1.1 what is depression

Question 1

DSM 5 criteria of depression

Answer 1

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

Question 2

the threshold issue in diagnosing MDD

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 2

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

Question 3

depression - age & gender

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 3

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

Question 4

depression - epidemiology

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 4

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

Question 5

depression - comorbidities

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 5

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

Question 6

the roots of depression

3 key observations on why some people become depressed

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 6

1. 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
2. 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
3. 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

Question 7

the roots of depression

predisposing and protective factors

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 7

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

Question 8

the roots of depression

precipitating & perpetuating factors

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 8

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

Question 9

the roots of depression

the diathesis-stress model

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 9

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

Question 10

the roots of depression

differential susceptibility model

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 10

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

Question 11

the roots of depression

gene-environment interaction

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 11

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

Question 12

the roots of depression

the neural pathways of depression

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 12

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

Question 13

interventions to reduce the burden of depression

types of prevention interventions

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 13

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

Question 14

interventions to reduce the burden of depression

interventions for remission and recovery from depressive episodes

A Lancet–World Psychiatric Association Commission (Herman et al)

Answer 14

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

Question 15

dysthymia

Depression and Other Common Mental Disorders (WHO)

Answer 15

(aka persistant depressive disorder)

a persistent form of mild depression, symptoms are similar, but tend to be less intense and last longer

Question 16

symptoms profile - DSM & ICD

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 16

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

Question 17

clinical subtypes of depression

melancholic depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 17

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

Question 18

clinical subtypes of depression

psychotic depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 18

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

Question 19

clinical subtypes of depression

mixed depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 19

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

Question 20

clinical subtypes of depression

anxious depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 20

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

Question 21

clinical subtypes of depression

atypical depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 21

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

Question 22

clinical subtypes of depression

seasonal depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 22

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

Question 23

severity of depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 23

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

Question 24

neurocognition and depression

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 24

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

Question 25

clinical staging

what is clinical staging

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 25

clinical staging = indicates where a patients stands along the continuum of the course of depression

takes into consideration the response of the disorder to therapies, with reference to treatment resistance

Question 26

clinical staging

stage 1

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 26

the prodromal stage

either specific symptoms or subthreshold depressive symptoms

large inter-individual variability but for a specific patient, episodes tend to share a similar prodromal symptomatology

Question 27

clinical staging

stage 2

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 27

the patient presents the first depressive episode

Question 28

clinical staging

stage 3

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 28

the residual phase (doesn’t have to occur)

marked by specific symptoms or by residual depressive symptoms, or by dysthymia

residual symptoms are a strong predictor of relapse

rollback phenomenon: as the episode remits it progressively recapitulates, in reverse order, many of the symptoms that were seen during the time
- so, if a person first developed sleeping problems, then loss of appetite, and then feelings of hopelessness, the recovery might start with the last symptom developed and finish with the first one
- the condition ‘’Rolls back’’ through the various stages

Question 29

clinical staging

stage 4

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 29

characterised by:
- recurrent depression
- double depression; depressive episodes superimposed on dysthymia

Question 30

clinical staging

stage 5

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 30

chronic depressive episode - e.g. episode lasting at least two years without interruption

Question 31

clinical staging

implications & importance of staging

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 31

staging allows to determine whether symptoms are a residual symptomatology of a previous episode (i.e., higher risk of relapse) or can be viewed as subthreshold depression

treatment planning: staging allows selection of a specific treatment geared to the phase of development of depressive disorder
- sequential model: a two-step approach, where one type of treatment (ie psychotherapy) is employed to address symptoms which another type of treatment (ie meds) has been unable to improve

staging can be used to provide patients with treatment appropriate to their resistance

Question 32

personality traits & depression/treatment

Maj et al

The clinical characterization of the adult patient with depression aimed at personalization of management

Answer 32

personality traits, particularly neuroticism, may impact on how the patient responds to treatment

neuroticism:
- a precursor for MDD episodes
- the disposition to experience negative effects, incl sadness, anger and anxiety
- neuroticism may need to be treated first to the extent that the depression is secondary to neuroticism

personality traits impact treatment outcomes:
- people high on conscientiousness may be more likely to adhere to treatment
- people high on openness will be more receptive to exploratory insight
- people high on extraversion may be more comfortable in a group therapy

co-occurrence of depression and personality disorder is best treated with a combination of pharmaco and psychotherapy