Propylene Glycol as a Pharmaceutical Excipient in Pediatrics

Propylene Glycol as a Pharmaceutical Excipient in Pediatrics Disha Patel The Utilization of Propylene Glycol as a Pharmaceutical Excipient in the Pediatric Field Abstract As a widely used excipient in pediatric formulations, propylene glycol functions as a solvent, emulsifier, humectant, and hygroscopic agent. It is a clear, colorless liquid whose properties enable it to have pharmacodynamic applications. Oftentimes, propylene glycol is combined with other mediations to enhance its penetration. For instance, a combination of 20% propylene glycol and 5% lactic acid in a semiocculusive cream base is used as a highly effective and well-tolerated keratolytic in patients with lamellar ichthyosis and possibly could be in various other hyperkeratotic diseases. Unfortunately, though to a lesser degree, this excipient is associated with toxic effects such as hyperosmolality, hemolysis, and lactic acidosis. Also, in concentrations greater than 10%, propylene glycol may act as an irritant in some patients (Health Effects 2). From a pharmacokinetic viewpoint, there is a potential of renal toxicity associated with propylene glycol and lorazepam. The high concentra tion of propylene glycol contained in certain intravenous drug products, such as phenytoin, diazepam, digoxin, and etomidate, may induce thrombophlebitis. Here, the patients increased serum creatinine concentrations are likely to have resulted from exposure to propylene glycol due to lorazepam infusion. Serum osmolality and osmol gap may be useful markers for propylene glycol toxicity. Much like the above mentioned applications, through its chemical composition, propylene glycol has the ability to exert a beneficial effect on pediatric formulations (Webbook 5). Introduction Propylene glycol, which is also known Propane-1,2-diol, is a colorless, viscous, organic liquid with a slightly sweet taste. This excipient is utilized in food, cosmetics and pharmaceutical preparations. Examples of pharmaceutical applications include therapeutic drugs such as vaccines, cough syrups, local anesthetics, antiseptics, vitamins, and hormones. It is produced through the fermentation of yeast and carbohydrates. Propylene glycol is industrially made from propylene oxide. It is made from either a catalytic or a non-catalytic method which exposes the propylene into extremes of temperature and a small amount of sulfuric acid or alkali to yield propylene glycol for industrial purposes (Frequently Asked Questions about Propylene Glycol 1). It is concluded that, with extensive research, this excipient is categorized as safe in the body. According to the Agency for Toxic Substances Disease Registry, in the body, under conditions of normal low exposure, propylene glycol is quickly metabolized and excreted. Its metabolic pathway is comparable to that of sugar: propylene glycol is quickly converted into lactic acid, similar to what happens with the energy in the muscles when exercising. Afterwards, the lactic acid is excreted via urine (Database of Select Committee on GRAS Substances (SCOGS) Reviews 2). Surprisingly, from a toxicological point of view, alcohol is more toxic than propylene glycol. Propylene glycol has been used safely for more than 50 years in a large variety of applications. As a result, it is effectively used in prescription medications such amoxicillin (500 mg), clindamycin hydrochloride (150 mg 300 mg), gabapentin (300 mg), lyrica (50 g 75 mg), and omeprazole (20 mg) (Result Filters 4). Through statistical data, it is overwhelmingly evident that there is a continually growing market for propylene glycol. According to the IHS website, United States (19%), Western Europe (39%), Japan (17%), and China (80%) had the largest consumption (Inactive Ingredients in Pharmaceutical Products 5). Since it has been proven safe with a relative low toxicity level, it is projected that the consumption of propylene glycol will rise (IHS Home Page 4). The Effects of Propylene Glycol in Pediatrics Pharmaceutical medications are composed of two very essential ingredients: active pharmaceutical ingredients (APIs) and excipients. The purpose of the active pharmaceutical ingredient in a drug is to elicit a specific therapeutic effect on the patient. Specifically, when the drug is consumed, it will exert a necessary effect on the body in order to produce an ideal outcome: the therapeutic response (TOXICOLOGICAL PROFILE FOR PROPYLENE GLYCOL 3). The component of the drug is the excipient, which is an inactive ingredient utilized for possible multifunctional usage. For instance, an excipient