The social and psychological bases of depression and suicide

Question 1

What is the difference between depression and feeling sad/blue?

Answer 1

Feeling sad or fed up is a normal reaction to stressful or upsetting experiences and most people recover quite quickly

Depression is more than ‘just’ feeling sad or upset. Not a sign of personal weakness or a condition that can be wished or willed away.

People with a depressive disorder cannot merely “pull themselves together” and get better

Question 2

How many people are effected by depression?

Answer 2

Depression is a common mental disorder. Globally, more than 264 million people of all ages suffer from it - WHO

Causes great distress and suffering for individual with depression

Disrupted relationships

Economic and societal consequences:
- Prevents people from working (e.g job loss, absenteeism)

Question 3

What is sub threshold depressive symptoms

Answer 3

Falls below the criteria for major depression (used to b called unipolar depression) and are defined as at least one key symptom of depression but with insufficient other symptoms and/or functional impairment to meet criteria

Question 4

What is Dysthymia?

Answer 4

Symptoms that are sub threshold for depression but lasts at last 2 years

Question 5

What is bipolar disorder?

Answer 5

Bipolar disorder - also called manic-depressive illness. Characterised by serve highs (mania) and lows (depression)

Question 6

What are the 3 factors that make up major depression?

Answer 6

• Loss or interest and enjoyment in ordinary things and experiences
• Low / depressed mood
• Emotional, cognitive, physical and behavioural symptoms

Question 7

What should the assessment for depression include?

Answer 7

The number and severity of symptoms, duration of the current episode and course of illness

Question 8

What is th main principle we want to assess for depression?

Answer 8

Biopsychosocial

Question 9

What are the key symptoms for depression?

Answer 9

Key symptoms;
- Persistent sadness or low mood
- Marked loss of interest or pleasure
(at least one of these, most days, most of the time for at last 2 weeks)

If any of the above present, ask about associated symptoms:
- Disturbed sleep (increase/decrease)
- Decreased or increased appetite and/or weight
- Fatigue or loss of energy
- Agitation or slowing movements
- Poor concentration or indecisiveness
- Feelings of worthlessness or excessive or inappropriate guilt
- Suicidal thoughts or acts.

Then ask about duration and associated disability, past and family history of mood disorders and availability of support

Question 10

What are some of the emotional symptoms depressed people will experience?

Answer 10

ANHEDONIA - Loss of interest or pleasure in hobbit and activities that were once enjoyed

Persistent sadness or low mood, unresponsive to circumstances

Irritability, tearfulness

Question 11

What are a range of cognitive symptoms depressed people may feel?

Answer 11

Negative via of the self:
- Lowered self-esteem and self confidence
- Feelings of guilt and worthlessness
- Feelings of hopelessness and helplessness
- Pessimistic and recurrently negative thoughts about oneself, world and future ~ Known as the ‘Negative cognitive triad’
- Poor concentration and reduced attention, difficulty making decisions
- Mental slowing or rumination
- Suicidal ideation may be present

Question 12

What are some biological/behavioural symptoms you can see in depressed people?

Answer 12

• Lowered appetite, weight loss, binge eating, weight gain
• Insomnia, early-morning awakening, feeling worse in morning
• Low energy, fatigue
• Loss of labido
• Social withdrawal

Question 13

What does the NICE guidelines recommend that doctors look out for and ask to patients?

Answer 13

Be alert as possible for depression - particularly in people with a past history of depression or a chronic physical health problem associated with functional impairment.

Consider asking people who may have depression 2 questions specifically;
- Durning the last month, have you often been bothered, feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest for pleasure in doing things?

Question 14

What are some risk factors for depression?

Answer 14

Depression has no single cause, it results from a combination of factors;
- Genetic and family factors
- Early life experiences
- Stressful life events
- Social support
- Gender

These are known as vulnerability factors

Question 15

Is depression genetic and are there family factors?

