Depression is the number one cause of disability worldwide, affecting more than 300 million people, according to the World Health Organization. Symptoms include prolonged sadness, irritability, sleep disturbance, anxiety, aches, pessimism, lack of motivation, and thoughts of death or suicide. Depression is typically treated with some combination of medication and psychotherapy. Studies have already found some clues to how depression changes the brain. For example, parts of the prefrontal cortex and the hippocampus appear to shrink, while the amygdala, a part of the brain involved in processing emotions related to fear, gets larger. Recently, there have been studies examining how the depressed brain changes in response to psychotherapy. This research can help us understand why psychotherapy is effective and perhaps find ways to make it more effective. It can also help us understand how to best compliment psychotherapy with medication, which is, in itself a complicated subject. This area of research is still fairly new, but some interesting results have already emerged. A recent review and meta-analysis of existing research has found that psychotherapy does appear to change important emotional processing areas of the brain. The most consistent result after examining 17 studies was that the amygdala was less active after patients underwent psychotherapy such as cognitive behavioral therapy, or CBT, or psychodynamic psychotherapy. This result was to be expected, since previous studies had found that an overactive amygdala is common in depressive patients. The studies also found that an area in prefrontal cortex called the left precentral gyrus became less active after psychotherapy. This is thought to be a region responsible for rumination on worries and negative emotions. They also found increased activation in a prefrontal area called the left rostral anterior cingulate, which is an area involved in regulating emotions. In major depression, the connection between this area and the amygdala is weak and it appears psychotherapy might strengthen it. In the hippocampus, a region involved with memory and is typically underactive in depressive patients, some studies found more activity after psychotherapy and others found less. In non-depressed patients, the hippocampus appears to be a sort of bouncer, letting positive or neutral stimuli through, while shunting dangerous stimuli off to the amygdala. In depressed patients, an underactive hippocampus may shunt more stimuli toward the amygdala, leading to more anxiety. It could be that in depressed patients who have gone through psychotherapy, areas of the prefrontal cortex take over the heavy lifting for the hippocampus. More stimuli are still shunted to the amygdala, but the prefrontal cortex gets better at moderating the fight-or-flight response. This area of research has a long way to go but the preliminary results underscore an important point: psychotherapy causes real changes in the brain, just as medications do.
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