1.1 what is depression Flashcards
DSM 5 criteria of depression
5 (or more) symptoms, at least 2 weeks & represent a change from previous functioning
at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
- depressed mood most of the day, nearly every day (in children and adolescents, can be irritable mood)
- markedly diminished interest or pleasure in activities
- significant weight loss or weight gain - or decrease/increase in appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or excessive or inappropriate guilt
- diminished ability to think or concentrate, or indecisiveness
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
the threshold issue in diagnosing MDD
A Lancet–World Psychiatric Association Commission (Herman et al)
number of symptoms required for a diagnosis (min 5) has been a controversial topic
subthreshold depression (ie conditions characterised by the presence of less than 5 symptoms) didn’t differ from diagnosable depression w/ respect to many variables
BUT lowering the threshold for diagnosing depression could reinforce medicalisation of normal sorrow, driving inappropriate and unnecessary treatment
the way to solve this was to adopt at least one core depressive symptom
ie either (1) depressed mood; (2) loss of interest or pleasure), most of the time for at least 2 weeks
depression - age & gender
A Lancet–World Psychiatric Association Commission (Herman et al)
gender differences
consistently found more common in women than in men
- the difference is first apparent at about age 12, and peaks in adolescence, at age 16
age differences:
- age of onset: 26 years in high-income and 24 years in low-income countries
- has been neglected among adolescents where moodiness is quite prevalent
- within the elderly population: depression is often ascribed to normal ageing, to losses, or to physical illness
depression - epidemiology
A Lancet–World Psychiatric Association Commission (Herman et al)
about 4.7% of the world’s population have an episode of depression in any 12-month period
among those who seek treatment, depression is often an intermittent recurrent disorder over the life course, commonly with partial remission between episodes
people with depression are 20x more likely to die due to suicide
depression - comorbidities
A Lancet–World Psychiatric Association Commission (Herman et al)
comorbidities w other mental disorders:
- anxiety
- substance use disorders
comorbidities with physical disorders
- associated with a wide variety of chronic physical disorders - e.g. asthma, cancer, cardiovascular disease, obesity, cognitive impairment, chronic pain & dementia
- these reflect causal effects of physical disorders and vice versa, and effects of common antecedents (ie low-SES; adverse lifestyle factors) which affect body and mind
the problem of spurious association = occurs when the same set of symptoms is double counted to arrive at both a psychiatric and a physical diagnosis
- equally important is the misattribution of depressive symptoms to physical illness → results in failure to recognise depression and under-estimating the influence of depression on the course of physical illness
the roots of depression
3 key observations on why some people become depressed
A Lancet–World Psychiatric Association Commission (Herman et al)
- depression tends to run in families, often jointly with BPD, substance use, and anxiety disorders
- children of neurodivergent parents have an elevated risk of developing depression even when not raised by their biological parents - onset of depression in adolescents and adults is in most cases preceded by childhood-onset disorders like ADHD and anxiety disorders
- however, most children with ADHD/anx disorders will not develop depression as adults - most early episodes of depression have an onset shortly after a stressful life event
- especially after an event involving loss, disappointment, or humiliation, particularly in people primed by early loss, neglect, or trauma
no single factor provides a complete explanation of why depression develops
the roots of depression
predisposing and protective factors
A Lancet–World Psychiatric Association Commission (Herman et al)
predisposing factors:
- childhood symptoms or disorders (oppositional-defiant disorder, ADHD & anxiety disorders)
- family history of depression
- genetic risk
- experiencing maltreatment during critical periods increases risk
- personality traits like neuroticism
- interpersonal style might be a risk factor
- biases in information processing that result in interpretations that are pessimistic and self-critical
- low levels of physical activity and unhealthy dietary patterns
- sexual abuse & IPV
- income inequality
protective factors:
- history of secure attachment
- cognitive abilities
- self-regulation abilities
- positive peer or community support
the roots of depression
precipitating & perpetuating factors
A Lancet–World Psychiatric Association Commission (Herman et al)
precipitating factors = occur shortly before the onset of depression
- possibly interact w/predisposing factors in triggering the disorder
- stressful life events
individuals w/depression have an increased propensity to experience acute stressors leading to a self-perpetuating pattern of stress generation - factors contributing to recurrence:
- substance use
- behavioural patterns such as social withdrawal
- cognitive biases in attention, memory and interpretation
- a ruminative response style
the roots of depression
the diathesis-stress model
A Lancet–World Psychiatric Association Commission (Herman et al)
a conceptualisation that encompasses many factors contributing to depression
following an acute stressor, a person who carries a diathesis (or vulnerability) that renders them sensitive to the stressor will develop depression
the diathesis could have both biological and psychological features
each person can carry a number of vulnerabilities that might add on to an overall diathesis or might result in sensitivity to different types of stressors
- a person with a high degree of vulnerability might develop depression even with a mild stressor
- a person with a low degree of vulnerability might only become depressed if encountering a stressor of extraordinary severity
the model is proven w/out reasonable doubt
the roots of depression
differential susceptibility model
A Lancet–World Psychiatric Association Commission (Herman et al)
accounts for the fact that vulnerability can change over time due to biological events (ie childbirth) and changes in the external environment
e.g. exposure to adverse environments earlier in life might not be sufficient to cause depression, but could create a vulnerability making the indiv more likely to develop depression
the same characteristic might make an individual sensitive to negative effects of adverse experiences and beneficial effects of positive experiences
