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Treating Post-Holiday Let-Down & Depression
Depression continuing education social worker CEUs

Section 26
Selected Readings Bibliography/Authors/Instructors

CEU Answer Booklet | Table of Contents
| Depression
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

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Additional Readings

"Stay active to beat the post-holiday blues; depression is common this time of year, but staying busy can keep you mentally and physically healthy." Healthy Years 5.1 (2008): 4+. Academic OneFile. Web. 29 Mar. 2010.

While the holiday season is associated with good cheer and excitement about the promise of a new year, an estimated one million Americans will find themselves experiencing post-holiday depression when the gift-giving and parties come to an end.

"Holidays are supposed to be a season of joy and happiness, but many people don't feel it," says Helen Lavretsky, MD, a geriatric psychiatrist at UCLA's Stewart and Lynda Resnick Neuropsychiatric Hospital. "Reasons for depression include grief, divorce, major changes, lack of sunlight or physical exercise, relationship problems, spiritual or anger issues, financial stress, sleep deprivation, and more."

Signs of depression. Because families are such a focus at this time of year, it's not unusual for the memories of those who have died or even just moved away to be even stronger and harder to release.

If you think you or a loved one may be vulnerable to depression, look for signs such as diminished interest in or enjoyment of activities; changes in appetite and sleep patterns; lack of energy; low self-esteem; feelings of hopelessness, unresolved grief or inappropriate guilt; social withdrawal; or even suicidal thoughts.

"If you have three or more of those symptoms, which have lasted for over two weeks, you should seek medical help or professional counseling," Dr. Lavretsky says.
Depression can also manifest in physical symptoms, such as headaches, dizziness, muscle pain, and nausea. Unexplained pain symptoms are more common among people with psychiatric disorders, research shows. Depression-related changes in sleeping and eating patterns can also contribute to declining health, Dr. Lavretsky says.

Preventive measures. Before depressive symptoms appear, you can take steps to shield yourself from troubling mood changes. Taking care of your physical health, for example, can improve your mental outlook, Dr. Lavretsky says.

She recommends a mix of exercise--four or five days a week of cardiovascular training, such as jogging or bicycling, as well as three or four days of weight training, along with yoga or Tai Chi. If you haven't had much regular exercise, you should talk to a doctor about any possible limitations.
Yoga or dance classes, or a membership at the local health club, can not only help you work off some calories acquired during the holidays, but also can give you something new to look forward to each day--an especially helpful tool for shaking the blues, Dr. Lavretsky suggests. Similar benefits can be found by starting a new hobby and doing volunteer work.

Treatment options. Talk therapy has been shown to be effective in treating depression. A counselor might opt for one of three types of talk therapy, including cognitive therapy, which seeks to change your thinking about troubling issues; behavioral therapy, which helps you gain control over your actions; and interpersonal therapy, which helps you relate better with others.

Even patients with mild to moderate depression can benefit from antidepressant medication, as well. Three types of medications shown to be effective are tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs). As with any medication, antidepressants can have side effects and some drugs are more effective than others at also relieving physical symptoms.

Dr. Lavretsky also recommends spending time with relatives and friends who enrich your life, and limiting or avoiding altogether the people and situations that negatively impact you and your feelings.
"Usually people who are feeling depressed are not doing what would help themselves feel better," Dr. Lavretsky says. "Figure out what's draining you and eliminate it."


"Happy holidays--without stress and depression: these 10 practical tips for coping with the pressures of the holiday season may help you avoid the 'holiday blues.'." Mind, Mood & Memory 2.11 (2006): 4+. Academic OneFile. Web. 29 Mar. 2010..

Not all of us feel joyous during the holiday season. For some, this special time for festivities, feasting, and family reunions can generate overwhelming stress: Instead of peace and joy, the holidays may bring symptoms of depression, with feelings such as sadness, anxiety, regret, fatigue, disappointment, and loneliness.

Symptoms of holiday depression may also include changes in sleep patterns, anxiety, restlessness, feelings of worthlessness or hopelessness, irritability, loss of interest in activities you usually enjoy, or crying for no reason. These symptoms often develop when people are overwhelmed by the physical and psychological demands of the holiday season.

