Week 7 - Treating Depression Flashcards
Phenomenology of Depressive Disorders
Leading cause of disability worldwide
—10% of all disability
High functional impairment – pervasive across situations
—Relationships, vocation, self-care
Highly comorbid
—Anxiety, alcoholism and drugs, eating disorders
Associated with suicidality
—High mortality rates – 3rd leading cause of death in 15-24 year olds
Episodic
May or may not be linked to precipitating events
Major Depressive Episode
DSM - 5
5 or more of 9 symptoms, over at least 2 weeks, representing a change from previous functioning
At least one of the symptoms present must be
(1) depressed mood
or (2) anhedonia.
Symptoms cause clinically significant distress of impairment in functioning
Nat attributable to physiological effects of substance or med. condition
MDE: DSM -5 (9 symtpoms)
(1) Depressed mood
(2) Diminished interest or pleasure
(3) Significant weight loss or gain (or increase/decrease in appetite)
(4) Insomnia or hypersomnia
(5) Psychomotor agitation or retardation
(6) Fatigue or loss of energy
(7) Feelings of worthlessness or excessive/inappropriate guilt
(8) Diminished ability to think or concentrate & indecisiveness
(9) Recurrent thoughts of death or suicide*
Symptoms: Four Components
What comprises mood disturbance?
Thoughts (cognition) – hopeless, worthless
Behavior – psychomotor agitation vs. retardation, eating fluctuations, sleep problems, suicidality
Physiology/sensations – sad expression, irritability, somatic complaints (pain, aches)
Feelings – sadness, lack of pleasure
Suicidal Ideation
ALWAYS do a risk assessment for clients reporting a depressed mood, even if they do not voluntarily mention suicidal ideation
Depression present in 40-60% of completed suicides
People with depression 25x suicide risk compared to general population
Non-suicidal Self Injury –> borderline, substance use, eating, depressive disorders
Maladaptive way to regulate emotions
Ask something like: “Sometimes when people feel depressed, they have thoughts of suicide. Has this ever happened to you”?
Suicide & Anti-depressants
Untreated depression carries a greater suicide risk
Contradictory evidence for increased suicide risk
Individual variability; genetics impact on tolerance, dose effects
Some evidence that risk is increased in children/adolescents, within first few months
Anyone commencing/changing/reducing antidepressant use should be regularly monitored by GP/psychiatrist
MDE Specifiers
Single or recurrent episode
—Recurrent: Presence of 2 or more MDEs
Estimation of severity (mild/moderate/severe)
Examples of other specifiers:
- Anxious features
- Mixed features
- Melancholic features
- Psychotic features (potential for misdiagnosis)
- Catatonia
- With peripartum onset
- With Seasonal pattern
Major Depressive Disorder
further dsm notes
Symptoms not attributable to another medical condition or substance
Be aware of possibility of dementia in older clients
Clinically significant impact on functioning
There should be NO history of manic or hypomanic episodes
MDE: Course
Symptoms typically develop over days to weeks
When untreated, MDEs tend to last approx. 4 months or longer.
Relapse Risk
- -After 1 episode, 60% will experience a 2nd (even if receiving TAU)
- -After 2 episodes, 70% will experience a 3rd
- –After 3 episodes, 90% will experience a 4th
Major Depressive Disorder: Statistics
Gender Differences
–In adults & adolescents, females present twice as often with MDD, similar rates found x-cultures Childhood: no gender differences
Family Pattern
–1.5 to 3.0 times more common in 1st degree relatives
Prevalence
- -Different studies have presented varying data on prevalence
- —Lifetime risk in community samples: 10- 25% for women; 5 - 12% for men
- —Prevalence appears unrelated to ethnicity, income, education or marital status
Duration varies:
–Minimum duration of episodes 2 weeks
–Most have at least 2 episodes – on average 5 to 6
Most recover from episode < 6 months
Relapse reduces with increased remission time
Persistent Depressive Disorder (DSM-5)
DSM-IV: Dysthymic Disorder
Depressed mood most of the day, more days than not, for at least 2 years
Has never been without symptoms for more than 2 months at a time
When depressed, 2 (or more) symptoms are present
Persistent Depressive Disorder (DSM-5)
(DSM-IV: Dysthymic Disorder)
SYMPTOMS
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or indecisiveness
Feelings of hopelessness
PDD: Statistics
Gender Differences similar to MDD
Family Pattern
- -increased prevalence of PDD when 1st degree relative had MDD
- -increased prevalence of PDD & MDD when a 1st degree relative has PDD
Prevalence
–Lifetime prevalence rates: 6%
Course
- –Typically early, insidious onset, with chronic course
- –Prognosis generally regarded as poor in comparison with MDD
- –Some studies suggest recovery in 10 – 15% of clients 1 yr. after diagnosis
- –Evidence for effectiveness of CBT & IPT
Psychometric Assessment Options
Presence/severity of depression:
- -Beck Depression Inventory-II
- -Depression, Anxiety, Stress Scale
Processes underlying depression
- -Rumination: Response Styles Questionnaire (CBT & ACT)
- -Rosenberg Self-esteem Scale (CBT)
- -Automatic Thoughts Questionnaire (CBT & ACT)
- -Acceptance & Action Questionnaire (ACT)
- -Personal Values Questionnaire (ACT
