Depression Flashcards
Depression as a word
Feeling sad or miserable, relatively common at all ages, often temporary, not necessarily part of a disorder
Depression as a psychological disorder
Two varieties in DSM 5:
Major Depressive Disorder
Persistent Depressive Disorder aka dysthymia
Major Depressive Disorder
Period of at least two weeks of depressed mood and significant impairment in functioning
Persistent Depressive Disorder
Low-grade depression which lasts for at least a year in children and 2 in adults
Major Depressive Disorder DSM Criteria (come back to recap)
5 or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning, at least one of the symptoms is either
- *Depressed mood most of the day, nearly every day, as indicated by subjective report or observation by others (in kids/adolescents, irritable)
- *Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
Other symptoms:
- Significant wait loss when dieting or wait gain (change of more than 5% of body weight in a month) (or in kids failure to make expected weight gain) or decrease/increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation (slow speech, shows up on neuropsych testing) nearly every day (observable by others, not merely subjective feelings)
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate, indecisiveness
- Recurrent thoughts of death, passive suicidal ideation or active
Distress or impairment
Not attributable to substance
Not explained by another disorder
Never manic or hypomanic episode
Major depressive disorder combinations
Over 1400 ways symptoms can be expressed
Persistent Depressive Disorder (Dysthymia) Criteria A
Depressed mood most of the day, more days than not, for at least two years (in kids and adolescents, one year)
Persistent Depressive Disorder (Dysthymia) Criteria B
Presence while depressed of two or more of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
Persistent Depressive Disorder (Dysthymia) Criteria C
During 2 year period, individual has never been without symptoms in Criteria A and B for more than 2 months at a time
Persistent Depressive Disorder (Dysthymia) Criteria Rule Ours
No manic or hypomanic
Not better explained by psychotic disorder
Not bc of substance
Cause impairment
Double Depression
When a major depressive episode occurs in an already dysthymic individual, occurs in 75% of people with PDD
Depression in childhood
5% of kids 10-20% of adolescents experience major depression
For a long time believed children didn’t have cognitive or emotional level sufficient for depression
But they do experience depression, childhood depression is similar to adult depression
What depression looks like in preschool
- Somber, tearful, lack of exuberance
- Excessively clingy
- Irritable or bored for no apparent reason
- Sleep disruption
- Changes in appetite
What happens after very early depression
Children 3-5 w MDD are more likely to show recurrent symptoms of depression later in life
Depression as a chronic experience, not a phase
Childhood depression prevalence
Relatively uncommon in early childhood
More common in middle childhood
Spikes dramatically during transition to adolescence
Average age 14
High rate persists through early adulthood then tapers
Gender disparity in depression
In childhood, comparable
Profound difference- more for girls- during early adolescence and persists
By midpoint of puberty, females twice as likely to experience depression, this disparity persists into adulthood
Females also more likely to experience reccurrent episodes
Why are females more prone to depression?
- Hormones aren’t sufficient to explain this
- Stressful experiences- trauma (higher population level bc SA and DV) and chronic strain (expectations placed on you, inequities in life, sexual objectification, etc erode quality of life and change how women think about themselves and their place in society)- ties in with the HPA access
- Cognitive style- patterns of thinking that predispose people to depression, women’s marked more by rumination- a risk factor for depression
Rumination
Way of responding to situations by repetitively focusing on distress, its causes, and consequences
Rumination and depression
Indicator of future depression
Rumination exacerbates and worsens depression
In lab, inducing rumination increases negative affect, even in short term
Rumination and gender
Women more likely to ruminate
Why does the gender difference emerge in early adolescence?
Affective- time of heightened emotional reactivity
Biological- pubertal transition, developmental stage (neuroendocrine changes + hormonal changes) activates genetic vulnerabilities (ie predispositions to depression)
Cognitive- cognitive style such as rumination that exacerbates A and B
Co-rumination
Extensively and repetitively discussing and revisiting problems and negative emotions with friends, especially prevalent among adolescent girls
Support Trap
Co-rumination associated with feeling close and connected to friends, it is emotionally fulfilling, but doesn’t outweigh the cost of ruminating
Adolescents with high baseline co-rumination show increased onset of depression during adolescence and shorter time to depressive onset
Girls more likely to co-ruminate than boys, explaining gender differences
Depression contagion
Girls with friends who have high levels of depressive symptoms are more likely to become depressed, party bc of co-rumination
Co-Rumination-Rumination Trap
Co-ruminating with friends can lead to ruminating in isolation
Hard to disengage with rumination
Depression in nonbinary youth
Depends on stigma and discrimination
Youth supported in gender identity show comparable rates of depression and don’t show spikes at puberty
Stigma and lack of support for gender identity increase risk for depression and suicidality
Monoamines
Dopamine, serotonin, norepinephrine
Monoamine hypothesis of depression
People w depression have depleted monoamines in brain’s symptoms
Studies over 70 years show these involved in symptoms of depression
Antidepressant meds work on monoamines
Genes associated with depression code for secretion or metabolism of monoamines
Prevailing biological model of depression
Monoamine holes
Monoamines change with first dose of antidepressant but takes 4-6 weeks to take effect
Meds don’t work for some people
Other biological mechanism
