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Social Work & Case Management for Depression
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs

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• Define depression (symptoms)
• Learn how to ask strengths-based assessment questions
• Identify a range of potential causes for depression
• Explore activities and interventions that can help people address some of the underlying causes

• Depression represents a cluster of symptoms
• Diagnosis with depression only requires people to have a few of the symptoms
• Depression indicates the loss of something important
• A variety of different things can cause depression
• Emotions: Anger, anxiety, grief, guilt, shame
• Thoughts: Cognitive distortions
• Relationships: Poor self-esteem, unhealthy/unsupportive relationships, need for extremal validation
• Physical: Neurochemical imbalances, poor nutrition, exhaustion, insufficient sleep, medication side effects
• Environmental: High stress environments that prevent relaxation/rest and increase hopelessness/helplessness

Depression Assessment
• What does depression mean to you? (apathy, sadness, mood swings)
• Which symptoms are most bothersome for you and why?
• For each symptom
• What makes depression worse?
• What makes depression better?
• How was life more pleasurable prior to getting depressed?
• What is different during times when you are NOT depressed?
• How do you expect life to be different when your depression is gone?
• Ability to feel pleasure/Apathy/Emotional Flatness
• Memory issues
• Difficulty concentrating
• Sleep issues
• Lack of motivation
• Fatigue
• Pain
• Irritability/Agitation
• Fight or flight stress symptoms

• HPA-Axis hyperactivity causes the release of inflammatory cytokines which cause symptoms of behavioral depression (lethargy, reduced locomotor activity and food intake, increased sleep) in the effort to conserve energy for physiological repair
Reduce HPA-Axis Activation
• Get quality sleep
• Sleep deprivation increases risk for major depression, which in turn increases risk for decreased sleep
• Sleep disturbances contribute inflammatory disorders and major depressive disorder
• Increased HPA-Axis activation after sleep deprivation
• Create a routine
• Eliminate blue-light
• Reduce stimulants
• Address pain and apnea (article 2)
• Improve the sleep environment (noise, allergens, light, temperature)
• Other factors: Shift work, time zones, safety/PTSD
• Antidepressants: Many antidepressants with activating effects may disrupt sleep, while those with sedative properties improve sleep, but may cause problems in long-term due to oversedation

Reduce HPA-Axis Activation
• Relaxation
• Biofeedback
• Progressive muscular relaxation
• Meditation and yoga
• Recreation
• Forest / Eco Therapy
• Address medication side effects
• Psychotropics
• Beta Blockers
• Statins
• Anticholinergic (bladder, Parkinson’s, COPD, Asthma, motion sickness)
• Opioids
• Corticosteroids
• Certain antibiotics (levofloxacin and ciprofloxacin)
• Birth control / HRT

Reduce HPA-Axis Activation
• Improve nutrition
• Access to nutrition
• Transportation
• Affordability
• Cooking
• Awareness of nutritional principles
• Macros
• Hydration
• Dehydration had negative effects on vigor, affect, short-term memory, and attention
• Aspartame
• Addictive behaviors
• Alter dopamine, serotonin, norepinephrine levels
• Impacts of different types of neurotransmitters
• Stimulants
• Depressants
• Alcohol
• Gaming/Gambling
• Sex/Pornography

• Thyroid
• Impact mood, libido and energy levels
• Estrogen
• Impacts neurotransmitters that affect sleep, mood, memory, libido, pain perception, learning and attention span.
• Increased estrogen may alter the availability of serotonin
• Low testosterone may alter the availability of serotonin
• Enhances libido, improves stamina and sleep, assists brain function, and is associated with assertive behavior and a sense of well-being.

