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How to Include
Psychosocial Approaches
in the Treatment of Anxiety
& Depressive Disorders
ienzee@wustl.edu
Abstract
Anxiety and depressive
disorders are the most common
psychiatric disorders, causing
high personal and economic
burden. Psychosocial approaches,
such as psychotherapy or mindbody instruction, along with
self-help approaches, exercise,
and proper sleep hygiene are
effective solo or additive (to
pharmacotherapy) strategies.
Many physicians are less familiar
with these methods for treating
anxiety/depressive disorders.
This article seeks to illuminate
psychosocial approaches for
depression and anxiety that act
additively or independently of
pharmacotherapy and explain
how physicians can utilize them.
Introduction
Today's societ)' is fast paced,
one that values the quick fix. Anxiety
and depressive disorders are among
the most common conditions
treated in the primary care setting.
In this setting, the key is that many
depressed/anxious individuals are
cognizant of antidepressants that
are widely prescribed and look to
such medications to provide rapid
and complete relief from their
symptoms. Hence, for most patients
the questions that arise are when to
use antidepressant medications and
whether medication alone is enough
to adequately manage jseople for
their depressive or anxiety disorder.
Medication alone will not be enough,
or even appropriate, for many of these
individuals.
FEATURE REVIEW
A growing body ot research indicates that psychosocial
approaches such as mindtulness-based stress reduction
(MBSR), cognitive-behavioral therapy (CBT), or group
psychotherapy are effective both alone and in combination
with traditional pharmacotherapy'. Other studies support
the ideas that exercise, sleep hygiene, and activities that
promote self-help are also effective means of treatment in
combination with medication, or in lieu' (for individuals with
milder symptoms or who do not wish to take a pill). The
authors of this article hope to demonstrate that treatment of
anxietv' and depressive disorders in primary care should be
comprehensive, meaning inclusive of psychosocial approaches.
If individuals have subclinical levels ot anxiet>' or depression
and are good candidates v\ho are willing and capable of
compl)ing to a treatment regimen (Tables 1 and 2) then
treatment should begin witli selt-help techniques, mindbody techniques, other techniques (exercise, sleep hygiene,
light therapy), and traditional psychotherapy, as dictated by
symptom severity. If symptom severity rises to clinical levels,
then medication and/or additive therapeutic approaches
should be used.
FEATURE REVIEW
Table 1
Treatment options and in-office actions to take when referring a patient for a particular treatment plan
Psychotherapy
Good For
How to Refer
Therapy in general
CognitiveBehavioral Therapy:
Includes exposure
exercises,
relaxation training,
and cognitive
restructuring
Books
Internet/apps
n/a
MBSR/meditation
Yoga
Exercise
Sleep Hygiene
Alcohoi/drug
cessation
Self-help
Mind-body
Miscellaneous
Light Therapy
National Institute of Mental Health, Anxiety and Depression Association of America, National Alliance on Mental Illness, Mindfulness-Based Stress Reduction
FEATURE REVIEW
Table 2
Appropriate Psychotherapy Referrals
When to suggest psychosocial approaches in lieu of medication, with
medication, and contraindications to treatment options.
In lieu of medication:
Cognitive impairments
Psychotic
Suicidal
Therapy is unaffordable
Exercise
A walk around the block to improve one's mood may
seem clich to some, but physical activity has been proven
to elicit anxiolvtic and antidepre.ssant effects.'' Biological
patlivvays activated by exercise include increased central
norepinephrine transmission, serotonin svTithesis, metabolism
and fceta-endorphins, and increased neurogenesis and
svTiaptic plasticitv' in key brain regions involved in mood/
anxietj; Additional p.sychological benetits include increased
selt-etficacy and behavioral activation. There is not an allencompassing exercise regimen for therapeutic administration
to treat anxiet\' and depressive disorders in a clinical setting.
It is generally recommended that a patient exercise at least
three to four times per week for 20-30 minutes'^ and that
moderate activity, such as walking, is just as effective as
strenuous activities like running.'* Probably most important
in a recommendation is that the patient find a physical activity
that they enjoy doing and are likely to maintain.