Sadness vs Depression
Sadness is only 1 of at least 5 symptoms
Sadness typically has an identifiable trigger that precedes it
Sadness will tend to naturally remit
Sadness likely to fluctuate with distractions
Sadness less likely to significantly impact on functioning
Adaptive function of dysphoria
Dysphoria: emotional state characterised by dissatisfaction, unhappiness, uneasiness
Incentive-disengagement theory: dysphoria inhibits goal-seeking behaviour if an obstacle cannot be overcome => conserve resources
Dysphoria leads to adaptive disengagement of ineffective goal seeking, & prevent the premature pursuit of alternatives
Anxiety protects against threat, dysphoria protects against futility
From Dysphoria to Depression
Experiential Avoidance (ACT): evaluate dysphoria as not ok»_space; self-criticism for feeling bad, behaviours to escape the feeling
Rumination: verbal process of trying to answer self-imposed questions about the meaning, causes & consequences of an event
- -2 really unhelpful components:
- —Inward-directed attention to the psychological experience (“I feel so awful”, “this is terrible”)
- —Unbalanced analysis & critical evaluation of the event & the self…projected to the future
LOTS of empirical support for rumination as the main culprit
Misplaced focus on trying to minimise a problem, but some problems cannot be solved
In response to a range of negative life events, people with a ruminative style significantly more likely to develop depression
Results in increased self-blame, self-criticism & -ve evaluation (“what is WRONG with me?”)
Ruminators have increased pessimism about +ve future events, better free recall of past –ve life vents
Inhibits effective problem-solving
–Ruminators less confident/satisfied with solutions, less likely to commit to solutions, more likely to request more “thinking time” (i.e. more rumination)
Depression: Etiology
Numerous factors implied in etiology of Major Depressive Disorder.
- -Genetic Factors
- -Biological Factors
- -Lifestyle factors
- -Interpersonal Factors
- -Environmental
- -Cognitive Factors
- -Behavioural Factors
Each of these factors interact with & influence the others
Depression: Genetic Factors
Literature indicates a significant genetic contribution in depression.
–Genetic factors stronger in Bipolar Disorder.
Biological children of depressed parents remain at risk even when reared in a different family.
Concordance rate
- -Monozygotic twins = 50%
- -Dizygotic twins = 10-25%
Lifestyle Factors
Sleep
- -As well as a symptom, disturbed sleep can precede a depressive episode
- -Emotion regulation can be impaired by lack of sleep
- -Some evidence that depression/anxiety improves following insomnia treatment
Exercise
- -Impacts on energy levels, can be a means of socialising
- -Empirical support for regular, moderate exercise alone as an effective treatment for mild-moderate depression
- -16 weeks of regular exercise as effective as anti-depressants
- -Increasing from nil – 3 times/wk x 30 mins. x aerobic exercise level: results in 20% reduced depression risk over 5 yrs
Nutrition
- -Impact on energy, concentration, etc
- -Nutritional psychiatry – emerging evidence for role of gut health
- -Nutritional deficits in eating disorders associated with mood instability, impaired emotional regulation, cognitive rigidity
Sleep Hygiene
Establish regular sleep patterns, even on weekends
Only try to sleep when sleepy
—If no sleep after 20 mins, get up & do something calming or boring, in dim light
Avoid caffeine, nicotine & alcohol 4-6 hrs prior to bed
Do not eat, work, watch TV or use computer in bed
No naps, no matter how tired
Establish a sleep ritual 15mins prior to bed
Maintain daytime routine, even after poor sleep
Don’t check the time
Ensure bedroom is quiet, dark & comfortable
Screens: blue light mimics daylight & stimulates brain
Turn off at least 30 mins. – 2 hrs before bed
Differentiating between biological and psychological depression
Hyett, M., Breakspear, M.,
Friston, K.J., Guo, C. C. & Parker, G. B. (2015). Disrupted effective connectivity of corticol systems supporting attention an dinteroception. JAMA Psychiatry, 72(4), 350-358.
Biological (melancholic depression) – brain signature different to non-melancholic depression in networks related to attention and interoception >
1. disrupted circuits linking basal ganglia and prefrontal cortex;
- significant disconnect between the brain’s insular cortex (regulates sensitivity to internal feeling states) and the brain system that controls attention (average incoming connections to attention system lower by nearly 50%)
- decreased effective connectivity between insula and right frontoparietal networks
- decreased effective connectivity between insula and executive networks
Differentiating between biological and psychological depression
Melancholic depression and neurotransmitters:
Disturbances in neurotransmitters serotonin yet also noradrenaline and dopamine +> SSRIs may not be sufficient – better response to SNRIs (serotonergic and noradrenergic inhibitors) or trycyclics
Biological depression and psychological depressive disorders differ in that the latter +> is principally driven by psychological or personality-based factors => actual episodes generally triggered by social stressors (even though some times difficult to identify).