Although holiday depression is usually transitory (most cases occur sometime between Thanksgiving and a few days after the holidays end in January), it can be deeply disturbing while it lasts. Fortunately for those who are susceptible to the holiday blues, there are steps that can be taken to manage depression and perhaps even avoid it altogether.

"Many factors combine at this time of year to increase stress on individuals," says Joel Pava, PhD, Director of Psychotherapy Services for the Depression Clinical and Research Program at Massachusetts General Hospital. "Media depictions of happy families enjoying the holidays together can make people who are isolated feel lonely and unloved. Advertisements for fabulous gift possibilities can make your own presents seem inadequate. You may feel pressure from having too much to do, from increased family tensions or from not having enough money.

"But much of this distress comes from measuring yourself against an imagined ideal. If you try to form more realistic expectations for the holidays, it may help you avoid feelings such as anxiety, failure, disappointment or sadness that can trigger depression. Try setting a few specific goals for the holidays (such as preparing a special family meal or visiting with a favorite relative, or donating time, money or goods to the needy) and then following through on these goals. Sensible planning can help prevent you from feeling overwhelmed, and can give you a basis to appreciate your accomplishments and to feel a sense of achievement."

THE HOLIDAY STRESSORS
In addition to normal everyday responsibilities, the holidays bring pressures to attend parties, go shopping for presents, bake and cook, and organize special events. Routines are altered, with less time for sleeping and relaxing. Festivities bring the temptation to overindulge in food and drink. House guests demand attention, as do children or grandchildren on vacation from school, and relatives who have special needs for the holidays. Errands, cleaning and other physical chores add to the burden, causing excess fatigue.

Psychological stress mounts as well. Among the issues commonly associated with holiday stress or depression are:

Family pressures: Holidays are often times of heightened tension in families. Conflicts and misunderstandings may arise as people gather to celebrate the holidays, and coping with complex family relationships can result in even more strain. High expectations may lead to disappointments, and resentments may build over such issues as chores, finances and gift-giving. Those separated from loved ones during the holidays may suffer feelings of loneliness and sadness.

Financial limitations: A restricted budget may limit the ability to give generous gifts, resulting in feelings of regret and inadequacy. Overspending during the holidays, on the other hand, can lead to guilt and financial worries.

Unrealistic expectations: Trying to create the ideal holiday by demanding that everything be perfect can lead to frustration, disappointment and depression. Focusing on what you "should" do rather than on what you can do creates unnecessary stress, resentment and fatigue.
Lifestyle changes: The death of a loved one or the breakup of a marriage may be especially deeply felt at holiday time.

Feelings of isolation: Over-commercialization and constant bombardment with media coverage featuring images of happy families and friends celebrating the season can lead to depression during the holidays. People who feel their holiday experience does not measure up to the ideal may feel isolated, rejected, and alone.

Seasonal effects: The reduced sunshine and short days of winter associated with the holiday months in northern states may trigger Seasonal Affective Disorder (SAD), a type of depression that affects as many as 10 percent of individuals living in colder regions.

Post-holiday letdown: Excess fatigue and stress can combine with feelings of disappointment associated with the holiday season to increase depression after the holidays are over.

HEADING OFF HOLIDAY STRESS
You can minimize stress and depression during the holiday season and help protect yourself from developing more serious chronic depression by being aware of holiday stressors and taking action to manage them. Try these 10 suggestions for heading off holiday stress:

1. Adopt a realistic attitude about the holidays. Don't overburden yourself with elaborate plans and too many activities in an attempt to have a "perfect" season. Accept that not everything will go according to plan. Spread celebrations out over several days to reduce stress. Keep things simple and focus on the true meaning of the holidays.

2. Organize. Set specific goals and pace yourself to prevent stress and fatigue. Make lists to help keep track of activities and chores. Prioritize.

3. Make a budget. Overspending can result in anxiety and financial strain. Before you shop, plan how much you intend to spend and try to stick to your budget. Remind yourself that where presents are concerned, it truly is the thought that counts.

4. Ask others to pitch in. Don't try to do everything yourself. Enlisting the help of others can give your friends and relatives a chance to participate in holiday preparations and help you avoid fatigue. Ask for emotional support if you need it as well.

