/10

Principles for assessment

• Comprehensive assessment that does not rely simply on a symptom count

• Consider degree of functional impairment and/or disability and duration of the episode

Anti-depressants:Which Ones?

“Multiple randomized trials of patients in the primary care setting have found similar efficacy for drug therapy and psychotherapy with no clear predictors of which treatment is best for individual patients.”

Up To Date. Initial Treatment of depression in adults. 2010

ADM: How to Choose?which antidepressant less important

than treating patients with

• medications that they can tolerate• sufficient doses to achieve symptom

remission

ADM: How to Choose:

• What has worked in the past?-if it worked before, try it

again• Positive response in a first degree

relative• Less danger of overdose

ADM: How to choose?

• Most psychotropic medications used in the treatment of depression work via manipulating serotonin, norepinephrine, and/or dopamine

Serotonin• “…a chemical of thought,

movement and behavior, as well as digestion, ejaculation, and evacuation.

• The body’s all-purpose neurotransmitter, involved in sleep, mood, appetite…”

Hanson, D. 2008. The Chemical Carousel

Norepinephrine

• The ‘engergizer’, associated with focused attention

• Motivation to win a reward• Responsible for the “adrenaline

surge”• It is the brain’s “go” signal• Also important in memory

Dopamine• “Pleasure chemical”• Linked to experiences of joy• Attention, movement, problem

solving, anticipation of a reward• Creates the desire to repeat a

pleasant experience

Hanson, 2008.

Most Bothersome Symptom?

• Vegetative?• Energized?• Anxious?

SSRIs

• Selective serotonin or serotonin Specific reuptake inhibitors

• Inhibit reuptake of 5H-T, so more serotonin at synaptic cleft

SSRIs

• Citalopram (Celexa)• Escitalopram (Lexapro)• Fluoxetine (Prozac)• Fluvoxamine (Luvox)• Paroxetine (Paxil)• Sertraline (Zoloft)

Differences among SSRIs…

• Fluoxetine long half-life– Less control– Takes longer to be eliminated– If patient discontinues drug, less likely

to have side effects– Minimizes withdrawal– Poor compliance, misses doses

SSRI Differences

• Paroxetine– Drug holiday for sexual side effects bc

relatively short 1/2 life– Better control– Patient with better compliance

Adverse Effects: Maximize!

• SE from agitating to sedating– Fluoxetine: energizing and long acting

• Depressed patient without energy• Vegetative patient• Not for the very anxious patient

– Paroxetine: sedating and short acting• Use in patient with depression

w/insomnia• High discontinuation from SE

Others?• Intangible…some patients just do

better with one than another for no apparent reason…

• Sertraline– Post MI anhedonia– Lower SE profile– Pre-menstrual dysphoric disorder

• Citalopram– Substrate cytochrome P450– Mildly sedating

• Escitalopram– Good SE profile

Comparison of SSRIs DRUG SEDAT ION

OR

ACTIVATION?

ANTICHOL INERGIC

SEROTO NIN NE DO PAMINE

CITALOPRAM,

ESCITA LOPRAM

+ SEDAT ION

+/++

ACTIVATION

0 +++ 0 0

FLUOXETINE + SEDAT ION

+/++

ACTIVATION

+ +++ 0/+ 0/+

PAROXET INE ++ SEDAT ION

+ACTIVATION

+ +++ 0 0

SERTRALINE 0 SEDAT ION

+/++

ACTIVATION

0 +++ 0 0

SSRI Common adverse

effects

• Headache– Usually controlled with

acetaminophen– Keep well hydrated– May take 3-4 weeks to resolve

SSRICommon side effects

• Associated with increased risk of bleeding, esp in older people or people taking other drugs that have potential to damage the GI mucosa or interfere with clotting

• Consider adding gastroprotective drug if on NSAID or ASA

SSRIs-Class Effects• GI disturbance-often loose stools

– Take with food– Except paroxetine bc of anti-cholingergic effect– Sertraline-lose 1/3 dose effect on empty

stomach

• Nausea– Take with food and adequate water– Use at bedtime– Consider adding short course of ranitidine

(H2RA…not Tagamet)

• May take 3-4 weeks to resolve

SSRI Side Effects

• Weight gain after several weeks• Initially mild anorexia• May lower seizure threshold