the roots of depression
gene-environment interaction
A Lancet–World Psychiatric Association Commission (Herman et al)
occurs when a genetic variant makes an individual more sensitive to the effect of an environmental exposure
stressful life events are more likely to lead to depression in individuals who have a higher load of genetic risk variants
the roots of depression
the neural pathways of depression
A Lancet–World Psychiatric Association Commission (Herman et al)
the genes associated with depression are expressed in the prefrontal cortex and the anterior cingulate
widely assumed that depression is unlikely to be a disease of a single gene, brain region, or neurotransmitter system;
crucial role of cortico-limbic circuitry in the experience of depression, with different regional abnormalities emerging at different ages and developmental stages
interventions to reduce the burden of depression
types of prevention interventions
A Lancet–World Psychiatric Association Commission (Herman et al)
universal interventions: offered to an entire population rather than specific groups
selective interventions: targeted to individuals or groups at a higher than average risk for depression
indicated interventions: targeted to individuals showing signs of subthreshold depression
interventions to reduce the burden of depression
interventions for remission and recovery from depressive episodes
A Lancet–World Psychiatric Association Commission (Herman et al)
WHO recommends a choice between two types of treatment for any individual;
1. for those with mild depression; a set of structured psychological treatments based on CBT or interpersonal psychotherapy
2. treatment with antidepressant medication (in particular SSRIs)
some people benefit with no treatment (ie spontaneous remission)
combined treatments work better than does either treatment (meds or therapy) alone
dysthymia
Depression and Other Common Mental Disorders (WHO)
(aka persistant depressive disorder)
a persistent form of mild depression, symptoms are similar, but tend to be less intense and last longer
symptoms profile - DSM & ICD
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
The DSM and ICD criteria for depression are almost identical - all criteria are shared except for hopelessness about the future, which only the ICD includes
There is some evidence supporting the validity of these lists
- BUT there is also some evidence that other components of depression are not included on these lists - particularly anxiety and somatic complaints
gender may play a role in the symptoms presented
- men: anger attacks, aggression, irritability, and risk taking behavior
overall: some evidence supports the notion that the symptom profile may have value in predicting the response to treatments, however, the evidence is preliminary
clinical subtypes of depression
melancholic depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
the presence of either loss of pleasure in all or almost all activities, or lack of reactivity to usually pleasurable stimuli
plus at least 3 of the following:
- distinct quality of depressed mood (despair and or moresness, or empty mood)
- worsening of depression in the morning
- early-morning awakening
- anorexia or weight loss
- excessive guilt
clinical subtypes of depression
psychotic depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
defined by the presence of delusions/hallucinations during the depressive episodes
- lack of persistence of these outside the episode
in many patients some recurrent episodes are psychotic and some are not
- psychotic features as a specifier rather than a distinct diagnosis
psychotic features are associated with increased suicidality, particularly during an acute episode
combination treatment with antidepressant and an antipsychotic is superior
clinical subtypes of depression
mixed depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
introduced first in the DSM-5 but not incl in the ICD11
- DSM-5 requires the presence of at least 3 manic/hypomanic symptom out of a list of seven
criticised bc it doesn’t involve features typical of mixed depression such as agitation and irritability
the presence of manic/hypomanic symptoms is associated with higher anxiety, substance use, suicidality, impairment and family history of bipolar
clinical subtypes of depression
anxious depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
depression with anxious distress (DSM5)
depression with prominent anxiety symptoms (ICD11)
DSM5 specifier requires presence of at least 2 out of 5 symptoms;
- feeling tense
- feeling restless
- difficulty concentrating bc of worry
- fear something awful may happen
- feeling that one may lose control
patients have higher SI, poorer health, quality of life and greater chronicity
clinical subtypes of depression
atypical depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
characterized by mood reactivity (mood improvement in response to actual or potential positive events), sensitivity to rejection, extreme anergia, and reverse vegetative features of increased appetite and increased sleep
doesn’t seem to influence treatment outcomes for psychotherapy and meds
clinical subtypes of depression
seasonal depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
based on the lifetime pattern of depressive episodes
the most common pattern is autumn/winter onset, with spring/summer resolution
symptoms are hypersomnia, hyperphagia, and carbohydrate craving
bright light therapy is effective for seasonal depression
severity of depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
severity associated with health-related quality of life, impairment, suicidality, and response to treatments
DSM-5: depression is classified as mild, moderate or severe BASED on the number of symptoms, the level of distress caused by the symptoms, and the degree of impairment in social/occupational functioning
- mild depression - few, if any symptoms in excess of those required to make the diagnosis
- moderate depression - between mild and severe
- severe depression - the number of symptoms is substantially in excess of that required to make the diagnosis, markedly interfere with functioning
neurocognition and depression
Maj et al
The clinical characterization of the adult patient with depression aimed at personalization of management
cognitive deficits are a core dimension of the depression - may be antecedent to the formal diagnosis and persist during ‘asymptomatic’ states
deficits in: exec functioning, attention/concentration, learning/memory & processing speed
cognitive deficits may be progressive in depressive patients especially for learning/memory - aligns w hippocampal atrophy
impact on treatment: if cognitive deficits present, psychotropic drugs that interfere with cognitive functions should be discontinued