can be binders, coatings, diluents, disintegrants, fillers, flavors, colors, lubricants, glidants, sorbents, preservatives, sweeteners, and solubilizing agents. Oftentimes, they do acquire some extent of therapeutic acclivity, though less than the API. Similar to many other drugs, propylene glycol functions both, as an API and excipient-an indication that multiple functions can have multiple benef its (AccessMedicine [41168448] 2). Additionally, medications are tailored to a specific age group to maximize the therapeutic effect for the patient. Therefore, criteria for an ideal drug for the pediatric population will undoubtedly differ from the criteria for the geriatric population. Routes of administration suitable for pediatrics include oral, topical, rectal, inhalation, injectable and drop (eye, ear, and nose). Propylene glycol enters the body as an alcohol and metabolizes in the bodys enzyme pathways. These pathways do not mature in humans until 12 to 30 months of age. Proper judgment when administering a propylene glycol-based formulation to neonates is crucial in order to prevent potential complications (PubChem 1). In comparison to adults, new born babies have a propylene glycol half-life of 16.9 hours rather than a significantly lower 5 hour half-life for adults. In one study, the use a multivitamins whose contents included propylene glycol resulted in serum osmolality in low-birth-weight premature babies. However, in another research activity, phenobarbital injections containing propylene glycol were deemed to have an inconsequential effect on the osmolar gap (AccessMedicine [40400741] 4). A higher amount of propylene glycol delivered per dose, such as 3 grams, is known to cause more seizures in infants, in comparison to those receiving lesser amounts per dose, such as 300 mg. In a population of 262 patients treated for burns, roughly 3 percent were the result of topical propylene glycol which resulted in hyperosmolality (Potential Safety Concerns with the Large Amount of Propylene Glycol 2). Since propylene glycol is a liquid excipient, it affects the gastrointestinal tract. However, studies of people and animals show that if you have repeated eye, skin, nasal, or oral exposures to propylene glycol for a short time, you may develop some irritation. Furthermore, extensive studies performed have concluded that there are no severe risks of propylene glycol in infants. Thus, it is assumed to be safe if consumed in moderation. The oral liquid formulation also illustrates a high compliance rate amongst infants. Simple considerations such as route of administration and effective concentrations can help achieve a therapeutic response (AccessMedicine [40400741] 6). The chemical composition of propylene glycol is relatively simple: alcohol groups with a hydrocarbon backbone. To an extent, this simplistic structure plays a broad role in various applications ranging from industrial to pharmaceutical uses. Generally, neonates can be exposed to propylene glycol orally or topically. Absorption through oral intake is significantly more effective than on the skin. Once propylene glycol reaches the site of action, it is rapidly metabolized and subsequently excreted (A-Z Index 9). In the blood stream, the half-life of the excipient is approximately 2-4 hours in adults. However, in neonates, it is drastically longer (17 hours). Pertaining to its mechanism of action, it is further metabolized to lactate which is further metabolized to pyruvate, carbon dioxide, and water. Through utilization of the gluconeogenic pathway, glucose is formed. Even though the safety the propylene is apparent, extremely large exposures to propylene glycol have the potential to r esult in lactic acidosis and hyperosmotic changes in the blood (Health Effects 4). Extensive research has provided sufficient evidence on the safety and quality of this excipient. To begin, numerous sources indicate that propylene glycol has a dramatically low degree of toxicity. It is associated with moderately low concern for acute toxicity by ingestion, skin contact, and inhalation. There have been reports of altered nervous system function because of high oral exposure to propylene. Normal metabolism of this excipient can be negatively affected through blood pH and osmotic changes. Furthermore, animal studies also confirm the relative low risk of propylene glycol (Webbook 2). For example, a longitudinal study performed on rodents with extremely high exposures to the excipient presented no indication of adverse effects. Consequently, a similar study performed on cats illustrated hematological changes. High aerosol