Lecture 2: Prevention of depressive disorders Flashcards
When is major depressive disorder diagnosed?
9 symptoms in total
5 symptoms of which at least 1 or 2:
Key symptoms:
- Depressive mood (feeling ‘down’)
- Loss of interest
Other symptoms:
- Weight gain or loss
- Insomnia or hypersomnia
- Psychomotoric agitation or reduction
- Tiredness/ loss of energy
- Feelings of worthlessness
- Reduced concentration
- Recurring thoughts about death
What are the most important mood disorders?
- Major depression (2 weeks, 5 symptoms)
- Minor depression (2 weeks, 2-4 symptoms)
- Dysthymia (at least 2 years, 2 symptoms)
- Bipolar disorder (also manic episodes)
Minor depression not in DSM-5
Why diagnose?
Practical, but depression is now more often seen as a continuum
Prevalence (3), prognosis (2), comorbidity (1)
- Twice as high in women
- Decreases with age
- High incidence
- High relapse (50% after two years)
- Not all patients seek treatment (60 - 80%)
- Almost half has comorbid anxiety disorder (46%) + other comorbidities
Depression in baby’s
- Anaclitic depression
- Infant depression
Prevalence, young children, primary school, adolescents, young adults?
What is the average age of onset?
Young children (2-4 years): 1%
Primary school: 2%
Adolescents: 0,4 - 8,3%
Young adults: 7,2%
Average age of onset = 15 - 25 years
Onset of depression, theories?
Biological theories:
- Genetics
- Dysregulation of neurotransmitters
- Brain deviations
- Hormonal factors
Psychological theories:
- Behavior theory
- Cognitive theory
- Psychodynamic theory (unresolved conflicts)
- Interpersonal theory (disruptions/ difficulties in social relationships/ loss of relationship)
AND stress vulnerability model
What treatment options are there for depression? (3)
Biological treatment:
- Antidepressants
- Electroconvulsive therapy (ECT)
- Light therapy
Psychological treatments:
- CBT
- Interpersonal psychotherapy
- Behavioral activation
- Etc.
Other treatments:
- Acupuncture
- Exercise
What factors add to the burden of the disease?
- High prevalence
- High societal cost
- 5.6% of all YLD
Why is prevention important?
Treatments are effective but the uptake is low (28% in HIC, 7% in LIC), especially in high risk groups (adolescents, young adults, older adults, minorities)
AND even with optimal uptake and evidence based treatments, it is estimated that the burden of disease can only be reduced with 33%
What is needed to reduce the burden of depressive disorders?
Basic research for a better understanding of depression, leading to more knowledge on what to do about it
Clinical research on:
- Prevention
- More effective treatments (e.g. personalized)
- Simplifying treatments and better dissemination (especially in low resourced settings)
What are the main advantages (3) and disadvantages (2) of universal prevention?
Advantages:
- Low stigma
- Can be conducted in specific settings (school, work, etc.)
- Can be integrated into existing broader programs
Disadvantages:
- Difficult to show efficacy in trials (huge sample sizes are needed)
- Relatively small effects (do they work?)
Why is universal prevention often no prevention at all?
Often you show that the average symptom level goes down, but this probably an indirect way of treating people
- People with subthreshold depression and/ or a mental disorder show a reduction of existing symptoms
Small effect sizes in trials could mean two things:
- Very large impact because it reaches the complete population, a small effect has a large impact
- No impact at all because a small effect has a bigger chance of being an artifact because of low quality or a bias we cannot measure
What is the MYRIAD trial?
The MYRIAD trail examined mindfullness and found no effect on depression at all
Name positive and negative aspects of selective prevention of depression
Positive:
- Can be adapted very well to the needs of the at risk population
Negative:
- Usually the effects on incidence are not measured
- Many participants already have mental disorders
- Low predictive value of most known risk factors: most people will not develop depression.
What are advantages (3) and disadvantages (1) of indicated prevention of depression?
Advantages:
- Effects on incidence can be examined relatively well
- They have modest but significant impact on the incidence
- It’s relatively easy to identify participants through screening
Disadvantage:
- Uptake is often low
Where are we with respect to the prevention of depression?
4 items
- It’s unclear if universal prevention works
- Selective prevention is promising but may very well be just indirectly ‘treating’ people with existing problems
- The predictive strength of risk factors is low
- Indicated prevention works but the uptake is low
What steps need to be taken to improve the prevention of depressive disorders?
5 items
- Basic research into the causes of depression
- More investment in public mental health research
- Research on universal and selective prevention (large trials with multiple target populations)
- Research into uptake of indicated prevention and increasing effects of interventions
- More research into big determinants and structural embedding of prevention
What important determinants of depression are not targeted?
-
Poor parenting
- Risky prenatal behavior
- Emotional neglects
- Rejection
- Lack of structure
- Over-control and over-involvement - Inter- parental conflict, family instability
- Childrens maladaptive personality traits (e.g. low-self control)
- Poor social and problem solving skills
Prevention of depressive disorders should…
… Start early in life
… Focus on children and parents
… be long-term and stuctural
What are potentially important determinants of depression?
- Inqualities
- Social status
- Migration
