Mood Disorders: Depression

Question 1

Current approaches to diagnosis of depression (major depressive disorder)

Answer 1

Depressed mood for more than 2 weeks.
Feeling depressed, sad, empty or hopeless.
Loss of interest in previously enjoyed activities (anhedonia).
Plus at least four of: weight loss/gain or change in appetite, insomnia or hypersomnia, loss of energy or excessive fatigue, motor restlessness or slowed movements, diminished concentration, ability to think or indecisiveness, feelings of worthlessness or guilt, recurrent thoughts of death, suicidal ideation or suicide attempt.

Question 2

Specifiers in MDD

Answer 2

Extensions to diagnosis to clarify variability.
Severity of depression (mild, moderate, severe)
Number of episodes (single, recurrent)
Degree of recovery between episodes (full or partial)
Depression with or without psychotic features (paranoia, delusions, hallucinations)

Question 3

3 new changes to depressive disorders

Answer 3

Bereavement no longer excluded from a diagnosis of major depression.
Dysthymic disorder renamed ‘persistent depressive disorder’ (less severe but more chronic)
Addition of ‘disruptive mood dysregulation disorder’ (severe and persistent irritability eg extreme temper outbursts)

Question 4

Particular features of suffers depressions

Answer 4

MDD with melancholic features
MDD with catatonic features
MDD with peripartum onset
MDD with season pattern 
MDD with mixed features
MDD with anxious distress

Question 5

Prevalence of depression

Answer 5

In Australia:
3.1% in men,
5.1% in women over a 1 year period.
Women are twice as likely to to experience depression as men.

Question 6

Risk factors associated with depression

Answer 6

High levels of anxiety and substance abuse = increased risk of depression in young people.
History of depression
Ongoing family conflict
History of sexual or physical abuse
Residing in a rural area
Being of aboriginal or Torres Strait islander descent
Having a parent with a psychological disorder
Poverty

Question 7

Age of onset of depression

Answer 7

Median age is approx 30 years
Can affect people of any age
Young as 3 years old

Question 8

Course of depression

Answer 8

50% of those with a depressive disorder will recover within 6 months following treatment.
Many who recover from a first episode will have another episode within 5 years.
Increase rate of relapse: earlier age of onset, continued experience of some symptoms, multiple prior depressive episodes, ongoing life stressors, history of depression in family.

Question 9

Problems associated with depression

Answer 9

Increased risk of suicide attempts.
Impaired social and occupational functioning.
Co-morbid anxiety disorders.
Increased physical health problems.

Question 10

Rate of suicide in community from depressive disorders

Answer 10

Approx 3.5%

Higher rate for male suicide (6.9%) than female suicides (1.1%).

Question 11

Aetiology of depression: biological factors

Answer 11

Genetic component: family history of depression increases risk by 2-3 times.
Polymorphism on 5-HTTLPT gene + aversive life events = increased risk of depression.
Neurotransmitter imbalances
Hyperactivity in the hypothalamic-pituitary-adrenal axis (production of excess stress hormones)
Potential structural or functional abnormalities in the pre-frontal cortex, hippocampus, anterior cingulate cortex and the amygdala.

Question 12

Neurotransmitter imbalances in depression

Answer 12

Main neurotransmitters implicated in depression are serotonin, noradrenaline, and dopamine (monoamines).
Involved in regulation of sleep cycles, motivation, and appetite.
Abnormalities in the number and sensitivity of receptors available to take up monoamines.

Question 13

Aetiology of depression: environmental factors

Answer 13

Stressful life events (acute: financial disaster, chronic: living with abusive partner) can act as casual triggers.
Growing up in violent, disruptive, hostile family.
Environmental risks usually interact with biological and learnt psychological vulnerabilities to trigger depression.
Possible to reduce the impact of stressful life experiences by increasing social support.

Question 14

Aetiology of depression: psychological factors - cognitive theories

Answer 14

Depressive attributional style: seeing negative events as due to internal, global, and stable factors.
Beck’s negative cognitive triad: depressed people hold a negative view of the self, the world, and the future, and this view is maintained by cognitive distortions.

Question 15

Aetiology of depression: psychological factors - behavioural theories

Answer 15

Some life events or stresses can reduce the opportunity to experience positive reinforcers, which in increases risk of depression.
Also highlights role of poor coping skills.

Question 16

Aetiology of depression: psychological factors - psychoanalytic theories

Answer 16

Depression is a form of pathological grief.

Question 17

Aetiology of depression: social factors

Answer 17

Interpersonal difficulties: high expressed emotion (relationships involving hostility, criticism, and over-involvement) have been linked to depression.
Lack of intimate relationships: particularly a risk factor for women.

Question 18

Aetiology of depression: protective factors

Answer 18

Good interpersonal skills
High levels of family cohesion
Being connected with one’s community 
Achievement in a valued pursuit
Optimism and low anxiety
Openness to experiences
Effective coping skills

Question 19

Treatment of depression: pharmacological and psychical approaches

Answer 19

Medication (antidepressants)
Repetitive transvestism magnetic stimulation
Vagus nerve stimulation (increase activity in hypothalamus and amygdala)
Bright light therapy for seasonal affective disorder
Electroconvulsive therapy (for severe depression)

Question 20

Treatment of depression: psychological approaches

Answer 20

CBT is the most widely-used and well supported psychological intervention for depression.
Pleasant activity scheduling (increase number of rewarding activities)
ABC model: Activating events trigger dysfunctional Beliefs that in turn result in negative Consequences.
Interpersonal psychotherapy (IPT)
Psychodynamic therapy

Question 21

Interpersonal psychotherapy (IPT)

Answer 21

Short-term psychological treatment
Addresses the client’s interpersonal problems as a way of improving their psychological symptoms.
Eg interpersonal disputes (wife not feeling supported by husband) or life transitions (becoming a parent).
Therapist helps resolve dysfunctional interpersonal relationships.

Question 22

Psychodynamic therapy

Answer 22

Therapies focused on uncovering and resolving unconscious conflicts that drive psychological symptoms.

Question 23

Relapse prevention

Answer 23

Most common method is antidepressant medication
Continue active phase of psychological treatment eg CBT: plan how to cope with future triggers to depressed mood; develop a plan for how to respond if symptoms re-emerge

Question 24

Prevention of depression

Answer 24

Most preventive interventions have CBT or interpersonal skills (teach cognitive, interpersonal, and coping skills)
Internet delivery of treatment and prevention programs may be promising.