concentrations inhaled by rats caused minor nasal and ocular signs that may have been due to mild irritation or drying effects of propylene glycol on mucous membranes. On a positive note, there is no correlation to cancer from the use of propylene glycol (AccessMedicine [45774923] 1). Pharmacological Profile of Propylene Glycol Propylene glycol, with a formula C3H8O2, is readily miscible with water, acetone, and chloroform. In reference to its structure, it contains an asymmetrical carbon atom, so it has two enantiomers. Since the commercial product is a racemic mixture, pure optical enantiomers can be achieved by the hydration of optically pure propylene oxide. Upon the mixture of propylene glycol and water, the freezing point of water is drastically depressed. Because of this, it is used as a de-icing fluid for vehicles. With the exception of ethylene glycol, glycols are generally known to be non-corrosive and have low volatility and toxicity. Even with the strict criteria established for pediatrics, propylene glycol satisfies the requirements for safe administration to pediatric patients (A-Z Index 5). Furthermore, it is derived from propylene oxide and its production methods include either catalytic- proceeds at 150  °C to 180  °C in the presence of ion exchange resin or a small amount of sulfuric acid or alkali, or non-catalytic- high-temperature process at 200  °C to 220  °C (IHS Home Page 3). Even though this paper focuses mainly on propylene glycol’s purpose as an excipient in pediatric formulations, it has an overwhelmingly degree of other applications. A certain amount (45%) is used as chemical feedback for the manufacture of unsaturated polyester resins. Chemically speaking, propylene glycol reacts with a mixture of unsaturated maleic anhydride and isophthalic acid to give a copolymer. Continuing further crosslinking, thermoset plastics are produced from the unsaturated polymers. Similarly, propylene glycol also reacts with propylene oxide to produce oligomers as well as polymers that are utilized to form polyurethanes (Frequently Asked Questions about Propylene Glycol 2). As proven be multiple research articles, this excipient is proven safe. The extent of safety is measured by plasma concentration: â€Å"Serious toxicity generally occurs only at plasma concentrations over 1 g/L, which requires extremely high intake over a relatively short period of time.† However, there is always an uncertainty and accidental occurrences. For instance, rare cases of propylene glycol poison were largely related to either inappropriate intravenous administration or accidental ingestion of enormously large quantities by children (Hazardous Substance Fact Sheet 9). Conclusion As proven through this research paper, propylene glycol is an effective ingredient for pediatric use. Since there was no established linkage between cancer and its use, it is popular for multiple uses. Several considerations should be utilized in formulating pediatric medications-specifically, the ingredients in the formulation. With its multiple uses, propylene glycol is well-suited for children for its safety and effectiveness. Like all ingredients, propylene glycol may produce adverse effects in the patient, but drastically less harmful than others. Since an enormous quantity must be consumed before toxicity level is reached, it is well suited for children. With viscous properties, upon consumption, it has the potential to elicit a faster therapeutic effect on the patient. Therefore, it is both potent and efficacious. In all, this ingredient proves to be a significant element to the overall formulation of a medication, regardless of the age group targeted (Webbook 5). Bibliography A-Z Index. ATSDR. N.p., n.d. Web. 13 Apr. 2014. http://www.atsdr.cdc.gov/phs/phs.asp?id=1120tid=240>. Database of Select Committee on GRAS Substances (SCOGS) Reviews. AccessData. N.p., n.d. Web. 13 Apr. 2014. http://www.accessdata.fda.gov/scripts/fcn/fcnDetailNavigation.cfm?rpt=scogsListingid=262>. Frequently Asked Questions about Propylene Glycol. N.p., n.d. Web. 13 Apr. 2014. http://www.propylene-glycol.com/uploads/PropyleneGlycolAdvocacybrochure.pdf>. Hazardous Substance Fact Sheet. New Jersey Department of Health. N.p., n.d. Web. 13 Apr. 2014. http://nj.gov/health/eoh/rtkweb/documents/fs/3595.pdf>. Health Effects. ATSDR. N.p., n.d. Web. 13 Apr. 2014. http://www.atsdr.cdc.gov/ToxProfiles/tp189-c2.pdf>. InactiveIngredients in Pharmaceutical Products: Update (Subject Review). Peditrics. N.p., n.d. Web. 13 Apr. 2014. http://pediatrics.aappublications.org/content/99/2/268.full#sec-11>. Potential Safety Concerns with the