– Not usually clinically significant at normal doses

– But consider other meds that may have same effect

SSRI side effects• Agitation

– Reduce the dose by 25% and gradually reintroduce

– Trazaodone great for helping with sleep• Sedating antidepressant• Low abuse potential• Onset of action = 1/2 - 1 hr• Peaks 2-3 hr• Full stomach will delay effect

SSRIs

• Fluoxetine, fluvoxamine and paroxetine associated with a higher propensity for drug interactions than other SSRIs

• Paroxetine is associated with higher incidence of discontinuation symptoms than other SSRIs

*LOW SODIUM*• At the end of the presentation, a

NP-PhD in psych approached me and told me I should share with the group that SSRIs can cause low sodium!

• I hadn’t heard that before…so please take note. Could be extremely important especially in the depressed population!

When effective?

• Try a medication for 4-6 weeks for beginning to see a response

• Trial of 3 months necessary for true response

• Then try another SSRI• In 6 months, go to different class

(SNRI, TCA…)

SNRIs

• Target norepinephrine (NE) and serotonin

• 2nd line agents, depending upon co-morbidities and symptom presentation

• Try for SSRI resistant depression

Venlafaxine

• Dose dependent• Higher dose, higher BP• Consider for patient who presents

with depression and chronic pain• Menopausal symptoms-low dose

Sallly Miller, PhD. NCNP Conference. 2007

Venlafaxine• Greatest suicide risk of SNRIs• more likely to cause side effects that

will cause patient to stop taking the med

• Consider increasing the doses gradually• Higher doses can exacerbate cardiac

arrhythmias

Duloxetine

• NE slightly lower doses• Diabetic peripheral neuropathy• Urinary incontinence?

Desvenlafaxine• Active metabolite of venlafaxine• Approved for MDD• May cause more nausea, HTN• May give with or w/o food• Don’t divide, crush, chew or dissolve• Matrix tablet-may see ‘ghost tablet’ in stool• Cost for 30 days: $108.71

Prescriber’s Letter. Detail Document # 260802. Accessed 9/18/10

Bupropion

• Inhibits re-uptake of NE, dopamine– Very activating– Contraindicated in patients with or at

an increased risk of seizures– Slight risk of arrhythmias

Mirtazapine-Remeron

• Noradrenergic antagonist-blocks presynaptic alpha-adrenergic 5HT2

• Mildly anti-cholingergic• Lots of sedation• Weight gain• Great GI profile

Trazodone-Desyrel

• Good for anxious depression• Very sedating• ‘Anxiety receptor site’• Blocks 5-HT2A, inhibits reuptake

of 5-HT

Combined Neurotransmitter Reuptake Inhibitors Drug Sedation or

Activation

Anti-

Cholinergic

Serotonin NE Dopamine

Bupropion Sedation 0

Activation

+++

+ 0 + +++

Venlafaxine Sedation +

Activation +/++

0 +++ +/++ 0

Duloxetine Sedation +

Activation +/++

0 +++ +++ 0

Mirtazapine Sedation ++++

Activation 0

+ + + 0

Desvenlafaxine Sedation 0 +++ +/++ 0

Pharmacokinetics of Non-TCA Antidepressants Half-Life (hours) Time to steady state (days)

Escitalopram 27-32 6

Citalopram 33 7

Fluoxetine 84 14-28

Fluvoxamine 15 10

Sertraline 26 7

Paroxetine 21 4-14

Buproprion 14 Variable

Mirtazepine 20-40 3-4

Venlafaxine 5 + or – 2* 3

Desvenlafaxine 11 4-5

*not including active metabolite

2007 Fitzgerald Health Education Associates, Inc.

TCAs• Dry mouth• Blurred vision• Constipation• Urinary retention• Memory impairment• Postural Hypotension• Cardiac arrthythmias

Suicidality• One of the main reasons TCAs are

used less frequently now than SSRIs is because of how fatal they are in overdose.

• Thanks to the NP, PhD in psych who approached me after the talk to remind me of this fact! (Sorry, I don’t remember your name!).

