Lecture 11 - Depression

Question 1

Mdep - Description

Answer 1

• – low mood and lack of enjoyment. Lacking concentration and energy, changes in appetite and sleep patterns, feelings of guilt, hopelessness, and despair, and can lead to suicidal thoughts.
  
  • Dysthymia – low-grade (mild or moderate) depression, lasting for at least 2 years. Can have periods of no/extreme symptoms. Feelings of tiredness, inadequacy, depression, and poor sleep. Usually can cope with basic demands.
    
    • Prevalence – 15% of people will experience a depressive disorder at some point. 6.2% of adults 12 months, 4.1% all ages. 5.1% males, 3.1% females. 1.3% experience dysthymia within a year (1.5% female, 1% male). Age of onset – 25 yo.

Question 2

Mdep - Aetiology

Answer 2

• Cognitive model – learned helplessness (internal, global, stable attributional styles). Dysfunctional thinking. Beck’s model – negative experiences in childhood leading to dysfunctional beliefs, which are inactive until triggered by a negative life event. Situations are interpreted negatively (negative views about oneself, the world, and the future), leading to depressive symptoms, which reinforce the negative thoughts.
• Behavioural models – focus on operant conditioning and a lack of reinforcers in the environment.
• Biopsychosocial model – biological vulnerability, psychological vulnerability, and a triggering stressful life event contribute to depression. Activation of stress hormones, negative cognitions (attributions, sense of hopelessness, dysfunctional attitudes/schemas), and problems in interpersonal relationships and a lack of support.

Question 3

Mdep - Assessment

Answer 3

• – number, severity, duration of symptoms and RISK ASSESSMENT ESSENTIAL.
  
  • Hamilton Rating Scale for Depression (HRSD) – clinician administered. Most widely used interview scale, severity/change in depression. 15-20 minutes. 5/3 point scale. 0-7 Normal.
  • Cornell Dysthymia Rating Scale (CDRS) – clinician administered. Severity and frequency of dysthymia symptoms. 20 minutes. 0-4 scale. Better than HRSD for dysthymia. 0-80 range.
  • Depression Anxiety Stress Scales (DASS) – self-report. 42/21 item scale. Severity over the past week. 4 point scale. Dimensional rather than categorical – continuum.
  • Beck Depression Inventory (BDI)­ – self-report. Most widely used self-rating scale. Symptoms over past 2 weeks. 5-10 minutes. 4 point scale. 0-13 minimal; 14-19 mild; 20-28 moderate; 29-63 severe
  • Geriatric Depression Scale (GDS) – self-report. 30/15 items, 5-15 minutes. Cognitive impairments and visual deficits. Yes/no responses, 5+ indicates depression. Just asking them whether they have felt sad or depressed could be just as valid a screening tool.

Question 4

Mdep - Diagnosis

Answer 4

• – depressed mood and loss of interest in previously pleasurable activities for 2+ weeks. 3+ symptoms – disturbance in appetite, sleep disturbance, low energy level, motor restlessness or slowed movements, poor concentration and indecisiveness, feelings of worthlessness/excessive guilt, recurrent thoughts of death/suicide. Cannot have manic/hypomanic episode.
  
  • Specifiers – anxious distress, mixed features, melancholic features, atypical features, psychotic features (mood in/congruent), catatonia, peripartum onset, seasonal onset.
  • Dysthymia – depressed mood for most of the day, more days than not, 2+ years. 2+ symptoms – poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness. Never without these symptoms for more than 2 months at a time. Specifiers – pure dysthymic (no MDE), persistent MDE, intermittent MDE (with/without current episode).

Question 5

Mdep - DSM-5 Changes & Diff Diagnosis

Answer 5

• DSM-5 Changes – omission of the bereavement exclusion. Addition of Disruptive Mood Dysregulation Disorder and Premenstrual Dysphoric Disorder. Dysthymia is now known as Persistent Depressive Disorder.
• Differential Diagnosis – grief (emptiness/loss rather than depression, tied to deceased, preoccupation with memories of the deceased, suicidal thoughts focused on joining them).

Question 6

Mdep - EBT

Answer 6

• – Lv 1 CBT, IPT, Psychodynamic, Self-Help. Lv 2 – Solution-Focused Brief Therapy, DBT, Emotion-Focused, Psychoeducation. Level 3 – ACT, MBCT.
  
  • Interpersonal Therapy – learning new ways of managing and interacting. 12-16 sessions. Interrelation of the social and mood problems.
  • Brief Psychodynamic Therapy – focus on the past, emotions, the therapeutic alliance, and recurring themes. No different between CBT. Not manualised so difficult to evaluate.
  • Self-Help – can be used as a sole or supplementary therapy. CBT techniques applied to oneself. Usually no more than moderate depression, and need positive attitude towards self-help.
  • CBT – more effective than WL, less likelihood of relapse vs medication, large effect sizes and well-maintained. Individual more effective than group.
    
    • Cognitive Processes – errors in logic, ruminative response style, overgeneralisation, reduced metacognitive awareness.
    • Behavioural experiments – engagement (introducing CBT), activity scheduling (routine is important, targeting avoidance behaviours), testing negative automatic thoughts, relapse and recurrence (identification of possible triggers).
  • Medication – increasing serotonin, noradrenaline, and dopamine. SSRIs (best balance between cost/benefit), TCAs (more side effects and hazardous in OD), atypical (SNRIs – greater efficacy at increased doses), MOAIs (more severe adverse reactions), alternatives (St John’s wort, better than placebo but not recommended for clinical levels). Low levels of adherence for depression – non-persistence (since they’re feeling better), or non-compliance (I forgot) – 1/3 discontinued against medical advice, leading to poor outcomes.
  • Electro-Convulsive Therapy

Question 7

Mdep - Challenges

Answer 7

• Behavioural Activation – helping them to access natural positive reinforcers in their lives, setting them up for success and joy.
• Administration of DASS at the beginning of the session – how does that fit with how you are feeling? Add a couple of risk assessment questions.
• Inability to identify pleasurable events – can’t just give them suggestions, they need to come to it themselves.
• External life stressors – we don’t have as much control over it but it still needs to be addressed since there could be something that genuinely sucks happening at the moment.
• Therapist fatigue – it is exhausting trying to engage someone with catatonic depression in discussion. Can feel lethargic, like you’re not getting anywhere