Chapter 5 (Lecture) Flashcards
Major Depressive Disorder (MDD) symptoms
- severely low mood
- characterised by anhedonia (lack of enjoyment and pleasure and interest)
- sense of worthlessness
- changes in appetite
- low energy
- thoughts of death
symptoms must last at least two weeks
- prevalence and incidence of MDD is increasing globally for all age groups
diagnosis of MDD
requires presence of 5 or more criteria, AND impairment of work/school or personal functioning - persisting for at least 2 weeks
- MDD classified into mild, moderate, and severe levels: greater number/intensity of symptoms, higher severity
Prevalence of depression and demographics
Depression is more commonly experiences among:
- women
- single individuals
- those divorced, separated, or widowed
- unemployed individuals
Classification of MDD
2017: 300 million people globally experienced clinical depression
2005-2015: 18% increase in prevalence
WHO estimated it is the #1 cause of disability globally (very high burden, comparable to serious physical conditions like cancer and heart disease)
Change of MDD with DSM-5
Elimination of the “bereavement exclusion”
- previously depression symptoms stemming from loss of loved one/grief would not be deemed major depression
- removal of the exemption intended to communicate that MDD diagnosis may be accurate even in context of grief
- controversy: not excluding grief may overly medicalise mourning, and lead to over-diagnosis and over-treatment
Classification of Persistent Depressive Disorder (previously called dysthymia)
- chronic low mood over a period of 2 years or more
- symptoms include MDD characteristics, but diagnosis requires the presence of fewer symptoms
Symptoms must last at least two years (persistent):
- feeling low, limited/excess appetite, sleep disruptions, lethargy, sense of failure, lack of hope/faith in self/future
- Think of it as less intense than MDD, but perhaps longer term
- Debate whether we should consider it distinct from MDD or a variant
Classification of Premenstrual Dysphoric Disorder (PMDD)
New to DSM-5
- changing mood and appetite, irritability, during the luteal phase of the menstrual cycle (time between ovulation and menstruation)
- distinguished from premenstrual syndrome by the severity of symptoms and increased impact on daily functioning
some critics note that the addition of “disorder” is overly medicalising a natural biological process and women’s bodies/minds (constructing these as “inherently ill”)
- further controversy: creation of this diagnosis coincides with the extension of a patent for a medication intended to treat it (new medication “Sarafem”, is Prozac renamed - fem used for feminine)
Disruptive Mood Dysregulation Disorder (DMDD)
new to DSM-5
- diagnosis applied to children between the ages of 6-18
- Children w DMDD exhibit extreme anger and irritability that seems disproportional to the triggering situation (unwarranted)
- added to DSM to address (mis)diagnosis of bipolar disorder among children
Controversy - questions validity and utility
- clinical descriptions overlaps with Oppositional Defiant Disorder
- children with DMDD are often treated with antipsychotics (why not antidepressants?)
- some claim it medicalises what may be normal phases of emotional development among children, and labelling influences processes related to identity
- Allen Frances (chairperson of DSM-4) encourages practitioners to ignore DMDD and refuse to diagnose it
Bipolar Disorder
Involves experiencing episodes of mania (high energy) and episodes of depression, previously termed “manic depression”
- mania episodes: elevated moods and increased engird lasting at least a week
- DSM mentions “distinct periods of abnormally and persistently elevated, expansive, or irritable mood” and “abnormally and persistently increased goal-directed activity or energy”
- some people w mania report decreased need for sleep, inflated self esteem, flight of ideas, distractibility, may engage in compulsive and potentially harmful activities (substances, sex, gambling)
Bipolar Disorder and its complicated phenomena
Mania is a key diagnostic feature, distinct from “unipolar” depression
- individual experiences BOTH mania and episodes of depression, oscillating between the two
Complicated phenomena:
- some people find manic episodes frightening and may end up being hospitalised
- others enjoy the emotional high
- some descriptions over-emphasise the mania, overlooking the depressive component
What are the different forms of mania in bipolar disorder?
Hypomania: refers to milder forms of mania - elevated mood w lesser degrees of functional impairment than true episodes of mania
- decreased need for sleep, high energy, self-confidence, very optimistic
True mania: is more severe compared to hypomania, and may include psychosis and lead to incarceration or hospitalisation
Different types of bipolar disorder (3)
Bipolar 1 (I): features depression and mania
Bipolar 2 (II): hypomania and more severe depression (less mania, more depression)
Cyclothymic disorder: The most mild form, with swings between mild depression and hypomania
Mood Disorders: Treatment
- Psychotherapy: CBT
- Differing psycho-pharmaceuticals: tricyclic antidepressants, SSRIs, and Lithium
- Electroconvulsive therapy (ECT): used when other treatments fail and usually for severe depression
- Antidepressant medications (ADMs): are particularly important in relation to conceptualisation and management of mood disorders
Clinical Perspective: Antidepressants
- antidepressants are taken by 1 in 10 Americans aged 12+
- SRRIs are also used for anxiety
- antidepressants are believed to safe and effective, but recent research shows an increased risk of suicide in children and youth
- other research critiques the true effectiveness of these meds when compared to placebos
Case Study 1: Antidepressants and the placebo effect
Analysis by Kirsh and Sapirstein found that when using SSRIs for the treatment of MDD:
- 25% of the response to the drugs was duplicated in non-treatment control groups
- 50% of the response to the drugs was due to the placebo effect
- 25% of the response to the drugs was a true effect of medication
All available data (published and unpublished): placebo effect accounts for 80% of patient response to the medication
75% of published trials show significant benefit of medications compared to placebo
Unpublished trials show only 12% of trials demonstrated benefits
- conclusions: prescribing SSRIs is “insufficient” and recommend that psychotherapy, exercise, and acupuncture provide the same benefit, with lower risk of side effects
Case Study 1: What is clinically significant improvement?