5. Expect change. Trying to create a holiday season that is just like holidays in the past is likely to generate disappointment. Accept that each holiday season is unique and try to enjoy what this year brings.

6. Acceptothers the way they are. The holidays are not the time to change your friends, settle family differences or discuss sensitive issues. Be patient with others--they may be under stress, too.

7. Be sociable. Loneliness can be a special problem in the holiday season. To avoid isolation that could lead to depression, make it a point to contact family and friends, engage in social activities and reach out to help others, including doing volunteer work.

8. Get plenty of rest. Sleep deprivation and too little "down time" during the holidays can lead to fatigue and stress and deplete your emotional reserves.

9. Take care of your health. Eat healthy, low-fat foods and avoid consuming excessive amounts of alcohol. Try to find time for exercise. For those who suffer from SAD, eliminating caffeine, increasing ambient light levels, and getting outside for some time in the sun may help improve mood.

10. Seek professional help if you have symptoms of depression--such as disturbed sleep, changes in appetite, and feelings of hopelessness, sadness, irritability, guilt or anxiety--that last for more than two weeks and/or interfere with your normal routine. You may be suffering from major depression that can be treated with talk therapy, medication or a combination of the two.

WHAT YOU CAN DO
Try these tips for protecting yourself from seasonal stresses that can bring on depression.
* Learn to say no. Taking on too many responsibilities can make you feel overwhelmed and anxious.
* Admit your feelings. You don't have to be happy all the time during the holidays. Accept that you will feel sadness, anger and other normal feelings, even at this special time of year.
* Go easy on yourself. You don't have to be a super cook, a perfect gift-giver or the most doting grandmother ever. Try to judge yourself less and enjoy yourself more.
* Arrange for time alone. We all need time to relax and recharge, even during the holidays. Make some time for yourself.

LOOKING FOR NEW FRIENDS? TRY THESE SEVEN SUGGESTIONS
Close social bonds provide an important buffer against loneliness, stress and depression. People who are socially isolated are two to three times more likely to experience depression and other health problems than those who have strong social networks, research shows.

To maximize your mental health and prevent social isolation and depression, make an effort to get involved in social activities and build strong bonds with others. Here are a few suggestions that may help you enlarge your circle of friends:

* Volunteer to help out in your community. Joining a group effort to benefit others can increase your sense of belonging and boost feelings of self-worth--both powerful antidotes to depression.
* Participate in sports or recreational programs. You'll get fit and make friends at the same time.
* Cultivate a sense of humor. It appeals to others, and helps you maintain perspective and equilibrium in difficult moments.
* Make friends with upbeat people who enjoy life, and do your best to emulate them. An optimistic attitude can help prevent depression.
* Identify and acknowledge your needs, then learn to ask for--and accept--help from others. Healthy friendships involve both giving and taking.
* Talk about your fears and failures with friends. Sharing problems eases the anxiety and stress that can lead to depression, while toughing it out usually increases feelings of isolation.
* Learn to accept praise from others. This enhances both your self-esteem and your bonds with others.


Barker, Jason, and Chris D. Meletis. "Seasonal Affective Disorder: avoiding the winter blues." Townsend Letter for Doctors and Patients 246 (2004): 92+. Academic OneFile. Web. 29 Mar. 2010.

Seasonal Affective Disorder (SAD) sometimes known as "winter depression" or "winter blues" belongs to a group of depressive disorders known as major depressive disorder. Characterized by ongoing or recurrent depressive episodes that are associated with changing seasons into the winter months, with symptoms subsiding during the spring and summer months, SAD is a mood disorder associated with periods of depression and is related to seasonal variations of light. SAD may begin insidiously in younger people (20-30 years of age) appearing as mild to moderate depressive occurrences. Social withdrawal, sadness, anxiety, and irritability are key features, while associated atypical depressive symptoms of increased sleep and lethargy, and increased appetite (especially for "starchy" carbohydrates) and concomitant weight gain is common as well. (1) Women are more often affected for unknown reasons. (2)