Answer 15

About 3 fold increase risk for major depression in the first-degree relatives (parents, siblings, children) of individuals with major depression versus the general population

Twin and adoption studies shows there may be a genetic component (46% for monozygotic twins compared to 20% for dizygotic)

Question 16

How can early life experiences impact someone developing depression?

Answer 16

Early life events such as;
- Poor parent child relationship
- Marital discord and divorce
- Neglect
- Physical and sexual abuse

Can all increase a person’s vulnerability to depression in later life

Question 17

How can early childhood loss impact depression?

Answer 17

The rate of depression was almost 3 times higher among women who had lost their mother at an early age.

Early loss of mother somewhat increased the risk of such neglect and abuse

Subsequent work showed that a child’s experience of;
- Marked parental neglect
- Physical abuse from a core tie
- Sexual abuse from anyone irrespective of any parental loss was critical

These show the importance of humiliation and entrapment in the development of depression

Question 18

How do stressful life events contribute to depression ?

Answer 18

Most depressions are preceded by a recent stressful event;
- Failure at work, at school, loss of job
- Marital separation
- Rejection by a loved one
- Death of a child
- Illness of a family member
- Physical illness

These can all influence the onset and course of depression

However, not everyone who experiences stressful life events experiences depression, and not everyone who has a family history of depression experience goes on to experience depression themselves.

Question 19

How can social support impact depression ?

Answer 19

Availability of good-quality support from friends and family offers protection to individual in dealing with stressors which may otherwise precipitate a depressive episode

Lack of intimate or confiding relationship can increase the risk of depression

Question 20

Is there a genetic link to depression ?

Answer 20

Yes, it appears that genetic factors influence overall risk of illness BUT also influence the sensitivity of individuals to be the depressogenic effects of environmental adversity
- Gene-by-environment interaction

Genes on their own do not cause depression!

Question 21

What sex is more at risk to depression ?

Answer 21

Major depression seem to be more common in women. Many factors may contribute to this;
- Women may express and report symptoms more than men
- Hormones
- Early life stress, e.g- sexual abuse (girls are more likely to be sexually abused)
- Additional stressed such as responsibilities both at home and work, single parenthood, caring for children and ageing parents

Question 22

How can chronic illness affect depression?

Answer 22

Although people with chronic illness generally function well, psychologically, there is a significant minority who might be at risk for depression
- Documented for stroke, cancer, heart, HIV patients

“Depression is approximately 2 - 3 times more common in patients with a chronic physical health problem than in people who have good physical health and occurs in about 20% of people with a chronic physical health problem - NICE

Get cycle of adapting unhealthy behaviours (e.g smoking) -> not adhering to medical regimens -> direct effect on physiological mechanisms

Question 23

How can assessing depression in chronically ill patients be problematic?

Answer 23

Assessing depression in chronically ill patients be problematic;
- as many signs of depression, such as fatigue, insomnia, or weight loss may also be an expression of the disease
- Drug treatments can also cause depression as a side effect, socially hypertensive, corticosteroids, and chemotherapy agents

Question 24

How can depression affect coronary heart disease (CHD)?

Answer 24

Major depression is associated with 2-4 fold increased risk for cardiac mortality among patients hospitalised for MI

Depressed people without cardiac disease also have a significantly increased risk of cardiac mortality

Depressed CHD patients are less likely to adhere to;
- Cardiac medication regions
- Lifestyle risk factor interventions
- Cardiac rehabilitation programmes

E.g patients in the 1st few weeks after coronary angiography holder depressed patients adhered to prophylactic aspirin regimen less than non-depressed patients

Depression may promote maladaptive health practices such as smoking

Depression may contribute CHD by triggering dysregulation of neurohormonal systems responsible for cortisol and catecholamine secretion

Question 25

What are the relationships between depression and CVS disorder

Answer 25

Depression -> behavioural factors (e.g physical, inactivity, med non-adherence, smoking) -> Biological factors (e.g inflammation, heart rate, variability, catecholamines) -> Cardiovascular disease -> Manifestations (e.g symptom burden, motional distress, function limitation).

