Depression is a disease that is quite common in medical practice. It manifests itself primarily in the affective sphere and is accompanied by severe somatic, motivational, autonomic disorders. In the treatment of depression, two directions are developing: pharmacological and non-pharmacological.
The widespread and well-founded pharmacotherapy of depression is still insufficiently effective in 25% of cases due to poor tolerance to drugs and the resistance of the disease itself (S. Dilsaver et al., 1983, S.P. Oskolova, 1985).
In this regard, non-pharmacological methods of treatment, which also have their own pathogenetic rationale, play a significant role.
– breathing and relaxation training;
– light therapy (phototherapy);
– sleep deprivation (sleep deprivation);
– electroconvulsive therapy.
Psychotherapeutic treatments are divided into psychodynamic, non-directive, rational, and interpersonal psychotherapy.
The basic principles of psychodynamic therapy were developed by Bullack. There are ten most important mental manifestations that are subject to research and correction (self-esteem, self-flagellation, anger, disappointment, feelings of loss, narcissism, denial of latent anger, etc.). Classical psychoanalysis is not indicated for severe depression.
Nondirective psychotherapy is based on the concepts of Rogers, Maslow, and Perls. The patient expresses his thoughts and feelings, and the therapist, without imposing his interpretations, helps to understand himself. An important condition for treatment is empathy – the ability of the psychotherapist to put himself in the patient’s place, to look at the world through his eyes. The focus is on the current situation.
Rational psychotherapy is aimed at eliminating irrational ideas expressed by patients with depression. It is more effective in patients with depression compared to the psychodynamic method. There are indications that it is comparable to or even more effective than drug therapy, especially for mild to moderate depression.
Interpersonal psychotherapy was developed by Klerman, Weisman, and others. It improves the social adaptation of patients and interpersonal contacts, reduces the secrecy of patients, makes it possible to express their thoughts and feelings. It has been shown that interpersonal therapy for some manifestations of depression, for example, in relation to social maladjustment, can effectively reduce it, which is comparable to drug therapy.
Thus, it should be noted that psychotherapy is especially effective for mild or minor depression, characterized by decreased mood and some somatic complaints. In general, it should be noted that psychotherapy should be performed by an experienced specialist. However, the treatment of autonomic disorders and sleep disorders is better corrected by combination with drug therapy.
Respiratory relaxation training (DRT)
Depressive disorders are often combined with anxiety, according to A.F. Schatzberg (1995), at 31 – 62%. Therefore, in these cases, it is advisable to use DRT, which combines elements of mental and muscle relaxation with chest excursions in the inhalation – exhalation rhythm. When performing DRT, it is necessary to observe several principles: the gradual inclusion of the diaphragm in breathing, the formation of a certain ratio between the duration of inhalation and exhalation – a ratio of 1: 2. The transition to the abdominal type of breathing causes the Hering-Breuer reflex, which helps to reduce the activity of the reticular formation of the brainstem, reduce mental stress, reduce hyperventilation syndrome and anxiety. Reduced and deeper breathing optimizes the processes of pulmonary ventilation and diffusion, improves microcirculation.
Light therapy (phototherapy)
Among the recently used non-drug treatments for depression and various somatovegetative disorders associated with it, bright white light therapy has begun to be used. Interest in this method has increased in recent decades in connection with the treatment of seasonal affective disorders (W. Rosental, A. Levy; 1982-1984.) , selective hyperphagia of carbohydrates. Body weight increases. Blood levels of melatonin increase in patients with SBP. With an increase in the light phase of the day, the severity of symptoms decreases. In 1980, A. Levy reported on the blockade of melatonin by bright white light. After that, light therapy began to be used in the treatment of various disorders: seasonal and non-seasonal affective disorders, insomnia, etc. Treatment with bright white light is based on its effect through the retina, hypothalamus, b-adrenergic receptors of the pineal gland membrane. Light helps to reduce melatonin, increase serotonin and dopamine. Our experience (Ya.I. Levin, A.R. Artemenko, 1996, A.D.Solovieva, E.Ya. Fishman, 1997) showed that bright white light reduces the level of depression, improves sleep, and vegetative manifestations accompanying depression.