SAD was not officially recognized as a clinical disorder until the 1980's. SAD is relatively common, occurring in 11% of patients who have major depression (3) with a prevalence of 1%-3% in Canada, 1.3%-3% in Europe, and 0.9% or less in Asia (4) while total North American incidence is 6%. (5) It is estimated that SAD occurs in 13% to 17% of first-degree relatives of people with SAD. (6) Symptoms of SAD include, but are not limited to:

* Regularly occurring symptoms of depression (lethargy, fatigue, anxiety, inability to cope, social avoidance, insomnia)
* Increased appetite, sleep time, and weight gain during fall or winter months
* Resolution of symptoms in the spring and summer months
* Symptoms have occurred during the past two years, with an absence of non-seasonal depressive episodes
* Loss of libido, not interested in sex or physical contact
* Craving for carbohydrates and sweet foods, increased appetite leading to weight gain

Humans, much like animals, are affected by seasonal light variation. Animals experience reproductive cycle, sleep/wake, and hibernation behavioral changes that are largely attributed to seasonal sunlight amounts. Although human activity patterns are largely ungoverned by seasonal sunlight levels, human circadian rhythms (biologic clocks) are affected by sunlight despite the relative control of our living environments. With changing seasons, our internal rhythms begin to change and in susceptible individuals, their biologic clockwork may easily become out of sync with established daily schedules. Accordingly, the most difficult times of year for people with SAD are December, January and February.

Although the exact cause of SAD is not entirely known, much speculation rests on decreased exposure to sunlight during the winter months as the primary etiologic factor for this condition. Interestingly, a meta analysis of the research investigating the incidence of SAD in correlation with latitude revealed a relatively weak, albeit positive link between extremes of latitude and occurrence of SAD. The average prevalence of SAD is twice as high in North America compared to Europe, and a similar link does exist in Europe although this is much less than that of North America. (7) The authors of this study concluded that the influence of latitude on SAD is relatively small in comparison to other factors such as climate, genetic susceptibility, and social-cultural context.

A definitive link between climate and SAD was explored in another study in which weather data was gathered in accordance with completed depression symptom surveys from study participants over a course of 4 years. No significant links between depression survey scores and cloud cover, rainfall or atmospheric pressure were noted, however a significant correlation between depression scores and amount of sunshine, global radiation, temperature and length of daylight was noted, emphasizing the role of sunshine deprivation as a contributory factor to SAD. (8)

Melatonin
Melatonin is a neurotransmitter produced within the pineal gland, located deep within the brain. It has numerous functions in the body, and levels are regulated to some extent by sunlight exposure. Melatonin secretion is increased during hours of darkness, and decreases with sunlight exposure. Various studies indicate that melatonin plays a role in the regulation of circadian rhythms, (9) and investigations into the role of melatonin as a causative factor of SAD have revealed various results. Previously, excessive melatonin production was indicated as a main causative factor in SAD, partially because of the hypnotic, or sleep-inducing effects of it when administered outside of the body and because it was produced in higher amounts during times of darkness. Recently, it was recommended that melatonin be used as a treatment for SAD when administered in the late afternoon or early evening. This approach was used because it was thought that precise timing of melatonin administration could shift the sleep-wake cycle, decreasing daytime somnolence. Efficacy of this approach is yet to be clearly determined in treating SAD, however melatonin as a sleep aid is effective in people with insomnia from other causes.

Phototherapy
Phototherapy, also known as light therapy, is the use of certain wavelengths of artificial light to treat SAD. Phototherapy was put into clinical use after it was demonstrated that exposing animals to light altered their circadian and seasonal rhythms, and that light exposure had the ability to suppress nocturnal melatonin secretion. Multiple studies of light therapy and SAD exist, with most demonstrating a positive effect on SAD symptoms in 60% to 90% of those treated, with the average clinical response of approximately 65%.

Phototherapy is usually prescribed in terms of "lux," a unit of luminance as perceived by the retina, and descriptors such as intensity, wavelength, and duration of daily exposure are included in the prescription. Typically, indoor lighting emits 500 lux, while high noon on a cloudless summer day can emit 50,000 lux. Cloudy days range from 1,000 to 5,000 lux. Light therapy is received, and the effects of it are mediated through the eyes. A common misconception is that this therapy is effected through the skin, however that is a separate biochemical process--vitamin D synthesis occurs in the skin, as rays of sunlight are absorbed.