Large Amount of Propylene Glycol. Natap. N.p., n.d. Web. 13 Apr. 2014. http://www.natap.org/2000/may/potential_safety051500.htm>. Propylene Glycol. PubChem. N.p., n.d. Web. 13 Apr. 2014. http://pubchem.ncbi.nlm.nih.gov/summary/summary.cgi?cid=1030>. Propylene Glycol. Webbook. N.p., n.d. Web. 13 Apr. 2014. http://webbook.nist.gov/cgi/cbook.cgi?ID=C57556Mask=8>. Propylene Glycols. IHS Home Page. N.p., n.d. Web. 13 Apr. 2014. http://www.ihs.com/products/chemical/planning/ceh/propylene-glycols.aspx>. Result Filters. National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 13 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/14524641>. St. Johns University Academics Schools Libraries. AccessMedicine. N.p., n.d. Web. 13 Apr. 2014. http://accessmedicine.mhmedical.com.jerome.stjohns.edu/content.aspx?bookid=348sectionid=40381672jumpsectionID=40400741>. St. Johns University Academics Schools Libraries. AccessMedicine. N.p., n.d. Web. 13 Apr. 2014. http://accessmedicine.mhmedical.com.jerome.stjohns.edu/content.aspx?bookid=388sectionid=45764289jumpsectionID=45774923>. St. Johns University Academics Schools Libraries. AccessMedicine. N.p., n.d. Web. 13 Apr. 2014. http://accessmedicine.mhmedical.com.jerome.stjohns.edu/content.aspx?bookid=392sectionid=41138958jumpsectionID=41168448>. TOXICOLOGICAL PROFILE FOR PROPYLENE GLYCOL. Agency for Toxic Substances and Disease Registry. N.p., n.d. Web. 13 Apr. 2014. http://www.atsdr.cdc.gov/toxprofiles/tp189.pdf>.

Codes :: essays research papers

CALIFORNIA CODES HEALTH AND SAFETY CODE 13113.8. (a) On and after January 1, 1986, every single-family dwelling and factory-built housing, as defined in Section 19971, which is sold shall have an operable smoke detector. The detector shall be approved and listed by the State Fire Marshal and installed in accordance with the State Fire Marshal's regulations. Unless prohibited by local rules, regulations, or ordinances, a battery-operated smoke detector shall be deemed to satisfy the requirements of this section. (b) On and after January 1, 1986, the transferor of any real property containing a single-family dwelling, as described in subdivision (a), whether the transfer is made by sale, exchange, or real property sales contract, as defined in Section 2985 of the Civil Code, shall deliver to the transferee a written statement indicating that the transferor is in compliance with this section. The disclosure statement shall be either included in the receipt for deposit in a real estate transaction, an addendum attached thereto , or a separate document. (c) The transferor shall deliver the statement referred to in subdivision (b) as soon as practicable before the transfer of title in the case of a sale or exchange, or prior to execution of the contract where the transfer is by a real property sales contract, as defined in Section 2985. For purposes of this subdivision, "delivery" means delivery in person or by mail to the transferee or transferor, or to any person authorized to act for him or her in the transaction, or to additional transferees who have requested delivery from the transferor in writing. Delivery to the spouse of a transferee or transferor shall be deemed delivery to a transferee or transferor, unless the contract states otherwise. (d) This section does not apply to any of the following: (1) Transfers which are required to be preceded by the furnishing to a prospective transferee of a copy of a public report pursuant to Section 11018.1 of the Business and Professions Code. (2) Tra nsfers pursuant to court order, including, but not limited to, transfers ordered by a probate court in the administration of an estate, transfers pursuant to a writ of execution, transfers by a trustee in bankruptcy, transfers by eminent domain, or transfers resulting from a decree for specific performance. (3) Transfers to a mortgagee by a mortgagor in default, transfers to a beneficiary of a deed of trust by a

Charles dikenson biography :: essays research papers fc