Tricyclic Antidepressants Generic/Brand FDA approved

Indications

Anti-

cholinergic

Arrhythmias sedation Weight

gain

Amitriptyline/Elavil depression ++++ +++ ++++ ++++ Desipramine/Norpramine Depression + ++ ++ +

Doxapin/Adapin,

Sinequan

Depression

and/or

anxiety

+++ ++ +++ ++++

Imipramine/Tofranil Depression +++ +++ +++ ++++ Nortriptylline/Pamelor Depression ++ ++ ++ +

Tricyclics-unapproved but common uses

• Amitriptyline commonly used for bulimia nervosa and neuralgias

• Norpramine-bulimia, panic disorder, premenstrual syndrome– Contraindicated in acute recovery

post MI– Prolongation of QRS or QT and high

doses

Common uses…

• Doxepin-depression and/or anxiety associated with alcoholism

• Pamelor-smoking cessation

Treatment Resistant Depression

• Response: 50% reduction in symptoms• Remission: almost complete absence of

symptoms• 8 week clinical trials only 35-40%

achieve remission• Goal: Remission

Prescriber’s Letter Detail Document 250510, accessed 10-8-10

Strategies:

• Dosage increase• Switching antidepressant• Combining antidepressants• Augmentation with non-

antidepressant

Assessing Response• Earliest:

– Increased interest and pleasure in activities

– Improvements in psychomotor retardation

• 3-4 weeks with no response or 6 weeks with partial response despite adherence, consider diagnosis reassessment or change therapy

Dose Optimization

• Increase dose if tolerated• Esp for partial responders• Consider after 2 weeks• If no response, consider med

change

Switching ADM

• 4-8 weeks after dose optimization with no response or partial response

• Achieves remission about 25% time

• Can stay in the same class

STAR*D Trial

• Patients who didn’t respond to citalopram were just as likely to respond to sertraline as as to extended release venlafaxine or sr bupropion

•Taper paroxetine and venlafaxine to prevent withdrawal

•Fluoxetine-consider a 4-7 day washout when switching due to long T-1/2

•Failing two SSRIs, consider a different class

•Consider co-morbidities

•Pain-SNRI or TCA

•Anxiety, agitation, insomnia-mirtazapine

•SSRI induced sexual SE-add bupropion, mirtazapine

Combining Antidepressants

• Avoids risk of withdrawal symptoms and loss of benefit from 1st ADM

• Drug 2 may counteract Drug 1’s Ses• Most common combo is Bupropion

plus SSRI• SSRI plus TCA

– Keep TCA low range (25-75mg) bc SSRI can increase TCA levels

Combining ADMs

• Trazodone (Desyrel) 50-150mg plus SSRI or venlafaxine for sedating effect

• Trazadone plus fluoxetine or paroxetine can inhibit the elimination of trazodone’s metabolite, leading to CNS stimulation

Combining ADMs

• Mirtazapine/SSRI, bupropion, or venlafaxine has showed improvement

• Little data• Consider for patients with

nervousness, insomnia or sexual side effects

MAOI’s

• Combinations can cause life threatening serotonin syndrome or hypertensive crisis

• Leave to the specialists!

Data does NOT support combining venlafaxine with other SSRIs

Or combining two SSRIs.

Augmentation with Non-ADM

• Treat concomitant conditions• Improve specific symptoms• Quick onset of other meds• Buspirone (BuSpar)

– Improves SSRI-induced sexual Ses– Good choice for depressed patients

with anxiety

Aumentation with non-ADM

• Atypical Antipsychotics– Used with SSRI improve NE and

serotonin release through blockade of 5-HT2A receptors

– Improvements in sexual function and sleep

– Likely effective at lower doses than schizophrenia, minimizing SEs

Augmentation with Atypical Antipsychotics• Aripiprazole (Abilify)-add-on treatment

for MDD in adults– Starting dose when adding to ADM is 2-5mg– Can increase by 2-5mg weekly– Maximum 15mg/daySE: akathisia, restlessness, insomniaMay help to add mirtazapine for akathisia

Symbyax-combination fluoxetine/olanzapine

• treatment of bipolar depression and derpession in patients who have failed 2 ADM of sufficient dose and duration

•Starting dose 6/25 QHS

•Caution: hypotension, hepatic impairment

•Most common adverse effects:

•Weight gain

•Increased appetite

•Dry mouth

•Sonmolence

•Fatigue

Quetiapine (Seroquel, Seroquel XR)

•Treatment resistant depression

•Dose qhs

•50mg day one and two, then 150mg daily

•Watch lipids, weight gain, diabetes, tardive dyskinesia!