Sleep Hygiene
sleep is an aspect of daily life that might be overlooked
when dealing with a depressed or anxious patient, but sleep
has an important effect on physical and emotional health.
Many depressed or anxious individuals will present with
insomnia as a chief or major complaint. Poor sleep hygiene
can exacerbate insomnia and other types of disturbances
leading to restless sleep.'" Additionally, individuals who have
proper sleep hygiene are shown to have better physical health
and lower levels of anxiety and depression.'' Poor sleep
hygiene includes one or more of these features:
1.
2.
Table 3
Resources for Patients Suffering from Anxiety and/or
Depression
Books
1. Williams, Mark, and Danny Penman. Mindfulness: An Eight-week
Plan for Finding Peace in a Frantic World. Emmaus, PA: Rodale, 2011.
(288 pages, kindle edition, audiobook)
2. Kabat-Zinn, Jon. Mindfulness for Beginners: Reclaiming the Present
Moment--and Your Life. Boulder, CO: Sounds True, 2012. (120 pages,
kindle edition, audiobook)
3. Davis, Martha, Elizabeth Robbins. Esheiman, and Matthew McKay.
The Relaxation & Stress Reduction Workbook. Oakland, CA: New
Harbinger Publications, 2000. (392 pages, kindle edition)
4. Burns, David D. The Feeling Good Handbook. New York, N.Y., U.S.A.:
Plume, 1999. (768 pages)
5. Orsillo, Susan M., and Lizabeth Roemer. The Mindful Way through
Anxiety: Break Free from Chronic Worry and Reclaim Your Ufe. New
York: Guilford, 2011. (307 pages, kindle edition)
6. llardi, Stephen S. The Depression Cure: The 6-step Program to Beat
Depression without Drugs. Cambridge, MA: Da Capo Lifelong, 2009.
(Therapeutic lifestyle book, 304 pages, kindle edition, audiobook)
7. Williams, J. Mark G. The Mindful Way through Depression: Freeing
Yourseif from Chronic Unhappiness. New York: Guiiford, 2007. (273
pages, kindle edition with video/audio, audiobook)
8. Knaus, Wiiliam J. The Cognitive Behaviorai Workbook for
Depression: A Step-by-step Program. Oakland, CA: New Harbinger
Publications, 2006. (336 pages, kindle edition)
9. Benson, Herbert. The Relaxation Response. New York: Morrow,
1975. (240 pages, kindle edition)
Apps (iPhone)
1. MyThoughts+
2. LiveHappy
3. iStress
4. Gratitude Journai
5. The Habit Factor
Apps (Android)
1. DBTSeif-help
2. Stop Panic and Anxiety
3. Worry Box
4. Depression CBT Self-Help Guide
5. Anxiety
Websites
1. www.selfhelpzone.com
2. www.abct.org
3. www.relatedness.org
4. www.adaa.org/understanding-anxiety/depression
5. www.anxietybc.com
6. www.get.gg/anxiety.htm
7. www.helpguide.org/mentai/depression_tips.htm
8. www.helpguide.org/mental/anxiety_self_help.htm
9. www.mindfullivingprograms.com/whatMBSR.php
FEATURE REVIEW
Conclusion
For most patients with depression or anxiet)' disorders,
treating with medication alone is an extremely limited
treatment plan. Though pharmacotherapy in the form of
antidepressants or anxiolytics is often used to treat anxiety
and depressive disorders, there is significant research
suggesting that this, in many clinical cases, is not enough for
individuals to experience remission and may be unnecessary
in more mild cases. Psychotherapy treatments like CBT
and psychodynamic therapy along with techniques that
classically fall under the "alternative medicine" umbrella
such as meditation, MBSR, and yoga all have positive results
as monotherapy or in combination with pharmacotherapy.
Additionally, simple solutions that individuals struggling
with subclinical depression or anxiety can apply to their
daily life such as proper sleep hygiene, exercise, and .selfhelp techniques (books, internet sites, phone apps) are
an effective means of reducing anxiety or depression, as
an adjunct to other therapies or as a first step for mild
(subclinical) cases. In order to treat patients and help
alleviate their symptoms and impairments, it is imperative
that all treatment avenues are considered and weighed for
their positive effects.
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Disclosure
None reported.
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