Charles Dickens Biography   Ã‚  Ã‚  Ã‚  Ã‚  Charles Dickens was one of the most popular writers of all time. Dickens was very observant of life, and had a great understanding of humanity.   Ã‚  Ã‚  Ã‚  Ã‚  Charles John Huffam Dickens was born in Portsmouth, England, on February 7, 1812. When he was two years old he and his family moved to London. Dickens father, John Dickens, was a poor clerk who worked for the navy, and he also spent time in prison for debt. When John was not in prison he lacked the money to adequately support his family. When Charles was twelve he worked in a London factory. That job was so miserable that the misery of the experience stayed with him his whole life. Dickens became a newspaper reporter in the late 1820’s. He specialized in covering debates in Parliament and also wrote feature articles. This helped him develop his skill portraying his character’s speech realistically. His first book was â€Å"Sketches by Boz† in 1836; it consisted of articles he wrote for monthly magazine. The book that got him famous was â€Å"The Posthumous Papers of the Pickwick Club. This book describes the adventures and misadventures of a group of people in an English countryside. Dickens founded and edited two highly successful magazines. Those magazines were â€Å"Household Words† and â€Å"All Year Round†. Dickens was always in the news, and was honored, and recognized everywhere he went. In 1836 Dickens married Catherine Hogarth. Catherine had a sister named Mary, who died in 1837. Dickens grieved so much over her death that some people believe that he loved her more then he loved Catherine. Catherine was a good wife but she wasn’t a very intelligent woman. She an Dickens had ten children, and separated in 1858. Dickens had a vast amount of physical and mental energy. He had so much energy that he could record all of his activities and make it interesting to read. Dickens had a life other than writing. He spent much of his free time with his friends from the worlds of art and literature. He also enjoyed drama. He went to the theater as often as he could. When he was rich and famous, he produc ed and acted in amateur theatrical productions. Dickens was also a giving person. When he was not socializing or in the theater, he was giving to various charities. These charities included giving money toward build schools for the poor school children and loans that enabled the poor to move to Australia.

Major Depressive Disorder: Theories and Therapies Essay

1. Major Depressive Disorder Definition and Symptoms Major Depressive Disorder may be diagnosed as one or more episodes of a Major Depressive Episode. Symptoms of a major depressive episode include depressed mood, diminished interest or pleasure in activities, weight changes, sleep problems, slowing of speech or agitation, fatigue or loss of energy, feelings of worthlessness and/or guilt, difficulties in thinking, concentrating, or indecisiveness, and thoughts of death, suicide, or suicide attempts. These symptoms are not due to another medical or psychological reason, and they cause clinically significant distress or functional impairment. 4th ed. , text rev. ; DSM-IV-TR; American Psychiatric Association, 2000) The cause of depression is not completely understood. It is, most likely, a combination of reasons, which may include chemical imbalances in the brain, psychological, or environmental factors, and genetics. Severe life stressors, such as divorce, or job loss, often contribute to depression. In a twelve month period, 6. 7% of the U. S. population is depressed. Of those that are depressed, 30. 4% are severe, or 2. 0% of the total U. S. population. Lifetime prevalence in the U.  S. is 16. 5% of the population. (National Institute of Mental Health (NIMH), Prevalence) Women are 70% more likely than men to experience depression during their lifetime. (NIMH, Demographics) The National Institute of Mental Health also reports that Blacks are 40% less likely than Whites, to experience depression in their lifetime. The World Health Organization (WHO) estimates the total number of years a person may lose to illness, disability, or death. They have rated Unipolar Depression number one in diseases and disorders, with a loss of 10. years, well above heart disease and cancer. (NIMH, Leading Individual Diseases/Disorders) 2. Cognitive Theory and Symbolic Interaction Theory of Major Depressive Disorder Cognitive Theory (CT) Early negative experiences are overgeneralized and become a part of one’s schema. The theory, developed by Beck, asserts that one’s negative and dysfunctional view of one’s self leads to depression. Thought distortions, such as absolute thinking, selective abstraction, and personalization, set one up for failure, and perpetuate the negative thinking, leading to depression. Maladaptive thinking and behavior may be learned or caused by inexperience. Symbolic Interaction Theory (SIT) A person gives meanings to objects, experiences, and to self. Social interaction with others helps to define those meanings. Symbols and meanings develop and change over time. Self-conception comes from one’s social interactions with other’s, and how one believes the other person perceives them. If a person believes others are looking at them and