•Use lowest effective dose for shortest duration

•When switching, start Seroquel XR while tapering ADM

Atypical Antipsychotics• Glucose monitoring

– Check fasting glucose in patients who develop symptoms of dibetes

– Baseline fasting glucose– Periodically in patients with risk factors

• Metabolic effects• Risk of sudden cardiac death• Black box warning re Suicidality

Augmentation con’t• Risperdal and Geodon also being studied• Lamotrigine (Lamictal) mood stabilizer• improves several symptoms of

depression:– Mood, lack of interest, decreased energy,

impaired cognition– SE: dizziness, headache, nausea, sleepiness– Like lithium, may be good adjunct for

patients with bipolar

Lithium• Improves depression with poor

response to TCIs• Efficacy with SSRIs not so good-both

serotonergicSerum concentration monitoring

• Adverse effects (weight gain, tremor)• Serotonin syndrome

•71% of 503 depressed, treatment-seeking out patients had HDRS scores less than 22

Zimmerman, Posternak, Chelminski. 2002

Depression is never an accident; it is perfectly designed to tell you something important about how your life is going.

Therapeutic listening skills….

Tools to take home!

Thought Work

• Acceptance and Commitment Therapy

• Byron Katie• Brooke Castille• Martha Beck, PhD.

Thought Work• The technique of stepping back,

becoming the Compassionate Watcher of my thoughts.

• Becoming aware of the stories I am Telling Myself.

• Realizing: I am a Person who has thoughts…I am not my thoughts.

Acceptance and Commitment Therapy

• Grew out of Cognitive Behavioral Therapy

• Examines the role of language and thoughts in suffering

• Based on the assumption that most unwanted internal experiences cannot be eliminated or controlled, so they must be accepted.

Valued Actions

• Heavy emphasis on values-based living

• Knowing one’s sense of direction dignifies one’s experiences

Lizard Fears

• Human brain evolved for survival• Lack or Attack fears• Lack: Not enough food, water,

shelter, sex• Attack: saber toothed tigers

Top 10 Lizard Tunes

• Write them down• Put them to music

– Twinkle twinkle– Happy birthday

Self-Coaching 101• Circumstance• Thoughts• Feelings• Actions• Results

Brooke Castillo

Self-Coaching ModelBrooke Castillo

• Circumstances: things that happen in the world, facts

• Thoughts: things that happen in your mind

• Feelings:not physical sensations, but emotional feelings in your body

• Actions: what we DO in the world• Results: what we see in the world, the

effect of our action

• Circumstance:57 yoAAf hx of HTN. Flat affect and various

somatic complaints. Recent change in job responsibilities from working night shift in laundry room to more physical house-keeping.

• Thought: Evening shift people are slobs, they leave

this place a mess, making my job so much harder. My supervisor doesn’t care…

SC 101• Feelings: anger, frustration,

victimized, powerless• Actions: work with hostility, isolate

from other workers, avoid supervisor

• Results: HTN increased, insomnia, dreads going to work, angry at home.

Being in the place of the watcher.

How are you reacting to your thoughts?

How can you change your thoughts?

Thoughts cause Feelings and you can change your thoughts.

Regardless of circumstances, you can always change the thoughts.

The result of your actions caused by your feelings will always prove the original thought….brains compelled to gather evidence to support the original thought.

Result: HTN increased, insomnia, dreads going to work, angry at home.

Will always prove the original thought:

“This job is killing me…The evening shift people are slobs. They leave this place a mess, making my job harder…my supervisor doesn’t care…”

Intervene at level of THOUGHT.

Notice your thoughts about the circumstance.

Change the thought to something that feels slightly better, or flip it around.

This will give you the power to change your feeling about the circumstances.

In the moment of asking, “what am I thinking?” you assume the position of the watcher.

This process alone can create new wiring, allows a person to make conscious decisions and a feeling of control.

How to change the thought?

• a full thought turnaround

• slightly better thought

1. Write down the painful thought

2. Write down the feeling the thought is causing

3. Try to find a slightly better-feeling-thought you know is true…

• they’re sloppiness is job security for me

•Maybe the shift before them left them a mess

•I can ask my supervisor to keep me in mind the next time there’s an opening

•It’s kind of satisfying to make the room look nice

•I’m getting a little exercise

•I can imagine that it’s my Mother’s room in her nursing home

SC 101 Example 2• 24 yocm recently completed detox from

methadone• Circumstance: No GF• Thought: I deserve one. Look at all the losers

with GFs. I can’t get one.• Feelings: loneliness, frustration, desperate• Actions: Passing cards out to people with his

number. Avoiding actually speaking to girls. Watching others with contempt.

