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Section 11
Depression and Bipolar Disorder

CEU Question 11 | CE Test | Table of Contents | Bipolar
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

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On the last track, we discussed three difficulties in prescribing medication to bipolar children.  These three difficulties included:  taking regular doses; rebellious teens; and side effects.  We also included two techniques for combating these difficulties, which were Medication Routine and Other Non-Medicinal Treatments.

On this track, we will examine three non-medicinal treatments for depression.  These treatments include  electroconvulsive therapy; light therapy; and repeated transcranial magnetic stimulation.

3 Non-Medical Treatments for Depression

1. Electroconvulsive Therapy
The first non-medicinal antidepressant therapy is electroconvulsive therapy, or ECT.  Many parents are reluctant to try this method because of the stigma that goes with it.  Often, parents find it disturbing that their child will be subject to electric shocks and seizures.  However, Drs. Mark Bertagnoli and Carrie Borchardt completed a study in which 67 percent of bipolar children treated with ECT improved.  This procedure is usually given to a child or adolescent client three times the first week, and twice each week after for a total of six to nine or fifteen to twenty completely painless treatments, depending on the degree of response. 

During the procedure, the client is put to sleep with a short-acting barbiturate and a drug is administered to paralyze the muscles to prevent contracting and fractures.  An electrode is then placed above the temple of the non-dominant side of the head and a second in the middle of the forehead.  A very small current of electricity is passed through the brain causing a seizure.  The client breathes pure oxygen through a mask and his or her heart is monitored as well as the seizure activity. 

For adolescents, the seizure threshold is extremely low and the first treatment is administered at the lowest possible level.  However, adolescents develop tolerance quickly and by the third or fourth treatment, the energy is increased.  After the treatment, many clients experience temporary memory loss and confusion, but these side effects vanish after an hour or so.

Parents Unsure about ECT
Tiffany was an eleven year old bipolar client whose depressive states were such that many of her medications did very little and were never enough to keep her stable.  She said she was frightened by the thoughts that came to her during depression and hated the lack of energy she had.  I suggested to her mother, Lucy, that Tiffany might benefit from ECT.  At first, Lucy was reluctant, having formed certain opinions about the procedure. 

To help Lucy see the benefit of ECT, I gave her several pamphlets and books to read to help her learn more about it.  After a few weeks, Tiffany was in her first session.  Because of the degree of her depression, Tiffany required more treatment sessions than many clients, 20 in all.  However, once she had finished her sessions, Tiffany stated, "I have so much more energy now, and it’s not the kind I have when I’m crazy.  I feel good about myself and the bad thoughts are gone."  Think of your "Tiffany".  Could her deep depression benefit from ECT?

2. Light Therapy
The second non-medicinal antidepressant treatment is light therapy.  This therapy is most effective for clients whose depression is directly affected by the seasonal change and lack of sunlight.  To combat this depression, I suggest to many of my clients to try buying a light box.  A light box is a specially designed light that simulates sun rays by emitting all wavelengths. 

The timing of circadian rhythms varies in relation to mood in a predictable way in rapid-cycling clients.  Specifically, the phase of temperature, the excretion of a metabolite or norepinephrine and melatonin secretion all occur earlier in the day in a hypomanic state than in a depressed state.  This bright light can shift the phase of circadian rhythms, with morning light shifting the rhythms to an earlier time and evening light delaying them.  Manipulating these phase shifts could treat the depressed phase of the illness.

Tony was a 12 year old bipolar client whose depressive states made an all time low in the months of October to March.  Tony stated, "I like the summer.  When I feel bad, it’s not the same kind of bad as in the winter.  When it’s cold and dark, I feel like dirt."  To treat his seasonal affective disorder, I suggested to Tony’s father Mark that Tony be treated with a light box. 

Light Sessions
For his light sessions, Tony sat about two feet away from the light box while it was on.   Every minute or so, Tony was instructed to look into the light for a few seconds.  While he was not looking at the light, Tony played video games, read a book, or watched television.  His treatment only required he use the light box fifteen minutes a day.  In about two weeks, Tony reported a more stable condition.  Keep in mind that children under the age of eight have a higher sensitivity to light and should be exposed to a much less intense light box.

3. Repeated Transcranial Stimulation
In addition to ECT and light therapy, a third non-medicinal antidepressant therapy is repeated transcranial magnetic stimulation or r-TMS.  This treatment involves using a coiled magnet aimed at the left prefrontal cortex of the brain, which may be able to speed up the motor nerve pathways in clients suffering from depression.  This treatment involves a client sitting in a lounge chair while a small but powerful coiled electromagnet is placed on the scalp.  This creates a strong magnetic field that passes through the skull. 

When this rapidly changing magnetic field encounters the brain’s nerve cells, it causes an electric current that depolarizes them.  The client receives forty stimulations in two seconds and this is repeated twenty times  There are very low side effects, such as an occasional headache, but this treatment is in its infancy, and more research must be done to determine whether it is effective on children and adolescents.

On this track, we presented three non-medicinal treatments for depression.  These three treatments included  electroconvulsive therapy; light therapy; and repeated transcranial magnetic stimulation.

On the next track, we will examine the three key aspects of stress on bipolar child clients:  biological processes; social factors; and transitions.  We will also include three techniques to reduce these stresses, which are Acclimation, Point System and Transition Form.

Peer-Reviewed Journal Article References:
Gellersen, H. M., & Kedzior, K. K. (2018). An update of a meta-analysis on the clinical outcomes of deep transcranial magnetic stimulation (DTMS) in major depressive disorder (MDD). Zeitschrift für Psychologie, 226(1), 30–44.

Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function.Stigma and Health, 4(3), 330–336.

Meyerhoff, J., & Rohan, K. J. (2016). Treatment expectations for cognitive-behavioral therapy and light therapy for seasonal affective disorder: Change across treatment and relation to outcome. Journal of Consulting and Clinical Psychology, 84(10), 898–906.

Tsai, J., Huang, M., & Lindsey, H. (2019). Perceptions and knowledge related to electroconvulsive therapy: A systematic review of measures.Psychological Services. Advance online publication.

Online Continuing Education QUESTION 11
What are three non-medicinal treatments that can be used for depression in bipolar child clients? To select and enter your answer go to CE Test


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