judging them negatively, self perception is negative. Depression is caused by negative thinking and perceptions. Etiology: Compare and Contrast In both Cognitive Theory and Symbolic Interaction Theory, dysfunctional and negative thinking about self, form the basis for the depression. Both theories involve thoughts and feelings formed from internal and external stimuli. In both theories, beliefs are based on interpretations rather than reality. In CT, the depression is more self centered and self inflicted. It is more internally based and controlled, while SI depends more on negative external stimuli. Symbolic Interaction Theory adds the concept of interaction with others, while Cognitive Theory does not. Cognitive Theory suggests cognition and behavior are learned and built upon, while Symbolic Interaction Theory suggests thoughts and actions taking place in the present and are dynamic, changing according to the present experience. Dynamics: Compare and Contrast Cognitive Theory and Symbolic Interaction Theory both assert that beliefs about self will strongly determine the way the individual behaves. CT and SIT both assert that people process external information and then apply it to themselves. Both involve irrational thinking. In both theories, the epressed person makes thought leaps, assumptions that are not supported. In Cognitive Theory, one may assume that because they had a negative experience in one situation, it will always be experienced the same way. In Symbolic Interaction Theory one may assume that an interaction with a person, or certain types of people will always be the same. CT may involve a situation the person experiences alone or with others, while SIT naturally would include interaction with others. Cognitive Theory of Depression builds and grows stronger with each negative experience, while Symbolic Interaction is more in the present. The negative and distorted thoughts of a depressed person are reactionary. c. Motivation for change: Compare and Contrast In Cognitive Theory and Symbolic Interaction Theory, motivation for change would include the need for love, support, and interaction with others. We are social beings and need that interaction. Depression separates one from others because it becomes mentally and physically difficult to function. With that separation comes confirmation of the distorted, negative self beliefs. Ruminations drag the depressed person further away from truth (cognitive) and people (interaction). Major Depression is not an illness one can pull out of alone. Although it would be possible without professional help, it wouldn’t be possible without other people. There would be no purpose to change. In Cognitive Theory, motivation for change would include a positive self image and the ability to enjoy one’s life. Motivation for change in Symbolic Interaction Theory would include positive self image and enjoying one’s life, as well as rejoining society, and having a positive impact on others. 3. Major Depressive Disorder Interventions  According to the American Psychiatric Association (APA) practice guidelines, acute phase treatment for patients with major depressive disorder may include pharmacotherapy, depression-focused psychotherapy, the combination of medications and psychotherapy, or other somatic therapies such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or light therapy. The treatment chosen should depend on the severity of symptoms, other illnesses or stressors present, patient and doctor preference, and past treatment outcomes. In their study of depressed patients, Budd, James, & Hughes (2008) found that patients felt Cognitive Behavioral Therapy helped them more than any other therapy. Pharmacotherapy Antidepressant medication is generally the first treatment recommended for depression. Some of the first drugs used to treat depression were tricyclic antidepressants (TCAs), such as Elavil. They affect the neurotransmitters norepinephrine and serotonin. They are used less often because of side effects. Monoamine oxidase inhibitors (MAOIs), such as Narwal, were also used in early treatments for patients with treatment resistant depression. Because of food interactions and the need for dietary restrictions, these medications are also used less often. Selective serotonin reuptake inhibitors (SSRIs), such as Prozac, work by increasing the amount of the neurotransmitter serotonin available to the brain. Seratonin and Norepinephrin reuptake inhibitors (SNRIs), such as Effexor, increase the amount of serotonin and norepinephrine neurotransmitters that can be used by the brain. Mirtazapine, a brand name is