Standard dosages of phototherapy used in effective studies were 2,500 lux for up to 2 hours per day. Other sources describe 10,000 lux for only 30 minutes per day as effective as well. Researchers place more emphasis on timing of exposure than on duration of treatment for clinical efficacy. In this regard, morning exposure is more effective than evening exposure. Interestingly, the type of light is also not considered as important as intensity, although studies indicate that white light is superior to incandescent or fluorescent light. Tanning lights, which emit ultraviolet light, should generally be avoided due to their negative effects on skin health.

Botanical Medicine: St. John's wort
In addition to light therapy, pharmacotherapy with antidepressants comprises the standard medical treatment for SAD. However, tricyclic, monoamine oxidase inhibitor (MAOI's) and selective serotonin reuptake inhibitor (SSRI's) therapies are rife with side effects for many patients, making compliance with antidepressant therapy difficult for SAD. A literature review of the effects of St. John's wort (Hypericum perfoliatum) indicates that this botanical medicine has efficacy in several biochemical pathways that play a central role in depressive pathogenesis, including the MAO, serotonin, GABA, and dopamine neurotransmitter systems. (10) Although no single constituent of the herb has been indicated in the plant's effectiveness in treating depressive disorders, the efficacy of St. John's wort is similar to that of standard pharmaceutical therapeutics. (11)

For treatment of SAD, St. John's wort has been demonstrated in clinical studies to be effective for treating this type of depression as well. Patients who qualified under DSM-III-R criteria as majorly depressed with seasonal patterns, were treated for four weeks with 900 milligrams of standardized hypericum perfoliatum daily with light therapy. At the end of the study, patients' depressive symptoms were analyzed using the Hamilton Depression Scale (a standard measure of depressive symptomology) and were significantly reduced, leading the authors to conclude that hypericum perfoliatum displays promise as an effective therapy in SAD. (12) Another study involving the use of hypericum perfoliatum in SAD revealed that when taken in combination with light therapy, patients experienced significant improvement in anxiety, libido loss, and insomnia. (13)

St. John's wort is a clinically effective botanical medicine that can be used as an adjunctive treatment in SAD. This being said, however, persons wishing to use hypericum are encouraged to contact a physician that is knowledgeable in the use of botanical medicines, as several widely used pharmaceutical medications can interact negatively with this herb, especially when used with pharmaceutical antidepressant medications. In order to provide the greatest effective treatment regimen for treating SAD, however, hypericum perfoliatum has few side effects and is therefore better tolerated than standard pharmaceuticals.

Exercise and Depression
Much research exists exploring the curative effects of exercise on depressive disorders. Even more so, exercise plays a major role in the treatment of SAD, and because of this, it may stand to reason that lack of exercise is a contributor to SAD symptomology. Exercise therapy in conjunction with other treatments (phototherapy, dietary manipulation/supplementation) has demonstrated interesting results, not only in treating SAD symptoms, but also on other health outcomes. One study had subjects perform exercise in both a brightly lit and normally lighted gym for a period of 8 weeks. Both groups experienced "effectively relieved" depressive symptoms. (14) A similar study revealed nearly the same results, increasing the health-related quality of life in wintertime, and was an effective intervention for improving mood. (15) Another study examined the combined effects of exercise and phototherapy on mood, body weight and oxygen consumption in females with SAD. Again, SAD subjects responded favorably to the exercise and light therapy. (16)

It is known that exercise and physical activity play an important role in the treatment and prevention of depressive disorders and anxiety, and that depressed people tend to exercise less frequently than those who are not depressed. Specifically, strength training and aerobic exercise exert the greatest anti-depressive effects. (17) In a study designed to measure various moods following exercise bouts, depressed mood scores were significantly reduced, while feelings of fatigue increased. (18) The majority of studies involving exercise and depression positively indicate the antidepressant, anxiolytic, and mood-enhancing effects of aerobic exercise, not to mention protection from the harmful effects of stress on the depressed patient, whether symptoms are seasonal or continuous. Exercise is popularly known to increase the levels of "feel-good" chemicals in the body known as endorphins and enkephalins. Produced in the body as a "side effect" of exercise and other biologic processes, these chemicals are responsible for relieving pain and the so-called runner's high, among other effects. It is possible that endorphins and enkephalins play a role in alleviating depression as well. Exercise provides lasting resilience to the effects of stress, and because of this, will serve people with SAD in alleviating the seasonal symptoms of depression and the stress that accompanies this occurrence.

