Depression W8 L15 412 Flashcards
Depression: Symptom versus Syndrome versus Disorder
Symptom
Feeling or emotion of sadness
Very common (40% at any given time)
Syndrome
Cluster of common symptoms
“Negative affect” and dimensional view of depression
Disorder / Diagnosis
Syndrome with minimum duration
Syndrome with required impairment
Core Features of depression?
At least one of the following, most of the day, nearly every day, for two weeks:
Dysphoria
prolonged sadness
some sadness normal, even needed in life, but prolonged and distressing no good. Nearly everyday for two weeks but for children …
Irritability
excessive sensitivity, hostility, and moodiness
unique to children and adolescents
Anhedonia
loss of pleasure or interest in previously enjoyable activities
Major Depressive Disorder
5 Symptoms Total needed (9 possible)
During the same two week period
At least one of:
Depressed mood, most of the day, nearly every day OR irritability (children
and adolescents only), most of the day, nearly every day
Anhedonia (loss of interest or pleasure), most of the day, nearly every day
Significant weight loss or gain or decrease or increase in appetite nearly every
day (In children, consider failure to make expected weight gains)
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (observable by others), extreme sluggishness walking through molasses.
Fatigue or loss of energy nearly every day
Feelings or worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think or concentrate, or indecisiveness, nearly every day,
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
Persistent Depressive Disorder (Dysthymia)
Depressed or irritable mood for most of the day, more days than not, as indicated by either subjective account or by observation by others, for at least 1 year
(In adults, mood must be depressed and must last for 2 years)
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
During the 1 year period, the person has never been without the symptoms for more than 2 months at a time
Persistent Depressive Disorder (Dysthymia)
Specification / co-occurrences
Pure dysthymic syndrome
Full criteria for major depression have not been met in the
preceding year
With persistent major depressive episodes
Full criteria for a major depressive episode have been met
throughout the preceding year
With intermittent major depressive episodes
Person has met criteria for one or more major depressive episodes during the preceding year
Depression Diagnoses
Categorical (same in kind) versus dimensional
Recall that one disadvantage of a categorical approach is that there are a group of individuals who will not quite make the cutoff
Many children and adolescents will have subclinical depression
They will not quite make diagnostic criteria, but they have a significant number of symptoms
Show significant impairment (e.g., academic, social)
At greater risk for going on to develop depression as well as other disorders and difficulties (e.g., substance use)
Epidemiology of Major Depressive Disorder (MDD)
Prevalence
1% of preschool children
2% of schoolchildren
Note that these could be underestimates
8% of adolescents lifetime
Cultural and contextual differences
Higher symptoms in minority youths
Likely reflects SES differences
Life stressors and daily hassles important
More hassles for children in low-SES environments
Epidemiology
Gender differences
NO gender differences in childhood – between 6 and 11 years
of age, boys and girls are equally likely to be depressed
Between ages 13 and 15, ratio becomes 2 girls:1 boy, driven by increase in girls
This maintains through adulthood
Gender Differences in Depression
A lot of research has been done to try and understand why adolescent girls (and women) are so much more likely to experience depression
Important to note that no one variable explains the difference
Likely a combination of factors:
Higher experience of stressors and trauma
Biological
Dysregulated HPA axis – overly reactive to stress
Coping styles
Gender Differences in Depression
Higher experience of stressors and trauma
Robust link between stress and depression
Girls/women far more likely to be sexually assaulted
Women are more likely to live in lower-SES conditions
Biological
Gender differences in depression
Coping styles
Rumination
Thinking about a problem constantly, but never moving to active problem-solving
In the context of depression: Why do I feel like this? Why is this happening to me? What’s going to happen to me? I’ll never get better. I’ll never feel good again. This is so unfair.
Course and Prognosis of depression
For a long time, people thought that children could
not be depressed
Within the psychoanalytic tradition, children lacked sufficient superego development to be depressed. WRONG!
Even very young children can be depressed
May be hard for adults to see it
Many of the symptoms of depression are internal
Sadness, shame, guilt, feelings of worthless
Behavioral profile is hetergeneous, withdrawal less assertive or conversely could be more aggressive,
Avoidance, reduced assertiveness, but some children are more aggressive and hostile
Depression in Preschoolers?
Was originally thought that preschoolers would only show “masked” symptoms of depression
E.g., aggression, somatic symptoms
Outward manifestations of an underlying depressed mood
Would not show the “typical” symptoms of depression
Luby et al. 2003, depression of preschoolers,
Luby et al. (2003) tested this hypothesis
Parents of preschoolers completed a psychiatric
interview
Ended up with three groups of children MDD (59 children)
ODD/ADHD No disorder
Procedure:
Psychiatric interview asked about typical symptoms
Also asked about “masked symptoms”
Results:
Typical symptoms often showed high specificity/sensitivity
Absence Of symptôme jeans nô disorder.