• Result: No GF. Depressed, isolating.

Change the Thought• New Thought: It’s highly likely I’m going to

meet girls now that I’m in recovery. I’ve got a lot more to offer.

• Feelings: hopeful, peaceful, less desperate• Actions: discuss with counselor, observe

relationships that seem to be working, read helpful books. Focus on your recovery

• Result: more confidence, willing to speak to a girls without expectations of liason

Thought Work or Inquiry

Byron Katie

• Suffering Thought• Is it true?• Can you absolutely know it’s true?• How do you react when you think this

thought?• Who would you be without the

thought?• Turnaround

Inquiry/The Work36 yoAAm incarcerated 8 years.

Productive Citizen class, be out in next couple months. Resentments.

• Painful Thought: My mother shouldn’t have given me away

• Is that true?• Can you absolutely know it’s true?

– She couldn’t care for me

•Who would I be without this thought?

•Believe a woman could love and stay with me

•Not feel so angry toward my mother

•Build a relationship with her

Turnaround: Opposite, Self, Others

1. My mother should have given me away

•Couldn’t care for me

•Great act of love

•Opened doors for me

2. I shouldn’t have given myself away

• betrayed myself, not honoring myself,

• ending up in prison

3. I shouldn’t have given my mother away:

• I’ve given away my relationship with her because I’ve been so hurt and angry

38 yo morbidly obese cf chronic lymphedema, depression, anxiety. Years earlier had witnessed her mother’s death after long illness.

Limiting Belief/Painful Thought: “I wasn’t there for my mother.”

1. Is that true?

well…

2. Can you absolutely know it’s true?

3 reasons why it might NOT be true

-sat up together many nights talking, laughing

-put off going to college

-responsible for her meds

3. How do I react when I’m having this thought?

-stuck

-undeserving

-sad, trapped

4. Who would I be without this thought?

-free

-light

-making plans for school

Turnaround statement:

1. Opposite: I was there for my mother.

2. Self: I wasn’t there for me.

3. Other: My mother wasn’t there for me.

Provide evidence for each statement, without forcing it.

Is there a thought that is more true for you?

The Change Cycle

Dr. Martha Beck, PhD

48 yocf in long term relationship presents with somatic complaints. Feeling ‘out of sorts’, distracted, sleeping problems. Little interest and pleasure in doing things. Recently paid off mortgage.

Catalytic Event: Joyful event/transition

Paying off the mortgage threw her into Square One.

Redefinition of self. Not the “starving artist” anymore.

Look at the story, look at the thoughts.

May need to go through a grieving process.

Yeeha!

Hello Square Two--Dream and Scheme!!

56 yocm was a body builder by hobby. Seven years earlier severely injured his back while working out. Had surgery and was on daily high dose opiates til he came for AOD.

Felt great physically, but at 1 month f/u stated he’d “never been more depressed in his entire life”.

Catalytic Event: Back Injury, traumatic event threw him into the Change Cycle.

Had not gone through a grieving process to allow transition into square 2: Dream and Scheme.

Follow up visit 1 month-making plans to return to school. Family life much improved.

Depression is never an accident; it is perfectly designed to tell you something important about how your life is going.

Grazi!!joan517shep@gmail.com

Beck, Martha. Life Coach Training Handbook. 2008.

Castillo, Brooke. Self-Coaching 101, http://www.brookecastillo.com/

Fournier, DeRubeis et al. Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta- analysis. JAMA 2010; 303 (1):47-53

Hamilton MA. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.

Hyman, Mark. “Why Antidepressants Don’t Work for Treating Depression”

http://www.ultrawellness.com/

Katie, Byron Kathleen. http://www.thework.com/index.php

Lee S, Walker JR, Jakul L, Sexton K. Does elimination of placebo responders

in a placebo run-in increase the treament effect in randomized clinical trials? A meta-analytic evaluation. Depress Anxiety. 2004; 19(1):10-19.

National Guideline Clearing House, Depression. The treatment and

management of depression in adults. 2009.

Strosahl, K.and Robinson, P. The Mindfulness and

Acceptance Workbook for Depression, 2008.