- larger drug/placebo difference would be found among more severely depressed patients
- NHS 2004 treatment guidelines: 3 point different on Hamilton Depression Scale (HAM-D) was deemed “clinically significant” (real improvement)
- 2008 meta-analysis: showed ADM treatment brought average improvement of 10.13 points on the HAM-D
- Placebo shows 8.34 points of improvement on average (more than clinically significant)
- psychotherapy gives same benefits as ADMs, so does exercise and acupuncture
- Patients surveys indicate 75% would prefer psychotherapy to ADMs
- Relapse rates are higher in relation to ADMs compared to other treatments
Biases in the reporting of antidepressants
- Publication Bias: unpublished results obscure true picture of effectiveness, as these trials more often show negative effects, medications not more effective than placebo
- Outcome reporting bias: negative effects not mentioned in a published paper
- Spin bias: may include negative outcome but focuses on other outcomes/analyses
- Citation bias: publications showing positive results are cited 3 times more often than those with negative results
Case Study 2: Is cognitive therapy enduring or are antidepressants iatrogenic (illness caused by medical examination or disease)
- Belief that severe depression requires ADMs was tested
- Patients were randomly assigned to either: Pill placebo (PLA), ADM, CBT
- At the end of 8 weeks (effectiveness results): PLA 25%, ADM 50%, CBT 43%
- At the end of 16 weeks: ADM 57.5%, CBT 58.3%
- Patients who did CBT were much less likely to relapse
- Patients taking placebo were likely to relapse
- ADM got strong continuation medication effect & relapse risk reduced 50%
Conclusion:
- CBT has more enduring positive results and a reduced risk of relapse compared to ADMs
- ADM interferes with CBT reducing its enduring effect, but placebo does not have this effect
- Therefore, potential iatrogenic effects of ADM, meaning the medication and side effects may lead to disease or negative outcomes
- This could explain why we don’t see improvements related to the prevalence or course of depression
- Unmedicated patients typically do better than medicated ones, but those receiving meds may be more unwell or more severe
What is the continuation phase?
period between when ADMs lift mood and when the depressive episode would resolve on its own
- better to stay on meds during this phase (analogy w antibiotics), symptoms are only gone because of meds
- relapse due to ceasing medications is probable
Case Study 2: Analysing the common perception that antidepressants “work”
- ADMs have complicated effects
- commonly understood to function by increasing levels of neurotransmitters - serotonin
- but they do not truly increase overall level of serotonin, they enact short term reallocation within the brain (more extracellular, less intracellular) - total level stays the same
- ADMs cause long-term overall decline in the pool of serotonin (depletion over long period), full consequences not yet completely known
Case Study 3: Antidepressant medication and psychotherapy (Benoit Mulsant)
- point to the high rate of prescription of antidepressants, which is partially attributable to lack of access to CBT
- wait times to access a psychiatrist in Ontario are 3-12 months
- capacity problem: Ontario is estimated to have 15 psychiatrists per 100,000 population
- access problem: health insurance does not cover psychologists and counsellors - psychotherapy only available through private insurance and for wealthier patients
Side effects:
- ADMs can lead to suicide
- poor quality therapy may result in worsening of depression or anxiety
What is the overall experience and the meaning of mood disorders?
- clinical diagnosis may not reflect the individual experience of having a mental illness, but can provide some sense of certainty or relief for some
- this is especially true for people whose experiences vary from the status quo
- the meaning of mental illness can be seen not as a static medical definition, but rather as a dynamic phenomena, subject to individual interpretation
How does mass media influence experience and the meaning of mood disorders?
- media shapes our understanding of mental health and illness due to depictions that are highly stigmatising and negative
- there has been efforts to reframe portrayals of mental health in a more positive way
- depicting mental illness in a complex and multifaceted way which calls for social and institutional change as a response to illness would be an improvement
How does social media influence experience and the meaning of mood disorders?
- people w mental illness report that sharing their experiences and connecting w others w similar experiences is empowering
- can fight stigma and raise awareness of real struggles as well as help people and provide forms of treatment
- However, social media has an association w increasing rates of depression
- quality of media use (not just frequency) is linked to rates of depression
How does art and pop culture influence experience and the meaning of mood disorders?
- artistic and literary depictions can help convey the complexity of experiences of mental illness
- some clinicians are exploring ways in which clinical treatment and metaphor and literary analysis might intersect
- making sense of mental health in this way allows us to evaluate the assumptions and limitations of scientific knowledge