Remora, is a non-adrenegic and specific serotonergic antidepressant. Buproprion, found in the brand Wellbutrin, is a norepinephrine-dopamine reuptake inhibitor. All of these drugs may be used in the treatment of depression. (NIMH) Psychotherapy Psychotherapy, sometimes referred to as talk therapy, educates a patient about mental illness and provides tools, or strategies, to improve the patient’s mental health, as well as social functioning. There are several different types of psychotherapy. Psychotherapy for Major Depression is usually used in conjunction with medication. Cognitive Behavioral Therapy (CBT) Developed by Aaron Beck in the 1960’s, CBT helps the patient understand how thoughts can influence behavior. CBT helps a person focus on his or her current problems and how to solve them. The patient learns how to identify distorted or unhelpful thinking patterns, recognize and change inaccurate beliefs, relate to others in more positive ways, and change behaviors accordingly. (NIMH) Interpersonal Psychotherapy (IPT) Interpersonal Psychotherapy was developed in the 1980’s, by Gerald Kerman and Myrna Weissman, to treat depression. (Markowitz & Weissman, 2012) Mood, and it’s relation to social circumstances, is examined, and the patient learns how to react positively to negative circumstances. It is time limited and has been proven to be an effective treatment for depression. (Markowitz & Weitzman, 2012) Rational Emotive Behavioral Therapy (REBT) Similar to CBT, Rational Emotive Behavioral Therapy focuses on changing cognitive, emotional, and behavioral problems. The therapy was developed by Albert Ellis, Ph. D. , in 1955. Ellis asserts, â€Å"It is largely our thinking about events that leads to emotional and behavioral upset. Working with the present in mind, the patient is encouraged to look at the negative thinking that leads to negative emotions and behaviors†. Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-Based Cognitive Therapy was developed by Drs. Zindel Segal, Mark Williams, and John Teasdale. It is an eight-session program based on eastern spirituality. Developed for use in preventing depression relapse, it focuses on the patient’s awareness of personal thought patterns and emotions. Knowing the ruminations and self-critical thinking that precedes depression, the patient is taught how to divert the depression. (American Psychological Association) Somatic Therapies Deep Brain Stimulation (DBS) Electrodes are placed on specific areas of the brain that stimulate the brain continuously through a pulse generator implanted under the skin. A long term follow up study by Kennedy and his colleagues (2011), found social functioning and physical health continued to improve for up to six years after the treatment. The response rate was high at 60%, and the remission rate was 30%, based on the Hamilton Depression Rating Scale. (Kennedy et al. , 2011) Repetitive Transcranial Magnetic Stimulation (rTMS) Repetitive Transcranial Magnetic Stimulation was first used in a study for treatment of depression in 1993, and approved by the FDA in 2008. The neural pathway, from the frontal cortex of the brain to the limbic area, is stimulated. This pathway is believed to be deficient in depressed patients. A pulsating, alternating magnetic field above the scalp sends an electric current through the brain. The electrical current flows to the cortex, depolarizing neurons, and sends signals to the limbic region. This procedure is preformed while the patient is awake. It produces minor twitches, has few side effects, and is non-invasive. The study I read showed a 65% improvement in symptoms. (George & Post, 2011) Electroconvulsive Therapy (ECT) Electroconvulsive therapy (ECT), or shock therapy, is usually used on treatment-resistant depression. A seizure is produced by an electrical shock to the brain. This shock changes the chemical balance in the brain. A patient generally has several procedures a week at first. Procedures are reduced to once a week and then once a month. The amount of ECT needed varies with each person. Memory loss and other cognitive effects sometimes occur, but usually diminish with time. (National Institute of Mental Health) It is important that a skilled Psychiatrist perform the procedure because the effectiveness of the treatment depends on the accuracy of the physician’s skills. (Lisanby, 2007) Vagus Nerve Stimulation (VNS) Vagus nerve stimulation sends electrical pulses from a surgically implanted generator in the chest to the vagus nerve. Every few seconds a pulse runs through the nerve to the part of the brain that is thought to effect