Nutrition for Depression
Proper nutrition is essential for all people, and even more so for those with any type of adverse health conditions, including SAD. Complete nutrition provides the body with all of the materials it needs to perform at its highest levels. The natural state of the human body is one of perfect health and function. Supplying the body with the nutrients it needs to perform up to this standard is often a foregone conclusion. The highest state of being is health, and when the organism is lacking the raw materials necessary to achieve this state, imperfections in health begin to emerge.

Depressed individuals often have deficiencies of several different B vitamins, namely folic acid and vitamin B12, especially among the elderly. (19) Both folic acid and B12 play essential roles in energy-producing biochemical processes. They act as molecular messengers in the formation of brain neurotransmitters, which act as the chemical messenger "language" of the brain, allowing it to perform its multiple functions. Folic acid and B12 play several roles in the formation of precursor molecules that allow the brain to manufacture two specific neurotransmitters that are important in depression, serotonin and dopamine. Deficiencies of both neurotransmitters are implicated as playing a role in the condition of depression. Supplying adequate amounts of each vitamin will allow the body to supply itself with the necessary precursors for optimal health status.

It is also important to mention that the role of nutrition, and of specific vitamins, (especially those belonging to the B-vitamin group) is at this time becoming more and more widely recognized for playing an important part in complete health. Oftentimes, vitamins are easily overlooked by conventional physicians as having no part in the overall scheme of health. However, the medical evidence that is mounting in opposition to this outlook continues to grow at an exponential rate. Providing the body with a complete armamentarium of necessary biochemical cofactors provides the greatest opportunity for disease-free performance. To summarize, a balanced diet comprised of lean proteins, complex carbohydrates, beneficial fats, and a multimineral and vitamin supplement will afford the cleanest, most energetic fuel for the human organism.

Other possible nutritional/supplemental interventions in depression and SAD include 5-hydroxy/tryptophan (5-HTP) and S-Adenosyl-methionine (SAMe). 5-HTP is a compound extracted from the seeds of Griffonia simplicifolia, a plant native to the African continent. 5-HTP is an amino acid that serves as the final precursor molecule in the formation of the neurotransmitter serotonin. 5-HTP is a more effective and efficient variation of the amino acid tryptophan, allowing for greater production of serotonin (low levels are implicated in depression) and other neurotransmitters responsible for feelings of well-being. SAMe is derived from another amino acid known as methionine. SAMe is useful in a number of clinical conditions, and is specifically used in cases of depression because of its action as a methyl donor. As a methyl donor, SAMe assists in the production of nucleic acids, proteins, phospholipids, monoamines, neurotransmitters and the metabolism of vitamin B 12 and folate, all of which play a role in healthy brain function. A review of the studies investigating SAMe and depression have shown that SAMe performed better than placebo and was as effective as tricyclic antidepressants in relieving symptoms of depression, and that it has a quicker onset of action than standard antidepressant medications, is free of side effects, and is well tolerated as a medicine. (20)

Conclusion
There are many theories about the causes of SAD and depression, most of which are tied into biochemical insufficiencies. SAD however, as a seasonal depressive disorder has a direct causative link to decreased amounts of sunlight during the winter months. This being said however, does not exactly provide a substantiative causative reason for why some people have SAD and others do not. Biologic theories provide some explanation for the cause of this cluster of symptoms, in that wintertime is a period of decreased activity, and conservation of energy for survival during these months of low food availability may lead to decreased activity. Despite this reasoning, and the fact that the majority of humans today do not need to "hibernate" throughout the winter months, a cause for the symptoms of SAD needs to be addressed prior to medicating the patient. Addressing fitness and exercise levels, nutritional adequacy, and providing regular exposure to light can be used to offset SAD symptoms. The addition of medication in the form of a botanical medicine (Hypericum perfoliatum) and nutritional supplements such as SAMe and 5-HTP provide another arm of defense for the person trying to cope with seasonal affective disorder.