• Cortisol
• Cortisol is made by the adrenal glands.
• Helps the body adapt to stress by increasing heart rate, respiration, and blood pressure by impacting serotonin and norepinephrine levels
• Cortisol levels increase early in the morning to prepare to meet the demands of the day, and gradually decrease throughout the day (“circadian rhythm”).
• DHEA can also increase libido and sexual arousal. It improves motivation, engenders a sense of well-being, decreases pain, facilitates the rapid eye movement (REM) phase of sleep, enhances memory and enhances immune system function. Dr. Elise Schroder

• Get a physical to identify and address what may be causing any imbalances
• Eat a low-glycemic diet
• “The less sleep you get, the higher your cortisol will be; the more sleep you get, the lower your cortisol will be.” John Romaniello, co-author of Man 2.0 Engineering the Alpha: A Real World Guide to an Unreal Life.
• Final Thoughts on Hormonal Imbalances:
• Hormonal imbalances affect many millions of people
• Symptoms include feeling anxious, tired, irritable, gaining or losing weight, not sleeping well and changes in sex drive, focus and appetite
• Causes for hormonal imbalances include poor gut health, inflammation, high amounts of stress, genetic susceptibility, and toxicity
• Natural treatments include eating an anti-inflammatory diet, consuming enough omega-3s, getting good sleep, exercising and controlling stress

• Exercise
• Guided imagery
• Muscle Relaxation
• Alternate focus
• TENS therapy
• Physical therapy
• Hydrotherapy
• Ice/Heat
• Hypnosis
• Anger/Resentment/Jealousy/Envy/Guilt
• Anger is half of the fight or flight
• It pushes people away and/or asserts dominance/control
• Excessive anger can
• Exhaust the stress-response system
• Contribute to negative cognitions
• Impair relationships
• Cause physical harm
• Anger/Resentment/Jealousy/Envy/Guilt
• Activity (Group or Individual)
• When you are angry, what do you notice?
• What are your anger triggers?
• How can you address each trigger to feel safer and more empowered?
• Anxiety
• Anxiety is the other half of fight or flight
• Chronic anxiety/worry/stress will also exhaust the stress response system causing neurochemical and hormonal imbalances and increasing muscle tension and pain
• This causes the body to adapt to excessive stress chemicals by shutting down the receptors à apathy
• Anxiety makes it harder to sleep exhaustion  hormonal imbalances  depression

• Grief
• Grief is sadness/depression experienced as a result of loss
• The grief process involves
• Anger (at self, other, existential)
• Depression
• Helplessness to change the situation
• Hopelessness that you will move on
• Losses are not just about death

• Happiness… (Duh!)
• You cannot be happy and depressed at the same time
• Happiness chemicals reduce stress and depression chemicals (I know, real clinical explanation there!)
• Increase the happy times
• Comedians
• Children (even youtube videos of babies laughing)
• Animal Videos

• Negative thinking styles
• Contribute to exhaustion
• Highlight what is out of your control
• Heighten a sense of helplessness/hopelessness (depression)
• Cognitive distortions
• All-or-Nothing (Nobody ever)
• Self-fulfilling prophesies

• Poor self-esteem
• Contributes to self-loathing, shame and a feeling of unlovability
• Negatively impacts relationships (loneliness/rejection)
• Often causes a person to seek external validation
• Activity:
• Complete a self-esteem inventory
• For all the characteristics you don’t have, answer the question:
• If your child/best friend had this flaw, would I still love them?
• Unhealthy/unsupportive relationships
• Negative relationships can take a toll on self esteem
• Fears of abandonment can maintain high levels of stress and feelings of helplessness
• Fail to buffer people against stress à exhaustion  neurotransmitter imbalances depression
• High stress environments
• Prevent relaxation/rest
• Increase hopelessness/helplessness
• Increase stress hormones / decrease relaxation hormones
• Activity
• Design a low stress area in
• Your home (bedrooms are good)
• At work/school
• Identify ways to reduce the stress in your environment in both places (noise, interruptions, poor lighting, negativity)
• Identify ways to turn the negative into a positive

• Depression is the cluster of symptoms created when there is a neurochemical imbalance in the brain.
• What causes the imbalance can be emotional, cognitive, physical, interpersonal, environmental or some combination of the above.
• Part of the strengths based approach means helping people see what they already are doing to prevent or deal with the symptoms
• Biopsychosocial means
• Examining all causative factors
• Recognizing that all factors are reciprocal in nature.