The Social and Psychological Bases of Depression and Suicide

Question 1

What does depression cause?

Answer 1

• Causes great distress and suffering for the individual with depression.
• Disrupted relationships.
• Economic and societal consequences:
  
  • Prevents people from working (e.g. job loss, absenteeism).

Question 2

What are the different affective disorders?

Answer 2

• Major depression
  
  • ​Unipolar depression
• Subthreshold depressive symptoms
  
  • ​Which fall below the criteria for major depression, and are defined as at least one key symptom of depression but with insufficient other symptoms and / or functional ipairment to meet the criteria for full diagnosis.
• Dysthmia
  
  • ​Depressive symptoms that are subthreshold for depression but lasts at least 2 years.
• Bipolar disorder
  
  • ​Also called manic-depressive illness. Characterised by severe highs (mania) and lows (depression).

Question 3

Describe the range of issues associated with major depression.

Answer 3

Question 4

How is the severity of depression assessed?

Answer 4

• Assessment should inclde the number and severity of symptoms, duration of the current episode and course of illnes.
• Take into account the degree of functional impairment and / or disability associated with the possible depression and the duration of the episide.

Question 5

What are the key symptoms of depression?

Answer 5

• Persistent sadness or low mood; and/or
• Marked loss of interests or pleasure.
• At least one of these, most days, most of the time for at least 2 weeks.
• If any of above present, ask about associated symptoms:
  
  • disturbed sleep (decreased or increased compared to usual)
  • decreased or increased appetite and/or weight
  • fatigue or loss of energy
  • agitation or slowing of 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 social support.

Question 6

What are the emotional symptoms of depression?

Answer 6

• Loss of interest or pleasure in hobbies and activities that were once enjoyed - anhedonia.
• Persistent sadness or low modd, unresponsive to circumstances.
• Irritability, tearfullness.

Question 7

What are the cognitive symptoms of depression?

Answer 7

• Negative view 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, the world and the future - ‘negative cognitive triad’
• Poor concentration and reduced attention, difficulty making decisions.
• Mental slowing or rumination.
• Suicidal ideation may be present.

Question 8

What are the biological / behavioural symptoms of depression?

Answer 8

• Lowered appetite, weight loss, sometimes weight-gain.
• Insomnia, early-morning awakening, feeling worse in the morning.
• Low energy, fatigue.
• Loss of libido.
• Social withdrawl.

Question 9

What are the questions you should ask people with a past Hx of depression or a chronic physical health problem with associated functional impairment?

Answer 9

• “During the last month, have you often been bothered by feeling down, depressed or hopeless?”
• “During the last month, have you often been bothered by having little interest or pleasure in doing things?”

Question 10

What are the genetic and family risk factors for depression?

Answer 10

• “About 3-fold increased risk for major depression in the first-degree relatives (parents, siblings, off- spring) of individuals with major depression versus the general population”.
• Possibly a genetic component:
  
  • “.. Concordance for lifetime major depression of 46% for monozygotic twins compared with 20% for dizygotic twins…”

Question 11

What early life experiences are risk factors for depression?

Answer 11

• Early life experiences such as:
  
  • Poor parent-child relationship
  • Marital discord and divorce
  • Neglect
  • Physical and sexual abuse
• … can increase a person’s vulnerability to depression in later life.
• Early childhood loss
  
  • Brown & Harris (1978): interviewed women in Camberwell (London).
    
    • 15-20% were moderately to severely depressed and not receiving treatment
    • The rate of depression was almost 3 times higher among women who, before age 11, had lost their mother and who also experienced a severe recent loss.
  • Subsequent work showed that a hild’s experience of:
    
    • Marked parental neglect
    • Physical abuse from a core tie
    • Sexual abuse from anyone irrespective of any parental loss was critical
  • Early loss of mother - somewhat increased the risk of such neglect and abuse.

Question 12

What stressful life events are risk factors for depression?

Answer 12

• Most depressions are preceded by a recent stressful event:
  
  • Failure at work, at school, loss of a job
  • Marital separation
  • Rejection by a loved one
  • Death of a child
  • Illness of a family member
  • Physical illness
  • Humiliation and entrapment in lifetime are also important
• These can influence the onset and course of depression

Question 13

Describe the relationship between social support and depression.

Answer 13

• Availability of good-quality support from friends and family offers protection to the 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 14

What is the Gene-by-Environment interaction?

Answer 14

It appears that genetic factors influence overall risk of illness BUT also influence the sensitivity of individuals to the depressogenic effects of environmental adversity.

Note - genes on their own DO NOT cause depression.

Question 15

Describe the relationship between depression and gender.

Answer 15

• Major depression seem to be more common in women. 2:1 rate of depression in women compared to men.
• 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 stresses such as responsibilities both at home and work, single parenthood, caring for children and aging parents

Question 16

Describe the relationship between depression and chronic illness.

Answer 16

• 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 two to three 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”.
• Depression may be linked to chronic illness in various ways:
  • Adapting unhealthy behaviours (e.g., smoking, bad diet, lack exercise, poorer sleep, alcohol and substance abuse).
  • Not adhering to medical regimens.
  • Direct effects on physiological mechanisms.

Question 17

Describe the problems associated with assessing depression in a patient who has a concurrent chronic illness.

Answer 17

• Assessment of depression in chronically ill patients can be problematic:
  
  • As many signs of depression, such as fatigue, insomnia, or weight loss may also be an expression of the disease itself.
  • Drug treatments can also cause depression as a side effect, especially hypertensives, corticosteroids, and chemotherapy agents.

Question 18

Describe the association between depression and coronary heart disease (CHD).

Answer 18

• Major depression is associated with 2- to 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 regimens
  • Lifestyle risk factor interventions
  • Cardiac rehabilitation programmes
• Depressionmaypromotemaladaptivehealthpracticessuch as smoking.
• Depression may contribute CHD by triggering dysregulation of neurohormonal systems responsible for cortisol and catecholamine secretion.

Question 19

What are the treatment options for depression?

Answer 19

• Pharmacological treatments
• Psychological treatments
• Physical activity (mild and moderate depression or persistent subthreshold depressive symptoms)
• Electroconvulsive treatment (for severe and complex depression)

Question 20

What are the low-intensity psychosocial interventions?

Answer 20

• For people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person’s preference:

– individual guided self-help based on the principles of cognitive behavioural therapy (CBT).

– computerised cognitive behavioural therapy (CCBT).

– a structured group physical activity programme.

Question 21

Describe CBT.

Answer 21

• 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 behaviour.

Question 22

What are the psychological interventions for relapse prevention?

Answer 22

• People with depression who are considered to be at significant risk of relapse or who have residual symptoms, should be offered one of 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 cognitivetherapy:
    
    • for people who are currently well but have experienced three or more previous episodes of depression.

Question 23

What are the health system risk factors for suicide?

Answer 23

• Health care access, access to means to suicide, media reporting.
• Stigma against seeking help for suicidal behaviour / mental health issues / substance abuse.

Question 24

What are the community / relationship risk factors for suicide?

Answer 24

• War / disaster
• Discrimination; isolation; abuse / violence

Question 25

What are the individual risk factors for suicide?

Answer 25

* Previous suicide attempts * Mental disorders * Harmful use of alcohol * Financial loss * Chronic pain * Family Hx of suicide

Question 26

What do you do if you have a patient who is assessed to be at a suicidal risk?

Answer 26

* 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.