HPA axis
Glutamate- another neurotransmitter
Brain structures like hippocampus and amygdala
Glutamate
- Excitatory neurotransmitter- increases likelihood a neuron will fire, has an indirect role in monoamines
- Helps transmit nerve impulses quickly and efficiently
- Involved in formation and retrieval of memories
Ketamine
- New treatment for depression, works on glutamate
- Works quickly- hours or days
Is depression chronic? (come back to this and before)
For some people, chronic and recurrent
50% youth with MDD will have another depressive within 5 years and 75% in next several decades
Stress plays a role in recurrent MDD
Stress Sensitization Model
Stress and depression are connected
First episodes of MD are more likely to come after significant life stressors
Later episodes are more likely to come after minor stressors
As stress and episodes of depression accumulate over time, it takes smaller levels of stress to tip someone into a depressive episode
HFAD
High functioning after depression
HFAD details
10-20% people w MDD show this
One episode
They thrive not just compared to other people who have had single episodes of depression but also compared to people who have never been depressed
Report more life satisfaction, greater self-acceptance, better relationships, autonomy, self-direction, confidence, productivity
Subsets of people experience MDD and go on to show thriving
Cognitive style
A particular way of thinking
Hopelessness Theory
People with depression make attributions that are internal, stable, and global to explain why negative events happen
Internal- believe they are responsible for it
Stable- the reason they are to blame will not change with time
Global- this reason applies to most things in most situations
For positive situations- attribute it to
External- something outside self
Unstable- unlikely to happen again
Specific- seen as unique to the event
Result of hopelessness theory
Negative attributional style results in individuals taking personal blame for negative events that would have been difficult for them to control, which produces helplessness
Helplessness contributes to hopelessness, which promotes further depression
Beck’s Theory of Depression
People with depression or at risk for it make negative interpretations of life events bc they have information processing biases
Cognitive Model
Situation- in response to any situation, our minds make steady stream of - Automatic Thoughts- these produce an - Emotional Response - we notice emotional responses but not nec thoughts
Fundamentally different than how many people think about experiences and emotions, Beck says we don’t have emotional responses to situations, we have emotional responses to our interpretation of situations
Automatic thoughts produce emotional responses
Example of cognitive model
Situation: lower test grade than anticipated
Automatic thoughts: lots of options
Emotional response: diff based off of these
Beck’s Cognitive Triad
People w depression or at risk for it hold negative automatic thoughts about self, world, future
Negative automatic thoughts in children
Grow as children do, more prominent in older children and adolescents than preschoolers, similar in content to adult negative cognitions - perceived incompetence, low self-worth, inaccurate inferences or explanations for events
Beck thinks negative thoughts are important
Because they are responsible for producing symptoms of depression, they are malleable so can help w treatment
Connection bw thoughts, feelings, behavior
Way we think is directly connected to emotions we have and way we act; all linked, mutually influence each other, if we modify one we can change the others
Cognitive Behavioral Therapy
Most consistently supported treatment for depression
Short-term, 12-20 sessions
Very focused on learning to identify negative automatic thoughts and modifying them, will in turn modify emotional experiences, and adding behaviors that bring feelings of pleasure and accomplishment
Common CBT misconception
CBT doesn’t mean a more positive thought, but a more balanced or nondistorted one, identifying cognitive distortions
Meds for youth
No significant efficacy at younger ages
Black box warning- risk of a suicidal event doubles relative to placebo- 4% teens taking SSRIs reported suicidal thoughts and behaviors, 2% w placebo
Treatment for Adolescents with Depression Study
RCT w Prozac and CBT
Coincided w concerns about increasing suicidal thoughts
CBT/Prozac/Combo- started same, all successful, more gradual decline w CBT, after week 18 CBT and fluox not significantly different, all same at end
Fluox more rapid improvement CBT
Teens taking only fluox were more likely to have a suicidal event than CBT
Meds + therapy is best, not bc it worked better, but more rapid improvement buffered by decrease in suicidal events
Treatment for Adolescents with Depression Study 2
Most 12-20 sessions, usually 25-50% relapse, so did 36
It did
More improvement in 36 weeks than 12, lower relapse rate, combined treatment still better for rate of improvement and minimizing suicide risk
If brain changes in responses to experiences we have and therapy and medication are experiences, we can expect
Neural changes in response to treatment
Neuroimaging + treatment
Pre/post fMRIs show reduced limbic system activation w/meds
Not w CBT, this shows changes in frontal lobe activation
Both neural changes but different mechanisms of action, similar end results but achieve symptom reduction differently
Scalable interventions
Tested pragmatic, brief, single-session interventions for adolescent depression, online, 30 minutes long
Include core elements of empirically supported treatments focused on growth mindset and behavioral activation ?
Compared to supportive intervention, growth mindset and behavioral activation interventions show declines in depressive symptoms and hopelessness @ 3mo follow up
Growth mindset showed increases in perceived agency, decreased generalized anxiety and COVID-related trauma symptoms, higher discontinuation rate
Effect sizes statistically significant but small relative to traditional interventions
Scalable intervention advantages
Free/cheap
Brief
Widely accessible
Doesn’t require a practitioner or physical clinic
Can be done at any time
Minimize drop out observed in longer term treatment ?