Question 26

What are our treatment options of depression ?

Answer 26

• Pharmacological
• Psychological
• Physical activity (mild and moderate depression persistent sub threshold)
• Electroconvulsive treatment (for severe and complex depression)

Question 27

How do we treat those with sub-threshold depression?

Answer 27

Consider offering;
- Individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
- Computerised cognitive therapy (CCBT)
- A structured group physical activity programme

Question 28

What is CBT?

Answer 28

• Short-term psychological treatment
• Emphasises the role of thinking in how we feel and what we do
• Identifying and challenging unhealthy modes of thinking that cause depressed feelings and behavioural
• Can be delivered one-to-one or in group settings

3 parts to it: Thoughts (cognition), Behaviour, Emotion (affect)

Question 29

What psychological interventions can b use to prevent relapse?

Answer 29

People with depression who are considered to be at significant risk of relapse or who has residual symptoms, should be offered on off the following psychological interventions;

Individual CBT;
- for people who have relapsed despite antidepressant medication
- for people with a significant history of depression and residual symptoms despite treatment

Mindfulness-based cognitive therapy;
- for people who are currently well but have experienced three or more previous episodes of depression

Question 30

Who is most likely to have suicidal behaviour ?

Answer 30

804,000 suicide deaths worldwide in 2012
- possibly underreported

In high income countries, 3 times as many men die of suicide than women do, but in low - and middle-income countries, the ratio is at 1.5 men to each woman

Suicide rates are highest among aged 70 or older (men and women and worldwide)

Globally 2nd leading cause of death among 15 - 29 year olds

Question 31

How many people died by suicide in the UK in 2018?

Answer 31

6,507 (+352 in ROI)

Men aged 35 - 44 highest rate in Scotland (highest in UK)

Men 3 times more likely than women

Question 32

What factors influence suicide?

Answer 32

Health system;
- Healthcare access, access to means to suicide, media reporting
- Stigma against seeking help for suicidal behavioural / mental health issues / substance abuse

Community / relationships;
- War / disaster
- Discrimination; isolation; abuse / violence

Individual factors;
- Previous suicide attempts
- Mental disorders
- Harmful use of alcohol
- Financial loss
- Chronic pain
- Family history of suicide

Question 33

What words / phrases do the Samaritans suggest you use and don’t use?

Answer 33

Use;
- A suicide
- Taken his / her / their own life
- Ended his / her / their own life
- Die by / death by suicide
- Suicide attempt
- Attempted suicide
- Person at risk of suicide

Don’t use
- Commit suicide
- Suicide victim
- Suicide ‘epidemic’, ‘wave’, ‘iconic site’, ‘hot spot’
- Cry for help
- A ‘successful’, ‘unsuccessful’ or ‘failed’ suicide attempt
- Suicide ‘tourist’ or ‘jumper’

Question 34

What is the big myth about those who talk about suicide?

Answer 34

Some people have heard that those who talk about suicide are less likely to do it than those who say nothing, this is not true.

It is not true that talking about suicide puts ‘the idea in their head’
- address motivation for suicide and develop alternatives to suicide
- Listen non-judgementally
- Do not be critical
- Do not say “cheer up”, “pull yourself together”

Question 35

What difficult question does NICE encourage you to ask?

Answer 35

Always ask people with depression directly about suicidal ideation and intent. If there is a risk of self harm or suicide;
- Asses whether the person has adequate social support and is aware of sources and is aware of help
- Arrange help appropriate to the level of risk
- Advise the person to see further help if situation deteriorates

Question 36

What should be done if a patient is assessed to be at a suicidal risk ?

Answer 36

If a patient is assessed to be at a suicidal risk;
- Additional support such as more frequent direct contacts with primary care staff or telephone contacts are particularly useful (e.g setting up appointments)
- Inquire about social support and awareness of sources of help
- Referral to specialists