 

- Blatt, Sidney PhD, Experiences of Depression: Theoretical, Clinical, and Research Perspectives, American Psychological Association: Washington DC, 2004.

- Boyum, Richard MA, Holiday Depression, SelfCounseling: Washington DC, 2004.

- Burke, Sara E.; Wang, Katie; Dovidio, John F. Witnessing Disclosure of Depression: Gender and Attachment Avoidance Moderate Interpersonal Evaluations. Journal of Social & Clinical Psychology. Jun2014, Vol. 33 Issue 6, p536-559.

- Gladstone, Tracy R. G.; Beardslee, William R.; The Prevention of Depression in Children and Adolescents: A Review; Canadian Journal of Psychiatry, April 2009, Vol 54 Issue 4, p212

- Giosan, Cezar; Cobeanu, Oana; Mogoase, Cristina; Muresan, Vlad; Malta, Loretta S.; Wyka, Katarzyna; Szentagotai, Aurora. Evolutionary cognitive therapy versus standard cognitive therapy for depression: a protocol for a blinded, randomized, superiority clinical trial. Trials. 2014, Vol. 15 Issue 1, p1-25.

- Kramer, Peter D. PhD, Against Depression, Penguin Group: New York, 2005.

- Maeda, Uta; Shen, Biing-Jiun; Schwarz, Ernst; Farrell, Kristen; Mallon, Stephen. Self-Efficacy Mediates the Associations of Social Support and Depression with Treatment Adherence in Heart Failure Patients. International Journal of Behavioral Medicine. Mar2013, Vol. 20 Issue 1, p88-96.

- Matos, Marcela; Pinto-Gouveia, José. Shamed by a Parent or by Others: The Role of Attachment in Shame Memories Relation to Depression. International Journal of Psychology & Psychological Therapy. 2014, Vol. 14 Issue 2, p217-244.

- Newman, Stephen C.; Bland, Roger C.; A population-based family study of minor depression; Depression & Anxiety; 2009, Vol 26 Issue 4, p389

- Philip J. Cowen and Michael Browning. What has serotonin to do with depression?. National Center for Biotechnology Information. World Psychiatry 14:2 - June 2015, p158-160.

-Pyne, Jeffrey M.; Fortney, John C.; Tripathi, Shanti; Feeny, David; Ubel, Peter; Brazier, John; How Bad Is Depression? Preference Score Estimates from Depressed Patients and the General Population; Health Services Research, August 2009, Vol 44 Issue 4, p1406

- Rachman, S. PhD & Jack Maser MA, Panic: Psychological Perspectives, LEA Publishers: Hillsdale, 1998
.
-Romer, Dan PhD & Herbert Hendin, Myth of Winter Holiday Suicide, Annenberg Public Policy Center: Washington DC, 2001.

- Shapero, Benjamin G.; Black, Shimrit K.; Liu, Richard T.; Klugman, Joshua; Bender, Rachel E.; Abramson, Lyn Y.; Alloy, Lauren B. Stressful Life Events and Depression Symptoms: The Effect of Childhood Emotional Abuse on Stress Reactivity. Journal of Clinical Psychology. Mar2014, Vol. 70 Issue 3, p209-223.

- Stein, Dan J. PhD, Clinical Manual of Anxiety Disorders, American Psychiatric Publishing: London, 2004.

-Taylor, Steven PhD, Anxiety Sensitivity: Theory, Research, and Treatment of the Fear of Anxiety, LEA Publishers: Mahwah, 1999..

-Wegener, Ingo; Alfter, Susanne; Geiser, Franziska; Liedtke, Reinhard; Conrad, Rupert, "Schema Change Without Schema Therapy: The Role of Early Maladaptive Schemata for a Successful Treatment of Major Depression", Psychiatry: Interpersonal & Biological Processes. Spring 2013, Vol. 76 Issue 1, p1-17.

- Wilson, Reid PhD, Don't Panic: Taking Control of Anxiety Attacks, Harper & Row Publishers: New York, 1999.

- Coordinating Author/Instructor: Tracy Appleton, LCSW, MEd

 
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