mood. (NIMH) Complimentary and Alternative Therapies The National Institute of Mental Health also lists St. John’s wort, S-adenosyl methionine (sometimes called SAMe), omega-3 fatty acids, light therapy, and acupuncture as complimentary and alternative therapies. Botox has also been studied as a treatment for depression, with the theory that suppressing frowning in a depressed person can decrease the depression. (Kruger, T. H. C. , et al. , 2012) 4. Theory and Treatment Links Cognitive Theory and Cognitive Behavioral Therapy a) Etiology Maintenance of depression by negative, automatic thoughts, and withdrawing from others, is the basis for Cognitive Theory. In Cognitive Behavioral Therapy (CBT) for depression, the client is taught to replace negative cognitive thoughts and behaviors with positive ones. Sterling Moorey (2010) developed a maintenance model of depression with six cycles depicted as a â€Å"vicious flower†. It is a tool to help clients understand depression: what causes it, and how it is maintained, as well as cognitive and behavioral changes to ameliorate it. The links between Cognitive Theory and Cognitive Behavioral Therapy can be seen clearly in the model as described below. b) Dynamics Testing negative thoughts and beliefs replaces automatic negative thinking. Problem solving and developing compassion replaces ruminating and self-attacks. Mood recognition replaces mood/emotions. Becoming physically active, and taking one step at a time, replaces withdrawal and avoidance. Experimenting with helpful behaviors replaces unhelpful behaviors. Motivation and physical symptoms are replaced by taking care of oneself and exercising. (Moorey, 2010) A link between Cognitive Theory and Cognitive Behavioral Therapy, is demonstrated when exercise is used as a treatment for depression. Exercise engages the patient mentally and physically. It changes behavior, increases health, and encourages interaction with others. It is positive change that can be used for intervention and prevention. (Martinson, 2008) c) Motivation for Change Cognitive Theory of Depression asserts that dysfunctional and negative beliefs about self causes and maintains depression. Gaining a positive self image based on cognitive behavioral changes will enable a depressed person to participate in, and enjoy life. Looking at difficulties and life events from a positive perspective, allows one to believe success is possible, and behave accordingly. Symbolic Interaction Theory and Interpersonal Therapy a. Etiology Looking at events from a dysfunctional and negative view, based on our interactions with others, perpetuates negative thoughts and feelings, according to the Symbolic Theory of Major Depressive Disorder. This was demonstrated in a study by Vranceanu, Gallo, and Bogart (2009). They found that women with depressed symptomatology reported more negative personal interactions and less positive support, than women who were not depressed. The negative reactions the depressed women received, may serve as reinforcers for dysfunctional beliefs. (p. 468) Interpersonal Therapy (IPT) links mood to the clients circumstances, helping the client to understand what triggers the depression. Often, negative circumstances involve a relationship, or some event that involves the client’s interpersonal functioning. (Markowitz and Weissman, 2012) Liverant, Kamholz, Sloan, & Brown (2011), showed there is a correlation between rumination and other forms of emotional suppression, such as avoidance and withdrawal. They found the more often emotional suppression was used, particularly rumination, the greater the intensity of sadness. b. Dynamics The negative thoughts and feelings the client has perceived from interactions with others, as well as personal relationship problems, are evaluated by the therapist. IPT is time-limited, and solution based. The therapist is understanding, supportive, and encouraging. Emotional acceptance of negative experiences may serve as a tool to reduce rumination, thus decreasing the symptoms of depression. (Liverant, et al. 2011) Interpersonal skills are taught so clients can learn to interact with others in more positive ways. c. Motivation for Change Motivation for change in both Symbolic Interaction Theory and Interpersonal Therapy is a return to a positive mood, the ability to enjoy life, and to interact with others in a positive way. Negative, dysfunctional beliefs attained through interaction with others, as demonstrated in Symbolic Interaction Theory, can b e changed by learning person skills to interact more positively with others, thus providing positive response and reducing depression.