Specificity is the likelihood that child without the disorder will not have the symptom
Anhedonia
Presence of anhedonia rules in the , inhérent in the discorder, specificity to the disorder.
Unlike sensitivity, where if you do not have sadness are not depressed, can have sadness without being depressed.
Do see some masked symptoms, but also see specificity of classic depression symptoms, like sadness or anhedonic.
Depression in Preschoolers sensitivity
Some typical symptoms also show high sensitivity
Sensitivity is the likelihood that a child with the disorder will have the symptom
Sadness/grouchiness
Absence of symptom rules out the disorder
Preschoolers
Note that for preschoolers, some modifications to DSM criteria need to be made so?
Depression in
Sadness and unhappiness versus sadness and depression
“Activities and play” versus “work and school”
Themes of suicide and death in play
Possible that 2-week duration used for older children and adults may not be applicable to young children
What is the Course of Depression?
Course
Untreated MDD lasts 8-12 months
Untreated dysthmic disorder (DD) lasts 2-5 years
Residual symptoms frequently present at end of episode
Residual symptoms strong risk factor for recurrence
Course of Depression
MDD recurrence
Preschoolers with depression are 4 times more likely than those without depression to meet criteria for major depressive disorder 2 years later
For children and adolescences who experience a major depressive episode, recurrence is common:
25% within 1 year
40% within 2 years
70% within 5 years
30% develop Bipolar Disorder (“BP switch”)
Most adults with MDD date the onset of first episode to adolescence teen
Course of Depression: Kindling hypothesis is?
First episodes frequently follow significant life stress
Biological changes that make you more reactive to stress in the future
Thus, later episodes may require less stress to begin
What is the Prognosis for depression
Depression recurs
Children and adolescents who have a depressive episode are
more likely to have depressive episodes as adults
Earlier it starts, the worse the prognosis is
More severe, chronic course, greater suicidality
Is depression in childhood/adolescence associated with likelihood of other disorders in adulthood?
Heterotypic continuity: other disorder assocItion in adulthood?
Is depression in childhood/adolescence associated with other problems in adulthood?
Prognosis Study of a longitudinal cohort in New Zealand
Followed them from birth
Met DSM-criteria for Major Depression at 15 to 16 years of age
Examined psychopathology, educational, and social outcomes in early adulthood
3.5x homotypic continuity.
More likely to have anxiety disorder in adulthood!
None of other things sig. Though.
Looking for effect of depression, controlling for a lot, so conservative!
Note also that these analyses took into account co- morbid conditions (e.g., conduct disorder)
Co morbid conditions usual come
First
Co-morbidity
For Major Depressive Disorder
Anxiety
wDysthymia, conduct problems, ADHD, substance use In general, co-morbid conditions come first
Anxiety, conduct disorder, ADHD
Again, these usual precede dysthmia
Co-morbidity
wDysthymia
, For Dysthmia: MDD
Anxiety, conduct disorder, ADHD
Again, these usual precede dysthmia
Ffected on Cognitive Functioning for those who are depressed
IQs in the normal range
Children with depression perform more poorly in
school
Symptoms of depression:
Poor concentration
Low energy
Fatigue
Explain Suicidality in depressed
Suicidality
SUICIDE: taking ones own life
SUICIDALITY: also includes attempts, intent,
ideation
Suicide is the second leading cause of death among Canadian children and adolescents (ages 10 to 19 years)
In 2008, 20.4% of all deaths for youth aged 10 to 19 were due to suicide, compared to 1.5% of all deaths in Canada
Two strongest predictors for suicidal behavior are:
Mood disorder,
being a young female
60% of children and adolescents with major depression report suicidal thoughts
Approximately 30% will attempt suicide
Girls are more likely to attempt suicide; however, they often use?
And Boys are more likely to use?
less lethal means (drugs, wrist cutting)
firearms, and as a result, are more likely to complete suicides
Among Canadian children and adolescents, most common method is suffocation
Accidental deaths by “choking game” may be misclassified
Research with adults on judgement of lethality (Brown et al., 2004, JCCP):
No relationship between person’s perception of lethality and actual lethality
This does not very by gender
No association between suicidal intent and lethality (also see Beck et al. 1975)
Means chosen do not tell you about person’s intent to die
What is Non-Suicidal Self Injury (NSSI)
Prevalence?
Deliberate, destruction of your own body tissue in the absence of intent to die
People are not good at judging lethality
Cutting, burning, biting
17% of adolescents report engaging in one of these
behaviors
Associated with a number of psychological disorders, including depression and anxiety
NSSI
Functional approach to NSSI
(risky painful) Behavior is reinforced by
intra- or interpersonal
Way to regulate negative mood
Intrapersonal negative reinforcement
Reduces or stops aversive thoughts and feelings
Intrapersonal positive reinforcement
Generates desired feelings
Way to obtain desired consequences in the environment
Interpersonal positive reinforcement
Care and attention
Interpersonal negative reinforcement
Less responsibility
Solution not to ignore, instead shift to positive behavior reinforcement.