Phototherapy is carried out according to the technique, which consists in the fact that the patient takes light sessions every day (preferably in the morning). The lamp cover is installed at an angle of 45 degrees in relation to a straight line drawn mentally from the center of the eyeball to the horizontal axis of the lamp. The patient is at a distance of 60 cm from the lamp; the session lasts 60 minutes, during the session the patient receives about 3500 – 4000 lux.
Sleep deprivation (sleep deprivation)
In 1966 W. Schulte introduced the treatment of depression by sleep deprivation into psychiatric practice. He showed that deprivation improves the condition of patients with psychogenic and organic depression. Later, other researchers noted its pronounced effect in depressive disorders. It is known that sleep disorders occur in 83 – 99% of patients with depression. Sleep disturbances along with other symptoms are a criterion for diagnosing depression. A study of sleep in patients with depression showed a decrease in its depth and an increase in motor activity during sleep. In the works of A.M. Wayne, R.G. Airapetova, 1983, 1984 it was shown that with various forms of depression, the latent periods of the first, second and third phases of sleep increase, there is a pronounced reduction of the fourth, most profound stage, the phase of slow sleep, a decrease in the latent period of the phase of REM sleep (REM) was revealed, which is associated with the pressure of REM sleep, characteristic for depression. Thus, subjective complaints of patients about sleep disorders are combined with objective changes during the night on the EEG.
Treatment is with total sleep deprivation. Patients do not sleep from the morning of the day preceding the sleepless night until the evening of the next day, i.e. sleep deprivation is 36 – 38 hours. Then there are two restorative nights, during which patients sleep naturally. After which the deprivation is repeated, if the condition improves, then a third sleep deprivation is performed. Sleep deprivation stops if the patient’s condition does not change or worsens after two sessions. When the condition improves, it is recommended to carry out two sleep deprivations per month. Sleep deprivation provides an improvement in mental state in 90% of patients. According to R.G. Ayrapetova (1984), the positive effect of sleep deprivation is especially noted in melancholy depression, where it is not inferior in effectiveness to antidepressants, adynamic depression. It is less effective in asthenic and anxious depression and has not been shown to have a beneficial effect in masked depression. Deprivation actually has a thymoleptic and disinhibitory effect that stimulates activity, while improving mood and physical activity. There is an activation of the REM sleep phase and synchronization in the EEG of wakefulness, which is of a compensatory nature and provides emotional stabilization.
Sleep deprivation therapy is indicated for any depression that is not accompanied by psychomotor agitation. It itself has a positive effect by reducing depression and significantly enhances the effect of antidepressant treatment, which can significantly reduce the dose of pharmacological drugs. The best results, as a rule, can be achieved with combination therapy: sleep deprivation in combination with antidepressants.
Electroconvulsive therapy (ECT)
This type of therapy for depressive disorders was especially widely used in psychiatry in the 30s and 50s, then a period of rejection began. In recent years, there has been renewed interest in this therapy. ECT is used mainly in patients with severe depressive disorders in specialized psychiatric hospitals, as well as in patients with contraindications to pharmacotherapy and in cases where other methods of treatment are ineffective. ECT is the treatment of choice in cases of extraordinary suicide attempts or persistent refusal to eat, where ineffective antidepressant therapy can lead to wasted time. ECT is considered to be the most effective treatment for depressive attacks and is a treatment for depression that prevents manic attacks. Therefore, it is effective in TIR, in which antidepressants increase the frequency of seizure changes, in psychotic depression, in which antidepressants help little or no help.
There are no absolute contraindications to ECT, but a number of factors and the existence of relative contraindications must be taken into account when prescribing. The patient is examined in the same way as during an operation performed under general anesthesia. ECT is considered a minor surgery. For its implementation, special instructions have been developed.
The mechanism of action of ECT has not been definitively established. There is evidence that ECT enhances dopaminergic transmission, affects opiate and peptide receptors. ECT is thought to improve mood and exercise. ECT in comparison with antidepressants faster eliminates vegetative manifestations of depression.
Neurologists, as a rule, deal with depression of mild or moderate severity, which is more often hidden, under the guise of chronic pain syndromes, autonomic disorders, metabolic endocrine disorders, etc. In these cases, psychotherapy, respiratory relaxation and light therapy have been successfully used.